Reduced mononuclear leukocyte ascorbic acid content in adults with insulin-dependent diabetes mellitus consuming adequate dietary vitamin C.

Several recent studies suggest that vitamin C (ascorbic acid [AA]) status may be altered in insulin-dependent diabetes mellitus (IDDM). We measured the AA content of mononuclear leukocytes (MN-AA) as an indicator of tissue vitamin C status in adults with IDDM and nondiabetic adults matched for age and sex. Dietary vitamin C intake and plasma AA were analyzed to ensure that vitamin C availability was adequate. Dietary vitamin C intakes were above recommendations and were not different between the groups. MN-AA was reduced by 33% on average (P less than .05) in adults with IDDM (1.75 microgram/mg total protein [TP]) when compared with nondiabetics (2.60 micrograms/mg TP). When MN-AA is indexed to the dietary vitamin C intake (MN-AA/100 mg diet C), the storage deficit in adults with IDDM averages 50% (P less than .05). This observation suggests an impaired tissue AA storage in adults with IDDM and supports the theory that intracellular scurvy contributes to the chronic degenerative complications of the disease.

Medial collateral ligament healing one year after a concurrent medial collateral ligament and anterior cruciate ligament injury: an interdisciplinary study in rabbits.

The optimal treatment for concurrent injuries to the medial collateral and anterior cruciate ligaments has not been determined, despite numerous clinical and laboratory studies. The objective of this study was to examine the effect of surgical repair of the medial collateral ligament on its biomechanical and biochemical properties 52 weeks after such injuries. In the left knee of 12 skeletally mature New Zealand White rabbits, the medial collateral ligament was torn and the anterior cruciate ligament was transected and then reconstructed. This is an experimental model previously developed in our laboratory. In six rabbits, the torn ends of the medial collateral ligament were repaired, and in the remaining six rabbits, the ligament was not repaired. Fifty-two weeks after injury, we examined varus-valgus and anterior-posterior knee stability; structural properties of the femur-medial collateral ligament-tibia complex; and mechanical properties, collagen content, and mature collagen crosslinking of the medial collateral ligament. We could not detect significant differences between repair and nonrepair groups for any biomechanical or biochemical property. Our data support clinical findings that when the medial collateral and anterior cruciate ligaments are injured concurrently and the anterior cruciate ligament is reconstructed, conservative treatment of the ruptured medial collateral ligament can result in successful healing.

Tensile and viscoelastic properties of human patellar tendon.

The tensile and viscoelastic properties of fresh-frozen, nonirradiated human patellar tendon were investigated in two groups of 15 specimens: one group was from individuals 29-50 years old and the other group was from individuals 64-93 years old. The central portion of each patella-patellar tendon-tibia complex was subjected to cyclic preconditioning, stress-relaxation, cyclic stress-relaxation, and load to failure tests. For each age group, stress-relaxation and stress-strain curves were obtained, from which percentage relaxation, ultimate tensile strength, strain at failure, modulus, and strain energy density were determined. Viscoelastic behavior was described with use of quasilinear viscoelasticity. The younger group showed a 46 +/- 9% (mean +/- SD) decrease in stress after 15 minutes, whereas the older group exhibited a 50 +/- 6% decrease. The values for ultimate tensile strength and strain at failure, respectively, were 64.7 +/- 15.0 MPa and 14 +/- 6% for the younger group and 53.6 +/- 10.0 MPa and 15 +/- 5% for the older group. Modulus values were 660 +/- 266 MPa for the younger group and 504 +/- 222 MPa for the older group. Except for ultimate tensile strength, which was 17% less for the older group than for the younger one, no statistically significant differences were found in tensile or viscoelastic properties. This study indicated that there were minimal differences in biomechanical properties of the substance of the patellar tendon between younger and older age groups.

Healing of the medial collateral ligament after a combined medial collateral and anterior cruciate ligament injury and reconstruction of the anterior cruciate ligament: comparison of repair and nonrepair of medial collateral ligament tears in rabbits.

The optimal treatment for a combined injury of the medial collateral and anterior cruciate ligaments is controversial, and the question remains as to whether repair of the medial collateral ligament and reconstruction of the anterior cruciate ligament improves healing of the medial collateral ligament. We compared reconstruction of the anterior cruciate ligament with and without repair of the medial collateral ligament in a rabbit model of a combined injury of these two ligaments. The anterior-posterior translation and varus-valgus rotation of the knee, the structural properties of the femur-medial collateral ligament-tibia complex, and the mechanical properties of the midsubstance of the medial collateral ligament were evaluated immediately after surgery and at 6 and 12 weeks postoperatively. Repair of the medial collateral ligament led to significantly less varus-valgus rotation of the knee than did no repair, but the anterior-posterior translation of the knees in the repair and nonrepair groups were not significantly different at any study time. At 12 weeks, the cross-sectional area and ultimate load in the repair group were 60 and 53% greater, respectively, than in the nonrepair group. Among 12 specimens that were repaired (six specimens at 6 weeks and six specimens at 12 weeks), failure occurred within the midsubstance in four (two at each time period); in all of the specimens that were not repaired, failure occurred at the tibial insertion site. There was no significant difference between the modulus of the modulus of the midsubstance in the repaired and the nonrepaired medial collateral ligaments.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of growth factors on matrix synthesis by ligament fibroblasts.

Although it has been reported that several growth factors modulate soft-tissue healing, the specific effects of growth factors on protein synthesis during ligament healing have not been widely investigated. In this study, we examined the effects of basic and acidic fibroblast growth factors, transforming growth factor beta 1, and epidermal growth factor on collagen and noncollagenous protein synthesis by cultured fibroblasts from medial collateral ligament and anterior cruciate ligament in vitro. Uptake of tritiated proline was used to measure synthesis of collagen and noncollagenous protein, and sodium dodecyl sulfate-polyacrylamide gel electrophoresis was used to analyze the type of collagens synthesized. Our data showed that transforming growth factor beta 1 increased both collagen and noncollagenous protein synthesis by medial collateral and anterior cruciate ligament fibroblasts on a dose-dependent basis. Collagen synthesis by cultured fibroblasts from the medial collateral and anterior cruciate ligaments was increased by treatment with transforming growth factor beta 1 by as much as approximately 1.5 times that of untreated controls. Although the response to transforming growth factor beta 1 by anterior cruciate ligament fibroblasts was equal to that by medial collateral ligament fibroblasts, the amounts of matrix proteins synthesized by anterior cruciate ligament fibroblasts were approximately half of that by medial collateral ligament fibroblasts. The increase was mostly in type-I collagen. Treatment of anterior cruciate ligament fibroblasts with epidermal growth factor increased collagen synthesis by approximately 25% but had little effect on medial collateral ligament fibroblasts. Neither basic nor acidic fibroblast growth factor increased either collagen or noncollagenous protein synthesis. These findings suggest that topical application of transforming growth factor beta 1, alone or in combination with epidermal growth factor, may have the potential to strengthen the ligament by increasing matrix synthesis during its remodeling and healing processes.

Culture-bound syndromes.

Since its inception, scholars have struggled with the concept of CBSs. This struggle is reflected in the continuing use of a term that is confusing and inaccurate. Most authors would agree that the term "culture-bound syndrome" was intended to describe forms of otherwise common mental illness that are rendered unusual because of the pathoplastic influence of culture. It was intended not only to describe specific syndromes, but also meanings of illness and non-Western notions of disease causation. The term has become an anachronism, for the word, "syndrome," implies specific disease entities, not illnesses of attribution of idioms of distress. Furthermore, the word "bound" implies that the entities described are restricted to a single culture. Close examination reveals that many of the so-called "culture-bound" syndromes are found in multiple cultures that have in common only that they are "non-Western." It may be unreasonable to expect one term to describe these different concepts. The most accurate of the designations offered might be "folk diagnostic categories." Perhaps the most difficult question remaining is "How can we understand (and classify) these phenomena in such a way that highlights their uniqueness but does not dismiss them as too rare and exotic to warrant attention?" The first step is to recognize that the CBSs are a heterogeneous group of conditions. We must next acknowledge that the concepts represented may be difficult for the average Western clinician to recognize but, in their respective cultures, are neither rare nor unusual. With 80% of our increasingly shrinking world coming from "non-Western" cultures, a familiarity with non-Western notions of disease causation is particularly important for modern clinicians. Many authors have recommended that those CBSs that are "true" syndromes be classified together with their Western counterparts. In order to do this, the folk labels need to be put aside and the fundamental components of each disorder examined. Each entity would have to be placed in the body of the classificatory manual, and defined by its symptoms, not by the fact that its form is highly influenced by culture.(ABSTRACT TRUNCATED AT 400 WORDS)

Identifying and assisting the impaired physician.

An impaired physician is one unable to fulfill professional or personal responsibilities because of psychiatric illness, alcoholism, or drug dependency. Current estimates are that approximately 15% of physicians will be impaired at some point in their careers. Although physicians may not have higher rates of impairment compared with other professionals, factors in their background, personality, and training may contribute and predispose them to drug abuse and mental illness, particularly depression. Many physicians possess a strong drive for achievement, exceptional conscientiousness, and an ability to deny personal problems. These attributes are advantageous for "success" in medicine; ironically, however, they may also predispose to impairment. Identifying impairment is often difficult because the manifestations are varied and physicians will typically suppress and deny any suggestion of a problem. Identification is essential because patient well-being may be at stake, and untreated impairment may result in loss of license, health problems, and even death. Fortunately, once identified and treated, physicians often do better in recovery than others and typically can return to a productive career and a satisfying personal and family life.

The clinical characteristics of possession disorder among 20 Chinese patients in the Hebei province of China.

OBJECTIVE: This paper describes the clinical characteristics of 20 hospitalized psychiatric patients in the Hebei province of China who believed they were possessed. METHODS: A structured interview focused on clinical characteristics associated with possession phenomena was developed and administered to 20 patients at eight hospitals in the province. All patients had been given the Chinese diagnosis of yi-ping (hysteria) by Chinese physicians before being recruited for the study. RESULTS: The subjects' mean age was 37 years. Most were women from rural areas with little education. Major events reported to precede possession included interpersonal conflicts, subjectively meaningful circumstances, illness, and death of an individual or dreaming of a deceased individual. Possessing agents were thought to be spirits of deceased individuals, deities, animals, and devils. Twenty percent of subjects reported multiple possessions. The initial experience of possession typically came on acutely and often became a chronic relapsing illness. Almost all subjects manifested the two symptoms of loss of control over their actions and acting differently. They frequently showed loss of awareness of surroundings, loss of personal identity, inability to distinguish reality from fantasy, change in tone of voice, and loss of perceived sensitivity to pain. CONCLUSIONS: Preliminary findings indicate that the disorder is a syndrome with distinct clinical characteristics that adheres most closely to the DSM-IV diagnosis of dissociative trance disorder under the category of dissociative disorder not otherwise specified.

HAART adherence in culturally diverse patients with HIV/AIDS: a study of male patients from a Veteran's Administration Hospital in northern California.

The objective of this study was to identify the factors that influence adherence to antiretroviral medication regimens in culturally diverse populations with human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) related to age, ethnicity, and intravenous drug use. The critical incident technique was used to identify factors determining adherence. Through a series of brief, focused interviews, patients were asked to recall specific incidents that affected their adherence to HIV medications. Patients' responses were grouped into categories using Ethnograph software. Two nurse experts, with 94% agreement, determined the reliability of the category listings. A chi(2) analysis compared the proportion of patients reporting each factor across age, ethnicity, and intravenous drug use categories. The total sample of 52 participants included 46 male outpatients with HIV/AIDS receiving care through a Veteran's Administration Hospital in northern California and 6 health care providers. The interviews yielded a total of 294 incidents. Six major categories were identified, and a taxonomy of critical factors determining highly active antiretroviral therapies (HAART) adherence was developed. The categories included reminders and cues (30%), planning (18%), response to HIV/AIDS (17%), HIV medication characteristics (14%), interactions with others (12%), and patient characteristics (10%). The two largest categories representing patient-related factors accounted for nearly half of the incidents. Patients most influenced by positive support from others included non-Caucasians, those under the age of 50 years, and those with fewer years of education. The taxonomy of adherence behaviors provides important information for developing culturally relevant patient adherence education programs and an essential foundation for developing future studies.

A cross-cultural review of sudden mass assault by a single individual in the oriental and occidental cultures.

A nonrandom sample of North American cases of sudden mass assault by a single individual (SMASI, n = 30) is compared with a nonrandom sample of Laotian amok cases (n = 18) and other amok studies. Perpetrators in both studies show evidence of social isolation, loss, depression, anger, pathological narcissism, and paranoia, often to a psychotic degree. The term "innovative perpetrator" is reintroduced and expanded upon. Similarities among samples far outweigh differences, leading the authors to conclude that SMASI and its appearance in different cultures is not a culture-bound syndrome.

The influence of the arts-and-crafts movement on the professional status of occupational therapy.

This paper explores why occupational therapists use arts and crafts as therapeutic modalities. Beginning with the turn-of-the-century origins of occupational therapy, the paper traces the similarities and differences in the ideas and beliefs of the founders of occupational therapy and the proponents of the arts-and-crafts movement.

The cultural aspects of home care delivery.

The home care therapist must create an occupational therapy program that stimulates the participation of the patient and the caretakers. This case study demonstrates the pervasive influence of culture on the patient's volitional, habituation, and performance subsystems. Careful analysis of human and nonhuman cues guide the therapist's goal and treatment decisions. As a participant observer, the therapist has the opportunity to enter the patient's world, adapt treatment to suit the patient's needs, and make occupational therapy a vital part of the recovery process.

A model to promote activity competence in elders.

This paper describes an occupational therapy home-based intervention in which purposeful activities were used to promote adaptation and competence in older adults with chronic disabilities. Seven home care therapists visited 17 randomly selected, community-living elders who were chronically disabled and who volunteered to participate in the program. The number of visits ranged from 3 to 10 and occurred over a 3-month period according to clients' needs and wishes. Therapists enhanced their ability to enter the client's social and cultural system by using participant-observation techniques and collaboratively identified activities. Therapists documented each home visit with a structured fieldnote form. An analysis of 112 field-notes indicated that therapists were able to understand a client's needs; this understanding resulted in small qualitative gains in areas identified as important by the client. Reilly's concept of an activity continuum was a useful framework from which to work with this population. The implications for program development, treatment outcomes, and accountability with this approach promote improved future treatment planning with the elderly with chronic disability.

Home adaptations for persons with chronic disabilities: an educational model.

This paper offers a method by which to train students in the provision of culturally relevant, in-home environmental adaptations for persons with chronic disabilities. On the basis of a theoretical framework, the student therapist learns about the client's life-style and offers adaptations that evolve from a collaborative problem-solving process. The training process has been developed and refined over a 3-year period. A case study illustrates the student's application of theory and practice and the outcome for the client of this service provision approach.

Power in the hypnotic relationship: therapeutic or abusive?

The unique relationship between hypnotist and subject has been theorized as one explanation for the effectiveness of hypnosis. This relationship carries a power differential, present in most therapeutic relationships, but accentuated by hypnosis. The power differential is sometimes perceived as the ability of the hypnotist to control the subject. Perceptions of hypnosis offered by stage hypnotists, the popular media, and some clinicians perpetuate the notion that the hypnotist has the ability to exert undue influence upon the client. The present article examines the relationship between hypnotist and subject focusing on issues of power and control. The authors examine the unique dynamics accompanying the use of hypnosis and their impact on the therapeutic dyad. Evidence is offered demonstrating the power differential, and how this differential can serve as either a positive or negative agent of change. Therapists should be aware of the dynamics created by using hypnosis. Implications for training therapists in the use of hypnosis are suggested.

A historical perspective on professional values.

This article demonstrates the use of historical research to improve present allied health practice. The relationship between social values and the emergence of occupational therapy during the progressive era (1890-1920) is explored. This energetic period of history provided an opportunity for physicians to assume social, moral, and scientific leadership in a society that longed for expert solutions to complex social problems. At the turn of the century, occupational therapy, physical therapy, medical social work, and speech therapy all expanded the influence of the physician's expertise. Occupational therapy was originally developed to care for chronically impaired individuals. The relationship established between the physician and the therapist over 75 years ago still influences the status of both professions today.