I'm Still Me: Inspiration and Instruction from Individuals with Brain Cancer.

Individuals with brain cancer face many challenges, including threats to cognition, personality, and sensory and motor functioning. These can alter one's sense of identity and result in despair. Chaplain-led spiritual interviews were conducted with 19 patients with brain cancer as part of a larger spiritual legacy intervention called "Hear My Voice." The majority was female (58%), married (68%) and had aggressive/advanced tumors (63%). Participants were 22-68 years of age and expressed the following religious affiliations: Protestant (42%), Catholic (21%), Muslim (5%), and none (32%). Framework analysis was applied to reduce and understand the interview data. Primary codes were relationships with: God or the spiritual, others, and self. Brain cancer was reported to deepen and enrich patients' commitment to these relationships. Struggle and grief were also revealed. Results suggest the continued vitality, growth and generativity of these participants and provide insight for chaplains and others on the medical team.

The feasibility and educational value of Hear My Voice, a chaplain-led spiritual life review process for patients with brain cancers and progressive neurologic conditions.

Research continues to establish the importance of spirituality for many persons with medical illnesses. This paper describes a pilot study titled, "Hear My Voice," designed to provide an opportunity for persons with progressive neurologic illnesses, including brain tumors and other neurodegenerative diseases, to review and discuss their spirituality with a board-certified chaplain, and to prepare a spiritual legacy document (SLD). First, we provide background information that underscores the importance of such a project for this patient population that is particularly vulnerable to cognitive impairment and communication difficulties. Second, we provide detailed methodology, including the semi-structured interview format used, the development of the SLD, and an overview of responses from participants and investigators. We also describe the quantitative and qualitative approaches to analysis taken with the aim of developing scientific validation in support of the Hear My Voice project.

Mutational profiling of sporadic versus toxin-associated brain cancer formation: initial findings using loss of heterozygosity profiling.

The role of environmental and occupational toxin exposure as a cause of or contributing factor for cancer development and progression is incompletely understood. A unique signature of specific mutational change to discriminate toxin-exposed from sporadic cancer is generally sought but not often encountered. We report an approach to better understand cancer causality based on the measurement of the cumulative DNA damage (via loss of heterozygosity) over a defined genomic region (chromosome 3) that is applicable to archival, fixative-treated tissue and cytology specimens of cancer. Our method was applied to (1) a cohort of 10 brain tumor subjects (9 gliomas, 1 hemangioblastoma) with potential exposure to chlorinated solvents and (2) a control cohort of sporadic brain cancer controls (7 gliomas, 1 hemangioblastoma). We show that brain tumors arising in potentially toxin-exposed subjects bear a significantly higher level of passenger LOH mutations compared to sporadic cancer controls. The methodology utilized tissue microdissection, PCR amplification and capillary electrophoresis (fragment analysis for LOH determination, DNA sequencing for specific point mutations), and examined a panel of 15 microsatellite markers distributed along both arms of chromosome 3 that aimed at capturing passenger mutational change accrued during stages of clonal expansion of neoplastic cells. This proof-of-principle study using mutational profiling for passenger LOH mutational damage provides support for the utility of this approach and further studies in order to differentiate between genotoxin-associated versus sporadic (unexposed) cancer development.

The patellar tendon bar! Is it a necessary feature?

The purpose of this investigation was to vary the load on the patellar tendon bar and to study the subsequent effect this has on the pattern of the pressure distribution at the stump-socket interface. Ten male subjects from the Southern General Hospital in Glasgow, UK participated in this study. Measuring systems utilising strain gauge and electrohydraulic technologies were designed, developed and constructed to enable pressure measurements to be conducted. One transducer, the patellar tendon (PT) transducer, was attached to the patellar tendon bar of the socket such that the patellar tendon bar was capable of being translated by +/-10 mm towards or away from the tendon. The results of this study showed that the position of the patellar tendon bar had no significant effect on the pressure distribution around the socket indicating that it is an unnecessary feature, which, we propose, may be eliminated during manufacture of a trans-tibial socket.

The effect of textured insoles on gait patterns of people with multiple sclerosis.

BACKGROUND: Somatosensory deficit is a common feature of MS. One method serving to combat impaired plantar sensation may be to provide enhanced sensory feedback from the sole of the foot by changing the characteristics of a shoe sole or surface. This study aimed to inspect the effect of textured insoles on gait patterns in a group of MS patients. METHODS: 14 patients with MS and 10 healthy control subjects were recruited for this study. Plantar sensation was evaluated using Semmes-Weinstein monofilaments. Kinematic, kinetic and EMG gait data were collected for MS patients walking with flat shoes only and again with shoes and a textured insole in contact with the sole of patients' feet. RESULTS: A reduction in plantar sensation was identified in the MS patient group compared to the control group. Wearing the textured insoles there was a significant increase in hip and knee sagittal plane excursion, maximum ankle dorsiflexion, knee flexion and in peak acceleration ground reaction force. Throughout the stance phase, EMG activity of shank muscles was typically found to increase whilst wearing the textured insoles. DISCUSSION AND CONCLUSION: Despite some positive changes in gait patterns when wearing textured insoles, an increased foot-shank angle in terminal stance suggests that patients did not propel their swing limb through increased contribution of ankle plantarflexor muscles, perhaps favouring more proximal muscle groups. Whilst the textured insoles may alter gait patterns in MS patients, their contribution to achieving a more regular gait pattern with sufficient propulsion from ankle plantarflexors remains uncertain.

The development and psychometric evaluation of a safety climate measure for primary care.

INTRODUCTION: Building a safety culture is an important part of improving patient care. Measuring perceptions of safety climate among healthcare teams and organisations is a key element of this process. Existing measurement instruments are largely developed for secondary care settings in North America and many lack adequate psychometric testing. Our aim was to develop and test an instrument to measure perceptions of safety climate among primary care teams in National Health Service for Scotland. METHOD: Questionnaire development was facilitated through a steering group, literature review, semistructured interviews with primary care team members, a modified Delphi and completion of a content validity index by experts. A cross-sectional postal survey utilising the questionnaire was undertaken in a random sample of west of Scotland general practices to facilitate psychometric evaluation. Statistical methods, including exploratory and confirmatory factor analysis, and Cronbach and Raykov reliability coefficients were conducted. RESULTS: Of the 667 primary care team members based in 49 general practices surveyed, 563 returned completed questionnaires (84.4%). Psychometric evaluation resulted in the development of a 30-item questionnaire with five safety climate factors: leadership, teamwork, communication, workload and safety systems. Retained items have strong factor loadings to only one factor. Reliability coefficients was satisfactory (α = 0.94 and ρ = 0.93). DISCUSSION: This study is the first stage in the development of an appropriately valid and reliable safety climate measure for primary care. Measuring safety climate perceptions has the potential to help primary care organisations and teams focus attention on safety-related issues and target improvement through educational interventions. Further research is required to explore acceptability and feasibility issues for primary care teams and the potential for organisational benchmarking.

Interface pressure profile analysis for patellar tendon-bearing socket and hydrostatic socket.

Conventionally, patellar tendon-bearing (PTB) sockets, which need high dexterity of prosthetist, are widely used. Lack of chartered and experienced prosthetist has often led to painful experience of wearing prosthesis and this will in turn deter the patients to wear the prosthesis, which will further aggravate stump shrinkage. Thus, the hydrostatic socket which demands relatively lower level of fabricating skill is proposed to replace the PTB socket in order to produce the equivalent, if not better, quality of support to the amputee patients. Both sockets' pressure profiles are studied and compared using finite element analysis (FEA) software. Three-dimensional models of both sockets were developed using MIMICS software. The analysis results showed that hydrostatic socket did exhibit more uniform pressure profiles than that of PTB socket. PTB socket showed pressure concentration near the proximal brim of the socket and also at the distal fibula. It was also found that the pressure magnitude in hydrostatic socket is relatively lower than that of PTB socket.

New skills for a new age: leading the introduction of public health concepts in healthcare curricula.

Health policy in the UK is going through significant changes. At the heart of the transformation is a dedicated focus on public health. The new primary-care-based health system will not only be premised on a specialist public health workforce, but also on broader based public-health-oriented health professionals. Within primary care, widening the foundation of health professionals with public health competencies suggests that higher education bodies will need to adapt their curricula to an approach that highlights population-based health principles, preventive philosophy, and public health concepts and methods. The first part of this paper describes the mapping of the public health content of healthcare curricula at one university in England, based on the 10 public health standard areas of competencies of the Faculty of Public Health Medicine. The second part examines, through the findings of a strengths, weaknesses, opportunities, threats (SWOT) analysis, the factors that advocates for a public-health-oriented educational strategy must examine before embarking on the instigation and development of public health concepts in the healthcare curricula. The aspects that necessitate consideration include strengths such as the prevailing policy, market forces, commitment, and motivation to the effort, and the availability of resources, information and external contacts. Features such as political drive and advocacy, interest in the education debate, collaborative links through joint working and partnerships, and ongoing internal reforms and restructuring could all act as opportunities. However, resistance and anxiety are to be expected, the operationalization of the effort and empowerment of those leading it need to be thought about, and issues of control and interests are critical. The presence of conflicting priorities and competition or the lack of vision and directives, or uncertainty about change, could act as threats and barriers to the effort. If shifting the 'traditional' healthcare curricula to a more 'innovative' public-health-oriented one is to be a success, administrators of educational change will need to take into account a 'melange' of factors and stakeholders involved in a gradual and incremental process.

Ultrasound image matching using genetic algorithms.

Image compounding reduces the artifacts inherent in ultrasound imaging, but accurate matching of images for compounding depends on their accurate placement in the compound image plane. A method is presented to reduce displacement errors during compounding of ultrasound B-scans of a normal human shank. A genetic algorithm was used to place matching B-scans in the compound image. The method was tested on a phantom and was shown to reduce, but not eliminate, mismatches due to the displacement of B-scans from their original position in the compound image plane. The results can be extended to applications in lower-limb prosthetics, where ultrasound imaging can be used to visualise the internal geometry of amputees' residual limbs.

Reciprocating gait prosthesis for the bilateral hip disarticulation amputee.

This paper describes the design, manufacture and use of a new prosthesis which produced reciprocating gait for a bilateral hip disarticulation amputee. A special mechanism used the hip extension moment during weight bearing to drive the contralateral limb through the swing phase. The user rapidly attained efficient and safe reciprocating gait, together with simple donning and doffing. The success of this project has major implications for hip disarticulation amputees in terms of profound improvements of their independence and self-esteem.

Identification of a 55-bp deletion in the glucocerebrosidase gene in Gaucher disease: phenotypic presentation and implications for mutation detection assays.

A 55-bp deletion in exon 9 of the glucocerebrosidase gene was identified in a 28-year-old male affected with Gaucher disease. The diagnosis was established during an evaluation for mild pancytopenia and was confirmed by bone marrow histology and biochemical studies. The patient is of German ancestry. Initial DNA testing indicated homozygosity for the N370S mutation. However, subsequent testing of the patient's parents suggested that the patient and his mother carried a null allele by our assay for N370S. Further molecular studies identified a 55-bp deletion in exon 9 of the glucocerebrosidase gene (g.6767_6822del55). This deletion has been previously reported in a patient with severe Gaucher disease (1), and is present in the glucocerebrosidase pseudogene. In the previously reported case, initial DNA testing also suggested the genotype N370S/N370S, but further mutation studies were undertaken because clinical severity was greater than expected for that genotype. In contrast, our patient has an unusually mild clinical course. Thus, clinical severity cannot be reliably used to determine when to test for the presence of the 55-bp deletion. While the 55-bp deletion is not reported to be common, its actual frequency may be underestimated since it eludes detection by many standard clinical assays for Gaucher disease. This report points out the need to consider this deletion mutation which may cause erroneous interpretation of results in existing assays for the common mutations N370S and L444P. Furthermore, the importance of recommending parental analysis for individuals who test homozygous for autosomal mutations is highlighted.

A methodology for studying the effects of various types of prosthetic feet on the biomechanics of trans-femoral amputee gait.

This paper reports on a methodology developed for studying the effects of various types of prosthetic feet on the gait of trans-femoral amputees. It is shown that an analysis in three planes of motion of not only the prosthetic, but also the sound limb provides important information on the performance of prosthetic feet. Two male trans-femoral amputees were tested with four different prosthetic feet; the Springlite II, Carbon Copy III, Seattle LightFoot and the Multiflex foot. A detailed analysis of the results of one amputee and a summary of the most important results of a second subject is presented. The tests were carried out at normal (1.16 m s(-1)) and fast (1.56 m s(-1)) walking speeds. Three dimensional gait analysis was carried out to derive the time curves of the joint angles, intersegmental moments and power at the ankle, knee and hip joints at both the prosthetic and sound sides. A higher first peak of the ground reaction force at the sound side with the Seattle LightFoot compared to that with the Springlite II, may be the result of the lower late stance dorsiflexion angle with the former. Compared to the other two feet, the Carbon Copy III and the Springlite II showed higher prosthetic dorsiflexing moments and positive power at late stance, which could assist in the push-off. The 3D intersegmental loads at the ankle and knee can be used as a guide for design and for compilation of standards for testing of lower limb prostheses incorporating flexible feet.

Prosthetic loading during kneeling of persons with transfemoral amputation.

Observations in the field of lower limb prosthetic rehabilitation have shown that several transfemoral prostheses show signs of wear on some components of the knee unit. This is thought to be a result of severe loading developed during activities associated with kneeling. Some prostheses may have failed due to repetitive action of such loading. In order to determine the nature and magnitude of the loads developed during kneeling by persons with transfemoral amputation, and to investigate the influence of various prosthetic parameters, an analysis of the results of 162 tests in prosthetic knee hyperflexion was undertaken. The services of four males with amputation were enlisted. The measurements involved simultaneous use of two Kistler force platforms, a six-channel strain gauge transducer mounted on the prosthetic shank, and a data acquisition system. The critical loads for this configuration were found to be the shear force on the knee hinge, the shear force imposed by the knee chassis on the shin, and the bending moment tending to hyperflex the knee. These loads ranged from 0.6 to 6.2 kN, 0.9 to 6.7 kN, and from 18.3 to 155.7 Nm, respectively. To achieve a comfortable kneeling position, some prostheses permit foot rotation about the pylon axis of 90 infinity to allow the shank to be approximately parallel to the ground. Tests were also conducted with the prostheses in this configuration and the most influential prosthetic parameter was found to be the external rotation of the foot (toe-out angle). During kneeling, it was found that the loading was dependent upon the position of the torso relative to the prosthesis, but loads were much higher than those developed during level walking.

Screening semen donors for hereditary diseases. The Fairfax cryobank experience.

OBJECTIVE: To study the carrier frequency of hereditary diseases in potential semen donors with no family history of a genetic disease. STUDY DESIGN: Carrier screening was performed on potential semen donors for chromosomal abnormalities, cystic fibrosis, alpha-1-antitrypsin deficiency, hemoglobinopathies, Tay-Sachs disease, Gaucher disease, Canavan disease, and hereditary breast and ovarian cancer (the BRCA1 185delAG mutation). The screening regimen used for each donor was dictated by his ethnic background. RESULTS: Among 361 individuals screened for chromosomal abnormalities, 1 carried an inversion, and 4 were possible mosaics. Fifteen of 407 potential donors carried cystic fibrosis, 18 of 209 carried alpha-1-antitrypsin deficiency, and 2 of 74 carried a hemoglobinopathy. No carriers of Tay-Sachs disease (56 screened), Gaucher disease (32 screened), Canavan disease (22 screened) or the BRCA1 185delAG mutation (22 screened) were found. CONCLUSION: Screening semen donors for a number of genetic diseases that are passed silently from generation to generation is warranted since family history alone cannot identify them.

Automatic segmentation of magnetic resonance images of the trans-femoral residual limb.

An automatic algorithm for the extraction of the skin and bone boundaries from axial magnetic resonance images of the residual limb of trans-femoral amputees is presented. The method makes use of K-means clustering and mathematical morphology. Statistical analysis of the results indicates that the computer-generated boundaries compare favourably to those drawn by human observers. The boundaries may be used in biomechanical modelling of the interaction between the residual limb and the prosthetic socket. The limb/socket interface determines the quality of prosthetic fit, therefore knowledge of this interface is important for the improvement of socket design in order to achieve patient comfort and mobility.

Prenatal determination of genotypes Kell and Cellano in at-risk pregnancies.

OBJECTIVE: To evaluate the accuracy of a DNA-based testing methodology in determining the KEL1 and KEL2 (Kell and Cellano) genotype of fetuses at risk for Kell or Cellano hemolytic disease. STUDY DESIGN: DNA was extracted from chorionic villus samples (CVS) or amniotic fluid (AF) cells, a portion of the Kell gene was amplified, the amplified product was cut with a restriction enzyme that recognizes the KEL1 nucleotide substitution, and the digested product was run on a polyacrylamide gel to separate the fragments. This analysis was routinely run on uncultured cells to provide rapid results. Testing of parental DNA was performed in conjunction with fetal analysis to ensure that their alleles were detectable with this DNA test. RESULTS: We determined the fetal KEL1 and KEL2 genotype in 1 CVS and 65 AF specimens. Forty-eight of them were determined to be KEL2, 17 were KEL1/2, and 1 was KEL1. Among the fetuses born to date, follow-up information was available on 14 of them, 11 KEL2 and 3 KEL1/2. In all 14 there was complete correlation between the DNA analysis and the serotype or clinical course. CONCLUSION: Determination of the fetal KEL1 and KEL2 genotype using this DNA-based method provides accurate and timely information that can aid the prenatal care of women sensitized to these Kell antigens.

Energy cost of walking: comparison of "intelligent prosthesis" with conventional mechanism.

OBJECTIVE: To determine physiological energy cost with Blatchford's "Intelligent Prosthesis" (IP) compared to energy cost with a conventional pneumatic swing phase control (PSPC) mechanism. DESIGN: Before-After trial: subjects fitted with IP walked on programmable treadmill at speeds: 6 min slow, 6 min fast, 8 min while speed changed, between slow, normal, and fast, every minute, and 6 min normal. Breath-by-breath analysis of subject's expired air determined average Vo2 (L/min) within each period. Procedure repeated after 1-week interval using PSPC prosthesis. Testing sessions supervised by experienced prosthetist. SETTING: Rehabilitation centre. SUBJECTS: Volunteer sample. Three men, unilateral transfemoral traumatic amputee patients, ages 39 to 59 years. Normally used ischial containment socket, Blatchford Endolite Stabilised Stance Flex knee with PSPC and Multiflex foot and ankle. INTERVENTIONS: Fitting, programming, and alignment of IP (own socket) by Bioengineering Unit's resident prosthetist, IP's microprocessor programmed to facilitate five walking speeds. MAIN OUTCOME MEASURE: Physiological energy cost (Vo2), of using IP compared to using PSPC mechanism. RESULTS: Two subjects displayed reduced Vo2 of between 5.6% and 9.0% using IP compared to PSPC prosthesis at a pace either faster or slower than their normal pace. Third subject showed no significant change in oxygen consumption despite IP unit being heavier. All subjects displayed reduced Vo2 (averaging 4.1%) using IP for period of variable speed walking. CONCLUSIONS: Although differences were small, they tend to indicate that use of the heavier IP unit lowered the energy cost of walking at speeds other than the amputee's normal pace.

Stump-socket interface pressure as an aid to socket design in prostheses for trans-femoral amputees--a preliminary study.

A system for measuring the stump-socket interface pressure was designed and built using a strain gauged type load cell. The system was utilized to study the pressure distribution in the quadrilateral and ischial containment type sockets. Two volunteer trans-femoral amputees fitted with both types of socket participated in the experiments. Pressures were measured while the subjects were standing and during walking. The maximum pressure recorded for standing was 34 kPa and for walking 95 kPa. Comparison made between the two sockets indicated that higher pressures were recorded at the proximal brim of the quadrilateral socket whereas the ischial containment socket produces a more evenly distributed pressure profile. The pressure distribution on the medial and lateral walls of both types of socket were similar but in the anterior and posterior walls, significant differences were noted. The results obtained from this study were compared with those found in published literature and the biomechanics of the two types of socket is discussed.

A fragile X mosaic male with a cryptic full mutation detected in epithelium but not in blood.

Individuals with developmental delay who are found to have only fragile X premutations present an interpretive dilemma. The presence of the premutation could be an unrelated coincidence, or it could be a sign of mosaicism involving a full mutation in other tissues. To investigate three cases of this type, buccal epithelium was collected on cytology brushes for Southern blot analysis. In one notable case, the blood specimen of a boy with developmental delay was found to have a premutation of 0.1 extra kb, which was shown by PCR to be an allele of 60 +/- 3 repeats. There was no trace of a full mutation. Mosaicism was investigated as an explanation for his developmental delay, although the condition was confounded by prematurity and other factors. The cheek epithelium DNA was found to contain the premutation, plus a methylated full mutation with expansions of 0.9 and 1.5 extra kb. The three populations were nearly equal in frequency but the 1.5 kb expansion was the most prominent. Regardless of whether this patient has clinical signs of fragile X syndrome, he illustrates that there can be gross tissue-specific differences in molecular sub-populations in mosaic individuals. Because brain and epithelium are more closely related embryonically than are brain and blood, cryptic full mutations in affected individuals may be evident in epithelial cells while being absent or difficult to detect in blood. This phenomenon may explain some atypical cases of the fragile X phenotype associated with premutations or near-normal DNA findings.