In search of Kipling's six honest serving men in upper limb rehabilitation: within participant case-crossover experiment nested within a web-based questionnaire.

PURPOSE: In search of Kipling's six honest serving men in upper limb rehabilitation after stroke, we sought to investigate clinicians' perspective of when and where to begin therapy, how much and what therapy to provide, and who and why (or not) to provide therapy.Materials & methods: Within-participant case cross-over experiments were nested within an anonymous web-based questionnaire (21 questions, three cases). Graph theory-based voting to produce ranked ordered lists and mixed-effect logistic regression were performed. RESULTS: In total, 225 Australian stroke clinicians responded: 53% occupational therapists, 61% working in acute/inpatient stroke setting. Most respondents indicated they did not have a protocol/expectation regarding when (62%), how much (84%) or what (60%) therapy to provide in their setting. Respondents ranked 24-h to 7-days post-stroke as the optimal time to commence therapy, and 30- to 60-min per day as the optimal dose to provide. Within-participant experiments demonstrated that greater motor recovery as time progressed increased the odds of offering therapy, while lack of motor recovery, shoulder pain, neurological decline and sole therapist reduced the odds. CONCLUSION: We need to develop an evidence base concerning Kipling's six honest serving men and equip clinicians with clinical decision-making skills aligned with this focus.IMPLICATIONS FOR REHABILITATIONMost clinicians did not have access to a protocol / clinical pathway which defines when, how much and what upper limb therapy to provide after stroke, which may be improved by providing individual clinicians with organisational support to make therapy decisions.To improve the personalisation of upper limb rehabilitation in clinical practice, we need to understand when and where after stroke to begin therapy, how much and what therapy to provide, as well as who and why (clinical decision-making) to provide therapy.Clinicians perceive clinical trials as successful if the therapy can demonstrate recovery that is greater than a minimal clinical important difference (MCID).

Outcomes of a 5-week individualised MDT outpatient (day-patient) treatment programme for functional neurological symptom disorder (FNSD).

AIM: We report results from a 5-week MDT treatment programme, with individualised sessions, for a selected group of patients with FNSD, delivered in a neuropsychiatric outpatient setting. Primary aims were to (1) reduce symptoms, (2) improve functional performance and (3) improve health status. METHODS: Treatment involved individual sessions of neuropsychiatry, cognitive behavioural therapy, physiotherapy, occupational-therapy, education and family meetings. Outcome measures collected at the beginning and end of treatment and at 6 months, were patient and clinician reported. Aims were assessed by the following: symptom reduction (PHQ15, PHQ9, GAD7, SPIN, Rosenberg); health and social functioning (HONOS, WSAS); functional performance (COPM); health status (EQ-5D-5L) and patient-rated perception of improvement (CGI). RESULTS: Analyses of 78 patients completing the programme and attending a 6-month review revealed high-baseline levels of disability compared to EQ-5DL population norms and high rates of disability and psychopathology as indicated by the WSAS and mental health indices (PHQ9, GAD7, SPIN, Rosenberg's self-esteem). At baseline, 92.3% met the IAPT caseness threshold for depression and 71% met the IAPT caseness threshold for anxiety. A Friedman ANOVA over the three time points and Dunn-Bonferroni post hoc tests indicated statistically significant improvements from admission to discharge and admission to 6-month follow-up. Sustained improvements were seen in somatic symptoms (PHQ15), depression (PHQ9), anxiety (GAD7), health and social functioning (HONOS), functionality (COPM), health status (EQ-5D-5L) and patient-rated clinical global improvement (CGI). CONCLUSION: An MDT can effectively deliver an outpatient programme for FNSD which can serve as an alternative to costlier inpatient programmes. Early identification and treatment of co-morbidities is advised.

White Matter Biomarkers Associated with Motor Change in Individuals with Stroke: A Continuous Theta Burst Stimulation Study.

Continuous theta burst stimulation (cTBS) is a form of noninvasive repetitive brain stimulation that, when delivered over the contralesional hemisphere, can influence the excitability of the ipsilesional hemisphere in individuals with stroke. cTBS applied prior to skilled motor practice interventions may augment motor learning; however, there is a high degree of variability in individual response to this intervention. The main objective of the present study was to assess white matter biomarkers of response to cTBS paired with skilled motor practice in individuals with chronic stroke. We tested the effects of stimulation of the contralesional hemisphere at the site of the primary motor cortex (M1c) or primary somatosensory cortex (S1c) and a third group who received sham stimulation. Within each stimulation group, individuals were categorized into responders or nonresponders based on their capacity for motor skill change. Baseline diffusion tensor imaging (DTI) indexed the underlying white matter microstructure of a previously known motor learning network, named the constrained motor connectome (CMC), as well as the corticospinal tract (CST) of lesioned and nonlesioned hemispheres. Across practice, there were no differential group effects. However, when categorized as responders vs. nonresponders using change in motor behaviour, we demonstrated a significant difference in CMC microstructural properties (as measured by fractional anisotropy (FA)) for individuals in M1c and S1c groups. There were no significant differences between responders and nonresponders in clinical baseline measures or microstructural properties (FA) in the CST. The present study identifies a white matter biomarker, which extends beyond the CST, advancing our understanding of the importance of white matter networks for motor after stroke.

Extraction of corticospinal tract microstructural properties in chronic stroke.

BACKGROUND: Information about the structural integrity of the corticospinal tract (CST) from diffusion-weighted imaging can improve our ability to understand motor outcomes in people with upper limb impairment after stroke, especially those with severe impairment. Yet, there is no consensus on which method of CST generation most accurately represents function and impairment in individuals with chronic stroke. NEW METHOD: The aim of the study was to compare different methods of CST reconstruction and resulting microstructural properties, as well as the relationship between these properties and motor function and impairment. Fifteen individuals with mild-moderate impairment and 15 with severe impairment who were in the chronic phase post-stroke underwent a diffusion-weighted imaging scan and motor function and impairment assessments. RESULTS: Different relationships existed between reconstruction methods, microstructural properties, and impairment and function. In severe stroke, fractional anisotropy (FA) emerged over and above apparent diffusion coefficient (ADC) and tract number to index CST integrity; FA correlated with impairment and function, whereas ADC and tract number did not correlate. No significant differences between methods or microstructural properties were found in mild-moderate stroke. COMPARISON WITH EXISTING METHODS: Our study demonstrates that CST reconstruction method influences the extraction of microstructural integrity in individuals with chronic severe stroke, with FA appearing to be the most representative method. A similar line of investigation is warranted earlier post-stroke. CONCLUSION: Differences in this data set highlight the need to establish a common methodology for CST reconstruction and analysis which may eliminate discrepancies in interpreting DWI and enhance biomarker use post-stroke for motor function.

Translationally controlled tumour protein (TCTP) is a novel glucose-regulated protein that is important for survival of pancreatic beta cells.

AIMS/HYPOTHESIS: This study used proteomics and biochemical approaches to identify novel glucose-regulated proteins and to unveil their role in pancreatic beta cell function. Translationally controlled tumour protein (TCTP) was identified to be one such protein, and further investigations into its function and regulation were carried out. METHODS: Global protein profiling of beta cell homogenates following glucose stimulation was performed using two-dimensional gel electrophoresis. Proteins were identified by mass spectroscopy analysis. Immunoblotting was used to investigate alterations in TCTP protein levels in response to glucose stimulation or cell stress induced by palmitate. To investigate the biological function of TCTP, immunolocalisation, gene knockdown and overexpression of Tctp (also known as Tpt1) were performed. Apoptosis was measured in Tctp knockdown or Tctp-overexpressing cells. Glucose-stimulated insulin secretion was carried out in Tctp knockdown cells. RESULTS: TCTP was identified as a novel glucose-regulated protein, the level of which is increased at stimulatory glucose concentration. Glucose also induced TCTP dephosphorylation and its partial translocation to the mitochondria and the nucleus. TCTP protein levels were downregulated in response to cell stress induced by palmitate or thapsigargin treatments. Gene knockdown by small interfering RNA led to increased apoptosis, whereas overproduction of TCTP prevented palmitate-induced cell death. CONCLUSIONS/INTERPRETATION: Regulation of TCTP protein levels by glucose is likely to be an important cyto-protective mechanism for pancreatic beta cells against damage caused by hyperglycaemia. In contrast, high concentration of palmitate causes cell stress, reduction in TCTP levels and consequently reduced cell viability. Our results imply that TCTP levels influence the sensitivity of beta cells to apoptosis.

Factors affecting pre-ovulatory follicle diameter in the mare: the effect of mare age, season and presence of other ovulatory follicles (multiple ovulation).

The importance of elucidating factors affecting reproductive performance and efficiency is of paramount concern to the equine industry. Oocyte viability is known to be one of the determinants of reproductive success and evidence suggests that it may be linked to follicle size. The aims of this study were, therefore, to ascertain: i) the average diameter and range of pre-ovulatory follicles in Thoroughbred mares; ii) whether this is affected by either mare age, time within the breeding season, or the presence of multiple pre-ovulatory follicles (MO). One thousand, four hundred and ninety two Thoroughbred mares, aged 2-26 years, were examined with ultrasound to ascertain ovulation date to within 24h, and pre-ovulatory follicle(s) (F1) diameter. Mares were divided into groups according to age (7 groups, 2-4 yr, 5-7 yr, 8-10 yr, 11-13 yr, 14-16 yr, 17-19 yr, >19 yr), time within the season (16 half-month groups, from Feb 1(st) to Sept 30(th)), and pre-ovulatory follicles (single, {SO} or multiple {MO}). Overall average F1 diameter was 39.95 ± 4.84 mm (range 22-50 mm). Mare age had a significant (P < 0.001) negative effect on F1 diameter (largest F1 38.95 ± 5.61 mm, mares 2-4 yrs; smallest F1 33.30 ± 4.66 mm, mares >19 yrs) as did season (largest F1 44.20 ± 3.95 mm, Feb 1(st)-14(th); smallest F1 33.74 ± 4.87 mm, Aug 15(th)-31(st)) and the presence of more than one pre-ovulatory follicle (MO F1 35.45 ± 4.53 mm; SO F1 37.44 ± 4.84 mm). In conclusion older mares, bred towards the end of the breeding season, especially if MO were present, were more likely to ovulate from smaller follicles. If, as suggested, small pre-ovulatory follicle size is associated with low oocyte viability, then this may account, at least in part, for the poor fertility rates characteristic of older MO mares, bred later in the season and so justify increased monitoring and careful reproductive management of such mares.

Paradigma de paz para conflictos por el agua

La presión sobre los recursos hidricos seguramente se incrementará durante las proximsa decadas, pero la humanidad tiene una historia de cooperacion mas que de lucha sobre este recurso. No obstante, se estan realizando esfuerzos conjuntos para construir un "paradigma de paz" en donde la resolucion de los conflictos por el agua, conduzca a la cooperación. Este artículo, brinda un amplio panorama sobre el tema

Paradigma de paz para conflictos por el agua

La presión sobre los recursos hidricos seguramente se incrementará durante las proximsa decadas, pero la humanidad tiene una historia de cooperacion mas que de lucha sobre este recurso. No obstante, se estan realizando esfuerzos conjuntos para construir un "paradigma de paz" en donde la resolucion de los conflictos por el agua, conduzca a la cooperación. Este artículo, brinda un amplio panorama sobre el tema

Long-term neurobehavioral outcomes in children with neuroblastoma and opsoclonus-myoclonus-ataxia syndrome: relationship to MRI findings and anti-neuronal antibodies.

OBJECTIVES: Opsoclonus-myoclonus-ataxia (OMA) syndrome affects 2% to 3% of patients with neuroblastoma. This study examined relationships between long-term neurobehavioral outcomes and potential biologic markers of OMA, including chronic changes on magnetic resonance imaging (MRI) brain scanning and prevalence of late antineuronal antibodies. STUDY DESIGN: Children with neuroblastoma and OMA were identified through medical record review of patients treated at the University of California at San Francisco Medical Center from 1979 to 1999. Eleven patients with a mean follow-up time of 7.6 years underwent standard neurologic, neurocognitive, developmental/behavioral, and academic assessments. Consenting patients underwent MRI brain scanning and a blood draw. Sera were analyzed for the presence of antineuronal immunoreactivity. RESULTS: Two (18%) patients had no observed neurologic abnormalities, 7 (64%) demonstrated mild deficits, and 2 (18%) had severe neurologic deficits. However, on neurocognitive, behavioral, and academic assessments, 6 (55%) children performed within the average range, 1 (9%) was moderately below average and 4 (36%) had severe cognitive and behavioral deficiencies. Brain MRI in 5 of 5 patients was notable for cerebellar atrophy without supratentorial involvement. Antineuronal activity was detected in sera of 0 of 10 children at follow-up. CONCLUSIONS: Certain patients with neuroblastoma associated OMA may achieve average-range neurobehavioral function in spite of residual neurologic abnormalities, with suggestion of continued improvement over time. Late cerebellar atrophy appears to be a common finding regardless of neurologic outcome, whereas antineuronal immune reactivity does not appear to be a long-term feature of OMA.

Hemostatic effects of antithrombin III supplementation during cardiac surgery: results of a prospective randomized investigation.

Failure to suppress thrombin generation during cardiac surgery promotes fibrin generation, fibrinolysis, and a consumptive coagulopathy. Acquired deficiencies of antithrombin III may play a contributory role. We hypothesized that antithrombin III supplementation to normal physiologic concentrations would decrease thrombin generation and potentially reduce peri-operative bleeding. Twenty patients undergoing coronary artery bypass graft surgery were randomized for this prospective, double-blind, placebo-controlled study. Ten patients received antithrombin III supplementation (50 U/kg) by intravenous infusion prior to incision, and 10 patients received a placebo. Blood samples were obtained pre-operatively, at 1 and 2 h following initiation of cardiopulmonary bypass (CPB), and at 1, 3, and 24 h after completion of CPB. Samples were analyzed for antithrombin III, thrombin-antithrombin III (TAT) complex, and D-dimer concentrations. Cumulative blood loss was recorded at 6 and 12 h after CPB. No statistically significant differences in patient demographics or total heparin dose administered were observed between groups. As expected, plasma antithrombin III concentrations were maintained near pre-operative values in the treatment group, but not in the placebo group. Despite this difference, no statistically significant alterations in generation of TAT complex, D-dimer, or blood loss occurred between groups. Antithrombin III supplementation to maintain normal physiologic concentrations during CPB did not alter significantly thrombin generation, fibrinolytic activity, or blood loss in adults undergoing elective cardiac surgery.

Interdisciplinary action supporting sexual assault prevention efforts in rural elementary schools.

The purpose of this study was to evaluate if knowledge is gained by rural, elementary school-aged children of sexual assault prevention concepts following implementation of an interdisciplinary prevention program. Rural children (N = 294 pretest and N = 301 posttest) were tested before and after delivery of a theater program developed for teaching sexual assault prevention concepts. The program was delivered to children enrolled in the 3rd and 4th grades of 3 rural elementary schools. Analysis of variance results indicate an increase in knowledge gained in all age groups. Significant difference in knowledge gained occurred in concept areas related to touch by authority figures, secrets, uncomfortable touch by individuals known to them, strangers, and boys' risk of abuse. Results support the need for ongoing interdisciplinary efforts to teach children sexual assault prevention concepts.

The process of restructuring and the treatment of obesity in women.

Obesity is a prevalent health behavior that is difficult to treat because of its complexity, constraints on provider time, and negligible insurer reimbursement. In this comparative case study the authors describe two obese women's weight loss and lifestyle change efforts while enrolled in a nine-month, multidisciplinary weight loss program. The researchers conducted three semistructured interviews during six months. Eight major themes were identified: (1) support networks. (2) internalization/externalization, (3) routines, (4) relapse, (5) change in perspective, (6) reward/punishment, (7) emotional issues, and (8) life balance. These themes parallel Johnson's three-stage theory of cognitive restructuring. (See Johnson, 1990, "Restructuring: An Emerging Theory on the Process of Losing Weight." Journal of Advanced Nursing, 15, 1289-1296.) Researchers reveal that complex health problems are replete with social and psychological factors that may undermine treatment success. Understanding a client's experience while attempting behavior change is crucial for the development of interventions that address difficult and costly health behaviors.

Bilateral synchronous tonsillar carcinoma.

Synchronous cancers occur in four per cent of patients with head and neck malignancies but no bilateral synchronous tonsillar carcinomas have been described in the English literature. We describe the first such case and discuss the prognostic aspect of this carcinoma. In the presence of contralateral neck nodes in patients with head and neck malignancies, a careful search should be made for a second head and neck primary.

Part-time residency training in internal medicine: analysis of a ten-year experience.

PURPOSE: To evaluate a ten-year experience (1983-1993) with a part-time residency curriculum. METHOD: In 1994, the authors analyzed the curriculum through interviews with graduates of a part-time residency track, surveys of faculty and graduates of a full-time residency program, and a quantitative comparison of faculty evaluations of those part-time and full-time residents. RESULTS: Both participants and full-time residents supported the part-time track and reported no adverse effect on the residency program as a whole. Analysis of faculty evaluations found that part-time residents scored significantly higher with respect to clinical skills (p = .0005) and humanistic skills (p = .0001), while there was no difference between the groups in leadership or teaching skills. CONCLUSIONS: This part-time residency curriculum provided a highly useful program track for a group of internal medicine residents with concomitant obligations, allowing them to complete their training in an uninterrupted fashion. The part-time structure did not adversely affect clinical competence and may have fostered humanistic attributes. The authors believe that this form of curriculum deserves wider consideration in residency training.

Endoscopic versus open saphenous vein harvest: the effect on postoperative outcomes.

BACKGROUND: Endoscopic vein harvest (EVH) has been promoted as a possible solution to the wound complications, incisional pain, and prolonged convalesce associated with open vein harvesting (OVH). The purpose of this study was to objectively compare the two techniques. METHODS: One hundred patients were prospectively randomized to EVH or OVH. Primary outcomes were wound complications, pain (Medical Outcomes Study Pain Survey), and general health (SF-12). Secondary outcomes were operative times and patient preferences. Patients were assessed at hospital discharge, 3, and 6 weeks postdischarge. RESULTS: No significant differences were detected in the primary outcomes: leg infection (p = 0.75), incisional pain (p = 0.74), physical health (p = 0.84), mental health (p = 0.47), and postoperative length of stay (p = 0.74). However, patient preference for EVH was highly significant (p < 0.01). CONCLUSIONS: EVH does not demonstrate significant differences compared with OVH. This, coupled with higher operating room costs, should limit its use until clinical benefit is shown. However, strong patient preference and demand for EVH overshadow equivocal clinical outcomes.

Patient-held oncology records.

Here, the author describes how an information booklet for oncology patients was developed. The booklet's positive reception suggests that the idea could be used in other settings.

Changes in student perceptions of interdisciplinary practice in the rural setting.

This study examined whether students' professional perceptions of interdisciplinary practice change following participation in a planned interdisciplinary experience in the rural setting, relative to their own profession and other health related disciplines. Data were collected from students enrolled in varied academic programs who participated in planned interdisciplinary experiences in the care of patients while in the clinical area through the Idaho Rural Interdisciplinary Training Project. Repeated measures multivariate and univariate analysis of variance revealed a significant change in students' perceptions of professional competence and autonomy of other disciplines and their own following the interdisciplinary experience in the clinical area. The data also revealed a significant change in students' perceptions at the completion of their clinical rotation of actual cooperation and resource sharing within and across professions. There was a significant gender effect and pretest to post-test effect following the interdisciplinary experience in the rural setting.