Impact of comprehensive gynecologic services on health maintenance behaviours among women with spinal cord injury.

PURPOSE: Women with spinal cord injury (SCI) and other physical disabilities often lack access to appropriate gynecologic health care and may be at higher risk for preventable gynecologic diseases and other health problems. The purpose of this study was to investigate the effects of a women's health clinic that was established to meet the needs of women with SCI and other disabilities. Specifically, this study examined the effect of clinic participation upon the rate of preventive gynecologic health care behaviours and assessed the relationship between physical and emotional functioning in women with SCI and other disabilities. METHOD: Participants (n =28) were women who completed surveys immediately prior to participation in the clinic, and at 3 and 12 month follow-ups. RESULTS: Results indicated a trend towards increased frequency of breast self-exam three months after initial participation in the clinic (p =0.11). Other rates of health promoting behaviours (exercise, diet and mammography) did not increase. Results also indicated that although physical functioning and life satisfaction were not related, women in this study did experience moderate to high levels of psychological distress. CONCLUSION: Results indicate that whole-woman health care may be important to increasing certain health behaviours among women with disabilities. Implications for comprehensive treatment are discussed.

The N400 component in parents of children with specific language impairment.

Children with specific language impairment (SLI) often have a family history of language disorder. In this study, ERPs in response to a visual semantic priming task were recorded in parents of children with SLI. Despite equal performance, the ERPs displayed differences in language processing: larger N400 amplitudes indicated that the parents, especially the fathers, were less primed by the preceding context. Difference waveforms showed that the fathers of SLI children, contrary to controls, had less differentiated responses to congruent versus incongruent sentences. We propose that the N400 observations may be residual markers of past language deficiencies in the fathers. No differences in the N400 effect were found in the mothers of SLI children.

Depression measures in outcomes research.

OBJECTIVE: To review critically the measures used to screen for depression for disability outcomes research and to recommend measures and needed research. DATA SOURCES: Review of literature pertaining to the development, testing, and use of depression measures for outcomes research. STUDY SELECTION: English language literature from scientists from a broad range of disciplines and research settings, focusing mainly on the Brief Symptom Inventory and the Center for Epidemiology Study-Depression scale. DATA EXTRACTION: A literature review was completed through MEDLINE. Based on the review, instruments were selected according to their use among people with disability and the reliability and validity of the instrument. Two instruments were selected for a complete review, and 5 instruments were selected for a brief review. DATA SYNTHESIS: A critical review of measures that have been and may be used to measure depressive symptomatology among people with disability. CONCLUSIONS: Screening measures of depression are easy to administer and score. Almost all have low respondent burden and good face validity, thereby contributing to a high participation rate for most studies. Some problems exist with the application of these instruments to people with disability (ie, overlap of symptoms of depression and indicators of physical impairment).

A model of outcomes research: spinal cord injury.

OBJECTIVE: To use spinal cord injury (SCI) care and research as a paradigm to illustrate how the principles and practices of outcomes research have been and can be applied to the sequelae of a specific disability. DATA SOURCES: Review of data sources and literature pertaining to outcomes of SCI. STUDY SELECTION: English language literature, health status and health services research agencies, academic and governmental research, and surveillance settings. DATA EXTRACTION: A critical review of measures that have been and may be used to measure the outcomes of SCI. Special attention was paid to data sources; the need for methodologic accommodations: the research balance between generic and condition-specific methods; and the measurement outcomes that are highly relevant to people with SCIs. DATA SYNTHESIS: There is a substantial research record related to the natural history, rehabilitation, survival, and long-term social reintegration of people with SCI, but relatively less addressing widely used generic health outcomes. CONCLUSION: Contemporary outcomes research is relevant to people with SCI and those who provide treatment. One area of special attention is the occurrence of secondary conditions. To a large extent, SCI outcomes research can use conventional methods and generic instruments. There also is a need to modify research methods and to refine and apply some measures specific to people with SCI.

Twin gestation in a woman with a uterus didelphys. A case report.

BACKGROUND: Twin gestation in a uterus didelphys is a rare condition, and the preferred labor course for these patients is unclear. CASE: A woman with a uterus didelphys presented at 14 weeks' gestational age. Serial ultrasound examinations demonstrated normally growing, diamniotic, dichorionic twins situated one in each uterine horn. The prenatal course was marked by intrauterine growth retardation, elevated liver functions and significant proteinuria. At 31 weeks' gestation, labor was induced; however, due to chorioamnionitis and arrest of cervical dilatation, cesarean section was performed 23 hours after rupture of membranes, and two viable female infants (1,480 and 1,421 g) were delivered. CONCLUSION: Twin gestation in a uterus didelphys is a rare condition, in which a trial of labor may be offered, with careful monitoring of both fetuses.

Medical rehabilitation length of stay and outcomes for persons with traumatic spinal cord injury--1990-1997.

OBJECTIVES: To describe changes in acute and rehabilitation length of stay (LOS) for persons with traumatic spinal cord injury (SCI), describe predictors of LOS, and explore year-1 anniversary medical and social outcomes. DESIGN: Longitudinal, exploratory study of patients with SCI. SETTING: Eighteen Model Spinal Cord Injury Centers across the United States. SAMPLE: A total of 3,904 persons discharged from the Model Systems between 1990 and 1997 who had follow-up interviews at 1 year postinjury. MAIN OUTCOME MEASURES: Rehabilitation LOS; injury anniversary year-1 presence of pressure ulcers; incidence of rehospitalization; community or institutional residence; and days per week out of residence. RESULTS: Acute rehabilitation LOS declined from 74 days to 60 days. Discharges to nursing homes and rehospitalizations increased between 1990 and 1997. Linear regression showed that lower admission motor Functional Independence Measure (FIM) scores, year of discharge from the Model System, method of bladder management, tetraplegia, race, education, marital status, discharge disposition, and age were related to longer LOS. At first anniversary, logistic regressions revealed that lower discharge motor FIM, injury level, and age were related to the presence of pressure ulcers, rehospitalization, residence, and time spent out of residence. Of those discharged to nursing homes, 44% returned to home by year 1, and these individuals had higher functional status and were younger. DISCUSSION: High functional status is associated with shorter LOS, discharge to the community, and time spent out of residence, indicating efficiency in the system. For 44.4% of individuals one or more of the following outcomes were observed by first year anniversary: rehospitalization; residing in a skilled nursing facility; having pressure ulcers; or infrequently leaving one's residence.

A meta-analysis of fibromyalgia treatment interventions.

OBJECTIVE: To evaluate and compare the efficacy of pharmacological and nonpharmacological treatments of fibromyalgia syndrome (FMS). METHODS: This meta-analysis of 49 fibromyalgia treatment outcome studies assessed the efficacy of pharmacological and nonpharmacological treatment across four types of outcome measures-physical status, self-report of FMS symptoms, psychological status, and daily functioning. RESULTS: After controlling for study design, antidepressants resulted in improvements on physical status and self-report of FMS symptoms. All nonpharmacological treatments were associated with significant improvements in all four categories of outcome measures with the exception that physically-based treatment (primarily exercise) did not significantly improve daily functioning. When compared, nonpharmacological treatment appears to be more efficacious in improving self-report of FMS symptoms than pharmacological treatment alone. A similar trend was suggested for functional measures. CONCLUSION: The optimal intervention for FMS would include nonpharmacological treatments, specifically exercise and cognitive-behavioral therapy, in addition to appropriate medication management as needed for sleep and pain symptoms.

Access to health care services among people with disabilities receiving Medicaid.

Few data exist describing Medicaid's success in providing health care services to people with disabilities. The access to care survey from the Medical Expenditures Panel Survey was used to collect access data from 502 individuals with disabilities in central Missouri receiving Medicaid under fee-for-service reimbursement. Nearly all of the respondents had a usual source of care, but two-thirds reported difficulties obtaining a needed health care service. Dental, optometric, and personal assistance services were most difficult to obtain. Provider non-participation, non-coverage of a service, and coverage restrictions were the most frequently cited barriers to obtaining care. Results suggest that people with disabilities have difficulty accessing needed health care services through the Missouri Medicaid fee-for-service system.

Complications of gynecologic laparoscopy.

STUDY OBJECTIVE: To examine the frequency of gynecologic laparoscopy complications from January 1996 to June 1996. DESIGN: Prospective review (Canadian Task Force classification II-1). SETTING: Tertiary center teaching hospital with 607 beds. PATIENTS: Two hundred thirty-four patients (age 15-70 yrs). INTERVENTIONS: Gynecologic laparoscopy. MEASUREMENTS AND MAIN RESULTS: The overall number of complications was 23 (9.8%). They were principally infection, extraperitoneal insufflation, and injury to blood vessels. Complication rates were examined by service (private, clinic, staff) and by type of laparoscopy (operative, diagnostic, laparoscopic-assisted vaginal hysterectomy). Of 11 (47.8%) complications that occurred during laparoscopic-assisted vaginal hysterectomy, 5 involved postoperative infection. CONCLUSION: The complication rate in this review was similar to that published in the literature, with the exception of ileus and infection, which occurred at higher rates in our institution. (J Am Assoc Gynecol Laparosc 6(3):317-321, 1999)

The Missouri Disability Epidemiology and Health Project.

INTRODUCTION: Estimates of disability in this country are as high as 20%. State health departments need to provide the core activities to deal with this public health problem including assessment, policy development, and assurance. A collaboration among academic institutions and the Missouri Department of Health (MDOH) is a model for providing this core. METHODS: A disability workgroup was established among bureaus of the MDOH and three universities. This group selected the disability domain of mobility impairments for initial work. Existing data from the Centers for Disease Control and Prevention's (CDC) Behavioral Risk Factor Surveillance System (BRFSS) in Missouri and data from the 1990 Census were analyzed. Dissemination of the findings involved community and consumer participation via an advisory group and a public health-sponsored conference on disability. In addition, new data collection efforts are underway using the BRFSS. Education and training activities include both public health students and public health practitioners in learning the content and methodology associated with disability epidemiology. RESULTS: Data analyses have identified rural geographic areas of the State with high levels of disability and a trend of increasing work disability since 1993. A selected key condition, arthritis, has been confirmed as having a high prevalence (28%) in Missouri. These data also demonstrate that there is a strong risk of limitations associated with arthritis [adjusted odds ratio (OR) 3.57; 95% confidence intervals 3.0, 4.2]. These results will be applied to program planning. CONCLUSIONS: The Missouri program is succeeding in providing both academic and public health practice partners with a productive experience that meets the needs of each.

Disease and family contributors to adaptation in juvenile rheumatoid arthritis and juvenile diabetes.

OBJECTIVE: Research in the areas of pediatric rheumatology and pediatric chronic illness has emphasized comprehensive models of adaptation involving risk and resistance factors. This study examined adaptation, within this framework, among a large sample of children with chronic illness and children without chronic illness. METHODS: A comprehensive battery of adaptation measures was administered to a sample of 107 children with juvenile rheumatoid arthritis, 114 children with insulin-dependent diabetes mellitus, and 88 healthy controls. RESULTS: Medical diagnosis was associated with mothers' depression and a composite measure of parental (mother and father) distress and passive coping. Children's emotional and behavioral functioning was not related to medical diagnosis, but mothers' depression and parental distress were associated with child behavior problems. CONCLUSION: Because parental distress was associated with child functioning, interventions to ameliorate parental distress may have beneficial effects on the children's behavior and on parents' reactions to their children.

The use and failure rates of protective equipment to prevent blood and bodily fluid contamination in the obstetric health care worker.

OBJECTIVE: To determine the frequency of use and the failure rate of protective equipment by obstetric staff during common obstetric procedures. METHODS: A prospective observational study was conducted of multiple obstetric procedures. The presence, area of specialty, level of training, and gender of each team member were recorded along with the use of protective equipment (cap, mask, eyewear, gown, gloves, and shoe protection). These observations were recorded by two trained observers. Blood and bodily fluid contamination of the protective equipment was quantified and recorded for each person. A forensic medicine reagent (Luminol; Cluefinders Inc., Tampa, FL) was used to detect trace amounts of blood on the inner surface of a selected subset of gowns that had gross external contamination but no obvious penetration. RESULTS: Two hundred forty-one obstetric procedures were observed involving 1022 medical personnel. The use of at least one piece of protective equipment was noted 88% of the time. Compliance with universal precautions by attending and resident physicians in all deliveries (vaginal, forceps, vacuum, cesarean) was observed in 65 (25.2%) medical personnel. The use of protective equipment varied by the type of procedure, area of specialty, and level of training of the team member. In the gowns examined with the forensic medicine reagent, 44% of the cases demonstrated laboratory evidence of penetration. The frequency of gown failure varied with the type of surgical gown used. CONCLUSION: Despite the mandate in the medical community for universal precautions, the rate of compliance remains low. However, even among the compliant medical staff, protective equipment labeled as impenetrable has a high failure rate.

Trajectories of adaptation in pediatric chronic illness: the importance of the individual.

This study used individual growth modeling to examine individual difference and group difference models of adaptation. The adaptation of 27 children with juvenile rheumatoid arthritis (JRA) and 40 children with insulin-dependent diabetes mellitus (IDDM) was tracked for 18 months from diagnosis. A control group of 62 healthy children was followed over the same time period. Clustering procedures indicated that child and family adaptation could be described by a number of distinct adaptation trajectories, independent of diagnostic group membership. In contrast, parental adaptation trajectory was associated with diagnostic group membership and control over disease activity for the JRA group and with diagnostic group membership for healthy controls. The observation of common patterns across trajectory sets, as well as the finding that trajectories were differentially related to a number of variables of interest, support the use of trajectories to represent adaptation to chronic disease.

Isolated unilateral fetal pleural effusion: the role of sonographic surveillance and in utero therapy.

OBJECTIVE: To discuss the necessity of close sonographic surveillance of small, isolated fetal pleural effusions as well as the selection criteria and benefits of in utero therapy utilizing thoracoamniotic shunts. METHODS: High-resolution ultrasound, fetal echocardiography, amniocentesis for viral cultures, cordocentesis, and thoracocentesis were performed to evaluate the underlying etiology of a unilateral pleural effusion. A Rodeck Rocket shunt was placed following sudden, rapid progression of the effusion and onset of severe fetal hydrops. RESULTS: Placement of the thoracoamniotic shunt resulted in near-complete drainage of the pleural effusion with normalization of intrathoracic anatomic relationships, subsequent complete resolution of fetal hydrops, and excellent postnatal outcome. CONCLUSIONS: Apparently stable, small pleural effusions can progress rapidly to severe hydrops and need to be followed closely. In appropriately evaluated and selected cases, thoracoamniotic shunt placement may result in resolution of fetal hydrops and prevent intrauterine fetal death.

A family retreat as a comprehensive intervention for children with arthritis and their families.

OBJECTIVE: Family resources and coping skills are important to adaptation to pediatric chronic illness. Psychological and educational interventions have been found to enhance the coping skills of children with juvenile rheumatic disease (JRD) and their families. We examined the efficacy of a 3-day family retreat as a multidisciplinary, comprehensive treatment. METHODS: Children with JRD and their caregivers completed questionnaires assessing the children's behavioral and emotional functioning, pain, strain on caregivers' work and leisure activities, and caregivers' psychological distress before and 6 months after the family retreat. Principal caregivers were both parents for 16 children, mothers only for 10 children, and an aunt for 1 child. RESULTS: Improvements were found in children's emotional functioning, strain on caregivers' work, and strain on caregivers' leisure activities. Reductions in reported pain were not consistently revealed. CONCLUSIONS: Family retreats are an efficacious, multidisciplinary approach to helping families of children with JRD cope with the disease and its manifestations. Importantly, retreats offer a comprehensive intervention package that might not be available to families on an individual basis.

Sex differences in anger expression, depressed mood, and aggression in children and adolescents.

The current study examined anger expression styles and their relationship to levels of depressed mood and aggressive behavior in male and female children and adolescents. Measures of anger, anger expression, and depressed mood were collected from both children and their parents. Hierarchical multiple regressions revealed that anger expression significantly predicted sadness but not aggression for females, after accounting for age and anger level. Among males, anger expression was important in predicting aggression but not sadness, whereas age and anger level best predicted sadness. These results suggest that age, anger level, and anger expression may be risk factors for depression and aggression among children and adolescents. Sex appears to be an important factor in anger expression styles and related depression and aggressive behavior.

Physical and mental practices of music students as they relate to the occurrence of music-related injuries.

OBJECTIVE: The purpose of this study was two-fold: To obtain descriptive information regarding general physical and mental habits of music students and to ascertain if there are any associations between specific daily activities or habits and the appearances of these injuries. STUDY DESIGN: Questionnaires were distributed to three hundred music students at Boston University. Of the 45 respondents, 19 students were willing to participate in an interview. Descriptive statistics were analyzed and comparisons were made to a similar study which was conducted at New England Conservatory in Boston, Massachusetts (Hagglund, K., Unpublished study, 1994). RESULTS: The results suggest that Boston University music students follow expected trends reported in previous research (Fishbein and Middlestadt, 1988; Manchester and Fielder, 1991; Hagglund, 1994). Eighty two percent (n=37) of the respondents were performance majors and the majority of them began playing their instrument at age 10. Out of the 45 respondents, 28 were female of whom 68% (n=19) reported having a music-related injury. Of the remaining 17 males, 53% (n=9) reported also having a music-related injury. Sophomores and juniors accounted for 15 (54%) of the total 28 musicians with injuries in this study. The typical practice habits that were described by the respondents included 2 h sessions, with 10-15 min breaks each hour. Most musicians disclosed to occasionally playing their instruments even when experiencing pain. RESULTS from this study suggest that as the hours spent playing increased, so did the incidence of injury. Medical attention from neurologists, general practitioners, performing arts specialists and laryngologists was pursued by 18 (64%) of the 28 injured musicians. Sixty-one percent of the respondents with injuries saw more than one rehabilitation specialists, including physical therapists (50%); Alexander/Feldenkrais teachers (44%) and massage therapists (28%). More than one treatment method was given to 74% of the injured. These treatment methods included methods such as: Altering posture, habits or playing technique, exercise and stretching, rest, ice and massage. Satisfaction in career and the ability to live up to self expectations was high, while performance anxiety was not bothersome for 82% of the respondents. Fifty-two percent reported reacting well to stress and 44% described having an average level of self-consciousness. Most respondents (89%) participated in some type of physical fitness, most exercising either one (30%) or three (23%) days a week, and 75% reported that they stretch prior to playing. CONCLUSION: This study provides information on the general habits of music studtents which can be beneficial to rehabilitation specialists, as well as other medical professionals treating musicians. By understanding the lifestyles and dynamics of being a musician, rehabilitation specialists can devise better individualized intervention and preventative strategies. Unfortunately, musicians remain uninformed on the current treatments, rehabilitation approaches, and most importantly the predisposing and preventative factors of music-related injuries. Occupational therapists, physical therapists and other rehabilitation specialists can and should be the professionals to provide guidance to the population of musicians on the above mentioned factors.

Comparisons of wrist postures in VDT operators using wrist rests and forearm supports.

OBJECTIVE: The purpose of this study was to examine wrist motions in video display terminal (VDT) workers using the Greenleaf Medical WristSystem. This study was developed because of the limited research about the effectiveness of ergonomic equipment for VDT operators, as well as the recent increase in cumulative trauma disorders (CTDs) among these workers. STUDY DESIGN: Twenty adult VDT operators with no history of CTD were recruited from Boston University and surrounding businesses. WristSensorTM gloves containing dual-axis sensors for detection of dynamic wrist movements were worn by participants. Calibrations were then performed through the Movement Analysis System (MAS) software, after which participants were requested to type using a wrist rest (condition A), using forearm supports (condition B), using the wrist rest and forearm supports together (condition C), and finally using no form of wrist or forearm support (condition D). It was assumed by the investigators that wrist extension and ulnar deviation would decrease when using the wrist rest or forearm support, with the greatest change occurring when using both types of support. Questionnaires requesting demographic information were completed by each participant. Contrast scores were also calculated and converted into t -tests and their corresponding P -values. RESULTS: The average degrees of motion for both right and left hands were: flexion 4.5°, extension 18.9°, ulnar deviation 15.3°, and radial deviation 2.0°. P-values for all four conditions in the left hand were found to be significant and are as follows: extension t(19) = 2.35, P < 0.025, flexion t(19) = 2.17, P < 0.025, ulnar deviation t(19) = 3.41, P < 0.0025, and radial deviation t(19) = 2.5, P < 0.025. The only significant P-value in the right hand was during ulnar deviation: t(19) = 2.7, P < 0.01. DISCUSSION: Research suggests that wrist extension greater than 15° and ulnar deviation greater than 20° can be predisposing factors to the development of CTDs. In this study, all four wrist motions remained under 20° during the three conditions using the wrist rest and forearm supports. A trend of continued decreases in ulnar deviation and wrist extension from using no supports to that requiring both types of supports was also observed. Specifically, the smallest degree of wrist extension appeared when participants used only the wrist rest; ulnar deviation was smallest when both supports were used. Right hand degree values were found to be generally larger than those for the left hand. It is hoped that these results can serve as a foundation for future investigation into the effectiveness of wrist and forearm supports in reducing CTDs.