Improving outcomes for amputees: The health-related quality of life and cost utility analysis of osseointegration prosthetics in transfemoral amputees.

AIM: Some amputees are unable to adequately ambulate using conventional socket prosthetics, osseointegrated prosthetics have been described as an alternative strategy in this patient group. This paper aims to assess the effect of osseointegrated prosthetics, commonly simply referred to as osseointegration, in transfemoral amputees on health-related quality of life and cost analysis. METHODS: Two centre analysis of patients receiving transcutaneous femoral osseointegration using The Osseointegration Group of Australia Osseointegration Prosthetic Limb (OGAP-OPL) implant. Retrospective health utility and cost analysis of prospectively collected patient reported health outcome data. Osseointegration cost was compared with the yearly cost of a poorly fitting conventional prosthetic determining cost/Quality Adjusted Life Year. RESULTS: Eighty amputees received osseointegration. Mean age was 39 years (range 20-57) and 66% were male (n = 53). The majority of subjects underwent unilateral (n = 62, 77.5%) rather than bilateral surgery (n = 18, 22.5%). Trauma was the most common indication (n = 59, 74%). Maximum follow up was 10.5-years. Mean preoperative EQ5D HUV in pooled data was 0.64 (SEM 0.025) increasing to 0.73 (0.036) at 5-years and 0.78 (0.051) at 6 years with continued improvement up to 10.5-years. In subgroup analysis those with a starting EQ5D HUV <0.60 reached a cost/QALY of <£30,000 at 5-years postoperatively and show statistically significant improvement in EQ5D HUV. The UK military experience was wholly positive with a mean starting EQ5D HUV of 0.48 (0.017) with significant (p < 0.05) improvement in EQ5D HUV at each time point and a resultant reducing cost/QALY at each time point being £28,616.89 at 5 years. CONCLUSION: There is both a quality of life and financial argument in favour of osseointegration in select patients with above transfemoral amputations. In those unable to mobilise satisfactorily with traditional prostheses and a pre-intervention score of <0.60, a consistent cost effectiveness and quality of life benefit can be seen. Such patients should be considered for osseointegration as these patients reap the maximum benefit and cost effectiveness of the device. This evidence lends strongly to the debate advocating the use of osseointegration through centrally funded resources, including the NHS.

Dietary Approach to Stop Hypertension with Sodium Reduction for Chinese Canadians (DASHNa-CC): A Pilot Randomized Controlled Trial.

BACKGROUND: There is a lack of culturally sensitive dietary interventions targeting Chinese Canadians despite unhealthy dietary behaviours being identified as the most important modifiable risk factor for hypertension in the Chinese population. AIMS: To determine the feasibility of a culturally sensitive dietary intervention for hypertension control; to examine the potential effects of the intervention on blood pressure and health-related quality of life among Chinese Canadians in community. METHODS: This study was a two-group pilot randomized controlled trial with 8 weeks follow up. Sixty self-identified Chinese Canadians, older than 45 years old and with grade one hypertension but not on antihypertensive medications were recruited in community. The control group received usual care and the intervention group received usual care plus newly developed DASHNa-CC intervention. The DASHNa-CC intervention consisted of a written manual, two classroom sessions, and one telephone booster call to provide healthy dietary and sodium reduction advice, integrated with Traditional Chinese Medicine food therapy recommendations for hypertension control. RESULTS: 618 Chinese Canadians participated in blood pressure screening, and 60 eligible participants recruited. Participants were highly satisfied with the intervention and adhered to the trial protocol. The lost to follow-up rate was 5%. At 8 weeks post-randomization, those in the intervention group had greater reductions in systolic blood pressure [3.8mmHg, t (55) = -1.58, p = 0.12] and higher physical health scores [t (55) = 2.13, p = 0.04] compared to those of the control group. There were no group differences in health care utilization. CONCLUSIONS: It is feasible to deliver the DASHNa-CC intervention in a Chinese Canadian community. The DASHNa-CC intervention may decrease blood pressure and improve health-related quality of life for Chinese Canadians.

2'-carboxy-D-arabitinol 1-phosphate protects ribulose 1, 5-bisphosphate carboxylase/oxygenase against proteolytic breakdown.

Trypsin-catalysed cleavage of purified ribulose 1,5-bisphosphate carboxylase/oxygenase (Rubisco) and the resultant irreversible loss of carboxylase activity were prevented by prior incubation with the naturally occurring nocturnal Rubisco inhibitor 2'-carboxy-D-arabitinol 1-phosphate (CA1P), as well as with ribulose 1,5-bisphosphate (RuBP), Mg2+ and CO2. CA1P also protected Rubisco from loss of activity caused by carboxypeptidase A. When similar experiments were carried out using soluble chloroplast proteases, CA1P was again able to protect Rubisco against proteolytic degradation and the consequent irreversible loss of catalytic activity. Thus, CA1P prevents the proteolytic breakdown of Rubisco by endogenous and exogenous proteases. In this way, CA1P may affect the amounts of Rubisco protein available for photosynthetic CO2 assimilation. Rubisco turnover (in the presence of RuBP, Mg2+ and CO2) may confer similar protection against proteases in the light.

The localisation of 2-carboxy-D-arabinitol 1-phosphate and inhibition of Rubisco in leaves of Phaseolus vulgaris L.

A recent controversial report suggests that the nocturnal inhibitor of Rubisco, 2-carboxy-D-arabinitol 1-phosphate (CAIP), does not bind to Rubisco in vivo and therefore that CA1P has no physiological relevance to photosynthetic regulation. It is now proved that a direct rapid assay can be used to distinguish between Rubisco-bound and free CA1P, as postulated in the controversial report. Application of this direct assay demonstrates that CA1P is bound to Rubisco in vivo in dark-adapted leaves. Furthermore, CA1P is shown to be in the chloroplasts of mesophyll cells. Thus, CA1P does play a physiological role in the regulation of Rubisco.

Conversion of D-hamamelose into 2-carboxy-D-arabinitol and 2-carboxy-D-arabinitol 1-phosphate in leaves of Phaseolus vulgaris L.

[1-14C]Hamamelose (2-hydroxymethyl-D-ribose) was synthesized by reaction of ribulose 5-phosphate with potassium [14C]cyanide, catalytic hydrogenation of the resulting cyanohydrin, and dephosphorylation of the product. Its identity was established by a chromatographic comparison with hamamelose isolated from the bark of witch hazel (Hamamelis virginiana L.). Following vacuum infiltration of the [1-14C]hamamelose into leaf discs from Phaseolus vulgaris L., 14C-labeled 2carboxy-D-arabinitol (CA) and 2-carboxy-D-arabinitol 1-phosphate (CA1P) were formed, in the dark. Conversion of hamamelose to both CA and CA1P in the leaf discs was inhibited by dithiothreitol and sodium fluoride, although at high concentrations of these inhibitors conversion into CA was still evident when conversion into CA1P was totally inhibited. Wheat (Triticum aestivum L.) leaves converted hamamelose into CA without formation of CA1P. Leaves from P. vulgaris contained 68 nmol.g-1 fresh weight of hamamelose in the light and 35 nmol.g-1 fresh weight in the dark. A pathway for the biosynthesis of CA1P from Calvin cycle intermediates is proposed which includes the sequence: hamamelose --> CA --> CA1P.

2-Carboxyarabinitol 1-phosphate (CA1P) formation through a phosphate exchange reaction catalysed by the CA1P phosphatase from French bean (Phaseolus vulgaris L.).

Transfer of the phosphate group of 2-carboxy-D-arabinitol 1-phosphate (CA1P) to 14C-labelled 2-carboxy-D-arabinitol (CA) was catalysed by extracts from leaves of Phaseolus vulgaris. This phosphotransferase activity co-purified with CA1P phosphatase, described previously. This activity was increased, up to 16-fold, by addition of bicarbonate ions at pH 9-10, suggesting rate enhancement by enzyme carbamylation. A V(max) of 1.5 mumol/min per mg of protein and a K(m) (for CA) of 1.8 mM were estimated for the exchange reaction, with the purified phosphatase. 2-Carboxy-D-arabinitol 1,5-bisphosphate and 2-carboxy-D-ribitol 1,5-bisphosphate, but not D-ribulose 1,5-bisphosphate, could replace CA1P as phosphate donor to [14C]CA.

Incorporation of carbon from photosynthetic products into 2-carboxyarabinitol-1-phosphate and 2-carboxyarabinitol.

The synthesis of 2-carboxy-D-arabinitol-1-phosphate (CA1P), the naturally occurring inhibitor of ribulose-1,5-bisphosphate carboxylase/oxygenase, was studied in leaves of the French bean Phaseolus vulgaris, L. Leaves were supplied with air containing 14CO2 in the light then the plants were transferred to normal air in the light or in the dark. Leaf samples were frozen in liquid nitrogen, ground to a powder and extracted with acid. Lipids, pigments and cations were removed from the extract and CA1P and 2-carboxy-D-arabinitol (CA) recovered by anion exchange chromatography. The CA1P was further purified by its specific binding to purified ribulose-1,5-bisphosphate carboxylase/oxygenase. CA and CA1P were identified by chromatographic properties and n.m.r. spectra. When plants were kept for 15 h in darkness after exposure to 14CO2, up to 2.2% and 5.5% of the radioactivity in the extracts was present in CA1P and CA, respectively. The most radioactivity appeared in these compounds when photosynthesis from 14CO2 took place at low photosynthetic photon flux density (PPFD). Under such conditions, radioactivity was detected in CA1P after only 10 min. During subsequent exposure to normal air (12CO2) at low PPFD the amount of radioactivity in CA1P remained almost constant for 6 h; in darkness the rate of incorporation of radioactivity into CA1P reached a maximum after 2 h and the radioactivity was still increasing 6 h later. At low PPFD, the amount of CA1P in the leaves reached a maximum after 2 h. In darkness, the amount of CA1P began to increase rapidly after a lag of almost 1 h, well ahead of the increase in radioactivity in CA1P.

Purification and properties of a phosphatase in French bean (Phaseolus vulgaris L.) leaves that hydrolyses 2'-carboxy-D-arabinitol 1-phosphate.

An enzyme that releases P(i) from 2-carboxy-D-arabinitol 1-phosphate, a naturally occurring tightly binding inhibitor of ribulose 1,5-bisphosphate carboxylase/oxygenase (EC 4.1.1.39), was purified from leaves of French bean seedlings. It was a monomeric protein of M(r) about 56,000. Catalytic activity was stimulated by increased concentrations of inorganic salts to a maximum at an ionic strength above 0.2. NADPH and D-fructose 1,6-bisphosphate increased the activity of the enzyme in both the presence and absence of 0.2 M-KCl. The pure enzyme did not require dithiothreitol for activity. The pH optimum was 7, the Km for 2-carboxy-D-arabinitol 1-phosphate was 0.43 mM and the specific activity 6.8 mumol/min per mg of protein. The enzyme had little or no activity against phosphate ester intermediates of photosynthetic metabolism and glycolysis but hydrolysed the 1,5-bisphosphates of 2'-carboxy-D-ribitol and 2'-carboxy-D-arabinitol more rapidly than 2'-carboxy-D-arabinitol 1-phosphate.

Discharge functional capacity and self-efficacy of men after coronary artery bypass graft surgery.

Fatigue and activity intolerance are reported to persist for several weeks after discharge after coronary artery bypass graft (CABG) surgery. This may be due to early discharge, which limits the time, prior to leaving hospital, to achieve an adequate functional level for the performance of many activities of daily living. Alternatively, it may be related to level of self-confidence, or self-efficacy (SE), in one's ability to perform physical activity. High SE may result in overexertion during the vulnerable, early post-discharge phase of recovery, whereas low SE may cause underexertion. The limited number of cardiac rehabilitation programs in Canada for this phase of recovery precludes close guidance and monitoring during physical activity for most patients. Prior to prescribing safe and effective home exercise at discharge, it is essential to assess functional level, cardiovascular responses to physical activity, and perceived level of confidence in ability to perform physical activity. The purpose of this descriptive study was to measure functional capacity, hemodynamic responses to low level exercise, and self-efficacy at discharge after CABG surgery. Twenty-one men completed a self-efficacy questionnaire (SEQ) and a low-level graded exercise test (LL-GXT) using a modified Naughton protocol, on the day of discharge. Results revealed that discharge functional capacity ranged from 1.0 METs to 4.3 METs, peak heart rate ranged from 82-150 beats.min-1, and peak systolic blood pressure from 114-200 mmHg. Subjects were more confident in their ability to tolerate psychological stressors than physical activity. Furthermore, there was no correlation between SE for physical activity and the physiological variables except HR.(ABSTRACT TRUNCATED AT 250 WORDS)

Oral ciprofloxacin therapy of infections due to Pseudomonas aeruginosa.

The efficacy and safety of oral ciprofloxacin, a fluoroquinolone, were evaluated in the treatment of infection due to Pseudomonas aeruginosa. 96 infections in 71 patients were treated. Substantial underlying disease was present in most of the patients, and 25 (35%) were seriously ill. 52% of pseudomonas isolates were carbenicillin-resistant, and 31% gentamicin-resistant. The overall clinical response rate was 77%-28 of 35 exacerbations of cystic fibrosis respiratory disease, 17 of 19 urinary infections, 4 of 6 osteomyelitis, and 11 of 15 soft tissue infections. The bacteriological cure rate was 34%-0 of 35 cystic fibrosis, 4 of 17 respiratory infections, 17 of 19 urinary infections, 4 of 6 osteomyelitis, and 8 of 15 soft tissue infections. Ps aeruginosa developed resistance to ciprofloxacin in 25 of 96 infections. Side-effects were generally slight with nausea in 14 (15%) the most common, and there were only two substantial superinfections.

Pseudomonas aeruginosa skin infections in persons using a whirlpool in Vermont.

Four guests at a ski resort in Vermont reported contracting a characteristic papular, pustular, or vesicular rash after using the resort's whirlpool. Pseudomonas aeruginosa serotype 1, bacteriophage type 86, was isolated from a pustule on one patient, water within the whirlpool, and the whirlpool diatomaceous earth filter. This appears to be the first outbreak of dermatitis associated with P. aeruginosa serotype 1. Previous reports of whirlpool-associated dermatitis outbreaks have identified serotype 9 and 11 isolates of P aeruginosa as the causative agents.

Ticarcillin for treatment of serious infections with gram-negative bacteria.

Ticarcillin, a semisynthetic penicillin, was evaluated in the treatment of 75 serious gram-negative infections, 50 of which were caused by Pseudomonas aeruginosa. The overall rate of response was 81%. Septicemia and urinary tract infections responded more frequently (93%) than infections of the lower respiratory tract (71%). Response to therapy was comparable to results achieved previously with larger doses of carbenicillin. Response was not correlated with levels of drug in serum. Patients with nonfatal underlying disease were the most likely to respond to treatment. Ticarcillin-resistant organisms were isolated during therapy in 39% of the cases, and superinfection occurred in 12%. Colonization with resistant organisms did nto correlate with success or failure of therapy, severity of underlying disease, or levels of ticarcillin in serum. The clinical response and incidence of colonization were not altered by concurrent use of gentamicin, nor was the development of superinfection affected. Combination of ticarcillin and gentamicin in treatment of 19 patients did not produce toxicity. Eosinophilia, phlebitis, and hypokalemia occurred, as seen with carbenicillin, but major toxicity was not encountered.