A qualitative study exploring the ritual-like activity and therapeutic relationship between Pilates teachers and clients with persistent low back pain

BACKGROUND AND PURPOSE

Pilates is a commonly recommended exercise modality for the management of persistent low back pain. Whilst guidelines recommend the use of exercise for low back pain, research suggests that no one exercise is superior, creating a question over the mechanism of effect. The patient-practitioner relationship may be important in managing low back pain; however, the relationship between Pilates teachers and clients is not well understood. The purpose of this study was to identify the components of the relationship between Pilates teachers and clients with persistent low back pain, explore key influences on the relationship, and ascertain the nature of the relationship.

METHOD

We conducted a qualitative, ethnographically-informed study at eight sites in the South of England, observing 24 Pilates sessions and interviewing 9 Pilates teachers and 10 clients with persistent low back pain. Fieldnotes and interview transcripts were analysed thematically.

RESULTS

The findings demonstrate a complex, multi-faceted interaction that occurs during Pilates sessions, grounded within certain health perceptions, and predicated on expectations of individuality, choice and expertise. A key finding reveals the perceived importance of mastery of prescribed movements with control and precision, in which clients particularly value the authority of the teacher in a directive learning environment.

CONCLUSION

We contend that the role of the Pilates teacher in this study facilitated the alleviation of clients' distress through the application of ritual-like Pilates activity. We conclude that the relationship between Pilates teachers and clients with persistent low back pain may be considered a therapeutic relationship.

Delivery Models and Health Economics of Supportive Care Services in England: A Multicentre Analysis

AIMS

Improvements in cancer treatment have led to more people living with and beyond cancer. These patients have symptom and support needs unmet by current services. The development of enhanced supportive care (ESC) services may meet the longitudinal care needs of these patients, including at the end of life. This study aimed to determine the impact and health economic benefits of ESC for patients living with treatable but not curable cancer.

MATERIALS AND METHODS

A prospective observational evaluation was undertaken over 12 months across eight cancer centres in England. ESC service design and costs were recorded. Data relating to patients' symptom burden were collected using the Integrated Palliative Care Outcome Scale (IPOS). For patients in the last year of life, secondary care use was compared against an NHS England published benchmark.

RESULTS

In total, 4594 patients were seen by ESC services, of whom 1061 died during follow-up. Mean IPOS scores improved across all tumour groups. In total, £1,676,044 was spent delivering ESC across the eight centres. Reductions in secondary care usage for the 1061 patients who died saved a total of £8,490,581.

CONCLUSIONS

People living with cancer suffer with complex and unmet needs. ESC services appear to be effective at supporting these vulnerable people and significantly reduce the costs of their care.

Hereditary renal cancer patient and public involvement group: A collaborative, consensus decision process to develop a communication tool for patient use

Patient and public involvement (PPI) must be more frequently embedded within clinical research to ensure translational outcomes are patient-led and meet patient needs. Active partnerships with patients and public groups are an important opportunity to hear patient voices, understand patient needs, and inform future research avenues. A hereditary renal cancer (HRC) PPI group was developed with the efforts of patient participants (n = 9), pooled from recruits within the early detection for HRC pilot study, working in collaboration with researchers and healthcare professionals (n = 8). Patient participants had HRC conditions including Von Hippel-Lindau (n = 3) and Hereditary Leiomyomatosis and Renal Cell Carcinoma (n = 5), and public participants included two patient Trustees (n = 2) from VHL UK & Ireland Charity. Discussions among the enthusiastic participants guided the development of a novel patient information sheet for HRC patients. This communication tool was designed to aid patients when informing family members about their diagnoses and the wider implications for relatives, a gap identified by participants within group discussions. While this partnership was tailored for a specific HRC patient and public group, the process implemented can be employed for other hereditary cancer groups and could be transferable within other healthcare settings.

Reduction in the need for unplanned stenting with the use of platelet glycoprotein IIb/IIIa blockade in percutaneous coronary intervention

Data from the 5 large randomized, double-blind, placebo-controlled trials that used glycoprotein IIb/IIIa inhibitors during percutaneous transluminal coronary angioplasty were pooled for a total of 10,691 patients. We found that the use of glycoprotein IIb/IIIa inhibitors in percutaneous coronary interventions significantly decreases the need for unplanned stenting for abrupt closure.

Needle-wire localization of an infratemporal fossa foreign body using computed tomography

We report a case involving the localization and surgical removal of a traumatically introduced foreign body deep within the infratemporal fossa. Needle-hookwire placement with computed tomographic guidance allowed the precise localization and marking of the foreign body. Surgical removal under local anesthesia and without extensive exploration was, therefore, possible. The details of the localization and marking techniques are described. Needle-hookwire localization under computed tomographic guidance should be considered for deeply located foreign bodies in the head and neck area.

Regulation of the ATP-dependent calcium uptake activity of heart sarcolemmal vesicles by endogenous cytosolic proteins

In a previous study we described the inhibitory action of a cytosolic protein fraction from heart muscle on ATP-dependent Ca2+ uptake by sarcoplasmic reticulum; further, this inhibition was shown to be blocked by an inhibitor antagonist, also derived from the cytosol (Narayanan et al. Biochim Biophys Acta 735: 53-66, 1983). The present study examined the effects of the endogenous cytosolic Ca2+ transport inhibitor and its antagonist on ATP-dependent Ca2+ uptake by sarcolemmal vesicles isolated from rat and canine heart. The cytosolic inhibitor caused strong inhibition (up to 97%) of Ca2+ uptake by sarcolemma (SL); this inhibition could be reversed by the cytosolic inhibitor antagonist. Studies on the characteristics of inhibition revealed the following: a) Inhibition was dependent on the concentration of the inhibitor (50% inhibition with approximately 80 micrograms inhibitor protein). b) The inhibitor reduced the velocity of Ca2+ uptake without appreciably influencing the apparent affinity of the transport system for Ca2+ but caused greater than 2-fold decrease in its apparent affinity for ATP. c) The rates of unidirectional passive Ca2+ release from actively Ca2+ loaded SL vesicles were not altered by low concentrations of the inhibitor (less than 100 micrograms/ml) which were effective in producing marked inhibition of Ca2+ uptake; at higher concentrations (greater than 100 micrograms/ml), the inhibitor caused increase in the rates of passive Ca2+ release. These findings demonstrate that the activity of the ATP-driven Ca2+ pump of cardiac SL can be regulated in vitro by endogenous cytosolic proteins.

Health needs of older adults displaced to Sudan by war and famine: questioning current targeting practices in health relief

The high rates of death, disability and illness and the scarcity of resources associated with relief operations for victims of oppression, war and famine have led to some support systems of triage for health and nutritional care in relief. Two vulnerable groups have often been given priority for targeting in health relief--young children and their mothers. This paper reports the findings of a study of the health needs of another vulnerable group, older adults, among those who had been recently displaced to Sudan in 1984-1985 by the war and famine in Tigray region of Ethiopia. The study attempted to determine the extent to which morbidity events and migration affected the life-style of older adults and the socio-economic support mechanisms which were available to them. The findings indicate that older adults (those over 45 years of age) were a very small proportion of the population and that over half of those aged 60 years and over (defined as 'elderly' in this paper) had been left behind in Tigray. This may well indicate that disability, illness or both, forced many older adults, particularly those most in need, to remain in Tigray. Among older adults living in Sudan, high levels of minor disability, social isolation and total economic dependency indicated vulnerability, but older adults had not been specifically considered in health policies and plans. Their primary needs were basic--for cloth, food, shelter, transport, seeds, oxen and farming tools. We conclude that priority in relief should be to support individuals, families and entire communities by adequately providing for basic needs. Furthermore, international relief agencies should give equal consideration to those who remain in their homes and those who migrate for assistance. This approach would take into consideration quality of life, not just the number of lives saved among those who reach the camps and shelters, and would assume responsibility for 'Health for All', not just for selected 'vulnerable groups'.

Microvascular revascularization of the tongue

Revascularization of the tongue, employing microvascular techniques, is useful in cases where the blood supply to this organ must be interrupted to allow for adequate exposure or for adequate margins. A case is presented in which the left lingual artery was divided for purposes of exposure and the right artery was interrupted to encompass the entire tumor. This patient also underwent a total laryngopharyngectomy with jejunal free flap interposition. The blood supply of the tongue was successfully reestablished by anastomosing the right lingual artery to the right facial artery. The patient made an uneventful recovery.

Insufficiency os pubis fractures in rheumatoid arthritis

There is a paucity of information regarding insufficiency fractures of the os pubis in rheumatoid arthritis. While only 7 such fractures have been recorded thus far in the English literature, we have encountered 5 os pubis fractures in the past 4-year period. We report these cases to heighten awareness of their existence, describe their sometimes misleading clinical presentations, and to discuss possible etiologic factors.

Surgical management of infected median sternotomy: closed irrigation vs. muscle flaps

Mediastinitis remains a serious complication of median sternotomy which requires prompt and aggressive surgical management. Debridement and closed irrigation has been the conventional mode of treatment. Failure to respond results in open drainage and delayed healing with its associated increased morbidity and mortality. Secondary closure with rectus muscle flaps has been a marked advance in the treatment of these patients. In an attempt to define guidelines for the treatment of mediastinitis complicating median sternotomy, a retrospective review of 2,400 cardiac surgical cases at St. Vincent's Hospital from 1977 through 1982 was performed. There were 25 cases (1%) of mediastinitis. Debridement and closed irrigation was successful in 16 patients (64%) with an average postoperative hospital stay of 19 days. Failure resulted in open drainage in 2 patients (8%) with an average hospital stay of 66 days and debridement and secondary closure by rectus muscle flaps in 7 patients (28%) with an average hospital stay of 28 days. There were no deaths in the entire series. Failure to respond to closed irrigation was not due to delay in diagnosis. The length of time between operation and the first sign of sternal dehiscence did not vary significantly. Sternal dissolution, the presence of anaerobic organisms, large volumes of purulent and necrotic material, however, were responsible for continued mediastinitis and further sternal dehiscence. Open irrigation and delayed closure with muscle flaps should be reserved for these patients and appears to decrease significantly morbidity and length of hospital stay. Surgical debridement and closed irrigation, however, remains the primary method of treatment of the less virulent forms of mediastinitis following median sternotomy.

Reversal of renovascular hypertension: a comparison of changes in blood pressure, plasma renin, and sodium balance in two models in rats

Blood pressure changes produced by removal of the renal artery clip in two forms of experimental renovascular hypertension in the rat (two-kidney one-clip and one-kidney one-clip hypertension) have been studied in relation to sodium balance and the renin angiotensin system. Continuous records of arterial blood pressure in conscious, freely moving animals with hypertension of less than 6 weeks' duration showed similar baseline values. After unclipping, blood pressure fell to normal levels within 12 hours of operation, and the pattern of the fall was identical in both models. Plasma renin concentration was elevated in two-kidney hypertension and fell to normal by 24 hours after operation, remaining unchanged 6 days later, whereas in one-kidney hypertension it was normal before and after unclipping. Sodium balance became positive in two-kidney hypertension within 24 hours of unclipping and remained so at 7 days, and was significantly different from that in unclipped loose-clip controls (+2.54 +/- 0.55 mmol vs. +0.46 +/- 0.55 mmol at 7 days, P less than 0.05). In one-kidney hypertension, sodium balance was negative during the first 24 hours after operation, and remained slightly negative at 7 days compared with loose-clip controls (-0.34 +/- 0.23 mmol). The similarity in the pattern of blood pressure fall in these two models of renovascular hypertension, despite qualitative differences in the response of sodium balance and the renin-angiotensin system, suggests that a common mechanism is activated by unclipping. This mechanism cannot be explained solely in terms of changes in sodium balance or activity of the renin-angiotensin system.

Cell membrane handling of sodium, sodium balance, and blood pressure

A variety of abnormalities in cell membrane cation handling have been reported in hypertension. It is not known whether abnormal transport serves as a marker of an underlying disturbance in cell membrane function or whether one or more of the abnormal transport processes participate directly in the sequence of events that cause hypertension. One critical area is the response of membrane sodium transport to salt depletion and loading. To elucidate a possible relationship between changes in sodium balance, membrane cation transport, and blood pressure, we studied the effect of salt depletion and loading in two cells from two separate species--the rat thymocyte and the human white blood cell. In each, severe salt depletion significantly reduced ouabain-sensitive sodium efflux, while salt loading produced a non-significant increase. No significant changes in the sodium efflux rate constant were observed in thymocytes from Okamoto-Kyoto spontaneously hypertensive rats or from rats with Goldblatt one-kidney, one-clip or deoxycorticosterone-salt hypertension when they were compared with appropriate controls. However, both Okamoto-Kyoto hypertensive rats and Kyoto controls showed a highly significant fall in the sodium efflux rate constant with age. These findings indicate that the reduction in sodium pumping observed in hypertensive human patients is not attributable directly or indirectly to salt excess, since in the two species studied reduced sodium pumping was a physiological response to salt depletion. Further, altered membrane transport of sodium may reflect factors that affect cell composition (such as age) rather than participate directly in the pathogenesis of hypertension.

Sjögren's syndrome with pseudolymphoma treated with chrysotherapy

A 72-year-old woman presented with a 10 X 10 cm pseudolymphoma of the lung and Sjögren's syndrome. She was treated with weekly chrysotherapy for 4 years and had gradual diminution of the lung mass over this period along with normalization of her parotid gland scintiscan. In addition her rheumatoid factor titer (RF) of 1:160,000 fell to zero, IgM level became normal and lymphocyte mitogen response improved. On 5-year followup the patient remains stable with a negative RF, normal IgM and stable chest radiographs.

Chemical renal medullectomy. Effect on urinary prostaglandin E2 and plasma renin in response to variations in sodium intake and in relation to blood pressure

We have studied the possible vasodepressor role of the renal medulla by chemical medullectomy. Bromoethylamine hydrobromide (200 mg/kg) was injected to induce selective renal medullary necrosis in rats. The acute effects on sodium balance and long-term effects on blood pressure, plasma renin concentration (PRC) and urinary prostaglandin E2 (PGE2) were studied and compared with saline injected controls. There was an immediate and sustained increase in urine volume of low osmolality. Direct blood pressure in conscious free-moving animals was higher at 2 and 10 weeks after injection in medullary-damaged rats, although this was only significant at 10 weeks (136 +/- 3.3 vs 118 +/- 4.5 mm Hg, p less than 0.01). An initial negative sodium balance returned to normal by 7 days and rats with established medullary damage tolerated a wide range of sodium intakes. Although there was no evidence of sodium retention on the normal diet, with very high sodium loads some sodium retention was apparent since PRC was suppressed and body weight increased. Plasma creatinine and creatinine clearance were normal. PRC in rats with medullary damage was unchanged on normal diet and rose to similar levels as in control rats on low sodium intake. Urinary PGE2 was markedly reduced (148 +/- 54 vs 536 +/- 71 ng/day, p less than 0.01) in medullary damaged rats, consistent with the renal medulla being the major source of urinary PGE2. High salt intake increased urinary PGE2 in normal and proportionally in medullary damaged rats, whereas on a low sodium intake, urinary PGE2 was not different from that on the normal diet in either group.(ABSTRACT TRUNCATED AT 250 WORDS)

Traumatic injuries of the portal vein. The role of acute ligation

Injuries to the portal vein are rare but have a high risk with a mortality of 50--70% secondary to exsanguinating hemorrhage. When managing injuries to the portal vein, lateral venorrhaphy, end to end anastomosis, or an interposition graft should be attempted whenever possible. However, in a hemodynamically unstable patient or when confronted with a nonreconstructable injury, acute portal vein ligation may be the procedure of choice as it is safely tolerated in some 80% of patients. Of eleven reported patients in whom the portal vein was ligated acutely for traumatic injury, six survived. Four of the nonsurvivors died of massive associated injuries. Of the six surviving patients, five tolerated acute ligation of the portal vein without complication. Should portal vein ligation be performed a "second look" operation is essential in 24 hours to examine the bowel for viability. A portosystemic shunt with its inherent complications should not be done as a primary procedure when attempts at reconstruction of the portal vein have failed. Shunting should be reserved for those few patients who develop stigmata of portal hypertension or impending infarction of the bowel.