Long-term Results of Comprehensive Clubfoot Release Versus the Ponseti Method: Which Is Better?

Background

Clubfoot can be treated nonoperatively, most commonly using a Ponseti approach, or surgically, most often with a comprehensive clubfoot release. Little is known about how these approaches compare with one another at longer term, or how patients treated with these approaches differ in terms of foot function, foot biomechanics, or quality-of-life from individuals who did not have clubfoot as a child.

Questions/purposes

We compared (1) focused physical and radiographic examinations, (2) gait analysis, and (3) quality-of-life measures at long-term followup between groups of adult patients with clubfoot treated either with the Ponseti method of nonsurgical management or a comprehensive surgical release through a Cincinnati incision, and compared these two groups with a control group without clubfoot.

Methods

This was a case control study of individuals treated for clubfoot at two separate institutions with different methods of treatment between 1983 to 1987. One hospital used only the Ponseti method and the other mainly used a comprehensive clubfoot release. There were 42 adults (24 treated surgically, 18 treated with Ponseti method) with isolated clubfoot along with 48 healthy control subjects who agreed to participate in a detailed analysis of physical function, foot biomechanics, and quality-of-life metrics.

Results

Both treatment groups had diminished strength and motion compared with the control subjects on physical examination measures; however, the Ponseti group had significantly greater ankle plantar flexion ROM (p < 0.001), greater ankle plantar flexor (p = 0.031) and evertor (p = 0.012) strength, and a decreased incidence of osteoarthritis in the ankle and foot compared with the surgical group. During gait the surgical group had reduced peak ankle plantar flexion (p = 0.002), and reduced sagittal plane hindfoot (p = 0.009) and forefoot (p = 0.008) ROM during the preswing phase compared with the Ponseti group. The surgical group had the lowest overall ankle power generation during push off compared with the control subjects (p = 0.002). Outcome tools revealed elevated pain levels in the surgical group compared with the Ponseti group (p = 0.008) and lower scores for physical function and quality-of-life for both clubfoot groups compared with age-range matched control subjects (p = 0.01).

Conclusions

Although individuals in each treatment group experienced pain, weakness, and reduced ROM, they were highly functional into early adulthood. As adults the Ponseti group fared better than the surgically treated group because of advantages including increased ROM observed at the physical examination and during gait, greater strength, and less arthritis. This study supports efforts to correct clubfoot with Ponseti casting and minimizing surgery to the joints, and highlights the need to improve methods that promote ROM and strength which are important for adult function.

Level of Evidence

Level III, prognostic study.     

The Joys of Caring for Older Adults: Training Practitioners to Empower Older Adults

Many older adults lack knowledge concerning the consequences of a sedentary lifestyle, atypical disease symptoms, the adverse effects of multiple medication use, and the hazards of frequent hospitalizations. Medically trained healthcare providers and community health practitioners can provide older adults with this information through health education classes. However, these healthcare professionals must continually update their knowledge as the science of gerontology and geriatrics is always expanding. The advanced certificate in gerontology administration program at LIU-Brooklyn hosted a 3-h train-the-trainer seminar, which was attended by 62 healthcare professionals to raise awareness concerning the realities of aging and to describe a range of behaviors that support health. For approximately 90 min, the keynote speaker presented issues and solutions that addressed the before-mentioned areas of knowledge deficit, followed by a question and answer period. Participants were asked to use an anonymous survey evaluation form featuring both quantitative and qualitative questions to rate the seminar. Close-ended questions were developed on a five-point scale ranging from 5 = strongly agree to 1 = strongly disagree. These items were analyzed to compute frequency and percent. The participants rated the seminar favorably with 98 % stating that they learned the benefits of exercise for older adults; 97 % learned how to avoid the hazards of hospitalization. Evaluations of the seminar suggest that it is feasible to develop educational programs targeting healthcare professionals and community health practitioners.     

A systematic review and meta-analysis of the ethnic density effect in psychotic disorders

Purpose

A number of studies have found an ethnic density effect in psychotic disorders, where the incidence for ethnic minorities increases as the neighbourhood proportional ethnic composition decreases [Morgan and Hutchinson, Psychol Med 40:705–709, (2010); Singh, Psychol Med 39:1402–1403, (2009); Schofield et al., Psychol Med 41:1263–1269, (2010)]. However, there is a mixed picture with some studies reporting no effect [Schofield et al., Psychol Med 41:1263–1269, (2010)]. This review aimed to establish the existence of the effect by answering the review question: is there an ethnic density dose effect in the prevalence of psychotic disorders?

Methods

A systematic review and meta-analysis was conducted by two independent reviewers using PsychINFO, Web of Science and PubMed databases. Studies were measured against eligibility criteria and then pooled with any discrepancies discussed between reviewers. Studies were then assessed for quality using a standardised quality assessment.

Results

In total, eight studies were included. A meta-analysis was conducted which found that the incidence of psychotic disorders was higher in low ethnic density areas than high ethnic density areas. A narrative synthesis reflected the complexity when results were broken down by individual ethnic groups where some ethnic groups had inverse or no associations with ethnic density. The synthesis also analysed methodological differences between studies.

Conclusions

The review reports evidence of an overall ethnic density dose effect for ethnic minorities, but with more mixed results for individual ethnic groups. The possible mechanisms behind this effect are explored, including exposure to racism, social capital and social cohesion hypotheses. The wide-ranging implications of the review are discussed along with recommendations for future research to continue to inform public health policy.     

Progressive Nephron Loss in Aging Kidneys: Clinical–Structural Associations Investigated by Two Anatomical Methods

Two major studies of structural changes associated with aging in human kidneys are reviewed and new information presented. The studies are the Monash University stereologically analyzed series of 319 autopsy kidneys from the United States in which 44% were white and the Mayo Clinic CT angiogram/biopsy analysis of 1,388 US kidney donors in which 97% were white. Hypertension rates in the Monash series were 48% and included moderate and severe hypertension. In the Mayo Clinic study, 12% had mild hypertension. The studies showed no relationship between glomerular number and hypertension except for a weak relationship with older white women in the Monash series. An inverse relationship was present between glomerular number and glomerular volume, a reciprocity that tended to enhance glomerular mass and by inference filtration capacity with lower nephron numbers. This relationship seemed to be present whether low nephron numbers were intrinsic or acquired. In the Mayo Clinic studies, pretransplant iothalamate clearances demonstrated that single nephron (SN) glomerular filtration rates (GFR) were similar throughout the range of glomerular number in subjects younger than 70 years, but that increased SNGFR correlated with nephron hypertrophy and increased nephrosclerosis particularly at 70 years of age and over. Hypertension at least through middle age cannot be related to a deficiency of glomeruli, but glomeruli are lost with later aging in association with adaptive nephron hypertrophy that can maintain GFR near normal. These studies help define an age-related nephropathy that overlaps with hypertension as a potential cause of end-stage renal disease when glomerulosclerosis is advanced.     

Evaluation of the Safety of a Plant-Based Infant Formula Containing Almonds and Buckwheat in a Neonatal Piglet Model

A randomized neonatal piglet trial was conducted to evaluate the safety and the effects of a plant-based formula containing almonds and buckwheat as the main ingredients on growth and plasma parameters. From postnatal day (PND) 2 to 21, the piglets were fed a dairy-based milk formula (Similac Advance) or a plant-based formula (Else Nutrition) and all piglets were euthanized at day 21. No diarrhea was observed after PND 8 and all the piglets completed the trial. Body growth, kcal intake, the complete plasma count parameters and hematological parameters were within the reference range in both groups. Organ growth and development was similar between the two groups. Plasma glucose was higher in the dairy-based-fed piglets relative to the plant-based at 2 weeks of age. Liver function biomarkers levels were greater in the plasma of the plant-based compared to the dairy-based fed group. In addition, calcium levels were higher in the plant-based fed piglets at 1 week of age. Thus, the plant-based formula tested in this study was well tolerated by the piglets and supported similar growth compared to dairy-based milk formula. Therefore, the results support the safety of the tested plant-based infant formula during the neonatal period in comparison to the dairy-based formula fed group.     

Depressive symptoms associated with scleroderma

Objective. To examine the prevalence and correlates of depressive symptoms among patients with systemic sclerosis (SSc; scleroderma). Method. Fifty-four outpatients with scleroderma were administered the Beck Depression Inventory, the Neuroticism-Extraversion-Openness Personality Inventory, the Health Assessment Questionnaire, and the Psychosocial Adjustment to Illness Scale. In addition, patients underwent a comprehensive clinical assessment, and pulmonary function tests were obtained. Results. Nearly half of the patients had mild depressive symptoms, and an additional 17% had symptoms in the moderate-to-severe range. Younger patients, those with digital ulceration, and those with more self-rated functional impairment had more depressive symptoms, but there were few other relationships between depressive symptoms and either demographic or physician-rated medical variables. In contrast, there were highly significant relationships between depression and aspects of personality, psychosocial adjustment to illness, and social support. Conclusion. Depressive symptoms in patients with SSc are more strongly related to personality, self-rated disability, and adequacy of emotional support than to objective medical indices of illness severity. Depression in scleroderma is a debilitating comorbid condition that should be recognized and treated in its own right.