Biomechanics of the foot in rheumatoid arthritis: identifying abnormal function and the factors associated with localised disease 'impact'.

BACKGROUND: Rheumatoid arthritis is a chronic inflammatory joint disease which affects the joints and soft-tissues of the foot and ankle. The aim of this study was to evaluate biomechanical foot function and determine factors associated with localised disease burden in patients with this disease. METHODS: Seventy-four rheumatoid arthritis patients (mean (standard deviation) age, 56 years (12); median (interquartile range) disease duration, 13 (5,19)) and 54 able-bodied adults (mean (standard deviation) age, 55 years (12)) completed the Leeds foot impact scale. Biomechanical foot function was measured using three-dimensional instrumented gait analysis. Disease activity score, the number of swollen and tender foot joints, and rearfoot and forefoot deformity were recorded. Sequential multiple linear regression was undertaken to identify independent predictors of foot disease burden. FINDINGS: The median (interquartile range) Leeds foot impact scale scores in the impairment and activity/participation subscales were 13 (10,14) and 17 (12,22) for the rheumatoid arthritis and 1 (0,3) and 0 (0,1) for the able-bodied adults, P<0.0001 both subscales. The patients had significantly higher numbers of swollen (P<0.0001) and tender foot joints (P<0.0001) and greater rearfoot (P<0.0001) and forefoot (P<0.0001) deformity. Rheumatoid arthritis patients walked slower (P<0.0001) and had altered biomechanical foot function. Sequential regression analysis revealed that when the effects of global disease activity and disease duration were statistically controlled for, foot pain, the number of swollen foot joints and walking speed, and foot pain and walking speed were able to predict disease burden on the Leeds foot impact scale impairment (P<0.0005) and Leeds foot impact scale activity/participation (P<0.0005) subscales, respectively. INTERPRETATION: In this cohort of rheumatoid arthritis patients, foot pain, swollen foot joint count and walking speed were identified as independent predictors of impairment and activity limitation and participation restriction. The foot disease burden model comprises important elements of pain, inflammatory and functional (biomechanical) factors.

How many chaplains per 100 inpatients? Benchmarks of health care chaplaincy departments.

Reports the results of a questionnaire survey of a sample of chaplaincy departments directors (N = 370) designed to answer the following questions: How many chaplains do various types of hospitals employ per 100 inpatients? What is the relationship between the number of employed chaplains and departmental Clinical Pastoral Education (CPE) programs? How much effort do departments give to outpatient ministry? What percentage of ministry do volunteer chaplains provide? Provides tentative answers to inform the strategic planning processes of chaplains and administrators.

Factors associated with HIV-infected women's use or intention to use AZT during pregnancy.

Despite the effectiveness of the antiviral drug AZT (zidovudine) in reducing perinatal transmission, many HIV-infected women continue to have reservations about taking the medication during pregnancy. To examine the factors influencing HIV-infected women's willingness to take AZT during pregnancy, focused interviews were conducted with 51 HIV-infected women of reproductive age living in New York City. Nearly all the women held reservations about taking it during pregnancy. Barriers to their use of AZT during pregnancy included (a) fear of toxic effects on baby, (b) fear of toxic effects for themselves, (c) fear of drug resistance, (d) belief that AZT is unnecessary among "healthy" women, and (e) previous birth to a healthy baby without using AZT. However, several factors also positively increased women's willingness to take AZT during pregnancy: (a) belief that they owe it to the baby to take AZT, (b) positive relationships with their physician, (c) peers or friends have taken AZT during pregnancy, and (d) previous experience taking AZT during pregnancy. These findings suggest significant areas for intervention to increase the use of AZT during pregnancy, thereby reducing perinatal transmission.

Racial differences in attitudes toward protease inhibitors among older HIV-infected men.

Recent advances in the treatment of HIV infection, particularly those associated with the advent of a new class of medications--protease inhibitors (PIs)--have focused interest on the problem of medication non-adherence. Earlier research on antivirals suggests that patient attitudes toward a medication or treatment play an important role in influencing its use. Attitudes toward PIs were explored using data from a study of late middle-aged and older adults (ages 50-67) living with HIV/AIDS (N = 38) who had been or were currently users of PIs at the time of accrual in late 1997. Comparisons were made between African American and White men with regard to perceptions of: medication efficacy, self-efficacy, physician competence, quality of life, side effects, skipping medication doses and the timing of protease initiation. Results of these analyses suggest significant differences between White and African American men. African American men not only expressed significantly more doubt regarding their ability to utilize PIs and adhere to PI treatment regimens than Whites, but also reported significantly more doubt regarding physician competence with regard to PIs. African American men were also more likely than Whites to question the timing of their initiation of treatment with PIs. The findings suggest that these racial differences may be important for creating patient education strategies and the targeting of non-adherence prevention efforts.

Perceiving benefits in adversity: stress-related growth in women living with HIV/AIDS.

This study examines perceptions of illness-related positive of change or stress-related growth among a sample of African American, Puerto Rican, and non-Hispanic White women (n = 54) living with HIV/AIDS in New York City, USA. While these women acknowledged the negative stresses of living with HIV/AIDS, 83% reported at least one positive change in their lives that they attributed to their illness experience. A number of different domains of potential growth were identified including: health behaviors, spirituality, interpersonal relationships, view of the self, value of life, and career goals. While growth was reported by nearly all the women, some variation was found in the forms of growth reported in relation to the women's ethnic/racial background, class, and IV drug use history. These data suggest an expanded conceptualization of stress-related growth that includes behavioral aspects of growth in response to stress and illness, and which takes into account the diverse ways in which growth may be experienced.

Child survivors of parental death from cancer or suicide: depressive and behavioral outcomes.

Depressive symptoms, social competence, and behavior problems of prepubescent children bereaved within 18 months of parental death from cancer (57 families, 64 children) or suicide (11 families, 16 children) were compared. Most children reported normative levels of depressive symptoms. Children whose parents died from suicide, compared with those whose parents died from cancer, reported significantly more depressive symptoms, involving negative mood, interpersonal problems, ineffectiveness, and anhedonia. Parental reports of children's competence and behavior were similar to a normative sample of children and did not differ between the children bereaved by parental cancer or suicide. Additional research should focus on other factors, such as family psychopathology, stresses, and impact of stigma, which may influence the course of bereaved children.

Effects of bilateral posteroventral pallidotomy on gait of subjects with Parkinson disease.

BACKGROUND: Most studies documenting the effect of pallidotomy on parkinsonian gait have reported unilateral surgery and used qualitative scales or timed tests that only provide measures of walking speed. OBJECTIVE: To document the effect of bilateral posteroventral pallidotomy on the walking patterns of patients with Parkinson disease (PD). DESIGN: Case series of gait evaluations performed 1 month before and 1 month after surgery, with antiparkinson medication withheld for 8 hours overnight. SETTING: Movement analysis laboratory of a clinical research center. PATIENTS: Consecutive sample of 8 men and 3 women with a diagnosis of PD scheduled for bilateral pallidotomy. INTERVENTION: Bilateral posteroventral pallidotomy. MAIN OUTCOME MEASURES: A 3-dimensional motion-capture system allowed calculation of temporal and spatial measurements and joint angular displacements of the lower extremities and trunk during gait. RESULTS: Pallidotomy significantly increased average walking speed from 0.214 statures/s preoperatively to 0.440 statures/s postoperatively (where stature indicates body height) (P = .03). A faster postoperative walking speed was achieved almost exclusively by increasing average stride length from 0.24 to 0.47 statures (P = .03) rather than changing average gait cycle time (1.32 to 1.37 seconds; P = .08). A forward stepwise multiple regression analysis (P<.001) revealed that 96% of the change in stride length postoperatively could be explained by the combination of changes in foot-floor angle, knee, and hip excursion during gait. CONCLUSIONS: Bilateral posteroventral pallidotomy was associated with a 2-fold increase in walking speed. Previous studies have demonstrated that walking speed is an important indicator of locomotor performance and level of disability in patients with PD, so the increase in postoperative walking speed likely provided a functional benefit.

Coping with Negative Emotions: The Cognitive Strategies of HIV-infected Gay/Bisexual Men.

While the managing of negative emotions has been identified as a central adaptive task for those living with chronic illnesses such as HIV/AIDS, little is known about the specific coping strategies used to achieve this task. The present study employed unstructured interviews to examine illnessspecific cognitive strategies used by an ethnically diverse sample of HIV-infected men who have sex with men (MSM) in their attempts to manage the negative emotions associated with the illness. Fourteen specific cognitive strategies were identified, many of which were specific to coping with chronic illness or HIV/AIDS. These strategies were categorized into four major conceptual categories: (1) distancing the threat of death; (2) reducing the sense of victimization; (3) gaining a sense of control; and (4) mentally preparing for emotional upset. The findings have implications for what coping assessments may be neglecting and may provide insights for therapeutic application.

Hope and resilience in suicide ideation and behavior of gay and bisexual men following notification of HIV infection.

Upon being notified that they are positive for HIV, people often experience terror and confusion. At the beginning stages of coping with HIV diagnosis, suicide ideation and behavior may arise as the infected person begins to envision frightening images of a future life with AIDS. We examined the narratives of gay men who contemplated or attempted suicide soon after they had learned of their HIV infection. We found that suicidal ideation and attempt often provoked a process of coping with HIV disease, leading to a redefinition of the meaning of HIV, enhancing one's sense of control over life, and prompting a renewed effort at self-help and help seeking, a new commitment to life, and a reappraisal of personal goals. We recommend that clinicians and HIV counselors be cognizant of these positive symbolic functions of suicidality in coping with HIV infection. Allowing people who were recently diagnosed with HIV to discuss suicidality may allow them to move toward acceptance and commitment to life.

Symptom interpretation: implications for delay in HIV testing and care among HIV-infected late middle-aged and older adults.

Physical symptoms and the attributions assigned to them are fundamental aspects of individuals' illness representations and influence health behaviours. The effects of the presence or absence of symptoms and the interpretation of these symptoms on the initiation of HIV testing and medical care are explored using data from a psychosocial study of HIV illness in late middle-aged and older men and women. The absence of symptoms negatively influenced willingness both to seek testing and to seek medical care. While the presence of symptoms would be expected to lead to testing and the initiation of medical care, the effect of symptoms was dependent on causal interpretations of the symptoms. Symptoms attributed (or misattributed) to other illnesses or to normal aging did not lead to initiation of testing or care. These results appear to be due to people's lay belief that illness must include symptoms and due to a resistance against accepting an illness identity. This research suggests that HIV education and counselling should emphasize the need for individuals at risk for HIV to seek testing and medical care even if symptoms of the disease are absent.

Symptom Interpretation and Medication Adherence among Late Middle-age and Older HIV-infected Adults.

All individuals, whether healthy or ill, have bodily 'expectancies'. Symptoms recognized as deviations from these expectancies necessitate interpretive activities. The behavioral implications of symptom interpretations are explored using data from a psychosocial study of the adaptation to HIV illness among late middle-aged and older men and women. Thematic analysis revealed that rather than the mere presence of symptoms, it was the attributions made for these symptoms that influenced whether patients adhered to multidrug antiviral medications. Decreased adherence was reported when symptoms were interpreted as side-effects because these symptoms were interpreted as evidence that the medications were making them sicker or had greater risks than benefits. Similarly, the failure of medications to relieve symptoms also negatively influenced adherence because they were interpreted as not having any effect. In nearly all cases, physicians were not consulted until after non-adherence, if at all. Implications of symptom interpretations for patient care and intervention are discussed.

Factors associated with HIV-infected women's delay in seeking medical care.

Data from an investigation of HIV-infected African-American, Puerto Rican and non-Hispanic white women's treatment behaviour and decision-making are presented. Findings are based on a thematic analysis of the narrative accounts of 31 women who exhibited significant delay in seeing a physician about their HIV infection after testing positive for HIV antibodies. Analysis of the women's qualitative interview data indicated that a variety of barriers impeded them from actively pursuing treatment. The women's psychological responses to learning their serostatus were the most pervasive factors associated with delaying seeking care. Implications of the analysis for informing the design of secondary prevention efforts to move women into treatment earlier are discussed, such as the need to develop interventions or supportive services designed to assist women in coming to terms with their infected status.

Correlates of depressive symptomatology among adult daughter caregivers of a parent with cancer.

BACKGROUND: As a consequence of advances and changes in the detection and treatment of cancer, increasing demands are being placed on familial caregivers of elderly cancer patients. Understanding the factors that place familial caregivers at risk of poor psychological outcomes and threaten their ability to provide adequate care is important for maintaining chronically ill patients in the community. METHODS: Dyads comprised of 164 cancer outpatients (ages 60-90 years) and their adult caregiving daughter completed structured telephone interviews. Hierarchical regression was used to determine the individual and cumulative effect of five domains of potential predictors on the daughters' depressive symptomatology (Center for Epidemiologic Studies Depression Scale [CES-D]). RESULTS: The domains that were shown to be significantly predictive of a daughter's level of depressive symptomatology were daughter sociodemographics, constraints on/facilitators of caregiving, and caregiver burden. The domains of disease/patient characteristics and the daughter's appraisal of the caregiving situation were not found to be significant. The total model suggests that having a health-limiting condition, a greater sense of filial obligation, and greater caregiver burden were correlated with higher CES-D scores, whereas having graduated college, having other social roles, having favorable attitudes regarding her caregiving experience, and providing care in a greater number of domains of care were correlated with lower scores. CONCLUSIONS: These findings demonstrate the importance of focusing on situational factors that may function to constrain or facilitate caregiving when investigating caregiver depression.

Forefoot deformity, pain, and mobility in rheumatoid and nonarthritic subjects.

OBJECTIVE: To evaluate how painful metatarsal arthritis affects foot and ankle mechanics and mobility. METHODS: We studied 16 symptomatic forefeet in 10 patients with rheumatoid arthritis (RA) and compared them with 14 asymptomatic forefeet in 7 nonarthritic subjects. RA limbs with significant disease at other locations were excluded. We measured pain and deformity of the foot using a visual analog scale and a modified articular index. A video based 3 dimensional gait analysis system and force platform were used to collect data on subjects walking barefoot at a self-selected pace according to an established protocol. Mobility level was quantified using the Sickness Impact Profile (SIP) ambulation subscale. RESULTS: We observed considerable pain and deformity of the forefeet of RA subjects. During gait, motion and force measures revealed that RA subjects significantly (p < 0.005) delayed and reduced forefoot loading, which minimized use of the foot as a rigid level for push off. As a result, stride lengths were shorter and gait was slower compared to nonarthritic subjects. SIP scores revealed that these changes in gait resulted in moderate disability in RA subjects (p=0.05). CONCLUSION: Impairments of the forefoot due to RA include pain and deformity, which produce characteristic stance phase abnormalities in foot function, a slow walking speed, and moderate disability.

A three-dimensional musculoskeletal database for the lower extremities.

A three-dimensional musculoskeletal database of the lower extremities has been developed for use in human musculoskeletal models. The locations of idealized muscle attachments on the pelvis, both femurs, both tibias and fibulas, and both feet were accurately digitized for 52 dried skeletal specimens. The mean specimen heights were 177.5 cm (male) and 166.2 cm (female) and the mean specimen age at the time of death was 48.8 yr. Statistical accumulation and scaling techniques were used to generate highly representative normative models, which were divided into groups and tested for differences based on gender and race. From the test results, the pelvis was divided into a male model (RMS = 8.6 mm), a black female model (RMS = 7.0 mm) and a white female model (RMS = 7.3 mm). The foot was separated into black (RMS = 3.7 mm) and white models (RMS = 3.6 mm). Single models were used for the femur (RMS = 6.5 mm) and the tibia/fibula (RMS = 3.7). Containing over 12000 anatomical landmarks digitized from 52 dried skeletons, this study represents an improvement over previous databases by an order of magnitude.

Barriers and pathways to testing among HIV-infected women.

Through in-depth interviews the testing experiences of HIV-infected women were examined. The barriers that impeded the women from recognizing their at-risk status and from seeking testing once their vulnerability was acknowledged are discussed. Also described are the pathways that led women into testing. The data reveal that lack of understanding about risk behaviors, ignorance of their partner's risk practices, lack of information about HIV-related symptoms, and perceived invulnerability to infection were the principal barriers to women recognizing their at-risk status. The women's accounts also indicate that psychological factors--fear and denial--are the principal barriers to seeking testing once one acknowledges vulnerability. Finally, the data show that few women made a thoughtful proactive decision to be tested but rather seemed to be led by circumstances to learn their status, sometimes unwittingly.

Effects of withdrawal of bracing in matched pairs of children with osteogenesis imperfecta.

OBJECTIVES: To evaluate the effects of withdrawal of long-leg braces (hip-knee-ankle-foot orthoses [HKAFO]) on activity and ambulation in children with osteogenesis imperfecta. DESIGN: A prospective, randomized cross-over trial, that describes the effects of withdrawing HKAFO. PATIENTS: Ten children who were ambulatory with the assistance of braces. All had type III or IV osteogenesis imperfecta. Children were paired for age and clinical severity. Strength testing, fractures, and independence in daily activity were monitored at 4-month intervals for 32 months (16 months each of braced and unbraced periods). Gait was analyzed during braced and unbraced conditions. RESULTS: Muscle strength declined .35 grade during unbraced and .1 grade during braced intervals. Children spent more time in upright activity during braced intervals than during unbraced intervals (p = .17). Children were more independent in daily activities during braced than during unbraced periods (p = .14). Seventeen fractures of lower extremities occurred during all the unbraced periods, and 8 occurred during the braced intervals (p = .08); the fracture rate was higher during unbraced intervals. (p = .06) Bracing was associated with increased hip flexion and stride length and decreased transverse plane pelvic rotation. CONCLUSION: Withdrawal of HKAFO in children with osteogenesis imperfecta who had achieved upright activity was not associated with significant decrease in muscle strength or independence, but there was an associated increase in fracture rate that nearly reached significance.

Coping and mood in HIV-positive women.

To date, little empirical research on the association of coping style with mood in HIV-positive women has been carried out. The extant literature on HIV-positive men suggests that active coping is related to diminished distress while avoidant coping is associated with elevated distress. Previous research with HIV-positive women has not consistently confirmed these relationships. To add to this literature, scores from a sample of 145 HIV-positive women who completed the Ways of Coping Questionnaire and the Mental Health Inventory were analyzed. Correlations indicated that an escape-avoidance strategy was associated with more negative emotions. Other strategies related to negative emotions included accepting responsibility and a self-controlling approach. These findings are consistent with those previously reported for HIV-positive men, suggesting that similar kinds of coping strategies may be associated with positive and negative moods among HIV-positive men and women.

HIV-infected women: barriers to AZT use.

AZT has become a mainstay drug in efforts to slow disease progression in HIV-infected individuals. Further, recent evidence indicates that AZT use by pregnant infected women and their neonates may reduce the risk of vertical transmission. In a study of HIV-infected women's treatment-related behavior, attitudes toward the use of this drug were examined. Data were gathered through unstructured interviewing techniques. The data from the first 71 women accrued revealed that negative attitudes towards its use were widely prevalent. Women viewed the drug as highly toxic, prescribed indiscriminately, inadequately tested in women and minorities, promoted for the wrong reasons and inappropriate while they were feeling well. The findings suggest that removing attitudinal barriers to the use of AZT will be important to both primary and secondary prevention efforts.