Efficacy of combined local mechanical vibrations, continuous passive motion and thermotherapy in the management of osteoarthritis of the knee.

OBJECTIVES: We evaluated the efficacy of combined mechanical vibrations, continuous passive motion (CPM) and heat on the severity of pain in management of osteoarthritis of the knee (OA-K). METHODS: In this controlled, double crossover study, 71 OA-K patients were randomized in Phase 1 to receive 4 weeks active treatment consisting of two 20-min sessions per day (34 patients, Group AB) or treatment with a sham device (37 patients, Group BA). This was followed by a 2-week washout period (Phase 2). In Phase 3, patients crossed over so that Group AB was treated with the sham device and Group BA received active treatment for an additional 4 weeks. Patient assessments of pain (visual analog scale, VAS) and Western Ontario and McMaster Universities (WOMAC) OA index were performed at baseline and at study weeks 2, 4, 6, and 10. Net treatment effects were estimated by comparing outcomes between active and sham treatment study phases. RESULTS: Treatment benefits were noted for both of the trial's two pre-specified primary endpoints, VAS and WOMAC. VAS was reduced at all follow-up time points for patients receiving active treatment compared to sham treatment with a net treatment effect of 14.4+/-4.1 mm (P=0.001). Similarly, the WOMAC score was reduced significantly with active treatment at all measured points with a net effect of 8.8+/-1.9 points (P<0.001). The secondary endpoints, range of motion (ROM) and treatment satisfaction, also improved with active vs sham treatment. CONCLUSION: Four weeks treatment with combined CPM, vibration and local heating significantly decreases pain, improves ROM and the quality of life in patients with OA-K (ClinicalTrials.gov registration number: NCT00858416).

The slippery slope: prediction of successful weight maintenance in anorexia nervosa.

BACKGROUND: Previous research has found that many patients with anorexia nervosa (AN) are unable to maintain normal weight after weight restoration. The objective of this study was to identify variables that predicted successful weight maintenance among weight-restored AN patients. METHOD: Ninety-three patients with AN treated at two sites (Toronto and New York) through in-patient or partial hospitalization achieved a minimally normal weight and were then randomly assigned to receive fluoxetine or placebo along with cognitive behavioral therapy (CBT) for 1 year. Clinical, demographic and psychometric variables were assessed after weight restoration prior to randomization and putative predictors of successful weight maintenance at 6 and 12 months were examined. RESULTS: The most powerful predictors of weight maintenance at 6 and 12 months following weight restoration were pre-randomization body mass index (BMI) and the rate of weight loss in the first 28 days following randomization. Higher BMI and lower rate of weight loss were associated with greater likelihood of maintaining a normal BMI at 6 and 12 months. An additional predictor of weight maintenance was site; patients in Toronto fared better than those in New York. CONCLUSIONS: This study found that the best predictors of weight maintenance in weight-restored AN patients over 6 and 12 months were the level of weight restoration at the conclusion of acute treatment and the avoidance of weight loss immediately following intensive treatment. These results suggest that outcome might be improved by achieving a higher BMI during structured treatment programs and on preventing weight loss immediately following discharge from such programs.

Perioperative Mortality Does Not Explain Racial Disparities in Gastrointestinal Cancer.

BACKGROUND: Racial minorities with gastrointestinal cancer suffer disproportionately poor overall and disease-specific survival. We used a nationally representative sample to examine the relationship between race/ethnicity and mortality and determine whether these disparities were observed in the perioperative period. MATERIALS AND METHODS: The Nationwide Inpatient Sample (NIS) was used to examine patients undergoing surgery for cancers of the esophagus, stomach, pancreas, colon and rectum ("GI cancer") between 2008 and 2012. Logistic regression was used to evaluate whether race/ethnicity was associated with perioperative mortality after adjusting for sociodemographic characteristics, perioperative factors and presentation (ER vs elective). RESULTS: A total of 110,044 subjects were identified, including 75.8% Whites, 10.5% Black patients, 7.2% Hispanic patients, and 3.1% Asian/Pacific Islanders (API). Whites were generally older than minorities. In adjusted multivariable generalized linear mixed logistic models, no increase in perioperative mortality was seen for minorities. Worse outcomes were observed for those with higher Elixhauser comorbidity score (OR 6.90, CI 5.96-7.99), lower income region (OR 1.24, CI 1.10-1.40), males (OR 1.54, CI 1.42-1.68), and those without private insurance (Medicare OR 1.34, CI 1.16-1.55; Medicaid OR 1.27, CI 1.02-1.58; self-pay OR 1.64, CI 1.24-2.17). Differences in mortality were predominantly driven by comorbidities (pseudo %ΔR2 = 38.56%) and only minimally by race (pseudo %ΔR2 = 0.49%). CONCLUSION: Minority groups do not suffer higher rates of perioperative mortality for GI cancer surgeries after controlling for clinical and demographic factors. Future work to address cancer disparities should focus on areas in the cancer care trajectory such as cancer screening, surveillance, socioeconomic factors, and access.

Psychosocial risk factors of child and adolescent completed suicide.

BACKGROUND: Few psychosocial risk factors for completed suicide in children and adolescents have been studied systematically. The present study was designed to examine the environmental, social, and familial characteristics of a large representative sample of child and adolescent suicides. METHODS: A case-control, psychological autopsy of 120 of 170 consecutive suicides younger than 20 years and 147 community age-, sex-, and ethnically matched control participants in the greater New York, NY, area. RESULTS: There was a significant independent impact of the psychosocial factors on increasing suicide risk among children and adolescents, beyond that risk attributable to psychiatric illness. The most notable risks were derived from school problems, a family history of suicidal behavior, poor parent-child communication, and stressful life events. Sex, ethnicity, and age modified the relationships of a few of the psychosocial factors. CONCLUSIONS: Socioenvironmental circumstances add significantly to a teenager's risk of suicide. The overall effect size on increasing suicide risk of the psychosocial factors is comparable with that for diagnostic factors, highlighting the importance of considering socioenvironmental factors when assessing suicide risk.

Maintenance therapy for chronic depression. A controlled clinical trial of desipramine.

BACKGROUND: Previous studies have shown the efficacy of antidepressants in the treatment of chronic depression. We report the results of a long-term study comparing desipramine hydrochloride and placebo for maintenance therapy of remitted patients with chronic depression. METHODS: Outpatients who met DSM-III-R diagnostic criteria for "pure" dysthymia (n = 51), dysthymia with current major depression ("double depression") (n = 64), or chronic major depression (n = 14) were treated on an open basis with desipramine. Full and partial remitters after 10 weeks entered a continuation phase of open treatment with desipramine for 16 weeks. Remitted patients then were randomized to continue desipramine treatment or tapered to placebo treatment for a maintenance phase of up to 2 years. Relapse rates and time to relapse during maintenance therapy were compared between the two treatment groups. RESULTS: Acute-phase treatment results did not differ significantly according to chronic depression subtype. Remission persisted with a high degree of stability during the continuation phase. Relapse rates during the maintenance phase were 52% for the placebo group and 11% for the active desipramine group (chi 2 = 8.1, P = .004). Most placebo relapses occurred during the first 6 months of maintenance therapy. Active medication was significantly more effective than placebo in that subgroup entering the maintenance phase in full remission and in those patients who fulfilled criteria for a diagnosis of pure dysthymia or double depression on entry to the study. CONCLUSION: Long-term maintenance treatment with desipramine appeared to be effective in the prevention or postponement of relapse of depression in patients who responded to desipramine during the acute and continuation phases.

Desipramine for the treatment of "pure" dysthymia versus "double" depression.

The authors report results of an 8-week, open trial of desipramine in 42 patients with DSM-III-R dysthymia with a concurrent diagnosis of major depression ("double" depression) and 33 patients with dysthymia who had no other depressive diagnosis ("pure" dysthymia). Either complete or partial remission was achieved by 70% of the patients with "pure" dysthymia. This compared favorably with but was not significantly different from results in the "double" depression group.

Divalproex treatment for youth with explosive temper and mood lability: a double-blind, placebo-controlled crossover design.

OBJECTIVE: The authors sought to replicate open-label findings showing that specific criteria for explosive temper and mood lability identify disruptive youth who improve while receiving the anticonvulsant divalproex sodium. METHOD: Twenty outpatient children and adolescents (ages 10-18) with a disruptive behavior disorder (oppositional defiant disorder or conduct disorder) met the specific criteria for explosive temper and mood lability. They received 6 weeks of divalproex treatment and 6 weeks of placebo by random assignment. Independent evaluators blind to group assignment assessed response at the end of each phase. RESULTS: At the end of phase 1, eight of 10 subjects had responded to divalproex; zero of 10 had responded to placebo. Of the 15 subjects who completed both phases, 12 has superior response taking divalproex. CONCLUSIONS: This preliminary study replicates open-label findings showing that divalproex is an efficacious treatment for explosive temper and mood lability in disruptive children and adolescents.

The effect of estrogen replacement on early Parkinson's disease.

OBJECTIVE: To determine the effect of estrogen in postmenopausal women with early PD. BACKGROUND: The role of estrogen in PD is highly disputed, with some studies suggesting a prodopaminergic effect and others suggesting an antidopaminergic effect. Owing to controversy and the small sample sizes of prior studies, further investigation is warranted. METHODS: A retrospective chart review was carried out from a computerized database of patients at Columbia-Presbyterian, including only women who had symptoms of presumed PD for less than 5 years and who had not yet been on L-dopa at their first visit. Multiple regression was performed to assess the effects of estrogen on disease, measured by total Unified Parkinson's Disease Rating Scale (UPDRS) score, as a function of symptom duration, age at onset, education, smoking, dopamine agonist, and deprenyl use. RESULTS: Of the women who were not on L-dopa and had PD for less than 5 years at their first visit, 34 were found to have received estrogen at some time and 104 had never received estrogen. Excluding the women who had taken dopamine agonists, analysis yielded a multiple regression coefficient of 0.52 (p < 0.001). Estrogen use was negatively correlated with UPDRS score; age at onset and symptom duration were positively correlated (p < 0.05). CONCLUSIONS: We found a positive association between estrogen use and lower symptom severity in women with early PD not yet taking L-dopa. These results indicate that estrogen therapy should not be avoided and may be beneficial in early PD, at least prior to the initiation of L-dopa.

Elevation of blood beta-carboline alkaloids in essential tremor.

BACKGROUND: beta-Carboline alkaloids are normal body constituents but are also potent tremor-producing chemicals that are naturally present in the food chain. OBJECTIVE: To explore the hypothesis that high concentrations of beta-carboline alkaloids are associated with essential tremor (ET). METHODS: One hundred cases and 100 controls were frequency matched on age, sex, and ethnicity. Blood concentrations of harmane and harmine were quantified by high-performance liquid chromatography, blinded to clinical information. RESULTS: The mean log blood concentration of harmane was higher in cases than controls (0.72 +/- 0.53 vs 0.51 +/- 0.64 g(-10)/mL; p = 0.01). A nonparametric test on nontransformed data (median harmane = 5.21 g(-10)/mL in cases and 2.28 g(-10)/mL in controls) confirmed this difference (p = 0.005). The mean log blood concentration of harmine was 0.20 +/- 0.48 g(-10)/mL in cases and 0.10 +/- 0.65 g (-10)/mL in controls (p = 0.20). Log harmane concentrations were stratified based on the median value; 62% of cases vs 39% of controls had a high log harmane concentration (p = 0.001). Mean log harmane concentration was similar in the cases with (0.74 +/- 0.58 g(-10)/mL) and without (0.71 +/- 0.50 g(-10)/mL) an affected relative (p = 0.83). CONCLUSIONS: Blood concentrations of harmane were measured in ET cases compared with controls. Concentrations were elevated in cases with and without a family history of ET.

Cost-effectiveness analysis of long-term moderate exercise training in chronic heart failure.

The purpose of this study is to perform a cost-effectiveness analysis of long-term moderate exercise training (ET) in patients with stable chronic heart failure. In particular, the study focuses on the survival analysis and cost savings from the reduction in the hospitalization rate in the exercise group. In the past 10 years, ET has been shown to be beneficial for patients with stable class II and III heart failure in many randomized clinical trials. However, the cost-effectiveness of a long-term ET program has not been addressed for outcomes related to morbidity/mortality end points or health care utilization. We examined the cost-effectiveness of a 14-month long-term training in patients with stable chronic heart failure. The estimated increment cost for the training group, $3,227/patient, was calculated by subtracting the averted hospitalization cost, $1,336/patient, from the cost of ET and wage lost due to ET, estimated at $4,563/patient. For patients receiving ET, the estimated increment in life expectancy was 1.82 years/person in a time period of 15.5 years, compared with patients in the control group. The cost-effectiveness ratio for long-term ET in patients with stable heart failure was thus determined at $1,773/life-year saved, at a 3% discount rate. Long-term ET in patients with stable chronic heart failure is cost-effective and prolongs survival by an additional 1.82 years at a low cost of $1,773 per/life-year saved.

Preoperative and intraoperative predictors of postoperative morbidity, poor graft function, and early rejection in 190 patients undergoing liver transplantation.

HYPOTHESIS: Preoperative and intraoperative variables predict in part adverse outcome after liver transplantation. DESIGN: Prospective, blinded, cohort study. SETTING: Tertiary care hospital. SUBJECTS: A total of 190 adult patients undergoing primary liver transplantation. MAIN OUTCOME MEASURE: Adverse outcome was prospectively defined as either in-hospital death or prolonged postoperative hospitalization (>14 days) associated with morbidity. Potential preoperative and intraoperative risk factors were collected. Associations were tested by univariate analysis followed by multivariate analysis in which preoperative factors were entered before intraoperative factors. RESULTS: Adverse outcome occurred in 44.7% of patients. Incidences of other complications were as follows: in-hospital mortality (8.4%), primary graft nonfunction (4.2%), poor early graft function (1.1%), and early rejection (31.2%). Univariate predictors of adverse outcome were United Network for Organ Sharing status (P =.003), Child-Turcotte-Pugh score (P =.02), POSSUM physiological score (P =.002), recipient age (P =.01), preoperative serum high-density lipoprotein cholesterol level (P =.03), preoperative serum creatinine level (P =.002), preoperative serum total IgG level (P =.004), duration in hospital preoperatively (P =.03), operative duration (P<.001), allogeneic erythrocyte transfusions (P<.001), total intraoperative fluids (P =.002), and use of inotropic agents (P =.01). In the final multivariate model, predictors of adverse outcome were United Network for Organ Sharing status (P =.03), recipient age (P =.002), and total intraoperative fluids (P =.04). Most patients who died or had a prolonged hospitalization exhibited dysfunction of more than 1 organ system, including pulmonary, renal, and infectious complications. CONCLUSIONS: Adverse outcome occurs frequently after liver transplantation, usually involves multiple organ systems, and is predicted in part by several preoperative and intraoperative factors.

Neurological soft signs: one-year stability and relationship to psychiatric symptoms in boys.

OBJECTIVE: This study had two main objectives: (1) to examine the 1-year stability of neurological soft signs and (2) to examine the longitudinal relationship between soft signs and psychiatric symptoms in young boys. METHOD: A consecutive series of 56 boys from a high-risk sample received standardized psychiatric and soft sign assessments at study intake. Approximately 1 year later, 48 (86%) of these boys received a reassessment of their psychiatric and soft sign status. RESULTS: Soft signs exhibited marked stability across the 1-year period (intraclass correlation = .70, p < .001). Symptoms of both internalizing and externalizing disorders correlated with poor performance on the soft sign examination. For both internalizing and externalizing symptoms, the association with soft signs occurred primarily among individuals with persistently high scores on symptom scales across the two assessments. CONCLUSIONS: Performance on a standardized neurological soft sign examination is stable over a 1-year period. Soft signs measured with this examination relate to both internalizing and externalizing symptoms in young boys, particularly when symptoms are relatively stable over time. Further research should consider the clinical significance of childhood soft signs.

Psychometrics of neurological soft signs.

OBJECTIVE: To examine the psychometrics of neurological soft signs in young children. METHOD: In a sample of 42 children from the community, two examiners simultaneously rated soft signs using a standardized examination. A subsample (n = 33) was reexamined twice over the next week to estimate test-retest reliability. RESULTS: Total score exhibited acceptable internal consistency as well as interrater and test-retest reliability. Psychometrics for individual items appeared less satisfactory than for the total score. DISCUSSION: Although examiners can reliably rate a variety of soft signs, more research examining test-retest reliability is needed. A reliable examination might be useful in future efforts to document the neuropsychiatric correlates of soft signs.

Acute response of social functioning in dysthymic patients with desipramine.

Despite some evidence that short-term antidepressant treatment improves social dysfunction in depressed patients, little is known about the response of specific social impairments in dysthymic patients to antidepressant medication. We examined the effect of acute (10 weeks), open-label desipramine (DMI) treatment on social functioning in subjects with DSM-III-R dysthymia. Social functioning was assessed with the social adjustment scale self-report (SAS-SR) at baseline and at week 10. Compared with DMI nonresponders DMI responders showed significantly greater improvement in overall social functioning (F2,45 = 5.46, P < 0.0001) and in enjoyment of leisure time (F2,45 = 14.38, P < 0.0001) on the SAS-SR. Dysthymic patients who respond to DMI improve significantly in social functioning. Diminished capacity to enjoy leisure time may be a state marker of depression in some chronically depressed patients.

Six months of desipramine for dysthymia: can dysthymic patients achieve normal social functioning?

BACKGROUND: There is evidence that antidepressant medication improves social dysfunction during acute treatment in dysthymic patients but it is unknown if the gain in social functioning persists or progresses with longer-term antidepressant treatment. We examine the effect of 6 months of desipramine treatment on social functioning in dysthymic patients. METHODS: Forty-six subjects with DSM-III-R dysthymia (70% with superimposed major depression) who had responded to 10 weeks of open-label desipramine (DMI) treatment received 16 additional weeks of continuation DMI. Social functioning was measured at weeks 0, 10 and 26 with the Social Adjustment Scale-Self Report. RESULTS: Euthymia was maintained and a marginally significant trend for further improvement in overall social functioning appeared during continuation treatment. Only 24% of subjects achieved normative level of social adjustment after 6 months of DMI treatment. LIMITATIONS: The main limitation was the lack of a placebo control group. CONCLUSION: Acute improvement in social functioning persists during continuation treatment. However, most dysthymic patients did not achieve a community level of social adjustment. Significant social dysfunction persists in dysthymic patients with low levels of depressive symptomatology after 6 months of intense DMI treatment.

Sexual orientation in adolescents who commit suicide.

It has been suggested that there is a strong relationship between suicidal behavior and homosexuality in adolescence. It has been further suggested that it is due to the stigmatization and feelings of isolation that are experienced by many gay adolescents. Much of the literature that has given support to these hypotheses has been conducted on uncontrolled nonrepresentative samples and its generalizability is open to question. An opportunity to examine the relationship in an unselected sample arose in a case control, psychological autopsy study of 120 of 170 consecutive suicides under age 20 and 147 community age, sex, and ethnic matched controls living in the Greater New York City area. Homosexuality was defined as having had homosexual experiences or having declared a homosexual orientation. Three teenagers and no controls met these criteria. The difference was not significant. The circumstances of death were examined and are described. In no instance did suicide directly follow an episode of stigmatization. All three suicides had evidence of significant psychiatric disorder before death. In spite of opportunities for biased reporting, it is concluded that this study finds no evidence that suicide is a common characteristic of gay youth, or that when suicide does occur among gay teenagers, that it is a direct consequence of stigmatization or lack of support.

Laryngopharyngeal sensory deficits in patients with laryngopharyngeal reflux and dysphagia.

There are no reliable means of quantifying the edema that results from acid exposure to the posterior larynx in patients with laryngopharyngeal reflux (LPR). However, it is possible to quantify laryngopharyngeal sensitivity in these patients by endoscopic administration of air pulses to the laryngeal mucosa in order to elicit the laryngeal adductor reflex. The purpose of this study was to determine whether patients with LPR have sensory deficits in the laryngopharynx, and whether treatment of these patients with a proton pump inhibitor (PPI) results in resolution of sensory deficits. Flexible endoscopic evaluation of swallowing with sensory testing was prospectively performed in 54 patients with dysphagia without neurologic disease and in 25 healthy controls. The laryngopharyngeal sensory level, posterior laryngeal edema, and LPR were assessed. We defined LPR as passage of food material from the esophageal inlet retrograde into the hypopharynx. Patients with LPR were placed on 3 months of omeprazole or lansoprazole and then retested. Patients without LPR were placed on H2 blockers for 3 months and then retested. In the dysphagia group, 48 of 54 patients (89%) had edema of the posterior larynx, and 42 of 54 (78%) had laryngopharyngeal sensory deficits. We noted LPR in 38 of 54 (70%). In the control group, 1 of 25 subjects (4%) had edema, sensory deficits, and LPR. The differences in incidence of edema, sensory deficits, and LPR between the dysphagia group and the control group were significant (p < .001, chi2 test). Twenty-three patients with LPR placed on a PPI returned for follow-up, with improvement in laryngeal edema in 14 of the 21 (67%) who had pretreatment edema and resolution of sensory deficits in 15 of the 19 (79%) who had pretreatment deficits. In the non-LPR, non-PPI group, 11 of 16 patients returned for follow-up, with improvement in laryngeal edema in none of the 11 and improvement in sensory deficits in 1 of the 11 (9.1%). The differences in improvement in laryngeal edema and sensory deficits between the LPR, PPI group, and the non-LPR, non-PPI group were significant (p < .01, Fisher's exact test). We conclude that patients with dysphagia and edema of the posterior larynx as a result of LPR have sensory deficits in the laryngopharynx. Treatment of these patients with a PPI appears to result in resolution of laryngopharyngeal edema and improvement of sensory deficits, both subjectively and objectively.

Endoscopic evaluation of swallowing as an alternative to 24-hour pH monitoring for diagnosis of extraesophageal reflux.

Patients with symptoms of extraesophageal reflux may not be eager to undergo 24-hour pH probe monitoring for the sake of a definitive diagnosis. It has been anecdotally noted that extraesophageal reflux can be detected during an endoscopic swallowing evaluation. The purpose of this pilot study was to demonstrate that flexible endoscopic evaluation of swallowing with sensory testing (FEESST) can be implemented to identify and subsequently treat patients with extraesophageal reflux. Over a 6-month period, FEESST was prospectively performed in 20 healthy control subjects and in 20 patients with dysphagia. The dysphagic patients did not have a history of stroke or chronic neurologic disease. Attention was specifically directed toward noting the presence or absence of reflux into the laryngopharynx during the endoscopic swallowing evaluation. None of the control subjects were noted to have reflux during FEESST, but 18 of the 20 patients with dysphagia were found to have reflux during the evaluation; this difference was statistically significant (p < .001, Fisher's exact test). We conclude that FEESST is useful as a means of diagnosing extraesophageal reflux in patients with dysphagia.

An organizational climate intervention associated with increased handwashing and decreased nosocomial infections.

Handwashing practices are persistently suboptimal among healthcare professionals and are also stubbornly resistant to change. The purpose of this quasi-experimental intervention trial was to assess the impact of an intervention to change organizational culture on frequency of staff handwashing (as measured by counting devices inserted into soap dispensers on four critical care units) and nosocomial infections associated with methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). All staff in one of two hospitals in the mid-Atlantic region received an intervention with multiple components designed to change organizational culture; the second hospital served as a comparison. Over a period of 8 months, 860,567 soap dispensings were recorded, with significant improvements in the study hospital after 6 months of follow-up. Rates of MRSA were not significantly different between the two hospitals, but rates of VRE were significantly reduced in the intervention hospital during implementation.

Blood lead levels in incinerator workers.

Questions have been raised concerning the safety of mass burn incineration and its role in solid waste management. In 1989, the New York City Office of Occupational Safety and Health examined air levels of metals in New York City incinerators and found that workers were exposed to air lead levels as high as 2500 micrograms/m3 while cleaning the electrostatic precipitators in the plant. In order to determine the biologic significance of these exposures to the workers, blood samples were taken from 56 incinerator workers and 25 controls and analyzed for lead and erythrocyte protoporphyrin levels. Incinerator workers were found to have a mean blood lead of 11.0 micrograms/dl as compared to the control group level of 7.4 micrograms/dl. Risk factors for increased blood lead levels were analyzed using multiple regression analyses. Wearing a personal protective device "always" or not and the interaction of smoking and cleaning the precipitator more than seven times in the past year were found to be significant predictors for blood lead. These results indicate that lead in municipal incinerator ash from electrostatic precipitators is bioavailable and that the effects of such exposure can be minimized by wearing personal protective devices, not smoking, and rotating the work force to minimize precipitator ash contact.