Stroke rehabilitation: can we do better?
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Cerebrovascular Disorders↗
Biomedical subjects
A Forster
Publications and source records attributed to A Forster.
The rhombotin gene family encode related LIM-domain proteins whose differing expression suggests multiple roles in mouse development.
The rhombotin (RBTN1 or Ttg-1) gene was first identified at a chromosome translocation in a T-cell acute leukaemia and later used to isolate two related genes (RBTN2 or Ttg-2 and RBTN3). Complete characterization of these genes in man and mouse shows that all three encode cysteine-rich proteins with typical LIM domains. RBTN1 and RBTN3-derived proteins have 98% identity in the LIM domains but are located on separate chromosomes in man and in mouse while RBTN1 and RBTN2, both located on human chromosome 11p but are on separate chromosomes in mouse, are only 48% identical in this part of the protein. The exon organization of RBTN1 and RBTN3 genes are similar, both having an intron, absent from the RBTN2 gene, in the LIM2-encoding region. The remarkable similarity between rbtn-1 and rbtn-3 proteins is parallelled in their expression patterns in mouse development, since both genes show high expression in restricted areas of the brain, but little lymphoid expression. rbtn-2 expression, however, is more ubiquitous. This gene shows a low level of thymus expression but high expression in fetal liver, adult spleen and B-cell lines, consistent with a role in B-cell development. These results suggest multiple cellular targets for the action of these proteins during development.
Adult↗
The Bradford community stroke trial: results at six months.
OBJECTIVE: Comparison of day hospital attendance and home physiotherapy for stroke patients leaving hospital to determine which service produces greater functional and social improvement for the patient, reduces emotional stress for the care giver, and lessens the need for community support. DESIGN: Stratified, randomised trial of stroke patients attending day hospital two days a week or receiving home treatment from a community physiotherapist. The six month assessment results are reported in this paper. SUBJECTS: Patients over 60 years old resident within the Bradford metropolitan district discharged home after a new stroke with residual disability. SETTING: Four day hospitals in two health authorities and domiciliary work undertaken by experienced community physiotherapists. MAIN OUTCOME MEASURES: Barthel index, functional ambulatory categories, Motor Club assessment, Frenchay activities index, and Nottingham health profile were used. Carers' stress was indicated by the general health questionnaire. Treatment given and community care provided were recorded. RESULTS: Of 124 patients recruited, 108 were available for reassessment at six months. Both treatment groups had significantly improved in functional abilities between discharge and six months. The improvements were significantly greater for patients treated at home (Mann-Whitney test; Barthel index, median difference 2 (95% confidence interval 0 to 3) p = 0.01; Motor Club assessment, median difference 2 (1 to 5), p = 0.01). The home treated patients received less treatment (median difference 16 (11 to 21) treatments, p less than 0.001). More than a third of patients in both groups showed depressed mood, and a quarter of care givers were emotionally distressed. CONCLUSIONS: Home physiotherapy seems to be slightly more effective and more resource efficient than day hospital attendance and should be the preferred rehabilitation method for aftercare of stroke patients. New strategies are needed to address psychosocial function for both patients and care givers.
Activities of Daily Living↗
[Ambulatory surgery. Attitude of patients].
Whilst day care surgery is well developed in English-speaking countries for its medical, social and economic advantages, for ill-defined reasons a small proportion of ambulatory operations is performed in Switzerland. The purpose of this study was to determine the patients' attitude towards day care surgery in order to inform the general population concerning the development of this type of surgery. One hundred and ten hospitalized patients about to undergo unilateral repair of inguinal hernia were questioned: 58 percent were unfavourable, 22 percent were favourable and 20 percent would be favourable if a home care system was organized. The factors responsible for this negative attitude towards day care surgery are analysed, and proposals are made to overcome the patients, reluctance.
Adolescent↗
Immunoglobulin VH-T cell receptor C alpha fusion mRNA resulting from chromosome inversion include the T cell-associated 5' exon ET.
A human T cell lymphoma has been described in which an inversion of chromosome 14 results in fusion of an immunoglobulin heavy chain VH with a T cell receptor J alpha segment, potentially resulting in a chimeric protein with immunoglobulin VH region recognition plus T cell receptor effector functions. Examination of the mRNA species expressed from the IgT gene in this lymphoma shows a variety of forms but all IgT mRNA include the T cell-specific exon, ET, previously located in the distal part of the VH locus. In such mRNA species, the normal leader exon of the Ig VH segment, which encodes most of the hydrophobic signal peptide, is replaced by the short ET exon encoding mainly non-hydrophobic residues. Two forms of this mRNA exist which lack the Ig VH leader sequence and thus potentially yield non-membrane proteins in the T cell lymphoma.
Alternative Splicing↗
Human RAG2, like RAG1, is on chromosome 11 band p13 and therefore not linked to ataxia telangiectasia complementation groups.
Ataxia telangiectasia (A-T) is an inherited, recessive, cancer-prone disease with associated immunodeficiency and chromosome abnormalities involving TCR loci. The latter phenomena implicate errors of the enzyme(s) responsible for assembly of antigen receptor genes (recombinase) in disease pathogenesis. Here we report the location of a human recombination activating gene (RAG2), in addition to RAG1, on chromosome 11, band p13, thereby formally demonstrating linkage of these genes in humans and showing that they are not linked to the known locus responsible for the A-T syndrome.
Ataxia Telangiectasia↗
Epidural morphine reduces halothane MAC in humans.
The effect of epidural morphine sulphate (4 mg in 10 ml saline) on the minimum alveolar concentration of halothane was investigated in a double-blind, randomized fashion in ten adult patients undergoing abdominal surgery, and compared with the minimum alveolar concentration of halothane after epidural administration of 10 ml saline in a similar group of patients. Morphine sulphate, administered through the epidural catheter 98 +/- 33 min before to skin incision reduced the minimum alveolar concentration of halothane by 28% (0.57% vs 0.78%, P < 0.05).
Adjuvants, Anesthesia↗
Comparison of hyperbaric solutions of bupivacaine and tetracaine during continuous spinal anaesthesia.
The aim of this study was to compare two equipotent solutions of hyperbaric bupivacaine and tetracaine in 30 elderly patients undergoing elective hip surgery under continuous spinal anaesthesia. With the patient in the supine position, 2 ml (8 mg) of either hyperbaric solution (density 1.030) were administered in a double-blind and randomized fashion. The median maximum sensory and temperature discrimination levels (T5 and T4) were similar with both solutions. The duration of analgesia was not different (114 +/- 23 min for bupivacaine and 125 +/- 35 min for tetracaine). Thirteen out of fifteen patients receiving bupivacaine and all 15 patients receiving tetracaine had complete motor blockade. The haemodynamic changes and vasopressor requirements were comparable. The plasma catecholamine levels measured at four different times remained unchanged and were not different between the two groups at any time. The authors conclude that, during continuous spinal anaesthesia, equipotent hyperbaric solutions of bupivacaine and tetracaine have similar anaesthetic and haemodynamic effects.
Aged↗
[Peridural anesthesia for surgery of the ankle and foot: effect of the sitting position].
The effects of the sitting position on the quality of both sensory and motor blockade of segments L5 and S1 and the haemodynamic consequences during epidural anaesthesia were studied on 39 patients undergoing ankle or foot surgery. After insertion of an epidural catheter with the patient in the lateral position, 19 patients were kept sitting for 15 min following the injection of the local anaesthetic and 20 remained supine for the duration of anaesthesia (control group). All patients received a dose of 20 ml of 1.73% carbonated lidocaine with epinephrine 1:200,000. The quality and time of onset of the sensory blockade for segments L1-S2 as well as its cephalad spread were comparable in both groups. Fourteen patients of the sitting group achieved motor blockade of more than three of five myotomes compared with five patients in the supine group (P less than 0.001). The maximum decrease in mean arterial pressure occurred sooner in the sitting group (14 +/- 9 min) than in the control group (21 +/- 10 min; P less than 0.01) and was more severe (-24 +/- 10% vs -16 +/- 10% respectively; P less than 0.05). Our results indicate that placing the patient in the sitting position for 15 min after inducing epidural anaesthesia does not influence caudal sensory blockade but does increase the depth of motor blockade.
Adult↗
Comparison between clonidine and epinephrine admixture to lidocaine in brachial plexus block.
The admixture of clonidine or epinephrine to lidocaine for brachial plexus block was studied with regard to duration of block, postoperative analgesia, and plasma concentrations of lidocaine. Thirty-three patients of ASA physical status I and II received an admixture of either clonidine (150 micrograms; n = 15) or epinephrine (200 micrograms; n = 18) to 40 mL of 1% lidocaine in a randomized, double-blind fashion. Bone surgery predominated in those patients receiving clonidine and soft-tissue surgery in those receiving epinephrine (P less than 0.05). Onset and duration of block were not different between the groups. With the admixture of clonidine, fewer patients were completely pain free for greater than 12 h (13.3%) and pain scores (visual analogue scale 0-10) were higher 6 h after the block (median 4; range 0-6) than with epinephrine (61.1%; median 2; range 0-7, respectively; P less than 0.05). In patients who had received clonidine, peak plasma concentrations of lidocaine were higher (10.29 +/- 2.96 mumol/L) and occurred earlier (23.7 +/- 9.3 min; mean +/- SD) than in those treated with epinephrine (6.9 +/- 1.71 mumol/L; 72.5 +/- 56.2 min; P less than 0.05). This indicates the absence of a local vasoconstrictor effect of clonidine and implies a reduced margin of safety with regard to local anesthetic toxicity. Although clonidine does not offer advantages compared with epinephrine, it may be a useful adjunct to local anesthetics in those patients in whom the administration of epinephrine is contraindicated.
Adult↗
[Physical performance and sedation: comparative study of the effects of a benzodiazepine (temazepam) and of a non-benzodiazepine hypnotic (zolpidem)].
It is well-known that many athletes experience some form of precompetition stress that may result in insomnia during the night before their competition. Yet, sleep withdrawal even if only partial, has a negative influence on performance, particularly when the type of exercise requires good psychomotor performance The purpose of the present study was to investigate whether the intake of a hypnotic drug would have negative effects on physical performance capacity. The authors have compared the effects of oral temazepam, a medium half-life benzodiazepine vs oral zolpidem, a short half-life non-benzodiazepine drug, vs placebo. A randomized double-blind trial was used to assess endurance, resistance, strength and coordination in 26 athletes. The results did not show any differences between the three groups, neither in physical performance characteristic nor in coordination. It is concluded that as regards the performance capacity, there is no risk for stressed athletes to use sleep inducers the night before their competition.
Adult↗
T-cell acute lymphoblastic lymphoma induced in transgenic mice by the RBTN1 and RBTN2 LIM-domain genes.
Two members of the RBTN gene family, RBTN1/Ttg-1 and RBTN2/Ttg-2, were found by their association with T-cell tumour-specific chromosomal translocations and are thought to be involved in the aetiology of such T-cell tumours. Here a transgenic mouse model is described in which T-cell tumours are induced by the presence of RBTN1 and RBTN2 transgenes that direct expression in thymus-derived cells. The latency period for lymphoid tumour appearance is variable, and tumours occur in a small proportion of transgenic animals that develop T-cell acute lymphoblastic malignancies. No significant increase in the rate of tumour development was observed in RBTN1 transgenic mice infected with Moloney murine leukaemia virus, nor did tumours arise in mice bearing a construct in which RBTN1 was expressed from the insulin transcriptional promoter. These data, which provide formal proof of the oncogenic activity of these genes, suggest that aberrant expression of transcription factor genes, such as RBTN1 and RBTN2, functions in tumour aetiology by disturbing some aspect of T-cell differentiation.
Animals↗
Mechanism of analgesia induced by hypnosis and acupuncture: is there a difference?
Hypnosis and acupuncture can alleviate experimentally induced pain but the mechanism of analgesia remains unclear for both techniques. Experimental pain was induced by cold pressor test (CPT) in 8 male volunteers. Analgesic effect of hypnosis (HA) and acupuncture (AA) was assessed before and after double-blind administration of placebo or naloxone, in a prospective, cross-over study. We found that pain intensity was significantly lower with HA as compared with AA, both with naloxone (P less than 0.001) and placebo (P less than 0.001). Within HA or AA groups, pain scores did not differ significantly when naloxone or placebo was administered. During AA, however, pain scores were similar to control values when naloxone was given (P = 0.05) but decreased significantly with placebo (P less than 0.002). Analog scales for pain intensity and pain relief showed a good correlation (r = 0.94). Plasma levels of beta-endorphins did not change significantly in any combination. Heart rate, peripheral arterial blood pressure and skin conductance were very insensitive indices to assess pain intensity or relief, as well as intensity of acupuncture stimulation or depth of hypnotic trance. We conclude: (1) HA and AA can significantly reduce pain from CPT, and HA is more effective than AA: (2) HA and AA are not primarily mediated by the opiate endorphin system; and (3) plasmatic levels of beta-endorphins are not significantly affected by either HA or AA nor by naloxone or placebo administration.
Acupuncture Analgesia↗
Impairment of vasomotor reflexes in the fingertips of leprosy patients.
A method is described for eliciting fingertip vasomotor reflexes by inspiratory gasp and contralateral hand cold challenge. The results of the two tests are reproducible on replicate testing and, when taken together, have proved reliable for detection of impairment of autonomic reflexes in 10 newly registered leprosy patients who did not have any obvious deformity. Similar, but less severe, impairment of vasomotor reflexes was noted in a group of 10 fully treated, apparently cured ex-leprosy patients, none of whom showed clinically obvious neuropathy. Both the new patients and the ex-patients were significantly different from healthy contacts and from healthy Europeans, who were indistinguishable by this test. Evidence is presented suggesting that impairment of these vasomotor reflexes is mainly due to damage to the efferent pathway in the peripheral nerves. The method might prove valuable for investigation of early nerve damage in new patients or during reversal reactions in leprosy at a stage before irreversible damage is done.
Adult↗
Evaluation of the effect of perineuronal morphine on the quality of postoperative analgesia after axillary plexus block: a randomized double-blind study.
A randomized, double-blind study was performed on 50 patients scheduled for elective hand and forearm surgery under axillary plexus block to evaluate the effect of perineuronal morphine on the quality of postoperative analgesia. Patients were divided into two groups. In group A (n = 25) 5 mg of preservative-free morphine in 1.0 mL of 0.9% saline was added to the local anesthetic solution (20 mL of 1% plain lignocaine, 20 mL of 0.5% plain bupivacaine). They also received an intramuscular placebo injection of 1.0 mL of 0.9% saline in the upper thigh. In group B (n = 25), 1.0 mL of 0.9% saline was added to the local anesthetic solution and patients received an intramuscular injection of 5 mg of preservative-free morphine in 1.0 mL of 0.9% saline in the thigh. The addition of morphine to the local anesthetic solution for the axillary block did not shorten the onset time of the block, improve the quality of postoperative pain relief, or provide longer lasting analgesia than that obtained with intramuscular morphine.
Adolescent↗
Comparison of hypobaric, hyperbaric, and isobaric solutions of bupivacaine during continuous spinal anesthesia.
This study was designed to compare the anesthetic properties of hypobaric bupivacaine with those of isobaric and hyperbaric solutions when administered in the supine position in an elderly population undergoing hip surgery using continuous spinal anesthesia. Plain bupivacaine (0.5%) was mixed with equal volumes of 10% dextrose (hyperbaric), 0.9% NaCl (isobaric), or distilled water (hypobaric) to obtain 0.25% solutions. In a double-blind fashion, all patients received 3 mL (7.5 mg) of their particular solution injected through the spinal catheter in the horizontal supine position. The sensory level obtained in the hyperbaric group (median, T4; range, T3-L3) was significantly higher than in both the isobaric (median, T11; range, T6-L1) and hypobaric (median, L1; range, T4-L3) groups. A motor blockade of grade 2 or 3 was obtained in 14 of 15 and 12 of 15 patients in, respectively, the hyperbaric and isobaric groups, but only in 8 of 15 patients in the hypobaric group. After the initial injection of 3 mL (7.5 mg), a sensory level of T10 and a motor blockade of grade 2 or 3 was obtained in 14 of 15, 5 of 15, and 3 of 15 patients in the hyperbaric, isobaric, and hypobaric groups, respectively. All remaining patients received 1 or 2 additional milliliters (2.5-5 mg) and achieved these required anesthetic conditions, except for one patient in the hyperbaric group and eight patients in the hypobaric group in whom anesthesia was achieved with hyperbaric tetracaine. The decrease in mean arterial pressure was significantly more severe in the hyperbaric (30%) than in either the isobaric (18%) or hypobaric (14%) groups.(ABSTRACT TRUNCATED AT 250 WORDS)
Aged↗
Impairment of fingertip vasomotor reflexes in leprosy patients and apparently healthy contacts.
Fingertip blood-flow velocity and its control by vasomotor reflexes were studied in leprosy patients and in healthy controls with a laser Doppler flowmeter. In newly registered patients, the flow was significantly lower than in the healthy controls, and even lower values were recorded in the long-standing patients with lower limb ulcers and/or deformity. The newly registered patients showed substantially impaired vasomotor reflex responses in the fingertips to cold challenge of the opposite hand or deep inspiratory gasp. Low blood flow and impairment of vasomotor reflexes were more prominent in those leprosy patients who showed clinical evidence of neuropathy and/or histological evidence of reaction in a punch biopsy of leprosy skin lesions. This aspect of dysautonomia to cold challenge was particularly prominent in apparently healthy, fully treated ex-patients. There was an unexpectedly high prevalence of impairment of vasomotor reflexes in newly registered and apparently healthy, adequately treated leprosy patients. The method is very sensitive, and it remains to be established whether the lesions it detects are nonprogressive residues, or previous nerve damage, or an indication of on-going nerve damage. A minority of leprosy contacts showed impairment of vasomotor reflexes. Those with two or more affected fingers were more likely to have had a higher level of exposure to Mycobacterium leprae than those with one or no affected fingers. The cause of this unexpected impairment of fingertip vasomotor reflexes in a minority of leprosy control workers has not yet been determined.
Adolescent↗
[Role of benzodiazepines in neuroanesthesia].
For the induction of anesthesia in neurosurgical patients, the choice between thiopental and midazolam cannot be done on the basis of their respective cardiovascular, respiratory or cerebral effects, since they are similar. Among the advantages of midazolam are the absence of histamine release and excitatory effects. On the contrary the onset and the duration of action as well as the intensity of sedation are less predictable with midazolam when compared to thiopental. Therefore thiopental remains the first drug of choice in this clinical setting. For preoperative sedation in neurosurgical patients, the use of benzodiazepines should be limited, since they can induce respiratory depression mainly in patients with cranial trauma or with chronic obstructive pulmonary disease. The preoperative administration of a benzodiazepine in neurosurgical patients who are under chronic treatment should be decided individually, according to the level of the conscience of the patient and on the half life of the drug.
Anesthesia, Intravenous↗