"Metacognitive Reflection and Insight Therapy" (MERIT) for the Occupational Therapy Practitioner

Background. Metacognitive Reflection and Insight Therapy (MERIT) is a manualized, evidence-based approach that supports occupational participation through its focus on the inter-related constructs of meaning making, positionality, and self-definition (Lysaker et al., 2020). MERIT's core tenets parallel the fundamentals of occupational therapy, making it an ideal guiding methodology for mental health occupational therapy practice. Purpose. We outline key constructs of MERIT and detail how occupational therapy practitioners can apply MERIT to support occupational engagement. Key Issues. Few manualized, evidence-based interventions exist to guide occupational therapy mental health practice (Kirsch et al., 2019). Detailing MERIT and its application in occupational therapy is an important first step in future studies of its feasibility, acceptability, and effectiveness in this context. Implications. MERIT provides a clear methodology for delivering mental health occupational therapy services that is amenable to large-scale hybrid implementation and effectiveness studies, thereby supporting practice and rigour in research.

Bridging the humanities and health care with theatre: Theory and outcomes of a theatre-based model for enhancing psychiatric care via stigma reduction

OBJECTIVE

This article describes the rational, methods, implementation, and effectiveness of Identity Development Evolution and Sharing (IDEAS), an evidence-supported, narrative theater-based training that reduces stigma among health care providers to increase health care equity in psychiatric rehabilitation.

METHOD

The IDEAS model has been used to reduce provider bias toward patients. From May 2017 to January 2020, we interviewed people from three patient groups who have been harmed by stigma, including Black women, transgender, and gender-diverse people, and people with substance use disorders. These interviews informed the creation of three theatrical scripts that were performed by professional actors for audiences of health care providers from January 2020 to May 2022. The performances aimed to raise conscious awareness of implicit provider biases and to provide a reflective opportunity to ameliorate these biases. The purpose of IDEAS is to improve experiences in health care settings such as psychiatric rehabilitation of patients from groups who have been harmed by stigma. We used paired-samples t tests to compare pre/postprovider stigma, measured via the Acceptance and Action Questionnaire-Stigma (AAQ-S).

RESULTS

Sociodemographic factors for providers who viewed IDEAS were similar across all three performances. IDEAS significantly decreased AAQ-S scores (t = 11.32, df = 50, M = 13.65, 95% confidence limit: [11.32, 15.97], p < .0001).

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

IDEAS reduces provider stigma to support positive clinical encounters with diverse patient populations. These findings are relevant for psychiatric rehabilitation settings, which seek to establish positive rapport between providers and patients. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

A developmental formative evaluation of a pilot participatory music program for veterans with housing insecurity

BACKGROUND

Interventions are needed to improve well-being and promote community reintegration among Veterans with housing insecurity. The objective was to conduct a developmental formative evaluation of a participatory music program.

METHODS

This single-site, pilot study implemented a participatory music program at a U.S. Department of Veterans Affairs (VA) Homeless Domiciliary that included one-hour sessions (group music instruction and ensemble playing), 3 times per week for 3 months. Intervention development was guided by the Model of Human Occupation (MOHO). Evaluation was guided by the MOHO and the Consolidated Framework for Implementation Evaluation (CFIR). Qualitative data were collected via semi-structured interviews from participants and non-participants, and were analyzed using an interdisciplinary, constant comparison qualitative analysis technique.

RESULTS

Sixteen program participants and 8 non-participants were enrolled, age range 26-59 (mean 41; standard deviation, 11) years; 75% were White. The sample for this study (N = 12) included five participants and seven non-participants. Semi-structured interview responses produced three salient themes illuminating Veterans' perspectives: (1) key characteristics of the intervention (the relative advantage of the participatory program over other problem-focused programs; the importance of a supportive, encouraging teaching; the group setting; the role of music); (2) the therapeutic power of the program (based on it being enjoyable; and serving as an escape from preoccupations); and (3) the context and culture (which included Veterans supporting each other and the Domiciliary setting).

CONCLUSIONS

Veterans described the benefits of a participatory music intervention compared to problem-based groups, which included enjoyment, skill acquisition facilitating pride, escape, reconnecting with their identity prior to current problems, and experiencing positive aspects of Veteran culture such as mutual support and discipline. These data support ongoing research about participatory music programs to support Veterans with housing insecurity.

The use of peer support groups for emergency physicians during the COVID-19 pandemic

Objective

To test the feasibility, receptivity, and preliminary effectiveness of peer support groups for emergency medicine physicians during the COVID-19 pandemic and gain a better understanding of their experiences with peer support.

Methods

This pilot study used a quasi-experimental design to assess change in symptoms of distress, anxiety, depression and burn-out before and after participating in a virtual, group-based peer support intervention for a duration of 8 weeks. Pre-post change analyses were performed using two-sided, paired t tests. Feasibility was measured by attendance data to demonstrate the use of the intervention. Receptivity was measured using a global change rating and net promoter score at the end of each session and 8-week period, respectively. During the final session, qualitative data on physician experience was collected and then analyzed using conventional content analysis.

Results

Twenty-four emergency medicine physicians participated in the pilot study. The attendance goal was met by 20 (24, 83%) physicians and 19 (22, 86%) physicians reported they would recommend peer support groups to a friend of colleague. Positive standardized response mean effect sizes indicated modest improvement in nine of 12 symptom measurements with marginal significance (p < 0.10) for improvement in guilt [20, Effect Size (ES) = 0.45] and depression (21, ES = 0.39). Qualitative findings revealed high overall benefit with few adverse impacts of participation.

Conclusions

Results demonstrate high physician receptivity, feasibility, and benefit from participation in peer support groups. Promising signs of improvement in distress, anxiety, depression, and burn out symptoms warrant additional studies with larger sample sizes and more robust research designs to establish the evidence base for peer support in the physician population.

Narrative Theater to Examine and Mitigate Anti-Black Racism Within Occupational Therapy

Theater has long-standing roots in social justice and holds promise for reducing racist attitudes and behaviors. Objectives of this study were to (a) collect and theatrically portray narratives from Black occupational therapy students and practitioners to a national audience and (b) examine the impact of the theatrical performance on anti-Black racism among attendees. The Identity Development Evolution and Sharing (IDEAS) model guided translation of narratives into a filmed performance. Paired t-test of pre/post administration of the Acceptance and Action Questionnaire-Stigma (AAQ-S) measured changes in stigma beliefs. Qualitative thematic analysis of an open-ended post-survey question elucidated experiences of the performance. The performance engendered significant decreases in stigma; qualitative data elucidated potential mechanisms of change. This study provides insight into experiences of anti-Black racism within occupational therapy and offers a promising means for occupational therapists to engage in anti-Black racism.

Feasibility and Acceptability of Music Imagery and Listening Interventions for Analgesia: Protocol for a Randomized Controlled Trial

Background

Chronic pain and access to care are identified as critical needs of the Veterans Health Administration. Music imagery and music listening interventions have shown promise as effective nonpharmacological options for pain management. However, most studies have focused on acute pain, passive music experiences, and in-person delivery.

Objective

In this study, we aimed to examine the feasibility and acceptability of 2 music interventions delivered through telehealth for chronic musculoskeletal pain, trial design, and theoretical model before conducting a fully powered efficacy or comparative effectiveness trial.

Methods

FAMILIA (Feasibility and Acceptability of Music Imagery and Listening Interventions for Analgesia) is a 3-arm, parallel group, pilot trial. A total of 60 veterans will be randomized to one of the three conditions: music imagery, music listening, or usual care. Aim 1 is to test the feasibility and acceptability of a multicomponent, interactive music imagery intervention (8-weekly, individual sessions) and a single-component, minimally interactive music learning intervention (independent music listening). Feasibility metrics related to recruitment, retention, engagement, and completion of the treatment protocol and questionnaires will be assessed. Up to 20 qualitative interviews will be conducted to assess veteran experiences with both interventions, including perceived benefits, acceptability, barriers, and facilitators. Interview transcripts will be coded and analyzed for emergent themes. Aim 2 is to explore the effects of music imagery and music listening versus usual care on pain and associated patient-centered outcomes. These outcomes and potential mediators will be explored through changes from baseline to follow-up assessments at 1, 3, and 4 months. Descriptive statistics will be used to describe outcomes; this pilot study is not powered to detect differences in outcomes.

Results

Recruitment for FAMILIA began in March 2022, and as of July 2022, 16 participants have been enrolled. We anticipate that enrollment will be completed by May 2023. We expect that music imagery and music listening will prove acceptable to veterans and that feasibility benchmarks will be reached. We hypothesize that music imagery and music listening will be more effective than usual care on pain and related outcomes.

Conclusions

FAMILIA addresses four limitations in music intervention research for chronic pain: limited studies in veterans, evaluation of a multicomponent music intervention, methodological rigor, and internet-based delivery. Findings from FAMILIA will inform a fully powered trial to identify putative mechanisms and test efficacy.

Trial Registration

ClinicalTrials.gov NCT05426941; https://tinyurl.com/3jdhx28u

International Registered Report Identifier (IRRID)

DERR1-10.2196/38788

Protocol for evaluating external facilitation as a strategy to nationally implement a novel stigma reduction training tool for healthcare providers

Background

Identity Development Evolution and Sharing (IDEAS) is a theatre-based intervention for reducing healthcare provider stigma. IDEAS films are created by collecting narratives from people who have experienced discrimination and healthcare inequity, partnering with professional playwrights to create theatrical scripts that maintain the words of the narratives while arranging them into compelling storylines involving several interviews, and hiring professional actors to perform and record scenes. IDEAS implementation requires a moderator to establish a respectful learning environment, play the filmed performance, set ground rules for discussion, and moderate a discussion between healthcare providers who viewed the film and invited panelists who are members of the minoritized population being discussed. IDEAS’ impact on provider stigma is measured via pre/post Acceptance and Action Questionnaire – Stigma (AAQ-S) data collected from participating providers. The objectives of this manuscript are to provide narrative review of how provider stigma may lead to healthcare inequity and health disparities, describe the conceptual frameworks underpinning the IDEAS intervention, and outline methods for IDEAS implementation and implementation evaluation.

Methods

This manuscript describes a hybrid type 3 design study protocol that uses the Consolidated Framework for Implementation Research (CFIR) to evaluate external facilitation, used as an implementation strategy to expand the reach of IDEAS. CFIR is also used to assess the impact of characteristics of the intervention and implementation climate on implementation success. Implementation success is defined by intervention feasibility and acceptability as well as self-efficacy of internal facilitators. This manuscript details the protocol for collection and evaluation of implementation data alongside that of effectiveness data. The manuscript provides new information about the use of configurational analysis, which uses Boolean algebra to analyze pathways to implementation success considering each variable, within and across diverse clinical sites across the USA.

Discussion

The significance of this protocol is that it outlines important information for future hybrid type 3 designs wishing to incorporate configurational analyses and/or studies using behavioral or atypical, complex, innovative interventions. The current lack of evidence supporting occupational justice-focused interventions and the strong evidence of stigma influencing health inequities underscore the necessity for the IDEAS intervention.

Comparing narrative-informed occupational therapy in adult outpatient mental health to treatment as usual: A quasi-experimental feasibility study with preliminary treatment outcomes

This paper describes implementation of a narrative-informed occupation-based service in an outpatient community mental health setting that addressed several gaps, including 1) the need for outcome data on occupational therapy in this setting; 2) an ongoing mental health provider shortage; and 3) a need for innovative approaches to supporting mental health. We found a significant improvement from baseline to post-intervention in occupational participation, and dose of occupational therapy was significantly related to improvements in the areas of roles, habits, values, long-term goals, social environment, and readiness for change. This study suggests future, larger effectiveness studies of narrative-informed occupation-based interventions delivered by occupational therapists in outpatient community mental health are warranted.

Organizational conditions that influence work engagement and burnout: A qualitative study of mental health workers

Objective: Clinician burnout in healthcare is extensive and of growing concern. In mental health and rehabilitation settings, research on interventions to improve burnout and work engagement is limited and rarely addresses organizational drivers of burnout. This study sought to elaborate on the organizational influence of burnout and work engagement in mental health. Methods: We randomly selected 40 mental health clinicians and managers who were participating in a burnout intervention and conducted semi-structured interviews to understand their views of organizational conditions impacting burnout and work engagement. Data were analyzed using a thematic analytical approach. Results: Analyses yielded three major themes where organizational contexts might reduce burnout and increase work engagement: (a) a work culture that prioritizes person-centered care over productivity and other performance metrics, (b) robust management skills and practices to overcome bureaucracy, and (c) opportunities for employee professional development and self-care. Participants also referenced three levels of the organizational context that they believed influenced burnout and work engagement: front-line supervisors and program managers, organizational executive leadership, and the larger health system. Conclusions and Implications for Practice: Findings point to several possible targets of intervention at various organizational levels that could guide the field toward more effective ways to reduce burnout and improve work engagement. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Changing the Face of Health Care: A Participatory Theater Intervention for Promoting Retention of Under-Represented Minority Students in Health Care

Date Presented Accepted for AOTA INSPIRE 2021 but unable to be presented due to online event limitations.

Health workforce diversity and under-represented minority student enrollment in health professions programs are major sources of concern for allied health professions. We used sequential mixed methods to examine the impact of a participatory theater intervention on minority students’ engagement in their educational journeys toward becoming health care professionals, with the goal of promoting diversity in health care education, and found a significant increase in meaningful participation.

Primary Author and Speaker: Sally Wasmuth

Contributing Authors: NiCole Keith, Kevin T. Pritchard

Supporting Occupational Justice for Transgender and Gender-Nonconforming People Through Narrative-Informed Theater: A Mixed-Methods Feasibility Study

IMPORTANCE

Societal stigma gravely impedes occupational justice for transgender and gender-nonconforming (TGNC) people, producing vast health disparities for this population.

OBJECTIVE

To test the feasibility of an intervention to reduce stigma and improve the well-being of TGNC people.

DESIGN

A parallel, mixed-methods design was used to test feasibility in the areas of acceptability, demand, and limited efficacy.

SETTING

Community.

PARTICIPANTS

Forty-two audience members and 5 TGNC interviewees.

INTERVENTION

Virtual, narrative-informed play reading and moderated discussion about gender diversity and affirmative care. Outcomes and Measures: The valid and reliable Acceptance and Action Questionnaire-Stigma was used to assess stigma beliefs. An open-ended, qualitative question assessed TGNC interviewees' experiences.

RESULTS

Recruitment and participant responses to the intervention indicated feasibility in the areas of acceptability, demand, and limited efficacy. However, future efforts at obtaining a diverse TGNC sample are needed.

CONCLUSIONS AND RELEVANCE

The intervention decreased stigma beliefs in audience members and offered a positive experience for TGNC participants. Feasibility outcomes warrant future efficacy testing. What This Article Adds: This article adds an innovative intervention for promoting occupational justice to support the health and well-being of TGNC people. The community-based intervention facilitates change in societal attitudes and stigmatizing beliefs.

A Mixed-method Analysis of Community-Engaged Theatre Illuminates Black Women's Experiences of Racism and Addresses Healthcare Inequities by Targeting Provider Bias

Theatre has been a powerful means of eliciting social change. This paper describes methods and outcomes of a theatre project to reduce healthcare inequities experienced by Black women. We conducted narrative interviews with a convenience sample of Black women and conducted thematic analysis of interview transcripts to learn about their experiences of healthcare and to inform development of a professional theatrical production. To assess the impact of the performance on the audience, we used a single post-test concurrent mixed-methods design using a self-created Likert-type survey that included space for open-ended responses. Ten Black women completed narrative interviews. Thematic analysis revealed 5 main themes: being ignored, being accused, being talked-down to, fearing harm, and being hurt. Narratives were used to create a script that centered on these themes, and that was professionally produced and performed. Audience members (n = 113, 25% healthcare providers) produced a mean total post-test score of 19.28 (agree/strongly agree) on a 25-point survey with 2 items scoring in the 2 to 3 range (disagree/not sure). Thematic analysis data revealed the extent to which Black women experienced discrimination in multiple settings. Quantitative survey data suggested audience members conceptually understood and were aware of inequity, but open-ended responses revealed this information was new for some, and prior knowledge for others. The audience reported planning to change personal behaviors that may contribute to inequity. Participants were unsure if they had contributed to inequity in the past. The performance stimulated conversation about implicit bias and discrimination and encouraged audience members to examine their contributions to the problem. Future pre-post studies are needed to better assess the impact of the performance. Theatre has the potential to illuminate the extent and nature of discrimination in healthcare and society, and to foster conversations that allow audience members to consider their own potential contributions to discrimination.

Teaching pursed-lip breathing through music: MELodica Orchestra for DYspnea (MELODY) trial rationale and protocol

BACKGROUND

Patients with chronic obstructive pulmonary disease (COPD) commonly experience dyspnea, which may limit activities of daily living. Pursed-lip breathing improves dyspnea for COPD patients; however, access to pursed-lip breathing training is limited.

METHODS

The proposed MELodica Orchestra for DYspnea (MELODY) study will be a single-site pilot study to assess the safety, feasibility, and efficacy of a music-based approach to teach pursed-lip breathing. Patients with COPD and moderate-severe dyspnea are randomized to intervention, education-control, or usual care control groups. Intervention patients meet twice weekly for eight weeks for melodica instruction, group music-making, and COPD education. Safety, feasibility, and efficacy is assessed qualitatively and quantitatively.

RESULTS

This manuscript describes the rationale and methods of the MELODY pilot project.

CONCLUSIONS

If pilot data demonstrate efficacy, then a multi-site randomized control trial will be conducted to evaluate program effectiveness and implementation.

The Opioid Crisis: OTs’ Perceptions and Experiences From the Front Lines

Date Presented 03/28/20

Limited literature exists regarding OT’s role in the opioid crisis. To develop and support that role, it is important to understand practitioners’ perceptions and experiences in treating the population. This research study, through qualitative content analysis, explores barriers and supports to addressing opioid prevention, use, and addiction in practice. The results provide a foundation for future research establishing OT’s role in the opioid crisis.

Primary Author and Speaker: Jessica Daniel

Contributing Authors: Sally Wasmuth

Insight Into the Occupational Lives of Adults With Borderline Personality Disorder (BPD): A Grounded Theory Approach

Date Presented 04/06/19

This study uses a grounded theory approach to understand how borderline personality disorder (BPD) affects occupational participation. Environment, occupation, and internal experiences are discussed in the context of the lives of 18 participants with BPD. Affirming occupations provided escape from harmful environments and promoted positive internal experiences. By contrast, absence of affirming occupations resulted in problematic environmental challenges and distressing internal experiences.

Primary Author and Speaker: Emily Mokol

Additional Authors and Speakers: Kyra Jo Gaerke, Sally Wasmuth, Trevor Manspeaker, Karolina Szymaszek

Occupation-Based Theater Intervention for Individuals With Substance Use Disorder

Date Presented 4/20/2018

People with substance use disorder participated in a 6-wk theater intervention to supplement recovery. This study examined the qualitative experience of participants before, during, and 6 mo after the intervention to understand changes in addictive behavior after this occupation-based intervention.

Primary Author and Speaker: Sally Wasmuth

Additional Authors and Speakers: Michaela Thomas, Haley Hackman, Danyele Clingan, Jill Hecht, Aubriana Adney

Theater-Based Community Engagement Project for Veterans Recovering From Substance Use Disorders

In this study, we examine the feasibility and acceptability of a 6-wk, interdisciplinary, occupation-based theater project for facilitating community engagement and substance use disorder (SUD) recovery in veterans. All data were collected at baseline, postintervention, and 6-wk and 6-mo follow-up intervals. Of the invited veterans, 24% consented to participate (n = 14), and 50% were retained (n = 7). Average attendance was 91%. Considerable improvements in social and occupational participation were noted at postintervention and at 6-wk follow-up but were not retained at 6 mo. No important change in self-efficacy was noted. Of the participants, 86% remained abstinent for 6 wk following the intervention. Theater provides a feasible and acceptable resource for potentially facilitating SUD recovery. Larger controlled effectiveness studies of theater are needed to examine whether robust and notable recovery outcomes in people with SUDs can be linked to participation in theater.

Occupation-Based Intervention for Addictive Disorders: A Systematic Review

Addictive disorders disrupt individuals' occupational lives, suggesting that occupational therapists can play a crucial role in addiction rehabilitation. Occupation-based interventions are those in which an occupation is performed, and occupations are defined as those activities a person engages in to structure time and create meaning in one's life. This review asked: In persons with addictive disorders, are occupation-based interventions more effective than treatment as usual in improving short and long-term recovery outcomes? A systematic literature search was performed by a medical librarian in Ovid MEDLINE, PsychINFO, Social Work Abstracts, OTSeeker, HealthSTAR, CINAHL, and ACPJournalClub. Authors screened 1095 articles for inclusion criteria (prospective outcome studies examining the effectiveness of an occupation-based intervention with a sample primarily consisting of a diagnosis of a substance-related or addictive disorder and with at least five participants), and two authors appraised the resulting 66 articles using a standard appraisal tool, yielding 26 articles for qualitative synthesis and 8 with shared outcome measures for quantitative analysis. Occupation-based interventions in the areas of work, leisure, and social participation were found to have been used to treat addictive disorders. Occupation-based interventions in the area of social participation all elicited better outcomes than their respective control/comparison groups. Not all occupation-based interventions in the area of leisure elicited better outcomes than their comparison group, but in the eight articles with shared outcome measures, quantitative analysis demonstrated leisure interventions produced larger effect sizes than social participation interventions.

Occupation-Based Intervention for Addictive Disorders: A Systematic Review

Date Presented 4/17/2015

This systematic review examined whether occupation-based interventions are more effective than standard interventions in improving recovery outcomes in persons with addiction(s). Occupation-based interventions are contrasted from more didactic therapeutic approaches.

Exploring Addiction-as-Occupation

Introduction

Despite advances in addiction research and practice, addiction remains a significant public health problem with strikingly high relapse rates and low treatment retention rates. This study explored whether the concept of addiction-as-occupation aligned with the experiences of ten persons with addiction(s), and suggests that further development of a model based on this concept may help to elucidate and address some barriers to addiction recovery services.

Methods

Semi-structured interviews were performed to gain descriptions of the occupational lives and first-hand experiences of ten persons with addiction(s). Transcripts were analysed using a qualitative thematic analysis methodology.

Results

Seven themes were identified in the data: connection, locus of control, penetration, habituation, identity, motivation, and coping/escape. Participants in this study described their addictions using occupational terms, and addressed both the gains and harms of performing their addictions.

Conclusion

Further investigation of experiences of addiction-as-occupation could be useful for informing occupational therapy interventions for substance-related and addictive disorders. Potential implications and contributions of a conceptual model based on the notion of addiction-as-occupation, as well as areas for future research, are discussed.

Sub-lytic C5b-9 induces functional changes in retinal pigment epithelial cells consistent with age-related macular degeneration

PURPOSE

There is evidence for complement dysfunction in age-related macular degeneration (AMD). Complement activation leads to formation of the membrane attack complex (MAC), known to assemble on retinal pigment epithelial (RPE) cells. Therefore, the effect of sub-lytic MAC on RPE cells was examined with regard to pro-inflammatory or pro-angiogenic mediators relevant in AMD.

METHODS

For sub-lytic MAC induction, RPE cells were incubated with an antiserum to complement regulatory protein CD59, followed by normal human serum (NHS) to induce 5% cell death, measured by a viability assay. MAC formation was evaluated by immunofluorescence and FACS analysis. Interleukin (IL)-6, -8, monocytic chemoattractant protein-1 (MCP-1), and vascular endothelial growth factor (VEGF) were quantified by enzyme-linked immunosorbent assay (ELISA). Intracellular MCP-1 was analysed by immunofluorescence, vitronectin by western blotting, and gelatinolytic matrix metalloproteinases (MMPs) by zymography.

RESULTS

Incubation of RPE cells with the CD59 antiserum followed by 5% NHS induced sub-lytic amounts of MAC, verified by FACS and immunofluorescence. This treatment stimulated the cells to release IL-6, -8, MCP-1, and VEGF. MCP-1 staining, production of vitronectin, and gelatinolytic MMPs were also elevated in response to sub-lytic MAC.

CONCLUSIONS

MAC assembly on RPE cells increases the IL-6, -8, and MCP-1 production. Therefore, sub-lytic MAC might have a significant role in generating a pro-inflammatory microenvironment, contributing to the development of AMD. Enhanced vitronectin might be a protective mechanism against MAC deposition. In addition, the increased expression of gelatinolytic MMPs and pro-angiogenic VEGF may be associated with neovascular processes and late AMD.

Renal insufficiency is independently associated with a distal distribution pattern of symptomatic lower-limb atherosclerosis

OBJECTIVES

The purpose of this study was to assess the impact of renal insufficiency (RI) on the distribution pattern of peripheral arterial disease (PAD). We hypothesised that RI is associated with a distally accentuated involvement of the peripheral arterial tree.

DESIGN

This is a retrospective analysis.

MATERIALS AND METHODS

Analysis was based on a consecutive series of 2709 patients with chronic PAD of atherosclerotic origin undergoing primary endovascular treatment of lower-extremity arteries. Atherosclerotic pattern was grouped into femoropopliteal (n=2085) and infragenicular (n=892) disease according to target lesions treated while using iliac disease (n=1133) as reference. Univariable and multivariable multinomial regression analyses were performed to assess relation with RI. Results are shown as relative risk ratio (RRRs) with 95% confidence intervals (95% CIs). A p<0.05 was considered statistically significant. RI was defined as glomerular filtration rate (GFR)<60 ml min(-1) 1.73 m(-2).

RESULTS

Presence of RI was an independent risk factor for a centrifugal lesion pattern (RRR 1.48, 95% CI: 1.17-1.86, p=0.001). Moreover, a decrease in GFR by 10 ml min(-1) 1.73 m(-2) was associated with an RRR of 1.08 for below-the-knee arterial disease (95% CI: 1.03-1.13, p=0.003).

CONCLUSION

Presence and severity of RI are independent predictors of a distal obstructive pattern in patients with symptomatic PAD.

Improvement of herpetic stromal keratitis with fumaric acid derivate is associated with systemic induction of T helper 2 cytokines

Fumaric acid derivates have been shown to stimulate T helper-2-cytokines (interleukin (IL)-4, -5) without affecting the T-helper-1-cytokine (IL-2, interferon (IFN)-gamma)-response. Herein, the influence of systemic treatment with the fumaric acid derivate dimethylfumarate (DMF) on the secretion of T helper-cytokines and the development of HSV-1 stromal keratitis (HSK) was studied in mice. The corneas from BALB/c mice were infected with 10(5) PFU of HSV-1 (KOS strain). While one group of mice was treated intraperitoneally with PBS, another group of mice received DMF at 15 mg/kg of body weight. Expression of IL-2, -4, -10 and IFN-gamma was analysed in HSV-1 activated lymphocytes by ELISA. The severity of epithelial and stromal herpetic keratitis was investigated clinically. Corneas were studied for the inflammatory cell infiltration, and the CD3-, CD4- and CD8-positive cells were analysed by immunohistochemistry. The IL-2, -4, 10 and IFN-gamma content was measured in the corneas. Virus replication in the eyes was analysed by a plaque-assay. The DTH-response, the HSV-specific T cell proliferation and the serum neutralizing antibody-titres were investigated. DMF increased IL-4 and IL-10, but not IL-2 and IFN-gamma, secretion in activated lymphocytes from the spleen. Incidence and severity of stromal HSV-1 keratitis was reduced in the DMF group (P < 0.01). In the corneas from DMF-treated mice, the numbers of CD3+ and CD4+ cells were decreased and IL-4 was increased. Severity of epithelial disease and the virus-clearance from the eyes did not differ between the PBS and DMF group of mice. DTH, HSV-specific T cell proliferation and the neutralizing antibody-titres were not impaired. DMF increased the T helper-2-cytokine secretion in activated lymphocytes. After corneal HSV-1 infection, corneas from DMF treated mice had increased IL-4 content. This is associated with an improvement of herpetic stromal keratitis and reduced corneal T cell infiltration. DMF did not impair the systemic antiviral response.

[Do antisense oligonucleotides improve viral immunopathology?]

BACKGROUND

Tumor necrosis factor (TNF)-alpha as a proinflammatory cytokine is of great importance during the development of herpes simplex virus-1 keratitis (HSK). In this study the local administration of antisense oligonucleotides (ASON) targeting TNF-alpha was examined for its usefulness in ameliorating this disease.

METHODS

Uptake and efficacy of the oligonucleotides were studied in vitro by fluorescence microscopy and flow cytometry. Substance- and sequence-specific influences on the development of HSK were scrutinized in an animal model.

RESULTS

Quick and stable uptake of FITC-labeled ASON by isolated spleen and lymph node cells was proved. The production of TNF-alpha by these cells after stimulation with HSV antigen or concanavalin A (ConA) was clearly downregulated after addition of ASON. In vivo, incidence and development of HSK were ameliorated after subepithelial corneal injection of ASON targeting TNF-alpha. When buffer and control oligonucleotides were given, no significant influence on the disease was found.

CONCLUSION

The ASON effectively reduced TNF-alpha secretion in vitro and suppressed the development of experimental HSK in vivo.

Influence of dimethylfumarate on experimental HSV-1 necrotizing keratitis

BACKGROUND

This study was performed to investigate the influence of fumaric acid esters on the course of herpes stromal keratitis (HSK).

METHODS

The corneas of BALB/c mice were inoculated with 105 plaque-forming units of herpes simplex virus 1 (HSV-1, KOS strain). Groups of mice were treated intraperitoneally with phosphate buffered saline (PBS) (control mice), or with dimethylfumarate (DMF) at 15 mg/kg of body weight dissolved in PBS daily for 28 days pre-infection and for 14 days post-infection. The course of HSV-1 keratitis was studied clinically. Corneal sections were examined for inflammatory cell infiltration. The numbers of CD3, GR-1, CD11b and F4/80-expressing cells infiltrating the corneas were analyzed by immunohistochemistry.

RESULTS

On day 14 after HSV infection, 72% of the mice in the control group had severe HSK. The development of HSK was reduced by DMF treatment in the DMF group (22%) (P=0.004). The total number of inflammatory cells and infiltration of polymorphonuclear-neutrophils (PMNs) were reduced in the corneas of DMF-treated mice. Compared to the PBS-treated mice, numbers of CD3, CD11b, GR-1 and F4/80-positive cells were reduced in the DMF group of mice.

CONCLUSIONS

The course of experimental herpes stromal keratitis can be improved with systemic fumaric acid ester treatment. The improvement of keratitis correlates with a reduced corneal infiltration of T cells and mononuclear cells.

[Amniotic membrane transplantation improves experimental herpetic keratitis. Modulation of matrix metalloproteinase-9]

PURPOSE

Transplantation of human amniotic membrane (AMT) accelerates the healing of experimental ulcerative herpetic keratitis. Here the expression and activity of matrix metalloproteinase (MMP)-9 was studied.

METHODS

BALB/c mice were corneally infected with HSV-1. Whereas the infected corneas of mice in group 1 were covered with AM, tarsorrhaphies were performed in others (group 2). After 2 days, the appearance of corneal ulcers and stromal inflammation was judged clinically, and the corneal PMN infiltration was studied histologically. The expression of MMP-9 in the corneas was localized by immunohistochemistry and analyzed by Western-blot technique. The MMP-9 activity in the corneas was determined by zymography.

RESULTS

On day 14, the ulcerating corneas had a dense PMN infiltration, the ulcers and the majority of PMNs were highly positive for MMP-9, and the active forms of MMP-9 were detected. Gelatinolytic activity was found in these corneas by zymography. Compared with the mice of group 2, ulceration, stromal inflammation and neovascularization markedly improved clinically and histologically within 2 days in mice of group 1. This was associated with a reduced expression of MMP-9 in corneal tissue and in PMNs. The gelatinolytic activity of MMP-9 was reduced after AMT.

CONCLUSIONS

These observations suggest that improvement of herpetic corneal ulcers and reduced corneal neovascularization after AMT may result from a reduced expression and activity of MMP-9.

[Amniotic membrane transplantation improves herpetic keratitis by local and not by systemic effects]

PURPOSE

The immune mediated HSV-1 stromal keratitis (HSK) rapidly improves after amniotic membrane transplantation (AMT). This study investigated whether AMT modulates the T cell response and whether the anti-inflammatory action of AMT is due to local or systemic effects.

METHODS

Corneas of BALB/c mice were infected with 10(5) (PFU) of HSV-1. Animals with ulcerating keratitis on day 14 post-infection were divided into 4 groups: group 1 ( n=12): right eye AMT;group 2 ( n=12): right eye tarsorrhaphy; group 3 ( n=8): right eye tarsorrhaphy, left eye AMT;group 4 ( n=8): both eyes tarsorrhaphy. The mice were examined for clinical signs of HSV keratitis after 2 days. Corneal sections were studied histologically and the inflammatory cell infiltration was studied by immunohistochemical staining. DTH response and the HSV-specific 3H-thymidin-uptake were compared between the groups.

RESULTS

Compared to group 2, ulceration and stromal inflammation was profoundly improved in group 1 ( p<0.01). The corneas in the AMT mice had fewer inflammatory cells, CD3+,CD4+ and CD8+ cells than the control mice ( p<0.01). There were no significant differences between groups 1 and 2 with respect to the delayed type hypersensitivity reaction (DTH response) and the HSV-specific 3H-thymidin uptake. AMT or tarsorrhaphy on the left eyes in groups 3 and 4 had no influence on the course of keratitis or the T cell response.

CONCLUSIONS

Ulcerating herpetic keratitis markedly improves after AMT. Our observations indicate that this is caused predominantly by local and not by systemic AMT-related effects.