NB housing study protocol: investigating the relationship between subsidized housing, mental health, physical health and healthcare use in New Brunswick, Canada.

BACKGROUND: Income and housing are pervasive social determinants of health. Subsidized housing is a prominent affordability mechanism in Canada; however, waitlists are lengthy. Subsidized rents should provide greater access to residual income, which may theoretically improve health outcomes. However, little is known about the health of tenants who wait for and receive subsidized housing. This is especially problematic for New Brunswick, a Canadian province with low population density, whose inhabitants experience income inequality, social exclusion, and challenges with healthcare access.  METHODS: This study will use a longitudinal, prospective matched cohort design. All 4,750 households on New Brunswick's subsidized housing wait list will be approached to participate. The survey measures various demographic, social and health indicators at six-month intervals for up to 18 months as they wait for subsidized housing. Those who receive housing will join an intervention group and receive surveys for an additional 18 months post-move date. With consent, participants will have their data linked to a provincial administrative database of medical records.  DISCUSSION: Knowledge of housing and health is sparse in Canada. This study will provide stakeholders with a wealth of health information on a population that is historically under-researched and underserved.

Low immunoglobulin A levels detected via the tissue transglutaminase assay can reveal previously undetected monoclonal proteins.

Increased awareness of coeliac disease and the 2009 NICE guidance has led to an increase in patients being screened for Immunoglobulin A deficiency. We have shown previously that this provides an opportunity for the early identification of other underlying primary immunodeficiency, e.g. common variable immunodeficiency. In this context, the underlying gastrointestinal problem appears to be related to bacterial overgrowth. Here, we demonstrate that in addition this also provides an opportunity to reveal underlying secondary immunodeficiency due to other causes in patients with gastrointestinal presentation, notably lymphoproliferative disorders. In one 3-month period, of 60 cases reviewed for low Immunoglobulin A, we found four new paraproteins through this testing route; one symptomatic multiple myeloma, one asymptomatic multiple myeloma, one monoclonal gammopathy of uncertain significance and one in a known chronic lymphocytic leukaemia patient.

Child care: implications for overweight / obesity in Canadian children?

INTRODUCTION: Over recent decades, two prominent trends have been observed in Canada and elsewhere: increasing prevalence of childhood overweight and obesity, and increasing participation of women (including mothers) in the paid labour force and resulting demand for child care options. While an association between child care and children's body mass index (BMI) is plausible and would have policy relevance, its existence and nature in Canada is not known. METHODS: Using data from the National Longitudinal Survey of Children and Youth, we examined exposure to three types of care at age 2/3 years (care by non-relative, care by relative, care in a daycare centre) in relation to change in BMI percentile (continuous and categorical) between age 2/3 years and age 6/7 years, adjusting for health and sociodemographic correlates. RESULTS: Care by a non-relative was associated with an increase in BMI percentile between age 2/3 years and age 6/7 years for boys, and for girls from households of low income adequacy. CONCLUSION: Considering the potential benefits of high-quality formal child care for an array of health and social outcomes and the potentially adverse effects of certain informal care options demonstrated in this study and others, our findings support calls for ongoing research on the implications of diverse child care experiences for an array of outcomes including those related to weight.

Are accident and emergency consultants as accurate as consultant radiologists in interpreting plain skeletal radiographs taken at a minor injury unit?

The objective of this study was to compare the accuracy of an accident and emergency (A&E) consultant in interpreting plain skeletal radiographs with that of a consultant radiologist (CR). It took the form of a retrospective study of 2133 radiographs taken in a Minor Injury Unit (MIU). A&E consultant reports on these films were compared with those of a CR and also with a gold standard. The A&E consultant diagnoses achieved an accuracy of 98.5% (CR 97.8%), sensitivity of 97.8% (CR 98.1%), specificity of 98.8% (CR 97.7%), positive predictive value of 97.3% (CR 95.1%) and negative predictive value of 98.97% (CR 99.07%) (gold standard of 100%). In conclusion, the A&E consultant reports of plain skeletal radiographs generated from an MIU were as accurate as those of a consultant radiologist. This could have significant implications for the wet reporting of A&E departmental radiographs.

Prospective evaluation of an outpatient heart failure management program.

BACKGROUND: Although considerable effort has been devoted to the follow-up of hospitalized patients, the effectiveness and process of heart failure outpatient management have not been well demonstrated. METHODS AND RESULTS: All new patients referred to the program from April 1997 to September 1998 were followed and managed by comprehensive strategies including preemptive hospitalization. Quality of life (QOL) and patients' self-care adherence behaviors were measured at baseline, 3 months, and 6 months. Clinical outcomes were compared for the 6 months before and 6 months after referral. A total of 108 patients were recruited. Patients' self-care knowledge score was improved over time (difference score = 0.9, P <.01). The proportion of patients weighing themselves daily increased by 24% (P =.02). The proportion of patients with New York Heart Association (NYHA) class III to IV was 67.6% at baseline and 49.1% at 6 months (P =.01). Compared with 6 months before referral, the program intervention was accompanied by a 52% reduction in the risk of hospitalization for cardiovascular causes (56.1% v 27.2%, P <.001) and a 72% reduction in emergency room visits (53.6% v 14.5%, P <.01). The total hospital admissions for cardiovascular causes decreased by 59% from 94 to 39; the total emergency room visits decreased by 77% from 83 to 19. The patients' QOL was improved over time with a change score of 11.2 (P <.001) at 3 months and 10.7 (P <.001) at 6 months. CONCLUSION: Our study shows the effectiveness of this heart failure outpatient management program.

Long-distance education in radiology via a clinical telemedicine system.

The objectives of the present study are to examine quality of learning, improved comprehension, and the preferred method of learning with teleradiology. Thirteen pairs of medical students transmitted 2,133 radiological series of skeletal injuries telemedically from a community hospital to the main emergency department. Students marked their diagnosis, quality of learning, improvement in comprehension, and preferred method of learning, each marked on a Likert scale. The quality of learning of the 13 sessions marked by the pairs of the students was ranked as excellent = 6, good = 16, fair = 4, unsatisfactory = 0, poor = 0. This was in contrast with the radiological series, which was marked as excellent = 55% or poor or unsatisfactory = 27.5%, most of the poor marks, as explained by the students, being awarded to transmissions in the second half of what had been very long sessions. The pre-tuition comprehension improved from 73 series marked as poor, and 1,037 series marked as unsure. The preferred method of tuition was teleradiology only in 21.8%, teleradiology teaching enhanced by clinical features, lectures and personal study in 62%. Teleradiological sessions needed to be reduced to an hour. Teleradiological teaching is a good method as long as the session lasts no more than 60 minutes, is interrupted by a 10-minute coffee break, and is supplemented by clinical features, lectures, and personal study.

How do teleconsultations for remote trauma management change over a period of time?

We obtained follow-up information about the new patients seen at a minor accident and treatment service (MATS) staffed by emergency nurse practitioners (ENPs). A previous study, of 150 teleconsultations in a six-month period starting in April 1996, was used for comparison. In the present series, 150 teleconsultations occurring in a four-month period starting in April 1999 were studied; the patients constituted 5.6% of the 2658 new attenders or 3.8% of the 3936 total attenders. In comparison with the study three years before, falling teleconsultation rates were partly offset by increasing numbers of attenders and an extension of the ENPs' roles and skills. Teleconsultation rates rose when the number of consultant-run clinics was curtailed and ENP-run clinics replaced some of them. Eligibility to request and report more radiographs reduced the need for teleconsultations, and subsequently teleconsultations for help with interpretation of radiographs fell as the ENPs became more experienced. Specialty residents trusted ENP judgement and accepted telephoned direct admission of cases to their wards. Fewer teleconsultations were required for soft-tissue injuries. Telemedicine is an excellent educational tool.

Paranasal sinus surgery through a frontonasal flap in sedated, standing horses.

OBJECTIVE: To report experience with paranasal sinus surgery through a frontonasal flap in sedated, standing horses. STUDY DESIGN: Treatment of 10 horses with naturally occurring paranasal sinus disease through a frontonasal bone flap created with the horses standing. ANIMALS: Ten adult horses. METHODS: After restraint and sedation, local anesthetic was injected subcutaneously along the proposed incision line over the conchofrontal sinus and was instilled into the sinuses through a small hole created in the frontal bone. A 3-sided, rectangular, cutaneous incision that extended through the periosteum was created over the frontal and nasal bones. The incision was extended into the conchofrontal sinus using a bone saw, and the base of the flap, on the midline of the face, was fractured. The sinuses were explored, and the horse was treated for the disease encountered. The flap was repositioned; subcutaneous tissue and skin were sutured separately. RESULTS: The horses had few signs of discomfort during creation of the bone flap and during disease treatment. Diseases encountered included inspissated exudate in the ventral conchal sinus (five horses), feed and exudate throughout the sinuses (one horse), occlusion of the nasomaxillary aperature (one horse), polyp (one horse), osteoma (one horse), and progressive ethmoidal hematoma (one horse). CONCLUSION: In selected cases, surgery of the paranasal sinuses can be performed safely on sedated and standing horses through a frontonasal bone flap. CLINICAL RELEVANCE: Performing surgery through a frontonasal bone flap with the horse standing and sedated, rather than anesthetized, eliminates risks and expense of general anesthesia.

Treatment response and athletic outcome of foals with tarsal valgus deformities: 39 cases (1988-1997).

OBJECTIVE: To evaluate the response to various treatments and long-term outcome of foals with tarsal valgus deformities. DESIGN: Retrospective study. ANIMALS: 39 foals with tarsal valgus deformities. PROCEDURE: Data collected from medical records, included signalment, history, reason for admission, and clinical findings. Radiographic views of the tarsus were evaluated for incomplete ossification of tarsal bones and were classified as normal in appearance, type-I incomplete ossification, or type-II incomplete ossification. Treatment and athletic outcome were documented for each foal. RESULTS: Radiographic assessment revealed that 22 of 39 foals (56%) had concomitant tarsal valgus deformities and incomplete ossification of the tarsal bones. Eight of 19 foals with tarsal valgus deformities that were treated with periosteal stripping responded favorably. Foals < or = 60 days old were significantly more likely to respond to periosteal stripping than older foals. Five of 8 foals with tarsal valgus deformities that were treated with growth plate retardation responded favorably. Eleven of 21 foals with long-term follow-up performed as intended. Compared with foals with type-II incomplete ossification, foals with tarsal bones that had a normal radiographic appearance or type-I incomplete ossification were significantly more likely to perform as intended. CONCLUSIONS AND CLINICAL RELEVANCE: Foals with tarsal valgus deformities should have lateromedial radiographic views of the tarsus obtained to assess the tarsal bones for incomplete ossification, which will affect athletic outcome. Because foals with type-II incomplete ossification of the tarsal bones respond poorly to periosteal stripping alone, treatment by growth-plate retardation is recommended.

Nonsurgical treatment of suprascapular nerve injury in horses: 8 cases (1988-1998).

OBJECTIVE: To determine the outcome of horses with suprascapular nerve injury treated with stall rest alone. DESIGN: Retrospective case series. ANIMALS: 8 horses. PROCEDURE: Information on signalment, history, limbs affected, severity of lameness, degree of muscle atrophy, gait abnormalities, and results of radiography and electromyography was obtained from medical records. All horses were treated with stall rest. Follow-up information on severity of lameness, gait abnormalities, degree of muscle atrophy, time between injury and resolution of gait abnormalities, and outcome was obtained during reexamination at the hospital or through telephone conversations with owners. RESULTS: In 4 horses, the injury was a result of trauma; in the other 4, the injury was suspected to be a result of trauma. All horses had pronounced instability of the shoulder joint during the weight-bearing phase. Follow-up information was available for 7 horses. Shoulder joint instability resolved in all 7 horses within 3 to 12 months (mean, 7.4 months) after the original injury. Two horses had complete return of the supraspinatus and infraspinatus muscle mass 15 and 18 months after the injury. Two horses used as broodmares before the injury and 4 of 5 horses used for riding or in race training before the injury were able to return to preinjury activities. CLINICAL IMPLICATIONS: Horses with suprascapular nerve injury treated with stall rest alone have a good prognosis for recovery of normal gait and return to performance; however, the recovery period may be prolonged.

A comparison of impulsive and instrumental subgroups of batterers.

Previous research on subtypes of batterers has revealed at least two distinct types of batterers. One group (Type 1) demonstrates suppressed physiological responding during conflicts with their wives, tends to use violence in nonintimate relationships and manifests Million Clinical Multiaxial Inventory (MCMI-II) scale elevations on the Antisocial and Aggressive-Sadistic scales. The second group (Type 2) manifests violence in the intimate relationship only and reports dysphoria. The current study extends our knowledge of these two groups by using a cluster analysis to assess personality disorder and relating the results to each group's attachment style, anger, trauma scores, and scores on a self-report of Borderline Personality Organization (BPO). An instrumental group (Type 1) showed an Antisocial-Narcissistic-Aggressive profile on the MCMI-II and reported more severe physical violence. An impulsive group (Type 2) showed a mixed profile on the MCMI-II with Passive-Aggressive, Borderline, and Avoidant elevations, high scores on a self-report of BPO, higher chronic anger, and Fearful attachment. Both types of abusive men reported a Preoccupied attachment style, but only the Impulsive men reported an accompanying Fearful attachment style.

Incomplete ossification of the tarsal bones in foals: 22 cases (1988-1996).

OBJECTIVE: To determine outcome for foals with incomplete ossification of the tarsal bones and to determine whether clinical and radiographic abnormalities at the time of initial examination were associated with outcome. DESIGN: Retrospective study. ANIMALS: 22 foals. PROCEDURE: Information on signalment, history, owner's initial complaint, clinical findings, whether tarsus valgus was evident, and radiographic abnormalities was obtained from medical records. Radiographic lesions were classified as type I (i.e., incomplete ossification with < 30% collapse of the affected bones) or type II (incomplete ossification with > 30% collapse and pinching or fragmentation of the affected bones). Follow-up information was obtained via telephone conversations with owners. RESULTS: Foals were between 1 day and 10 months old when first examined. Eleven were premature (i.e., < 320 days of gestation) or were twins. Sixteen had tarsus valgus. Severity of radiographic lesions was associated with outcome; 4 of 6 foals with type-I incomplete ossification of the tarsal bones performed as intended, but only 3 of 16 foals with type-II incomplete ossification of the tarsal bones performed as intended. CLINICAL IMPLICATIONS: For foals with incomplete ossification of the tarsal bones, severity of the radiographic lesions was associated with outcome. Foals with type-II incomplete ossification of the tarsal bones have a guarded prognosis for athletic soundness.

Gastrointestinal ulceration and pulmonary aspergillosis in a llama treated for parelaphostrongylosis.

A 9-year-old llama examined because of hind limb paresis was found to have parelaphostrongylosis. Despite treatment with ivermectin, fenbendazole, cimetidine, and ceftiofur, the llama developed gastrointestinal ulceration and pulmonary aspergillosis and was euthanatized. Parelaphostrongylus tenuis is a parasite of white-tailed deer, but ruminants can serve as aberrant or dead-end hosts after accidentally ingesting snails or slugs carrying third-stage larvae of the parasite. Gastrointestinal ulceration and pulmonary aspergillosis can develop secondarily in llamas with chronic disease. Treatment of gastrointestinal ulceration in llamas is difficult, because efficacy of commonly used antiulcer drugs in llamas has not been established.

Evaluation of telemedical support to a free-standing minor accident and treatment service.

We studied all patients attending a free-standing minor accident and treatment service (MATS) run by emergency nurse practitioners (ENPs). In a six-month period, 5563 patients were seen in the MATS, of whom 2843 (51%) were new attenders. A teleconsultation was carried out with 150 of these patients (2.7% of all cases). The most common reason (39%) was to discuss a radiograph with an accident and emergency consultant. The accuracy of the telemedicine-assisted radiographic diagnosis was checked subsequently by a review panel. The ENPs' working diagnoses (made by viewing the films) had a sensitivity of 90% and a specificity of 96%; this was improved by telemedicine assistance to 97% and 99%, respectively. The telemedicine patients were also surveyed several months after being seen in the MATS; their replies indicated that the telemedicine diagnoses had been correct.

Ablation of the cranial portion of the preputial cavity in a pig.

A technique for surgical ablation of the cranial portion of the preputial cavity including the preputial diverticulum in pigs is described. The technique was performed on a 5-month-old 83.2-kg (183-lb) Hampshire barrow that had ulceration and fibrosis of the preputial cavity secondary to chronic preputial diverticulitis. The pig recovered without difficulties and was able to urinate normally after surgery.

Client personality disorders affecting wife assault post-treatment recidivism.

Previous evaluations of wife assault treatment outcome have focused generically on whether groups "succeed" or not without a clear criterion of what constituted success. The present study examines the question for whom groups generate the greatest reduction in post-treatment abuse and for whom they work least well. It was found that certain types of personality disordered men had the worst post-treatment prognosis. Specifically, men with high scores on borderline personality, antisocial personality, and avoidant personality fared least well after treatment. However, taken as a generic group, men in treatment had significantly reduced post-treatment abusiveness whether reported by themselves or their wives.

Identification of functionally important helical faces in transmembrane segments by scanning mutagenesis.

We applied mutational analysis to a protein domain that functions in neither catalysis nor binding but, rather, in transmembrane signaling. The domain is part of chemoreceptor Trg from Escherichia coli. It contains four transmembrane segments, two from each subunit of the homodimer. We used cysteine scanning to investigate the functional importance of each of 54 residues in the two transmembrane segments. Cysteines at some positions resulted in subtle but significant reductions in tactic response. Those positions defined a specific helical face on each segment, implying that the segments function as helices. The functionally important faces corresponded to structural, helical packing faces identified independently by biochemical studies. All functionally impaired receptors exhibited altered signaling properties, either reduced signaling upon stimulation or induced signaling in the absence of stimulation. The distribution of substitutions creating these two phenotypes implied that conformational signaling involves movement between the two transmembrane helices within a subunit and that signaling is optimal when stable interactions are maintained across the interface between subunits.

Trauma symptoms and PTSD-like profiles in perpetrators of intimate abuse.

The presence of chronic trauma symptoms and similarity to a specific profile for post-traumatic stress disorder (PTSD) were assessed in a group 132 wife assaultive men and 44 demographically matched controls. Men who committed intimate abuse experienced more chronic trauma symptoms than nonabusive controls. A composite profile on the MCMI-II for wife assaulters demonstrated peaks on 82C (negative/avoidant/borderline), as have two independent studies of the profile of men diagnosed with PTSD. However, the assaultive population had higher scores on the antisocial personality scale and lower scores on anxiety and dysthymia. This PTSD-like profile on the MCMI-II was associated significantly with more frequent anger and emotional abuse of the subject's partner. The trauma origin for these men may have been parental treatment: experiencing frequent trauma symptoms as an adult was significantly related to negative recollections of parental treatment, specifically parental coldness/rejection and physical abuse.

Adolescent parricide: an integration of social cognitive theory and clinical views of projective-introjective cycling.

Case histories of parricide by adolescents frequently reveal a history of abuse on the part of the victim and acute depression and suicidal ideation by the adolescent. This paper seeks to integrate an established concept of suicide as escape from "aversive self-awareness" through cognitive deconstruction with clinical observations of "projective-introjective cycling" of aggressive impulses, as a means of better understanding and preventing violence toward intimate others.