Low-Level Prenatal Toxin Exposures and Breastfeeding Duration: A Prospective Cohort Study

Abstract

Introduction Maternal exposure to tobacco smoke is associated with shortened breastfeeding duration, but few studies have examined the effects on breastfeeding outcomes of low level exposures to other toxic chemicals. Moreover, it is unclear if passive smoking is associated with duration of breastfeeding. Our objective was therefore to examine the effect of low-level prenatal exposures to common environmental toxins (tobacco smoke, lead, and phthalates) on breastfeeding exclusivity and duration. Methods We conducted an analysis of data from the Health Outcomes and Measures of the Environment (HOME) Study. Serum and urine samples were collected at approximately 16 and 26 weeks gestation and at delivery from 373 women; 302 breastfed their infants. Maternal infant feeding interviews were conducted a maximum of eight times through 30 months postpartum. The main predictor variables for this study were gestational exposures to tobacco smoke (measured by serum cotinine), lead, and phthalates. Passive smoke exposure was defined as cotinine levels of 0.015–3.0 μg/mL. Primary outcomes were duration of any and exclusive breastfeeding. Results Serum cotinine concentrations were negatively associated with the duration of any breastfeeding (29.9 weeks unexposed vs. 24.9 weeks with passive exposure, p = 0.04; and 22.4 weeks with active exposure, p = 0.12; p = 0.03 for linear trend), but not duration of exclusive breastfeeding. Prenatal levels of blood lead and urinary phthalate metabolites were not significantly associated with duration of any or exclusive breastfeeding. Conclusions Passive exposure to tobacco smoke during pregnancy was associated with shortened duration of any breastfeeding.

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Treatment Outcome, Duration, and Costs: A Comparison of Performance Indicators Using Data from Eight Mental Health Care Providers in The Netherlands

Abstract

Assessing performance of mental health services (MHS) providers merely by their outcomes is insufficient. Process factors, such as treatment cost or duration, should also be considered in a meaningful and thorough analysis of quality of care. The present study aims to examine various performance indicators based on treatment outcome and two process factors: duration and cost of treatment. Data of patients with depression or anxiety from eight Dutch MHS providers were used. Treatment outcome was operationalized as case mix corrected pre-to-posttreatment change scores and as reliable change (improved) and clinical significant change (recovered). Duration and cost were corrected for case mix differences as well. Three performance indicators were calculated and compared: outcome as such, duration per outcome, and cost per outcome. The results showed that performance indicators, which also take process variability into account, reveal larger differences between MHS providers than mere outcome. We recommend to use the three performance indicators in a complementary way. Average pre-to-posttreatment change allows for a simple and straightforward ranking of MHS providers. Duration per outcome informs patients on how MHS providers compare in how quickly symptomatic relief is achieved. Cost per outcome informs MHS providers on how they compare regarding the efficiency of their care. The substantial variation among MHS providers in outcome, treatment duration and cost calls for further exploration of its causes, dissemination of best practices, and continuous quality improvement.

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A randomized controlled trial to examine the impact of aquatic exercise training on functional capacity, balance, and perceptions of fatigue in female patients with multiple sclerosis

Publication date: Available online 20 July 2017
Source:Archives of Physical Medicine and Rehabilitation
Author(s): Mehdi Kargarfard, Ardalan Shariat, Lee Ingle, Joshua A. Cleland, Mina Kargarfard
ObjectiveTo assess the effects of 8-weeks aquatic exercise training program on functional capacity, balance, and perceptions of fatigue in women with multiple sclerosis (MS).DesignA randomized controlled design.SettingReferral center of a multiple sclerosis society.ParticipantsWomen (age: 36.4 ±8.2) diagnosed with relapsing-remitting (RR-type) MS. After undergoing baseline testing by a neurologist, participants were allocated to either an intervention (aquatic training program) or a control group.InterventionsThe intervention consisted of an 8-week aquatic training program (3 supervised training sessions per week; session duration; 45-60 min; 50-75% estimated maximum heart rate).Main measuresSix-minute walk test (6-MWT); balance (Berg Balance Scale; BBS), and perceptions of fatigue (Modified Fatigue Impact Scale; MFIS), at baseline and after an 8 week intervention. Differences over time between the experimental and control groups were assessed by a 2x2 (group by time) repeated measures analysis of variance (ANOVA).Results32 women completed the 8-week aquatic training intervention (experimental group, n=17; controls, n = 15). All outcome measures improved in the experimental group; 6-MWT performance (451±58 m to 503±57 m; P<0.001); BBS (pre-test mean, 53.59±1.70; post-test mean, 55.18±1.18; P<0.001), and in the MFIS (pre-test mean, 43.1±14.6, post-test mean, 32.8 ±5.9;P<0.01). A significant group-by-time interaction was evident between the experimental and controls groups for 6-MWT:P<0.001, ηp²=0.551; BBS:P<0.001, ηp²=0.423; and MFIS: P<0.001, ηp²=0.679.ConclusionsAquatic exercise training improved functional capacity, balance, and perceptions of fatigue in women with MS.



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Treatment with Chemotherapy and Cognitive Functioning Among Older Adult Cancer Survivors

Publication date: Available online 20 July 2017
Source:Archives of Physical Medicine and Rehabilitation
Author(s): Ruth T. Morin, Elizabeth Midlarsky
ObjectiveTo investigate whether treatment of cancer with chemotherapy, when compared to surgery and radiation, differentially affects cognitive functioning among older adults.DesignData were examined prospectively from two years prior to cancer diagnosis to four years after cancer diagnosis. Distinct classes of cognitive functioning were identified using latent class growth analysis techniques (LCGA). Treatment type was assessed as a predictor of class membership.SettingData were collected from a large population-based cohort in the context of the Health and Retirement Study.Participants403 older adults with a new diagnosis of cancer, who were still alive 4 years after their diagnosis. Participants had provided informed consent for the data collection, and the use of the data was approved by the Institutional Review Board of Columbia University, Teachers College.InterventionsNot applicable.Main Outcome MeasureCognition (degree of immediate recall and delayed recall of a word list).ResultsFindings indicated that three classes of cognitive functioning best fit the data, specifically High, Middle, and Low Recall classes. Individuals treated with chemotherapy were significantly more likely to be in the High Recall class, with no effect of receiving surgery or radiation. When interactions with demographic predictors were entered into the model, an age x treatment interaction was present, such that individuals under 80 were more likely to both receive chemotherapy and have high recall cognition.ConclusionsThree distinct classes of cognitive functioning emerged among older adults with cancer. Treatment with chemotherapy predicted likely membership in the High Recall class in this sample of cancer survivors, however this was due to an age by treatment interaction. Implications for understanding cognitive sequelae of cancer in late life are discussed.



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Prevalence and characteristics of work-anxiety in medical rehabilitation patients – a cross-sectional observation study

Publication date: Available online 20 July 2017
Source:Archives of Physical Medicine and Rehabilitation
Author(s): Beate Muschalla, Michael Jöbges
ObjectiveTo investigate frequency, type and characteristics of work-anxieties in somatic rehabilitation inpatients. Work-anxieties are serious disorders which affect occupational functioning and often go along with long-term sick leave. Somatic patients may suffer from work-related participation problems due to their chronic health condition. Work-anxieties need specific diagnostic and treatment.DesignThis is a cross-sectional observation study.SettingWe investigated inpatients from a neurological, orthopedic and cardiologic rehabilitation clinic.Participants1610 patients (18-65 years) were investigated for work-anxieties in a short structured interview.Main outcome measuresPatients who scored high in at least two out of nine work-anxiety leading symptoms and reported impairment were investigated with a differential-diagnostic interview on work-anxieties, and with the MINI interview on non-work-related common mental disorders. Patients also filled in a self-rating on their subjective symptom load and sociodemographic data.ResultsAbout 20-27% of the investigated somatic rehabilitation inpatients (altogether n=393) got a work-anxiety diagnosis. Orthopaedic patients report highest work-anxiety and have longest preceding sick leave (20.6 weeks in past 12 months). Orthopaedic patients suffer from work-related adjustment anxieties, social anxieties, and workplace phobia, while cardiology patients are more often affected from hypochondriac anxieties. Anxieties of insufficiency and worrying occur equally in all indications.ConclusionsAbout one quarter of somatic rehabilitation patients is in need of additional diagnostic attention due to work-anxieties. Differential diagnostic of work-anxiety is needed for initiating adequate therapeutic action. Somatic rehabilitation physicians should be aware of work-anxieties in their patients, especially in orthopaedic patients with preceding long-term sick leave.



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A difficult diagnosis of hepatocellular carcinoma recurrence after liver transplant

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Predictors of increased cost and length of stay in the treatment of postoperative spine surgical site infection

Background ContextWhile many risk factors are known to contribute to development of a post-operative surgical site infection (SSI) following spinal surgery, little is known regarding the costs associated management of this complication, or predictors for which patients that will require increased resources for management of SSI.PurposeThe aim of this study is to identify specific risk factors for increased treatment costs and length of stay in the management of a postoperative SSI.Study Design/SettingRetrospective cohort study of all patients undergoing spine surgery at a single institution over three consecutive years.

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