Optimizing a stroke caregiver support programme in practice with Participatory Action Research

Family caregivers (FCG) play a key role in the day-to-day care of stroke survivors. Most FCG support programmes are complex public health interventions. Often, they are designed top-down without key stakeholder participation. Hence, when implementing these programmes in real world settings, they may experience “teething problems”. Optimization in practice and actively engaging its stakeholders to accurately fit the programme to the needs in practice may enhance the programmés chance of success.

The Participatory Action Research (PAR) strategy was chosen for the optimization of a German primary prevention programme for stroke FCGs. Immediately after the development of the preliminary support concept (5 Conceptual Building Blocks - CBB), conducted top-down by the academic research team, iterative PAR-cycles (observe - reflect - plan - act) were applied. Together with the stakeholders (service providers and FCG), three steps were taken: (1) verifying and fitting the preliminary CBBs, (2) detecting, developing, verifying and fitting new blocks, and (3) prioritizing all blocks. For data collection a multi-methodological design was chosen.

Through PAR, a matured FCG support concept was obtained, containing eight CBBs. The five preliminary CBBs: ‘Content’, ‘Human resources’, ‘Personalized approach’, ‘Timing’, and ‘Setting’, were optimized and prioritized as core blocks, providing the base for individual caregiver support. Three new CBBs: ‘Network building’, ‘Communication’, and ‘Social safety-net’ were assigned as facilitating blocks, interlinking and securing the programme within the existing support system.

PAR was found to be essential for both systematically detecting conceptual weaknesses of the preliminary concept and adjusting its components to the needs of the key stakeholders, before full-scale implementation. Involvement of stakeholders, with high levels of participation, will enhance the acceptance of the matured concept and its feasibility in practice.

Social functioning and subclinical psychosis in adolescence: a longitudinal general adolescent population study

OBJECTIVES

To investigate the longitudinal relationship between subclinical psychotic symptoms and social functioning in a representative general population sample of adolescents.

METHOD

Data were derived from a routine general health screening of 1909 adolescents in a circumscribed region. Baseline measurement was in the second grade of secondary school (T0), and follow-up occurred approximately 2 years later (T1). Social functioning and subclinical psychotic symptoms of hallucinations and delusions were assessed at both time points.

RESULTS

Baseline (T0) social problems preceded follow-up (T1) subclinical delusions, but not T1 subclinical hallucinations. Similarly, T0 delusions preceded social problems at T1, but T0 hallucinations did not.

CONCLUSION

This longitudinal general population study demonstrated a bidirectional association between social problems and delusions, but found no link between social problems and hallucinations. This may reflect a downward negative spiral where delusional thoughts and social problems reinforce each other.

Vitamin D₃ improves respiratory adjustment to fatigue and H-reflex responses in paraplegic adult rats

We previously demonstrated that vitamin D₂ (ergocalciferol) triggers axon regeneration in a rat model of peripheral nerve transection. In order to confirm the regenerative potential of this neuroactive steroid, we performed a study in which vitamin D₃ (cholecalciferol) was delivered at various doses to paralytic rats. After spinal cord compression at the T10 level, rats were given orally either vehicle or vitamin D₃ at the dose of 50 IU/kg/day or 200 IU/kg/day. Three months later, M and H-waves were recorded from rat Tibialis anterior muscle in order to quantify the maximal H-reflex (H(max)) amplitude. We also monitored the ventilatory frequency during an electrically induced muscle fatigue known to elicit the muscle metaboreflex and an increase in respiratory rate. Spinal cords were then collected, fixed and immunostained with an anti-neurofilament antibody. We show here that vitamin D-treated animals display an increased number of axons within the lesion site. In addition, rats supplemented with vitamin D₃ at the dose of 200 IU/kg/day exhibit (i) an improved breathing when hindlimb was electrically stimulated; (ii) an H-reflex depression similar to control animals and (iii) an increased number of axons within the lesion and in the distal area. Our data confirm that vitamin D is a potent molecule that can be used for improving neuromuscular adaptive mechanisms and H-reflex responses.

Season of birth and not vitamin D receptor promoter polymorphisms is a risk factor for multiple sclerosis

Both genetic and environmental factors contribute to multiple sclerosis, the most common neurodegenerative disorder with onset in young adults. The objective of the current study is, based on the hypothesis that environmentally predisposed individuals are at risk for multiple sclerosis, to investigate whether they also carry genetic variants within the vitamin D machinery. Using medical files and DNA samples from 583 trios (a patient and both parents) of the French Multiple Sclerosis Genetics Group as well as data from the French Statistics Bureau, we aimed to assess whether: (1) a seasonality of birth was observed in French multiple sclerosis patients; (2) three single nucleotide polymorphisms within the promoter region of the vitamin D receptor were associated with multiple sclerosis susceptibility; and (3) the combination of a high risk month of birth and vitamin D receptor polymorphisms were correlated to multiple sclerosis incidence. We observed a significantly reduced number of individuals born in November who were later diagnosed as multiple sclerosis patients. However, we found no association between the three studied vitamin D receptor polymorphisms and multiple sclerosis. In conclusion, our data suggest that high levels of vitamin D during the third trimester of pregnancy could be a protective factor for multiple sclerosis.

Neurotrophin expression in the adult olfactory epithelium

Published reports of neurotrophin expression in the olfactory system are incomplete because of missing data and conflicting results. Previous studies used a variety of fixation procedures and antibodies on different species and different ages. The aim of the present study was to examine expression of neurotrophins and their receptors using optimized methodologies: five methods of fixation, multiple antibodies, a variety of immunochemical protocols, and RT-PCR. We show here that (i) transcripts for all neurotrophins and their receptors are found in the adult olfactory epithelium; (ii) all neurotrophins are expressed in the supporting cells and the neuronal layers of the undisturbed adult olfactory epithelium while NT4 is found additionally in the horizontal basal cells; (iii) neurotrophin immunoreactivity required a fixative that included parabenzoquinone (not used in previous studies of olfactory tissue); (iv) TrkB and TrkC are restricted to the globose basal cell and neuron layers while TrkA is found in the horizontal basal cells and in the supporting cells where it co-localizes with the low affinity receptor for NGF (p75NTR). These findings confirm that neurotrophins are produced within the olfactory epithelium, suggesting autocrine and paracrine regulation of olfactory neurogenesis.

[Chronic instability in the ankle area]

For ankle sprains, the initial radiological work-up must include weight-bearing AP and lateral stress views of the sprained and healthy ankle. Films are taken in auto-varus. Other explorations included arthroMRI, arthroscanner or MRI which can be indicated preoperatively to confirm suspected cartilage injury or an associated ligament tear. These techniques should be employed when pertinent information can be expected according to the clinical situation and the operator's experience. In the emergency setting, ultrasonography can provide a simple low-cost confirmation of joint hematoma which is more precise than x-rays with a positive predictive value of nearly 100%. The objective and subjective clinical outcome after surgical anatomic repair or ligamentoplasty are quite similar. The two principal differences relate to persistent subjective instability and post-operative surgical complications. Thus there are advantages and disadvantages for each option advantage for anatomical repair because of the low rate of surgical complications and advantage for ligament repairs which stabilize the subtalar joint with a low rate of residual instability.

The combination of shared family environment and individual-specific developmental deviance as a cause for treated psychiatric morbidity in children

OBJECTIVE

There is an incomplete understanding of why some children growing up in the same family are in need of treatment for psychiatric morbidity whilst their siblings are not. The present paper examined the possible role of individual-specific developmental risk factors.

METHOD

Three case-control analyses were conducted: i) 80 children referred to the Community Mental Health Centre (cases) and 320 population controls, ii) 68 healthy siblings of cases and 272 population controls, and iii) 80 children and 68 healthy siblings. Measures of development and psychosocial circumstances were obtained from routine, longitudinal, standardized child medical records.

RESULTS

Given shared family environments, additional presence of delays in speech and motor development contributed most to differential sibling mental health outcomes. In addition, cases displayed both earlier expression and more severe levels of developmental behavioural deviance than their healthy siblings, who in turn had higher levels of behavioural deviance than population controls.

CONCLUSION

In siblings sharing a familial risk environment, development of psychiatric morbidity may be canalized through additional individual-specific developmental exposures.

La réparation nerveuse périphérique : 30 siècles de recherche

INTRODUCTION

Nerve injury compromises sensory and motor functions. Techniques of peripheral nerve repair are based on our knowledge regarding regeneration. Microsurgical techniques introduced in the late 1950s and widely developed for the past 20 years have improved repairs. However, functional recovery following a peripheral mixed nerve injury is still incomplete.

STATE OF ART

Good motor and sensory function after nerve injury depends on the reinnervation of the motor end plates and sensory receptors. Nerve regeneration does not begin if the cell body has not survived the initial injury or if it is unable to initiate regeneration. The regenerated axons must reach and reinnervate the appropriate target end-organs in a timely fashion. Recovery of motor function requires a critical number of motor axons reinnervating the muscle fibers. Sensory recovery is possible if the delay in reinnervation is short. Many additional factors influence the success of nerve repair or reconstruction. The timing of the repair, the level of injury, the extent of the zone of injury, the technical skill of the surgeon, and the method of repair and reconstruction contribute to the functional outcome after nerve injury.

CONCLUSION

This review presents the recent advances in understanding of neural regeneration and their application to the management of primary repairs and nerve gaps.

Vitamin D3 and brain development

Evidence for the presence of the vitamin D receptor in brain implies this vitamin may have some function in this organ. This study investigates whether vitamin D(3) acts during brain development. We demonstrate that rats born to vitamin D(3)-deficient mothers had profound alterations in the brain at birth. The cortex was longer but not wider, the lateral ventricles were enlarged, the cortex was proportionally thinner and there was more cell proliferation throughout the brain. There were reductions in brain content of nerve growth factor and glial cell line-derived neurotrophic factor and reduced expression of p75(NTR), the low-affinity neurotrophin receptor. Our findings would suggest that low maternal vitamin D(3) has important ramifications for the developing brain.

Decreased expression of the two D2 dopamine receptor isoforms in bromocriptine-resistant prolactinomas

Bromocriptine or other dopamine agonists are usually effective for the treatment of prolactin-secreting adenomas. Five to 18% of prolactinomas, however, do not respond to such therapy. We have shown previously that such resistance to bromocriptine correlates with reduced binding to the D2 receptor subtype of dopamine, the major PRL inhibiting factor. In the present work, we demonstrated that reduced binding actually corresponds to decreased expression of the gene coding for the D2 receptor in the pituitary from bromocriptine-resistant patients, as shown by 4-fold lower levels of the corresponding mRNAs compared to those coding for actin. The existence of two D2 receptor isoforms, D2S and D2L generated by alternative splicing, has been described in several tissues, including the pituitary. Both are negatively coupled to adenylyl cyclase and inhibit prolactin secretion, but, in addition, the shortest one (D2S) is more efficiently coupled to phospholipase C. Consequently, we also investigated whether expression of a particular D2 receptor isoform was preferentially affected in resistant adenomas. The proportion of messengers corresponding to the short receptor isoform (D2S) was lower in resistant compared to responsive adenomas: D2S/D2L = 0.74 +/- 0.08 and 1.00 +/- 0.07, respectively. In parallel, much lower levels of D2 receptor mRNAs were found in growth hormone-secreting adenomas, with a D2S/D2L ratio comparable to those of both normal human pituitary and bromocriptine-sensitive prolactinomas (1.05 +/- 0.11). Thus, resistance to bromocriptine therapy seems to involve defects in D2 dopamine receptor expression and possibly in posttranscriptional splicing.

Anaphylatoxin C5a production during short-term submaximal dynamic exercise in man

We studied the effects of short-term submaximal exercise on the plasma levels of myeloperoxidase ([MPO]) and C5a anaphylatoxin ([C5a]), taken as specific markers of polymorphonuclear neutrophil (PMN) and complement activation, respectively. Eleven young, healthy male volunteers were subjected to a constant-load concentric exercise on a cycle ergometer (20 min at 80% maximal oxygen uptake). Mean resting MPO and C5a concentrations were 437 +/- 113 and 0.47 +/- 0.21 ng/ml, respectively. During exercise, [MPO] and [C5a] increased significantly (p < 0.001) towards respective peak values of 649 +/- 131 and 1.3 +/- 0.6 ng/ml. A rapid decrease of both [MPO] and [C5a] was observed during recovery. The similar time course of [MPO] and [C5a] changes and the highly significant relationship between these two variables (r = 0.651; p < 0.001) argues for the possible involvement of the complement anaphylatoxin C5a in the process of PMN degranulation. During exercise, the number of circulating PMN increased (+80%; p < 0.001) and remained practically unchanged up to 20 minutes of recovery. As [MPO] and PMN count were not significantly related (r = 0.2; p < 0.1), we concluded that the activation of PMN was independent of their mobilization.

[Mobilization of leukocytes during sub-maximal dynamic exercise]

Increase of blood leucocytes induced by a dynamic exercise has been studied in 10 adult male subjects (age: 22 +/- 2 years; body weight 73 +/- 10 kg; VO2max: 54 +/- 8 ml O2/kg.min. The exercise consisted of a 20 minutes test on a cycle ergometer at a work rate eliciting a total energy expenditure roughly equal to 80% of the maximal aerobic power (80% VO2max). During exercise the absolute number of circulating leucocytes (n Leu) increased significantly toward a maximal value reached in most cases at the end of exercise. The maximal values of n Leu--expressed as percentage of n Leu measured at rest--in the different blood leucocyte types (monocytes:n Mono; granulocytes:n GR; natural killer cells:n NK) and lymphocyte subsets (lymphocytes:n LY; lymphocytes T:n T; lymphocytes B:n B; lymphocytes T helper:n T4; lymphocytes T suppressor:n T8)--were as follows:n Mono:240%; n GR:170%; n NK:490%; n LY:220%; n T:200%; n B:190%; n T4:140%; n T8:190%. With the exception of n GR, n Leu decreased during recovery at a rate depending on the leucocyte type. The n T4/n T8 ratio, equal to 1 at rest, was reduced by about 40% during exercise. This ratio rose after exercise and reached a value equal to that measured at rest after 20 minutes recovery. In agreement with FERRY (1989), we concluded that exercise is accompanied by a selective mobilization of the different leucocyte types. The magnitude of this phenomenon and the kinetics of n Leu recuperation depend on cell types.