Efficacy of birth ball exercises on labour pain management.

OBJECTIVES: To evaluate the efficacy of a birth ball exercise programme conducted by physiotherapists on pain relief, psychological care, and facilitation of the labour process at a labour ward in a regional hospital. DESIGN: Case series with before-after comparisons. SETTING: Kwong Wah Hospital, Hong Kong. PARTICIPANTS: Chinese women admitted to the labour ward for spontaneous vaginal delivery between April and August 2012 were recruited. Physiotherapists taught birth ball exercises in groups or individually for 30 minutes. Labour pain intensity, back pain intensity, frequency of labour pain, stress and anxiety levels, and subjective pressure level over the lower abdomen were captured before and after birth ball exercises. Most of the parameters were measured using self-reported visual analogue scales. After the exercise session, physiotherapists measured the women's satisfaction level. Midwives recorded pethidine usage. RESULTS: A total of 203 pregnant women participated in this programme; 181 were in the latent phase group, whereas 22 were categorised into the no-labour-pain group. In both groups, there were statistically and clinically significant differences in back pain level, stress and anxiety levels, as well as pressure level over the lower abdomen before and after the exercise (P<0.05). In the latent phase group, significant decreases in labour pain and frequency of labour pain were demonstrated. Mean satisfaction scores were high, with visual analogue scale scores higher than 8.2 in both groups. Pethidine usage showed a further decreasing trend (6.4%) compared with the past 2 years. CONCLUSION: Birth ball exercise could be an alternative means of relieving back pain and labour pain in the labour ward, and could decrease pethidine consumption in labouring women.

The development of a strength-focused mutual support group for caretakers of children with cerebral palsy.

OBJECTIVE: To examine the efficacy of a strength-focused mutual support group for reducing stress and enhancing psychological well-being of the caretakers of children with cerebral palsy. METHODS: This pre- and post-intervention outcome study, conducted by Department of Orthopaedics and Traumatology, Duchess of Kent Children's Hospital, recruited 12 primary caretakers of children with cerebral palsy in Hong Kong. A strength-focused support group manual was developed to help such caretakers to identify and cultivate the character strengths of their children and enhance their own positive emotions. Participants were asked to complete a full set of questionnaires at 3 time-points: before and immediately after the intervention (consisting of 4 weekly sessions), and after the 1-month follow-up booster session. Two additional questionnaires were administered before each session to check mood. Parenting stress, anxiety, depression, social support, hope, and other psychological well-being measures were also assessed. RESULTS: Half of the caretakers (n = 6) who had attended the full intervention programme were included in the data analysis. Participants exhibited a significantly lower level of parental stress and higher hope level both after the 4 intervention sessions and at the booster session. Their perceived social support was significantly increased when the group was ongoing but not after it ended. CONCLUSION: This group intervention programme could effectively help caretakers reduce their parenting stress and enhance their hopefulness. Launching a similar programme with more sessions and regular follow-up sessions might help maintain positive effects and establish a social support network.

Dynamic treatment for proximal phalangeal fracture of the hand.

PURPOSE: To assess a protected mobilisation programme (dynamic treatment) for proximal phalangeal fracture of the hand, irrespective of the geometry. METHODS: Clinical and radiological results of 32 consecutive patients with proximal phalangeal fracture of the hand treated from January 2001 to February 2007 were evaluated. Our supervised rehabilitation programme was strictly followed to gain full range of movement of the proximal interphalangeal joint and to prevent the development of an extension lag contracture. Patients were followed up for a mean period of 15 (range, 13-16) months. Results were evaluated using the Belsky classification. RESULTS: The results were excellent in 72% of the patients, good in 22%, and poor in 6%. Some patients defaulted follow-up, which made long-term assessment difficult. The poor results may have been related to patient non-compliance or default from rehabilitation. Many good results upgraded to excellent following further rehabilitation. CONCLUSION: Skeletal stability, not rigidity, is necessary for functional movements of the hand. Proximal phalangeal fractures can be effectively treated by closed methods, using the stabilising effect of soft tissues (zancolli complex-metacarpophalangeal retention apparatus) and external devices (metacarpophalangeal block splint), thus enabling bone healing and movement recovery at the same time.

Study of wrist posture, loading and repetitive motion as risk factors for developing carpal tunnel syndrome.

Occupational risk factors of carpal tunnel syndrome (CTS) are popular current research targets, with main emphasis put on wrist posture and dynamics. In this study, we do not intend to pinpoint individual occupations, but aim to identify high risk wrist postures and actions which may occur across various occupations. It is hoped that prevention can thus be instituted in a general population by directing at the particular causative wrist actions rather than exclusively targeting isolated occupations. We performed a case-control study with 166 cases and 111 controls recruited from different hospitals in Hong Kong in 2004. All cases and controls completed the survey on their general health condition, smoking status, wrist posture and motion as well as psychosocial status at the time of diagnosis of CTS. Frequent flexion OR = 4.436 (95% CI: 1.833-10.734), frequent extension OR = 2.691 (95% CI: 1.106-6.547) of the wrist were found to be associated with CTS. Frequent sustained forceful motion of the wrist OR = 2.588 (95% CI: 1.144-5.851) was also found to be associated with CTS. Neutral wrist position and repetitive wrist motion were not associated with CTS. Adjustment was made for age, sex, BMI, smoking and psychosocial stress. Our study confirms that frequent flexion, extension and sustained force of the wrist increase the risk of developing CTS.

A case of disseminated Mycobacterium marinum infection following systemic steroid therapy.

We describe the dissemination of Mycobacterium marinum infection from the right middle finger to the whole extremity and two legs, with the involvement of tendons and joints, in a patient who was treated with a steroid when Mycobacterium marinum infection was not suspected. The patient was successfully treated with a combined surgical and medical approach.

Incidence of oral tissue trauma after the administration of general anesthesia.

BACKGROUND: Administration of general anesthesia necessitates certain amounts of manipulation or instrumentation within the mouth that may cause some oral tissue injuries. The purpose of this study was to determine the incidence of oral tissue trauma after receiving general anesthesia. Some possible risk factors were explored. METHODS: Four hundred and four adult patients receiving surgical procedures under general anesthesia facilitated by endotracheal intubation were included in this prospective survey. In each patient detailed oral and dental conditions were evaluated and recorded by an oral surgeon before and after operation. The extent of oral tissue trauma were computed and the type and character of the injury were recorded. RESULTS: Twenty-eight patients (6.9%) were found to sustain various degrees of oral trauma that included soft tissue laceration, tooth fracture, prosthesis damage, tooth avulsion, ecchymosis and numbness of tongue. Preexistence of missing tooth, crown, and residual root were some possible risk factors that might predispose to complication. CONCLUSIONS: Oral tissue trauma as it seems to be a common anesthetic complication that should be considered as a recognized hazard of general anesthesia. Understanding and recognizing oral anatomical condition and pathological change before anesthesia may help the anesthesiologists in preventing oral and dental complications and thus to avoid legal suits.

Continuous epidural analgesia for painless labor does not increase the incidence of cesarean delivery.

BACKGROUND: Continuous epidural analgesia is a popular technique provided for labor pain relief. However, the possible association between epidural analgesia and increased rate of cesarean delivery is always a concern. The purpose of this study was to explore if epidural analgesia would affect the rate of cesarean delivery in healthy term parturient women. METHODS: A retrospective review of obstetric records of 822 parturients was done to compute the proportions and odds ratio of cesarean delivery between parturients receiving epidural analgesia for labor pain relief and those not receiving. RESULTS: Results indicated that the overall proportion of cesarean delivery was 11.1% in the epidural group as against 16.2% in the control group and the odds ratio was 0.65 (95% confidence interval: 0.37 to 1.08). The difference between groups was not statistically significant. However, for nulliparous women alone, the proportions of cesarean delivery were 11.6% and 25.1% in exposure group and control group respectively. The odds ratio was 0.39 (95% CI: 0.20 to 0.71). This difference was statistically significant. CONCLUSIONS: The findings may support the conclusion that continuous epidural analgesia for pain relief during labor would not increase the rate of cesarean delivery. In contrast, it may reduce this risk in nulliparas.

Subunit exchange of small heat shock proteins. Analysis of oligomer formation of alphaA-crystallin and Hsp27 by fluorescence resonance energy transfer and site-directed truncations.

alphaA-Crystallin, a member of the small heat shock protein (sHsp) family, is a large multimeric protein composed of 30-40 identical subunits. Its quaternary structure is highly dynamic, with subunits capable of freely and rapidly exchanging between oligomers. We report here the development of a fluorescence resonance energy transfer method for measuring structural compatibility between alphaA-crystallin and other proteins. We found that Hsp27 and alphaB-crystallin readily exchanged with fluorescence-labeled alphaA-crystallin, but not with other proteins structurally unrelated to sHsps. Truncation of 19 residues from the N terminus or 10 residues from the C terminus of alphaA-crystallin did not significantly change its subunit organization or exchange rate constant. In contrast, removal of the first 56 or more residues converts alphaA-crystallin into a predominantly small multimeric form consisting of three or four subunits, with a concomitant loss of exchange activity. These findings suggest residues 20-56 are essential for the formation of large oligomers and the exchange of subunits. Similar results were obtained with truncated Hsp27 lacking the first 87 residues. We further showed that the exchange rate is independent of alphaA-crystallin concentration, suggesting subunit dissociation may be the rate-limiting step in the exchange reaction. Our findings reveal a quarternary structure of alphaA-crystallin, consisting of small multimers of alphaA-crystallin subunits in a dynamic equilibrium with the oligomeric complex.

Cultured human trabecular meshwork cells express functional growth factor receptors.

PURPOSE: To compare the mRNA expression of growth factor receptors in cultured human trabecular meshwork (HTM) cells with ex vivo HTM tissues and to determine whether HTM cells generate a physiologic response after exposure to exogenous growth factors. METHODS: The reverse transcription-polymerase chain reaction (RT-PCR) method was used to detect the expression of various growth factor receptor mRNAs using early passaged, cultured HTM cells from donors of several ages. RT-PCR on ex vivo HTM tissues from healthy donors and donors with glaucoma were also used to compare and contrast mRNA expression with cell culture results. After the exogenous administration of growth factors, cell proliferation and extracellular acidification rate studies were used to measure the functional responses of HTM cells to growth factors. RESULTS: Amplification products of the expected size for 15 growth factor receptors were detected in cultured HTM cells and in ex vivo HTM tissues. The administration of exogenous growth factors showed that (a) hepatocyte growth factor (HGF), epidermal growth factor (EGF), insulinlike growth factor (IGF)-1, tumor necrosis factor (TNF) alpha, platelet-derived growth factor (PDGF)-AA, PDGF-BB, PDGF-AB, and basic fibroblast growth factor (FGF-2) stimulated cell proliferation, whereas FGF-1 (acidic), transforming growth factor (TGF) alpha, interleukin (IL)-1alpha, nerve growth factor (NGF), and FGF-7 (keratinocyte growth factor [KGF]) had no significant influence on cell proliferation; (b) TGF-beta isoforms significantly inhibited EGF-stimulated trabecular meshwork cell proliferation; and (c) FGF-1 (acidic), TGF-alpha, EGF, IL-1alpha, IL-1beta, HGF, TNF-alpha, PDGF-AA, and IGF-1 significantly stimulated extracellular acidification, whereas FGF-2 (basic), FGF-7 (KGF), TGF-beta1-beta3 and NGF had no significant influence on extracellular acidification. CONCLUSIONS: These studies show that mRNA for numerous growth factor receptors can be detected in cultured HTM cells and in ex vivo HTM tissues. They also show that many of the receptors are functional, because exogenous growth factor administration elicits a physiologic response. In vivo, these receptors may be activated by growth factors present within the aqueous humor (aquecrine/paracrine) or by growth factors synthesized and released locally by trabecular meshwork cells themselves (autocrine). Specific growth factors acting through high-affinity receptors may be involved in maintaining the normal microenvironment of the HTM and also may be involved in the pathogenesis of primary open-angle glaucoma.

Subunit exchange of alphaA-crystallin.

alpha-Crystallin, the major protein in the mammalian lens, is a molecular chaperone that can bind denaturing proteins and prevent their aggregation. Like other structurally related small heat shock proteins, each alpha-crystallin molecule is composed of an average of 40 subunits that can undergo extensive reorganization. In this study we used fluorescence resonance energy transfer to monitor the rapid exchange of recombinant alpha-crystallin subunits. We labeled alphaA-crystallin with stilbene iodoacetamide (4-acetamido-4'-((iodoacetyl)amino)stilbene-2,2'-disulfonic acid), which serves as an energy donor and with lucifer yellow iodoacetamide, which serves as an energy acceptor. Upon mixing the two populations of labeled alphaA-crystallin, we observed a reversible, time-dependent decrease in stilbene iodoacetamide emission intensity and a concomitant increase in lucifer yellow iodoacetamide fluorescence. This result is indicative of an exchange reaction that brings the fluorescent alphaA-crystallin subunits close to each other. We further showed that the exchange reaction is strongly dependent on temperature, with a rate constant of 0.075 min-1 at 37 degrees C and an activation energy of 60 kcal/mol. The subunit exchange is independent of pH and calcium concentration but decreases at low and high ionic strength, suggesting the involvement of both ionic and hydrophobic interactions. It is also markedly reduced by the binding of large denatured proteins. The degree of inhibition is directly proportional to the molecular mass and the amount of bound polypeptide, suggesting an interaction of several alphaA-crystallin subunits with multiple binding sites of the denaturing protein. Our findings reveal a dynamic organization of alphaA-crystallin subunits, which may be a key factor in preventing protein aggregation during denaturation.

Gene structure and chromosome localization of the G gamma c subunit of human cone G-protein (GNGT2).

Phototransduction in the vertebrate rod and cone photoreceptors is regulated by structurally homologous and yet distinct groups of signaling proteins. We have previously identified in bovine retinas a cone-specific G-protein gamma subunit (G gamma c, previously named G gamma b), which may play a key role in coupling the cone visual pigment to phosphodiesterase (O. C. Ong et al., 1995, J. Biol. Chem. 270:8495-8500). We report here the characterization of human G gamma c and its gene structure. Human G gamma c subunit shares a high degree of sequence identity with the corresponding bovine G gamma c isoform (85%) and human rod G gamma 1 (63%). The protein is specifically localized in cones, as indicated by immunohistochemical staining using anti-G gamma c antibodies. Nucleotide sequence analysis of the G gamma c gene (GNGT2) reveals a structure consisting of three exons and two introns, with the intron splice sites similar to that of the rod G gamma 1 gene (GNGT1). By using fluorescence in situ hybridization, we have further localized the human GNGT2 gene to chromosome 17q21. The elucidation of the G gamma c gene structure would facilitate the identification of genetic defects associated with cone degeneration.

Real-time monitoring of reduced beta-adrenergic response in fibroblasts from patients with pseudohypoparathyroidism.

The activation of cell-surface receptors usually produces a transient increase of the extracellular acidification rate in culture cells that can be detected with a biosensor-based instrument. We describe here the application of this method in monitoring hormonal response of Galphas-deficient fibroblasts from patients with pseudohypoparathyroidism type Ia (PHP-Ia). We found that following exposure to isoproterenol, the mean acidification response of fibroblasts from four PHP-Ia patients was only 18% of the response in normal cells. In contrast, these two groups of fibroblasts had similar levels of response to insulin and dibutyryl cAMP. This is the first reported experimental evidence correlating reduced Galphas activity with diminished cellular responsiveness to hormones in cultured living cells. Our results also indicate that this approach will be useful for rapid screening of other metabolic diseases caused by abnormal cellular signaling.

Molecular cloning and characterization of the G protein gamma subunit of cone photoreceptors.

The phototransduction process in cones has been proposed to involve a G protein that couples the signal from light-activated visual pigment to the effector cyclic GMP phosphodiesterase. Previously, we have identified and purified a G beta gamma complex composed of a G beta 3 isoform and an immunochemically distinct G gamma subunit (G gamma 8) from bovine retinal cones (Fung, B. K.-K., Lieberman, B. S., and Lee, R. H. (1992) J. Biol. Chem. 267, 24782-24788; Lee, R. H., Lieberman, B.S., Yamane, H. K., Bok, D., and Fung, B. K.-K. (1992a) J. Biol. Chem. 267, 24776-24781). Based on the partial amino acid sequence of this cone G gamma 8, we screened a bovine retinal cDNA library and isolated a cDNA clone encoding G gamma 8. The cDNA insert of this clone includes an open reading frame of 207 bases encoding a 69-amino acid protein. The predicted protein sequence of G gamma 8 shares a high degree of sequence identity (68%) with the G gamma (G gamma 1) subunit of rod transducin. Similar to rod G gamma 1, it terminates in a CIIS motif that is the site for post-translational modification by farnesylation. Messenger RNA for G gamma 8 is present at a high level in the retina and at a very low level in the lung, but is undetectable in other tissues. Immunostaining of bovine retinal sections with an antipeptide antibody against the N-terminal region of G gamma 8 further shows a differential localization of G gamma 8 to cones with a pattern indistinguishable from that of G beta 3. This finding suggests that G beta 3 gamma 8 is a component of cone transducin involved in cone phototransduction and color vision.

Continuous epidural morphine and lidocaine for postoperative pain control in obstetric and gynecologic operation.

BACKGROUND: Postoperative wound pain is a remarkable distress and may precipitate major complication. We attempted to develop a reliable and effective technique for postoperative analgesia that is safe and simple enough to be provided in an ordinary ward of a rural hospital. MATERIALS AND METHODS: A retrospective study of continuous epidural infusion of morphine 7.5 mg in 60 mL diluted lidocaine for postoperative pain control in 156 patients in the past year was undertaken. Among the patients, one hundred and twelve patients had undergone. Cesarean Section, and 44 patients had uterine or adnexal operations. All patients received epidural anesthesia. RESULTS: Effective analgesia was achieved in all cases throughout the postoperative period. Pain relief was long lasting and there were only 5 patients (3.2%) who required some additional narcotics. The mean interval between completion of the operation and passage of flatus was 33.2 h. Only 48 patients (30.8%) complained of skin itching, 39 patients (25.0%) reported nausea and vomiting and 62 cases (39.7%) experienced constipation. Urinary retention after Foley catheter removal was noted in 9 cases (5.8%). No major complication pertaining to the technique was encountered. CONCLUSIONS: We concluded that continuous epidural infusion of morphine and diluted lidocaine is an effective, simple and safe technique for postoperative pain control in obstetric and gynecologic operation and it can be administered routinely even in a rural hospital.

Evaluation of supraclavicular brachial plexus block in upper extremity surgery.

The supraclavicular brachial plexus blockade performed by palpation of the first rib as the primary landmark has been done in 60 patients in the past two years. Forty of the patients had undergone orthopedic surgery and 20 patients had soft tissue operations. Effective analgesia was achieved in 57 cases. Duration of the operations ranged from 15 to 490 min with a mean time of 130.6 min. The pain relief was long lasting that only 23 patients required additional analgesia in the post-operative period. The mean interval between completion of the operation and analgesia requirement was 11.3 h. Only 9 out of these 23 patients needed more than one doses. No complication pertaining to the technique was encountered.

Low back pain of women during pregnancy in the mountainous district of central Taiwan.

Two hundred women with apparently normal pregnancies were interviewed in the obstetric wards within 24 to 48 hours after delivery. Of the parturients, 54.5% had been bothered by low back pain in some degree during pregnancy; nine of them were unable to continue their daily work because of severe pain. The pain had reportedly begun mostly during the sixth to eighth month of pregnancy, and was related to strenuous work, previous symptoms of backache during menstruation or a history of low back pain attacks before pregnancy. About half reported pain radiating to the buttocks and lower extremities, where the severity may be affected by posture. Almost 95% of the patients ignored the symptom and considered it as a part of pregnancy. The pain ceased spontaneously in 62.4% of the cases within the first 48 hours postpartum.