Cost-effectiveness of mifepristone and misoprostol versus misoprostol alone for the management of missed miscarriage: an economic evaluation based on the MifeMiso trial

OBJECTIVE

To assess the cost-effectiveness of mifepristone and misoprostol (MifeMiso) compared with misoprostol only for the medical management of a missed miscarriage.

DESIGN

Within-trial economic evaluation and model-based analysis to set the findings in the context of the wider economic evidence for a range of comparators. Incremental costs and outcomes were calculated using nonparametric bootstrapping and reported using cost-effectiveness acceptability curves. Analyses were performed from the perspective of the UK's National Health Service (NHS).

SETTING

Twenty-eight UK NHS early pregnancy units.

SAMPLE

A cohort of 711 women aged 16-39 years with ultrasound evidence of a missed miscarriage.

METHODS

Treatment with mifepristone and misoprostol or with matched placebo and misoprostol tablets.

MAIN OUTCOME MEASURES

Cost per additional successfully managed miscarriage and quality-adjusted life years (QALYs).

RESULTS

For the within-trial analysis, MifeMiso intervention resulted in an absolute effect difference of 6.6% (95% CI 0.7-12.5%) per successfully managed miscarriage and a QALYs difference of 0.04% (95% CI -0.01 to 0.1%). The average cost per successfully managed miscarriage was lower in the MifeMiso arm than in the placebo and misoprostol arm, with a cost saving of £182 (95% CI £26-£338). Hence, the MifeMiso intervention dominated the use of misoprostol alone. The model-based analysis showed that the MifeMiso intervention is preferable, compared with expectant management, and this is the current medical management strategy. However, the model-based evidence suggests that the intervention is a less effective but less costly strategy than surgical management.

CONCLUSIONS

The within-trial analysis found that based on cost-effectiveness grounds, the MifeMiso intervention is likely to be recommended by decision makers for the medical management of women presenting with a missed miscarriage.

TWEETABLE ABSTRACT

The combination of mifepristone and misoprostol is more effective and less costly than misoprostol alone for the management of missed miscarriages.

'The rollercoaster of follow-up care' after bariatric surgery: a rapid review and qualitative synthesis

Benefits of bariatric surgery for obesity related comorbidities are well established. However, in the longer term, patients can become vulnerable to procedure specific problems, experience weight regain and continue to need monitoring and management of comorbidities. Effective longer term follow-up is vital due to these complex needs post-surgery. Current guidance recommends annual long-term follow-up after bariatric surgery. However, attendance can be low, and failure to attend is associated with poorer outcomes. Understanding patients' experiences and needs is central to the delivery of effective care. This rapid review has synthesized the current qualitative literature on patient experiences of healthcare professional (HCP) led follow-up from 12 months after bariatric surgery. A recurring theme was the need for more and extended follow-up care, particularly psychological support. Enablers to attending follow-up care were patient self-efficacy as well as HCP factors such as a non-judgemental attitude, knowledge and continuity of care. Barriers included unrealistic patient expectations and perceived lack of HCP expertise. Some preferences were expressed including patient initiated access to HCPs and more information preoperatively to prepare for potential post-surgery issues. Insights gained from this work will help identify areas for improvement to care in order to optimize longer term outcomes.

Patients' experiences of deep brain stimulation for Parkinson's disease: a qualitative systematic review and synthesis

OBJECTIVE

To review and synthesise qualitative research studies that have explored patients' experience of deep brain stimulation (DBS) in advanced Parkinson's disease (PD).

DESIGN

Systematic review and meta-synthesis of 7 original papers, using metaethnography.

SETTING

Studies conducted in Denmark, France and Sweden.

PARTICIPANTS

116 patients who had undergone DBS and 9 spouses of patients.

RESULTS

Prior to surgery, the experience of advancing PD is one of considerable loss and a feeling of loss of control. There are significant hopes for what DBS can bring. Following surgery, a sense of euphoria is described by many, although this does not persist and there is a need for significant transitions following this. We suggest that normality as a concept is core to the experience of DBS and that a sense of control may be a key condition for normality. Experience of DBS for patients and spouses, and of the transitions that they must undertake, is influenced by their hopes of what surgery will enable them to achieve, or regain (ie, a new normality).

CONCLUSIONS

There is a need for further qualitative research to understand the nature of these transitions to inform how best patients and their spouses can be supported by healthcare professionals before, during and after DBS. In assessing the outcomes of DBS and other treatments in advanced PD, we should consider how to capture holistic concepts such as normality and control. Studies that examine the outcomes of DBS require longer term follow-up.

The use of qualitative methods to inform Delphi surveys in core outcome set development

Background

Core outcome sets (COS) help to minimise bias in trials and facilitate evidence synthesis. Delphi surveys are increasingly being used as part of a wider process to reach consensus about what outcomes should be included in a COS. Qualitative research can be used to inform the development of Delphi surveys. This is an advance in the field of COS development and one which is potentially valuable; however, little guidance exists for COS developers on how best to use qualitative methods and what the challenges are. This paper aims to provide early guidance on the potential role and contribution of qualitative research in this area. We hope the ideas we present will be challenged, critiqued and built upon by others exploring the role of qualitative research in COS development.

This paper draws upon the experiences of using qualitative methods in the pre-Delphi stage of the development of three different COS. Using these studies as examples, we identify some of the ways that qualitative research might contribute to COS development, the challenges in using such methods and areas where future research is required.

Results

Qualitative research can help to identify what outcomes are important to stakeholders; facilitate understanding of why some outcomes may be more important than others, determine the scope of outcomes; identify appropriate language for use in the Delphi survey and inform comparisons between stakeholder data and other sources, such as systematic reviews. Developers need to consider a number of methodological points when using qualitative research: specifically, which stakeholders to involve, how to sample participants, which data collection methods are most appropriate, how to consider outcomes with stakeholders and how to analyse these data. A number of areas for future research are identified.

Conclusions

Qualitative research has the potential to increase the research community’s confidence in COS, although this will be dependent upon using rigorous and appropriate methodology. We have begun to identify some issues for COS developers to consider in using qualitative methods to inform the development of Delphi surveys in this article.

BDNF-expressing marrow stromal cells support extensive axonal growth at sites of spinal cord injury

Bone marrow stromal cells (MSCs) constitute a heterogeneous cell layer in the bone marrow, supporting the growth and differentiation of hematopoietic stem cells. Recently, it has been reported that MSCs harbor pluripotent stem cells capable of neural differentiation and that simple treatment of MSCs with chemical inducing agents leads to their rapid transdifferentiation into neural cells. We examined whether native or neurally induced MSCs would reconstitute an axonal growth-promoting milieu after cervical spinal cord injury (SCI), and whether such cells could act as vehicles of growth factor gene delivery to further augment axonal growth. One month after grafting to cystic sites of SCI, native MSCs supported modest growth of host sensory and motor axons. Cells "neurally" induced in vitro did not sustain a neural phenotype in vivo and supported host axonal growth to a degree equal to native MSCs. Transduction of MSCs to overexpress brain-derived neurotrophic factor (BDNF) resulted in a significant increase in the extent and diversity of host axonal growth, enhancing the growth of host serotonergic, coerulospinal, and dorsal column sensory axons. Measurement of neurotrophin production from implanted cells in the lesion site revealed that the grafts naturally contain nerve growth factor (NGF) and neurotrophin-3 (NT-3), and that transduction with BDNF markedly raises levels of BDNF production. Despite the extensive nature of host axonal penetration into the lesion site, functional recovery was not observed on a tape removal or rope-walking task. Thus, MSCs can support host axonal growth after spinal cord injury and are suitable cell types for ex vivo gene delivery. Combination therapy with other experimental approaches will likely be required to achieve axonal growth beyond the lesion site and functional recovery.

Neural stem cells constitutively secrete neurotrophic factors and promote extensive host axonal growth after spinal cord injury

Neural stem cells (NSCs) offer the potential to replace lost tissue after nervous system injury. This study investigated whether grafts of NSCs (mouse clone C17.2) could also specifically support host axonal regeneration after spinal cord injury and sought to identify mechanisms underlying such growth. In vitro, prior to grafting, C17.2 NSCs were found for the first time to naturally constitutively secrete significant quantities of several neurotrophic factors by specific ELISA, including nerve growth factor, brain-derived neurotrophic factor, and glial cell line-derived neurotrophic factor. When grafted to cystic dorsal column lesions in the cervical spinal cord of adult rats, C17.2 NSCs supported extensive growth of host axons of known sensitivity to these growth factors when examined 2 weeks later. Quantitative real-time RT-PCR confirmed that grafted stem cells expressed neurotrophic factor genes in vivo. In addition, NSCs were genetically modified to produce neurotrophin-3, which significantly expanded NSC effects on host axons. Notably, overexpression of one growth factor had a reciprocal effect on expression of another factor. Thus, stem cells can promote host neural repair in part by secreting growth factors, and their regeneration-promoting activities can be modified by gene delivery.

Influence of life-history parameters on organochlorine concentrations in free-ranging killer whales (Orcinus orca) from Prince William Sound, AK

Certain populations of killer whales (Orcinus orca) have been extensively studied over the past 30 years, including populations that use Puget Sound, WA, the inside waters of British Columbia, Southeastern Alaska and Kenai Fjords/Prince William Sound, Alaska. Two eco-types of killer whales, 'transient' and 'resident', occur in all of these regions. These eco-types are genetically distinct and differ in various aspects of morphology, vocalization patterns, diet and habitat use. Various genetic and photo-identification studies of eastern North Pacific killer whales have provided information on the male-female composition of most of these resident pods and transient groups, as well as the approximate ages, reproductive status and putative recruitment order (birth order) of the individual whales. Biopsy blubber samples of free-ranging resident and transient killer whales from the Kenai Fjords/Prince William Sound, AK region were acquired during the 1994-1999 field seasons and analyzed for selected organochlorines (OCs), including dioxin-like CB congeners and DDTs. Concentrations of OCs in transient killer whales (marine mammal-eating) were much higher than those found in resident animals (fish-eating) apparently due to differences in diets of these two killer whale eco-types. Certain life-history parameters such as sex, age and reproductive status also influenced the concentrations of OCs in the Alaskan killer whales. Reproductive female whales contained much lower levels of OCs than sexually immature whales or mature male animals in the same age class likely due to transfer of OCs from the female to her offspring during gestation and lactation. Recruitment order also influenced the concentrations of OCs in the Alaskan killer whales. In adult male residents, first-recruited whales contained much higher OC concentrations than those measured in non-first-recruited (e.g. second recruited, third recruited) resident animals in the same age group. This study provides baseline OC data for free ranging Alaskan killer whales for which there is little contaminant information.

Chronic intrathecal infusions after spinal cord injury cause scarring and compression

Intrathecal infusions are used in a number of rodent studies to deliver substances to the injured spinal cord. Whereas this method has been successful in certain paradigms, two potential limitations of this model have not been extensively reported: (1) scar formation at the catheter tip, which can lead to infusion failure, and (2) damage to the spinal cord caused by the catheter itself. Thus, the purpose of the present study was threefold: (1) to determine intrathecal infusion efficiency over 14 days following spinal cord injury; (2) to examine possible secondary damage caused by intrathecal tubing; and (3) to explore whether alternative protocols that avoid such damage are effective. Adult Fischer 344 rats were subjected to spinal cord lesions at T7, followed by placement of an intrathecal catheter attached to an Alzet minipump. Seven or 14 days following injury and catheter placement, tube patency was evaluated by diffusion of Evans Blue dye from the minipump. Results indicate that infusion was efficient 7 days following injury but was markedly reduced after 14 days. Further, histology and immunocytochemistry 14 days after injury demonstrated compression damage to the cord where the tubing rested. Alternative protocols, including intrathecal infusions through metal cannulae, or "drip" infusions directly over the lesion, did not improve delivery. These data suggest that results from rodent studies using infusion from catheters placed adjacent to lesion sites may be attributable to acute or subacute effects of the delivered substance. Future rodent studies using intrathecal infusions should include rigorous evaluation of infusion efficiency and possible secondary tissue damage.

Neurotrophic factors, cellular bridges and gene therapy for spinal cord injury

Injury to the adult mammalian spinal cord results in extensive axonal degeneration, variable amounts of neuronal loss, and often severe functional deficits. Restoration of controlled function depends on regeneration of these axons through an injury site and the formation of functional synaptic connections. One strategy that has emerged for promoting axonal regeneration after spinal cord injury is the implantation of autologous Schwann cells into sites of spinal cord injury to support and guide axonal growth. Further, more recent experiments have shown that neurotrophic factors can also promote axonal growth, and, when combined with Schwann cell grafts, can further amplify axonal extension after injury. Continued preclinical development of these approaches to neural repair may ultimately generate strategies that could be tested in human injury.

Interleukin-6 (IL6) and cellular response to facial nerve injury: effects on lymphocyte recruitment, early microglial activation and axonal outgrowth in IL6-deficient mice

Nerve injury triggers numerous changes in the injured neurons and surrounding non-neuronal cells. Of particular interest are molecular signals that play a role in the overall orchestration of this multifaceted cellular response. Here we investigated the function of interleukin-6 (IL6), a multifunctional neurotrophin and cytokine rapidly expressed in the injured nervous system, using the facial axotomy model in IL6-deficient mice and wild-type controls. Transgenic deletion of IL6 caused a massive decrease in the recruitment of CD3-positive T-lymphocytes and early microglial activation during the first 4 days after injury in the axotomized facial nucleus. This was accompanied by a more moderate reduction in peripheral regeneration at day 4, lymphocyte recruitment (day 14) and enhanced perikaryal sprouting (day 14). Motoneuron cell death, phagocytosis by microglial cells and recruitment of granulocytes and macrophages into injured peripheral nerve were not affected. In summary, IL6 lead to a variety of effects on the cellular response to neural trauma. However, the particularly strong actions on lymphocytes and microglia suggest that this cytokine plays a central role in the initiation of immune surveillance in the injured central nervous system.

Chest wall peritoneal dialysis catheter placement in infants with a colostomy

The presence of a colostomy in infants with end-stage renal disease (ESRD) receiving peritoneal dialysis (PD) is associated with an inherent risk for contamination and the development of a PD catheter-associated infection. A two-piece presternal catheter designed to reduce the incidence of such infections has been used in a small number of children, but the implantation of the catheter is technically difficult, and there is a risk of disconnection of the two parts secondary to rapid patient growth in the first year of life. Alternatively, a conventional Swan neck catheter, larger than typically required, can be placed with its exit site located on the chest wall. Over the past three years, we adopted this novel approach in two patients with ESRD and a colostomy in whom PD catheters were placed at ages 4 days and 12 days, respectively. During a combined follow-up of 50 months, only one episode of peritonitis and no episodes of exit-site or tunnel infection have been observed. This experience supports the use of this unique approach to PD catheter placement in infants with ESRD and a colostomy.

Regulation of the cell adhesion molecule CD44 after nerve transection and direct trauma to the mouse brain

CD44 is a cell surface glycoprotein involved in cell adhesion during neurite outgrowth, leukocyte homing, and tumor metastasis. In the current study, we examined the regulation of this molecule 4 days after neural trauma in different forms of central and peripheral injury. Transection of the hypoglossal, vagus, or sciatic nerve led to the appearance of CD44-immunoreactivity (CD44-IR) on the surface of the affected motoneurons, their dendrites, and their axons. Fimbria fornix transection led to CD44-IR on a subpopulation of cholinergic neurons in the ipsi- and contralateral medial septum and diagonal band of Broca and colocalized with galanin-IR. Central projections of axotomized sensory neurons to the spinal cord (substantia gelatinosa, Clarke's column) also showed an increase in CD44-IR, which was abolished by spinal root transection. Nonneuronal CD44-IR was mainly restricted to sites of direct injury. In the crushed sciatic nerve, CD44-IR was found on the demyelinating Schwann cells and on infiltrating monocytes and granulocytes. Direct parasagittal transection of the cerebral cortex led to CD44-IR on resident astrocytes and on leukocytes entering the injured forebrain tissue. CD44-IR also increased on reactive retinal astrocytes and microglia after the optic nerve crush. Additional time points in the retina and hypoglossal nucleus (days 1, 2, and 14) and cerebral cortex (day 2) injury models also showed the same cell type pattern for the CD44-IR. Finally, polymerase chain reaction analysis confirmed the posttraumatic expression of CD44 mRNA and detected only the standard haematopoietic CD44 splice isoform both in direct and indirect brain injury models. Overall, the current study shows the widespread, graded appearance of CD44-IR on neurons and on nonneuronal cells, depending on the form of neural injury. Here, the ability of CD44 to bind to a variety of extracellular matrix and cell adhesion proteins and its common presence in different forms of brain pathology could suggest an important role for this cell surface glycoprotein in the neuronal, glial, and leukocyte response to trauma and in the repair of the damaged nervous system.

Impaired axonal regeneration in alpha7 integrin-deficient mice

The interplay between growing axons and the extracellular substrate is pivotal for directing axonal outgrowth during development and regeneration. Here we show an important role for the neuronal cell adhesion molecule alpha7beta1 integrin during peripheral nerve regeneration. Axotomy led to a strong increase of this integrin on regenerating motor and sensory neurons, but not on the normally nonregenerating CNS neurons. alpha7 and beta1 subunits were present on the axons and their growth cones in the regenerating facial nerve. Transgenic deletion of the alpha7 subunit caused a significant reduction of axonal elongation. The associated delay in the reinnervation of the whiskerpad, a peripheral target of the facial motor neurons, points to an important role for this integrin in the successful execution of axonal regeneration.

A Descriptive Analysis of Music Therapists' Perceptions of Delivering Services in Inclusive Settings: A Challenge to the Field

The purpose of this study was to examine the perceptions of music therapists toward inclusion (providing services within general education settings) and to determine their willingness to provide their services in these settings. A questionnaire was sent to 560 music therapists of which 373 responded (67%). A descriptive analysis indicated that although the vast majority of music therapists are providing their services in a segregated setting, they (a) overwhelmingly know about inclusion, (b) perceive benefits to clients with and without disabilities, and (c) are willing to provide their services within an inclusive setting. Why then do therapists so overwhelmingly provide their services in noninclusive settings? Possible answers to this question as well as the challenge this creates to the field of music therapy are discussed.

Molecular signals for glial activation: pro- and anti-inflammatory cytokines in the injured brain

Injury to the central nervous system leads to cellular changes not only in the affected neurons but also in adjacent glial cells. This neuroglial activation is a consistent feature in almost all forms of brain pathology and appears to reflect an evolutionarily-conserved program which plays an important role for the repair of the injured nervous system. Recent work in mice that are genetically-deficient for different cytokines (M-CSF, IL-6, TNF-alpha, TGF-beta 1) has begun to shed light on the molecular signals that regulate this cellular response. Here, the availability of cytokine-deficient animals with reduced or abolished neuroglial activation provides a direct approach to determine the function of the different components of the cellular response leading to repair and regeneration following neural trauma.

Neuroglial activation repertoire in the injured brain: graded response, molecular mechanisms and cues to physiological function

Damage to the central nervous system (CNS) leads to cellular changes not only in the affected neurons but also in adjacent glial cells and endothelia, and frequently, to a recruitment of cells of the immune system. These cellular changes form a graded response which is a consistent feature in almost all forms of brain pathology. It appears to reflect an evolutionarily conserved program which plays an important role in the protection against infectious pathogens and the repair of the injured nervous system. Moreover, recent work in mice that are genetically deficient for different cytokines (MCSF, IL1, IL6, TNFalpha, TGFbeta1) has begun to shed light on the molecular signals that regulate this cellular response. Here we will review this work and the insights it provides about the biological function of the neuroglial activation in the injured brain.

Symptoms of patients with myasthenia gravis receiving treatment

The symptoms of myasthenia gravis (MG) are often simply classified as excessive fatigue rather than evaluated as different signs of disease progression. The purpose of this study was to evaluate the medical symptoms of patients with MG who had been under treatment for many years. Patients diagnosed with MG were compared to healthy controls. A survey questionnaire was used and differences were evaluated using non-parametric statistics. Health care givers should be aware of these differences in order to facilitate early appropriate treatment, to decrease disability, and to increase the quality of life.

Immune surveillance in the injured nervous system: T-lymphocytes invade the axotomized mouse facial motor nucleus and aggregate around sites of neuronal degeneration

Although the CNS is an established immune-privileged site, it is under surveillance by the immune system, particularly under pathological conditions. In the current study we examined the lymphocyte infiltration, a key component of this neuroimmune surveillance, into the axotomized facial motor nucleus and analyzed the changes in proinflammatory cytokines and the blood-brain barrier. Peripheral nerve transection led to a rapid influx of CD3-, CD11a (alphaL, LFA1alpha)- and CD44-immunoreactive T-cells into the axotomized mouse facial motor nucleus, with a first, low-level plateau 2-4 d after injury, and a second, much stronger increase at 14 d. These T-cells frequently formed aggregates and exhibited typical cleaved lymphocyte nuclei at the EM level. Immunohistochemical colocalization with thrombospondin (TSP), a marker for phagocytotic microglia, revealed aggregation of the T-cells around microglia removing neuronal debris. The massive influx of lymphocytes at day 14 was also accompanied by the synthesis of mRNA encoding IL1beta, TNFalpha, and IFN-gamma. There was no infiltration by the neutrophil granulocytes, and the intravenous injection of horseradish peroxidase also showed an intact blood-brain barrier. However, mice with severe combined immunodeficiency (SCID), which lack differentiated T- and B-cells, still exhibited infiltration with CD11a-positive cells. These CD11a-positive cells also aggregated around phagocytotic microglial nodules. In summary, there is a site-selective infiltration of activated T-cells into the mouse CNS during the retrograde reaction to axotomy. The striking aggregation of these lymphocytes around neuronal debris and phagocytotic microglia suggests an important role for the immune surveillance during neuronal cell death in the injured nervous system.

Transforming growth factor beta's 1, 2 and 3 inhibit proliferation of ramified microglia on an astrocyte monolayer

The transforming growth factor beta's (TGFbeta) are a multipotent family of cytokines with strong immunosuppressive and neurotrophic effects. In the current study, we examined the effect of the TGFbeta's 1, 2 and 3 on the proliferation of ramified microglia cultured on top of a confluent astrocyte monolayer. All three TGFbeta isoforms inhibited proliferation. PCR analysis also showed the presence of mRNA for the TGFbeta receptors type I and II and for all 3 TGFbeta isoforms in microglia, astrocytes and in co-cultures. Moreover, removal of this endogenous TGFbeta activity with antibodies against TGFbeta1 and TGFbeta3 strongly stimulated microglial proliferation. These inhibitory effects on the proliferation of ramified microglia suggest that TGFbeta's may play an important role in the regulation of the microglial population under normal conditions and after injury or disease in the central nervous system.

Population control of microglia: does apoptosis play a role?

Brain lesions, even of the most subtle type, are accompanied by the activation of microglia, the main immune cells of the brain. Microglial cells dramatically increase in number through proliferation and adhere to the injured neurons, where they displace the synaptic input. After proliferation, microglia gradually migrate into the nearby parenchyma and appear to decrease in number. Here we examined the possible involvement of apoptosis in the regulation of the microglial cell number using Terminal transferase mediated d-UTP Nick End-Labelling (TUNEL). In vitro, cell death is a common phenomenon in microglial cell cultures, and is enhanced by the withdrawal of the mitogen, granulocyte-macrophage colony stimulating factor. In vivo, application of the TUNEL-reaction revealed TUNEL-positive microglia beginning at day 4, with a peak 7 days after transection of the facial nerve. Surprisingly, TUNEL-labelling in vivo was localized on the outer side of the nuclear membrane and in the microglial cytoplasm, with very little staining within the nucleus itself. These TUNEL-labelled cells also lacked other classic morphological signs of apoptosis, like membrane blebbing, chromatin condensation and apoptotic bodies. These data suggest that the regulation of post-mitotic microglia is not mediated by the classic pathway of apoptosis.

Regulation of CD44 in the regenerating mouse facial motor nucleus

CD44 is a cell adhesion molecule which plays an important role in cell movement and adhesion, e.g. in lymphocyte homing and tumour metastasis. Here we studied the expression of CD44 mRNA and protein immunoreactivity in the facial nucleus after nerve injury and during the ensuing regeneration. Transection of the facial nerve led to a strong up-regulation of CD44, peaking 4 days after injury on the motoneurons of the axotomized facial nucleus. Use of the polymerase chain reaction confirmed the de novo expression of CD44 and detected only the standard haematopoietic CD44 isoform. Western blotting also detected the 76 kDa protein subtype, in line with the predicted size of the haematopoietic CD44 variant. At the ultrastructural level, CD44 immunoreactivity was restricted to the surface of the neuronal perikarya, their dendrites and axons. It was not seen in the adjacent activated astrocytes, microglia or vascular endothelia. This study shows strong up-regulation of the cell adhesion molecule CD44 on the regenerating motoneurons in the axotomized facial nucleus. These data suggest that CD44 may play a role in neurite outgrowth, in synaptic stripping or in the adhesion of activated glial cells to the perikaryal surface of the axotomized motoneurons.

Procurement coordinator support group

This article describes a support group for procurement coordinators. The group was initiated to help coordinators assist grieving donor families and to cope with their own reactions to stressful events. The theory underlying support groups is presented as a guide to understanding the purpose and process of the group. Issues of concern to coordinators are discussed along with strategies for facilitating group discussions and reducing stress.

Impaired neuroglial activation in interleukin-6 deficient mice

Astrocyte activation is a ubiquitous hallmark of the damaged brain and has been suggested to play an important regulatory role in the activation, survival, and regeneration of adjacent neurons, microglia, and oligodendrocytes. Little is known, however, about the endogenous signals that lead to this activation of astrocytes. Here we examined the regulation of interleukin 6 (IL6), a proinflammatory cytokine, its receptors, and the effects of IL6-deficiency in a model of traumatic central nervous system injury in the axotomized mouse facial motor nucleus. Facial nerve transection led to a massive but transient upregulation of IL6 mRNA in the disconnected motor nucleus, while IL6-receptor subunits were constitutively expressed on motoneurons and astrocytes. Absence of IL6 in genetically IL6-deficient mice led to massive reduction in the number of activated GFAP-positive astrocytes, a more moderate decrease in microglial activation and proliferation, and an increase in the late neuronal response to axotomy. These results emphasize the role of IL6 in the global regulation of neurons, astrocytes, and microglia and their activation in the injured nervous system.

Regulation of thrombospondin in the regenerating mouse facial motor nucleus

Thrombospondin (TSP) is a multifunctional extracellular matrix protein that plays a role in neuronal migration and axonal outgrowth in the developing central nervous system. In the current study we have examined the localization and regulation of TSP immunoreactivity (TSP-IR) during neuronal regeneration in the axotomized facial motor nucleus using Western blotting and light and electron microscopy. Transection of the facial nerve led to a gradual increase in TSP-IR in the regenerating motoneurons, peaking 4-7 days after injury (DAI). In addition to regenerating neurons, axotomy also caused a rapid upregulation of TSP-IR on activated microglia throughout the facial nucleus, with a maximum of 2-3 DAI, and a second increase at 14-21 DAI on microglial aggregates surrounding degenerating motoneurons and in neuronophagic microglia. In summary, injury leads to the induction of thrombospondin on axotomized neurons and activated microglia, peaking at the times of maximal posttraumatic microglial proliferation and during neuronal phagocytosis. Since thrombospondin is a multimodal extracellular matrix protein with a variety of cell attachment sites, thrombospondin might serve to link microglia and injured neurons, followed by microglial proliferation and removal of the neuronal debris.

Early and rapid de novo synthesis of Alzheimer beta A4-amyloid precursor protein (APP) in activated microglia

Upon acute activation, microglia, the immuneffector cells of the brain parenchyma, express the amyloid precursor protein (APP) that is otherwise prominent in pathological structures related to Alzheimer's disease. In this disease complex amyloid-bearing neuritic plaques contain beta A4-amyloid protein, the APP, and numerous inflammatory proteins. The accompanying activation of microglia has mostly been viewed as a secondary reaction to amyloid deposits. Activation of microglia was performed in a graded fashion. Transection of peripheral nerves such as the facial or sciatic nerve causes a microglial reaction within hours in the nucleus of origin or in projection areas of the CNS. A predominantly glial up-regulation of APP mRNA and protein could be detected as early as 6 h post lesion not only at the site of affected neuronal cell bodies but also in corresponding projection areas. Its time course suggests rapid transneuronal signalling to glial cells in the projection area. Light and electron microscopy demonstrate that microglia, which are cells of mononuclear phagocyte lineage and comprise up to 20% of all glial cells, are the dominant source for non-neuronal APP expression. Ultrastructurally, brain perivascular cells within the basal lamina constitutively express APP and thus are a possible source of vascular amyloid. Additionally, microglia express leukocyte-derived (L)-APP mRNA and protein that have recently been described in mononuclear cells of the immune system. Increased L-APP expression may serve as a potential marker for glial/microglial activation. Such immune-mediated amyloidogenesis initiated by microglia might have implications for the treatment of neurodegenerative diseases.

The benefits and costs of caregiving and care receiving for daughters and mothers

In accordance with social exchange theory (Thibaut and Kelley, 1959), this study examined the outcomes of caregiving for elderly mothers and their caregiving daughters (N = 141 pairs). Data were gathered through face-to-face interviews. Principal components factor analyses revealed three factors for mothers: Helplessness, Feeling Loved, and Anger; and three factors for daughters: Insufficient Time, Frustration, and Anxiety. Block regressions with an initial block of demographic variables and a second block of situational variables were performed to determine the relative influence of these two sets of independent variables on caregiving outcomes. The regressions revealed limited influence of demographic variables and significant influence of situational variables. Of particular importance for daughters is the role of perceived intimacy with the mother: Daughters with better relationships experience fewer caregiving costs. Mothers' health plays a critical role in the outcomes of care receiving: Mothers in poorer health experience greater helplessness and are less likely to feel loved.

Effects of short-term training on cardiac function during prolonged exercise

To determine the relationship between the training-induced increases in plasma volume (PV) and alterations in cardiac performance during prolonged submaximal cycle exercise, seven male subjects were studied prior to and following a short-term (3 d) training period (2 h.d-1 at 65% VO2max). Mean (range) VO2max was 3.42 l.min-1 (2.96-3.87). Training resulted in a 20% increase (P less than 0.05) in plasma volume (PV) and a 12% increase (P less than 0.05) in total blood volume (TBV). In contrast, training had no effect (P greater than 0.05) in altering exercise VO2, VCO2, VE BTPS, or RER. Cardiac output (Q) was higher (P less than 0.05) posttraining at all exercise sampling times (30, 60, 90, and 120 min). The elevations in Q were accompanied by an average decrease (P less than 0.05) in stroke volume (SV) of 22 ml. Arteriovenous O2 (a-v O2) difference was depressed (P less than 0.05) during exercise following the training. Although elevations (P less than 0.05) in core temperature (degrees C) occurred during the exercise, the training-induced PV increases did not affect thermoregulatory behavior. These results indicate that an early adaptive response to exercise training is an elevation in Q, an increase in SV, and a reduction in HR. These effects persist during prolonged exercise in spite of the progressive increase in body heat content. It is proposed that the increase in Q serves primarily to increase muscle blood flow and maintain arterial O2 delivery, while the altered cardiodynamic behavior serves to increase cardiac reserve, providing a greater tolerance to prolonged heavy exercise.

Autonomy and decision making between single older women and their caregiving daughters

We examined perceptions of decisional autonomy and decision-making processes among 64 elderly, single mothers and their caregiving daughters. Mothers were highly involved in decisions affecting their lives, ranging from daily care to major health decisions; daughters were particularly influential over major health, financial and housing decisions. Mothers' level of personal care dependency was negatively associated with both mothers' and daughters' confidence in the mothers' decision-making abilities.

Muscle energetics during prolonged cycling after exercise hypervolemia

This study examined the question of whether increases in plasma volume (hypervolemia) induced through exercise affect muscle substrate utilization and muscle bioenergetics during prolonged heavy effort. Six untrained males (19-24 yr) were studied before and after 3 consecutive days of cycling (2 h/day at 65% of peak O2 consumption) performed in a cool environment (22-23 degrees C, 25-35% relative humidity). This protocol resulted in a 21.2% increase in plasma volume (P less than 0.05). During exercise no difference was found in the blood concentrations of glucose, lactate, and plasma free fatty acids at either 30, 60, 90, or 120 min of exercise before and after the hypervolemia. In contrast, blood alanine was higher (P less than 0.05) during both rest and exercise with hypervolemia. Measurement of muscle samples extracted by biopsy from the vastus lateralis muscle at rest and at 60 and 120 min of exercise indicated no effect of training on high-energy phosphate metabolism (ATP, ADP, creatine phosphate, creatine) or on selected glycolytic intermediate concentrations (glucose 1-phosphate, glucose 6-phosphate, fructose 6-phosphate, lactate). In contrast, training resulted in higher (P less than 0.05) muscle glucose and muscle glycogen concentrations. These changes were accompanied by blunting of the exercise-induced increase (P less than 0.05) in both blood epinephrine and norepinephrine concentrations. Plasma glucagon and serum insulin were not affected by the training. The results indicate that exercise-induced hypervolemia did not alter muscle energy homeostasis. The reduction in muscle glycogen utilization appears to be an early adaptive response to training mediated either by an increase in blood glucose utilization or a decrease in anaerobic glycolysis.

Training-induced hypervolemia: lack of an effect on oxygen utilization during exercise

To investigate the effect of training-induced increases in plasma volume on maximal aerobic power, 8 male subjects (age 19 to 24 yr) underwent a 4-d training program (2 h X d-1) at an estimated 71% maximal aerobic power. Following training, plasma volume measured using 131I-human serum albumin increased by 20.3% (P less than 0.01) whereas red cell volume remained unchanged and total blood volume increased by 12.3% (P less than 0.01). During progressive sub-maximal cycle exercise, oxygen consumption, carbon dioxide production, ventilation, and blood lactate concentration remained unchanged following the training whereas heart rate was significantly elevated (P less than 0.05). Significant post-training elevations were also noted in carbon dioxide production (P less than 0.05), blood lactate (P less than 0.01), and peak power output (P less than 0.05) during maximal exercise. Maximal aerobic power and ventilation were not altered. It is concluded that hypervolemia induced by short-term exercise training does not affect oxygen consumption either during sub-maximal or maximal exercise.

Hemostatic imbalances produced by plasma exchange

Ten patients who underwent intensive therapeutic plasma exchange were studied prospectively to determine the nature and extent of changes induced in their coagulation mechanisms. The patients' plasma was replaced with serum albumin and normal saline. Significant changes were noted acutely in the prothrombin time, activated partial thromboplastin time, plasma fibrinogen, and platelet counts. Chronically, significant decreases were found in plasma fibrinogen concentrations and platelet counts. Intensive plasma exchange with fluids devoid of coagulation factors results in defects in the normal hemostatic mechanism.

Detection and isolation of minor lipid constituents

The use of thick layers of adsorbent for the concentration and subsequent isolation of neutral lipid constituents is described. Lipids not perceptible by conventional methods are demonstrated in concentrates of bovine heart extracts and identified as fatty aldehydes, O-alk-1-enyl diglycerides (neutral plasmalogens), and O-alkyl diglycerides (alkoxydiglycerides).