Nestling telomere shortening, but not telomere length, reflects developmental stress and predicts survival in wild birds.

Developmental stressors often have long-term fitness consequences, but linking offspring traits to fitness prospects has remained a challenge. Telomere length predicts mortality in adult birds, and may provide a link between developmental conditions and fitness prospects. Here, we examine the effects of manipulated brood size on growth, telomere dynamics and post-fledging survival in free-living jackdaws. Nestlings in enlarged broods achieved lower mass and lost 21% more telomere repeats relative to nestlings in reduced broods, showing that developmental stress accelerates telomere shortening. Adult telomere length was positively correlated with their telomere length as nestling (r = 0.83). Thus, an advantage of long telomeres in nestlings is carried through to adulthood. Nestling telomere shortening predicted post-fledging survival and recruitment independent of manipulation and fledgling mass. This effect was strong, with a threefold difference in recruitment probability over the telomere shortening range. By contrast, absolute telomere length was neither affected by brood size manipulation nor related to survival. We conclude that telomere loss, but not absolute telomere length, links developmental conditions to subsequent survival and suggest that telomere shortening may provide a key to unravelling the physiological causes of developmental effects on fitness.

Telomere shortening and survival in free-living corvids.

Evidence accumulates that telomere shortening reflects lifestyle and predicts remaining lifespan, but little is known of telomere dynamics and their relation to survival under natural conditions. We present longitudinal telomere data in free-living jackdaws (Corvus monedula) and test hypotheses on telomere shortening and survival. Telomeres in erythrocytes were measured using pulsed-field gel electrophoresis. Telomere shortening rates within individuals were twice as high as the population level slope, demonstrating that individuals with short telomeres are less likely to survive. Further analysis showed that shortening rate in particular predicted survival, because telomere shortening was much accelerated during a bird's last year in the colony. Telomere shortening was also faster early in life, even after growth was completed. It was previously shown that the lengths of the shortest telomeres best predict cellular senescence, suggesting that shorter telomeres should be better protected. We test the latter hypothesis and show that, within individuals, long telomeres shorten faster than short telomeres in adults and nestlings, a result not previously shown in vivo. Moreover, survival selection in adults was most conspicuous on relatively long telomeres. In conclusion, our longitudinal data indicate that the shortening rate of long telomeres may be a measure of 'life stress' and hence holds promise as a biomarker of remaining lifespan.

Vocational perspectives after spinal cord injury.

OBJECTIVE: To give insight into the vocational situation several years after a traumatic spinal cord injury (SCI) and describe the personal experiences and unmet needs; to give an overview of health and functional status per type of SCI and their relationship with employment status. DESIGN: Descriptive analysis of data from a questionnaire. SETTING: Dutch rehabilitation centre with special department for patients with spinal cord injuries. SUBJECTS: Fifty-seven patients with a traumatic SCI, aged 18-60 years, admitted to the rehabilitation centre from 1990 to 1998. MAIN MEASURES: Questionnaire with items related to vocational outcome, job experiences, health and functional status. RESULTS: Of 49 patients who were working at the moment of SCI 60% currently had a paid job. Vocational outcome was related to a higher educational level. A significant relation between the SCI-specific health and functional status and employment was not found. The respondents who changed to a new employer needed more time to resume work, but seemed more satisfied with the job and lost fewer working hours than those who resumed work with the same employer. In spite of reasonable to good satisfaction with the current work situation, several negative experiences and unmet needs were reported. CONCLUSIONS: Despite a high participation in paid work following SCI, the effort of the disabled worker to have and keep a job should not be underestimated.

Participation and satisfaction after spinal cord injury: results of a vocational and leisure outcome study.

STUDY DESIGN: Survey. OBJECTIVES: Insight in (1) the changes in participation in vocational and leisure activities and (2) satisfaction with the current participation level of people with spinal cord injuries (SCIs) after reintegration in society. DESIGN: Descriptive analysis of data from a questionnaire. SETTING: Rehabilitation centre with special department for patients with SCIs, Groningen, The Netherlands. SUBJECTS: A total of 57 patients with traumatic SCI living in the community, who were admitted to the rehabilitation centre two to 12 years before the current assessment. MAIN OUTCOME MEASURES: Changes in participation in activities; current life satisfaction; support and unmet needs. RESULTS: Participation expressed in terms of hours spent on vocational and leisure activities changed to a great extent after the SCI. This was mainly determined by a large reduction of hours spent on paid work. While 60% of the respondents successfully reintegrated in work, many changes took place in the type and extent of the job. Loss of work was partially compensated with domestic and leisure activities. Sports activities were reduced substantially. The change in participation level and compensation for the lost working hours was not significantly associated with the level of SCI-specific health problems and disabilities. As was found in other studies, most respondents were satisfied with their lives. Determinants of a negative life satisfaction several years following SCI were not easily indicated. Reduced quality of life was particularly related to an unsatisfactory work and leisure situation. CONCLUSIONS: Most people with SCI in this study group were able to resume work and were satisfied with their work and leisure situation.

Vocational reintegration following spinal cord injury: expectations, participation and interventions.

STUDY DESIGN: Survey. OBJECTIVES: To explore the process of reintegration in paid work following a traumatic spinal cord injury (SCI), including the role of early expectations of individual patients regarding return to work, indicators of success of job reintegration and a description of reintegration interventions and barriers. SETTING: Dutch rehabilitation centre with special department for patients with spinal cord injuries. METHODS: Descriptive analysis of data gathered by a mailed questionnaire, which was returned by 57 persons (response 83%) with traumatic SCI, aged 18-60 years, and data of earlier expectations reported by the individual patients during the rehabilitation admission following SCI from 1990 to 1998. RESULTS: Of 49 respondents who were employed at the moment of the SCI, 45% expected to be able to resume work. These positive expectations were associated with a higher educational level. In 67%, return to work was successful. The chance to reintegrate successfully was better if the patient expected to resume work. Logistic regression analysis did not reveal other significant indicators. About one-third of the 49 respondents working preinjury followed vocational retraining, which was successful for most of them so far. In the majority of work situations modifications have been made, such as job adaptations and reduction of working hours. Several unmet needs regarding reintegration interventions were also reported. CONCLUSIONS: Positive expectations regarding resumption of work after a SCI are an important indicator of successful reintegration in work. An active role of the rehabilitation team is recommended in drawing up a vocational reintegration plan to prepare the patient, the employer and professionals involved in the reintegration process.

Efficacy of coughing in tetraplegic patients.

STUDY DESIGN: A randomized cross-over design study in six tetraplegic patients. OBJECTIVES: To investigate the efficacy of coughing in tetraplegic patients. SUMMARY OF BACKGROUND DATA: In tetraplegic patients, pulmonary complications due to insufficient clearance of bronchial mucus frequently are described. Coughing in tetraplegic patients is thought to be insufficient because of severely impaired expiratory muscle function. More recently, however, it has been reported that many tetraplegic patients may have dynamic airway compression and thus a more or less effective cough. METHODS: Mucus clearance was measured using a radioactive aerosol tracer technique during 45 minutes on 2 days: once without intervention, and once with voluntary coughing in the period 15 to 30 minutes (once every 30 seconds). Measurements were done in a randomized order. For each day, individual slopes for the decrease in radioactivity were calculated, reflecting mucus transport in the peripheral, central, and the whole lung region. RESULTS: Significant differences in slopes were found between the control day and the cough day in the peripheral lung region for the interval 0 to 30 minutes and in the whole lung region for the interval 0 to 30 minutes and 0 to 45 minutes. The improvement of mucus clearance due to coughing, however, was relatively small in these patients, only 3% after 45 minutes: from 4% whole lung clearance during quiet breathing to 7% whole lung clearance during coughing. CONCLUSION: Tetraplegic patients may achieve a statistically significant increase in their bronchial mucus transport by voluntary coughing.

Prediction of functional outcome after spinal cord injury: a task for the rehabilitation team and the patient.

STUDY DESIGN: Descriptive analysis of data gathered in an information system. OBJECTIVES: To explore the predictions of professionals and patients regarding functional outcome after spinal cord injury related to the final results after inpatient rehabilitation, in order to make prognostics of rehabilitation outcome more successful and enlarge the role of the patient in selecting realistic rehabilitation goals. METHODS: Data from 55 patients with spinal cord injury admitted to the rehabilitation centre. Expectations of the rehabilitation team and the patients regarding future independence in performing six daily activities were compared to the functional results at discharge. The results of patients with different level and extent of lesion were analyzed. RESULTS: In 52% of all performed skills, independence was achieved at discharge. Professionals and patients made similar predictions. If they both expected independence after rehabilitation. 90% of the skills were performed independently at discharge. If they both did not expect independence only 3% of the functional results were positive. Of all combined predictions 64% was correct. Correct predictions were most often found regarding self-care skills of patients with paraplegia and regarding mobility of patients with complete lesions. Prediction of self-care outcome of patients with tetraplegia is far more complicated. There was a considerable variation in predictions of mobility potential, especially regarding patients with incomplete lesions. If the team and patients agreed upon expected independence in mobility skills of these patients, the final results were mostly positive. CONCLUSIONS: Prediction of functional outcome after spinal cord injury was most successful if the expectations of the team and patients were combined. Prognosis of self-care outcome of patients with paraplegia and mobility potential of patients with complete spinal cord lesions was usually clear at admission. However, selection of realistic goals concerning self-care skills of patients with tetraplegia and mobility skills of patients with incomplete lesions is far more complicated. Gradual adjustment of objectives is needed during the rehabilitation process in close collaboration between the professionals and the patients.

Functional outcome of patients with spinal cord injury: rehabilitation outcome study.

OBJECTIVE: To increase our knowledge of neurological recovery and functional outcome of patients with spinal cord injuries in order to make more successful rehabilitation programmes based on realistic goals. DESIGN: Descriptive analysis of data gathered in an information system. SETTING: Rehabilitation centre in The Netherlands with special department for patients with spinal cord injuries. SUBJECTS: Fifty-five patients with traumatic spinal cord lesions admitted to the rehabilitation centre from 1988 to 1994. MAIN OUTCOME MEASURES: The functional improvement was presented in terms of progress in independence in nine daily activity skills. Independence was rated on a four-point scale. RESULTS: From admission to discharge, lesions in 100% of patients with tetraplegia and 96% of patients with paraplegia remained complete. Significant progress in independence was made in self-care, ambulation and bladder and bowel care. Differences were found in the extent of functional improvement between subgroups of patients with different levels and extent of lesion. Contrary to expectations based on theoretical models, patients with complete paraplegia did not achieve maximal independence in self-care. Independent walking was only attained by patients with incomplete lesions. Regarding outcome of bladder and bowel care, poor results were found, especially the independence in defaecation and toilet transfers. CONCLUSIONS: The results of this study provided more insight into the functional outcome of a group of patients with traumatic spinal cord injury. More research is needed to evaluate the rehabilitation programmes for these patients.

Rehabilitation of patients with spinal cord lesions in The Netherlands: an epidemiological study.

Very little is known about the occurrence of spinal cord lesions and results of the rehabilitation of patients with such lesions in the Netherlands. This study was conducted to describe the process of rehabilitation in the Dutch situation, to assess the incidence of spinal cord lesions in a regional rehabilitation centre and to characterise differences between traumatic and non-traumatic spinal cord lesions regarding age, level and extent of lesion. In this study 293 patients were included who were admitted to the rehabilitation centre between 1982 and 1993. Sixty-six per cent of this group came from the university hospital. The mean length of stay in the rehabilitation centre was 154 days. After completing the rehabilitation programme 94% of patients went home. Sixteen new SCI patients per million per year were admitted to the rehabilitation centre. Of our group 52% had a non-traumatic lesion, which concerned older patients with more incomplete lesions. In our opinion close collaboration between the university hospital and the rehabilitation centre is needed for optimal rehabilitation. Attention to independent living programmes and appropriate housing facilities can shorten the length of stay and increase the number of discharges of patients to their own environment. For patients with non-traumatic spinal cord lesions special programmes should be made available.

Relapse rate and subsequent parental reaction after successful treatment of children suffering from nocturnal enuresis: a 2 1/2 year follow-up of bibliotherapy.

Results 2 1/2 years after an enuresis nocturna training are presented, including rate of success, percentage and duration of relapse for 113 children (mean age 11.6 year at the start of the training). The bibliotherapeutic treatment by parents did not require any intervention by a professional. Behaviour of parents in the event of a relapse differed between training conditions. Children in the Arousal condition recovered faster from a relapse, 90% of their parents used the Arousal training again at relapse or did not intervene at all and none of them consulted a professional. Clearly they had confidence in the method of Arousal training: combining the alarm device with reinforcement for correct behaviour at the time the alarm goes off. Parents in control conditions did not use the alarm device as often as the parents in the Arousal condition, but tried other means with less success, including consulting professionals.

Arousal training for children suffering from nocturnal enuresis: a 2 1/2 year follow-up.

Arousal Training is a fast, simple, and effective form of bibliotherapy for nocturnal enuresis with non-clinical children between 6 and 12 years of age. The parents act as therapists. They reward the operant behavior-pattern following the urine alarm. The success rate is 98% (N = 41), which is significantly high when compared to the control conditions (79%, N = 86). There was a response rate of 100% and no drop-out from therapy. All parents (N = 127) completed and returned the record. The results of a follow-up of this bibliotherapy (N = 113) 2 1/2 years later are presented. The success rate of Arousal Training was still significantly higher (92% continent) when compared to the urine device with specific instructions (77%) and urine alarm only (72%). Arousal Training is the treatment of choice for non-clinical enuretic children between 6 and 12 years of age.

Options in the management of perforations of the esophagus.

A study of 90 cases of esophageal perforation in the antibiotic era emphasizes individualized treatment and options of therapy based on a fundamental understanding of modifying pathophysiologic factors. If the patient is seen during the first 24 hours, surgical repair and irrigating tube drainage continue to be the treatment of choice in the thoracic and abdominal regions, with certain exceptions. The exceptions include small perforations proved by a thin media esophagram or esophagoscopy without pleural involvement or constitutional symptoms. Such patients may be treated nonoperatively, with gastric drainage, antibiotics, and parenteral alimentation. However, for large perforations with extensive contamination of the mediastinum and pleura, an esophageal exclusion operation may be life saving. In the cervical region, irrigating tube drainage may be just as effectual as repair and drainage. In patients seen after 24 hours, size of the perforation and the amount of mediastinopleural infection, rather than the time that has elapsed, dictate optimal treatment.

Tension pneumopericardium following blunt chest trauma.

A 12-year-old victim of an automobile-pedestrian accident appeared to develop severely compromised cardiac output shortly after intubation and positive pressure ventilation. Anteroposterior and lateral chest films showed air within the pericardial sac. After pericardiocentesis and withdrawal of air, cardiac function improved markedly as evidenced by a rise in blood pressure and a slowing of the pulse. A catheter was left in the pericardial sac for several days. The patient remained hemodynamically stable throughout the hospital stay and was subsequently discharged. Documentation of this degree of tamponade from air in the pericardium is quite uncommon.

Aortoesophageal fistula.

With the advent of cardiovascular and bypass procedures, aortoesophageal fistula has progressed from the stage of a pathologic curiosity to a treatable lesion. Although the causes of aortoesophageal fistula are varied, a remarkably consistent clinical picture emerges from study of this condition. Chiari's triad of midthoracic pain, sentinel hemorrhage, and a symptom-free interval followed by fatal exsanguination remains the most important clinical finding today. Although contrast esophagography, esophagoscopy, and aortography are important diagnositc aids, immediate left thoracotomy may be the only means of making the diagnosis and saving the patient when hemorrhage is profuse. In most cases (80 per cent of the present series) there is a symptom-free period varying from hours to days from the original sentinel hemorrhage to the final exsanguination. This permits the informed surgeon trained in cardiovascular technics an opportunity to salvage some of these patients. The various methods of aortic and esophageal repair are discussed.

Technique for using soft, flexible catheter stents in aortocoronary vein bypass operations.

A technique using soft, flexible catheter stents in performing coronary vein bypass surgery is presented which makes small vessel anastomoses easy and assures accuracy of suture placement with clear identification of the vessel lumen and an anastomosis without stenosis. It provides an essentially bloodless field without having to cross-clamp the aorta. The technique has been used to our complete satisfaction in all patients since we first started vein bypass operations in 1970. A review of the last 205 elective aortocoronary bypass grafts in 100 consecutive patients using this technique reveals a mortality of only 1% and an operative and postoperative myocardial infarction rate of 5%. About half the patients had left ventricular dysfunction with elevated end-distolic pressures, and 68% had had previous myocardial infarctions. Seventy percent of the patients are at present asymptomatic, 24% are improved, and only 4% show no improvement over their preoperative status during follow-up of one to three and one-half years.