The effect of a multidisciplinary team approach on weight gain in nonorganic failure-to-thrive children

Failure-to-thrive (FTT) is a chronic symptom accounting for 1% of all patients admitted to pediatric hospitals. FTT, which is traditionally attributed to organic (OFTT) and/or nonorganic (NFTT) causes, results in undernutrition. Undernutrition has potentially serious effects on child development, behavior, and cognitive skills. We undertook a study of children with FTT to determine whether multidisciplinary team treatment resulted in improved weight gain compared with children treated in a primary care setting. Fifty-three children with NFTT referred to our outpatient FTT consultative clinic and 107 children with NFTT identified as comparison subjects from our primary care clinic (PCC) were enrolled in the study. Growth outcomes over a 6-month follow-up were analyzed using growth quotient (GQ) analysis. Children followed in the multidisciplinary team clinic grew better (GQ = 1.75 +/- 0.39 SD) than did children in the PCC (GQ = 1.18 +/- 0.42 SD, p less than .001). The use of a multidisciplinary team offers special advantages in the rapid correction of undernutrition in children with NFTT.     

Excess mortality attributable to hip fracture in white women aged 70 years and older.

OBJECTIVE: The purpose of this study was to estimate the excess mortality attributable to hip fracture. METHODS: The 6-year survival rate of community-dwelling White female hip fracture patients aged 70 years and older entering one of seven hospitals from 1984 to 1986 (n = 578) was compared with that of White female respondents aged 70 years and older interviewed in 1984 for the Longitudinal Study on Aging (n = 3773). RESULTS: After age, education, comorbidity, and functional impairment were controlled, the mortality differential between the two groups accumulated to an excess among hip fracture patients of 9 deaths per 100 women 5 years postfracture. Among those with three or more functional impairments or one or more comorbidities, the excess was 7 deaths per 100: the effect of the fracture had disappeared in these groups by 4 years. In contrast, those with two or fewer impairments and those with no comorbidities had a continuing trend of increased mortality, with an excess of 14 deaths per 100 by 5 years. CONCLUSIONS: There is an immediate increase in mortality following a hip fracture in medically ill and functionally impaired patients, whereas among those with no comorbidities and few impairments, there is a gradual increase in mortality that continues for 5 years postfracture.     

The Boston AIDS Survival Score (BASS): a multidimensional AIDS severity instrument.

OBJECTIVES: This study developed a new acquired immunodeficiency syndrome (AIDS) severity system by including diagnostic, physiological, functional, and sociodemographic factors predictive of survival. METHODS: Three-hundred five persons with AIDS in Boston were interviewed; their medical records were reviewed and vital status ascertained. RESULTS: Overall median (+/- SD) survival for the cohort from the first interview until death was 560 +/- 14.4 days. The best model for predicting survival, the Boston AIDS Survival Score, included the Justice score (stage 2 relative hazard [RH] = 1.25, 95% confidence interval [CI] = 0.80, 1.96; stage 3 RH = 1.76, 95% CI = 1.15, 2.70), a newly developed opportunistic disease score (Boston Opportunistic Disease Survival Score; stage 2 RH = 1.35, 95% CI = 0.90, 2.02; stage 3 RH = 2.10, 95% CI = 1.38, 3.18), and measures of activities of daily living (any intermediate limitations, RH = 1.84, 95% CI = 1.05, 3.21; any basic limitations, RH = 2.60, 95% CI = 1.44, 4.69). This model had substantially greater predictive power (R2 = .17, C statistic = .68) than the Justice score alone (R2 = .09, C statistic = .61). CONCLUSIONS: Incorporating data on clinically important events and functional status into a physiologically based system can improve the prediction of survival with AIDS.     

Profound pulmonary shunting without edema following stereotaxic biopsy of hypothalamic germinoma. Case report

Hypoxemia is a nearly constant accompaniment of head injury. Diverse theories have been proposed to explain this relationship. The authors report the case of a patient who suffered an episode of severe, transient, arterial oxygen desaturation during "controlled" brain trauma: an otherwise uneventful stereotaxic biopsy of a small germinoma of the hypothalamus. Evidence is provided that pure ventilation-perfusion mismatching, without pulmonary edema, underlay the hypoxemia. The hypothalamus is intimately involved in matching pulmonary ventilation to perfusion; the hypoxemia of various brain injuries may be mediated by perturbation of this structure.     

Extramarital Involvement: A Core Relationship Issue in Need of a Coherent Model, Comprehensive Research, and Empirically Based Intervention

Clinical interventions for extramarital involvement (EMI) have outpaced empirical knowledge about both risk factors for infidelity and effective treatments. Allen et al. (this issue) provide a systematic review of current knowledge organized around stages of the development of EMI and factors concerning the involved partner, the spouse, the couple's relationship, and the interpersonal context. Their review identifies significant gaps in knowledge for which research is needed. Because EMI has multiple determinants, conceptual models and research on it must be multivariate. This comment focuses on priorities for increasing knowledge about EMI, including (a) clarification of variation in definitions and personal standards for EMI through consideration of participants' subjective experiences as well as the views of outsiders (researchers, clinicians); (b) improved qualitative research using interview methods designed to minimize biased questioning by investigators and biased reporting by subjects, to tap individuals' internal experiences with the developmental process of EMI; (c) nonblaming research on characteristics of the noninvolved spouse and the couple's interaction that predict EMI; and (d) adaptation of generic preventive and relationship enrichment interventions for couples involving communication skill-building and psychoeducation, to include information about ways to "inoculate" relationships against commonly unexpected risks of EMI.     

Cholinergic amacrine cells of the chicken retina: a light and electron microscope immunocytochemical study

Cholinergic amacrine cells of the chicken retina were detected by immunohistochemistry using an antiserum against affinity-purified chicken choline acetyltransferase. Three populations of cells were detected: type I cholinergic amacrine cells had cell bodies on the border of the inner nuclear and inner plexiform layers and formed a prominent laminar band in sublamina 2 of the inner plexiform layer, while type II cholinergic amacrine cells had cell bodies in the ganglion cell layer, and formed a prominent laminar band in sublamina 4 of the inner plexiform layer. Type III cholinergic amacrine cell bodies were located towards the middle of the inner nuclear layer, and their processes were more diffusely distributed in sublaminas 1 and 3-5 of the inner plexiform layer. Type I and type II cells were present at densities of over 7000 cells/mm2 in central areas declining to less than 2000 cells/mm2 in the temporal retinal periphery. The cells were organized locally in a non-random mosaic, with regularity indices ranging from 3 peripherally to over 5 centrally. Neither at the light nor electron microscopic levels was a lattice of cholinergic dendrites of the kind reported by Tauchi and Masland [J. Neurosci. 5, 2494-2501 (1985)] detectable. Within the two prominent dendritic plexuses, a major feature of the synaptic interactions of the type I and type II cholinergic cells was extensive synaptic interaction between cholinergic processes. Apart from this, there was little, if any, input to cholinergic processes from non-cholinergic amacrine cells, but there was input from bipolar cells. Output from the cholinergic amacrine cell processes was directed towards non-cholinergic amacrine cells as well as other cholinergic amacrine cells, and ganglion cells.     

Natural rhythm: evidence for occult 40 Hz gamma oscillation in resting motor cortex

Fast gamma oscillations, often at 40 Hz, have been demonstrated throughout the brain including the thalamus, auditory, visual and motor cortices. The function of gamma rhythms is elusive, but several authors have hypothesized that they contribute to the "binding" of diverse information into a single coherent percept, and to the synchronization of movement. In skeletal muscle a "Piper rhythm" around 40 Hz is commonly observed during maximal voluntary contraction, and has been shown to correlate with activity of similar frequency in a limited area of contralateral motor cortex. Gamma rhythms are detected primarily during complex cortical activity, and are seldom recorded at rest or coherently over wide areas. Here we use bihemispheric transcranial magnetic stimulation (TMS) to study time-dependent correlations between evoked motor potentials from non-homologous muscles in opposite limbs of normal volunteers. The results suggest the presence of an occult, synchronous 40 Hz rhythm across broad areas of resting motor cortex in both hemispheres.