Considerations for at-home upper-limb rehabilitation technology following stroke: Perspectives of stroke survivors and therapists.

Introduction: This study investigated the needs of stroke survivors and therapists, and how they may contrast, for the design of robots for at-home post stroke rehabilitation therapy, in the Ontario, Canada, context. Methods: Individual interviews were conducted with stroke survivors (n = 10) and therapists (n = 6). The transcripts were coded using thematic analysis inspired by the WHO International Classification of Functioning, Disability, and Health. Results: Design recommendations, potential features, and barriers were identified from the interviews. Stroke survivors and therapists agreed on many of the needs for at-home robotic rehabilitation; however, stroke survivors had more insights into their home environment, barriers, and needs relating to technology, while therapists had more insights into therapy methodology and patient safety and interaction. Both groups felt a one-size-fits-all approach to rehabilitation robot design is inappropriate. Designs could address a broader range of impairments by incorporating household items and breaking activities down into their component motions. Designs should incorporate hand and wrist supports and activities. Designs should monitor trunk and shoulder motion and consider incorporating group activities. Conclusion: While therapists can provide insight in the early stages of design of rehabilitation technology, stroke survivors' perspectives are crucial to designing for the home environment.

Are oral fluid testing devices effective for the roadside detection of recent cannabis use? A systematic review.

OBJECTIVES: Although laws related to drug impairment may deter some drivers, enforcement requires effective detection. There are different methods and devices to test for cannabis use, but it is unclear if these devices meet the necessary criteria to be implemented at the roadside. This systematic review synthesized research that investigated on-site oral fluid drug screening devices. STUDY DESIGN: This is a systematic review. METHODS: Eight databases (PubMed, Web of Science, MEDLINE, Engineering Village, Embase, Compendex, CINAHL, and Scopus) were searched to identify research that had evaluated the effectiveness of oral fluid testing devices. Fifteen articles that used an on-site testing device to detect cannabis use were selected for review. RESULTS: There is a lack of standardized test protocols with respect to biological matrices used for confirmation analysis (blood and oral fluid), concentration detection cutoff, population sample, and contamination with other drugs (alcohol). There is also a lack of device consistency making it difficult to draw conclusions. Sensitivity, specificity, and accuracy of nine devices showed that none of the current devices meet the minimum requirements suggested by the ROSITA, ROSITA-2, and DRUID projects (80% for all three parameters). CONCLUSIONS: The results of this systematic review indicated that the devices with the ability to detect lower Δ9-tetrahydrocannabinol concentration levels achieved better results with respect to sensitivity, specificity, and accuracy than those with higher detection levels. However, research must be focused on developing a roadside detection oral fluid technique that meets the ROSITA, ROSITA-2, and DRUID projects' guidelines.

Occurrence and levels of potentially harmful elements (PHEs) in natural waters of the gold mining areas of the Kette-Batouri region of Eastern Cameroon.

This study was designed to determine the extent to which alluvial and bedrock gold mining activities in the Kette-Batouri region of Eastern Cameroon are responsible for the discharge of potentially harmful elements (PHEs) into natural water bodies. This is considered to be of great public concern, since elevated levels of PHEs in these water bodies, which are widely used for domestic purposes, could have adverse health and environmental effects on the population and nearby ecosystems. The investigation into the levels of PHEs in natural water bodies of this area was conducted to ascertain the toxicity posed by mine waste stockpiles as data from the literature on this subject are scarce. Forty-two water samples from the region were analysed for some 60 PHEs by ICP-OES, of which 22 that were not below the detection limit were considered for further data analysis. Maximum total concentrations in water of As, Cr, Pb, and V and Zn are above the World Health Organization (WHO) maximum allowable concentration (MAC) levels and are as follows (µg l-1): As (21.90-50.9); Cr (1.80-57.30); Pb (0.50-34.70); V (24.70-77.20) and Zn (3.10-481.70). This information is consistent with that of our recent research efforts which have indicated moderate pollution by heavy metals in the soils with a slight deterioration of site quality in this region. The data generated from this investigation is important in the formulation of water management strategies and recommendations for remediation of water bodies at abandoned mine sites for meeting water quality standards.

Development and preliminary validation of a patient-reported outcome measure for swallowing after total laryngectomy (SOAL questionnaire).

OBJECTIVES: To develop and validate a laryngectomee-specific questionnaire to investigate swallowing function. This paper describes the generation of questionnaire items, pretesting with laryngectomees and a preliminary validation. DESIGN: This study employed 2 phases: questionnaire development and questionnaire validation. Items were developed from patient (n = 10) and clinician (n = 6) focus groups. Content checking, acceptability and face validity were determined through pretesting with 10 laryngectomees and via consensus feedback from 35 speech and language therapists. During preliminary validation, the 17-item final questionnaire was administered to 3 different groups. Discrimination amongst groups was established by comparing questionnaire responses of a laryngectomee group (n = 19) with known dysphagic (n = 19) and non-dysphagic groups (n = 20). Questionnaire responses from the reference dysphagic group were compared with an instrumental assessment of swallowing, the modified barium swallow (MBS). SETTING: Large urban teaching hospital. PARTICIPANTS: Speech and language therapists, laryngectomees, non-dysphagic volunteers, post-radiotherapy dysphagic patients. MAIN OUTCOME MEASURE: Preliminary validation of SOAL questionnaire. RESULTS: Normal, laryngectomee and dysphagic groups had significantly different SOAL scores, as did laryngectomees with different degrees of swallowing impairment (Kruskall Wallis, P << 0.001). The subjective SOAL score had a strong positive correlation with the reference measure of ratings on the MBS (r = 0.5; P = 0.03). CONCLUSIONS: The swallowing outcome after laryngectomy (SOAL) questionnaire is a simple, self-administered tool to assess swallowing function post-total laryngectomy. Further specific testing with a laryngectomy cohort is necessary for full validation. Its potential value lies in screening for dysphagia in clinics or during long-term follow-up of laryngectomees.

Environmental health impacts of East African Rift volcanism.

The East African Rift Valley (EARV) is a structure of a major order in the Earth's crust. Accompanying volcanic activity has influenced greatly the nature of the soils and the geochemistry of ground and surface waters, an influence that is reflected in water and food quality. Direct volcanic impacts result from the up-welling of volatile, potentially harmful elements (PHE), such as F, As, and Hg, that dissolve directly into groundwaters. Intense tropical weathering results in clear redistribution of all but the most refractory elements to form distinct zones of micronutrient deficiencies and PHE excesses. Of concern, too, is human exposure to volcanic materials such as dust and clay-enriched soil fractions. Further alteration of the landscape geochemistry is being brought about by pollution from human activities, with increasing health concerns in many ecosystems of the region. This review shows that the unique distribution pattern of trace elements, imprinted by the East African Rift volcanism and modified by weathering and anthropogenic factors, correlates with a number of geochemical diseases in man and animals. It is submitted that accurate diagnoses of these diseases and associated health conditions, and prescription of appropriate remedies, must be founded upon a fundamental understanding of how the elements were naturally distributed in the first place. This can only be realised through the construction of complete geochemical databases for the region.

Ankle and first metatarsophalangeal joint dorsiflexion in children with clubfoot.

It has been hypothesised that the stiffness of the plantar aponeurosis after clubfoot surgery affects push-off. Because the first metatarsophalangeal (MTP) joint motion relies on the plantar aponeurosis, it was important to determine whether there was a lack of first MTP joint motion in children with clubfoot that also affected push-off. By examining the motion of the first MTP joint using a motion analysis system and passive motion techniques, then correlating these with gait characteristics, the authors found that the first MTP joint was not affected in children with clubfoot. The authors found that a motion analysis system could be used to determine range of motion accurately.

Kinematics and kinetics of the hip, knee, and ankle of children with clubfoot after posteromedial release.

Clubfoot is a bony deformity characterized by inversion, adduction, and equinus that often require surgical intervention. This study assessed the gait kinetics and kinematics of children with unilateral and those with bilateral clubfoot, comparing them with age-and gender-matched normal (control) children. Patient satisfaction also was examined using a questionnaire, and muscle strength was evaluated at the ankle and knee. In evaluating the kinematics, it was important to note that deviations occurred at the ankle of children with clubfoot. Differences in kinematics and kinetics at the hip and knee between normal children and those with clubfoot resulted from lack of motion at the ankle. Furthermore, the strength of ankle plantarflexors was weak, which reduced plantarflexion during push-off. This restricted motion may have been caused by residual bony deformities and muscle tightness resulting from the original condition that contributed to muscle stiffness during gait.

Periodic expression of the cyclin-dependent kinase inhibitor p57(Kip2) in trophoblast giant cells defines a G2-like gap phase of the endocycle.

Endoreduplication is an unusual form of cell cycle in which rounds of DNA synthesis repeat in the absence of intervening mitoses. How G1/S cyclin-dependent kinase (Cdk) activity is regulated during the mammalian endocycle is poorly understood. We show here that expression of the G1/S Cdk inhibitor p57(Kip2) is induced coincidentally with the transition to the endocycle in trophoblast giant cells. Kip2 mRNA is constitutively expressed during subsequent endocycles, but the protein level fluctuates. In trophoblast giant cells synchronized for the first few endocycles, the p57(Kip2) protein accumulates only at the end of S-phase and then rapidly disappears a few hours before the onset of the next S-phase. The protein becomes stabilized by mutation of a C-terminal Cdk phosphorylation site. As a consequence, introduction of this stable form of p57(Kip2) into giant cells blocks S-phase entry. These data imply that p57(Kip2) is subject to phosphorylation-dependent turnover. Surprisingly, although this occurs in endoreduplicating giant cells, p57(Kip2) is stable when ectopically expressed in proliferating trophoblast cells, indicating that these cells lack the mechanism for protein targeting and/or degradation. These data show that the appearance of p57(Kip2) punctuates the completion of DNA replication, whereas its turnover is subsequently required to initiate the next round of endoreduplication in trophoblast giant cells. Cyclical expression of a Cdk inhibitor, by terminating G1/S Cdk activity, may help promote the resetting of DNA replication machinery.

A combined residency in family medicine and internal medicine at Eastern Virginia Medical School.

This paper describes the first operational four-year combined family medicine/internal medicine residency designed to qualify residents for board examination in both disciplines, which began at Eastern Virginia Medical School in 1995. The authors describe key program features, including their block rotation schedule, interdisciplinary ambulatory precepting, and plans for achieving 50% ambulatory training experience, as well as their difficulties in implementing a collaborative core didactic experience. The authors present faculty survey data indicating that internal medicine faculty members are more likely to view the combined residency as a resource, while family medicine faculty members would like to concentrate on the categorical residency. A recent survey of combined residents indicates that they are satisfied with their choice of combined training and optimistic about the opportunity of garnering additional skills relative to their internal medicine and family medicine counterparts. The authors suggest that successfully implementing this interdisciplinary effort requires an atmosphere of mutual respect and an effort to find opportunities to positively affect the training experiences of both combined residents and their resident partners in family medicine and internal medicine.

Normal development of preimplantation mouse embryos deficient in gap junctional coupling.

The connexin multigene family (13 characterized members in rodents) encodes the subunits of gap junction channels. Gap junctional intercellular coupling, established during compaction of the preimplantation mouse embryo, is assumed to be necessary for development of the blastocyst. One member of the connexin family, connexin43, has been shown to contribute to the gap junctions that form during compaction, yet embryos homozygous for a connexin43 null mutation develop normally, at least until implantation. We show that this can be explained by contributions from one or more additional connexin genes that are normally expressed along with connexin43 in preimplantation development. Immunogold electron microscopy confirmed that roughly 30% of gap junctions in compacted morulae contain little or no connexin43 and therefore are likely to be composed of another connexin(s). Confocal immunofluorescence microscopy was then used to demonstrate that connexin45 is also assembled into membrane plaques, beginning at the time of compaction. Correspondingly, embryos homozygous for the connexin43 null mutation were found to retain the capacity for cell-to-cell transfer of fluorescent dye (dye coupling), but at a severely reduced level and with altered permeability characteristics. Whereas mutant morulae showed no evidence of dye coupling when tested with 6-carboxyfluorescein, dye coupling could be demonstrated using 2',7'-dichlorofluorescein, revealing permeability characteristics previously established for connexin45 channels. We conclude that preimplantation development in the mouse can proceed normally even though both the extent and nature of gap junctional coupling have been perturbed. Despite the distinctive properties of connexin43 channels, their role in preimplantation development can be fulfilled by one or more other types of gap junction channels.

Embryonic expression of the putative gamma subunit of the sodium pump is required for acquisition of fluid transport capacity during mouse blastocyst development.

The sodium/potassium pump, Na+,K+-ATPase, is generally understood to function as a heterodimer of two subunits, a catalytic alpha subunit and a noncatalytic, glycosylated beta subunit. Recently, a putative third subunit, the gamma subunit, was cloned. This small protein (6.5 kD) coimmunoprecipitates with the alpha and beta subunits and is closely associated with the ouabain binding site on the holoenzyme, but its function is unknown. We have investigated the expression of the gamma subunit in preimplantation mouse development, where Na+, K+-ATPase plays a critical role as the driving force for blastocoel formation (cavitation). Using reverse transcriptase-polymerase chain reaction, we demonstrated that the gamma subunit mRNA accumulates continuously from the eight-cell stage onward and that it cosediments with polyribosomes from its time of first appearance. Confocal immunofluorescence microscopy revealed that the gamma subunit itself accumulates and is localized at the blastomere surfaces up to the blastocyst stage. In contrast with the alpha and beta subunits, the gamma subunit is not concentrated in the basolateral surface of the polarized trophectoderm layer, but is strongly expressed at the apical surface as well. When embryos were treated with antisense oligodeoxynucleotide complementary to the gamma subunit mRNA, ouabain-sensitive K+ transport (as indicated by 86Rb+ uptake) was reduced and cavitation delayed. However, Na+, K+-ATPase enzymatic activity was unaffected as determined by a direct phosphorylation assay ("back door" phosphorylation) applied to plasma membrane preparations. These results indicate that the gamma subunit, although not an integral component of Na+,K+-ATPase, is an important determinant of active cation transport and that, as such, its embryonic expression is essential for blastocoel formation in the mouse.

Multiple members of the connexin gene family participate in preimplantation development of the mouse.

The connexin gene family, of which there are at least 12 members in rodents, encodes the protein subunits intercellular membrane channels (gap junction channels). Because of the diverse structural and biophysical properties exhibited by the different connexins, it has been proposed that each may play a unique role in development or homeostasis. We have begun to test this hypothesis in the preimplantation mouse embryo in which de novo gap junction assembly is a developmentally regulated event. As a first step, we have used reverse transcription-polymerase chain reaction (RT-PCR) to determine the connexin mRNA phenotype of mouse blastocysts, and have identified transcripts of connexins 30.3, 31, 31.1, 40, 43, and 45. Quantitative measurements indicated that all six of these connexin genes are transcribed after fertilization. They can be divided into two groups with respect to the timing of mRNA accumulation: Cx31, Cx43, and Cx45 mRNAs accumulate continuously from the two- or four-cell stage, whereas Cx30.3, Cx31.1, and Cx40 mRNAs accumulate beginning in the eight-cell stage. All six mRNAs were found to co-sediment with polyribosomes from their time of first appearance, indicating that all six are translated. The expression of Cx31.1 and Cx40 was examined by confocal immunofluorescence microscopy; whereas both could be detected in compacting embryos, only Cx31.1 could be seen in punctate membrane foci indicative of gap junctions. Taken together with other results (published or submitted), our findings indicate that at least four connexins (Cx31, 31.1, 43 and 45) contribute to gap junctions in preimplantation development. The expression of multiple connexin genes during this early period of embryogenesis (when there are only two distinct cell types) raises questions about the functional significance of connexin diversity in this context.

The doctor, the patient: a first-year course for personal and professional growth.

BACKGROUND AND OBJECTIVES: Medical education has tended to focus primarily on the biomedical aspects of care while neglecting the human side of patients and students. To help students become aware of student, patient, and family issues that may impact the doctor-patient relationship, a first-year course was developed. METHODS: This course consists of 12 didactic sessions and 10 small-group meetings led by family medicine faculty. Topics include self-assessments, analysis of videotaped doctor-patient interactions, genogram development, and family systems. Students have evaluated the course for content, strengths, weaknesses, and impact. RESULTS: This course was highly rated by the students. The students reported gaining insight into personal issues that might impact their interaction with patients. Students also became aware of the importance of family issues to their patients' health and well-being. CONCLUSIONS: Through courses like this, students may gain deeper insight into issues that impact them, their patients, and the doctor-patient relationship.

Cardiac malformation in neonatal mice lacking connexin43.

Gap junctions are made up of connexin proteins, which comprise a multigene family in mammals. Targeted mutagenesis of connexin43 (Cx43), one of the most prevalent connexin proteins, showed that its absence was compatible with survival of mouse embryos to term, even though mutant cell lines showed reduced dye coupling in vitro. However, mutant embryos died at birth, as a result of a failure in pulmonary gas exchange caused by a swelling and blockage of the right ventricular outflow tract from the heart. This finding suggests that Cx43 plays an essential role in heart development but that there is functional compensation among connexins in other parts of the developing fetus.

A family physician-counselor program for medical students.

BACKGROUND: Impairment among medical students has increased over the past decade, thus requiring programs to identify and manage student needs. METHODS: At Eastern Virginia Medical School, first-year medical students are assigned personal physician-counselors from the Department of Family and Community Medicine. These physicians provide health care and assist students in identifying and managing new or preexisting medical and psychosocial problems. Students meet with their physician-counselors during the first week of school to develop rapport and to complete a screening history and genogram. Subsequent small group meetings help students adjust to life in medical school. RESULTS: Psychosocial problems such as alcoholism, mental illness, substance addiction, and sexual abuse have been identified among students and/or their families, and management strategies have been initiated. This program has been evaluated highly by both faculty and students. CONCLUSIONS: This program has been helpful in identifying problems and implementing treatment strategies for medical students.

A criterion-based review of preventive health care in the elderly. Part 2. A geriatric health maintenance program.

Although the geriatric population is growing rapidly and using an increasing portion of health care dollars, no consensus exists about the best approach to preventive medicine in this age group. The most comprehensive review to date is the 1989 United States Preventive Services Task Force (USPSTF) recommendations. However, the USPSTF did not specifically address the unique situation of the elderly. Consequently, we have evaluated numerous screening tests and preventive interventions for the elderly by systematically applying the geriatric-specific criteria for preventive services proposed in Part 1 of this article (J Fam Pract 1992; 34: 205-224). Tests and interventions were measured against specific screening criteria and put into one of three categories: those that have been proven effective, those that may be effective but about which more research is needed, and those that are not effective. Recommendations were compared with those of the USPSTF. Proof of the efficacy of most screening tests and interventions in the current literature was found to be lacking, pointing to the need for substantial future research in this area.