Brazilian version of the Care Transitions Measure: translation and validation.

AIM: To translate, adapt and evaluate psychometric properties of the complete (15 items) and reduced (three items) versions of the Care Transitions Measure into Brazilian Portuguese. INTRODUCTION: The Care Transitions Measure assesses the quality of care transitions, from the perspective of patients. As accomplishing effective transitions is a challenge to healthcare systems, the instrument provides an opportunity to assess care transitions and improve quality initiatives. METHODS: A three-phased design was used for cross-cultural adaptation, pre-testing and evaluation of psychometric properties of the measurement in a Brazilian hospital. After forward translation, back translation and expert committee review, patients evaluated the instrument in a pre-test. Psychometric testing included face and content validity, reliability, stability and factorial analysis. RESULTS: Cross-cultural adaptation was completed successfully with a high clarity rate. Internal consistency was good in the 15-item version and was moderate in the three-item version. Test-retest reliability showed good stability of the two versions over time. The three-item version had satisfactory criterion validity. Four factors were extracted for the 15-item measure. LIMITATIONS: Samples were restricted to a group of patients from one hospital in southern Brazil. Future studies should test the measurement's construct and predictive validity. CONCLUSIONS: The translated version of the Care Transitions Measure has good face and content validity, reliability and stability. It has shown to be a valid measurement for evaluating the quality of care transitions in Brazil. IMPLICATIONS FOR NURSING AND HEALTH POLICY: Results are beneficial for nurses, managers and policy makers for evaluating care transitions and support the need for changes in policies and practices.

The effects of asymmetric tonic neck reflex during reaching movement following stroke: preliminary results.

Previous studies and clinical observations reveal that stroke survivors show the resurgence of the asymmetric tonic neck reflex (ATNR) both in static and dynamic conditions during maximal efforts. This observation may imply more reliance on the brainstem pathways following stroke. However, the effect of ATNR during a dynamic condition that represents more natural movement, such as reaching, has not been studied before. During reaching movements, the application of a robot controlled haptic environment is important to quantify the effect of ATNR following stroke. Therefore, this paper reports the use of a novel setup using the ACT(3D) robotic device to investigate and quantify this reflexive behavior. Our preliminary results demonstrate that the effect of ATNR is significant in the stroke population when abducting the shoulder at 25% of maximum ability. These results show that the ATNR affects reaching distance especially when shoulder loading in abduction is required. In conclusion, these preliminary results provide evidence that the effect of ATNR in stroke subjects during reaching task can be quantified by using a novel 3-D robotic setup.

Bilateral pulmonary thromboembolism and Budd-Chiari syndrome in a patient with Crohn s disease on oral contraceptives.

Budd-Chiari syndrome can be defined as an interruption or diminution of the normal blood flow out of the liver. Patients with Budd-Chiari syndrome present with varying degrees of symptomatology that can be divided into the following categories: fulminant, acute, subacute and chronic. The subacute form is the most common presentation. A majority of patients with Budd-Chiari syndrome have an underlying hypercoagulability state. We present the case of a young woman with Crohn s disease on oral contraceptives who developed bilateral pulmonary thromboembolism and Budd-Chiari syndrome.

[Clinical presentation, diagnosis, and long-term outcome of 29 patients with Wilson's disease]. / Presentación clínica, diagnóstico y evolución a largo plazo en 29 pacientes con enfermedad de Wilson.

OBJECTIVE: To analyze the clinical characteristics, treatment, and follow-up of a cohort of 29 patients with Wilson's disease (WD) within the region of Murcia. PATIENTS AND METHOD: We reviewed the medical records of 29 cases of WD (mean age, 20.3 +/- 13.4 years) diagnosed during the last 16 years. RESULTS: The most frequent reason for consultation was upon discovering a high transaminase level in almost half the patients, followed by tremors or dystonia in 17% of patients, respectively. A Kayser-Fleischer ring was observed in 17/29 (58.6%) of patients (100% of patients with pure neurological involvement and 35% of patients with pure clinical hepatic disease; p < 0.001). Blood copper levels not associated with ceruloplasmin as well as cupruria were notably superior in patients with neurological symptoms and in those with liver cirrhosis at the time of diagnosis. Patient clinical symptoms remained stable with D-penicillamine or trientine, or improved during the observation period, for 18 out of 29 patients (62%), while 11 out of 29 patients (38%) got worse. CONCLUSIONS: In our region patients with WD are diagnosed at a younger age, and in most cases for hepatic disease. Patients with neurological disease or liver cirrhosis had a high level of free copper not associated to ceruloplasmin and cupruria. The disease had a favorable evolution in all patients but those diagnosed with hepatic disease or advanced neurological disease.

Factores de riesgo de enfermedad cardiovascular en adultos jóvenes / Risk factors of cardiovascular disease among young adults

BACKGROUND: A precise knowledge of the prevalence and importance of cardiovascular risk factors will facilitate the development of preventive strategies. AIM: To study cardiovascular risk factors among healthy young adults. SUBJECTS AND METHODS: Eight hundred and fifty subjects aged 22 to 28 years, living in two cities in Valparaiso province, were studied. Weight, height and blood pressure were recorded. A fasting blood sample was obtained from 806 individuals (54% female), to measure plasma lipids, glucose and insulin levels, to estimate their homeostasis model assessment scores (HOMA) and to evaluate the occurrence of metabolic syndrome. RESULTS: Five percent of the studied population had high blood pressure, 14% had obesity, 57% smoked, 25% had high total cholesterol levels, 10.5% had high levels of low density lipoprotein cholesterol, 46% had low levels of high density lipoprotein cholesterol, 16% had high triglyceride levels, 36% had insulin resistance, 7% had a metabolic syndrome, 14% were heavy drinkers and 38% were sedentary. Women had a higher prevalence of obesity and metabolic syndrome. In only 24% of the studied subjects, no risk factor was identified. CONCLUSIONS: A high prevalence of cardiovascular risk factors was found in this population of young adults.

Influence of polymeric enteral nutrition supplemented with different doses of glutamine on gut permeability in critically ill patients.

OBJECTIVES: To evaluate the effect of glutamine-supplemented polymeric enteral formulas on the recovery of gut-permeability abnormalities in critically ill patients. METHODS: Twenty-three patients were randomized to receive a conventional casein-based enteral formula (ADN), ADN plus glutamine in a dose of 0.15 g x kg(-1) x d(-1) or ADN plus 0.30 g x kg(-1) x d(-1) of glutamine for 8 d. The lactulose mannitol permeability test (L/M) was performed at baseline and at the end of the study. Nineteen healthy volunteers served as controls for the L/M test. RESULTS: An increase in permeability compared with control subjects was observed in patients at baseline (mean +/- standard error of the mean; L/M ratio: 0.11 +/- 0.03 and 0.025 +/- 0.004, respectively; P < 0.02). The L/M ratio improved after the period of enteral nutrition as a whole (initial L/M: 0.11 +/- 0.03, final L/M: 0.061 +/- 0.01; P < 0.03), but no difference was found between groups. CONCLUSIONS: Even though polymeric enteral nutrition was associated with a significant improvement in the L/M ratio, glutamine supplementation did not show a specific influence in improving recovery of gut permeability in critically ill patients.

A neuroprosthesis for high tetraplegia.

BACKGROUND: This case report describes a neuroprosthesis that restored shoulder and elbow function in a 23-year-old man with chronic C3 complete tetraplegia. Before implementation of the neuroprosthesis, electrodiagnostic testing revealed denervation from C5 to T1, with the greatest degree of denervation in the C8 and T1 myotomes. Thirteen percutaneous intramuscular electrodes were implanted into muscles acting on the shoulder and elbow of one upper limb. Before functional testing, the subject underwent a conditioning regimen to maximize the strength and endurance of the implanted muscles. RESULTS: After completion of the 8-week exercise regimen, stimulated active range of motion against gravity included 60 degrees of shoulder abduction, 45 degrees of shoulder flexion, 10 degrees of shoulder external rotation with the shoulder passively abducted to 90 degrees, and 110 degrees of elbow flexion. Stimulated elbow extension lacked 20 degrees of full extension with gravity eliminated. After system setup, the subject was able to pick up mashed potatoes on a plate with a utensil and bring them to his mouth using the neuroprosthesis and a balanced forearm orthosis. A switch mounted on the headrest of the subject's wheelchair and a position sensor mounted on the contralateral shoulder allowed the subject to control movement of his upper limb.

Three-dimensional shoulder kinematics in individuals with C5-C6 spinal cord injury.

The shoulder kinematics of five able-bodied subjects and those of five arms in three subjects with spinal cord injuries at C5 or C6 levels were measured as the subjects elevated their arms in three different planes: coronal, scapular and sagittal. The range of humeral elevation was significantly reduced in all spinal cord injury (SCI) subjects relative to able-bodied subjects. Over this restricted range of humeral motion, the scapula of SCI subjects tended to be medially rotated, relative to able-bodied subjects, and the protraction and spinal tilt angles of the scapula of the SCI subjects indicated scapular winging. These results are consistent with paralysis or at least with significant weakness of the serratus anterior muscle. If further study confirms this hypothesis, functional neuromuscular stimulation of the serratus anterior muscle via a nerve cuff electrode may be an effective intervention for improving shoulder function in C5-C6 SCI.

Model-based development of neuroprostheses for restoring proximal arm function.

Neuroprostheses with the use of functional neuromuscular stimulation (FNS) have the potential to restore elbow and shoulder function lost to paralysis because of spinal cord injury (SCI). The human shoulder is highly flexible and thus provides a large range of motion to the arm and hand, although at the expense of precarious stability of the articulations. The complexity of the shoulder has prevented widespread use of FNS at this joint. However, musculoskeletal modeling of the elbow and shoulder has the potential to significantly speed the development of neuroprostheses by allowing many mechanical issues to be resolved in simulation prior to implementation in human subjects. This paper describes our rationale for the use of musculoskeletal modeling, the model we are using, and several practical applications of the model to study the potential use of shoulder and elbow muscle FNS to restore function following cervical SCI.

Influence of fitness on the integrated neuroendocrine response to aerobic exercise until exhaustion.

A group of trained and sedentary men performed an incremental graded exercise-test to exhaustion in order to assess the organic response of the two main stress-activated systems: the sympathetic nervous system with its endocrine component (the adrenal medulla), and the hypothalamic-pituitary-adrenal (HPA) axis. Maximal plasma concentrations of ACTH, cortisol and endogenous opioids (beta-endorphins) were obtained at the end of the exercise-test in the trained group. Thus ACTH increased from basal value of 21.25 +/- 2.5 pg/ml to 88.78 +/- 11.8 pg/ml at the end of the exercise (p<0.01); cortisol, from 16.56 microg/dl +/- 4.94 microg/dl to 23.80 +/- 4.57 microg/dl in min 15 of the recovery period (p<0.001); and beta-endorphin from 21.80 +/- 8.33 pmol/ml to 64.36 +/- 9.8 pmol/ml in min 3 of the recovery period (p<0.05). Catecholamine levels were increased from initial values at the end of the effort test in both control and trained groups. Control subjects exhibited a higher responsiveness compared to trained and showed superior intrinsic stimulation of the sympathetic nervous system. These results reveal a different response according to fitness in a physical stress situation.

APC stimulated by CpG oligodeoxynucleotide enhance activation of MHC class I-restricted T cells.

Oligonucleotides containing unmethylated CpG motifs (cytosine-phosphorothioate-guanine oligodeoxynucleotide (CpG ODN)) are potent immunostimulatory agents capable of enhancing the Ag-specific Th1 response when used as immune adjuvants. We evaluated the cellular mechanisms responsible for this effect. Development of a CTL response was enhanced when mice were immunized with peptide-pulsed dendritic cells (DCs) treated with CpG ODN. However, in vitro, CpG ODN had no direct effect on highly purified T cells. In vitro, CpG ODN treatment of peptide- or protein-pulsed DCs enhanced the ability of the DCs to activate class I-restricted T cells. The presence of helper T cells enhanced this effect, indicating that treatment with CpG ODN does not obviate the role of T cell help. The enhanced ability of CpG ODN-treated DCs to activate T cells was present but blunted when DCs derived from IL-12 knockout mice were used. Fixation of Ag-pulsed, CpG ODN-treated DCs limited their ability to activate T cells. In contrast, fixation had little effect on DC activation of T cells when DCs were not exposed to CpG ODN. This indicates that production of soluble factors by DCs stimulated with CpG ODN plays a particularly important role in their ability to activate class I-restricted T cells. We conclude that CpG ODN enhances the development of a cellular immune response by stimulating APCs such as DCs, to produce IL-12 and other soluble factors.

A robotic manipulator for the characterization of two-dimensional dynamic stiffness using stochastic displacement perturbations.

Experimental techniques for estimating the two-dimensional dynamic stiffness of the human arm over a wide range of conditions have been developed. A robotic manipulator has been developed to create loads against which subjects perform various tasks and also to impose perturbations onto the endpoint of the arm to allow estimation of its mechanical properties. The manipulator can produce static endpoint forces exceeding 220 N in any direction in its plane of motion, and this plane can be vertically translated and tilted over wide ranges to study arm dynamic stiffness in many functionally relevant planes. It can impose stochastic position and force perturbations whose bandwidth exceeds that of the arm. These random perturbations avoid undesirable volitional reactions and allow the efficient estimation of stiffness dynamics using experimental trials of short duration. The ability of this manipulator to characterize inertial-viscoelastic systems was tested using several two-dimensional physical systems whose properties were independently characterized. The endpoint dynamic stiffness properties of a human arm were estimated as an example of the use of the manipulator in studying upper limb mechanical properties. The system properties characterized by these methods will be useful in probing normal neural arm control strategies and in developing rehabilitation interventions to improve arm movements in disabled individuals.

(AC)23 [Z-2] polymorphism of the aldose reductase gene and fast progression of retinopathy in Chilean type 2 diabetics.

A recent case-control study suggests that the allele (AC)23 of a variable number tandem repeat (VNTR) associated to the aldose reductase (ALR2) gene could be related to early retinopathy in Type 2 diabetics. By means of a longitudinal-retrospective study, we aimed to seek for a relationship between the rate of progression of retinopathy and the (AC)23 allele of the VNTR associated to the ALR2 gene. A random sample was obtained of 27 Type 2 diabetics (aged 68.1 +/- 10.6 years, diabetes duration = 20.7 +/- 4.8 years, mean HbA1 = 10.6 +/- 1.6%). The mean HbA1 was the arithmetic average of 2.2 measurements per patient per year of total glycosilated hemoglobin (Gabbay method, normal range: 4.2-7.5%). Retinopathy was graded by an Ophthalmologist in a scale from zero to four score points. The genotype of the (AC), VNTR was determined by 32P-PCR plus sequenciation in a Perkin-Elmer laser device. The Mann-Whitney test and either chi2 or Fisher's exact test were used. A P < 0.05 was considered as statistically significant. The retinopathy progression rate (RPR, points x year(-1)) was calculated by dividing the increment of retinopathy score (delta Retinopathy Score, [points]), by the duration of the follow up [years]. The 12 diabetics having the (AC)23 allele had a mean RPR 8.9 times higher (0.40 +/- 0.61 points x year(-1)) than the 15 patients who had alleles other than (AC)23 (0.045 +/- 0.099 points x year(-1), P = 0.037). Both groups were similar with respect to: mean HbA1 (10.5 +/- 1.4 and 10.7 +/- 1.7%, P = 0.95), age at diagnosis (48.5 +/- 6.3 and 46.3 +/- 14.0 years, P = 0.81), diabetes' duration (21.3 +/- 4.7 and 20.2 +/- 4.9 years, P = 0.41) and serum creatinine (0.89 +/- 0.2 and 1.13 +/- 0.5 mg dl(-1), P = 0.35). We concluded that, in Type-2 diabetics having similar glycemic control, the (AC)23 allele of the VNTR associated to the ALR2 gene, is associated to a 8.9 times faster progression of retinopathy than in patients who have other alleles.

[Transcranial cytokine gradient and intestinal permeability in acute severe brain injury]. / Gradiente transcraneana de citoquinas y permeabilidad intestinal en la injuria cerebral aguda severa.

BACKGROUND: Acute brain injury is associated with a bimodal hypermetabolic state probably caused by cytokine secretion and high hormone and catecholamine concentrations. In a first stage, the brain would produce these substances and afterwards, another production source, most probably the splanchnic territory, would perpetuate the hypermetabolic state. AIM: To investigate the cytokine production source and to assess intestinal permeability in acute brain injury in the absence of cerebral ischemia and systemic oxygen deficit. PATIENTS AND METHODS: Arterial systemic and cerebral venous bulbar interleukin 1 beta and interleukin 6 levels were measured during the first seven days of evolution in 15 patients with acute brain injury. Serum lactate, the oxygen/lactate ratio, gastric intramucosal pH and intestinal permeability using the lactulose/mannitol test were also assessed in the same period. RESULTS: High arterial and venous interleukin 1 beta and interleukin 6 levels were detected. A positive gradient for interleukin 6 levels was detected throughout the study period with normal intramucosal pH, lactate and oxygen/lactate ratio. There was also an early impairment of intestinal permeability in these patients. CONCLUSIONS: High arterial and venous cytokine concentrations were detected in patients with acute brain injury. The positive gradient for interleukin 6 suggests a brain origin for this cytokine. Intestinal permeability is also altered in these patients.

Metabolic and hormonal changes during aerobic exercise in distance runners.

A group of long-distance runners is studied in order to clarify aspects concerning neuroendocrine mechanisms regulating organic adaptation to maximum effort, with special interest in the function of the growth hormone in fat metabolism and the possible use of ketone bodies as an alternative source of energy. A test is designed on a treadmill with a gradient of 3% and progressive increases in speed of 2 Km/h every 10 min, starting at 6 Km/h, and continuing until exhaustion. Masks are worn to enable the breath by breath measurement of expired gases and the subjects are monitored electrocardiographically using V5. For blood sample collection an antecubital vein is catheterized with a system enabling the replacement of the blood volume extracted by means of perfusion with physiological saline solution, and the increasing concentration of hormones in the blood is evaluated. The results obtained, indicate that epinephrine as well as GH hormones increase significatively from 20 min of exercise in runners promoting changes from carbohydrates to lipids as fuels to carry out exercise. The concomitant variations in energy substrates support the former hypothesis of work. Moreover, the muscle could employ acetylCoA originating from acetoacetate as an alternative metabolic source of fuel during maximum effort.

[Aldose reductase gene polymorphism and rate of appearance of retinopathy in non insulin dependent diabetics]. / Polimorfismo del gen de aldosa reductasa y velocidad de aparición de retinopatía en diabéticos no insulinodependientes.

BACKGROUND: Recent studies suggest that polymorphisms associated to the aldose reductase gene could be related to early retinopathy in noninsulin dependent diabetics (NIDDM). There is also new interest on the genetic modulation of coagulation factors in relation to this complication. AIM: To look for a possible relationship between the rate of appearance of retinopathy and the genotype of (AC)n polymorphic marker associated to aldose reductase gene. PATIENTS AND METHODS: A random sample of 27 NIDDM, aged 68.1 +/- 10.6 years, with a mean diabetes duration of 20.7 +/- 4.8 years and a mean glycosilated hemoglobin of 10.6 +/- 1.6%, was studied. The genotype of the (AC)n, polymorphic marker associated to the 5' end of the aldose reductase (ALR2) gene was determined by 32P-PCR plus sequenciation. Mutations of the factor XIII-A gene were studied by single stranded conformational polymorphism, sequenciation and restriction fragment length polymorphism. RESULTS: Four patients lacked the (AC)24 and had a higher rate of appearance of retinopathy than patients with the (AC)24 allele (0.0167 and 0.0907 score points per year respectively, p = 0.047). Both groups had similar glycosilated hemoglobin (11.7 +/- 0.2 and 10.5 +/- 1.6% respectively). Factor XIII gene mutations were not related to the rate of appearance of retinopathy. CONCLUSIONS: Our data suggest that the absence of the (AC)24 allele of the (AC)n polymorphic marker associated to the 5' end of the aldose reductase gene, is associated to a five fold reduction of retinopathy appearance rate.

[Prevalence of islet cell antibodies among 1021 relatives of type 1 diabetics]. / Prevalencia de anticuerpos anti islotes pancreáticos en 1,021 parientes de diabéticos tipo 1.

BACKGROUND: An immunological damage of beta cells in the islets of Langerhans, plays a role in the pathogenesis of type 1 diabetes. Recently, the identification of individuals in pre clinical phase and with high risk of developing type 1 diabetes, has become possible by means of the detection of immune markers such as islet cell antibodies (ICA) and the measurement of first phase response of insulin (FPRI). SUBJECTS AND METHODS: We studied 1,021 first degree relatives of type 1 diabetics, aged 4 to 35 years. ICA were measured using poly-IgG peroxidase in sections of human pancreas. In those subjects with positive ICA and normal oral glucose tolerance test, the FPRI was measured. FPRI was defined as the sum of insulinemias at minutes 1 and 3 after a three minutes 0.5 g/kg glucose load. RESULTS: Thirty subjects were ICA (+), defined as having more than 20 juvenile diabetes foundation units (prevalence of 2.9%). No differences in age, sex and closeness of familial relationship was found between ICA (+) and ICA (-) individuals. FPRI was measured in 24 subjects with normal oral glucose tolerance test and was normal in five. Seventeen subjects had a decreased response (between percentiles 1 and 5) and two had a response below percentile 1. No relationship between ICA levels and FPRI was found. CONCLUSIONS: The early detection of populations at risk of developing type 1 diabetes should be regarded as an important tool to better understand the natural history of the disease and to develop preventive programs in the future.

Multiple-input, multiple-output system identification for characterization of limb stiffness dynamics.

This study presents time-domain and frequency-domain, multiple-input, multiple-output (MIMO) linear system identification techniques that can be used to estimate the dynamic endpoint stiffness of a multijoint limb. The stiffness of a joint or limb arises from a number of physiological mechanisms and is thought to play a fundamental role in the control of posture and movement. Estimates of endpoint stiffness can therefore be used to characterize its modulation during physiological tasks and may provide insight into how the nervous system normally controls motor behavior. Previous MIMO stiffness estimates have focused upon the static stiffness components only or assumed simple parametric models with elastic, viscous, and inertial components. The method presented here captures the full stiffness dynamics during a relatively short experimental trial while assuming only that the system is linear for small perturbations. Simulation studies were performed to investigate the performance of this approach under typical experimental conditions. It was found that a linear MIMO description of endpoint stiffness dynamics was sufficient to describe the displacement responses to small stochastic force perturbations. Distortion of these linear estimates by nonlinear centripetal and Coriolis forces was virtually undetectable for these perturbations. The system identification techniques were also found to be robust in the presence of significant output measurement noise and input coupling. These results indicate that the approach described here will allow the estimation of endpoint stiffness dynamics in an experimentally efficient manner with minimal assumptions about the specific form of these properties.

Sex differences in estrogenic regulation of preproenkephalin mRNA levels in the medial preoptic area of prepubertal rats.

Opioids have been implicated in sexual differentiation of the brain and in the regulation of reproductive behavior and endocrinology of mammals. Previous studies have indicated that estrogen administration in adults regulates preproenkephalin MRNA levels in several hypothalamic brain nuclei. We have determined preproenkephalin mRNA levels in estrogen-treated juvenile male and female rats to investigate the developmental pattern of estrogenic regulation of enkephalinergic neurons in the medial preoptic area. Rats were treated with estradiol benzoate (20 microgram/kg/day) or oil from day 21 to 23. Sections of the medial preoptic area (mPOA) were studied by in situ hybridization histochemistry at the single cell level and quantified with the assistance of an image analysis system. Our data indicate that males contain higher levels of preproenkephalin mRNA per neuron than females. In addition, our results indicate that estrogen causes an upward shift in the amount of mRNA expressed per cell, females demonstrating a greater response to estrogen than males. An increase in soma cell area following estrogen treatment was observed only in female mPOA enkephalinergic neurons. Taken together, these results indicate a sex difference in total preproenkephalin levels and in estrogenic regulation of preproenkephalin mRNA in the POA of juvenile rats. These results are discussed in relation to the differential role opioids may play in male and female reproductive physiology.