Newborn behaviour to locate the breast when skin-to-skin: a possible method for enabling early self-regulation.

AIM: The aim of this study was to provide a more detailed analysis of the infant's behavioural sequence that begins immediately after birth and terminates with grasping the nipple, suckling and then falling asleep. METHOD: Twenty-eight full-term infants were videotaped immediately after birth. A video protocol was developed to examine infant behaviours identified from five random videotapes. RESULTS: When birth crying had stopped, the babies showed a short period of relaxation and then successively became alert. They went through an 'awakening phase', an 'active phase' with movements of limbs, rooting activity and looking at the mother's face, a 'crawling phase' with soliciting sounds, a 'familiarization phase' with licking of the areola, and a 'suckling phase' and last a 'sleeping phase'. Five factors related to the time spent to locate the breast: more number of looks at the breast 10-20 min after birth (p < 0.0001); and exposure to meperidine (p = 0.0006) related to increased time. Early start of crawling (p = 0,0040); increased number of 'soliciting sounds' (p = 0.0022); and performing hand-breast-mouth movements (p = 0.0105) related to shorter time. CONCLUSION: Inborn breastfeeding reflexes were depressed at birth, possibly because of a depressed sensory system. It is hypothesized that when the infant is given the option to peacefully go through the nine behavioural phases birth cry, relaxation, awakening, activity, crawling, resting, familiarization, suckling and sleeping when skin-to-skin with its mother this results in early optimal self-regulation.

Treatment efficacy of intermittent claudication by surgical intervention, supervised physical exercise training compared to no treatment in unselected randomised patients I: one year results of functional and physiological improvements.

OBJECTIVES: to compare the effect of surgery, exercise and simple observation on maximum exercise power in claudicants. DESIGN: prospective, randomised study. METHODS: a total of 264 unselected claudicants were randomised to supervised exercise training, invasive treatment (open surgical or endovascular procedures) or observation. One year treatment outcomes were analysed on an intention to-treat basis. RESULTS: invasively treated patients showed a significant improvement in maximum walking power, stopping distance, post-ischaemic blood flow and big toe pressure at one year. Patients randomised to physical exercise training or to the control group did not improve in any outcome measure. CONCLUSION: invasive treatment increased walking capacity, leg blood pressure and flow. Supervised physical exercise training offered no therapeutic advantage compared to untreated controls.

Treatment efficacy of intermittent claudication by invasive therapy, supervised physical exercise training compared to no treatment in unselected randomised patients II: one-year results of health-related quality of life.

OBJECTIVE: to compare the effectiveness of invasive therapy, supervised physical training and no treatment in terms of health-related quality of life (HRQL) in patients with intermittent claudication (IC). DESIGN: a prospective, randomised, controlled study. MATERIALS: a total of 253 unselected patients with stable IC were sequentially randomised into 3 balanced treatment groups. At 1 year follow-up data from a battery of generic and disease specific HRQL questionnaires, and global indices of quality of life and physical condition were available in 171 patients. RESULTS: compared with a non-diseased reference group, claudicants were substantially limited in daily physical functioning, but little affected regarding emotional, cognitive and social functioning, or well-being. Invasive therapy yielded significantly greater improvements in some aspects of physical functioning and walk-related symptoms than training. Training was not superior to invasive therapy on any HRQL dimension and superior to no treatment on only one dimension. Treatment effects, however, were generally small-to-moderate and levels of physical dysfunction in all groups remained higher than reference values. CONCLUSIONS: invasive therapy is more effective than supervised training in alleviating illness-specific symptoms and improving certain aspects of physical functioning - the primary HRQL domains impacted on by IC and the principal goals of its treatment. However, since treatment effect sizes were at most moderate and given that untreated claudicants reported at most small deterioration in HRQL, the level of evidence supporting invasive therapy is modest.

Partner relationships, functioning, mood and global quality of life in persons with spinal cord injury and traumatic brain injury.

The aim of this study was to assess and compare spinal cord injured (SCI) and traumatic brain injured (TBI) persons and people from the general population concerning partner relationships, functioning, mood and global quality of life. One hundred and sixty seven SCI persons, 92 TBI persons and 264 controls participated in the study. The median age was: SCI persons 33 years (range 19 to 79 years), TBI persons 40 years (range 20 to 70 years), and controls 31 years (range 19 to 79 years). Age at injury ranged among SCI persons from 14 to 76 years (Md 28 years), and among TBI persons from 16 to 56 years (Md 32 years). Half of the SCI group (51%), 58% of the TBI group and 59% of the controls had a stable partner relationship at the time of the investigation. Many of these SCI and TBI relationships (38% and 55% respectively) were established after injury. Both SCI and TBI persons showed significantly more depressive feelings compared with the controls. Perceived quality of life (global QL rating) was significantly lower in the SCI group compared with the controls, whereas the ratings of TBI persons and controls did not differ significantly. SCI and TBI persons did not differ significantly in level of education, perceived quality of life or distress. In all three groups, global quality-of-life ratings were significantly lower among single persons compared to those with a partner relationship. It was concluded that both SCI and TBI appear to affect overall quality of life and mental well-being negatively. The number of partner relationships contracted after injury among both SCI and TBI persons indicates, however, that the injury is not a major barrier to establishing close partner relationships. Being in good spirits, that is, lack of depressive feelings has a profound impact on the perception of a high quality of life in all three groups. For the SCI and TBI persons, a high level of physical and social independence were further positive determinants of a perceived high quality of life.

Sexual adjustment and its predictors after traumatic brain injury.

The aim of this study was to investigate the impact of traumatic brain injury (TBI) on sexual ability, activity and satisfaction and to relate the findings to neurological status, functioning and well-being. A total of 92 TBI persons (65 men, 27 women) participated. Their ages ranged from 20-70 years (median 40 years); the median age at injury was 32 years, ranging from 16-56 years. The elapsed time since injury ranged from 1-20 years (median 9 years). The participants were examined according to a procedure including neurological examination, self-assessment of general health status and functioning and mood, and collection of data on social conditions. A structured study-specific questionnaire was developed to assess various aspects of sexuality before and after the injury. Fifty-three of the participants had a stable partner relationship at the time of the investigation. This study showed that a TBI commonly alters sexual functioning as well as desire. Many of the respondents reported decreased ability to achieve an erection, decreased ability to experience organism, decreased sexual desire and diminished frequency of intercourse. A high degree of physical independence and maintained sexual ability were the most important predictors for sexual adjustment. Considering that many TBI persons in this study reported physiological sexual disturbances and decreased sexual ability, it is important to inform patients about possibilities of optimizing their sexual ability. Organized programmes of sexuality education should be an integral component of TBI rehabilitation.

The impact of intermittent claudication on quality of life evaluated by the Sickness Impact Profile technique.

Unselected patients suffering from intermittent claudication (n = 148) were invited to take part in a prospective study. Physical examination and several circulatory investigations were performed including a treadmill walking test, bicycle ergometry and a quality of life examination (Sickness Impact Profile, SIP, technique). The SIP has been reported to be sensitive enough to identify specific dysfunction profiles in several clinical conditions, but it has not been used on patients with intermittent claudication. The aim of this study was to determine to what extent quality of life was influenced by reduced walking ability in patients with intermittent claudication. If so, the SIP technique should then be a useful tool for determination of the degree of reduced exercise capacity in patients who may benefit from surgery instead of conservative treatment. A majority of the SIP categories, Sleep and rest, Emotional behaviour, Body care and movement, Home management, Mobility, Social interaction, Ambulation and Overall SIP were shown to be useful in confirming objective dysfunctions in our patients. The correlation between maximum walking ability and SIP scores indicated an approximate cut-off limit at 70 W walking capacity. Thus, significant reductions in everyday life function were demonstrated in patients with maximum walking ability below 70 W. Patients with intermittent claudication also suffered from several other dysfunctions in addition to walking disability. These factors may, as well, impact on quality of life without walking disability. Our results demonstrated that quality of life assessment by the SIP technique was a sensitive method for evaluation of overall dysfunction in patients with intermittent claudication.(ABSTRACT TRUNCATED AT 250 WORDS)

Co-variation between walking ability and circulatory alterations in patients with intermittent claudication.

Unselected patients (n = 183) with subjective symptoms of intermittent claudication were examined clinically and by various circulatory tests (calf blood-flow, ankle, toe pressures). The aims of the present study were to evaluate to what extent the central or peripheral circulation is limiting in unselected patients with subjective symptoms of intermittent claudication, to determine the co-variation between the maximum walking capacity and traditional haemodynamical measures mentioned above and to evaluate to what extent a traditional bicycle ergometer exercise test and treadmill walking test give similar information regarding maximum performance. Eighty-five per cent of all patients were or had been smokers and 16% were diabetics. The mean ankle/brachial blood pressure index was 0.58 +/- 0.02 and the average post-ischemic maximum calf bloodflow was 13.3 +/- 0.6 ml/min/100 ml tissue. Leg arterial insufficiency was the limiting factor of walking capacity in 90% of all patients at 87 +/- 2 W corresponding to a walking distance of 282 +/- 13 m, while leg exhaustion was the limiting factor in 80% of the patients during test on the bicycle ergometer at maximum 84 +/- 2W. The mean maximum walking capacity for all patients was 86 +/- 3W and the mean maximum capacity on the bicycle ergometer was 87 +/- 2W. The ankle/brachial index showed only a weak correlation (r = 0.30, p < 0.002) to walking capacity. Our results demonstrate that the maximum walking capacity on a treadmill agrees with mean values of maximum exercise capacity on a bicycle ergometer.(ABSTRACT TRUNCATED AT 250 WORDS)

Muscle enzyme adaptation in patients with peripheral arterial insufficiency: spontaneous adaptation, effect of different treatments and consequences on walking performance.

1. The activities of phosphofructokinase (PFK), citrate synthetase (CS), lactate dehydrogenase (LDH), 3-hydroxyacyl-CoA dehydrogenase (ACDH) and cytochrome-c oxidase(Cyt-ox) in the calf muscle tissue were compared in subjects with intermittent claudication (n = 38) and controls (n = 20). The activities of CS, ACDH and Cyt-ox were increased and the activity of Cytox was positively correlated to the maximal walking distance (MWD) in the patients. 2. Thirty-three patients with intermittent claudication were randomized to three treatment groups: (1) operative surgery, (2) operative surgery supplemented with physical training and (3) physical training alone. Before and after 6-12 months of treatment, symptom-free walking distance (SFWD), MWD, ankle-brachial blood pressure quotient (ankle index), maximal plethysmographic calf blood flow (MPBF) and the activities of PFK, CS, LDH, ACDH and Cyt-ox were measured. 3. SFWD and MWD increased in all three groups. Ankle index and MPBF increased in groups 1 and 2, but were unchanged in group 3. The activities of Cyt-ox and CS decreased with operation, but the activity of Cyt-ox was further augmented with training in group 3. Overall, the change in ankle index explained 80-90% of the variability in walking performance. In a separate analysis, the increased activity of Cyt-ox in group 3 was positively correlated to, and explained 31% of the variability in, the improvement in SFWD. 4. These findings indicate that both physical activity and a reduced calf blood flow are necessary conditions for the enzymatic adaptation to take place. A causal relationship between metabolic adaptation in the muscle tissue and walking performance is suggested.(ABSTRACT TRUNCATED AT 250 WORDS)

Intermittent claudication--surgical reconstruction or physical training? A prospective randomized trial of treatment efficiency.

This study reports the initial evaluation of treatment efficiency in 75 patients with intermittent claudication who were randomized to three treatment groups: 1) reconstructive surgery, 2) reconstructive surgery with subsequent physical training, and 3) physical training alone. Before treatment, there were no statistically significant differences between the groups in age, sex, smoking habits, symptom duration of claudication, ankle-arm blood pressure quotient (ankle-index), maximal plethysmographic calf blood flow, symptom-free and maximal walking distance, the history of other atherosclerotic manifestations or in the medical treatment. The walking performance was improved in all three groups at follow-up 13 +/- 0.5 months after randomization. Surgery was most effective, but the addition of training to surgery improved the symptom-free walking distance even further. In pooled observations of the three groups, age, symptom duration, and a history of myocardial ischemic disease correlated negatively with walking performance after treatment. In the operated group, the duration of claudication and a history of myocardial ischemic disease correlated negatively with the walking performance. This was not the case when patients were censored if limited by other symptoms than intermittent claudication after treatment. In the trained group, the duration of claudication correlated negatively to symptom-free and maximal walking distance. Ankle-index and maximal plethysmographic calf blood flow after treatment and the change of these variables with treatment correlated positively with both symptom-free and maximal walking distance when results were pooled for all patients. Although this mainly was a consequence of the improved blood flow after surgery, the change of maximal plethysmographic calf blood flow also correlated with symptom-free but not with maximal walking distance in the trained group. The results demonstrate that, compared with physical training alone, operation alone or in combination with subsequent training are superior treatment modalities in patients with intermittent claudication.

Results of reconstructive surgery in the upper limb of tetraplegic patients.

Forty three out of 62 tetraplegic patients operated on in Sweden during 1970 to 1984 with various reconstructive procedures in the arm and hand have been reexamined. The results show that reconstruction of elbow extensor, key grip and finger flexor are all very valuable procedures if performed on correct indications. All but 4 patients improved by surgery and in many instances the surgical treatment facilitated return to work.

Axonal transport of synapsin I- and cholinergic synaptic vesicle-like material; further immunohistochemical evidence for transport of axonal cholinergic transmitter vesicles in motor neurons.

The axonal transport of organelles in motor axons in the sympathectomized rat sciatic has been studied using two antisera which recognize specific components of synaptic vesicles. Anti-synapsin I recognizes synapsin I (SYN I) which is affiliated with the external membrane of synaptic vesicles, while rabbit-anti-synaptic vesicle antiserum (RASVA) recognizes integral membrane glycoproteins in cholinergic synaptic vesicles. Immunofluorescence studies, including cytofluorimetric scanning, show that immunoreactive (IR) material recognized by both antisera: rapidly accumulate proximal to a crush; the material has a granular appearance in the microscope; is redistributed in an isolated segment, and that the transport of the material is sensitive to vinblastine. Thus the proximodistal transport has the characteristics of fast axonal transport. Furthermore, recycling organelles, accumulating on the distal side of a crush are recognized by RASVA, but carry only very little SYN I-IR. The results give further support to the hypothesis that motor cholinergic axons transport axonal cholinergic vesicles towards the motor endplates.

The contribution of cholinergic enzymes and acetylcholine from the lumbar sympathetic chain to the rat sciatic nerve.

This study was performed to investigate how much of the acetylcholine (ACh), choline acetyltransferase (ChAT) and ACh-esterase (AChE) in the rat sciatic nerve originate from the somatic motor input and from the automatic sympathetic input, respectively. The somatic motor axons to the sciatic nerve were eliminated by surgical transsection of the spinal roots, (rhizotomy) and the autonomic component was removed by surgical resection of the lumbar sympathetic chain bilaterally (sympathectomy). Also combined operations were performed. In intact (non-crushed) sciatic nerve rhizotomy caused a reduction in ACh content by 70%, in ChAT-activity by 55%, and in AChE-activity by 41%. Sympathectomy alone had very little influence on ACh and ChAT, but reduced AChE by 20%. After crushing the nerve 13 hours before sacrifice, all three substances accumulated proximal to the crush region as described previously. When compared to the control group, sympathectomy alone caused a reduction in accumulated amounts of AChE only, while ACh and ChAT accumulations were essentially unchanged. Rhizotomy alone caused a substantial reduction in accumulated amounts of all three substances, but most prominently in ACh and ChAT-amounts. After sympathectomy in combination with rhizotomy ACh-accumulations were very low, and enzyme activities were reduced more than in the group with rhizotomy alone. A certain amount of residual ChAT and AChE was present in the nerve, and the location of this is discussed. The fact that combined sympathectomy and rhizotomy lowered ACh accumulations significantly more than would be expected from the results after either operation alone is commented upon.

Immunocytochemical studies on axonal transport in adrenergic and cholinergic nerves using cytofluorimetric scanning.

The axonal transport of adrenergic and cholinergic axonal organelles in rat sciatic nerve has been studied using a cytofluorimetric scanning (CFS) technique. This technique gives quantitative data on material which accumulates in a nerve relative to a crush, as well as morphological and morphometrical information about the accumulated axons in the nerve. One important advantage is that several substances can be measured in the same nerve segment, thus reducing the number of animals needed. The substances must be made fluorescent, and in this study we have investigated noradrenaline (NA), using formaldehyde induced fluorescence, and dopamine beta-hydroxylase (DBH), tyrosine hydroxylase (TH), neuropeptide Y (NPY) and two cholinergic vesicle components (a transmembrane glycoprotein and synapsin I) using indirect immunofluorescence. The antisera used for labelling immunoreactive material (IR) were produced in rabbit or goat (DBH). In adrenergic axons NA, DBH-IR and TH-IR accumulated with time after crushing the nerve as described earlier with biochemical techniques. After reserpine, the amounts of amine granules transported distally in the sciatic nerve initially fell, but recovered during day 2 after reserpine. At day 4 the amount of NA and DBH-IR which was transported distally in the axons was supranormal, 160% and 140% of control, respectively, but the level of NPY-IR was not increased, even falling to subnormal at day 4, indicating different mechanisms for regulating the synthesis of DBH and NPY which are suggested to co-exist in axonal adrenergic large dense core vesicles. In cholinergic motor axons organelles, recognized by rabbit-anti-cholinergic synaptic vesicles-antiserum (RASVA) and by anti-synapsin I-antiserum, are transported distally at a rapid rate.(ABSTRACT TRUNCATED AT 250 WORDS)

Paraplegia in unstable thoracolumbar injuries. A study of conservative and operative treatment regarding neurological improvement and rehabilitation.

Thirty-seven patients with unstable thoracolumbar fractures and paraplegia were studied: 11 patients were given exclusively conservative treatment, 14 patients were treated conservatively after laminectomy with or without fusion, and 12 patients were treated with Harrington instrumentation. None of the 12 cases with complete paraparesis at admission to the hospital improved their neurological status. In patients with moderate and severe but not complete paraparesis one month after injury, the neurological improvement continued for several years and in many the neurological restitution was complete. There was no difference between the three treatment groups regarding the neurological improvement. A new Rehabilitation Index was constructed with special reference to paraplegic patients. One month after the injury the Rehabilitation Score in the Harrington group was considerably higher than in the other groups. After three months the score was equalized in the conservatively treated group and the Harrington group whereas the score of the laminectomy-fusion group remained lower as long as two years after injury. Thirty-two patients were followed-up two years after the injury. Irrespective of the treatment, 30 of 32 patients had reached their maximal ADL scores at the follow-up. In 19 patients the bladder function was satisfactory. Eleven patients could walk independently. Twelve patients used wheel-chairs. Twenty-eight patients managed outdoor transportation without help. Twenty-four patients (75 per cent) had returned to work. Complaints about back deformity, skin problems and pain at direct pressure over the fracture site were significantly more frequent in the conservative and laminectomy-fusion groups. The treatment with open reduction, fusion and stabilization with Harrington rods considerably reduced the immobilization and hospitalization time. The complications were few. - The Harrington operation resulted in an early rehabilitation, which is of great psychological importance for the patient. - Our study confirms the disadvantages of laminectomy followed by conservative treatment reported by other authors.

The influence of supraspinal impulse activity on the intra-axonal transport of transmitter-related substances in rat motor neurons.

The content and intra-axonal transport of acetylcholine (ACh) and the ACh-metabolizing enzymes choline-acetyl-transferase (CAT) and ACh-esterase (AChE) in the rat sciatic nerve were studied after various experimental procedures. The procedures involved: (1) spinal cord transection (SCT) at the thoracic level 1 day to 3 weeks prior to experiments, to abolish nerve activity of the lower motor neurons (in the lumbar intumescence-sciatic nerve) from supraspinal centres; (2) physical training for 2 h daily during 2 weeks in a rodent treadmill, to increase nerve activity from supraspinal levels; and (3) the use of selective neurotoxins to cause degeneration of descending bulbospinal monoaminergic (MA) neurons. The results of these studies demonstrate that supraspinal nerve influence can modify the axonal transport of ACh and cholinergic enzymes in the rat sciatic nerve, and that descending monoamine (MA) pathways may, at least to some extent, participate in this modulation of intraneuronal dynamics in the motor neuron. Since it has been shown by many investigators that factors which have a trophic influence on skeletal muscle cells both in vitro and in vivo are present in motor nerves and transported along the axons in a distal direction, we suggest that the synthesis and axonal transport of such factors may also be under control of supraspinal nerve activity. Therefore, it is possible that metabolic changes and dystrophy of muscles occurring in patients with lesions of the 'upper motor neuron-type' may also, in addition to other factors, be dependent on changes in intra-axonal transport of various substances in the lower motor neuron.

Influence of descending bulbospinal monoamine neurons on axonal transport of acetylcholine and cholinergic enzymes.

The influence of descending bulbospinal monoamine (MA) neurons on the intra-axonal transport of acetylcholine (ACh) and related enzymes (cholineacetyltransferase, CAT, and ACh-esterase, AChE) in rat sciatic nerve was studied in crush experiments following intracisternal injections of specific neurotoxins. The injection of 6-hydroxydopamine (6-OH-DA) and 5,6-dihydroxytryptamine (5,6-diOH-TA) (50 micrograms X 2) caused a degeneration of catecholamine (CA) and 5-hydroxytryptamine (5-HT) nerve terminals, respectively, and a combination of the two neurotoxins caused a loss of virtually all MA terminals in the lumbar spinal cord. The results of the neurotoxin injections were controlled by the Falck-Hillarp fluorescence method. The effect of neurotoxin treatment on the enzyme activities in the sciatic nerve was very small. The ACh levels of uncrushed nerves and in nerves proximal to a crush performed 12 hours before dissection decreased following either 6-OH-DA or 5,6-diOH-TA. However, the combination treatment with both 6-OH-DA and 5,6-diOH-TA had no influence on ACh accumulation and transport, as compared to the control group. In a previous study we have shown that mid-thoracic spinal cord transection increased AChE-transport while ACh-transport was decreased. The results of this study indicate that the bulbospinal MA neurons may be involved (perhaps indirectly) i the regulation of ACh levels and transport in motor neurons, but less important for the modulation of the cholinergic enzymes.