Exercise participation barrier prevalence and association with exercise participation status in individuals with spinal cord injury.

STUDY DESIGN: Pass-code protected web survey. OBJECTIVES: Defining exercise participation barrier prevalence and association with exercise participation status in adults with spinal cord injury (SCI). SETTING: World-wide web. METHODS: Individuals ≥18 years with ShCI in the United States completed a pass-code protected website survey (N=180). Odds ratios (OR) and OR 95% confidence interval (95% CI) assessed association between barrier presence and exercise participation. RESULTS: No differences existed between exercisers and non-exercisers with respect to age, gender, injury level, injury duration, education level, or employment status. A larger percentage of non-exercisers reported household annual incomes <$7,500. The five most prevalent barriers were not associated with participation status (all OR 95% CI included 1). Low prevalence (≤13%) characterized four of the five barriers most strongly related to being a non-exerciser. Identifying too lazy, too difficult, or no interest as a barrier decreased odds of being an exerciser by 86%, 83%, and 71%, respectively. Not liking exercise decreased the odds of being an exerciser by 90%. CONCLUSION: Highly prevalent barriers were not associated with exercise participation status, whereas low prevalence barriers were strongly related to being a non-exerciser. Internal barriers had the strongest association with exercise participation status. The possible association between socioeconomic factors and exercise participation may be underappreciated. The most effective interventions to increase exercise participation may be multifocal approaches to enhance internal perceptions about and motivation to exercise, increase knowledge of how and where to exercise, while also reducing program and transportation financial costs.

Fatty acids and the control of bilirubin levels in blood.

The evidence that changes in the hepatic intracellular concentration of non-esterified fatty acids affect the clearance of bilirubin from blood by the liver is reviewed. Such a mechanism would in particular explain the rise in plasma bilirubin levels during fasting.

Double-blind comparison of olsalazine and sulphasalazine in active ulcerative colitis.

Fifty-six patients with ulcerative colitis of mild to moderate severity were entered into a randomized, double-dummy comparison of sulphasalazine, 3 g/day, with olsalazine, 3 g/day. Patients were assessed clinically, and by sigmoidoscopy and biopsy, on entry and at 5 weeks. Both agents produced a similar reduction in stool frequency and in the passage of blood and mucus. Improvements in sigmoidoscopic and histological appearances of the rectal mucosa were observed to a similar extent in both groups of patients. Two patients treated with olsalazine were withdrawn because of increased diarrhoea attributable to the medication. Two patients given sulphasalazine for the first time developed a skin rash. Other side-effects seen during the trial were mild. In this small short-term study, oral olsalazine appeared to be as effective as sulphasalazine in the treatment of mild to moderate ulcerative colitis.

5-amino-salicylate in the management of inflammatory bowel disease.

The role of aminosalicylates in the treatment of idiopathic bowel disease is reviewed, with emphasis on how the different formulations can be used in different clinical manifestations. Although not fully understood, the possible mechanisms of action of these agents are discussed and their adverse reactions noted. Their use in clinical practice, both in acute disease and in remission, is outlined with particular reference to the different delivery characteristics of the aminosalicylates, thus allowing their use according to the distribution of the disease. Finally, benefits that might come from maintenance therapy, including possible reduction in post-operative recurrence of Crohn's disease and the risk of colorectal cancer are mentioned.

Dapsone and severe hypoalbuminaemia in dermatitis herpetiformis.

A case of severe hypoalbuminaemia in a patient on long-term dapsone treatment for dermatitis herpetiformis is described. The mechanism for this complication is uncertain, but increased intravascular albumin catabolism has been suggested.

Effects of anesthetic agents and abdominal surgery on liver blood flow.

The cause of postoperative liver dysfunction is often unclear, but a decrease in liver blood flow during anesthesia and/or major surgery may be important. Plasma half-life and clearance of indocyanine green were therefore measured in 42 patients before, during and after anesthesia and abdominal surgery. In 13 patients, liver blood flow was also estimated from indocyanine green extraction using hepatic vein catheterization. The major finding was an early decrease in estimated liver blood flow after induction of anesthesia, but not later during or after surgery. Mean indocyanine green half-life increased by 26% (p less than 0.005), mean indocyanine green plasma clearance decreased by 19% (p less than 0.01) and mean estimated hepatic blood flow decreased by 36% (p less than 0.005) during the first 30 min of anesthesia. These changes were greater in males and in patients older than 55 yr, but changes were similar with each of three anesthetic groups. Half-life, but not indocyanine green clearance, was also significantly prolonged by mid-operation in the older (greater than 55 yr) patients and in those undergoing lower abdominal surgery. We suggest that this period of reduced liver blood flow during anesthesia is caused by the effects of neuromuscular blocking agents and may contribute to postoperative liver damage.

Polyarteritis nodosa of the liver: a report of two cases.

Two patients with liver disease due to polyarteritis nodosa are described. They presented in a similar manner, with a swinging fever, a polymorphonuclear leucocytosis and high alkaline phosphatase levels, but the natural history of the illness was different, with revocery in one and death in the other.

The association between fasting hyperbilirubinaemia and serum non-esterified fatty acids in man.

1. The concentrations of plasma total and unconjugated bilirubin and of serum nonesterified fatty acids (NEFA) have been measured in two healthy subjects during fasts of up to 21 h. 2. Fasting was either continuous or interrupted by various procedures that altered the concentrations of NEFA and total bilirubin. 3. When NEFA concentrations were increased by the administration of noradrenaline, heparin or caffeine, bilirubin concentrations also rose. 4. When NEFA concentrations were lowered by insulin, bilirubin concentrations fell. 5. Meals of 3-138 kJ and more, taken during the fasting period, lowered total bilirubin and NEFA concentrations in both subjects, whereas the effects of smaller meals were less consistent. 6. These studies demonstrate a statistically significant correlation between total bilirubin and NEFA during uninterrupted fasting and an association between these variables under other experimental conditions. They suggest that the control of bilirubin concentrations in the blood is linked to lipid metabolism.

Plasma bilirubin and serum free fatty acids after myocardial infarction.

Fasting concentrations of plasma bilirubin were measured in 34 patients on admission to hospital and daily for 7 days after uncomplicated myocardial infarction. Mean concentrations increased significantly to reach maximum levels on the second day after admission, and fell during the following 5 days to reach the admission level by the 7th day. Unconjugated bilirubin accounted for most of this rise. Serum concentrations of free fatty acids (FFA), measured simultaneously in 12 patients, were highest within 12 hr of the onset of symptoms, when their level was significantly higher than at any time after the first day. It is suggested that the transient hyperbilirubinaemia after uncomplicated myocardial infarction is frequent and may result from interference by FFA with bilirubin metabolism.

Patients appreciate premedication for endoscopy.

Upper gastrointestinal endoscopy without sedation by means of a small diameter (9 mm) instrument is feasible but patients often remember the procedure as unpleasant, do not wish to have it repeated, and compare it unfavourably with a barium meal. In contrast, endoscopy with a larger instrument (13 mm) after diazepam sedation is usually well tolerated and often regarded as no more uncomfortable than a barium meal. Even when a narrow instrument is used, patients still benefit from premedication with diazepam, although return to normal activity is slower because of drowsiness.

Aldehyde disinfectants and health in endoscopy units. British Society of Gastroenterology Endoscopy Committee.

Summary of main recommendations(1) Glutaraldehyde, used in most endoscopy units in the United Kingdom for the disinfection of flexible gastrointestinal endoscopes, is a toxic substance being an irritant and a sensitiser; symptoms associated with glutaraldehyde exposure are common among staff working in endoscopy units.(2) The Control of Substances Hazardous to Health Regulations 1988 (COSHH) obliges the employer to make a systematic assessment of risk to staff of exposure to glutaraldehyde and institute measures to deal effectively with exposure.(3) At present glutaraldehyde remains the first line agent for the disinfection of flexible gastrointestinal endoscopes. Other agents are being developed; a standard means of assessment for flexible endoscope disinfectants should be devised.(4) Equipment and accessories that are heat stable should be sterilised by autoclaving; disposable accessories should be used wherever possible.(5) Flexible gastrointestinal endoscopes should be disinfected within automated washer/disinfectors; trays, bowls or buckets for this purpose are unacceptable.(6) Local exhaust ventilation must be used to control glutaraldehyde vapour. Extracted air may be discharged direct to the atmosphere or passed over special absorbent filters and recirculated. Such control measures must be regularly tested and records retained.(7) Endoscope cleaning and disinfection should be carried out in a room dedicated to the purpose, equipped with control measures to maintain the concentration of glutaraldehyde vapour at a level certainly below the current occupational exposure standard of 0.2 ppm and preferably below the commonly used working limit of 0.1 ppm. Sites other than the endoscopy unit where endoscopy is regularly performed, such as the radiology department, should have their own fully equipped cleaning and disinfection room.(8) COSHH limits the use of personal protective equipment to those situations where other measures cannot adequately control exposure. Such equipment includes nitrile rubber gloves, apron, chemical grade eye protection, and respiratory protective equipment for organic vapours.(9) Monitoring of atmospheric levels of glutaraldehyde should be performed by a competent person such as an occupational hygienist; the currently preferred method of sampling uses a filtration technique, the commercially available meters being less reliable.(10) Health surveillance of staff is mandatory; occupational health records must be retained for 30 years.(11) Endoscopy staff must be informed of the risks of exposure to glutaraldehyde and trained in safe methods of its control. Only staff who have completed such an education and training programme should be allowed to disinfect endoscopes.(12) The unsafe use of glutaraldehyde has significant health and legal consequences; the safe use of glutaraldehyde may have revenue consequences that contribute significantly to the cost of gastrointestinal endoscopy.

Treatment of active Crohn's disease by exclusion diet: East Anglian multicentre controlled trial.

Elemental diet is as effective in producing remission of Crohn's disease (CD) as is corticosteroid treatment, but most patients relapse soon after resumption of a normal diet. We have investigated the efficacies of dietary modification and oral corticosteroids in maintaining remission achieved with elemental diet. In a multicentre trial, 136 patients with active CD were started on elemental diet and other treatment was withdrawn. 43 (31%) declined to continue elemental diet for 14 days, but 78 (84%) of the remaining 93 achieved remission and were randomly assigned corticosteroids (38) or diet (40). Corticosteroid treatment started at 40 mg prednisolone daily, which was tapered and stopped after 12 weeks; that group received dietary advice on healthy eating. The diet group received "tapered" placebo and were instructed to introduce one new food daily, excluding any that precipitated symptoms. Assessment of progress for up to 2 years was made by physicians unaware of group assignment. Intention-to-treat analysis showed median lengths of remission of 3.8 (interquartile range 5.0) months in the corticosteroid group and 7.5 (15.3) months on diet, and relapse rates at 2 years, adjusted for withdrawals, of 79% and 62%, respectively (p = 0.048). Clinical improvement in the diet group was associated with significant changes in plasma albumin and alpha 1-antichymotrypsin concentrations and erythrocyte sedimentation rate. Food intolerances discovered were predominantly to cereals, dairy products, and yeast. Diet provides a further therapeutic strategy in active Crohn's disease.