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Background Physical activity has been shown to mitigate many of the effects of cancer treatment, yet it often is not embraced by the patient or made part of the nursing standard of care. Objectives This pilot study evaluates the impact of the Oncology Nursing Society's Get Up, Get Moving program, a personalized, home-based, nurse-led physical activity coaching program. Methods Patients with cancer in the intervention and control groups completed the SF-36® and the Godin Leisure-Time Exercise Questionnaire at weeks 1 and 12. All patients were initially counseled on exercise. A nurse called each member of the intervention group weekly to encourage physical activity and asked about fatigue, nausea, and step count. The control group was contacted at 6 weeks and 12 weeks only. Findings The program, coupled with nurse telephone calls, increased steps, decreased fatigue, and maintained health-related quality of life among patients in the intervention group. The control group had a decrease in steps, a decline in their SF-36 general health score, and an increase in fatigue. Nurse coaching positively affects physical activity, which may help to decrease cancer treatment side effects.

Skeletal fractures, a common injury in physically abused children, often go undetected and untreated for significant lengths of time and are sometimes incidentally discovered radiographically. Our objective was to review current literature for scientific studies of pediatric fracture healing with associated timelines. We conducted a search of Embase, EBSCOhost, MEDLINE (PubMed), and Web of Science for literature published from the earliest available up to August 2018. We evaluated the included articles for quality, with consideration for use in clinical and forensic settings. Of a total of 313 full-text articles evaluated, 10 met study inclusion criteria. The patient age range among studies was 0-17 years, with children younger than 1 year included in the majority of studies. The fracture locations included in studies were primarily fractures of the upper limb and pectoral girdle, followed by fractures of the lower limb. The radiographic features of healing varied greatly among the studies. Timelines of common fracture healing variables differed significantly among studies. Scientific, radiographic studies of pediatric fracture healing are limited. Gaps in knowledge regarding fracture healing highlight the need for future research and validation studies. Fracture healing timelines derived from existing timelines should be used with caution.

Neonicotinoids have been the most commonly used insecticides since the early 1990s. Despite their efficacy in improving crop protection and management, these agrochemicals have gained recent attention for their negative impacts on non-target species such as honeybees and aquatic invertebrates. In recent years, neonicotinoids have been detected in rivers and streams across the world. Determining and predicting the exposure potential of neonicotinoids in surface water requires a thorough understanding of their fate and transport mechanisms. Therefore, our objective was to provide a comprehensive review of neonicotinoids with a focus on their fate and transport mechanisms to and within surface waters and their occurrence in waterways throughout the world. A better understanding of fate and transport mechanisms will enable researchers to accurately predict occurrence and persistence of insecticides entering surface waters and potential exposure to non-target organisms in agricultural intensive regions. This review has direct implications on how neonicotinoids are monitored and degraded in aquatic ecosystems. Further, an improved understanding of the fate and transport of neonicotinoids aide natural resource practitioners in the development and implementation of effective best management practices to reduce the potential impact and exposure of neonicotinoids in waterways and aquatic ecosystems.

Estimating medical care productivity is a central economic challenge. This paper develops a satellite account for the US health sector that appropriately measures health care productivity and applies that to the elderly population between 1999 and 2012. The central output of the satellite account is health. The primary input is medical care; we also examine the impact of behavioral risk factors. Our empirical work measures the change in medical spending and health outcomes for a comprehensive set of 80 conditions. We estimate that medical care has positive productivity as a whole, with aggregate productivity growth of 9% over the time period. However, there is significant heterogeneity in productivity by condition. At the upper end, care for cardiovascular disease has been extremely productive. In contrast, care for people with mental illness and musculoskeletal conditions has been costly but not productive.

Introduction Le risque evolutif de l’infection au nouveau coronavirus (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], responsable de la maladie a coronavirus-2019 [COVID-19]) dans la population de patients atteints de rhumatismes inflammatoires chroniques (RIC) sous traitements immunomodulateurs (disease-modifying-anti-rheumatic drugs [DMARDs]) est incompletement connu. Cette population de patients immunodeprimes est consideree jusqu’a preuve du contraire comme une population a risque de formes severes de COVID-19. Cette etude a ete menee pour evaluer le degre de severite et l’issue de l’infection a SARS-CoV-2/COVID-19 chez les patients avec RIC exposes a des DMARDs, en pratique courante rhumatologique, au sein d’un des epicentres francais de la pandemie. Patients et methodes Nous avons mene entre mars et aout 2020 une etude observationnelle retrospective monocentrique aux hopitaux civils de Colmar (Alsace ; France) dediee a la collection des donnees des patients suivis pour un RIC ou une maladie auto-immune systemique qui ont developpe une infection a SARS-CoV-2, documentee par RT-PCR sur prelevements nasopharynges, ou de facon retrospective par la serologie (IgM/IgG diriges contre le SARS-CoV-2) et/ou sur la mise en evidence d’une pneumopathie bilaterale typique au scanner thoracique. Les caracteristiques cliniques des patients et les modalites d’immunomodulation (DMARDs conventionnels [csDMARDs], biologiques [bDMARDs] ou cibles [tsDMARDs]) ont ete collectees et analysees au regard de l’evolution benigne, moderee ou severe du COVID-19 et de l’issue de l’infection (guerison/deces). Resultats Un total de 19 patients, dont 9 polyarthrites rhumatoides, 6 spondyloarthrites, 2 syndromes de Sjogren primaire, 1 arterite a cellules geantes et 1 maladie de Still de l’adulte, ont ete confirmes par RT-PCR pour 10 patients (52,6 %), par serologie pour 8 patients (42,1 %) et sur la base d’un pattern compatible au scanner thoracique pour 1 patients (5,3 %). Sept patients (36,8 %) beneficiaient d’une association de traitements fonds combinant un csDMARDs avec un bDMARDs ou un tsDMARDs. Parmi les 15 patients sous csDMARDs (78,9 %), 11 etaient traites par methotrexate (MTX) (57,9 %), dont 2 en association a l’hydroxychloroquine (10,5 %), 3 recevaient du leflunomide (15,8 %), et 1 de l’azathioprine (5,3 %). Dix patients (52,6 %) etaient sous bDMARDs au debut des symptomes de COVID-19, dont 6 (31,6 %) sous anti-TNF alpha, 3 (15,8 %) sous anti-IL6R, tocilizumab et 1 patient (5,3 %) sous anti-CD20, rituximab. Une seule patiente (5,3 %) etait traitee par tsDMARD, baricitinib, en combinaison au MTX. Au total, 18 des 19 patients (94,7 %) analyses ont gueri sans sequelles. Parmi eux, 14 (73,7 %) ont developpe une forme benigne et 4 (21,1 %) une forme moderee necessitant une hospitalisation, mais sans transfert en soins intensifs. Une seule forme severe de COVID-19, compliquee de syndrome de detresse respiratoire aigue dont l’issue a ete fatale (5,3 %), a ete observee chez un patient de 83 ans, avec comorbidites cardiovasculaires, traite en monotherapie par anti-TNF alpha monoclonal (golimumab) pour une spondyloarthrite axiale. Conclusion Quelles que soient les modalites d’immunomodulation et le type de rhumatisme inflammatoire, le profil evolutif dans cette cohorte montre une predominance de formes benignes de COVID-19, avec guerison sans sequelles. L’âge et les comorbidites cardiovasculaires semblent dominer le pronostic, davantage que l’exposition a un traitement immunosuppresseur.

Recent pathogenic Escherichia coli contamination of fresh vegetables that originated from irrigation water has increased awareness and importance of identifying sources of E. coli entering agroecosystems. However, inadequate methods for accurately predicting E. coli occurrence and sources in waterways continue to limit the identification of appropriate and effective prevention and treatment practices. Therefore, the primary objectives of this study were to: (1) Determine the concentration of E. coli during storm events in a hydrologic controlled stream situated in a livestock research operation that is located in the Central Flyway for avian migration in the United States. Great Plains; and (2) Identify trends between E. coli concentrations, grazing rotations, and avian migration patterns. The study sampled five rainfall events (three summer and two fall) to measure E. coli concentrations throughout storm events. A combination of cattle density and waterfowl migration patterns were found to significantly impact E. coli concentrations in the stream. Cattle density had a significant impact during the summer season (p .0001), while waterfowl density had a significant impact on E. coli concentrations during the fall (p = .0422). The downstream reservoir had exceedance probabilities above the Environmental Protection Agency freshwater criteria 85% of the growing season following rainfall events. Based on these findings, implementation of best management practices for reducing E. coli concentrations during the growing season and testing of irrigation water prior to application are recommended.

Understanding the value of medical care requires comparing cost changes with changes in health outcomes. Aggregate cost changes are known in detail, but changes in the health of people have not been comparably measured, nor has research related changes in spending to changes in population health. We compare change in medical expenditures by disease with changes in quality-adjusted life expectancy (QALE) by disease over time in the Medicare population. Data come from the 1999 and 2012 Medicare Current Beneficiary Survey (MCBS), an ongoing study of Medicare beneficiaries. We collapse the large group of medical conditions imputed in the MCBS to a more succinct 26 categories. To estimate changes in health by disease, we use propensity score models to attribute mortality and health related quality-of-life (HRQOL) to each disease. We account for both changing disease prevalence and changes in the impairment associated with different diseases. QALE increased for 16 of the 26 conditions, with the greatest improvements for heart disease (0.4 years), cardiovascular risk factors (hypertension, hyperlipidemia, diabetes; 0.3 years) and digestive conditions (0.2 years), and the greatest declines for mental health conditions (-0.14 years), and dementia (-0.26 years). Comparing these changes with changes in expenditures by disease points to conditions for which investment has yielded improvement in quality as well as length of life (stroke, ischemic heart disease) and those for which investment has been less successful in improving population health (dementia, mental health). Results can inform further in-depth study of disease treatment cost-effectiveness and policies that guide treatment decisions.

International audience

As health care financing, organization, and delivery innovations proliferate, the need for comprehensive, detailed data on medical spending has never been more apparent. This study builds on previous work to provide a more comprehensive accounting of medical spending at the individual level than has been done in the past. We account for spending by the entire population: the civilian, non-institutionalized population that is the subject of past studies, as well as high medical spenders, the institutionalized, the incarcerated, and active-duty military personnel. We use within-imputation and other adjustments to build a micro dataset and reconcile survey data based on our estimate of medical spending to the National Health Expenditure Accounts (NHEA). The micro dataset we build can be used for more detailed policy evaluations that more closely reflect true national personal health expenditure at the individual level.

Chronic kidney disease is a persistent chronic health condition commonly seen in pediatric nephrology programs. Our study aims to evaluate the sensitivity of the Patient Reported Outcomes Measurement Information System (PROMIS) pediatric instrument to indicators of disease severity and activity in pediatric chronic kidney disease. This cross sectional study included 233 children 8–17 years old, with chronic kidney disease from 16 participating institutions in North America. Disease activity indicators, including hospitalization in the previous 6 months, edema, and number of medications consumed daily, as well as disease severity indicators of kidney function and coexisting medical conditions were captured. PROMIS domains, including depression, anxiety, social-peer relationships, pain interference, fatigue, mobility, and upper extremity function, were administered via web-based questionnaires. Absolute effect sizes (AES) were generated to demonstrate the impact of disease on domain scores. Four children were excluded because of missing glomerular filtration rate (GFR) estimations. Of the 229 children included in the final analysis, 221 completed the entire PROMIS questionnaire. Unadjusted PROMIS domains were responsive to chronic kidney disease activity indicators and number of coexisting conditions. PROMIS domain scores were worse in the presence of recent hospitalizations (depression AES 0.33, anxiety AES 0.42, pain interference AES 0.46, fatigue AES 0.50, mobility AES 0.49), edema (depression AES 0.50, anxiety AES 0.60, pain interference AES 0.77, mobility AES 0.54) and coexisting medical conditions (social peer-relationships AES 0.66, fatigue AES 0.83, mobility AES 0.60, upper extremity function AES 0.48). The PROMIS pediatric domains of depression, anxiety, social-peer relationships, pain interference, and mobility were sensitive to the clinical status of children with chronic kidney disease in this multi-center cross sectional study. We demonstrated that a number of important clinical characteristics including recent history of hospitalization and edema, affected patient perceptions of depression, anxiety, pain interference, fatigue and mobility. The PROMIS instruments provide a potentially valuable tool to study the impact of chronic kidney disease. Additional studies will be required to assess responsiveness in PROMIS score with changes in disease status over time.

Atrazine, one of the most widely used herbicides in the world, threatens human health along with terrestrial and aquatic biota. Recent reports have found atrazine in drinking water to be associated with increased birth defects and incidences of Non-Hodgkin's Lymphoma, with higher levels of significance from exposure to both atrazine and nitrate-N. The Midwest region of the United States, which includes Nebraska, is one of the leading regions for high nitrate-N concentrations and agrochemicals, including atrazine, in surface waters. Therefore, the objective of this study was to provide a case study for completing an environmental risk analysis for the potential exposure of atrazine and nitrate-N to ecosystems and humans through interaction with surface waters using two approaches: (1) Identify watersheds across Nebraska that were at risk for exceeding atrazine and nitrate-N maximum contaminant limits (MCLs) in surface water; and (2) Determine the specific times of year where risks were greatest. Factors were then analyzed using Geographic Information System (GIS) software to identify areas of high risk. Impairments for both nitrate-N and atrazine in the surface water were found predominately during the early growing season in the southeastern region of Nebraska, in watershed areas with the highest amount of corn production and annual precipitation. Further, the methodology developed in this study has the potential for application in regions with higher dependency on surface water to determine multiple agrochemical load influxes from upstream regions and evaluate other surface water contaminants during the same time periods.

Background Data describing inpatient health care utilization in children with nephrotic syndrome and related severe complications are limited. Our goals were to describe the charges, length of stay (LOS), and number of hospitalizations among children, adolescents, and young adults with nephrotic syndrome. Study Design A cross-sectional analysis of the Kids' Inpatient Database (KID) database from the Healthcare Cost and Utilization Project (HCUP). The HCUP-KID is an all-payer database of hospital discharges for children, adolescents, and young adults in the United States compiled every 3 years by the Agency for Healthcare Research and Quality. Setting & Participants HCUP-KID data were obtained for the 2006 and 2009 cohort years. We identified patients by searching discharges for nephrotic syndrome International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Predictor Patient demographics, disease complications in children, adolescents, and young adults hospitalized with nephrotic syndrome. Outcome Number of hospitalizations, mean charges, and LOS for children, adolescents, and young adults hospitalized with nephrotic syndrome. Results There were 6,308 hospitalization discharges in children, adolescents, and young adults with a primary or secondary diagnosis of nephrotic syndrome reported by 38 and 44 states in 2006 and 2009, respectively, representing an estimated 9,934 discharges nationally. Nephrotic syndrome resulted in an estimated 48,700 inpatient days and charges totaling $259 million. The mean charge per hospitalization was ∼$26,500 (SE, $1,100) and LOS was 5 days (SE, 0.1). 16% of discharges for nephrotic syndrome had a diagnosis code for at least one severe complication, including thromboembolism (3.6%), septicemia (3.8%), peritonitis (2.6%), pneumonia (5.4%), or diabetes (2.4%). Multivariable analysis showed age 15 years or older, race, higher socioeconomic status, acute renal failure, thromboembolic disease, hypertension, and infections predicted higher mean hospitalization charges. Limitations The HCUP-KID database collects data on a hospitalization level. Consequently, health care utilization on an individual patient level or in the outpatient environment is not possible. Conclusions We present a comprehensive description of inpatient health care utilization in children, adolescents, and young adults with nephrotic syndrome. The complications of nephrotic syndrome, including thromboembolism, infection, and hypertension, contribute significantly to these charges.

To evaluate inpatient health care utilization for children with systemic lupus erythematosus (SLE) with and without kidney disease.The Healthcare Cost and Utilization Project Kids' Inpatient Database for the years 2000, 2003, and 2006 was used for this analysis. SLE hospitalizations from the 2006 cohort were identified and classified as those with versus without kidney involvement by International Classification of Diseases, Ninth Revision, Clinical Modification codes. Analyses were performed to examine determinants of hospitalization charges and changes in charges over time.In the US, 7,390 SLE-related pediatric hospitalizations generated $267 million in total charges in 2006. Of these, 4,193 discharges had kidney involvement. The average hospitalization charge was greater for SLE patients with kidney involvement compared to those without kidney involvement ($43,100 versus $28,500; P0.0001). In multivariate analysis, kidney involvement remained a significant predictor of hospitalization charges, independent of demographic and hospital characteristics (P0.0001). SLE-associated acute kidney failure, transplant, and end-stage kidney disease resulted in greater hospitalization charges than SLE without kidney involvement by $74,900 (P0.0001), $32,700 (P = 0.0002), and $27,400 (P0.0001), respectively.In the US,7,000 hospitalizations occurred in 2006 among children with SLE, with nearly 57% demonstrating kidney involvement. Kidney involvement is a major determinant of hospitalization charges for these children. This study represents one of the first large-scale assessments of in-hospital health care utilization by children with SLE.

The potential for improving response rates by changing from one mode of data collection to another mode and the consequences for measurement and nonresponse errors are examined. Data collection from 8999 households was done in two phases. Phase 1 data collection was conducted by telephone interview, mail, interactive voice response, or the Internet, while Phase 2 focused on nonrespondents to Phase 1, and was conducted by a different mode, either telephone or mail. Results from our study suggest that switching to a second mode is an effective means of improving response. We also find that for the satisfaction–dissatisfaction questions asked in this survey, respondents to the aural modes (telephone and IVR) are significantly more likely than are respondents to the visual modes (mail and web) to give extreme positive responses, a difference that cannot be accounted for by a tendency towards recency effects with telephone. In general, switching to a second mode of data collection was not an effective means of reducing nonresponse error based on demographics.

Objectives: Questions exist about using mass mailings to recruit representative samples to participate in clinical trials. The MESA Prevention Study (Medical, Epidemiologic and Social Aspects of Aging), a randomized controlled clinical trial to prevent urinary incontinence (UI), utilized a mass mailing recruitment procedure to recruit a representative sample of women to participate in a behavioral modification program. This paper seeks to expand the literature of mass mailing recruitment strategies for prevention studies by describing the procedures used to recruit healthy, continent, post-menopausal women aged 55–80 years. Methods: Sociodemographic data collected from recruited subjects is compared with on-line national census data to evaluate the representativeness of the sample recruited from a purchased mailing list. Results: The mass mailing procedure resulted in 3.3% positive response. Of those that returned a positive response, 37.6% were deemed eligible at first screening. Comparisons of study demographic data with state and county census data indicate that the sample obtained was representative of the communities. Conclusions: The mass mailing strategy was an effective means of recruiting a representative sample of women, aged 55–80. Short falls and recommendations for successful community sample recruitment strategies for clinical trials in older adult women are elaborated upon.

This study describes acquisition of knowledge and motor skill in bladder training (BT) and pelvic floor muscle training (PFMT) and adherence following a behavioral modification program (BMP). Essentially continent (0-5 episodes in past year) community-dwelling older women (n = 359) were randomized to treatment (n = 164), a 2-h group education session supplemented by one brief individualized session of approximately 10 min, or control (n = 195), no instruction, and followed for 12 months. Knowledge, motor skill, and adherence to the BMP were documented. Changes in pelvic muscle function and voiding interval were used to validate self-reported adherence. Following group instruction, mean BT and PFMT knowledge was 90 and 86%, respectively; 68% demonstrated correct PFMT technique without additional instruction, 29% required brief instruction, and 3% were unable to learn PFMT technique. Adherence ranged from 63 to 82% for PFMT and 58 to 67% for BT. Group instruction supplemented with brief individual instruction as needed is an effective teaching method for BT and PFMT.

Resume Les zoonoses sont un champ en constante evolution. Streptococcus equi subsp. ruminatorum est une sous-espece de streptocoque du groupe C identifiee pour la premiere fois en 2004. Recemment, un premier cas d’infection humaine a ete rapporte. Nous rapportons ici un second cas d’infection par cette sous-espece chez l’homme. Il s’agit d’un homme de 70 ans qui a presente une spondylodiscite aigue associee a une endocardite de la grande valve mitrale. Le germe a ete identifie dans les hemocultures. L’evolution a ete favorable sous antibiotherapie. Cette situation pathologique a fait decouvrir une hypogammaglobulinemie associee, a un myelome stade I. L’interrogatoire a mis en evidence un contact frequent avec des chevaux dont deux presentaient, quelques jours avant les signes cliniques du patient, un episode infectieux des voies aeriennes superieures. Le diagnostic d’infection a S. equi a ete confirme retrospectivement par la serologie chez ces animaux. Cette observation originale conforte le role de S. equi subsp. ruminatorum en pathologie humaine et a permis de suspecter un mode de transmission jusque-la non decrit qui est direct par une porte d’entree cutanee. Ce fait clinique met aussi en lumiere l’importance pour le diagnostic du recours aux techniques de biologie moleculaire dont l’utilisation devrait etre systematique en cas d’infection streptococcique du groupe C dans un contexte evocateur de zoonose.

Joint Bone Spine - In Press.Proof corrected by the author Available online since samedi 19 juillet 2014

La Presse Medicale - In Press.Proof corrected by the author Available online since mercredi 10 juin 2015

Background and objectivesNephrotic syndrome (NS) represents a common disease in pediatric nephrology typified by a relapsing and remitting course and characterized by the presence of edema that can significantly affect the health-related quality of life in children and adolescents. The PROMIS pediatric measures were constructed to be publically available, efficient, precise, and valid across a variety of diseases to assess patient reports of symptoms and quality of life. This study was designed to evaluate the ability of children and adolescents with NS to complete the PROMIS assessment via computer and to initiate validity assessments of the short forms and full item banks in pediatric NS. Successful measurement of patient reported outcomes will contribute to our understanding of the impact of NS on children and adolescents.DesignThis cross-sectional study included 151 children and adolescents 8-17 years old with NS from 16 participating institutions in North America. The children completed the PROMIS pediatric depression, anxiety, social-peer relationships, pain interference, fatigue, mobility and upper extremity functioning measures using a web-based interface. Responses were compared between patients experiencing active NS (n = 53) defined by the presence of edema and patients with inactive NS (n = 96) defined by the absence of edema.ResultsAll 151 children and adolescents were successfully able to complete the PROMIS assessment via computer. As hypothesized, the children and adolescents with active NS were significantly different on 4 self-reported measures (anxiety, pain interference, fatigue, and mobility). Depression, peer relationships, and upper extremity functioning were not different between children with active vs. inactive NS. Multivariate analysis showed that the PROMIS instruments remained sensitive to NS disease activity after adjusting for demographic characteristics.ConclusionsChildren and adolescents with NS were able to successfully complete the PROMIS instrument using a web-based interface. The computer based pediatric PROMIS measurement effectively discriminated between children and adolescents with active and inactive NS. The domain scores found in this study are consistent with previous reports investigating the health-related quality of life in children and adolescents with NS. This study establishes known-group validity and feasibility for PROMIS pediatric measures in children and adolescents with NS.

The objective of this study was to evaluate the healthcare utilization of hospitalized children with hypertension. The Healthcare Cost and Utilization Project Kids' Inpatient Database, years 1997, 2000, 2003, and 2006, was used to identify hypertension hospitalizations. We examined the association of patient and hospital characteristics on hypertension charges. Data from each cohort year were used to analyze trends in charges. We found that 71282 pediatric hypertension hospitalizations generated $3.1 billion in total charges from 1997 to 2006. Approximately 68% were 10 to 18 years old, 55% were boys, and 47% were white. Six percent of claims with a diagnosis code for hypertension also had a diagnosis code for end-stage renal disease or renal transplant. The frequency of hypertension discharges increased over time ( P =0.02 for each of age groups 2–9 years and 2–18 years; P =0.03 for age group 10–18 years), as well as the fraction of inpatient charges attributed to hypertension ( P P P =0.03, respectively). During the 10-year study period, the frequency of hypertension-associated hospitalizations was increasing across all of the age groups, and the fraction of charges related to hypertension was also increasing. The coexisting condition of end-stage renal disease resulted in a significant increase in healthcare charges.

In the USA, Washington is a highly urbanized state with about three quarters of its population residing in just seven of thirty-nine counties. In the 1970s, urban residents were less satisfied with their quality of community life (QOL) compared to residents in rural communities. This presented somewhat of a paradox because urban residents had better overall objective conditions, such as higher levels of education and income. In this chapter, QOL in Washington is revisited to determine if the urban–rural paradox has persisted and which factors influence perceived differences in QOL. Data on the objective indicators of QOL in Washington indicate that the gap has widened between urban and rural counties since the 1970s, in which urban counties have become more advantaged. The authors conducted the 2008 Washington Community Survey (WCS), a general public household survey, to obtain measures of subjective QOL in urban and rural communities, as well as demographic characteristics. Survey results show that the trend in perceived QOL has reversed, with urban residents more satisfied with the QOL in their community compared to rural residents in Washington. In addition, the authors identify several community- and individual-level characteristics that significantly influence the perceived QOL in each region and propose a way of crafting state policies that accommodates urban–rural differences in the state.

The field of zoonoses changes constantly. Streptococcus equi subsp. ruminatorum is a group C Streptococcus subspecies first identified in 2004. The first case of human infection with this agent was reported in 2007. Here, we report a second case. A 70-year-old man had acute spondylodiscitis and endocarditis involving the anterior mitral valve leaflet. S. equi subsp. ruminatorum was identified in the blood cultures. Antibiotic therapy was successful in eradicating the infection. The workup showed hypogammaglobulinemia with stage I myeloma. He reported frequent contacts with horses including two that exhibited symptoms of upper airway infection a few days before his symptoms started. Serological tests indicated S. equi infection in both animals. This unusual case confirms that S. equi subsp. ruminatorum can cause human disease. In addition, our patient was probably contaminated via the skin, a mode of transmission that has not been described previously. It also highlights the usefulness of molecular biology tests, which should be performed routinely in patients with group C streptococcus infections and evidence suggesting a zoonosis.

Past research suggests a positive correlation between self-efficacy (SE) and adherence to behavioral interventions. Less is known about SE and adherence in behavioral programs that are preventive in nature and specific to urinary incontinence (UI). Using treatment-group data from a previously reported randomized controlled trial, the authors assess the role of SE in predicting adherence to pelvic-floor muscle training (PFMT) for UI prevention in a sample of postmenopausal women. Results indicate that at 12 months follow-up, nearly 70% of participants reported medium or high adherence, performing the recommended PFMT regimen 2 to 3 times per week or more. Summary scores of both Task SE, β = .25, SE (β) = .08, p < .01, and Regulatory SE, β = .43, SE (β) = .06, p < .0001, predict adherence. Also, the authors found a modest decline in self-efficacy scores over time. These findings highlight the importance of SE in sustained behavioral change.

This exploratory study assesses factors predicting adherence to a behavioral intervention to prevent urinary incontinence. Community-dwelling, post-menopausal women (N = 164) were taught pelvic floor muscle training (PFMT) and bladder training (BT) and followed with surveys for 1 year. Content analysis of open-ended responses coded descriptions of approaches participants used to incorporate PFMT into daily life. Exploratory bivariate and logistic regression analyses determined predictors of approach used and adherence. Results indicate women incorporated PFMT into their lives using either a routine or ad hoc approach. Those using a routine approach at 3 months were 12 times more likely to adhere (odds ratio [OR] = 12.4, confidence interval [CI] = 4.0-38.8, p < .001) at a high level at 3 months and significantly more likely to maintain that level 12 months post-intervention (OR = 2.7, CI = 1.2-6.0, p < .014). Practicing BT was related to high adherence.

We determined whether a behavioral modification program (BMP) taught to groups of continent older women would decrease the incidence of urinary incontinence, increase pelvic muscle strength and improve voiding control.We performed a randomized, controlled trial comparing a BMP treatment group to a control, no treatment group in ambulatory, postmenopausal, continent women (0 to 5 days of incontinent episodes in the previous year) 55 years and older who were followed for 12 months. Qualified volunteers from 4 Michigan counties were randomly assigned to a control or a treatment group, consisting of a 2-hour classroom presentation on BMP followed 2 to 4 weeks later with individualized evaluation to test knowledge, adherence and skills in behavioral techniques, and brief reinforcement of the technique as needed. Followup was done by telephone and mail every 3 months except month 12, when all participants underwent final clinical evaluation. Outcome measures were continence status, pelvic floor muscle strength and voiding frequency/intervoid interval.A total of 195 control and 164 treated participants completed the study. Baseline data on the 2 groups were not statistically different. At 12 months the treatment group was statistically significantly better than the control group in continence status (p = 0.01), pelvic muscle strength (pressure score p = 0.0003 and displacement score p0.0001), improved voiding frequency (p0.0001) and intervoid interval (p0.0001).To our knowledge we report the first randomized, controlled trial of BMP for preventing urinary incontinence in older women. It demonstrated feasibility and efficacy in improving continence status, pelvic muscle strength and voiding control as long as a year after treatment.

We report a case of a 72-year-old man who presented with bilateral panuveitis in a context of unclassified arthritis. The recurrence of uveitis associated with ear chondritis led to the diagnosis of relapsing polychondritis. Ocular symptoms are frequent in the course of relapsing polychondritis, but uveitis is a rare symptom and could compromise the visual outcome.

Background The impact of recent guidelines for early detection and prevention of chronic kidney disease (CKD) on patient awareness of disease and factors that might be associated with awareness have not been well described. Methods Awareness rates were assessed in 2992 adults (age, ≥20 years) with CKD stages 1 to 4 from a nationally representative, cross-sectional survey (National Health and Nutrition Examination Survey 1999-2004). Awareness of CKD was defined by an answer of yes to “Have you ever been told you have weak or failing kidneys?” Potential predictors of awareness included demographics, access to care, and clinical and lifestyle factors, which were assessed by standardized interviewer-administered questionnaires and physical examinations. We examined independent associations of patient characteristics with awareness in those with CKD stage 3 (n = 1314) over 6 years using multivariable logistic regression. Results Awareness improved over time in those with CKD stage 3 only (4.7% [95% confidence interval {CI}, 2.6%-8.5%], 8.9% [95% CI, 7.1%-11.2%], and 9.2% [95% CI, 6.1%-13.8%] for 1999-2000, 2001-2002, and 2003-2004, respectively; P = .04, adjusted for age, sex, and race). Having proteinuria (odds ratio, 3.04 [95% CI, 1.62-5.70]), diabetes (OR, 2.19 [95% CI, 1.03-4.64]), and hypertension (OR, 2.92 [95% CI, 1.57-5.42]) and being male (OR, 2.06 [95% CI, 1.15-3.69]) were all statistically significantly associated with greater awareness among persons with CKD stage 3 after adjustment. Chronic kidney disease awareness increased almost 2-fold for those with CKD stage 3 over recent years but remains low. Persons with risk factors for CKD (proteinuria, diabetes, hypertension, and male sex) were more likely to be aware of their stage 3 disease. Conclusion Renewed and innovative efforts should be made to increase CKD awareness among patients and health care providers.

LEARNING OUTCOME: Infection with HIV was associated with significant decrements in growth, weight gain and CD4+ T-lymphocyte count Poor growth, weight loss, low energy intake and depletion of CD4+ T-lymphocyte cell counts are prominent findings in infants and children with human immunodeficiency virus infection (HIV). The purpose of this study was to analyze on a cross-sectional basis the relationship between growth, body weight, nutrient intake, CD4+ T-lymphocyte cell counts and HIV status in infants and children perinatally exposed to HIV infection. The children (n=48 HIV-infected, n=35 uninfected, age 0-12y) attended a pediatric infectious disease clinic in New York City. Anthropometric measurements and CD4+ T-lymphocyte counts were obtained from medical records and food intake was assessed from multiple 24-hour dietary recall records for 34 HIV-exposed children. Statistical analysis (T-tests, chi square tests) showed that infants and children infected with HIV weighed less (NCHS-weight for age z-score - .57 vs .01, p=.04) and were shorter in stature (length for age z-score - .90 vs - .42, p=.04) than uninfected children. The mean CD4+ T-lymphocyte count of infected children was significantly lower (743 vs 2316, p=.000) than that of uninfected children. Infected children, whose CD4+ levels

The case record of a seventy-three year old man with congenital dextrocardia and situs inversus viscerum complicated by hypertension, coronary artery disease and myocardial infarction is presented. Electrocardiographic recordings of the limb leads, with and without reversal of the arm lead wires, and of the precordial leads of the V series derived from both right and left chest areas are presented. In this instance the electrocardiographic findings in precordial leads taken over the right chest point to fresh anteroseptal infarction; those leads recorded from the left chest were not informative. This serves to emphasize the fact that precordial leads should be recorded from the right side of the chest rather than the left in order that the exploring precordial electrode may overlie the area of cardiac damage, and thus manifest maximal changes in the electrocardiogram. We agree that the electrocardiogram may best be interpreted by application of the usual criteria to the limb leads taken with the arm lead wires reversed although in this case the limb leads yielded no information of diagnostic significance.

THE COEXISTENCE of disease of the biliary tract and disease of the heart is well known. Willius and Brown 1 analyzed eighty-six unselected consecutive necropsies on patients with proved coronary sclerosis. Chronic cholecystitis with or without cholelithiasis was present in 26 per cent. Laird 2 found cardiac lesions in 77 per cent of a series of 65 patients with disease of the gallbladder. In 109 cases of cholecystitis Schwartz and Herman 3 found evidence of cardiac disease in 63 per cent. An incidence of only 41 per cent was found in another 109 medical patients without clinically recognized disease of the biliary tract or cardiac disease. These and other reports show that there is an increased incidence of cardiac disorders in patients with disease of the biliary tract. There are many physiopathologic factors common to the two diseases, such as age, disturbed metabolism, obesity, diet and infection. Surgical intervention for

Sulfadiazine is probably the least toxic of the sulfonamide compounds in common use today and causes the lowest incidence of drug eruption. Ensworth and his associates1reported only 4 cases of drug rash in a series of 239 cases of pneumonia treated with sulfadiazine. In a series of 660 treated with sulfadiazine by Dowling and Lepper,210 instances of dermatitis occurred. These were scarlatiniform, morbilliform and urticarial, and all subsided on cessation of administration of the drug. However, more serious dermatologic complications have been reported. Raffetto and Nichols3reported a nearly fatal pemphigus-like rash occurring in a 10 year old girl following sulfadiazine therapy. REPORT OF CASE D. J., a white man aged 20, was admitted to the Station Hospital March 4, 1943 complaining of sore throat and cough. On physical examination a small area of consolidation was found in the base of the left lung posteriorly.

Excerpt The deleterious effects of large doses of vitamin D, although well established, have not received sufficient emphasis in the therapy of those chronic conditions, notably arthritis, for whic...

Background Childhood obesity is a growing health concern known to adversely affect quality of life in children and adolescents. The Patient Reported Outcomes Measurement Information System (PROMIS) pediatric measures were developed to capture child self-reports across a variety of health conditions experienced by children and adolescents. The purpose of this study is to begin the process of validation of the PROMIS pediatric measures in children and adolescents affected by obesity. Methods The pediatric PROMIS instruments were administered to 138 children and adolescents in a cross-sectional study of patient reported outcomes in children aged 8–17 years with age-adjusted body mass index (BMI) greater than the 85th percentile in a design to establish known-group validity. The children completed the depressive symptoms, anxiety, anger, peer relationships, pain interference, fatigue, upper extremity, and mobility PROMIS domains utilizing a computer interface. PROMIS domains and individual items were administered in random order and included a total of 95 items. Patient responses were compared between patients with BMI 85 to