A paradigm change to inform fibromyalgia research priorities by engaging patients and health care professionals

Background: Research objectives should be focused toward advancing knowledge that has meaningful impact on health. However, research agendas are mostly driven by the health care community, with limited input from patients.

Aims: In this study, prioirities of uncertainties for the management of fibromyalgia (FM) that could propel future research were identified by a defined process using the James Lind Alliance Priority Setting Partnership (JLA-PSP) methodology.

Methods: As a first step, a survey was distributed across Canada that engaged patients, caregivers, and health care professionals to provide narrative input to eight open-ended questions regarding FM care. Responses were thematically condensed and synthesized into an initial list of 43 uncertainties used to guide a comprehensive literature search. Questions already effectively addressed in the literature were excluded, leaving 25 uncertainties that were ranked during a one-day consensus workshop.

Results: Three broad themes emerged: the value of personalized targeted treatment and subgrouping of patients; the efficacy of various self-management strategies and educational initiatives; and identification of the ideal health care setting to provide FM care. Opioids and cannabinoids were the only specific pharmacologic interventions ranked as needing further research.

Conclusions: The prioritized questions highlight the importance of recognizing the heterogeneity of FM symptoms, the need for a personalized treatment approach, and a better understanding of the value of self-management strategies. This is the first study that uses an established and transparent methodology to engage all FM stakeholders to help inform researchers and funding bodies of clinically relevant research priorities.

Creating an inclusive mall environment with the PRECEDE-PROCEED model: a living lab case study

PURPOSE

Although public environments provide opportunities for participation and social inclusion, they are not always inclusive spaces and may not accommodate the wide diversity of people. The Rehabilitation Living Lab in the Mall is a unique, interdisciplinary, and multi-sectoral research project with an aim to transform a shopping complex in Montreal, Canada, into an inclusive environment optimizing the participation and social inclusion of all people.

METHODS

The PRECEDE-PROCEDE Model (PPM), a community-oriented and participatory planning model, was applied as a framework. The PPM is comprised of nine steps divided between planning, implementation, and evaluation.

RESULTS

The PPM is well suited as a framework for the development of an inclusive mall. Its ecological approach considers the environment, as well as the social and individual factors relating to mall users' needs and expectations. Transforming a mall to be more inclusive is a complex process involving many stakeholders. The PPM allows the synthesis of several sources of information, as well as the identification and prioritization of key issues to address. The PPM also helps to frame and drive the implementation and evaluate the components of the project.

CONCLUSION

This knowledge can help others interested in using the PPM to create similar enabling and inclusive environments world-wide. Implication for rehabilitation While public environments provide opportunities for participation and social inclusion, they are not always inclusive spaces and may not accommodate the wide diversity of people. The PRECEDE PROCEDE Model (PPM) is well suited as a framework for the development, implementation, and evaluation of an inclusive mall. Environmental barriers can negatively impact the rehabilitation process by impeding the restoration and augmentation of function. Removing barriers to social participation and independent living by improving inclusivity in the mall and other environments positively impacts the lives of people with disabilities.

Liver glucagon receptors (GluR): effect of exercise and fasting on binding characteristics, GluR-mRNA, and GluR protein content in rats

The purpose of the study was to investigate the effects of acute exercise and fasting on glucagon receptor (GluR) binding characteristics, GluR-mRNA, and protein content in rat liver. Liver homogenates were prepared and plasma membranes were purified by aqueous 2-phase affinity partitioning in rats fed at rest (control) and after 180 min of swimming exercise and 24 h of fasting (7 rats/group). Saturation curve of plasma membranes incubated with [125I]-glucagon showed significant higher GluR density following exercise and fasting than in the control group (8.19±0.29 and 8.01±0.65 vs. 3.09±0.12 pmol/mg of proteins, respectively). When compared to control rats, GluR Kd was also higher following exercise and fasting (0.46±0.05 and 0.56±0.13 vs. 0.33±0.05 nM, respectively; significantly different for fasting only). Expression of GluR-mRNA and protein content were both significantly higher (~100% and ~90%, respectively) following the 24-h fast than in the control rats, but not following exercise. These results, in line with the literature showing an increased sensitivity of the liver to glucagon following exercise and fasting, indicate that an increased density of GluR on plasma membranes can be obtained by 2 complementary mechanisms: externalization of pre-existing GluR from intracellular pools operative in response to the prolonged exercise, and de novo synthesis of GluR operative only in response to fasting. The reduction in plasma insulin concentration and/or depletion of liver glycogen stores, which results from both prolonged exercise and fasting, could be involved in the control of these mechanisms.

Metabolic fate of a large amount of 13C-glycerol ingested during prolonged exercise

We have shown that the oxidation rate of exogenous glycerol and glucose during prolonged exercise were similar when ingested in small amounts (0.36 g/kg) (J Appl Physiol 90:1685,2001). The oxidation rate of exogenous carbohydrate increases with the amount ingested. We, thus, hypothesized that the oxidation rate of exogenous glycerol would also be larger when ingested in large amount. The study was conducted on six male subjects exercising for 120 min at 64 (2)% VO(2)max while ingesting 1 g/kg of (13)C-glycerol. Substrate oxidation was measured using indirect respiratory calorimetry corrected for protein oxidation, and from V(13)CO(2) at the mouth. The (13)C enrichment of plasma glucose was also measured in order to follow the possible conversion of (13)C-glycerol into glucose. In spite of the large amount of glycerol ingested and absorbed (plasma glycerol concentration = 8.0 (0.3) mmol/l at min 100), exogenous glycerol oxidation over the last 80 min of exercise [8.8 (1.6) g providing 4.1 (0.7)% of the energy yield] was similar to that observed when 0.36 g/kg was ingested. The comparison between the (13)C enrichment of plasma glucose and the oxidation rate of (13)C-glycerol showed that a portion of exogenous glycerol was converted into glucose before being oxidized, but also suggested that another portion could have been directly oxidized in peripheral tissues.

Time-dependent changes in CRH concentrations and release in discrete brain regions following global ischemia: effects of MK-801 pretreatment

The excitatory actions of corticotropin-releasing hormone (CRH) in the brain and the neuroprotective effects of CRH antagonists in models of ischemia suggest a role for this peptide in the cascade of events leading to cellular damage. The present study aimed to characterize endogenous activation of CRH in discrete brain regions following global ischemia. Time-dependent changes in CRH concentrations were assessed in 10 brain regions including hippocampal, parahippocampal, and hypothalamic regions as well as the amygdala and the frontal cortex at three post-ischemic intervals: 4, 24, and 72 h (Experiment 1). The impact of pretreatment with a neuroprotective dose of the NMDA antagonist (5R,10S)-(+)-5-Methyl-10,11-dihydro-5H-dibenzo[a,d]cyclohepten-5,10-imine hydrogen maleate (MK-801; hydrogen maleate) on 24-h ischemia-induced CRH concentrations in the 10 brain regions was also determined (Experiment 2). In vivo microdialysis was used to assess dynamic fluctuations in CRH release at the dorsal hippocampus (CA1 pyramidal layer) and central nucleus of the amygdala (CeA; Experiment 3). Our findings revealed a rapid elevation of CRH concentrations at the piriform cortex (Pir) and hypothalamic nuclei following global ischemia. This was followed by decreased CRH concentrations at the amygdala, the frontal cortex (FC), the CA3, and the hypothalamus 24-h post-ischemia. MK-801 reversed the decreases in the hypothalamic nuclei but not in the other brain regions. Seventy-two hours post-ischemia, CRH levels returned to control values in all regions except the dentate gyrus (DG) where elevated CRH levels were observed. In vivo, a significant increase in CRH release in response to global ischemia was found at the CeA with no alterations at the CA1. These findings support brain region-specific ischemia-induced CRH alterations and suggest that CRH actions to mediate neuronal damage at the hippocampal CA1 layer may be indirect.

Disease knowledge in a high-risk population for cystic fibrosis

Cystic fibrosis (CF) has high incidence (1/936 live births) and carrier rate (1/15 inhabitants) in Saguenay-Lac-Saint-Jean (SLSJ). One objective of a major enquiry among several subsets of individuals from this high-risk population for CF was to evaluate the knowledge of the disease and its genetic transmission. The overall score of correct answers pertaining to the clinical signs of CF among medical doctors (general practitioners and specialists) was 42.2 and 65.6%, respectively; it was 84.2% for questions regarding the genetic transmission of CF. The knowledge of the clinical signs was reasonable among CF patients and their parents (about 65% of correct answers), but it was much higher for the genetics (over 88% among parents). Aunts and uncles of CF children were poorly informed of the clinical signs (33.9% of correct answers) but well informed of the genetic transmission (73.8%). Specific subsets of the SLSJ population showed important gaps in the knowledge of the clinical signs of CF but, overall, they were well informed of its genetic transmission.

Increased density of glucagon receptors in liver from endurance-trained rats

The binding properties of glucagon receptors were determined in plasma membranes isolated from liver of untrained (n = 6) and swimming endurance-trained Sprague-Dawley male rats (n = 7; 3 h/day, 5 days/wk, for 8 wk). Plasma membranes were purified from liver by aqueous two-phase affinity partitioning, and saturation kinetics were obtained by incubation of plasma membranes (10 microg of proteins/150 microl) with (125)I-labeled glucagon at concentrations ranging from 0.15 to 3.0 nM for 30 min at 30 degrees C. Saturating curve analysis indicated no difference in the affinity of glucagon receptors (0.57 +/- 0.06 and 0.77 +/- 0.09 nM in untrained and trained groups, respectively) but a significant higher glucagon receptor density in liver from untrained vs. trained rats (3.09 +/- 0.12 vs. 4.28 +/- 0.19 pmol/mg proteins). These results suggest that the reported increase in liver glucagon sensitivity in endurance-trained subjects (Drouin R, Lavoie C, Bourque J, Ducros F, Poisson D, and Chiasson J-L. Am J Physiol Endocrinol Metab 274: E23-E28, 1998) could be partly due to an increased glucagon receptor density in response to training.

Reproductive attitudes of couples having a child with cystic fibrosis in Saguenay-Lac-Saint-Jean (Quebec, Canada)

Cystic fibrosis (CF) has a high incidence (1/936 live births) and carrier rate (1/15 inhabitants) in Saguenay-Lac-Saint-Jean. One objective of a major enquiry among several subsets of individuals from this high-risk population for CF was to evaluate the reproductive behaviour of couples with a CF child attending the comprehensive CF clinic in Chicoutimi. The knowledge of the recurrence risk resulted in deciding against further progeny or in reducing the number of children. More reliable contraception methods after the birth of the CF child, but not prenatal diagnosis, were used. Although a minority of parents with a CF child would abort a CF foetus, they apparently started viewing pregnancy interruption for CF after prenatal diagnosis as an acceptable reproductive option.

Erythropoietin (rHuEPO) doping: effects of exercise on anaerobic metabolism in rats

The purpose of this study was to investigate the effects of recombinant human erythropoietin (rHuEPO) administration on energy metabolism during exercise. Specifically, the contribution of anaerobic (glycogen) metabolism during exercise was evaluated. Sprague-Dawley rats were randomly assigned to an experimental [rHuEPO] (600 U x kg(-1) of Eprex, every 3 days) or control (equivalent volume of saline) group. After 15 days of treatment, animals from both groups were randomly subjected to either a 30-minute exercise (swimming with 5% body weight added) or resting period. They were sacrificed at the end of the exercise period. Their liver and muscles were quickly removed and frozen in liquid nitrogen. Blood was also sampled. rHuEPO administration resulted in a significant (P < 0.05) increase of hematocrit (from 42 +/- 2 to 54 +/- 7 L/L). In the rHuEPO group, both muscle glycogen and free fatty acids were higher whereas lactate was lower at the conclusion of the exercise period (P < 0.05). These results suggest that energy substrate utilization during exercise is affected by enhanced oxygen availability. Finally, a lower overall contribution to energy production from anaerobic metabolism during exercise followed rHuEPO administration.

Plasma galanin immunoreactivity in the rat after swimming

The purpose of our experiment was to study plasma immunoreactive galanin in the rat after swimming. Four groups of rats were used. At rest, one group was studied after an intravenous injection of D-glucose while another group received a corresponding saline injection. The two remaining groups, treated respectively with glucose and saline, were investigated after a 30-min swimming session. After 30 min of rest in their respective cages, or after swimming, the animals were anesthetized for immediate blood sampling. The main observation was that plasma galanin was higher after swimming than after rest only in glucose-treated rats, in the vena cava (11.82 +/- 2.90 vs. 5.05 +/- 1.65 pM) and the portal vein (15.75 +/- 3.74 vs. 6.58 +/- 1.75 pM). Both saline- and glucose-treated groups had a significant increase of plasma norepinephrine from rest to swimming in the vena cava. A decrease of plasma insulin was observed in the portal vein of exercised glucose-treated rats, while plasma glucose was higher in the portal vein of this group. In conclusion, after swimming, plasma galanin level was increased only in glucose-treated rats. A significant correlation was also observed between plasma galanin and glucose (r = 0.69, p < 0.01), suggesting that the presence of glucose is necessary to induce galanin liberation during exercise.

Impaired modulation of AMPA receptors by calcium-dependent processes in streptozotocin-induced diabetic rats

The mechanisms by which diabetes impairs cognitive function are not well-established. In the present study, we determined the electrophysiological and biochemical nature of disturbances in the mechanism of long-term potentiation (LTP) in diabetic rats. As previously reported, the administration of streptozotocin (STZ) was found to reduce the magnitude of LTP in the CA1 region of the hippocampus, while the same treatment did not interact with the capacity of the hippocampus to generate long-term depression induced by low-frequency stimulation. In addition, STZ treatment did not modify the component of excitatory postsynaptic potentials mediated by activation of the N-methyl-D-aspartate (NMDA) subtype of glutamate receptors, suggesting that NMDA receptor function remained intact in STZ-treated slices. At the biochemical level, the capacity of calcium to increase [3H](RS)-alpha-amino-3-hydroxy-5-methylisoxazole propionic acid (3H-AMPA) binding to glutamate/AMPA receptors in rat brain tissue sections was markedly affected in most regions of the hippocampus of STZ-treated rats. Moreover, changes in 3H-AMPA binding properties elicited by both exogenous phospholipase A2 and melittin, a potent activator of endogenous phospholipases, were also altered in synaptoneurosomes from diabetic rats. Taken together, the present data suggest that the loss of LTP maintenance in STZ-treated rats is more likely the result of disruption of calcium-dependent processes that are suspected to modulate postsynaptic AMPA receptors during synaptic potentiation. Understanding the biochemical factors participating in the impairment of AMPA receptor modulation might provide important clues revealing the very basis of memory deficits in diabetes.

Binding properties of glutamate receptors in streptozotocin-induced diabetes in rats

The biochemical mechanisms by which diabetes modulates cognitive function are not well established. Here, we determined the effects of streptozotocin (STZ) administration on the binding properties of alpha-amino-3-hydroxy-5-methylisoxazolepropionic acid (AMPA) and N-methyl-D-aspartate (NMDA) subtypes of glutamate receptors in rats, using quantitative autoradiographic analysis of (3)H-AMPA and [(3)H]glutamate binding on brain tissue sections. The STZ injection (70 mg/kg intraperitoneally) produced a reduction of (3)H-AMPA binding in various brain regions, an effect that is due to a decrease in receptor affinity. The STZ-induced reduction of (3)H-AMPA binding varied in different brain structures, being more pronounced in the striatum, cerebral cortex, and hippocampus and almost absent in the cerebellum. Western blots performed on hippocampal membranes revealed that the decrease in (3)H-AMPA binding is possibly associated with changes in immunologic properties for one glutamate receptor subunit (GluR1). Finally, the effect of STZ-induced diabetes appeared to be specific to the AMPA subtype of glutamate receptors, as the same treatment did not modify [(3)H]glutamate binding to NMDA receptors. These changes in AMPA receptor properties may have important implications for understanding the biochemical mechanisms underlying cognitive impairment in diabetes.

Plasma catecholamine response in trained rats following hemorrhage

The purpose of this study was to evaluate the effect of physical training on hemorrhage-induced catecholamine release in rats. The training program consisted of swimming 5 days a week from 15 min in the first week to 2.5 hours in the 14th week. The rats were divided into four groups. Two groups (one trained and the other untrained) were studied during hemorrhage. The third and fourth groups (one trained and the other untrained) were not subjected to hemorrhage. After 14 weeks, trained rats had a lower heart rate than untrained animals at rest (311.86 +/- 8.9 vs. 361.33 +/- 12.13 bpm, p < .002) for a similar body weight. The trained and untrained groups had the same blood pressure, hematocrit, and norepinephrine responses following hemorrhage. However, plasma epinephrine concentration was lower in the trained rats 15 and 25 min following hemorrhage. These results suggest a decrease of the hemorrhage-induced epinephrine secretion in trained rats. An alteration of the relationship of arterial baroreflexes and of their hormonal effectors is a potential mechanism for the reduced plasma epinephrine level in trained hemorrhaged rats.

Capsaicin-sensitive nerves and endurance exercise in the rat

The purpose of our study was to clarify the role of capsaicin-sensitive nerves in the control of plasma catecholamine and glucose concentrations during exercise. In vehicle-treated rats, plasma epinephrine (E) and norepinephrine (NE) levels were significantly higher in animals exercised to exhaustion than in the group sacrificed at rest. However, it was not the case for the neonatally capsaicin-treated animals. The epinephrine and norepinephrine levels were not significantly higher in the capsaicinized animals exercised to exhaustion than in those studied at rest. As a result, plasma epinephrine and norepinephrine levels were higher in control than in capsaicinized exhausted animals. Impairment of capsaicin-sensitive nerves by the neonatal capsaicin treatment prevented the exercise-induced increase of catecholamine output despite a significant decrease in plasma glucose levels and a lower liver glycogen content at rest. We suggest that this impairment of catecholamine output during exercise was caused by depletion of substance P in C-fibers directed to the adrenal medulla. This is supported by the observation of a lower plasma epinephrine level in capsaicin-treated rats. We conclude that C-fibers are therefore involved in the control of catecholamine secretion by the adrenal medulla during exercise to exhaustion. However, such an impairment of catecholamine output was not associated with a further decrease in plasma glucose levels or a shorter time-to-exhaustion. This also suggests that a partial dysfunction of the adrenal medulla is not sufficient to alter exercise endurance and plasma glucose levels.

Hereditary nonspherocytic hemolytic anemia due to pyruvate kinase deficiency: a prevalence study in Quebec (Canada)

Fifty-eight cases of hereditary nonspherocytic hemolytic anemia due to pyruvate kinase deficiency were collected from both laboratories that have performed the assay since 1972 and from attending physicians in the province of Quebec. Using the postal addresses of the probands, a prevalence map was constructed according to the administrative regions of the province of Quebec. The prevalence was found to be higher in eastern Quebec (1/81,838) than in western Quebec (1/139,086). Fifty probands were of French Canadian origin whereas the remaining 6 were recent immigrants.