‘Getting your Life Back on Track after Stroke’: A Phase II Multi-Centered, Single-Blind, Randomized, Controlled Trial of the Stroke Self-Management Program Vs. the Stanford Chronic Condition Self-Management Program or Standard Care in Stroke Survivors

Background

Self-management is seen as a primary mechanism to support the optimization of care for people with chronic diseases such as symptomatic vascular disease. There are no established and evidence-based stroke-specific chronic disease self-management programs. Our aim is to evaluate whether a stroke-specific program is safe and feasible as part of a Phase II randomized-controlled clinical trial.

Methods

Stroke survivors are recruited from a variety of sources including: hospital stroke services, local paper advertisements. Stroke South Australia newsletter (volunteer peer support organization), Divisions of General Practice, and community service providers across Adelaide, South Australia. Subjects are invited to participate in a multi-center, single-blind, randomized, controlled trial. Eligible participants are randomized to either; standard care, standard care plus a six week generic chronic condition self-management group education program, or, standard care plus an eight week stroke specific self-management education group program. Interventions are conducted after discharge from hospital. Participants are assessed at baseline, immediate post intervention and six months.

Study Outcomes

The primary outcome measures determine study feasibility and safety, measuring, recruitment, participation, compliance and adverse events. Secondary outcomes include: positive and active engagement in life measured by the Health Education Impact Questionnaire, improvements in quality of life measured by the Assessment of Quality of Life instrument, improvements in mood measured by the Irritability, Depression and Anxiety Scale, health resource utilization measured by a participant held diary and safety.

Conclusion

The results of this study will determine whether a definitive Phase III efficacy trial is justified.

A comparison of covert and overt attention as a control option in a steady-state visual evoked potential-based brain computer interface

EEG data were recorded from occipital scalp regions of subjects who attended to an alternating checkerboard stimulus in one visual field while ignoring a similar stimulus of a different frequency in the opposite visual field. Classification of left/right spatial attention is attempted by extracting steady-state visual evoked potentials (SSVEPs) elicited by the stimuli to assess the potential use of such a spatial selective attention paradigm in a brain computer interface (BCI). Experimental setup and analysis procedure in a previous study in which eye movement is permitted are replicated in order to quantify differences in classification performance using overt and covert attention. Four variations of the basic paradigm, involving both feedback and addition of extra mental load, are studied for comparison. The average accuracy is found to be reduced by approximately 20% in the switch from overt to covert attention when no other specifications of the task are changed.

A novel technique of concurrent esophagoscopy and transgastrostomy gastroscopy to dilate a completely obstructed distal esophageal stricture in a child following fundoplication

We report a successful dilation of a completely obstructed distal esophageal stricture in a 4-year-old boy with combined immune deficiency syndrome, at 2 and half years after fundoplication and gastrostomy tube insertion. Barium studies and esophagoscopy had revealed complete obstruction of the lower esophagus. Transgastrostomy gastroscopy demonstrated a pinhole lumen through the fundoplication wrap; a guide wire was passed into the esophagus; and the stricture was dilated with Savary dilators. We presumed that the stricture was secondary to chronic esophagitis. The stricture was identified and successfully dilated using a novel technique of concurrent esophagoscopy and transgastrostomy gastroscopy.

Comparison of wild-type and UV-mutant beta-glucanase-producing strains of Talaromyces emersonii with potential in brewing applications

A screen of 46 UV-mutant strains of the moderately thermophilic fungus Talaromyces emersonii yielded two mutants (TC2, TC5) that displayed gross morphological differences to the parent strain and enhanced activity against mixed linkage cereal beta-glucans. Activity against beta-(1, 3)(1, 4)-D: -glucan from barley (BBGase) was measured during growth of the mutant and wild-type strains on a variety of carbon sources, ranging from solka floc to crude cereal fractions. In liquid culture, TC2 and TC5 secreted 1.2- to 8.6-fold more BBGase than the parent strain and markedly less beta-glucosidase (exo-activity); enzyme levels were dependent on the carbon source. Cellulose induced high BBGase. However, beet pulp, wheat bran, carob and tea-leaves were cheap and effective inducers. T. emersonii wild-type, TC2 and TC5 crude enzyme preparations achieved similar end-points during the hydrolysis of commercial barley beta-glucan (13.0-16.9%), but were more active against crude beta-glucan from barley (16.0-24.2% hydrolysis). The products of hydrolysis were quantified by high-performance anion-exchange chromatography. Mash trials indicated that enzyme preparations from all three organisms effected a significant reduction in wort viscosity and residual mash beta-glucan. Finally, TC2 and TC5 produce more efficient beta-glucan-depolymerizing enzymes; and wheat bran and solka floc can be used to provide inexpensive and potent enzyme cocktails with potential in brewing applications.

Endoscopic perforation rates at a Canadian university teaching hospital

BACKGROUND

Despite advances in training, operative techniques and endoscopic technology, upper and lower endoscopic procedures continue to have potential for intestinal perforation. Perforation rates provided to patients at the time of consent have frequently been derived from historical cohorts and survey datasets.

OBJECTIVE

This study examined the perforation rates of upper and lower endoscopic procedures at a major Canadian tertiary care centre.

METHODS

Inpatient and outpatient gastroscopies and colonoscopies performed during a three year period were evaluated. Endoscopies with perforations occurring within 14 days of procedure were retrospectively isolated using the International Classification of Diseases - 9th Revision code descriptions, then retrieved and hand searched to confirm a procedure-related perforation. Data were extracted to identify risk factors and patient outcomes.

RESULTS

A total of 21,217 endoscopies (13,792 gastroscopies and 7425 colonoscopies) were reviewed. Of these, 359 were identified, isolated and hand searched for confirmation of a perforation event. Eighteen were found to have an endoscopy-associated perforation. Ten perforations occurred with colonoscopy (0.13%) (incidence, 1.3/1000 procedures), resulting in one death (0.013%) (incidence, 0.13/1000 procedures). Eight perforations occurred with gastroscopy (0.06%) (incidence, 0.6/1000 procedures), resulting in zero mortality. Of colonoscopy procedures the rate of perforation with diagnostic colonoscopy was 0.13% (incidence, 1.3/1000 procedures) and with therapeutic colonoscopy was 0.14% (incidence, 1.4/1000 procedures). Of gastroscopy procedures the rate with therapeutic gastroscopy was 0.15% (incidence, 1.5/1000 procedures). No perforations occurred with diagnostic gastroscopy.

CONCLUSION

Gastroscopy and colonoscopy procedures, especially those with therapeutic maneuvers, continue to carry morbidity and mortality risks associated with perforation.

Clinical experience with infliximab for Crohn's disease: the first 100 patients in Edmonton, Alberta

OBJECTIVE

To determine whether the clinical efficacy and safety of infliximab in diverse clinical referral practices was similar to that seen in the randomized, controlled clinical trials.

METHODS

Data were gathered from a review of charts of 109 consecutive patients with inflammatory and/or fistulizing Crohn's disease who received infliximab infusions. Responses were recorded based on the physician's global clinical assessment and classified as complete, partial or nonresponse.

RESULTS

One hundred nine patients were treated with one to nine infusions of infliximab at a dose of 5 mg/kg and followed up for a median of 24 weeks (range one to 40 weeks). Fifty-four patients were treated for inflammatory disease, 38 for fistulizing disease and 17 for both. Clinical response occurred in 73% (17% complete response, 55% partial response). The clinical response rate did not vary relative to patient demographics, disease distribution, indication for infliximab, or the concomitant use of corticosteroids or immune modifiers. For those taking concomitant immune modifiers, the response rate was 75%. The median time to response was two weeks (range one to six weeks). The median duration of response was 12 weeks (range six to 88 weeks). Reduction or cessation of steroids was possible in 17 of 32 patients. Adverse events related to infliximab occurred in 7% of patients. These events were characterized as mild and did not require stoppage of infliximab therapy, except in one patient who had a treatable anaphylactic-like infusion reaction.

CONCLUSIONS

The patient group in the present study realized significant clinical benefit, with minimal adverse effects, following treatment with infliximab. Clinical response rates paralleled those previously described in placebo controlled trials and retrospective clinical practice reviews. Nevertheless, the complete response rate (ie, remission) in this patient group was lower than that previously described.

A case of Histoplasma capsulatum causing granulomatous liver disease and Addisonian crisis

A 56-year-old man with persistently elevated liver enzyme levels, fatigue, lethargy and a 9.0 kg weight loss over six months underwent a percutaneous liver biopsy that demonstrated multiple granulomas. Screening serologies were positive for histoplasmosis, and he was started on itraconazole treatment. He returned to hospital the same night with coffee-ground emesis and in Addisonian crisis requiring parenteral steroids and intensive care unit support. An abdominal computed tomography scan revealed bilaterally enlarged, nonenhancing adrenal glands suggestive of infarcts, presumed secondary to histoplasmosis. Treatment was initiated with amphotericin B, and Histoplasma capsulatum was cultured from his urine and cerebrospinal fluid. A serum immunodiffusion test was also positive for both H and M bands, indicating active infection with Histoplasmosis species. His serum and urine samples were also weakly positive for the antigen. Despite complications of renal failure, pneumonia and congestive heart failure, he recovered with medical therapy and was discharged home to complete a prolonged course of itraconazole therapy. While hepatic granulomas often reflect an occult disease process, the cause may remain undiscovered in 30% to 50% of patients despite exhaustive investigations. H capsulatum is an uncommon cause of granulomatous liver disease, and with its protean clinical presentation, a high index of suspicion is needed to make the diagnosis and avoid the potentially high fatality rate associated with disseminated infection.

The representation of "false cognates" in the bilingual lexicon

The results of repetition priming studies with homographs such as BANK suggest that semantic constraints restrict priming to the specific meaning invoked during the study phase. Cross-language priming studies with "false cognates" (words with similar form but unrelated meanings) suggest that form similarity may be sufficient to support repetition priming, and they do not therefore support this claim. The relevant studies have used language cues (e.g., seeing the word ESTATE in the context of other Italian words) as distinct from semantic cues (e.g., INVERNO-ESTATE) to constrain meaning, however, so that interpretation is correspondingly uncertain. The experiment described in this paper was designed to answer this question: Does sequential exposure to the English word pair MANOR-ESTATE during the study phase facilitate lexical decision to the second of these words during sequential exposure to the Italian word pair INVERNO-ESTATE (i.e., winter-summer) during the test phase of the experiment? In the experiment reported below, interpretation of false cognates was constrained by meaning rather than language, and cross-language repetition priming was eliminated for false cognates. The results suggest that lexical representation in bilinguals is organized along morphological lines rather than by language.

Gastric cancer and other endoscopic diagnoses in patients with benign dyspepsia

BACKGROUND

It has been suggested that endoscopy could be replaced with non-invasive assessment of helicobacter status in the initial work up of young dyspeptic patients without sinister symptoms.

AIMS

To determine the incidence of gastro-oesophageal malignancy in young dyspeptic patients.

METHODS

The Alberta Endoscopy Project captured clinical and demographic data on all endoscopies performed from April 1993 to February 1996 at four major adult hospitals in Alberta. The endoscopic and histological diagnosis in a subgroup of patients under 45 years of age without alarm symptoms that had undergone gastroscopy was reviewed. In addition, a random list of 200 patients was generated and their medical records reviewed in order to assess the proportion with symptoms suitable for a non-invasive management strategy.

RESULTS

Gastroscopy was performed in 7004 patients under 45 years. In 3634 patients (56% female) alarm type symptoms were absent; 78.9% of patients had symptoms amenable to a non-invasive initial approach, giving a corrected sample size of 2867 patients (correction factor 0.789). Three gastric cancers, one case of moderate dysplasia, 10 biopsy proved cases of Barrett's oesophagus, and 19 oesophageal strictures/rings were detected within this sample. The corrected prevalence of gastric cancer in this select population was 1.05 per thousand patients.

DISCUSSION

Endoscopy yielded three gastric cancers in this sample of under 45 year old dyspeptic patients without sinister symptoms. While initial non-invasive screening with one-week triple therapy for helicobacter positive individuals is unlikely to have a detrimental outcome the physician is advised to consider endoscopy in patients with persisting, recurrent, or sinister symptoms.

The utility of endoscopy in the management of patients with gastroesophageal reflux symptoms

OBJECTIVE

The utility of endoscopy in the management of patients with symptoms of gastroesophageal reflux disease (GERD) is unclear. The purpose of this prospective study was to assess the impact of endoscopy on the subsequent management of patients with uncomplicated reflux symptoms.

METHODS

A total of 742 patients underwent endoscopy for symptoms of GERD. Endoscopists recorded the therapy before endoscopy, the findings of endoscopy, and the treatment recommendations after endoscopy.

RESULTS

There was no difference in pre-endoscopy therapy or grade of esophagitis in subjects undergoing endoscopy for failed therapy versus GERD symptoms alone. After endoscopy, the most common strategy for patients taking omeprazole was to maintain or increase the dose. For those taking an H2 blocker before endoscopy, the most common outcome was to switch the patient to omeprazole, independent of the grade of esophagitis.

CONCLUSIONS

Most patients undergoing endoscopy for symptoms of GERD were switched to omeprazole regardless of the endoscopic findings. No esophageal cancer was identified and the incidence of Barrett's esophagus was low. It appears that endoscopy itself did not change the management of patients receiving H2-blocker therapy. A trial of a proton pump inhibitor before endoscopy should be considered.

Cholestatic hepatocellular injury with azathioprine: a case report and review of the mechanisms of hepatotoxicity

Azathioprine is a drug commonly used for the treatment of inflammatory bowel disease, organ transplantation and various autoimmune diseases. Hepatotoxicity is a rare, but important complication of this drug. The cases reported to date can be grouped into three syndromes: hypersensitivity; idiosyncratic cholestatic reaction; and presumed endothelial cell injury with resultant raised portal pressures, venoocclusive disease or peliosis hepatis. The components of azathioprine, 6-mercaptopurine and the imidazole group, may play different roles in the pathogenesis of hepatotoxicity. The strong association with male sex, and perhaps with human leukocyte antigen type, suggests a genetic predisposition of unknown type. Many of the symptoms of hepatotoxicity, such as nausea, abdominal pain and diarrhea, can be nonspecific and can be confused with a flare-up of inflammatory bowel disease. As well, the subtype resulting in portal hypertension can occur without biochemical abnormalities. A 63-year-old man with Crohn's disease who is presented developed the rare idiosyncratic form of azathioprine hepatotoxicity, but also had a severe disabling steroid myopathy, peripheral neuropathy, resultant deep venous thrombosis and pulmonary embolism related to immobility, and a nosocomial pneumonia. His jaundice and liver enzyme levels improved markedly on withdrawal of the drug, returning to almost normal in five weeks. Treating inflammatory bowel disease effectively while trying to limit iatrogenic disease is a continuous struggle. Understanding the risks of treatment is the first important step. There must be a low threshold for obtaining liver function tests, especially in men, and alertness to the need to discontinue the drug or perform a liver biopsy should patients on azathioprine develop liver biochemical abnormalities, unexplained hepatomegaly or signs of portal hypertension.

Comparison of the utilization of endoscopy units in selected teaching hospitals across Canada

There is no information on the number of endoscopic procedures performed at major teaching hospitals across Canada. The directors of endoscopy units at eight teaching hospitals from Halifax to Vancouver volunteered demographic information on the unit at their location. There was a very wide range of endoscopic utilization, with approximately comparable rates of out-patient versus in-patient procedures and of gastroscopies versus colonoscopies, but there was no obvious linking of the ratios of in-patients:out-patients versus total number of designated gastrointestinal beds or total number of hospital beds. Thus, the appropriateness of endoscopic procedures needs to be based on standards of practice and accepted indications. The number of endoscopies performed per endoscopy unit support staff varied widely (from 323.7 to 1065.3 per year), and it would be interesting to learn whether this represents an opportunity for cost-saving in some units.

Esophageal candidiasis in AIDS. Successful therapy with clotrimazole vaginal tablets taken by mouth

In this paper we describe the results of oral therapy of esophageal candidiasis with clotrimazole vaginal tablets in 25 homosexual men with AIDS, of whom 19 had oral candidiasis and 16 had esophageal symptoms. Therapy with clotrimazole vaginal tablets, 100 mg, taken by mouth cleared the esophageal symptoms, oral candidiasis, and esophageal lesions completely in all 25 men. Clotrimazole vaginal tablets are a useful alternative to other antifungal agents for the treatment of esophageal candidiasis in AIDS patients.

Purification and characterization of a labile rat glutathione transferase of the Mu class

A labile GSH transferase homodimer termed 11-11 was purified from rat testis by GSH-agarose affinity chromatography followed by anion-exchange f.p.l.c. The enzyme is unstable in the absence of thiol(s) and has relatively low affinity for both 1-chloro-2,4-dinitrobenzene (Km 4.4 mM) and GSH (Km(app.) 4.4mM). Its mobility on SDS/polyacrylamide-gel electrophoresis is slightly less than that of subunits 3 and 4 and its pI is 5.2. Subunit 11 has a blocked N-terminal amino acid residue, but after CNBr cleavage fragments accounting for 113 amino acid residues were sequenced and showed 65% homology with corresponding sequences in subunit 4, indicating that it is a member of the Mu family. GSH transferase 11 is a major isoenzyme in testis, epididymis, prostate and brain and present at lower concentrations in other tissues.

Single-step purification and h.p.l.c. analysis of glutathione transferase 8-8 in rat tissues

GSSG selectively elutes two GSH transferases from a mixture of rat GSH transferases bound to a GSH-agarose affinity matrix. One is a form of GSH transferase 1-1 and the other is shown to be GSH transferase 8-8. By using tissues that lack this form of GSH transferase 1-1 (e.g. lung), GSH transferase 8-8 may thus be purified from cytosol in a single step. Quantitative analysis of the tissue distribution of GSH transferase 8-8 was obtained by h.p.l.c.

Autoantibodies to the thyroid microsomal/thyroid peroxidase antigen are polyclonal and directed to several distinct antigenic sites

A detailed examination of the epitopes recognized by autoantibodies (aAbs) to the thyroid microsomal antigen/thyroid peroxidase (TMA/TPO) in patients with thyroid autoimmune disease has been made using a combination of immunochemical and enzymatic techniques. Our results demonstrate the the autoimmune response to thyroid microsomal antigen/thyroid peroxidase (TMA/TPO) is multifocal and far more heterogeneous than hitherto recognized. By immunoblotting with aAbs, antigenic determinants on the TMA/TPO have been recognized that are either susceptible to polypeptide denaturation and/or sensitive to the effects of reducing agents. Furthermore, these aAbs can inhibit, to varying degrees, the enzymatic activity of solubilized preparations of TPO in microsomes, as ascertained by peroxidation of guaiacol and iodide. A large proportion of the autoimmune response is directed to the guaiacol peroxidation site. The data support the view that the autoimmune reactivity to the TMA/TPO is a specific polyclonal response with a minimum of six distinct, independent determinants that are recognized by aAbs.