Self-management and peer support among people with arthritis on a hospital joint replacement waiting list: a randomised controlled trial.

INTRODUCTION: To evaluate the efficacy of a self-management support program including a 6 week self-management course, individualised phone support and goal setting in osteoarthritis patients on a waiting list for arthroplasty surgery. METHOD: Randomised controlled trial of 152 public hospital outpatients awaiting hip or knee replacement surgery who were not classified as requiring urgent surgery. Participants were randomised to a self-management program or to usual care. The primary outcome was change in the Health Education Intervention Questionnaire (HeiQ) from randomisation to 6 month follow-up. Quality of life and depressive symptoms were also measured. Changes in pain and function were assessed using the Western Ontario and McMaster Universities (WOMAC) Arthritis Index. RESULTS: At 6 month follow-up, health-directed behaviour was significantly greater in the intervention [mean 4.29, 95% confidence interval (CI) 3.99-4.58] than the control (mean 3.81, 95% CI 3.52-4.09; P=0.017). There was also a significant effect on skill and technique acquisition for the intervention (mean 4.37, 95% CI 4.19-4.55) in comparison to control (mean 4.11, 95% CI 3.93-4.29; P=0.036). There was no significant effect of the intervention on the remaining HeiQ subscales, WOMAC pain or disability, quality of life or depressive symptoms. DISCUSSION: The arthritis self-management program improved health-directed behaviours, skill acquisition and stiffness in patients on a joint replacement waiting list, although the observed effects were of modest size (Cohen's d between 0.36 and 0.42). There was no significant effect on pain, function or quality of life in the short term. Self-management programs can assist in maintaining health behaviours (particularly walking) in this patient group. Further research is needed to assess their impact on quality of life and over longer periods.

Sum frequency generation study of Langmuir Blodgett film architecture.

We present sum frequency generation vibrational spectroscopy data on monolayer films of pure stearonitrile and mixed films of stearonitrile and ferric stearate deposited by the Langmuir Blodgett technique. Films ranging in composition from pure stearonitrile to 65% stearonitrile/35% ferric stearate deposit in a head-to-tail, Z-type architecture while films of composition <65% stearonitrile deposit in a head-to-head, tail-to-tail, Y-type structure. The vibrational spectra of the monolayer films corresponding to these two different architectures show distinct and characteristic features in their CH stretching regions. Spectral analysis indicates little difference in the modes associated with the terminal methyl groups but large differences in the methylene CH(2) vibrational modes. These spectral differences are consistent with alkyl chains that possess uncompensated methylene oscillator strength arising from portions of the chain that are bent. This behavior is consistent with the energetics expected from a close-packed monolayer of stearonitrile molecules whose CN headgroups possess sizable dipole moments and are expected to adopt a large center-to-center angle to minimize electrostatic, dipole-dipole repulsive interactions.

Highly ordered polymer films of amphiphilic, regioregular polythiophene derivatives.

The fabrication and characterization of highly ordered thin films made from amphiphilic, regioregular polythiophene derivatives are described. Films of poly(3-(11-(2-tetrahydropyranyloxy)undecyl)thiophene (PTHPUDT) were prepared by the Langmuir-Blodgett technique. The amphiphilic nature of the polymer affords layer-by-layer deposition and the formation of multilayer films of head-to-head and tail-to-tail Y-type structure. X-ray diffraction studies indicate bilayer separations of approximately 30 A. Anisotropic optical absorption in the plane of the film indicates that the thiophene backbones are preferentially oriented along the dipping direction. Further, polarized light microscopy studies indicate that these films are highly birefringent and that the optical retardation is uniform over the entire film. Ellipsometry studies confirm the sizable magnitude of the birefringence. Optical second-harmonic generation studies of multilayer films provide information regarding both the thiophene orientation within the film and the anisotropic distribution of chromophores in the surface plane. Taken together, these data offer strong evidence of highly ordered films in which the hydrophobic polythiophene chains lie parallel to the substrate surface with their alkyl chains oriented normal to the surface, as dictated by the hydrophilic nature of the alkyl chain's terminal tetrahydropyran functional group. As such, these films offer the potential for elucidating the connection between polymer morphology and physical property in materials that are otherwise subject to a sufficiently complex distribution of morphologies that such a correspondence is precluded.

Endotoxin-induced alterations in glucose transport in isolated adipocytes.

2-Deoxyglucose and 3-O-methylglucose were used to assess endotoxin-induced changes in glucose transport in rat adipocytes. 6 h after Escherichia coli endotoxin injection insulin-stimulated 2-deoxyglucose uptake was significantly depressed (V decreased, Km unaltered), phosphorylation of 2-deoxyglucose was seemingly unimpaired; basal 3-methylglucose entry was significantly increased, insulin-stimulated uptake was unaltered. Insulin significantly reduced Km in control and endotoxin-treated cells. Cytochalasin B-insensitive uptake of both 2-deoxy-glucose and 3-methylglucose, a small fraction of total transport, increased significantly in endotoxic cells. Endotoxin reduced spermine- and insulin-stimulated 2-deoxyglucose uptake to a similar extent. Results are consistent with the hypotheses that (1) a site of endotoxin-induced insulin resistance is at the cell membrane level and may reflect a decrease in number of activity of effective carrier units, rather than alterations in affinity, (2) endotoxin does not compromise the hexokinase system, (3) the cell membrane-localized effect of endotoxin on hexose transport is not necessarily mediated by the insulin receptor and (4) the entry of 2-deoxyglucose and 3-methyl-glucose may involve two separate transport systems.

Developmental Regulation of Respiratory Activity in Pea Leaves.

The developmental pattern of mitochondrial respiratory activity in pea (Pisum sativum) leaves has been investigated in an attempt to determine changes in mitochondrial function as plant cells mature. NADH and succinate dehydrogenase and cytochrome c oxidase activities remained relatively constant during cell maturation (from d 0 to d 14). Alternative oxidase and glycine decarboxylase activity, however, were low in young leaf tissue (d 0-6) but increased substantially as the tissue matured (d 7-14) and gained photorespiratory activity. Western blot analysis of the alternative oxidase protein revealed that it was primarily in an oxidized state in young leaves (d 0-6) but switched dramatically to the reduced form of the protein as the pea cells matured (d 7-14). The switch to the reduced form of the protein correlated with an increase in alternative oxidase activity. Results are discussed in terms of the changing function of plant mitochondria during leaf development.

The effect of some foreign anions on suxamethonium blockade of the isolated rat diaphragm preparation.

1. The pharmacology of suxamethonium blockade of the rat phrenic nerve-diaphragm preparation has been studied in the presence of some foreign anions.2. Blockade proceeded in two distinct phases in both normal and modified Krebs solution.3. In normal Krebs solution the characteristics bore no close resemblance to either depolarizing or competitive type blockade.4. In the presence of foreign anions the characteristics of the blockade more closely resembled those of depolarization.5. There was an increase in the sensitivity of the motor end-plate region of the muscle to the depolarizing action of acetylcholine, carbachol and suxamethonium in the presence of the anions.6. Although the anions enhanced the depolarizing activity of suxamethonium, the blocking potency of the drug was unaltered.7. It is suggested that end-plate depolarization plays little part in suxamethonium blockade of the isolated rat diaphragm and that desensitization is the primary cause of the blockade.

The role of the sympathetic nervous system in the cardiovascular responses to angiotensin in the pithed rat.

1. Angiotensin (200-500 ng, intravenously) produced a biphasic pressor response accompanied by reflex bradycardia in rats anaesthetized with sodium pentobarbitone. In pithed rats and in anaesthetized animals treated with a ganglion blocking agent there was a similar pressor response but an increase in the heart rate which was coincident with the second phase of the pressor response. In pithed preparations an increase in cardiac contractile force accompanied the heart rate changes.2. Acute or chronic adrenalectomy did not alter the pressor responses and chronotropic effect of angiotensin in the pithed rat. Propranolol abolished the chronotropic and inotropic action of angiotensin, but left the biphasic pressor response unaltered. Bethanidine, or pretreatment with reserpine, altered the pressor response to a simple rise, and also abolished the chronotropic action of angiotensin. Phentolamine also abolished the second pressor component. Desmethylimipramine produced a marked potentiation of the cardiovascular effects of angiotensin at all dose levels tested (10-500 ng).3. It is concluded that in the rat only large doses of angiotensin are capable of indirectly stimulating the sympathetic nerves either at the site of their ganglionic cells or their post-ganglionic nerve ending.

The contribution of the sympathetic nervous system to the development and maintenance of experimental hypertension in the rat.

1. Experimental hypertension in the rat, induced either by renal artery stenosis or by treatment with deoxycorticosterone acetate (DCA) developed maximally over a period of 8 weeks. In both types of hypertension the rate of development was unaffected by immunosympathectomy or by chemical sympathectomy following the administration of 6-hydroxydopamine.2. The effect of 6-hydroxydopamine on chronic renal hypertensive rats was to produce a hypotensive action of longer duration than when similarly administered to DCA-induced hypertensive or normotensive rats. Reserpine (5-10 mg/kg intraperitoneally) produced a more marked hypotensive effect on both types of hypertensive rats although it was of much shorter duration.3. It is concluded that experimental hypertension of renal origin or induced by DCA treatment can develop even though most of the sympathetic nervous system has been destroyed. The maintenance of chronic hypertension in these conditions may depend on the adrenal glands or a hormonal system as yet undetected.

The effects of anticholinesterases on synaptic transmission through nicotinic and muscarinic receptors in rat sympathetic ganglia in vivo.

1 Stimulation of the entire spinal sympathetic outflow at supramaximal voltage and 25-100 Hz, in the chlorisondamine-treated, pithed, adrenalectomized rat produced a delayed pressor response (late pressor response; LPR).2 The LPR was abolished by phenoxybenzamine, bretylium or a small dose of atropine (25-50 mug/kg), suggesting the involvement of ganglionic muscarinic receptors.3 In the presence of atropine at a dose level (15 mug/kg) which did not influence the LPR, the anticholinesterases physostigmine, neostigmine and Ro 02-0683 but not BW 284C51 markedly enhanced and prolonged the LPR, whereas all of them reduced the pressor responses to AHR-602.4 After blockade of the ganglionic muscarinic receptors with a large dose of atropine (250 mug/kg) the four anticholinesterases did not influence responses to DMPP or noradrenaline and only slightly enhanced responses to preganglionic nerve stimulation at 6 Hz in the absence of chlorisondamine.5 It is concluded that inhibition of butyrylcholinesterase accounts for the enhancement and prolongation of the LPR by anticholinesterases.

Prospective evaluation of an assessment strategy for geriatric urinary incontinence.

The objectives of this study were to design and prospectively evaluate a strategy to assess geriatric urinary incontinence in primary care settings. A management plan for urinary incontinence was determined for 264 elderly incontinent patients (205 females and 59 males) based on a clinical evaluation, simple tests of lower urinary tract function, and several criteria for referral for further evaluation derived from the literature on incontinence. Of the 264 patients, 168 (64%) also consented to undergo a urologic and formal urodynamic evaluation. Half of these 168 patients met at least one criterion for referral for further evaluation. At least one-quarter of the patients who met one or more of the criteria were found not to require surgical intervention, and probably did not benefit from the urologic and urodynamic evaluation. Among 84 patients who did not meet any of the criteria for referral, the urologic and urodynamic evaluation changed the initial treatment plan in only 10 (12%). The risks associated with the treatment plan based on the clinical assessment in these patients were, however, relatively small. While further refinement and testing in larger numbers of incontinent patients are needed, the data presented document that a substantial proportion of elderly patients with a treatable and often ignored problem can be appropriately managed based on a relatively simple and inexpensive assessment, which can easily be carried out in primary care settings.

Local anesthesia for urologic procedures.

The ability to perform a variety of urologic procedures (urethrotomy, prostate surgery, penile prosthesis insertion, and bladder neck suspension) under local anesthesia in an outpatient setting is a significant advance in patient care. The surgical techniques are described that will allow the urologist to incorporate these procedures into practice.

Bone fixation technique for transvaginal needle suspension.

Bone fixation of the suprapubic suspension sutures has been used in conjunction with transvaginal needle suspension in 115 women with genuine stress urinary incontinence over the last two years with excellent results being obtained. Utilizing the pubic tubercle as the fixation point for the suspension sutures (rather than the anterior abdominal wall) has decreased postoperative discomfort and obviated the need for any synthetic material.

Urodynamic findings in interstitial cystitis.

The urodynamic findings in 41 women with proven interstitial cystitis were reviewed. All subjects had pain during bladder filling with sensory instability and limited functional capacity. Despite an average symptom duration of 5.7 years, all women had normal bladder wall compliance during cystometry. Fourteen of 41 women had additional significant urodynamic findings.

Delayed bladder dysfunction after abdominoperineal resection: an indicator of local recurrence.

It is generally not appreciated that the delayed onset of voiding dysfunction after abdominoperineal resection for rectal carcinoma may be the first sign of local pelvic recurrence. We herein present a series of 5 patients who were referred for urodynamic evaluation of voiding dysfunction beginning nine to twenty-four months after the original operative procedure. Urodynamic evaluation revealed low bladder wall compliance in 4 patients, and detrusor hyperreflexia in 1 patient. Computerized tomography scans confirmed the local tumor recurrence in all cases. The delayed onset of voiding complaints after abdominoperineal resection should prompt a high index of suspicion that a local tumor recurrence may be present.

Feasibility of outpatient percutaneous bladder neck suspension under local anesthesia.

OBJECTIVES: To demonstrate the feasibility of outpatient percutaneous bladder neck suspension (BNS) under local anesthesia to treat stress urinary incontinence (SUI) in females. METHODS: Since October 1994, 40 women with SUI (mean age 59.6+/-12.0 years) underwent outpatient percutaneous BNS with "Z" suture anchoring of the anterior vaginal wall and pubocervical fascia. The suspension sutures were secured to percutaneously placed bone anchors. The procedure was performed under local anesthesia. Pain during surgery was evaluated with an analogue scale graded from 0 (no pain) to 5 (severe pain). RESULTS: In 98% of the BNS, the procedure was successfully performed with the patient under local anesthesia. Conversion to general anesthesia was necessary for only 1 patient due to knee pain in the lithotomy position. No major complications were observed. Patients rated their perioperative pain as 1.0+/-0.6 (that is, minimal pain). Patients required pain medications for a mean of 2.4+/-1.3 days postoperatively. Mean duration of recovery (defined by a return to normal activities) was 2.2+/-1.0 weeks; 92% of the patients were continent postoperatively, and no recurrence of urethral hypermobility was observed. CONCLUSIONS: Our results demonstrate the feasibility of outpatient percutaneous BNS performed in patients under local anesthesia without significant morbidity. Continued follow-up will be necessary to determine the long-term efficacy of this procedure.

Mechanical complications associated with mentor inflatable penile prosthesis.

The Mentor inflatable penile prosthesis was developed in an attempt to decrease the mechanical failure rate of the various prostheses' components. We herein report on the reliability of the device in 46 men implanted with the Mentor device from December 1982 to June 1987. Prior to manufacturer device modification in 1985, mechanical failure mainly attributable to input tubing cracks occurred in 10 of 30 implantations. Since device improvement in April 1985, the mechanical failure rate has decreased to 4 percent. The Mentor inflatable penile prosthesis has been a mechanically reliable device since design improvement in 1985.

Role of urologist in diagnosis of multiple sclerosis.

This report presents 7 patients with confirmed cases of multiple sclerosis (MS) in whom the diagnosis of MS was first suspected by the urologist. Review of these 7 cases identifies three factors that increased the suspicion of MS at the time of urologic evaluation: a history of neurologic symptoms, abnormalities on a brief neurologic examination, and abnormal basic urodynamic evaluation. Urologists attuned to the possible diagnosis of MS in patients who present with symptoms of voiding dysfunction can facilitate the proper diagnosis with a basic office evaluation.

Giant vesical calculi in the female.

We herein report a case of giant vesical calculi in the female bladder. To the best of our knowledge, these calculi represent the largest group of vesical calculi ever removed from the female bladder. The etiologic factors that contribute to bladder calculus formation in the female are discussed.

Modified Pereyra bladder neck suspension after previously failed anti-incontinence surgery. Surgical technique and results with long-term follow-up.

Fifty-four female patients with persistent or recurrent stress urinary incontinence who underwent between 1 and 9 previously unsuccessful operative procedures were treated with transvaginal mobilization of the urethra and anterior vaginal wall with subsequent modified Pereyra bladder neck suspension. The important points of this technique are reviewed. With minimum follow-up of twenty-four months, a 94 per cent cure rate was achieved with minimal morbidity in this difficult group of patients.

Cost-effective treatment of female stress urinary incontinence: modified Pereyra bladder neck suspension.

We herein report on the cost effectiveness of the modified Pereyra bladder neck suspension (MPBNS) compared with the Marshall-Marchetti-Krantz (MMK) retropubic suspension procedure. A total of 82 cases was reviewed retrospectively. The MPBNS was found to provide a 41 per cent cost savings with significantly shorter duration of intravenous fluid administration, shorter duration of postoperative indwelling catheter drainage, shorter operative time, and significantly shorter postoperative hospitalization. Early postoperative intermittent catheterization was a major factor in facilitating early discharge after MPBNS.