SCI peer health coach influence on self-management with peers: a qualitative analysis.

STUDY DESIGN: A process evaluation of a clinical trial. OBJECTIVES: To describe the roles fulfilled by peer health coaches (PHCs) with spinal cord injury (SCI) during a randomized controlled trial research study called 'My Care My Call', a novel telephone-based, peer-led self-management intervention for adults with chronic SCI 1+ years after injury. SETTING: Connecticut and Greater Boston Area, MA, USA. METHODS: Directed content analysis was used to qualitatively examine information from 504 tele-coaching calls, conducted with 42 participants with SCI, by two trained SCI PHCs. Self-management was the focus of each 6-month PHC-peer relationship. PHCs documented how and when they used the communication tools (CTs) and information delivery strategies (IDSs) they developed for the intervention. Interaction data were coded and analyzed to determine PHC roles in relation to CT and IDS utilization and application. RESULTS: PHCs performed three principal roles: Role Model, Supporter, and Advisor. Role Model interactions included CTs and IDSs that allowed PHCs to share personal experiences of managing and living with an SCI, including sharing their opinions and advice when appropriate. As Supporters, PHCs used CTs and IDSs to build credible relationships based on dependability and reassuring encouragement. PHCs fulfilled the unique role of Advisor using CTs and IDSs to teach and strategize with peers about SCI self-management. CONCLUSION: The SCI PHC performs a powerful, flexible role in promoting SCI self-management among peers. Analysis of PHC roles can inform the design of peer-led interventions and highlights the importance for the provision of peer mentor training.

A pilot study of a telehealth intervention for persons with spinal cord dysfunction.

STUDY DESIGN: Single-blind randomized controlled trial of 6 months' duration. OBJECTIVES: To evaluate the efficacy of a novel telehealth intervention, 'CareCall', on reducing pressure ulcers and depression and enhancing the use of appropriate health care. SETTING: General community, Massachusetts and Connecticut, United States METHODS: 'CareCall' is an automated, interactive voice response system that combines patient education, cognitive behavioral interventions, screening and referrals, with alerts to a nurse telerehabilitation coordinator for direct non-emergent phone follow up. Participants consisted of a convenience sample of 142 persons with multiple sclerosis or spinal cord injury using a wheelchair >6 h per day. The intervention group received CareCall (n=71) The control group received usual care (n=71). The main outcome measures were: The pressure ulcer scale for healing tool, Patient Health Questionnaire-9 depression scale, Cornell Services Index and Craig Hospital Inventory of Environmental Factors-Short Form Question 5. RESULTS: CareCall achieved a reduction in presence of pressure ulcers at 6 months in women (P<0.0001). Among those with baseline depression, CareCall reduced 6-month severity of depression, adjusting for age and gender (P<0.047). CareCall did not have a significant impact on health-care utilization (OR=1.8, P=0.07), but did significantly improve participants' report of health-care availability (OR=2.03, P<0.04). CONCLUSION: This is the first study to demonstrate the efficacy of a largely automated telehealth intervention for adults with spinal cord dysfunction. Future research needs to replicate this study in a larger, multisite trial.

Use of subcutaneous venous access ports to treat refractory ascites.

To assess the feasibility of peritoneal ports for management of patients with cirrhotic refractory ascites, 10 ports were placed in nine patients for frequent outpatient paracentesis. Retrospective review and telephone interviews were used to assess port performance. Kaplan-Meier analysis revealed a median duration of port patency of 255 days. In 1,557 port days, four access problems prompted further interventional evaluation. Three cases of bacterial peritonitis and one catheter obstruction developed. The use of subcutaneous venous access ports to allow control of ascites by nursing personnel is a promising alternative for management of patients with refractory ascites. Additional studies are needed to determine long-term effectiveness and safety.

Intrauterine epidermal necrosis.

BACKGROUND: Epidermal necrosis in a neonate is an uncommon event with a variety of potential cases. RESULT: We report a case of intrauterine epidermal necrosis in a preterm infant, with death occurring soon after birth. The histopathology of the denuded skin revealed full-thickness epidermal necrosis and calcification within both the epidermis and follicular structures. CONCLUSION: We believe this represents the fourth reported case of lethal intrauterine epidermal necrosis and follicular calcification.

Heme oxygenase-1 gene expression as a stress index to ocular irritation.

PURPOSE: Predicting the toxic potential of compounds to the ocular surface has depended on the Draize test for the past half century. Alternatives to Draize testing have recently been sought for a number of reasons. Stress gene expression has emerged as a means of quantifying cellular reaction and, thus, the toxic potential of the compound in question. This study examines the expression of the major stress response gene heme oxygenase-1 (HO-1) in a human corneal epithelial cell line (HCE-T) following challenges with a number of known ocular irritants. METHODS: HCE-T was used to investigate the effect of ocular irritants on cell viability and HO-1 expression. Irritants tested included hydrogen peroxide, isopropyl alcohol, sodium hydroxide and trichloroacetic acid. HCE-T cells were grown to 80% confluency and treated with the listed irritants at a concentration range of 10-100 microM. Cell viability and northern blot analysis were performed following a 24 and 48 hr incubation period. RESULTS: HCE-T cells expressed HO-1 mRNA and HO activity similar to other human cell lines. Northern blot analysis demonstrated that levels of HO-1 mRNA transcripts increased regularly after exposure to the irritants in a concentration-dependent manner. Studies on the effect of various inhibitors and inducers of HO-1 on cell viability showed that inhibition of HO-1 potentiates the cytotoxic effect of ocular irritants. In contrast, pre-induction of HO-1 in HCE-T decreases the effect of various irritants on cell viability. CONCLUSIONS: These results are consistent with the idea that HO-1 mRNA levels may be used as an indicator of toxicity resulting from ocular irritants and that HCE-T cells respond to stress in a fashion similar to other human cell lines. This strategy for testing may be important in the development of an alternative to Draize testing. The results of this study also suggest that HO-1 may constitute a part of the protective defense mechanism against chemical injury.

Adolescents and popular culture. A psychodynamic overview.

Adolescents occupy a difficult and seemingly elusive developmental space, which makes them enigmas to most adults, including psychotherapists. Building upon dynamic theory such as that formulated by Winnicott or Erikson, this paper explores the relationship between adolescents and material elements of popular culture within a psychodynamic and developmental framework. Theoretical perspectives are integrated with case material to illustrate some of the roles of popular music and fashion in the lives of teenagers as a means of expression and in potential therapeutic alliance formation, dynamic understanding and working through developmental conflicts in displacement.

Expression and activity of epidermal growth factor receptor in late fetal rat lung is cell- and sex-specific.

Epidermal growth factor (EGF) augments late fetal lung maturation by advancing the ontogeny of fetal lung development and by stimulating surfactant synthesis. Previous studies have indicated that fibroblastalveolar epithelial cell communications mediate surfactant synthesis in the fetal lung and EGF acts through such a mechanism. We investigated the hypothesis that is differential activity and expression of the epidermal growth factor receptor (EGF-R) in fetal lung fibroblasts during the canalicular stage of lung development mediates EGF effects. To test this hypothesis, we examined fetal rat lung fibroblasts (FLFs) and type II cells of late gestation (canalicular and saccular stages; 17-22 days) by EGF-R binding techniques, SDS-PAGE, and Western blot analysis. Specific EGF binding increased 181% in day 18 female FLFs, with male FLFs exhibiting a similar increase on day 19. In contrast, specific EGF binding was low in type II cells, did not increase during late gestation, and there were no sex-specific differences. SDS-PAGE and Western blot analysis revealed a predominant 170-kDa EGF-R band in fibroblasts that increased with gestation (peak = 19 days), and was stronger in females. Immunoprecipitation of EGF-treated cells demonstrated the tyrosine kinase activity of the identified receptor. In contrast, type II cells showed minimal signal that did not increase until day 21 of gestation. We also examined whole fetal lung sections by immunohistochemistry to determine cell-specific expression of the EGF-R in vivo. Immunohistochemistry revealed specific EGF-R staining in columnar and cuboidal epithelia of small conducting airways and in mesenchyme of epithelial-mesenchymal borders (including subepithelial mesenchyme). In contrast, alveolar epithelia showed minimal staining, while subalveolar mesenchyme EGF-R staining peaked at day 19 of gestation. We conclude that cell-specific and sex-specific differences in EGF-R binding and EGF-R immunolocalization appears in the fetal lung at a developmental stage that is critical for alveolar epithelial cell differentiation. The results suggest a role for EGF-R activation in late fetal alveolar epithelial cell maturation, which is mediated through mesenchymal-epithelial cell communication.

Delphi-panel analysis of appropriateness of high-dose chemotherapy and blood cell or bone marrow autotransplants in diffuse large-cell lymphoma.

Although high-dose chemotherapy and a blood cell or bone marrow autotransplant are commonly used to treat people with diffuse large-cell lymphoma, there is controversy whether this is better than conventional-dose chemotherapy. Subject-selection and time-to-treatment biases preclude comparison of data from uncontrolled trials and there are few date from randomized trials. We used a Delphi-panel group judgment process to determine appropriateness of high-dose chemotherapy and a blood cell or bone marrow transplant. Results were compared to those of randomized trials. Nine lymphoma experts from diverse geographic sites and practice settings were panelists. Boolean MEDLINE searches of lymphoma and chemotherapy and an autotransplant formed the dataset. Panelists were asked to rate appropriateness of high-dose chemotherapy and an autotransplant compared to conventional-dose chemotherapy. Clinical variables were permuted to define 80 clinical settings rated by the panelists on a 9-point ordinal scale. Results were used to determine an appropriateness index reflecting the mean and distribution of ratings. The relationship of appropriateness indices to permuted clinical variables was considered by analysis of variance and recursive partitioning. In people with initial diffuse large-cell lymphoma, autotransplants were never rated appropriate. They were rated uncertain in all settings except in people never receiving chemotherapy and in those with a complete response to chemotherapy and an international prognostic index < 3, where they were rated inappropriate. In people with recurrent lymphoma, autotransplants were rated appropriate in those with a complete or partial response to chemotherapy, uncertain in those with a less than partial response and in those not receiving re-induction chemotherapy and inappropriate in people with CNS lymphoma. These conclusions agree with results of randomized trials.

The natural history of multiple sclerosis and its diagnosis.

The definition of multiple sclerosis (MS) provides a framework for the findings of the disease. This definition encompasses multiple lesions in the central nervous system which appear over time and emphasizes the spacial distribution of the lesions. Due to the significant degree of variability in the presentation of MS, the definition has evolved in terms of probability for the diagnosis given the findings.

Therapeutic and symptomatic treatment of multiple sclerosis.

The treatment of multiple sclerosis (MS) is a dynamic field that is rapidly evolving. It encompasses tow main areas. The first is the direct treatment of MS itself, having evolved from using primarily steroids to the newest immunotherapies that come from the extensive research into the immune system and the role it plays in so many diseases. The second area for treatment is in the management of the effects or symptoms resulting from MS.

Brain abscess and psychosis as a complication of a halo orthosis.

The halo vest orthosis is commonly used for stabilization after cervical spinal cord injury. Well-documented complications of halo use include skin breakdown, pin loosening, and loss of reduction. Brain abscess associated with halo use has been rarely reported. A case of a 23-year-old man is presented with spinal cord injury and halo stabilization. He developed extreme agitation and psychosis. Diagnostic imaging showed a brain abscess. After treatment for the abscess, his behavioral symptoms resolved. This article reviews the halo orthosis, its possible complications, and its routine management. Early recognition of important signs of symptoms in patients with halos as possible indicators of brain abscess is emphasized.

Listening to people with cancer.

Modern oncologic treatment includes prescriptive remedies for patient-defined illnesses as well as physician-defined diseases. To obtain needed information, oncologists must be skilled as discriminative, analytical, supportive, critical, and appreciative listeners. Listening skills help to establish rapport, confirm understanding, and exchange background information. The neuropsychiatric needs of impaired patients and oncologists should be identified and remedied to improve oncologist-patient communication. Improvements in listening skills makes the oncologist's work more meaningful and helps their patients to feel more confident.

Clonidine-induced bradycardia in patients with spinal cord injury.

Clonidine is being used increasingly for treatment of spasticity in patients with spinal cord injury. Though hypotension, dry mouth, and constipation are well-documented possible adverse effects, the possibility of clonidine-induced bradycardia is less well recognized and is rare. This report describes a patient who developed spasticity following a traumatic spinal cord injury. After clonidine was initiated, the patient's spasticity improved. However, he developed significant bradycardia. Once clonidine was discontinued, the resting heart rate returned to normal. This case illustrates an unusual adverse effect of clonidine. Possible mechanisms by which clonidine decreases spasticity are described, probable mechanisms of induced bradycardia are reviewed, and specific treatment recommendations for the use of clonidine in spinal cord injured patients are presented.

The renal response to exogenous parathyroid hormone in treated pseudohypoparathyroidism.

Resistance to the renal actions of parathyroid hormone (PTH) in pseudohypoparathyroidism (PsH) may be improved after treatment with vitamin D or its metabolites, but reports conflict. We have examined the renal response to infusion of 35 micrograms of 1-38 PTH in patients with PsH type I (n = 8) and PsH type II (n = 1) during treatment and related this to prevailing endogenous serum PTH and calcium levels. Nine patients with postsurgical or idiopathic hypoparathyroidism (HP) served as controls. The urinary cAMP increase (delta cAMP) was lower (p < 0.001) in the PsH type I (175 +/- 6.4 nmol/l glomerular filtrate) than in the HP group (3251 +/- 515 nmol/l glomerular filtrate). delta cAMP in the PsH type I subjects was dependent on endogenous PTH concentrations (r = -0.76; p = 0.046) and serum calcium (r = 0.74; p = 0.037). Phosphaturic responses (expressed as % decrease in TmPO4/glomerular filtration rate) were lower (p = 0.013) in the PsH type I (28.8 +/- 3.75) compared with those of the HP patients (43 +/- 3.48). The phosphaturic responses in the PsH type I patients were strongly dependent on endogenous PTH (r = 0.94; p < 0.001) and serum calcium levels (r = 0.94; p < 0.001) so that the responses of subjects with normal or low PTH levels were no different (p = 0.16) from the HP group. Renal handling of calcium and sodium in response to exogenous PTH was identical in patients with PsH (types I and II) and HP. Renal tubular reabsorption during a calcium infusion was normal in all patients with PsH. These results emphasise the importance of the modulatory effects due to associated biochemical abnormalities in PsH on the responses to exogenous PTH. They also confirm that renal handling of calcium and sodium is probably normal in treated PsH.

Health status and quality of life following cardiac transplantation.

There is little information regarding the functional status and quality of life of cardiac transplant patients. This investigation is the largest study describing outcome up to 10 years after cardiac transplantation. We conducted a cross-sectional survey of 200 cardiac transplant recipients using the Sickness Impact Profile and a supplementary questionnaire. The response rate was 48%. The median duration post-cardiac transplantation was 2.3 years (range, 0.5 to 9.7 years). The median age was 53 years (range, 27.1 to 68.7). In comparison to previously published studies, our sample of cardiac transplant recipients had worse quality of life than normals, similar scores to cardiac arrest survivors and post-myocardial infarction patients, and better quality of life than patients with low back pain. We found that those not working (44%) reported a lower quality of life. Musculoskeletal-neurologic complaints were highly prevalent, with generalized weakness in 54% responding, fatigue in 42%, and low back pain in 37%. Lower quality of life was found in patients reporting a higher number of musculoskeletal-neurological disorders. We conclude that there are specific areas for rehabilitation intervention in patients post-cardiac transplantation, and suggest areas for future research directed towards enhancing quality of life for cardiac transplant recipients.

Dural spinal cord arteriovenous malformation.

After multiple hospital admissions and an inpatient rehabilitation stay, a 68-year-old woman was transferred to our rehabilitation facility with a paraparesis of unknown etiology. Previous studies included four CT scans and three MRIs which did not demonstrate the lesion. A myelogram was noncharacteristic. The correct diagnosis, confirmed by selective angiography, was ultimately contingent upon recognition of the clinical features and natural history of dural spinal cord arteriovenous malformations (SCAVM). The unusual combination of this multitude of nondiagnostic imaging studies in the uncommon dural SCAVM served to delay diagnosis and treatment. Such delay may have great functional consequences. This report illustrates the importance of suspecting SCAVM and recognizing its features. Emphasis is placed on the physiatrist's role in assuring proper diagnosis to expedite a timely treatment and to obtain the best functional outcome. A brief review of the classification, clinical features, pathophysiology, diagnosis, and prognosis of SCAVM is presented.

Sequential expression of new gene programs in inducer T-cell clones.

We have prepared a cDNA probe that detects genes that are rapidly and abundantly expressed after exposure of inducer T-lymphocyte clones to antigen or mitogen. All inducer cells tested express a characteristic set of new mRNA, and these mRNAs are not expressed after activation of other lymphocytes. This initial burst of mRNA synthesis is paralleled by synthesis and secretion of a family of polypeptides that mediate inducer cell activity, including T- and B-cell growth factors, interferon, and molecules that bind to antigen. Expression of this initial genetic program precedes mitosis and is replaced within 74 hr by a different genetic program, which may control further cell division. The action of these sequential sets of genetic programs defines two stages of the cell's differentiation and accounts for altered expression of the cell's immunological functions.