Water-based therapeutic exercise in stroke: a scoping review.

PURPOSE: To (1) describe the state of the literature on water-based therapeutic exercise (WBTE) for people living with stroke, (2) describe the content and structure of interventions, (3) summarize the effects of interventions described in the literature, and (4) identify gaps in the literature limiting application and implementation. MATERIALS AND METHODS: Scoping review methodology described by Arksey and O'Malley (2005) and Levac et al. (2010). Electronic databases were searched for articles with eligibility criteria including: (1) adult stroke survivors (18 years or older) of any type (ischemic/hemorrhagic) or stage (acute/chronic) in any setting, and (2) the study intervention involved WBTE to address a post-stroke deficit. RESULTS: 40 articles were included in this review. Five trials had a treatment control, 20 had an active comparison. Calculated intervention effect sizes demonstrated a strong effect of WBTE on balance and gait related outcomes in 80% of controlled and comparison trials. CONCLUSIONS: This scoping review highlights common parameters of WBTE interventions and provides an inventory of the differences in the treatment approaches utilized in this population. Opportunities for future work include the development of a standardized treatment protocol, qualitative or mixed methodology research, and greater inclusion of more individuals with more severe stroke-related impairments. IMPLICATIONS FOR REHABILITATIONWater-based therapeutic exercise is an approach that may allow stroke survivors to carry out challenging activities in a safe and accessible environment.Water-based interventions for stroke survivors appear to have a beneficial impact on walking and balance.Given that an aquatic environment offers an opportunity for individuals with more significant physical impairments to carry out early practice of walking and balance related tasks, clinicians should explore the feasibility and effectiveness for this subset of stroke survivors.

Sleep, physical activity, and psychological outcomes in children and adolescents with pediatric onset multiple sclerosis.

BACKGROUND: Sleep, physical activity (PA) and sedentary behavior (SED) have bidirectional associations with mental health in children. The relationships among sleep, PA, SED, with depressive and fatigue symptoms have not been investigated in Pediatric Onset Multiple Sclerosis (POMS) but are needed to inform sleep and PA behavior change interventions. OBJECTIVES: (1) To describe sleep quality including: sleep efficiency, latency, total sleep time, number of awakenings, time in bed, and wake after sleep onset using actigraphy in children and adolescents ages 11 to 18 diagnosed with POMS, and to compare these sleep metrics to those of an age- and sex-matched non-MS group (2) To examine the relationship between time spent in sedentary, light (LIPA), moderate and vigorous PA (MVPA), sleep quality, with depression, fatigue, and quality of life in children and adolescents with POMS and an age and sex matched non-MS group. METHODS: A cross-sectional study recruited children and adolescents with POMS ages 11 to 18 years followed at a tertiary pediatric hospital (Toronto, Canada) and an age and sex matched non-MS group from the general population. Participants were consented prior to initiation of study procedures. Participants wore an Actiwatch monitor and GT3X accelerometer and completed standardized questionnaires validated to capture data on sleep disturbances, depression, fatigue, and quality of life. Objective sleep data were collected using an Actiwatch including sleep efficiency, total sleep time, number of awakenings, wake after sleep onset (WASO), and sleep latency. A GT3X accelerometer was used to collect PA data including time spent in SED, light (LPA), and moderate to vigorous (MVPA) PA. Correlational analyses and tests of difference were used to compare the groups. RESULTS: 25 POMS (21F; 16.6 years ±1.1 yrs., median Expanded Disability Status Scale (EDSS) =1.5, IQR=1) and 25 Non-MS (22 F; 16±1.3 yrs.) took part. POMS had higher BMI (T= -5.1, P<0.001) compared to Non-MS. No differences in sleep efficiency (MS mean = 87%, vs. 88%) sleep time (MS Mean = 7.3 hrs. vs. 7.4 hrs.,), WASO (MS mean=37 mins. vs. 36 mins), latency (MS mean=15 mins vs. 11 mins), SED (MS mean =763 mins. vs. 730 mins) or PA (MS, mean LPA = 68 mins. vs 60 mins; MS mean MVPA = 12.7 mins. vs. 12.4 mins). Within POMS, higher sleep efficiency was associated with more SED (SR= 0.4, p = 0.05), while higher sleep efficiency was associated with less SED in Non-MS (SR = -0.7, p< 0.0). In children with POMS, less sleep time, shorter sleep onset latency and more WASO was associated with more SED (SR range = -0.45 to -0.58, P< 0.01). Higher sleep efficiency was associated with less fatigue. Less WASO was associated with lower depression, lower fatigue (SR = 0.67, p<0.01) and better quality of life (SR= -0.6, p<0.01). Greater LPA was associated with lower sleep onset latency (-0.45, p<0.05). CONCLUSIONS: Children with POMS did not differ in Actiwatch monitored sleep quality metrics. However, within the POMS group sleep quality was associated with better fatigue, depression and QOL. Further, total sleep time, WASO and latency associated with time spent SED and LPA, which independently associate with mental health outcome. Longitudinal work should determine the temporal associations between WASO, sleep latency, sleep time, PA, and mental health outcomes and whether reallocation of specific sleep or PA behaviors (time to sleep, total sleep time, sedentary to MVPA) result in improved depression fatigue, or quality of life in children and adolescents with POMS.

Navigating uncharted water: research ethics and emotional engagement in human inquiry.

Sensitive research necessitates routine ethical practices of confidentiality, anonymity and worthiness. However, when co-constructing narratives with participants, the nurse researcher also faces unexplored ethical issues that arise out of the emotional intensity and professional responsibility inherent in the relationship. Such issues may be recognized and managed using clinical supervision in addition to academic supervision. Researcher vulnerability adds depth and complexity to human inquiry.

The rights and responsibilities of citizenship for service users: some terms and conditions apply.

ACCESSIBLE SUMMARY: What is known about the subject? Citizenship is an important yet largely overlooked concept within psychiatric and mental health nursing practice Many service users are subject to legally mandated restrictions that place conditions on their rights and responsibilities as citizens. What this paper adds to existing knowledge? Even though service users have legal status as citizens, they continue to experience many conditions on their rights and responsibilities. Concerns about services users' trustworthiness and doubts about their levels of insight impact on their status as full citizens. What are the implications for practice? Nurses' understandings of the conditions placed on the citizenship rights and responsibilities of service users will ensure inclusive and less restrictive care and treatment Integration of the principles of therapeutic reciprocity and procedural justice within practice will help nurses balance both the rights of services users and legal restrictions on their liberty and autonomy INTRODUCTION: Service users have long been lobbying for equal participation as citizens, yet citizenship is an important and largely overlooked concept within nursing education and practice. AIMS: The study explored service users' understandings of their rights and responsibilities of citizenship and the conditions placed on these. METHODS: A total of 17 service users participated in semi-structured interviews. Isin's theory of the content of citizenship was used to analyze the data using a framework approach. RESULTS: Service users experience conditional citizenship that includes barriers to their participation and their rights and responsibilities that others in society enjoy. DISCUSSION: When the world of the service user is constructed through the language of the biomedical model, nurses may unwittingly reinforce psychiatric labels and thus perpetuate the stereotype that service users lack the competence to fully enact their rights and responsibilities. IMPLICATIONS FOR PRACTICE: When providing care, nurses should incorporate the notion of therapeutic jurisprudence and the principles of reciprocity, procedural justice and the implementation of advanced directives to reduce conditions on service users' status as citizens.

Complications of phenol neuroloysis.

Phenolic stellate ganglion blockade caused triparesis in one patient, and phenolic neurolysis of cervical posterior roots caused respiratory arrest in another. These complications illustrate the dangers of the spread of phenol beyond the intended site of neurolysis with resultant local anesthesia, direct neural damage, vascular damage, and infarcts.

Peripheral neuropathy with IgM kappa monoclonal immunoglobulin directed against myelin-associated glycoprotein.

Three patients with a monoclonal IgM kappa paraproteinemia had a slowly progressive segmental demyelinating peripheral neuropathy. Sural nerve biopsies showed predominantly large fiber loss, with widening of the intraperiod line of myelin associated with active demyelination. Immunoblot analysis showed reactivity of IgM to myelin-associated glycoprotein (MAG) of human myelin. An enzyme-linked immunosorbent assay (ELISA) was developed to provide a simple quantitative technique for detection of antibodies to MAG. Treatment with corticosteroids, immunosuppressive agents, and plasmapheresis produced no significant improvement.

Differential effects of diabetes on microsomal metabolism of various substrates. Comparison of streptozotocin and spontaneously diabetic Wistar rats.

We have examined the effect of recent onset diabetes on several aspects of hepatic microsomal metabolism in both streptozotocin (STZ)-induced and spontaneously diabetic BioBreeding (BB) male and female Wistar rats. Differential alterations of the diabetic state on hepatic microsomal enzyme activities were observed. Female diabetic rats exhibited no change in benzo [a]pyrene (BP) hydroxylase activity, a decrease in testosterone delta 4-hydrogenase, and an increase in aniline hydroxylase. On the other hand, male diabetic rats demonstrated a decrease in hepatic BP hydroxylase activity, no change in testosterone delta 4-hydrogenase, and an increase in aniline hydroxylase. Insulin treatment corrected these effects. No change in kidney BP hydroxylase activity was apparent in either female or male diabetics. There were no marked differences between the chemically induced and genetic models of diabetes with respect to the metabolism studies. Serum testosterone levels were significantly lower than control in male BB diabetics, whereas no change was apparent in female diabetics. Light microscopy and serum insulin determinations indicated that the spontaneously diabetic animals we examined were not severely diabetic. From electrophoresis of hepatic microsomal proteins we determined that spontaneous diabetes of short duration does alter the protein distribution in the cytochrome P-450 region. We conclude that the acute effects of STZ-induced and spontaneous diabetes on hepatic microsomal metabolism are quantitatively and qualitatively similar, despite probable differences in etiology of the diabetic state.

An institutional outbreak of Salmonellosis due to lactose-fermenting Salmonella newport.

An institutional outbreak of salmonellosis predominantly due to a lactose-fermenting Salmonella newport is described. Control of the outbreak was hampered by delay in the initial recognition of the aberrant strain. On primary culture, salmonellae were detected on bismuth sulfite agar only; colonies that formed on MacConkey agar and Salmonella-Shigella agar could not be differentiated from lactose-fermenting nonpathogenic organisms. The reactions in triple sugar iron were atypical for Salmonella. The lactose-fermenting property was plasmid-mediated and was readily transferable. Phage typing suggested chicken as a possible source of the strain. The need for awareness of the occurrence of such strains of Salmonella that may not be recognized by cultural procedures in common use, the necessity of the routine use of bismuth sulfite agar in procedures for isolation of salmonellae, and the use of lysine iron agar in conjunction with the triple sugar iron agar are emphasized.

Evidence that variation among untreated rabbits in hepatic progesterone 21-hydroxylase activity is indicative of enzyme heterogeneity rather than a transient inductive effect.

Previous work has shown that the 21-hydroxylation of progesterone in the hepatic microsomal fraction of outbred NZW rabbits varies over a tenfold range. In contrast, the 16-hydroxylase activity is relatively constant and is not correlated to the activity of the 21-hydroxylase. The distribution of the 21-hydroxylase activity is roughly bimodal with about one-third of the animals (21-H) exhibiting 21-hydroxylase activity exceeding 1 nmol/min/mg microsomal protein, whereas the remainder (21-L) generally exhibit an activity that is less than 1 nmol/min/mg protein. To determine if this was due to a transient phenomenon, liver punch biopsies were collected from 28 rabbits at intervals of approximately three weeks for at least three serial samples. The 21- and 16-hydroxylase activities were determined in the postmitochondrial fractions of these biopsy samples. A substantial variability in both 21- and 16-hydroxylase activities was observed for serial biopsy samples from individual rabbits. The variation of the 16-hydroxylase activity paralleled, however, that of the 21-hydroxylase, thus suggesting that the variation between biopsy samples for individual rabbits was due to factors such as contamination with blood and connective tissue, which would affect both activities equally. Rabbits, therefore, were phenotyped as 21-H or 21-L on the basis of the 21/16-hydroxylase ratio. The mean ratio was 3.2 +/- 1.2 and 0.8 +/- 0.3 for rabbits phenotyped as 21-H and 21-L, respectively. Similar values for this ratio were obtained for the other group of rabbits phenotyped as 21-H and 21-L, 3.8 +/- 1.6 and 0.5 +/- 0.2, respectively, following the isolation of microsomes from whole liver homogenates. The ratio of 21/16-hydroxylase activity was found to be relatively constant for biopsy samples obtained from the same animal over the course of this study, thus indicating that the elevated 21-hydroxylase activity is not a transient phenomenon.

Asperger's syndrome and autism: neurocognitive aspects.

The objectives of this study were to see: (1) whether children with Asperger's Syndrome (AS) have similar neurocognitive deficits compared to nonretarded, or high-functioning autistic (HFA) children; and (2) whether the essential cognitive deficit among these children is in language or abstract problem solving. Subjects with AS, HFA, and a control group of socially impaired child psychiatric outpatient controls (OPC) were compared on a battery of neuropsychological tests. The results indicated that the AS and HFA groups differed little but that large differences from the OPC were observed on all tests. When the AS and HFA with FSIQ above 85 were compared to the OPC, outstanding deficits on motor coordination, language comprehension, and facial recognition were observed. Finally, some evidence is presented to suggest that the pattern of deficits of AS and HFA subjects varied by developmental level. The implications of these results for a neurological theory of autism are discussed.

A post-mortem comparison of the cortical cholinergic system in Alzheimer's disease and Pick's disease.

Assessment of neurochemical markers in the frontal cortex indicates that choline acetyltransferase is significantly decreased in Alzheimer's and Gerstmann-Straussler dementias but not in Pick's dementia. It therefore appears that the cholinergic innervation of the cortex from the basal forebrain is intact in Pick's disease. Cortical somatostatin was decreased only in Alzheimer's disease (AD), indicating that loss of somatostatin is not a constant feature in different forms of dementia. Muscarinic binding sites were unaltered in Pick's disease and Gerstmann-Straussler syndrome but were decreased in a subpopulation of AD patients. These data suggest that in some cases of AD a significant loss of cholinoceptive neurones in the cortex is evident.

Cauda equina paraganglioma.

Two paragangliomas resected from the cauda equina had similar morphology, both containing cells having dense core secretory granules with no associated sustentacular or supporting cells. The cells were arranged in characteristic lobules that were surrounded by basement membrane and separated by a fibrovascular stroma. This tumor, although rarely found elsewhere in the central nervous system, does occur in the region of the filum terminale, and causes a clinical syndrome typical of tumors in that area.

Two forms of encephalitis in opportunistic toxoplasmosis.

Two adult patients receiving immunosuppressive therapy experienced toxoplasma cerebritis. In one, the brain findings were typical of this form of the disease in adults, but the clinical features and brain lesions of the other were atypical, and had some resemblance to those seen in congenital toxoplasmosis. It is suggested that two patterns of encephalitis can occur in opportunistic toxoplasma infections, a common form with random foci of gland necrosis associated with numerous intracerebral organisms, and another with vascular lesions and periventricular necrosis. The latter has morphologic features in common with congenital encephalitis, and may also have a similar pathogenesis.

Atypical vascular proliferation in benign soft tissue tumors.

Atypical endothelial proliferation and continuing growth of small vessels were found to be the main features of two benign soft tissue tumors. Lack of history of injury and insidious onset suggested neoplasia, but the morphology was that of a reactive rather than neoplastic process. Ultrastructural study of the relationship of the endothelial cells to one another and to perithelial cells was helpful in making this distinction. The process appeared to have begun in an organizing thrombus or hematoma, in one case in relation to an occluded artery, and in the other in an abnormally vascular area of skeletal muscle. It is known that endothelial hyperplasia can occur in reparative reaction of this type. The prominent muscular development of small vessels in the cases reported here suggests that abnormal flow or intraluminal pressure could have been a stimulant to atypical growth.

Endocardial fibroelastosis after replacement of mitral valves with tilting disk prostheses. A report of two cases.

Left ventricular endocardial fibroelastosis developed in two patients whose mitral valves were replaced by tilting disk prostheses. The distribution of the lesions was compatible with their being caused by a hemodynamic effect of the prosthetic valves. The fibroelastosis appeared to have been of no clinical importance in one patient, but in the other, the endocardial thickening was greater and was probably a factor in causing cardiac decompensation.

Long-term vocational functioning after severe closed head injury: a controlled study.

Vocational functioning at least 2 years postinjury was examined in a group of 57 severely closed-head injured (CHI) patients and 50 nonbrain-injured spinal-cord injured (SCI) patients. The two groups were equated on the following preinjury parameters: age, education, socioeconomic status (SES), male/female ratio, and marital status. The CHI and SCI patients had a similar number of members who were employed at follow-up. However, mean follow-up socioeconomic status was significantly lower in the CHI group and premorbidly employed CHI patients suffered a greater loss of SES than did premorbidly employed SCI patients. These results indicate that the degree of vocational impairment after severe CHI goes beyond impairment seen with another chronic disabling condition (i.e., SCI) that is associated with severe physical impairment but not neuropsychological impairment. In the CHI group, the following variables were all correlated with SES at follow-up: preinjury education, posttraumatic amnesia duration, degree of neuropsychological impairment soon after injury, and emotional adjustment at follow-up.

What determines the need for nursing home admission in a universally insured population?

OBJECTIVES: People in lower socio-economic groups are more likely to experience disability and cognitive impairments at earlier ages than those in higher status groups. As a result, the need for nursing home care would be expected to be greater among older people of lower socio-economic status. This study examines the effects of income and education on the probability of nursing home entry in a universally insured elderly population. METHODS: Using a prospective observational study design, a range of predictors of nursing home admission was examined over a three-year period in a representative sample of 7220 residents, aged 60 years or older, in a Canadian province. Individual census records and computerized administrative records of health care utilization were linked to form a database for analysis. RESULTS: An increased risk of institutionalization was associated with older age, male gender, unmarried status and self-reported disability. In addition, lower household income and lower attained education were independently associated with a higher risk of nursing home admission. CONCLUSIONS: These results emphasize the independent role of socio-economic status in accentuating or accelerating the need for institutional care towards the end of life. It is important that these effects are recognized in policies that determine the finance of both nursing home care and formal community-based supportive care.

Neuropsychological significance of variations in patterns of academic performance: verbal and visual-spatial abilities.

Forty-five 9- to 14-year-old children with learning disabilties whose WISC Full Scale IQs fell within the range of 86-114 were divided into three groups on the basis of their patterns of reading, spelling, and arithmetic achievement. Group 1 was composed of children who were uniformly deficient in reading, spelling, and arithmetic; children in Group 2 were relatively adept at arithmetic as compared to their performance in reading and spelling; Group 3 was composed of children whose reading and spelling performances were average or above, but whose arithmetic performance was relatively deficient. The performances of these children on 16 dependent measures were compared. The performances of Groups 1 and 2 were superior to that of Group 3 on measures of visual-perceptual and visual-spatial abilities; Group 3 performed at a superior level to that of Groups 1 and 2 on measures of verbal and auditory-perceptual abilities. The results are discussed in terms of the relationships between varying patterns of academic abilities and patterns of brain-related behaviors, and the nature of the neuropsychological abilities that may limit performance on arithmetic calculation tasks.

Intrasellar germinoma associated with hyperprolactinemia.

We report two young adult patients with hyperprolactinemia and neuroendocrine deficits due to predominantly intrasellar germinomas. In both cases the diagnosis of germinoma was confirmed histologically after transsphenoidal surgery. This very rare type of tumor may be intrasellar and it may mimic prolactinoma or craniopharyngioma. Dynamic testing of pituitary function and computed tomography scanning are of value in the early detection of this malignant but radiocurable lesion.

Electron microscopy in iris nevus syndrome.

In a patient with the clinical features of the iris nevus syndrome who was treated for glaucoma a cataract developed later. The sector of iris removed during cataract extraction was examined by electron microscopy and was found to be covered by ectopic corneal endothelium with an underlying atypical Descemet's membrane. Abnormalities in the iris included aggregates of melanophagic cells in the anterior stroma and fibrosis in relation to the ectopic endothelium. These findings suggest that many of the iris abnormalities seen in this disorder occur on a reactive basis.