Implementing Activity-Based Therapy for Spinal Cord Injury Rehabilitation in Canada: Challenges and Proposed Solutions

Activity-based therapy (ABT) is a therapeutic approach with multiple benefits including promoting neurorecovery and reducing the likelihood of secondary complications in people living with spinal cord injury (SCI). Barriers and facilitators to ABT implementation for SCI rehabilitation have been studied from various perspectives through qualitative research. However, these viewpoints have not been synthesized to identify challenges of and strategies for implementing ABT across the Canadian healthcare system. Thus, the purpose of our study was to examine the current state of ABT in Canadian healthcare settings according to users' perspectives. Our main objectives were to compare barriers and facilitators to ABT implementation across Canadian healthcare settings according to users' perspectives and to identify optimal intervention strategies for ABT delivery across the Canadian healthcare system from acute to community care. We searched Scopus, CINAHL, OvidMedline, and other sources. Eligible articles were qualitative or mixed methods studies exploring ABT for adults with SCI in a Canadian healthcare setting. We analyzed qualitative findings through a thematic synthesis followed by a deductive content analysis. The Mixed Methods Appraisal Tool was used for critical appraisal. Nine articles were included. The thematic synthesis revealed two main themes: (1) factors influencing acceptance and adaptation of ABT across healthcare settings in Canada and (2) proposed solutions. The deductive analysis applied the Behaviour Change Wheel (BCW) to identify limited components of behaviour and appropriate interventions. To address ABT implementation challenges across the Canadian healthcare system, evidence-based interventions should target BCW subcategories of reflective motivation, social opportunity, and physical opportunity.

Spontaneous rupture of the right aortic sinus resulting in a sterile aorto-atrial fistula in a pet rabbit (Oryctolagus cuniculus)

Aortocardiac fistula is a broad term used to describe defects between the aorta and other cardiac chambers that can occur in humans and animals. A 1.5-year-old, 1.7 kg, male castrated Holland lop rabbit (Oryctolagus cuniculus) was presented for a two-week history of a heart murmur with corresponding cardiomegaly on radiographs. Physical examination confirmed a grade-V/VI continuous heart murmur on the right sternal border with a regular rhythm and a gallop sound. Echocardiography revealed an aortic-to-right-atrial fistula causing severe left-sided volume overload. Based on the echocardiographic findings, rupture of the right aortic sinus was suspected. Due to the poor prognosis, euthanasia was elected. On necropsy, a fistula was found connecting the right aortic sinus with the right atrium, without evidence of an inflammatory response nor evidence of an infectious etiology. The sudden onset of a heart murmur supported acquired fistulation from a ruptured aortic sinus (also known as the sinus of Valsalva), though a congenital malformation could not be completely excluded.

Investigating adaptive sport participation for adults aged 50 years or older with spinal cord injury or disease: A descriptive cross-sectional survey

CONTEXT

Spinal cord injury or disease (SCI/D) can lead to health challenges that are exacerbated with aging. Adaptive sport is understood to provide health benefits for the SCI/D population. Prior literature investigating adaptive sport in this population pertains to adults with SCI/D who are <50 years of age. However, most Canadians with SCI/D are >50 years of age.

OBJECTIVES

This study aimed to: (1) Compare demographics of those who do and do not participate in adaptive sport; (2) Describe the characteristics of adaptive sport that adults aged ≥50 years with SCI/D participate in; and (3) Identify barriers and facilitators to adaptive sport participation in this age group.

METHODS

This descriptive, cross-sectional survey was carried out using an online survey. Analytical statistics were used to address objective one, while descriptive statistics were employed for objectives two and three.

PARTICIPANTS

Responses from 72 adults aged ≥50 years, residing in Canada, living with a SCI/D for >6 months were included in the analysis.

RESULTS

Findings revealed that adaptive sport participants aged ≥50 years with SCI/D were more likely to identify as men, be younger individuals (50-59 years), and report greater satisfaction with physical health (P < 0.05). Adaptive sport participants most commonly played individual sports at the recreational level. Common barriers pertained to physical capacity, travel, and COVID-19; common facilitators included social support, desire to improve health, and having friends/peers who also participate.

CONCLUSION

Future research should investigate strategies to enhance facilitators and mitigate barriers to adaptive sport participation in order to improve access.

Factors influencing the clinical adoption of quantitative gait analysis technology with a focus on clinical efficacy and clinician perspectives: A scoping review

INTRODUCTION

Quantitative gait analysis (QGA) has the potential to support clinician decision-making. However, it is not yet widely accepted in practice. Evidence for clinical efficacy (i.e., efficacy and effectiveness), as well as a users' perspective on using the technology in clinical practice (e.g., ease of use and usefulness) can help impact their widespread adoption.

OBJECTIVE

To synthesize the literature on the clinical efficacy and clinician perspectives on the use of gait analysis technologies in the clinical care of adult populations.

METHODS

This scoping review followed the Joanna Briggs Institute (JBI) methodology for scoping reviews. We included peer-reviewed and gray literature (i.e., conference abstracts). A search was conducted in MEDLINE (Ovid), CENTRAL (Ovid), EMBASE (Ovid), CINAHL (EBSCO) and SPORTDiscus (EBSCO). Included full-text studies were critically appraised using the JBI critical appraisal tools.

RESULTS

A total of 15 full-text studies and two conference abstracts were included in this review. Results suggest that QGA technologies can influence decision-making with some evidence to suggest their role in improving patient outcomes. The main barrier to ease of use was a clinician's lack of data expertise, and main facilitator was receiving support from staff. Barriers to usefulness included challenges finding suitable reference data and data accuracy, while facilitators were enhancing patient care and supporting clinical decision-making.

SIGNIFICANCE

This review is the first step to understanding how QGA technologies can optimize clinical practice. Many gaps in the literature exist and reveal opportunities to improve the clinical adoption of gait analysis technologies. Further research is needed in two main areas: 1) examining the clinical efficacy of gait analysis technologies and 2) gathering clinician perspectives using a theoretical model like the Technology Acceptance Model to guide study design. Results will inform research aimed at evaluating, developing, or implementing these technologies.

FUNDING

This work was supported by the Walter and Maria Schroeder Institute for Brain Innovation and Recovery and AGE-WELL Graduate Student Award in Technology and Aging [2021,2022].

Exploring the Experiences and Perceptions of Adults With Spinal Cord Injury or Disease Aged 50 Years or Older on Participation in Sports

Background

Sports are physical activities that provide physical, psychological, and social benefits for individuals with spinal cord injury/disease (SCI/D). However, most sports research has been completed on individuals with SCI/D who are aged >50 years, even though the majority of people with SCI/D are aged >50 years. Despite substantial evidence supporting sports for older adults not living with a disability, there is currently no research examining the impact of sports for adults with SCI/D aged ≥50 years.

Objectives

To explore the perceptions and experiences of individuals with SCI/D aged 50 years or older who participate in sports in the community.

Methods

Fifteen adults with SCI/D aged ≥50 years who participated in community-based sports were interviewed. Interviews were audio-recorded and transcribed verbatim. Conventional content analysis was applied to the data.

Results

The overarching theme identified was that sports are fun and adaptable physical activities that have the potential to optimize physical, psychological, and social health in all people with SCI/D, regardless of age. Within this overarching theme, six categories surfaced: (1) importance of participating in sports later in life, (2) prioritizing health over performance, (3) uncertainties about participating in sports later in life, (4) reflections on participating in sports later in life, (5) beliefs on alternative sports involvement, and (6) advice for other aging adults with SCI/D considering sports.

Conclusion

Sports are perceived to provide physical, psychological, and social benefits for individuals with SCI/D aged 50 years or older. Findings will inform the development of future adaptive sports programs for older individuals with SCI/D.

Communicating Standing and Walking Data after Spinal Cord Injury: A Patient-Engaged, Qualitative Study

Background

The Standing and Walking Assessment Tool has been implemented by physical therapists across Canada, but there is no standardized communication tool to inform inpatients living with spinal cord injury (SCI) about their standing and walking ability.

Objectives

To identify how inpatients with SCI are currently receiving feedback on their standing and walking ability, and to determine if and how they would like to receive information on their standing and walking.

Methods

Ontario's Patient Engagement Framework informed study protocol development. Inpatients with SCI were recruited from a rehabilitation centre in Canada. Purposeful sampling considering severity of SCI and sex was adopted. Three to four months following discharge from inpatient rehabilitation, a semi-structured interview was conducted to explore participants'experiences and preferences regarding feedback on standing and walking ability during inpatient SCI rehabilitation. Interviews were audio-recorded and transcribed verbatim. A conventional content analysis was completed.

Results

Fifteen individuals with SCI (5 female, 10 male) participated. Four themes emerged from the transcripts: (1) motivation for standing and walking, (2) current standing and walking practice, (3) participant preferences for feedback on standing and walking ability, and (4) perceptions of preexisting tools.

Conclusion

Information on standing and walking ability was shared with inpatients with SCI in a variety of ways. Participants identified various preferences for the nature, format, and frequency of feedback concerning standing and walking ability during inpatient rehabilitation, which suggests the need for an individualized approach to communicating this information.

A qualitative exploration of allied health providers' perspectives on cultural humility in palliative and end-of-life care

BACKGROUND

Cultural factors, including religious or cultural beliefs, shape patients' death and dying experiences, including palliative and end-of-life (EOL) care preferences. Allied health providers must understand their patients' cultural preferences to support them in palliative and EOL care effectively. Cultural humility is a practice which requires allied health providers to evaluate their own values, biases, and assumptions and be open to learning from others, which may enhance cross-cultural interactions by allowing providers to understand patients' perceptions of and preferences for their health, illness, and dying. However, there is limited knowledge of how allied health providers apply cultural humility in palliative and EOL care within a Canadian context. Thus, this study describes Canadian allied health providers' perspectives of cultural humility practice in palliative and EOL care settings, including how they understand the concept and practice of cultural humility, and navigate relationships with patients who are palliative or at EOL and from diverse cultural backgrounds.

METHODS

In this qualitative interpretive description study, remote interviews were conducted with allied health providers who currently or recently practiced in a Canadian palliative or EOL care setting. Interviews were audio-recorded, transcribed, and analyzed using interpretive descriptive analysis techniques.

RESULTS

Eleven allied health providers from the following disciplines participated: speech-language pathology, occupational therapy, physiotherapy, and dietetics. Three themes were identified: (1) Interpreting and understanding of cultural humility in palliative and EOL care (i.e., recognizing positionality, biases and preconceived notions and learning from patients); (2) Values, conflicts, and ethical uncertainties when practicing cultural humility at EOL between provider and patient and family, and within the team and constraints/biases within the system preventing culturally humble practices; (3) The 'how to' of cultural humility in palliative and EOL care (i.e., ethical decision-making in palliative and EOL care, complexities within the care team, and conflicts and challenges due to contextual/system-level factors).

CONCLUSIONS

Allied health providers used various strategies to manage relationships with patients and practice cultural humility, including intra- and inter-personal strategies, and contextual/health systems enablers. Conflicts and challenges they encountered related to cultural humility practices may be addressed through relational or health system strategies, including professional development and decision-making support.

Factors Influencing the Clinical Adoption of Quantitative Gait Analysis Technologies for Adult Patient Populations With a Focus on Clinical Efficacy and Clinician Perspectives: Protocol for a Scoping Review

BACKGROUND

Quantitative gait analysis can support clinical decision-making. These analyses can be performed using wearable sensors, nonwearable sensors, or a combination of both. However, to date, they have not been widely adopted in clinical practice. Technology adoption literature has highlighted the clinical efficacy of technology and the users' perspective on the technology (eg, ease of use and usefulness) as some factors that influence their widespread adoption.

OBJECTIVE

To assist with the clinical adoption of quantitative gait technologies, this scoping review will synthesize the literature on their clinical efficacy and clinician perspectives on their use in the clinical care of adult patient populations.

METHODS

This scoping review protocol follows the Joanna Briggs Institute methodology for scoping reviews. The review will include both peer-reviewed and gray literature (ie, conference abstracts) regarding the clinical efficacy of quantitative gait technologies and clinician perspectives on their use in the clinical care of adult patient populations. A comprehensive search strategy was created in MEDLINE (Ovid), which was then translated to 4 other databases: CENTRAL (Ovid), Embase (Ovid), CINAHL (EBSCO), and SPORTDiscus (EBSCO). The title and abstract screening, full-text review, and data extraction of relevant articles will be performed independently by 2 reviewers, with a third reviewer involved to support the resolution of conflicts. Data will be analyzed using content analysis and summarized in tabular and diagram formats.

RESULTS

A search of relevant articles will be conducted in all 5 databases, and through hand-searching in Google Scholar and PEDro, including articles published up until December 2022. The research team plans to submit the final scoping review for publication in a peer-reviewed journal in 2023.

CONCLUSIONS

The findings of this review will be presented at clinical science conferences and published in a peer-reviewed journal. This review will inform future studies designed to develop, evaluate, or implement quantitative gait analysis technologies in clinical practice.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/39767.

The impact of sport participation for individuals with spinal cord injury: A scoping review

BACKGROUND: Spinal cord injury (SCI) leads to various physical, psychological, and social challenges. Sport is a holistic physical activity that may target these challenges. No literature systematically summarizes the overall impact of sport participation for those with SCI. OBJECTIVE: To comprehensively report the findings of quantitative studies investigating the impact of sport on the physical, psychological, and social health of individuals with SCI. METHODS: Six databases were searched: APA PsycInfo, CINAHL, Embase, Emcare, Ovid Medline, and PubMed (non-Medline). Studies were included if (a) participants were adults with SCI for ≥12 months, (b) outcomes resulting from ≥3 months of sport participation were investigated, (c) sport occurred in the community setting, and (d) comparisons of sport and non-sport conditions were analyzed. Details regarding study characteristics, participants, sport(s), and outcomes were extracted. Methodological quality was assessed using the Modified Downs and Black checklist. RESULTS: Forty-nine studies were included. Study quality ranged from poor to moderate. Sport participation showed favourable results for outcomes including function, quality of life, and community integration. Mixed results were found for outcomes including cardiac function, depressive symptoms, and employment. No significant associations were found for postural control, resilience, and education. CONCLUSIONS: The review findings suggest sport may be a promising intervention for addressing some challenges associated with SCI.

Exploring sport participation in individuals with spinal cord injury: A qualitative thematic synthesis

Context: Individuals with spinal cord injury (SCI) are susceptible to various physical, psychological, and social challenges. Sport is an activity that may holistically address these concerns. No existing research provides an overview of the current landscape of SCI-specific sport participation.Objective: To synthesize the findings of qualitative studies exploring the perceptions of people with SCI participating in sport, in relation to physical, psychological, and social health.Methods: This thematic synthesis included studies published in APA PsycInfo, CINAHL, Embase, Emcare, Medline, and PubMed. Eligible articles studied adults who had a SCI for ≥12 months and explored experiences following ≥3 months of sport participation using qualitative or mixed-methods. Articles were excluded if participants with SCI composed less than one-third of the study sample. From 8473 unique titles and abstracts screened, 47 articles underwent full-text review and 14 articles were included. The Mixed Methods Appraisal Tool was used to critically appraise the 13 qualitative studies and one mixed-methods study.Results: The overarching theme was that sport facilitates the progression to living an enriching life with SCI. Four sub-themes were identified within this theme: adjusting to SCI, factors influencing sport initiation, outcomes resulting from sport participation, and reshaping views of SCI. Participants detailed many benefits of sport, including improved fitness, independence, confidence, and sense of community. Beyond the participants themselves, sport helped reshape views of SCI by breaking stereotypes and inspiring others.Conclusion: Sport can play a crucial role in facilitating the progression to living an enriching life following SCI.

The impact of falls and fear of falling on participation, autonomy, and life satisfaction among individuals with spinal cord injury: A brief report

CONTEXT

Qualitative research suggests that falls can have a negative psychosocial impact on the lives of individuals with spinal cord injury (SCI). However, it is unclear whether these qualitative findings are supported by quantitative psychosocial metrics. This paper examines whether falling and/or having a fear of falling impacts participation, autonomy, and life satisfaction among individuals with SCI.

METHODS

Falls and fear of falling were tracked over six months using a survey and phone check-ins conducted approximately every three to four weeks. The Life Satisfaction 9 and Impact on Participation and Autonomy Questionnaires were administered at baseline and after six months. Responses on the questionnaires were statistically compared between fallers and non-fallers as well as participants with and without a fear of falling during the tracking period.

FINDINGS

Of the 65 community-dwelling adults with chronic SCI, 38 were categorized as fallers (aged 54.29 ± 13.73, 19.55 ± 14.20 years post-SCI, AIS A-D) and 27 were non-fallers (aged 57.78 ± 12.21, 17.93 ± 17.24 years post-SCI, AIS A-D). Our results revealed no significant differences between fallers and non-fallers in their perceived participation, autonomy, or life satisfaction at baseline or after six months. At the last check-in, 34 participants denied a fear of falling, while 31 had a fear of falling. Perceived autonomy outdoors (P=0.02), total life satisfaction (P=0.04), satisfaction with life as a whole (P=0.00) and self-care (P=0.01) differed between participants with and without a fear of falling after six months.

CONCLUSION

Fear of falling, rather than falls, may impact participation, autonomy, and life satisfaction in the SCI population.

Comparing the causes, circumstances and consequences of falls across mobility statuses among individuals with spinal cord injury: A secondary analysis

OBJECTIVE

To compare the occurrence of falls and fall-related injuries, and the circumstances of falls among individuals with spinal cord injury (SCI) who ambulate full-time, use a wheelchair full-time and ambulate part-time.

DESIGN

A secondary analysis.

SETTING

Community.

PARTICIPANTS

Adults with SCI.

INTERVENTION

None.

OUTCOME MEASURES

The occurrence and circumstances of falls and fall-related injuries were tracked over six-months using a survey. Participants were grouped by mobility and fall status. A chi-square test compared the occurrence of falls and fall-related injuries, and the time and location of falls, and a negative binomial regression was used to predict the likelihood of falls by mobility status. Kaplan-Meier analysis was used to determine differences in the time to first fall based on mobility status. Group characteristics and causes of falls were described.

RESULTS

Data from individuals who ambulated full-time (n = 30), used a wheelchair full-time (n = 27) and ambulated part-time (n = 8) were analyzed. Mobility status was a significant predictor of falls (P < 0.01); individuals who used a wheelchair full-time had a third of the likelihood of falling than those who ambulated full-time (P < 0.01). Type of fall-related injuries differed by mobility status. Those who ambulated full-time fell more in the daytime (P < 0.01). Individuals who ambulated full-time and part-time commonly fell while walking due to poor balance, and their legs giving out, respectively. Those who used a wheelchair full-time typically fell while transferring when rushed.

CONCLUSION

Mobility status influences the likelihood and circumstances of falls. Mobility status should be considered when planning fall prevention education/training for individuals with SCI.

Activity-based therapy in the community for individuals living with spinal cord injury or disease: qualitative interviews with clinicians

PURPOSE

Activity-based therapy (ABT) is a restorative approach that promotes neurological recovery below the level of injury in individuals with spinal cord injury or disease (SCI/D). This study sought to understand how ABT and its associated technologies were being used in community-based facilities across Canada.

METHODS

One to two participants from ten community-based ABT facilities completed a semi-structured interview that queried types of technologies or techniques used in ABT, and barriers and facilitators to providing ABT for individuals with SCI/D. Interviews were audio-recorded and transcribed verbatim, and analyzed using an interpretive description approach to identify themes and categories.

RESULTS

The overarching theme that emerged was that ABT in the community is a client-centered approach characterized by variety in techniques, clinicians, and clientele. The researchers identified three categories within this theme: characteristics of ABT in the community, perceived challenges, and a need for advocacy. Participants advocated for earlier implementation, increased education, and reduced costs of ABT to address the challenges with implementation and accessibility.

CONCLUSIONS

The use of ABT and its associated technologies varied across participating community-based facilities in Canada, despite a consistent focus on client goals and well-being. Addressing system-level limitations of ABT may improve implementation and accessibility in Canada.Implications for rehabilitationActivity-based therapy (ABT) is a group of interventions targeting recovery of sensory and motor function below the level of injury in individuals with spinal cord injury or disease (SCI/D).ABT in the community emphasizes a client-centered approach and is characterized by variety in techniques, clinicians, and clientele.Participants advocated that earlier implementation, reduced costs, and increased education will help overcome barriers to providing ABT, ultimately assisting to facilitate neurorecovery in individuals with SCI/D.Challenges in implementation, accessibility, and knowledge of ABT exist, highlighting a need to explore and address system-level limitations in Canada.

Perspectives of people living with a spinal cord injury on activity-based therapy

PURPOSE

Activity-Based Therapy (ABT) targets recovery of function below the injury level in individuals with spinal cord injury (SCI). This qualitative study is the first to capture the perspectives of individuals with SCI on community ABT programs in Canada.

METHODS

Ten participants (6 males, aged 23.0-65.0 years, 2.5-23.0 years post-SCI) were recruited using purposive sampling, and completed semi-structured interviews. Interview questions explored benefits and challenges, facilitators and barriers to access, and motivations for participating in ABT. Themes were identified using conventional content analysis and collaboratively analyzed using the DEPICT model.

RESULTS

An overarching theme of ABT as a key part of participants' evolving and lifelong recovery process emerged. Motivations for initiating ABT included dissatisfaction with early rehabilitation, and a desire to improve function and stay active. Participants perceived that ABT contributed to neurological recovery, physical and mental health benefits, independence, and hope. Factors contributing to recovery and factors limiting accessibility and participation in ABT were identified. Participants discussed advocating for ABT, and how ABT empowered self-management.

CONCLUSIONS

ABT was perceived to play a significant role in promoting ongoing recovery and well-being in individuals with SCI. Addressing limitations in awareness and availability of ABT may improve participation in ABT programs.Implications for rehabilitationActivity-Based Therapy (ABT) targets recovery of function and sensation below the level of injury in individuals with spinal cord injury (SCI).ABT plays a key role in the evolving and lifelong recovery process of individuals with SCI.Participants reported that ABT has a positive impact on physical, functional, and psychosocial domains, leading to improved independence and quality of life.Awareness and availability of ABT remain limited, highlighting a need to further explore and address factors limiting access to this therapy.

Autologous fat transplantation alters gene expression patterns related to inflammation and hypoxia in the irradiated human breast

BACKGROUND

Radiation-induced fibrosis, an adverse effect of breast cancer treatment, is associated with functional and cosmetic impairment as well as surgical complications. Clinical reports suggest improvement following autologous fat transplantation, but the mechanisms underlying this effect are unknown. A global gene expression analysis was undertaken to identify genetic pathways dysregulated by radiation and evaluate the impact of autologous fat transplantation on gene expression.

METHODS

Adipose tissue biopsies were taken synchronously from irradiated and contralateral non-irradiated breasts, before and 1 year after autologous fat transplantation. Whole-genome gene expression analyses were performed, and Hallmark gene set analysis used to explore the effect of radiotherapy and autologous fat transplantation on gene expression.

RESULTS

Forty microarrays were analysed, using bilateral biopsies taken from ten patients before and after autologous fat transplantation. Forty-five pathways were identified among the 3000 most dysregulated transcripts after radiotherapy in irradiated compared with non-irradiated breast (P ≤ 0·023; false discovery rate (FDR) no higher than 0·026). After autologous fat transplantation, 575 of the 3000 genes were again altered. Thirteen pathways (P ≤ 0·013; FDR 0·050 or less) were identified; the top two canonical pathways were interferon-γ response and hypoxia. Correlative immunohistochemistry showed increased macrophage recruitment in irradiated tissues.

CONCLUSION

The present findings contribute to understanding of how autologous fat transplantation can ameliorate radiation-induced fibrosis. This further supports the use of autologous fat transplantation in the treatment of radiation-induced fibrosis. Surgical relevance Clinical studies have indicated that autologous fat transplantation (AFT) stimulates regression of chronic inflammation and fibrosis caused by radiotherapy in skin and subcutaneous fat. However, there is a paucity of biological evidence and the underlying processes are poorly understood. Human data are scarce, whereas experimental studies have focused mainly either on the effect of irradiation or AFT alone. The present results indicate that radiotherapy causes dysregulated gene expression in fibrosis-related pathways in adipose tissues in humans. They also show that AFT can cause a reversal of this, with several dysregulated genes returning to nearly normal expression levels. The study provides biological evidence for the impact of AFT on radiation-induced dysregulated gene expression in humans. It supports the use of AFT in the treatment of radiation-induced fibrosis, associated with severe morbidity and surgical challenges.

A literature-based algorithm for the assessment, management, and monitoring of drug-induced QTc prolongation in the psychiatric population

BACKGROUND

Certain psychotropics and a number of other medications used to treat medical conditions in psychiatric patients can increase the risk of prolonging the corrected QT (QTc) interval on the electrocardiogram, which puts patients at risk of life-threatening ventricular arrhythmias such as torsades de pointes. Pharmacists are often consulted about medications which are known to prolong the QTc interval. Although this information is often accessible, advising how to identify, assess, manage, and refer psychiatric patients at risk for drug-induced QTc prolongation is more challenging.

OBJECTIVES

The objective of this project was first to review the literature, which describes guidelines and recommendations for the assessment and management of drug-induced QTc prolongation, and then to design an algorithm to be used by pharmacists working closely with mental health professionals or who provide care to psychiatric patients.

METHODS

A review of the literature was undertaken. Predefined keywords were used to perform the database search in MEDLINE, EMBASE, and International Pharmaceutical Abstracts to identify reviews, reports and guidelines on the assessment, prevention and monitoring of drug-induced QTc prolongation with an emphasis on psychotropic medications and management in the psychiatric population.

RESULTS

The electronic database search retrieved 637 relevant citations. These were initially screened by title and all duplicates were removed. The abstracts were then reviewed for relevancy based on the inclusion/exclusion criteria. Additional citations were retrieved from the bibliography of the articles identified in the initial search. A total of 79 articles describing QTc prolongation in the psychiatric population were thoroughly examined, but only 31 articles were selected to guide the development of the algorithm.

CONCLUSION

The literature-based algorithm developed provides a stepped-based approach for the assessment, monitoring, and management of drug-induced QTc prolongation in the psychiatric population. The algorithm may assist mental health clinicians in the decision-making process when psychiatric patients are prescribed medications known to increase the QTc interval.

Attitudes about Organ and Tissue Donation among the General Public and Blood Donors in Hong Kong

Context

The cadaveric organ and tissue donation rate in Hong Kong is not satisfactory; 1 million blood donors are registered and more than 300 000 are active. However, the current attitudes toward organ and tissue donation in the general public and blood donors of Hong Kong are unknown.

Methods

Random general public (n = 1018) and blood donors (n = 1227) of Chinese origin, with age ranging from 16 to 60 years, were interviewed using a standard verified questionnaire that examines attitudes and knowledge of organ and tissue donation.

Results

The mean age of the general public and blood donors were 32.6 and 28.9 years, respectively. Of the general public, 44.4% were men and among blood donors, 60% were men. About 56% of both groups thought that organ donation is an obligation of citizens. Blood donors were more aware than the general public about the types of organs that can be donated. When compared with the general public, a significantly higher percentage of blood donors were willing to donate their organs (81% vs 53%), had heard about organ donation cards (98.3% vs 89.5%), and had signed the cards (49.9% vs 22.6%). About 70% of both groups who had signed a card were carrying it. Thirty-nine percent of the general public and 17% of blood donors had not decided whether they would donate. For blood donors, 49.7% were willing to donate their relatives' organs, compared with 41.8% of the general public. Most individuals in both groups would not object to their relatives' decision to donate. About two thirds of individuals in both groups disagreed with the concept of an opt-out law, though only 20% of the general public and 14.4% of blood donors would refuse donation if an opt-out law were in practice.

Conclusions

This study shows that blood donors have better knowledge of organ donation and are more willing to donate their organs and sign an organ donation card than the general public. However, a substantial proportion of blood donors have not signed a donor card. It would be useful to design promotion programs to facilitate blood donors' participation in organ donation.

Level 5 Lymphadenopathy Warrants Heightened Suspicion for Clinically Significant Pathology

We conclude that patients presenting with level 5 lymphadenopathy should be investigated with heightened clinical vigilance. Our results suggest that up to 80 % will harbour clinically significant pathology requiring further medical treatment, three quarters of which will be malignancy. We report an observational study of histological outcomes of level 5 lymph node biopsies from a regional histopathology department across 5 years. 184 subjects were identified as having a biopsy of a lymph node from the level 5 region within the study period. One hundred and fifty six cases (84.8 %) had clinically significant pathology on final histology requiring further medical treatment. Lymphoma accounted for the highest number of cases (n = 72, 39.1 %), followed by metastatic carcinoma (n = 65, 35.3 %) and granulomatous change (n = 17, 9.2 %). Gender and laterality were not shown to be independent predictors of pathology significance (p > 0.05).

Ceramides are associated with inflammatory processes in human mediastinal adipose tissue

BACKGROUND AND AIM

Ceramides are poorly characterized in human adipose tissue. The aim of this study was to investigate concentrations of different ceramide species in human subcutaneous and visceral adipose tissue depots and to determine associations between ceramides and global gene expression profiles.

METHODS AND RESULTS

Concentrations of six ceramide species were determined in plasma and in subcutaneous and mediastinal adipose tissue from 10 overweight subjects (BMI 29.4 ± 4.9 kg/m(2)). In the adipose tissue biopsies gene expression arrays were performed and relationships between ceramides and gene expression analyzed. Immunostaining of the two adipose tissue depots was performed in an independent group of 10 patients. Mediastinal adipose tissue contained significantly higher concentrations (p < 0.05) of all six ceramide species than the subcutaneous depot. Of the six ceramides in plasma, concentrations of only two (Cer d18:1/18:0 and Cer d18:1/22:0) correlated significantly (p < 0.05) with the corresponding species in mediastinal adipose tissue, but there were no significant correlations between ceramides in plasma and subcutaneous adipose tissue. Multivariate analysis identified significant correlations between the total ceramide concentration and global gene expression within mediastinal, but not subcutaneous adipose tissue, according to cross-validation. Gene ontology analysis of genes related to ceramides in the mediastinal depot revealed that genes positively correlated with ceramides were associated mainly with immune and inflammatory categories, while genes negatively correlated with ceramides were associated mainly with lipid and carbohydrate metabolism.

CONCLUSIONS

Ceramides in human mediastinal adipose tissue may be involved in inflammation and lipid and carbohydrate metabolism.

Continuous on-line monitoring of secretion from rodent pituitary endocrine cells using fluorescent protein surrogate markers

We have developed a system to use secreted fluorescent proteins (FPs) as surrogate markers for the continuous on-line monitoring of hormone release from perfused tissue slices. We have tested this system using GH-GFP transgenic rats with green fluorescent protein (GFP) targeted to the secretory vesicles (SVs) of pituitary growth hormone (GH) cells. Brief exposures of vibratome slices to GH secretagogues [GH-releasing hormone (GHRH), GH-releasing peptide-6 (GHRP-6)] or somatostatin caused changes in FP output that correlate with hormone secretion, subsequently measured in fractions of perfusate by radioimmunoassay. The temporal resolution of this method was capable of revealing differences in the kinetics of response to GHRH and GHRP-6 between wild-type and dwarf (dw/dw) rats harbouring the GH-GFP transgene. We further tested the utility of the system by generating transgenic mice with red FPs targeted to secretory vesicles (PRL-mRFP(sv)) and to the cytoplasm (PRL-DsRed(cyto)) of lactotrophs. Dopamine had no effect on the FP output from pituitary slices of PRL-DsRed(cyto) mice but inhibited output from those of PRL-mRFP(sv) animals, with a rebound increase of release after removal, which again correlated with hormone output measured in the perfusate by radioimmunoassay. The inhibition of monomeric RFP secretion by dopamine was dose-dependent, as was stimulation by low concentrations of oxytocin. The temporal resolution afforded by this method provides useful insight into the release kinetics from large populations of pituitary cells, and fills a temporo-spatial gap between single vesicle and single cell monitoring of exocytosis in milliseconds, and in vivo sampling studies of release into the bloodstream on a time scale of minutes.

Three-dimensional ultrasound features of the polycystic ovary in Chinese women

OBJECTIVES

To quantify the three-dimensional (3D) ultrasound characteristics of ovaries in Chinese women with polycystic ovarian syndrome (PCOS) and to compare these with previous data on a Caucasian cohort with PCOS.

METHODS

3D pelvic ultrasound was performed in 40 Chinese women with PCOS and 40 controls. Ovarian volume, stromal volume and echogenicity, and antral follicle count (AFC) were measured and ovarian blood flow was quantified using both 3D power Doppler and two-dimensional (2D) pulsed wave Doppler. These data were compared with previously published data on a Caucasian cohort with PCOS.

RESULTS

Compared with controls, women with PCOS had a higher AFC (median (range), 15 (11-30) vs. 5.5 (1-10) per ovary, P < 0.01), ovarian volume (12.32 (8.10-16.16) mL vs. 5.64 (2.62-8.81) mL, P < 0.01) and stromal volume (9.74 (6.44-13.56) mL vs. 4.07 (1.52-6.67) mL, P < 0.01) but were comparable in stromal echogenicity and ovarian blood flow as measured by 3D power Doppler or 2D pulsed wave Doppler indices. However, in comparison with a previously reported Caucasian cohort with PCOS, the ovaries of Chinese women with PCOS had a significantly smaller stromal volume (median (range), 9.74 (6.44-13.56) mL vs. 10.79 (5.65-17.12) mL, P < 0.05), were less echogenic as reflected in a lower mean gray value (22.43 (13.13-35.50) vs. 32.36 (19.35-53.71), P < 0.01), and had reduced ovarian blood flow as reflected in a lower flow index (30.19 (23.32-44.88) vs. 33.54 (21.88-51.65), P < 0.05).

CONCLUSION

Based on 3D ultrasound measurements, Chinese women with PCOS have an increased stromal volume compared with controls. However, their stromal volume, echogenicity and vascularity is significantly lower than that in Caucasian women with PCOS. The possible etiology for these differences is discussed.

Visible and near-infrared calibrations for quality assessment of fresh phase I and II mushroom (Agaricus bisporus) compost

Previous studies have shown that visible and near-infrared spectra (Vis-NIR) of dry and milled compost can be used for generating partial least squares (PLS) calibrations of phase II compost parameters including ammonia, nitrogen dry matter (NDM), dry matter (DM), pH, conductivity, carbon, microbial population, and potential productivity. The objective of this study was to develop robust calibrations for some of the key parameters from the spectra of fresh phase I and II composts. Samples of substrates from six commercial production yards were obtained during winter and summer months of 2000-2004 to monitor changes in quality and were analyzed for the test factors. Vis-NIR reflectance measurements of fresh samples (740) were made over the range of 400-2500 nm. After mathematical pretreatments, PLS calibrations of the key parameters were developed using the NIR (1100-2500 nm) and visible and NIR (400-2500 nm) regions and subsequently validated using an independent sample set of 123 phase I and II samples obtained during 2004-2005. The phase I and II standard errors of laboratory measurements of ammonia, pH, conductivity, DM, NDM, and ash were lower than the standard error of predictions of the same parameters, respectively, by the best NIR or Vis-NIR models. The degree of precision for some of the calibrations, especially ammonia, NDM, and DM, is suitable for composters to monitor changes in quality parameters during production. The laboratory measurement errors for phase I samples were greater than those of the phase II samples, except for ash, due to a higher degree of heterogeneity in the substrate. The calibrations, especially for pH, conductivity, and ash, need to be improved with new sample sets. A major advantage of NIR spectroscopy is the ability to assess substrate quality for a range of target parameters simultaneously, within a few hours of receiving the samples. The main drawbacks are the expensive instrumentation, expertise, and training necessary for operating the spectrometer and a dedicated chemometrician required for maintaining the equations compared to the reference methods.

Active mobilisation after flexor tendon repair: comparison of results following injuries in zone 2 and other zones

PURPOSE

To prospectively study the role of active mobilisation after flexor tendon repair.

METHODS

The standard modified Kessler's technique was used to repair 46 digits in 32 patients with flexor tendon injuries. Early active mobilisation of the repaired digit was commenced on the third postoperative day. Range of movement was monitored and recovery from injury in zone 2 was compared with injury in other zones.

RESULTS

There were 24 and 22 injuries in zone 2 and other zones respectively. The total active motion score of the American Society for Surgery of the Hand was measured. Patients with zone-2 injuries achieved similar results to those with other-zone injuries apart from a 3-week delay in recovery. The final results were good to excellent in 71% and 77% of zone-2 and other-zone cases respectively (p < 0.05). There were 2 ruptures in zone-2 and one rupture in zone-3 repairs (6.5%).

CONCLUSION

Preliminary results of this study showed that active mobilisation following flexor tendon repair provides comparable clinical results and is as safe as conventional mobilisation programmes although recovery in patients with zone-2 injury was delayed.

TNF and TNFR polymorphisms in severe sepsis and septic shock: a prospective multicentre study

Tumour necrosis factor (TNF) is an important pro-inflammatory cytokine produced in sepsis. Studies examining the association of individual TNF single nucleotide polymorphisms with sepsis have produced conflicting results. This study investigated whether common polymorphisms of the TNF locus and the two receptor genes, TNFRSF1A and TNFRSF1B, influence circulating levels of encoded proteins, and whether individual polymorphisms or extended haplotypes of these genes are associated with susceptibility, severity of illness or outcome in adult patients with severe sepsis or septic shock. A total of 213 Caucasian patients were recruited from eight intensive care units (ICU) in the UK and Australia. Plasma levels of TNF (P = 0.02), sTNFRSF1A (P = 0.005) and sTNFRSF1B (P = 0.01) were significantly higher in those who died on ICU compared to those who survived. There was a positive correlation between increasing soluble receptor levels and organ dysfunction (increasing SOFA score) (sTNFRSF1A R = 0.51, P < 0.001; sTNFRSF1B R = 0.53, P < 0.001), and in particular with the degree of renal dysfunction. In this study, there were no significant associations between the selected candidate TNF or TNF receptor polymorphisms, or their haplotypes, and susceptibility to sepsis, illness severity or outcome. The influence of polymorphisms of the TNF locus on susceptibility to, and outcome from sepsis remains uncertain.

Attitudes about organ and tissue donation among the general public and blood donors in Hong Kong

CONTEXT

The cadaveric organ and tissue donation rate in Hong Kong is not satisfactory; 1 million blood donors are registered and more than 300,000 are active. However, the current attitudes toward organ and tissue donation in the general public and blood donors of Hong Kong are unknown.

METHODS

Random general public (n = 1018) and blood donors (n = 1227) of Chinese origin, with age ranging from 16 to 60 years, were interviewed using a standard verified questionnaire that examines attitudes and knowledge of organ and tissue donation.

RESULTS

The mean age of the general public and blood donors were 32.6 and 28.9 years, respectively. Of the general public, 44.4% were men and among blood donors, 60% were men. About 56% of both groups thought that organ donation is an obligation of citizens. Blood donors were more aware than the general public about the types of organs that can be donated. When compared with the general public, a significantly higher percentage of blood donors were willing to donate their organs (81% vs 53%), had heard about organ donation cards (98.3% vs 89.5%), and had signed the cards (49.9% vs 22.6%). About 70% of both groups who had signed a card were carrying it. Thirty-nine percent of the general public and 17% of blood donors had not decided whether they would donate. For blood donors, 49.7% were willing to donate their relatives' organs, compared with 41.8% of the general public. Most individuals in both groups would not object to their relatives' decision to donate. About two thirds of individuals in both groups disagreed with the concept of an opt-out law, though only 20% of the general public and 14.4% of blood donors would refuse donation if an opt-out law were in practice.

CONCLUSIONS

This study shows that blood donors have better knowledge of organ donation and are more willing to donate their organs and sign an organ donation card than the general public. However, a substantial proportion of blood donors have not signed a donor card. It would be useful to design promotion programs to facilitate blood donors' participation in organ donation.

Different effects of a single amino acid substitution on three adjacent epitopes in the gp41 C-terminal tail of a neutralizing antibody escape mutant of human immunodeficiency virus type 1

The envelope protein of human immunodeficiency virus type 1 (HIV-1) comprises the outer gp 120 SU domain and the anchoring gp41 TM domain, and the conventional view is that it has a single transmembrane region with the following C-terminal sequence situated entirely within the virion. However, we have recently proposed that the gp41 C-terminal region comprises three transmembrane regions and an external loop structure. Part of this loop is the peptide 731PRGPDRPEGIEEEGGERDRDRS752 that carries three antibody epitopes, 734PDRPEG739, 740IEEE743, and 746ERDRD750. PDRPEG is not detected in virions but reacts with its cognate MAb (C8) in Western blots, IEEE is a linear and non-neutralizing epitope, and ERDRD is a conformational and neutralizing epitope. Here we show that escape mutants selected with neutralizing ERDRD-specific antibody had a single 732R-->G substitution, 14 residues upstream of the cognate epitope, and no longer bound the selecting antibody. The same amino acid substitution altered epitope PDRPEG in the virion so that it now reacted with MAb C8, but left epitope IEEE unaffected. Introduction of 732R-->G by site-specific mutagenesis into the gp41 of cloned HIV-1 NL4-3 virions allowed them to escape neutralization by ERDRD-specific IgG, and confirms that 732R makes a major contribution to the neutralizing conformation of the 731-752 region of the C-terminal tail of gp41.

Pecam-1 is a modulator of stat family member phosphorylation and localization: lessons from a transgenic mouse

PECAM-1 (CD31) is a member of the immunoglobin (Ig) superfamily of cell adhesion molecules whose expression is restricted to hematopoietic and vascular cells. PECAM-1 can recruit adapter and signaling molecules via its immunoreceptor tyrosine activation motif (ITAM), suggesting that PECAM-1 plays a role in signal transduction pathways. To study the involvement of PECAM-1 in signaling cascades in vivo, we used the major histocompatibility (MHC) I gene promoter to target ectopic PECAM-1 expression in transgenic mice. We noted an attenuation of mammary gland development at early stages of virgin ductal branching morphogenesis. STAT5a, a modulator of milk protein gene expression during lactation, was localized to the nuclei of ductal epithelial cells of 6-week-old virgin PECAM-1 transgenics, but not in control mice. This correlated with decreases in ductal epithelial cell proliferation and induction of p21, an inhibitor of cell cycle progression. Using in vitro model systems we demonstrated PECAM-1/STAT5a association and found that residue Y701 in PECAM-1's cytoplasmic tail is important for PECAM-1/STAT5 association and that PECAM-1 modulates increases in STAT5a tyrosine phosphorylation levels. We suggest that by serving as a scaffolding, PECAM-1 can bring substrates (STAT5a) and enzymes (a kinase) into close proximity, thereby modulating phosphorylation levels of selected proteins, as previously noted for beta-catenin.

PECAM-1 shedding during apoptosis generates a membrane-anchored truncated molecule with unique signaling characteristics

Shedding of cell surface molecules, including growth factor receptors, provides a mechanism by which cells regulate signal transduction events. Here we show that platelet-endothelial cell adhesion molecule (PECAM)-1 is shed from the endothelial cell surface during apoptosis and accumulates in the culture medium as a approximately 100 kDa soluble protein. The cleavage mediating the shedding is matrix metalloproteinase (MMP) dependent, as GM6001, a broad-spectrum MMP inhibitor, inhibits PECAM-1 accumulation in the culture medium in a dose-responsive manner. In addition to the 100 kDa soluble fragment, PECAM-1 cleavage generates the formation of a truncated (Tr.) approximately 28 kDa molecule, composed of the transmembrane and the cytoplasmic PECAM-1 domains. Transfections of the full-length (Fl) and the Tr. PECAM-1 gene constructs into endothelial and nonendothelial cells were performed. We found 1) significantly more gamma-catenin and SHP-2 bound to the truncated than to the full-length PECAM-1; 2) stable expression of the truncated PECAM-1 in SW480 colon carcinoma cells resulted in a dramatic decrease in cell proliferation, whereas expression of comparable levels of the full-length PECAM-1 had no effect; 3) the decrease observed in cell proliferation is due, in part, to an increase in programmed cell death (apoptosis) and correlated with continuous caspase 8 cleavage and p38/JNK phosphorylation. These results support the intimate involvement of PECAM-1 in signal transduction cascades and also suggest that caspase substrates (e.g., PECAM-1) may possess distinct and unique functions on cleavage.

Bioelectronic detection of point mutations using discrimination of the H63D polymorphism of the Hfe gene as a model

BACKGROUND

A bioelectronic detection platform has recently been developed that facilitates the detection and characterization of nucleic acids. The DNA chip platform is compatible with homogeneous assays because separate labeling and wash steps are not required. A one-step, bioelectronic detection assay was developed to genotype patient samples with respect to the H63D polymorphism of the Hfe gene, associated with hereditary hemochromatosis.

METHODS AND RESULTS

Electrode arrays were modified with DNA capture probes that were perfectly matched to the wild-type or mutant allele of H63D. Amplicons containing the polymorphic site were hybridized with the capture probes on the electrode arrays in the presence of electronically labeled reporter (signaling) probes. Voltammetric analysis of the electrode arrays was conducted first at ambient temperature and then at elevated temperature. The electronic signal was preferentially diminished at elevated temperature from electrodes that hybridized with mismatched target amplicons.

CONCLUSION

An assay for bioelectronic genotyping of the H63D polymorphism was developed and used with six patient specimens to show the feasibility of this system as a model for point mutation detection.

Putative measure of peripheral and brainstem frequency-following in humans

The human brainstem frequency-following response (FFR) registers phase-locked neural activity to periodic auditory stimuli. FFR waveforms were extracted from the electroencephalogram by averaging responses to repeated auditory stimulation. Two channels of data were simultaneously recorded from horizontally (electrodes placed in ear canals) and vertically (vertex scalp referenced to midline) oriented electrode configurations. Eight participants each received a total of 2000 tone repetitions for each of ten stimulus frequencies ranging from 133 to 950 Hz. FFRs were quantified by fast-Fourier spectral analysis. The largest spectral intensities at the stimulus frequency were recorded in the horizontal FFR, which also followed higher frequencies and showed better signal-to-noise ratios then did the vertical FFR. The horizontal FFR pattern suggests an acoustic nerve origin, while the vertical FFR pattern suggests a central brainstem origin.

Platelet-endothelial cell adhesion molecule-1 (CD31), a scaffolding molecule for selected catenin family members whose binding is mediated by different tyrosine and serine/threonine phosphorylation

Platelet-endothelial cell adhesion molecule (PECAM)-1 is a 130-kDa glycoprotein commonly used as an endothelium-specific marker. Evidence to date suggests that PECAM-1 is more than just an endothelial cell marker but is intimately involved in signal transduction pathways. This is mediated in part by phosphorylation of specific tyrosine residues within the ITAM domain of PECAM-1 and by recruitment of adapter and signaling molecules. Recently we demonstrated that PECAM-1/beta-catenin association functions to regulate beta-catenin localization and, moreover, to modulate beta-catenin tyrosine phosphorylation levels. Here we show that: 1) not only beta-catenin, but also gamma-catenin is associated with PECAM-1 in vitro and in vivo; 2) PKC enzyme directly phosphorylates purified PECAM-1; 3) PKC-derived PECAM-1 serine/threonine phosphorylation inversely correlates with gamma-catenin association; 4) PECAM-1 recruits gamma-catenin to cell-cell junctions in transfected SW480 cells; and 5) gamma-catenin may recruit PECAM-1 into an insoluble cytoskeletal fraction. These data further support the concept that PECAM-1 functions as a binder and modulator of catenins and provides a molecular mechanism for previously reported PECAM-1/cytoskeleton interactions.