Constraint-Induced Movement therapy can improve hemiparetic progressive multiple sclerosis. Preliminary findings

Objective

To evaluate whether Constraint-Induced Movement therapy (CI therapy) may benefit chronic upper extremity hemiparesis in progressive multiple sclerosis (MS).

Methods

Five patients with progressive MS, who had chronic upper extremity hemiparesis and evidence for learned non-use of the paretic limb in the life situation, underwent 30 hours of repetitive task training and shaping for the paretic limb over 2–10 consecutive weeks, along with physical restraint of the less-affected arm and a “transfer package” of behavioral techniques to reinforce treatment adherence.

Results

The patients showed significantly improved spontaneous, real-world limb use at post-treatment and 4 weeks post-treatment, along with improved fatigue ratings and maximal movement ability displayed in a laboratory motor test.

Conclusions

The findings suggest for the first time that slowly progressive MS may benefit from CI therapy. Further studies are needed to determine the retention of treatment responses.

Marginalization of girl mothers during reintegration from armed groups in Sierra Leone

BACKGROUND

Although the widespread presence of girls who participate in fighting forces is increasingly recognized, they remain a highly marginalized group globally, receiving little attention either during or after armed conflict. This is especially true for "girl mothers," girls who return to communities with children born while members of fighting forces.

AIM

The concept of marginalization (Hall et al. 1994) is used to examine what happens to girl soldiers, especially girl mothers, in the aftermath of armed conflict when they seek to reintegrate back into their communities.

METHODS

This analysis, as part of a larger study of reintegration of girl mothers, is based on field work with girls who were in fighting forces in northwest Sierra Leone, especially those who returned with children.

FINDINGS

The type and level of marginalization these girls experience is consistent with the conceptualization of marginalization; however, they lack voice and experience shame and vulnerability. Moreover, economics were fundamentally related to their marginalization. The girls' access to resources was significantly constrained because the area was heavily impacted by the war and because of widespread poverty throughout Sierra Leone.

DISCUSSION

The findings raise important questions about marginalization of girls affected by war. Girls and girl mothers experience an extremely high level of marginalization; however, some aspects are not consistent with the original conceptualization of marginalization. Theory development in nursing needs to incorporate multiple voices, especially those of the very marginalized and be done in such a manner that benefits and empowers.

Clinical use of a shortened alcohol withdrawal scale in a general hospital

BACKGROUND

Multi-item scales for monitoring alcohol withdrawal reactions have been used since the 1970s, and since 1985 we have used a modified version of the Clinical Institute Withdrawal Assessment (CIWA) in our general hospitals. This study was conducted to determine whether a shorter version of the scale would prove easier to use without loss of accuracy.

METHODS

A simultaneous 'crossover' clinical audit using two hospitals. The shortened scale was developed from the existing one, and had 10 items as opposed to the previous 18. The patients were followed throughout their course and the incidences of complication, the frequency of sedation, the delay in initiating monitoring and the ease of use were recorded.

RESULTS

There were 106 patients managed with the old scale and 96 with the new. The rate of complication was not different, being 16% in patients managed using the old scale and 14.5% using the new scale; the rates of sedation were 49 and 48%, respectively. Patients managed with the new scale had a shorter course with a median duration of 27.6 h compared with 40 h. The time from admission to first recording of a score was 5.4 h for the new scale and 4.8 h for the old, which is not a significant difference. Both scores were used according to instructions, but staff reported that the shortened scale was easier to use.

CONCLUSIONS

We conclude that a shortened form of the CIWA alcohol withdrawal scale works as well as the original and is simple to use.

African dust clouds are associated with increased paediatric asthma accident and emergency admissions on the Caribbean island of Trinidad

A retrospective ecological study of paediatric asthma patients who attended the Accident and Emergency (A and E) department of the Paediatric Priority Care Facility at the Eric Williams Medical Sciences Complex in relation to Saharan dust visibility and other climatic variables for the period 23 May 2001 to 13 May 2002 was undertaken to determine if there is an association between paediatric A and E asthma visits and Saharan dust cloud cover. A Poisson regression model was used to determine the statistical relationship between acute paediatric asthma A and E visits and Saharan dust cover with and without other variables such as climatic parameters and month. During the study period, there were 2,655 A and E visits for acute asthma. There was an association between increased paediatric asthma admissions and increased Saharan dust cover. The best fitting model estimated that in one month, such as June, a deterioration of visibility due to increased Saharan dust cover from no dust (visibility =16 km) to very dusty (visibility =7 km) would increase a daily admission rate of 7.8 patients to 9.25 when climate variables such as barometric pressure and humidity were kept constant.

Proinflammatory Cytokines Upregulate mRNA Expression and Secretion of Vascular Endothelial Growth Factor in Cultured Human Airway Smooth Muscle Cells

Airflow obstruction in chronic airway disease is associated with airway and pulmonary vascular remodeling, of which the molecular mechanisms are poorly understood. Paracrine actions of angiogenic factors released by resident or infiltrating inflammatory cells following activation by proinflammatory cytokines in diseased airways could play a major role in the airway vascular remodeling process. Here, the proinflammatory cytokines interleukin (IL)-1beta, and tumor necrosis factor (TNF)-alpha were investigated on cell cultures of human airway smooth muscle (ASM) for their effects on mRNA induction and protein release of the angiogenic peptide, vascular endothelial growth factor (VEGF). IL-1beta (0.5 ng/mL) and TNF-alpha (10 ng/mL) each increased VEGF mRNA (3.9 and 1.7 kb) expression in human ASM cells, reaching maximal levels between 16 and 24 and 4 and 8 h, respectively. Both cytokines also induced a time-dependent release of VEGF, which was not associated with increased ASM growth. Preincubation of cells with 1 microM dexamethasone abolished enhanced release of VEGF by TNF-alpha. The data suggest that human ASM cells express and secrete VEGF in response to proinflammatory cytokines and may participate in paracrine inflammatory mechanisms of vascular remodeling in chronic airway disease.

A randomised controlled trial of morphine versus phenobarbitone for neonatal abstinence syndrome

BACKGROUND

The incidence of neonatal abstinence syndrome (NAS) has increased 10-fold over the last decade in Glasgow. In the Princess Royal Maternity Hospital, it now accounts for 17% of special care baby unit (SCBU) admissions.

OBJECTIVE

To compare opiate replacement therapy (morphine sulphate) with the present standard treatment (phenobarbitone) for management of NAS. The primary study end point was duration of pharmaceutical treatment. Secondary end points were the requirement for additional drugs and the requirement for SCBU admission.

DESIGN

Double blind, randomised controlled clinical trial.

METHODS

Differential diagnoses were excluded, and two consecutive Lipsitz scores > 4 defined NAS requiring treatment. Infants were randomised to receive morphine sulphate or phenobarbitone. Treatments were identical in appearance, odour, and volume. Increments, decrements, and discontinuation of treatments were protocol driven.

RESULTS

Seventy five infants participated. All mothers received opiate replacement therapy (methadone) during pregnancy and most used other drugs (n = 62, 83%). No significant difference in maternal drug use patterns was observed between treatment groups. Median treatment duration was four days shorter with opiate replacement (8 v 12 days, Mann-Whitney U test, p = 0.02). Phenobarbitone treated infants tended to require second line treatment (47% v 35%, chi(2) test, p = 0.11) and SCBU admission (62% v 30%, chi(2) test, p = 0.04) more often.

CONCLUSIONS

Opiate replacement therapy appears to be superior for management of symptomatic NAS when maternal opiate use is prevalent. The shorter treatment duration and lower requirement for higher intensity nursing may have significant cost implications. Tailoring NAS treatment to local maternal drug use may result in similar benefits.

Pro-inflammatory cytokines induce c-fos expression followed by IL-6 release in human airway smooth muscle cells

BACKGROUND

Airway smooth muscle (ASM) is considered to be a target for mediators released during airway inflammation.

AIMS

To investigate the expression of c-fos, a constituent of the transcription factor activator protein-1, in human ASM cells. In addition, to measure the release of interleukin (IL)-6 into the conditioned medium of stimulated ASM cells, as well as DNA biosynthesis and changes in cell number.

METHODS

Serum-deprived human ASM cells in the G0/G1 phase were stimulated with the pro-inflammatory cytokines; tumour necrosis factor-alpha, IL-1beta, IL-5 and IL-6. The expression of mRNA encoding the proto-oncogene c-fos was measured by Northern blot analysis. Cell proliferation was assessed by [3H]-thymidine incorporation assays and cell counting, and IL-6 levels in cell-conditioned medium were measured by enzyme-linked immunosorbent assay.

RESULTS

All of the cytokines investigated induced a rapid (within 1 h) and transient increase in the expression of mRNA encoding c-fos, followed by the expression and enhanced release of IL-6. Cell proliferation remained unchanged in cytokine-stimulated cells.

CONCLUSIONS

Cytokine-induced c-fos expression in human ASM cells could be described as a marker of cell 'activation'. The possible association of these results with airway inflammation, through secondary intracellular mechanisms such as cytokine production, is discussed.

Self-other representations and relational and overt aggression in adolescent girls and boys

Aggressive behavior in girls has received far less attention than similar problems in boys. This study examined self-representation, and others' representation of self, as predictors of relational aggression, overt aggression, and assaultive behavior in 32 girls and 52 boys, 10 to 17 years of age, referred for assessment due to significant aggressive and delinquent behavior problems. As predicted, negativity of self-representation predicted relational aggression in girls but not boys. Negativity of self-representation also predicted overt aggression and assaultive behavior in both girls and boys. Parental representations of self were not predictive in this sample; however, negativity of peer representations of self, was associated with increased relational aggression in girls and decreased relational aggression in boys. Negativity of peer representations of self also predicted overt aggression and assaultive behavior in both girls and boys. Results suggest that the evaluation of self-other representations may be valuable in the assessment of risk for gender specific patterns of aggression.

Bioethics for clinicians: 18. Aboriginal cultures

Although philosophies and practices analogous to bioethics exist in Aboriginal cultures, the terms and categorical distinctions of "ethics" and "bioethics" do not generally exist. In this article we address ethical values appropriate to Aboriginal patients, rather than a preconceived "Aboriginal bioethic." Aboriginal beliefs are rooted in the context of oral history and culture. For Aboriginal people, decision-making is best understood as a process and not as the correct interpretation of a unified code. Aboriginal cultures differ from religious and cultural groups that draw on Scripture and textual foundations for their ethical beliefs and practices. Aboriginal ethical values generally emphasize holism, pluralism, autonomy, community- or family-based decision-making, and the maintenance of quality of life rather than the exclusive pursuit of a cure. Most Aboriginal belief systems also emphasize achieving balance and wellness within the domains of human life (mental, physical, emotional and spiritual). Although these bioethical tenets are important to understand and apply, examining specific applications in detail is not as useful as developing a more generalized understanding of how to approach ethical decision-making with Aboriginal people. Aboriginal ethical decisions are often situational and highly dependent on the values of the individual within the context of his or her family and community.

Tumor necrosis factor-alpha enhances mRNA expression and secretion of interleukin-6 in cultured human airway smooth muscle cells

Airway smooth muscle (ASM) is considered to be an end-target cell for the effects of mediators released during airway wall inflammation. Several reports suggest that activated ASM may be capable of generating various proinflammatory cytokines. We investigated the effects of tumor necrosis factor (TNF)-alpha, a potent proinflammatory cytokine, on cultured human ASM cells by examining the expression and release of the cytokine interleukin (IL)-6, cell proliferation, and the expression pattern of c-fos and c-jun, two nuclear proto-oncogenes constituting the activator protein-1 transcription factor. Growth-arrested cell monolayers were stimulated with human recombinant TNF-alpha in a concentration- and time-dependent manner. TNF-alpha stimulated the expression of IL-6 messenger RNA (mRNA), which was detected after 15 min, reaching a maximum at 1 h. IL-6 protein was readily detected in ASM cell-conditioned medium after 2 h of TNF-alpha stimulation. Protein levels increased in a time- and concentration-dependent manner. Release of IL-6 elicited by TNF-alpha was significantly inhibited by dexamethasone, cycloheximide, and nordihydroguaiaretic acid (NDGA). TNF-alpha did not alter DNA biosynthesis up to 48 h or cell numbers up to 120 h. Northern blot analysis of proto-oncogene expression revealed that c-fos and c-jun mRNA levels were elevated after 30 min of TNF-alpha incubation with maximum levels at 1 h and 45 min, respectively. Expression of c-fos mRNA was downregulated by NDGA. Four hours of TNF-alpha treatment resulted in translocation of c-jun immunofluorescence from the cytoplasm to the nucleus in human ASM cells. Our results suggest that despite the lack of a mitogenic response to TNF-alpha, upregulation of primary response genes in human ASM cells may account for the induction of proinflammatory cytokines, such as IL-6, in human airways.

Ethnicity affects the postprandial regulation of glycogenolysis

We investigated the effect of nutrient intake on glucose metabolism in normal Mexican-Americans (n = 6) and European-Americans (n = 6). Subjects were studied after an 18-h fast and after 5-6 h of ingestion of hourly meals that supplied 6.35 or 12.75 micromol glucose. kg(-1). min(-1). Endogenous glucose production (EGP), gluconeogenesis (GNG), and glycogenolysis (GLY) were estimated by mass isotopomer analysis with [U-(13)C]glucose infusions. Fasting EGP, GNG, and GLY did not differ between the groups. Food ingestion lowered the molar rate of GNG by only 31%. However, while consuming the lower quantity of nutrients, Mexican-Americans had higher plasma glucose (P < 0.05), a 39% higher rate of EGP (P < 0.05), and a 68% (P < 0.025) higher rate of GLY than the European-Americans. At the higher intake, EGP and GLY were suppressed completely in both groups. There was a linear relationship between insulin concentrations, EGP, and GLY in both groups, but the slope of the line was significantly (P < 0.05) greater in the European-Americans. We conclude that the sensitivity of GLY to nutrient intake differs between ethnic groups and that this may play a role in the increased predisposition of Mexican-Americans to type II diabetes.

Quantitation of monosaccharide isotopic enrichment in physiologic fluids by electron ionization or negative chemical ionization GC/MS using di-O-isopropylidene derivatives

The aldonitrile pentaacetate and other derivatives lack ions in the electron ionization (EI) spectra possessing an intact hexose structure and thus must be analyzed by chemical ionization GC/MS in order to study multiple isotopomers. We report methods for quantitation of hexose di-O-isopropylidene acetate (IPAc) or pentafluorobenzoyl (PFBz) esters. These were prepared in a two-step procedure using inexpensive reagents that do not adversely impact the isotopomer structure of the sugar. The acetate derivative possesses an abundant [M - CH3] ion in the EI spectrum which is suitable for quantitative analysis of isotopomers. The negative chemical ionization (NCI) spectrum of the corresponding pentafluorobenzoyl derivative has a dominant molecular anion. Moreover, the PFBz derivative is about 100-fold more sensitive than the acetate, which offers some advantages for analysis of minor hexoses found in plasma. Isotopic calibration curves of [U-13C]glucose are linear over the 0.1-60% tracer/tracee range tested. The useful range for isotopic tracer studies is 25-2500 pmol for EI analysis of the acetate derivative and 0.1-55 pmol for NCI analysis of PFBz derivative (sample amount injected). For most studies where sample size is not limited, EI-GC/MS analysis of the IPAc derivative is preferred. NCI-GC/MS analysis is reserved when sample size is limiting or when studies involve hexoses other than glucose that are normally present at low concentration.

Characterization of a phase 1-d epitope on Salmonella typhi flagellin and its role in the serodiagnosis of typhoid fever

A monoclonal antibody (MAb) directed against Salmonella typhi 52 kDa flagellin protein has been previously produced by our group. In this study, we have demonstrated that the epitope specific to the MAb is unique to phase 1-d. To map the epitope, plasmids encoding different regions of S. typhi flagellin gene were constructed. Analysis of protein produced from each recombinant plasmid indicated that the epitope specific to the MAb resided within amino acids 171-303 (region IV) of S. typhi flagellin protein. The recombinant region IV flagellin was used to develop an ELISA for the detection of IgM antibody to S. typhi in serum. In the hemoculture-positive typhoid group, the developed ELISA was positive in 77 of 92 cases. In patients with non-typhoidal Salmonella, gram-positive and gram-negative bacteria or dengue virus, the ELISA was negative in all 78 cases. Two from 116 healthy control subjects had positive reactions with the assay. The calculated sensitivity, specificity, positive and negative predictive values of the test were 83.7%, 99.0%, 97.5% and 92.8%, respectively. With such high validity together with the requirement of only a single serum specimen and one day for performing the test, the developed ELISA should become a valuable diagnostic test for typhoid fever.

The Pad1+ gene encodes a subunit of the 26 S proteasome in fission yeast

We have isolated a fission yeast mutant, mts5-1, in a screen for mutations that confer both methyl 2-benzimidazolecarbamate resistance (MBCR) and temperature sensitivity (ts) on Schizosaccharomyces pombe. This screen has previously isolated mutations in the 26 S proteasome subunits Mts2, Mts3, and Mts4. We show that the mutation in the mts5-1 strain occurs in the pad1(+) gene. pad1(+) was originally isolated on a multicopy plasmid that was capable of conferring staurosporine resistance on a wild type strain. mts5-1/pad1-1 has a similar phenotype to 26 S proteasome mutants previously isolated in the same screen and we show that Pad1 interacts genetically with two of these subunits, Mts3 and Mts4. In this study we describe the identification of Pad1 as a subunit of the 26 S proteasome in fission yeast.

Angiotensin II induces hypertrophy of human airway smooth muscle cells: expression of transcription factors and transforming growth factor-beta1

Increased smooth muscle mass due to hyperplasia and hypertrophy of airway smooth muscle (ASM) cells is a common feature in asthma. Angiotensin II (Ang II), a potent vasoconstrictor and mitogen for a wide variety of cells, has recently been implicated in bronchoconstriction in asthmatics. However, a possible mitogenic role as well as underlying molecular mechanisms of this octapeptide in human ASM cells are not yet known. We studied the effects of Ang II on ASM cell proliferation and growth and on the expression of three transcription factors, egr-1, c-fos, and c-jun, as well as a cytokine, transforming growth factor-beta1 (TGF-beta1). Human ASM cells were isolated by enzymatic digestion of bronchial smooth muscle obtained from lung resection tissue. Confluent cells were growth-arrested and subsequently incubated with Ang II (100 nM) for different time periods and processed for the measurement of cell growth and gene expression. Ang II significantly induced DNA and protein synthesis in human ASM cells at 8 h, resulting in a net increase in the accumulation of protein over DNA (i.e., cellular hypertrophy) at 16 h of incubation. Cell counts and MTT-reduction assay, however, showed no increase in cell number as a result of Ang II stimulation. Ang II stimulated the expression of egr-1 and c-fos as early as 15 min, reaching maximum levels at 45 min, whereas the expression of c-jun peaked at 2 h of Ang II exposure. Furthermore, steady-state mRNA levels of TGF-beta1 were upregulated by Ang II after 4 h and reached peak levels at 16 h of incubation. Secretion of biologically active TGF-beta1 from human ASM cells was significantly (P <= 0.02) enhanced by Ang II incubation after 8 h, which remained elevated until 24 h. Our results suggest that the Ang II-induced transient early expression of transcription factors may regulate autocrine genes like TGF-beta1, of which the subsequent late upregulation could contribute to cellular hypertrophy during, for example, airway remodeling in asthma.

An unusually severe phenotype for familial adenomatous polyposis

Familial adenomatous polyposis (FAP) is a dominantly inherited predisposition to the development of many hundreds to thousands of adenomatous polyps of the colon. The mean age of onset is around 15 years, symptoms may arise in the third decade, and the median age for the development of colonic cancer is 35-40 years. Prophylactic colectomy reduces the risk of death from colorectal cancer to such an extent that late sequelae such as upper gastrointestinal tumours have become the main cause of mortality in appropriately managed patients. The age at which colonic surveillance begins reflects the natural history of the disease. Onset of polyp formation and cancer in childhood is very unusual, but has recently been associated with a specific mutation at codon 1309 in exon 15 where a more severe phenotype is sometimes observed. The case histories of two families are reported in which there is childhood onset of polyps in the youngest generation and in one case a carcinoma, in whom mutations have been identified in exon 11 of the APC gene. Several other affected relatives were diagnosed at ages ranging from 5-48 years, some already with a cancer at the time of first screening. Since the aim of screening for colonic polyps is prevention of colonic cancer, family members at risk should be offered genetic assessment and direct mutation testing where this is possible, usually in the early teens. In the absence of a genetic test (the situation in about one third of families) or in a known gene carrier, annual colonoscopy examination is advised from the same age. Clinicians should take note of the family history and be prepared to consider much earlier intervention if symptoms occur in a child with a family history of FAP. Where childhood onset of polyps has occurred, other children at risk in the family must be offered earlier genetic testing and endoscopic surveillance.

Maternal health care at a Japanese American relocation camp, 1942-1945: a historical study

BACKGROUND

From late summer of 1942 until the fall of 1945, approximately 120,000 ethnic Japanese were confined behind barbed wire within 10 relocation camps in the United States. Although histories have been written about the relocation camps, little data are available about women's lives. This study explored women's lives and experiences with pregnancy, childbirth, and child care in a Japanese-American relocation camp.

METHODS

Twenty women who were ages 18 to 31 years at the time of internment at Heart Mountain, Wyoming Japanese American Relocation Camp, and one caucasian nurse who worked in the obstetric unit of the camp's hospital were interviewed. Archival, demographic, and historical data, including some prenatal records, provided information about maternity and public health care for pregnant women and new mothers.

RESULTS

Obstetric hospital practices were typical of the 1940s in the United States. Community public health services for new mothers included formula kitchens and well-baby clinics. Infant mortality statistics from 1942 to 1945 at Heart Mountain were comparatively better for the same time period than for the state of Wyoming or the United States. These outcomes may have reflected the camp's extensive social and family support, adequate housing and food, and universal access to maternity services.

CONCLUSIONS

The Heart Mountain internment provides a story about how women's lives are impacted by war. Since World War II, civilians, especially women and children, have increasingly been targeted during wars with profound impact upon the health of mothers and babies.

Binding of histone H1 to DNA is indifferent to methylation at CpG sequences

The possibility that histone H1 binds preferentially to DNA containing 5-methylcytosine in the dinucleotide CpG is appealing, as it could help to explain the repressive effects of methylation on gene activity. In this study, the affinity of purified H1 for methylated and non-methylated DNA sequences has been tested using both naked DNA and chromatin. Based on a variety of assays (bandshifts, filter-binding assays, Southwestern blots, and nuclease sensitivity assays), we conclude that H1 has no significant preference for binding to naked methylated DNA. Similarly, H1 showed the same affinities for methylated and non-methylated DNA when assembled into chromatin in a Xenopus oocyte extract. Thus potential cooperative interaction of H1 with polynucleosomal complexes is not enhanced by the presence of DNA methylation.