39 CAN BEHAVIOURAL CHANGE INTERVENTIONS IMPROVE SELF-EFFICACY AND EXERCISE ADHERENCE AMONG PEOPLE WITH PARKINSON’S? A SYSTEMATIC REVIEW

Background

People with Parkinson’s (PwP) lead sedentary lifestyles compared to healthy peers. Personal influences including low self-efficacy and poor outcome expectation appear to predict exercise adherence more accurately than disease severity. The purpose of this review is to identify successful behavioural-change interventions that promote self-efficacy and exercise adherence among PwP.

Methods

Databases including EBSCO, Medline, CINAHL, Web of Science, PubMed, Embase, Scopus, Google Scholar and Cochrane Library were searched from inception to 2020. Interventional studies including a behavioural-change intervention were included. Title, abstract and full-text screening was conducted by two independent reviewers. The Cochrane Risk of Bias Tool and Robins-I were used to assess the Risk of Bias. Data was extracted by two independent reviewers. The outcomes of interest were self-efficacy, quality of life, physical function, and exercise adherence. A narrative synthesis was completed and mapped to the Theoretical Domains Framework, to produce practice-orientated outcomes.

Results

Seventeen studies (n=1319) were included. Risk of bias was generally moderate. A multicomponent behavioural-change intervention encompassing education, behavioural strategies and support groups appeared to improve quality of life, physical function, and exercise adherence in PwP. No intervention improved self-efficacy. Self-monitoring, goal setting, social supports, feedback, self-managements skills and action planning improved long-term adherence.

Conclusion

No intervention changed self-efficacy. However, it appears that a multicomponent intervention is essential to improve exercise adherence. Trials directly comparing different intervention types and adequate follow-up periods are limited, preventing a conclusive finding of the most effective behavioural-change intervention to promote exercise adherence among PwP.

Pathology in Practice

In collaboration with the American College of Veterinary Pathologists.

'PDSAFE' - a multi-dimensional model of falls-rehabilitation for people with Parkinson's. A mixed methods analysis of therapists' delivery and experience

OBJECTIVE

To explore the clinical reasoning of physiotherapists using PDSAFE; according to disease severity and their experiences of treatment delivery in a large fall-prevention trial for people with Parkinson's (PwP).

DESIGN

A descriptive study of delivering PDSAFE. Semi-structured interviews explored therapists' experiences.

SETTING

A two-group, home-based, multi-centred, single-blinded, randomised controlled trial showed no overall effect on fall reduction between groups but demonstrated a significant secondary effect relating to disease severity with benefits to balance, falls efficacy and near-falls for all.

PARTICIPANTS

Physiotherapists with a background in neurology and older-person rehabilitation were trained in the delivery of PDSAFE INTERVENTION: A multi-dimensional, individually tailored and progressive, home-based programme.

RESULTS

Fifteen physiotherapists contributed to the 2587 intervention sessions from the PDSAFE trial and six of those physiotherapists took part in the interviews. The personalised intervention was reflected in the range of strategies and exercises prescribed. Most commonly prescribed fall-avoidance strategies were 'Avoiding tripping', 'Turning' and 'Freezing Cues' and all possible combinations of balance and strength training within the programme were selected. PwP with greater disease severity were more likely to have received less challenging strategies, balance and strengthening exercises than those with lower disease severity. Therapists considered the focus on fall events and fall avoidance strategies an improvement on 'impairment only' treatment. The presence of cognitive deficits, co-morbidities and dyskinesia were the most challenging aspects of delivering the intervention.

CONCLUSION

Falls management for PwP is complex and compounded by the progressive nature of the condition. Physiotherapists both delivered and positively received PDSAFE. (248 words) The trial registration number is ISRCTN 48152791.

AB1351-HPR A HAND EXERCISES MHEALTH APP FOR PATIENTS WITH RHEUMATOID ARTHRITIS: DEVELOPMENT, DESIGN AND USABILITY STUDY IN TURKEY

Background:

The Strengthening and Stretching for Rheumatoid Arthritis of the Hand (SARAH) programme has been shown to provide long term improvement in hand function for patients with rheumatoid arthritis (RA) affecting their hands. In Turkey, limited number of physiotherapists work in rheumatology departments so there is an opportunity to use the digital technologies for exercise prescription and follow up to improve access to treatment.Growing research evidence supports the effectiveness of mHealth interventions for improving exercise adherence and motivation.To our knowledge,there is no hand exercises mHealth program for patients with rheumatoid arthritis designed by experts with the user-centered method.

Objectives:

The aim of our study is to develop and design a smartphone application for structured hand exercise program for patients with RA in Turkey and to test its usability.

Methods:

We used a qualitative user-centered design approach with 2 phases.PHASE 1:we conducted focus group meetings to discuss the content, feature and design of app to produce a prototype version of smartphone software for RA hand training program.The Focus Group consisted of two physiotherapists and three hand therapists working in the field in different rheumatology or hand rehabilitation clinics,two software-computer engineers, and three patients with RA who had previously participated in hand therapy. The focus group met 4 times during phase 1. PHASE 2:we investigated the usability of prototype version of the rheumatoid hand exercise smartphone app software. All focus group members (n=10) and 6 patients used the app for one week.All users filled the usability questionnaire and provided written feedback on the app. Revisions were made and the revised version was tested. We put the revised app in digital markets in Turkish and English.

Results:

The major themes identified from the Focus Group discussions during phase 1 were (a)Login techniques (b)self-monitoring (c)exercises types/frequency/diary, (d) patient education, (e)behavioral change and encouragement (f)exercise adherence. Patients and therapist all agreed the login needed to be easy. Patients wanted to be able to monitor their pain levels and hand function in the app. Patients thought the SARAH exercise were suitable for the app. A patient said:‘SARAH exercises is beneficial for my hand and tendon gliding exercise,I will be happy to see these exercises in app’. Patients wanted exercise reminders using push up notifications to encourage exercise were proposed and included.A patient commented ‘in themorning and after work, motivational push up messages could be beneficial for exercise habit.”During the phase 2,we identified a need for education on how to use digital app, ways to provide patient follow up to monitor adherence, the need to allow patients to select the amount of notifications. This feedback was incorporated into the final version.

Conclusion:

mHealth applications represent an easily accessible bridge between patients and health professionals for home-based programs. Using a user-centered approach ensured that we developed an application that met the needs of therapists and patients. Physiotherapists are using the app in rheumatology clinics in Turkey and long-term usability and feasibility studies are ongoing.

References:

[1]Argent R, Patient Involvement With Home-Based Exercise Programs: Can Connected Health Interventions Influence Adherence? JMIR Mhealth Uhealth 2018.

[2]Lamb SE, Strengthening and Stretching for Rheumatoid Arthritis of the Hand Trial (SARAH).Lancet. 2015,385(9966).

[3]Azevedo R, Smartphone application for rheumatoid arthritis self-management: cross-sectional study revealed the usefulness, willingness to use and patients’ needs.Rheumatol Int.2015, 35(10).

Disclosure of Interests:

None declared

Evaluating the value of intrapartum fetal scalp blood sampling to predict adverse neonatal outcomes: A UK multicentre observational study

OBJECTIVE

To evaluate the value of fetal scalp blood sampling (FBS) as an adjunct test to cardiotocography, to predict adverse neonatal outcomes.

STUDY DESIGN

A multicentre service evaluation observational study in forty-four maternity units in the UK. We collected data retrospectively on pregnant women with singleton pregnancy who received FBS in labour using a standardised data collection tool. The primary outcome was prediction of neonatal acidaemia diagnosed as umbilical cord arterial pH < 7.05, the secondary outcomes were the prediction of Apgar scores<7 at 1st and 5th minutes and admission to the neonatal intensive care unit (NICU). We evaluated the correlation between the last FBS blood gas before birth and the umbilical cord blood and adjusted for time intervals. We constructed 2 × 2 tables to calculate the sensitivity, specificity, positive (PPV) and negative predictive value (NPV) and generated receiver operating curves to report on the Area Under the Curve (AUC).

RESULTS

In total, 1422 samples were included in the analysis; pH values showed no correlation (r = 0.001, p = 0.9) in samples obtained within an hour (n = 314), or within half an hour from birth (n = 115) (r=-0.003, p = 0.9). A suboptimal FBS pH value (<7.25) had a poor sensitivity (22%) and PPV (4.9%) to predict neonatal acidaemia with high specificity (87.3%) and NPV (97.4%). Similar performance was noted to predict Apgar scores <7 at 1st (sensitivity 14.5%, specificity 87.5%, PPV 23.4%, NPV 79.6%) and 5th minute (sensitivity 20.3%, specificity 87.4%, PPV 7.6%, NPV 95.6%), and admission to NICU (sensitivity 20.3%, specificity 87.5%, PPV 13.3%, NPV 92.1%). The AUC for FBS pH to predict neonatal acidaemia was 0.59 (95%CI 0.59-0.68, p = 0.3) with similar performance to predict Apgar scores<7 at 1st minute (AUC 0.55, 95%CI 0.51-0.59, p = 0.004), 5th minute (AUC 0.55, 95%CI 0.48-0.62, p = 0.13), and admission to NICU (AUC 0.58, 95%CI 0.52-0.64, p = 0.002). Forty-one neonates had acidaemia (2.8%, 41/1422) at birth. There was no significant correlation in pH values between the FBS and the umbilical cord blood in this subgroup adjusted for sampling time intervals (r = 0.03, p = 0.83).

CONCLUSIONS

As an adjunct tool to cardiotocography, FBS offered limited value to predict neonatal acidaemia, low Apgar Scores and admission to NICU.

The use of computer adaptive tests in outcome assessments following upper limb trauma: a systematic review

Aims

Outcome measures quantifying aspects of health in a precise, efficient, and user-friendly manner are in demand. Computer adaptive tests (CATs) may overcome the limitations of established fixed scales and be more adept at measuring outcomes in trauma. The primary objective of this review was to gain a comprehensive understanding of the psychometric properties of CATs compared with fixed-length scales in the assessment of outcome in patients who have suffered trauma of the upper limb. Study designs, outcome measures and methodological quality are defined, along with trends in investigation.

Materials and Methods

A search of multiple electronic databases was undertaken on 1 January 2017 with terms related to "CATs", "orthopaedics", "trauma", and "anatomical regions". Studies involving adults suffering trauma to the upper limb, and undergoing any intervention, were eligible. Those involving the measurement of outcome with any CATs were included. Identification, screening, and eligibility were undertaken, followed by the extraction of data and quality assessment using the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) criteria. The review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria and reg istered (PROSPERO: CRD42016053886).

Results

A total of 31 studies reported trauma conditions alone, or in combination with non-traumatic conditions using CATs. Most were cross-sectional with varying level of evidence, number of patients, type of study, range of conditions and methodological quality. CATs correlated well with fixed scales and had minimal or no floor-ceiling effects. They required significantly fewer questions and/or less time for completion. Patient-Reported Outcomes Measurement Information System (PROMIS) CATs were the most frequently used, and the use of CATs is increasing.

Conclusion

Early studies show valid and reliable outcome measurement with CATs performing as well as, if not better than, established fixed scales. Superior properties such as floor-ceiling effects and ease of use support their use in the assessment of outcome after trauma. As CATs are being increasingly used in patient outcomes research, further psychometric evaluation, especially involving longitudinal studies and groups of patients with specific injuries are required to inform clinical practice using these contemporary measures. Cite this article: Bone Joint J 2018;100-B:693-702.

Implementing exercise in cancer care: study protocol to evaluate a community-based exercise program for people with cancer

BACKGROUND

Clinical research has established the efficacy of exercise in reducing treatment-related side-effects and increasing wellbeing in people with cancer. Major oncology organisations have identified the importance of incorporating exercise in comprehensive cancer care but information regarding effective approaches to translating evidence into practice is lacking. This paper describes the implementation of a community-based exercise program for people with cancer and the protocol for program evaluation.

METHODS/DESIGN

The Life Now Exercise program is a community-based exercise intervention designed to mitigate and rehabilitate the adverse effects of cancer and its treatment and improve physical and psychosocial wellbeing in people with cancer. Involvement in the program is open to people with any diagnosis of cancer who are currently receiving treatment or within 2 years of completing treatment. The 3-month intervention consists of twice weekly group-based exercise sessions administered in community exercise clinics under the supervision of exercise physiologists trained to deliver the program. Evaluation of the program involves measures of uptake, safety, adherence and effectiveness (including cost effectiveness) as assessed at the completion of the program and 6 months follow-up.

DISCUSSION

To bridge the gap between research and practice, the Life Now Exercise program was designed and implemented to provide people with cancer access to evidence-based exercise medicine. The framework for program implementation and evaluation offers insight into the development of feasible, generalizable and sustainable supportive care services involving exercise. Community-based exercise programs specifically designed for people with cancer are necessary to facilitate adherence to international guidelines advising patients to participate in high-quality exercise.

TRIAL REGISTRATION

ACTRN12616001669482 (retrospectively registered 5 Dec 2016).

The administration of intermittent parathyroid hormone affects functional recovery from trochanteric fractured neck of femur: a randomised prospective mixed method pilot study

Aims

We wished to assess the feasibility of a future randomised controlled trial of parathyroid hormone (PTH) supplements to aid healing of trochanteric fractures of the hip, by an open label prospective feasibility and pilot study with a nested qualitative sub study. This aimed to inform the design of a future powered study comparing the functional recovery after trochanteric hip fracture in patients undergoing standard care, versus those who undergo administration of subcutaneous injection of PTH for six weeks.

Patients and Methods

We undertook a pilot study comparing the functional recovery after trochanteric hip fracture in patients 60 years or older, admitted with a trochanteric hip fracture, and potentially eligible to be randomised to either standard care or the administration of subcutaneous PTH for six weeks. Our desired outcomes were functional testing and measures to assess the feasibility and acceptability of the study.

Results

A total of 724 patients were screened, of whom 143 (20%) were eligible for recruitment. Of these, 123 were approached and 29 (4%) elected to take part. However, seven patients did not complete the study. Compliance with the injections was 11 out of 15 (73%) showing the intervention to be acceptable and feasible in this patient population.

Take home message: Only 4% of patients who met the inclusion criteria were both eligible and willing to consent to a study involving injections of PTH, so delivering this study on a large scale would carry challenges in recruitment and retention. Methodological and sample size planning would have to take this into account. PTH administration to patients to enhance fracture healing should still be considered experimental.

Cite this article: Bone Joint J 2016;98-B:840–5.

A longitudinal investigation of work environment stressors on the performance and wellbeing of office workers

This study uses a longitudinal within-subjects design to investigate the effects of inadequate Indoor Environmental Quality (IEQ) on work performance and wellbeing in a sample of 114 office workers over a period of 8 months. Participants completed a total of 2261 online surveys measuring perceived thermal comfort, lighting comfort and noise annoyance, measures of work performance, and individual state factors underlying performance and wellbeing. Characterising inadequate aspects of IEQ as environmental stressors, these stress factors can significantly reduce self-reported work performance and objectively measured cognitive performance by between 2.4% and 5.8% in most situations, and by up to 14.8% in rare cases. Environmental stressors act indirectly on work performance by reducing state variables, motivation, tiredness, and distractibility, which support high-functioning work performance. Exposure to environmental stress appears to erode individuals' resilience, or ability to cope with additional task demands. These results indicate that environmental stress reduces not only the cognitive capacity for work, but the rate of work (i.e. by reducing motivation). Increasing the number of individual stress factors is associated with a near linear reduction in work performance indicating that environmental stress factors are additive, not multiplicative. Environmental stressors reduce occupant wellbeing (mood, headaches, and feeling 'off') causing indirect reductions in work performance. Improving IEQ will likely produce small but pervasive increases in productivity.

Bacteria Isolated From the Skin of Congo African Grey Parrots ( Psittacus erithacus ), Budgerigars ( Melopsittacus undulatus ), and Cockatiels ( Nymphicus hollandicus )

Little is known about the normal bacterial flora of the skin of birds. To identify the bacterial organisms that reside on the integument of companion psittacine birds in a normal physiologic state, skin cultures were taken from 75 psittacine birds comprising 25 Congo African grey parrots ( Psittacus erithacus ), 25 budgerigars ( Melopsittacus undulatus ), and 25 cockatiels ( Nymphicus hollandicus ). All birds were adults and in good health with no underlying identifiable diseases, had not been on antibiotics in the preceding 2 months or longer, and had no skin or feather abnormalities. Cultures were taken from the axillary region and incubated on bovine blood agar plates. Positive cultures were identified for 52 out of 75 birds, and a total of 89 bacterial colonies grew. The most frequently identified bacterial organisms belonged to the genus Staphylococcus followed by Corynebacterium. Several other genera of bacteria were also isolated. Of the 89 bacterial colonies, 25 were identified to the species level and 50 to the genus level, and 14 were identified as either a nonfermenter or coliform.

Osteosarcoma of the tibiotarsus with possible pulmonary metastasis in a ring-necked dove (Streptopelia risoria)

An unknown-age, adult female ring-necked dove (Streptopelia risoria) was presented with an ulcerated mass on the medial side of the right tibiotarsus. Radiographs revealed severe boney lysis with proliferative periosteal reaction. Surgical amputation was performed at the level of the mid femur and histopathologic examination of the mass identified an osteosarcoma. At the 6-month recheck, the bird was in good condition with no evidence of tumor regrowth or metastasis; however, at 8 months, the dove was found dead. On necropsy, a large mass was present in the coelomic cavity invading the left pulmonary parenchyma. Histopathologic examination indicated a spindle cell sarcoma. Immunohistochemical staining for osteocalcin and osteonectin was performed on the confirmed osteosarcoma in the tibiotarsus and the spindle cell sarcoma mass. Results indicated positive intracytoplasmic immunoreactivity for osteocalcin and osteonectin in the confirmed osteosarcoma neoplasm. Very rare positive cytoplasmic immunoreactivity occurred in the spindle cell sarcoma.

Multidisciplinary management of ornithine transcarbamylase (OTC) deficiency in pregnancy: essential to prevent hyperammonemic complications

Ornithine transcarbamylase (OTC) deficiency is the most common inborn error in the metabolism of the urea cycle with an incidence of 1 in 14,000 live births. Pregnancy can trigger potentially fatal hyperammonemic crises. We report a successful pregnancy in a 29-year-old primiparous patient with a known diagnosis of OTC deficiency since infancy. Hyperammonemic complications were avoided due to careful multidisciplinary management which included a detailed antenatal, intrapartum and postnatal plan. Management principles include avoidance of triggers, a low-protein diet and medications which promote the removal of nitrogen by alternative pathways. Triggers include metabolic stress such as febrile illness, particularly gastroenteritis, fasting and any protein loading. In our case the patient, in addition to a restricted protein intake, was prescribed sodium benzoate 4 g four times a day, sodium phenylbutyrate 2 g four times a day and arginine 500 mg four times a day to aid excretion of ammonia and reduce flux through the urea cycle.

The risks of red cell transfusion for hip fracture surgery in the elderly

BACKGROUND AND OBJECTIVES

The benefits and indications for blood transfusion among surgical patients are controversial. There is evidence which suggests that blood transfusion is associated with poor clinical outcomes and risks of infection, but there are few data in the elderly population.

MATERIALS AND METHODS

Data were collected on haemoglobin concentrations and transfusions in 919 patients undergoing hip fracture repair at a university hospital over a 2-year period. 28-day and 180-day mortality were specified as primary outcomes. A composite infection outcome (chest infections, urinary tract infections and wound infections) was the main secondary outcome. Preoperative, operative and/or postoperative transfusions were the main exposure variable. Regression analyses were used to explore the associations between transfusion and outcomes, adjusting for pre-defined preoperative variables.

RESULTS

300 patients (32·6%) were transfused at least once during their admission. There was no evidence of a significant difference in either 28-day survival or 180-day survival between transfused and non-transfused hip fracture patients. The transfused group had higher adjusted composite infection rate (HR, 1·91; 95% CI, 1·41-2·59, P < 0·001) and prolonged length of stay in hospital than the non-transfused group (HR, 1·15; 95% CI, 1·07, 1·23, P < 0·001). Anaemia at the time of admission, extra capsular fracture and using walking aids in an indoor setting were preoperative variables, which predicted the need for transfusion.

CONCLUSION

Among an elderly population with hip fracture, blood transfusion was not associated with changes in mortality, but was associated with an increased rate of postoperative infection. These data add to the wider literature about adverse clinical outcomes in patients receiving blood transfusions and emphasises the need for prospective trials to evaluate the role of transfusion in the elderly.

Role for protein kinase C in controlling Aplysia bag cell neuron excitability

Targeting signalling molecules to ion channels can expedite regulation and assure the proper transition of changes to excitability. In the bag cell neurons of Aplysia, single-channel studies of excised patches have revealed that protein kinase C (PKC) gates a non-selective cation channel through a close, physical association. This channel drives a prolonged afterdischarge and concomitant neuropeptide secretion to provoke reproductive behaviour. However, it is not clear if PKC alters cation channel function and/or the membrane potential at the whole-cell level. Afterdischarge-like depolarizations can be evoked in cultured bag cell neurons by bath-application of Conus textile venom (CtVm), which triggers the cation channel through an apparent intracellular pathway. The present study shows that the CtVm-induced depolarization was reduced by nearly 50% compared to control following dialysis with the G-protein blocker, guanosine-5'-O-2-thiodiphosphate (GDP-β-S), or treatment with either the phospholipase C inhibitor, 1-[6-[[(17β)-3-Methoxyestra-1,3,5(10)-trien-17-yl]amino]hexyl]-1H-pyrrole-2,5-dione (U-73122), or the PKC inhibitor, sphinganine. Neurons exposed to the PKC activator, phorbol 12-myristate 13-acetate (PMA), displayed depolarization with accompanying spiking, and were found to be far more responsive to depolarizing current injection versus control. Immunocytochemical staining for the two typical Aplysia PKC isoforms, Apl I and Apl II, revealed that both kinases were present in unstimulated cultured bag cell neurons. However, in CtVm-treated neurons, the staining intensity for PKC Apl I increased, peaking at 10 min post-application. Conversely, the intensity of PKC Apl II staining decreased over the duration of CtVm exposure. Our results suggest that the CtVm-induced depolarization involves PKC activation, and is consistent with prior work showing PKC closely-associating with the cation channel to produce the depolarization necessary for the afterdischarge and species propagation.

125. ELEVATED FSH INCREASES PRIMORDIAL FOLLICLE RESERVE WITHOUT INCREASING PRIMORDIAL FOLLICLE FORMATION OR DECREASING OOCYTE QUALITY

Declining ovarian follicle reserve and oocyte quality with age can dictate the mammalian female reproductive lifespan. Elevated circulating levels of follicle-stimulating hormone (FSH) coincides with reproductive ageing in women, and is predicted to accelerate the depletion of ovarian follicle reserve by increasing the recruitment of remaining follicles. Unexpectedly, we found that transgenic expression of human FSH (TgFSH) increased primordial follicle reserve in mature GnRH-deficient hypogonadal (hpg) female mice functionally lacking endogenous gonadotrophin secretion1. Advancing our finding of increased primordial reserve in TgFSH-hpg mice, we find that total primordial follicle numbers is significantly increased (60%) in mature 26 week old non-hpg TgFSH females compared to WT controls. Thus, the FSH-induced increase in primordial reserve is maintained despite increased ovulation rate2 in mature TgFSH females. Embryo transfer experiments showed that embryos derived from 26 week old TgFSH females developed normally in recipient WT females, indicating no significant reduction in the viability of oocytes or early embryos produced by TgFSH mice. In addition, equal primordial numbers in 5 day old TgFSH versus WT ovaries suggested that FSH-induced changes to ovarian reserve was not due to an increased initial primordial follicle pool. Initial analysis of postnatal gene expression (qPCR) found elevated expression of granulosa cell markers (Kit-L, inhibin β) in TgFSH-hpg vs non-Tg hpg ovaries, indicating FSH actions during early follicle development. Therefore, contrary to a classical view that preantral follicles are gonadotrophin-independent, we provide in vivo evidence demonstrating FSH-induced changes to early follicle populations, as well as elevated FSH activity increasing or maintaining primordial reserve without compromising oocyte quality. (1) Allan CM et al. J Endocrinol. 2006; 188(3): 549–57.(2) McTavish KJ et al. Endocrinology. 2007; 148(9): 4432–9.

An open label study of the effects of rituximab in neuromyelitis optica

Eight patients with worsening neuromyelitis optica were treated with rituximab to achieve B cell depletion. Treatment was well tolerated. Six of eight patients were relapse free and median attack rate declined from 2.6 attacks/patient/year to 0 attacks/patient/year (p = 0.0078). Seven of eight patients experienced substantial recovery of neurologic function over 1 year of average follow-up. The pretreatment median Expanded Disability Status Scale score was 7.5, and at follow-up examination was 5.5 (p = 0.013).

Does the type of flooring affect the risk of hip fracture?

BACKGROUND

The number of hip fractures occurring worldwide in 1990 was estimated at 1.7 million and is predicted to rise to 6.3 million by 2050. The vast majority occur as a result of simple falls and the impact of the femoral trochanter with the floor. Previous studies have addressed the problem from the patient's side of the impact. Little research has been carried out on the other surface involved in the impact, the floor. STUDY LOCATION: 34 residential care homes.

METHODS

(1) The mechanical properties of the floor were measured with force transducers. (2) The number and location of falls and fractures on the various floors were recorded prospectively for 2 years. The threshold for reporting falls in different care homes was assessed using a standardised set of scenarios.

RESULTS

A total of 6,641 falls and 222 fractures were recorded. Wooden carpeted floors were associated with the lowest number of fractures per 100 falls. The risk of fracture resulting from a fall was significantly lower compared to all other floor types (odds ratio 1.78, 95% CI 1.33-2.35). The mean impact force was significantly lower on wooden carpeted floors: 11.9 kN compared to the other floor types.

DISCUSSION

The possible implications of our findings are considerable. Residents of homes are typically frail and many have a propensity to falls. In designing safer environments for older people, the type of floor should be chosen to minimise the risk of fracture. This may result in a major reduction in fractures in the elderly.

Plasma adrenocorticotropin (ACTH) concentrations and clinical response in horses treated for equine Cushing's disease with cyproheptadine or pergolide

Plasma ACTH levels have been variable in horses with a positive clinical response for therapy for equine Cushing's Disease (ECD). Therefore, our purpose was to determine the value of monitoring plasma adrenocorticotropin (ACTH) levels during treatment of equine Cushing's disease (ECD) with either cyproheptadine (n = 32) or pergolide (n = 10). First, we validated the chemiluminescent ACTH assay (specificity, precision, accuracy, intra-assay and interassay variations) and tested methods of handling the whole blood from the time of collection to when the ACTH was assayed. The sensitivity and specificity of high plasma ACTH levels for detecting ECD was determined in a retrospective study on hospitalised horses (n = 68). Surveys were sent to veterinarians who submitted equine ACTH levels that were high initially and had at least 2 ACTH samples to determine the value of monitoring ACTH levels during therapy of ECD. The ACTH chemiluminescent assay was valid. The ACTH was stable when whole blood was collected and held in plastic tubes for 8 h before separating the plasma. The sensitivity and specificity of plasma ACTH levels for detecting ECD were 84% (n = 19,95% CI 60,97) and 78% (n = 49,95% CI 63,88), respectively. Treated horses generally showed a decrease in plasma ACTH. Plasma ACTH levels may be helpful when monitoring therapy of ECD, although improvement in clinical signs should be considered most important. There were no differences between cyproheptadine and pergolide in terms of improvements in any of the clinical signs.

Screening for chlamydia in general practice

OBJECTIVE

To determine the prevalence of genital Chlamydia trachomatis infection in young patients presenting to general practitioners and to evaluate selective screening, based on risk factors, including gender.

METHODS

A cross sectional survey of 508 consecutive patients aged 18-24, presenting to six general practices and one youth clinic in Mackay, North Queensland. We screened urine for chlamydia using Ligase chain reaction.

RESULTS

Of 508 samples, 25 were positive (5%). The only factors with increased risks of infection were attendance at a youth clinic and recent change in sexual partner. It was as high in men as in women.

CONCLUSION

Prevalence of chlamydia infection may be high enough to support screening of all patients aged 18-24, depending on cost effectiveness studies.

Mild-to-moderate uncomplicated hypertension: further analysis of a cost-effectiveness study of five drugs

A cost-effectiveness model was designed to explore the effect of adding a new angiotensin-II inhibitor, telmisartan, to the therapeutic options for treating mild-to-moderate uncomplicated hypertension. Incorporating the cost of drugs, physician visits, and adverse-event treatments, the model concluded that availability of telmisartan on formulary may shorten the mean time and costs to control. The stability of the initial findings over a range of sensitivity analyses lends credence to the model conclusions that availability of telmisartan on formulary improves the therapeutic options of care for hypertension.

The small heat shock-related protein-20 is an actin-associated protein

PURPOSE

The activation of cyclic nucleotide-dependent signaling pathways in vascular smooth muscle is important for the prevention of vein graft spasm and neointimal hyperplasia. Cyclic nucleotide-dependent relaxation is associated with an increase in the phosphorylation of a small heat shock-related protein (HSP20). In this investigation, we examined the mechanisms by which HSP20 may modulate relaxation.

METHODS

The relaxation responses of the bovine carotid artery smooth muscles were determined in a muscle bath. HSP20 phosphorylation was quantitated with isoelectric-focusing immunoblots. The association with actin was determined with coimmunoprecipitation and cosedimentation. Molecular sieving columns were used to examine the macromolecular associations of HSP20.

RESULTS

The activation of cyclic nucleotide signaling pathways leads to the complete relaxation of carotid smooth muscle. This relaxation response is associated with an increase in the phosphorylation of HSP20. Actin coimmunoprecipitated with HSP20, and the association of actin with recombinant HSP20 in vitro was phosphorylation-state dependent. Finally, HSP20 exists in large (>100 kDa) aggregates, which dissociate with the activation of cyclic nucleotide signaling pathways.

CONCLUSION

These data support a role of HSP20 phosphorylation in mediating smooth muscle relaxation, possibly via a direct interaction of large aggregates of HSP20 with the contractile elements.

Heat shock protein expression in umbilical artery smooth muscle

Postpartum vasospasm in the umbilical arteries may be due to impaired vasorelaxation secondary to alterations in the expression of heat shock proteins. The contractile responses of pre- and full-term bovine umbilical artery smooth muscles were determined in a muscle bath. Heat shock protein expression was determined in bovine and human arterial tissues using western blotting with specific antisera. Full-term bovine and human umbilical artery smooth muscle was refractory to relaxation induced by the nitric oxide donor, sodium nitroprusside. This impaired vasorelaxation was associated with the expression of the inducible form of the heat shock protein, HSP70i, and increases in the expression of the small heat shock protein, HSP27. Small heat shock proteins have been implicated in modulating contraction and relaxation responses in vascular smooth muscles. Thus, alterations in heat shock protein expression may play a role in umbilical artery vasospasm.

Small heat shock proteins and vasospasm in human umbilical artery smooth muscle

Human umbilical artery smooth muscle is uniquely refractory to cyclic nucleotide-dependent vasorelaxation. Small heat shock proteins (HSPs) have been implicated as contractile regulatory proteins. Thus, we hypothesized that alterations in the phosphorylation of small HSPs may contribute to human umbilical artery smooth muscle vasospasm. Physiologic contractile responses were determined in a muscle bath and compared with phosphorylation events determined with whole-cell phosphorylation and 2-dimensional gel electrophoresis. Precontraction of bovine carotid artery smooth muscle with serotonin followed by relaxation with forskolin was associated with increases in the phosphorylation of HSP27 and HSP20. Precontraction of umbilical artery with serotonin followed by forskolin treatment led to increases in the phosphorylation of HSP27. However, the umbilical artery smooth muscle did not relax, nor was there an increase in the phosphorylation of HSP20 with forskolin treatment. These data suggest that impaired cyclic nucleotide-dependent relaxation of umbilical artery smooth muscle is associated with a lack of phosphorylation of HSP20.

Cellular mechanisms of cyclic nucleotide-induced vasorelaxation

PURPOSE

Endothelial-derived vasorelaxants such as prostacyclin and nitric oxide (NO) induce vascular smooth muscle relaxation through activation of cyclic nucleotide-dependent cellular signalling pathways. However, the specific events that lead to dissociation of actin and myosin and relaxation are not known. The purpose of this investigation was to determine the late phase signaling events that modulate vascular smooth muscle relaxation.

METHODS

Fresh bovine carotid artery smooth muscle (BCASM) contractile responses were determined in a muscle bath under Ca(2+)-containing and Ca(2+)-free conditions. Physiologic responses were correlated with phosphorylation events using whole cell phosphorylation and two-dimensional gel electrophoresis.

RESULTS

Cyclic nucleotide-dependent vasorelaxation can occur without detectable changes in intracellular Ca2+ concentrations. However, vascular smooth muscles that had been precontracted with the phosphatase inhibitor calyculin were refractory to relaxation. Vascular smooth muscle relaxation was associated with an increase in the phosphorylation of two 20 kDa proteins under Ca(2+)-containing and Ca(2+)-free conditions.

CONCLUSIONS

These results suggest that Ca(2+)-independent mechanisms may also modulate vascular smooth muscle relaxation. Two possible late phase signaling mechanisms include phosphatase activation and an increase in the phosphorylation of two 20 kDa phosphoproteins.

Nitric oxide is an autocrine feedback inhibitor of vascular smooth muscle contraction

BACKGROUND

Substances that increase intracellular calcium ([Ca2+]i), such as potassium chloride and serotonin, are known to induce vascular smooth muscle (VSM) contraction. One form of nitric oxide synthase, which converts L-arginine to nitric oxide, exists as a Ca(2+)-calmodulin dependent enzyme. The objective of this study was to determine whether agonists that induce VSM contraction by increasing [Ca2+]i might also activate Ca(2+)-calmodulin dependent nitric oxide synthase in VSM.

METHODS

Strips of bovine carotid arterial smooth muscle denuded of endothelium were equilibrated in a physiologic muscle bath. A maximal contractile response to high extracellular potassium chloride and serotonin was established. The strips were then preincubated with NG-monomethyl-L-arginine (L-NMMA), a structural analog of L-arginine and specific inhibitor of nitric oxide synthase, and again treated with either KCl or 5-hydroxytryptamine.

RESULTS

The contractile responses of muscle strips to KCl or 5-hydroxytryptamine were significantly greater in muscle strips pretreated with L-NMMA than responses in the absence of L-NMMA (p < 0.02, Student's t test). To determine whether this response was Ca2+ dependent, phorbolester-induced contractions in Ca(2+)-free conditions were examined. No difference was noted in the magnitude of Ca(2+)-free, phorbol ester-induced contractions in the presence and absence of L-NMMA.

CONCLUSIONS

These data thus suggest that Ca(2+)-calmodulin dependent nitric oxide synthase is functionally present in VSM and may function as an autocrine regulatory mechanism of VSM contraction.