Development of an intervention to manage knee osteoarthritis risk and symptoms following anterior cruciate ligament injury.

INTRODUCTION: Anterior cruciate ligament (ACL) injury is a risk factor for developing knee osteoarthritis (OA). We developed an intervention to support people manage risk factors for OA. METHODS: We conducted one-on-one interviews with 20 individuals with OA symptoms 6-15 years post ACL injury and used a nominal group process during a workshop with 40 patients and healthcare professionals (HCPs) to elicit information on the intervention content and delivery characteristics (timing, HCPs, and methods). Interview data were analyzed using content analysis. Nominal group ideas with importance ratings ≥5 of 7 met criteria for inclusion. Results were integrated, considering similarities and differences. RESULTS: Eight content categories were identified: 1. understanding knee injury and expectations about recovery; 2. understanding OA risk; 3. understanding OA signs and symptoms; 4. managing OA risk; 5. managing knee OA symptoms; 6. information for influencers; 7. credible sources; and, 8. updates on new evidence and treatments. Delivery timing reflected a lifespan approach from time of injury through symptomatic knee OA management. Although multiple media for delivery were identified, introductory face-to-face discussions and opportunity for re-accessing HCPs were critical. All HCPs who treat people with ACL should be familiar with and able to deliver the intervention. CONCLUSIONS: This co-development approach identified that an intervention to support people with ACL injury to limit and manage knee OA requires content embedded within an easily accessible, multi-media delivery model with capacity for check-back with HCPs that is appealing to different age groups and personal preferences over the lifespan post injury.

In vivo increase of the human lens equatorial diameter during accommodation.

The movement of the human lens equator during accommodation was examined in vivo. High-resolution ultrasound images of the lens equator were obtained from young human subjects whose amplitude of accommodation was controlled with 1% tropicamide and 2% pilocarpine. To avoid errors that otherwise arise from eye rotation or other movement, the cornea and sclera were used as positional references in comparative studies of the video images obtained from the unaccommodated and accommodated states. During accommodation, the movement at the lens equator involved small displacement; i.e., < 100 microns, and the equator did not move anteriorly or posteriorly but peripherally toward the sclera. These results indicate that the lens equator is under increased zonular tension during accommodation, in contradiction to Helmholtz's widely accepted theory of accommodation.

The effect of gravity on the amplitude of accommodation.

We measured the amplitude of accommodation in the supine and prone positions of young subjects. We found that gravity does not influence accommodative amplitude. These findings support Schachar's zonular function and accommodative hypotheses that the lens is stable and under tension during accommodation.

A physical model demonstrating Schachar's hypothesis of accommodation.

Schachar's hypothesis of accommodation states that there is increased zonular tension during accommodation and the observed in vivo changes in lenticular curvature that occur during accommodation are the result of zonular forces. To demonstrate that there can be steepening of the central curvature of the lens with increased zonular tension, profile photographs of an equatorially unstretched and stretched gelatin-filled balloon and profile photographs from the literature of an unstretched and equatorially stretched human lens were digitized. Their radii of curvature were determined. We found that equatorial stretching of both the gelatin-filled balloon and the human lens produced central curvature steepening that was consistent with Schachar's hypothesis of accommodation.

Experimental support for Schachar's hypothesis of accommodation.

To determine the physical effect of a change in the equatorial lenticular diameter on optical power, sclera-ciliary bodies of bovine eyes were stretched radially. The effective optical power and lenticular equatorial diameter were measured. We found that an increase in the equatorial diameter of the bovine lens produced an increase in its effective optical power. Our results directly contradict Helmholtz's hypothesis of accommodation and its modifications. These results support Schachar's hypothesis of accommodation, which states that there is increased zonular tension during accommodation.

Nova scotia fetal risk project.

Family physicians delivering obstetrical care in Nova Scotia were invited to participate in a fetal risk project, conducted from 1971 to 1975. Thirty percent of the physicians participated, and data were collected on 17,270 patients, using the Goodwin, Dunne and Thomas(4) fetal risk scoring system. Patients scoring four to ten on the entire system accounted for 60% of stillbirths and 68% of neonatal deaths; when the 68% of neonatal deaths; when the non-gestational portion alone was used, patients scoring three to six accounted for 52% of stillbirths and 57% of neonatal deaths. When the scoring system was altered, patients scoring three to six accounted for 61% of stillbirths and 62% of neonatal deaths. Patients of participants did not appear to fare better than those of non-participants.

Evaluation of fetal monitoring by telemetry.

A radiotelemetry system for the direct monitoring of fetal heart rate and intrauterine pressure during labor has been evaluated at 5 different institutions. A conventional fetal scalp electrode and a special intrauterine pressure sensor are connected to a radio transmitter placed on the patient's thigh. The receiver can be located up to 50 feet away from the transmitter and is either a self-contained monitor or a unit that converts a conventional fetal monitor to a telemetric one. The telemetry recordings are of similar quality to those obtained from conventional monitors. Telemetry allows for greater patient comfort and mobility as well as greater convenience to the clinical staff. Continuous data can be obtained from patients while they are ambulatory or sitting in a chair as well as while they are in bed.

Sinusoidal fetal heart rate pattern associated with alphaprodine administration.

Sinusoidal fetal heart rate patterns were observed in 42.5% of a group of 40 women who had received alphaprodine (Nisentil) for relief of labor pain. Analysis showed that the pattern appeared approximately 19 minutes following alphaprodine administration and persisted for approximately 60 minutes. In a control group of 18 patients who did not receive narcotic analgesia, and intermittent sinusoidal pattern was observed in one patient. All babies with sinusoidal heart rate during labor had 1-minute Apgar scores of 7 or greater except two in the study group. Both these neonates had low Apgar scores directly associated with complications at delivery. All 5-minute Apgar scores were 7 or greater, and there were no perinatal deaths.

Fetal bradycardia without fetal distress: case presentation and review of the literature.

A case of a term pregnancy with a persistent fetal heart rate of 65 to 80 beats/min is presented. Initially this was presumed to be due to congenital heart block. Subsequent fetal ECG revealed blocked atrial extrasystoles. Review of the literature showed 31 previously reported cases of heart block diagnosed in utero. A review of this literature is discussed and the importance of differentiating bradycardia due to heart block from bradycardia due to fetal distress is emphasized.

Practical prenatal care. I. Initial prenatal care.

Most factors which place the mother or fetus at risk are present at the time of the initial prenatal visit or develop during the pregnancy and before admission to the hospital. As many as 40 per cent of all high risk patients may be detected at the initial prenatal visit.

Labor - when is it too long?

Labor is a progressive phenomenon. Careful evaluation of the course of labor is necessary to detect abnormalities early and to prevent prolonged labor. Once an abnormality of labor is detected, the condition of the mother, fetus, and pelvis must be evaluated to determine if treatment should allow a vaginal delivery or abdominal delivery.

Five years' experience with intrauterine transfusion.

Five years' experience with intrauterine transfusion involving 94 transfusions on 50 fetuses forms the basis of the paper. Twenty-three fetuses survived, which represents an overall salvage of 46%. Of 22 fetuses who received intrauterine transfusions before 28 weeks' gestation, seven (31.9%) survived, which justifies the attempt. Of 28 fetuses who received intrauterine transfusions after 28 weeks' gestation, 16 (57.1%) survived, which compares favourably with other series. A comparison of two different procedural techniques shows no statistically significant difference in ultimate results. Indications for amniocentesis are outlined and intrauterine transfusion was advised if the optical density difference fell in Liley's zone III (or a very high zone II) and rose at a rate which anticipated a zone III reading prior to 32 weeks' gestation. A pediatric assessment and therapeutic management of the 33 live births are presented. Twenty-eight babies received exchange transfusions. Five were excluded for reasons outlined in the text. Ten of the live-born died neonatally. The 23 survivors continue to thrive mentally and physically and follow-up continues.