Prevalence of CKD, Diabetes, and Hypertension in Rural Tanzania.

INTRODUCTION: Chronic kidney disease (CKD), diabetes, and hypertension play a disproportionate role in the growing public health challenge posed by noncommunicable diseases (NCDs) in East Africa. The impact of these NCDs may pose the greatest challenge in rural areas with limited screening and treatment facilities, although precise prevalence estimates of these conditions in rural Tanzania are lacking. METHODS: The prevalence of CKD, diabetes, and hypertension, were estimated from a probability sample of adults (n = 739) residing in 2 communities within Kisarawe, a rural district of Tanzania. Following consent, participants were studied in their homes. Random point-of-care (POC) measures of glycosylated hemoglobin and blood pressure, were obtained. Serum creatinine, drawn at the POC and measured at Muhimbili National University, was used to calculate estimated glomerular filtration rate with the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. RESULTS: The median age was 35 years (interquartile range 25-45 years). Overall the pooled prevalence for CKD stages III, IV, and V was 12.4% (95% confidence interval [CI] = 10.2-14.8). Surprisingly, the prevalence of CKD stage V (3.0%; 95% CI = 2.1-4.4) was high among the youngest age group (18-36 years). The prevalence estimates for prehypertension and hypertension were 38.0% (95% CI = 34.6-41.5) and 19.9% (95% CI = 17.1-22.9), respectively. The prevalence estimates for prediabetes and diabetes were 25.7% (95% CI = 22.6-29.1) and 14.8% (95% CI = 12.4-17.6), respectively. CONCLUSION: Although this pilot study had a relatively small sample size, the prevalence estimates for CKD, diabetes, and hypertension were higher than we expected based on previous estimates from Tanzania. CKD was not significantly associated with diabetes or hypertension, suggesting the possibility of an alternative causality.

Mindfulness meditation in older adults with postherpetic neuralgia: a randomized controlled pilot study.

This parallel-group, randomized controlled pilot study examined daily meditation in a diverse sample of older adults with postherpetic neuralgia. Block randomization was used to allocate participants to a treatment group (n = 13) or control group (n = 14). In addition to usual care, the treatment group practiced daily meditation for six weeks. All participants completed questionnaires at enrollment in the study, two weeks later, and six weeks after that, at the study's end. Participants recorded daily pain and fatigue levels in a diary, and treatment participants also noted meditation practice. Results at the 0.10 level indicated improvement in neuropathic, affective, and total pain scores for the treatment group, whereas affective pain worsened for the control group. Participants were able to adhere to the daily diary and meditation requirements in this feasibility pilot study.

Elevated cytokines, thrombin and PAI-1 in severe HCPS patients due to Sin Nombre virus.

Sin Nombre Hantavirus (SNV, Bunyaviridae Hantavirus) is a Category A pathogen that causes Hantavirus Cardiopulmonary Syndrome (HCPS) with case fatality ratios generally ranging from 30% to 50%. HCPS is characterized by vascular leakage due to dysregulation of the endothelial barrier function. The loss of vascular integrity results in non-cardiogenic pulmonary edema, shock, multi-organ failure and death. Using Electric Cell-substrate Impedance Sensing (ECIS) measurements, we found that plasma samples drawn from University of New Mexico Hospital patients with serologically-confirmed HCPS, induce loss of cell-cell adhesion in confluent epithelial and endothelial cell monolayers grown in ECIS cultureware. We show that the loss of cell-cell adhesion is sensitive to both thrombin and plasmin inhibitors in mild cases, and to thrombin only inhibition in severe cases, suggesting an increasing prothrombotic state with disease severity. A proteomic profile (2D gel electrophoresis and mass spectrometry) of HCPS plasma samples in our cohort revealed robust antifibrinolytic activity among terminal case patients. The prothrombotic activity is highlighted by acute ≥30 to >100 fold increases in active plasminogen activator inhibitor (PAI-1) which, preceded death of the subjects within 48 h. Taken together, this suggests that PAI-1 might be a response to the severe pathology as it is expected to reduce plasmin activity and possibly thrombin activity in the terminal patients.

Differential associations between maternal scaffolding and toddler emotion regulation in toddlers born preterm and full term.

BACKGROUND: Parental "scaffolding" behavior has been associated with developmental outcomes in at-risk children. AIMS: Because there are limited empirical data regarding how scaffolding is associated with emotion-based developmental skills, the purpose of this study was to compare associations between maternal verbal scaffolding and toddler emotion regulation, including fewer displays of negative affect and increased contentment and enjoyment during play, in toddlers born preterm and full term. STUDY DESIGN: This study was a cross-sectional cohort design. Maternal and toddler behavior was assessed during 5 min of videotaped free play with standardized toys. SUBJECTS: 131 toddlers (18-22 months) and their mothers were included (77 born preterm; 54 born full term). OUTCOME MEASURES: Toddler emotion regulation, negative affect, and dyadic mutual enjoyment were coded from videotaped play. RESULTS: The association between maternal scaffolding and emotion regulation was different for dyads with a toddler born preterm versus full term, wherein the association was positive for toddlers born preterm and non-significant for toddlers born full term. Similarly, the association between maternal scaffolding and negative affect was different for the two groups: negative for toddlers born preterm and non-significant for toddlers born full term. Finally, the association between maternal scaffolding and mutual enjoyment was positive for toddlers born preterm and non-significant for toddlers born full term. CONCLUSIONS: Our findings highlight early differences in mother-child interactive style correlates of children born preterm compared to those born full term. Maternal scaffolding behavior may be uniquely associated with emotion regulation and a positive dyadic encounter for toddlers born preterm.

A randomized, masked, placebo-controlled study of darbepoetin alfa in preterm infants.

BACKGROUND: A novel erythropoiesis stimulating agent (ESA), darbepoetin alfa (Darbe), increases hematocrit in anemic adults when administered every 1 to 3 weeks. Weekly Darbe dosing has not been evaluated in preterm infants. We hypothesized that infants would respond to Darbe by decreasing transfusion needs compared with placebo, with less-frequent dosing than erythropoietin (Epo). METHODS: Preterm infants 500 to 1250 g birth weight and ≤48 hours of age were randomized to Darbe (10 µg/kg, 1 time per week subcutaneously), Epo (400 U/kg, 3 times per week subcutaneously) or placebo (sham dosing) through 35 weeks' gestation. All received supplemental iron, folate, and vitamin E, and were transfused according to protocol. Transfusions (primary outcome), complete blood counts, absolute reticulocyte counts (ARCs), phlebotomy losses, and adverse events were recorded. RESULTS: A total of 102 infants (946 ± 196 g, 27.7 ± 1.8 weeks' gestation, 51 ± 25 hours of age at first dose) were enrolled. Infants in the Darbe and Epo groups received significantly fewer transfusions (P = .015) and were exposed to fewer donors (P = .044) than the placebo group (Darbe: 1.2 ± 2.4 transfusions and 0.7 ± 1.2 donors per infant; Epo: 1.2 ± 1.6 transfusions and 0.8 ± 1.0 donors per infant; placebo: 2.4 ± 2.9 transfusions and 1.2 ± 1.3 donors per infant). Hematocrit and ARC were higher in the Darbe and Epo groups compared with placebo (P = .001, Darbe and Epo versus placebo for both hematocrit and ARCs). Morbidities were similar among groups, including the incidence of retinopathy of prematurity. CONCLUSIONS: Infants receiving Darbe or Epo received fewer transfusions and fewer donor exposures, and fewer injections were given to Darbe recipients. Darbepoetin and Epo successfully serve as adjuncts to transfusions in maintaining red cell mass in preterm infants.

Association of maternal scaffolding to maternal education and cognition in toddlers born preterm and full term.

AIM: Parental behaviour described as 'scaffolding' has been shown to influence outcomes in at-risk children. The purpose of this study was to compare maternal verbal scaffolding in toddlers born preterm and full term. METHODS: The scaffolding behaviour of mothers of toddlers born preterm and healthy full term was compared during a 5-min videotaped free play session with standardized toys. We compared two types of scaffolding and their associations with socio-demographic, neonatal medical factors and cognition. RESULTS: The mothers of toddlers born full term used more complex scaffolding. Maternal education was associated with complex scaffolding scores for the preterm children only. Specifically, the preterm children who were sicker in the neonatal period, and whose mothers had higher education, used more complex scaffolding. In addition, children born preterm, who had less days of ventilation, had higher cognitive scores when their mothers used more complex scaffolding. Similarly, cognitive and scaffolding scores were higher for children born full term. CONCLUSION: Our findings highlight early differences in mother-child interactive styles of toddlers born preterm compared with full term. Teaching parents play methods that support early problem-solving skills may support a child's method of exploration and simultaneously their language development.

Comparison of the Bayley II Mental Developmental Index and the Bayley III Cognitive Scale: are we measuring the same thing?

AIM: To better understand differences between Bayley Scales 3rd edition (Bayley III) Cognitive Scale and Bayley Scales 2nd edition (Bayley II) Mental Developmental Index (MDI) in 18-22-month-old children born term and preterm and to create a conversion algorithm using Bayley II MDI to calculate Bayley III Cognitive score. METHODS: This study included 51 term and 26 preterm children between 18 and 22 months, ages adjusted for prematurity. Children's scores on Bayley II MDI and Bayley III Cognitive Scale were compared using t-tests. The items from Bayley II MDI were used to calculate a score for the Bayley III Cognitive Scale. ANCOVA was used to create a conversion scale. RESULTS: Bayley III Cognitive scores were significantly higher than Bayley II MDI scores for term and preterm toddlers combined and separately (p < .0001). A conversion formula to convert Bayley II MDI to a Bayley III Cognitive score was calculated. CONCLUSION: Term and preterm children had similarly elevated scores on the Bayley III calculated Cognitive score compared to the previous Bayley II MDI score. The use of a conversion algorithm may be helpful in studies that used both Bayley editions to get comparable outcome measurements within a clinical or research paradigm.

Expression of the proapoptotic protein Bax is reduced in bronchial mucous cells of asthmatic subjects.

The present studies were designed to determine whether our findings in mice showing that the Bcl-2-associated protein X (Bax), which plays a role in the resolution of allergen-induced mucous cell metaplasia, can be applied to asthma in humans. Immunostaining of autopsy tissues from mild and severe asthmatic subjects showed a significant reduction in the percentage of Bax-positive mucous cells compared with those from nonasthmatic controls. To exclude the possibility that postmortem changes may have affected Bax expression, Bax mRNA levels in airway epithelial cells obtained from nonsmoking asthmatic subjects were compared with those from nonasthmatic controls. Because the number of cells obtained by bronchial brushings is limited, we developed a robust preamplification procedure of cDNA before quantitative real-time PCR to allow detection of 100 gene targets from limited sample size, even when it was prepared from partially degraded RNA. cDNA was prepared by reverse transcription from RNA isolated from bronchial epithelial cells obtained by bronchial brushings from well-characterized subjects without lung disease and from subjects with mild asthma. Quantitative analysis showed that Bax mRNA levels were significantly reduced in samples obtained from asthma patients compared with nonasthma controls. Furthermore, Bax mRNA levels were reduced when primary airway epithelial cells from 10 individuals were treated in culture with the T helper 2 cytokine IL-13. These studies show that Bax expression is reduced in airway epithelial cells of even mild asthmatic subjects and suggest that restoring Bax expression may provide a clinical approach for restoring the normal numbers of epithelial cells and reduced mucous hypersecretion in asthma.

Effect of chronic maternal methadone therapy on intrapartum fetal heart rate patterns.

OBJECTIVE: Treatment of maternal opioid dependence with methadone is associated with a delay in fetal heart rate (FHR) accelerations in nonstress tests. The objective of this investigation was to determine the effect of methadone maintenance therapy on intrapartum FHR patterns. METHODS: This retrospective cohort study compared intrapartum FHR tracings from 56 methadone-treated patients > or =36 weeks gestation with a control group of nonsubstance using patients matched for maternal age, parity, gestational age, and ethnicity. Blinded FHR interpretation included the recording of baseline, variability, accelerations, and late or severe variable decelerations. The 8-point FHR scoring system was based on the National Institute of Child Health and Human Development Research Planning Workshop guidelines. We considered a 25% reduction in the score during the latent phase to be significant. RESULTS: The median maintenance dose of methadone was 70 mg daily, with a range between 20 mg and 130 mg. Each patient tested negative for other substances on urine screening before admission. The significantly lower FHR score in the methadone group (mean difference, 1.4; 95% confidence interval, 1.1 to 1.7) was attributed to a lower baseline (P <.05), less moderate or marked variability (P <.01), and a lower proportion of accelerations during the first stage of labor (P <.01). A higher proportion of methadone-exposed fetuses had late or severe variable decelerations in the second stage (44.2% vs 22.9%; P <.03). Analgesic needs, operative vaginal or cesarean delivery rates, and Apgar scores less than 7 at 1 and 5 minutes were not significantly different between the two groups. CONCLUSIONS: Chronic maternal methadone treatment affects intrapartum FHR patterns by reducing the variability, baseline, and proportion of accelerations during the first stage. These subtle drug-induced effects do not compromise intrapartum decision-making or immediate newborn adjustments.

Prevalence of low cortisol values in term and near-term infants with vasopressor-resistant hypotension.

OBJECTIVE: To determine the prevalence of low cortisol values and to evaluate clinical responses to hydrocortisone in ill term and near-term newborns. STUDY DESIGN: Retrospective cohort study including infants >or=35 weeks gestational age who were mechanically ventilated, received vasopressor therapy, and had a cortisol concentration obtained for evaluation of vasopressor-resistant hypotension. In those infants treated with hydrocortisone, physiologic responses were evaluated and correlated with cortisol values (<15 vs >or=15 microg/dl). RESULTS: A total of 32 infants had cortisol values obtained; 18 (56%) were <15 microg/dl. In all, 21 infants were treated with hydrocortisone of whom 13 had cortisol values <15 microg/dl. These 13 infants showed decreased heart rate, dopamine support and fluid bolus requirements after treatment, compared to infants with values >or=15 microg/dl (n=8). CONCLUSIONS: A significant number of hypotensive, mechanically ventilated infants have evidence of inadequate adrenal function. Hydrocortisone therapy resulted in hemodynamic stabilization in this population.

Sleep Dynamic Therapy for Cerro Grande Fire evacuees with posttraumatic stress symptoms: a preliminary report.

BACKGROUND: Sleep disturbance is common among disaster survivors with posttraumatic stress symptoms but is rarely addressed as a primary therapeutic target. Sleep Dynamic Therapy (SDT), an integrated program of primarily evidence-based, nonpharmacologic sleep medicine therapies coupled with standard clinical sleep medicine instructions, was administered to a large group of fire evacuees to treat posttraumatic insomnia and nightmares and determine effects on posttraumatic stress severity. METHOD: The trial was an uncontrolled, prospective pilot study of SDT for 66 adult men and women, 10 months after exposure to the Cerro Grande Fire. SDT was provided to the entire group in 6, weekly, 2-hour sessions. Primary and secondary outcomes included validated scales for insomnia, nightmares, posttraumatic stress, anxiety, and depression, assessed at 2 pretreatment baselines on average 8 weeks apart, weekly during treatment, posttreatment, and 12-week follow-up. RESULTS: Sixty-nine participants completed both pretreatment assessment, demonstrating small improvement in symptoms prior to starting SDT. Treatment and posttreatment assessments were completed by 66 participants, and 12-week follow-up was completed by 59 participants. From immediate pretreatment (second baseline) to posttreatment, all primary and secondary scales decreased significantly (all p values < .0001) with consistent medium-sized effects (Cohen's d = 0.29 to 1.09), and improvements were maintained at follow-up. Posttraumatic stress disorder subscales demonstrated similar changes: intrusion (d = 0.56), avoidance (d = 0.45), and arousal (d = 0.69). Fifty-three patients improved, 10 worsened, and 3 reported no change in posttraumatic stress. CONCLUSION: In an uncontrolled pilot study, chronic sleep symptoms in fire disaster evacuees were treated with SDT, which was associated with substantive and stable improvements in sleep disturbance, posttraumatic stress, anxiety, and depression 12 weeks after initiating treatment.

Nightmare frequency in sexual assault survivors with PTSD.

Sexual assault survivors with post-traumatic stress disorder (PTSD) were assessed for frequency of nightmares, measured retrospectively on the Nightmare Frequency Questionnaire (NFQ) and prospectively on nightmare dream logs (NLOG). Retrospective frequency was extremely high, averaging occurrences every other night and an estimated number of nightmares greater than five per week. Test-retest reliability data on the NFQ yielded weighted kappa coefficients of .85 (95% CI, .74-.95) for nights and .90 (95% CI, .83-.97) for nightmares. Correlations between retrospective and prospective nightmare frequencies ranged between .53 (P = .001) for nights and .63 (P = .001) for nightmares. Correlations between frequency and distress measures (anxiety, depression, post-traumatic stress) yielded coefficients ranging from (r = .28-.53). Compared with intrusive, cumbersome and time-consuming prospective measurements, the NFQ appears reliable, convenient, and equally useful in assessing nightmare frequency in a group of sexual assault survivors. Nightmare frequency, prevalence, distress and impairment are discussed.

Sleep-disordered breathing, psychiatric distress, and quality of life impairment in sexual assault survivors.

Using American Academy of Sleep Medicine research criteria, sleep-disordered breathing (SDB) was assessed in a pilot study of 187 sexual assault survivors with posttraumatic stress symptoms. Nightmares, sleep quality, distress, and quality of life were also assessed along with historical accounts of prior treatments for sleep complaints. Presumptive SDB diagnoses were established for 168 patients. Twenty-one of 168 underwent sleep testing, and all met objective SDB diagnostic criteria. There were no clinically meaningful differences in age, body-mass index, sleep quality, distress, or quality of life measures between 21 confirmed SDB cases and 147 suspected cases not tested. Compared with 19 women without SDB, 168 women with diagnosed or suspected SDB reported significantly worse nightmares, sleep quality, anxiety, depression, posttraumatic stress, and impaired quality of life. Despite suffering from sleep problems for an average of 20 years, which had not responded to repeated use of psychotropic medications or psychotherapy, few of these women had been referred to sleep specialists. SDB appears widespread among sexual assault survivors seeking help for nightmares. Research is needed to clarify the associations among SDB, distress, and physical and mental health impairment in trauma patients.