Quality of life in asthma: a comparison of community and hospital asthma patients

This study compares the quality of life of a community sample of people with asthma in South Australia, using population norms, people suffering from other chronic diseases, and a sample of asthma patients from two hospital clinics. A representative population survey was performed by trained interviewers in spring 1995 of 3001 respondents aged > or = 15 years. A physician's diagnosis of current asthma was reported by 299 (9.9%). The hospital clinic sample had a physician's diagnosis and lung function evidence of asthma (n = 293). All completed the SF-36 health survey. Standardized SF-36 scores, adjusted for age, sex, and social class, were significantly lower for respondents with asthma, compared with population norms, across all subscales of the SF-36 (p < 0.05). Physical component summary (PCS) and mental component summary (MCS) scores were not significantly different in people in the community sample with asthma from scores in people with diabetes and arthritis. PCS and MCS scores did not differ for those with similar symptom frequency in the community and hospital asthma samples, except that hospital patients with frequent symptoms had significantly lower MCS scores (p < 0.01). Asthma has a major impact on the health-related quality of life in the community, comparable to other chronic diseases. The SF-36 performs uniformly in asthma in different situations.

Stiffness properties of the human lumbar spine: a lumped parameter model

OBJECTIVE

To characterise with a mechanical model, the force-displacement response of the human lumbar spine to postero-anterior loading.

DESIGN

Single case with repetition.

BACKGROUND

Previous attempts to characterise the spine's force-displacement response have been simplistic and only considered the loading curve. These approaches ignored valuable information such as viscosity, non-linear elasticity and inertia of the lumbar spine.

METHODS

The Spinal Assessment Machine applied a postero-anterior load to the spines of 23 asymptomatic subjects and measured the force-displacement response. The data was analysed by two methods; by a traditional linear regression of part of the loading curve and by a new method where an equation including non-linear stiffness and damping was used to characterise the whole force-displacement relationship.

RESULTS

The equation developed was found to account for virtually all of the variance in the raw data (R2 > 0.993). Four elements derived by the equation determine the contributions of linear elasticity, non-linear elasticity, linear viscosity and non-linear viscosity to the overall stiffness.

CONCLUSIONS

Considering the excellent fit of the new equation to the raw data and its poor correlation with existing measures, it is proposed that the traditional measures provide an incomplete description of the force-displacement response. Relevance. Therapists use their perception of the force-displacement response of the spine to select the type of manipulative treatment to apply. To study this aspect of patient care, devices capable of measuring spinal stiffness have been developed, however to date the obtained data has been analysed only simply. A lumped parameter mechanical model incorporating non-linear damping and stiffness provides a more complete description of the force-displacement response and thus may offer added insight into the manipulative treatment of spinal pain.

A pilot study of chronomodulated infusional 5-fluorouracil chemoradiation for pancreatic cancer

BACKGROUND

Dose limiting acute toxicity from chemoradiation for pancreatic cancer occurs in 15% -20% of patients treated with post-operative adjuvant therapy. Reported here is a pilot study using chronomodulated infusional 5-fluorouracil (5-FU) chemoradiation (CIC) for pancreatic cancer, a treatment designed to reduce normal tissue toxicity and maintain efficacy, with specific evaluation of acute and late morbidity, patterns of disease progression, and survival.

PATIENTS AND METHODS

Twenty-three patients with adenocarcinoma of the pancreas were treated with 5-FU CIC between January 1997 and September 1999. The median age was 64, and there were 9 males and 14 females. Six patients were considered unresectable and seventeen others were treated post-operatively. The median external beam irradiation dose was 50.4 Gy. 5-FU infusion was given five days per week (300 mg/m2/d) and the median total dose was 8.4 g/m2. The chronomodulated 5-FU infusion consists of a low basal infusion rate for 16 hours followed by an eight-hour escalating-deescalating infusion peaking at 10 p.m. All patients were followed from the time of initial diagnosis until last follow-up or death; the median follow-up was 16 months.

RESULTS

No RTOG grade 3 or 4 hematologic toxicity occurred. Twelve of seventeen patients treated postoperatively have been controlled locally, and seven patients have no evidence of disease. The median survival is 28 months and one-year actuarial survival is 88% in the group of resected patients. The 6 patients treated for unresectable disease have a median survival of 13 months.

CONCLUSIONS

Acute toxicity of 5-FU CIC appears to be less frequent and less severe than that reported with flat infusional or bolus 5-FU based chemoradiation used for adjuvant post-operative therapy for pancreatic cancer. This method may warrant further examination, as it may be attractive for the elderly or those who cannot tolerate the toxicity associated with standard post-operative treatment protocols.

A randomized controlled trial of a passive accessory joint mobilization on acute ankle inversion sprains

BACKGROUND AND PURPOSE

Passive joint mobilization is commonly used by physical therapists as an intervention for acute ankle inversion sprains. A randomized controlled trial with blinded assessors was conducted to investigate the effect of a specific joint mobilization, the anteroposterior glide on the talus, on increasing pain-free dorsiflexion and 3 gait variables: stride speed (gait speed), step length, and single support time.

SUBJECTS

Forty-one subjects with acute ankle inversion sprains (<72 hours) and no other injury to the lower limb entered the trial.

METHODS

Subjects were randomly assigned to 1 of 2 treatment groups. The control group received a protocol of rest, ice, compression, and elevation (RICE). The experimental group received the anteroposterior mobilization, using a force that avoided incurring any increase in pain, in addition to the RICE protocol. Subjects in both groups were treated every second day for a maximum of 2 weeks or until the discharge criteria were met, and all subjects were given a home program of continued RICE application. Outcomes were measured before and after each treatment.

RESULTS

The results showed that the experimental group required fewer treatment sessions than the control group to achieve full pain-free dorsiflexion. The experimental group had greater improvement in range of movement before and after each of the first 3 treatment sessions. The experimental group also had greater increases in stride speed during the first and third treatment sessions. DISCUSSION AND CONCLUSION Addition of a talocrural mobilization to the RICE protocol in the management of ankle inversion injuries necessitated fewer treatments to achieve pain-free dorsiflexion and to improve stride speed more than RICE alone. Improvement in step length symmetry and single support time was similar in both groups.

Prevalence, morbidity and management of adult asthma in South Australia

This paper reviews asthma-related data obtained between 1987 and 1997 from self-report population surveys of adults in South Australia. A multistage, systematic, clustered area sample of adults (>15 years) was selected from a random sample of Australian Bureau of Statistics collector districts, and interviewed at home by trained health interviewers. The self-report prevalence of doctor-diagnosed asthma increased from 5.6% in 1987 to 12.2% in 1997. Morbidity measured as days lost from usual activities and nights awakened by asthma remained high, but hospitalization rates are trending down. The ownership of asthma action plans peaked in 1995 and has declined. The ownership of peak flow meters increased between 1992 and 1997, and the ownership of nebulisers remained constant. Evidence-based interventions are required to improve asthma management.

A strategy for modeling ground water rebound in abandoned deep mine systems

Discharges of polluted water from abandoned mines are a major cause of degradation of water resources worldwide. Pollution arises after abandoned workings flood up to surface level, by the process termed ground water rebound. As flow in large, open mine voids is often turbulent, standard techniques for modeling ground water flow (which assume laminar flow) are inappropriate for predicting ground water rebound. More physically realistic models are therefore desirable, yet these are often expensive to apply to all but the smallest of systems. An overall strategy for ground water rebound modeling is proposed, with models of decreasing complexity applied as the temporal and spatial scales of the systems under analysis increase. For relatively modest systems (area < 200 km2), a physically based modeling approach has been developed, in which 3-D pipe networks (representing major mine roadways, etc.) are routed through a variably saturated, 3-D porous medium (representing the country rock). For systems extending more than 100 to 3000 km2, a semidistributed model (GRAM) has been developed, which conceptualizes extensively interconnected volumes of workings as ponds, which are connected to other ponds only at discrete overflow points, such as major inter-mine roadways, through which flow can be efficiently modeled using the Prandtl-Nikuradse pipe-flow formulation. At the very largest scales, simple water-balance calculations are probably as useful as any other approach, and a variety of proprietary codes may be used for the purpose.

Rapid-sequence tandem transplant for children with high-risk neuroblastoma

BACKGROUND

The majority of patients with high risk neuroblastoma (NB) still relapse.

PROCEDURE

We designed a Phase II trial for children with advanced NB utilizing a program of induction chemotherapy followed by tandem high-dose chemoradiotherapy with stem cell rescue (HDC/SCR) in rapid sequence. Fifty-five patients were evaluable, ages 1-14 years, and 97 cycles of HDC/SCR have been completed to date. Pheresis was possible for every patient, despite their young age, with an average of 7.2 x 10(6) CD34+ cells/kg available to support each HDC/SCR cycle.

RESULTS

Engraftment was rapid, with median time to neutrophil engraftment of 11 days. Five patients who completed the first HDC course did not complete the second and there were four toxic deaths. With a median follow-up of 24 months from diagnosis, 38 of 55 patients (3-year EFS 59%) remain event-free. A subset of the patients received stem cells purged by CD34 selection. The engraftment and EFS of these patients are similar to the overall group.

CONCLUSION

This work demonstrates that a tandem transplant regimen for high-risk NB is a feasible treatment strategy in children and may improve disease-free survival.

Mode structure and ray dynamics of a parabolic dome microcavity

We consider the wave and ray dynamics of an electromagnetic field in a parabolic dome microcavity. The structure of the fundamental s wave involves a main lobe in which the electromagnetic field is confined around the focal point in an effective volume of the order of a cubic wavelength, while modes with finite angular momentum have a structure that avoids the focal area and have correspondingly larger effective volumes. The ray dynamics indicate that the fundamental s wave is robust with respect to small geometrical deformations of the cavity, while the higher order modes are unstable, giving rise to optical chaos. We discuss the incidence of these results on the modification of the spontaneous emission dynamics of an emitter placed in such a parabolic dome microcavity.

Comparing wobble board and jump-landing training effects on knee and ankle movement discrimination

The effects of two training programs on movement discrimination ability, at the ankle and knee, were assessed from the left and right lower limbs of forty-four football players. All players in three Under 18 Victorian Football League (VFL) squads were allocated to either wobble board training, jump landing training, or no-training conditions. Pre-tests to assess discrimination of extent for active movements made while standing were carried out on both ankles and knees of all subjects, using an automated device to accurately set the different movement stop points. Five distances were used, between 10.5 degrees and 14.5 degrees from horizontal for ankle inversion, and between 30.3 degrees and 31.7 degrees from vertical for knee flexion. From a series of 50 inversion movements and 50 knee flexion movements, matrices of absolute judgement by actual movement extent were produced. Non-parametric signal detection analysis was applied to the discrimination score. All subjects were retested after eight weeks. Improvement in discrimination of ankle movements into inversion from pre-test (0.65) to post test (0.70) for the wobble board trained group was significantly larger than the change in the jump-landing trained and the untrained groups (Jump Landing: Pretest: 0.64 to Post-test: 0.64 and Control; Pretest: 0.63 to Post-test: 0.64). Discrimination of knee flexion movements improved significantly from pre-test to post-test in all three groups. These data demonstrate that wobble board training can improve discrimination of discrete ankle inversion movements, an effect interpreted as enabling greater accuracy in the making of inversion movements in foot preparation prior to ground contact.

Magnitude estimation of manually assessed elastic stiffness: stability of the exponent

Magnitude estimations were obtained for manual assessments of pure elastic stiffness stimuli (metal springs). 20 subjects of varied experience in manual assessment of spinal stiffness volunteered to participate. The mean exponent of the power function relating perceived magnitude of elastic stiffness to measured physical magnitude was 1.65. Exponents varied across the 20 individuals but were stable across testing sessions held at least 2 weeks apart, and the size of the exponent was not related to prior experience.

Shown to be useful. Survey shows positive results for first-ever set of national physical activity guidelines

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Tandem high-dose therapy in rapid sequence for children with high-risk neuroblastoma

PURPOSE

Advances in chemotherapy and supportive care have slowly improved survival rates for patients with high-risk neuroblastoma. The focus of many of these chemotherapeutic advances has been dose intensification. In this phase II trial involving children with advanced neuroblastoma, we used a program of induction chemotherapy followed by tandem high-dose, myeloablative treatments (high-dose therapy) with stem-cell rescue (HDT/SCR) in rapid sequence.

PATIENTS AND METHODS

Patients underwent induction chemotherapy during which peripheral-blood stem and progenitor cells were collected and local control measures undertaken. Patients then received tandem courses of HDT/SCR, 4 to 6 weeks apart. Thirty-nine patients (age 1 to 12 years) were assessable, and 70 cycles of HDT/SCR were completed.

RESULTS

Pheresis was possible in the case of all patients, despite their young ages, with an average of 7.2 x 10(6) CD34(+) cells/kg available to support each cycle. Engraftment was rapid; median time to neutrophil engraftment was 11 days. Four patients who completed the first HDT course did not complete the second, and there were three deaths due to toxicity. With a median follow-up of 22 months (from diagnosis), 26 of 39 patients remained event-free. The 3-year event-free survival rate for these patients was 58%.

CONCLUSION

A tandem HDT/SCR regimen for high-risk neuroblastoma is a feasible treatment strategy for children and may improve disease-free survival.

Morphology and growth patterns of developing thalamocortical axons

It is increasingly evident that the actions of guidance factors depend critically on the cellular and molecular context in which they operate. For this reason we examined the growth cone morphology and behavior of thalamic fibers in the relatively natural environment of a slice preparation containing the entire pathway from thalamus to cortex. Axons were labeled with DiI crystals and imaged with a laser-scanning confocal microscope for up to 8 hr. Their behavior was analyzed in terms of morphology, extension rates, shape of trajectory, frequency of branching, and percentage of time spent in advance, pause, and retraction. Thalamic fibers had distinct and stereotyped growth patterns that related closely to their position; within the striatum growth cones were small and elongated, rarely extending filopodia or side branches. Axons grew quickly, in straight trajectories, with minimal pauses or retractions. When they reached the ventral intermediate zone, axons slowed down, often coming to a complete stop for up to several hours, and their growth cones became larger and more complex. During pauses there were continuous extensions and retractions of filopodia and/or side branches. When advance resumed, it was often to a different direction. These results demonstrate consistent regional variations in growth patterns that identify an unexpected decision region for thalamic axons. They provide the basis for examining the roles of guidance cues in an accessible yet intact preparation of the thalamocortical pathway and allow for an evaluation of previously suggested pathfinding mechanisms.

Home care by outreach nursing for chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is characterised by progressive airflow obstruction, worsening exercise performance and deterioration in health. It is associated with significant morbidity, mortality and costs to health care systems. Care strategies, such as outreach nursing in the community, may reduce this burden.

OBJECTIVES

To evaluate the effectiveness of outreach respiratory health care worker programmes for patients with COPD in terms of improving lung function, exercise tolerance and health related quality of life (HRQL) of patient and carer, and reducing mortality and hospital service utilisation.

SEARCH STRATEGY

A search was carried out using the Cochrane Airways Group database. Bibliographies of identified RCTs were searched for additional relevant RCTs. Authors of identified RCTS were contacted for other published and unpublished studies.

SELECTION CRITERIA

Only randomised control trials of patients with COPD were included. The intervention was an outreach nurse visiting patients in their homes, providing support, education, monitoring patient status and providing liaison with physicians. Interventions that used nurse practitioners who provided therapeutic intervention were also included. Studies in which the therapeutic intervention under test was physical training were not included.

DATA COLLECTION AND ANALYSIS

Data extraction and study quality assessment were performed independently by two reviewers. Where further or missing data was required, authors of studies were contacted.

MAIN RESULTS

Four studies were found. Three assessed mortality following twelve months of care (n=96, 152 and 301), and one after seven months(n=75). Meta-analysis demonstrated that mortality was not significantly reduced by the intervention, Peto Odds Ratio 0.72; 95 % confidence interval 0.43, 1.21. Post hoc subgroup analysis suggested that mortality was reduced by the outreach nursing programme in patients with less severe disease. Significant improvements in health related quality of life were reported in one study in moderate COPD, but not in a study in patients with severe disease. No changes in lung function or exercise performance were found in the studies where data were available. Hospital admissions were reported in only one study in patients with severe disease and no benefit was observed.

REVIEWER'S CONCLUSIONS

Patients with moderate COPD may have mortality and health related quality of life gains from a nursing outreach programme, but there are no data about reductions in hospital utilisation. Patients with severe COPD do not appear to have benefit from such programmes and one large study found no reduction in hospital admissions in such patients.

Ability to discriminate movements at the ankle and knee is joint specific

Measures of discrimination for movements of different extent at the ankle (inversion) and knee (flexion) were obtained for the right and left legs from 59 male footballers. The finding of significant association between discriminability scores at common joints was interpreted in terms of the motor program.

Night splint treatment for plantar fasciitis. A prospective randomized study

A prospective randomized study of 116 patients with plantar fasciitis was performed to determine the effectiveness of adjuvant night splint therapy in relieving the acute symptoms of plantar fasciitis. Patients were randomized into one of two groups. Patients in Group 1 were treated with 1 month of oral antiinflammatory medication, Achilles stretching exercises, and shoe recommendations. Patients in Group 2 received identical treatment but also used a dorsiflexion night splint for 3 months. Blinded clinical review of patients was performed at 4, 6, and 12 weeks. Health status data Short Form 36 also was collected at these times and again at an average 19 months of followup. Overall, 68% of patients reported improvement with this nonoperative protocol for a 12-week period. No statistical difference was seen with the presence or absence of a night splint. In addition, no differences in improvement rates were observed with gender, duration of antecedent symptoms, the presence of bilateral symptoms, or the presence of a heel spur. Age older than 45 years did prove to be a statistically significant poor prognostic factor for improvement at the 12-week follow-up. Short Form 36 data obtained at baseline showed significantly lowered perception of health when compared with age matched controls. Patients in both treatment groups had significant improvement in Short Form 36 scores with 12 weeks of conservative care.

The effect of a respiratory home nurse intervention in patients with chronic obstructive pulmonary disease (COPD)

BACKGROUND

Chronic obstructive pulmomary disease (COPD) is associated with substantial mortality, morbidity, and costs to the health care system. With the increasing interest in outreach care programmes it is important to evaluate their impact upon patients and health services, for conditions such as COPD.

AIM

To determine the effectiveness of an outreach respiratory nurse in a shared care approach, with collaboration between general practitioners and hospital services, in the management of patients with severe COPD.

METHODS

Patients with severe COPD attending The Queen Elizabeth Hospital, Adelaide participated in a randomised controlled trial of a home based nursing intervention (HBNI) over 12 months with outcome measures including mortality rate, hospital service utilisation, FEV1 and health related quality of life (HRQL) using a modified Dartmouth Primary Care Co-operative Quality of Life questionnaire.

RESULTS

There were 48 subjects in each study arm, with no differences in mortality rate (eight deaths in the HBNI group and seven in the control group), hospital admissions, length of stay, number of outpatient and Emergency Service visits. The study had inadequate follow-up of FEV1 and HRQL within the control group. Within the HBNI group, a small improvement in HRQL (in three of ten indices measured) was demonstrated, despite a deterioration in FEV1 (11% reduction, p=0.04) compared to baseline. Quality of life of HBNI subjects' carers did not change.

CONCLUSION

An increased level of care given by an outreach respiratory nurse in a shared care approach for patients with severe COPD produced small improvements in HRQL but did not result in the prevention of deaths or reduced health care utilisation.

Sitting balance I: trunk-arm coordination and the contribution of the lower limbs during self-paced reaching in sitting

The effects of reach distance and type of task on the functional relationship between the trunk, upper limb segments and the lower limbs during self-paced reaching in sitting were examined. Two-dimensional kinematic, kinetic and electromyography (EMG) data were collected as six healthy subjects reached forward under three distance (60, 100, 140% arm's length) and two task (reaching to press a switch, reaching to grasp a glass) conditions. The results demonstrate that type of task affected primarily the temporal aspects of coordination, with the grasp task taking consistently longer than the press task. In contrast, reach distance affected both the spatio-temporal aspects of coordination between the trunk and arm segments and the active contribution of the lower limbs. As reach distance increased, the magnitude of trunk and upper-arm segmental motion increased, whereas forearm segmental motion decreased. However, at each reach distance the path of the hand was relatively straight and there was remarkable consistency in the relationship between trunk and arm segments both within and between subjects suggesting that despite the presence of redundant degrees of freedom, the individual uses a parsimonious coordinative pattern. The vertical ground reaction force (GRF) and EMG data demonstrated that the lower limbs actively contributed to support the body mass when the object was located at 140% arm's length.

Pre-emptive use of aerosolized ribavirin in the treatment of asymptomatic pediatric marrow transplant patients testing positive for RSV

Respiratory syncytial virus is a common virus which frequently causes severe lower tract disease in immunocompromised patients. The mortality rate in bone marrow transplant patients with lower tract disease varies from 31% to 100%, depending upon the treatment used, time before initiation of treatment, and whether patients are pre- or post-engraftment. Therapy with inhaled ribavirin has been used with limited success in decreasing mortality rate. Because of concern about conversion from upper respiratory tract disease to lower respiratory tract disease, we conducted a pilot study using aerosolized ribavirin in asymptomatic RSV-positive patients. Patients had NP washes performed on a weekly basis during the RSV season, for the presence of RSV. If patients were positive, but asymptomatic, and could have their transplant postponed, they were treated with ribavirin until negative. Patients who could not be postponed received aerosolized ribavirin, and began transplant conditioning. During this study, we performed 145 nasal aspirations for RSV on 25 patients; 10 aspirates were positive in seven asymptomatic patients. All positive events were successfully treated with ribavirin, which cleared the RSV for a minimum of 3 weeks. No patients became symptomatic. Thus, we conclude that ribavirin can clear asymptomatic infections in immunocompromised pediatric transplant patients.