Post-polio syndrome: assessments, pathophysiology and progression

While there have been many reports of the decline in motor function in patients with prior-polio, there have been few reports of quantitative changes in muscle function and the pathophysiological mechanisms for the deterioration are poorly understood. This paper describes the establishment of a postpolio clinic and the principles adopted in quantitative muscle testing using twitch interpolation. Peripheral endurance and/or voluntary drive to muscles is impaired in about 30% of prior-polio patients attending the clinic. Progression of these deficits is slow and not easily predicted by factors associated with the original illness.

Changes in serum chondroitin sulphate epitopes 3-B-3 and 7-D-4 in early rheumatoid arthritis

OBJECTIVES

The aims of the present rheumatoid arthritis (RA) study were (1) to examine the levels of serum 3-B-3 and 7-D-4 to find out whether they are different from controls, (2) to find out whether the concentrations of these epitopes change with disease duration in early RA and (3) whether the serum concentrations of 3-B-3 and 7-D-4 in early RA are prognostic for subsequent disease progression.

METHODS

The concentrations of 3-B-3 and 7-D-4 in sera were quantitated by immunoassays.

RESULTS

The levels of 3-B-3 and 7-D-4 were significantly lower in RA than in controls (3- to 30-fold, P < 0.001). Changes in 3-B-3 and 7-D-4 were apparent with disease duration. At first presentation, the 3-B-3 concentration was lowest and increased at 12 months (3-fold, P < 0.001). This increase was transient since by 24 and 36 months the concentrations were not different to those at first presentation. The level of 7-D-4 was also lowest when the patients first presented at clinic and increased with time at 6 months (2-fold, P < 0.001). The increase was more prolonged for 7-D-4, remaining elevated at 12, 24 and 36 months. The lack of correlations of serum 3-B-3 and 7-D-4 with clinical measurements showed that these markers were not prognostic for disease severity.

CONCLUSIONS

The levels of 3-B-3 and 7-D-4 differed between RA and control sera, and changed with disease duration. These markers were not prognostic in predicting disease outcome.

Accuracy of centre of pressure measurement using a piezoelectric force platform

OBJECTIVE

To evaluate the accuracy in determining centre of pressure when using a force platform for stabilometry research.

DESIGN

Technical report.

BACKGROUND

Previous studies have determined the accuracy of locating the centre of pressure by applying force through a single point. In human stabilometry research however, force is distributed across two feet and the centre of pressure located between the feet.

METHODS

Forces were applied to a Kistler force platform using a force applied through a single point as well as when force was distributed between two metal blocks.

RESULTS

Errors in calculating centre of pressure were substantially larger when force was applied through a single point than when the force was distributed between two blocks.

CONCLUSIONS

Evaluating centre of pressure accuracy by applying force through a single point overestimates the errors inherent in human stabilometry research.

RELEVANCE

Evaluating changes in the centre of pressure of human subjects standing on a force platform is a common tool for evaluating control mechanisms of balance. Accurate information regarding the centre of pressure is essential for the validity of this research.

Endothelial cell "memory" of inflammatory stimulation: human venular endothelial cells store interleukin 8 in Weibel-Palade bodies

The expression and secretion of interleukin (IL)-8, the prototype member of the C-X-C subfamily of chemokines, can be induced by diverse inflammatory stimuli in many cells, including endothelial cells (EC). Upon de novo synthesis, IL-8 localizes intracellularly in the Golgi apparatus, from where it is secreted. In addition to this constitutive secretory pathway, we describe a depot storage and separate regulated secretory pathway of IL-8 in EC. The prolonged stimulation of primary human EC with inflammatory mediators resulted in the accumulation of IL-8 in Weibel-Palade bodies, where it colocalized with von Willebrand factor. IL-8 was retained in these storage organelles for several days after the removal of the stimulus and could be released by EC secretagogues such as phorbol myristate acetate, the calcium ionophore A23187, and histamine. These findings suggest that storage of IL-8 in Weibel-Palade bodies may serve as the EC "memory" of a preceding inflammatory insult, which then enables the cells to secrete IL-8 immediately without de novo protein synthesis.

Pain and cognitive status in the institutionalized elderly: perceptions & interventions

The purposes of this study were to examine the relationship between: (1) nurses' ratings of pain and corresponding administration of pain medication to elderly long-term care residents, and (2) cognitive status of the elderly and pain medication orders/administration. Participants were 83 residents, 60 years of age and older, in two groups: cognitively impaired (n = 64), and cognitively intact (n = 19). For comparison purposes, 19 of the cognitively impaired subjects were matched on age and diagnosis to provide control for potentially painful conditions. A retrospective medication review of the resident's charts was conducted to compare medication orders and administration on analgesics that were scheduled and p.r.n. (given as needed). The pain ratings of 25 RNs using a visual analogue scale were correlated with pain medications given to the resident on the day of the rating. Results indicated that RNs' ratings of resident pain and the administration of pain medications were not significantly correlated. In addition, cognitively impaired residents were prescribed significantly less scheduled medication and received significantly less pain medication (either p.r.n. or scheduled) than the cognitively intact elderly. Implications for practice and research are discussed.

Mortality following spinal cord injury

This study analyzed the mortality in 1453 spinal cord injured patients admitted early after injury to a specialised Spinal Injuries Unit within a University teaching hospital over a 40-year period. The cohort comprised 55.3% patients with cervical lesions and 44.7% patients with thoracic/lumbar lesions. Those patients who died within 18 months of the spinal injury (132) were excluded from the final analysis. Standardised Mortality Ratios, survival rates and life expectancy ratios were calculated for specific ranges of current attained age and duration since injury with reference to level and degree of spinal cord injury. The projected mean life expectancy of spinal cord injured people compared to that of the whole population was then estimated to approach 70% of normal for individuals with complete tetraplegia and 84% of normal for complete paraplegia (Frankel grade A). Patients with an incomplete lesion and motor functional capabilities (Frankel grade D) are projected to have a life expectancy of at least 92% of the normal population.

Vibration perception threshold: are multiple sites of testing superior to single site testing on diabetic foot examination?

Vibration perception threshold (VPT) values, measured at different anatomic locations on the foot and ankle, and the time to assess VPT and sensory perception using two difference modalities in 102 diabetic patients were compared. VPT was evaluated at the great toe, fifth metatarsal and ankle. Differences in VPT at these three sites, in addition to differences in duration of testing comparing single site (great toe) to multiple sites, and to standard SWMF testing were assessed. No significant difference in VPT between the great toe and fifth metatarsal was found for patients both with and without loss of protective sensation (LOPS). Mean VPT was significantly higher at the ankle compared with both the great toes and fifth metatarsals. However, the difference between ankle and great toe was not significant between patients with and without LOPS [3.9 +/- 11.2 (12%) vs. 3.0 +/- 10.8 (16%) volts, respectively, p > 0.6]. Testing of one site took approximately half the time of Semmes-Weinstein 10-gram monofilament wire SWMF testing (40.5 +/- 16.9 vs. 22.3 +/- 9.1 seconds, p < 0.01) and less than one third the time of three-site VPT testing (10.5 +/- 26.1 vs. 22.3 +/- 9.1 seconds, p < 0.01). There may not be a significant practical benefit in multiple site VPT testing when compared with single site testing on the great toe alone. The value of multiple site testing is further called into question when one notes that the great toe VPT remains the only site tested for sensitivity and specificity for ulceration.

Crime is a public health problem

Crime is a public health issue. It shares common causes with ill health, particularly poverty, and fear of violent crime is itself a major cause of anxiety. Community development in pre-school education, parental education, and among ethnic minorities, both reduces crime and promotes better health, for example in reducing the effects of alcohol and illicit drugs. Health workers should contribute in full to community development.

Primary healthcare workers: training needs in mental health

Particular attention is currently being given to the role of primary healthcare workers in supporting people with mental health problems in primary care (McFadyen et al, 1996). The aim of this study was to survey the views of primary healthcare workers regarding their previous mental health training and to identify their current perceived mental health training needs. A sample of 200 primary healthcare workers within Trent Health Region were interviewed using a short semi-structured interview schedule. Forty-six completed questionnaires were also received. An additional 22 respondents participated in exploratory in-depth interviews. Respondents included GPs, health visitors, practice nurses, district nurses, midwives and community psychiatric nurses. The need for further training in communication skills, particularly basic counselling skills, was highlighted. Respondents also perceived a need for additional training in coping with their own personal stress, the assessment and treatment of depression and stress/anxiety management in clients. Several themes which developed from the research were explored, including communication skills training, problems with collaborative working, coping with personal stress, the prevention of burnout and depression training. The reason why some respondents had no mental health training needs whatsoever was also addressed.

Transcytosis and surface presentation of IL-8 by venular endothelial cells

Chemokines have been convincingly implicated in actuating inflammatory leukocyte emigration. To affect the circulating leukocytes, tissue-derived chemokines have to traverse the endothelial cells (ECs). This was thought to be accomplished by chemokine diffusion through the intercellular gaps. On the contrary, we show by electron microscopy that the prototype chemokine IL-8 is internalized by venular ECs abluminally and transcytosed to the luminal surface. Here, it is presented to the adherent leukocytes on the EC membrane, predominantly in association with the EC projections. The intact C terminus of IL-8, the molecule's "immobilization" domain, is required for the EC binding, transcytosis, and consequently, the in vivo proemigratory activity of IL-8, indicating that the described subcellular interactions of IL-8 with the ECs are functionally relevant.

Neonatally wounded skin induces NGF-independent sensory neurite outgrowth in vitro

An in vitro model was established to investigate factors underlying the sensory hyperinnervation of neonatal rat skin wounds that has been observed in vivo (Reynolds and Fitzgerald, J. Comp. Neurol. 358 (1995) 487-489). Explants of normal and wounded rat dorsal foot skin were co-cultured with explants of embryonic chick or newborn rat dorsal root ganglia for 24 h and the number of sensory neurites counted. Explants of skin surrounding a wound made at birth were taken 3 (P3) or 10 (P10) days later and compared with normal skin of the same age. In addition, explants were taken from adult skin wounded 3 and 10 days earlier. At P3, normal skin induced weak neurite outgrowth (mean 13.1 +/- 2.1 neurites per ganglion explant) but skin that had been wounded 3 days earlier, at birth, induced three times more neurite outgrowth (37.8 +/- 3.3). Ten days after wounding at birth, neurite outgrowth was still substantial (40.9 +/- 3.3) although at that age (P10), even normal skin stimulates substantial growth (37.4 +/- 2.9). Normal adult skin also stimulated neurite outgrowth (28.7 +/- 0.45) but this was not increased by wounding 3 or 10 days earlier, and this was enhanced 3 days but not 10 days after wounding. Anti-NGF (nerve growth factor) added to the culture medium blocked the constitutive neurite stimulating activity from normal P10 and adult skin but was ineffective in blocking the neurite stimulating activity produced by neonatal wounding. It is concluded that skin wounding at birth results in release of one or more sensory neurotrophic factors that stimulate rat and chick dorsal root ganglia neurite outgrowth for at least 10 days, but which do not include NGF.

Quantitative assessments of elbow flexor muscle performance using twitch interpolation in post-polio patients: no evidence for deterioration

A large number of patients previously affected by polio have symptoms, including increased weakness and fatigue, which are collectively known as a post-polio syndrome. Prospective measurements of strength and endurance using twitch interpolation in post-polio patients are lacking and hence the exact rate of decline in muscle function in these patients is not well defined. We therefore measured performance of the elbow flexor muscles twice, at a mean of 2.5 years apart in a group of selected post-polio subjects (Group A, n = 13) and matched control subjects (n = 11), and in a second group of unselected polio patients from a post-polio clinic (Group B, n = 40) at a mean of 1.7 years apart. All subjects performed 10 attempted maximal voluntary isometric contractions of the elbow flexor muscles, during which voluntary activation of the elbow flexor muscles was measured using a sensitive form of twitch interpolation. The first group of selected polio subjects (Group A) and matched control subjects also performed 45 min of submaximal exercise. During this time, at 5-min intervals, maximal voluntary force, voluntary activation and the amplitude of twitch responses to single and paired stimuli were measured in order to investigate central and peripheral components of muscle fatigue. There was no change in the polio patients' strength, voluntary activation or peripheral muscle endurance between testing sessions, despite an 80% probability of detecting a 2.5% change per year in these variables. The unselected group of patients from the post-polio clinic (Group B) showed no change in maximal voluntary strength or voluntary activation between the first and second test. There was an absence of decline in muscle performance in these polio patients over the test interval, despite a subjective deterioration in muscle function consistent with the 'post-polio syndrome'. This supports the view that symptoms of the post-polio syndrome are not due to a progressive neuronal dysfunction.

Paying for water

Water has been taken for granted as an essential public health need since the Victorian sanitary revolution. Water has come back on to the public health agenda in the United Kingdom because of recent policy changes and their untoward environmental and social impacts; along with water privatization and tough new environmental directives, there have been serious water pollution incidents, water shortages, water debt and disconnection. Along with concern about protecting individual rights to a clean safe water supply, there is concern about the ability of national water resources to meet all our communities' needs, without unacceptable environmental damage. A national plan is needed for the conservation of water and protection of water resources and the environment; adequate central funds are needed to see that this happens. There should be greater emphasis on local water management and a key role for local authorities; there should be fair pricing, protection of water supplies for the poorest and most vulnerable, and a ban on water disconnection to domestic users, on public health grounds. More research is needed into the potential adverse health impact of people on prepayment meters disconnecting themselves. There is a place for water metering as the most rapidly deliverable means of controlling peak demand, reducing overall consumption and avoiding a large-scale environmentally damaging solution to supply more water. However, control of leakage offers the largest potential saving and is the most cost-effective means to protect existing water supply. We question whether private water companies, geared to maximizing profit and share dividends, can deliver a national plan for the protection and management of water resources, for the good of the environment and future generations. The public health lobby must become more actively engaged in the debate about the supply, protection and price of our most precious public health asset-water.

Abduction strength following intramedullary nailing of the femur

OBJECTIVES

To assess hip abductor function, strength and complaints following insertion of a femoral intramedullary nail.

DESIGN

Retrospective clinical review.

SETTING

Department of Orthopaedics, Adelaide Women's and Children's Hospital, Adelaide. Department of Orthopaedic Surgery and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia.

PATIENTS

1. 32 of 37 patients who had an intramedullary nail inserted for an isolated femoral shaft fracture at the Royal Adelaide Hospital between 1987 and 1990. 2. 14 of 18 patients who had closed femoral shortening for leg length discrepancy, at the Adelaide Women's and Children's Hospital between 1985 and 1987. Patients with pathology involving the abductor mechanism were excluded. 3. 40 asymptomatic controls.

INTERVENTION

Intramedullary fixation for femoral shaft fractures or as part of closed femoral shortening. All procedures were performed on a traction table via a gluteal splitting approach with reamed nails.

MAIN OUTCOME MEASUREMENTS

Complaints included, pain, stiffness, limp and diminished walking distance. Examination of abductor function and measurement of abductor strength. Radiological assessment at followup.

RESULTS

Complaints included trochanteric pain (40%, 40%), thigh pain (10%, 8%) and limp (13%, 42%) in the femoral fracture and closed femoral shortening groups respectively. There was significant difference in the abduction strength (p < 0.01) and abduction ratio (p < 0.01) between the control and each treatment group. Abductor weakness correlated (r = 0.30) with the incidence of complaints.

CONCLUSION

Pain, limp and weakness are common following insertion of a femoral intramedullary nail. Agluteal retracting approach may minimize abductor weakness.

Living conditions, inequalities in health, human rights and security: a European perspective in a global context

This paper examines the living conditions and inequalities affecting health, human rights and security in developed Western countries. Possible remedies based on experience in Sandwell Health District, West Midlands, are considered and analogies drawn with global initiatives.