[Show abstract][Hide abstract] ABSTRACT: This study assessed the effects of cerebral malaria (CM) and severe malarial anemia (SMA) on individual neurocognitive domains. Eighty children with CM, 86 with SMA, and 61 community children (CC) were assessed for gross motor skills, fine motor skills, visual reception, receptive language, and expressive language a week after discharge (CM or SMA) or at enrolment (CC), and 6 and 12 months later. At 12-months follow-up, children with CM had significantly lower scores than CC for all outcomes. Children with SMA had significantly lower scores than CC for visual reception, receptive language, and expressive language, and scores that were lower but did not reach significance for gross and fine motor skills. Children with CM had significantly lower scores than children with SMA for fine motor skills. Children with SMA and CM have long-term impairment in multiple neurocognitive domains. Fine motor skills may be affected more profoundly in CM than SMA.
Learning and Individual Differences 01/2015; · 1.58 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Context. Vulvar pain level may fluctuate in women with vulvodynia even in the absence of therapy; however, there is little evidence suggesting which factors may be associated with variability. Objective. Determine the feasibility of using smartphones to collect prospective data on vulvar pain and factors that may influence vulvar pain level. Methods. 24 clinically confirmed women were enrolled from a population-based study and asked to answer five questions using their smartphones each week for one month. Questions assessed vulvar pain level (0-10), presence of pain upon wakening, pain elsewhere in their body, treatment use, and intercourse. Results. Women completed 100% of their scheduled surveys, with acceptability measures highly endorsed. Vulvar pain ratings had a standard deviation within women of 1.6, with greater variation on average among those with higher average pain levels (P < 0.001). On the weeks when a woman reported waking with pain, her vulvar pain level was higher by 1.82 on average (P < 0.001). Overall, average vulvar pain level was not significantly associated with the frequency of reporting other body pains (P = 0.64). Conclusion. Our smartphone tracking system promoted excellent compliance with weekly tracking of factors that are otherwise difficult to recall, some of which were highly associated with vulvar pain level.
Pain research and treatment. 06/2014; 2014:659863.
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[Show abstract][Hide abstract] ABSTRACT: Malaria in highland areas of Kenya affects children and adults. Local clinicians include symptoms other than fever when screening for malaria because they believe that fever alone does not capture all cases of malaria.
[Show abstract][Hide abstract] ABSTRACT: Background. Cerebral malaria (CM) is associated with long-term neurocognitive impairment in children 5 years of age and older. No prospective studies to date have assessed neurocognitive impairment in children with CM <5 years of age, or in children with severe malarial anemia (SMA), a form of severe malaria estimated to affect as many as 5 million children annually. Methods. Children <5 years of age presenting to Mulago Hospital, Kampala, Uganda, with CM (n=80) or SMA (n=86) were assessed for overall cognitive ability, attention, and associative memory one week after discharge and 6 and 12 months later. Z-scores for each domain were computed based on scores of 61 healthy community children (CC), who were also tested at enrollment and 6 and 12 months later. Groups were compared using mixed linear models, adjusted for age, weight for age, and child's education. Results. At 12 months, children with CM had lower adjusted scores than CC in cognitive ability (P<0.001), attention (P=0.02), and associative memory, (P=0.002). Children with SMA had lower scores than CC in cognitive ability (P=0.01) but not attention or associative memory. Cognitive ability scores in children with CM and SMA did not differ significantly. Conclusions. In children <5 years of age, SMA is associated with long-term impairment in cognitive ability, while CM is associated with additional impairment in the areas of attention and associative memory. SMA may be a major contributor to long-term neurocognitive impairment in children in sub-Saharan Africa.
[Show abstract][Hide abstract] ABSTRACT: Background. Tools that estimate recent and long-term malaria transmission in a population would be highly useful for malaria elimination programs.Methods. The prevalence of antibodies to 11 P. falciparum antigens was assessed by cytometric bead assay or ELISA in 1,000 people in a highland area of Kenya over 14 months, during a period of interrupted malaria transmission.Results. Antibodies differed by antigen in acquisition with age: rapid (>80% antibody positive by age 20 years, 5 antigens), moderate (>40% positive by age 20 years, 3 antigens), or slow (<40% positive by age 20 years, 3 antigens). Antibody seroreversion rates in the 14 months between samples decreased with age rapidly (7 antigens), slowly (3 antigens), or remained high at all ages (schizont extract). Estimated antibody half-lives in individuals >10 years of age were long (40 to >80 years) for 5 antigens, moderate (5 - 20 years) for 3 antigens, and short (<1 year) for 3 antigens.Conclusions. Antibodies to P. falciparum antigens in malaria endemic areas vary by age, antigen, and time since last exposure to P. falciparum. Multiplex P. falciparum antibody testing could provide estimates of long-term and recent malaria transmission and potentially of a population's susceptibility to future clinical malaria.
The Journal of Infectious Diseases 04/2014; · 5.85 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Evaluate the association of abdominal visceral and subcutaneous fat, independent of total body fat, with cardiometabolic risk factors and insulin resistance among youth.
Visceral and subcutaneous fat, percent total body fat, insulin resistance (adjusted for lean body mass: Mlbm), blood pressure, glucose, insulin, and lipids were obtained in 472 youth ages 6-18 years. Linear regression, adjusted for age, sex, race, Tanner stage, and percent total body fat, was used to evaluate associations of visceral and subcutaneous fat with cardiometabolic risk factors.
Visceral fat was associated inversely with Mlbm (p=0.003) and positively with fasting insulin (p=0.002) and triglycerides (p=0.002). Visceral fat levels above the mean were associated inversely with HDL cholesterol (p=0.002), and positively systolic blood pressure (p<0.0001) and non-HDL cholesterol (p<0.0001). Subcutaneous fat was associated inversely with Mlbm (p=0.003) and HDL cholesterol (p<0.05), and positively with fasting glucose (p<0.05), fasting insulin (p=0.0003), systolic blood pressure (p=0.005), and triglycerides (p=0.003). Subcutaneous fat levels above the mean were associated with non-HDL cholesterol (p=0.0002).
These findings suggest that there may be a threshold level of visceral and subcutaneous fat (regardless of total body fat), that when exceeded in childhood, is more likely to be associated with many cardiometabolic risk factors. Triglycerides and insulin resistance appear to be associated with these fat depots at even lower thresholds of abdominal adiposity.
[Show abstract][Hide abstract] ABSTRACT: Scattered reports of multiple maxima in posterior distributions or likelihoods for mixed linear models appear throughout the literature. Less scrutinised is the restricted likelihood, which is the posterior distribution for a specific prior distribution. This paper surveys existing literature and proposes a unifying framework for understanding multiple maxima. For those problems with covariance structures that are diagonalisable in a specific sense, the restricted likelihood can be viewed as a generalised linear model with gamma errors, identity link and a prior distribution on the error variance. The generalised linear model portion of the restricted likelihood can be made to conflict with the portion of the restricted likelihood that functions like a prior distribution on the error variance, giving two local maxima in the restricted likelihood. Applying in addition an explicit conjugate prior distribution to variance parameters permits a second local maximum in the marginal posterior distribution even if the likelihood contribution has a single maximum. Moreover, reparameterisation from variance to precision can change the posterior modality; the converse also is true. Modellers should beware of these potential pitfalls when selecting prior distributions or using peak-finding algorithms to estimate parameters.
International Statistical Review 03/2014; · 0.72 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study explores characteristics that distinguish higher and lower CT use by patients and referring physicians in a population of members of a large health insurance plan.
We analyzed 310,467 CT scan claims from 2009-10 in a health plan serving approximately 1.5 million members. Patients who used CT scans and their referring physicians were classified into utilization categories. Characteristics distinguishing higher from lower utilization categories were identified.
Among patients receiving CT scans, patient characteristics that distinguished higher from lower utilization of scans were: male, older, seeing more total providers, using more prescription and total resources, classified as frail, having higher treatment group severity, and having government insurance. Among physicians ordering scans, physician characteristics that distinguished higher from lower referrals for CT scans were: male, board-certified, in group practice, and in particular specialties. Ownership interest was associated with higher claim volumes in a curvilinear manner but was not associated with claims per physician. Higher total referral counts were related to single-specialty practice type and larger group size. External reviewers (4 physicians) observed that the empirical relationships had plausible explanations based on reasonable medical decision-making.
Aggregate-level review of claims for CT scans in a health plan revealed no striking anomalies in associations of patient and referring physician characteristics with higher utilization. Claims research that examines particular conditions and patients with high utilization rates and physicians with high referral rates would advance the evidence base for quality improvement.
Journal of the American College of Radiology: JACR 11/2013;
[Show abstract][Hide abstract] ABSTRACT: Low bone mineral density (BMD) has been reported in recipients of pediatric hematopoietic cell transplantation (HCT), but it is unclear whether age at HCT has a role. The objective of this cross-sectional study was to determine if patients treated with HCT before the age of 10 years have long-term BMD deficits compared with patients transplanted at an older age and with sibling controls. The study included 151 HCT recipients (87 males), age at study 24.7±8.6 years treated with HCT for hematologic malignancies at age 10.9±6.4 years, and 92 healthy sibling controls (49 males), age at study 22.3±8.0 years. Dual-energy x-ray absorptiometry was performed to measure BMD Z-scores for total body BMD (TBMD), lumbar spine BMD (LBMD) and femoral neck BMD (FNBMD, for subjects 20 years at study visit). Patients <10 years at HCT had significantly lower TBMD and FNBMD Z-scores (by 0.5 and 0.8 s.d., respectively) compared with controls (P=0.003 and P=0.0001, respectively) and patients >18 years at HCT (P=0.04 and P=0.004, respectively) at an average of 14 years after HCT. In conclusion, this study identified young age at transplant as an important risk factor for bone deficits in young adulthood, suggesting that efforts to reduce bone loss should focus on this patient population.Bone Marrow Transplantation advance online publication, 14 October 2013; doi:10.1038/bmt.2013.156.
Bone marrow transplantation 10/2013; · 3.00 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A previous randomized controlled trial (RCT) by Schiffman et al. (2007)(15) compared four treatments strategies for temporomandibular joint (TMJ) disc displacement without reduction with limited mouth opening (closed lock). In this parallel group RCT, 106 patients with magnetic resonance imaging (MRI)-confirmed TMJ closed lock were randomized between medical management, non-surgical rehabilitation, arthroscopic surgery, and arthroplasty. Surgical groups also received rehabilitation post-surgically. The current paper reassesses the effectiveness of these four treatment strategies using outcome measures recommended by the International Association of Oral and Maxillofacial Surgeons (IAOMS). Clinical assessments at baseline and at follow-up (3, 6, 12, 18, 24, and 60 months) included intensity and frequency of TMJ pain, mandibular range of motion, TMJ sounds, and impairment of chewing. TMJ MRIs were performed at baseline and 24 months, and TMJ tomograms at baseline, 24 and 60 months. Most IAOMS recommended outcome measures improved significantly over time (P≤0.0003). There was no difference between treatment strategies relative to any treatment outcome at any follow-up (P≥0.16). Patient self-assessment of treatment success correlated with their ability to eat, with pain-free opening ≥35mm, and with reduced pain intensity. Given no difference between treatment strategies, non-surgical treatment should be employed for TMJ closed lock before considering surgery.
International Journal of Oral and Maxillofacial Surgery 09/2013; · 1.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background: Previous case reports and animal studies suggest periodontitis is associated with bisphosphonate-related osteonecrosis of the jaw (BRONJ). We conducted a case-control study to evaluate the association between clinical and radiographic measures of periodontal disease and BRONJ. Methods: 25 BRONJ patients were matched with 48 controls. Trained examiners measured probing depth (PD), clinical attachment level (CAL), and bleeding on probing (BOP) on all teeth except third molars, and gingival and plaque indices on six index teeth. Alveolar bone height was measured from orthopantomograms. Most BRONJ cases were using antibiotics (48%) or a chlorhexidine mouthrinse (84%) at enrollment. Adjusted comparisons of cases vs. controls used multiple linear regression. Results: The average number of BP infusions was significantly higher in BRONJ cases compared to controls (38.4 vs 18.8, p=0.0001). In unadjusted analyses, BRONJ cases had more missing teeth (7.8 vs 3.1, p=0.002) and high average CAL (2.18 vs 1.56 mm, p=0.047) and percent of sites with CAL ≥3 mm (39.0 vs 23.3, p=0.039) than controls. Also, BRONJ cases had lower average bone height (as a fraction of tooth length, 0.59 vs 0.62, p=0.004) and more teeth with bone height under half of tooth length (20% vs 6%, p=0.001). These differences remained significant after adjusting for age, sex, smoking, and number of bisphosphonate infusions. Conclusions: BRONJ patients have fewer teeth, greater CAL, and less alveolar bone support compared to controls after adjusting for number of bisphosphonate infusions. Group differences in antibiotics and chlorhexidine rinse usage may have masked differences in the other clinical measures.
Journal of Periodontology 06/2013; · 2.57 Impact Factor