Short-term effectiveness of a community-implemented falls prevention referral service

Purpose: To evaluate the effectiveness of the 16-week evidence-based Steady Steps exercise referral scheme at improving physical function, balance confidence, and quality of life (QoL) of community-dwelling older adults at risk of falling.

Method: A non-experimental, practice-based study involving a retrospective analysis of participant outcomes. Pre–post comparisons of three performance-based measures of gait and balance and of person-reported outcomes for balance confidence and QoL were performed. Effectiveness was evaluated in terms of statistically significant changes and relative to published fall-risk thresholds and minimal detectable changes (MDCs) or minimum clinically important differences.

Results: One hundred and thirty-six participants completed the program over 19?months. Statistically significant differences were observed for all outcomes (p?40% reported clinically important improvements in QoL.

Conclusions: While the non-experimental design precludes conclusive evidence of causation, the highly significant and clinically meaningful improvements observed in individuals who completed the evidence-based Steady Steps program support its translation of evidence into effective practice. Continued implementation and evaluation of such practices and their longer-term effects are warranted.

• Implications for Rehabilitation

• Falls in older adults represent an escalating public health problem, and rehabilitation professionals are charged with developing and/or identifying feasible and effective evidence-based programs that target and reduce falls risk in this population.

• Our findings support Steady Steps as an effective third-sector referral rehabilitation service that successfully translates research evidence-based exercise interventions into effective practice, positively impacting physical function, balance confidence and quality of life (QoL) in community-dwelling older adults.

• Our study provides practice-based evidence of the effectiveness of exercise interventions that are progressively challenging, deliver a high dose of moderate to high intensity and target the main falls risk factors of muscle weakness and gait and balance impairment.

• In spite of their limitations, non-experimental, practice-based approaches provide rehabilitation professionals with feasible opportunities for evaluating existing services, such as Steady Steps, and contributing to the overall evidence-base for falls prevention and management.

     

Association of baseline levels of markers of bone and cartilage degradation with long-term progression of joint damage in patients with early rheumatoid arthritis: the COBRA study

OBJECTIVE: The known risk factors for radiologic progression in rheumatoid arthritis (RA) are not optimally discriminative in patients with early disease who do not have evidence of radiologic damage. We sought to determine whether urinary C-terminal crosslinking telopeptide of type I (CTX-I) and type II (CTX-II) collagen (markers of bone and cartilage destruction, respectively) are associated with long-term radiologic progression in patients with early RA. METHODS: This was a prospective study of 110 patients with early RA who were participating in the COBRA (Combinatietherapie Bij Reumato?de Artritis) clinical trial and followup study, a randomized controlled trial comparing the efficacy of oral pulse prednisolone, methotrexate, plus sulfasalazine with sulfasalazine alone. We investigated the relationship between baseline levels of urinary CTX-I and CTX-II and the mean annual progression of joint destruction over a median of 4 years, as measured by changes in the modified Sharp score (average of 2 independent readers). RESULTS: In multivariate logistic regression analysis, baseline urinary CTX-I and CTX-II levels in the highest tertile were the strongest predictors of radiologic progression (Sharp score increase >2 units/year; odds ratio 7.9 and 11.2, respectively), independently of treatment group, erythrocyte sedimentation rate (ESR), Disease Activity Score in 28 joints, rheumatoid factor (RF), and baseline joint damage (Sharp score). The likelihood ratios for a positive test were 3.8 and 8.0 for CTX-I and CTX-II, respectively, which compared favorably with the likelihood ratios for the ESR (3.0), baseline joint damage (1.6), and RF (1.8). When patients were grouped according to the presence (Sharp score >/=4, n = 49) and absence (Sharp score <4, n = 61) of joint damage at baseline, CTX-I and CTX-II levels were predictive only in those without baseline joint damage (odds ratio 14.9 and 25.7, respectively). CONCLUSION: High baseline levels of urinary CTX-I and CTX-II independently predict an increased risk of radiologic progression over 4 years in patients with early RA, especially those without radiologic joint damage. Urinary CTX-I and CTX-II may be useful for identifying individual RA patients at high risk of progression very early in the disease, before erosions can be detected radiographically. Such patients may be in special need of treatments that inhibit bone and cartilage degradation.     

Evidence for diploidy in metacyclic forms of African trypanosomes.

The DNA contents of bloodstream form trypanosomes (life cycle stages circulating in the blood of the vertebrate host) of four African Trypanosoma species and of metacyclic forms (the life cycle stage that is injected into the vertebrate by the tsetse fly during its bite) of the same four species were measured by cytofluorometry of individual cells or nuclei. The results showed unambiguously that the metacyclic forms cannot be considered to be products of meiosis containing only half of the DNA of bloodstream forms, in contrast to what was previously reported for Trypanosoma brucei [Zampetti-Bosseler, F., Schweizer, J., Pays, E., Jenni, L. & Steinert, M. (1986) Proc. Natl. Acad. Sci. USA 83, 6063-6064] during an attempt to localize the gametes in the life cycle after experimental evidence of sexual gene exchange in this parasite was reported.     

Patients at the outpatient rheumatology clinic: do they really need to be there?

BACKGROUND: The workload at many outpatient clinics within the Dutch health care system has been growing relentlessly, resulting in unacceptable waiting lists and reduced accessibility. Assessing streams of patients and introducing a method of accelerated referral of patients back to the general practitioner (GP) under specialist guidance could help to alleviate these problems. METHODS: Seventeen GPs collaborated with rheumatologists during a 2-year period in a 'joint consultation' model in which GPs and rheumatologists discussed patients together. All patient charts belonging to patients who had been referred to the outpatient clinic by these 17 GPs were identified. Rheumatologists assessed whether or not these patients could be referred back to the participating GPs under the guidance of the specialist in the joint consultation model. RESULTS: Of 276 eligible patients, 121 were discharged from the outpatient clinic. Eighty-seven patients required specialist follow-up, 22 patients refused to participate, and six patients were not entered into the study by the rheumatologist. Some 21 patients eventually entered the study, 18 of whom were referred back to the GP. CONCLUSION: The role of joint consultation appears to be limited. Improving the referral behavior of GPs should take precedence over transferring follow-up from the outpatient clinic to the primary care level.     

Septic arthritis of the pubic symphysis: review of 100 cases

We report a novel case of septic arthritis of the symphysis pubis due to Streptococcus pneumoniae and review 99 previously reported cases of infection of this joint. Typical features of pubic symphysis infection included fever (74%), pubic pain (68%), painful or waddling gait (59%), pain with hip motion (45%), and groin pain (41%). Risk factors included female incontinence surgery (24%); sports, especially soccer (19%); pelvic malignancy (17%); and intravenous drug use (15%). Septic arthritis of the pubic symphysis is often misdiagnosed as osteitis pubis, a sterile inflammatory condition. Causative organisms differed according to risk factors. Staphylococcus aureus was the major cause among athletes, Pseudomonas aeruginosa among intravenous drug users, and infections among patients with pelvic malignancies were usually polymicrobial, involving fecal flora. Patients with recent urinary incontinence surgery usually had monomicrobial infection, with no predominant pathogen. Since osteomyelitis is present in 97% of patients, we recommend antibiotic courses of 6 weeks' duration. Surgical debridement is required in 55% of patients.     

Transient effects of quick changes in myocardial metabolism and perfusion pressure on coronary vasomotor responses

Summary The effects of transient changes in coronary transmural pressure on the coronary vasomotor tone was studied in 23 anesthetized dogs. Increases and decreases of the coronary transmural pressure were obtained by constrictions of various duration (2 to 20 s) of the descending thoracic aorta.The maneuvers were performed in animals with intact cardiac innervation, with the vagi sectioned and with vagal section together with -blockade. In the absence of -blockade the increase in the transmural pressure caused a transient increase in the coronary vasomotor tone attributable to a myogenic contractile response and the extravascular compression. This contractile response was not observed when the transmural pressure was increased in the presence of high vasomotor tone after -blockade. In all animals a transient hyperemia was seen with its peak 8 to 12 s after the release of the aortic constriction. Since its timing and amplitude were independent of the duration of the constriction, the metabolic effect of the increased ventricular afterload, although it may have contributed to the decrease of the coronary resistance, cannot be considered entirely responsible for the hyperemia, which was otherwise compatible with a myogenic vasodilatory response triggered by the sudden fall of the transmural pressure at the release of the constriction.It is concluded that, in the coronary circulation of the intact dog, transient changes in transmural pressure can induce vasomotor responses in which myogenic and metabolic mechanisms combine together in regulating the coronary flow. Changes in extravascular compression can also affect the flow when the experimental maneuver implies changes in the diastolic left ventricular pressure and volume. With the present experimental procedure the myogenic responses have been evidenced when the metabolic factors would have been expected to produce opposite changes in the vasomotor tone.The experiments were conducted according to the ethic protocol indicated by the Italian Government Act DL n. 116 of January 27, 1992 on the protection of animals used in scientific experiments.     

Analysis of temporal requirements for myocardial tissue velocity imaging.

AIMS: Movements of myocardial walls include components of high velocity and short duration calling for a high sampling rate in the acquisition of tissue velocity imaging data. This study aims at establishing the optimal sampling requirements for tissue velocity imaging measurements. METHODS AND RESULTS: In 16 healthy individuals, tissue velocity imaging data were acquired at a frame rate of 141-203 frames/s for a subsequent off-line analysis using software enabling a reduction of the sampling rate to 50%, 25% and 12.5% of the initial frame rate. Different components of the myocardial velocity profile were measured at each of these frame rates. The deviation of the results from the initial values increased markedly at decreasing frame rates, producing an underestimation of peak systolic and diastolic velocities, most other measured parameters being overestimated. A cut-off point for an acceptable < or =10% deviation of the results corresponded to at least 70 frames/s for peak systolic and early diastolic velocity, and to at least 100 frames/s for other systolic and diastolic parameters. CONCLUSION: A high sampling rate is essential for a proper rendering of tissue velocity imaging signals, too low frame rates resulting in inferior accuracy of the results. This should be kept in mind while viewing reported tissue velocity imaging data.     

The prevalence and incidence of clinical and asymptomatic Lyme borreliosis in a population at risk

A past history of clinical Lyme borreliosis and the 6-month incidence of clinical and asymptomatic Lyme borreliosis was studied prospectively in a high-risk population. In the spring, blood samples were drawn from 950 Swiss orienteers, who also answered a questionnaire. IgG anti-Borrelia burgdorferi antibodies were detected by ELISA. Positive IgG antibodies were seen in 248 (26.1%), in contrast to 3.9%-6.0% in two groups of controls (n = 101). Of the orienteers, 1.9%-3.1% had a past history of definite or probable clinical Lyme borreliosis. Six months later a second blood sample was obtained from 755 participants, 558 (73.9%) of whom were seronegative initially; 45 (8.1%) had seroconverted from negative to positive. Only 1 (2.2%) developed clinical Lyme borreliosis. Among all participants, the 6-month incidence of clinical Lyme borreliosis was 0.8% (6/755) but was much higher (8.1%) for asymptomatic seroconversion (45/558). In conclusion, positive Lyme serology was common in Swiss orienteers, but clinical disease occurred infrequently.     

Description of fecal shedding of Cryptosporidium parvum oocysts in experimentally challenged dairy calves

The objective was to describe the probability of Cryptosporidium parvum fecal oocyst shedding at different magnitudes of exposure, the pattern of fecal shedding over time, and factors affecting fecal shedding in dairy calves. Within the first 24 h of life, 36 calves were experimentally challenged with C. parvum oocysts at one of four possible magnitudes of oral exposure (1?×?10³, 1?×?10⁴, 1?×?10⁵, and 1?×?10⁶ oocysts), and 7 control calves were sham dosed. Fecal shedding occurred in 33 (91.7 %) experimentally challenged calves and in none of the control calves. There was a difference in the log-total number of oocysts counted per gram of feces dry weight among the four exposure groups; calves with the lowest magnitude of exposure (1?×?10³ oocysts) shed less than the other three groups. At higher magnitudes of exposure, there was more variability in the range of fecal oocyst shedding. There was an inverse relationship between the log-total amount of oocysts counted per gram of feces dry weight and the number of days to the onset of fecal shedding per calf, i.e., the more time that elapsed to the onset of fecal shedding, the fewer oocysts that were shed. The pattern of fecal shedding over time for all calves shedding oocysts was curvilinear; the number of oocysts increased with time, reached a peak, and declined. Therefore, the dynamics of oocyst shedding can be influenced in part by limiting exposure among calves and delaying the onset of fecal oocyst shedding.