Rehabilitation services for children: Therapists’ perceptions

The objective of this study was to examine occupational therapists' (OT) and physiotherapists' (PT) perceptions regarding waiting time and the quality and quantity of the services they provide for children with disabilities. A survey was sent by post to all paediatric OTs and PTs in Quebec, Canada. A Service Delivery Questionnaire included questions regarding therapist/client characteristics, waiting times and quality and quantity of services provided. The Measure of Processes of Care for Service Providers (MPOC-SP) rated use of family-centred care by responding clinicians. Waiting times were longest for OT services (p<0.0001), speech/language interventions (p<0.0001) and services in rehabilitation and community health centres (p<0.0001). Quality of services was rated higher by PTs, experienced therapists and those using more methods of keeping up-to-date. The frequency and duration of services varied according to profession, type of clientele and setting. According to clinicians directly involved in the provision of rehabilitation services, long delays exist for children waiting for rehabilitation services, and perceived quality of services differs according to specific therapist and client characteristics. These findings will assist those involved in planning the distribution of co-ordinated rehabilitation services for children.

Systematic comparison of nonmelanoma skin cancer microarray datasets reveals lack of consensus genes

BACKGROUND

DNA microarray technology has revealed vast numbers of gene expression alterations associated with human malignancies. Assigning validity and biological significance to these changes, however, remains a considerable hurdle. Recently, microarray analysis has been applied to the study of nonmelanoma skin cancer.

OBJECTIVES

To compare experimental data rigorously in order to strengthen conclusions regarding the pathogenesis of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), and to evaluate systematically the experimental and statistical parameters that may impact the degree of consensus among differentially expressed genes (DEGs) between studies.

METHODS

We performed a systematic comparison of 10 studies that applied DNA microarray technology to study BCC/SCC.

RESULTS

A total of 1133 DEGs collectively reported across the studies were compared, and 64 DEG overlaps were found: 18 DEG overlaps in SCC vs. SCC study comparisons, 18 DEG overlaps in BCC vs. BCC study comparisons and 28 DEG overlaps in BCC vs. SCC study comparisons. We documented differences in several experimental methods that may account for the relative lack of consensus between studies, including sample type, tissue procurement/handling, microarray chip and statistical analysis. The two most dysregulated biological pathways across all studies involved genes with enzymatic and structural/adhesion functions.

CONCLUSIONS

DEGs that were found to overlap across two or more studies and biological pathways with the largest representation of DEGs across studies may be particularly relevant to disease pathogenesis and serve as targets for future therapy. In future work, more consistent experimental methods across laboratories may improve the validity of reported DEGs and strengthen conclusions drawn from microarray data.

Discordance in injury reporting between youth-athletes, their parents and coaches

Hiring experienced health professionals to collect data on sport injuries is expensive, limits resources, and may be prohibitive for surveillance studies. The objective of this study was to obtain pilot data on whether youth self-report deserves further study. We followed 67 recreational and elite soccer players aged 11-17 for one season and compared responses of injured players with those of their parents/coaches. We defined our main outcome of discordance as any disagreement in responses between the youth, parent and coach (triad). When one person didn't know the answer, we categorised the responses as "concordance" if the other two members agreed. We omitted data when two people responded "Don't Know". Of 10 injuries that could be analysed, 29/30 interviews occurred within 21 days. For factual questions analysed, there was 100% concordance for the type and side of injury, and place where the injury occurred. There were 1-2 discordant triads for each of time of day, activity during injury and specific body part injured. There were greater discordances for date of injury, first-aid treatment, and opinions concerning underlying reasons for the injury. Interview-report by youth themselves should be explored as a possible low cost method of documenting youth sport injuries.

Clinical case management of revolving door patients - a semi-randomized study

OBJECTIVE

To assess the effectiveness of psychiatric clinical case management.

METHOD

Subjects with at least three admissions in the previous 2 years were randomized into a clinical case management group (CMG; n = 122) and a standard care group (SCG; n = 95). Individuals who refused or were not located were included in a third, non-randomized no-treatment group (NTG; n = 153). Parameters assessed included utilization of in-patient services and psychosocial functioning.

RESULTS

We found no difference between the CMG and the SCG in psychosocial functioning as evaluated by interviewers, and no difference between the three groups in hospitalization. In subjects' self-ratings, the CMG showed slight improvement in psychosocial functioning.

CONCLUSION

Clinical case management did not prove itself superior to standard care in a revolving door population.

Parental experience of home adaptation for children with motor disabilities

Home adaptation is essential in increasing independence of children with disabilities and reducing the burden of care for parents. Physical and occupational therapists involved in home adaptations are faced with various challenges in meeting the needs and expectations of parents. This study aimed at exploring the experience of parents throughout the home adaptation process. We conducted an exploratory qualitative study, whereby we interviewed a sample of 11 parents of children with motor disabilities, using focus groups and individual interviews. Dominant themes that emerged were financial and organizational constraints, child's independence/self-esteem, respect of temporal aspects, safety, respect for parent's roles, need for information, and appearance of the home. Parents wish physical and occupational therapists to take on roles that extend beyond provision of home adaptation, such as those of consultants and advocates.

Serum cartilage oligomeric matrix protein (COMP) levels in knee osteoarthritis in a Brazilian population: clinical and radiological correlation

OBJECTIVES

In this study we present data on serum cartilage oligomeric matrix protein (COMP) levels in a Brazilian population with isolated knee osteoarthritis (OA) compared to healthy controls. Clinical and radiological correlations with COMP levels were also evaluated.

METHODS

Two hundred and seventy-two patients seen at the Rheumatology Division of the Federal University of São Paulo (UNIFESP) with a symptom of 'pain in the knees' for at least 3 months were invited to participate in this study. History and clinical examination were performed in all patients. Eighty-six patients with clinical isolated knee OA according to the American College of Rheumatology (ACR) criteria and without other causes of pain in the knee were included. Fifty-eight healthy individuals were selected, matched for age and sex, and used as controls. OA evaluation included Lequesne and Western Ontario and MacMaster Universities osteoarthritis index (WOMAC) questionnaires, visual analogue scale (VAS) for pain and standard knee X-rays. Blood samples were taken from all participants and serum COMP levels were measured by enzyme-linked immunosorbent assay (ELISA). OA radiological analysis was performed using the Kellgren and Lawrence (K/L) grading scale.

RESULTS

Patients with symptomatic knee OA presented significantly higher serum COMP levels compared to healthy controls and to those with non-symptomatic narrowing of the articular space (p<0.001). Patients with clinical evidence of knee OA and without radiological abnormalities (K/L grade 0 or 1) had intermediate serum COMP levels, significantly higher than those observed in healthy controls (p<0.03).

CONCLUSIONS

We observed increased serum COMP levels in patients with symptomatic radiological knee OA. High serum COMP levels may also indicate cartilage damage in selected symptomatic patients without significant radiological abnormalities.

21. Optimal care in rheumatoid arthritis: Preliminary findings from a focus group study

The objective of our work was to identify facilitators of optimal care, as well as potential barriers, for patients with rheumatoid arthritis (RA). The design was a focus group study. Individuals with established RA were identified through invitation letters sent using a random sample of the Quebec Arthritis Society mailing list. Patients were eligible for participation if they had a diagnosis of RA confirmed by a rheumatologist and if they had sought care within the McGill Réseau Universitaire Intégré de Santé network. We planned a series of focus group meetings (90 minutes each) to obtain sufficient data in terms of spectrum of ideas. In each moderator-led group, participants were asked to discuss five questions related to quality care. A co-moderator was available to document non-verbal communication, with audio-taping of all sessions and professional transcription for data analysis. Qualitative content analysis, based on grounded theory, was the chosen means of identifying recurring themes and categories. Two focus group sessions have been completed with two more scheduled. Preliminary findings indicate the importance of good communication between family physicians, specialists, and allied health care workers. Final coding of transcripts and computer-assisted content analysis is being completed. However it appears that focus group may be useful in studying optimal care for chronic diseases such as RA. Our preliminary findings emphasize the necessity of good communication among health care providers. Ultimately we hope to generate knowledge that can be transformed into better health for Canadians with arthritis and other chronic diseases.

Irestatin, a potent inhibitor of IRE1α and the unfolded protein response, is a hypoxia-selective cytotoxin and impairs tumor growth

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Background: The unfolded protein response (UPR) is an adaptive response to the toxic accumulation of misfolded proteins in the endoplasmic reticulum (ER), and is activated in solid tumors. IRE1a is a core component of the UPR and responds to ER stress through activation of its dual kinase and endonuclease domains. The IRE1a endonuclease splices the mRNA for XBP-1, generateing a potent transcription factor that is required for tumor growth. Methods: We developed a fibrosarcoma cell line expressing a fusion of unprocessed XBP-1 inserted upstream of firefly luciferase. Under ER stress, IRE1a catalyzes the removal of a 26-nt intronic sequence from the XBP-1 mRNA, introducing a shift in reading frame that permits translation of luciferase. We screened a chemical library of 66,000 small molecules for inhibitors of XBP-luciferase activity and identified 12 molecules, termed irestatins, which consistently inhibited the IRE1a signaling module without affecting the activity of a control CMV-luciferase reporter. We pursued several of the most potent irestatins, including irestatin 9389, which inhibited XBP-luciferase activity with an IC50 of ∼25 nM. Results: Irestatin-mediated inhibition of the IRE1a endonuclease impairs the growth of malignant myeloma cells and inhibits the survival of oxygen-starved tumor cells in vitro. Exposure to irestatin 9389 (2.5 μM) had a negligible effect on the survival of HT1080 cells cultured under normal oxygen conditions. However, in cells cultured under hypoxia for 48 hours, irestatin 9389 inhibited colony formation by nearly 80-fold (48% vs. 0.62%). A two-week course of treatment with single-agent irestatin 9389 (50 mg/kg) administered every other day by i.p. bolus injection was well tolerated and strongly inhibited the growth of subcutaneous HT1080 tumor xenografts (1790 ± 380 mm3 vs. 480 ± 210 mm3; P<0.01). Conclusion: Irestatins define a novel class of hypoxia- and ER stress-selective agents targeted to the underlying physiological response to the tumor microenvironment. Intratumoral inhibition of the UPR can potentiate cell death and impair tumor growth. Molecular intervention against central components of the UPR may represent an effective therapeutic strategy in cancer treatment.

No significant financial relationships to disclose.

Assessment of differences in HLA-A, -B, and -DRB1 allele mismatches among African-American and non-African-American recipients of deceased kidney transplants

Among recipients of deceased donor kidney transplants, African-Americans experience a more rapid rate of kidney allograft loss than non-African-Americans. The purpose of this study was to characterize and quantify the HLA-A, -B, and -DRB1 allele mismatches and amino acid substitutions at antigen recognition sites among African-American and non-African-American recipients of deceased donor kidney transplants matched at the antigen level. In recipients with zero HLA antigen mismatches, the degree of one or two HLA allele mismatches for both racial groups combined was 47%, 29%, and 11% at HLA-DRB1, HLA-B, and HLA-A, respectively. There was a greater number of allele mismatches in African-Americans than non-African-Americans at HLA-A (P < .0001), -B (P = .096), and -DRB1 loci (P < .0001). For both racial groups, the HLA allele mismatches were predominantly at A2 for HLA-A; B35 and B44 for HLA-B; but multiple specificities for HLA-DRB1. The observed amino acid mismatches were concentrated at a few functional positions in the antigen binding site of HLA-A and -B and -DRB1 molecules. Future studies are ongoing to assess the impact of these HLA mismatches on kidney allograft loss.

Care pathways in early rheumatoid arthritis

OBJECTIVE

To determine the proportion of family physicians who diagnose rheumatoid arthritis (RA) correctly and to note how they report they would manage RA patients.

DESIGN

Mailed survey (self-administered questionnaire) requesting comments on vignettes.

SETTING

Province of Quebec.

PARTICIPANTS

Computer-generated random sample of family physicians registered with the Quebec College of Family Physicians.

MAIN OUTCOME MEASURES

The proportion of family physicians who recognized RA and their reported management strategies.

RESULTS

Most respondents recognized the vignette presentation as a case of RA; 133/138 (96.4%) indicated RA as their provisional diagnosis, and all but 1 of the remaining respondents listed RA as a differential diagnosis. Of those who considered RA as a provisional or possible diagnosis, 107 (77.5% of all respondents) suggested referring the patient to a rheumatologist. Among the physicians who suggested referral, none indicated they would initiate disease-modifying antirheumatic drugs (DMARDs).

CONCLUSION

Almost all respondents considered RA as a provisional or differential diagnosis. Although many suggested referring the patient to a rheumatologist, almost a quarter did not. Initiating DMARDs before referring patients to rheumatologists appears to be rare. Since DMARDs given during the early stages of RA are known to decrease damage and dysfunction, ways to increase their use and optimize care pathways for new-onset inflammatory arthritis are urgently needed.

Acute decompensated heart failure: best evidence and current practice

Heart failure (HF) is one of the leading cardiovascular health problems in Europe and the United States. Acute decompensated HF remains a lethal diagnosis with a morbidity and mortality that often exceeds neoplastic or infective diseases. The incidence of HF continues to increase despite an intensive effort to increase education and delivery of healthcare to these affected patients. Yet, current guidelines in the United States do not address the management of acute decompensated HF, and focus predominantly on chronic stable systolic HF as well as patients with left ventricular dysfunction. Although the European Society of Cardiology has established some parameters for the management of acute HF, these guidelines are largely established by expert opinion, and are predominantly devoid of prospective randomized data in this cohort of patients. Current pharmacotherapies for acute decompensated HF include diuretics, neurohormonal antagonists, vasodilators, and inotropes. Regrettably, all of these drugs have their limitations in acute HF. Neurohormonal antagonists reduce morbidity and mortality, but may be inadequate to achieve and maintain the necessary hemodynamic relief required in advanced HF; while, bolus diuretics, a mainstay of initial symptomatic relief, may be maladaptive and up-regulate adverse neurohormonal regulatory mechanisms longterm with no positive impact on longterm mortality. Today, for those advanced HF patients who remain symptomatic despite optimal conventional therapy, limited treatments exist; but as newer therapies evolve, the options will expand to include more than palliative care, heart transplant and ventricular assist devices for these patients.