The Effect of Manual Therapy Plus Exercise in Patients with Lateral Ankle Sprains: A Critically Appraised Topic with a Meta-Analysis

A high percentage of patients with lateral ankle sprains report poor outcomes and persistent neuromuscular impairment leading to chronic ankle instability and re-injury. Several interventions have been proposed and investigated, but the evidence on manual therapy combined with therapeutic exercise for pain reduction and functional improvement is still uncertain. The purpose was to study the effectiveness of adding manual therapy to therapeutic exercise in patients with lateral ankle sprains through a critically appraised topic. The literature search was performed in PubMed, PEDro, EMBASE and CINAHL databases, and only randomized clinical trials were included according to following criteria: (1) subjects with acute episodes of lateral ankle sprains, (2) administered manual therapy plus therapeutic exercise, (3) comparisons with therapeutic exercise alone and (4) reported outcomes for pain and function. Three randomized clinical trials (for a total of 180 patients) were included in the research. Meta-analyses revealed that manual therapy plus exercise was more effective than only exercises in improving dorsal (MD = 8.79, 95% CI: 6.81, 10.77) and plantar flexion (MD = 8.85, 95% CI 7.07, 10.63), lower limb function (MD = 1.20, 95% CI 0.63, 1.77) and pain (MD = -1.23; 95% IC -1.73, -0.72). Manual therapy can be used with therapeutic exercise to improve clinical outcome in patients with lateral ankle sprains.

Cloud Computing Mobile Application for Remote Monitoring of Bell's Palsy

Mobile applications provide the healthcare industry with a means of connecting with patients in their own home utilizing their own personal mobile devices such as tablets and phones. This allows therapists to monitor the progress of people under their care from a remote location and all with the added benefit that patients are familiar with their own mobile devices; thereby reducing the time required to train patients with the new technology. There is also the added benefit to the health service that there is no additional cost required to purchase devices for use. The Facial Remote Activity Monitoring Eyewear (FRAME) mobile application and web service framework has been designed to work on the IOS and android platforms, the two most commonly used today. Results: The system utilizes secure cloud based data storage to collect, analyse and store data, this allows for near real time, secure access remotely by therapists to monitor their patients and intervene when required. The underlying framework has been designed to be secure, anonymous and flexible to ensure compliance with the data protection act and the latest General Data Protection Regulation (GDPR); this new standard came into effect in April 2018 and replaces the Data Protection Act in the UK and Europe.

Cutaneous cooling to manage botulinum toxin injection-associated pain in patients with facial palsy: A randomised controlled trial

INTRODUCTION

Botulinum toxin injections are an effective, well-established treatment to manage synkinesis secondary to chronic facial palsy, but they entail painful injections at multiple sites on the face up to four times per year. Cutaneous cooling has long been recognised to provide an analgesic effect for cutaneous procedures, but evidence to date has been anecdotal or weak. This randomised controlled trial aims to assess the analgesic efficacy of cutaneous cooling using a cold gel pack versus a room-temperature Control.

MATERIAL AND METHODS

The analgesic efficacy of a 1-min application of a Treatment cold (3-5 °C) gel pack versus a Control (room-temperature (20 °C)) gel pack prior to botulinum toxin injection into the platysma was assessed via visual analogue scale (VAS) ratings of pain before, during and after the procedure.

RESULTS

Thirty-five patients received both trial arms during two separate clinic appointments. Cold gel packs provided a statistically significant reduction in pain compared with a room-temperature Control (from 26.4- to 10.2-mm VAS improvement (p < 0.001)), with no variance noted secondary to age, the hemi-facial side injected or the order in which the Treatment or Control gel packs were applied.

CONCLUSION

Cryoanalgesia using a fridge-cooled gel pack provides an effective, safe and cheap method for reducing pain at the botulinum toxin injection site in patients with facial palsy.

The needs of persons with lupus and health care providers: a qualitative study aimed toward the development of the Lupus Interactive Navigator™

Objective

Systemic lupus erythematosus is an inflammatory autoimmune disease associated with high morbidity and unacceptable mortality. A major challenge for persons with lupus is coping with their illness and complex care. Our objective was to identify the informational and resource needs of persons with lupus, rheumatologists, and allied health professionals treating lupus. Our findings will be applied toward the development of an innovative web-based technology, the Lupus Interactive Navigator (LIN™), to facilitate and support engagement and self-management for persons with lupus.

Methods

Eight focus groups were conducted: four groups of persons with lupus ( n = 29), three groups of rheumatologists ( n = 20), and one group of allied health professionals ( n = 8). The groups were held in British Columbia, Ontario, and Quebec. All sessions were audio-recorded and transcribed verbatim. Qualitative analysis was performed using grounded theory. The transcripts were reviewed independently and coded by the moderator and co-moderator using 1) qualitative data analysis software developed by Provalis Research, Montreal, Canada, and 2) manual coding.

Results

Four main themes emerged: 1) specific information and resource needs; 2) barriers to engagement in health care; 3) facilitators of engagement in health care; and 4) tools identified as helpful for the self-management of lupus.

Conclusion

These findings will help guide the scope of LIN™ with relevant information topics and specific tools that will be most helpful to the diverse needs of persons with lupus and their health care providers.

Feeding difficulties in children with inherited metabolic disorders: a pilot study

BACKGROUND

In children with inherited metabolic disorders (IMD), feeding difficulties are often assumed to be inherent, although there is little evidence describing their frequency or severity. The present study aimed to describe feeding patterns/difficulties among children with IMD on protein-restricted diets from one centre.

METHODS

Data from an observational, pilot study of 20 IMD children, nine females (median age, 2.7 years; range, 1-6 years) were compared with data obtained from a retrospective historical group of 15 healthy children (HC), 12 females, aged 1-5 years (median 3.0 years). Caregivers completed a feeding assessment questionnaire, and three separate video recordings were taken of each child eating at home.

RESULTS

The main feeding problems identified by the caregivers' questionnaire in the IMD group (compared to HC) were: poor appetite (55% versus 7%; P = 0.004), limited food variety (55% versus 27%; P = 0.04) and lengthy mealtimes (70% versus 20%; P = 0.006). During mealtimes, children from the IMD group were more likely to vomit, exhibit negative behaviour, get distracted and self-feed less often. From video recordings of meals, although the median meal duration was similar for the two groups (18 min IMD versus 16 min HC), the HC ate twice the quantity of food (3.4 mouthfuls min(-1) versus 1.5 mouthfuls min(-1) ; P < 0.001). During mealtimes, IMD caregivers were less likely to talk to their children (median parent to child communications: IMD group, seven in 10 min; HC, 17 in 10 min). Eighty-three percent of IMD children regularly ate alone.

CONCLUSIONS

In children with IMD on protein restrictions, severe feeding difficulties were common. Caregivers need to focus more attention on the social aspects of feeding. Further larger scale studies are required.

Accuracy of home enteral feed preparation for children with inherited metabolic disorders

BACKGROUND

Many children with rare chronic disorders require home enteral tube feeds (HETF) consisting of multiple modular ingredients. Feeds are often complex and the risk of errors during their preparation is high. The consequences of over- or under-concentration can be critical. The aim of the present prospective observation study was to assess the accuracy, skills and technique of caregivers when preparing and administering HETF.

METHODS

Fifty-two HETF patients (median age 7.5 years, range 0.7-18.0 years) with inherited metabolic disorders (IMD) requiring special feeds were recruited. Using observation and a structured questionnaire, a practical assessment of feed preparation and storage by the main caregiver was undertaken by an independent dietitian and nurse in the child's home, including hygiene practices, accuracy of measuring recipe ingredients, and storage of both ingredients and prepared feeds.

RESULTS

The majority (85%; n = 44) of feeds were based on >1 ingredient (median 3; range 1-6). Almost half (48%; n = 25) of caregivers measured feed ingredients inaccurately. Of the 31% (n = 16) using scoops, 31% used incorrect measuring spoons and 25% did not level scoops appropriately. Some 45% (n = 20/44) of carers measured liquid ingredients inaccurately. Hygiene practices during feed preparation were poor, including a lack of hand washing (31%: n = 16) and incorrect storage procedures for unused feed ingredients (56%; n = 29).

CONCLUSIONS

Practices in the preparation of modular HETF for children with IMD were not ideal. A combination of inaccuracy, poor hygiene, inappropriate storage, and long feed hanging times increases both metabolic and microbial risk. Better education, regular monitoring and the development of ready-to-use or preweighed ingredients would be beneficial.

A comparison of damage accrual across different calendar periods in systemic lupus erythematosus patients

Therapeutic approaches in systemic lupus erythematosus (SLE) have evolved over the last few decades, but their impact on prevention of organ damage is unknown. The objective of this study was to compare new cumulative damage in SLE patients across different calendar periods. Patients from a large SLE cohort were divided into two subcohorts; the first diagnosed and followed between 1978 and 1988 (cohort #1, n=100) and the second between 1989 and 1999 (cohort #2, n=51). Initial Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SLICC/ACR DI) scores, and changes in scores over the observation intervals, were compared for the two groups. Logistic regression estimated adjusted odds ratios (OR) comparing damage accrual between the two cohorts. Medication exposures were noted. Baseline characteristics were similar between the two groups. At first assessment, the adjusted OR for a SLICC/ACR DI score > or =1 was 1.79 (95% CI 0.82, 3.88) for cohort #1 versus cohort #2. At the end of the observation interval, the adjusted OR for a SLICC/ACR DI score > or =1 was 1.22 (0.58, 2.55) for cohort #1 versus cohort #2. The adjusted OR for accruing damage over the observation interval in cohort #1 versus cohort #2 was 0.94 (0.39, 2.44). Increased medication exposure was evident for cohort #2 compared to cohort #1. Despite increased therapeutic measures used for patients in more recent periods, our data do not establish a clear difference in damage accrual. This emphasizes the need for strategies to effectively treat lupus-specific manifestations, while minimizing side effects and comorbidities.

The persistence of anticardiolipin antibodies is associated with an increased risk of the presence of lupus anticoagulant and anti-beta2-glycoprotein I antibodies

OBJECTIVE

We studied antiphospholipid antibodies (aPL) in blood samples from a cohort of individuals followed for thrombosis to determine whether the persistent presence of anticardiolipin antibodies (aCL) is associated with a greater likelihood of having lupus anticoagulant and/or anti-beta2-glycoprotein I antibodies (LA/abeta2GPI).

METHODS

Blood samples from 353 individuals who had been tested for aCL on at least two occasions were tested for abeta2GPI and LA. Two groups were defined: aCL-persistent, who tested aCL-positive on at least two occasions, and aCL non-persistent, who tested aCL-positive on fewer than two occasions. Multivariate logistic regressions were performed using LA/abeta2GPI, LA and abeta2GPI as outcome variables and the percentage of aCL-positive tests as the predictor variable, adjusted for age, gender, family history of cardiovascular disease (CVD), systemic lupus erythematosus (SLE), smoking and number of venous (VT) and arterial thromboses (AT).

RESULTS

Sixty-eight (19%) individuals were aCL persistent and 285 (81%) were aCL non-persistent. LA/abeta2GPI was found in 36 (53%) of the aCL persistent group and 38 (13%) of the aCL non-persistent group. The two groups were similar for age, gender and smoking. Family history of CVD, SLE, VT and AT were more frequent in the aCL persistent group. Multivariate analyses revealed that odds ratios for LA/abeta2GPI, LA and abeta2GPI were 1.34 [95% confidence interval (CI) = 1.22-1.47], 1.36 (95% CI = 1.24-1.50) and 1.47 (95% CI = 1.31-1.65) respectively for each 10% increase in aCL-positive tests vs 0% positive tests.

CONCLUSION

Persistence of aCL positivity is associated with an increased risk of LA/abeta2GPI.

Associations between physical fitness and activity patterns during adolescence and cardiovascular risk factors in young adulthood: the Northern Ireland Young Hearts Project

The aim of the present study was to examine relationships between cardiovascular disease (CVD) risk factor status in young adulthood (mean age = 22.5 yrs) and antecedent physical fitness and physical activity at ages 12 and 15 years. The data were obtained from the Young Hearts Project, a longitudinal observational study of CVD risk factors in a representative sample of young people from Northern Ireland. Physical fitness was measured by the 20-metre endurance shuttle run, and physical activity and sports participation by a self-report recall questionnaire. CVD risk factors examined included serum total cholesterol (TC) and HDL cholesterol concentrations, the TC:HDL ratio, systolic and diastolic blood pressure and body fatness (sum of four skinfolds). Linear regression analyses showed modest relationships between physical fitness in adolescence and both TC:HDL ratio and body fatness in young adulthood. No such relationships were apparent for adolescent physical activity. The promotion of physical fitness during adolescence may reduce exposure to other risk factors lasting into early adulthood.

Adaptation and validation of the rheumatoid arthritis quality of life scale for use in Canada

OBJECTIVE

The Rheumatoid Arthritis Quality of Life questionnaire (RAQoL) was developed simultaneously in the UK and the Netherlands to measure quality of life in patients with RA. We adapted and validated the RAQoL for the English-Canadian and French-Canadian languages and culture.

METHODS

The UK RAQoL was translated into French-Canadian by a bilingual translation panel. Separate lay panels were then used to ensure that this and the English-Canadian instruments were appropriate for use with Canadian patients. Interviews were conducted with 15 French-Canadian and 15 English-Canadian patients with RA to determine the content validity. Reliability and construct validity were established by means of test-retest mail surveys conducted with 92 French-Canadian and 87 English-Canadian RA patients. The survey consisted of the adapted RAQoL, the Health Assessment Questionnaire (HAQ), and a demographic questionnaire.

RESULTS

The RAQoL was successfully adapted for both the French and English-Canadian cultures. Field testing showed both versions to be well received by respondents. Of the French-Canadian patients included in the postal survey, 52 responded at Time 1 and 50 at Time 2. For the English-Canadian sample, 54 responded at both time points. Missing data rates for the RAQoL were low and floor and ceiling effects were minimal. Test-retest reliability was good for both versions: 0.87 for the French-Canadian and 0.95 for the English-Canadian. Alpha coefficients (0.92 for the French-Canadian, 0.93 for the English-Canadian) showed the items to be adequately interrelated and scores on the measure showed moderate to high correlations with the HAQ, confirming construct validity. Both versions of the RAQoL were also able to distinguish patient groups that differed according to perceived health status and perceived severity of RA. In addition, the French-Canadian version was able to distinguish patients who rated today as bad or very bad from those who rated today as good or very good.

CONCLUSION

The new versions of the RAQoL were well received by both French and English speaking Canadians. The psychometric quality of the adapted questionnaires means they are suitable for inclusion in clinical trials involving patients with RA.

Do lupus disease activity measures detect clinically important change?

OBJECTIVE

New scales for the clinical assessment of patients with systemic lupus erythematosus (SLE) are valid and reliable, and quantitate disease activity. We assessed the responsiveness to change of 2 widely used standardized multi-item lupus activity measures, the revised Systemic Lupus Activity Measure (SLAM-R) and the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), and their ability to detect clinically relevant changes.

METHODS

Ninety-six (96) patients with definite SLE participated in this study. The group mean age was 45.0 (13.7) years, 91% were female, and the mean disease duration was 14.9 (7.5) years. Sociodemographic information, lupus activity (SLAM-R, SLEDAI), and damage were recorded at baseline. At each of the 5 monthly followup visits, the activity measures were repeated and a transition scale asked the physician if their patient's lupus activity had changed. Five different methods were used to compare the responsiveness of the activity measures studied: 1. the effect size; 2. the standardized response mean; 3. the control standardized response mean; 4. the area under the curve of a receiver operating characteristic (ROC) curve; and 5. a new multiple response modeling approach.

RESULTS

Both SLAM-R and SLEDAI are responsive. SLAM-R is consistently, although moderately, more responsive than SLEDAI. All 5 methods of evaluating responsiveness yielded a consistent ranking of disease activity measures.

CONCLUSION

SLAM-R and SLEDAI are responsive measures of lupus activity. SLAM-R appears to be more responsive than SLEDAI.

Learning from discordance in patient and physician global assessments of systemic lupus erythematosus disease activity

OBJECTIVE

Differences have been described between patient and physician assessments of well being in several chronic illnesses, and these differences may affect outcome. Disagreement may lead to dissatisfaction and to behaviors with dangerous consequences. We describe and identify predictors of patient-physician differences on ratings of disease activity in systemic lupus erythematosus (SLE).

METHODS

Data collected on 154 patients included age, education, disease duration, and patient and physician global assessments of lupus activity on a 10 cm visual analog scale (VAS), the Health Assessment Questionnaire (HAQ), the Medical Outcome Study Short-Form 36 (SF-36), the Systemic Lupus Disease Activity Index (SLEDAI), the Systemic Lupus Activity Measure (SLAM-R), and the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI). Multiple linear regression models were performed using patient VAS scores, physician VAS scores, and patient minus physician VAS scores as the dependent variables, and age, disease duration, selected SF-36 and SLAM-R subscales, and SDI as independent variables.

RESULTS

Patients were 90% female and 80% Caucasian, with a mean education of 13 +/- 2.8 years and a mean age of 43.1 +/- 13.6 years. The overall mean disease duration was 10.5 +/- 7.8 years. Physicians overscored patients by 2.5 cm in 6% of the cases and patients overscored physicians in 16% of the cases. The best multivariate model to predict overall differences included SF-36 mental health and SLAM-R kidney scores.

CONCLUSION

Patient-physician differences may result from a divergence in focus. Patients score lupus activity based on their psychological status, while physicians rely more heavily on the physical effect of the disease.

Association between IgM response to IgG damaged by glyoxidation and disease activity in rheumatoid arthritis

OBJECTIVE

To determine the association of serum IgG advanced glycation endproducts (AGE) and IgM anti-IgG-AGE antibodies with clinical measurements of rheumatoid arthritis (RA) disease activity.

METHODS

The study group consisted of 62 patients with RA and 16 control patients with osteoarthritis. Patient derived variables included perceived disease activity (10 cm visual analog scale, VAS) and Health Assessment Questionnaire (HAQ) results. Clinical measures of RA activity consisted of tender and swollen joint counts and a physician evaluation of disease activity (by VAS) as well as history of nodules, bone erosions, Sjogren's syndrome, and vasculitis documented by chart review. Patient sera were evaluated for glucose, glycosylated hemoglobin, and presence of RF, IgG-AGE and IgM anti-IgG-AGE. The nitroblue tetrazolium colorimetric and aminophenyl boronic acid methods were used for measurement of IgG-AGE, along with an ELISA for measurement of IgM anti-IgG-AGE.

RESULTS

Significant correlations were found between the presence of IgM anti-IgG-AGE and clinical measurements of swollen joint count and physician VAS.

CONCLUSION

IgM anti-IgG-AGE appears to be associated with clinical measurements of RA activity and represents a new marker of more active disease in RA.

Discordance between patients and their physicians in the assessment of lupus disease activity: relevance for clinical trials

Discordance between patient and physician assessment of lupus activity occurs frequently and its determinants are not known. Examples of discordance between patients and physicians in other disease models can be found in the literature. A better understanding of the discordance between patients and physicians can help us achieve a shared decision-making model of health care, improve patient satisfaction, improve patient compliance, and improve physician understanding of how lupus impacts on their patients. Understanding discordance also impacts on the design and interpretation of clinical trials.

Can health utility measures be used in lupus research? A comparative validation and reliability study of 4 utility indices

OBJECTIVE

To assess validity and reliability of 4 utility indices in patients with systemic lupus erythematosus (SLE).

METHODS

Twenty-five patients with stable SLE underwent assessment of disease activity [Systemic Lupus Disease Activity Measure (SLAM-R) and SLE Disease Activity Index (SLEDAI)] and damage [Systemic Lupus Collaborating Clinics/American College of Rheumatology Damage Index (SLICC/ACR DI)] and completed a health survey [Medical Outcome Survey Short Form-36 (SF-36)] and 4 utility measures: the visual analog scale (VAS), the time trade-off (TTO), the standard gamble (SG), and the McMaster Health Utilities Index Mark 2 (HUI2). To assess validity, Pearson's correlations were calculated between the SF-36 subscales and the utility measures. To assess reliability, intraclass correlations or kappa coefficients were calculated between first and second assessments, performed from 2 to 4 weeks apart, in patients without important clinical change in disease activity.

RESULTS

Disease activity from a SLAM-R varied from 0 to 14 (median = 4) and SLEDAI from 0 to 18 (median = 0). All subscales of the SF-36 correlated well with the VAS [lowest r = 0.56, 95% confidence interval (CI) (0.17, 0.80)] and poorly with the SG [maximum r = 0.41, CI (-0.01, 0.70); minimum r = 0.10, CI (-0.32, 0.50)]. The subscales of bodily pain (r = 0.56), mental health (r = 0.45), physical functioning (r = 0.62), role-emotional (r = 0.47), social functioning (r = 0.49) and vitality (r = 0.44) correlated significantly with TTO. All subscales correlated significantly [lowest r = 0.48, CI (0.09, 0.75)] with the HUI2 index of pain. Intraclass correlations for the VAS (ICC = 0.67) and TTO (ICC = 0.60) were good. They were fair for the SG (ICC = 0.45). The kappa coefficient was poor (0.32) for the HUI attribute of pain, but varied from fair (0.46) to excellent (0.88) for the remaining attributes. Regression analysis showed that a model incorporating the SLAM-R value and SF-36 subset of mental health was a good predictor of VAS and TTO utility measures.

CONCLUSION

The VAS, TTO, and to some extent, the HUI2, when compared with the SF-36 health survey, are valid and reliable measures to assess health related quality of life in a group of patients with SLE and may be useful for future research in this population. On the basis of these results the usefulness of the SG is questionable in these patients.

The needs of patients with arthritis: the patient's perspective

OBJECTIVE

To identify concerns and learning interests of patients with arthritis.

METHODS

A questionnaire was developed, pilot tested, and then used to evaluate 197 patients with arthritis, including osteoarthritis (OA) (n = 41), rheumatoid arthritis (RA) (n = 57), back disease (n = 55), systemic lupus erythematosus (n = 27), and systemic sclerosis (SSc) (n = 17). Twenty concerns and 12 learning interests were rated. Questionnaires were also administered to assess physical disability (Health Assessment Questionnaire), psychological disability (Arthritis Impact Measurement Scales 2), and pain (visual analog scale). Participants addressed accessibility of health services, satisfaction with their physician, psychosocial needs, use of self-help groups, and behavioral strategies used to assist coping. Patients with RA, OA, and back disease, at both a community and a hospital center, were tested to assess whether concerns and learning interests differed based on site of treatment. Analytic methods included analysis of variance, factor analysis, and multiple linear regression.

RESULTS

There were no differences in concerns or learning interests based on treatment site. Between diagnostic groups, patients with SSc were more interested in learning about self-help groups. The most frequently reported concern was worsening of the illness. The majority of respondents were interested in learning more about topics that were illness specific. The physician was chosen as the preferred source of information, and the preferred format was in writing. On factor analysis, the 20 concerns were reduced to 5 factors: psychological, coping, medication, social, and financial. Three factors were identified for learning interests: the illness, traditional health management topics, and nontraditional health management topics. Stepwise multiple linear regression revealed predictors for the 5 concern and 3 learning interest factors. The concerns were best predicted by self-reported disease severity, physical disability, and psychological distress, while learning interests were best predicted by self-reported disease severity, pain, and self-help group membership.

CONCLUSION

Concerns and learning interests of persons with arthritis did not differ based on the center of treatment or the diagnosis, but can be predicted by the level of pain and simple measures of disability. Better understanding of the relationship between health status and patient-perceived needs will result in improved patient-centered care.

Systemic lupus erythematosus, a disease associated with low levels of clusterin/apoJ, an antiinflammatory protein

OBJECTIVE

To measure the serum levels of clusterin, an antiinflammatory protein, which binds and inactivates complement, in patients with systemic lupus erythematosus (SLE) to determine whether the levels correlate with disease.

METHODS

The levels of serum clusterin were measured by ELISA in 80 patients with SLE (76 female, 4 male). Clinical and serological information was gathered on 115 visits. Overall disease activity scores were determined using the Systemic Lupus Activity Measure-Revised.

RESULTS

Serum clusterin levels were significantly decreased in patients with SLE and correlated inversely with disease activity (p < 0.00001). Low clusterin levels were significantly associated with skin ulcers (p < 0.0001), loss of hair (p = 0.002), proteinuria (p = 0.018), low platelet count (p = 0.03), and arthritis (p < 0.0001). The clusterin levels did not correlate with either systemic complement consumption, as measured by C3 or C4, or with prednisone use.

CONCLUSION

A highly significant correlation was observed between low levels of serum clusterin and a number of SLE disease features. This deficiency of clusterin could directly or indirectly affect the disease process. Individuals lacking sufficient amounts of clusterin systemically likely have poor control of antibody mediated inflammation at sites of apoptosis where autoantigens are exposed.

Prostanoid signaling, localization, and expression of IP receptors in rat thick ascending limb cells

It is widely held that only one prostacyclin (IP) receptor exists that can couple to guanine stimulatory nucleotide binding proteins (Gs) leading to activation of adenyl cyclase. Although IP receptor mRNA is expressed in vascular arterial smooth muscle cells and platelets, with lower level expression in mature thymocytes, splenic lymphocytes, and megakaryocytes, there is no molecular evidence for IP receptor expression in renal epithelial cells. The purpose of the present study was to obtain molecular evidence for the expression and localization of the IP receptor and to study the signaling pathways of IP receptor in rat medullary thick ascending limb (MTAL). Biochemical studies showed that IP prostanoids do not increase cAMP in rat MTAL. However, in the presence of vasopressin, inhibition of cAMP formation by prostacyclin (PGI2) analogs is pertussis toxin sensitive and does not activate protein kinase C. In situ hybridization studies localized IP receptor mRNA expression to MTAL in the rat kidney outer medulla. The results of RT-PCR of freshly isolated RNA from MTAL, with primers specific for the mouse IP receptor cDNA, produced an amplification product of the correct predicted size that contained an expected Nco I endonuclease restriction site. We conclude that rat renal epithelial cells express the IP receptor, coupled to inhibition of cAMP production.

Inhibition of lupus anticoagulant activity by hexagonal phase phosphatidylethanolamine in the presence of prothrombin

We have previously demonstrated that lupus anticoagulant antibodies from patients with systemic lupus erythematosus (SLE) specifically recognize hexagonal (II) phase phosphatidylethanolamine (PE), but not bilayer PE (Thromb Haemost 1989; 62: 892). In those studies, the involvement of proteins in this recognition was not evaluated. To address this issue, we have isolated IgG lupus anticoagulant antibodies from the plasma of SLE patients and evaluated the inhibition of lupus anticoagulant activity by hexagonal (II) phase PE in the presence and absence of purified plasma proteins. All six of the IgG lupus anticoagulant antibodies tested were inhibited by hexagonal (II) phase PE in the presence, but not the absence, of human prothrombin. In contrast, little or no inhibition was observed with prothrombin alone or with PE in combination with either beta2-glycoprotein I or annexin V. These data indicate that, for certain lupus anticoagulant antibodies, inhibition by hexagonal (II) phase PE is dependent on prothrombin, suggesting that these antibodies recognize a complex of PE and prothrombin.

Impact of disease activity and cumulative damage on the health of lupus patients

To test if lupus activity and damage predict physical function and general health in lupus was the objective of this study. Ninety-six patients with lupus were seen at baseline and monthly for 4 months. Sociodemographic characteristics and lupus damage (SLICC/ACR DI), were collected at baseline while lupus activity (SLAM-R, SLEDAI), health status measures (HAQ, SF-36) and immunological tests were collected at each visit. Associations of lupus activity and damage with general health and physical function were evaluated. Baseline health status measures were greatly impaired and comparable to those of severe medical illnesses. In cross-sectional analyses, baseline activity score measured by SLAM-R, but not by SLEDAI, correlated with most subscales of SF-36. Baseline damage score SLICC/ACR DI correlated only with the HAQ and the physical function subscale of SF-36. Differences in both activity measures (SLAM-R and SLEDAI) over time correlated with change in health status measures while baseline cumulative damage (SLICC/ACR DI) correlated with the average level of physical function only. Lupus activity measures, SLAM-R and SLEDAI, although differing cross-sectionally, both reflected patients' health status performance over time and lupus damage measure, SLICC/ACR DI, performed well in assessing physical function. Lupus patients scores for health are poor and comparable to those found in severe medical illnesses.

The relationship between disease activity and expert physician's decision to start major treatment in active systemic lupus erythematosus: a decision aid for development of entry criteria for clinical trials

OBJECTIVE

To explore the relationship between patients' systemic lupus erythematosus (SLE) activity and physicians' decision to treat with steroids or alternative medication.

METHODS

Baseline information and clinical status was extracted from case histories of 30 patients with lupus and represented in clinical vignettes. These vignettes were then mailed to 60 physicians (rheumatologists and immunologists with experience in the treatment of lupus), asking them in each case whether they would initiate treatment or not. The relationship between the 38 complete responses and the SLE Activity Measure (SLAM-R) and SLE Disease Activity Index (SLEDAI) lupus activity scores was analyzed using a general additive model.

RESULTS

SLE disease activity measured by SLAM-R or SLEDAI is a significant predictor (p < 0.0001) of physicians' decision to initiate treatment for patients with lupus. Variation between physicians was observed but was mostly due to a few outliers. Some other variations remained unexplained by patients' SLE disease activity, damage, or by specific organ involvement.

CONCLUSION

We present reference tables and curves for research that may be used as a basis to derive standardized quantitative criteria for entry in clinical trials. More research is needed on how these tools can be used by clinicians to guide them in their decision to treat or not.

Direct and indirect medical costs incurred by Canadian patients with rheumatoid arthritis: a 12 year study

OBJECTIVE

To perform the first prospective longitudinal study of direct (health services utilized) and indirect costs (diminished productivity represented by income loss) incurred by patients with rheumatoid arthritis (RA) in Saskatoon and Montreal, followed for up to 12 and 4 years, respectively.

METHODS

1063 patients reported on health status, health services utilization, and diminished productivity every 6 months.

RESULTS

Annual direct costs were $3788 (1994 Canadian dollars) in the late 1980s and $4656 in the early 1990s. Given that the average age exceeded 60 years, few participated in labor force activities or considered themselves disabled from the labor force and their indirect costs were substantially less, $2165 in the late 1980s and $1597 in the early 1990s. Institutional stays and medications made up at least 80% of total direct costs. Lengths of stay in acute care facilities remained constant, but the rate of hospitalization increased in the early 1990s, increasing average hospital costs per patient from $1563 in the late 1980s to $2023 in the early 1990s. For nonacute care facilities, rate of admission as well as length of stay increased over time, increasing costs per patient in Saskatoon 5-fold, from $291 to $1605. Those with greater functional disability incurred substantially higher direct and those under 65 years incurred higher indirect costs.

CONCLUSION

Direct costs are higher than indirect costs. The major component is due to institutional stays that, in contrast to other direct cost components, is increased in the older and more disabled. Measures to reduce longterm disability by earlier, more aggressive intervention have the potential to produce considerable cost savings. However, it is unknown which strategies will have the greatest effect on outcome and accordingly, how resources can be optimally allocated.

Developmental regulation of Zbu1, a DNA-binding member of the SWI2/SNF2 family

The SWI2/SNF2 gene family has been implicated in a wide variety of processes, involving regulation of DNA structure and chromatin configuration, mitotic chromosome segregation, and DNA repair. Here we report the characterization of the Zbu1 gene, also known as HIP116, located on human chromosome band 3q25, which encodes a DNA-binding member of this superfamily. Zbu1 was isolated in this study by its affinity for a site in the myosin light chain 1/3 enhancer. The protein has single-stranded DNA-dependent ATPase activity, includes seven helicase motifs, and a RING finger motif that is shared exclusively by the RAD5, spRAD8, and RAD16 family members. During mouse embryogenesis, Zbu1 transcripts are detected relatively late in fetal development and increase in neonatal stages, whereas the protein accumulates asynchronously in heart, skeletal muscle, and brain. In adult human tissues, alternatively spliced Zbu1 transcripts are ubiquitous with highest expression in these tissues. Gene expression is also dramatically induced in human tumor lines and in Li-Fraumeni fibroblast cultures, suggesting that it is aberrantly regulated in malignant cells. The developmental profile of Zbu1 gene expression and the association of the protein with a tissue-specific transcriptional regulatory element distinguish it from other members of the SWI2/SNF2 family and suggest novel roles for the Zbu1 gene product.

Automated DNA sequencing requiring no DNA template purification

A critical component in automated fluorescent DNA sequencing is good quality of DNA template. In an effort to reduce the dependence of sequencing success on DNA template quality, the effect of heat-soaked PCR on automated sequencing reactions has been examined. We have found that the heat-soaked PCR protocol considerably improves the overall quality of sequence data and significantly reduces the dependence on the quality of DNA templates. The improvement is corroborated by our ability to obtain over 500 bp of readable sequence per reaction using DNA from E. coli lysates as template obviating DNA purification.

Modular elements of the MLC 1f/3f locus confer fiber-specific transcription regulation in transgenic mice

The two proteins encoded by the fast alkali myosin light chain (MLC) 1f/3f locus are developmentally regulated, muscle specific, and expressed exclusively in fast-twitch fibers. Their expression is independently regulated by two separate promoters and a downstream enhancer. Previous studies showed a reporter gene directed by the rat MLC If promoter and MLC enhancer to exhibit correct skeletal muscle-specific expression in transgenic mice during development and to be preferentially expressed in fast-twitch Type IIB fibers [Donoghue et al., (1991) J. Cell B.ol. 115:423-434]. The MLC 3f promoter also directed muscle-specific expression of a CAT reporter gene in adult transgenic mice and showed little dependence upon the enhancer. Here, we show that the MLC 3f promoter also directs transgene expression in the fast-twitch fibers of adult skeletal muscle, but almost exclusively to fiber Types IIA and IIX. MLC 3f transgene expression occurs in only a subset of the fiber types that express the endogenous locus, indicating modular elements included in the transgene confer fiber-specific transcription regulation. MyoD protein was also found to be restricted to fiber Types IIA and IIX, providing evidence for its possible role in mediating fiber-specific gene expression.

Community mental health nursing and the elderly client: a case presentation

Elderly people suffering mental illness often isolate themselves from the community and any form of help and, therefore, from mental health professionals. This paper shows that these people can benefit from the skills of a community mental health nurse: a nurse who can form a trusting and therapeutic relationship and act as a mediator between the client and the community, the client and other health professionals, and the client and government departments. The role the community mental health nurse plays in co-ordinating service, in health promotion and in resolving ethical issues is discussed.

Low-dose methotrexate with leucovorin (folinic acid) in the management of rheumatoid arthritis. Results of a multicenter randomized, double-blind, placebo-controlled trial

OBJECTIVE

To determine whether the side effects of methotrexate can be decreased by the concurrent use of leucovorin, without affecting the efficacy of the methotrexate.

METHODS

We conducted a multicenter randomized, double-blind, placebo-controlled trial of leucovorin administration, 2.5-5.0 mg orally, to be given 24 hours after the single, weekly, oral dose of methotrexate. Every 3 weeks for 52 weeks, patients were evaluated for rheumatic disease activity and side effects. Dosage adjustments for both methotrexate and leucovorin were made as needed, according to a defined protocol. The primary outcome evaluated was the frequency of study withdrawals because of side effects and/or inefficacy. Secondary outcomes evaluated included the frequency of side effects and the relative efficacy of methotrexate in the leucovorin and placebo treatment groups.

RESULTS

Ninety-two evaluable patients were analyzed (44 took leucovorin and 48 placebo). Twenty-two patients withdrew early because of side effects unresponsive to our protocol, and 1 because of inefficacy; 17 had been taking placebo and 6 had been taking leucovorin (35% versus 14%, P < 0.02). The number of visits during which side effects were reported was reduced by almost 50% in the leucovorin treatment group (P < 0.001). There were significant reductions in the frequencies of all common side effects. At 52 weeks, disease activity was similar in both patient groups.

CONCLUSION

The methotrexate-leucovorin protocol used significantly reduces common side effects of methotrexate therapy without significantly altering efficacy.

Thyroid dysfunction in rheumatoid arthritis: a controlled prospective survey

OBJECTIVES

To determine whether thyroid dysfunction is found with increased frequency in patients with rheumatoid arthritis (RA).

METHODS

A controlled prospective survey was conducted on a cohort of patients with RA derived from a hospital clinic and a private surburban rheumatology practice. A control group with similar demographic features was generated from the same sources and included subjects with either osteoarthritis or fibromyalgia. Consecutive patients were evaluated over a six month period. The evaluation included a complete history and physical examination, and determination of serum thyroxine, free thyroxine, triiodothyronine, thyroid stimulating hormone (IRMA), antinuclear antibodies, and rheumatoid factor.

RESULTS

Of the 91 women with RA evaluated, 29 (30%) had evidence of thyroid dysfunction compared with 10 (11%) of 93 controls. The excess thyroid dysfunction is due to either hypothyroidism or Hashimoto's thyroiditis and was independent of age, increasing duration of disease, rheumatoid factor, and antinuclear antibodies.

CONCLUSIONS

Thyroid dysfunction is seen at least three times more often in women with RA than in women with similar demographic features with non-inflammatory rheumatic diseases such as osteoarthritis and fibromyalgia.

Characterization of the heterogeneity of polyethylene glycol-modified superoxide dismutase by chromatographic and electrophoretic techniques

Covalent attachment of polyethylene glycol (PEG) chains to the enzyme Cu,Zn-superoxide dismutase (SOD) produces a heterogeneous mixture of modified protein species. The heterogeneity of the product (PEG-SOD) derives from a variable stoichiometric combination of PEG with individual SOD molecules in addition to the polydispersity of the PEG reagent. Characterization of PEG-SOD presents significant challenges due in part to this heterogeneity in addition to the hybrid nature of the modified enzyme. The application of classical methods of protein characterization is not always successful for these PEG-proteins requiring the development of alternative or modified procedures. A series of chromatographic techniques including reversed-phase, ion-exchange, size-exclusion, and hydrophobic interaction high-performance liquid chromatography along with electrophoretic techniques including isoelectric focusing, sodium dodecyl sulfate-polyacrylamide gel electrophoresis, and capillary zone electrophoresis have been developed for assessing the degree of heterogeneity of PEG-SOD samples which encompass a range of different stoichiometries. Examples will be given demonstrating the application of these techniques to characterize PEG-SOD samples of different composition produced during the course of the reaction between SOD and an activated PEG reagent.

Myotonic dystrophy mutation: an unstable CTG repeat in the 3' untranslated region of the gene

Myotonic dystrophy (DM) is the most common inherited neuromuscular disease in adults, with a global incidence of 1 in 8000 individuals. DM is an autosomal dominant, multisystemic disorder characterized primarily by myotonia and progressive muscle weakness. Genomic and complementary DNA probes that map to a 10-kilobase Eco RI genomic fragment from human chromosome 19q13.3 have been used to detect a variable length polymorphism in individuals with DM. Increases in the size of the allele in patients with DM are now shown to be due to an increased number of trinucleotide CTG repeats in the 3' untranslated region of a DM candidate gene. An increase in the severity of the disease in successive generations (genetic anticipation) is accompanied by an increase in the number of trinucleotide repeats. Nearly all cases of DM (98 percent or 253 of 258 individuals) displayed expansion of the CTG repeat region. These results suggest that DM is primarily caused by mutations that generate an amplification of a specific CTG repeat.

Myotonic dystrophy mutation: an unstable CTG repeat in the 3' untranslated region of the gene

Myotonic dystrophy (DM) is the most common inherited neuromuscular disease in adults, with a global incidence of 1 in 8000 individuals. DM is an autosomal dominant, multisystemic disorder characterized primarily by myotonia and progressive muscle weakness. Genomic and complementary DNA probes that map to a 10-kilobase Eco RI genomic fragment from human chromosome 19q13.3 have been used to detect a variable length polymorphism in individuals with DM. Increases in the size of the allele in patients with DM are now shown to be due to an increased number of trinucleotide CTG repeats in the 3' untranslated region of a DM candidate gene. An increase in the severity of the disease in successive generations (genetic anticipation) is accompanied by an increase in the number of trinucleotide repeats. Nearly all cases of DM (98 percent or 253 of 258 individuals) displayed expansion of the CTG repeat region. These results suggest that DM is primarily caused by mutations that generate an amplification of a specific CTG repeat.

High dose intravenous methotrexate for refractory rheumatoid arthritis

Eight patients with active rheumatoid arthritis were given high dose intravenous methotrexate (MTX) (500 mg/m2) followed by oral leucovorin every 2 weeks for up to 6 months. All patients enrolled had previously failed conventional MTX therapy. Five patients completed 6 months of therapy. Three withdrew early, one due to inefficacy, one due to gastrointestinal intolerance and one due to sciatica requiring hospital admission. Fifty percent or greater improvements were seen in 5 of 8 clinical variables in those patients who completed 6 months of therapy. Six of 8 improvements achieved statistical significance at 24 weeks. Upon discontinuing therapy, patients flared within 8 to 12 weeks. Those who were maintained by low dose MTX after the high dose protocol were able to sustain their improvement throughout the subsequent 6 months of followup.

Kinetics of expression of ACh receptor alpha-subunit mRNA in denervated and stimulated muscle

Levels of the acetylcholine receptor (AChR) alpha-subunit mRNA were quantified in chick leg muscle, both after section of the sciatic nerve and following electrical stimulation of the denervated leg musculature. Whereas a lag period of approximately 17 h intervenes between the nerve section and the increase in message level, electrical stimulation leads to an immediate decline, which proceeds with a half-life of 3-4 h, similar to the decay induced by treatment with actinomycin D. The asymmetry in the kinetics of activation and repression can be accommodated by several regulatory schemes of which the simplest contains an autocatalytic loop as recently proposed by Changeux (The New Biologist 3: 413-429, 1991).

Combination methotrexate and sulfasalazine in the management of rheumatoid arthritis: case observations

Four patients with rheumatoid arthritis received a combination of methotrexate and sulfasalazine for a mean of 24 months (range 20-28 months). All 4 patients experienced clinical improvement, with a reduction in the number of involved joints and in morning stiffness. In all 3 patients who had previously taken methotrexate, we were able to reduce the dosage, and the prednisone dosage was reduced in 2 of 3 patients who had previously taken that drug. No serious toxicity was observed in any patient.

The trauma table as an alternative to the Hubbard tank in burn care

Because of disadvantages associated with the use of the Hubbard tank in the management of burn patients, the burn team at the University of Alabama replaced the tank with a trauma table that had been manufactured to their specifications. The trauma table is capable of being hydraulically raised or lowered, and maneuvered into Trendelenburg's position or its reverse. Another feature of the table is side rails that can be lowered. In contrast to the Hubbard tank, the trauma table has the following associated advantages: (1) quicker treatment sessions; (2) less pain to the patient; (3) elimination of patient exposure to contaminated water; (4) more comfort for the therapist; and (5) greater ease in patient handling, for example, rolling the patient onto a stretcher or bringing the patient into a sitting position.

Isolation of transforming sequences of two human lung carcinomas: structural and functional analysis of the activated c-K-ras oncogenes

Human lung tumors PR310 and PR371 maintained in nude mice contain activated c-K-ras oncogenes detectable by the ability of their DNAs to induce the morphological transformation of NIH 3T3 mouse fibroblasts. Using phage libraries constructed with DNA from NIH 3T3 mouse fibroblast transformants, we have isolated human sequences that span greater than 40 kilobase pairs of the c-K-ras oncogene. Based on the conservation of these human sequences in mouse fibroblast transformants, we conclude that the transforming ability of the oncogene activated in these tumors resides within a 43- to 46-kilobase-pair DNA region. No clear differences were observed between the structures of the PR310 and PR371 cloned oncogene sequences. Nucleotide sequence analysis in concert with DNA transfection experiments suggests that the PR371 oncogene has been activated by a single base change in the first exon, which results in the substitution of cysteine for glycine in position 12 of the predicted amino acid sequence. The genetic alteration responsible for the transforming activity of the PR310 oncogene, however, does not reside in the first exon. These results indicate that the activation of the c-K-ras oncogene in human lung cancer can occur by different mutational events.

Isoleucine Epimerization for Dating Marine Sediments: Importance of Analyzing Monospecific Foraminiferal Samples

The rate of isoleucine epimerization in fossil planktonic foraminifera is strongly species-dependent. Alloisoleucine/isoleucine ratios of two species of the same age can vary by more than a factor of 2. This finding, in combination with the known temporal and spatial variability of foraminiferal assemblages, demonstrates the critical importance of basing geochronological studies of marine sediments on monospecific samples. One rapidly epimerizing species generates a calibration curve of potentially high precision for dating sediments between the ages of about 50,000 to 400,000 years.

The jumping mechanism of Xenopsylla cheopis. III. Execution of the jump and activity

The flea's hind legs are the chief source of jumping power, but in species which execute large jumps, take-off is accelerated by elastic energy released from a resilin pad (homologous with the wing hinge ligaments of flying insects) situated in the pleural arch. A central click mechanism, operated by a rapid twitch of the trochanteral depressor (the starter muscle), synchronizes the separate sources of energy which power the jump. Ciné photos confirm the morphological evidence that the flea takes off from the trochanters, not the tarsi. The loss of wings, associated with lateral compression of the body and the shortening of the pleural ridge (which thus lowers the position of the pleural arch) together with modifications of the direct and indirect flight muscles, are some of the main morphological features associated with the change from a flying to a saltatorial mode of progression. The flea's take-off basically resembles that of other Panorpoid insects (Diptera, Mecoptera, etc.). The release of elastic energy from the pleural arch is a system by which the force used to move the wings of flying insects is rapidly fed back into the legs and adds power to the jump.