Integrated care improves risk-factor modification after stroke: initial results of the Integrated Care for the Reduction of Secondary Stroke model.

OBJECTIVE: Despite evidence demonstrating that risk-factor management is effective in reducing recurrent cerebrovascular disease, there are very few structured care programmes for stroke survivors. The aim was to implement and evaluate an integrated care programme in stroke. METHODS: 186 patients with stroke were randomised to either the treatment (integrated care) or control (usual care) group and were followed up over 12 months. The Integrated Care for the Reduction of Secondary Stroke (ICARUSS) model of integrated care involved collaboration between a specialist stroke service, a hospital coordinator and a patient's general practitioner. The primary aim was to promote the management of vascular risk factors through ongoing patient contact and education. RESULTS: In the 12 months poststroke, systolic blood pressure (sBP) decreased in the treatment group but increased in controls. The group difference was significant, and remained so when age, sex, disability and sBP at discharge were accounted for (p = 0.04). Treatment patients also exhibited better modification of body mass index (p = 0.007) and number of walks taken (p<0.001) than controls. Rankin scores indicated significantly reduced disability in treatment patients relative to controls in the year poststroke (p = 0.003). CONCLUSIONS: Through an integrated system of education, advice and support to both patient and GP, the ICARUSS model was effective in modifying a variety of vascular risk factors and therefore should decrease the likelihood or recurrent stroke or vascular event.

The training & support programme for parents of children with ataxia: a pilot study.

The aim of the study was to evaluate the impact of the Training and Support Programme among parents of children with ataxia. A total of 39 parents expressed an interest in the TSP, 27 (mean age 41; range 25-58) returned baseline questionnaires and completed the study. Twenty-four children (mean age 12.5 years, SD=12.4) received the TSP. Data were collected by self-administered questionnaires mailed to parents immediately before attending the TSP and at 4-month follow-up. Interviews were conducted with 10 parents immediately following TSP completion. Comparisons over time revealed significant decreases in parental anxious mood (p=.011), depressed mood (p=.046) and perceived stress (p=.020) and significant improvements in generalized self-efficacy (p=.010), satisfaction with life (p=.045) and parental health status (p=.020). Parents reported improvements in children's mobility, "jumping legs", sleep patterns, energy and activity levels, relaxation, and happiness (e.g., more smiles). Parents felt closer to their children and one parent had become "more accepting" of their child's ataxia. Results indicate that the TSP may enhance the psychosocial well-being of parents of children with ataxia although a randomized controlled trial would be necessary to determine whether the changes reported here are in fact due to attending the TSP.

Massage intervention for promoting mental and physical health in infants aged under six months.

BACKGROUND: Infant massage is increasingly being used in the community for low-risk babies and their primary care givers. Anecdotal claims suggest benefits for sleep, respiration, elimination and the reduction of colic and wind. Infant massage is also thought to reduce infant stress and promote positive parent-infant interaction. OBJECTIVES: The aim of this review was to assess the effectiveness of infant massage in promoting infant physical and mental health in population samples. SEARCH STRATEGY: Searches were undertaken of CENTRAL 2005 (Issue 3), MEDLINE (1970 to 2005), PsycINFO (1970 to 2005), CINAHL (1982 to 2005), EMBASE (1980 to 2005), and a number of other Western and Chinese databases. SELECTION CRITERIA: Studies in which babies under the age of six months were randomised to an infant massage or a no-treatment control group, and utilising a standardised outcome measuring infant mental or physical development. DATA COLLECTION AND ANALYSIS: Weighted and standardised mean differences and 95% confidence intervals are presented. Where appropriate the results have been combined in a meta-analysis using a random effects model. MAIN RESULTS: Twenty-three studies were included in the review. One was a follow-up study and thirteen were included in a separate analysis due to concerns about the uniformly significant results and the lack of dropout. The results of nine studies providing primary data suggest that infant massage has no effect on growth, but provides some evidence suggestive of improved mother-infant interaction, sleep and relaxation, reduced crying and a beneficial impact on a number of hormones controlling stress. Results showing a significant impact on number of illnesses and clinic visits were limited to a study of Korean orphanage infants. There was no evidence of effects on cognitive and behavioural outcomes, infant attachment or temperament. The data from the 13 studies regarded to be at high risk of bias show uniformly significant benefits on growth, sleep, crying and bilirubin levels. AUTHORS' CONCLUSIONS: The only evidence of a significant impact of massage on growth was obtained from a group of studies regarded to be at high risk of bias. There was, however, some evidence of benefits on mother-infant interaction, sleeping and crying, and on hormones influencing stress levels. In the absence of evidence of harm, these findings may be sufficient to support the use of infant massage in the community, particularly in contexts where infant stimulation is poor. Further research is needed, however, before it will be possible to recommend universal provision.

The psychological well-being and self-efficacy of carers of children with disabilities following attendance on a simple massage training and support programme: a 12-month comparison study of adherers and non-adherers.

OBJECTIVES: The Training and Support Programme (TSP) is an 8-week programme in which carers of children with disabilities receive instruction in simple massage techniques to use with their child. The aims of the present study were firstly to compare, adherers and non-adherers on measures of psychological well-being and self-efficacy and secondly, to examine whether, for adherers, the positive benefits of attending the TSP reported immediately after the Programme were maintained at 12-month follow-up. DESIGN: Eighty-two carers took part in the study. Data were collected 12-months after completion of the TSP by self-report questionnaires mailed to carers. For comparisons between adherers and non-adherers at 12-month follow-up a between-groups design was used. For comparisons over time, a within-subjects design was used. RESULTS: Adherers had significantly higher levels of self-efficacy for managing their child's psychosocial well-being, self-efficacy for carrying out the massage, and significantly better psychological well-being at follow-up compared to non-adherers. Furthermore, there were no significant differences over time on self-efficacy for managing their child's psychosocial well-being, self-efficacy for giving massage and levels of anxiety and depression at 12-month follow-up for adherers, suggesting that their improvements noted immediately post-programme were maintained at follow-up. Significant decreases on self-efficacy and depression were noted for non-adherers and there was a trend towards deterioration in anxious mood. CONCLUSION: In conclusion, the present study suggests that the positive benefits the TSP has for carers of children with disabilities can be maintained if carers continue to practise the massage at home with their child.

[Effect of tea polyphenol on the demineralization and remineralization of enamel in vitro].

OBJECTIVE: To investigate the effect of tea polyphenol (TP) on the mineralization behaviour of enamel in two sterile, in vitro systems. METHODS: In the demineralization study, sound enamel sections were pH-cycled. Treatments were 2000 mg/L TP, 200 mg/L TP, 2000 mg/L TP + 100 mg/L fluoride, 100 mg/L fluoride, and deionized water. In the remineralization study, surface-softened enamel was used and pH-cycled as above. Test treatments were 2000 mg/L TP, 2000 mg/L TP + 250 mg/L fluoride, 250 mg/L fluoride, and deionized water. The acidic buffers were retained for calcium analysis. The enamel was analysed before and after pH-cycling by microhardness. RESULTS: In the demineralization study, the calcium depletion rates(CDR) were (0.43 +/- 0.05), (0.49 +/- 0.006), (0.21 +/- 0.02), (0.21 +/- 0.03) and (0.50 +/- 0.11) microgram/(mm2.h) respectively. The Knoop hardness values(KHV) percent reduction were 94.19 +/- 3.50, 96.62 +/- 0.63, 74.74 +/- 4.09, 77.79 +/- 3.11 and 97.32 +/- 4.03 respectively. There were no significant differences within either the TP-only groups or the fluoride groups, but the fluoride groups were significantly more efficacious than the TP-only groups (P < 0.05). In the remineralization study, the KHV percent increase were -11.96 +/- 10.1, -21.32 +/- 11.3, -49.52 +/- 24.6 and -4.24 +/- 8.51 respectively. Notably more remineralization was observed in the fluoride group. There were no significant differences between the other groups (P > 0.05). CONCLUSION: The data of this in vitro study suggest that TP has no effect on de/remineralization of enamel blocks and there is no synergetic action of TP and fluoride in a sterile system. This finding supports the proposition that tea polyphenols exert an anti-caries effect via an anti-microbial mode-of-action.

Normalization of hypertensive responses during ambulatory surgical stress by perioperative music.

OBJECTIVE: The purpose of this study was to determine whether cognitive appraisals of stress level and hypertensive responses to ambulatory ophthalmic surgery can be ameliorated by patient-selected music. METHODS: We studied 40 elderly individuals requiring ophthalmic surgery, 20 in an experimental group (mean age, 74 years) and 20 in a control group (mean age, 77 years). All patients had an established resting blood pressure <140/90 mm Hg. In the experimental group self-selected music was provided by headphones throughout the preoperative, surgical, and postoperative periods. In the control group patients had neither headphones nor music. All patients received similar (weight-determined) doses of alfentanil and midazolam during surgery. Heart rate, blood pressure, and patient-reported stress and coping levels were the dependent variables. RESULTS: In both groups, blood pressure values were normal (approximately 129/82 mm Hg) during screening examinations 1 week before surgery. On the day of surgery both groups displayed increased preoperative blood pressures (approximately 159/92 mm Hg) associated with increases in heart rate (by approximately 17 beats/min). Intraoperative blood pressures in the experimental group returned quickly to screening baseline values, whereas the control group experienced persistent elevations in intraoperative blood pressure similar to preoperative levels. Over the course of the surgical experience, patients with music reported significant reductions in perceived stress and increases in coping abilities (p < .001), whereas those without music did not. CONCLUSIONS: The perceived stress of ambulatory surgery in geriatric patients is associated with a clinical hypertensive response that is ameliorated by self-selected perioperative music, which also decreases perceived stress and increases patients' sense of personal control and well-being.

Developmentally regulated expression of Thy-1 in structures of the mouse sensory-motor system.

Thy-1 is a cell-surface molecule of the immunoglobulin superfamily which is expressed at high levels in the mature nervous system. Thy-1 has been implicated in regulating axonal outgrowth and synaptic function, but little is known regarding its cellular localization and expression in the central nervous system (CNS) during development or in adulthood. In this study, Thy-1 gene expression and protein localization were examined in sensory-motor and related areas of the adult and postnatally developing mouse CNS. Thy-1 mRNA expression was restricted to neurons; immunoreactivity was densely distributed throughout the neuropil of all regions examined, often delineated the neuronal plasmalemma, and labeled axons in white matter tracts of the brain and spinal cord. In adulthood, immunolabeling was regionally widespread and was present relatively homogeneously throughout all cell-dense layers of sensory-motor cortex, throughout most thalamic nuclei, globus pallidus, and spinal cord. Developmentally, however, Thy-1 expression and localization exhibited a spatially and temporally staggered sequence leading to the adult pattern. In sensory-motor cortex, Thy-1 expression in layer V preceded expression in other layers; in the barrel field, labeling of barrel septa preceeded a gradually increasing intensity of immunolabeling of barrel centers; in the thalamus, Thy-1 exhibited a differential onset and temporal pattern of expression across different nuclei associated with motor, sensory, or limbic systems; in the caudate nucleus, Thy-1 expression was greatest during the first postnatal week of life before declining during subsequent development. Taken together, the adult distribution and developmental patterns leading to it form a unique profile in comparison with other structurally related glycosyl-phosphatidylinositol (GPI)-anchored neural cell adhesion molecules. The pattern and timing of Thy-1 expression across layers and nuclei during early postnatal development are more complex than previously recognized, thus perhaps reflecting varied roles for Thy-1 in aspects of structural or functional maturation which proceed independently of the timing of neurogenesis, migration, and dendritic and axonal growth.

Biofeedback in the treatment of faecal incontinence.

Faecal incontinence is a distressing condition that affects approximately 1% of the population. Poor anal canal function can be determined by physiological testing using manometry and electromyographic techniques. Surgical repair of the anal canal does not always restore continence but biofeedback training either alone or in combination with other techniques such as muscle stimulation allows restoration of some degree of functional integrity of the anal canal musculature. Biofeedback training offers a non-surgical approach to incontinence with good success rates and prolonged after benefits. However, patient motivation is crucial as the exercise techniques taught need to be continued on a permanent basis if continence is to be maintained.

Oral delivery and clearance of antiplaque agents from Triclosan-containing dentifrices.

Oral delivery and clearance of Triclosan and zinc were studied following use of three commercially available Triclosan-containing toothpastes. One paste contained 0.3 per cent Triclosan and 2 per cent PVM-MA copolymer, one contained 0.3 per cent Triclosan and 5 per cent sodium pyrophosphate and the third contained 0.3 per cent Triclosan and 0.75 per cent zinc citrate trihydrate. Each gave similar total oral retention of Triclosan (37 per cent-46 per cent of the dose). However, clinically important product differences were observed in the salivary clearance of Triclosan and in Triclosan delivery to plaque. The Triclosan/zinc paste delivered more Triclosan to oral reservoirs (as measured by the area under the salivary clearance curve) than either the Triclosan/PVM-MA or the Triclosan/pyrophosphate paste (p < 0.001). The Triclosan/zinc paste produced higher Triclosan levels in plaque than the Triclosan/PVM-MA paste (109 micrograms/g versus 78 micrograms/g, p < 0.05). Zinc was effectively delivered to oral surfaces by the Triclosan/zinc paste, and was cleared more slowly than Triclosan (single-reservoir t1/2 = 50 min). After use of the Triclosan/zinc paste the zinc level in plaque was 153 micrograms/g, a seven-fold increase over the control. These results demonstrate that good delivery of Triclosan requires a highly optimised formulation. Furthermore, they suggest that the superior clinical effects of the Triclosan/zinc paste are due to a combination of superior delivery of Triclosan to oral sites of action together with effective delivery of a second, complementary antiplaque agent, zinc.

Cisplatin-MECY (methotrexate-leucovorin rescue plus cyclophosphamide) versus cisplatin-CHAD (cyclophosphamide, hexamethylmelamine, doxorubicin, and cisplatin) as initial chemotherapy in stage III-IV ovarian adenocarcinoma.

Thirty-three patients with advanced-stage ovarian adenocarcinomas, with no prior chemotherapy, were treated with weekly cisplatin (DDP) for four courses followed by five monthly courses of one of two randomly assigned multidrug combinations. These combinations were high-dose methotrexate-leucovorin plus cyclophosphamide (MECY) or cyclophosphamide, hexamethylmelamine, doxorubicin, and DDP (CHAD). Patients with no clinically measurable disease after 6 months of therapy were evaluated by laparoscopy. In the absence of disease progression at the time of the laparoscopy the study design called for a repeat cycle of four weekly DDP courses and another five monthly courses of the assigned multidrug combination. All patients with no evidence of disease after 1 year of treatment had a second-look laparoscopy which, if negative, was followed by a second-look laparotomy. This report includes all of the consecutively entered patients observed for a minimum of 1 year or to death. DDP-MECY and DDP-CHAD were similarly active for overall response rates and complete response rates according to laparoscopic criteria. However, DDP-MECY had a statistically significantly lower relapse rate (P less than 0.02) and a statistically significantly higher negative second-look laparotomy rate than did DDP-CHAD. Using all entered patients, with no exclusions from analysis, eight of 17 patients (47%) treated with DDP-MECY had negative second-looks after 1 year of treatment. This compares with one of 16 (6%) negative second-looks in patients treated with DDP-CHAD (P less than 0.02). The high negative second-look rate with DDP-MECY is exciting. Positive cytologic washings at the 6-month laparoscopic evaluation were highly predictive that residual disease would be found at the 1-year second-look surgery. Only one patient with positive peritoneal cytology after 6 months of treatment was found to have a negative second-look after 1 year of therapy.

Immunoreactive arginine-vasopressin in Brattleboro rat ovary.

Homozygous (di/di) Brattleboro rats have normal hypothalamic levels of oxytocin and neurophysin I, but undetectable levels of neurophysin II and arginine-vasopressin (AVP). This defect has been presumed to be at the genomic or transcriptional level, as AVP messenger is reported to be drastically reduced, if not absent, from the hypothalamus of Brattleboro rats. Recent studies suggest de novo production of various neuropeptides in the mammalian gonad, including AVP. We report here the detection and localization of immunoreactive (ir) AVP in the luteal cells of adult homozygous Brattleboro rats, and the modulation of this ovarian ir-AVP by gonadotropins. These findings are thus consistent with a tissue-specific defect of AVP expression in the magnocellular neurones of the Brattleboro rat, and suggest that a comparable defect does not occur in the ovaries of such animals.

Sotalol, hypokalaemia, syncope, and torsade de pointes.

Thirteen patients developed syncope and a prolonged QTc interval while taking therapeutic doses of sotalol. Polymorphous ventricular tachycardia was observed in 12 patients, and criteria typical of torsade de pointes were present in 10. In 12 patients sotalol had been given with hydrochlorothiazide in a combined preparation, Sotazide, but with inadequate or no potassium supplementation. Serum potassium concentrations were reduced in eight patients. Four patients were taking other drugs known to prolong the QT interval, including disopyramide (three patients) and tricyclic antidepressants (two patients). The QT interval returned to normal in all patients after withdrawal of the drugs and correction of the hypokalaemia. Thus even in low dosage sotalol may be hazardous in the presence of hypokalaemia or when combined with drugs that also prolong the QT interval. The use of sotalol concurrently with potassium losing diuretics, such as the combined preparation Sotazide, may expose the patient to unnecessary risk and should be avoided unless the class III antiarrhythmic action of this unique beta adrenoreceptor blocking agent is also required.

High-dose methotrexate with "RESCUE" plus cyclophosphamide as initial chemotherapy in ovarian adenocarcinoma. A randomized trial with observations on the influence of C parvum immunotherapy.

In a prospective randomized study, the chemotherapeutic combination of high-dose methotrexate-citrovorum factor rescue plus cyclophosphamide (MECY) has been shown to be statistically significantly superior to the combination of 5-fluorouracil plus cyclophosphamide (FUCY) in the treatment of Stage III-IV ovarian adenocarcinoma. With MECY, an overall objective remission rate of 67% and a complete remission rate of 48% were achieved. All patients had undergone no treatment except for surgery. In addition to the chemotherapy, patients were randomly allocated to receive or not receive nonspecific immunotherapy with Corynebacterium parvum; this immunotherapy had no apparent effect on the chemotherapeutic response. The study demonstrates a high degree of activity for the MECY regimen, and a comparison between the results with MECY in this study and melphalan in an earlier prospective randomized study provides statistical evidence favoring MECY over single-agent melphalan in the treatment of this disease.