More than Tuskegee: understanding mistrust about research participation

This paper describes results of a qualitative study that explored barriers to research participation among African American adults. A purposive sampling strategy was used to identify African American adults with and without previous research experience. A total of 11 focus groups were conducted. Groups ranged in size from 4-10 participants (N=70). Mistrust of the health care system emerged as a primary barrier to participation in medical research among participants in our study. Mistrust stems from historical events including the Tuskegee syphilis study and is reinforced by health system issues and discriminatory events that continue to this day. Mistrust was an important barrier expressed across all groups regardless of prior research participation or socioeconomic status. This study illustrates the multifaceted nature of mistrust, and suggests that mistrust remains an important barrier to research participation. Researchers should incorporate strategies to reduce mistrust and thereby increase participation among African Americans.

Estimating minimal clinically important differences of upper-extremity measures early after stroke

OBJECTIVE

To estimate minimal clinically important difference (MCID) values of several upper-extremity measures early after stroke.

DESIGN

Data in this report were collected during the Very Early Constraint-induced Therapy for Recovery of Stroke trial, an acute, single-blind randomized controlled trial of constraint-induced movement therapy. Subjects were tested at the prerandomization baseline assessment (average days poststroke, 9.5d) and the first posttreatment assessment (average days poststroke, 25.9d). At each time point, the affected upper extremity was evaluated with a battery of 6 tests. At the second assessment, subjects were also asked to provide a global rating of perceived changes in their affected upper extremity. Anchor-based MCID values were calculated separately for the affected dominant upper extremities and the affected nondominant upper extremities for each of the 6 tests.

SETTING

Inpatient rehabilitation hospital.

PARTICIPANTS

Fifty-two people with hemiparesis poststroke.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Estimated MCID values for grip strength, composite upper-extremity strength, Action Research Arm Test (ARAT), Wolf Motor Function Test (WMFT), Motor Activity Log (MAL), and duration of upper-extremity use as measured with accelerometry.

RESULTS

MCID values for grip strength were 5.0 and 6.2 kg for the affected dominant and nondominant sides, respectively. MCID values for the ARAT were 12 and 17 points, for the WMFT function score were 1.0 and 1.2 points, and for the MAL quality of movement score were 1.0 and 1.1 points for the 2 sides, respectively. MCID values were indeterminate for the dominant (composite strength), the nondominant (WMFT time score), and both affected sides (duration of use) for the other measures.

CONCLUSIONS

Our data provide some of the first estimates of MCID values for upper-extremity standardized measures early after stroke. Future studies with larger sample sizes are needed to refine these estimates and to determine whether MCID values are modified by time poststroke.

Very Early Constraint-Induced Movement during Stroke Rehabilitation (VECTORS): A single-center RCT

BACKGROUND

Constraint-induced movement therapy (CIMT) is among the most developed training approaches for motor restoration of the upper extremity (UE).

METHODS

Very Early Constraint-Induced Movement during Stroke Rehabilitation (VECTORS) was a single-blind phase II trial of CIMT during acute inpatient rehabilitation comparing traditional UE therapy with dose-matched and high-intensity CIMT protocols. Participants were adaptively randomized on rehabilitation admission, and received 2 weeks of study-related treatments. The primary endpoint was the total Action Research Arm Test (ARAT) score on the more affected side at 90 days after stroke onset. A mixed model analysis was performed.

RESULTS

A total of 52 participants (mean age 63.9 +/- 14 years) were randomized 9.65 +/- 4.5 days after onset. Mean NIHSS was 5.3 +/- 1.8; mean total ARAT score was 22.5 +/- 15.6; 77% had ischemic stroke. Groups were equivalent at baseline on all randomization variables. As expected, all groups improved with time on the total ARAT score. There was a significant time x group interaction (F = 3.1, p < 0.01), such that the high intensity CIT group had significantly less improvement at day 90. No significant differences were found between the dose-matched CIMT and control groups at day 90. MRI of a subsample showed no evidence of activity-dependent lesion enlargement.

CONCLUSION

Constraint-induced movement therapy (CIMT) was equally as effective but not superior to an equal dose of traditional therapy during inpatient stroke rehabilitation. Higher intensity CIMT resulted in less motor improvement at 90 days, indicating an inverse dose-response relationship. Motor intervention trials should control for dose, and higher doses of motor training cannot be assumed to be more beneficial, particularly early after stroke.

Exogenous human surfactant for treatment of severe respiratory distress syndrome: a randomized prospective clinical trial

We performed a randomized, prospective clinical trial comparing intratracheal administration of human surfactant with conventional treatment with intermittent mandatory mechanical ventilation alone for treatment of severe respiratory distress syndrome in preterm infants of less than 30 weeks gestation. Twenty-two infants (mean gestational age 27.0 weeks, mean birth weight 987 gm) were given surfactant, and 23 infants (mean gestational age 27.2 week, mean birth weight 1055 gm) received intermittent mandatory ventilation. Infants given surfactant required less FiO2 during the first week, had lower mean airway pressure during the first 48 hours, and had improved ventilatory index and a/A PO2 ratio. Death or the occurrence of bronchopulmonary dysplasia was significantly less among infants given surfactant (P = 0.019). Pneumothorax, pulmonary interstitial emphysema, and need for FiO2 greater than or equal to 0.3 for greater than 30 days was significantly less in the surfactant group. This trial confirms the efficacy of treatment with human surfactant in preterm infants with severe respiratory distress syndrome.

Cyclooxygenase 2-dependent prostaglandin E2 modulates cartilage proteoglycan degradation in human osteoarthritis explants

OBJECTIVE

To examine cyclooxygenase-2 (COX-2) enzyme expression, its regulation by interleukin-1 beta (IL-1 beta), and the role of prostaglandin E(2) (PGE(2)) in proteoglycan degradation in human osteoarthritic (OA) cartilage.

METHODS

Samples of human OA articular cartilage, meniscus, synovial membrane, and osteophytic fibrocartilage were obtained at knee arthroplasty and cultured ex vivo with or without IL-1 beta and COX inhibitors. COX expression was evaluated by immunohistochemistry and Western blot analysis. The enzymatic activity of COX was measured by conversion of arachidonic acid to PGE(2). Cartilage degradation was evaluated by measuring the accumulation of sulfated glycosaminoglycans in the medium.

RESULTS

IL-1 beta induced robust expression of COX-2 and PGE(2) in OA meniscus, synovial membrane, and osteophytic fibrocartilage explants, whereas low levels were produced in OA articular cartilage. IL-1 beta also induced cartilage proteoglycan degradation in OA synovial membrane-cartilage cocultures. Increased proteoglycan degradation corresponded to the induction of COX-2 protein expression in, and PGE(2) production from, the synovial membrane. Dexamethasone, neutralizing IL-1 beta antibody, or the selective COX-2 inhibitor, SC-236, attenuated both the IL-1 beta-induced PGE(2) production and cartilage proteoglycan degradation in these cocultures. The addition of PGE(2) reversed the inhibition of proteoglycan degradation caused by SC-236.

CONCLUSION

IL-1 beta-induced production of COX-2 protein and PGE(2) was low in OA articular cartilage compared with that in the other OA tissues examined. IL-1 beta-mediated degradation of cartilage proteoglycans in OA synovial membrane-cartilage cocultures was blocked by the selective COX-2 inhibitor, SC-236, and the effect of SC-236 was reversed by the addition of exogenous PGE(2). Our data suggest that induction of synovial COX-2-produced PGE(2) is one mechanism by which IL-1 beta modulates cartilage proteoglycan degradation in OA.

Disappearance of vesicoureteric reflux during long-term prophylaxis of urinary tract infection in children

Seventy-five children aged 3 weeks to 12 years and found on investigation of symptomatic urinary infection to have vesicoureteric reflux were managed conservatively with continuous low-dose prophylaxis. Serial cystographic and renal growth studies were performed during seven to 15 years' follow-up. Reflux disappeared spontaneously in 53 children (71%) and from 79% of the affected ureters. This occurred at any age and not only in infancy or at puberty. The initial severity or reflux was the most important factor affecting the outcome. Reflux disappeared from 85% of ureters of normal calibre but from only 41% of dilated ureters. Gross reflux associated with existing severe renal scarring was least likely to disappear. Nevertheless, reflux stopped in 12 of the 19 initially scarred renal units (63%). Reflux was as likely to disappear in children who had a recurrence of urinary infection as in those who had no further infection. Renal growth appeared to be normal in 93% of kidneys and fresh or extending scarring was seen in only two children. Management programmes for children with vesicoureteric reflux should take into account the self-limiting nature of three-quarters of the reflux found on investigating uncomplicated urinary tract infection.

Does the application of constraint-induced movement therapy during acute rehabilitation reduce arm impairment after ischemic stroke?

BACKGROUND AND PURPOSE

Motor dysfunction after unilateral deafferentation in primates can be overcome by restraining the unaffected limb. We asked whether a constraint-induced movement (CIM) program could be implemented within 2 weeks after stroke and whether CIM is more effective than traditional upper-extremity (UE) therapies during this period.

METHODS

Twenty-three persons were enrolled in a pilot randomized, controlled trial that compared CIM with traditional therapies. A blinded observer rated the primary end point, the Action Research Arm Test (ARA). Inclusion criteria were the following: ischemic stroke within 14 days, persistent hemiparesis, evidence of preserved cognitive function, and presence of a protective motor response. Differences between the groups were compared by using Student's t tests, ANCOVA, and Mann-Whitney U: tests.

RESULTS

Twenty subjects completed the 14-day treatment. Two adverse outcomes, a recurrent stroke and a death, occurred in the traditional group; 1 CIM subject met rehabilitation goals and was discharged before completing 14 inpatient days. The CIM treatment group had significantly higher scores on total ARA and pinch subscale scores (P:<0.05). Differences in the mean ARA grip, grasp, and gross movement subscale scores did not reach statistical significance. UE activities of daily living performance was not significantly different between groups, and no subject withdrew because of pain or frustration.

CONCLUSIONS

A clinical trial of CIM therapy during acute rehabilitation is feasible. CIM was associated with less arm impairment at the end of treatment. Long-term studies are needed to determine whether CIM early after stroke is superior to traditional therapies.

Hydrocephalus: a previously unrecognized predictor of poor outcome from supratentorial intracerebral hemorrhage

BACKGROUND AND PURPOSE

Although several factors have been identified that predict outcome after intracerebral hemorrhage (ICH), no previous study has investigated the impact of hydrocephalus. The purpose of this study was to determine whether the presence of hydrocephalus after ICH would predict mortality and functional outcome.

METHODS

Patients with spontaneous supratentorial ICH were identified in our prospectively collected database to determine the following: age, sex, race, past medical history; Glasgow Coma Scale (GCS) score and blood pressure on admission; use of mechanical ventilation, mannitol, and ventriculostomy; and medical complications. CT scans performed within 24 hours of hemorrhage were retrospectively analyzed to determine lesion size and location, pineal shift, cisternal effacement, intraventricular hemorrhage (IVH), and hydrocephalus. Outcome was determined with use of hospital disposition (dead, nursing home, rehabilitation, home) and functional outcome (Functional Independence Measure [FIM]) at 3 months. Patients with and without hydrocephalus were compared and univariate and multivariate analyses performed to determine whether hydrocephalus was an independent predictor of mortality. Data are presented as mean+/-SD.

RESULTS

Of the 81 patients studied, 40 had hydrocephalus. Those with hydrocephalus were younger (57+/-15 versus 67+/-15 years), had lower GCS scores (8.2+/-4.2 versus 11+/-2.9), were more likely to have ganglionic or thalamic hemorrhages, and were intubated more frequently (70% versus 27%). Hospital mortality was higher in patients with hydrocephalus (51% versus 2%), and fewer patients went home (21% versus 35%). Those who died had higher hydrocephalus scores (9.67+/-7.1 versus 5.75+/-4.5). Outcome was no different if a ventriculostomy was placed. The final logistic regression model included hydrocephalus score, gender, GCS, and pineal shift, and it correctly predicted 85% of patients as dead or alive. Multivariate analyses indicated that hydrocephalus is an independent predictor of mortality.

CONCLUSIONS

We conclude that hydrocephalus is an independent predictor of mortality after ICH.

A systematic review of stress and stress management interventions for mental health nurses

BACKGROUND

Health care professionals in the United Kingdom (UK) appear to have higher absence and sickness rates than staff in other sectors, and stress may be a reason for nurses leaving their jobs. These problems need to be addressed, particularly in the mental health field, if current service provision is to be maintained.

AIM

The aim was to identify stressors, moderators and stress outcomes (i.e. measures included those related to stress, burnout and job satisfaction) for mental health nurses, as these have clear implications for stress management strategies.

METHOD

A systematic review of research published in English between 1966 and 2000 and undertaken in the UK that specifically identified participants as mental health nurses was carried out to determine the effectiveness of stress management interventions for those working in mental health nursing. Studies from non-UK countries were examined as potential models of good practice. The study was limited to primary research papers that specifically involved mental health nurses, where the health outcomes measured were stressors, moderators and stress outcomes and where sufficient data was provided.

RESULTS

The initial search identified 176 papers, of these 70 met the inclusion criteria. Seven studies have been reported since the completion of the review and have been included in this article. Sixty-nine focused on the stressors, moderators and stress outcomes and eight papers identified stress management techniques. Relaxation techniques, training in behavioural techniques, stress management workshops and training in therapeutic skills were effective stress management techniques for mental health nurses. Methodological flaws however, were detracted from the rigour of many of the studies.

CONCLUSIONS

The review demonstrated that a great deal is known about the sources of stress at work, about how to measure it and about the impact on a range of outcome indicators. What was found to be lacking was a translation of these results into practice, into research that assessed the impact of interventions that attempt to moderate, minimize or eliminate some of these stressors.

Broad antitumor and antiangiogenic activities of AG3340, a potent and selective MMP inhibitor undergoing advanced oncology clinical trials

We studied AG3340, a potent metalloproteinase (MMP) inhibitor with pM affinities for inhibiting gelatinases (MMP-2 and -9), MT-MMP-1 (MMP-14), and collagenase-3 (MMP-13) in many tumor models. AG3340 produced dose-dependent pharmacokinetics and was well tolerated after intraperitoneal (i.p.) and oral dosing in mice. Across human tumor models, AG3340 produced profound tumor growth delays when dosing began early or late after tumor implantation, although all established tumor types did not respond to AG3340. A dose-response relationship was explored in three models: COLO-320DM colon, MV522 lung, and MDA-MB-435 breast. Dose-dependent inhibitions of tumor growth (over 12.5-200 mg/kg given twice daily, b.i.d.) were observed in the colon and lung models; and in a third (breast), maximal inhibitions were produced by the lowest dose of AG3340 (50 mg/kg, b.i.d.) that was tested. In another model, AG3340 (100 mg/kg, once daily, i.p.) markedly inhibited U87 glioma growth and increased animal survival. AG3340 also inhibited tumor growth and increased the survival of nude mice bearing androgen-independent PC-3 prostatic tumors. In a sixth model, KKLS gastric, AG3340 did not inhibit tumor growth but potentiated the efficacy of Taxol. Importantly, AG3340 markedly decreased tumor angiogenesis (as assessed by CD-31 staining) and cell proliferation (as assessed by bromodeoxyuridine incorporation), and increased tumor necrosis and apoptosis (as assessed by hematoxylin and eosin and TUNEL staining). These effects were model dependent, but angiogenesis was commonly inhibited. AG3340 had a superior therapeutic index to the cytotoxic agents, carboplatin and Taxol, in the MV522 lung cancer model. In combination, AG3340 enhanced the efficacy of these cytotoxic agents without altering drug tolerance. Additionally, AG3340 decreased the number of murine melanoma (B16-F10) lesions arising in the lung in an intravenous metastasis model when given in combination with carboplatin or Taxol. These studies directly support the use of AG3340 in front-line combination chemotherapy in ongoing clinical trials in patients with advanced malignancies of the lung and prostate.

Delays in rod-mediated dark adaptation in early age-related maculopathy

OBJECTIVE

To determine whether there are disturbances in the rod-mediated kinetics of dark adaptation in early age-related maculopathy (ARM).

DESIGN

Comparative, observational case series.

PARTICIPANTS

Twenty older adults with early ARM as defined by one or more large (> 63 microm) drusen, focal hyperpigmentation, or both, but no choroidal neovascularization or geographic atrophy, and 16 adults in the same age range with none of these fundus features. All participants had 20/25 visual acuity or better in the tested eye.

METHODS

Dark adaptation functions were measured using a modified Humphrey Field Analyzer (Zeiss Humphrey Systems, Dublin, CA) to assess the rate of rod-mediated sensitivity recovery at 12 degrees on the vertical meridian in the inferior visual field after exposure to the equivalent of a 98% bleach. Baseline (prebleach) scotopic sensitivity, visual acuity, contrast sensitivity, and photopic sensitivity were also measured.

MAIN OUTCOME MEASURES

Rod-cone break; second and third components of rod-mediated dark adaptation; time to baseline sensitivity; and baseline (prebleach) scotopic sensitivity.

RESULTS

Although their visual acuity was at least 20/25, patients with early ARM on average exhibited deficits in almost all rod-mediated parameters of dark adaptation as compared with age-similar healthy participants. For example, the rod-cone break was delayed approximately 10 minutes in early ARM patients as compared with healthy participants. Age-related maculopathy patients were more likely to fall outside the normal reference range for variables representing dark adaptation kinetics than for steady-state visual functions such as scotopic sensitivity. For example, 85% of ARM patients fell outside the normal reference range in at least one dark adaptation kinetic parameter, whereas only 25% of ARM patients fell outside the normal reference range for steady-state scotopic sensitivity.

CONCLUSIONS

Rod-mediated kinetic parameters of dark adaptation, which reflect the sensitivity recovery of the visual cycle, are disrupted early in ARM pathogenesis.

The Impact of Mild Stroke on Meaningful Activity and Life Satisfaction

Patients with mild stroke are assumed to achieve full recovery with little or no intervention. However, recent studies suggest that such patients may experience persistent disability and difficulty with complex activities. We prospectively assessed the impact of mild stroke (National Institutes of Health Stroke Scale [NIHSS] score </= 5) with standard assessments of function, health-related well-being, activity participation, and stroke-specific quality of life. Of 771 patients admitted over 12 months, 377 had an NIHSS score of </= 5; of these, 244 met additional inclusion criteria, and 219 were assessed 6 months after stroke onset. Despite full independence in basic activities of daily living, many patients (87%) reported residual stroke-related changes. On average, 7 (standard deviation [SD] = 6.21) stroke-related problems (SD = 6.21) were reported on the Stroke-Adapted Sickness Impact Profile (SA-SIP). Changes in work, driving, and recreational activities were reported. Motor impairment as measured by the NIHSS or the Functional Independence Measure (FIM) motor subscale did not influence scores on outcome measures. Regression analysis predicting life satisfaction (R2 = .62) was computed. Our results indicated that SA-SIP score, emotional well-being, and activity participation were significant, but age, race, sex, NIHSS score, and FIM motor and cognitive scores were not significant. In our sample, the determinants of life satisfaction after mild stroke differed from those reported after more severe stroke. Given the mild motor impairments in our sample, other, more subtle consequences of stroke, such as depression, impaired executive function or attention, or other neurologic impairments, may play more important roles in life satisfaction.

Development of new renal scars: a collaborative study

In a study of the factors surrounding the development of renal scars clinical data and serial radiographs were analysed in 74 infants and children (66 girls and eight boys) without duplex kidney or obstruction. The development of new scars was seen radiologically in 87 kidneys (74 previously normal and 13 previously scarred). New scarring was extensive in 16 kidneys. Thirty four children were aged 5 or over when scarring occurred. Urinary infection occurred in all the children. Diagnosis and effective treatment were delayed in 45 of them; 58 suffered further urinary infections between the baseline intravenous urogram and the first showing new scarring. Vesicoureteric reflux was seen in 67 of the children. Investigation and treatment varied widely, and few children received long term prophylaxis. Social problems interfered with the management of 22 children. Early diagnosis, prompt effective treatment, investigation, and long term supervision of children with urinary infection are essential if renal scarring is to be reduced; those over the age of 5 are still vulnerable.

Physical activity attenuates age-related biomarker alterations in preclinical AD

OBJECTIVE

To examine whether engagement in physical activity might favorably alter the age-dependent evolution of Alzheimer disease (AD)-related brain and cognitive changes in a cohort of at-risk, late-middle-aged adults.

METHODS

Three hundred seventeen enrollees in the Wisconsin Registry for Alzheimer's Prevention underwent T1 MRI; a subset also underwent (11)C-Pittsburgh compound B-PET (n = 186) and (18)F-fluorodeoxyglucose-PET (n = 152) imaging. Participants' responses on a self-report measure of current physical activity were used to classify them as either physically active or physically inactive based on American Heart Association guidelines. They also completed a comprehensive neuropsychological battery. Covariate-adjusted regression analyses were used to test whether the adverse effect of age on imaging and cognitive biomarkers was modified by physical activity.

RESULTS

There were significant age × physical activity interactions for β-amyloid burden (p = 0.014), glucose metabolism (p = 0.015), and hippocampal volume (p = 0.025) such that, with advancing age, physically active individuals exhibited a lesser degree of biomarker alterations compared with the physically inactive. Similar age × physical activity interactions were also observed on cognitive domains of Immediate Memory (p = 0.042) and Visuospatial Ability (p = 0.016). In addition, the physically active group had higher scores on Speed and Flexibility (p = 0.002) compared with the inactive group.

CONCLUSIONS

In a middle-aged, at-risk cohort, a physically active lifestyle is associated with an attenuation of the deleterious influence of age on key biomarkers of AD pathophysiology. However, because our observational, cross-sectional design cannot establish causality, randomized controlled trials/longitudinal studies will be necessary for determining whether midlife participation in structured physical exercise forestalls the development of AD and related disorders in later life.

Sensitivity to changes in disability after stroke: A comparison of four scales useful in clinical trials

Although most current stroke intervention trials use disability scales to determine outcome, little is known about the sensitivity to change of these scales. The use of a more sensitive measure would increase the statistical power of rehabilitation treatment trials. We applied four well-known disability scales to a group of stroke rehabilitation inpatients to compare sensitivity to change. Ninety-five consecutive admissions to a stroke rehabilitation service were assessed for disability on admission and discharge. Two global scales, the Modified Rankin Scale (MRS) and the International Stroke Trial Measure (ISTM), were compared with two activities of daily living (ADL) scales, the Barthel Index (BI) and the Functional Independence Measure (FIM). We determined the number of patients that each scale detected a clinically significant change in disability. Standardized response means (SRM) and receiver operating characteristic (ROC) analyses were performed. The MRS detected change in 55 subjects, including all who changed on the ISTM; the ISTM detected change in only 23 subjects. The BI detected change in 71 subjects but demonstrated ceiling effects with 26% of subjects scoring >95. The FIM was most sensitive, detecting change in 91 subjects; no patient achieved a maximum score. The SRM of the FIM was superior to that of the BI (2.18 versus 1.72), and ROC analysis revealed C-statistics of 0.82 for the BI, 0.59 for the MRS, and 0.51 for the ISTM. Global scales were much less sensitive to changes in disability than were ADL scales. Though ADL scales may take longer to administer, their increased sensitivity may make them more useful in treatment trials by allowing fewer subjects to be enrolled.

Land Animals in the Silurian: Arachnids and Myriapods from Shropshire, England

A new assemblage of arthropod cuticles from Upper Silurian rocks in Shropshire, England, includes at least two centipedes and a trigonotarbid arachnid. This unequivocal terrestrial fauna from the Silurian constitutes the earliest direct record of land animals. The presence of predatory arthropods suggests that complex terrestrial ecosystems were in place by the late Silurian (414 x 10(6) years before present) and that the animal invasion of the land occurred earlier than was previously thought.

Treating vulvovaginal atrophy/genitourinary syndrome of menopause: how important is vaginal lubricant and moisturizer composition?

Vaginal dryness is a common condition that is particularly prevalent during and after the menopause, and is one of the symptoms of vulvovaginal atrophy/genitourinary syndrome of menopause. The impact of vaginal dryness on interpersonal relationships, quality of life, daily activities, and sexual function can be significant, but is frequently underestimated. Furthermore, barriers exist to treatment-seeking, and this condition is often underreported and undertreated. Greater education about vaginal dryness and the range of available treatments is essential to encourage more women to seek help for this condition.

Personal lubricants and moisturizers are effective at relieving discomfort and pain during sexual intercourse for women with mild to moderate vaginal dryness, particularly those who have a genuine contraindication to estrogen, or who choose not to use estrogen. However, there is a distinction between lubricants and moisturizers, and notable differences between commercially available products. Women should be advised to choose a product that is optimally balanced in terms of both osmolality and pH, and is physiologically most similar to natural vaginal secretions. A series of recommendations for the use of vaginal lubricants and moisturizers, either on their own or in combination with systemic or topical hormone replacement therapy, is presented.

Measurement of Upper-Extremity Function Early After Stroke: Properties of the Action Research Arm Test

OBJECTIVE

To examine the responsiveness and validity of the Action Research Arm Test (ARAT) in a population of subjects with mild-to-moderate hemiparesis within the first few months after stroke.

DESIGN

Data were collected as part of the Very Early Constraint-Induced Therapy for Recovery from Stroke trial, an acute, single-blind randomized controlled trial of constraint-induced movement therapy. Subjects were studied at baseline (day 0), after treatment (day 14), and after 90 days (day 90) poststroke.

SETTING

Inpatient rehabilitation hospital; follow-up 3 months poststroke.

PARTICIPANTS

Fifty hemiparetic subjects.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

At each time point, subjects were tested on: (1) the ARAT, (2) clinical measures of sensorimotor impairments, (3) in the kinematics laboratory where they performed reach and grasp movements, and (4) clinical measures of disability. Blinded raters performed all evaluations. Analyses at each time point included calculating effect size as indicators of responsiveness, and correlation and regression analyses to examine relationships between ARAT scores and other measures.

RESULTS

The ARAT is responsive to change, with effect sizes greater than 1.0 and responsiveness ratios of 7.0 at 3 months poststroke. ARAT scores were related to sensorimotor impairment measures, 3-dimensional kinematic measures of movement performance, and disability measures at all 3 time points.

CONCLUSIONS

The ARAT is a responsive and valid measure of upper-extremity functional limitation and therefore may be an appropriate measure for use in acute upper-extremity rehabilitation trials.

Upper extremity use in people with hemiparesis in the first few weeks after stroke

The purposes of this report were to: 1) determine the amount of upper extremity use in people with hemiparesis post stroke during their inpatient rehabilitation stay, and 2) to examine the relationships between upper extremity use and impairments and activity limitations at this early time point after stroke. We studied 34 subjects with mild-to-moderate acute hemiparesis (mean time since stroke = 9.3 days) and 10 healthy control subjects. Upper extremity use was measured over 24 hours using bilateral wrist accelerometers. Upper extremity impairments and activity limitations were measured using standard clinical techniques and tests. We found that healthy control subjects use their dominant and nondominant upper extremities 8-9 hours per day. Hemiparetic subjects used their affected and unaffected upper extremities substantially less than control subjects, 3.3 and 6.0 hours per day, respectively. Seven of ten impairment level measures and each of the activity level measures were related to affected upper extremity use. The impairment measures that were related to upper extremity use were those measures that assessed the ability to activate muscles (ie active range of motion and force production) and the measurement of shoulder pain. Our data show that affected upper extremity use is minimal during the inpatient rehabilitation stay, especially given that patients in this setting are required to have 3 hours of therapy per day. We speculate that accelerometer measurements of upper extremity use could be used in a variety of settings and that the objective information they provide would be of great value to clinicians as they select treatments and evaluate progress.

Prophylactic treatment of very premature infants with human surfactant

We undertook a randomized, controlled trial to determine whether human surfactant administered endotracheally at birth to very premature infants (gestational age, 24 to 29 weeks) would prevent the respiratory distress syndrome or reduce its severity. Thirty-one treated infants (birth weight, 938 +/- 286 g) were compared in a blinded fashion with 29 control infants (birth weight, 964 +/- 174 g). The lecithin/sphingomyelin ratio was less than 2 in all infants, and phosphatidylglycerol was not present in amniotic fluid or tracheal fluids at birth, indicating a deficiency of surfactant in the lungs. The principal dependent variables were neonatal death, the incidence of bronchopulmonary dysplasia, and the infant's requirement for respiratory support (and its complications). The surfactant-treated group had significantly fewer deaths than the control group (16 percent vs. 52 percent, P less than 0.001), fewer cases of bronchopulmonary dysplasia (16 percent vs. 31 percent), and significantly fewer cases of pulmonary interstitial emphysema (P less than 0.001) and pneumothorax (P less than 0.02). Prophylactic treatment with human surfactant also substantially reduced the period of neonatal intensive care. We conclude that treatment with human surfactant offers promise for improving the survival of very premature infants with a surfactant deficiency and for reducing the pulmonary sequelae of the respiratory distress syndrome.

Psychometric and Clinimetric Validity of the 31-Item Rhinosinusitis Outcome Measure (RSOM-31)

Descriptions of rhinosinusitis (RS) patients and evaluation of treatment effectiveness are currently hindered by the lack of a valid measure of health status and quality of life. The RSOM contains 31 RS-specific items (e.g., runny nose, cough, facial pain/pressure), grouped into 7 domains (nasal, eye, sleep, ear, and general symptoms; practical problems, and emotional consequences), and was created from discussions with RS patients. Two categorical rating scales were selected for patients to indicate the Magnitude and Importance of each item. The RSOM score is calculated as the sum of the Magnitude X Importance scores. The goal of this project was to validate the RSOM-31. In 142 patients who completed the RSOM, the average age was 45 and there were 86 women. The average total RSOM score was 5.8 (0.8—15.1 = good—bad). The domains most affected were sleep (7.7), general problems (6.4), nasal (6.3), and emotional (6.2). The RSOM score correlated significantly with an overall global quality of life question (r = 0.36); and the Vitality (r = 0.50), General Health (r = 0.47), Social Functioning (r = 0.46), and Role-Physical (r = 0.41) sub-scales of the Medical Outcomes Study Short-Form 36. The average total RSOM score decreased over time (indicating improvement) and was correlated with the patient's assessment of their response to treatment (F Value 6.49; P < 0.0001). This study demonstrates that the 31-item RSOM is a valid measure of RS health status and quality of life.

Driving performance in persons with mild senile dementia of the Alzheimer type

OBJECTIVE

To assess the effect of mild senile dementia of the Alzheimer type (SDAT) on driving ability.

DESIGN

Cross-sectional study with correlation analysis.

SETTING

A university-based Alzheimer's Disease Research Center, which evaluates community-living older adult volunteers, and the university's Program in Occupational Therapy.

PARTICIPANTS

Healthy elderly controls (n = 13) and subjects with very mild (n = 12) and mild (n = 13) SDAT. Dementia severity was staged by the Washington University Clinical Dementia Rating.

MEASUREMENTS

The driving ability of participants on the in-car road test was scored independently by a driving instructor, blinded to the study design and to the dementia status of the subjects, and an unblinded occupational therapist. Interview-based perceptions of driving ability were obtained independently from the subjects and their collateral sources. Attentional and visuospatial performances of the subjects were assessed prior to the road test.

RESULTS

All control and very mild SDAT subjects were judged to be "safe" drivers (ie, passed the in-car road test), but five (40%) of the mild SDAT subjects had driving impairment sufficient to "fail" the road test. Neither subject self-assessment nor caregiver perceptions of driving ability consistently predicted driving performance. Attentional task performance correlated well with road test results.

CONCLUSIONS

Some SDAT subjects retain "safe" driving skills. The greater the dementia severity, the greater the likelihood of poor driving ability. Performance-based (road test) evaluations are necessary to properly determine driving skills at present, but attention and other cognitive screening measures should be developed.

Stress and burnout in community mental health nursing: a review of the literature

There is a growing body of evidence that suggests that many community mental health nurses (CMHNs) experience considerable stress and burnout. This review aimed to bring together the research evidence in this area for CMHNs working within the UK. Seventeen papers were identified in the literature, seven of which looked at stress and burnout for all members of community mental health teams (CMHTs) and the remaining 10 papers focused on CMHNs. The evidence indicates that those health professionals working as part of community teams are experiencing increasing levels of stress and burnout as a result of increasing workloads, increasing administration and lack of resources. For CMHNs specific stressors were identified. These included increases in workload and administration, time management, inappropriate referrals, safety issues, role conflict, role ambiguity, lack of supervision, not having enough time for personal study and NHS reforms, general working conditions and lack of funding and resources. Areas for future research are described and the current study of Welsh CMHNs is announced. This review has been completed against a background of further significant changes in the health service. In the mental health field, specific new initiatives will have a significant impact on the practice of community mental health nursing. A new National Framework for Mental Health, along with a review of the Mental Health Act (1983), will undoubtedly help to shape the future practice of mental health nursing.

Progesterone receptor isoform A but not B is expressed in endometriosis

We previously demonstrated that 17beta hydroxysteroid dehydrogenase type 2, the enzyme that inactivates estradiol to estrone, is expressed in luteal eutopic endometrium in response to progesterone but not in simultaneously biopsied peritoneal endometriotic tissue. This molecular evidence of progesterone resistance, together with the clinical observation of resistance of endometriosis to treatment with progestins, led us to determine the levels of progesterone receptor (PR) isoforms PR-A and PR-B in eutopic endometrial and extra-ovarian endometriotic tissues. It was proposed that progesterone action on target genes is mediated primarily by homodimers of PR-B, whereas the truncated variant PR-A acts as a repressor of PR-B function. Immunoprecipitation, followed by Western blot analysis, was performed to detect bands specific for PR-A and PR-B in paired samples of endometriotic and eutopic endometrial tissues simultaneously biopsed from 18 women undergoing laparoscopy during various phases of the menstrual cycle. PR-B was present in 17 of 18 eutopic endometrial samples, and its level increased in the preovulatory phase, as expected, whereas PR-A was detected in all samples (n = 18) with a similar, but less prominent, cyclic variation in its levels. In endometriotic samples, however, no detectable PR-B could be demonstrated, whereas PR-A was detected in all samples (n = 18), albeit in much lower levels and without any cyclic variation in contrast with the eutopic endometrium. Levels of PR-A and PR-B in endometriotic and eutopic endometrial tissues were determined and compared after normalization to total protein and estrogen receptor-alpha levels. Using RNase protection assay, we also demonstrated indirectly that only PR-A transcripts were present in endometriotic tissue samples (n = 8), whereas both PR-A and PR-B transcripts were readily detectable in all eutopic endometrial samples (n = 8). This was indicative that failure to detect PR-B protein in endometriotic tissues is due to the absence of PR-B transcripts. We conclude that progesterone resistance in endometriotic tissue from laboratory and clinical observations may be accounted for by the presence of the inhibitory PR isoform PR-A and the absence of the stimulatory isoform PR-B.