Risk factors for recurrent falls in older adults: A systematic review with meta-analysis.

Older adults who fall recurrently (i.e., 2 or more falls/year) are at risk of functional decline and mortality. Understanding which risk factors for recurrent falls are most important will inform secondary fall prevention strategies that can reduce recurrent falls risk. Thus, we conducted a systematic review with meta-analysis to determine the relative risk of recurrent falls for different types of falls risk factors. MEDLINE, EMBASE, PsycINFO, and CINAHL databases were searched on April 25, 2019 (Prospero Registration: CRD42019118888). We included peer-reviewed prospective studies which examined risk factors that contributed to recurrent falls in adults aged ≥ 60 years. Using the falls risk classification system of Lord and colleagues, we classified each risk factor into one of the following domains: 1) balance and mobility; 2) environmental; 3) psychological; 4) medical; 5) medication; 6) sensory and neuromuscular; or 7) sociodemographic. We calculated the summary relative risk (RR) for each domain and evaluated the risk of bias and quality of reporting. Twenty-two studies were included in this systematic review and meta-analysis. Four domains predicted recurrent falls: balance and mobility (RR:1.32;95 % CI:[1.10, 1.59]), medication (RR:1.53;95 % CI:[1.11, 2.10]), psychological (RR:1.35;95 % CI:[1.03, 1.78]), and sensory and neuromuscular (RR:1.51;95 % CI:[1.18, 1.92]). Each of these four domains can be viewed as a marker of frailty. The risk of bias was low, and the study quality was high (minimum:19/22). Older adults with markers of frailty are up to 53 % more likely to experience recurrent falls. Strategies that identify and resolve frailty markers should be a frontline approach to preventing recurrent falls.

The use of the Körperkoordinationstest für Kinder in the talent pathway in youth athletes: A systematic review.

OBJECTIVES: Identifying talented athletes from an early age to accelerate their development requires the investment of substantial resources. Due to the need for multifactorial approaches to talent identification, motor competence assessments are increasingly prevalent in contemporary testing batteries. Therefore, the aim of this review was to evaluate the literature on the use of a product-oriented motor competence assessment tool, the Körperkoordinationstest für Kinder (KTK) in the talent pathway and determine whether it is warranted in such programs. METHODS: Three electronic databases (i.e. PubMed, SPORTDiscus and Web of Science) were searched for studies that used at least one component of the KTK to assess motor competence for talent detection, identification, development and selection in athletic populations. A total of 21 articles were included in the review, of which seven used the full version of the KTK and 14 used modified versions or individual components of the battery. The quality of included studies was assessed using a modified version of the Joanna Brigg's Institute Critical Appraisal Checklist. RESULTS: The analysed literature suggests that the KTK can successfully distinguish between athletes of different competition levels and across different sporting domains, however, findings should be interpreted with caution due to the cross-sectional nature of the studies. Furthermore, the moving sideways subtest displayed the greatest discriminative power for athletes of different competition levels. Motor competence was not affected by maturation and did not differ between genders or playing positions. CONCLUSIONS: Collectively, these findings suggest that the KTK is a useful motor competence assessment in the talent pathway.

Jaundice caused by a clinically undetectable T-cell lymphoma infiltrating the sphincter of Oddi.

Malignant lymphoma rarely presents with jaundice. We describe a patient who had a unique etiology for painless jaundice, dilated ducts, and a normal ampulla of Vater. A Whipple's procedure was performed for the suspicion of pancreatic cancer, and initial pathological review detected only mild focal chronic pancreatitis. Seven months later, the patient developed ascites, retroperitoneal mass, and splenomegaly caused by a T-cell lymphoma. Reevaluation of the Whipple's specimen revealed previously unrecognized microscopic infiltration and fibrosis of the sphincter of Oddi by atypical T-lymphocytes. Obstructive jaundice caused by a clinically undetectable primary duodenal T-cell lymphoma has not been previously reported and is contrasted with other causes of jaundice associated with malignant lymphoma and ampullary lesions.

Screening for conduct problems: does the predictive accuracy of conduct disorder symptoms improve with age?

OBJECTIVES: To investigate the influence of age on the predictive accuracy of conduct disorder (CD) symptoms for future CD and to evaluate the usefulness of CD symptoms as a screening tool in normal populations. METHOD: Two cohorts were derived from the Canadian National Longitudinal Survey of Children and Youth based on age at baseline (cohort 1: ages 5-6, n = 881; cohort 2: ages 8-9, n = 859). CD symptoms were assessed with behavior symptom checklists at baseline and the 2-year follow-up assessment. Predictive accuracy (PA) was evaluated with logistic regression and receiver operating characteristic curves. RESULTS: The PA of teacher-identified CD symptoms, alone or in combination with other risk factors (gender, socioeconomic status, familial factors), was higher in the older cohort. PA increased when CD symptoms were combined with other risk factors. However, none of the predictors evaluated achieved minimum criteria for sensitivity and positive predictive value of at least 50%. CONCLUSIONS: The PA of CD symptoms improves with age. However, the results show that the PA of CD symptoms assessed at a single point in time in children in normal populations is insufficient. Screening initiatives that use this approach to detect risk for CD should be abandoned.

Cost-utility analysis in depression: the McSad utility measure for depression health states.

Cost-utility analysis, used increasingly over the past decade to analyze costs and effects in treating physical diseases, has received little attention in psychiatry. This article briefly introduces the concepts and methods of utility measurement and illustrates it using depression as an example. The authors describe the McSad health state classification system for depression, a direct utility measure for depression, and report results of an application of McSad among 105 patients who had a recent history of depression. Utility measures express patient preferences for specific health states on a scale ranging from 0, representing death, to 1, representing perfect health. These scores provide the weights used to calculate the number of quality-adjusted life-years gained by an intervention or service. McSad allows a patient's depression health state to be classified according to level of functioning in six dimensions of depression and to be compared with other hypothetical depression health states in order to produce utility scores indicating the patient's relative preferences.

Development and testing of a utility measure for major, unipolar depression (McSad).

OBJECTIVE: To develop and test a direct utility measure (McSad) for major, unipolar depression. METHODS: A depression specific, multi-attribute health state classification system was created; clinical validity was evaluated by experts using specially designed structured exercises; a cross-sectional survey was conducted to obtain directly measured utilities for depression health states. SETTING: Tertiary care, university medical centre. PARTICIPANTS: Three psychiatrists, 3 psychiatric nurses and 3 social workers assessed depression health state clinical validity. Survey participants were referred by psychiatrists and consisted of 105 outpatients, currently in remission with at least one episode of major, unipolar depression in the past two years. SURVEY RESULTS: Respondent self-health state utility (mean and 95% confidence interval (CI)) was 0.79 (0.74-0.83). Utilities for hypothetical, untreated depression health states were: mild depression, 0.59 (0.55-0.62); moderate depression, 0.32 (0.29-0.34); severe depression, 0.04 (0.01-0.07). Fifty-six percent of respondents rated severe depression worse than being dead. Utilities for the hypothetical health states were not correlated with self-health utility. The intra-class correlation coefficient (ICC) was satisfactory for 13 of the 14 health states assessed. CONCLUSIONS: McSad was feasible and acceptable in patients with a history of major unipolar depression. The utilities for mild, moderate and severe untreated depression show the low health-related quality of life associated with depression. Initial assessments of test-retest reliability and validity yielded satisfactory results but further studies are needed to extend our knowledge of the measurement properties of McSad.

Predicting conduct problems: can high-risk children be identified in kindergarten and grade 1?

Externalizing behavior symptoms (EBS) in childhood are a strong predictor of future conduct problems. This study evaluated their predictive accuracy using logistic regression and receiver operating characteristic curve techniques. EBS, alone and in combination with other child and familial risk factors, were used to predict conduct problems 30 months later in a nonclinic population of kindergartners and Grade 1 children. The sensitivity (Sn) and positive predictive value (PPV) of EBS alone were below preset criteria of > or = 50% for each (prevalence < or = 15%). Sn and PPV increased when other child and familial factors were combined with symptoms but did not exceed the preset criteria. From a developmental perspective, substantial stability of EBS exists over time. However, from the perspective of prevention science, significant levels of misclassification will occur when EBS are used to designate high-risk status under the low-prevalence conditions of normal populations.

Serratia marcescens pseudobacteraemia in neonates associated with a contaminated blood glucose/lactate analyzer confirmed by molecular typing.

Three episodes of Serratia marcescens pseudobacteraemia occurred on a neonatal intensive care unit. Following the first two cases, one full term and one pre-term infant, the source was identified as a glucose/lactate analyzer. Blood culture and environmental isolates of the organisms involved were indistinguishable when subjected to pulsed-field gel electrophoresis of Spe 1 digests and PCR ribotyping. Failure to recognize pseudobacteraemia in neonates results in inappropriate therapy for the individual and increased antibiotic pressures on the unit. Attention to the possibility of cross infection when using automated analyzers is required to minimize the risks of true or pseudoinfection to patients.

What does early antisocial behaviour predict? A follow-up of 4- and 5-year-olds from the Ontario Child Health Study.

OBJECTIVE: To examine the predictive accuracy of antisocial behaviours among 4- and 5-year-old children for problem behaviours 4 years later (ages 8 and 9 years). METHOD: Data from the Ontario Child Health Study (1983) and Follow-up (1987) are used. Predictive accuracy is conceptualized using positive predictive value (PPV) and sensitivity. The predictive accuracy of early antisocial behaviors for the 1987 outcomes is examined overall, by gender, by variable thresholds of predictor and outcome be gender, and by using contextual variables alone or in combination with antisocial behaviour recorded in 1983. Resulting: The predictive accuracy of 1983 antisocial behaviour for 1987 outcome is generally modest and differs by gender (better for boys for externalizing disorder [PPV = 41%, sensitivity = 57%]; better for girls for internalizing disorder [PPV = 13%, sensitivity = 80%]; better for boys for conduct problems [PPV = 54%, sensitivity = 21%]¿. Using either gender-specific thresholds or gender-neutral thresholds does not alter predictive accuracy in a consistent way, nor does the use of a single contextual variable. Use of a cumulative risk index increases PPV but decreases sensitivity. CONCLUSION: The predictive accuracy of antisocial behaviour in 4-and 5-years-old children over 4 years in a nonclinical community population is limited. The clinical, research, and policy implications of this work are discussed.

Critical appraisal of the health research literature: prevalence or incidence of a health problem.

This article identifies and discusses criteria that can be used by health professionals to critically appraise research articles that estimate the prevalence or incidence of a disease or health problem. These guidelines will help determine the validity and usefulness of such community assessment studies. The criteria relate to the validity of the study methods (design, sampling frame, sample size, outcome measures, measurement and response rate), interpretation of the results and applicability of the findings. The research question "What is the prevalence of dementia in Canada?" is used as an example for this paper.

Health state utilities in knee replacement surgery: the development and evaluation of McKnee.

OBJECTIVE: 1. To develop McKnee, a classification system and direct utility measure for health states associated with knee replacement (KR) surgery. 2. To apply McKnee in a before-after study of KR surgery to: (i) gain experience with McKnee in an elderly population; (ii) confirm the practicality and usefulness of the McKnee system; (iii) assess self-health utility one week before and 3 mo after surgery; (iv) evaluate the stability of 3 clinical marker health states describing mild, moderate, and severe knee disability; (v) compare self-health utility scores with Short Form 36 (SF-36). METHODS: 1. Instrument development: The McKnee modified Health Utilities Index was developed and used to describe self-health and clinical marker health states: the clinical validity of the clinical marker states was evaluated by 5 clinicians involved in the care off KR patients. 2. Instrument evaluation: McKnee and the SF-36 were administered to 48 patients with osteoarthritis one week before and 3 mo after KR surgery. RESULTS: Before-after study: McKnee was feasible and acceptable in the older patient group studied (mean age in years, SD: 69.9, 8.6). No change in self-health utility (mean, SD) was observed at 3 mo postsurgery: before -0.78, 0.17; after -0.78, 0.21. On the SF-36, only the change scores for pain and health transition were statistically significant. Utilities (mean, SD) for the clinical marker health states were: mild -0.80, 0.20; moderate -0.55, 0.28; and severe -0.48, 0.31. The clinical marker mean utility scores were stable between the baseline and 3 mo assessment, but the intraclass correlation coefficients for individual scores were low. CONCLUSION: McKnee provides a preference based measure of health related quality of life that can be used to obtain and interpret clinically the knee disability utility scorers needed for cost-utility studies and medical decision-making models about KR surgery. The McKnee system provides a practical and useful method for classifying knee disability health states and obtaining direct measurements of utility scores for selected health states.

Conduct disorder: long-term outcomes and intervention effectiveness.

OBJECTIVE: To review the literature on conduct disorder in two areas: long-term outcome and the effects of interventions. METHOD: The sources of the articles for review were computer searches, but the articles were selected for this review to illustrate key findings in the long-term outcome area and to review critically four intervention strategies to prevent or treat conduct disorder, namely, parent- and family-targeted programs, social-cognitive programs, peer and school-based programs, and community programs. RESULTS: Conduct problems in childhood predict the same increased rates of psychiatric disorder overall in men and women but the patterns are different: for externalizing disorders, the prediction is stronger in men and for internalizing disorders, the prediction is stronger in women. In the intervention domain, the literature provides limited evidence of the effectiveness of either primary or secondary prevention. CONCLUSIONS: Prospective studies of community samples of children provide the best opportunity to understand more thoroughly the adult outcomes of conduct disorder. Because of the heavy burden of suffering of conduct disorder, and the limited effectiveness of clinical interventions, there is a compelling argument in favor of an increased emphasis on primary prevention efforts.

Modelling the population health impact of musculoskeletal diseases: arthritis.

OBJECTIVE: A model adjusting for reductions in quality and quantity of life was developed to estimate the population health impact of musculoskeletal diseases. METHODS: Using arthritis as the prototype, prevalence, mortality, and severity data from a variety of sources were combined to model a hypothetical cohort of 1,000 individuals through life. Quality adjusted life years and population health expectancy were calculated for those with arthritis and compared to the general population. RESULTS: Without adjusting for quality of life, a cohort of 1,000 women and 1,000 men at age 15 years could expect 65,010 and 58,735 life years, respectively. Adjusting for quality of life, women with arthritis could expect 61,719 life years, and men 57,123 life years. The unadjusted population health expectancy was 65.0 for girls and 58.7 for boys (at age 15 years). Adjusting for quality of life, the population health expectancies were 61.7 and 57.1, years for women and men, respectively. CONCLUSION: Using this model, the typical adult woman with arthritis can expect to lose 3.3 healthy years of life, and a man, 1.6 healthy years of life. Overall, the model provided a general methodology for determining the population health impact of musculoskeletal diseases. In addition, it is hoped that the methodology will stimulate further research into this area, raise awareness about the uses and limitations of currently available data, and provide a useful model for monitoring the impact of interventions.

Physical disability among Canadians reporting musculoskeletal diseases.

About one million Canadian adults are estimated to have physical disabilities attributed to a musculoskeletal condition, a prevalence of 50.1/1,000 adults (all rates expressed/1,000). The specific musculoskeletal disease rates were arthritis/rheumatism (27.2), back (16.2), "other" (4.6), trauma (3.6) and bone (0.6). More women reported disabling musculoskeletal disease (61.0 versus 38.6, respectively). Prevalence rates increased with age from 6.2 among Canadians aged 15-24 years, to 264.7 aged 85 years and over. Limitations of mobility were more common than those of agility. Adults in institutions reported more disabilities than did adults in households (means 7.7 and 4.4, respectively).

Low-dose cyclosporin versus placebo in patients with rheumatoid arthritis.

144 patients with severe rheumatoid arthritis from six centres were randomised to receive oral cyclosporin or placebo for 6 months. The initial daily dose of cyclosporin was 2.5 mg/kg, which was increased cautiously with monitoring of serum cyclosporin levels and creatinine; the mean stabilisation dose was 3.8 mg/kg. There were significant improvements in the cyclosporin-treated patients compared with the controls in the major outcomes of reduction of active joints (23% improvement), pain (24%), and functional status (16%); global improvement was 27%. In the cyclosporin group serum creatinine increased by a mean of 15.6 mumols/l and mean arterial blood pressure by 6.27 mmHg; these increases were controlled in all but 2 patients by dose adjustment without withdrawal from the study.

Methotrexate in rheumatoid arthritis. Impact on quality of life assessed by traditional standard-item and individualized patient preference health status questionnaires.

In a double-blind, randomized trial of methotrexate vs placebo in rheumatoid arthritis, the effect of treatment on physical, social, and emotional function was measured in two different ways: the same, standard measurements in all patients, and individualized measurements selected by the patients at the start of the trial as representing the functions they most wanted to have improved by treatment. On the standard measurements, methotrexate-treated patients fared better than placebo-treated patients in their physical, social, and emotional function by 11%, 5%, and 6%, respectively, results that, although statistically significant, were small. However, methotrexate-treated patients were 29% better in the individualized measures, a result that was both highly statistically significant and greater than the differences in the standard measurements or in joint counts, grip strength, proximal interphalangeal joint circumference, morning stiffness, or walking time. Because the individualized measurements were as efficient as the best direct joint examination measures, yet reflected functional outcomes of greatest importance to individual patients, they constitute useful measures for such trials.

Outbreak of cryptosporidiosis among young children attending a day-care centre in Durban.

During an outbreak of an enteric illness occurring among infants and toddlers in a day-care centre in Durban, Cryptosporidium was detected in 51 (73%) of 70 children. Two (10%) of 20 staff members were also found to have cryptosporidiosis. Symptoms occurred in all but 4 of the Cryptosporidium-positive infants and toddlers and lasted for 1-33 days. Oocyst excretion often persisted after cessation of symptoms and continued for up to 50 days in some children. Transmission is considered to have occurred predominantly by person-to-person spread. Measures to prevent transmission of enteric-type diseases were implemented and coincided with cessation of the outbreak.