Sitting balance: its relation to function in individuals with hemiparesis

OBJECTIVES

To evaluate test-retest reliability of sitting balance measures in healthy subjects and individuals with hemiparesis secondary to stroke, to evaluate the ability of the balance measures and Functional Independence Measure (FIM) to document changes over time, and to compare changes in the balance measures and FIM to each other.

METHOD

Six nonpatient subjects were evaluated for test-retest reliability. Fourteen subjects with hemiparesis were tested every 2 weeks during their hospitalization on their ability to lean to either side, lean forward, and maintain a symmetrical posture. Maximum displacement was recorded using the Balance System. FIM scores were obtained for each testing session.

RESULTS

Test-retest reliability for nonpatient subjects was high and for patients was moderate to high. Leaning forward and to the paretic side showed the greatest number of correlations with the FIM scores. All of the FIM scales and the forward lean measure documented progress.

CONCLUSIONS

The protocol developed to test sitting balance, using the Balance System, seems appropriate for use with patient populations. The ability to lean maximally to either side or forward or sit symmetrically is not strongly related to function.

The Hopelessness Scale for Children: psychometric properties with hospitalized adolescents

This study examined the internal consistency and factor structure of the Hopelessness Scale for Children with 201 adolescent inpatients (M age = 15.4 years). In comparison to the psychometric properties of the scale found with younger children, our findings suggest adequate, but lower, internal consistency reliability and a weak core factor structure. The results are discussed in terms of possible changes in the child scale or the alternative use of an adult measure of hopelessness with adolescents.

Autotransplants in multiple myeloma: what have we learned?

Of 496 consecutive patients with multiple myeloma (MM) enrolled in clinical trials of tandem transplants with peripheral blood stem cells support, 470 (95%) completed the first autotransplant with melphalan 200 mg/m2 (MEL 200) and 363 (73%) completed the second transplant with either MEL 200 (40%), MEL 140 mg/m2 (MEL 140) with total-body irradiation (17%), or a combination of alkylating agents (16%), depending on the response status prior to the second transplant; 31 patients up to age 60 years received an allograft as the second transplant. The median interval from first to second transplant was 5 months. Treatment-related mortality during the first year after transplantation was 7%, and complete remission (CR) was obtained in 36%; the median durations of event-free survival (EFS) and overall survival (OS) after transplant were 26 and 41 months, respectively. Low beta 2-microglobulin ([B2M] < or = 2.5 mg/L) and C-reactive protein ([CRP] < or = 0.4 mg/dL) were the most significant standard parameters associated with both prolonged EFS and OS. Median OS exceeded 5.5 years in the one third of patients with both low B2M and CRP. When cytogenetics were included in the analysis, the presence of 11q abnormalities and/or complete or partial deletion of chromosome 13 ("unfavorable karyotype") became a dominant negative feature for both EFS and OS. In addition to these pretransplant parameters, attainment of CR and application of two transplants within 6 months both significantly extended EFS and OS. The group of patients (7%) with high B2M and CRP with either IgA isotype or unfavorable karyotype had the worst prognosis (EFS, < or = 10 months; median OS, < or = 12 months) and will require novel therapy. We conclude that tandem transplants are feasible in the majority of patients up to age 70 years, effecting CR in one third of all patients. Median OS was greater than 5.5 years, regardless of pretransplant features, if the first transplant was applied within 12 months of initial treatment and the second transplant no more than 6 months later.

Ki- 1-positive anaplastic large cell lymphoma of the masticator space with intracranial extension

Ki- 1-positive anaplastic large cell lymphoma (ki- 1 ALCL) is a recently recognized form of non-Hodgkin lymphoma occurring predominantly in the skin and/or peripheral lymph nodes. We report the clinical, pathologic, and radiographic findings of a case of Ki- 1 ALCL arising within the masticator space and extending intracranially into the epidural space.

How much does inferior capsular shift reduce shoulder volume?

The purpose of this study was to quantitate the effect of inferior capsular shift on shoulder volume. Four fresh frozen cadaveric shoulders were analyzed. Volume before and after shift was determined using 3 techniques: (1) Magnetic resonance imaging sequences were digitized to computer and analyzed for volume via a 35-mm camera using Cue 2 software. The capsule was delineated by contrast between light and dark regions. Volume was calculated by summing the total area of respective slices. (2) Ultrasound images, obtained after surgical exposure of the capsule, were digitized. Volume was calculated using the formula for a prolate ellipsoid. (3) An 18-gauge needle was used to inject and evacuate saline via an anterior approach. Quantity of aspirated fluid provided a direct measure of volume. Inferior capsular shift was performed. After the operation, measurements were repeated. Inferior capsular shift reduced volume in all shoulders with each technique. On average, inferior capsular shift reduced joint volume by 57 %). A measurable reduction in shoulder joint volume is an effect of capsular shift. This measurement may have clinical application if volume is an indicator of instability or laxity.

Comparison of efficacy of sulbactam: ampicillin to ampicillin and saline for treatment of experimentally induced Escherichia coli diarrhea in neonatal calves

A study was conducted to compare the efficacy of sulbactam: ampicillin (SAMP) (3.3:6.6 mg/kg body weight (BW), IM, q24 h) to that of ampicillin trihydrate (AMP) (6 mg/kg BW, IM, q24 h) and 0.9% saline (SAL) (3 mL IM, q24 h) for the treatment of diarrhea in calves induced by oral inoculation with Escherichia coli strain B44 (O9:K30:K99:H-). Treatment was initiated when severe diarrhea was noted (T0) and continued for at least 3 d; or for 24 h after clinical signs resolved; or for a maximum duration of 7 d. Starting at T0, calves were examined twice daily: appetite; rectal temperature (TEMP); and fecal consistency (FECAL), mental status (ATTD), eye position (EYE), and skin elasticity (SKIN) scores were recorded. Feces collected at T0 were submitted for bacteriology, electron microscopy, and parasitology. A complete blood count was performed at T0 and T3 (24 h after third treatment). Severely dehydrated, depressed, and anorexic calves were euthanized and considered mortalities. Cause of death was determined by post mortem examination. A total of 30 calves were included in the study. Three calves were excluded from final analysis. E. coli strain B44 was cultured from feces of all calves at T0. At T2 (24 h after second treatment) mean TEMP of SAMP calves was significantly higher (P < 0.05) than mean TEMP of SAL calves; EYE and SKIN scores of SAMP calves were significantly lower (P < alpha beta = 0.025) than those of SAL and AMP calves; and ATTD and FECAL scores of SAMP calves were significantly lower (P < alpha beta = 0.025) than in SAL calves. At T3, SAMP calves had significantly lower (P < 0.05) mean hematocrit than SAL calves and lower mean total plasma protein concentration than AMP and SAL calves. Mean fibrinogen concentration in SAMP calves at T3 was significantly lower (P < 0.05) than that of calves receiving either SAL or AMP. The number of surviving SAMP calves (10/10) was significantly higher (P < alpha beta = 0.025) than the number of surviving SAL calves (2/9), but not significantly different from the surviving AMP calves (3/8).

Hugging perfusion balloon salvage of a right coronary artery angioplasty

A case is described in which hugging balloons, one a perfusion and the other a non-perfusion balloon, were used to salvage a failed coronary angioplasty. A discussion concerning balloon combinations, techniques, and therapeutic options is included.

Influence of interleukin-2 regimens on circulating populations of lymphocytes after adoptive transfer of anti-CD3-stimulated T cells: results from a phase I trial in cancer patients

The adoptive transfer of anti-CD3-stimulated T killer (T-AK) cells was tested with different bolus and infusional interleukin-2 (IL-2) regimens, and anti-CD3 stimulation procedures to determine immunologic and antitumor effects in patients with a variety of advanced cancers. Indium-111 labeling was used to observe traffic patterns of the infused T-AK. Autologous peripheral blood mononuclear cells were obtained by leukapheresis. Cyclophosphamide (300 mg/m2) was given to most patients immediately after leukapheresis. The harvested cells were activated ex vivo with anti-CD3 overnight or for 4 days, at which time cells were reinfused and an IL-2 regimen was begun. Treatment was repeated 28 days later. This treatment regimen induced significant increases in leukocytes, lymphocytes, and eosinophils in patients in most treatment cohorts. Circulating lymphocytes were predominantly CD3+ T cells with preferential expansion of the CD8+ subset. Patients receiving cells stimulated in vitro for 4 days had significant T-cell lymphocytosis with either infusional or bolus plus infusional IL-2 regimens. T-cell viability was decreased in culture after a second 4-day stimulation with anti-CD3 at day 28; this decrease could be prevented by adding IL-2 to the culture media. Cells stimulated overnight required both bolus and infusional IL-2 to show an atypical lymphocytosis in vivo. Overnight-stimulated T-AK did not show decreases in in vitro viability at the day 28 restimulation. Indium-III-labeled cells trafficked to the liver, spleen, and bone marrow. No increase in uptake was observed in tumor deposits. There were 2 patients with partial responses, 5 with minor responses, 19 with stable disease, and 88 with progressive disease. The length of in vitro anti-CD3 stimulation, and the dose and timing of IL-2 administration in vivo results in different circulating leukocyte populations after adoptive T-AK infusion. Generally, the CD8+ T-cell subset was preferentially expanded by this treatment approach. Repeated ex vivo stimulation with anti-CD3 may cause cell death.

Soluble versus cell-bound CD4, CD8 from bronchoalveolar lavage: correlation with pulmonary diagnoses in human immunodeficiency virus-infected individuals

Identification and assessment of cell populations in bronchoalveolar lavage (BAL) specimens may he used to follow the course of a disease state or response to specific therapy. Beyond cellular assessment, there are indications that the presence and quantity of soluble surface antigens released from activated cells may lead to improved understanding and facilitated diagnosis of a number of disease states. This study evaluated soluble markers (sCD4 and sCD8) in BAL and serum from HIV-infected individuals undergoing diagnostic bronchoscopy, and compared these values to flow cytometry-quantified BAL and peripheral blood cell CD4 and CD8. Patient pulmonary diagnosis (based on cytology and microbiology) was compared with patient blood and BAL-soluble and cell-bound CD4 and CD8 to determine the relationship of these markers to disease states in this population. Serum sCD8 in patients with fungal infections was significantly elevated above sCD8 in patients with Pneumocystis carinii or pulmonary bacterial infections, p = 0.0001. BAL sCD4/sCD8 ratio was also significantly different in patients with bacterial vs. fungal pulmonary infections, p = 0.01. These findings suggest that soluble markers, particularly elevated sCD8, may be an important indication of pulmonary disease progression in these HIV+ patients with fungal infections.

Maintaining esthetic restorations in the periodontal practice

Esthetic dentistry comprises one of the most rapidly growing segments of our profession, and patients receiving this type of treatment are often maintained on an alternating schedule. Improper maintenance care can quickly destroy many of these restorations. This article will serve as a resource for dental professionals who wish to offer these special patients customized maintenance care.

Effectiveness and safety of diltiazem or lisinopril in treatment of hypertension after heart transplantation. Results of a prospective, randomized multicenter trail

OBJECTIVES

The purpose of this study was to determine the effectiveness and safety of diltiazem or lisinopril for treatment of hypertension after heart transplantation.

BACKGROUND

Systemic hypertension is common after heart transplantation, and to date there are no randomized, prospective multicenter treatment trials.

METHODS

Members of the Cardiac Transplant Research Database Group developed and implemented a prospective, randomized multicenter trial of the effectiveness and safety of diltiazem or lisinopril in the treatment of hypertension in cyclosporine-treated patients after heart transplantation.

RESULTS

One hundred sixteen patients with hypertension (blood pressure > or = 140/90 mm Hg) after heart transplantation were randomized for > or = 3 months of treatment. Of 55 diltiazem-treated patients, 21 (38%) were responders (diastolic blood pressure < 90 mm Hg), 23 (42%) were nonresponders (diastolic blood pressure > or = 90 mm Hg), and 11 (20%) were withdrawn from the study. Of 61 lisinopril-treated patients, 28 (46%) were responders, 22 (36%) were nonresponders, and 11 (18%) were withdrawn. There was no difference in baseline characteristics or percent responders between the two groups. Systolic pressure decreased from 157 +/- 2.3 to 130 +/- 2.0 mm Hg (mean +/- 1 SEM) in the diltiazem-treated responders and from 153 +/- 2.1 to 127 +/- 2.7 mm Hg in the lisinopril-treated responders (p < 0.0001). Diastolic pressure decreased from 100 +/- 0.9 to 85 +/- 1.6 mm Hg in the diltiazem-treated responders and from 100 +/- 1.0 to 84 +/- 2.0 mm Hg in the lisinopril-treated responders (p < 0.0001). There were a total of 35 reported adverse events, 22 of which led to withdrawal of the patient from the study. All drug-related side effects were considered minor and resolved with discontinuation of the drug.

CONCLUSIONS

These results indicate that both diltiazem and lisinopril are safe for treatment of hypertension after heart transplantation, although titrated monotherapy with either drug controlled the condition in < 50% of patients.

The effect of soft cervical collars on persistent neck pain in patients with whiplash injury

OBJECTIVE

To assess the efficacy of soft cervical collars in the early management of whiplash-injury-related pain.

METHODS

A controlled, clinical trial was conducted in an urban ED. Adults with neck pain following automobile crashes indicated their initial degrees of pain on a visual analog scale. Patients with cervical spine fractures or subluxation, focal neurologic deficits, or other major distracting injuries were excluded. Patients were assigned to receive a soft cervical collar or no collar based on their medical record numbers. Pain at > or = 6 weeks postinjury was coded as none, better, same, or worse, and analyzed as 3 dichotomous outcomes: recovered (pain = none); improved (pain = none or better); and deteriorated (pain = worse).

RESULTS

Of 250 patients enrolled, 196 (78%) were available for follow-up. Of these patients, 104 (53%) were assigned to the soft cervical collar group, and 92 (47%) to the control group. These groups were similar in age, gender, seat position in the car, seat belt use, and initial pain score. Pain persisted at > or = 6 weeks in 122 (62%) patients. The groups showed no difference in follow-up pain category (p = 0.59). There was no significant difference between the 2 groups in complete recovery (p = 0.34), improvement (p = 0.34), or deterioration (p = 0.60). The study had a power of 80% to detect an absolute difference of at least 20% in recovery, 17% in improvement, and 7% in deterioration (2-tailed, alpha = 0.05).

CONCLUSIONS

Most patients with whiplash injuries have persistent pain for at least 6 weeks. Soft cervical collars do not influence the duration or degree of persistent pain.

Sex steroid hormones and macrophage function

Macrophages are versatile cells whose activities are programmed by environmental signals. In this review, we discuss the potential impact of sex steroid hormones on macrophage activation and production of various effector molecules. The evidence accumulated to date supports the postulate that estrogens, progesterone, androgens and testosterone profoundly influence host defense by controlling the ability of macrophages to participate in immune responses.

A double-blind randomized comparison of lidocaine and saline for cervical anesthesia

OBJECTIVE

To compare bacteriostatic saline and buffered lidocaine for cervical anesthesia to blunt the reported pain during brief suction curettage.

METHODS

A double-blind randomized clinical trial was conducted on women presenting for pregnancy termination procedures. Participants received either paracervical submucosal injections of bacteriostatic saline or 1% buffered lidocaine just before cervical dilation. Self-reported pain intensity was assessed at three time points during and 30 minutes after the procedure.

RESULTS

Fifty-two of 135 eligible women presenting for pregnancy termination procedures participated in the study. Pain intensity ratings in lidocaine and saline treatment subjects did not differ significantly at any point. Our study had a power of 0.94 to detect more than a 15% difference on the 21-point box scale between the two solutions. Only one patient requested her block be repeated, and she had received lidocaine originally. Furthermore, of those women receiving lidocaine, 11% reported mild toxicity symptoms.

CONCLUSION

To minimize lidocaine toxicity for a brief suction curettage procedure, bacteriostatic saline or very dilute lidocaine could be considered for the paracervical injection solution. The local anesthetic mechanism may be distention rather than blockage of specific autonomic nerves when there is no waiting period. This would mean that the term paracervical block could be changed to cervical anesthesia.

Epstein-Barr virus reactivation in hairy leukoplakia

Hairy leukoplakia, often seen in patients with acquired immunodeficiency syndrome, is strongly associated with Epstein-Barr virus (EBV) infection and questionably associated with human papillomavirus (HPV) infection. To date, most in situ hybridization (ISH) studies suggest that the EBV is localized only to the superficial squamous layers, favoring the theory of lingual infection by saliva rather than by reactivation of latent lingual infection. We describe 11 formalin-fixed, paraffin-embedded specimens from patients with lingual hairy leukoplakia that we examined for the presence of the EBV, HPV, cytomegalovirus, and human immunodeficiency virus. We used standard DNA ISH for the EBV and cytomegalovirus and polymerase chain reaction ISH for the EBV, HPV, and human immunodeficiency virus. The EBV was present in all 11 specimens according to polymerase chain reaction ISH studies but in only seven specimens according to conventional DNA ISH. Polymerase chain reaction ISH localized the EBV to the basal and parabasal layers in addition to the strong localization in the upper epithelial layers. No evidence for HPV or cytomegalovirus DNA was found. The human immunodeficiency virus was focally localized to rare superficial squamous cells in seven specimens. The presence of EBV DNA in basal and parabasal lingual cells, as well as localization of latency-associated proteins in these layers, suggests that hairy leukoplakia in patients with acquired immunodeficiency syndrome might represent a reactivation of latent lingual infection accompanied by a dramatic increase in viral copy number in the more mature, superficial, squamous cells. The human immunodeficiency virus was also found in seven specimens, but the significance of this new finding is uncertain and requires further study. There is no evidence to suggest that the HPV is involved in the development of hairy leukoplakia.

Progesterone inhibits inducible nitric oxide synthase gene expression and nitric oxide production in murine macrophages

The purpose of this study was to determine whether the female hormones estradiol-l7 beta (E2) and progesterone (P4) influence inducible nitric oxide synthase (iNOS) and the production of nitric oxide (NO) by interferon-gamma(IFN-gamma)-and lipopolysaccharide (LPS)-activated mouse macrophages. Treatment with P4 alone caused a time- and dose-dependent inhibition of NO production by macrophage cell lines (RAW 264.7, J774) and mouse bone marrow culture-derived macrophages as assessed by nitrite accumulation. RAW 264.7 cells transiently transfected with an iNOS gene promoter/luciferase reporter-gene construct that were stimulated with IFN-gamma/LPS in the presence of P4 displayed reduced luciferase activity and NO production. Analysis of RAW 264.7 cells by Northern blot hybridization revealed concurrent P4-mediated reduction in iNOS mRNA. These observations suggest that P4-mediated inhibition of NO may be an important gender-based difference within females and males that relates to macrophage-mediated host defense.

Tumor necrosis factors: pivotal components of pregnancy?

Tumor necrosis factor alpha is a major component of the infection-stimulated cytokine milieux associated with preterm labor and pregnancy termination. As a consequence, this potent factor is thought by some to have exclusively negative effects on the course of pregnancy. Yet in humans and other mammals, messenger RNA hybridizing with tumor necrosis factor alpha cRNA probes and protein detected by anti-tumor necrosis factor alpha have been identified in normal cycling and pregnant uteri, placentas, and embryos, consistent with an important role for tumor necrosis factor in female reproduction and embryonic development. Here, evidence for this intriguing dichotomy is presented, unresolved aspects are discussed, and potential roles for uteroplacental and embryonic tumor necrosis factor are proposed.

Family care related to alpha-fetoprotein screening

A family's coping repertoire may be challenged when the result of a standard prenatal maternal serum alpha-fetoprotein screening is not within a normal range. Abnormal screening results can cause families to experience anxiety and confusion at a time when they may need to make difficult decisions. The nurse's role is to provide information and emotional support and to coordinate health care services for optimal family coping.

MR of the pituitary in patients with Prader-Willi syndrome: size determination and imaging findings

Prader-Willi syndrome (PWS) is an unusual genetic disorder characterized by short stature, obesity, hypogonadism, hypotonia, cognitive impairment, and dysmorphic facies. There is an interstitial deletion of the proximal long arm of chromosome 15 in about 70 % of patients. Some of these clinical features suggest a central hypothalamic/pituitary dysfunction, and recent investigations have demonstrated a marked impairment in spontaneous growth hormone (GH) secretion. We studied 15 GH-deficient PWS patients by magnetic resonance imaging (MRI) to determine whether there was a diminution in the gross morphological size of the anterior pituitary gland, the site of GH synthesis. We also set out to catalog the pertinent imaging findings in this patient population. Our results indicate that this is the first report documenting pituitary size by MRI in PWS patients. No statistically significant difference was found in the height of the anterior pituitary gland in PWS patients compared with either normal children or children with isolated GH deficiency. An interesting imaging finding is that three of 15 patients (20 %) demonstrated complete absence of the posterior pituitary bright spot (PPBS), and a fourth patient demonstrated a small PPBS. These observations reflect an objective physiologic disturbance in the hypothalamus. The clinical and radiologic implications of these findings are discussed.

Tissue-specific in vivo protein-DNA interactions at the promoter region of the Xenopus 63 kDa keratin gene during metamorphosis

The Xenopus 63 kDa keratin gene is developmentally regulated and is expressed only in the epidermis. Full activation of the 63 kDa keratin gene requires two regulatory steps, the first independent and the second dependent on the thyroid hormone triiodothyronine (T3). Sequence analysis of a genomic clone of the 63 kDa keratin gene identified potential AP2 and SP1 binding sites upstream of the transcription initiation site. Electrophoretic mobility shift assays using purified or enriched proteins, as well as HeLa nuclear extract in conjunction with AP2- and SP1-specific antibodies, have been used to demonstrate that human AP2 and SP1 bind elements upstream of the transcription initiation site. In vivo footprinting with ligation mediated PCR revealed several footprints, within 350 bp upstream of the transcription initiation site, including those at the AP2 and SP1 sites, that are unique to epidermal cells which express the keratin gene. These footprints were absent in blood cells and XL177 cells which do not express the gene. Comparison of footprints between cells which express the 63 kDa keratin gene at low or high levels showed that the same binding sites are occupied, indicating that these sites are required for basal as well as T3-induced expression of the 63 kDa keratin gene.

Factors in the quality of patient evaluations in general hospital psychiatric emergency services

OBJECTIVES

The study examined the usefulness of a three-perspective model for determining the quality of evaluations in psychiatric emergency services. The model was used to evaluate the hypothesis that the provision of high-quality care in emergency services is primarily influenced by service objectives related to patients' clinical characteristics rather than by institutional constraints, such as workload or physical facilities, or by social biases, such as clinicians' attitudes toward patients or perceptions of community expectations.

METHODS

The evaluation of 683 persons assessed in nine California public facilities were independently observed. Multivariate techniques were used to test the relative importance of patients' clinical characteristics, possible sources of social bias among clinicians, and institutional constraints in influencing three quality-of-care dimensions: technical quality, the art of patient care, and optimum investment of time.

RESULTS

The findings generally confirmed the hypothesis that patients' clinical characteristics have more influence on the quality of care provided than institutional constraints or social biases. However, one institutional constraint--increased workload demands--led to reduced technical quality and to less than optimal use of time. Further, social biases reflected in the clinician's like for and preconceptions about the patient also influenced the quality of their evaluations.

CONCLUSIONS

The model is a useful tool for examining quality of care in the psychiatric emergency service. Increasing workload pressures negatively affect quality of care.