The effects of floor space and nest box access on the physiology and behavior of caged laying hens

Confinement housing appears to be at the forefront of concern about laying hen welfare. This experiment examined the effects of floor space during rearing (315 or 945 cm2/bird) and adulthood (542 or 1648 cm2/bird) and access to a nest box on the welfare of caged laying hens. Measurements of the normality of biological functioning, such as plasma, egg albumen and yolk and fecal corticosterone concentrations, and heterophil to lymphocyte ratios, behavioral time budgets, mortality and efficiency of productivity, and measurement of hen preferences, such as choice behavior in Y maze tests, were used to assess hen welfare. There were no effects of treatment on physiological measurements. Hens given less space during adulthood spent less time mobile, inedible pecking, drinking, and preening and spent more time resting and feed pecking and sitting (P < 0.05). Hens with access to a nest box spent more time resting (P = 0.046) and less time sham dust bathing (P = 0.044) than hens without access to a nest box. There were no effects of space allowance on choice behavior for space or a nest box over food; however, hens with access to a nest box chose the nest box over food more than hens without access to a nest box (P = 0.0053). The present experiment provides no convincing evidence that either reducing space allowance in adulthood from 1648 to 542 cm2/bird or eliminating access to a nest box results in disruption of biological function. Less space and no access to a nest box did not increase the choice for more space or a nest box, respectively, over food in the preference tests. However, reduced floor space reduced behavioral freedom and denying access to a nest box eliminated the opportunity for the motivated behavior of laying their eggs in a discrete enclosed nest box, both of which presumably provide hens with the opportunity for positive affective experiences.

Validity of three rating scales for measuring pain intensity in youths with physical disabilities

BACKGROUND

There is growing evidence confirming that youths with physical disabilities are at risk for chronic pain. Although many scales for assessing pain intensity exist, it is unclear whether they are all equally suitable for youths. The aim of this study was to address this knowledge gap by comparing the validity of the Numerical Rating Scale (NRS-11), the Wong Baker FACES Pain Rating Scale (FACES), and a 6-point categorical Verbal Rating Scale (VRS-6) for assessing pain intensity among youths (aged 8-20) with physical disabilities.

METHODS

One hundred and thirteen youths (mean age = 14.19 years; SD = 2.9) were interviewed and asked to rate their current pain intensity and recalled (in the past week) worst, least, and average pain with the NRS-11 and the FACES. Participants were also asked to rate their average pain intensity during the past 4 weeks using a VRS-6, and were administered measures assessing pain interference, disability and psychological functioning.

RESULTS

Analyses showed that all of the pain intensity measures were associated positively with each other. Nevertheless, the NRS-11 appeared to out-perform both the VRS-6 and in particular the FACES scale with respect to: (1) the associations with the validity criterion (i.e. pain interference, disability and psychological functioning) and (2) a lack of any moderating effect of age on the association between the measure and the criterion variables.

CONCLUSIONS

The findings support the validity of the NRS-11 for assessing pain intensity in youths with physical disabilities between the ages of 8 and 20 years.

Long-term cardiac and vascular disease outcomes following adjuvant tamoxifen therapy: current understanding of impact on physiology and overall survival

The relative impact of tamoxifen therapy in women with breast cancer on overall survival, especially as it pertains to cardiac and cardiovascular outcomes, remains under debate in the literature. This review focuses specifically on outcomes of studies that examined large clinical trials with longest duration in patient follow-up relative to these parameters in which compliance with therapy could be documented. Over time, evidence supports potential cardioprotective effects and capacity of adjuvant therapy to improve lipid profiles in women treated with tamoxifen. While some benefit to cardiac health is supported, outcomes related to cardiovascular events remain variable across studies and challenging to interpret. In summary, overall survival in women treated with tamoxifen over time has increasingly shown a trend towards positive outcomes in the context of evaluation of post-treatment cardiac and vascular health. Potential mechanisms underlying the cardioprotective effects of tamoxifen are briefly discussed.

P5-18-12: Perception, Practice and Toxicity of Adjuvant Treatment of HER2+ Breast Cancer in Wisconsin

INTRODUCTION: Multiple trastuzumab-containing (neo)adjuvant regimens are used for HER2+ BrCa, but the experience with these regimens in routine practice is not reported. Some oncologists select TCH based on BCIRG 006, whereas others prefer anthracycline-based therapy. We evaluated whether oncologists’ perceptions of these regimens match clinical experience.

METHODS: We surveyed 151 Wisconsin (WI) oncologists regarding factors impacting selection of TCH versus AC-TH; 65 (42%) responded. At the same time, we reviewed 200 cases of HER2+ BrCa treated with adjuvant trastuzumab from 2003 to 2010 at the University of Wisconsin Carbone Cancer Center (UW) and the Marshfield Clinic. We collected baseline patient and tumor characteristics, regimen administered, and toxicities as assessed by lab values, cardiac ejection fraction (EF), hospitalizations, dose reductions/delays, and ability to complete therapy.

RESULTS: Two-thirds of surveyed oncologists prefer anthracycline-based therapy over TCH. Of oncologists preferring TCH, 20 of 23 had been in practice for &gt;10 years. Oncologists perceived that AC-TH and TCH were equally likely to be completed. The majority of physicians select therapy based on patient age and stage, with a preference for AC-TH for node-positive disease and TCH for early stage (T1a-bN0) tumors. Despite BCIRG 006 remaining unpublished at the time of the survey, peer-review publication was cited as the most important factor in selecting this regimen. Although use of granulocyte colony stimulating factor (GCSF) in BCIRG 006 has not reported, 50% of oncologists indicated routine use with cycle 1 of TCH. Of the 200 cases reviewed, 114 women received AC-TH, 48 women received TCH, and 38 had other regimens. The median age was 53 years old, 52% had node positive disease. Acute toxicity trended higher with TCH. For example, there were fewer dose modifications/delays for AC-TH than TCH (31% vs. 46%, p=0.07). This may have been due to common use of GCSF with AC-TH (77% vs. 33% use with TCH). Neutropenic fever (NF) was higher with TCH, reaching 25% incidence when administered without GCSF. However, NF did not occur in the 8 TCH patients who received cycle 1 GCSF. There was no correlation between NF and patient age. The incidence of left ventricular EF decline leading to cessation of trastuzumab was similar for both regimens (19.4% AC-TH vs. 14.6% TCH; p = 0.64). Trastuzumab was completed as planned in 70% of patients. Although EF decline was most common explanation, 13% of early trastuzumab discontinuations occurred for other reasons.

CONCLUSION: TCH and AC-TH are the most commonly administered adjuvant regimens for WI women with HER2+ BrCa. Amongst WI oncologists, TCH is perceived as safer, but is less likely to be recommended for node-positive BrCa. This retrospective analysis suggests that acute myelosuppression is greater for TCH, with a significant rate of NF. Per ASCO guidelines, these data suggest GCSF should be used routinely with TCH due to high rate of FN. We were intrigued that oncologists who have been in practice longer are more likely to choose TCH. The reasons for this are unclear, but are perhaps related to prior experience with long-term cardiotoxicity with AC-TH.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-18-12.

The possible role of hemochromatosis in testicular cancer

Hemochromatosis is a genetic disorder of iron metabolism that results in elevated iron absorption in the intestines, which leads to progressive iron accumulation in a variety of organs. Studies have shown that excessive iron deposits in the liver due to hereditary hemochromatosis leads to cirrhosis, which can put an individual at increased risk for developing hepatocellular carcinoma. Testicular atrophy, sometimes caused by excessive iron deposition in the testes, is a risk factor for testicular cancer. Therefore, the possible role of hereditary hemochromatosis in testicular cancer is explored.

Glutamine administration in patients undergoing cardiac surgery and the influence on blood glutathione levels

BACKGROUND

Cardiac surgery with an extracorporeal circulation cardiopulmonary bypass (CPB) is characterized by an oxidative stress response. Glutathione (GSH) belongs to the major antioxidative defense. In metabolic stress, glutamine (GLN) may be the rate-limiting factor of GSH synthesis. Decreased GLN plasma levels were observed after various critical states. We evaluated, in patients undergoing open heart surgery with CPB, the effects of a peri-operative GLN supplementation on GSH in whole blood and assessed their influence on the Sequential Organ Failure Assessment score and the intensive care unit length of stay.

METHODS

In this prospective, randomized, double-blinded study, we included 60 patients (age older than 70 years, ejection fraction <40% or mitral valve replacement) undergoing an elective cardiac surgery with CPB. We randomly assigned each subject to receive an infusion with either GLN (0.5 g/kg/day, group 1) or an isonitrogeneous, isocaloric, isovolemic amino acids solution (group 2) or saline (group 3).

RESULTS

From the first post-operative day GLN plasma levels in group 1 were significantly increased compared with the other groups. With saline GSH the levels decreased significantly post-operatively compared with GLN. We observed a significant correlation between GLN delivery and GSH levels.

CONCLUSIONS

A peri-operative high-dose GLN infusion increased plasma GLN concentrations and maintained the GSH levels after cardiac surgery with CPB.

Anomalous thermal expansion in rare-earth gallium perovskites: a comprehensive powder diffraction study

Crystal structures of rare-earth gallium perovskites LaGaO(3), PrGaO(3), NdGaO(3) and Pr(1-x)Nd(x)GaO(3) (x = 0.25, 0.50, 0.75) solid solutions were investigated in the temperature range 12-300 K by high-resolution powder diffraction using synchrotron or neutron radiation. The previously reported negative thermal expansion in the b direction of the PrGaO(3) lattice has been found to be persistent in Pr(1-x)Nd(x)GaO(3) solid solutions and its magnitude has been revealed as proportional to the amount of praseodymium. Evaluation of the obtained temperature evolution of cell dimensions indicated a weak anomalous behaviour of the b lattice parameter in NdGaO(3), and its origin is supposed to be the same as in PrGaO(3), i.e. a coupling of the crystal electric field levels with phonon excitations of about 23-25 meV energy. The performed bond length analysis revealed an anomalous behaviour of both LnO(12) (Ln-rare-earth) and GaO(6) coordination polyhedra, which can be a structural manifestation of anomalous thermal expansion in the considered compounds.

Polymorphism of K(2)Co(2)Mo(3)O(12): variations in the packing schemes and changes in molybdenum coordination under high pressure

Within systematic studies on the K-Co-Mo-O system so-called high-temperature and high-pressure modifications of K2Co2Mo3O12 were found. The Birch-Murnaghan fits for the ambient-conditions modification alpha (Z = 4) and the high pressure phase II (Z = 8) lead to V0 = 1193.09 (4) A3, K =30.8 (8) GPa, K'0= 5.4 (4) and V0 = 2170 (10) A3, K =51 (2) GPa with K'0 fixed at 4.0, respectively. The high-pressure phase transition is denoted as pseudoreconstructive [Wiesmann et al. (1997). J. Solid State Chem. 132, 88-97], because some [MoO4] tetrahedra turn into edge-sharing pairs of [MoO5] pyramids or face-sharing pairs of [MoO6] octahedra. The new phases are presented and compared with the alpha phase.

Relationship of taurine and other amino acids in plasma and in neutrophils of septic trauma patients

Recently, an interdependency of plasma taurine and other amino acids as well as metabolic and clinical variables implicating therapeutic options was reported. This result may be an indication that plasma taurine levels are directly related to intracellular levels. Therefore, the aim of this study was to analyse the possible relationship between taurine levels in plasma and in neutrophils, the relationship to other amino acids, and variables quantifying metabolic impairment and severity of sepsis in multiple trauma patients developing sepsis. After multiple trauma taurine decreased significantly in plasma in thirty-two patients as well as within the neutrophil and does not recover in sepsis. Lower individual levels in the neutrophil did not follow lower individual levels in plasma and no correlation of taurine in plasma and in the neutrophils could be observed. In sepsis, only plasma showed an interdependency of taurine, aspartate, and glutamate. No association between taurine plasma or intracellular levels and SOFA score as indicator for severity of sepsis or metabolic variables was observed. After multiple trauma and in sepsis, taurine uptake in cells (which is regulated in different ways), and intracellular taurine (which serves e.g. as an osmolyte) can be influenced. Therefore a prediction of the neutrophil taurine pool seems not fully possible from taurine plasma levels. Intracellular taurine has some unique properties explaining the missing interdependency despite some similarities in osmoregulation and metabolic interactions to other amino acids. The association of taurine, aspartate, and glutamate in plasma cannot be simply transferred to the neutrophils intracellular level. The clinical meaning of the plasma correlation remains unclear. A dependency of plasma and neutrophil taurine to severity of sepsis and to metabolic variables seems not possible because of the multifactorial pathophysiology of sepsis.

Outcome prediction in a surgical ICU using automatically calculated SAPS II scores

The objective of this study was to establish a complete computerized calculation of the Simplified Acute Physiology Score (SAPS) II within 24 hours after admission to a surgical intensive care unit (ICU) based only on routine data recorded with a patient data management system (PDMS) without any additional manual data entry. Score calculation programs were developed using SQL scripts (Structured Query Language) to retrospectively compute the SAPS II scores of 524 patients who stayed in ICU for at least 24 hours between April 1, 1999 and March 31, 2000 out of the PDMS database. The main outcome measure was survival status at ICU discharge. Score evaluation was modified in registering missing data as being not pathological and using surrogates of the Glasgow Coma Scale (GCS). Computerized score calculation was possible for all investigated patients. The 459 (87.6%) survivors had a median SAPS II of 28 (interquartile range (IQR) 13) whereas the 65 (12.4%) decreased patients had a median score of 43 (IQR 16; P < 0.001). Of the physiological variables for SAPS II score calculation, bilirubin was missing in 84%, followed by PaO2/FiO2 ratio (34%), and neurological status (34%). Using neurological diagnoses and examinations as surrogates for the GCS, a pathological finding was seen in only 8.8% of all results. The discriminative power of the computerized SAPS II checked with a receiver operating characteristic (ROC) curve was 0.81 (95% confidence interval (CI): 0.74-0.87). The Hosmer-Lemeshow goodness-of-fit statistics showed good calibration (H = 5.55, P = 0.59, 7 degrees of freedom; C = 5.55, P = 0.68, 8 degrees of freedom). The technique used in this study for complete automatic data sampling of the SAPS II score seems to be suitable for predicting mortality rate during stay in a surgical ICU. The advantage of the described method is that no additional manual data recording is required for score calculation.

Low plasma glutamine after multiple trauma: relationship with intracellular glutamine in polymorphonuclear neutrophils during prolonged ICU stay

BACKGROUND

Aim of the study was to evaluate whether low plasma glutamine (GLN) is related to low intracellular GLN in stress-affected cells such as polymorphonuclear neutrophil (PMN). We hypothesized, that because low plasma GLN is assumed to have an impact on clinical outcome, stress-affected cells may also show low GLN contents.

METHODS

Thirty-nine consecutive severely injured trauma patients staying at least 10 days at a surgical intensive care unit (ICU) of a university hospital were separated into two groups: group one (n = 16) with low plasma GLN (< 420 micromol/l in average during ICU stay), and group two (n = 23) with normal plasma GLN. Initial blood samples for GLN analyses were collected within 24 h of admission at ICU. Further blood samples were taken on days 5 and 10 at 08:00 hours.

RESULTS

Patients in both groups showed no differences regarding demographic data, surgical interventions or infections. Acute physiology and chronic health evaluation (APACHE) II and the sequential organ failure assessment (SOFA) score and mortality rate were also comparable. During the study period, intracellular PMN GLN contents and concentrations did not differ between both groups. On the first day, intracellular PMN GLN content in the low plasma GLN group peaked at 5.01 +/- 3.06 x 10(-16) mol and in normal plasma GLN group at 4.73 +/- 2.57 x 10(-16) mol above the level of healthy individuals. In both groups, content decreased significantly towards the end of the observation period (group one: 2.79 +/- 1.59 x 10(-16) mol and group two: 2.63 +/- 1.71 x 10(-16) mol). A correspondent course could be observed for cell volumes. In contrast, variation of intracellular GLN concentrations remained within the reference range throughout the observation period: group one 836 +/- 510 micromol/l on day 1 and 582 +/- 331 micromol/l on day 10, and group two 788 +/- 428 micromol/l on day 1 and 548 +/- 356 micromol/l on day 10. No correlation between plasma GLN and intracellular GLN was found in either group.

CONCLUSION

No association between low plasma GLN and low intracellular GLN in PMN was found in a cohort of severely injured trauma patients with a minimum stay of 10 days at ICU.

[Correlation of a computerized SOFA score and derived measures with length of stay at an operative ICU]

OBJECTIVE

The purpose of this study was to assess whether or not the information on progression of illness and therapeutic interventions included in a computerized SOFA (Sequential Organ Failure Assessment) score and derived measures (maximum SOFA, total maximum SOFA and delta SOFA) influences the correlation with length of stay (LOS) at an operative intensive care unit (ICU).

METHODS

During a period of one year 524 patients aging over 18 years who stayed more than 24 hours at an operative ICU were included into this study. Based on SQL scripts (Structured Query Language), a computerized SOFA score and the derived measures "maximum-SOFA", "total-maximum-SOFA" and "delta-SOFA" of all patients were retrospectively calculated for each day at ICU using routine data recorded with the patient data management system ICUData (IMESO GmbH, Hüttenberg, Germany). "Maximum-SOFA" and "total-maximum-SOFA" are measures for the severity of illness or cumulative organ dysfunction. "Delta-SOFA" measures the magnitude of organ dysfunction developing during ICU stay and is therefore potentially influenced by therapeutic measures. Analysis was based on exact LOS in hours.

RESULTS

Mean LOS of the whole collective was 5.2 +/- 6.8 days (median 2.8, range 1 - 51). Correlation of LOS depending on score results increased from "admission-SOFA" (r = 0.280), to "maximum-SOFA" (r = 0.444), "total-maximum-SOFA" (r = 0.503), and "delta-SOFA" (r = 0.576).

CONCLUSION

Therefore, the sum of information on progression of illness and therapeutic interventions included in derived measures improves the correlation with LOS at an ICU compared to the "admission-SOFA".

Enteral nutrition practice in a surgical intensive care unit: what proportion of energy expenditure is delivered enterally?

The object of this study was to document enteral feeding practice in critically ill patients in a surgical intensive care unit. We asked what proportion of measured energy expenditure is delivered enterally. Patient, material, and therapy-related factors should be assessed and related to enteral nutrition. Sixty patients receiving enteral nutrition for a period of at least 10 days were included in the study. Mean daily energy expenditure was 27.8+8.7 kcal/kg. Mean daily enteral delivered calories reached 19.7+/-10.3 kcal/kg (P<0.05). Twenty-one out of 60 (35%) patients were fed isocalorically; 46% of enteral nutrition days failed to reach 80% of energy expenditure. Ten out of 30 patients (33%) fed over a gastric tube were nourished isocalorically in comparison to 8 out of 20 patients (40%) fed over a duodenal tube. Factors associated with hypocaloric enteral feeding in multiple logistic regression were abdominal, pelvic and lumbal spine trauma, gastrointestinal intolerance, problems with the feeding tube, additional surgical interventions, airway management and use of fentanyl. In the course of the study, gastrointestinal complications were the cause for more than 50% of insufficient enteral delivery cases, while therapy and material related reasons contribute to only a minor part.Abdominal, pelvic and lumbal spine traumas are associated with a higher possibility towards developing problems with enteral delivery, as shown by odds-ratios greater than eight. These diagnoses amounted in our investigation to nearly 40% and make a great difference to medical patients. Therefore, recommendations for optimising enteral feeding must take the concerned patient collective into account.

[Outcome measurement in musculoskeletal diseases: recommendation for a core set of scales for use in rehabilitation]

By application of a standardized core set of outcome measurement instruments, comparison between studies as well as meta-analyses in rehabilitation research can be facilitated. The German Society for Rheumatology has commissioned its working group on rehabilitation with the development of a proposal for such a core set of outcome measurement instruments. In a first step, dimensions for outcome measurement in rehabilitation were defined by a group of experts which represented rehabilitation hospitals, acute care hospitals, and research groups specialized in outcome measurement. The Delphi method was used in a multiple step consensus process. In a second step, instruments and procedures to operationalize the relevant dimensions were chosen. Reliability, validity, sensitivity to change, and practicability were used as criteria for selecting measurement instruments. The main intention of the proposed core set of outcome measurement instruments is to facilitate the processes of planning and carrying out rehabilitation research studies. Furthermore, the proposed instruments can be used for clinical documentation systems as well as for internal or external quality assurance programs.

The stress protein BiP is overexpressed and is a major B and T cell target in rheumatoid arthritis

OBJECTIVE

The ubiquitously expressed intracellular protein formerly designated p68 has been identified as autoantigen at both the antibody and the T cell level in rheumatoid arthritis (RA).

METHODS

We used 2 independent approaches, Edman degradation and matrix-assisted laser desorption ionization-time-of-flight mass spectrometry, to characterize p68, and we compared its features with those of the endoplasmic reticulum stress protein BiP.

RESULTS

In synovial sections from RA patients, BiP was highly overexpressed as compared with control sections. Under in vitro stress conditions, BiP was found to translocate to the nucleus and the cell surface. BiP-specific autoantibodies were present in 63% of 400 RA patients, in 7% of 200 patients with other rheumatic diseases, and in none of the healthy subjects. Thus, BiP-specific autoantibodies represent a new diagnostic marker in RA. Furthermore, we found that BiP-specific T cell reactivity was altered in RA. In healthy individuals and patients with other rheumatic diseases, BiP-reactive T cells were undetectable. In RA, overt T cell reactivity to BiP was observed or could be induced by specifically blocking antigen presentation to potentially regulatory T cells.

CONCLUSION

Since overexpression of BiP has been shown to decrease the sensitivity of cells to killing by cytotoxic T cells, BiP overexpression and BiP-specific autoimmunity may be involved in the pathogenesis of RA.

Oculo-palatal-cerebral syndrome: a second case

Oculo-palato-cerebral syndrome is an extremely rare disorder consisting of low birth weight, microcephaly, short stature, persistent hyperplastic primary vitreous, microphthalmia, large ears, small hands and feet, cleft palate, joint hypermobility, developmental delay, and cerebral atrophy. There has been one report of a consanguineous family with three affected children, suggesting autosomal recessive inheritance. We report on the second case of this disorder. Our patient, a 2-year-old boy, had growth delay, microcephaly, bilateral persistent hyperplastic primary vitreous with right microphthalmia, long ears with thickened helices, small hands and feet, highly arched palate, joint hypermobility, hypoplastic nails, frontal cerebral atrophy and thinning of the corpus callosum on brain magnetic resonance imaging, and mild developmental delay. He has much milder features than those seen in the previously reported cases.

Influence of colloid fluids on polymorphonuclear granulocyte function in vivo

BACKGROUND

Granulocytes have a role in the immediate immune response. In a previous investigation we could demonstrate in vitro a moderate increase of the complement receptors CR1 (CD35) and CR3 (CD11b/CD18) on the surface of polymorphonuclear neutrophils (PMN) after incubation of whole blood with colloids. To elucidate the clinical significance, we investigated if these changes were also present in vivo.

METHODS

The study was performed prior to anaesthesia for orthopaedic surgery. A total of 60 ASA-I patients was evaluated. Patients received in a randomised manner 7 mL/kg of the following solutions: human albumin 5% (HA), gelatine 4% (GEL), hydroxyethylstarch solution 6% with MW 200,000 Da, degree of substitution 0.5 (HES), or Ringer's solution. Prior to the infusion, at the end (30 min) and again 30 min later, blood samples were taken. Blood was incubated with fluorescein-conjugated monoclonal antibodies (CD11b, CD16, CD35, CD62L) and analysed with flow cytometry.

RESULTS

HA, GEL, HES, and Ringer's solution failed to induce significant differences in the expression of complement receptors CR1 (CD35) and CR3 (CD11b/CD18), Fc gamma receptor IIIb (CD16), and of L-selectin (CD62L) receptor on the surface of PMN.

CONCLUSIONS

Application of colloids like HA, GEL, or HES in moderate amounts shows no short-term effect on adhesion or activation molecules on granulocytes. However, in high doses, infused in situations such as multiple trauma and sepsis, the consequences on the function of PMN may be speculative and require further investigations.

Regional hemostatic status and blood requirements after total knee arthroplasty with and without tranexamic acid or aprotinin

Antifibrinolytics seem to reduce postoperative blood loss after total knee arthroplasty. Few studies have shown the impact of these drugs on the mechanisms of coagulation. The purpose of this study was to examine coagulation/fibrinolysis variables as well as blood loss after total knee arthroplasty with and without antifibrinolytics in the operated limb on a regional level. Thirty-six patients were randomized into one of three groups to receive aprotinin, tranexamic acid, or no medication. We took blood samples of the femoral vein before deflating the tourniquet and after 5, 10, 30, 60, 120 min and on the first postoperative day. The implantation of a knee prosthesis in artificial ischemia caused a significant activation of coagulation and fibrinolysis in the regional circulation. Tranexamic acid and aprotinin did not cause a significant modulation of fibrinolysis variables or a significant reduction of postoperative bleeding and transfusion requirements. One of the differences in comparison to other studies was the decreased total blood loss. The use of bone cement as well as surgical hemostasis before wound closure may be regarded as reasons for this. Therefore, primarily these methods should be used because there is no increased risk of adverse drug effects.

IMPLICATIONS

After total knee arthroplasty total blood loss may be kept in a low range if methods such as cemented knee prosthesis and surgical hemostasis are used. In this case aprotinin and tranexamic acid did not cause a significant modulation of fibrinolysis variables or a significant reduction of postoperative bleeding.

[The immunologic homunculus in rheumatoid arthritis. A new viewpoint of immunopathogenesis in rheumatoid arthritis and therapeutic consequences]

Autoreactivity plays a major role in the pathogenesis of RA. The rheumatoid factor has been and still is for now more than 50 years the only autoreactivity that is clinically applied in the diagnosis of RA. This well reflects the current way of thinking that a single antigen or a single cause drives an individual into disease. Although by now many other autoantigens and autoreactivities have been described, their discovery was always on the search for the one and only autoreactivity that causes RA. This includes also immune reactivities directed against xenogenic antigens. But, none of the known RA-associated autoreactivities is present in all RA patients and none of them occurs exclusively in RA. Thus, the observed sensitivities and specificities are well below 100%. Therefore, RA has often been postulated to consist of various immunological subentities with similar clinical symptoms. Nevertheless, none of the autoreactivities correlates with a distinct clinical feature or course of disease. It is about time to say good-bye to the idea that a single antigen or immunoreactvity causes and maintains rheumatoid arthritis. In this paper we present RA as the clinical outcome of an immune system that has shifted from a healthy to an autoimmune steady state. This is accomplished by many different reactivities and autoreactivities that occur either in parallel or one after the other. The entirety of the known RA-associated reactivities and (auto)antigens is presented in detail. The major RA-relevant autoantigens comprise BiP, citrulline, the Sa-antigen, hnRNP A2, p205, IgG, calpastatin, calreticulin, collagen and the shared HLA-DR epitope. The accumulation of factor--involving autoreactivities, cytokines, environmental and genetic factors--that challenge the normal regulatory mechanisms of the immune system lead to a regulatory catastrophe. In individuals developing the clinical features of RA the immune system has been regulated to a new--autoimmune--steady state. This attractor "rheumatoid arthritis" has many features of what has originally been described by Irun Cohen as the immunological homunculus: The healthy immune system is configured such as to direct its attention to major self-antigens. Thus it creates an autoreactivity to many autoantigens as a prerequisite for regulatory mechanisms that are sufficient to control them. The shift from the normal to rheumatoid attractor involves the inflammatory cytokines TNF-alpha, IL-1 and IL-6, autoreactive T- and B cells directed at a variety of synovial and systemic antigens, activated dendritic cells and macrophages, tissue destruction and genetic factors such as the association with shared epitope. Environmental factors involved may also, but do not necessarily, include infection. With the appearance of clinical features of RA, naive, potentially autoreactive T cells infiltrate the synovial compartment and become activated by dendritic cells and other APCs. The autoantigenic peptides that are presented to these T cells are derived from inflammatory cell and tissue destruction as well as from tissue repair and remodeling processes. These T cells proliferate and either provide help to B cells with the specificity to the same antigens or cause direct cytopathic tissue damage. Thereby, more and novel antigens are generated, released and presented again to naive or primed autoreactive T cells. These processes involving cytokines, tissue destruction and autoreactive T cells are sufficient to maintain RA even without the permanent presence of a triggering agent. The recursive autoimmune processes are well consistent with the finding of the many different autoreactivities in RA and their respective sensitivities and specificities. The massive influx of T cells into the arthritic joint is accompanied by the anergization of over 90% of T cells in this compartment--which further substantiates the concept of the RA attractor within the self-regulating immune system. Thereby, the RA-attracted immune system is not able to completely downregulate the inflammation and the local tissue damage/repair. Thus, the immune system is permanently stimulated and suddenly by chance shifts to a stable state different from the healthy system--reaching the wide fields of rheumatoid arthritis which in itself is self-sustaining as the healthy state before disease onset.

Children with burn injuries: purposeful activity versus rote exercise

OBJECTIVE

This study was designed to compare measures of pain when children with burn injuries were engaged in a purposeful activity, specifically a play activity, versus rote exercise.

METHOD

Two 6-year-old children participated in a study using a single-subject, randomized multiple treatment design to compare two conditions: purposeful activity and rote exercise. Data were gathered for each session on four dependent measures: number of repetitions of therapeutic exercise completed, number and type of overt distress behaviors displayed, scores on self-report scales of pain intensity, and overall enjoyment of the activity.

RESULTS

Visual inspection of the graphed data suggested that, early in the rehabilitation process, the use of a play activity in comparison to rote exercise yielded better outcomes in terms of all four dependent measures. Additionally, the data implied that there may be a point later in the rehabilitation of a child with a burn injury when rote exercise may be as effective as play activities in meeting therapeutic goals.

CONCLUSION

This study supports the belief that purposeful activity can yield results equal to or better than those achieved using rote exercise. Replication of this study is warranted, and the development is indicated of a measure of overt behavioral distress that is more appropriate than those currently available for children with burn injuries.

Pain in persons with cerebral palsy

OBJECTIVE

To examine the nature and scope of pain in persons with cerebral palsy (CP).

DESIGN

Standardized interviews to assess demographics, pain experiences, and the impact of pain on activities.

SUBJECTS

Ninety-three adults with CP recruited from medical clinics at the University of Washington and local residential and community housing for persons with developmental disabilities.

MAIN OUTCOME MEASURES

Weekly and 3-month pain intensities, chronic pain grade, interference in daily activities caused by pain, and pain-exacerbating and pain-relieving factors.

RESULTS

Sixty-two subjects (67%) reported one or more areas of pain of > or =3 months' duration. Lower extremity pain and back pain were the most common complaints. Fifty-six percent of the subjects reporting pain indicated it occurred daily. Mean average pain intensity, graded on a scale of 0 (no pain) to 10 (pain as bad as could be), was 3.16 (SD = 2.45) in the preceding week and 4.45 (SD = 2.34) in the previous 3 months. Approximately 53% of subjects reporting pain indicated their average pain was of moderate to severe intensity (average pain rated as > or =5). Using Von Korff's Chronic Pain Grade classification system, the majority of subjects who reported pain fell into either grade I (low disability, low pain intensity; 51%) or grade II (low disability, high pain intensity; 39%). Subjects reported many factors that exacerbate pain (eg, stress or weather) or decrease it (eg, exercise or rest).

CONCLUSIONS

The data suggest that pain is common in adults with CP. In many subjects, pain levels were moderate to intense.

p205 is a major target of autoreactive T cells in rheumatoid arthritis

OBJECTIVE

The p205 autoantigen and interleukin-2 (IL-2) function synergistically to stimulate T lymphocytes from patients with rheumatoid arthritis (RA), and a p205-derived amino acid sequence is identical to an immunoglobulin sequence located within a domain that is reactive with rheumatoid factors (RF). This study was conducted to analyze in detail the T cell immune response against p205 and to investigate whether immunity to p205 may play a role in T cell-mediated immunopathology in active RA.

METHODS

Cibachron blue, protein A-Sepharose, and gel filtration on Sephacryl were used successively to enrich p205 from synovial fluid (SF). T lymphocytes from RA patients were isolated from the peripheral blood (PB), lymph nodes, and SF, and p205 and peptides derived from known sequences were assessed by T cell proliferation assays in the presence of IL-2.

RESULTS

P205-specific proliferation of T cells was observed in PB as well as in SF. When p205 was isolated from RA SF, proliferation of RA T cells peaked on day 3. With p205 purified from SF from trauma patients, there was a significant shift of the maximum T cell proliferation to day 8. T cells were of CD4 or CD8 phenotype, and B cells did not proliferate to a significant degree. The T cell response to p205 was always higher for SF mononuclear cells (SFMC) compared with PBMC (P < 0.001). In 1 RA patient who underwent repeated leukapheresis, this led to a reproducible decline in p205-specific T cell proliferation to control levels. PB T cells specifically proliferating in response to p205 were detected in 20 of 32 RA patients (63%). Of 26 patients with other inflammatory rheumatic diseases, only 1 showed a minor response to p205, while normal donors did not demonstrate a significant T cell proliferation. A synthetic p205-derived peptide, with an amino acid sequence identical to an immunoglobulin sequence located in the area where RF binds, was reactive with T cells from RA patients.

CONCLUSION

P205 appears to be a major target of autoreactive T cells in RA. P205-specific T cells are primed and more abundant at the site of inflammation. As a T cell target in RA, p205 may well be an antigen involved in the initiation of RF production.

[Dose-response relationship of clonidine with epidural administration of ropivacaine in orthopedic procedures of the lower extremities]

OBJECTIVE

The aim of this study was to investigate preliminarydose-range effects of clonidine added to ropivacaine for epidural analgesia in elective orthopedic surgery of the lower limbs with doses, causing a minimum of cardiovascular side effects.

METHODS

60 patients were randomly assigned to receive in a double-blind fashion a mixture of 1 mg/cm height ropivacaine plus saline or 1 mg/cm ropivacaine plus 25 micrograms, 50 micrograms, 75 micrograms, 100 micrograms or 150 micrograms clonidine for epidural analgesia. The sensory and motor function were determined at defined time intervals for 30 minutes. Heart rate and blood pressure were controlled and sedation score was judged. The postoperative 2-segment-regression of pin-prick and the onset of pain were recorded.

RESULTS

The six groups were comparable in demographic data and in term of onset time. The prolongation of analgesia reached 513 +/- 92 min (p = 0.002) for 150 micrograms clonidine, 460 +/- 148 min (p = 0.073) for 100 micrograms clonidine, 440 +/- 86 min (p = 0.057) for 75 micrograms clonidine compared with 347 +/- 114 min for saline. In an equal manner, 2-segment-regression for pin-prick was extended to 251 +/- 47 min (p = 0.018) for 150 micrograms clonidine, 238 +/- 33 min (p = 0.034) for 100 micrograms clonidine, 229 +/- 29 min (p = 0.027) for 75 micrograms clonidine and 178 +/- 43 min for saline. Heart rate dropped down in all groups. Mean arterial pressure decreased significantly in the groups with 75, 100 and 150 micrograms clonidine. Sedation score increased continuously from 0.6 +/- 0.5 (saline) to 1.8 +/- 0.8 (150 micrograms clonidine).

CONCLUSION

We conclude that 150 micrograms clonidine significantly enhances the duration of analgesia of epidurally administered ropivacaine in a mean of 171 mg. This time interval is longer than the one with 200 mg ropivacaine alone. But, there are side effects in form of decrease of arterial pressure. Cardiovascular monitoring seems to be essential. Because of the enhanced analgesia duration, the time interval for reloading epidural anaesthesia are increased.

The Test of Sensory Functions in Infants: test-retest reliability for infants with developmental delays

OBJECTIVE

The Test of Sensory Functions in Infants (TSFI) is one tool that occupational therapists use to identify sensory processing disorders among infants. However, data on the reliability of TSFI scores with infants with developmental delays are lacking.

METHOD

Test-retest reliabilities for TSFI total test and subtest scores were determined with a sample of 26 infants with developmental delays. All infants were between 10 months and 18 months of age. The test-retest interval ranged from 5 days to 10 days. Magnitudes of difference between test and retest scores and percentages of agreement among the TSFI classification categories (i.e., normal, at-risk, deficient) also were determined to examine relationships between test scores.

RESULTS

Reliability for the total test score was borderline, with an intraclass correlation coefficient of .78. Reliability coefficients for the five subtests ranged from .54 to .74. Percentage of agreement for the total test classification categories between test and retest was adequate (81%). Percentages of agreement for subtest classification categories were low, ranging from 58% to 68%.

CONCLUSION

TSFI scores should be interpreted cautiously and used only in conjunction with findings from additional developmental assessments and clinical observations for infants with developmental delays.

Therapists' perceptions of pediatric occupational therapy interventions in self-care

OBJECTIVES

This study examined the congruence between pediatric occupational therapists' self-care interventions and occupational therapy's philosophical base, which focuses on performance of self-care skills as primary in evaluation and intervention.

METHOD

A questionnaire was mailed to 252 therapists serving children ages birth to 6 years. The questionnaire asked for therapists' perceptions about the importance, uniqueness, and frequency of 10 areas of intervention, including self-care.

RESULTS

Perceived importance of self-care was found to be strongly related to perceived frequency of self-care intervention. Practice setting was significantly associated with perceptions of uniqueness of self-care, and team membership status was significantly associated with importance of self-care. Most respondents perceived self-care intervention to be important (86%) and unique (80%) to occupational therapy. Seventy percent regularly provided intervention for self-care.

CONCLUSIONS

The therapists' perceptions reflected continued regard for self-care as an important and unique area of pediatric occupational therapy but were somewhat discrepant with the actual frequency of self-care interventions.

[Effects of various feeding regimens in multiple trauma patients on septic complications and immune parameters]

OBJECTIVE

The aim of this study was to investigate the incidence of septic complications, the immunological changes by the course of lymphocyte subsets and metabolic parameters on polytraumatised patients when given nutritional support in form of early enteral and total parenteral nutrition. Furthermore, we looked for differences between a standard enteral diet and a diet supplemented with arginine, omega-3-fatty acids, nucleotide, and selenium.

METHODS

30 polytraumatised patients with an Acute Physiology and Chronic Health Evaluation II (APACHE II)-Score > 10 points, who received nutritional support for a minimum of 7 days, were randomised to a "supplemented enteral group" (group 1), an "enteral standard group" (group 2), or a "parenteral group" (group 3). In the first both groups there were early enteral feeding. The patients of group 3 were fed isonitrogenous and isocaloric to group 2. Leucocytes, lymphocytes, CD3(+)-, CD4(+)-, CD3+HLA-DR(+)-, CD8(+)-, CD19(+)-subsets, natural killer-cells (CD56+) and metabolic parameters were measured on days 1, 3, 5, 7.

RESULTS

Septic complications occurred in 2 patients in group 1, in 1 patient in group 2 and in 4 patients in group 3. The total number of lymphocytes had an increase on day 7 in group 1 (1420/microliter) and group 2 (1620/microliter) and were higher compared with group 3 (1044/microliter). On day 7 T-cells (CD3+) were 1107/microliter in group 1, 1014/microliter in group 2 and 770/microliter in group 3, T-helper-cells (CD4+) rose on day 7 higher in the enteral fed groups (group 1:746/microliter, group 2:719/microliter) than in group 3 (570/microliter). No significant differences between the groups were seen by CD3+HLA-DR(+)-cells, T-suppressor-cells (CD8+), B-cells (CD19+) and natural killer-cells (CD56).

CONCLUSION

Early enteral nutrition seems to stabilise the immunosuppression of polytraumatised patients in an earlier phase. There is a consolidation of the lymphocyte counts, and of T(CD3+)- and T-helper-cells (CD4+). This could be the immunological correlate for the number of septic complications in the enteral fed groups. Therefore polytraumatised patients should be fed rather early enteral than parenteral when possible. In the initial phase after the trauma the way of nutritional support has more importance on the immune system as nutritional contents. So, in this form of studying, there is no advantage of immunonutrition.

Necrotizing periorbital cellulitis

We report traumatic necrotizing periorbital cellulitis attributed to group A beta-hemolytic streptococci in a 4-year-old child. The infection was successfully treated via surgical cleansing, drainage, and grafting. The virulence of this organism requires an aggressive approach to the patient with periorbital cellulitis, which is refractory to intravenous antibiotics. Early treatment may limit extensive eyelid necrosis, the resultant secondary deformity, and the need for multiple reconstructive procedures.

Relaxation training: a self-help approach for children with headaches

Children and adolescents frequently complain about recurrent nonmalignant headaches. Relaxation exercises are one possible treatment for these headaches. As the role of occupational therapy in pediatric pain management emerges, relaxation training is becoming one of the treatment activities. The present study investigated the efficacy of progressive relaxation exercises in reducing headache complaints, particularly those headaches of a mixed variety. Ten subjects with a mean age of 11.5 years completed the 6-week self-help program. A multiple-baseline across-subjects design was used. Baseline periods were randomly assigned and ranged from 7 to 25 days with treatment introduced in a time-staggered fashion across subjects. After completing their treatment, 8 of the 10 subjects had a mean increase of 15% in headache-free days. Specific guidelines for relaxation training are provided in the outlined treatment program.

Long-term follow-up of relaxation training for pediatric headache disorders

The long-term effects of relaxation training for pediatric headache disorders was determined for 17 of 20 original participants from a prospective control-group experimental design study with random assignment to autogenic relaxation, progressive relaxation, autogenic plus progressive relaxation, or waiting list control groups. Long-term follow-up data were obtained at an average of 51 months post-treatment. All participants reported some increases in headache activity. Participants in the three relaxation treatment groups, however, had significantly more headache-free days and less severe headaches compared to the control group. There were no significant effects of treatment for headache duration, medication intake and rest time due to headache. Twelve of the 13 treated participants indicated relaxation training was effective in relieving headaches, with 7 reporting they practiced relaxation exercises within the past month. The results generally support the long-term benefits of relaxation in reducing headaches originating in childhood.

Behavioral assessment of chronic headaches in children

Although headache is one of the most common somatic complaints of children and adolescents, little is known about its phenomenology. Pediatric headache diagnosis and implications for treatment are often based on parental reports of consequent pain behaviors. Information on how parents assess and respond to children's headache activity is needed. This study identified how children with chronic, recurrent nonmalignant headaches communicated their headache occurrences to their mothers and how mothers responded to suspected headache occurrences. Specific guidelines are offered to assist nurses in the behavioral assessment and management of chronic pediatric headaches.

Use of the carbon dioxide laser in the drainage of subretinal fluid

Hemorrhage and retinal perforation are two sight-threatening complications associated with techniques employed to drain subretinal fluid in rhegmatogenous retinal detachment. We hypothesized that the carbon dioxide (CO2) laser would reduce these complications because of its cauterizing action and high absorption in water. The CO2 laser was compared with a conventional technique of using a penetrating diathermy electrode to drain subretinal fluid in rabbits with experimentally detached retinas. No hemorrhage occurred in 223 drainage trials using the CO2 laser, whereas hemorrhage occurred in 21 (4.8%) of 434 trials using the penetrating diathermy electrode. Furthermore, a depth of saline of only 45 microns protected the retina from perforation at CO2 laser dose adequate for drainage. These results indicate that further evaluation of the CO2 laser in treating human retinal detachment is warranted.

Bacteremia caused by CDC group Ve-1 in previously healthy patient with granulomatous hepatitis

This is a case report of CDC group Ve-1 bacteremia in an otherwise healthy patient with granulomatous hepatitis.

[Value of physical therapy from the viewpoint of the patient. Results of a questionnaire]

Physiotherapy is well regarded by all patients with diseases of the locomotor system. In a questionnaire aimed at the self-evaluation of "non-proven remedies", we offered hospitalized patients of the Rheumaklinik Bad Bramstedt questions regarding classical forms of physiotherapy. Of 1600 questionnaires distributed, 447 (27.9%) could be counted and analysed. Categorized into four major groups of rheumatic diseases (rheumatoid arthritis/inflammatory diseases of joints, ankylosing spondylitis, osteoarthritis and degenerative spine disease, including minor rheumatic complaints) we collected patients' opinions of different therapies. In addition, we set up a list of preferred therapies and a list of negative therapies, estimated as less helpful or even harmful, as well as a list of therapies which patients would like to try. The results confirm the value of classical methods of physiotherapy (exercises, pelotherapy, massage), which had a high degree of acceptance and effectiveness.

The reliability of measurements of the lumbar spine using ultrasound B-scan

Diagnostic ultrasound is used in research and clinical settings to determine the size of the lumbar spinal canal. When the technique was first introduced, measurements were obtained directly from an A-scan while concurrently viewing a B-scan. However, measurements obtained directly from a B-scan are now commonly used despite the undetermined reliability of the technique. To determine the reliability, 50 randomly selected ultrasound B-scan examinations were read on two separate occasions by three investigators. For each spinal level, the mean intraobserver error (same investigator), from the first to the second reading was determined, as was the interobserver error (between investigators) and the error due to variability in obtaining the ultrasound images. The resultant errors were approximately double those reported previously for the technique using A-scan. Interobserver variations were the major source of measurement error.

Ultrasound of the spine in focal stenosis and disc disease

In the course of reviewing ultrasound scans of the lumbar spine in 67 symptomatic patients, focal stenosis, either as an isolated finding or in conjunction with diffuse stenosis, was noted in 44 patients. The results of ultrasonograms are compared with findings at myelography and surgery. In addition, using gray-scale technique, we found it possible to examine areas of focal stenosis and to visualize herniated discs with a high degree of accuracy. The finding of focal stenosis alone was associated with disc herniation in 53% of patients who came to surgery. Where ultrasound identified a "triple density" representing soft-tissue protrusion between two bony landmarks within the extradural space resulting in focal stenosis, the sensitivity for indicating disc disease was 89%.

[Thermographic diagnosis of arthritis in peripheral joints]

The measurement of absolute temperatures on the surface of the human body using quantitative thermography allows this technique to be used in rheumatology, for the diagnosis and monitoring the course of inflammatory diseases of the locomotor system. The patient is exposed to a room temperature of 18 degrees C and the skin temperature measured over the joint for a defined area (region of interest). Inflamed joints show distinctly higher absolute temperatures than normal ones within the observation time of 40 minutes. Moreover, the skin over healthy joints cools faster and to a greater extent than skin over inflamed joints, whose temperatures remain the same or even rise minimally in more acute cases. Using two measurements, the determination of the absolute temperatures (static thermography), and the changes in these temperatures within a definite time interval (dynamic thermography) it is thus possible to establish a diagnosis of arthritis in the regions of the peripheral joints with the help of standardised nomograms with an accuracy of more than 90%, and to follow the course of the disease more exactly.

Thermologic methods in clinical pharmacology-skin temperature measurement in drug trials

With the increasing availability of thermographic equipment the definition of "thermography" and "thermologic methods" is important, since differing techniques and standards may be applied. Recommendations are given for optimum use of skin-surface temperature measurements in the assessment of clinical drug trials. Sites for thermographic measurement, different methods for quantitation, and sources of further information are included. A brief checklist of minimal technical requirements and an example of information for patients are also included.