Management of thoracic spine pain and dysfunction: A survey of clinical practice in the UK

BACKGROUND

The thoracic spine (TS) is relatively under-researched compared to the neck and low back. As the challenge of managing spinal pain persists, understanding current physiotherapy clinical practice for TS pain and dysfunction is necessary to inform future research in this area.

OBJECTIVE

To investigate physiotherapy practice for managing thoracic spine pain and dysfunction (TSPD) in the UK, with a secondary focus on examining differences across settings and expertise.

DESIGN AND METHOD

A cross sectional e-survey informed by existing evidence was designed. Comprising closed and open questions, the survey is reported in line with Checklist for Reporting Results of Internet E-Surveys. Eligible participants were UK-trained physiotherapists managing patients with TSPD, recruited for 9 weeks up to 8/2/16. Data analysis included descriptive analyses (closed questions) and thematic analysis (open questions).

RESULTS

From the 485 respondents, fulfilling the required sample size, key findings included.

EXAMINATION

Active motion testing, palpation and postural assessment was 'always' undertaken by >89% of respondents.

MANAGEMENT

Active (exercises) and passive (e.g. mobilisations) techniques were used by >85% of respondents, with ∼50% using manipulation, taping and acupuncture. Practice settings: Although broadly similar passive techniques were used more in private practice and sport. Expertise: Broadly similar patterns were seen for use of exercise across levels of expertise, although differences observed for electrotherapy and manipulation.

CONCLUSION

Despite limited research exercise is widely used in all areas of practice and across all level of expertise. Further research is required to investigate exercise prescription for TSPD and implementation of evidence-based practice.

Acupuncture for the Treatment of Sweating Associated with Malignancy

Acupuncture was used to treat a 60–year old woman with unexplained sweating associated with inoperable lung cancer that prevented her from sharing a bed with her husband. Other measures failed to improve her sweating, but she responded well to a course of acupuncture allowing her to continue sharing the marital bed.

An antibiotic formulary for a tertiary care foot clinic: admission avoidance using intramuscular antibiotics for borderline foot infections in people with diabetes

AIMS

To develop an antibiotic foot formulary for the empirical treatment of diabetes-related foot infections presenting to our service. Subsequently, to asses costs associated with the introduction of our protocol, in particular to assess the effect on admissions avoidance and any cost savings achieved.

METHODS

We reviewed several existing antibiotic protocols. We analysed data on costs related to treatment and admission rates prior to and after the introduction of the protocol.

RESULTS

We rationalized our antibiotic protocol and adapted the Infectious Disease Society of America guideline by introducing a category of 'moderate infection-borderline admission' to our classification. This enabled the administration of outpatient intramuscular antibiotics. After introducing the rationalized protocol, our average antibiotic prescribing costs for a 3-week course of treatment fell from £17.12 to £16.42. Over 22 months of follow-up, 26 episodes were eligible for treatment with intramuscular antibiotics. Over the same time period, 121 people were admitted directly from the foot clinic. The costs saved as a result of avoided or delayed admission for those 26 episodes was over £76 000. For 12 people who required subsequent admission, their length of hospital stay was significantly shorter than those admitted directly [9.25 days (range 2-25) vs. 16.11 (2-64), P = 0.045].

CONCLUSIONS

By modifying the Infectious Disease Society of America classification and adopting a protocol to administer outpatient oral and intramuscular antibiotics, we have led to substantial cost savings, shorter hospital admissions and also have developed a successful admissions avoidance strategy.

Synthetic pillows contain higher levels of cat and dog allergen than feather pillows

The use of non-feather pillows has increased over the last few decades. Recently, we found significantly higher levels of dust mite allergens in synthetic pillows than in feather ones. This study investigated the levels of pet allergens in feather and synthetic pillows. Dust samples were collected from 14 pairs of pillows (consisting of one synthetic fibre-filled and one feather-filled). Each pair of pillows had been on the same bed for at least 2 years. The pillows were vacuumed for 1 min on each side through a 355-microm diameter mesh onto a 5-microm vinyl filter, producing a sample of fine dust. Samples were extracted, and cat (Fel d 1) and dog (Can f 1) allergens determined using monoclonal antibody-based enzyme-linked immunosorbent assay (ELISA). Results were expressed both as total amount of allergen recovered and concentration of allergen per unit weight (ng/g). Total levels of pet allergens were significantly higher in the synthetic pillows (Fel d 1: 6.7-fold difference [95% CI 1.5-29.7], p=0.01; Can f 1: 8-fold difference [95% CI 1.6-39.5], p=0.01). Similarly, when the results were expressed as ng/g, synthetic pillows contained significantly more allergens than feather pillows (Fel d 1: 3.7-fold difference [95% CI 1.3-10.1], p=0.01); Can f 1: 4.4-fold difference [95% CI 1.5-13.2], p=0.01). We have therefore demonstrated that synthetic pillows contain significantly more pet allergens than feather pillows, supporting the view that tightly woven encasements surrounding feather pillows act as a barrier for allergens.

Manchester Asthma and Allergy Study: low-allergen environment can be achieved and maintained during pregnancy and in early life

BACKGROUND

Early exposure to dust mite allergens may be critical for primary sensitization. Reducing exposure may offer a realistic chance for primary prevention of sensitization and asthma, but it is essential to implement measures that can achieve and maintain the low-allergen environment.

OBJECTIVE

Our purpose was to assess the effectiveness of mite allergen avoidance measures in achieving and maintaining a low-allergen environment during pregnancy and in the first year of life.

METHODS

The Manchester Asthma and Allergy Study is a prospective, prenatally randomized study that follows the development of asthma and atopy in a cohort of infants at high risk (both parents atopic) who are randomly allocated to full mite allergen avoidance or to a normal regimen. Avoidance measures comprise (1) mite-proof covers (mattress, pillow, and quilt) for parental bed, (2) high-filtration vacuum cleaner, (3) vinyl flooring in infant's bedroom, (4) new crib and portable crib mattresses encased in mite-proof material, (5) benzyl benzoate (Acarosan) applied on carpets and soft furniture, (6) bed linens washed in hot water weekly, and (7) washable soft toys. Dust samples from the parental bed, bedroom floor, living room floor, infant's mattress, and nursery floor were collected between the 10th and 14th weeks of pregnancy, immediately after birth, and then at age 6 months and 1 year, and Der p 1 levels were determined by mAb-based ELISA.

RESULTS

Recovered Der p 1 from maternal mattress was reduced by 97. 25% (95% confidence interval [CI] 95.25%-98.41%) during the second and third trimesters of pregnancy, with the effect persisting for 6 months (98% reduction, 95% CI 97.25%-99.1%) and 12 months (97.6% reduction, 95% CI 95.7%-98.6%) after the birth (active vs control, P <.000001). Total Der p 1 from bedroom floor in the active group was reduced by 53.7% (95% CI 25.7%-71.2%) in samples collected within 4 weeks of the child's birth, with the percentage reduction being 62. 8% (95% CI 39.3%-77.2%) at 6 months and 26.5% (95% CI -24% to 57.1%) at 1 year (active compared vs control, P <.007). Der p 1 levels in crib mattress and nursery floor in the active group were extremely low (crib mattresses geometric mean [95% CI] 2.3 ng [1.6-3.4] at birth, 6.8 ng [4.5-10] at age 6 months, and 15.6 ng [9.8-24.8] at age 1 year [active vs control, P =.001]; nursery 1 ng [0.9-1.1] at birth, 1.7 ng [1.2-2.5] at age 6 months, and 2 ng [1.3-3.5] at age 1 year [active vs control, P <.00001]). The total amount of allergen recovered at age 1 year was 29-fold (95% CI 15.1- to 56.7-fold) higher in the control group than in the active group.

CONCLUSIONS

The avoidance measures used in this study achieved and maintained a low mite allergen environment during pregnancy and in the first year of life in homes of infants at risk of atopy.

Relationship between mite, cat, and dog allergens in reservoir dust and ambient air

BACKGROUND

Standardized methods to measure allergen exposure are essential to assess the relationship between exposure, sensitization, and asthma. Most studies have measured allergen levels in reservoir dust, although air samples may be more representative as a measure of inhaled allergen. The aim of this study was to define the relationship between mite, cat, and dog allergen content in the reservoir dust and the levels in the ambient air.

METHODS

Dust samples from the living-room floor (LF) and sofa (S) were collected in 127 homes: 62 without and 65 with pets (31 dogs, 34 cats). Air samples were taken in the same room, with a high-volume pump for 1 h (flow 60 l/min). Der p 1, Fel d 1, and Can f 1 were determined by mAb-based ELISA.

RESULTS

Airborne Der p 1 was below the detection limit (0.8 ng/m3) in all homes, with reservoir levels (GM and range) being 1.14 microg/g (0.2-66) and 1.15 microg/g (0.2-127) in LF and S, respectively. Airborne Can f 1 was detected in 40/62 homes without pets (range 0.6-12.4 ng/m3) and in all homes with dogs (range 0.5-99 ng/m3). In the multiple linear regression analysis, Can f 1 level in the LF was an independent correlate of the airborne Can f 1 (P=0.01, homes with dogs; P=0.04, homes without dogs). Fel d 1 was detected in the air in 16/62 homes without pets (range 0.16-1.8 ng/m3) and in all homes with cats (range 0.4-22.3 ng/m3). Fel d 1 level in the LF was an independent correlate of the airborne Fel d 1 in homes without cats (P=0.008), but airborne levels in homes with cats did not correlate with reservoir levels.

CONCLUSIONS

The aerodynamics of each allergen must be taken into account when assessing exposure: while levels in reservoir dust are the best available index for mite allergens, airborne levels might be more suitable for defining exposure to pets. If air samples are difficult to obtain, levels of Can f 1 and Fel d 1 in the LF samples should be used as a surrogate measure of personal exposure.

Antianxiety properties of the angiotensin II antagonist, DUP 753, in the rat using the elevated plus-maze

The angiotensin II receptor antagonist, DUP 753 (Losartan), was compared with diazepam for antianxiety properties in the rat using the elevated plus-maze. Oral diazepam (5 mg kg-1) resulted in a significantly greater number of entries of rats into the open arms of the maze, an increase in time spent in the open arms and a decreased time spent in the closed arms. Oral doses of DUP 753 likewise resulted in significantly greater numbers of entries into the open arms (active at 0.0001, 0.001, 0.01 and 0.1 mg kg-1), increased time spent on the open arms (active at 0.0001-0.01 mg kg-1) and a decreased time spent in the closed arms (active at 0.0001, 0.01 and 0.1 mg kg-1). Larger (1.0 mg kg-1) or smaller (0.00001 mg kg-1) doses of DUP 753 were not active.

Design and synthesis of some substrate analogue inhibitors of phospholipase A2 and investigations by NMR and molecular modeling into the binding interactions in the enzyme-inhibitor complex

A series of substrate analogue inhibitors of pancreatic phospholipase A2 has been designed and synthesized. The compounds were tested in a novel dual-screening system based on parallel assays with monomeric and micellar substrates. Intermolecular nuclear Overhauser effects between vinylic protons on one inhibitor and identified active site residues on the bovine pancreatic enzyme have been observed in solution NMR studies of the enzyme-inhibitor complex. It can be deduced from both the biochemical results and the NMR data that the mode of interaction between this type of inhibitor and the active site of phospholipase A2 is essentially the same, irrespective of the presence or absence of an aggregated phospholipid surface. A model of the binding between the enzyme and inhibitor which incorporates the two-dimensional NMR data has been developed. The model can account for the activity of modified inhibitor structures and can be extrapolated to an assessment of the mode of binding of the natural substrate itself.

Bombesin stimulates the rapid activation of phospholipase A2-catalyzed phosphatidylcholine hydrolysis in Swiss 3T3 cells

In Swiss 3T3 fibroblasts bombesin stimulated the release of arachidonic acid in a time- and dose-dependent manner. Arachidonate levels were significantly elevated after only a 2-s stimulation with the agonist. Furthermore, by measuring the arachidonate content of cellular phospholipids after cell activation, it was shown that there was selective depletion from phosphatidylcholine over the same time course. The corresponding production of lysophosphatidylcholine suggested the involvement of a phosphatidylcholine-specific phospholipase A2. Initial arachidonic acid release was not dependent on the presence of extracellular calcium, not activated by treatment of the cells with thapsigargin, and was unaffected by down-regulation of protein kinase C activity, or by treatment of the cells with the protein kinase C inhibitor staurosporine. These data strongly suggest that occupation of the bombesin receptor is closely coupled to activation of phospholipase A2 which results in the rapid release of arachidonic acid from phosphatidylcholine.

FPL 62064, a topically active 5-lipoxygenase/cyclooxygenase inhibitor

FLP 62064 [N-(4-methoxyphenyl)-1-phenyl-1H-pyrazole-3-amine] is a dual inhibitor of prostaglandin synthetase and 5-lipoxygenase. The compound had anti-inflammatory activity in vivo in a number of models. It inhibited peritoneal inflammation induced by immune-complex when given locally. When applied to the skin, FPL 62064 inhibited UV irradiation-induced erythema and PGE2 formation in the guinea pig and also oedema formation and eicosanoid production in the mouse ear produced by arachidonic acid. Co-injected with arachidonic acid in rabbit skin, FPL 62064 inhibited oedema and eicosanoid formation.

Enhancement of leukotriene C4 release from primate airway macrophages by cellular interactions

1. Cells were obtained from the lungs of Macaque monkeys by bronchoalveolar lavage in order to study the role of cellular interactions in the release of leukotriene C4 (LTC4). 2. In normal monkeys, macrophages were the most abundant cell type recovered, whereas in monkeys sensitized with Ascaris suum there was an increase in the numbers of eosinophils and mast cells recovered. 3. Challenge of cells from both groups of animals with an optimal concentration of opsonized zymosan (OPZ) resulted in the time-dependent release of LTC4 from macrophages. However, release was significantly greater in cells obtained from sensitized donors compared to normal donors. 4. Density-gradient centrifugation of cells lavaged from sensitized donors was used to prepare fractions containing both eosinophils and mast cells. Addition of these cells to macrophage populations obtained from non-sensitized donors caused a significant enhancement of OPZ-induced LTC4 release. In the absence of macrophages no significant release of LTC4 was detected from eosinophil/mast cell-containing fractions stimulated with OPZ, despite the fact that the zymosan had been phagocytosed by the eosinophils. 5. There was a significant correlation between the percentage enhancement of LTC4 release and the number of eosinophils added. However, there was not a significant correlation with the number of mast cells added. 6. These results suggest that a cellular interaction between macrophages and eosinophils may be important in the regulation of mediator synthesis and release. The precise mechanism of this effect remains to be elucidated.

Rat eosinophil-mediated antibody-dependent cellular cytotoxicity: investigations of the mechanisms of target cell lysis and inhibition by glucocorticoids

Purified eosinophils from the peritoneal washings of N. brasiliensis infected rats demonstrated antibody-dependent cellular cytotoxicity (ADCC) for 51Cr-labelled chicken erythrocytes. The F(ab')2 fragment of the antibody did not support cytotoxicity thereby demonstrating the importance of the eosinophil Fc receptor to this activity. Bystander lysis of erythrocytes did not occur, indicating that the eosinophil does not release lytic agents free into the medium. Cytochalasin B (1.25-5 micrograms/ml) colchicine (10(-5)-10(-3) M) and chloroquine (10(-4)-10(-3) M) inhibited eosinophil ADCC. Inhibition was also demonstrated by methylprednisolone, 10(-7)-10(-3) M and this inhibition was blocked by the protein synthesis inhibitor, cycloheximide (25 micrograms/ml). Cycloheximide alone had no effect. This block of steroid inhibition by cycloheximide suggests that the steroid effect on this system may be mediated by a newly synthesized protein and implies that the eosinophil may possess a glucocorticoid receptor.

The role of sodium ions in ATP formation by the sodium pump

A study has been made to characterize ATP synthesis from ADP and P 1 by the sodium pump with membranes isolated from rabbit kidney. Incorporation of 32 P 1 into ATP was measured. ATP was not formed in a one-step reaction. Synthesis was dependent upon two separate incuba­tions in which incorporation of P 1 into phosphoprotein was followed by transfer of phosphate to ADP. The experimental conditions for the first reaction were different from those for the second (phosphate transfer) reaction. The latter took place only when a high Na concentration (at least 0.5 M) was added. ATP formation was prevented by both K and ouabain. The sequence of reactions could be repeated after washing to remove Na ions, indicating that the driving force for the reactions could be regenerated. The dissipation of ionic gradients was not involved because the Lubrol-solubilized pump was also able to synthesize ATP. It was concluded that the energy for ATP synthesis was derived from specific and reversible interactions of Na ions with the pump. The reactions for ATP synthesis by the sodium pump have been summarized in the form of a cycle.

Observations on ouabain binding and membrane phosphorylation by the sodium pump

A study has been made of ouabain binding and the formation of phosphoprotein from ATP and inorganic phosphate (Pi) with plasma membranes from rabbit and guinea-pig kidney cortex. The aim of the work was first to see whether apparently conflicting results in the literature arise from membranes being prepared by different methods and, secondly, to evaluate the results in relation to the Na pump mechanism. Three different methods were used to prepare membranes, types A, Au and B. The preparations differed markedly when ouabain binding was supported by Mg alone both in the amount bound and in the affinity. Mgdependent binding was influenced by 1 mM Pibut the extent of stimulation varied according to the preparations. The main effect of Piwas to decrease the equilibrium dissociation constant marginally for type A membranes but eightfold for type B membranes. In contrast, the maximum number of binding sites was little affected. The membrane affinity for ouabain in relation to Mg and Pitherefore depended on the method of preparation. In the reaction with Mg-ATP, type Au and B membranes were both phosphorylated to about the same extent. On the other hand, they reacted differently with Pi, type B membranes being phosphorylated (in the presence of Mg and ouabain) to the same extent as with ATP, whereas under the same conditions, type Au membranes gave only 15 % of the phosphorylation found with ATP. The phosphoprotein, however formed, whether from ATP or Pi, or type Au or type B membranes, migrated in the same way on gel electrophoresis to give a relative molecular mass of approximately 90000. With each preparation, over a tenfold range of ATPase activity, there was a constant value of 1.2 in the ratio of the maximum phosphorylation by ATP compared with the maximum number of ouabain-binding sites. These results show that membranes prepared in different ways exhibit some consistent properties of the Na pump but also striking anomalies. In view of likely morphological differences in the preparations, it is concluded that the inconsistent features, notably the responses to Mg and Pi, are an unreliable guide to the pump mechanism.

Hydrogen-ion titration studies on erythrocyte membranes

1. H+ titration was used to detect the presence of ionizable groups on human erythrocyte plasma membranes. Between pH2.9 and 11.3, two significant peaks of H+ association/dissociation occur in the differential from of the titration curve, one at pH3. 1. And the other at pH10.3. 2. After disruption of membrane structure by exposure to high pH or by the addition of sodium dodecyl sulphate, maxima of H+ association/dissociation were seen at pH3.1,4.3,6.5,10.3 and 10.7. 3. Spectrophotometric assay and selective chemical treatments were used to identify several of the titratable residues. 4. The degree of eleectrostatic interaction between titratable charged groups was investigated by comparing the titration characteristics of the membranes before and after modification of membrane structure.