No clinical difference between fixed- and mobile-bearing cruciate-retaining total knee arthroplasty: a prospective randomized study.

PURPOSE: It is hypothesized that mobile polyethylene bearings in total knee arthroplasty (TKA) may confer benefits with regard to range of motion and have improved clinical outcome scores in comparison with an arthroplasty with a fixed-bearing design. Our study compares clinical outcomes between patients who undergo TKA with either a rotating platform or fixed bearing using a posterior cruciate-retaining design. METHODS: Three hundred and thirty-one patients were randomized to receive either a rotating-platform (161 patients) or a fixed-bearing (170 patients) implant. All patients were assessed pre-operatively and at 1 and 2 years post-operatively using standard tools (range of movement, Oxford Knee Score, American Knee Society Score, SF12 and Patella Score). RESULTS: There was no difference in pre- to 2-year post-operative outcomes between the groups with regard to improvement in range of motion (10° ± 16 vs. 9° ± 15), improvement in Oxford Knee Score (-17.6 ± 9.9 vs. -19.1 ± 8.4), improvement in American Knee Society Score (49.5 ± 24.7 vs. 50.7 ± 21.0), function (23.6 ± 19.6 vs. 25.0 ± 22.5) and pain (34.9 ± 16.2 vs. 35.8 ± 14.1) subscores, improvement in SF12 Score (10.0 ± 16.3 vs. 12.3 ± 15.8) or improvement in Patella Score (9.7 ± 7.4 vs. 10.6 ± 7.1). CONCLUSION: No difference was demonstrated in clinical outcome between patients with a rotating-platform and fixed-bearing posterior cruciate-retaining TKA at 2-year follow-up. LEVEL OF EVIDENCE: I.

Developmental Trajectories for Visuo-Spatial Attention are Altered by Prenatal Alcohol Exposure: A Longitudinal FMRI Study.

Functional magnetic resonance imaging (fMRI) reveals brain activation abnormalities during visuo-spatial attention and working memory among those with fetal alcohol spectrum disorders (FASD) in cross-sectional reports, but little is known about how activation changes over time during development within FASD or typically developing children. We studied 30 controls and 31 individuals with FASD over 2 years (7-14 years at first participation) with a total of 122 scans, as part of the Collaborative Initiative on Fetal Alcohol Spectrum Disorders. Despite comparable performance, there were significant group differences in visuo-spatial activation over time bilaterally in frontal, parietal, and temporal regions. Controls showed an increase in signal intensity in these multiple regions whereas FASD participants showed a decrease in brain activation. Effects were also found in 2 small independent samples from the USA, corroborating the findings from the larger group. Results suggest that the long-lasting effect of prenatal alcohol may impact the maturation of visuo-spatial attention and differentiate those with FASD from controls. Based on this first longitudinal fMRI study in FASD children, our novel findings suggest a possible neural mechanism for attention deficits common among individuals with FASD.

New data on the epidemiology of adult drinking and substance use among American Indians of the northern states: male and female data on prevalence, patterns, and consequences.

The quantity, frequency, and variability of alcohol and other substance use is described in a random sample of 1,436 enrolled members of four tribes from the northern United States. Overall, males begin regular drinking at an earlier age than do females (17 vs. 18.1 years), and more males drink alcohol than females (70.7% to 60.4%). There are some very heavy drinkers who drink daily in these populations, but most drinkers are binge drinkers. On any typical day abstinence from alcohol is the modal pattern. That is, most respondents indicated very infrequent drinking, and among the older age groups (40+), there is a high rate of abstinence. Males drink more frequently and in larger quantities than females. The number of drinking days per month is 4.7 for males and 2.1 for females, and on those days when drinking occurs, the males consume an average of 5.7 drinks and females an average of 3.1. The highest prevalence of drinking and the heaviest drinking occur among those who are under the age of 30. With the exception of tobacco use, which is high in all age categories, the use of other drugs is highest in those under 30.

Fetal alcohol syndrome: an international perspective.

This article represents the proceedings of a workshop at the 2000 ISBRA Meeting in Yokohama, Japan. The chairs were Kenneth R. Warren and Faye J. Calhoun. The presentations were (1) Epidemiological research on fetal alcohol syndrome (FAS) in the United States, by Philip A. May; (2) An overview of fetal alcohol syndrome in the Western Cape Province of South Africa, by Denis L. Viljoen and Ting-Kai Li; (3) Diagnostic perspectives of fetal alcohol and tobacco syndromes, by Harumi Tanaka; (4) FAS among pupils of special boarding schools and orphanages in Moscow, Russia, by Galina S. Marinicheva and Luther K. Robinson; and (5) Research on FAS and FAE in Germany: Update and perspectives, by Goetz Mundle.

Patterns of cognitive-motor development in children with fetal alcohol syndrome from a community in South Africa.

BACKGROUND: Even though fetal alcohol syndrome (FAS) has been reported in nonwestern nations, there is a paucity of information on neurodevelopment in the affected children from those nations. This article reports on a study of cognitive-motor development in a group of children with FAS from a community in the Western Cape Province in South Africa. METHODS: Thirty-four children with FAS and 34 controls from grade 1 (school entry level) classes participated. The two groups comprised Afrikaans-speaking children of mixed ancestry (South African Colored) and were matched for age, sex, and family income. The Griffiths Mental Development Scales were used to assess cognitive motor development of the participants. RESULTS: A multivariate analysis of covariance was performed to test the group effect on the combined Griffiths subscales adjusting for maternal education. The results showed a significant group effect. Follow-up analyses revealed that a combination of four subscales (Speech and Hearing, Performance, Practical Reasoning, and Eye and Hand Coordination) primarily contributed to the overall effect. Although there was a marginal effect on the Personal-Social subscale, no significant effect on the Locomotor (gross motor) subscale was found. CONCLUSIONS: The results showed that the FAS group was markedly deficient only in higher-order cognitive-motor competencies.

Emotion-related learning in individuals prenatally exposed to alcohol: an investigation of the relation between set shifting, extinction of responses, and behavior.

The association between deficits in emotion-related learning, conceptual set shifting, and behavioral problems was investigated in individuals with substantial prenatal alcohol exposure. Twenty subjects with confirmed prenatal alcohol exposure (10 of whom were diagnosed as having Fetal Alcohol Syndrome) and 20 normal controls matched for age, gender, and ethnic background participated. The two groups were administered a battery of tests including two tests of emotion-related learning (visual discrimination reversal and extinction of reward-response associations), tests of conceptual set shifting and intellectual ability, and behavioral measures. The alcohol-exposed group made fewer reversals than the control group in visual discrimination reversal and exhibited more variability in extinction. These group differences remained significant after controlling for intellectual ability and conceptual set shifting. Variability in extinction and two measures of set shifting, perseverative errors on the Wisconsin Card Sorting Test and omission errors on reversal learning, were found to be robust predictors of parent-rated behavioral problems.

Estimating the prevalence of fetal alcohol syndrome. A summary.

Since the late 1970s, many studies have reported on the prevalence of fetal alcohol syndrome (FAS), alcohol-related birth defects (ARBD), and alcohol-related neurodevelopmental disorders (ARND). The three main types of research methods used in these studies are passive surveillance, clinic-based studies, and active case ascertainment. This article describes each of these methods, including their strengths and weaknesses, and summarizes the estimated prevalence of FAS produced by each of these approaches. The maternal risk factors associated with FAS and other alcohol-related anomalies include advanced maternal age, low socioeconomic status, frequent binge drinking, family and friends with drinking problems, and poor social and psychological indicators. Overall, the available literature points to a prevalence rate of FAS of 0.5 to 2 cases per 1,000 births in the United States during the 1980s and 1990s.

The effects of prenatal alcohol exposure on executive functioning.

Converging evidence from various research areas indicates that people who have been exposed to alcohol prenatally may exhibit impairments on the performance of relatively complex and novel tasks. These tasks include tests designed to measure executive functioning (EF)--the ability to plan and guide behavior to achieve a goal in an efficient manner. EF can be categorized into two domains, cognition-based EF and emotion-related EF. People prenatally exposed to alcohol show impaired performance on tests assessing both domains. Moreover, one cognition-based and two emotion-related measures of EF appear to be reliable and stable predictors of behavioral problems in alcohol-affected people. A deficit in flexible recruitment of brain regions to do complex tasks may underlie the EF deficits in people prenatally exposed to alcohol.

Epidemiology of fetal alcohol syndrome in a South African community in the Western Cape Province.

OBJECTIVES: This study determined the characteristics of fetal alcohol syndrome in a South African community, and methodology was designed for the multidisciplinary study of fetal alcohol syndrome in developing societies. METHODS: An active case ascertainment, 2-tier methodology was used among 992 first-grade pupils. A case-control design, using measures of growth, development, dysmorphology, and maternal risk, delineated characteristics of children with fetal alcohol syndrome. RESULTS: A high rate of fetal alcohol syndrome was found in the schools--40.5 to 46.4 per 1000 children aged 5 to 9 years--and age-specific community rates (ages 6-7) were 39.2 to 42.9. These rates are 18 to 141 times greater than in the United States. Rural residents had significantly more fetal alcohol syndrome. After control for ethnic variation, children with fetal alcohol syndrome had traits similar to those elsewhere: poor growth and development, congruent dysmorphology, and lower intellectual functioning. CONCLUSIONS: This study documented the highest fetal alcohol syndrome rate to date in an overall community population. Fetal alcohol syndrome initiatives that incorporate innovative sampling and active case ascertainment methods can be used to obtain timely and accurate data among developing populations.

PRIME-MD: its utility in detecting mental disorders in American Indians.

OBJECTIVE: To examine the utility of using PRIME-MD (Primary Care Evaluation of Mental Disorders) for diagnosing mental disorders in American Indians. METHOD: One hundred randomly selected, adult, American-Indian patients who receive health care services at an urban Indian Health Service primary care clinic were evaluated for mental disorder by three primary care physicians using the PRIME-MD diagnostic assessment procedure. The main outcome measures were PRIME-MD diagnoses, diagnoses by an independent mental health professional, and treatment/referral decisions. RESULTS: Eighteen percent of the patients had a threshold (met full DSM-IV criteria ) PRIME-MD diagnosis, and an additional 17 percent had a subthreshold PRIME-MD diagnosis. The most frequently occurring PRIME-MD diagnoses were: probable alcohol abuse/dependence, major depressive disorder, and generalized anxiety disorder. Over 60 percent of the patients with a PRIME-MD diagnosis who were known "somewhat" or "fairly well" to their physician had not been recognized as having that psychiatric disorder prior to the PRIME-MD assessment. Therapy and/or referral was initiated for nineteen of the twenty-seven patients with a PRIME-MD diagnosis who were not previously receiving treatment. The primary care physicians were able to complete the PRIME-MD evaluations within an average of 7.8 minutes. There was a fair agreement between the PRIME-MD diagnoses and the diagnoses of the mental health professional (kappa = 0.56; overall accuracy rate = 79%). CONCLUSIONS: The present study represents the first formal examination of the use of PRIME-MD with American Indians. The results are encouraging. Further studies using PRIME-MD with other urban groups and reservation populations are recommended.

Certification. Hospital versus national standards.

"Certification" and "credential" are frequently used terms in nursing. How these terms are used and what they mean to nursing practice is the focus of this article. Definitions, history, and application of these concepts are explored. Recommendations are made that a hospital not assume responsibility for the granting of certification or credentials to nursing staff members. Nurses and nursing administrators are urged to support nationally recognized certification programs.

Prevention of alcohol misuse: a review of health promotion efforts among American Indians.

PURPOSE: The purpose of this review is to provide an overview of a wide range of potentially useful strategies to address the prevention of alcohol misuse among American Indians. This broad approach to the review is useful because the extreme heterogeneity of the American Indian population requires that health promotion professionals explore many options and tailor their activities to specific communities. SEARCH METHOD: A literature search was initiated through MEDLINE using the following key words: prevention, alcohol, substance abuse, American Indian, and Native American. The search yielded 29 articles from the years 1982 through 1994. These articles, along with 45 previously identified in three overview articles, form the basis of the review and discussion in this paper. SUMMARY OF FINDINGS: As a group, American Indians experience many health problems that are related to alcohol misuse. Comparison of Indians to non-Indians shows that the age of first involvement with alcohol is younger, the frequency and amount of drinking is greater, and negative consequences are more common. Health promotion programs that address these issues must take into account American Indian heterogeneity and should use a comprehensive approach that addresses both heavy drinking and the sequelae of problems related to alcohol misuse. MAJOR CONCLUSIONS: Important concepts for providing health promotion services to this population are: cultural relevance must be carefully planned and monitored; individuals in the local community must be involved; the drunken Indian stereotype must be addressed; and community empowerment should be an important goal.

A multiple-level, comprehensive approach to the prevention of fetal alcohol syndrome (FAS) and other alcohol-related birth defects (ARBD).

A comprehensive program for the prevention of fetal alcohol syndrome (FAS) and alcohol-related birth defects (ARBD) must consider multiple approaches and utilize knowledge from a variety of academic disciplines. Issues related to culture, society, behavior, belief systems, and medicine must all be considered for both etiology and solutions. A broad paradigm such as a public health model integrates various elements of approach. Because FAS and other levels of ARBD form a spectrum, from severe to negligible damage, a variety of drinking patterns with various characteristics and etiologies have to be addressed. This paper describes a multiple-level, comprehensive program with primary, secondary, and tertiary prevention components. Practical recommendations are proposed for addressing ARBD in a variety of arenas. While secondary and tertiary prevention hold promise for short-term reduction of FAS and ARBD prevalence, comprehensive prevention serves both short- and long-term effects. Multiple level prevention efforts are well served by clear and compelling vision and mission statements, and require careful evaluation.

Dynamic visual acuity and contrast sensitivity for static and flickered gratings in a college sample.

For a sample of college observers, visual performance was assessed with three types of measures: (1) contrast sensitivity for a range of spatial frequency gratings with 4-Hz flicker, (2) contrast sensitivity for a range of stationary wallchart gratings, and (3) dynamic visual acuity (DVA) for a range of target velocities. Within each of these three performance measures, mean results were generally consistent with previous reports. However, across-test comparisons revealed little commonality of processes between either of the contrast sensitivity scores and the dynamic acuity scores. These findings are discussed in terms of the separate contributions to overall visual performance made by the increasingly popular contrast sensitivity function (CSF) and DVA.

A comparative study of abused and neglected American Indian children in the southwest.

Samples of target and control American Indian children in the Southwest United States are compared for child abuse/neglect and family alcohol abuse. Alcohol abuse is present in virtually all families that abuse/neglect children. However, alcohol abuse exists exclusive of the association with child abuse/neglect. The study demonstrates that alcohol abuse is a necessary, but not sufficient, condition for child abuse/neglect.

Alcohol policy considerations for Indian reservations and bordertown communities.

For some topics, particularly in public health, summaries are dangerous because they may create the idea that a single or simple solution exists. This topic is one where a summary can create a false expectation of simplicity. There is no simple or easy solution to the problem of alcohol abuse in any community, especially reservation and bordertown communities in the western United States. The solution is complex, it must be comprehensive, and it will take a great deal of effort over time to reduce alcohol and substance abuse in any individual community. Indian communities must develop a comprehensive, consistent, and clearly defined alcohol prevention/intervention policy. Such a policy must utilize a systematic, public health approach that considers the physical, mental, and social well being of each and every individual within the region. It must address all types of problematic alcohol consumption, from sporadic alcohol consumption (light and heavy) to regular alcohol abuse and chronic alcoholism, for the problems found in Indian and bordertown communities arise from a variety of different drinking patterns. Presented in this paper are a large number of policy and prevention options that have been used successfully in human societies in various parts of the world and in the United States. The intent of the paper is to present and describe the variety of options for addressing alcohol problems that have been found to be of value in the control and reduction of alcohol abuse and related problems. The three broad categories of approach are: controlling the supply of alcoholic beverages through statute and regulation; shaping drinking practices directly; and reducing the physical and social environmental risks. Indian tribal councils and Native communities can, if they so desire, consider, debate, and enact any or all of these measures. The important issue is that they should be aware of these ideas for prevention and consider them carefully. If the preventive measures described here can be applied systematically and reasonably within the social and cultural contexts of a Native community, then the ultimate result should be positive. Readers are encouraged to read this paper carefully, to study the tables and figures, and if more detail is desired, to consult some of the many references found in the back. Comprehensive and positive alcohol policy has been ignored for too long in Indian country, and the resultant toll in morbidity, mortality, and suffering is too high. This paper presents the ingredients for a comprehensive policy. Each community need to work its own recipe.

A comprehensive local program for the prevention of fetal alcohol syndrome.

A hospital based, comprehensive approach to the prevention of Fetal Alcohol Syndrome and Fetal Alcohol Effects that combines clinical assessment, community outreach, and epidemiologic knowledge to attack alcohol-related birth defects is described. The program includes training of clinicians and members of the community, baseline screening of suspected children, and alcohol consumption screening of pregnant women in prenatal clinics. The major, although not exclusive, focus of the program is on tertiary prevention undertaken with women defined as "high risk" for producing alcohol affected children. Of the 48 women referred to the program at the Tuba City, AZ, Indian Medical Center between January 1988 and July 1989, 39 (81 percent) became participants. Complete followup was possible on 31; 17 of them reported alcohol abstinence in July 1989, 18 months into the program. Of the 29 referred women who were pregnant at the time, 21 agreed to participate; of these, 19 (85.7 percent) were abstinent by the third trimester of pregnancy; 5 voluntarily accepted offers of contraceptive measures after the birth of their child.

A macro-level fetal alcohol syndrome prevention program for Native Americans and Alaska Natives: description and evaluation.

Presented here are a detailed description and outcome evaluation of a comprehensive, macro-level Fetal Alcohol Syndrome prevention program for Native Americans and Alaska Natives. The program was designed to provide native communities throughout the United States with the knowledge, skills and strategies to initiate primary, secondary and tertiary prevention measures on their own. The key to the program was the training of a cadre of trainers/advocates in all local Native American and Alaska Native communities served by the Indian Health Service. These people were then supported and assisted in their efforts through a variety of means. Evaluation results of knowledge gained indicate that the local trainers had substantial success in imparting FAS information to a variety of audiences (prenatal groups, school children and community groups). Further, the evaluation samples also indicate that the knowledge was retained by the groups over time (2-4 months) and that there may have been some general diffusion of knowledge among peers in local communities. This program is presented in the hope that it will be replicated and improved upon by similar programs using this model as a base.