Resting energy expenditure in adolescents with Down syndrome: a comparison of commonly used predictive equations.

BACKGROUND: Adolescents with Down syndrome (DS) are two to three times more likely to be obese than their typically developing peers. When preventing or treating obesity, it is useful for clinicians to understand an individual's energy intake needs. Predictive resting energy expenditure (REE) equations are often recommended for general use in energy intake recommendations; however, these predictive equations have not been validated in youth with DS. The aim of this study was to compare the accuracy of seven commonly used predictive equations for estimating REE in adolescents who are typically developing to REE measured by indirect calorimetry in adolescents with DS. METHODS: Adolescents with DS participated in a 90-min laboratory visit before 10:00 a.m. after a 12-h overnight fast and a 48-h abstention from aerobic exercise. REE was measured via indirect calorimetry, and estimated REE was derived using the Institute of Medicine, Molnar, Muller and World Health Organization equations. Mean differences between the measured and predicted REE for each equation were evaluated with equivalency testing, and P-values were adjusted for multiple comparisons using the Holm method. RESULTS: Forty-six adolescents with DS (age: 15.5 ± 1.7 years, 47.8% female, 73.9% non-Hispanic White) completed the REE assessment. Average measured REE was 1459.5 ± 267.8 kcal/day, and the Institute of Medicine equations provided the most accurate prediction of REE with a 1.7 ± 11.2% (13.9 ± 170.3 kcal/day) overestimation. This prediction was not statistically different from the measured REE [P-value = 0.582; 95% confidence interval (CI): -64.5, 36.7], and the difference between the measured and predicted REE was statistically equivalent to zero (P-value = 0.024; 90% CI: -56.1, 28.3). CONCLUSIONS: The results suggest that the Institute of Medicine equation may be useful in predicting REE in adolescents with DS. Future research should confirm these results in a larger sample and determine the utility of the Institute of Medicine equation for energy intake recommendations during a weight management intervention.

Evaluation of a TB infection control implementation initiative in out-patient HIV clinics in Zambia and Botswana.

SETTING: Out-patient human immunodeficiency virus (HIV) care and treatment clinics in Zambia and Botswana, countries with a high burden of HIV and TB infection. OBJECTIVE: To develop a tuberculosis infection control (TB IC) training and implementation package and evaluate the implementation of TB IC activities in facilities implementing the package. DESIGN: Prospective program evaluation of a TB IC training and implementation package using a standardized facility risk assessment tool, qualitative interviews with facility health care workers and measures of pre- and post-test performance. RESULTS: A composite measure of facility performance in TB IC improved from 32% at baseline to 50% at 1 year among eight facilities in Zambia, and from 27% to 80% at 6 months among 10 facilities in Botswana. Although there was marked improvement in indicators of managerial, administrative and environmental controls, key ongoing challenges remained in ensuring access to personal protective equipment and implementing TB screening in health care workers. CONCLUSION: TB IC activities at out-patient HIV clinics in Zambia and Botswana improved after training using the implementation package. Continued infrastructure support, as well as monitoring and evaluation, are needed to support the scale-up and sustainability of TB IC programs in facilities in low-resource countries.

Isolated in a technologically connected world?: Changes in the core professional ties of female researchers in Ghana, Kenya, and Kerala, India.

Using panel data gathered across two waves (2001 and 2005) from researchers in Ghana, Kenya, and Kerala, India, we examine three questions: (1) To what extent do gender differences exist in the core professional networks of scientists in low-income areas? (2) How do gender differences shift over time? (3) Does use of information and communication technologies (ICTs) mediate the relationship between gender and core network composition? Our results indicate that over a period marked by dramatic increases in access to and use of various ICTs, the composition and size of female researchers core professional ties have either not changed significantly or have changed in an unexpected direction. Indeed, the size of women's ties are retracting over time rather than expanding.

Palliative care for patients with chronic obstructive pulmonary disease: exploring the landscape.

Patients with chronic obstructive pulmonary disease experience a substantial symptom burden, high levels of psychosocial need and significant mortality. This epidemiological study reveals that the majority of patients are cared for in the public hospital system (64%) and generally die in hospital (72%) with a number of identifiable predictors of 6-month mortality. Our results suggest that palliative care services need to be redirected from a community-based admission focus to a model that is responsive to emergency and acute care hospital systems.

An algorithm for genetic testing of frontotemporal lobar degeneration.

OBJECTIVE: To derive an algorithm for genetic testing of patients with frontotemporal lobar degeneration (FTLD). METHODS: A literature search was performed to review the clinical and pathologic phenotypes and family history associated with each FTLD gene. RESULTS: Based on the literature review, an algorithm was developed to allow clinicians to use the clinical and neuroimaging phenotypes of the patient and the family history and autopsy information to decide whether or not genetic testing is warranted, and if so, the order for appropriate tests. CONCLUSIONS: Recent findings in genetics, pathology, and imaging allow clinicians to use the clinical presentation of the patient with FTLD to inform genetic testing decisions.

Effect of administration of oral contraceptives on the synthesis and breakdown of myofibrillar proteins in young women.

Oral contraceptive (OC) treatment has an inhibiting effect on protein synthesis in tendon and muscle connective tissue. We aimed to investigate whether OC influence myofibrillar protein turnover in young women. OC-users (24±2 years; Lindynette® n=7, Cilest® n=4) and non-OC-users (controls, 24±4 years n=12) performed one-legged kicking exercise. The next day, the myofibrillar protein fractional synthesis rate (FSR) was measured using stable isotopic tracers ((13)C-proline) while the subjects were fed standardized nutrient drinks. Simultaneously, a marker for myofibrillar protein breakdown, 3-methyl-histidine (3-MH), was measured in the interstitial fluid of the vastus lateralis. Measurements were performed in both legs. In general, myofibrillar protein FSR was lower in OC-users (two-way analysis of variance, P<0.05), although the difference seemed to depend on the OC type. Interstitial 3-MH in the skeletal muscle was not different between groups and did not vary by OC type. Exercise did not change myofibrillar protein FSR or 3-MH concentrations. Serum androstenedione and bioavailability of testosterone were lower in OC-users. In conclusion, the results indicate that the use of OC has an inhibiting effect on myofibrillar protein synthesis and the magnitude of the effect may depend on the type of OC. In contrast, there was no effect of OC on myofibrillar protein breakdown in the fed state.

Accuracy of polar F6 in estimating the energy cost of aerobic dance bench stepping in college-age females.

AIM: This study: 1) examined the accuracy of the Polar F6 for estimating energy expenditure (EE) in a sample of college-age women during aerobic dance bench stepping (ADBS) using predicted maximal oxygen consumption (VO2max) and maximal heart rate (HRmax), and 2) determined whether the use of actual measures of VO2max and HRmax improves the accuracy of the Polar F6 for estimating EE. METHODS: Thirty-two females had their VO2max and HRmax predicted by the Polar F6 heart rate monitor (HRM), and then performed a graded maximal exercise treadmill test to determine their actual VO2max and HRmax. The participants then followed a 20-min ADBS routine while stepping up and down off of a 15.24-cm bench at a cadence of 126 beats.min-1. During ADBS, the participants wore two F6 HRM that simultaneously collected data. To estimate EE, one HRM utilized their predicted VO2max and HRmax (PHRM) while the other HRM utilized their actual VO2max and HRmax (AHRM). RESULTS: The predicted HRmax significantly overestimated actual HRmax by 3.75 beats.min-1 on average, and the predicted VO2max overestimated actual VO2max by 2.63 ml.kg-1.min-1 on average (P<0.01). However, there were no significant differences between the PHRM and AHRM (P≥0.05). When compared to indirect calorimetry, the PHRM and AHRM significantly overestimated average EE by 28% (2.4 kcal.min-1) and 27% (2.0 kcal.min-1), respectively (P<0.05). CONCLUSIONS: Even when using actual measures of VO2max and HRmax, the Polar F6 is inaccurate in estimating EE during ADBS for college-age females.

Energy intake and expenditure during a 6-day cycling stage race.

Energy intake (EI) and energy expenditure (EE) are relatively easy to measure accurately over short periods in a laboratory setting, but less so during a multi-day competition. Our goal was to measure EI and EE as accurately as possible during a 6-day, 10-stage cycling race. We prepared all meals and supplements, assessed EI (weighed diet-records) and macrontrient intake, total EE (doubly labelled water), resting metabolic rate (respiratory gas exchange), exercise EE (power meters), and body mass. Body composition was measured several days before and after racing (dual x-ray absorptiometry). Body mass remained stable over the course of the race. The mean EI (27.3+/-3.8 MJ/day) nearly matched EE (27.4+/-2.0 MJ/day). The majority (62%) of EE was exercise EE. Macronutrient intake was within or exceeded the recommendations. Lean body mass increased and fat mass decreased in most of our participants. Our study indicates that EI can match high EE with adequate macronutrient intake during multi-day cycle racing and may be facilitated by appropriate foods being available at appropriate times. This optimization of nutritional provision supports positive changes in body composition.

A large-aperture low-cost hydrophone array for tracking whales from small boats.

A passive sonar array designed for tracking diving sperm whales in three dimensions from a single small vessel is presented, and the advantages and limitations of operating this array from a 6 m boat are described. The system consists of four free floating buoys, each with a hydrophone, built-in recorder, and global positioning system receiver (GPS), and one vertical stereo hydrophone array deployed from the boat. Array recordings are post-processed onshore to obtain diving profiles of vocalizing sperm whales. Recordings are synchronized using a GPS timing pulse recorded onto each track. Sensitivity analysis based on hyperbolic localization methods is used to obtain probability distributions for the whale's three-dimensional location for vocalizations received by at least four hydrophones. These localizations are compared to those obtained via isodiachronic sequential bound estimation. Results from deployment of the system around a sperm whale in the Kaikoura Canyon in New Zealand are shown.

Cognitive and motor assessment in autopsy-proven corticobasal degeneration.

OBJECTIVE: To investigate the clinical features of autopsy-proven corticobasal degeneration (CBD). METHODS: We evaluated symptoms, signs, and neuropsychological deficits longitudinally in 15 patients with autopsy-proven CBD and related these observations directly to the neuroanatomic distribution of disease. RESULTS: At presentation, a specific pattern of cognitive impairment was evident, whereas an extrapyramidal motor abnormality was present in less than half of the patients. Follow-up examination revealed persistent impairment of apraxia and executive functioning, worsening language performance, and preserved memory. The motor disorder emerged and worsened as the condition progressed. Statistical analysis associated cognitive deficits with tau-immunoreactive pathology that is significantly more prominent in frontal and parietal cortices and the basal ganglia than temporal neocortex and the hippocampus. CONCLUSION: The clinical diagnosis of corticobasal degeneration should depend on a specific pattern of impaired cognition as well as an extrapyramidal motor disorder, reflecting the neuroanatomic distribution of disease in frontal and parietal cortices and the basal ganglia.

Prophylactic versus preemptive oral valganciclovir for the management of cytomegalovirus infection in adult renal transplant recipients.

Prophylaxis reduces cytomegalovirus (CMV) disease, but is associated with increased costs and risks for side effects, viral resistance and late onset CMV disease. Preemptive therapy avoids drug costs but requires frequent monitoring and may not prevent complications of asymptomatic CMV replication. Kidney transplant recipients at risk for CMV (D+/R-, D+/R+, D-/R+) were randomized to prophylaxis (valganciclovir 900 mg q.d. for 100 days, n=49) or preemptive therapy (900 mg b.i.d. for 21 days, n=49) for CMV DNAemia (CMV DNA level>2000 copies/mL in >or=1 whole blood specimens by quantitative PCR) assessed weekly for 16 weeks and at 5, 6, 9 and 12 months. More patients in the preemptive group, 29 (59%) than in the prophylaxis group, 14 (29%) developed CMV DNAemia, p=0.004. Late onset of CMV DNAemia (>100 days after transplant) occurred in 11 (24%) randomized to prophylaxis, and none randomized to preemptive therapy. Symptomatic infection occurred in five patients, four (3 D+/R- and 1 D+/R+) in the prophylactic group and one (D+/R-) in the preemptive group. Peak CMV levels were highest in the D+/R- patients. Both strategies were effective in preventing symptomatic CMV. Overall costs were similar and insensitive to wide fluctuations in costs of either monitoring or drug.

Factors influencing discharge location following high lesion spinal cord injury rehabilitation in British Columbia, Canada.

STUDY DESIGN: Retrospective chart review. OBJECTIVE: To identify and describe factors that influence discharge location -- extended care unit (nursing home) or other (private home, group home, or acute care) -- following rehabilitation for individuals with a new high lesion spinal cord injury (SCI) (C1-C4) in British Columbia, Canada. SETTING: GF Strong Rehabilitation Centre, Vancouver, British Columbia, Canada. METHODS: Eligible clients were adults admitted to the GF Strong Rehabilitation Centre Spinal Cord Program between 1994 and 2003, with a new C1-4 lesion (traumatic or nontraumatic), and an ASIA score of A-C at time of discharge. Medical charts of 52 individuals were reviewed and data regarding individual characteristics, health-related characteristics, personal context, hospitalization factors, health resources, and other contextual factors were extracted. RESULTS: In total, 40% of clients were discharged to extended care units post rehabilitation. Seven variables were associated at a univariate level: age, employment at the time of injury, pre-existing medical conditions, social support, preinjury living situation, and insurance (worker's compensation or motor vehicle) or private funding for equipment. Four variables were associated at the multivariate level: age, preinjury living situation, and insurance or private funding for equipment. CONCLUSION: A range of individual, health-related, family and social policy variables influence discharge location following rehabilitation for high lesion SCI in British Columbia. The unique combination of variables presented by each individual should be considered by the rehabilitation team in the discharge planning process.

Breast cancer risk assessment in patients seen in a gynecologic oncology clinic.

The objective of this study was to determine if breast cancer risk assessment following the Gail model should be incorporated into a gynecologic oncology clinic. The Gail model was used to assess the risk of breast cancer in 329 patients with preinvasive lower genital tract disease (Pre, n = 86), invasive vulvar and cervical (Cx, n = 102), uterine (Ut, n = 87), and ovarian cancer (Ov, n = 54) seen in an inner city gynecologic oncology office. T-test, chi square test, and Pearson and Spearman correlation coefficients were used for statistical evaluation. A P-value of less than 0.05 was regarded significant. An estimated 5-year risk of breast cancer of 1.67 or more was noted in 9% of the Pre patients, 5% of Cx patients, 21% of the Ut patients, and 9% of the Ov patients. The difference between Cx and Ut patients was significant. The average 5-year risk was calculated at 0.77 for Pre patients, 0.77 for Cx patients, 1.18 for Ut patients, and 1.11 for Ov patients. These differences were significant, but mirror the age distribution. The average age was 43.6 for Pre patients, 52.2 years for Cx, 61.5 years for Ut, and 58.5 years for Ov patients; these differences were significant. When calculations were corrected for the mean age (53 years), there were no significant differences between groups regarding the average risk: Pre: 1.04, Cx: 0.81, Ut: 0.96, Ov: 0.97. Only eight patients (2.4%), six of them in the Pre and Cx group, would be expected to derive significant benefit from tamoxifen therapy. We conclude that elevated 5-year breast cancer risk to 1.67% or higher is noted in about 11% of patients seen in a gynecologic oncology office, mainly related to age and family history. Risk assessment and regular screening should be part of any follow-up exam.

Complete reconstitution of human IkappaB kinase (IKK) complex in yeast. Assessment of its stoichiometry and the role of IKKgamma on the complex activity in the absence of stimulation.

The IkappaB kinase (IKK) complex, composed of two catalytic subunits (IKKalpha and IKKbeta) and a regulatory subunit (IKKgamma), is the key enzyme in activation of nuclear factor kappaB (NF-kappaB). To study the mechanism and structure of the complex, we wanted to recombinantly express IKK in a model organism that lacks IKK. For this purpose, we have recombinantly reconstituted all three subunits together in yeast and have found that it is biochemically similar to IKK isolated from human cells. We show that there is one regulatory subunit per kinase subunit. Thus, the core subunit composition of IKKalpha.beta.gamma complex is alpha(1)beta(1)gamma(2), and the core subunit composition of IKKbeta.gamma is beta(2)gamma(2). The activity of the IKK complex (alpha+beta+gamma or beta+gamma) expressed in yeast (which lack NF-kappaB and IKK) is 4-5-fold higher than an equivalent amount of IKK from nonstimulated HeLa cells. In the absence of IKKgamma, IKKbeta shows a level of activity similar to that of IKK from nonstimulated HeLa cells. Thus, IKKgamma activates IKK complex in the absence of upstream stimuli. Deleting the gamma binding domain of IKKbeta or IKKalpha prevented IKKgamma induced activation of IKK complex in yeast, but it did not prevent the incorporation of IKKgamma into IKK and large complex formation. The possibility of IKK complex being under negative control in mammalian cells is discussed.

Training of providers in embryo transfer: what is the minimum number of transfers required for proficiency?

BACKGROUND: Embryo transfer represents one of the most critical procedures in the practice of assisted reproduction. The objective of this study was to identify retrospectively the minimum number of embryo transfers required to train providers properly in this skill. METHODS AND RESULTS: The study group consisted of 204 patients who received embryo transfers between January 1996 and March 2000 in a university-based programme of assisted reproduction. The main outcome measure was clinical pregnancies per embryo transfer. Five Fellow trainees performed a total of 204 embryo transfers for an overall pregnancy rate of 45.5% per embryo transfer (93/204). In comparison, the programme pregnancy rate per transfer for experienced providers was 47.3% (560/1179). A chronological graph of each individual trainee's experience for the first 50 embryo transfers performed suggested a lower initial pregnancy rate for three of the five trainees. To determine whether a learning curve might exist, results of the first 25 transfers were compared as a subgroup with the second 25 transfers. Pregnancy rates were lower for the 1-25 transfer subgroup than in the 26-50 subgroup for three of the five Fellow trainees, although the difference was not statistically significant. CONCLUSION: Clinical pregnancy rates of Fellows-in-training were indistinguishable statistically from those of experienced staff by 50 transfers.

Assessment of side effects in patients with chronic hepatitis C receiving combination therapy.

The purpose of this descriptive study is to review the adverse effects of combination therapy, interferon alfa-2b and ribavirin, in a sample of patients with chronic hepatitis C who were part of a larger multi-center trial (Bonkovsky, 1999). The sample (n = 13) was drawn from one hepatology practice in the northeastern United States. This secondary analysis reported sums, frequencies, means, and standard deviations for the sample. Patients who received 600 mg ribavirin per day in addition to interferon alfa-2B (Arm A) showed a mean of 9.5 different types of side effects. Patients who received 1000-1200 mg of ribavirin in addition to interferon alfa-2B (Arm B) had a mean of 8.6 different types of side effects. The highest-ranking side effects were fatigue (92%), insomnia (85%), alopecia (69%), and arthralgia (62%). A secondary analysis of the entire data set is required before confidence can be placed in the findings. Implications for nursing practice include the need for creative strategies to reduce the effects of fatigue, insomnia, alopecia, and arthralgia in patients with chronic hepatitis C.

Comparisons of adopted and nonadopted adolescents in a large, nationally representative sample.

There are conflicting findings about whether adopted children have more psychological and behavioral problems than nonadoptees. Research results are discrepant partly because many previous studies were based on small clinical samples or on samples biased by self-selection. A nationally representative school survey (Add Health) was used to compare adopted (n = 1,587) and nonadopted adolescents (total N = 87,165) across a wide variety of measures. Standardized mean differences show that adopted adolescents are at higher risk in all of the domains examined, including school achievement and problems, substance use, psychological well-being, physical health, fighting, and lying to parents. Demographic and background variable breakdowns show that the effect sizes for differences between adopted and nonadopted adolescents were larger for males, younger or older adolescents, Hispanics or Asians, and adolescents living in group homes or with parents of low education. Distributional analyses revealed approximately a 1:1 ratio of adopted to nonadopted adolescents in the middle ranges of the outcome variables but a ratio of 3:1 or greater near the tails of the distributions. These data clearly show that more adopted adolescents have problems of various kinds than their nonadopted peers; effect sizes were small to moderate based on mean differences, but comparisons of distributions suggest much larger proportions of adopted than nonadopted adolescents at the extremes of salient outcome variables.

Causes and costs of hospitalization of tuberculosis patients in the United States.

OBJECTIVE: To examine the costs, lengths of stay and patient characteristics associated with tuberculosis (TB) hospitalizations. METHODS: A prospective cohort study of 1493 TB patients followed from diagnosis to completion of therapy at 10 public health programs and area hospitals in the US. The main outcome measures were the following: 1) occurrence, 2) cost, and 3) length of stay of TB-related hospitalizations. RESULTS: There were 821 TB-related hospitalizations among the study participants; 678 (83%) were initial hospitalizations and 143 (17%) were hospitalizations during the treatment of TB. Patients infected with human immunodeficiency virus (HIV) (OR 1.8, 95% CI 1.2-2.6), and homeless patients (OR, 1.7 95% CI 1.1-2.8) were at increased risk of being hospitalized at diagnosis. Homeless patients (RR 2.5, 95%CI 1.5-4.3), patients who used alcohol excessively (RR 1.9, 95% CI 1.2-3.0), and patients with multidrug-resistant TB (RR 5.7, 95% CI 2.7-11.8) were at increased risk of hospitalization during treatment. The median length of stay varied from 9 to 17 days, and median costs per hospitalization varied from $6441 to $12968 among the sites. CONCLUSION: Important social factors, HIV infection, and local hospitalization practice patterns contribute significantly to the high cost of TB-related hospitalizations. Efforts to address these specific factors are needed to reduce the cost of preventable hospitalizations.

Hospitalization of homeless persons with tuberculosis in the United States.

OBJECTIVES: This study assessed whether homeless patients are hospitalized for tuberculosis (TB) more frequently and longer than other patients and possible reasons for this. METHODS: We prospectively studied hospitalizations of a cohort of TB patients. RESULTS: HIV-infected homeless patients were hospitalized more frequently than other patients, while homeless patients who had no insurance or whose insurance status was unknown were hospitalized longer. Hospitalization cost $2000 more per homeless patient than for other patients. The public sector paid nearly all costs. CONCLUSIONS: Homeless people may be hospitalized less if given access to medical care that provides early detection and treatment of TB infection and disease and HIV infection. Providing housing and social services may also reduce hospital utilization and increase therapy completion rates.