Endoneural abscess of common popliteal nerve as first clinical manifestation of leprosy: the first reported case in history in a low-incidence country.

A migrant from Palestine came to our attention for weakness of dorsiflexion of the left foot and hypoesthesia of the homolateral common peroneal nerve territory. Skin biopsies from skin lesions in the hypoesthetic area were not diagnostic. Radiological investigation showed focal nerve enlargement with a possible focal lesion. At this time, and given the uncertainty of the diagnosis, we had to choose between medical therapy with steroid and a surgical exploration of the nerve. We decided for the latter option. Intraoperatively, we found a focal round enlargement of the nerve. Epineurotomy was performed at that level, revealing a round caseous granulomatous mass that was excised. Microbiological examination revealed presence of Mycobacterium Leprae allowing diagnosis of leprosy. Medical therapy was then started, leading to resolution of clinical symptoms. Endoneural lepromatous abscesses are uncommon lesions that should be suspected in patients presenting with peripheral nerve dysfunction with anamnesis of travel in leprosy endemic regions or contacts with people from endemic regions with or even without skin lesions. Detection of endoneural abscesses is of critical importance because prompt surgical excision in conjunction with medical therapy leads to improvement of symptoms and permits correct diagnosis. In times of large human migrations from leprosy endemic areas, knowledge of this uncommon presentation of leprosy and its management will help lead to the best management of these patients.

Mechatronic design and implementation of a bicycle virtual reality system.

The aim of this study is to design and implement a virtual reality bicycle system based on a functional-based mechatronic design approach. The development of virtual reality technologies with haptic systems demands a proper integration of the involved disciplines to provide immerse experiences for users. The proposed design approach provides a formal manner to gather the subsystems in the mechatronic device. The developed system is divided in a Virtual Reality System (VRS) and a Physical System (PS) for the design process. The former includes an interactive virtual environment in which an Avatar is animated using a simple kinematic bicycle model. The latter includes an adapted mountain bicycle with haptic feedback mechanisms to interact with the user and to produce the corresponding inputs for the bicycle model. Both systems are integrated by a control behavior system that works under two operation modes, where the user carries out virtual tours and gets feedbacks from a stereoscopic display system, audio cues, and haptic mechanisms. A multibody simulation validates the consistency and the integration of the physical system. In addition, a set of experimental results show the performance of instrumentation elements, control strategies, and feedback mechanisms, to provide the user with an immersive experience in the virtual environment. A brief survey was carried out to assess the opinion of users about the virtual bicycle tours, providing feedback for future improvements. The different designed modules and sub-systems allow modifying and enhancing the VRS without major modifications of the PS, or allow enhancing the physical platform without affecting the functionality of the virtual environment.

[Interregional mobility for total knee arthroplasty]. / Mobilità interregionale e chirurgia protesica del ginocchio.

45.049 primary total knee replacements were performed in Italy in 2005, with large distribution all over the country. However referral to centers of excellence far from the area of residency is still common with massive interregional mobility. Aim of this study is to define this issue both in quantitative and qualitative terms. For the timeframe 2001-2005 the SDO database was used to calculate the number of discharges of both residents and non residents for each Region and for each year and the ability of each region to attract patients from other regions or the tendency of the resident population to migrate. Only 8 Regions present an attraction index better than the escape index. Among those 4 are located in the North of Italy, 2 in the Center and 2 in the South. Migration from the North or Center to the South was never observed. Interregional mobility for knee replacement is noteworthy. Such phenomenon is comparable to migration for other major procedures, especially the steady tendency of a south to north mobility. An accurate analysis of potential causes of migration as well as the empowering of southern and central centers is needed.

Screening for C677T and A1298C MTHFR polymorphisms in patients with epilepsy and risk of hyperhomocysteinemia.

Hyperhomocysteinemia can result from decreased methylenetetrahydrofolate reductase (MTHFR) enzyme activity, owing to genetic polymorphisms andor inadequate folate intake. This study was aimed at investigating the prevalence of C677T and A1298C MTHFR polymorphisms, and their impact on hyperhomocysteinemia in 95 epileptic patients and 98 controls. Double gradient-denaturing gradient gel electrophoresis screening revealed that the frequency of T677 polymorphic allele was similar between cases and controls (46.3% vs 42.3%), whereas that of C1298 allele was significantly higher in patients (30.5% vs 19.4%, p < 0.05). Significant differences between the two groups were also found for the frequencies of genotypes AA1298 (46.3% in cases vs 67.3% in controls, p < 0.01) and AC1298 (46.3% in cases vs 26.6% in controls, p < 0.01). Other genotype frequencies did not show any statistically significant differences. Haplotype frequencies significantly differed between the two groups. The CT677/AC1298 diplotype was significantly more frequent in epileptic patients than in controls (32.6% vs 18.4%, p < 0.05). Patients treated with enzyme-inducing antiepileptic drugs, having this diplotype and concomitant low folate concentration (i.e., < 3.4 nmol/L), exhibited plasma homocysteine levels significantly higher than normal values (27.1 +/- 2.44 micromol/L, p < 0.001). This increase, however, was lower than that observed in folate-deficient patients with diplotype TT677/AA1298 (41.3 +/- 3.41 micromol/L, p < 0.001). Indeed, these two diplotypes could be regarded as risk factors for hyperhomocysteinemia. Conversely, we found that the CC677/AA1298 diplotype was significantly more frequent in controls (p < 0.01), suggesting a protective role. Our study suggests that both C677T and A1298C MTHFR polymorphisms should be examined when assessing genetic risk factors of hyperhomocysteinemia in epilepsy.

Chemokines and pro-inflammatory cytokines in Down's syndrome: an early marker for Alzheimer-type dementia?

BACKGROUND: People with Down's syndrome (DS) show early Alzheimer-like dementia. It has been suggested that the pro-inflammatory cytokine class plays a role in Alzheimer's disease (AD). The study aims at verifying whether pro-inflammatory cytokines in DS are correlated with age, affective symptoms and intellectual decline to a different degree than in subjects with non-DS learning disabilities. CASES: 19 subjects with DS; controls: sex- and age-matched individuals with learning disabilities caused by perinatal ischaemic damage. The level of mental retardation was assessed according to DSM-IV; psychopathological symptoms were measured by the Assessment and Information Rating Profile. Serum levels of cytokines were determined with ELISA. RESULTS: DS patients showed higher levels of cytokines and chemokines, with the exception of RANTES; but the only significant difference detected was for MIP-1alpha. A correlation between the degree of mental retardation and IL-6, and between MIP-lalpha and age was found in patients with DS, but not in controls. CONCLUSIONS: The data obtained suggest a possible involvement of chemokines in the inflammatory and degenerative processes similar to AD in DS. Further longitudinal research is required to confirm these findings.

Making evidence-based practice a reality in your institution.

There are many barriers to ensuring that nursing practice is based on research evidence. This article provides several resources to help the practicing nurse identify what evidence is available upon which to make practice changes. Additionally, strategies for supporting change are discussed and a case study of one particular evidenced-based change--1:1 support by nurses for women in labor--is examined.

A Quality of Health Outcomes Model for guiding obstetrical practice.

PURPOSE: To describe the application of the Quality of Health Outcomes Model, introduced by the American Academy of Nursing Expert Panel on Quality of Health Care, to obstetrical care, particularly second-stage labor. ORGANIZING FRAMEWORK: The model is different from the more linear structure-process-outcome frameworks used in the past to a dynamic conceptualization of reciprocal relationships among the system, intervention, client, and outcome components. Analysis of these components can provide a comprehensive picture of the complexity of patient care decision making in hospital labor and delivery units. CONCLUSIONS: Research findings indicate that interventions such as cesarean delivery and epidural analgesia may result in several significant quality of health outcomes for women that should receive increased attention. Uses of this model for shaping best practices among physicians and nurses and for setting directions for priorities in future interdisciplinary research and health policy are discussed.

Health promotion and risk reduction in Malawi, Africa, village women.

OBJECTIVE: A train-the-trainer intervention was evaluated in which village leaders in Malawi, Africa, taught other villagers how to improve their health. DESIGN: Health knowledge and reported health practices were compared before and after the educational intervention in 15 villages in Chimutu, Malawi, Africa. SETTING: Surveys were completed by trained data gatherers in the village setting. PATIENTS/PARTICIPANTS: All men and women of childbearing age who were present in the village when data collection occurred were asked to participate. There were 187 participants in the preintervention survey and 175 participants in the postintervention survey. INTERVENTION: Seventy-six village women were trained, using low literacy techniques, to provide content on health promotion and risk reduction in pregnancy. Over 20,000 persons have received at least one health teaching session from the village trainers. RESULTS: The intervention resulted in reported changes in prenatal and postpartum care and in more births occurring in the hospital or clinic. Some positive nutritional changes were reported, although few changes in beliefs about use of herbal medicines or about the use of witchcraft were reported. CONCLUSIONS: A train-the-trainer approach is a sustainable intervention that appears to have positive benefits on the health of village women living in Malawi, Africa.

Postpartum smoking behaviors and immune response in mothers of term and preterm infants.

Infants exposed to secondhand smoke, especially preterm infants with a very low birth weight (VLBW), have an increased risk for developing health problems. Smoking has been associated with numerous health problems in mothers and may reduce immune functioning as well. The purposes of this study were to examine smoking in postpartum mothers of term and preterm infants and to examine the relationship between smoking and immune status. Peripheral blood was drawn on 142 women at four data-collection points and tested for cotinine, immune cell phenotypes, and immune functioning. Overall, 39% of the participants smoked in the postpartum period, but 49% of mothers who delivered preterm infants smoked compared to only 28% of mothers who delivered term infants. There was no difference in cotinine levels between the smokers in both groups of postpartum mothers, nor was smoking related to immune phenotypes or immune function. Given the documented health risks to the mother and infant and the significant number of women who continue to smoke in the postpartum period, it is imperative that health care providers continue to assess smoking status and provide smoking-cessation counseling at every encounter.

International nursing: the past 25 years and beyond.

International nursing has grown substantially in the last 25 years. Once practiced only during war time, with immigrant populations, or in peace time in consultative roles, international nursing is now common, with direct practice, education, consultation, and research collaboration as the roles in which nurses work across borders. A brief history of international nursing, forces that have influenced its growth, and an assessment of its future are discussed.

Maternal fatigue: implications of second stage labor nursing care.

The parameters of fatigue have been studied in recent years in relation to women's health and the childbearing period. Less research emphasis has been placed on second stage labor, a period of time that can encompass considerable physiologic and psychologic fatigue. Consideration to minimizing second stage labor fatigue by altering conventional support practices is needed. This includes minimizing long periods of strong pushing or bearing down efforts in conjunction with sustained breath holding, particularly for women receiving epidural anesthesia. The potential sequelae of second stage labor fatigue, recommendations for practice changes, and new research directions are discussed.

Nutrition and exercise in overweight and obese postpartum women.

This secondary analysis of a longitudinal, nonintervention study describes the nutritional and physical activity behavior of overweight and obese postpartum women and the differences in nutrition and physical activity when participants are evaluated according to four weight categories: underweight, normal weight, overweight, and obese. The sample consisted of 67 postpartal women [40 (60%) African American and 27 (40%) White] who gave birth vaginally to healthy term infants. No differences were present when overweight and obese women were compared with underweight and normal weight women relative to nutrition and physical activity. Nutritional imbalances were present for overweight and obese women relative to protein and fat intake. Overweight and obese postpartum women can be encouraged to lose weight using a nutritionally balanced approach by decreasing fat and protein intake, maintaining an adequate carbohydrate intake, and increasing their folacin intake.

Autoregulation of cortical blood flow during surgery for ruptured intracranial aneurysms.

BACKGROUND: Little information is available about the extent and the time course of possible impairment of cerebral circulation occurring after aneurysmal subarachnoid haemorrhage (SAH). The aim of this study was to correlate cerebral autoregulation, neurological impairment at surgery and timing of surgery in patients with ruptured intracerebral aneurysms. METHODS: Cortical blood flow (CoBF) was measured intraoperatively by a thermal diffusion probe in 77 patients during surgery for ruptured supratentorial aneurysms, who were operated on at different time intervals after bleeding. An autoregulation index (AI), expressed as the ratio between the change in CoBF and the change of mean arterial blood pressure at the time of rising the systemic blood pressure after occlusion of the aneurysm(s), was determined in each case. RESULTS: Among good-grade patients (WFNS grade I-II), those operated on days 0-2 after SAH had a significantly better autoregulatory response, compared either with patients who underwent surgery on days 3-7 after bleeding (p<0.01), or with those whose aneurysm was occluded more than 7 days after rupture (p<0.03). The mean AI of poor-grade patients (WFNS grade IV-V), who received surgery on days 0-2 after SAH, was significantly higher (p<0.01) compared with the corresponding value of good-grade patients. No significant difference was found between the mean AIs of patients who subsequently did, or did not, develop symptomatic vasospasm. CONCLUSIONS: It is concluded that good-grade patients operated on within 48 hours after bleeding take advantage of a preserved autoregulatory function during controlled hypotension.

Immune alterations associated with epidural analgesia for labor and delivery.

PURPOSE: Epidural analgesia is frequently used for the laboring woman and commonly regarded as safe. The association of epidural analgesia with fever, in the absence of infection, in this population can result in unnecessary sepsis workups in both neonates and mothers. Studies in other populations of patients have found that epidural anesthesia may be associated with alterations in white blood cell count parameters. This study was designed to determine if epidural analgesia is associated with alterations in immune profile or immune function in healthy afebrile postpartum women. DESIGN: This prospective quasi-experimental study examined a convenience sample of normal afebrile postpartum women in two groups for differences in immune profile and immune function based on whether they received epidural analgesia during labor and delivery. METHODS: Mothers who agreed to participate in the study and met inclusion criteria had blood drawn for immune profile and immune function studies within 24 hours of their delivery. This study looked at immune phenotypic profile, lymphocyte proliferative response, and NK lysis assays. RESULTS: No differences in immune profile or immune function were found based on administration of epidural analgesia. CLINICAL IMPLICATIONS: Nurses can be confident that the white blood cell count and other phenotypic measures of leukocytes are not affected by epidural analgesia. Thus the epidural analgesic technique appears not to alter immune measures of infection in postpartum women. In evaluating fever in postpartum mothers and neonates, nurses should consider prior receipt of epidural analgesia and measures of immune profile. In addition to fever and white blood cell counts, other signs and symptoms of infection should also be evaluated in postpartum women when infection is suspected.

Vulnerable infants: kinship care and health.

Kinship care, a type of foster care provided by relatives, has expanded rapidly in the last decade. This descriptive prospective study was part of a larger study on the costs to families caring for a preterm infant. Of the 224 families interviewed, 12 families (13 infants) participated in kinship care. Compared to infants in the larger study, kinship babies received inadequate health care follow-up, including immunizations, and had more rehospitalizations but fewer acute care visits. Children in kinship care appear to have more health problems compared to American children in general. A system is required within our health care structure for maintaining accurate health records, delivering special care to these babies, and providing supportive services to the kinship caregivers.

Childbearing in Malawi, Africa.

Malawi is a small, landlocked country in South Eastern Africa that faces many challenges in providing health care to childbearing women. Through a partnership between the faculty of the University of Pennsylvania, School of Nursing, faculty of the Kamuzu College of Nursing in Malawi, and the Malawi Ministry of Health and Population, an ongoing collaboration has led to research and demonstration projects designed to improve the health of women and children in Malawi. To underscore the cultural context within which childbearing occurs, care of the childbearing family in Malawi is described, as is research that has documented some of the similarities and differences between childbearing in Malawi and the United States.

PIP: An ongoing partnership between the University of Pennsylvania (US) School of Nursing, Kamuzu College of Nursing in Malawi, and the Malawi Ministry of Health and Population has led to research and demonstration projects intended to improve the health of women and children in Malawi. Essential to this collaboration has been an understanding of the similarities and differences between childbearing in Malawi and the US. Malawi has a maternal mortality rate of 620/100,000 live births and a child mortality rate of 234/1000 live births, largely as a result of socioeconomic factors. This article details the cultural context of pregnancy and childbirth in Malawi. It also describes the results of a survey conducted in 15 villages in Malawi in 1996 to evaluate the efficacy of an educational program aimed at empowering women to make safe choices during the childbearing process. The survey indicated a need for information about taking iron and antimalarials during pregnancy, the importance of seeking help as soon as problems develop during pregnancy, and the role of postpartum care. A train-the-trainer program is being conducted so local women leaders can provide health education to childbearing women in their villages.

Immune responses in mothers of term and preterm very-low-birth-weight infants.

Differences in the levels of immune cell subsets present in peripheral blood have been demonstrated based on sociodemographic factors such as age and race. Postpartal women, who are recovering from the immune changes that are concomitant with pregnancy, have lymphocyte and monocyte values that differ from other populations. A subgroup of postpartal women, mothers who deliver preterm very-low-birth-weight (VLBW) (< or = 1,500 g) infants, may have further differences in values of immune cell subsets and in immune functioning either because of hormonal factors or lifestyle changes or because of the stress they experience after their infant's birth and for the first few months of infant caretaking. This study examined anxiety, depression, and immune cell phenotypes in 30 mothers of VLBW infants and in 30 mothers of healthy term infants over the first 4 postpartal months to determine if mothers of preterm VLBW infants differed from mothers of healthy term infants in psychological and immunologic parameters. Additionally, lymphocyte proliferation and natural killer cell functional assays were performed in a subset of mothers. Mothers of VLBW infants had increased anxiety and decreased lymphocyte proliferation compared to mothers of term infants. When lymphocyte and monocyte subsets were compared over time between the two groups of mothers differences were found in CD8, CD20, CD3-/CD56+, CD14, and HLA class II Ia on monocytes. Mothers with high-fat diets had lower percentages of some monocytes (CD14), lymphocytes (CD4+/CD45RA+), and natural killer cells (CD3-/CD57+) during the first 4 postpartal months.

Lymphocyte, monocyte, and natural killer cell reference ranges in postpartal women.

Normative values for immune-cell subsets in postpartal women, who are recovering from the relative immunosuppression of pregnancy, have not been established. Considerable differences in normative values for subsets of immune cells have been demonstrated based on sociodemographic factors, such as age and race. In order to make accurate clinical decisions about postpartal women, comparisons with normal reference ranges are necessary. Therefore, flow cytometric data for 51 healthy women at 4 months postpartum are presented and changes over the first 4 postpartal months are documented. The levels of some lymphocyte cell subsets, such as CD4+/CD45RA+ and Ia on lymphocytes, remained stable over time. The levels of other lymphocyte cell subsets, such as CD4+/CD29+, increased over the first 4 postpartal months, while those of other cell subsets, such as CD8 and CD11b, increased between delivery and 2 months postpartum and then dropped again by the fourth postpartal month. The levels of two natural killer cell subsets (CD3-/CD16+ and CD3-/CD57+) rose from delivery until 1 month postpartum and then plateaued. Comparisons were made with reference ranges of nonpostpartal groups provided in the literature and in a study of healthy women being conducted in the same laboratory, and postpartal women were found to have lower values of CD8, CD3-/CD16+, CD4+/CD45RA+, CD20, and CD11b than those reported in the literature.