Contribution of incidence to increasing prevalence of multiple sclerosis in Alberta, Canada.

Alberta Health Care Insurance Plan (AHCIP) data were used to calculate prevalence and incidence rates for multiple sclerosis (MS) in the general population of Alberta from 1990 to 2004. Multiple sclerosis prevalence rose steadily each year over this time period, from 217.6/100,000 individuals in 1990 to 357.6/100,000 in 2004. Multiple sclerosis incidence fluctuated with a slight increase from 1990 to 2004, at 20.9/100,000 and 23.9/100,000, respectively. Age-specific prevalence rates were higher between ages 30 and 60 in 2004 than in 1990. The pattern of age-specific incidence rates was similar in 1990 and 2004, with a slight shift toward diagnosis in younger years. Gender-specific prevalence rates were higher for females in both 1990 and 2004, with a greater increase in females (43%) than males (29%). Gender-specific incidence rates were higher for females than males in both years, but there was no differential increase in incidence by gender from 1990 to 2004. The 2004 Alberta MS prevalence rate remains among the highest reported worldwide. Both increasing incidence and longer duration have likely contributed to increasing MS prevalence in the province.

Home adaptation: helping older people age in place.

As people age, decrements in sensory, motor, and cognitive function often jeopardize their ability to manage activities of daily living safely and comfortably in their own homes. The purposes of this article are to discuss common problems faced by many elders who want to remain at home, present information about possible solutions that increase their safety and comfort, and provide resources for additional information on assistive products.

Transmission of Mycobacterium tuberculosis from patients smear-negative for acid-fast bacilli.

BACKGROUND: The microscopic examination of sputum for acid-fast bacilli, is a simple and rapid test that is used to provide a presumptive diagnosis of infectious tuberculosis. While patients with tuberculosis with sputum smears negative for acid-fast bacilli are less infectious than those with positive smears, both theoretical and empirical evidence suggest that they can still transmit Mycobacterium tuberculosis. We aimed to estimate the risk of transmission from smear-negative individuals. METHODS: As part of an ongoing study of the molecular epidemiology of tuberculosis in San Francisco, patients with tuberculosis with mycobacterial isolates with the same DNA fingerprint were assigned to clusters that were assumed to have involved recent transmission. Secondary cases with tuberculosis, whose mycobacterial isolates had the same DNA, were linked to their presumed source case to estimate transmission from smear-negative patients. Sensitivity analyses were done to assess potential bias due to misclassification of source cases, unidentified source cases, and HIV-1 co-infection. FINDINGS: 1574 patients with culture-positive tuberculosis were reported and DNA fingerprints were available for 1359 (86%) of these patients. Of the 71 clusters of patients infected with strains that had matching fingerprints, 28 (39% [95% CI 28-52]) had a smear-negative putative source. There were 183 secondary cases in these 71 clusters, of whom a minimum of 32 were attributed to infection by smear-negative patients (17% [12-24]). The relative transmission rate of smear-negative compared with smear-positive patients was calculated as 0.22 (95% CI 0.16-0.32). Sensitivity analyses and stratification for HIV-1 status had no impact on these estimates. INTERPRETATION: In San Francisco, the acid-fast-bacilli smear identifies the most infectious patients, but patients with smear-negative culture-positive tuberculosis appear responsible for about 17% of tuberculosis transmission.

Sexual expression in a very old man: a nursing approach to care.

The needs of an elderly client at a college-managed nursing center were not entirely understood by those caring for him. Once his sexual needs were identified by his caregivers, the resources of the center were mobilized to help this 95-year-old man meet all of his needs in ways that provided support while helping him to maintain control over his lifestyle.

Outcomes of enhanced physical and occupational therapy service in a nursing home setting.

OBJECTIVE: The purpose of this study was to determine if 1.0 Full-time Equivalent (FTE) physical therapy (PT) and 1.0 FTE occupational therapy (OT) per 50 beds resulted in differences in functional status for nursing home residents when compared to 1.0 FTE PT and 1.0 FTE OT per 200 beds. DESIGN: Randomized control program evaluation, cost analysis. SETTING: Nursing home in the province of Alberta, Canada. PATIENTS: 115 residents assigned to 1 PT and 1 OT per 50 beds (enhanced group) versus 1 PT and 1 OT per 200 beds (control group) using stratified random allocation by severity of condition. INTERVENTIONS: Both groups received ongoing treatment, follow-up, and restorative interventions, but enhanced group received more hours of service. OUTCOME MEASURES: Functional Independence Measure (FIM), Functional Assessment Measures (FAM), and Clinical Outcome Variables Scale (COVS) recorded at 6-month intervals over a 2-year period. RESULTS: Mean score differences favored the enhanced group for the tests over the 2 years. Significance was observed on FIM Total at 6 and 12 months, FIM Self Care at 6 months, FIM Communication at 24 months, and FIM Psychosocial at 6, 12, 18, and 24 months; FAM Total at 6, 12, 18, and 24 months, FAM Self Care at 6 months, FAM Mobility at 12 months, FAM Communication at 6 and 24 months, FAM Psychosocial at 6, 12, 18, and 24 months, and FAM Cognition at 6 and 12 months; and COVS at 6, 12, 18, and 24 months. A cost analysis demonstrated that PT/OT offered at the 1:50 ratio would result in a cost savings in terms of nursing staff dollars for 30 long-term-care beds of $16,973 over the 2 years of the study compared to the 1:200 ratio. This equates to an annual cost savings of $283 per bed. CONCLUSIONS: Increasing the amount of PT/OT can have a positive effect on the functional status and cost of care of long-term care residents.

Factors predicting employment 1 year after traumatic spine fracture.

STUDY DESIGN: This prospective cohort study evaluates the employment status of 489 persons after traumatic spine fracture. OBJECTIVES: To determine the rate, type, and predictors of employment 1 year after traumatic spine fracture. SUMMARY OF BACKGROUND DATA: The limited existing literature regarding employment after spine fracture reports variable return-to-work rates, tends to be retrospective, and generally evaluates a limited number of predictor factors at a time. METHODS: Four hundred eighty-nine persons ranging in age from 15 to 64 years who had experienced a spine fracture were assessed by a single examiner at hospital discharge and 1 year postinjury. Employment status and type. discharge neural and functional status, pain level, demographics, injury level and severity, and early treatment details were evaluated. RESULTS: At 1 year postinjury, 54% of subjects were working. A higher percentage of the employed were working part time and for fewer weeks per year than preinjury. A higher percentage were working at unskilled clerical, sales, or service jobs than preinjury. The significant positive (+) and negative (-) predictors of employment were (from strongest to weakest); worked in year previous to injury (+); employed at time of injury (+); Worker's compensation Board coverage (-); spinal fracture surgery (+); high-level spine fracture (-); pain (-); Functional Independence Measure score (+); and days of stay in intensive care unit and spinal unit (-). CONCLUSIONS: For the first year after spinal fracture, unemployment is common. Those who do return to work are more likely to modify the amount and type of work they do and to have been employed preinjury.

Influence of gender on susceptibility to multiple sclerosis and age of onset in concordant sibships.

BACKGROUND: Research has produced conflicting findings about whether there is an excess of like-sexed pairs among concordant multiple sclerosis (MS) sibships. Although a positive correlation in onset age among sibling pairs overall has been reported, no data have been published describing age at onset correlations for like-sexed versus unlike-sexed pairs. The purpose of this study was to provide additional information on both issues. METHODS: Patients with an MS sibling were sought through the files of the University of Alberta MS clinic (Edmonton, Canada). The clinic neurologist either reviewed clinical/autopsy material or assessed relatives of index cases prior to accepting the relative as having MS. Pairs of siblings (excluding twins) were divided into (1) male-male pairs, (2) female-female pairs, and (3) female-male pairs. RESULTS: A total of 62 concordant sibling pairs were identified. There were 33 like-sexed pairs (6 male-male/27 female-female) and 29 unlike-sexed pairs. The observed number of like-sexed pairs was not significantly different from the expected frequency using 2 x 2 chi2 analysis, where expected values represent the binomial distribution predicted from the frequency of each sex as determined by total number of males and females. The age at onset intraclass correlation coefficient was -0.09 for sibling pairs overall, -0.22 for like-sexed pairs and +0.02 for unlike-sexed pairs. CONCLUSIONS: This study does not provide evidence for an association between disease susceptibility and gender in siblings concordant for MS; nor does it suggest that genetics plays a role in onset age.

Postural aberrations in low back pain.

The purpose of this study was to measure and describe postural aberrations in chronic and acute low back pain in search of predictors of low back pain. The sample included 59 subjects recruited to the following three groups: chronic, acute, or no low back pain. Diagnoses included disc disease, mechanical back pain, and osteoarthritis. Lumbar lordosis, thoracic kyphosis, head position, shoulder position, shoulder height, pelvic tilt, and leg length were measured using a photographic technique. In standing, chronic pain patients exhibited an increased lumbar lordosis compared with controls (p < .05). Acute patients had an increased thoracic kyphosis and a forward head position compared with controls (p < .05). In sitting, acute patients had an increased thoracic kyphosis compared with controls (p < .05). These postural parameters identified discrete postural profiles but had moderate value as predictors of low back pain. Therefore other unidentified factors are also important in the prediction of low back pain.

Incomplete neural deficits in thoracolumbar and lumbar spine fractures. Reliability of Frankel and Sunnybrook scales.

Because neural status is used both as a treatment determiner and outcome measure, a universal, reliable scale is required. Experienced personnel, provided with concise definitions, demonstrated high inter-rater reliability of Frankel and Sunnybrook scales (Pearson correlation coefficients 0.71-0.91), with 94-100% intra-rater agreement. Both scales correspond to total sensory and motor function but are insensitive to walking and bladder function. Frankel's wide clinical use, reliability, and simplicity identify it to be the preferred measurement system until a better alternative is developed. Discussion of neural status must include description of bladder and walking function.

Spine trauma and associated injuries.

A longitudinal, prospectively gathered data base of spine trauma has been developed. A review of 508 consecutive hospital admissions identified the presence of associated injuries in 240 (47%) individuals, most frequently involving head (26%), chest (24%), or long bones (23%). Twenty-two per cent had one associated injury, 15% had two, and 10% had three or more. Most spine fractures involved the lower cervical (29%) or thoracolumbar junction (21%). Comparisons of presence or absence of associated injuries and spine fracture level showed significant differences (p less than 0.001). Eighty-two per cent of thoracic fractures and 72% of lumbar fractures had associated injuries compared to 28% of lower cervical spine fractures. While there was no significant relationship between type of associated injury and spine fracture level, those with associated injuries were less likely to have a neural deficit (p less than 0.05). After hospital admission, there were seven deaths. Early assessment and transport of spine trauma victims must be carried out with appropriate management of associated injuries. Conversely, multiple trauma victims must be handled with due regard for a possible spine fracture. The value of spinal units with specially trained personnel is emphasized.

Educational and psychological assessment of children with learning disorders.

This article provides an overview of assessment in the educational process and a critical analysis of the standardized tests that are typically seen in educational and psychological reports.

Education of children with learning problems.

Approximately 10 per cent of all school-aged children have some type of learning disorder. These students are usually labeled mentally retarded, learning disabled, or emotionally disturbed/behavior disordered. The authors discuss the commonly used definitions of these disorders, the prognosis in school for children with learning disorders, the educational characteristics of these children, specific teaching and training approaches, and the administrative arrangement and physical environment for learning-disordered students.

Optic neuritis, diabetes mellitus and multiple sclerosis: a three-way association.

Patients with multiple sclerosis (MS) and a history of optic neuritis were compared with MS patients who had no such history for other illnesses among themselves and their family members. Significantly more of the patients with a history of optic neuritis than of those without (70% v. 41%) were diabetic or reported that at least one first- or second-degree relative had diabetes mellitus. No differences were found with regard to any other illnesses.

Multiple sclerosis and diabetes mellitus: further evidence of a relationship.

One hundred multiple sclerosis (MS) patients were compared to healthy controls to determine the prevalence of diabetes mellitus in their families. Significantly, more MS patients than controls were diabetic or reported at least one first degree relative (parent, sibling, child) with diabetes. The relationship between MS and diabetes persisted when second degree relatives (grandparents, aunts and uncles) were taken into consideration. A greater percentage of MS patients with another MS relative were diabetic or reported a first degree relative with diabetes mellitus than MS patients without an MS relative. However the difference was not statistically significant. Nor was there a significant difference when percentages reporting either a first or a second degree relative with diabetes were compared.

How multiple sclerosis is related to animal illness, stress and diabetes.

At the University of Alberta's multiple sclerosis research clinic 100 patients with multiple sclerosis were matched to control patients for age, sex, race and zone of residence before the age of 15 years. Case and control subjects were interviewed and information was collected by questionnaire on factors that might play a role in the development of multiple sclerosis. The only factors found to be significantly associated with the development of this disorder were a history of leisure time spent in physical activities before the onset of symptoms, exposure to animal illness -- specifically canine distemper -- and a history of severe or prolonged emotional stress. The study also confirmed a familial predisposition to multiple sclerosis and suggested a relation between the disorder and a personal or family history of diabetes mellitus.