Hantavirus pulmonary syndrome in Canada: An overview of clinical features, diagnostics, epidemiology and prevention.

Hantavirus pulmonary syndrome is a disease caused by the inhalation of excreta from infected deer mice. In Canada, the majority of hantavirus pulmonary syndrome cases occur in the western provinces of British Columbia, Alberta, Saskatchewan and Manitoba and the primary cause of the illness is the Sin Nombre virus. Only one case of hantavirus pulmonary syndrome has been documented in eastern Canada (Québec); however, Sin Nombre virus-infected deer mice have been identified across the country. Although cases are rare (yearly case numbers range from zero to 13 and the total number of confirmed cases in Canada now total 109), the mortality rate among infected individuals is approximately 30%. The majority of cases occur in the spring and early summer indicating seasonally-associated risk factors for viral exposure. In 2013 and 2014, a substantial increase in the number of hantavirus pulmonary syndrome cases was identified; however the cause remains unclear. No antivirals or vaccines are currently available and treatment is supportive. Public education, rodent control and the use of personal protective measures are key to avoid infections in at-risk populations.

Mental modes: priming of expertise-based dispositions in expertise-unrelated contexts

Why does the general demeanor of others change as soon as they begin to ‘talk shop’ or do something else that puts them into ‘work-mode’? We propose that such phenomena reflect an instance of incidental priming in which environmental cues activate actional ‘sets’ formed through extensive training in a particular domain (e.g., music). Accordingly, we demonstrated that, by activating a ‘musician set,’ incidental musically-related stimuli prime musicians to spend more time on a domain-irrelevant task rehearsing nonsense words as compared to controls or non-primed musicians, as this set should involve a tendency towards deliberative practice. This finding provides additional evidence for a central tenet of social cognition research-that the mere presence of ambient stimuli influences behavioral dispositions systematically, in ways that often escape one’s awareness(AU)

Stimulus control: the sought or unsought influence of the objects we tend to

Does the mere presence of the things we have tended to influence our actions systematically, in ways that escape our awareness? For example, while entering a tool shed, does perceiving objects that we once tended to (e.g., tools, musical instruments) influence how we then execute a simple action (e.g., flicking the shed’s light switch)? Ancient traditions (e.g., feng shui) and contemporary approaches to action production (e.g., continuous flow and cascade models) hypothesize that the answer is yes. Although relevant to several fields (e.g., motor cognition, social cognition), for various reasons this hypothesis cannot be tested by traditional choiceresponse time interference paradigms, which involve more complex processes than our tool shed scenario. Using new paradigms that resemble detection tasks, three studies demonstrated that ‘very incidental’ actionrelated distracters systematically interfere with simple, repeated actions that involve minimal response selection and decision-making processes. In Study 2, incidental musical notation interfered more with the simple actions of expert sight-readers than with the same actions of non-musicians. A similar pattern of effects was obtained with a fully experimental design. The implications for theories of action production, environmentally-driven automaticity, and social cognition are discussed(AU)

Implications of absolute fracture risk assessment for osteoporosis practice guidelines in the USA.

UNLABELLED: Application of the WHO fracture prediction algorithm in conjunction with an updated US economic analysis indicates that osteoporosis treatment is cost-effective in patients with fragility fractures or osteoporosis, in older individuals at average risk and in younger persons with additional clinical risk factors for fracture, supporting existing practice recommendations. INTRODUCTION: The new WHO fracture prediction algorithm was combined with an updated economic analysis to evaluate existing NOF guidance for osteoporosis prevention and treatment. METHODS: The WHO fracture prediction algorithm was calibrated to the US population using national age-, sex- and race-specific death rates and age- and sex-specific hip fracture incidence rates from the largely white population of Olmsted County, MN. Fracture incidence for other races was estimated by ratios to white women and men. The WHO algorithm estimated the probability (%) of a hip fracture (or a major osteoporotic fracture) over 10 years, given specific age, gender, race and clinical profiles. The updated economic model suggested that osteoporosis treatment was cost-effective when the 10-year probability of hip fracture reached 3%. RESULTS: It is cost-effective to treat patients with a fragility fracture and those with osteoporosis by WHO criteria, as well as older individuals at average risk and osteopenic patients with additional risk factors. However, the estimated 10-year fracture probability was lower in men and nonwhite women compared to postmenopausal white women. CONCLUSIONS: This analysis generally endorsed existing clinical practice recommendations, but specific treatment decisions must be individualized. An estimate of the patient's 10-year fracture risk should facilitate shared decision-making.

Cost-effective osteoporosis treatment thresholds: the United States perspective.

UNLABELLED: A United States-specific cost-effectiveness analysis, which incorporated the cost and health consequences of clinical fractures of the hip, spine, forearm, shoulder, rib, pelvis and lower leg, was undertaken to identify the 10-year hip fracture probability required for osteoporosis treatment to be cost-effective for cohorts defined by age, sex, and race/ethnicity. A 3% 10-year risk of hip fracture was generally required for osteoporosis treatment to cost less than $60,000 per QALY gained. INTRODUCTION: Rapid growth of the elderly United States population will result in so many at risk of osteoporosis that economically efficient approaches to osteoporosis care warrant consideration. METHODS: A Markov-cohort model of annual United States age-specific incidence of clinical hip, spine, forearm, shoulder, rib, pelvis and lower leg fractures, costs (2005 US dollars), and quality-adjusted life years (QALYs) was used to assess the cost-effectiveness of osteoporosis treatment ($600/yr drug cost for 5 years with 35% fracture reduction) by gender and race/ethnicity groups. To determine the 10-year hip fracture probability at which treatment became cost-effective, average annual age-specific probabilities for all fractures were multiplied by a relative risk (RR) that was systematically varied from 0 to 10 until a cost of $60,000 per QALY gained was observed for treatment relative to no intervention. RESULTS: Osteoporosis treatment was cost-effective when the 10-year hip fracture probability reached approximately 3%. Although the RR at which treatment became cost-effective varied markedly between genders and by race/ethnicity, the absolute 10-year hip fracture probability at which intervention became cost-effective was similar across race/ethnicity groups, but tended to be slightly higher for men than for women. CONCLUSIONS: Application of the WHO risk prediction algorithm to identify individuals with a 3% 10-year hip fracture probability may facilitate efficient osteoporosis treatment.

Attentional function as measured by a Continuous Performance Task in children with dyscalculia.

This study determined whether or not students with dyscalculia had difficulty with attention as measured by the Conners' Computerized Continuous Performance Test (CPT). Fifty-six control subjects and 27 subjects with dyscalculia were administered the CPT. Performance was measured using percent omission errors, percent commission errors, mean response time, SE of response times (SE-RT), and a calculated overall attention index (CPT Index). Compared with controls, subjects with dyscalculia had higher CPT Index scores, made more omission errors, and had more inconsistent response times (SE-RT). Multiple regression analysis of arithmetic scores showed that SE-RT and percent commission errors were the only CPT measures that contributed to the arithmetic scores. Problems with attention, as measured by the Conners' CPT, were associated with lower arithmetic achievement scores. Students who have difficulties in arithmetic may have more attentional problems than other children, and students with attentional difficulties may be at risk for difficulties in arithmetic.

Pharmacotherapy of disorders in mental retardation.

This is a review of pharmacotherapy in children and adolescents with mental retardation from the perspective of DSM and ICD disorders. The existing research is reviewed in young people with mental retardation but, when data are lacking, we examined the literature from adults with mental retardation and from typically-developing children. The literature is discussed for each of the following disorders: ADHD, anxiety disorders, bipolar disorder, conduct disorder, depression, enuresis, schizophrenia, self injury, and tics and movement disorders. With the possible exception of ADHD, there is a woeful lack of empirical data on most of these disorders in young people with mental retardation. Clinicians will often be forced to extrapolate from data on adults having mental retardation and from typically-developing children. The best policy is probably to treat such patients cautiously, while gathering data on the effects of such therapy in the hopes of beginning a data base.

Early ear problems and developmental problems at school age.

Retrospective history of middle ear disease was compared with developmental diagnosis in 507 consecutively referred school-age children. History of major ear problems was positively associated with discrepancies between the performance and verbal IQ on the WISC-R. History of major ear problems was positively associated with the presence of articulation disorders for children in the low social class, hyperactivity in the middle social class, and language problems in the high social class. A history of significant middle ear disease in early childhood should raise concerns for articulation difficulties and possible language problems in children presenting to clinicians with school problems.

Bone mass and vitamin D deficiency in adults with advanced cystic fibrosis lung disease.

Osteoporosis and fractures are increasingly recognized in children and adults with cystic fibrosis. To investigate the prevalence and pathogenesis of osteoporosis and low bone mass in adults with advanced pulmonary disease due to cystic fibrosis, we examined the relationships between bone mineral density (BMD), anthropomorphic variables, pulmonary status, glucocorticoid therapy, and vitamin D concentrations. BMD of the lumbar spine, hip, and proximal radius was measured by dual energy X-ray absorptiometry in 30 white adults (16 women), age 30 +/- 2 yr (mean +/- SEM). Compared with a normal control population, the patients had significantly reduced BMD at the lumbar spine (17 +/- 3%), total hip and femoral neck (24 +/- 3% and 20 +/- 4%, respectively). The radius was significantly less demineralized (4 +/- 2%; p <= 0.003) than the other sites. Moreover, only 21% of patients with cystic fibrosis had normal BMD (T score > -1.0) at the lumbar spine, 23% at the hip sites, and 39% at the radius. Age, weight, and body mass index (BMI) were most strongly correlated with bone mass, whereas glucocorticoid therapy and pulmonary function were not predictive. Despite oral vitamin D (400 to 800 IU daily), the mean serum 25-hydroxyvitamin D (25-OHD) concentration was at the low end of the normal range (16 +/- 2 ng/ml; normal 10 to 52 ng/ml); 8 of 20 patients (40%) had frankly low (<= 10 ng/ml) levels. BMD was significantly lower in patients with low 25-OHD concentrations at the lumbar spine (0.774 +/- 0.02 versus 0.913 +/- 0.04 g/cm2; p = 0.01) and total hip (0.648 +/- 0.04 versus 0.811 +/- 0.04 g/cm2; p = 0.01). Vertebral fractures were present in 19% of subjects and 41% had a confirmed history of previous fracture. In summary, osteoporosis, low bone mass, and fractures are common in adults with advanced cystic fibrosis lung disease. Despite oral supplements, vitamin D deficiency is also common and is associated with more severe demineralization at the lumbar spine and hip. We conclude that the widespread practice of oral supplementation with 400 to 800 units of vitamin D is ineffective in maintaining normal vitamin D stores in many patients with cystic fibrosis. To ensure adequacy of vitamin D stores, measurement of serum 25-OHD should be included in the routine management of patients with cystic fibrosis.

The challenges of peripheral bone density testing: which patients need additional central density skeletal measurements?

Lower cost, portable, peripheral bone mass measurement devices are being increasingly utilized for widespread bone mass testing. These devices are being placed in traditional medical settings as well as nontraditional settings, such as pharmacies and grocery stores. Increased bone mass testing is appropriate at menopause in women who are undecided whether to begin systemic estrogen replacement. Women may decide to begin estrogen replacement if they are aware they have low bone mass and understand that bone mass will predictably decline after the menopause (1). With the approval of alendronate and raloxifene for the prevention of osteoporosis, even women who cannot or will not utilize estrogen replacement may be offered preventive interventions if they are identified as having low bone mass. More accessible bone mass measurements and more approved pharmacologic interventions will shift the focus of osteoporosis management to strategies that emphasize the reduction of lifetime fracture risk as well as current fracture risk. It will also be an impetus to focus on earlier identification and intervention (2-4).

Prevalence of low femoral bone density in older U.S. adults from NHANES III.

Most estimates of osteoporosis in older U.S. adults have been based on its occurrence in white women, even though it is known to affect men and minority women. In the present study, we used dual-energy X-ray absorptiometry measurements of femoral bone mineral density (BMD) from the third National Health and Nutrition Examination Survey (NHANES III, 1988-1994) to estimate the overall scope of the disease in the older U.S. population. Specifically, we estimate prevalences of low femoral BMD in women 50 years and older and explore different approaches for defining low BMD in older men in that age range. Low BMD levels were defined in accordance with an approach proposed by an expert panel of the World Health Organization and used BMD data from 382 non-Hispanic white (NHW) men or 409 NHW women ages 20-29 years from the NHANES III dataset. For women, estimates indicate 13-18%, or 4-6 million, have osteoporosis (i.e., BMD > 2.5 standard deviations [SD] below the mean of young NHW women) and 37-50%, or 13-17 million, have osteopenia (BMD between 1 and 2.5 SD below the mean of young NHW women). For men, these numbers depend on the gender of the reference group used to define cutoff values. When based on male cutoffs, 3-6% (1-2-million) of men have osteoporosis and 28-47% (8-13 million) have osteopenia; when based on female cutoffs, 1-4% (280,000-1 million) have osteoporosis and 15-33% (4-9 million) have osteopenia. Most of the older U.S. adults with low femur BMD are women, but, regardless of which cutoffs are used, the number of men is substantial.

Prevalence of low femoral bone density in older U.S. women from NHANES III.

Data on the number of U.S. women with low femoral bone mineral density (BMD) are currently available only from indirect estimates. We used dual-energy X-ray absorptiometry (DXA) measurements of femoral BMD from phase 1 of the third National Health and Nutrition Examination Survey (NHANES III, 1988-1991) to estimate prevalences of low femoral BMD in women ages 50 years and older using an approach proposed recently by an expert panel of the World Health Organization (WHO). Cutpoints for low BMD were derived from BMD data of 194 non-Hispanic white (NHW) women aged 20-29 years from the NHANES III dataset. The prevalence of older U.S. women with femoral osteopenia (BMD between 1 standard deviation [SD] and 2.5 SD below the mean of young NHW women) ranged from 34-50% in four different femur regions, which corresponds to approximately 12-17 million women. The prevalence with osteoporosis (BMD > 2.5 SD below the mean of young NHW women) ranged from 17-20%, or approximately 6-7 million women. Prevalences were 1.3-2.4 times higher in NHW women than non-Hispanic black women (NHB), and 0.8-1.2 times higher in NHW versus Mexican American (MA) women. The estimated numbers of NHW, NHB, and MA women with osteopenia were 10-15 million, 800,000-1.2 million, and 300,000-400,000, respectively; corresponding figures for osteoporosis were 5-6 million, 200,000-300,000, and 100,000 respectively. Thus, the first data on BMD from a nationally representative sample of older women show a substantial number with low femoral BMD.(ABSTRACT TRUNCATED AT 250 WORDS)

Proximal femur bone mineral levels of US adults.

This paper describes bone mineral levels in the proximal femur of US adults based on a nationally representative sample of 7116 men and women aged 20 years and older. The data were collected in phase 1 of the third National Health and Nutrition Examination Survey (NHANES III, 1988-1991) using dual-energy X-ray absorptiometry, and included bone mineral density (BMD), bone mineral content (BMC) and area of bone scanned in five selected regions of interest (ROI) in the proximal femur: femur neck, trochanter, intertrochanter, Ward's triangle and total. These variables are provided separately by age and sex for non-HIspanic whites (NHW), non-Hispanic blacks (NHB) and Mexican Americans (MA). BMD and BMC in the five ROI tended to decline with age, whereas area did not. BMD and BMC were highest in NHB, intermediate in MA and lowest in NHW, but areas were highest in NHW, intermediate in NHB and lowest in MA. Men had greater BMD, BMC and area than women in all three race/ethnic groups. Differences by age, sex or race/ethnicity tended to be the largest in Ward's triangle, followed by the femur neck; patterns in the trochanter, intertrochanter and total ROI were reasonably similar to each other. This report provides extensive data on femur bone mineral levels of adults from one of the largest samples available to date and should be valuable as reference data for other studies which examine this skeletal site in adults.

The wrath of math. Deficiencies of mathematical mastery in the school child.

Mastery of mathematics involves the interactions of multiple developmental pathways. Children with mathematics disabilities often experience profound feelings of intellectual inadequacy that can erode self-esteem and academic motivation. This article delineates 16 interactive subcomponents that students who underachieve in mathematics can encounter. The article also discusses assessment and management issues for children with mathematics disabilities.

Interpersonal disabilities: social skill deficits in older children and adolescents. Their description, assessment, and management.

Good social skills are critical for peer acceptance and friendship formation, which are developmental missions for the older child and adolescent. Good social skills can be developed and can favorably influence other domains of function. A sensitive and comprehensive assessment and management plan is essential. Pediatricians have a unique vantage point because of their familiarity with a child, the family, the school and community, and their knowledge of child development and behavior. Pediatricians can therefore play a central role in the assessment, management, and follow-up of social skills problems.

Technical considerations for prophylactic mastectomy in patients at high risk for breast cancer.

A study of 5 patients and 10 mastectomy specimens was performed to identify the extent of surgery necessary to completely remove all breast tissue in patients having prophylactic mastectomies. A standard total mastectomy performed for breast cancer was shown to frequently leave breast tissue within the superficial pectoralis major muscle and the lower skin flap. Frozen section analysis of margins was found to be essential to clear the axillary extension of the breast and lower skin flap in particular. The value of more extensive surgery to remove all glandular elements of the breast in the high-risk patient remains to be demonstrated.

Contractile properties of fast muscle preparations regenerating in slow muscle beds.

Mechanical evidence is presented to show that fast muscle tissue regenerating in the bed of a slow muscle, and innervated by the slow muscle nerve, has contractile properties identical to those of a slow muscle regenerating in its own bed. The results do not support the idea that regenerating fast muscles are partially resistant to the transforming effects of a slow nerve.

The theoretically ideal donor site dressing.

Many of the choices for managing split-thickness skin graft donor sites are satisfactory, but none is ideal. Epidermal regeneration in a donor site is readily available for clinical study. We have reviewed experimental studies of epidermal regeneration and applied those results to the clinical study of a new donor site dressing. This dressing is a vapor-permeable, transparent, polyurethane film with a polyvinyl ether adhesive. Used on 100 patients, it was found to be safe and effective in allowing rapid and painless healing. Although the dressing is occlusive and theoretically could promote infection in a contaminated wound, no infections were encountered. Comparison was made with 15 patients managed by other methods. No marked difference in healing time was noted clinically. The striking advantage of the new dressing was painless healing.