Jeanelle Sheeder

A longitudinal study of T1 hypointense lesions in relapsing MS MSCRG trial of interferon β-1a

Background: T1 hypointense lesions (T1 black holes) are focal areas of relatively severe CNS tissue damage detected by MRI in patients with MS. Objective: To determine the natural history of T1 hypointense lesions in relapsing MS and the utility of T1 hypointense lesions as outcome measures in MS clinical trials. Methods: MR studies were from the Multiple Sclerosis Collaborative Research Group trial. Longitudinal results are reported in 80 placebo- and 80 interferon β-1a (IFNβ-1a)–treated patients with mild to moderate disability relapsing-remitting MS. Results: There was a small but significant correlation between T1 hypointense lesion volume and disability at baseline and on trial (r = 0.22, r = 0.28). In placebo patients there was a 29.2% increase in the mean volume of T1 hypointense lesions (median 124.5 mm3) over 2 years (p < 0.001 for change from baseline), as compared to an 11.8% increase (median 40 mm3) in the IFNβ-1a–treated patients (change from baseline not significant). These treatment group comparisons did not quite reach significance. The most significant contributor to change in T1 hypointense lesions was the baseline number of enhancing lesions (model r2 = 0.554). Placebo patients with more active disease, defined by enhancing lesions at baseline, were the only group to show a significant increase in T1 hypointense lesion volume from baseline. Conclusion: The development of T1 hypointense lesions is strongly influenced by prior inflammatory disease activity, as indicated by enhancing lesions. These results suggest that treatment with once weekly IM IFNβ-1a (30 mcg) slows the 2-year accumulation of these lesions in the brain.

Auditory M100 component 1: relationship to Heschl's gyri

This study was designed to localize the neuroanatomic generator of the 100 ms latency magnetic auditory evoked field (EF) component (M100) activated by an unattended tone pip. Magnetic EFs in response to 25 ms duration, 90 dB, 1 kHz tone pips were recorded from both hemispheres of nine normal adults, five males and four females, using a seven-channel second-order gradiometer. The source of the M100 was estimated, with confidence intervals, by a least squares based inverse solution algorithm. Magnetic resonance (MR) images of the brain were acquired with a 1.5 T system using a standard head coil. The superior temporal gyri (STG) were manually segmented from 1.7 mm thick coronal images, and the superior surfaces were then rendered from the 3-D volume data. Translation and rotation matrices were identified to locate the magnetoencephalography (MEG) determined sources within the reconstructed STGs. This population of 18 STGs in 9 individuals demonstrated two transverse gyri in 4 of 9 left hemispheres, and 5 of 9 right hemispheres. All 9 left hemisphere M100 sources were in or included Heschls gyrus(i) in the confidence intervals. Seven of the 9 included Heschls gyrus(i) on the right: the remaining two, both males, had sources slightly anterior to Heschls gyrus(i). We conclude that all M100 source location estimates were compatible with an auditory koniocortex source in or adjacent to Heschls gyri.

Addition of Metformin to a Lifestyle Modification Program in Adolescents with Insulin Resistance

OBJECTIVE To evaluate whether metformin, when added to a program of personal goal setting, improves weight loss and clinical status in obese adolescents. STUDY DESIGN In a randomized double-blind placebo controlled trial, 85 adolescents with insulin resistance were randomized to receive metformin (70%) or placebo (30%), along with monthly goal setting for diet and exercise modification. Anthropometric measures, fasting blood analysis, and glucose tolerance tests were performed at baseline and 6 months. RESULTS Mean age was 15.7 years. Mean body mass index (BMI) was 39.7 kg/m(2). 71% were female, 58% were Hispanic, and 34% were African-American. 76% of participants completed the study. Goal setting alone did not result in significant weight loss. In addition, there were no group differences between metformin and placebo in weight loss or measures of glucose metabolism. However, among females taking metformin, there was a significant decrease in BMI not seen in the placebo group. Furthermore, metformin adherence, when accompanied by lifestyle change, was a predictor of BMI decrease of 5% or more. 60% of 10 subjects who adhered to metformin and decreased portion size decreased BMI by >5%. CONCLUSIONS In this group of predominately minority adolescents, monthly goal setting alone did not lead to weight loss. Although the addition of metformin had no effect on weight loss overall, the agent did significantly increase weight loss among females and weight loss was predicted by degree of metformin adherence. However, weight loss was only found in those participants also reporting lifestyle change, particularly a decrease in portion sizes. These results suggest that metformin may be a useful agent to promote short-term weight loss among girls making modest lifestyle changes.

Screening for Postpartum Depression at Well-Child Visits: Is Once Enough During the First 6 Months of Life?

OBJECTIVE. Screening for maternal depression is gaining acceptance as a standard component of well-child care. We tested the feasibility of this policy and determined the prevalence and incidence of maternal depression at well-child visits during the first 6 months of life. METHODS. Providers in an adolescent-oriented maternity program were cued electronically, when they opened the electronic medical records of 0- to 6-month-old infants to conduct well-child visits, to ask the mothers to complete the Edinburgh Postpartum Depression Scale. Incident cases represented mothers who crossed the referral threshold (score of ≥10) after the first screening. RESULTS. Mothers usually brought their infants to the clinic, and none refused screening. Providers could act on 99% of the 418 screening cues; they administered the Edinburgh Postpartum Depression Scale 98% of the time and always referred mothers with scores of ≥10. Overall, 20% of the mothers scored ≥10. Scores were unstable at ≤3 postpartum weeks (κ = 0.2). Thereafter, the prevalence and incidence of scores of ≥10 decreased from 16.5% at 2 months to 10.3% and 5.7%, respectively, at 4 months. Prevalence increased to 18.5% at the 6-month visit, and incidence decreased to 1.9%. Repeat screening detected only 2 mothers (5.7%) with scores of ≥10. CONCLUSIONS. Electronic cueing improved compliance with the detection and referral phases of screening for maternal depression at well-child visits. Screening 2 months after delivery detects most mothers who become depressed during the first 6 postpartum months, and screening at the 6-month well-child visit is preferable to screening at the 4-month visit.

IUD use in adolescent mothers: retention, failure and reasons for discontinuation☆☆☆

BACKGROUND Many professional organizations recommend intrauterine device (IUD) use in adolescents, but data on performance of currently available devices in US teens are scant. We describe IUD continuation, side effect and pregnancy rates in parous adolescents. STUDY DESIGN Between 2002 and 2008, a cohort of 136 young mothers from an adolescent pregnancy/postpartum program received either a CuT380A or LNG-IUS for contraception. A minimum of 2 years postplacement, IUD status was ascertained by records review and phone interviews. Discontinuation, side effect and pregnancy rates by IUD type were calculated and compared. RESULTS Mean and median survival times were 25.1 and 14.1 months, respectively, and did not differ by IUD type. Twelve-month continuation was 55%. Of the 87 removals, the most common reasons were expulsion (14.2%), pain (12.2%), bleeding (7.4%), pregnancy desire (6.8%) and pregnancy (4.7%), and rates did not differ significantly by IUD type. First-year pregnancy rates with IUD in situ was 6.2% for the CuT380A and 3.7% for the LNG-IUS (p=.5). Rates of removal for bleeding and pain were similar for both devices. CONCLUSION Over half of parous adolescents who choose IUDs keep them for at least 1 year. Expulsion rates and pregnancy rates are higher than reported in the general population.

Identifying Postpartum Depression: Are 3 Questions as Good as 10?

BACKGROUND. Postpartum depression is the most common medical problem that new mothers face. Anxiety is a more prominent feature of postpartum depression than of depression that occurs at other times in life. Routine, universal screening significantly improves detection in primary health care settings. Thus, an ultrabrief scale that could be incorporated into a general health survey or interview would be useful. OBJECTIVE. We tested the hypothesis that, during the first 6 postpartum months, the 3-item anxiety subscale of the Edinburgh Postpartum Depression Scale is a better ultrabrief depression screener than 2 Edinburgh Postpartum Depression Scale questions that are almost identical to the widely used Patient Health Questionnaire. METHODS. A cohort of 199 14- to 26-year-old participants in an adolescent-oriented maternity program completed the Edinburgh Postpartum Depression Scale at well-child visits during the first 6 postpartum months. Three subscales of the Edinburgh Postpartum Depression Scale were examined as ultrabrief alternatives: the anxiety subscale (3 items; Edinburgh Postpartum Depression Scale-3), the depressive symptoms subscale (7 items; Edinburgh Postpartum Depression Scale-7), and 2 questions that resemble the Patient Health Questionnaire (Edinburgh Postpartum Depression Scale-2). The reliability, stability, and construct validity of the Edinburgh Postpartum Depression Scale and 3 subscales were compared. Criterion validity was assessed by comparison with a score of ≥10 on the full, 10-item Edinburgh Postpartum Depression Scale. RESULTS. A total of 41 mothers (20.6%) met study criteria for referral for evaluation of depression (Edinburgh Postpartum Depression Scale-10 score ≥ 10). The Edinburgh Postpartum Depression Scale-3 exhibited the best screening performance characteristics, with sensitivity at 95% and negative predictive value at 98%. It identified 16% more mothers as depressed than the Edinburgh Postpartum Depression Scale did. The performance of the Edinburgh Postpartum Depression Scale-2 was markedly inferior, with sensitivity at 48% to 80%. Moreover, the Edinburgh Postpartum Depression Scale-2 was unreliable for mothers who had not been depressed in the past. CONCLUSION. The brevity, reliability, and operating characteristics of the Edinburgh Postpartum Depression Scale-3 make it an attractive postpartum depression screening tool for primary health care settings in which the goal is to detect depression, not to assess its severity. Validation by diagnostic psychiatric interview is needed.

The thalamus and the schizophrenia phenotype: failure to replicate reduced volume.

BACKGROUND Thalamic abnormalities resulting in impaired attention and information processing may form a foundation for cognitive and perceptual disturbances in schizophrenia. Measurements of the thalamus in patients with schizophrenia have shown reductions relative to normal comparison subjects. METHODS In the current project, magnetic resonance images of the brain were obtained in 10 male and 11 female subjects with paranoid-type schizophrenia, and 15 male and 12 female normal comparison subjects. Total brain and bilateral thalamic volumes were calculated. RESULTS There were no significant diagnosis, hemisphere, or gender differences in thalamic volumes. CONCLUSIONS Structural thalamic abnormalities are not likely to universally and parsimoniously explain the schizophrenia phenotype. Abnormal thalamic size in patients with schizophrenia should be understood as reflecting one of several possible structural abnormalities contributing to production of the schizophrenia phenotype, but must be regarded with caution unless paired with functional studies.

Presence of the Metabolic Syndrome in Obese Adolescents Predicts Impaired Glucose Tolerance and Nonalcoholic Fatty Liver Disease

PURPOSE To evaluate whether the presence of metabolic syndrome (MS) in obese adolescents is associated with other comorbidities of obesity METHODS A total of 85 obese teens (70% female and 30% male) with fasting insulin >25 microU/ml and family history of type 2 diabetes mellitus and/or acanthosis nigricans were studied. Mean age was 15.8 +/- 1.7 years and body mass index (BMI) was 39.3 +/- 6.6 kg/m(2). Of the subjects, 54% were Hispanic and 35% black, 5% white, 5% American Indian, and 1% Asian. Laboratory analysis included fasting lipids, glucose, gamma-glutamyl transpeptidase (GGT), and oral glucose tolerance testing. Additional liver transaminase levels were determined and liver ultrasound (US) was performed to evaluate the presence and severity of fatty liver. RESULTS All subjects met MS criteria for children for waist circumference, 49% for blood pressure, 54% for high-density lipoprotein, 54% for triglycerides, and 20% for impaired fasting glucose (IFG) or impaired glucose tolerance [IGT]). In all, 47 subjects had three or more MS criteria. BMI was no different between groups with and without MS. Subjects with three or more MS criteria were more likely to have IGT (p = .004), elevated alanine aminotransferase (p = .039), elevated GGT (p = .036), fatty liver on US (p < .001), and more severe fatty liver (p = .001). CONCLUSIONS Abnormal glucose regulation and evidence of nonalcoholic fatty liver disease (NAFLD) were more common in subjects meeting three criteria for MS than in those meeting fewer criteria. The identification of MS provides value to the primary care provider. Those patients meeting criteria for MS should be evaluated for glucose intolerance and NAFLD.

A review of prenatal group care literature: the need for a structured theoretical framework and systematic evaluation.

The purpose of this article is to systematically review the literature on group-based prenatal care related to patient participation, attendance, satisfaction, knowledge, pregnancy and birth outcomes, and program cost. MEDLINE, CINAHL, and PsycINFO sources were searched for English-language articles published any time prior to June 2010. Manual searches of bibliographies were conducted and experts were consulted to identify possible sources. Descriptive, cross-sectional, cohort, and randomized control studies that assessed group-based prenatal care were selected. Of the 15 articles reviewed, 11 studies met inclusion criteria for analysis of the study attributes and outcome data related to patient participation, attendance, satisfaction, knowledge, as well as breastfeeding, pregnancy and birth outcomes, and program cost. Results from the review show that group prenatal care may be associated with improved patient and birth outcomes including reduction in the number of preterm deliveries, higher patient participation and satisfaction, and increased initiation of breastfeeding. Prenatal group care research is limited by relatively few studies, most of which lack rigor. The current model of prenatal group care lacks a theoretical framework for describing and evaluating group processes as well as intermediary factors of prenatal and birth outcomes. Research on group care would benefit from additional randomized controlled trials that assess cost and sustainability and formally evaluate group process and intermediary factors thought to account for improved outcomes.

Preparedness of Obstetrics and Gynecology Residents for Fellowship Training.

OBJECTIVE: To evaluate the perceptions of fellowship program directors of incoming clinical fellows for subspecialty training. METHODS: A validated survey by the American College of Surgeons was modified and distributed to all fellowship program directors in four subspecialties within obstetrics and gynecology: female pelvic medicine and reconstructive surgery, gynecologic oncology, maternal–fetal medicine, and reproductive endocrinology–infertility. The 59-item survey explored five domains concerning preparedness for fellowship: professionalism, independent practice, psychomotor ability, clinical evaluation, and academic scholarship. A Likert scale with five responses was used and tailored to each subspecialty. Standard statistical methods were used to compare responses between subspecialties and to analyze data within each subspecialty individually. RESULTS: One hundred thirty directors completed the survey, for a response rate of 60%. In the domain of professionalism, more than 88% of participants stated that incoming fellows had appropriate interactions with faculty and staff. Scores in this domain were lower for gynecologic oncology respondents (P=.046). Responses concerning independent practice of surgical procedures (hysterectomy, pelvic reconstruction, and minimally invasive) were overwhelmingly negative. Only 20% of first-year fellows were able to independently perform a vaginal hysterectomy, 46% an abdominal hysterectomy, and 34% basic hysteroscopic procedures. Appropriate postoperative care (63%) and management of the critically ill patient (71%) were rated adequate for all subspecialties. CONCLUSION: Graduating residents may be underprepared for advanced subspecialty training, necessitating an evaluation of the current structure of resident and fellow curriculum. LEVEL OF EVIDENCE: III