Binod Neupane

Phase 3 trials of stereotactic radiosurgery with or without whole-brain radiation therapy for 1 to 4 brain metastases: individual patient data meta-analysis.

PURPOSE To perform an individual patient data (IPD) meta-analysis of randomized controlled trials evaluating stereotactic radiosurgery (SRS) with or without whole-brain radiation therapy (WBRT) for patients presenting with 1 to 4 brain metastases. METHOD AND MATERIALS Three trials were identified through a literature search, and IPD were obtained. Outcomes of interest were survival, local failure, and distant brain failure. The treatment effect was estimated after adjustments for age, recursive partitioning analysis (RPA) score, number of brain metastases, and treatment arm. RESULTS A total of 364 of the pooled 389 patients met eligibility criteria, of whom 51% were treated with SRS alone and 49% were treated with SRS plus WBRT. For survival, age was a significant effect modifier (P=.04) favoring SRS alone in patients ≤50 years of age, and no significant differences were observed in older patients. Hazard ratios (HRs) for patients 35, 40, 45, and 50 years of age were 0.46 (95% confidence interval [CI] = 0.24-0.90), 0.52 (95% CI = 0.29-0.92), 0.58 (95% CI = 0.35-0.95), and 0.64 (95% CI = 0.42-0.99), respectively. Patients with a single metastasis had significantly better survival than those who had 2 to 4 metastases. For distant brain failure, age was a significant effect modifier (P=.043), with similar rates in the 2 arms for patients ≤50 of age; otherwise, the risk was reduced with WBRT for patients >50 years of age. Patients with a single metastasis also had a significantly lower risk of distant brain failure than patients who had 2 to 4 metastases. Local control significantly favored additional WBRT in all age groups. CONCLUSIONS For patients ≤50 years of age, SRS alone favored survival, in addition, the initial omission of WBRT did not impact distant brain relapse rates. SRS alone may be the preferred treatment for this age group.

Environmental Risk Factors for Community-Acquired Pneumonia Hospitalization in Older Adults

OBJECTIVES: To investigate the risk of hospitalization for pneumonia in older adults in relation to biophysical environmental factors.

Prognosis after West Nile Virus Infection

Context The long-term prognosis of West Nile virus infection is not well understood. Contribution In this longitudinal study of 156 patients with West Nile virus infection, physical and cognitive function seemed to return to population norms within about 1 year. Caution Patients who died were excluded from the analysis, and the analyses depended on statistical assumptions that the data did not always meet. Implication People infected with West Nile virus seem to recover physical and mental function within about 1 year. The Editors West Nile virus, endemic to Africa, Europe, the Middle East, and Asia, has caused recurrent outbreaks in the United States and Canada since 1999 (1, 2). Approximately 20% of infected persons develop a clinical presentation that can range from a mild influenza-like illness to neuroinvasive diseases, such as meningitis, encephalitis, and acute flaccid paralysis (3). Recent studies of persons infected with West Nile virus report that symptoms and signs, such as fatigue, cognitive dysfunction, and motor abnormalities, can persist for months after symptom onset (414). Little is known, however, about how physical and mental functioning changes over time or about long-term recovery among infected persons. Understanding such change patterns is essential to provide accurate prognostic information to patients and their families, as well as to help in the planning of care and evaluation of future interventions. Existing reports provide valuable information on self-reported outcomes (413) but have limitations, including single follow-up assessments (4, 69, 1113), follow-up until 12 months after symptom onset (4, 68, 1014), and lack of validated instruments to measure physical and mental functioning (48, 1113). Moreover, factors associated with slower recovery are unknown. The primary objectives of this study were to describe patterns of physical and mental outcomes after infection with West Nile virus by using longitudinal observations and to assess long-term outcomes. We hypothesized that such long-term outcomes would be worse in patients with neuroinvasive disease than in those with nonneuroinvasive disease. We conducted a longitudinal cohort study to develop prognostic curves for patient-relevant outcomes, such as physical and mental functioning, fatigue, and depression. We also assessed factors associated with delayed recovery of physical and mental outcomes. Methods Study Participants and Protocol Patients with positive West Nile virus IgM antibody-capture enzyme-linked immunosorbent assay (15) from serum or cerebrospinal fluid samples that was subsequently confirmed by plaque reduction neutralization assay (16) were eligible. We enrolled patients with neuroinvasive disease (meningitis, encephalitis, or acute flaccid paralysis) and nonneuroinvasive disease. We aimed to enroll participants within 4 weeks of symptom onset. To allow for feasibility of follow-up, we limited enrollment to geographic regions that had 4 or more infected individuals within an approximate radius of 200 km. Because complications of West Nile virus infection in children are generally less frequent, we excluded persons younger than age 18 years (17). Because the objective of the study was to assess prognosis attributable to West Nile virus, we excluded patients receiving experimental therapy for West Nile virus, as well as those being treated for an illness unrelated to West Nile virus that could interfere with interpretation of the outcome measures. Only 1 patient, who was receiving chemotherapy for a malignant solid organ condition, met the latter criterion. We classified participants with neuroinvasive disease by using previously published criteria for meningitis, encephalitis, and acute flaccid paralysis (4) (Table 1). We classified participants who met criteria for both meningitis and encephalitis as having meningoencephalitis. Only 3 patients had meningitis alone, so we combined them with the meningoencephalitis group for analysis. Table 1. Diagnostic Criteria for Meningitis, Encephalitis, and Acute Flaccid Paralysis We classified participants who were symptomatic but did not meet any of the case definitions for neuroinvasive disease as having nonneuroinvasive disease. We reviewed laboratory, hospital, and clinic medical records to confirm the case definition. Radiologic and laboratory assessments were performed at the discretion of the attending physician. Supportive care, such as physiotherapy or psychotherapy, was under the discretion of the attending physician. We enrolled the first participant on August 2003 and the last on November 2006, with the final follow-up visit on May 2007. Provincial laboratories in Canada conducted all West Nile virus testing and forwarded the names of the physicians whose patients tested IgM-positive for West Nile virus to the study office. We asked these physicians to approach the patients (whose identity remained unknown to the research team, thereby maintaining confidentiality) or their families to see whether they were willing to be contacted about the study. A research nurse then assessed patient eligibility and obtained informed consent. We obtained ethics approval for the study protocol from the relevant review committees at McMaster University, University of Manitoba, University of Saskatchewan, and University of Alberta. All patients or their designated surrogate decision makers who agreed to participate in the study gave informed consent. Outcomes A trained research nurse assessed outcomes on enrollment into the study (baseline visit); on days 10, 20, and 30; and then every month for 12 months. In our original protocol, we planned to obtain repeated measurements at 24 and 36 months for participants enrolled in the first year of the study and to measure outcomes at 24 months (third year of the study) for those participants enrolled in the second year. Because participants were being visited more frequently to obtain blood work for an unrelated study from 15 to 36 months from their enrollment in this study, we obtained additional measurements at 3-month intervals from 15 to 36 months in these participants. A trained research nurse made most assessments during home visits, minimizing missing visits or selection bias based on participants ability to travel (although participants in Saskatchewan and Manitoba were seen in an ambulatory care setting at a tertiary care hospital for their convenience). We recorded age, sex, medical history, and premorbid chronic illnesses. Categories of comorbid conditions included cardiac disease (coronary artery disease and congestive heart failure), peripheral vascular disease, chronic obstructive pulmonary disease, diabetes, renal failure, peptic ulcer disease, cancer, and rheumatologic disease. We assessed all these conditions through interviews with participants and review of medical records. To assess physical functioning, we used the Physical Component Summary (PCS) of the Short Form-36 (18, 19). The Short Form-36 measures 8 health constructs by using 8 scales with 2 to 10 items per scale (total of 36 questions); raw scores range from 0 to 100 but are adjusted for population norms by using a linear transformation (18). For the PCS subscale, scores are standardized to the general U.S. population (mean score, 50 [SD, 10]). Very high scores indicate no physical limitations, disabilities, or decrements in well-being, as well as a high energy level. Very low scores indicate substantial limitations in self-care and physical, social, and role activities; severe bodily pain; or frequent tiredness. To assess mental functioning, we used the Mental Component Summary (MCS) of the Short Form-36. These scores are also standardized to the general U.S. population (mean score, 50 [SD, 10]). Very high scores indicate frequent positive affect and absence of psychological distress and limitations in usual social and role activities due to emotional problems. Very low scores indicate frequent psychological distress and substantial social and role disability due to emotional problems (18). We used the Depression Anxiety Stress Scale (DASS) (20, 21) and the Fatigue Severity Scale (FSS) (22) beginning in 2004 to capture depressive symptoms and persistent fatigue noted among participants after the study had begun. The DASS is a 14-item scale that assesses dysphoria and lack of interest or involvement. Scores range from 0 (no symptoms) to 42. Among a general adult population, 80% of people have a score of 9 or less and 70% have a score of 6 or less (23). The FSS measures the perceived level of fatigue by using a Likert scale, in which the score ranges from 1 (low fatigue level) to 7 (high fatigue level). Two thirds of the general population have a score between 2.7 and 5.3 (24). Statistical Analysis Prognosis We used data from 57 of 64 participants with neuroinvasive disease (meningoencephalitis [n= 32], encephalitis [n= 22], and meningitis [n= 3]) and 92 with nonneuroinvasive disease to estimate prognosis. We excluded 7 patients with acute flaccid paralysis from the analysis because this number was too small to estimate prognostic curves, and we grouped 3 participants with meningitis with the 32 participants in the meningoencephalitis group. We used nonlinear mixed-effects modeling to estimate the parameters of nonlinear models for PCS, MCS, DASS, and FSS scores (25). We compared participants with neuroinvasive disease with those with nonneuroinvasive disease. Of participants with neuroinvasive disease, we compared those with meningoencephalitis with those with encephalitis. The fixed effects in the nonlinear mixed-effects analysis describe the average pattern of change over time, and they indicate the typical course of recovery in this population. The random effects in the nonlinear mixed-effects analysis allow for orderly variations in the pattern of change among patients. We estimated predicted change curves for each patient, and we estimated the degree of i

Predictors of inhospital mortality and re-hospitalization in older adults with community-acquired pneumonia: a prospective cohort study

BackgroundA better understanding of potentially modifiable predictors of in-hospital mortality and re-admission to the hospital following discharge may help to improve management of community-acquired pneumonia in older adults. We aimed to assess the associations of potentially modifiable factors with mortality and re-hospitalization in older adults hospitalized with community-acquired pneumonia.MethodsA prospective cohort study was conducted from July 2003 to April 2005 in two Canadian cities. Patients aged 65 years or older hospitalized for community-acquired pneumonia were followed up for up to 30 days from initial hospitalization for mortality and these patients who were discharged alive within 30 days of initial hospitalization were followed up to 90 days of initial hospitalization for re-hospitalization. Separate logistic regression analyses were performed identify the predictors of mortality and re-hospitalization.ResultsOf 717 enrolled patients hospitalized for community-acquired pneumonia, 49 (6.8%) died within 30 days of hospital admission. Among these patients, 526 were discharged alive within 30 days of hospitalization of whom 58 (11.2%) were re-hospitalized within 90 days of initial hospitalization. History of hip fracture (odds ratio (OR) = 4.00, 95% confidence interval (CI) = (1.46, 10.96), P = .007), chronic obstructive pulmonary disease (OR = 2.31, 95% CI = (1.18, 4.50), P = .014), cerebrovascular disease (OR = 2.11, 95% CI = (1.03, 4.31), P = .040) were associated with mortality. Male sex (OR = 2.35, 95% CI = (1.13, 4.85), P = .022) was associated with re-hospitalization while vitamin E supplementation was protective (OR = 0.37 (0.16, 0.90), P = .028). Lower socioeconomic status, prior influenza and pneumococcal vaccinations, appropriate antibiotic prescription upon admission, and lower nutrition risk were not significantly associated with mortality or re-hospitalization.ConclusionChronic comorbidities appear to be the most important predictors of death and re-hospitalization in older adults hospitalized with community-acquired pneumonia while vitamin E supplementation was protective.

Longitudinal Study of Influenza Molecular Viral Shedding in Hutterite Communities

BACKGROUND The nature of influenza viral shedding during naturally acquired infection is not well understood. METHODS A cohort study was conducted in Hutterite colonies in Alberta, Canada. Flocked nasal swabs were collected during 3 influenza seasons (2007-2008 to 2009-2010) from both symptomatic and asymptomatic individuals infected with influenza. Samples were tested by real-time reverse-transcription polymerase chain reaction for influenza A and influenza B, and the viral load (VL) was determined for influenza A positive samples. RESULTS Eight hundred thirty-nine participants were included in the cohort; 25% (208) tested positive for influenza viruses. They experienced 238 episodes of viral shedding, of which 23 (10%) were not accompanied by symptoms. For seasonal and pandemic H1N1, VL peaked at or before onset of acute respiratory infection. For H3N2, VL peaked 2 days after the onset of acute respiratory infection, which corresponded to peaks in systemic and respiratory symptom scores. Although the duration of shedding was shorter for asymptomatic participants, the peak level of VL shedding was similar to that of symptomatic participants. Viral loads for children and adults revealed similar patterns. CONCLUSIONS Molecular viral shedding values follow symptom scores, but timing of peak VL varies by subtype. Asymptomatic infections are infrequent.

Network meta-analysis using R: a review of currently available automated packages.

Network meta-analysis (NMA) – a statistical technique that allows comparison of multiple treatments in the same meta-analysis simultaneously – has become increasingly popular in the medical literature in recent years. The statistical methodology underpinning this technique and software tools for implementing the methods are evolving. Both commercial and freely available statistical software packages have been developed to facilitate the statistical computations using NMA with varying degrees of functionality and ease of use. This paper aims to introduce the reader to three R packages, namely, gemtc, pcnetmeta, and netmeta, which are freely available software tools implemented in R. Each automates the process of performing NMA so that users can perform the analysis with minimal computational effort. We present, compare and contrast the availability and functionality of different important features of NMA in these three packages so that clinical investigators and researchers can determine which R packages to implement depending on their analysis needs. Four summary tables detailing (i) data input and network plotting, (ii) modeling options, (iii) assumption checking and diagnostic testing, and (iv) inference and reporting tools, are provided, along with an analysis of a previously published dataset to illustrate the outputs available from each package. We demonstrate that each of the three packages provides a useful set of tools, and combined provide users with nearly all functionality that might be desired when conducting a NMA.

Live Attenuated Versus Inactivated Influenza Vaccine in Hutterite Children: A Cluster Randomized Blinded Trial

Influenza is a major cause of morbidity and mortality, resulting in excess hospitalization and death (13). Data from longitudinal studies suggest that children are an important source of community transmission of influenza (48). Vaccinating children against influenza not only protects them but can also provide indirect benefit through herd protection (that is, reducing the risk for influenza in susceptible persons by rendering immunity in others) (916). However, the choice of vaccine that best achieves herd protection remains uncertain (17, 18). Intranasal live attenuated influenza vaccine (LAIV) has been reported to provide 55% greater protection against influenza in children than inactivated influenza vaccine (IIV) (19, 20). Vaccinating children with LAIV compared with IIV should provide better community protection because of better direct protection of children and better indirect effects of herd protection. This question is of public health importance, particularly given differences in recommendations on preferential use of LAIV (2123). Most comparative influenza vaccine studies assess direct protection only (24). Understanding the comprehensive benefit of LAIV versus IIV requires evaluation of both direct and indirect effects. This is best addressed through a randomized, controlled trial; however, random assignment of the children of entire communities to vaccination with LAIV versus IIV is not possible in most settings. Hutterite colony members live communally and are relatively isolated from cities and towns, and influenza is regularly introduced into these colonies. This offers an opportunity to test the effect of vaccinating children with LAIV versus IIV on community protection in a cluster randomized trial (11). We hypothesized that a 70% or greater uptake of trivalent LAIV compared with a similar uptake of trivalent IIV among healthy children and adolescents would reduce laboratory-confirmed influenza by 50% in the LAIV versus IIV group. A 50% risk reduction was selected on the basis of a previous trial showing a 55% direct risk reduction in children who received LAIV compared with IIV (19). We also hypothesized that this would translate to a reduction in influenza-associated outcomes. Methods Study Colonies Residents of Hutterite colonies within 150 km of designated cities or towns in Alberta and Saskatchewan, Canada, were enrolled and followed from 22 October 2012 through 20 May 2015. Each colony was approached annually regarding whether it would enroll for the next influenza season. Colonies were excluded if the children did not receive any routine vaccinations or if local public health policy was to offer influenza immunization to persons beyond high-risk children (for example, those with cystic fibrosis). Hutterite colonies are small communities (for example, 70 to 120 residents) with single-family dwellings and communally shared buildings, such as the kitchen, dining hall, and school. Hutterite families shop in nearby towns for supplies and clothing not available in the colony. The children attend school in the colony. Vaccinated Children Healthy Hutterite children aged 36 months to 15 years (ages when they attend school; age 15 years is when Hutterite children are considered to have reached maturity) were eligible to be vaccinated. Exclusion criteria included anaphylactic reaction to a previous LAIV or trivalent influenza vaccine; known IgE-mediated hypersensitivity to eggs manifested as hives, swelling of the mouth and throat, difficulty breathing, hypotension, or shock; history of asthma; medically diagnosed or treated wheezing within 42 days before enrollment; GuillainBarr syndrome within 8 weeks of a previous influenza vaccine; anaphylactic reaction to any vaccine component; pregnancy; household contact with a severely immunocompromised person who was being cared for in a protective environment; and use of aspirin or salicylate-containing products within 30 days before enrollment. Other Hutterite Colony Members All other residents of Hutterite colonies were eligible to participate as nonvaccine recipients and could receive an influenza vaccine outside of the trial. Ethics approval was obtained at McMaster University, the University of Calgary, and the University of Saskatchewan. Participants gave written consent. Participants provided consent for children, and assent was also directly sought from children aged 7 to 15 years. Interventions In the LAIV group, healthy children aged 36 months to 15 years received a 0.2-mL dose of intranasal LAIV (FluMist [MedImmune]) recommended for the 2012 to 2013 (influenza A/California/7/2009[H1N1]pdm09, influenza A/Victoria/361/2011[H3N2], and influenza B/Wisconsin/1/2010like viruses), 2013 to 2014 (influenza A/California/7/2009[H1N1]pdm09, influenza A/Victoria/361/2011[H3N2], and influenza B/Massachusetts/2/2012like viruses), or 2014 to 2015 influenza seasons (influenza A/California/7/2009[H1N1]pdm09, influenza A/Texas/50/2012[H3N2], and influenza B/Massachusetts/2/2012like viruses). In the IIV group, healthy children aged 36 months to 15 years received a 0.5-mL intramuscular injection of IIV (Vaxigrip [Sanofi Pasteur]) recommended for the 3 influenza seasons. In both LAIV and IIV groups, previously unvaccinated children younger than 9 years at the time of immunization received a second dose of the vaccine 4 weeks after the first dose. Blinding and Allocation A statistician assigned colonies, using a random-number generator, within each of 5 geographic regions where participating Hutterite colonies were located to control for regional differences in influenza circulation. Allocation was to 1 of the 2 study groups (LAIV or IIV) in a 1:1 ratio. To minimize bias, we gave precedence to achieving a balance of colonies within strata or health regions as opposed to balancing overall cluster numbers between groups. We reduced the possibility of enrollment bias by allocating LAIV or IIV status to colonies after participant enrollment. Colonies were not randomly assigned again in the second and third year of the trial so that vaccine allocation remained the same over the entire study. In the event of a colony withdrawal, another colony from the same study region that met eligibility criteria was selected as a replacement and allocated to the same group as the colony that had withdrawn. Arrangements for vaccine shipment from the manufacturer to depots were made by an intermediary clinical trials research organization that received the randomization code from the statistician. To maintain blinding, children allocated to LAIV received a concurrent 0.5-mL saline injection to mimic IIV. Those allocated to IIV received a 0.2-mL dose of intranasal saline. Among children younger than 9 years who had never previously received seasonal influenza vaccine, those allocated to LAIV received a concurrent 0.5-mL intramuscular injection of sterile saline with the first and second dose of intranasal LAIV. Those in the IIV group received concurrent 0.2-mL doses of intranasal saline administered 4 weeks apart. For blinding purposes, different teams were used to vaccinate children or assess outcomes. Vaccines were prepared by nurses behind a privacy screen in the preparation room in the Hutterite colony. Surveillance staff, who assessed outcomes, were not involved in vaccination and were blinded to allocation status. Investigators, study coordinators, study monitors, and the data and safety monitoring board were all blinded. Follow-up The start date of the surveillance period for influenza was defined as 1 or more cases of laboratory-confirmed influenza in 2 consecutive weeks from public health surveillance regions that occurred at least 2 weeks after completion of study vaccination in a study colony; the stop date was defined as no cases of laboratory-confirmed influenza for 2 consecutive weeks in colonies within the health region. Participants were assessed twice weekly by using a standardized checklist of self- or parent-reported symptoms or signs. If any new symptoms were reported, the participant was contacted directly by research staff, who confirmed the symptoms and obtained flocked nasal swabs if 2 or more of the following symptoms were present: fever (temperature 38C), cough, nasal congestion, sore throat, headache, sinus problems, muscle aches, fatigue, ear ache or infection, or chills. We provided thermometers for study participants. Outcomes The primary outcome was laboratory-confirmed influenza A or B in all participants, the assessment of which began 2 weeks after vaccination to ensure adequate time for development of an immune response. For participants with 2 or more signs and symptoms, influenza was confirmed on the basis of detecting viral RNA in respiratory samples through duplex real-time reverse transcriptase polymerase chain reaction (RT-PCR). This test targeted the matrix gene for influenza A virus and the nonstructural gene for influenza B virus (25). All specimens with positive results on RT-PCR were then tested by using Centers for Disease Control and Prevention primers capable of differentiating wild-type from vaccine strains. We also assessed antimicrobial prescriptions, influenza-like illness (defined as a temperature 38.0C and cough) (26), medically attended visits for respiratory illness, school- or work-related absenteeism, emergency department visits, hospital admissions, and deaths. Although we had originally planned to capture hospitalizations, we decided before data collection to consider emergency department visits as a separate outcome from hospital admission. Further, we initially planned to analyze outcomes, including physician-diagnosed otitis media, lower respiratory tract infection, and pneumonia, but a reduction in resources limited our ability to validate these outcomes. We captured all hospitalizations and deaths and reported the number of events in each study group, but because of low numbers, we did not conduct analyses. Adverse Reacti

Systemic Therapy for Previously Untreated Advanced BRAF-Mutated Melanoma: A Systematic Review and Network Meta-Analysis of Randomized Clinical Trials

Importance Multiple effective first-line systemic treatment options are available for patients with advanced BRAF-mutated melanoma. A lack of head-to-head randomized clinical trials (RCTs) comparing targeted and immunotherapies leaves uncertainty regarding optimal first-line treatment. Objective To estimate the relative efficacy and safety of systemic therapies for advanced, treatment-naive, BRAF-mutated melanoma. Data Sources We searched MEDLINE, Embase, and the Cochrane Central Registry of Controlled Trials for phase 2 or 3 RCTs published up until April 29, 2016. Study Selection We included RCTs in which at least 1 intervention was a targeted (BRAF or MEK) or an immune checkpoint (cytotoxic T-lymphocyte–associated antigen 4 [CTLA-4] or programmed cell death 1 [PD-1]) inhibitor. Data Extraction and Synthesis Two reviewers performed study selection, data abstraction, and risk of bias assessment. We performed a Bayesian network meta-analysis using a fixed-effect model to combine direct comparisons with indirect evidence. We estimated hazard ratios (HRs) for overall survival (OS) and progression-free survival (PFS), and odds ratios (OR) for objective response rate (ORR) and serious adverse events. Results Sixteen eligible articles reporting 15 RCTs involving 6662 patients assigned to 1 of 10 treatment strategies were included. Both BRAF/MEK and PD-1 were associated with improved OS benefit compared with all other treatments except CTLA-4/granulocyte macrophage colony-stimulating factor. There was no significant difference in OS between BRAF/MEK and PD-1 (HR, 1.02; 95% credible interval [CrI], 0.72-1.45). The network meta-analysis showed a significant advantage of BRAF/MEK compared with all other treatment strategies for PFS. BRAF/MEK was associated with higher ORR (OR, 2.00; 95% CrI, 1.64-2.45) compared with BRAF alone, with both being superior in achieving ORR compared with other treatments. Chemotherapy and PD-1 were associated with lowest risk of serious adverse events. There was no significant difference in the risk of serious adverse events between chemotherapy and PD-1 (OR, 1.00; 95% CrI, 0.74-1.34). Conclusions and Relevance Compared with other treatments, BRAF/MEK and PD-1 inhibition significantly improved OS. The favorable safety profile of PD-1 inhibitors supports using this option as first-line therapy in circumstances where rapid response is not a priority.

Prognosis of West Nile virus associated acute flaccid paralysis: a case series

IntroductionLittle is known about the long-term health related quality of life outcomes in patients with West Nile virus associated acute flaccid paralysis. We describe the quality of life scores of seven patients with acute flaccid paralysis who presented to hospital between 2003 and 2006, and were followed for up to two years.Case presentationsBetween 2003 and 2006, 157 symptomatic patients with West Nile virus were enrolled in a longitudinal cohort study of West Nile virus in Canada. Seven patients (4%) had acute flaccid paralysis. The first patient was a 55-year-old man who presented with left upper extremity weakness. The second patient was a 54-year-old man who presented with bilateral upper extremity weakness. The third patient was a 66-year-old woman who developed bilateral upper and lower extremity weakness. The fourth patient was a 67-year-old man who presented with right lower extremity weakness. The fifth patient was a 60-year-old woman who developed bilateral lower extremity weakness. The sixth patient was a 71-year-old man with a history of Parkinsons disease and acute onset bilateral lower extremity weakness. The seventh patient was a 52-year-old man who presented with right lower extremity weakness. All were Caucasian. Patients were followed for a mean of 1.1 years. At the end of follow-up the mean score on the Physical Component Summary of the Short-Form 36 scale had only slightly increased to 39. In contrast, mean score on the Mental Component Summary of the Short-Form 36 scale at the end of follow-up had normalized to 50.ConclusionDespite the poor physical prognosis for patients with acute flaccid paralysis, the mental health outcomes are generally favorable.

What Psychological, Physical, Lifestyle, and Knowledge Factors Are Associated With Excess or Inadequate Weight Gain During Pregnancy? A Cross-Sectional Survey

OBJECTIVE Excess weight gain during pregnancy is associated with increased risks of overweight and obesity in both women and their children. Conversely, inadequate weight gain can predispose to growth restriction, which is also associated with childhood obesity. Because most pregnant women now gain more weight than is recommended in guidelines and a substantial portion gain less than the recommended amounts, we sought to determine factors associated with inappropriate weight gain, including physical, lifestyle, knowledge, and particularly psychological factors. METHODS We conducted a self-administered cross-sectional survey of English-speaking women with a live, singleton gestation. Biologically relevant variables significant at P < 0.10 were included in multiple logistic regression. RESULTS Three hundred thirty women completed the survey, a response rate of 90.7%. Gaining weight above the amount recommended in guidelines was associated with planning to do so (adjusted OR [aOR] 11.18; 95% CI 4.45 to 28.06), bedtime television (aOR 2.38; 95% CI 1.08 to 5.23), and higher emotional instability scores (aOR 1.26; 95% CI 1.10 to 1.44). Inadequate weight gain was associated with less satisfaction with body weight (aOR 4.84; 95% CI 1.56 to 15.02) and bedtime television (aOR 3.92; 95% CI 1.50 to 10.30), while self-efficacy towards healthy weight was protective (aOR 0.91; 95% CI 0.83 to 0.99). CONCLUSION Planned weight gain was most strongly associated with excess gestational weight gain, followed by bedtime television watching and emotional instability, while inadequate gain was associated with less satisfaction with body weight and bedtime television watching. Better characterization of psychological and other factors that predict inappropriate gain will be critical for providing a basis for interventions.