Rebuilding sustainable communities for children and families after disaster: recommendations from symposium participants in response to the April 27th, 2011 tornadoes.

Tuscaloosa, Alabama experienced a significant disaster, an EF4 tornado with 190 mile an hour winds on April 27, 2011. Fifty-two people were killed and more than 5,000 homes were severely damaged. Twelve percent of the city was destroyed and 7,000 people were immediately unemployed. This was a disaster of significant proportion and impacted everyone in the community of over 80,000. In an effort to address the needs of the community after this disaster a symposium was organized with a focus on helping children and families. More than 40 professionals and community members attended the symposium which was led by an international expert on disaster. Recommendations were established and distributed to the community and governmental organizations. The process for planning and implementing the symposium also may serve as a model for addressing future disasters.

Geographic variation in sperm traits reflects predation risk and natural rates of multiple paternity in the guppy.

Guppies (Poecilia reticulata) are models for understanding the interplay between natural and sexual selection. In particular, predation has been implicated as a major force affecting female sexual preferences, male mating tactics and the level of sperm competition. When predation is high, females typically reduce their preferences for showy males and engage more in antipredator behaviours, whereas males exploit these changes by switching from sexual displays to forced matings. These patterns are thought to account for the relatively high levels of multiple paternity in high-predation populations compared to low-predation populations. Here, we assess the possible evolutionary consequences of these patterns by asking whether variation in sperm traits reflect differences in predation intensity among four pairs of Trinidadian populations: four that experience relatively low levels of predation from a gape-limited predator and four that experience relatively high levels of predation from a variety of piscivores. We found that males in high-predation populations had faster swimming sperm with longer midpieces compared to males in low-predation populations. However, we found no differences among males in high- and low-predation populations with respect to sperm number, sperm head length, flagellum length and total sperm length.

Targeted inhibition of the Hedgehog pathway in established malignant glioma xenografts enhances survival.

Hedgehog pathway activity has been demonstrated in malignant glioma. However, its role in tumor growth has not been determined. Here we demonstrate that pharmacological inhibition of the Hedgehog pathway in established orthotopic malignant glioma xenografts confers a survival advantage. Pathway inhibition is measured in transplanted human tumor cells and not in host mouse brain. Correspondingly, survival benefit is observed only in tumors with an operational Hedgehog pathway. These data indicate that Hedgehog signaling regulates the growth of select malignant gliomas. We also demonstrate that Hedgehog pathway component and gene target expression segregate to CD133(+) tumor initiating cells. Treated mice eventually succumb to disease, thus, targeting the Hedgehog pathway in CD133(+) cells produces significant, but incomplete tumor regression. Therefore, our studies suggest that more complete tumor regression may require the inclusion of other therapeutic targets, including CD133(-) cells.

Geographic differences in event rates by model for end-stage liver disease score.

The ability of the model for end-stage liver disease (MELD) score to accurately predict death among liver transplant candidates allows for evaluation of geographic differences in transplant access for patients with similar death risk. Adjusted models of time to transplant and death for adult liver transplant candidates listed between 2002 and 2003 were developed to test for differences in MELD score among Organ Procurement and Transplantation Network (OPTN) regions and Donation Service Areas (DSA). The average MELD and relative risk (RR) of death varied somewhat by region (from 0.82 to 1.28), with only two regions having significant differences in RRs. Greater variability existed in adjusted transplant rates by region; 7 of 11 regions differed significantly from the national average. Simulation results indicate that an allocation system providing regional priority to candidates at MELD scores > or = 15 would increase the median MELD score at transplant and reduce the total number of deaths across DSA quintiles. Simulation results also indicate that increasing priority to higher MELD candidates would reduce the percentage variation among DSAs of transplants to patients with MELD scores > or = 15. The variation decrease was due to increasing the MELD score at time of transplantation in the DSAs with the lowest MELD scores at transplant.

Migraine practice patterns among neurologists.

OBJECTIVE: To assess the attitudes, knowledge, and practice patterns of US neurologists regarding migraine management relative to the US Headache Consortium Guidelines (the Guidelines). METHODS: Two samples of 600 neurologists each were selected from the American Academy of Neurology membership database. The first group received a Migraine Attitudes, Knowledge, and Practice Patterns (MKAPP) Survey. The second group received a Clinical Vignette (CV) Survey, presenting two patient histories and correspondent questions. RESULTS: The MKAPP Survey showed that most neurologists felt that migraine was primarily a disease of the brain with a well-established neurobiological basis (69%) and an important part of their practice (60%). Most (53%) indicated that they routinely used neuroimaging in evaluating severe headache, an approach not recommended by the Guidelines. Most favored acute treatment limits, but 36% did not agree with the Guidelines that acute treatment should be limited to 2 or 3 days/week. In the CV Survey, for vignette 1, most (91%) correctly diagnosed migraine, 31% requested neuroimaging in the absence of indications, 64% appropriately recommended a triptan, and 45% recommended a preventive medication in the absence of indications. For vignette 2, 78% diagnosed migraine, 71% appropriately ordered neuroimaging, 80% appropriately recommended a preventive medication, and 38% prescribed a triptan in face of clear contraindication. CONCLUSIONS: Educational initiatives aiming to increase the awareness of the Guidelines among neurologists should highlight the full range of migraine symptoms that support the diagnosis, appropriate use of neuroimaging, indications for preventive treatments, issues of triptan cardiovascular safety, and preventing rebound headaches.

Physical activity outcomes of CHAMPS II: a physical activity promotion program for older adults.

BACKGROUND: Despite well-known benefits of physical activity for older adults, about two thirds are underactive. Community-based programs are needed to facilitate increased physical activity. We examine the effectiveness of CHAMPS II, an inclusive, choice-based physical activity promotion program to increase lifetime physical activity levels of seniors. CHAMPS guided participants to choose activities that took into account their health, preferences, and abilities. It offered information on ways for them to exercise safely, motivate themselves, overcome barriers, and develop a balanced exercise regimen. METHODS: A 1-year randomized controlled trial was conducted with physically underactive seniors in a multispecialty group practice. Changes in self-reported physical activity by group were evaluated using ANCOVA, controlling for age and sex. RESULTS: Of 173 randomized subjects, 164 (95%) completed the trial. Subjects were aged 65 to 90 years (M = 74, SD = 6); 66% were female. The intervention group increased estimated caloric expenditure by 487 calories/week in moderate (or greater) intensity activities (MET >/= 3.0; p <.001) and by 687 calories/week in physical activities of any intensity (p <.001). Control group changes were negligible. Between-group analyses found that the changes were significantly different in both measures (p values <.05). Overweight persons especially benefited from this program. The program was as effective for women, older adults (75+), and those who did not set aside time to exercise at baseline. CONCLUSIONS: The program led to meaningful physical activity increases. Individually tailored programs to encourage lifestyle changes in seniors may be effective and applicable to health care and community settings.

Evidence-based pediatric nursing: does it have to hurt?

Pediatric nursing is deeply rooted in tradition and ritual. Although many practices remain relevant, others do not stand up to the challenge of an evidence-based nursing practice. Though intuition and tradition are important aspects of professional nursing practice, their incorporation into clinical practice can vary among practitioners. Although ample evidence to guide the practice of pain assessment and pain management in children exists, children remain undermedicated when compared to adults. This article explores the influence of practice traditions, personal bias, and the persistence of myths regarding pain in children on the practice of pain relief.

At one with death: destructive narcissism.

In this paper, narcissism is considered to be the relation of self with an idealized internal object, and Narcissus's romance with his reflection is taken to be a two-party affair. Destructiveness, an inborn capability, is distinguished from destructive narcissism, a two-party situation between the self and a sadistic internal figure built on the idealization of power. Too often, only half the narcissistic pair is analyzed. The internal object becomes the persecutor of self, while the sadism of self, projected onto the persecutor, goes unanalyzed. This paper takes up a clinical solution: how the analysis can seize the destructive internal object and resolve it down to its nucleus, the self.

Radiation therapy in cancer patients 80 years of age and older.

There is a paucity of clinical data regarding radiation therapy in elderly patients. This is a retrospective study of all patients aged 80 years and older who underwent treatment with external beam irradiation at a single site. There were a total of 183 patients treated with 226 courses of therapy. The mean age was 84 years (range: 80-98 years). Fifty-eight percent of the patients were male. The treatment was deemed palliative in 51% and curative in 49%. The primary cancer diagnoses were: prostate 36, lung 28, breast 25, head and neck 23, gastrointestinal 21, hematologic 12, gynecologic 11, skin 11, genitourinary 9, unknown primary 6, central nervous system 1. The patients were able to complete the prescribed therapy in 173 of 226 courses (77%). Treatment breaks during the radiation courses were required in 81 (36%) of the courses. Radiation therapy can be safely administered to an elderly population with both curative and palliative intent with the expectation of completion in more than 80% of patients. The reasons for inability to complete therapy as prescribed are multifactorial, but careful patient selection and attention to comorbidity may optimize outcome. Further research is needed to better define these parameters.

Heat shock transcription factors and the hsp70 induction response in brain and kidney of the hyperthermic rat during postnatal development.

Heat shock transcription factor (HSF) 1 levels increase in brain regions and decline in kidney during postnatal rat development. In both neonatal and adult rats, levels of HSF1 protein in brain and kidney are proportional to the levels of HSF DNA-binding activity and the magnitude of heat shock protein hsp70 induction after thermal stress. There appears to be more HSF1 protein in adult brain than is needed for induction of hsp70 after thermal stress, suggesting that HSF1 may have other functions in addition to its role as a stress-inducible activator of heat shock genes. HSF2 protein levels decline during postnatal rat development in brain regions and kidney. Gel mobility shift analysis shows that HSF2 is not in a DNA-binding form in the neonatal brain and kidney, suggesting that HSF2 may not be involved in the constitutive expression of hsps in early postnatal development. There is no apparent relationship between levels of HSF2 protein and basal levels of hsp90, hsp70, heat shock cognate protein hsc70, and hsp60.

Biomechanics of the first ray. Part II: Metatarsus primus varus as a cause of hypermobility. A three-dimensional kinematic analysis in a cadaver model.

Variation in functional stability of the first metatarsocuneiform joint was analyzed between transverse plane deviated (adducted) and corrected first metatarsal positions in a closed kinetic chain model. Six fresh frozen cadaver specimens with intact ankles and feet were fitted with a custom fabricated titanium metatarsal jig, which allowed for manipulation of the first metatarsal in the transverse plane. Specimens were mounted into a custom-made acrylic load frame and axially loaded to 400 N. Radiowave three-dimensional tracking transducers were attached to the following osseous segments: first metatarsal head and base, medial cuneiform, and second metatarsal. A dorsally directed load was applied to the first metatarsal segment and resultant movements were measured. Repeated testing was performed on a transverse deviated and corrected first metatarsal positions with the hallux plantargrade and maximally dorsiflexed to engage the windlass mechanism. With the windlass mechanism engaged and first metatarsal corrected, a 26% increase in first ray plantarflexion occurred from a deviated to a corrected first metatarsal position (p < or = .05). This suggests that the windlass mechanism is more efficient when the first metatarsal, sesamoid apparatus, and hallux position are properly aligned with the orientation of the plantar aponeurosis. Clinically, this may explain the correlation of first ray hypermobility with the progression of bunion severity. Our study validates the earlier work of Hicks and adds additional insight into the functional stability in the medial column of the foot.

Stroke prevention: narrowing the evidence-practice gap.

Many interventions reduce stroke risk. However, the full benefits of these interventions are not realized at current levels of utilization, as nearly all evidence-based or guideline-endorsed stroke prevention services are underused. The cause for such underuse is multifactorial and includes factors relating to both patients and providers, as well as to a health care system that has de-emphasized prevention at the expense of acute, technologically based care. Much like the evidence for stroke interventions themselves, there is a growing literature to support methods of implementing research evidence into clinical practice. There is still much to learn, however, about the effectiveness of interventions aimed at achieving changes in stroke prevention practice or the delivery of stroke prevention care. Nevertheless, there are many opportunities for providers, managed care organizations, and government to close the evidence-practice gap that exists for stroke prevention services. These opportunities exist in both the inpatient and outpatient setting, and depend on the neurologist taking a leading role in emphasizing the critical importance of risk factor identification and modification in all patients at risk for stroke.

Objective evaluation of improvement in optic neuropathy following radiation therapy for thyroid eye disease.

PURPOSE: While the literature supports the use of radiation therapy for thyroid eye disease, it does not sufficiently describe in detail the results of radiation therapy for optic neuropathy associated with thyroid eye disease. The objective of this study is to quantify the changes in parameters of optic neuropathy after orbital irradiation for thyroid eye disease. METHODS AND MATERIALS: Twelve consecutive patients with optic neuropathy from thyroid eye disease were followed by a single neuro-ophthalmology practice and treated by one radiation oncologist with radiation therapy from 1991 through 1995. All cases were prospectively followed for visual acuity, color vision, mean deviation, and/or foveal sensitivity and afferent pupillary defect. All patients received 2000 cGy in 10 fractions with megavoltage irradiation to the orbits. RESULTS: Ten of 12 patients were evaluated for follow-up (one moved out of this country and one had a stroke, which confounded interpretation of examination results). An analysis was performed retrospectively while treatment and evaluation remained uniform. Five men and five women formed the basis of this study with a median age of 60 years (35-76 years). Nineteen eyes were evaluated for thyroid optic neuropathy. Improvement in optic nerve function occurred in eight of ten patients. Improvement was seen either during radiotherapy or within 2 weeks of completion. No long-term adverse effects were noted. CONCLUSION: This study objectively demonstrates improvement in optic neuropathy from radiation therapy for thyroid eye disease.

Localization of the heat-shock protein Hsp70 to the synapse following hyperthermic stress in the brain.

Heat-shock proteins are induced in response to cellular stress. Although heat-shock proteins are known to function in repair and protective mechanisms, their relationship to critical neural processes, such as synaptic function, has received little attention. Here we investigate whether the major heat-shock protein Hsp70 localizes to the synapse following a physiologically relevant increase in temperature in the mammalian nervous system. Our results indicate that hyperthermia-induced Hsp70 is associated with pre- and postsynaptic elements, including the postsynaptic density. The positioning of Hsp70 at the synapse could facilitate the repair of stress-induced damage to synaptic proteins and also contribute to neuroprotective events at the synapse.

The use of refusal postcards in recruiting older adults.

This article examines whether a refusal postcard makes recruitment more efficient or instead reduces response rates to a telephone survey of older adults. Medicare health maintenance organization (HMO) members were randomly sampled in sequential phases. All samples received an initial contact letter from a HMO geriatrician. A refusal postcard was included in the first sample (N = 178); however, the remaining six samples did not receive this postcard (N = 1,003). An overall refusal rate of 32% was observed when postcards were included versus a 14% rate of refusal when postcards were excluded (p < .001). When potential respondents were reached by telephone, refusal rates were similar (9% versus 10%). Despite the higher refusal rate among the sample receiving the refusal postcard, no significant differences in demographics, health, and health behaviors were observed between the two final sample groups completing the survey. We conclude that refusal postcards greatly increase the refusal rates without offering any prescreening advantage in the recruitment process of older adults and could increase the costs of recruitment for a telephone survey. Furthermore, use of a refusal postcard precludes individuals from making fully informed decisions about participating in research.

An audit of measuring equipment in elderly care.

Accurate monitoring of weight and height is a vital element of nutritional assessment. Specialist equipment may be required for older patients. Accuracy depends upon calibration and maintenance of equipment.

Health-related quality-of-life effects of oxaprozin and nabumetone in patients with osteoarthritis of the knee.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly prescribed for the treatment of signs and symptoms of osteoarthritis (OA). Nabumetone and oxaprozin are 2 of the newer NSAIDs and have been shown to have similar safety and efficacy profiles. Nabumetone 1000 mg to 1500 mg once a day (QD) and oxaprozin 1200 mg QD are commonly recommended doses. This study compared the health-related quality of life (HRQOL) of patients receiving oxaprozin 1200 mg QD with that of patients receiving nabumetone 1000 mg QD or nabumetone 1500 mg QD for the treatment of signs and symptoms of OA of the knee. Two similarly designed, independent, randomized, double-masked, placebo-controlled clinical trials were conducted. In trial 1, patients were randomized to receive oxaprozin 1200 mg QD (n = 109), nabumetone 1000 mg QD (n = 110), or placebo (n = 109); in trial 2, patients received oxaprozin 1200 mg QD (n = 116), nabumetone 1500 mg QD (n = 115), or placebo (n = 116). HRQOL was measured by the Medical Outcomes Study Short-Form-36 Health Survey (1-week recall period) at baseline and weeks 2 and 6. Data from the 2 trials were combined to assess differences across the 4 groups in 8 domains and 2 summary scores at baseline, and changes in HRQOL scores at weeks 2 and 6. At week 2, the oxaprozin group showed significantly greater improvement than the placebo group in role physical, vitality, and mental component summary (MCS) scores (P < 0.05), and in physical functioning, bodily pain, social functioning, and physical component summary (PCS) scores (P < 0.01). The nabumetone 1500-mg group showed significantly greater improvement than the placebo group in bodily pain and social functioning (P < 0.05), and in vitality and MCS score (P < 0.01). No significant differences were observed between the nabumetone 1000-mg and placebo groups. At week 2, the oxaprozin group showed a greater change than the nabumetone 1000-mg group in PCS score (P < 0.05). At week 6, oxaprozin treatment resulted in significantly greater improvement than placebo in physical functioning, role physical, and bodily pain (P < 0.05); social functioning, role emotional, and mental health (P < 0.01); and vitality and MCS score (P < 0.001). The nabumetone 1500-mg group showed significantly greater responses than the placebo group in vitality (P < 0.05), mental health (P < 0.01), and MCS score (P < 0.001). The oxaprozin group had significantly better scores than the nabumetone 1500-mg group in the PCS (P < 0.05), and it showed significantly greater improvement than the nabumetone 1000 mg group in role physical and PCS score (P < 0.01) and in role emotional (P < 0.05). No statistically significant differences were found between placebo and nabumetone 1000 mg at week 6. Results of this study suggest that oxaprozin 1200 mg QD has a significant positive impact on the HRQOL of patients with OA of the knee compared with nabumetone 1000 mg QD and placebo.

Cellular localization of the heat shock transcription factors HSF1 and HSF2 in the rat brain during postnatal development and following hyperthermia.

The heat shock transcription factor HSF1 mediates the induction of heat shock genes in response to temperature elevation and other traumatic events. The induced hsps play roles in cellular repair and protective mechanisms. Immunocytochemistry revealed that in the unstressed rat, HSF1 was already prepositioned in the nucleus at abundant levels in both neuronal and glial cell types. Following a fever-like temperature, glial cells rapidly induced hsp70 whereas populations of large neurons did not. The lack of hsp70 induction in these neurons in vivo did not appear to be due to deficiencies in levels of nuclear HSF1. During postnatal development of the cerebellum, levels of HSF1 increased progressively from day 1 to 30. Members of the hsp gene set are also constitutively expressed in the unstressed animal and play roles as molecular chaperones. HSF2, which has been proposed as a developmental regulator of constitutive heat shock gene expression, demonstrated a developmental alteration in cellular localization, namely a nuclear distribution in neurons at postnatal day 2 and a cytoplasmic localization at day 30. During postnatal development the overall levels of neural HSF2 declined. This profile showed no obvious correlation with previously observed levels of constitutive hsp expression during postnatal neural development.

Attitudes of carers and the elderly occupants of residential homes to antimicrobial chewing gum as an aid to oral health.

OBJECTIVE: The aim of this study was to investigate the attitudes of elderly residents to using an antimicrobial chewing gum as an aid to oral health, and the opinion of their carers on such a procedure. DESIGN: A cross-sectional, multi-centre survey using a structured interview/questionnaire conducted with elderly residents and their carers. SETTING: In January 1998, 9 residential/nursing homes were chosen at random from all the homes in West Hertfordshire, 207 residents were asked to chew two pieces of gum twice daily for 7 days. SUBJECTS: The participants, 148 women and 59 men, were aged between 53-100 years (mean age 82.23 +/- 9.62 years). 47 carers, all female, were involved in distributing and collecting the gum. RESULTS: 122 residents (58.9%) were edentulous and 85 (41%) of the participants were partially dentate. Of those with teeth 23 (27%) had 21 teeth or more. 73 (35.2%) residents found that chewing the gum was difficult with 37 (17.9%) of this group being unable to chew (P < 0.0001 for those residents with no teeth/dentures or dentures unopposed by teeth or other dentures). 32 (18.6%) subjects disliked the flavour of the gum. Of the 170 residents who chewed the gum 99 (57.2%) found it reduced oral dryness and 78 (45.1%) reported it made their mouth feel healthy. 34 (53.6%) of the dentate and 47 (40.9%) of the edentate residents wished to keep using the gum (P < 0.05). 35 (74.5%) of the carers found it easy to distribute the gum and 29 (61.7%) thought that chewing gum was an acceptable method of maintaining oral health for residents. CONCLUSION: The antimicrobial gum investigated in this study was acceptable to many elderly occupants and their carers, significantly improving perceived oral health and oral dryness of residents.