Proposed guidelines for the management of nodding syndrome

Nodding Syndrome is a poorly understood neurologic disorder of unknown aetiology that affects children and adolescents in Africa. Recent studies have suggested that the head nods are due to atonic seizures and Nodding Syndrome may be classified as probably symptomatic generalised epilepsy. As part of the Ugandan Ministry of Health clinical management response, a multidisciplinary team developed a manual to guide the training of health workers with knowledge and skills to manage the patients. In the absence of a known cause, it was decided to offer symptomatic care. The objective is to relieve symptoms, offer primary and secondary prevention for disability and rehabilitation to improve function. Initial management focuses on the most urgent needs of the patient and the immediate family until ‘stability’ is achieved. The most important needs were considered as seizure control, management of behavioural and psychiatric difficulties, nursing care, nutritional and subsequently, physical and cognitive rehabilitation. This paper summarises the processes by which the proposed guidelines were developed and provides an outline of the specific treatments currently being provided for the patients.     

Comparison of periodontal open flap debridement versus closed debridement with Er,Cr:YSGG laser

Background

Traditional periodontal open flap debridement (OFD) results in reduced pocket depth (PD), clinical attachment loss (CAL), gingival recession (GR) and postoperative pain and discomfort. The quest to overcome these shortcomings has led to research into Er,Cr:YSGG laser assisted pocket therapy (ELAPT). This study was designed to compare the clinical outcomes of ELAPT versus OFD.

Methods

Fifteen patients with a PD of ≥5 mm and ≤8 mm at two sites were selected. Test sites (Group 1) were treated by ELAPT and the control (Group 2) by OFD. Clinical parameters were recorded at baseline, 3 and 6 months and included Plaque Index (PI), Gingival Index (GI), modified Sulcular Bleeding Index (mSBI), PD, CAL and GR.

Results

Both treatments produced a reduction in PI, GI, mSBI and PD, an increase in GR, and a gain in CAL at 3 and 6 months. The mean gain of CAL in Group 1 at 3 and 6 months (1.60 ± 0.78 and 1.80 ± 0.63) was similar (p > 0.05) to the value of Group 2 (1.93 ± 0.88 and 2.00 ± 0.54). GR increased significantly (p < 0.05) only in Group 2 at 3 and 6 months (1.80 ± 0.56 and 1.87 ± 0.64) compared to Group 1 (0.50 ± 0.68 and 0.60 ± 0.74).

Conclusions

ELAPT compared with OFD results in similar CAL gains with less GR and significant reductions in PD, GI and mSBI, and may be considered as an alternative to surgical therapy.     

Adverse Tissue Reactions in Modular Exchangeable Neck Implants: A Report of Two Cases

Dual-modular femoral stems with exchangeable necks theoretically allow optimization of hip joint biomechanics via selective restoration of femoral anteversion, offset, and limb length. A potential disadvantage is the possible generation of metal ions and debris by fretting and crevice corrosion at the additional stem-neck interface. We present 2 cases of early-onset adverse inflammatory tissue reactions as a result of accelerated corrosion at the stem-neck interface of a dual-modular implant, requiring subsequent revision of well-fixed components.     

Hospital Charges for Pediatric Heart Failure-Related Hospitalizations from 2000 to 2009

Scarce data exist regarding costs of pediatric heart failure-related hospitalizations (HFRH) or how costs have changed over time. Pediatric HFRH costs, due to advances in management, will have increased significantly over time. A retrospective analysis of Healthcare Cost and Utilization Project Kids’ Inpatient Database was performed on all pediatric HFRH. Inflation-adjusted charges are used as a proxy for cost. There were a total of 33,189 HFRH captured from 2000 to 2009. Median charges per HFRH rose from $35,079 in 2000 to $72,087 in 2009 (p < 0.0001). The greatest median charges were incurred in patients on extracorporeal membrane oxygenation ($442,134 vs $53,998) or ventricular assist devices ($462,647 vs $55,151). Comorbidities, including sepsis ($207,511 vs $48,995), renal failure ($180,624 vs $52,812), stroke ($198,260 vs $54,974) and respiratory failure ($146,200 vs $48,797), were associated with greater charges (p < 0.0001). Comorbidities and use of mechanical support increased over time. After adjusting for these factors, later year remained associated with greater median charges per HFRH (p < 0.0001). From 2000 to 2009, there has been an almost twofold increase in pediatric HFRH charges, after adjustment for inflation. Although comorbidities and use of mechanical support account for some of this increase, later year remained independently associated with greater charges. Further study is needed to understand potential factors driving these higher costs over time and to identify more cost-effective therapies in this population.     

Primary motor cortex long‐term plasticity in multiple system atrophy

In humans, intermittent and continuous theta‐burst stimulation (iTBS and cTBS) elicit long‐term changes in motor‐evoked potentials (MEPs) reflecting long‐term potentiation (LTP)‐ and depression (LTD)‐like plasticity in the primary motor cortex (M1). In this study, we used TBS to investigate M1 plasticity in patients with MSA. We also assessed whether responses to TBS reflect M1 excitability as tested by short‐interval intracortical inhibition (SICI), intracortical facilitation (ICF), short‐interval intracortical facilitation (SICF), and the input/output curves. We studied 20 patients with MSA and 20 healthy subjects (HS). Patients were clinically evaluated with the Unified Multiple System Atrophy Rating Scale. The left M1 was conditioned with TBS. Twenty MEPs were recorded from the right first dorsal interosseous muscle before TBS and 5, 15, and 30 minutes thereafter. In a subgroup of 10 patients, we also tested MEPs elicited by SICI, ICF, SICF, and input/output curves, before TBS. Between‐group analysis of variance showed that at all time points after iTBS MEPs increased, whereas after cTBS they decreased only in HS. In both subgroups tested, patients with predominant parkinsonian and cerebellar features, iTBS and cTBS left MEPs unchanged. MSA patients had reduced SICI, but normal ICF, SICF, and input/output curves. No correlation was found between patients' clinical features and responses to TBS and M1 excitability variables. These findings suggest impaired M1 plasticity in MSA. © 2013 International Parkinson and Movement Disorder Society     

Associations Between Macrolevel Economic Factors and Weight Distributions in Low- and Middle-Income Countries: A Multilevel Analysis of 200?000 Adults in 40 Countries

Objectives. We examined associations between macrolevel economic factors hypothesized to drive changes in distributions of weight and body mass index (BMI) in a representative sample of 200 796 men and women from 40 low- and middle-income countries.Methods. We used meta-regressions to describe ecological associations between macrolevel factors and mean BMIs across countries. Multilevel regression was used to assess the relation between macrolevel economic characteristics and individual odds of underweight and overweight relative to normal weight.Results. In multilevel analyses adjusting for individual-level characteristics, a 1–standard-deviation increase in trade liberalization was associated with 13% (95% confidence interval [CI] = 0.76, 0.99), 17% (95% CI = 0.71, 0.96), 13% (95% CI = 0.76, 1.00), and 14% (95% CI = 0.75, 0.99) lower odds of underweight relative to normal weight among rural men, rural women, urban men, and urban women, respectively. Economic development was consistently associated with higher odds of overweight relative to normal weight. Among rural men, a 1–standard-deviation increase in foreign direct investment was associated with 17% (95% CI = 1.02, 1.35) higher odds of overweight relative to normal weight.Conclusions. Macrolevel economic factors may be implicated in global shifts in epidemiological patterns of weight.Cardiovascular diseases are among the leading causes of death in low- and middle-income countries (LMICs),1 where mortality from such diseases has been increasing and is expected to continue doing so until 2030.2 In parallel to this trend, there has been an increase in average body mass index (BMI; defined as weight in kilograms divided by the square of height in meters) in most regions of the world.3 With population-based studies indicating a U- or J-shaped relation between BMI and cardiovascular disease mortality,4,5 these shifts in BMI may increase the proportion of the population at greatest risk for cardiovascular diseases. As such, increases in BMI may contribute to escalating cardiovascular disease mortality in LMICs,6 highlighting the need for understanding BMI patterns and predictors.Comparative longitudinal data that can be used to monitor BMI changes (often expressed according to prevalence of underweight, overweight, and obesity) across LMICs are scant; however, existing data suggest that the prevalence of underweight has decreased, the prevalence of overweight and obesity has increased, and, in general, there is a greater burden of overweight than underweight in most LMICs, particularly in urban areas.7–9 Shifts in the key determinants of weight, including diet and physical activity, are hypothesized to influence these patterns.3 Major changes in global dietary consumption have increased per capita food intake in LMICs, as well as the proportion of people’s daily diet derived from energy-dense and fatty foods.3,10–12 Although cross-national and longitudinal data on physical activity are limited, available evidence suggests that forms of transportation, employment, and leisure activities have become more sedentary and may contribute to changing patterns of weight at the population level.13,14Macrolevel economic factors, including economic development, urbanization, foreign investment, and trade liberalization, are hypothesized to drive shifting patterns of dietary composition, physical activity, and other determinants of nutritional outcomes.3,15 Economic growth and attendant increases in per capita income, for example, are associated with increased consumption of energy-dense foods,16 and recent cross-national analyses suggest that economic development is associated with a faster rate of growth in the prevalence of overweight among lower-income groups in LMICs.17,18 Urbanization is hypothesized to increase access to processed diets, reduce opportunities for physical activity, and expose residents to food marketing, thereby promoting a more sedentary lifestyle associated with less energy expenditure and greater caloric intake.15The influx of foreign direct investment (FDI), defined as investments by an enterprise in one country intended to acquire a lasting management interest in an enterprise operating in a foreign economy, represents one mechanism through which transnational corporations enter into new markets. FDI inflows are, along with greater openness to trade,19 hypothesized to be a key element in reshaping the global market for food, particularly in LMICs, by threatening traditional modes of agricultural production and facilitating the processing, distribution, and marketing of lower-cost, energy-dense food.20,21Despite the potential role that these macrolevel economic factors may play in shaping the epidemiological pattern of diet, behavior, and weight in LMICs, few empirical studies have investigated the relation between contextual factors and individual weight. A limited number of ecological studies have been conducted,9,22 but their results cannot be used to draw inferences about health at the individual level. Furthermore, the social patterning of diet and physical activity according to area of residence (urban or rural) and gender suggests that the macrolevel factors posited to drive changes in weight may have distinct implications for particular groups of individuals,23,24 and ecological studies cannot assess whether associations between macrolevel economic characteristics and weight vary according to such individual-level characteristics.We used data from a sample of approximately 200 000 adults from 40 LMICs to describe the ecological associations between macrolevel economic factors hypothesized to drive changes in determinants of weight (i.e., economic development, urbanization, FDI, trade liberalization) and average BMIs across countries and examine the association between macrolevel characteristics and the probability at the individual level of underweight and overweight or obesity relative to normal weight. We also assessed cross-level interactions of macrolevel factors with gender and area of residence.