'Like a sieve': an exploratory study on cognitive impairments in patients with multiple myeloma

The aim of this study was to obtain a more in-depth understanding of cognitive impairments and concerns as described by patients with multiple myeloma and the strategies used to cope with them. Semi-structured qualitative interviews were undertaken with 15 multiple myeloma patients of differing age ranges and at various stages of their disease. Various cognitive impairments, such as problems with short-term memory, poor recall and lack of concentration were observed and/or expressed in at least 10 out of 15 patients, all of them long(er)-term survivors. In some patients cognitive impairments significantly interfered with their personal and professional lives, and for some patients these were described as permanent. The patients used various coping strategies, from denial, taking notes, writing diaries, reading simpler texts, using talking books and videos, to using systems for counting medication to cope with the results of their cognitive impairment. Our findings differ from much of the contemporary literature which states that if cognitive impairments in cancer patients occur, they are mostly mild and transient. More proactive supportive care is needed to help patients with multiple myeloma to cope with poorer cognitive functioning.

Accuracy and dispersal of subacromial and glenohumeral injections in cadavers

OBJECTIVE

"Blind" shoulder injections are often inaccurate and infiltrate untargeted structures. We tested a hypothesis that optimizing certain anatomical and positional factors would improve accuracy and reduce dispersal.

METHODS

We evaluated one subacromial and one glenohumeral injection technique on cadavers.

RESULTS

Mean accuracy was 91% for subacromial-targeted and 74 and 91% (worst- and best-case scenarios) for joint-targeted injections. Mean dispersal was 19% for subacromial-targeted and 16% for joint-targeted injections. All results bettered those reported previously.

CONCLUSION

These "optimized" techniques might improve accuracy and limit dispersal of blind shoulder injections in clinical situations, benefiting efficacy and safety. However, evaluation is required in a clinical setting.

Cost comparison of at-home treatment of deep venous thrombosis with low molecular weight heparin to inpatient treatment with unfractionated heparin

AIMS

Low molecular weight heparins (LMWH) permit safe and effective treatment of uncomplicated deep venous thrombosis (DVT) at home. The aim of this study was to evaluate the cost minimization, cost shifting and patient satisfaction associated with at-home DVT treatment using the LMWH enoxaparin, compared to standard inpatient care in an Australian health-care setting.

METHODS

Subjects presenting with a principal diagnosis of uncomplicated DVT to the Emergency Department at The Queen Elizabeth Hospital, Adelaide, were recruited over 1997-1999. Costs to the hospital, to Federal funding (Medicare) and to patients were tracked prospectively, and satisfaction was also measured. Subjects were matched to historical controls (1994-1997) for age, gender and level of comorbidity (same or lower) by two medical officers who were blinded to costs. Control costs were obtained using the clinical costing system Trendstar, and adjusted for consumer price index.

RESULTS

Twenty-eight subjects participated in the at-home programme. Of these, 26 were discharged without any inpatient admission (including one who agreed to self-injection) and two were admitted briefly. Audit demonstrated that only 29% of eligible subjects were managed at home. Mean (SEM) total treatment cost was $756 (76) per patient for at-home, and $2,208 (146) for controls. Minimal cost shifts to patients and to Medicare occurred, and satisfaction was high.

CONCLUSIONS

At-home treatment of uncomplicated DVT using enoxaparin in an Australian metropolitan setting provides effective cost minimization, with little cost-shifting. Our cost minimisation estimates are conservative as most at-home subjects received enoxaparin twice daily (now used once per day) and controls had at least as high comorbidity. However, uptake of the at-home programme was limited.

Vertical ground reaction forces in patients with unilateral plantar heel pain - a pilot study

Plantar heel pain (PHP) is a foot pathology commonly reported in both athletic and non-athletic populations. The etiology of PHP is complex and identification of risk factors associated with PHP is required to predict who is at increased risk of injury. Excessive plantar heel force and pressures are intrinsic risk factors that may play a contributing role in the development of PHP. Limited research, however, has been undertaken in terms of ground reaction forces associated with PHP. The aim of the study was to test the hypothesis that there were significant differences in the vertical ground reaction forces and loading rates at rearfoot contact between symptomatic and contra-lateral asymptomatic feet in 23 subjects diagnosed with unilateral PHP. The equipment consisted of a portable force plate using a 10-m modular walkway sampled at 200 Hz by an independent observer. Paired t-tests demonstrated no significant difference (P0.05) in the vertical ground reaction forces and loading rates between the symptomatic and contra-lateral asymptomatic feet. The results suggest that single risk factors such as vertical ground reaction force and loading rates do not contribute to PHP. The authors conclude that a model that incorporates a multi-factorial approach to risk factors may lead to a better understanding into the etiology and management of those individuals who suffer from heel pathologies.

Factors which affect the CFU-GM content of the peripheral blood haemopoietic progenitor cell harvests in patients with acute myeloid leukaemia

Autologous peripheral blood haemopoietic stem cells (PBSC) were harvested from 30 patients with de novo acute leukaemia, 29 of whom had entered remission following standard chemotherapy. Correlation of CD34+ cells/kg to CFU-GM/kg in the harvests was good (correlation coefficient = 0.72, P < 0.001). We demonstrated significant associations between the CFU-GM content of the harvest and the following: time to platelets >50 x 10(9)/l post final induction course (P < 0.001), days to harvest from day 1 of intensification/mobilization (correlation coefficient = -0.73, P < 0.001), platelets >20 x 10(9)/l at time of harvest (P = 0.02), time to WBC >1.0 x 10(9)/l post intensification/mobilization (correlation coefficient = -0.70, P < 0.001), and WBC on day of harvest (correlation coefficient = 0.60, P < 0.001). In contrast, we found no relationship between the CFU-GM content of the harvest and patient age up to 65 years, presence of absence of coexistent features of trilineage myelodysplasia at diagnosis, number of induction courses to remission or total number of courses of chemotherapy prior to intensification/mobilization. Haemopoietic recovery after reinfusion of PBSC was highly correlated to the number of CFU-GM infused (neutrophils >0.5 x 10(9)/l rs = -0.72, P = 0.001; platelets >20 x 10(9)/l unsupported rs = -0.71, P = 0.001). Our results show that the number of induction courses received, and thus exposure to cytotoxic agents received, made no significant difference to subsequent CFU-GM harvest content. We collected superior harvests from those patients with faster platelet recovery following mobilization therapy. We also found that faster platelet recovery following the final induction therapy was a better predictor of the CFU-GM harvest following mobilization than was the neutrophil recovery following final induction.

Design, synthesis, and pharmacological characterization of (+)-2-aminobicyclo[3.1.0]hexane-2,6-dicarboxylic acid (LY354740): a potent, selective, and orally active group 2 metabotropic glutamate receptor agonist possessing anticonvulsant and anxiolytic properties

2-Aminobicyclo[3.1.0]hexane-2,6-dicarboxylic acid (9) was designed as a conformationally constrained analog of glutamic acid. For 9, the key torsion angles (tau 1 and tau 2) which determine the relative positions of the alpha-amino acid and distal carboxyl functionalities are constrained where tau 1 = 166.9 degrees or 202 degrees and tau 2 = 156 degrees, respectively. We hypothesized that 9 would closely approximate the proposed bioactive conformation of glutamate when acting at group 2 metabotropic glutamate receptors (mGluRs). The racemic target molecule (+/-)-9, its C2-diastereomer (+/-)-16, and its enantiomers (+)-9 (LY354740) and (-)-9 (LY366563) were prepared by an efficient, stereocontrolled, and high-yielding synthesis from 2-cyclopentenone. Our hypothesis that 9 could interact with high affinity and specificity at group 2 mGluRs has been supported by the observation that (+/-)-9 (EC50 = 0.086 +/- 0.025 microM) and its enantiomer (+)-9 (EC50 = 0.055 +/- 0.017 microM) are highly potent agonists for group 2 mGluRs in the rat cerebral cortical slice preparation (suppression of forskolin-stimulated cAMP formation) possessing no activity at other glutamate receptor sites (iGluR or group 1 mGluR) at concentrations up to 100 microM. Importantly, the mGluR agonist effects of (+)-9 are evident following oral administration in mice in both the elevated plus maze model of anxiety (ED50 = 0.5 mg/kg) and in the ACPD-induced limbic seizure model (ED50 = 45.6 mg/kg). Thus, (+)-9 is the first orally active group 2 mGluR agonist described thus far and is an important tool for studying the effects of compounds of this class in humans.

Synthesis of the four isomers of 4-aminopyrrolidine-2,4-dicarboxylate: identification of a potent, highly selective, and systemically-active agonist for metabotropic glutamate receptors negatively coupled to adenylate cyclase

The four isomers of 4-aminopyrrolidine-2,4-dicarboxylate (APDC) were prepared and evaluated for their effects at glutamate receptors in vitro. (2R,4R)-APDC (2a), an aza analog of the nonselective mGluR agonist (1S,3R)-1-aminocyclopentane-1,3-dicarboxylate (1S,3R)-ACPD, 1), was found to possess relatively high affinity for metabotropic glutamate receptors (mGluRs) (ACPD-sensitive [3H]glutamate binding IC50 = 6.49 +/- 1.21 microM) with no effects on radioligand binding to NMDA, AMPA, or kainate receptors up to 100 microM. None of the other APDC isomers showed significant mGluR binding affinity, indicating that this interaction is highly stereospecific. Both 1 and 2a were effective in decreasing forskolin-stimulated cAMP formation in the adult rat cerebral cortex (EC50 = 8.17 +/- 2.21 microM for 1; EC50 = 14.51 +/- 5.54 microM for 2a); however, while 1 was also effective in stimulating basal tritiated inositol monophosphate production in the neonatal rat cerebral cortex (EC50 = 27.7 +/- 5.2 microM), 2a (up to 100 microM) was ineffective in stimulating phosphoinositide hydrolysis in this tissue preparation, further supporting our previous observations that 2a is a highly selective agonist for mGluRs negatively coupled to adenylate cyclase. Microelectrophoretic application of either 1 or 2a to intact rat spinal neurons produced an augmentation of AMPA-induced excitation (95 +/- 10% increase for 1, 52 +/- 6% increase for 2a). Intracerebral injection of 1 (400 nmol) produced characteristic limbic seizures in mice which are not mimicked by 2a (200-1600 nmol, ic). However, the limbic seizures induced by 1 were blocked by systemically administered 2a in a dose-dependent manner (EC50 = 271 mg/kg, ip). It is concluded that (2R,4R)-APDC (2a) is a highly selective, systemically-active agonist of mGluRs negatively coupled to adenylate cyclase and that selective activation of these receptors in vivo can result in anticonvulsant effects.

Measuring muscle tone and movement

Abnormal or altered muscle tone in the neurologically damaged patient presents major problems for restoring motor function. Many nursing interventions, such as passive limb exercises and correct limb positioning, attempt to normalise muscle tone. The effect of abnormal tone on movement can be clearly seen, therefore it may be more appropriate to measure the 'quality' of movement. This article describes various methods of measuring muscle tone, such as video analysis, and examines the reliability of these techniques.

Functional tests in elderly osteoarthritic subjects: variability of performance

The purpose of this study was to evaluate the variability of performance of timed walking and sit-to-stand tests in elderly osteoarthritic subjects. Thirteen elderly subjects were asked to walk, as quickly as possible, along a flat corridor a distance of ten metres. The time and number of strides taken were recorded. Fourteen subjects were asked to perform a series of five sit-to-stand movements as quickly as possible from a plinth 48 cm high. Subjects performed three repeats of each test procedure with a two-minute rest period between each. This was undertaken on three separate occasions within a one-week period. A significant difference (p < 0.05) was observed for the time taken to complete the ten metres over the nine tests, but no significant difference was observed in the number of strides taken. The mean coefficient of variation for time taken was 7.3 per cent, which compares favourably with normal biological systems (1). No significant difference was observed for the time taken during the sit-to-stand test over the nine tests. These simple tests of functional ability may be confidently applied as sequential measures in the clinical setting.

Value of the Hybritech ICON Candida Assay in the diagnosis of invasive candidiasis in high-risk patients

A total of 314 sera from 114 patients at risk for invasive candidiasis were analyzed for the presence of antigenemia using the Hybritech enzyme immunoassay (EIA) for detection of Candida mannan in serum (ICON Candida Assay, Hybritech Inc., San Diego, CA). Fourteen patients (12%) had invasive candidiasis documented by positive blood cultures, deep biopsy culture, and histopathology or autopsy, and five patients had probable invasive candidiasis based on a single positive blood culture and no additional signs of candidiasis. Nine patients had candiduria, 43 patients had mucous membrane colonization, 25 patients were not colonized but received empiric amphotericin B, and 18 patients were not colonized and not treated with amphotericin B. All sera were enzymatically extracted, heat treated, and reacted in a solid-phase sandwich EIA. Test results were read visually and with the ICON reader. The sensitivity and specificity of the mannan EIA in detection of documented invasive candidiasis was 86% and 92%, respectively. The positive predictive value was 60% and the negative predictive value was 98%. Among all patients with invasive candidiasis (documented plus probable), the sensitivity was 68%, the positive predictive value 62%, and the negative predictive value 94%. Specimens were positive within 3 days of the first positive culture in 11 (79%) of 14 patients with documented invasive candidiasis.

Rehabilitation of muscle function. Part 2

This article describes the utilisation of a physiologically based research technique developed to facilitate the nursing care of patients with skeletal muscle wasting. The technique, which involved electrotherapeutic stimulation to the first dorsal interosseous muscle of a group of arthritic patients, demonstrates that patterned neuromuscular stimulation of skeletal muscle can have enormously beneficial effects in preserving and regenerating skeletal muscle. The reasons for the muscle wasting, and the subsequent vicious spiral of immobility, were reviewed in Part 1 (1), and both articles build on the concepts described in a previous paper published in Nursing Standard (2).

Rehabilitation of muscle function. Part 1

This article, which develops the concepts introduced in the authors' paper in last week's edition (1), is the first of two which review and summarise recent studies describing techniques to test the hypothesis that uniform frequency stimulation of skeletal muscle deprives the muscle of the type of signals that are necessary for rapid, appropriate and effective adaptation. Next week, clinical trials which have tested this hypothesis will be described, and the implications of the results for nurses involved in rehabilitation work discussed; Part 1 sets out the methodology of extracting the firing patterns of single motor units from a fatiguing muscle.

Rehabilitation: objective assessment of muscle function

The lack of an appropriate and objective measuring scale or tool has ensured that rehabilitation nurses' assessments of patients' muscle function have tended to be subjective and, arguably, inconsistent. Such inexact methods are no longer acceptable to the increasingly audit-conscious health service and research-oriented nursing profession. The authors introduce a means of completing an objective assessment of patients' muscle function which, they claim, will enable nurses to evaluate the efficacy of current and potential treatment options. In follow-up articles appearing in the next two editions of Nursing Standard, they discuss electrotherapeutic rehabilitation of skeletal muscle function.