By Karen Garloch, The Charlotte Observer, N.C.

Apr. 4–Boy’s gift links death, life Garrett Terrell’s organ donations

have helped more than 90 people Karen Garloch

Because Garrett Terrell had diabetes, he and his mother, Myra, often talked of the possibility that he might need a pancreas or kidney transplant when he got older.

Instead, in September 2003, Garrett himself became an organ donor.

He suffered a stroke, an unusual complication of diabetes in someone so young. A week later, when doctors in Concord declared him brain dead, Myra Terrell didn’t wait to be asked. She called LifeShare of the Carolinas and offered to donate her son’s organs.

“Garrett was the type of kid who would give you what he had,” Terrell said. “The decision to be a donor wasn’t a hard one. I was just his mouthpiece.”

So far, more than 90 people have benefited from Garrett’s organs, corneas, heart valves, bones and other tissue. And on Monday, his mother got to meet one of them.

“Oh, thank you,” said Cindy Marshall-Hope, the 49-year-old Gastonia grandmother who is living today with Garrett’s liver.

She spoke through sobs as she wrapped her arms tightly around Terrell in the unusual, arranged meeting at Carolinas Medical Center. “I’m so sorry for your loss,” Hope said.

Awkwardly at first, they sat and spoke as nine other people, from LifeShare, CMC and the Observer, watched.

Terrell offered two photo albums full of pictures from Garrett’s short life.

“He’s so handsome,” Hope said, as she turned the pages, learning about his love of Legos and monkeys, his Cub Scout camping trips and his middle-school friends.

“How have you survived?” Hope whispered.

“Day by day,” answered Terrell.

Hope struggled through emotion to say the words she had come to say: “You know I wouldn’t be here today if it wasn’t for your loss. At first I felt real guilty. I struggled with the sympathy for you, but at the same time, I was so grateful that I was going to live. I just thank you.”

Until Monday, the two women hadn’t known much about each other. They had exchanged four letters, always with last names and identifying information deleted by the LifeShare censors.

Custom in the United States is to keep donor families and organ recipients anonymous unless they express the desire to meet. This was the first time in its 35 years that LifeShare had arranged such a meeting, according to spokeswoman Debbie Gibbs.

The timing coincided with Monday’s visit to Charlotte by Reg Green, whose 7-year-old son, Nicholas, was killed in 1994 during a family vacation in Italy. His organs were donated to seven Italians, and the story prompted an international movement in support of organ donation that has been called the Nicholas Effect.

With Green looking on, Terrell and Hope shared details of their lives.

Terrell, a second-grade teacher assistant and bus driver for Weddington Hills Elementary in Concord, introduced her mother, Margaret Terrell. She also brought an 8-by-10 picture of a 2-year-old in Georgia who received one of her son’s heart valves. She hopes to meet him and his parents soon.

Hope, executive director of Gastonia’s Potters House, a Christian home for women who struggle with substance abuse, brought her son, Caleb Marshall, 15, and daughter, Shannon Rollins, 29, and pictures of her two grandchildren. Hope said she dedicated one of her Potters House buildings to Garrett’s memory.

When Garrett died on Sept. 22, 2003, Hope had been waiting four months for a liver transplant.

Her liver was failing due to hepatitis C, a disease she had contracted during 17 years as a heroin addict, Hope said. That addiction ended about 18 years ago, she said, when she became a Christian while in jail. Later, she got a college degree and started the Potters House to help women like herself.

“This affected a whole bunch of people,” Hope said. “The Lord knew what he was doing.”

The women haven’t decided what happens next.

“Do you ride horses?” Hope asked. “I’ve got six horses.”

They talked about going out to eat.

“This is one of those moment by moment things,” Terrell said. “… My circle of friends has just gotten bigger.”

To Become a Donor

— Sign a donor card, witnessed by two people. In the Carolinas, if a brain-dead accident victim is carrying a proper donor card, laws allow doctors to transplant organs and tissue without approval from the donor’s family.– Indicate your desire on your driver’s license. This is not a legal document, but an indication of intent.

— Tell family members about your wishes. Even if you have indicated your wishes on a donor card or driver’s license, it may be family members who give final consent.

More Information

— LifeShare of the Carolinas, (704) 512-3303, www.lifesharecarolinas.org . Provides organ donation services for the Charlotte area, Western North Carolina and York County, S.C.

— South Carolina Organ Procurement Agency, (800) 462-0755..

— Coalition on Donation: www.donatelife.net . Provides organ donation rules for all states.

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Copyright (c) 2006, The Charlotte Observer, N.C.

Distributed by Knight Ridder/Tribune Business News.

For information on republishing this content, contact us at (800) 661-2511 (U.S.), (213) 237-4914 (worldwide), fax (213) 237-6515, or e-mail [email protected].

By McFadden, Kathleen L; Stock, Gregory N; Gowen, Charles R III; Cook, Patricia

EXECUTIVE SUMMARY

The purpose of this study is to explore current strategies for reducing errors at U.S. hospitals. Reports by the Institute of Medicine highlight concerns about the staggering number of medical errors that occur in the U.S. healthcare system. These reports have exerted considerable pressure on hospitals to establish programs that reduce errors and improve patient safety.

A previous research study identifies seven critical strategies for reducing hospital errors based on a case study of four Chicago- area hospitals. These strategies include (1) partnership with stakeholders, (2) reporting errors free of blame, (3) open discussion of errors, (4) cultural shift, (5) education and training, (6) statistical analysis of data, and (7) system redesign. This article reports the results of our nationwide survey of 525 hospitals. We examined the perceptions of healthcare quality directors about the importance of these seven patient safety strategies, the factors that act as barriers, the level of adoption of these strategies, and the benefits resulting from implementation of these strategies.

Our results indicate that a considerable gap exists between current hospital practices and the perceived importance of various approaches to improving patient safety. Results of our regression analysis reveal that internal organizational barriers are associated with a larger gap between perceived importance and actual implementation. Moreover, the regression analysis also reveals that smaller gaps are associated with better error outcomes such as reduction in the frequency and severity of errors. The findings provide specific directions for enhancing patient safety programs at hospitals in the future.

Hospital administrators are currently struggling with the challenges associated with reducing medical errors and improving patient safety. Two reports by the Institute of Medicine (IOM) have served as the catalyst for the heightened awareness of and the immediate need to take action on these issues (Kohn, Corrigan, and Donaldson 2000; IOM 2001). These reports highlight the extent of the problem of errors in healthcare, explore the costs of these errors, and recommend improvements in healthcare delivery. The first report, To Err Is Human, suggests that medical errors account for more than 98,000 deaths per year in U.S. hospitals and that 58 percent of these error-related deaths may have been preventable. It acknowledges that the necessary system improvements require a “concerted effort” on the part of many individuals, from patients to policymakers. These IOM reports, along with the adoption of patient- safety goals by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), have put considerable pressure on healthcare organizations to find ways to reduce medical errors.

A medical error is defined as “the failure of a planned action to be completed as intended (i.e., an error of execution) or the use of a wrong plan to achieve an aim (i.e., an error of planning).” Some medical errors could lead to an adverse event, which is defined as “an injury caused by medical management rather than the underlying condition of the patient.” An adverse event attributable to error is a “preventable adverse event” (Kohn, Corrigan, and Donaldson 2000, 28).

Hospitals across the country are developing strategies for reducing medical errors and adverse events. They are at various stages in the development and implementation of their programs and are seeking to identify best practices. McFadden, Towell, and Stock (2004) used a case study approach (interviewing directors of quality, performance improvement, and risk managers at four hospitals in the state of Illinois) and identified seven strategies critical to the success of reducing hospital errors.

These strategies appear to reduce the likelihood of medical errors or decrease the magnitude of the effects of medical errors.

Our study extends the research by McFadden, Towell, and Stock, collecting input from a nationwide sample of professionals who work directly in the area of quality or risk management at hospitals throughout the United States. The specific objectives of our research were as follows:

1. To examine the extent to which each of the seven strategies are viewed as important in reducing hospital errors

2. To explore the level of implementation of the seven strategies in U.S. hospitals

3. To study the extent to which various factors act as barriers to implementing error-reduction strategies at U.S. hospitals

4. To determine the extent to which benefits have been realized as a result of implementing error-reduction strategies at U.S. hospitals

Prior literature has considered various error-reduction strategies. However, such research typically has examined only a relatively small subset of approaches to dealing with medical errors. This article takes a more systemsoriented perspective to explore how these potential strategies may work together as a coherent approach to reducing errors. Moreover, much of the prior research has been based on small samples or case studies. In contrast, our study is based on data collected from a broad sample of U.S. hospitals, which should yield greater confidence in the validity of its findings.

STRATEGIES FOR REDUCING ERRORS

The literature on patient safety has identified several strategies for reducing errors. In addition, the Agency for Healthcare Research and Quality published an extensive review of practices that appear to reduce the likelihood of adverse events. McFadden, Towell, and Stock (2004) reviewed the literature and derived a list of seven critical strategies, which are summarized below. The common theme that ties these strategies together is an emphasis on the process over the individual.

The first strategy critical to enhancing patient safety is to create a partnership with all stakeholders (Vanderveen 1991; Kumar and Subramanian 1998; Doolan and Bates 2002; Klein, Motwani, and Cole 1998). Stakeholders in a hospital include doctors, nurses, administrators, trustees, and patients. Working collaboratively in organizations to create ideas and test improvements tends to generate effective solutions (Kumar and Subramanian 1998). Creating a partnership with patients and families has also proven successful in improving healthcare processes (Bushell and Shelest 2002). It is important to understand the needs and perspectives of all constituents and to gain the support and commitment of top-level management in this process. Patient safety is a “team sport” that can only be achieved and sustained when all key stakeholders participate and contribute (Hudson 2004).

The second strategy is to develop an effective system for reporting errors without placing blame (Leape 1994; Uribe et al. 2002). Without a systematic method for identifying errors, patient safety is generally doomed to failure. An effective reporting system should be confidential, encourage reporting of errors, be impartial, and ensure no retribution for those reporting. A key factor to increasing the reporting of errors has been to establish trust within the organization (Firth-Cozens 2004). It is also important for error-reporting systems to go beyond the typical medical model of assigning blame when an error is reported and to offer incentives for reporting. A number of studies have examined the role of error reporting systems (see Doolan and Bates 2002; Chiang 2001; Walshe, Bennett, and Ingram 1995; Greene 1999), all of which suggest that the focus should be on the overall process rather than on the person reporting the error (Leape 1994).

The third strategy is to foster open discussions of errors (Klein, Motwani, and Cole 1998; Vanderveen 1991). For example, quality circles, a staple in manufacturing quality management, have been effective in the areas of quality improvement in a number of medical areas (Mullins and Schmele 1993). Small-group participants take part in a variety of exercises that identify risks, define goals, and measure progress. The intent is to foster an environment where individuals feel comfortable with discussing errors and where information and knowledge are shared freely. One study of 29 small rural hospitals in the western United States reports that 87 percent of the hospital staff felt comfortable or somewhat comfortable discussing the topic of medical errors (Cook et al. 2004).

The fourth strategy involves a cultural shift within an organization (Klein, Motwani, and Cole 1998; Ruchlin, Dubbs, and Callahan 2004). A culture is a set of beliefs and values shared by members of the organization. Creating a safety culture in healthcare involves making patient safety the number one priority within the hospital and having the commitment as well as the ability to address patient safety issues. Rather than apply the traditional approach of “naming, shaming, and blaming” when errors occur, a safety culture encourages and supports shared reporting of errors openly in a nonpunitive, positive environment. This means that the culture supports the idea that anyone can make mistakes. This strategy depends on shared values and nor\ms of behavior articulated by top management and translated into effective work practices (Gaba et al. 2003). The impact of culture on organizational performance is well documented in the literature (Johnson 2004).

The fifth strategy is to provide staff with education and training in error-reduction techniques (Becher and Chassin 2001; Huq and Martin 2000). Continuing medical education and training programs involve interventional risk management, which is an approach that can not only promote patient safety but also reduce malpractice lawsuits. Interdisciplinary training on patient safety has proven effective in strengthening healthcare teams and reducing errors (Cook et al. 2004).

The sixth strategy is to conduct statistical analysis on collected data on errors (Becher and Chassin 2001; Walshe, Bennett, and Ingram 1995). Simply collecting data is not sufficient. Quantitative techniques must be used to systematically analyze the data and understand the sources of medical errors (Plsek 1995; Klein, Motwani, and Cole 1998; Ruchlin, Dubbs, and Callahan 1998; Bedard and Johnson 1984). A common practice in hospitals today is training employees in the use of control chart analysis. However, as more comprehensive data are collected about errors, more sophisticated statistical modeling techniques can be employed to analyze more complex relationships and interactions that occur among variables that may be related to medical errors. This is important because research indicates that most errors stem from the interaction of several variables rather than from one underlying cause (Reason 1990; Chassin and Becher 2002).

The seventh strategy is to redesign the system of the process itself. System redesign refers to the implementation of changes in processes within a hospital and can result in improvements in overall quality of care (Leape 1994; Chiang 2001; Newman 1997; Bard 1994). The intent of this strategy is to reconstruct the system so that it is difficult or impossible to make a mistake. However, if a mistake does occur, employees are trained to correct it at the source.

BARRIERS TO ADOPTING ERROR-REDUCTION STRATEGIES

Prior research has also identified a number of factors that act as barriers to the implementation of error-reduction techniques. These barriers tend to fall into two major categories-internal and external. A partial list of internal barriers-those that originate within the hospital and are therefore under the control of individuals (administrators, medical staff, and other stakeholders) within the organization-may include a lack of support from top- level management, a lack of knowledge or understanding of errors, or a lack of resources such as staffing or money (Becher and Chassin 2001; Chiang 2001; Leape 1994; Uribe et al. 2002).

Other barriers to error-reduction strategies have origins that are external to the hospital. Probably chief among these external barriers is the threat of malpractice suits. Malpractice suits can affect both physicians and nurses, so they can represent significant deterrents to reporting of errors (Davis et al. 2002; Chiang 2001; Liang 1999; Becher and Chassin 2001; Fiesta 1998). In addition, cost pressures resulting from managed care have in some cases reduced the level of resources available for hospitals to devote to errors (Kovner and Gergen 1998). Media coverage of errors may also be considered an external barrier to implementation (Coffin 2002; Ceniceros 2002).

METHODOLOGY

This study employed a survey methodology to collect data on perceptions regarding the seven main strategies for reducing hospital errors. We used the directory of hospitals in the United States contained on the web site Hospitallink.com to obtain a list of hospitals to survey. This web site contains a fairly comprehensive list, including approximately 6,000 U. S. hospitals. From various links on the web site, we were able to obtain the addresses and telephone numbers for most of the hospitals. Items in the questionnaire were based on the relevant literature. The hospital questionnaire was pretested in a pilot survey sent to several quality directors in the Chicagoland area. Telephone interviews were also initially conducted to improve the clarity of the survey and reduce any ambiguity of the questions. Input from all these groups was incorporated into the final survey design.

We sent surveys via e-mail to a random sample of 930 hospitals. We stratified the sample based on geographic region to increase the generalizability of the findings. All 50 states were represented among the respondents; a breakdown of hospital respondents by region can be found in Figure 1. Typically, the title of those completing the survey was director of quality, director of performance improvement, director of safety, or risk manager. By contacting the hospitals by telephone first, we were able to ensure that the survey was e-mailed to the appropriate person.

FIGURE 1

Distribution of Respondent Hospitals by Region

Out of a total of 930 questionnaires e-mailed, 525 completed questionnaires were received, yielding a response rate of 56 percent. The average size of the hospitals responding was 155 beds. The number of physicians employed at these hospitals averaged 193, and on average the hospitals dedicated three full-time equivalent (FTE) employees to work on quality or risk management. In addition, 72 hospitals reported they were teaching hospitals. We asked respondents to provide information about both the perceived importance and level of implementation of the seven error-reduction strategies described earlier. Respondents also rated the levels of barriers to implementation as well as positive outcomes associated with these error-reduction strategies. The use of self-reported measures has been used and validated by previous researchers. For instance, Ward, Leong, and Boyer (1996) report that organizations are typically reluctant to share performance data because of confidentiality issues. Nonetheless, these researcher found a high correlation between objective data and perceptive performance measures. We used Harman’s one-factor test to check whether common method bias was present (Podsakoff and Organ 1986). Multiple factors were extracted, and the first factor did not account for a majority of the variance, suggesting that common method bias is not a significant influence on the results.

RESULTS

Descriptive Statistics

Table 1 provides the means and standard deviations for the perceived importance and implementation of the seven error- reduction strategies. Given that a score of 3 equates to medium importance, all strategies were viewed as highly important or important in reducing hospital errors (overall mean = 4.46). However, respondents reported only a moderate level of implementation of these strategies at their hospital (overall mean = 3.49). Respondents indicated the top three most important strategies were ( 1 ) reporting errors without blame, (2) developing a partnership with stakeholders, and (3) cultural shift. The three strategies with the highest implementation scores were ( 1 ) reporting errors without blame, (2) developing a partnership with stakeholders, and (3) education and training. The three strategies with the largest gaps between what respondents viewed as important and what strategies were actually implemented were (1) cultural shift, (2) system redesign, and (3) developing a partnership with stakeholders.

From the observed difference in the importance and the actual implementation of these strategies, we can infer that barriers to implementation may exist. Table 1 also provides descriptive statistics related to the extent to which the respondents viewed barriers to implementation of error-reduction systems. The most highly rated barrier was lack of resources (e.g., staffing, money), but it was only a “moderate” barrier to implementation (mean = 3.36).

Although the literature has identified several strategies for reducing errors, little evidence has been presented on the effectiveness of these strategies. Therefore, we wanted to determine to what extent the hospitals in the survey perceived benefits from implementing error-reduction strategies. Our findings indicate that the hospitals reported a moderate level of heightened awareness of errors, increased understanding of errors, improved quality, enhanced customer satisfaction, and reduced impact and frequency of errors. Mean and standard deviations of these outcomes are listed in Table 1.

Regression Analysis

These descriptive statistics present a summary of error- reduction strategies, barriers, and outcomes in U.S. hospitals. However, descriptive statistics do not show how these factors may be related. As we noted, the substantial gap between the perceived importance and actual implementation of errorreduction strategies suggests that barriers to implementation may be present in these hospitals. Our discussion also suggests that a smaller gap between importance and implementation may lead to better error-reduction outcomes. We now present results of additional analysis that investigates these proposed relationships.

We used principal components analysis (PCA) to reduce the large number of questionnaire items to a manageable number to be used in the regression analysis. (Details of the PCA are not reported here but are available from the authors upon request.) The results of the PCA showed that the questionnaire items actually represented a smaller set of underlying constructs. In particular, the PCA showed that the importance of the individual error-reduction strategies represented a single underlying factor; similarly, the implementation of the individual error-reduction strategies also represented a single factor. Therefore, we constructed a single overall variable representing the gap (referred to as GAP in the regression analysis) between perceived importance and actual implementation by subtracting the averageimplementation score from the average importance score for each hospital. In addition, the barriers to implementation loaded on three different factors. One of these factors represented barriers arising from sources external to the hospital (BARREXT), while the other two factors were associated with barriers arising from internal sources (BARRINT1 and BARRINT2).

TABLE 1

Questionnaire Variables

In addition, we also considered that quality managers in these hospitals likely have already been implementing more traditional quality management techniques such as benchmarking, quality teams, customer service evaluations, and statistical quality control. The PCA showed that these four techniques together represented a single quality management factor (QUAL_MGT). Finally, the PCA also showed that the set of error-reduction outcome items represented two constructs. The first factor could be interpreted as operational outcomes such as reduction in error frequency, cost savings, and reduction in error severity (OUT_OPER). The second factor may be interpreted as knowledge-related outcomes and include increased knowledge of errors and increased awareness of errors (OUT_KNOW). We also were interested in finding out whether certain hospital characteristics were related to error reduction; therefore, we also included the number of doctors (DOCS), the number of beds (BEDS), the number of full-time equivalent employees involved in error- reduction efforts (FTE), and the teaching status of the hospital (TEACH). Table 2 lists the variables used in the regression analysis and the individual questionnaire items comprising each variable.

The regression analysis results are available online at www.ache.org/pubs/jhmsub.cfm. Three regression models were estimated. In the first model, the gap between error-reduction importance and implementation (GAP) is the dependent variable. The results show that higher levels of the two internal barriers (BARRINT1 and BARRINT2) are associated with a larger gap, which is what we would expect. However, the external barrier variable is not statistically significant, which is surprising. Also, greater use of traditional quality management approaches (QUAL_MGT) is associated with a smaller gap, as is a greater number of FTEs involved in error- reduction efforts. Teaching hospitals (TEACH) are also associated with a smaller gap. What is somewhat surprising is that a higher number of doctors (DOCS) are associated with a larger gap. In the second and third regression models, error-reduction outcomes (OUT_OPER and OUT_KNOW) are the dependent variables. A larger gap between importance and implementation (GAP) is associated with lower levels of both operational and knowledge-related outcomes (OUT_OPER and OUT_KNOW). Also, greater use of traditional quality management techniques is associated with better outcomes in both models. Finally, a higher number of doctors (DOCS) are associated with better knowledge-related outcomes.

DISCUSSION

Interest and concerns in the area of patient safety and medical errors have accelerated in the last decade. Despite the challenges, our study indicates that U.S. hospitals are currently making excellent progress toward implementing strategies that enhance patient safety and reduce medical errors. On average, quality directors report at least a moderate level of implementation of all seven error-reduction strategies at their hospital. However, our results also reveal that a considerable gap exists between current hospital practices and the perceived importance of the various approaches. This indicates that there is room for improvement. Moreover, the results also show that reducing this gap will lead to better error-reduction outcomes.

TABLE 2

Regression Variable Descriptions

TABLE 3

Gap and Priority Scores of Importance Versus Implementation of Error-Reduction Strategies

While this study found the most popular technique for reducing errors is to develop reporting systems free of blame, fewer hospitals are statistically analyzing the data collected through reporting or not redesigning their systems based on the data. Our research indicates that we also have a way to go until a culture of safety is the norm in U.S. hospitals. We therefore wonder which of the seven strategies should receive the highest priority to target for healthcare reform. Consistent with the works of Meier and colleagues (1999) and Meier, Williams, and Humphreys (2000), we identified the highest priority strategies by considering both the gap scores and the importance scores, where strategies with both high importance and large gaps would receive the highest priority.

First, the raw mean scores of importance and implementation were multiplied by 20 to obtain a transformed score ranging from O to 100. Then a transformed gap score was calculated by subtracting the transformed implementation from the transformed importance. Finally, the priority score was calculated by averaging the transformed gap score and the transformed importance score. The results of this analysis are found in Table 3, which shows the order hospitals should use to prioritize the seven error-reduction strategies for future healthcare improvements. Hospitals should make creating a cultural shift toward patient safety a top priority. The second highest priority should involve developing a partnership with all stakeholders, followed by creating a reporting system free of blame.

Although developing priorities for system improvement is important, this study also highlights the need to focus on a comprehensive systems approach to safety. The systems approach to safety involves creating a safety culture with collaboration from all stakeholders of the hospital. The new culture should be one in which everyone feels comfortable and safe to discuss and learn from errors. An effective reporting system without blame should be put in place to discover sources of errors. The data obtained from both the reporting and discussing of errors should then be analyzed using appropriate statistical methodologies. Education and training should be implemented based on the findings of the data analysis. Finally, system redesign of processes is essential to effective error reduction.

Our research also shows that hospital managers should work to reduce internal barriers in their organizations, as doing so leads to a reduction in the gap between importance and implementation of error-reduction strategies. A lack of resources appears to be the primary barrier to implementation of effective strategies, followed by a lack of knowledge and understanding about errors. We suggest future research into how to bring about these sorts of organizational changes.

These findings provide insight into a very important issue of national and international importance. From a practical perspective, the results can be used as a guide to aid hospital administrators in designing more effective error-reduction systems. JCAHO has placed a strong emphasis on patient safety. Hospital accreditation has been increasingly tied to intervention and prevention of hospital errors. It is imperative that hospitals develop effective solutions to reduce medical errors to strengthen the quality of patient care nationwide.

PRACTITIONER APPLICATION

Patricia Cook, FACHE, director, Corporate Compliance and Quality, St. Anthony’s Medical Center, St. Louis, Missouri

Quality, risk, and compliance managers struggle with the question of reducing errors and even the more basic question of what constitutes an error. Much has been written since the Institute of Medicine’s publications in 2000 and 2001 about areas of highest risk, solutions to those concerns, and the bigger question of how to create a culture of safety within the hospital. The authors report a gap between recommendation and reality that is very real. The good news for healthcare is that the gap is being addressed daily in hospitals across the country through the formation of active and aggressive patient safety committees and development of performance improvement programs at the staff and unit levels.

Patient safety initiatives, such as The Leapfrog Group, the Institute for Healthcare Improvement’s 100k Lives campaign, and state and federal quality programs, have allowed facilities to focus on processes and systems that improve care and reduce both risk and errors. Many of these initiatives have also fostered partnership within facilities, putting together staff who would not have worked previously on issues and creating real and effective system redesign. As a result, we see improved education and training opportunities for staff.

The authors propose that one of the external barriers to error- reduction strategies is the threat of malpractice. That is not consistent with my experience. Rather, I find that employees are reporting errors that may result in a malpractice suit and are seeking information and assistance from risk management in how to proceed with the patient, family, and physician in resolving the issue in a timely, just, and fair manner. There is concern, however, about the initiatives that are calling for reporting of errors through a public data source. A report that aggregates errors by type of hospital may result in an increase in suits filed based on public information and may internally cause a decrease in reporting.

The use of benchmark data available from recognized external sources is helpful as well as hospitals collecting and analyzing data internally and, more importantly, sharing that data with senior leadership and board members. Such sharing will position hospitals to deal more effectively with allocation of resources in future budgets. Although there is no one-size-fits-all approach to bringing about change in an organization, this research assures hospitals that we are on the right road to transforming ourselves into quality organizations with actively functioning patient safety progra\ms that foster partnership, safe systems, and open dialog.

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Podsakoff, P. M., and D. W. Organ. 1986. “Self-reports in Organizational Research: Problems and Prospects.” Journal of Management 12 (4): 531-44.

Reason, J. 1990. Human Error. Cambridge, England: Cambridge University Press.

Ruchlin, H. S., N. L. Dubbs, and M. A. Callahan. 2004. “The Role of Leadership in Instilling a Culture of Safety: Lessons from the Literature.” Journal of Healthcare Management 49 (1): 47-59.

Uribe, C. L., S. B. Schweikhart, D. S. Pathak, G. B. Marsh, and R. R. Fraley. 2002. “Perceived Barriers to Medical-Error Reporting: An Exploratory Investigation.” Journal of Healthcare Management 47 (4): 263-80.

Vanderveen, L. 1991. “CQI System Puts Process into Improving Hospital.” Health Care Strategic Management 9 (2): 16-18.

Walshe, K., J. Bennett, and D. Ingram. 1995. “Using Adverse Events in Health-care Quality Improvement: Results from a British Acute Hospital.” International Journal of Health Care Quality Assurance 8 (1): 7-14.

Ward, P. T, G. K. Leong, and K. Boyer. 1996. “Manufacturing Proactiveness and Performance.” Decision Sciences 25 (2): 99-116.

Kathleen L. McFadden, Ph.D., professor of operations management, Department of Operations Management and Information Systems, Northern Illinois University, Dekalb, Illinois; Gregory N. Stock, Ph.D., associate professor of operations management, Department of Operations Management and Information Systems, Northern Illinois University; and Charles R. Gowen III, Ph.D., professor of management, Department of Management, Northern Illinois University

For more information on the concepts in this article, please contact Dr. McFadden at [email protected].

Copyright Health Administration Press Mar/Apr 2006

By ED SUSMAN

Doctors say they can kill off cancers in the liver by sending millions of microscopic radioactive glass beads into the tumor in a procedure that can be offered on an out-patient basis.

The microspheres of yttrium-90 — that have a diameter of one fifth the size of a human hair — are infused into the main artery of the liver through a catheter. The beads emit radiation directly into the tumor, effectively killing it while limiting harm to healthy tissue.

The procedure requires just a small incision in the leg where the catheter is inserted. Doctors then use imaging techniques to guide the catheter through the blood vessel system until it reaches the tumor site and the beads are released.

Yttrium-90 microspheres are the new kid on the block in fighting liver cancer and cancers that have spread to the liver, Robert Vogelzang, professor of medicine at Northwestern University Feinberg School of Medicine in Chicago, told United Press International Monday.

Numerous groups around the world are developing use of the microspheres which are approved for treatment in the United States. However, researchers reporting early results with the beads caution there is a learning curve associated with their use.

At the annual meeting of the Society for Interventional Radiology in Toronto, Canada, German doctors said the use of the microspheres appears to reduce the size of the tumors and may extend survival.

Tobias Jakobs, an interventional radiologist at the Institute of Clinical Radiology, Ludwig Maximilians University, Munich, said ‘Selective Internal Radiation Therapy is a valuable palliative treatment option in a very carefully selected patient population.”

He reported on 39 patients with liver metastases who were treated with yttrium-90 microspheres, in one of several discussions at the meeting of the use of the evolving treatment with the anti-cancer product. While the goal of the study is palliative – that is, to relieve symptoms but not necessarily to improve the chances of survival in patients in which cancer has spread to the liver — Jakobs suggested that our data show there is a tendency for a survival benefit.

In more than half of the patients, Jakobs said there was an objective response — meaning that the size of the tumor had been decreased by at least 50 percent.

However, Jakobs said that there was a learning curve in using the microspheres most effectively. He acknowledged that patients treated later in his work fared better than the first patients he treated. Other researchers said they had the same problems – most often using too many of the beads and having unwanted side effects.

Reduction of the recommended dosage maintained killing effect of the beads on the tumors, but reduced the adverse effects, they agreed.

The impact of the microspheres on the tumors appears to be long-lasting. Riad Salem, director of interventional radiology at Northwestern University, said the treatment appears to control the malignancies for at least two years in low-risk patients.

Salem enrolled 140 patients — 106 men and 34 women — into a study using the microspheres, 238 administrations of the particles. He divided patients into high-risk and low risk individuals based on standard classifications of patients. The low risk patients survived a median of 800 days compared to 258 days for high risk patients — a difference that was statistically significant.

This treatment with these microspheres appears to represent an efficacious therapy with acceptable toxicity, Salem said. Survival data in liver cancer is promising. He said 34 percent of the patients achieved at least a 50 percent reduction in the size of the tumors.

Yttrium-90 appears to be a very, very promising treatment modality in patients with liver cancer, said Janette Durham, professor of radiology at the University of Colorado Health Sciences Center, Denver, told UPI.

She also noted that there is a learning curve, but it appears to be a powerful new instrument in treating inoperable liver tumors.

Vogelzang said doctors have tried numerous treatments for liver cancer and cancers that spread to the liver. Over the years alcohol, and chemotherapy drugs have been directly infused into the liver. Other minimally-invasive, imaging guided treatments have included freezing tumors with devices that turn the tumors into ice, and other devices such as radiofrequency heat the tumors to kill them. He said the liver, because it is highly accessible by blood vessels and catheter-based treatment, may not need open surgery in cancer.

Yttrium-90 is the newest way of finding ways to destroy the cancer without major surgery, he told UPI. I think that open surgery for any treatment in the liver will be overtaken by these less invasive treatments.

By Jon Hurdle

ATLANTIC CITY — Merck & Co. concluded its defense of the latest Vioxx product-liability trial on Monday, saying that two men who blame the withdrawn pain drug for their heart attacks had a series of pre-existing health problems that caused their attacks.

Christy Jones, lead attorney for the drugmaker, said in closing arguments that both plaintiffs had serious coronary blockages that had been building up for years, and that those were responsible for the heart attacks.

“Both of these men had serious, severe coronary artery disease,” Jones told the jury. “That’s what caused the plaintiffs’ heart attacks.”

At the end of the closely watched Vioxx trial — the first to involve long-term users of the drug — Jones also rejected arguments by the plaintiffs’ attorneys that Merck had ignored the heart risks of Vioxx because it put profits before safety.

She said the company’s top scientists, including Dr. Briggs Morrison and Dr. Alise Reicin, both of whom testified during the trial, had gone to work for Merck because they wanted to find cures for serious diseases.

Jurors were being asked by plaintiffs’ attorneys to accept that, in developing the arthritis and pain medicine, people like Morrison and Reicin had suddenly become dominated by the desire to make money, Jones said.

“It’s not just that they put profits before safety. It’s that at the time they joined Merck they suddenly didn’t care any more. It means that Merck somehow duped doctors all over the country into prescribing the drug,” Jones said.

The plaintiffs are Thomas Cona, 60, of Cherry Hill, N.J., and John McDarby, 77, of Park Ridge, N.J., who both took Vioxx for more than 18 months before it was withdrawn.

Attorneys for Cona and McDarby are scheduled to give their closing arguments on Monday afternoon. The jury is expected to begin deliberating on Tuesday.

Merck voluntarily pulled the $2.5 billion-a-year drug from the market in September 2004 after a study showed it doubled

the risk of heart attack and stroke among people who used it for at least 18 months.

The plaintiffs say Merck knew the drug was dangerous years before its withdrawal, and continued to sell it because the company placed profits above safety.

Merck says it thoroughly tested the drug before and after it was approved by regulators.

During the trial, the jury of six women and two men heard that Merck was facing a decline in revenue because patents were expiring on a number of its other drugs, and it was looking for a “blockbuster” drug that would generate at least $1 billion a year in sales.

Merck faces almost 10,000 lawsuits over Vioxx, around half of which are filed in the company’s home state of New Jersey.

In six trials around the country, Merck has so far lost only one, in which a Texas jury awarded $253 million to the widow of a Wal-Mart worker who had used the drug. The widow was represented by Mark Lanier, who represents Cona in the current trial.

(Additional reporting by Bill Berkrot in New York)

By Layman, Elizabeth J; Bamberg, Richard

Health care employers of allied health personnel and the academic programs producing these professionals have had to cope with an environment of major changes and ongoing turbulence. To better understand the descriptions of and research on the health care environment in relation to strategic typologies, an integrative literature review was conducted. Drawing from multiple disciplines, the information presented offers potential models and approaches to assess and respond to a turbulent health care environment for both schools of allied health and allied health practice sites. The integrative literature review revealed that innovation can enhance profitability if not pursued with fragmentation of an organization’s core identity. Prospector and analyzer approaches appear to offer greater viability in a turbulent health care environment than reactor or defender types. Differentiation of services can be pursued to produce a unique reputation for a health care organization. J Allied Health 2006; 35:50-60.

STRATEGIC PLANNING is a key responsibility of leadership. Survival in a turbulent health care environment depends on skills in strategic management.’ Reflecting this view, more than 90% of leaders of schools of allied health rated strategic planning as an important or very important skill for deans.2 This skill becomes more important as business and corporate models are adopted and used in higher education.

The disciplines of allied health are positioned at the intersection of two industries with turbulent environments: health care and higher education. The health care environment has been described as turbulent.1,3 Other similar terms include uncertain, hyperturbulent, and unstable.4-6 These descriptions of the environment are derived from and build on the classic research of the 1950s through the 1970s.7-14 As a whole, higher education has faced boom and bust financing in past decades.15,16 In particular, allied health education has faced waxing and waning workforce needs, unevenly distributed across its academic programs.17 Selecting the appropriate strategy to cope with these turbulent environments is the responsibility of leadership in practice and in the academy.

Allied health practitioners across allied health practice sites in the continuum of care and academic leaders in schools of allied health can benefit from an understanding of the concept of environment. First, consultants and executives justify various goals and strategies in terms of environmental factors or changes in the environment. Grasping the underlying body of knowledge will help allied health practitioners and academic leaders to either successfully refute the consultants’ recommendations or to implement the executives’ strategic directives. second, applying the concept of environment will benefit practitioners and academic leaders in their managerial roles as they develop goals and strategies for their own departments or units. Third, because the supply and demand for allied health professionals varies over time and across health care sites, allied health professionals must be particularly savvy and alert as they manage their careers and position themselves for long-term staying power. Finally, as a prcis on the environment and its effect on health care organizations, this report serves as a means to individual leadership development.

Through an integrative review of the literature, this article provides ( 1 ) an overview of the health care environment over the past 20 years and a synopsis of the current environment for allied health education, (2) a summary of strategic typologies, including those used in health care, and (3) an outline of the outcomes of strategic choices with an emphasis on the turbulent environment of health care. The report closes with recommendations distilled from the literature.

Health Care Environment

Industrial and historical context are important to understand the health care environment. As Starbuck and Mezias note, “Someone from an industry that has been growing 3% per year might classify 10% as dynamic, while someone from an industry that has been growing 30% per year might regard 10% as static.”18 Therefore, explicitly anchoring this report within the industry and history of health care is meaningful.

TABLE 1. Theories of the Organizational Environment: Contributions of the Classicists

“Turbulence exists when changes faced by an organization are nontrivial, rapid, and discontinuous.”19 According to Achrol, short cycles of technological innovation and obsolescence and the explosion of knowledge drive turbulence.20 Based on these factors, most theorists characterize the world’s environment as turbulent and predict increasing turbulence.20,21 With 1981 as the demarcation line, Beekun and Ginn, using Emery and Trist’s typology, categorize the health care environment of the 1970s as “placid-clustered” and the 1980s as turbulent.10,22 Other researchers and theorists agree that the 1980s began the period of turbulence.23-25

Four macrodynamic trends in health care were the basis for this turbulence.22’26 The trends are (1) sociocultural (wellness, self- care, and consumerism), (2) technological (shorter life cycles, higher costs, and rapid obsolescence), (3) economic (the diagnosis- related group [DRG] payment system, cost cutting, and managed care), and (4) competitive (women’s clinics, urgent care centers, and competition).26 Turbulence is not uniformly experienced across the continuum of care. For example, turbulence began in the hospital industry with the implementation of the DRG payment system; a more recent implementation of a prospective payment system in the home health industry may similarly change its environment.27

Continued changes in health care financing, organization, and delivery increased the level of turbulence and uncertainty in the 1990s1,28,29 and 2000s.30-32 Friedman and Goes describe this turbulence for health care organizations as “unremitting.”31 As early as 2000, Rotarius and Liberman characterized the environment of health care as hyperturbulent.5 Scientific process, however, requires a systematic assessment against criteria derived from environmental typologies.

Allied Health Academic Environment

Schools of allied health face the additional challenges of the environment of higher education. Recent years have seen calls for accountability, as well as the ongoing cycles of public financing based on recession and prosperity.15,16 Edgerton, former deputy director of the Fund for Improvement of Postsecondary Education and past president of the American Association of Higher Education, emphasizes the transitory nature of leadership in higher education and the ongoing difficulties that problem presents.33 Another challenge is the shifting mix of allied health professionals in health care.34 Workforce needs are not uniform across allied health professions, sectors of the continuum of care, and geographic areas.17 Workforce needs affect numbers of students in academic programs and their subsequent job placement rates after graduation. Finally, it is perceived that the factors in the environment of health care have restricted the ability of academic programs to place students in sites for clinical education.35 The complexity of these situations increases the environmental turbulence for schools of allied health.

Major Environmental Typologies

The environment is the “totality of physical and social factors that are taken directly into consideration in the decision-making behavior of individuals in the organization.”8 Jurkovich elaborates that external environment is the “total set of sectors outside the organization which, in turn, is a role cluster bound together by a set of rules that prescribes behavior and establishes sanctions when rules are violated.”36 The external environment has been further delineated into the source of impact and the nature of impact.37 The contributions of the early researchers in the 1950s through the 1970s are listed in Table 1.7-14 These researchers hypothesized that a fit should occur between an organization and its environment.

Subsequent theorists and researchers expanded the work of the early environmental researchers. These expansions may prove fruitful for researchers in the allied health sectors of health care and the academy. For the hyperturbulent environment, in 1984, McCann and Selsky extended Emery and Trist’s typology from four environments to five.21 The fifth type is the “partitioned environment” in which “complexity and change exceed the collective adaptive capacity” of organizational members.21 Partitioning is the segmenting of the environment to better secure scarce resources and skills. Partitions can be based on geography, community, or human competencies. Most recently, in 2000, Zajac et al. proposed a model of dynamic strategic fit based on data from a turbulent period in the financial industry.38 Four quadrants of strategic change are derived: (1) beneficial strategic change, (2) insufficient strategic change, (3) excessive change, and (4) beneficial inertia. The first and fourth quadrants produce dynamic fit, while the second and third produce dynamic misfit. Of the “fit” quadrants, beneficial change was better in terms of performance than inertia. Of the “misfit” quadrants, excessive change was better in t\erms of performance than insufficient change.

It is incumbent on the researcher to specify the typology because, while the concept of environment is “easy enough to grasp intuitively, it has been given numerous definitions.”19 Moreover, researchers need to identify the typology because the meanings associated with terms vary by typology. For example, Burns and Stalker provide no definition of “stable,” apparently defaulting to the dictionary’s meaning.9 On the other hand, Jurkovich uses the language of “stable,””unstable,” and “instability” to refer to the predictability of variables: “both the value of important variables- independent and intervening-and the kinds of relevant variables in the set are changing unpredictably.”36 Clarity demands specification and definition.

Major Strategic Typologies

Typologies of organizational strategies have been developed through work with specific industries40,41 or environments42-44 or from consideration of generic activities.45,46 Some typologies were developed particularly in the health care industry.1,47,48 Table 2 summarizes the strategic typologies. Strategic typology aligns technology, structure, and process to the organization’s market.49

Research on Outcomes of Strategic Choices in Health Care

The research using strategic typologies identifies strategic responses that allow health care organizations to adapt to the turbulent environment (Table 3). The research also identifies problematic responses that diminish organizational performance and jeopardize survival. Miles and Snow’s typology is the most commonly used.

Miles and Snow describe 3 viable strategic approaches. (1) Prospectors are innovative and flexible, researching and exploiting new products and market opportunities. (2) The main trait of defenders is stability by offering only a limited range of products aimed at a narrow segment of the market. (3) Analyzers, who are a hybrid of types 1 and 2, use a stable core of services for profit and sustenance and monitor trends for selective entrance into new services where the institution may have a competitive advantage.40 The fourth approach, reactors, is a failure for long’term, strategic success due to inconsistencies in strategy, technology, structure, and process.

Using Miles and Snow’s typology, Beekun and Ginn studied hospitals’ shifts in strategies over time as the environment became turbulent.22 Chief executive officers (CEOs) of 76 acute care hospitals in the Northeast self-assessed their strategic types. The researchers found that “defenders decreased from 17 hospitals to 7, and reactors dropped from 13 to 6; prospectors increased from 22 to 30, and analyzers increased from 24 to 33.”22 Furthermore, the researchers concluded that the choice of strategy affected the closeness of the linkage between both internal functional areas and between the organization and external elements.22

Ginn also used Miles and Snow’s typology to examine the strategic choices of acute care hospitals in Texas during a turbulent period.23 Classifying 77 hospitals into strategic types, the researcher used both external assessment and self-typing. “Defenders were the most prevalent type in the period from 1976 through 1980. . . . Analyzers were the most prevalent type in the period from 1980 through 1985. … This shift was accomplished primarily by the movement of defenders to analyzer and prospector strategies, and not by some random shifting of all strategy types.”23 Moreover, in this study, prior strategy was the only predictor of strategy change; type of ownership, system membership, and size were not predictors.

Forte and Hoffman also used Miles and Snow’s typology in a single state, Florida, to assess the strategic actions of acute care hospitals.50 The researchers analyzed archival data (1981-1990) from the American Hospital Association and the Florida Hospital Cost Containment Board. The performance measure comprised several financial indicators (total margin, operating margin, total revenue relative to adjusted patient days, ratio of net operating revenue to the total number of beds, and percent occupancy). Both before and after the environmental shift, prospectors and analyzers had higher performance scores than reactors and defenders. Moreover, reactors who changed to prospectors performed better than reactors who did not change.

In 2003, Castle reported on his investigation of the strategic choices of nursing home facilities in five states.51 Data collection occurred in a changing environment after federal regulatory reforms to the nursing home industry were made. Using a questionnaire, 416 nursing facility administrators self-typed their organizations by the Miles and Snow strategic types. Of these facilities, 17% were prospectors, 25% defenders, 31% analyzers, and 27% reactors. The prospector orientation was generally associated with the highest quality outcomes in terms of low rates of physical restraint, urethral catheterization, and pressure ulcers. Based on results from a similar study of proprietary nursing homes in the early 1970s,52 Castle theorized that the “poor performance of nursing facilities in the past” was attributable to their orientations as analyzers or reactors.51

TABLE 2. Strategic Typologies

In 1994, Dansky and Brannon surveyed a sample of executives of home health agencies in 11 states.53 They used a researcher- designed variation of Miles and Snow’s framework. With a usable response rate of 34%, the researchers concluded that the analyzer orientation significantly predicted commitment to quality improvement, after controlling for degree of bureaucracy, ownership, size, and affiliation.

Shortell et al. examined strategic adaptation processes in turbulence.54,55 They compiled data from eight leading hospital systems composed of 366 hospitals in 45 states. Findings showed that hospitals changed their strategies from 1985 to 1987 in response to changes in the environment in nonrandom ways, most often influenced by their prior strategy.55 At both time points, analyzers and prospectors were the most common strategic types. In terms of numbers, the prospectors showed the greatest gain and the analyzers the greatest loss between the time points. Prospector hospitals operated in communities with the highest number of physicians per capita and the greatest population growth. This munificent environment attracted competitors; thus, prospectors faced the greatest degree of competition in their local markets. Defender hospitals were found in the least munificent environments with a higher percentage of their population below poverty level and fewer physicians per capita. Defenders faced the most regulated environment, while the environment of analyzer hospitals was not particularly competitive. The researchers theorized that this relatively noncompetitive environment allowed analyzers time to monitor trends and selectively develop new services. Reactor hospitals faced both stringent regulation and stiff competition, which may have prevented consistent formulation and implementation of strategy. All four strategic types had similar volumes of charity care, although consistent with their location, defenders provided the most charity and uncompensated care. In terms of financial indicators, prospectors were significantly more profitable and had a greater share of the market.54 Finally, for the future, the researchers “found a continuing shift toward analyzer and prospector orientations and away from the defender.”54

TABLE 3. Summary of Health Care Outcomes of Strategic Typology

Green et al. focused on 135 small to medium U.S. hospitals in a turbulent environment.56 These researchers modified Dess and Davis’ refinement of Porter’s typology, resulting in 28 competitive methods more aligned to the language of health care.56,57 Four strategic action orientations based on the 28 competitive methods were identified.

1. Strategic analyzers are externally focused. The unifying concept under this orientation is their “emphasis on strategic awareness” through offensive, proactive competition.56

2. Quality providers are internally focused. This orientation is characterized by the phrase “quality through highly skilled employees” and total quality assessment.56

3. Price negotiators are externally focused. These hospitals emphasize innovative pay practices, such as incentive-based programs, to lower labor costs and have “little regard for overall efficiency.”56

4. Cost-efficiency providers are internally focused. These hospitals focus on operational efficiencies but do not develop services or forecast future needs and, consequently, may lose sight of changing consumer needs.56

Lament et al. used Porter’s typology in the discontinuous environment (i.e., major upheavals) of acute care hospitals.45,58 The sample was 172 general, acute care hospitals in one state. The researchers examined objective data from the American Hospital Association and a state cost-containment publication. The researchers concluded that aligning strategy to the environment results in higher performance.58 Specifically, in discontinuous environments, Porter’s differentiation strategy will be associated with higher performance than will other strategy types.58

Kumar et al. conducted a large study on management practices in hospitals from which they were able to report on several phases.48,59,62 They used Porter’s typology,60 their own typology with two strategic approaches derived from Porter’s typology,48 and another Porter-derived typology derived by another group of researchers.61,62 Kumar et al. used Miles and Snow’s measure of external environment, modified for the hospital environment.60’62 The researchers surveyed hospital CEOs using random samples generated from the American Hospital Association’s list of hospitals. Findings from this research group’s various studies are described below.

Hospitals’ activities in environmental scanning vary across fou\r taxonomic groups: neophytes, inadequates, incompletes, and sophisticates.59 The groups are based on the presence of a comprehensive information system for scanning data and the hospitals’ abilities to collect and store scanning data, obtain market data, evaluate efficacy of new services, monitor customer satisfaction, and use scanning data in strategic planning. Environmental scanning of sophisticates is associated with significantly higher performance in terms of occupancy, expenditures, and payroll than environmental scanning of neophytes, inadequates, and incompletes.59

Hospital administrators adopting the cost leadership strategy perceive greater uncertainty related to the environmental sectors of suppliers and government/regulatory bodies.60 Those adopting the differentiation strategy perceive greater uncertainty in the sectors of customers and competitors.60

In an environment of high uncertainty in the sectors of competitors, customers, and finances, the differentiation strategy is associated with perceived superior performance in terms of return on capital, retaining customers, and controlling expenses.61 In an environment of low uncertainty, the cost leadership strategy leads to superior performance.61 Uncertainty in the sectors of suppliers and government/regulatory bodies is particularly associated with loss of viability of the cost leadership strategy.61

Hospitals with a market orientation demonstrate superior performance in terms of return on capital, success of new services, and success in controlling operating expenses.62 This outcome is strengthened in environments with high market turbulence and competitive hostility.62

Hospital administrators who perceived a stable and predictable environment were more likely to pursue an efficiency-oriented strategy, while administrators who perceived a dynamic and unpredictable environment were more likely to pursue a market- focused strategy.48 Hospitals pursuing a market-focused strategy performed better on three performance indicators: return on new services/facilities, growth in revenue, and market share. Efficiency- oriented hospitals performed better on the indicator of cost containment, while no difference was seen in the indicator of profit margin.48

Using the typology that they formulated, Topping et al. and Malvey et al. found that academic health centers usually utilized combinations of strategies from expansion and stabilization/ contraction.47,63 The researchers noted that the strategies of academic health centers were similar to the strategies of community hospitals and regional systems. The researchers doubted the viability of cost leadership, creation of managed care organizations and research operations, and focus/cost. For a turbulent environment, the researchers recommended innovative strategies based on distinctive competencies. For academic health centers, their competencies are rooted in their unique missions in high-tech and specialized care and research.63

Langabeer also investigated the strategies of 100 U.S. academic health centers in a turbulent environment.1 The researcher found that the strategies of product market and pricing had “substantial influence” on financial performance.1 For hospitals, the researcher defines “product market” as choosing the “optimal patient mix.”1 From this choice, the hospital derives its emphases on various services, such as primary care or surgical specialties. In this study, pricing was the most significant strategy for improving financial performance. The teaching hospitals were able to charge higher prices (premium pricing) corresponding to their perceived higher quality or reputations.

Ten sets of researchers did not use a typology.64-73 The_ findings of their studies, however, do relate to performance of health care organizations in turbulent environments. Leaders in health care may appreciate the relevant information these associated studies provide.

Drain et al. investigated the utility of a model for the prediction of closure of rural hospitals.64 The researchers used a random sample of 40 rural, nonfederal, acute care community hospitals from the American Hospital Association for 1985-1990. From cost report data, the researchers found that the model predicted the closure of hospitals with very low return on assets, very high uncompensated care burden, average to low financial support considerations, and average to high expenditures per adjusted discharge. The investigators concluded that the model provided information so that rural hospital leaders could evaluate and develop strategic initiatives.

Mick et al. also investigated the strategic management of rural hospitals in a national sample of 787 U.S. rural hospitals from 1983 to 1988.61 The researchers found the hospitals that adopted strategic initiatives had more frequent administrator turnover (i.e., instability in leadership). Some, although not all, of the administrator turnover could be explained by the rotation of administrators through multihospital chains.

Stephan et al. also examined the influence of the CEO and the curvilinear relationship between an organization’s multimarket contacts and the likelihood of entry into rivals’ markets.66 In this study, the sample was 395 acute care hospitals in California in 1980- 1986. Longer-term CEOs were more likely to act in ways consistent with the multimarket environment. However, newer CEOs did not act in ways consistent with mutual forbearance in the multimarket environment and thus exceeded acceptable levels of rivalry and competition. The researchers conjecture that this lack of astuteness or this sheer hubris could be detrimental to their hospitals.66

Thomas et al. also focused on the hospital CEOs, investigating the direct and indirect effects among their sensemaking processes and performance.6′ In 1987, questionnaires comprising two scenarios, each with 16 information cues, were sent to 545 public access hospitals in Texas. The usable response rate was 29%. The researchers found that when CEOs interpreted issues as controllable, they were more likely to effect changes in hospital services. Most importantly, hospitals that implemented more changes in services had higher performance in terms of occupancy, profitability, and admissions than those that did not.

Using a longitudinal design, Lee and Alexander followed changes in all U.S. community hospitals from 1981 to 1994.68 The researchers characterized the period as turbulent. Hospital closure was the dependent variable. Independent variables were the hospitals’ core structures, peripheral structures, organizational characteristics, and environmental characteristics. The researchers found that change in hospital specialty, a core change, reduced the risk of closure. Contrary to the researchers’ expectations, the two most frequent peripheral changes, downsizing and leadership change, resulted in more closures.”68 Moreover, “multiple core changes reduced closure risk, while multiple peripheral changes increased the risk.”68

Meyer et al. focused on industry-level analysis during discontinuous change.69 They studied medical-surgical hospitals in four counties contiguous to San Francisco Bay. The researchers collected data over 16 years, with the number of hospitals ranging between 45 and 57. Data collection methods included “structured interviews with industry experts and hospital CEOs, naturalistic observations, responses to mailed surveys, inspection of organizational documents, and analysis of secondary data.”69 From 1987 to 1989, the researchers found a rapid and “pronounced shift away from competition among free-standing hospitals toward affiliation into overlapping provider networks.”69 The researchers assert that these networks were an entrepreneurial response to discontinuous change in the health care industry.69 Finally, the researchers propose that discontinuous change within an industry “stimulates the formation of interorganizational relationships, . . . promotes experimentation with new organizational forms, . . . and precipitates affiliations spanning industry boundaries.”69

Ruef examined archival data from 617 hospitals in California for 1980-1990.70 The researcher found that generalist hospitals were more able to change their services or structures to fit changes in their environments than were specialty hospitals, possibly because generalist hospitals have less entrenched core technologies than do most specialty hospitals.

Irwin et al. investigated the effect of adoption of technology on hospitals.71 The sample was 169 general, shortterm, acute care hospitals in Florida. The researchers analyzed 1990 archival data from the American Hospital Association and the Florida Hospital Cost Containment Board. The researchers found that adoption of technological innovation by large hospitals in munificent environments did not result in a competitive advantage. Competitors in the market also adopted the technology, and overall there was underutilization resulting in insufficient revenues to offset the initial investment costs. On the other hand, smaller hospitals in poorer environments did show improved performance. The investigators theorized that technological innovation allowed these hospitals to differentiate themselves or to stanch the flow of patients to larger hospitals or they were simply more judicious in their acquisition of technology.

Walston and Kimberly studied reengineering as a strategy in a rapidly changing health care environment in 1996.72 They investigated the adoption of reengineering in general, medical- surgical hospitals with more than 100 beds in metropolitan statistical areas. The findings suggested that both economic and institutional factors influenced the adoption and extensiveness of reengineering, with institutional factors playing the greater role. Hospitals with the greater uncertainty in patient volumes engaged in fewer reengineering activities. Finally, the m\ost important factor in the adoption of reengineering was its adoption by competitors in the market area.

Using archival data and a 1989 listing of hospitals from the American Hospital Association, Zinn et al. also investigated interorganizational relationships.73 These researchers focused on interorganizational relationships relative to autonomy, contracts, and alliances. Autonomy was defined as the freedom to make decisions about use and allocation of internal resources independent of the demands and expectations of partners. Based on the data of 1,661 hospitals, the researchers concluded that hospitals with greater resources, contracts with preferred provider organizations, and a more favorable payer mix were more likely to join alliances. Conversely, hospitals in more competitive and less munificent environments, such as those with high penetration of health maintenance organizations and those in rural settings, were more likely to be contract managed.

Figure 1 summarizes the outcome results of the reviewed studies. The best predictor of future strategy is current strategy. Organizational stability with a core of services, along with flexibility for adoption of innovation, allows health care organizations to enter new service markets where they may have competitive edges. The best survival profile integrates these aspects.

Based on the review and summary figure, innovation can enhance profitability if not pursued with fragmentation of an institution’s core identity. Prospector and analyzer approaches appear to offer greater viability in a turbulent health care environment than reactor or defender types. Differentiation of services can be pursued to produce a unique reputation for a health care facility, such as regional Mayo Clinics derived from the original facility in Rochester, Minnesota. All in all, environmental assessment and awareness along with familiarity with strategic approaches are necessary to survive in a turbulent health care environment.

Recommendations

Based on the authors’ integrative review of this research literature, it appears that some strategic models are more useful in health care environments and possibly specifically in allied health practice settings. Several propositions that can be tested by future empirical research on the health care environment that will emerge over the next two decades can be derived. These propositions are displayed in Table 4 with suggestions for some specific measures of success. These propositions could be researched relative to the larger health care environment or at specific practice sites or departments of allied health professions.

Additionally, recommendations specifically pertaining to allied health academic faculty/researchers and to allied health practitioners are also made based on the reviewed literature. Because almost all of the research to date on the turbulent health care environment and the response of institutions and professionals has been outside the specific practice settings, departments, and institutions of allied health professionals, much can be done simply in the way of replicating past studies but using allied health practitioners and managers. More specific recommendations are below.

FIGURE 1. Research summary: outcomes of strategic choices in health care.

RECOMMENDATIONS FOR ALLIED HEALTH ACADEMIC FACULTY/RESEARCHERS

1. Use both objective and perceptual measures because both are relevant in complex, dynamic models of organizational adaptation.74,75

2. Specify the theoretical framework or typology and define terms operationally. Use inductive methods because these approaches more consistently identified types and performance over time than deductive approaches.76 Conduct longitudinal studies because cross- sectional approaches can sometimes be misleading.76

3. Consider investigating the practice environments of allied health professionals and the allied health academic environment in terms of Jurkovich’s 64 types36 or McCann and Selsky’s partitioned environment model.21

4. Conduct studies relative to today’s environment. Most typologies and models were investigated during the years bracketing the implementation of the Medicare inpatient prospective payment system. As one set of researchers noted, this implementation represented “a naturally occurring experiment where the entire competitive landscape shifted abruptly.”50 While this event proved fruitful at the time, more than 20 years have passed. Do the typologies and models show rigor over time? Are findings similar after implementation of the physician payment system of resource- based relative value scales or Medicare’s outpatient prospective payment system? Do findings from single-site studies (i.e., hospitals or nursing homes) generalize to organized delivery systems and alliances?

5. Assess allied health academic units relative to changes in the disciplines and degree levels of programs offered over the past 20 years, including perceptions of how the practice environment for the represented allied health professionals influenced decisions as to program closures and new program developments. Some schools or units of allied health have closed associate degree programs and now offer only baccalaureate and graduate programs to not spread available resources too thin in light of dwindling state and federal funding.77 Some allied health schools have chosen to offer only graduate-level programs,78 possibly in part due to the increasing entrylevel requirements of some allied health accrediting bodies and in part to concentrate resources on research intensification, while other schools have added associate degree programs,78 possibly to expand enrollment and increase the unit’s formula funding.

TABLE 4. Propositions for Future Research

6. Conduct studies using the Miles and Snow strategic types40 for various allied health practice sites and professions in relation to financial and organizational indicators of success as health care entities. Conduct the same studies but use Porter’s strategic types.45 Such research will determine whether certain strategic approaches are more successful overall in allied health or whether different approaches may be successful in different allied health professions or in different practice settings.

RECOMMENDATIONS FOR ALLIED HEALTH PRACTITIONERS

1. Consider pursuing professional development in environmental scanning and strategic planning and management to assume expanded roles in flatter, team-based health care organizations. Bezzina et al. from Canada applied the model of the professional practice leaders.79 In this study, the professional practice leaders developed shared clinical decision-making structures, assisted in the application of professional standards, and allocated budgets. Disciplines represented were clinical nutrition, diagnostic imaging, laboratory services, nursing, occupational therapy, pastoral care, pharmacy, physiotherapy, respiratory therapy, social work, and speech-language pathology.

2. Develop information systems to collect information in the environmental sectors with the greatest impact on the organization’s strategic initiatives, and collect these data specifically for allied health professionals in their practice sites, departments, or institutions.

Conclusions

Similar to health care institutions, schools of allied health have faced a turbulent environment in responding to the changing allied health personnel needs of the health care facilities served. Changes in numbers, levels, types, and skill mixes of allied health professionals have been necessitated in part by the changes that health care employers have made in response to a changing and turbulent health care environment. We have seen dramatic changes (i.e., a discontinuous environment) among health care employers relative to their need for certain health professionals. Cycles of shortage crises and oversupply within a decade are not uncommon in the allied health professions, leading to expansion of some schools of allied health and abrupt closures of others. Accrediting bodies for allied health academic programs in conjunction with various allied health professional organizations have added to the turbulence with requirements for an increased degree level to the master’s degree for some allied health programs. Such mandates have caused rifts in some schools of allied health among lead administrators, program directors or department chairs, and program faculty. Schools of allied health have struggled and continue to do so to find their particular niche in preparing allied health professionals for a viable, lifelong career. While some schools of allied health have narrowed their focus of academic offerings, others have broadened their offerings and/or implemented service- based units or practice plans to establish their niche.77,78

As educational institutions have become more accountable to consumers and have begun to operate more and more under a business model, the need for academic programs and schools of allied health to conduct environmental scanning and strategic planning has become more critical for survival. Lack of attention to gathering environmental data from the consumers (i.e., employers) of a school’s graduates and translating the outcomes of this environmental scanning to selection of viable strategic approaches can cause an allied health academic unit to fall victim to program or school closure. An infusion of administrative staff from the business world who have strong backgrounds in environmental assessment and organizational strategic planning may increase the chances for survival of allied health education programs or schools serving employers in a regional, hyperturbulent health care environment.

This integrative literature review provides the distinctions among key concepts and models for understanding the health care environment and strategic approaches. An understanding of these distinctions shouldallow allied health leaders to precisely assess their turbulent environments. By understanding these concepts as they apply to health care and other industries, allied health leaders can gain a broader view and situate the allied health professions in the current society. The major strategic typologies provided may serve as models of understanding and application for schools of allied health and allied health practice sites to survive their cyclic, turbulent environments relative to their unique but interconnected service markets. The application of the reviewed research offers an arena of research for allied health academic faculty by direct application to the specific practice sites, departments, and institutions of the individual allied health professions.

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Elizabeth J. Layman, PhD, RHIA, CCS, FAHIMA

Richard Bamberg, PhD, MT(ASCP)SH, CLDir(NCA), CHES

Dr. Layman is Professor and Chair, Department of Health Services and Information Management, and Dr. Bamberg is Professor and Chair, Department of Clinical Laboratory Science, School of Allied Health Sciences, East Carolina University, Greenville, North Carolina.

Received July 28, 2004; revision accepted March 23, 2005.

Address correspondence and reprint requests to: Elizabeth J. Layman, PhD, RHIA, CCS, FAHlMA, Department of Health Services and Information Management, School of Allied Health Sciences, East Carolina University, Greenville, NC 27858-4353. Tel 252-328-2202; fax 252-328-4470; e-mail [email protected].

Copyright Association of Schools of Allied Health Professions Spring 2006

By Gaudet, Marcia

Abstract

The ritual of cutting the wedding cake at weddings in the New Orleans area is preceded by another ritual tradition: unmarried female friends of the bride each “pull a ribbon,” to which a silver charm or “favour” is attached, from the cake. Charms can include a ring, a heart, a thimble, a button, a horseshoe, and a clover, each with a traditional meaning. An exploration of the possible derivations and routes of diffusion of this custom reveal that it has much more complex origins and meanings than is commonly assumed by most New Orleanians.

Introduction

The wedding cake-extraordinary and familiar, ritual symbol and dessert, a work of culinary art to be admired, and a food to be eaten-defies simple description or easy explanation. In his Foreword to Simon R. Charsley’s Wedding Cakes and Cultural History, William Woys Weaver writes:

… the Great Cake and its layers upon layers of sublimated meanings-erotic to commemorative-are certainly here to stay. It is a food that has become a veritable institution. A wedding without it would be a wedding without protocol, a rite without confirmation (Weaver 1992).

Mary Douglas has also called attention to “the ceremonial surrounding the cutting and distribution of the wedding cake” (Douglas 1982,105). At weddings in the New Orleans area, the ceremony of cutting the wedding cake is preceded by another ritual- pulling ribbons from the cake. I will explore some of the possible origins, routes of diffusion, and meanings of this custom, as well as its continuing popularity in a relatively small area of south Louisiana radiating from New Orleans. “Pulling a ribbon” is one of many wedding rituals in the New Orleans area that add a special sense of place and setting to the wedding, apart from being a well- known tradition that is meaningful for family and friends who come together to joyfully celebrate a marriage. [1]

Wedding cakes in the New Orleans area come with ribbons embedded in the icing. At the wedding reception, unmarried female friends of the bride are invited to “pull a ribbon.” A silver charm or “favour” hidden in the bottom layer of the cake is attached to each ribbon. Typically, each woman or young girl holds on to a ribbon as a photograph is taken, and then all “pull” simultaneously on cue.

Charms include a ring, a heart, a thimble, a button, a horseshoe, a clover-and sometimes a fleur-de-lis-an anchor, a dime, and also a penny. Each has a traditional meaning-the ring means “next to marry,” the heart means “true love,” the thimble or button means “old maid,” the horseshoe or the clover means “good luck,” the fleur- de-lis means “love will bloom,” the anchor means “hope,” the dime means “wealth,” and the penny means “poverty.” This event gets the attention of all the guests, and the moment of the pulling is followed by good wishes or teasing depending on which item a person pulls.

This tradition has been a part of wedding receptions in New Orleans itself, and in an area within about a fifty-mile radius of the city, including the adjacent river parishes (i.e. the parishes divided by the Mississippi River), for at least seventy-five years and probably much longer-according to dated memorabilia and personal narratives. The earliest wedding cake with ribbon pulls that I have been able to document was that of my mother, whose wedding took place at Evergreen Plantation near New Orleans, in 1928. One of my aunts, Olivia Gendron (now aged ninety-two years), has the white ribbon in her “Memory Book,” and written next to it is the comment, “Ribbon pulled from Boos’s wedding cake”-Boos being my mother’s nickname. The silver charm-a thimble-is no longer there, but she remembers that it was prophetic for her as she never married. Another aunt, Marguerite Hingle (now aged ninety-four years), also recalls pulling a ribbon in my mother’s wedding cake and remembers that she got the button; she did, however, marry a few years later. Both aunts described in detail the wedding, the cake, and the ritual of pulling the ribbons. They also did not think that it was unusual to have ribbons in the cake at that time as their own mother and grandmother always understood that ribbons were part of the wedding cake, and that only the unmarried girls present at the wedding could pull them.

Figure 1. Ribbon pulling at a New Orleans wedding in 1984.

Since the 1950s, the ribbon-pulling ritual has been considered an important photograph moment during a wedding reception, one that provides a requisite photograph for the wedding album (see Figure 1). In my own family’s photograph collections, for example, there are photographs of ribbon pulls at the weddings of at least four generations of brides.

The ribbon-pulls tradition in New Orleans and vicinity is not restricted to any religious or ethnic group. It is a city and area- wide tradition. Dianne Gaines, a New Orleans native, graduate of Xavier University, and wife of Louisiana writer Ernest Gaines, said that everyone she knew in the Creole and African American communities in New Orleans had ribbons in their wedding cakes in the 1950s and 1960s. This custom continues among these ethnic groups to the present day. [2]

Pulling a ribbon from the wedding cake is considered an honour-a sign of friendship or of close family ties to the bride. But there is also the possibility of offending people unless the recognised protocol concerning who gets asked to “pull” is observed. All unmarried bridesmaids pull a ribbon, and then young unmarried female relatives (sisters and cousins) of the bride and/or groom, as well as friends of the bride, are usually invited to “pull.”

Usually the maid of honour will have the job of asking girls to “pull” after conferring with the bride. Sometimes the bride tells young women before the wedding that she would like them to “pull a ribbon.” Where one stands in relation to where the wedding cake is placed is also important, since a popular belief is that the ring is usually on the ribbon to the right of the bride-often the position of the maid of honour.

The ribbon pulling precedes the cutting of the cake and it is performed in the absence of the groom. The bride is surrounded by young, unmarried women; the bridesmaids, and the friends, sisters, or cousins of the bride, gather round the cake while the bride stands right behind it. She is in command, and she usually makes sure that everyone is holding a ribbon. Then she gives the command to “pull.”

After the ribbons are pulled and everyone has licked the icing off of the charm and ribbon to identify the attached charm (usually followed by hugs and laughter and/or commiseration), the groom joins the bride to perform the ceremonial cutting of the cake-which usually consists of simply making the first slice into the cake. The caterer or someone else appointed to the task does the actual cutting up of the cake into slices for distribution to the guests.

Variants of the tradition, which emphasise the importance of the ring in the custom, have also developed. In the early 1960s, my uncle asked the bakery to put a ring on every ribbon in my cousin’s wedding cake, as he wished to avoid disappointing anyone. At the wedding of one of my nieces, however, the bakery failed to include a ring on any of the ribbons-a mistake not easily forgiven by those present who were determined to pull the ring. In 1999, a bride in her midthirties with all of her sisters and friends already married, arranged that her young nieces, aged from five to seventeen years, should pull the ribbons instead of the usual single marriageable women.

The custom of ribbon pulling at weddings is generally believed in New Orleans to be of French or French Creole origin, and many of the bakeries in the New Orleans area believe it to be a uniquely New Orleans custom-although it is not unknown in other parts. The kinds of charms used are available on several Internet sites, all of which describe this as a Victorian custom. [3] Jannice Moecklin, owner of the business “Swiss Confectionery” in New Orleans, said in an article “The Ribbon Pulls,” in New Orleans Magazine in 1998: “This is an old custom brought over from France. To the Creoles of New Orleans, this was an exciting part of the wedding event, and has continued to the present time.” She also said that, in the past, silver trinkets were baked in the wedding cake and that the custom of ribbon pulls seems to pertain only to the New Orleans area. Miss Lotus, who has been in charge of wedding cakes at Gambino’s bakery for fifty years, concurs. Although they order their sterling silver “wedding pulls” (the only kind Gambino’s uses) from New York, she maintains that New Orleans is the only place she knows of that has this tradition. She also said that even people who had moved away try to continue the custom and often get someone from New Orleans to call to Gambino’s to get the charms so that they can put them in their wedding cakes.

Although it is commonly assumed in New Orleans that ribbon pulls in wedding cakes are a French tradition, I have found no evidence to date to suggest that it was ever a custom in France. It is not mentioned by Van Gennep in his encyclopaedic study of French folklore and traditions, which includes an extensive survey of wedding and marriage traditions throughout France. Although van Gennep tal\ks about the presentation of the wedding cake, and says that in many places an enormous cake, le gteau de noces, is carried in by a strong young man who raises it above his head and dances it around the tables, as part of a ritual called danser les gateaux, no ribbons or charms are mentioned (Van Gennep 1946, vol. 2, 513-26). There is also no mention of this tradition in Simon Charsley’s (1992) Wedding Cakes and Cultural History.

Referring to Cajun weddings at the turn of the twentieth century, the latenineteenth-century Breaux Manuscript on Acadian folklife states:

As dessert, a huge wedding cake is carried in. It can take various shapes, but most usually it resembles the steeple of a church or the tower of Babel, ornamented with garlands, sugar flowers of various colors, and is topped with a bouquet of real flowers. It is divided into slices on a vast tray and the slices are offered to each guest. Some are sent to people who could not attend the feast (Ditchy 1966, 41-2).

There is no mention here of ribbons or charms. It would appear that ribbon pulls are not French at all, but were probably brought to the area by les Americains-the English, Scottish, or Irish immigrants who spoke English and who came to New Orleans from other areas of the United States, or who emigrated directly from their home countries to New Orleans. The city itself, of course, is not truly French either-despite the French Quarter and the French street names. The influence of Spanish, African American, Scottish, Irish, and later Italian immigrants, is arguably as significant as that of the French.

The New Orleans tradition of ribbon pulls in wedding cakes is related to various other customs with European roots, such as putting tokens or talismans in festival foods and celebration cakes. These include the practice of putting a baby or a bean in a Twelfth Night Cake or King Cake. In New Orleans, the King Cake, as it is usually called today, is a sweet yeast-bread shaped to form a crown and usually decorated with the traditional Mardi Gras colours using gold, purple, and green sugars. A bean or a small china doll was traditionally baked in the cake, but today a small plastic baby is usually hidden in the cake instead. The person who gets the bean or the baby in a piece of cake is king (or queen) for a week and is expected to provide the next King Cake for the group the following week, and so on until Mardi Gras. This tradition is still extremely popular in Louisiana during the Mardi Gras season, and one that was indeed brought there by the French (Gaudet 1989, 114-21; Henisch 2003, 579-80). Others are the English Christmas custom of putting silver charms in puddings, and the Irish Hallowe’en tradition of including some similar charms in cakes and tarts for divination purposes. In All Silver and No Brass, Henry Glassie observes in relation to county Fermanagh, Northern Ireland, that:

On Hallow Eve, girls engaged in light-hearted divination. Fruit cakes, called “bracks,” are still made for Hallowe’en with a ring baked into them. The girl whose slice includes the ring can expect to be married within the year (Glassie 1975, 115).

Jack Santino also mentions the inclusion of talismans in tarts and pies for Hallowe’en divination purposes in Northern Ireland. Such charms usually consist of a ring to betoken marriage, a button batchelorhood, sixpence wealth, and other trinkets with various meanings (Santino 1998, 123-6). He also reports on other divination charms and practices in Ireland, including the use of plates for divinatory purposes on Hallowe’en. Four plates are put on a table each containing divinatory charms-rosary beads to betoken that the girl who chooses it will become a nun, another with a ring to indicate marriage, one with nothing or water to signifying the prospect of being an old maid, and one with clay to intimate death (Santino 1998, 122-3; see also Lysaght 2001, 193-4). The latter talisman is a central motif in James Joyce’s short story “clay” in The Dubliners (Joyce 1966, 112). Santino also points out that Hallowe’en divination customs in Northern Ireland are typically playful traditions, and that they are generally the domain of women (Santino 1998, 119), much like the wedding cake ribbons and charms in New Orleans and surrounding area

Having ribbon pulls in wedding cakes is more specifically and more closely related, however, to a tradition Simon Charsley regards as being “distinctively Scottish,” and a custom that continues to be popular in Glasgow to this day (Charsley 1987, 98-101; 1992, 12- 13). According to Charsley, Scottish wedding cakes have inedible ornaments (often with ribbons attached) called favours on the cake, which are removed when the cake is cut and given by the bride and bridesmaids to the women guests (Charsley 1992, 12). In England, favours were once lightly tacked to the dress of the bride and pulled off by the bridesmaids: “In the seventeenth century favours were usually knots of ribbon which were distributed to those whom it was desired to associate with the wedding and to honour” (Charsley 1992,97). Favours were later moved from the dress to the cake. This practice died out in England but reappeared in Scotland in the twentieth century on the bride’s cake (Charsley 1992, 97).

The British wedding cake, now a typically dark, rich fruitcake with white icing, is apparently derived from elements dating originally from medieval and early modern times. The form as we know it, however, seems to have developed in the Victorian period (Charsley 1988, 237; 1992, 82), when the cake, an elaborate structure with a tendency to rise into tiers, became an important part of the wedding celebration. The earliest recipe, dating from 1665, for a baked wedding confectionery recorded from Britain is for a wedding pie (Charsley 1992, 47-8). In the early 1800s, the bride’s pie was still a principal dish at a wedding dinner (Charsley 1992, 45-7). A ring was baked in the pie, and the lady who got the ring would be thought to be the next bride (Charsley 1992, 48-9).

The custom of including a ring and a sixpence in a cake served at a wedding is known from the late nineteenth century in England and Scotland. W. T. Marchant, writing in 1879, offered the following instructions:

Make a common flat cake of flour, water, currants, etc.; put therein a wedding ring and a sixpence. When the company is about to retire on the wedding-day, the cake must be broken and distributed amongst the unmarried females. She who gets the ring in her portion of the cake will shortly be married; and the one who gets the sixpence will die an old maid (Marchant 1879, 21, quoted in Charsley 1992, 110).

It is probable that the New Orleans tradition evolved from both the custom of favours on the wedding cake and the custom of baking a ring and sixpence in the cake-customs probably brought by nineteenth- century Scottish and Irish immigrants to New Orleans, as well as school teachers who came from England and Scotland. [4] McKenzie’s Bakery, established in 1924 by a Scottish immigrant (Henry C. “Mack” McKenzie) that, by 2001, with its forty-nine pastry shops, had developed into the largest bakery chain in the area, is also likely to have been a significant influence on the practice of ribbon pulls in wedding cakes in the New Orleans area. When the shops were closed for two months in the summer of 2000 by the Board of Health because of health code violations, the news made headlines such as “Mourning McKenzie’s,””Traditions Under Assault,””We’re Losing Pieces of Our Culture” in the New Orleans Times-Picayune, and prompted many letters to the newspaper about the loss of New Orleans traditions. Even the editorial page joined in, stating:

In a place where food is far more than a biological necessity and traditions are deeply cherished, it’s not surprising that the demise of a local bakery chain has people in a funk (Times-Picayune, 18 and 19 May, 2000).

McKenzie’s re-opened under new ownership in the late summer of 2000, but was permanently closed in 2001. There is also some evidence that the charms in New Orleans wedding cakes, like those in Scotland and Northern England, were earlier baked in the cakes (“The Ribbon Pulls,” New Orleans Magazine 1998, 11).

Arnold van Gennep, in his Manuel de Folklore Franais Contemporain, stresses local inventiveness and variability as important elements in contemporary French folklore. The power of example should be added to this. A local tradition becomes a model to be followed by others who attend or hear about it. The tradition of ribbon pulls in wedding cakes, as it has evolved in New Orleans, appears to be the result of local inventiveness and the influence of example. This fascination with finding a token or “prize” in a cake may also be reinforced by the New Orleanians’ delight in finding the baby in the King Cake, as already mentioned. While still in operation, McKenzie’s Bakery alone baked over thirty thousand King Cakes a week during Mardi Gras season. [5] The power of example and local tradition is also apparent in the St Patrick’s Day parade in New Orleans where spectators along the parade routeaccustomed to begging “throw me something, mister” at Mardi Gras parades-are thrown cabbages and Irish potatoes as well as green beads and other green things.

Why do brides in the New Orleans area still have ribbon pulls in their wedding cakes, and why is a photograph of the ribbon-pulling event considered necessary for the wedding album? There are, no doubt, many reasons for this, including its role in the complex of wedding rituals that affirm marriage as an occasion for family and community celebration. Like the favours in Scotland, pulling a ribbon in the wedding cake is considered an honour, and the charm is a memento to be associated with the wedding. As Charsley points out in relation to the giving of favours at Glasgow weddings, the ribbon pulls could “be appropriately identifi\ed as a recognition of relationships, one small element in the elaborate chain of a socially significant exchange which surrounds this way of marrying” (Charsley 1987, 102).

Ribbon pulling is not something that is done only once in one’s lifetime. Most young women in the New Orleans area, unless they marry very young, are likely to have pulled many ribbons from wedding cakes. Denese Lea, now in her forties, who grew up in New Orleans, said, “The highlight for me at the reception was the ‘ribbon pull/ I wanted what was on the end of that ribbon.”

Linda Dgh has noted that the modern media represent marriage as the goal of media “princesses,” television and movie stars, as well as real princesses. In American Folklore and the Media, Dgh says, “The principal goal of modern heroines is marriage. The wedding is presented as a landmark of Marchen fulfillment no matter how many times the star has previously married” (Dgh 1994, 106). The popularity of ribbon pulls also seems to mirror this, but some changes in the ritual also reflect the outlook of the contemporary woman. While the ribbon with the ring attached still seems to be regarded the “prize pull” in the cake, more contemporary charms are appearing, such as a rocking horse betokening a baby, a jet plane representing travel and adventure, and a sand dollar betokening wealth. At some recent weddings, married friends were asked to pull a ribbon, and King Cake babies were put on some of the ribbons as a divination game to see who would have the next baby! New meanings are also being given to “old” traditional charms, and nowadays the thimble and scissors are said to mean “independence,” or “a positive choice,” rather than having any connotations of being an “old maid.”

Ribbon pulling is still a vital wedding tradition in the New Orleans area. It has changed to reflect the times. In the early 1960s, when we all pulled a ring in my cousin’s wedding cake, everyone was happy. Today, there are more choices for young women, and the ribbon pulls reflect this. Another sign of the times is the popularity of ribbon pulling charms on Internet websites, and in e- stores, such as ultimatewedding.com, bridesvillage.com, letthemeatcake.com, silverfantasy.com, weddingsforless.com, and so on. Here the Victorian origins of the talismans are explained, and the charms’ meanings are included on an instruction card. It is also suggested that the bride may wish to give such details at the bridesmaid luncheon or at the rehearsal dinner. With the “Click here to order!” ease of the Internet, local innovation as well as the power of example, may lead to new directions for folklore study.

Afterword

On 28 August 2005, New Orleans was devastated by the catastrophic hurricane Katrina and the subsequent flooding of the city. One month later, on September 24, Louisiana was hit by Hurricane Rita. The pulling of ribbons in wedding cakes may seem a rather trivial focus in the aftermath of so much loss and suffering. This custom, however, illustrates the importance and persistence of New Orleans cultural traditions. The maintenance, preservation, and celebration of cultural rituals such as Mardi Gras and king cakes, jazz funerals and the second line, caf au lait and beignets at the French Market, are part of New Orleans identity-a multicultural and multiracial identity that includes all classes and socioeconomic levels. Even before the physical New Orleans is rebuilt, its cultural traditions are likely to be resurrected, in some form, somewhere.

Notes

[1] Another example of New Orleans area wedding rituals is the “second line.” The term originally applied to the non-official members of a procession such as a jazz funeral, and its origins are clearly Afro-Creole. It also can apply to the distinctive rhythm of jazz music and the parading style of the followers of the jazz musicians. Once mainly associated with Afro-Creole culture, second lining is now a popular part of New Orleans area weddings, regardless of ethnicity. Typically a jazz trio leads the bridal couple who are followed by their guests as they parade around the reception area, waving decorated umbrellas and souvenir napkins. For more information on second lining, see Rgis (1999).

[2] A photograph of an African American wedding in the New Orleans Times-Picayune bridal tabloid, January 2004, had the caption: “[The bride] chose a traditional New Orleans wedding with all the trimmings.” The photograph shows the bride with her seven bridesmaids each holding a ribbon from the cake, and it does not give any explanation of the photograph or the context. The ribbon pull in wedding cakes is such a typical tradition in New Orleans that the assumption is that it needs no further comment (Times- Picayune, Sunday 18 January 2004, The Wedding Book Supplement, 3).

[3] The only printed references I found that attributed the New Orleans custom to Victorian origins were in New Orleans Magazine, vol. 37 (June 2003): 9. In “Julia Street with Poydras the Parrot: A monthly Pursuit of Answers to Eternal Questions,” Julia responds to a question from Orlando, Florida, about the “custom of the satin pulls on wedding cakes” in New Orleans:

The tradition is said to date back to Victorian England and is not unique to this area. Little silver charms on ribbons are baked or otherwise inserted into a cake. Bridesmaids tug on the ribbons to free the charms and keep them as mementos. There seem to be no hard and fast rules for the custom. In recent years, it has been practiced at most any celebration requiring a fancy cake and involving people who like to play with their food. You should find cake pulls at any shop selling wedding favors. Details surrounding their usage should be easy to find in wedding guides, but instructions often come with the charms.

[4] For example, the Gleason and Picard Institute in New Orleans was founded in 1880 by Mary C. Markey and other teachers who began their careers in England, teaching court etiquette to young women (“Julia Street with Poydras the Parrot,” New Orleans Magazine, vol. 34 [July 2000]: 8).

[5] For more on New Orleans King Cake traditions, see Gaudet (1992).

References Cited

Charsley, Simon R. “Interpretation and Custom: The Case of the Wedding Cake.” Man 22 (1987): 93-110.

_____. “The Wedding Cake: History and Meanings.” Folklore 99 (1988): 232-41.

_____. Wedding Cakes and Cultural History. London: Routledge, 1992.

Dgh, Linda. American Folklore and the Mass Media. Bloomington: Indiana University Press, 1994.

Ditchy, Jay K., ed. “Early Louisiana French Life: Folklore from the Anonymous Breaux Manuscript. Selected, Arranged, and Translated by George L. Reinecke.” Louisiana Folklore Miscellany 2 (1966): 1- 58.

Douglas, Mary. In the Active Voice. London: Routledge and Kegan Paul, 1982.

Gaudet, Marcia. “The New Orleans King Cake in Southwest Louisiana.” Mid-America Folklore, Fall (1989): 114-21.

Glassie, Henry. All Silver and No Brass. Bloomington: Indiana University Press, 1975.

Henisch, Bridget Ann. “Epiphany.” In Encyclopedia of Food and Culture, eds. Solomon H. Katz, and William Woys Weaver. Vol. 1. 579- 80. New York: Thomson Gale, 2003.

Joyce, James. “The Dubliners.” The Portable James Joyce. New York: Viking, 1966. First published 1914.

Lysaght, Patricia. “Hallowe’en in Ireland: Continuity and Change.” Zeitschriftfiir Volkskunde 97, no. 2 (2001): 189-200.

Marchant, W. T. Betrothals and Bridals: With a Chat about Wedding- cakes and Wedding Customs. London: Hill, 1879.

Regis, Helen A. “Second Lines, Minstrelsy, and the Contested Landscapes of New Orleans AfroCreole Festivals.” Cultural Anthropology 14, no. 4 (1999): 472-504.

“The Ribbon Pulls: Who Are the Lucky Ladies?” New Orleans Magazine, Unsigned article, 1998.

Santino, Jack. The Hallowed Eve. Dimensions of Culture in a Calendar Festival in Northern Ireland. Lexington: University Press of Kentucky, 1998.

Van Gennep, Arnold. Manuel de Folklore Franais contemporain: Ou Berceau la Tombe 2 vols. Paris: Picard, 1946.

Weaver, William Woys. Foreword to Wedding Cakes and Cultural History by Simon R. Charsley. London: Routledge, 1992.

Biographical Note

Marcia Gaudet is the Doris Meriwether/Board of Regents Professor of English at University of Louisiana at Lafayette, USA. She is the author of Tales From the Levee: The Folklore of St. John the Baptist Parish (1984), Porch Talk with Ernest Gaines (1990), and Carville: Remembering Leprosy in America (2004). She is editor of Mardi Gras, Gumbo, and Zydeco: Readings in Louisiana Culture (2003). In addition, she is compiler and editor of a book of stories and essays by Louisiana author Ernest J. Gaines, Mozart and Leadbelly: Stories and Essays (Knopf, 2005).

Copyright The Folklore Society Apr 2006

By House, Jennifer; Su, Jenny; Levy-Milne, Ryna

Abstract

Purpose: To identify definitions of healthy eating in terms of food characteristics, eating behaviours, barriers, and benefits in university students.

Methods: Four focus groups were conducted; verbatim transcripts were analyzed and coded using qualitative methods. Participants were nine students of dietetics and six students of other subjects. All were females in their third or fourth year at the University of British Columbia (UBC).

Results: Participants often described healthy eating as consuming all food groups of Canada’s Food Guide to Healthy Eating, with the associated notions of moderation and balance. Benefits of healthy eating were cited as a healthy weight, good physical appearance, feeling better, preventing disease, and achieving personal satisfaction. Barriers to healthy eating included lack of time, choice, taste preferences, and finances. There was some discrepancy between what the dietetics students perceived as barriers for clients (e.g., lack of information), and barriers the potential clients (other students) perceived for themselves.

Conclusions: As dietitians, we must try to understand our clients’ definitions of healthy eating and their barriers to achieving it, which likely differ from our own.

(Can J Diet Prac Res 2006;67:14-18)

Rsum

Objectif. Connatre les dfinitions d’une alimentation saine en termes de caractristiques des aliments, comportements alimentaires, obstacles et avantages chez des tudiants d’universit.

Mthodes. Quatre groupes de discussion ont t constitus; les transcriptions des discussions ont t analyses et codes l’aide de mthodes qualitatives. Neuf tudiantes en dittique et six tudiantes d’autres disciplines ont particip l’tude; elles taient en troisime ou quatrime anne l’Universit de Colombie-Britannique (UBC).

Rsultats. Plusieurs participantes ont dcrit l’alimentation saine comme tant la consommation de tous les groupes d’aliments du Guide alimentaire canadien pour manger sainement, en tenant compte des notions associes de modration et d’quilibre. Parmi les avantages d’une alimentation saine, elles ont mentionn un poids sant, une belle apparence physique, une sensation de mieux-tre, la prvention des maladies et la satisfaction personnelle. Le manque de temps, le choix, les gots et la situation financire ont t cits comme obstacles l’alimentation saine. On a not des diffrences entre ce que les tudiantes en dittique percevaient comme obstacles pour leurs futurs clients (par exemple, le manque d’information) et les obstacles que les clients potentiels (les autres tudiantes) percevaient eux-mmes.

Conclusions. titre de dittistes, nous devons essayer de comprendre les dfinitions de l’alimentation saine de nos clients et les obstacles qu’ils peroivent, car leurs points de vue semblent diffrer des ntres.

(Rev can prat rech ditt 2006;67:14-18)

INTRODUCTION

Many countries, including Canada, have developed guidelines to promote a healthy diet, including Canada’s Food Guide to Healthy Eating (CFGHE) and Canada’s Guidelines for Healthy Eating ( 1,2). Studies show that while people define healthy eating in accordance with dietary guidelines (3-5), they may perceive healthy eating messages as personally irrelevant (4). Few Canadian studies have examined what consumers understand by healthy eating, or their definitions of healthy eating. Quantitative comparison of students has been conducted in the United States (6), but not in Canada. The purpose of this research was to identify students’ definitions of healthy eating in terms of food characteristics, eating behaviours, barriers and benefits. In addition, these definitions of healthy eating were compared among students of dietetics and students of other subjects.

METHODS

This study used qualitative research methods to gather data through focus group interviews. Focus groups have been defined as “a group of individuals selected and assembled by researchers to discuss and comment on, from personal experience, the topic that is the subject of the research” (7). Compared to individual interviews, focus groups provide a more natural environment because participants are influenced by each other as they are in real life (8).

Participants

Participants included nine dietetics students and six students of other subjects from the University of British Columbia. All were females in their third or fourth year of study. The students of subjects other than dietetics were enrolled in various faculties, including agriculture and arts. Potential participants were recruited through announcements before lectures, and posters placed in different faculty buildings. Convenience sampling was used to recruit and all volunteers were accepted as participants.

The UBC Behavioural Research Ethics Board provided ethical approval for this project. Each participant signed an informed consent form before participating in a focus group.

Focus groups

Four focus groups, each with three to five participants, were conducted on the topic of what defines healthy eating. Two groups contained dietetics students and two groups contained students of other subjects, run separately so that participants would feel more comfortable sharing their knowledge and opinions. Each focus group was held at UBC and lasted approximately 45 minutes. A moderator (UBC graduate student) and comoderator (UBC undergraduate student) conducted each focus group. The moderator facilitated the discussion and the comoderator operated the tape recorder and took notes.

Participants were initially asked to build a collage (8) as a pictorial representation of what healthy eating meant to them, using poster board, magazine clippings and crayons. Each participant was then asked to explain their collage. After discussion, each focus group was asked the same set of questions, including:

“What foods do you see as unhealthy?”

“What influences the way you choose food?”

“Where do you get your nutrition information from?”

“What are the benefits of healthy eating?”

“What are the barriers to healthy eating?”

The moderator probed for additional information, based on the responses. For example, if organic food was described as healthy, the moderator asked the participant why they considered organic food healthier than nonorganic food.

To ensure trustworthiness in the research process, member checks (9) were conducted. At the end of each focus group session, the comoderator verbally summarized the main points made by participants to ensure that their interpretations of statements and ideas were accurate. One investigator was a dietitian, and the other was a dietetics student. To minimize the effect of the researchers’ background on the focus groups, the moderator kept verbal and non- verbal cues to a minimum.

Data analysis

Each focus group was tape-recorded and transcribed. The transcripts were coded and summarized by the student investigators using a constant comparative method of coding (8). Six general codes were developed, based on the questions asked during the focus groups: definitions of healthy eating, definitions of unhealthy eating, sources of nutrition information, influences on food choices, barriers to healthy eating, and benefits of healthy eating. The long table approach (8) was used to divide the focus group transcript dialogue into the six codes, to organize the responses by content. Within each general code, specific codes were further developed to identify major themes. A memo (8) was then constructed to describe common themes seen in each code.

RESULTS

Healthy eating collages

Participants in all focus groups centered their collage on the four food groups and nutrition messages seen in CFGHE. All focus groups mentioned another key message from CFGHE: moderation and variety. “That sums it up far healthy eating right there. Moderation.” Participants often mentioned that healthy eating should be individualized, which is another theme from CFGHE: “7 do what is right for me. “Other eating patterns not included in CFGHE were also considered healthy, such as small frequent meals, eating before hunger pains, and eating breakfast.

Other elements of healthy eating described only by dietetics students included emotional enjoyment: “A main point is that healthy eating, I consider it to be enjoyable. It makes you feel good about yourself. “Another idea unique to the dietetics groups was the general importance of meal planning, preparation, and the enjoyment of eating with others: “When I’m cooking with someone, we talk verbally about what we’re going to make and then we go and shop for the food… you cook it together and enjoy it. “Furthermore, some dietetics students also brought up a concern about being overly obsessive with healthy eating, and feeling good about themselves based on how they eat during the day: “Being interested in it [nutrition], or even obsessive about the topic, it changes how you eat.”

Students of other subjects were more concerned with the nutritional value of food, as opposed to the emotions attached to eating. Preparing food yourself so you know “what’s inside what you’re eating” was an idea unique to the other students. Organic foods were also mentioned as a part of healthy eating by this group: “[Organic food is] closer to how it was, I don’t know, originally brought up in nature. ” Consuming functional foods was also conside\red healthy eating by one member of these focus groups, when describing her collage: “/ also put broccoli here because broccoli’s supposed to be good for preventing cancer or something. And I have fish here as well for omega-3 fatty acids. “

Unhealthy eating

All participants associated unhealthy eating with specific foods, such as foods high in fat and saturated fat, deep fried foods, and processed foods: “It’s just foods that have really gone the distance from what their original form was. “High calorie foods with little nutritional value, such as “a lot of fast foods, meals on-the-go type of thing” were considered unhealthy, as were meals lacking variety. Most groups described fad diets as unhealthy, particularly the present trend of high protein, low carbohydrate diets. One dietetics student said: “Idon’t think it’s a sustainable way and it does have negative impacts on your body.”

Dietetics students often considered the use of supplements as unhealthy because they felt that: “people will become skewed in their judgment and start to rely on them [supplements]” instead of eating real foods. Dietetics students also believed that not following eating guidelines for disease prevention or management was unhealthy. Only dietetics students discussed the focus on weight loss as an ultimate goal, instead of overall health, as an unhealthy practice: “When I go to the bookstore… [the nutrition section] focuses on just weight loss and not health per se… implying that by losing weight you are healthier, which may not be the case.”

Other students thought that eating too much or too little was unhealthy, such as hinging and skipping meals. Eating at the right time was important to other participants because: “If you ‘re deprived of it you ‘re probably going to be like… 7 need that big piece of chocolate cake.'” This group defined snacking and late night eating as unhealthy.

Influences on food choices

A common theme for influence on food choices throughout all focus groups was family, upbringing, and culture: “If you grow up eating healthy foods, then you’re going to keep going with that. ” Taste preferences and cravings influenced what the participants choose to eat. Body image, such as preventing weight gain or maintaining a slim figure, was another factor that influenced participants’ food choices.

In addition, dietetics students felt that they were a biased group because they: “have so much more knowledge of food compared to the regular population.”Dietetics students felt that the public was more susceptible to follow “trends, fad diets, and new products, “and are influenced by “marketing and how they [stores] display the food. ” Food choices were also made to promote health, depending on individual lifestyle choices. For example, a vegetarian dietetics student mentioned that she chose food to ensure adequate amounts of iron in her diet. Dietetics students also mentioned that health scares have influenced their family members to choose ‘healthier’ foods: “There’s a history of heart disease in my family… once people start dying you pay attention and you make changes. “

A student of another subject stated that how she physically feels after eating certain food influences her choices: “/ think it [fast food] is really fattening… my stomach doesn ‘tfeel too well afterwards.” Only other students mentioned dial price and affbrdability of food products influenced their food choices.

Sources of nutrition information

An important source of nutrition information for participants was family members, particularly mothers and peers. School courses were mentioned as the main source of nutrition knowledge, especially by dietetics students. Government initiatives and programs, such as food labelling and CFGHE, as well as professionals such as dietitians, were sources of nutrition information. One student also obtained nutrition information from seminars and trainers at her gym.

All focus groups cited media, in the form of magazines, newspapers and television, as a source of nutrition information. Dietetics students conducted independent research from journals and the Internet, but placed strong emphasis on the reliability of sources. They agreed that the media were generally a poor source for reliable nutrition information, despite their strong influence on the public.

Barriers to healthy eating

Lack of time was described as a principal barrier to healthy eating among both dietetics students and other students. Participants felt that meal preparation for healthy eating was often too time consuming: “You’ll go to a vending machine and grab a candy bar or chips to satisfy you because you don’t have time to prepare yourself a proper lunch. ” Also, lack of choice on campus was a barrier: “There’s not a huge choice of healthy places to eat. ” Some other students described bad taste as a barrier to consuming healthy foods: “[brawn bread] tastes really bad and I’m willing to forfeit. “Other students also agreed that money was a barrier to eating healthy: “It’s expensive to eat healthy.”

Dietetics students perceived few barriers to healthy eating for themselves, but believed that lack of time, information, shopping and cooking skills were barriers for the general public: “They don’t have the time to do it [eat healthy], or the education to make the good choices. They just don’t know how to make their money go that far. “Another barrier dietetics students saw for the average consumer was the media’s influence to buy unhealthy products. They also agreed that although there are many long-term benefits of a healthy eating plan, lack of short-term effects (i.e., quick weight loss) creates another barrier for the public to eat healthy: “It’s hard to get people excited about that when you don’t see the results fast.”

Benefits of healthy eating

Both groups described appearance, such as a healthy weight, glowing skin, and physical physique, as a benefit of healthy eating. Also, feeling better physically and having “more energy from day to day “was considered a benefit of healthy eating.

One dietetics group thought that the good taste of healthy foods was a benefit to healthy eating, in contrast to some other students who viewed taste as a barrier to healthy eating. Dietetics students listed additional benefits of healthy eating not mentioned by the other students, such as health maintenance, disease prevention and personal satisfaction: “I’m much more satisfied if I’ve had a good day where I ate good meals and exercised and at the end of the day, you ‘re just really pleased with yourself. “

DISCUSSION

The results of this study show that participants defined healthy eating in accordance with Canadian dietary guidelines. All participants seemed knowledgeable about the messages disseminated through CFGHE, including the four food groups, moderation and variety. Overall, our results are consistent with die literature. Most studies have found that consumers define healthy eating as moderation, balance and variety (3,4,10). More specifically, consumers have defined healthy eating as low fat, natural, eating for disease prevention/management, and weight control (11). Additional definitions of healthy eating from our research participants included organic food, eating with others, and functional foods.

Our participants placed an emphasis on their upbringing and education as influences on eating and sources of nutrition information. Sources of nutrition information appear to be similar when comparing our participants’ results with those from Health Canada studies (5,10). In general, Canadians cite product labels as their most frequently used nutrition information source, followed by radio and TV, friends and relatives, and magazines or books (5). The dietetics students in our study were concerned with the reliability of nutrition information from media sources. This concern is likely justified, as a large European study found that 61% of the population trusted radio and television information to be accurate (4).

While most participants had a good understanding of healthy eating, barriers to achieving it still exist, particularly for the other participants. Barriers included expense and perceived poor taste of healthy foods, which is consistent with the literature (4,10). The dietetics groups did not mention expense as a barrier towards achieving healthy eating for themselves, but believed that it may be an obstacle for the general public, who may not be educated on how to shop for healthy foods on a budget. While dietetics students viewed lack of information, shopping and cooking skills as barriers to healthy eating for the general public (their future clients), the other students did not discuss these factors as barriers. Insufficient knowledge is generally not viewed as a major barrier to healthy eating (4,6). The dietetics students also described taste as a benefit to healthy eating, rather than a barrier as described by some other students. The dietetics students thought that lack of shortterm effects which may be seen with fad diets (i.e., quick weight loss) deterred the public from following healthy eating plans. Yet the other students described fad diets as unhealthy, and did not discuss lack of quick weight loss as a barrier to healthy eating. The dietetics students did not seem to understand some real barriers to healthy eating, potentially impacting their ability to counsel their clients successfully in the future.

Many Canadian consumer beliefs about the benefits of healthy eating were similar to our results, such as long-term health, more energy, and weight control (6,10). A unique benefit of healthy eating mentioned only by the dietetics students was personal satisfaction gained from eating well. This finding may be unique in comparison to studies with the average consumer, as dietetics students likely place a greater emphasis on what they eat.

The sample used in this study represented young womenwith university education. The demographic characteristics of age (18- 24), sex, and education have been correlated with having more knowledge about nutrition than do consumers over age 24, males, or those without a university education (5,12). There are likely healthy eating definitions that are not represented by this sample, so caution should be used when generalizing these findings to other groups. A factor limiting the generalizability of these findings is the small sample size. Generally, focus groups have six to eight participants (8). While our smaller focus group sizes were advantageous for participants’ comfort, it may have limited the range of experiences voiced. Because participants volunteered for this study, there is a possibility of self-selection bias in that the other participants may have been more interested in healthy eating than is the average university student.

Further study exploring the definitions of healthy eating with participants different from those in this sample would add to our knowledge. Possible participants could include males, different cultural groups, and perhaps registered dietitians compared to naturopaths or unregistered nutritionists. There has been little research on determining how people make food choices and how to overcome barriers to healthy eating. This study further solidifies the concept that healthy eating involves more than choosing just ‘healthy’ foods, but is also influenced by people’s backgrounds and feelings towards food.

RELEVANCE TO PRACTICE

How people choose food is an experience with psychological, social, and cultural influences (11). In creating successful nutrition goals for clients, dietitians can benefit from understanding the belief systems people have for healthy eating.

The sources of information and perceived barriers to healthy eating found in this study exposed challenges for nutrition professionals. For example, one common source of nutrition information for the participants was the media. As dietitians, it is important for our credible messages of healthy eating to make it into the media as often as possible. There was some discrepancy between what the dietetic students perceived as barriers for clients, and barriers the potential clients (the other students) perceived for themselves. As dietitians, we must try to understand our clients’ definitions of healthy eating and their barriers to achieving it, which likely differ from our own.

“That suras it up for healthy eating right there. Moderation.”

“It’s expensive to eat healthy.”

The dietetics groups did not mention expense as a barrier

References

1. Health & Welfare Canada. Canada’s Food Guide to Healthy Eating. Ottawa: Office of Nutrition Policy and Promotion; 1992. Available from: http:/ywww.hc-sc.gc.ca/hpfb-dgpsa/onpp-bppn/ food_guide_rainbow_e.html; accessed December 7, 2004.

2. Health & Welfare Canada. Canada’s Guidelines for Healthy Eating. Ottawa: Office of Nutrition Policy and Promotion; 1992. Available from: http:/ywww.hc-sc.gc.ca/hpfb-dgpsa/onpp-bppn/ food_guide_guidelines_e.html; accessed December 7, 2004.

3. Povey R, Conner M, Sparks P, et al. Interpretations of healthy and unhealthy eating, and implications for dietary change. Health Educ Res 1998;13(2):171-83.

4. Lappalainen R, Kearney J, Gibney M. A pan EU survey of consumer attitudes to food, nutrition and health: an overview. Food Quality and Preference 1998;9(6):467-78.

5. Health & Welfare Canada. What do Canadians know about nutrition? Ottawa: Office of Nutrition Policy and Promotion; 2002. Available from: www.hc-sc.gc.ca/hpfb-dgpsa/onpp-bppn/ factsheet_canada_knows_e.html; accessed July 5, 2004.

6. Brownlie T. Attitudes towards and perceived barriers to healthy eating among nutrition and non-nutrition students. FASEB 2001;15:A998.

7. Powell RA, Single HM. Focus group. Int J Qual Health Care 1996;8(5):499-504.

8. Krueger RA, Casey M. Focus groups: a practical guide for applied research. California: Sage Publications, Inc.; 2000.

9. Mays N, Pope C. Assessing quality in qualitative research. BMJ 2000:320:50-2.

10. Health & Welfare Canada. Healthy eating – consumer perspectives summary of qualitative research. Ottawa: Office of Nutrition Policy and Promotion; 2003. Available from: www.hc- sc.gc.ca/hpfb-dgpsa/ onpp-bppn/ healthy_eating_consumer_persp_e.html; acccessed July 5, 2004.

11. Falk LW, Sobal J, Bisogni CA, et al. Managing healthy eating: definitions, classifications and strategies. Health Educ & Behav 2001;28(4):425-39.

12. Reid DJ, Conrad SA, Henricks SM. Tracking nutrition trends, 1989 1994: an update on Canadians’ attitudes, knowledge and reported actions. Can J Publ Hlth 1996;Mar-Apr:113-8.

JENNIFER HOUSE, MSc, RD; JENNY SU, BSc, RD; RYNA LEVY-MILNE, PhD, RD, Division of Human Nutrition, University of British Columbia, Vancouver, BC

Copyright Dietitians of Canada Spring 2006

Skipping breakfast, smoking among the unhealthiest methods they use, study finds

While dieting is a common practice among college women, a new study has found that 83 percent of them diet no matter how much they weigh.

Worse, skipping breakfast and smoking are often the unhealthy techniques they use to try to reach their ideal size, said Brenda M. Malinauskas, lead author of the study, which appears in the March 31 online issue of Nutrition Journal.

She and her team polled 185 women college students, aged 18 to 24, about their dieting practices and physical activity. “I was a little bit surprised about the high percentage of women dieting,” said Malinauskas, an assistant professor in the department of nutrition and hospitality management at East Carolina University, in Greenville, N.C.

In previous research, she said, she recalls seeing a figure of about 70 percent.

“I don’t think it has increased,” she said of college dieting. “I think it might be the way we classified dieting.” Among the dieting behaviors she asked about were consciously eating less than you want, using artificial sweeteners, skipping breakfast, and smoking for weight control.

The researchers measured the women’s height and weight, as well as other measurements, and classified them as normal weight, overweight or obese. Many of the methods used to lose weight were used by the women regardless of their weight.

Consciously eating less was reported by 44 percent of the normal weight women, 57 percent of the overweight and 81 percent of the obese. Artificial sweeteners were used equally by normal weight and overweight, with 31 percent of each group using them. Only 5 percent of obese women reported using the artificial sweeteners.

Smoking cigarettes was used as a weight-control measure overall by 9 percent of respondents. And 32 percent said they skipped breakfast.

The use of laxatives after eating was reported by 3 percent, and vomiting to control weight was reported by 5 percent.

Eighty percent of the women said they exercised to lose or control weight, but they didn’t do enough to achieve that, Malinauskas said.

“We found a large percentage — 80 percent — used physical activity to control weight, but only 19 percent exercised to the level they would need to lose weight,” said Malinauskas.

Fifty-eight percent of the women said they felt pressure to be a certain weight, and that the pressure came from themselves, the media and friends.

As to the use of various practices, Malinauskas said, “we really didn’t find much difference due to body weight. I thought that we would have a higher frequency [of weight-control practices] in the overweight.” But that was not always the case.

The research points to the need for individual counseling of college women to help them learn which practices to lose and maintain weight are healthy and which are not, she said.

She suggests college women who need guidance in weight control seek out help at the student health center on campus, which is likely to include a registered dietitian on staff.

The study results come as no surprise to Connie Diekman, director of nutrition for Washington University in St. Louis.

“It’s an interesting study,” said Diekman. “It affirms something we see. It pretty much holds with the girls I work with. They often don’t know what healthy dieting is, they are focused only on the weight, as a number, but they aren’t looking on how to achieve a healthy weight in a healthy way.”

When she counsels college women and men, Diekman said, she encourages them to make behavioral changes slowly, not to make radical dietary changes they won’t be able to keep up. “Look at your current food choices,” she said she tells students. “Try to adjust portions or make better choices.”

She said she also encourages them to pay more attention to regular physical activity, especially since workouts are hit-and-miss for many college students. “If it’s a bad week at school, they cut back. If fun things are going on, they cut back. Overall, their physical activity is not at a level that would promote weight loss,” she added.

For breakfast skippers, she suggests: “Start with a cup of yogurt or a piece of string cheese or a banana. Just eat something. It’s a start.”

Skipping breakfast is linked to overeating later in the day, and to decreased school performance, she noted.

More information

To learn more about eating right, visit the American Dietetic Association (www.eatright.org ).

By Potter, Kirsten

ABSTRACT

Background and Purpose: Patients with Stiff-Person Syndrome (SPS) typically show stiffness and spasms, primarily of the trunk and proximal lower extremities. The purpose of this case report is to provide an overview of SPS and a description of the specific physical therapy management strategies used during a brief inpatient rehabilitation stay for a patient with SPS, illustrating the use of the patient/client management model in the Guide to Physical Therapist Practice. Case Description: The patient was a 33-year-old with a 3-year history of SPS. He spent 10 days in an in-patient rehabilitation hospital where he received physical therapy daily. The initial examination revealed impairments of pain, range of motion, reflex integrity, and motor function, along with abnormalities of posture, balance, and function. The procedural interventions included therapeutic exercise and functional retraining. Stretching exercises were categorized according to their priority and level of difficulty to accommodate for the patient’s varying symptoms, and relaxation exercises aimed to reduce the severity of the patient’s spasms. The functional retraining program included transfer and progressive gait training. Outcomes: The patient showed improvements in ankle range of motion, posture, and gait (distance, speed, and independence), despite continued problems with stiffness, spasms, and pain. Discussion: Physical therapists working with patients with SPS have challenges related to the paucity of information in the literature. The chronic, progressive, and variable nature of SPS indicates the need for life-long management, with the inclusion of an exercise program that can be adjusted accordingly, given the frequently changing symptoms experienced by the patient. As is shown with this case, it appears that physical therapy can improve function and some of the impairments associated with SPS.

Key Words: Stiff-Person Syndrome, physical therapy, Stiff-Man Syndrome, Moersch-Woltman Syndrome

INTRODUCTION

Stiff-person syndrome (SPS), also known as stiff-man syndrome or Moersch-Woltman Syndrome, was first described in 1956.’ The patients’ principal complaints included stiffness (ie, rigidity), primarily in the trunk muscles, that was superimposed by spasms, resulting in postural abnormalities, gait difficulties, and a tendency to ‘fall like a wooden man.’ Hence, Moersch and Woltman coined the term “stiff-man syndrome.”1

Although many articles have been published on SPS, there is a lack of information about physical therapy (PT) management of patients with SPS. A few authors recommend PT for patients with SPS,2-5 but little insight regarding specific PT management strategies is provided. However, given the impairments (eg, muscle stiffness and spasms) and functional limitations that result from SPS, patients may benefit from PT. Thus, the purpose of this paper is to provide an overview of SPS and to report a case describing the specific PT management strategies used during a brief inpatient rehabilitation stay for a patient with the condition. Additionally, the case report will illustrate the use of the patient/client management model as described in the Guide to Physical Therapist Practice?

EPIDEMIOLOGY

SPS is a rare condition with an unknown incidence and prevalence. From 1966 – 1999, approximately 100 cases were reported in the literature.7 Given the rarity of the syndrome, and thus, a lack of awareness and understanding, SPS is underdiagnosed. Although the condition is typically referred to as stiff man syndrome, the term stiff person syndrome is more suitable, as men and women tend to be equally affected.2 In McEvoy’s review of the literature on SPS, 43 cases were female and 51 were male; the average age at diagnosis was 40 years of age, with a range from 8 years to 76 years.8

ETIOLOGY AND PATHOLOGY

The cause of SPS is unclear. However, the frequent presence of antibodies against glutamic acid decarboxylase (GAD) in the serum and cerebrospinal fluid of patients with SPS points to an autoimmune process.9,10 Additionally, many patients with SPS have other types of autoimmune conditions, such as insulin dependent diabetes mellitus, thyroid disease, pernicious anemia, vitiligo, cancer, and myasthenia gravis.11-16 Interestingly, not all patients with SPS have antibodies against GAD, but the proportion who do is significantly higher than in patients with other neurological conditions.9

GAD is a cytoplasmic enzyme, stored at nerve terminals, that is responsible for the conversion of glutamate to γ-aminoburyric acid (GABA), an inhibitory neurotransmitter.17 In a healthy state, GABA and norepinephrine (an excitatory neurotransmitter) are in balance, normalizing the upper motor neuron impulses to lower motor neurons (LMN) and the LMN release of acetylcholine to skeletal muscles. However, in a person with SPS, antibodies directed against GAD are produced, likely resulting in a proportional increase in norepinephrine within the brainstem and spinal cord, causing excessive excitation to the LMN. This in turn increases the release of acetylcholine that excites skeletal muscles, causing increased stiffness.4

The pathologic site of involvement in SPS remains unclear. Levy18 reported reductions of GABA in the cerebrospinal fluid, motor cortex, posterior occipital cortex, and spinal cord. Spada and Spada4 postulated the site of involvement to the brainstem and spinal cord anterior horn cells. Brown et al19 suggested that spinal interneuronitis is the likely cause of stiff-leg syndrome. Floeter et al20 hypothesized that patients with SPS would have abnormalities of spinal inhibitory (ie, GABAergic) circuits, but found inconclusive results. However, Mamoli et al21 suggested a supra- spinal origin resulting in over-excitability of alpha motor neurons and disinhibition of polysynaptic neurons. This hypothesis has been supported by Sandbrink et al22 and Fleeter.23

DIAGNOSIS AND CLASSIFICATION

Due to the rarity and a lack of understanding of SPS, the diagnosis is often one of exclusion and can take months to years to confirm. Dalakas et al12 reported that the average time from onset of symptoms to diagnosis was 6.2 years (range 1 – 18). Tarsy and Miyawaki24 reported about a patient who was symptomatic for 22 years before a diagnosis of SPS was made. Many patients with SPS, particularly those with phobias,25 are often misdiagnosed as having conversion or other psychiatric disorders.26-28

In 1989, Lorish et al5 described 7 key criteria needed to definitively diagnose SPS (Table 1). In addition, the presence of antibodies against GAD in the serum and cerebrospinal fluid may assist in the diagnosis of SPS.9

Both Barker et al29 and Brown and Marsden30 proposed classification schemes, differentiating ‘classical’ SPS from its variants. Based on the collective works of these authors and others, it appears that there are 4 forms of SPS: classical stiff person syndrome, SPS with encephalitis and rigidity, stiff-limb syndrome, and jerkingleg syndrome. Table 2 compares the clinical presentations of the various forms of SPS.19,29-34

Table 1. Key Criteria to Diagnose SPS as Described by Lorish et al5

CLINICAL PRESENTATION AND DISEASE COURSE

The onset of SPS is insidious with primary symptoms of intermittent stiffness, rigidity, or tightness involving the trunk musculature1 that can result in low back pain.3 Over time, the stiffness spreads symmetrically to other muscles, most often those of the proximal bilateral lower extremities (BLE), and becomes more constant. In some patients, a stressful life event precedes the onset of permanent motor symptoms.26

There are varying reports regarding the distribution of motor symptoms. Although some authors state that the distal BLE, bilateral upper extremities (BUE), and facial muscles are typically not affected,8,11,35 others report that this is not the case.1,2,12,21,36,37 Toro et al2 stated that distal BLE muscles might be affected in severe cases. Moersch & Woltman1 reported that proximal involvement predominates, and the hands and feet are mildly affected, at most. They also noted that some patients experienced involvement of facial and neck muscles, interfering with breathing and swallowing. Layzer36 reported that approximately one quarter of patients have mild involvement of the bulbar muscles. Mamoli et al21 reported a case in which spasms resulted in cyanosis and what the authors referred to as ‘respiratory oppression.’ Clifton and Subramony37 discussed a patient with severe neck rigidity, resulting in an inability to turn the head. Dalakas et al12 reported facial muscle stiffness in the majority of their patients.

The course of SPS is slowly progressive, developing over several weeks or months, and, although symptoms rarely remit, they can stabilize over time. The stiffness often results in postural abnormalities, most notably an extreme lumbar lordosis with hypertrophy of the paraspinal muscles.5 In cases where neck and upper back muscles are involved, the patient may have a persistent kyphosis.8 Additionally, the abdominal muscles may be affected and have been reported to feel ‘board-like.’1 Patients often have a stiff-legged gait pattern and are prone to sudden falls, yet most can remain ambulatory with treatment.38 Due to the truncal involve\ment, most patients have difficulty bending over, affecting the ability to dress.5

The degree of stiffness tends to fluctuate and is superimposed by intermittent painful spasms triggered by a sudden stimulus, such as a touch, a fright, or a noise. Emotional upset may exacerbate the symptoms and many patients report a fear of walking in open spaces. The spasms are often bilateral and begin with a myoclonic jerk followed by tonic muscle contractions.39 Profuse sweating and a rise in blood pressure may accompany the spasms.8 The severity of pain appears to relate to the degree of spasms,1 which may cause muscle tearing, fractures, or damage to internal orthopedic hardware.36 The spasms tend to disappear during sleep, but may suddenly recur, awakening the patient.5 Patients have been known to have varying patterns of spasms, including crossed flexor responses of the BLE, extension and pronation of the BUE, trunk extension, or an opisthotonic posture.11,39

Table 2. A Comparison of the 4 Forms of Stiff-Person Syndrome.

As might be expected, patients with SPS often have emotional and psychological symptoms related to their condition. The most common problems appear to be depression and anxiety;27,40 however, substance abuse,27 including increased reliance on pain medications,28 panic disorder,41 increased emotionality and concern for bodily functions,42 and phobias25,26 have also been reported. The phobias most often develop after the motor symptoms and tend to be a situation-specific agoraphobia, and are most commonly related to walking quickly or in open areas. Also, quality of life is often diminished in patients with SPS.40

MEDICAL TREATMENT

A number of pharmacological agents have been reported to be helpful for patients with SPS; however, the majority of reports are anecdotal. Diazepam,21,24 baclofen,21,43-47 botulinum toxin A,48,49 tiagabine,50 and corticosteroids13 have generally been found to be helpful, as have plasmapheresis51 and intravenous administration of immunoglobulin.52 56

Patients may benefit from a multidisciplinary and holistic approach to care.28 Kiriakos and Franco41 advocate the use of antianxiety and antidepressant medications, relaxation training, and psychotherapy to deal with psychological problems. A few authors recommend PT for patients with SPS.2-5 Lorish et al described the results of various PT interventions for 7 patients, reporting that active range of motion (ROM), gentle prolonged stretching, low back exercises, and gait training with assistive devices appear to be most effective.5 Exercises determined to be useful included gastrocsoleus stretches, as well as pelvic tilts, knee to chest stretches, and isometric abdominal exercises to mobilize the low back. Hydrotherapy, relaxation techniques, and massage did not appear to be beneficial.5 Lorish et al did not, however, provide specific guidelines regarding prescription and implementation of exercises for patients with SPS. For example, specific strategies for adapting the therapeutic program to accommodate for the varying symptoms of SPS were not discussed.

Despite the mention of PT in various reports on the management of patients with SPS, there exists limited information to assist physical therapists in clinical decision-making. The remainder of this paper describes the PT management for a patient with SPS. The information from the examination, which was compiled through an interdisciplinary approach, is reported to provide a thorough picture of the patient’s condition. For example, the occupational therapist performed the examination of self-care and the neuropsychologist reported on his emotional state. However, the interventions relate exclusively to the PT plan of care. The patient signed an informed consent allowing the use of medical information and the photo for this report and received information on the institution’s policies regarding the Health Insurance Portability and Accountability Act.

CASE REPORT

Examination

History

“BG” was a 33-year-old male, with a primary diagnosis of SPS, made 3 years prior to admission. His symptoms at diagnosis included involuntary stiffness and spasms of his trunk that gradually progressed into the legs and face. Previous diagnostic testing, including magnetic resonance imaging, muscle biopsy, and electromyography, showed no specific abnormalities and blood was negative for anti-GAD antibodies. Trials of several muscle relaxant medications and intravenous immunoglobulin did not provide any significant relief.

For several months prior to admission to rehabilitation, BG noted worsening of his symptoms. The spasms were triggered by emotional stress and physical exertion; they often lasted for hours at a time and were followed by a prolonged exacerbation of his symptoms. He was having greater difficulty getting out of bed, requiring more assistance from his wife. His facial spasms were interfering with his ability to take medications or nutrition. He was hospitalized in an acute care facility and subsequently transferred to the rehabilitation hospital for comprehensive services to improve his symptoms and functional status. At admission to rehabilitation, BG described himself as “very disabled,” being unable to dress, bathe, or walk independently, and requiring a wheelchair for locomotion. His goals were to decrease his pain and improve his ability to walk.

BG’s past medical history included chronic anxiety and depression; anger management difficulties; a suicide attempt; tobacco, alcohol, and narcotic abuse (current smoker of one pack per day); hyperlipidemia; toxoplasmosis during childhood resulting in left eye blindness; and chronic bronchitis. His symptoms included occasional incontinence, headaches, shortness of breath, coughing, fatigue, weight loss, dysphagia, and chest pain. His medications at admission included valium and dantrium (muscle relaxants); celexa and trazodone (anti-depressants); acetaminophen (a pain reliever); colace, senokot, and dulcolax suppository (for constipation); albuterol nebulizer (a bronchodilator); nicotine patch (to aid in smoking cessation), and saline nasal spray (a nasal decongestant).

BG was married with 3 stepchildren. He had 2 children from a previous marriage, residing out of state. He and his family lived in a 2-story home with the bedroom and bathroom on the first floor. He rarely needed to access the second floor. He reported that he had 12 steps at the entrance to his home with one rail. Prior to his diagnosis he worked as a laborer, however, he was currently on disability due to his condition. His insurance included Medicare and Medicaid.

Systems review

A systems review of the cardiopulmonary system revealed a resting heart rate = 82 beats per minute, blood pressure = 120/72 mmHg, and respiratory rate =16 breaths per minute. There were no abnormalities of the integumentary system. There were apparent abnormalities of the musculoskeletal (decreased ROM of distal BLE) and neuromuscular systems (decreased ambulation and balance; slowed motor function of BLE), indicating the need for further examination, as detailed below.

Tests and Measures of Function

Assistive and adaptive devices

BG reported he used the following equipment: rolling walker, manual wheelchair with elevating leg rests and a cushion, tub bench, and grab bars in the shower and at the toilet. Because these devices were at the patient’s home, the fit, safety, and use were not assessed.

Gait, locomotion, & balance

BGs ability to maintain the sitting and standing positions were examined at rest and during function. BG was able to maintain sitting without back support and perform basic functional skills (eg, eating and grooming) without loss of balance. To maintain balance in standing, he generally required a rolling walker and contact guarding, but he could remove his hands from the walker and hold the position for approximately 5 seconds. Because of BG’s abnormalities of range of motion and posture (discussed later), more dynamic aspects of balance (eg, anticipatory and reactive postural control) were not safe; thus, a more comprehensive examination of balance was planned for later, once his foot position on the floor improved.

He independently propelled his wheelchair on level surfaces, but required minimum assistance to manage the leg rests. He was able to ambulate 20 to 30 feet on indoor level surfaces with the walker and contact guarding. He showed increased hip flexion with extreme ankle plantarflexion and inversion; additionally, he appeared to rely heavily on UE support on the walker.

The Functional Independence Measure (FIM),5 a test to determine the burden of care needed to complete activities of daily living and the Timed Up and Go Test (TUG)58-59 were administered. Both the FIM57,600 -63 and the TUGV) have been shown to be reliable and valid. The TUG was chosen because the patient had reported that his gait was slow and his endurance was limited, as was evidenced by his inability to walk more than 30 feet. The TUG requires a patient to stand up from a seated position, walk 3 meters, turn around, walk back to the chair, and sit down at a comfortable speed.59 However, BG reported difficulty with walking fast, so the TUG was administered at 2 speeds (comfortable and fast). This was felt to be an objective way to measure his ability to change movement speed, while being sufficiently short to accommodate for his limited endurance. Ambulation on stairs was not assessed upon admission. The results of the TUG and FIM are noted in Table 3.

Self-care & home management

BG rolled from right [Lef-right arrow] left and moved from supine [Lef-right arrow] sitting independently. He performed pivot transfers from bed [Lef-right arrow] chair and to the toilet and shower (using grab bars) with supervision. He was able to move from sit [Lef-right arrow] stand with the walker with contact guarding (ie, less than 25% manual assistance). He was able to eat in\dependently without assistive devices. BG required set-up for grooming and supervision for dressing and toileting. The assistance during these tasks was necessary due to concerns about his balance and safety brought about by his abnormal foot position that resulted in a small and unstable base of support. The Functional Independence Measure (FIM)57 scores for self-care are also reported in Table 3.

Tests and Measures of Impairment

Arousal, attention, & cognition

BG was alert and oriented; he was able to follow commands and no deficits in cognition were noted. The neuropsychologist reported that BG experienced feelings of hopelessness and helplessness, concerns about his disease and prognosis, and frustration.

Motor function

BG demonstrated adequate gross and fine motor coordination; he was able to manipulate small items (eg, buttons and pens) and could perform daily activities requiring UE function (eg, eating and grooming) without difficulty. However, his BLE active movement appeared slow. To measure LE movement speed, the time to perform 5 consecutive heel to knee movements in supine (while moving as quickly and accurately as possible) was recorded (Table 3).

Muscle performance

BLE strength was tested via manual muscle test using standard techniques, with scores from O to 5/5.M Results for the left LE were: iliopsoas 5, gluteus maximus 4+, gluteus medius 4+, adductors 4+, hamstrings 4, and quadriceps 5. The right LE was: iliopsoas 4+, gluteus maximus 4, gluteus medius 4+, adductors 4+, hamstrings 4-, and quadriceps 5. Due to BG’s relatively fixed foot position with reductions in ROM, testing of the tibialis anterior was considered to be invalid. Also, testing of the gastrocsoleus muscle group could not be performed using standard techniques64 due to the patient’s inability to stand on one foot. The occupational therapist determined the patient’s UE strength to be 4 throughout.

Table 3. Measurements of Outcomes at Admission and Discharge

Pain

BG reported constant pain that increased with anxiety and affected all aspects of life. Generally, his pain was mostly in the BLE, but would involve the trunk, BUE, and face at times of increased spasms. At the time of the PT examination, he reported his intensity of pain (while sitting unsupported at rest) as 5/10. At other times, his pain levels ranged from 4 to 10/10.

Posture

BG had no apparent postural deviations in sitting. In standing, he demonstrated increased hip flexion and plantarflexion with inversion of his feet and ankles (Figure 1), resulting in the contact of only his forefeet on the ground. A ruler was used to measure the distance from his heel to the floor (Table 3). Two measurements were taken on each LE and consistent results were obtained.

Range of motion

ROM was tested via observation, but when limitations were apparent, goniometric measurements were taken. BG’s BUE active ROM was tested in sitting and noted to be within normal limits. His BLE active-assisted ROM, tested supine, was also within normal limits except for dorsiflexion (Table 3). The ROM of the BLE was tested in an active-assistive manner in order to provide an additional stretch that would allow for increased ROM beyond what the patient could produce independently, in order to determine his maximum ROM. Trunk ROM as assessed via observation during functional activities (eg, reaching to the floor in sitting and moving from supine [Lef-right arrow] sitting) was within functional limits.

Figure 1. BG shown in standing at time of initial examination.

Reflex integrity

As reported in the Guide to Physical Therapist Practice,6 reflex integrity can be assessed via deep tendon reflexes and resistance to passive stretch. For this case, resistance to passive stretch was preferred over deep tendon reflex testing due to its ability to determine the degree of stiffness, the primary symptom of SPS, rather than the intensity of a stretch reflex. However, a consulting neurologist did examine BG’s deep tendon reflexes, stating they were “difficult to elicit.” During the initial examination, BG had increased resistance to passive movement of the all joints in the BLE. The stiffness seemed to be most severe in the extensor muscle groups and distally, in the calf muscles bilaterally, where hypertrophy was also noted. Given the fluctuations in symptom severity in patients with SPS, it is important to note that the patient was not experiencing a severe spasm at this time.

At a point later in BG’s rehabilitation, he did experience a severe, long-lasting spasm that was observed. At this time, he was supine in bed and was noted to have extreme stiffness of the BLEs and BUEs, in extensor and flexor muscles respectively, in addition to spasms of the jaw muscles with an inability to open his mouth. At this time, active and passive movement of BG’s limbs was impossible.

Sensory integrity

Light touch and proprioception, tested using standard methods as described by O’Sullivan and Schmitz,65 were normal.

EVALUATION

BG’s dominant symptom resulting from SPS was constant stiffness, with occasional spasms, exacerbated by anxiety. The stiffness and spasms led to pain, impairments of ankle ROM, and subsequent postural abnormalities, most notably an abnormal position of the foot on the floor and a reduced base of support. Subsequently, the patient required the use of a walker and manual assistance to prevent imbalance during transfers and gait. The stiffness also led to impairments of motor function; his BLE active movement was slow and appeared difficult. All of these factors were thought to lead to decreased speed and independence in functional mobility. Although BG was able to increase his functional movement speed (as shown by the 19.56 second difference when comparing the TUG results in the comfortable versus fast speed conditions), these results indicated extremely slow speed when compared to normal (less than 10 seconds).59 Ultimately, his pain and limited functional mobility contributed to his inability to work (especially given his employment as a laborer) and fulfill his roles within his family.

DIAGNOSIS

Given BG’s medical condition and multisystem (ie, neuromuscular and musculoskeletal) impairments, 2 diagnostic categories from the Guide to Physical Therapist Practice were selected.6 The primary diagnosis, “Impaired Motor Function and Sensory Integrity Associated with Progressive Disorders of the CNS,” was selected due to the progressive nature of SPS and BG s abnormalities of motor function. However, this diagnosis does not include impairments of posture and ROM within the inclusion criteria. A secondary diagnosis of “Impaired Posture” was chosen based on his abnormalities of standing posture and its incorporation of a few of BG’s impairments and functional limitations, as indicated by the inclusion criteria (eg, impaired joint mobility) and relevant ICD-9-CM codes (code 781: “Symptoms involving nervous and musculoskeletal systems”; 781.2 “Abnormality of gait”; and 781.92 “Abnormal posture”). Although a diagnosis of “Impaired Joint Mobility, Motor Function, Muscle Performance, and ROM Associated with Connective Tissue” was considered, it was not selected due to its emphasis on musculoskeletal pathological conditions. Additionally, there is no mention of impairments of posture in the inclusion criteria.

PROGNOSIS

Despite BG’s impairments upon admission to rehabilitation, he required little manual assistance with functional mobility and basic activities of daily living, provided he was using assistive devices. His cognition was intact, he had good family support, and he was motivated and interested in participating in PT. All of these factors were considered to be positive prognostic indicators.

Of concern, his medical history pointed toward a progressive disease course and it appeared that he had symptoms of both SPS (ie, the “classical” form) and stiff-limb syndrome (Table 2)19,29-34 When not m a severe spasm, BG’s symptoms were more pronounced distally, involving his ankles and feet, more consistent with stiff-limb syndrome. However, at times of severe spasm, he showed symptoms in his trunk, BUE, and facial muscles, more consistent with SPS. The literature suggests that the prognosis of these 2 syndromes differs.29-30 Patients with SPS have been found to respond well to muscle relaxant medications and often experience stabilization of their disease process after months to years of progression; those with stiff-limb syndrome typically have a poorer prognosis and response to medications, with many becoming wheelchair dependent.29,30 BG’s medical history appeared more consistent with a progressive and relentless course, as he had not experienced symptom stabilization and he was wheelchair dependent upon admission. Additionally, he experienced severe spasms on occasion, which could limit his ability to participate fully in PT, and it was expected that he would have a relatively short length of stay in rehabilitation.

Although it seemed unlikely that PT would alter BG’s disease course in the long-term, it was hoped that therapy would have some positive short-term and preventative effects. The PT goals focused on BG’s ability to independently complete his home exercise program and perform basic mobility skills. The degree to which stretching exercises would improve BG’s ankle ROM was unclear, as the literature did not provide significant insight into the potential for remediating ROM impairments. The functional mobility goals were selected because they would allow BG to return home and function independently.

The PT discharge goals included: (1) ambulate on level and unlevel surfaces independently with a device for at least 250 feet, (2) ambulate up and down one flight stairs with a device independently, (3) independent with his home exercise program, and (4) transfer from sit [Lef-right arrow] stand independently from a variety of surfaces (eg, bed, chair).

INTERVENTION

Cons\istent with the rehabilitation hospital’s typical procedures, BG was scheduled for PT daily for 2, 30-minute sessions on weekdays and 1, 30-minute session on weekends. Initially, it was thought that BG would be in rehabilitation for 2 to 3 weeks, yet he requested discharge after 10 days. BG missed portions of his scheduled PT sessions on 3 occasions; thus, on average, he was seen for 45 minutes per day. The procedural interventions focused on therapeutic exercise (stretching exercises and relaxation) and functional retraining.

Therapeutic Exercise

Because BG had a chronic and progressive condition with symptoms of stiffness and spasms, resulting in impairments of ROM and motor function, a self-stretching program was considered to be the most important part of the PT program and was prescribed with the goal of independent completion. The relative contributions of the musculosketal and neuromuscular systems in producing stiffness and spasms in patients with SPS have not been studied. However, studies conducted in patients with stroke suggest a musculoskeletal origin, with the problem being one of increased stiffness (ie, soft-tissue tightness), rather than spasticity (ie, a hyperactive stretch reflex).66,67 Given that SPS and stroke are both upper motor neuron lesions, it was thought that the stiffness and spasms that BG was experiencing might have a musculoskeletal origin, similar to that found in patients with stroke. Thus, it was hypothesized that a stretching program might reduce his stiffness, allowing for improved ROM and motor function.

The stretching program was consistent with that described by Lorish et aP and aimed to remediate current impairments of the affected distal BLE and prevent future loss of ROM in more proximal muscles. Other methods commonly used to treat contracture, such as splinting or casting, were not used due to lack of time, as the patient’s hospitalization stay was quite short. Furthermore, the stretching program was successful in improving BG’s range of motion, making more costly interventions unnecessary.

To prevent loss of extensibility of the paraspinal muscles, common in patients with SPS, BG was given lumbar flexion stretches (eg, knee to chest, sitting trunk flexion, and back flexion in quadruped). A lower trunk rotation stretch was prescribed to maintain BG’s ability to transfer supine [Lef-right arrow] sitting independently and to prevent loss of ROM of the lower trunk and hips. A stretch into hip external rotation with the LE flexed was done to assist with lower body dressing. A stretch of the hip adductors was prescribed to allow for an increased base of support in standing, which could improve BG’s balance. Whereas the above exercises were largely preventative in nature, the gastrocsoleus stretches aimed remediate tightness, increasing ROM into DF, enabling him to position his entire foot on the floor. It was thought that this would improve his stability for both balance and gait, which could subsequently reduce his need for his manual assistance and a walker. It was also thought that stretching might have a positive effect on reducing stiffness, allowing decreased pain and increased ease and speed of movement, thereby improving motor function.

BG was given a written exercise program (Appendix 1) at the time of the first treatment session. Verbal and manual cues, in addition to demonstration, were used as instructional strategies. The plan was to have BG perform the exercises during his therapy sessions. Once independent, he was to perform them on his own in his room. Each stretch was performed in a slow and prolonged fashion, with a minimum of a 30-second hold. Gentle prolonged stretching has been advocated by Lorish et al.5

Due to the daily variability in BG’s stiffness and activity tolerance, the exercises were categorized into groups, according to priority (high versus low) and ease of performance (easy versus difficult) (Appendix 1). The ‘easy’ exercises provided a gentle stretch or were performed in supine or sitting, positions that were simpler for BG to maintain. ‘Difficult’ exercises were done in more challenging positions (eg, quadruped) or provided a more vigorous stretch. For example, the single knee to chest stretch was considered to be a high priority exercise to reduce paraspinal muscle stiffness, a common problem in patients with SPS; it was ‘easy’ because it was performed in the supine position and provided a gentle stretch. By contrast, back flexion in quadruped was a low priority exercise because it stretched the same muscles as the single knee to chest stretch and was done in a ‘difficult’ position. The redundancy in the program provided BG with a variety of exercises to accommodate his varying symptoms and to reduce boredom. BG was instructed to do most of the high priority exercises every day and, depending on the severity of his symptoms, he could choose between those that were easier, or those that were more difficult.

On 2 occasions, when BG was experiencing periods of extreme spasms, a few techniques were tried to aide in relaxation and reduce the pain and spasms. These included rhythmic rotation68 of the BLE, done in supine on the long axis of the limb; static positioning of the BLE, in slight hip and knee flexion, over a bolster; passive stretching; breathing exercises; and gravity assisted stretching of the legs over a bolster. Vigorous stretching, necessary to gain ROM, was avoided at these times because it was feared that the force necessary to gain ROM would likely result in injury. Unfortunately, none of these techniques appeared to assist in the reduction of BGs symptoms. The physical therapist also suggested that BG be referred for evaluation for an intrathecal baclofen pump or other tone- reducing medications, as these have been useful in patients with SPS.21,24,43-50

Functional Retraining

Another component of BG’s program was functional retraining. The emphasis of gait training was on increasing BG’s endurance and independence when using a rolling walker. This was accomplished by progressively increasing the distance ambulated while reducing the amount of manual assistance given, according to BG’s tolerance and ability. Practice of sit [Lef-right arrow] stand was done on a variety of surfaces (eg, bed, mat, wheelchair, and toilet). In addition, ambulation on stairs, with the use of handrails and a step- to pattern, was initiated.

Family Training

In addition to the direct patient care provided, the physical therapist planned to include the patient’s wife in the therapy sessions. However, opportunities were limited due to her work and family obligations. She did, however, receive information regarding the patient’s progress and plans for discharge.

OUTCOMES

At BG’s request, he was discharged to home after a 10-day inpatient rehabilitation stay with referrals for home PT, OT, nursing, and a home health aide. BG made consistent progress in PT, despite ongoing problems with pain and spasms that were unchanged in intensity. He did, however, report improvement in his functional ability, attitude, and quality of life, stating that it “feels good to do the things I couldn’t do.”

To reflect true change in BG’s status, as opposed to that associated with his varying symptoms, an attempt was made to assure that the intensity of his symptoms were consistent at the time the initial and discharge examinations were conducted. To maximize reliability of testing, the same physical therapist performed both admission and discharge tests and measures. The discharge examination showed that BG met or exceeded all PT goals, with the exception of independent stair climbing with a device. Although it was difficult to determine if the categorization of exercises according to priority and level of difficulty enhanced BG’s adherence with the program, BG did achieve independence with the stretching program. This was accomplished within the final few days of his rehabilitation stay and was evidenced by his ability to independently perform his exercises and select those that were appropriate given his symptoms at that particular time.

BG achieved scores of 6 or 7, indicating modified or complete independence respectively, on nearly all mobility and activities of daily living items on the FIM (Table 3). He could ambulate with a rolling walker on level surfaces for distances up to 250 feet with supervision. He was able to ambulate very short distances (5 – 10 feet) without a device. Scores on the TUG comfortable and fast tests were reduced by 29.51 seconds and 17.29 seconds, respectively. Notably, when not in severe spasm, his foot position and ROM had improved substantially and his heels now contacted the floor when standing and walking, without a compensatory knee recurvatum. Additionally, BG was able to complete his activities of daily living, including some light housekeeping from a seated position. Table 3 reports the scores of the tests and measures at discharge.

DISCUSSION

This case report describes the PT management for a patient with stiff-person syndrome. The patient made good progress during 10 days of inpatient rehabilitation. It was felt that the primary focus on stretching exercises was appropriate given that BG had a chronic and progressive condition resulting in stiffness and loss of range of motion. BG showed dramatic improvements in ankle dorsiflexion ROM, allowing him to position his entire foot on the floor, helping to improve his posture and gait. His gait speed and distance improved and he achieved the ability to maintain standing and walk short distances without his walker, suggestive of improved balance. Importantly, BG was pleased with the progress that was made. Factors that may have positively influenced BG’s outcome included the therapy provided, changes in medication (including increases in dosages of valium and dantrium and the addition of ativan), and consistent emotional support.

BG presented sever\al challenges to the physical therapist. Most notably, SPS was a medical diagnosis unfamiliar to the physical therapist and little is written in the literature about the benefits of PT for patients with SPS. Thus, it was difficult to develop an evidence-based prognosis and PT program. In particular, developing goals was challenging; it was not clear at admission if remediation of BG’s impairments was feasible. While the Guide to Physical Therapist Practice6 and its patient/client management model were useful in conceptualizing the patients care and reporting this case, the Guide was not used extensively when selecting the test/measures and interventions. Rather, the physical therapist relied on her 18 years of clinical practice, including her experience with patients with other progressive neurological conditions. The scientific literature on SPS provided beneficial information regarding the pathological condition and expected clinical signs and symptoms, providing background information that enhanced the physical therapist’s understanding of this unfamiliar condition. This information also provided a basis upon which hypotheses could be formed regarding the underlying causes of the patient’s problems, emphasizing the need for a stretching program that could be adapted according to the patient’s variable symptoms.

It was difficult to plan BG’s PT sessions due to the variability in his symptoms on a daily basis. Also, BG’s short rehabilitation stay provided little opportunity to progress his program (eg, it was not feasible to advance to a lesser device for gait training) and may also have contributed to his not achieving all goals. Additionally, a longer length of stay would have allowed more time to examine and treat BG s balance.

As indicated by BG’s improvements, it does seem possible to partially remediate impairments in patients with SPS, even within a short time frame. Yet, BG’s pain and spasms did not improve during his rehabilitation stay. This could be due to the condition itself, in that the spasms (which are thought to relate to the pain)1 cannot be prevented or substantially reduced in severity through stretching and relaxation techniques. The ineffectiveness could also be explained by the implementation of relaxation techniques, which were used at times when BG was in a severe spasm, rather than on a regular and preventative basis. It appears that medications may be the only treatment that can effectively reduce the spasms.5,9,21,24,43-46,48-55

Opportunities for conducting clinical trials in patients with SPS are limited by the rarity of the condition. However, it would be viable and useful to publish more case reports on patients with SPS or variants of SPS. Issues that would be helpful to explore include various treatment methods not used in this case. For example, treadmill training with or without body weight support might allow for more substantial improvements in gait speed than were seen in this case. An exploration of the effect of modality use on reducing the patient’s pain, and thus anxiety and spasms, is warranted. As stated previously, examining the effectiveness of regular relaxation techniques on preventing or reducing spasms would be useful. Patients with SPS might benefit from longer rehabilitation stays, allowing for a greater breadth of treatments (eg, balance retraining as discussed previously) and progression of their programs. Finally, the impact of PT on the patient’s quality of life is worth studying, since this is diminished in patients with SPS.40

When developing BG s home stretching program, the exercises were categorized according to priority and ease of performance. This format would be applicable to any patient, but particularly those who experience fluctuations in symptoms. Thus, the effectiveness of this type of exercise prescription could be applied and studied for other patient populations who experience varying symptoms, such as those with Multiple Sclerosis or Parkinson disease.

CONCLUSION

Patients with SPS are likely to be referred to physical therapy due to the impairments and subsequent functional limitations posed by the condition. Yet, little information about PT management of these patients is found in the literature. This case report described the PT management for a patient with SPS, comprised of stretching exercises, techniques to decrease stiffness and aide in relaxation, and functional retraining. At discharge, the patient showed improvements in range of motion, posture, and gait despite the presence of continued stiffness, spasms, and pain.

ACKNOWLEDGEMENTS

I would like to acknowledge and thank “BG”, who so willingly shared his rehabilitation experience with the hope of helping others with Stiff-Person Syndrome. Also, thanks to Michael Fillyaw, MS, PT and Regi Robnett, MS, OTR/L for their thoughtful feedback during the preparation of this manuscript.

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Kirsten Potter, PT, MS, NCS

Associate Professor, University of New England, Portland, ME ([email protected])

Appendix 1. A Description of the Home Exercise Program (Adapted from Saunders Exercise Xpress, Exercise Software, Version 1, The Saunders Group, Inc., 4250 Norex Drive, Chaska, MN, 55318)

1. Sitting hamstring stretch: Sit with leg propped on a footstool; relax, letting the leg straighten; lean forward, keeping the back straight.

2. Back flexion in quadruped: Assume hands and knees position; bend knees to move buttocks toward heels.

3. Back extension (prone push-up): lie on stomach; prop up on elbows; press trunk upward, letting hips sag toward the bed.

4. Low back side-bending in quadruped: Assume hands and knees position; let hips sag sideways toward bed.

5. Single knee to chest: lie on back; pull one knee to chest.

6. Sitting back flexion: Sit in chair; bend forward, lowering chest toward knees.

7. Lower trunk rotation in hook-lying: lie on back with knees bent; rotate knees to one side, toward bed.

8. Hip adductor stretch in hook-lying: lie on back with knees bent and feet together; spread knees apart.

9. Hip external rotation stretch in supine (with LE in flexion): lie on back holding knee and ankle on one leg; hold knee stable and pull ankle toward chest.

10. Gastrocnemius wall stretch: Stand with hands up on a wall and feet in a stride position; point toes directly toward wall and hold heel down; lean into wall.

11. Soleus stretch in sitting: Sit in a chair with both feet on the floor; using both hands, press into one knee so that the heel moves toward floor.

12. Stretch into eversion in sitting: Sit in a chair with one leg crossed over the other; grasp one foot at the heel and mid-foot; turn the foot downward.

Exercise Categorization:

Low priority / Easy: Exercise # 1

Low priority / Difficult: Exercises #2-4

High priority / Easy: Exercises #5-12

Copyright Neurology Report Mar 2006

By Giacomini, Pier Giorgio; Napolitano, Bianca; Alessandrini, Marco; Di Girolamo, Stefano; Magrini, Antonio

Abstract

Benign paroxysmal positional vertigo (BPPV) is a high-prevalence vestibular end-organ disorder caused by the detachment of utricular otoconia which float in the posterior or lateral semicircular canal. In the majority of cases the etiology of BPPV is unknown and it may follow viral infection, vascular disorders or head trauma. BPPV may be recurrent, with some authors demonstrating a correlation between recurrence and female gender. We report herein on ten cases (out of 289 diagnoses of BPPV) of recurrent idiopathic BPPV, occurring in healthy women receiving oral contraceptive treatment, which ceased after treatment suspension. It has been hypothesized that the impaired water and electrolyte balance, the variations of endolymphatic pH and the impairment of glucose or lipid metabolism induced by oral contraceptive treatment may cause otoconial degeneration and subsequent otoconia detachment and BPPV. The rarity of the finding (10/289) could account for the poor attention paid to the hormonal pathogenesis of BPPV.

Keywords: Canalithiasis, hormonal, oral contraceptives, positional vertigo

Introduction

Benign paroxysmal positional vertigo (BPPV) is characterized by various degrees of acute vertigo attacks that are paroxysmal and last from seconds to minutes, being elicited by changes in head position [1]. The incidence of the disease is reported to be 10 in 100 000 [2], although no general agreement exists [3]. Nevertheless, BPPV is the most frequently observed pathology in otoneurological clinical practice [1]. The average age of onset is 50-60 years, with incidence increasing with age [4], and women are more affected than men, with a 2:1 ratio [5].

The etiology of BPPV may be idiopathic, post-traumatic, post- infectious or due to vascular disorders [6], although the higher prevalence in women seems more evident in ‘idiopathic’ forms of BPPV (female/ male ratio 2-3:1) [7]. It may therefore be hypothesized that hormonal disorders in women may be involved in the genesis of some forms of BPPV of unknown etiology. The underlying pathogenetic mechanism is almost generally accepted as the detachment of otoliths from the macula utriculi and their dislocation into the semicircular canals.

The natural course of BPPV may vary. Schuknecht [8] differentiated three forms of BPPV: self-limited, recurrent and permanent, according to the type of evolution. The self-limited form is the most frequent – it subsides spontaneously within weeks or months, without a tendency of recurrence [8]; the recurrent form manifests with episodes of vertigo which recur after variable periods of remission lasting for weeks or years; and the permanent form persists continuously for more than a year and is not responsive to rehabilitative treatment.

In many cases, a diagnosis of probable or possible etiology can be formulated if BPPV occurs in patients with pathological conditions likely to provoke the detachment and/or degeneration of macular otoconia or the alteration of endolymphatic metabolism [9]. Causes of otoconia detachment include Menire’s disease, chronic otitis, blood hyperviscosity and prolonged bed rest. BPPV is fundamentally considered an idiopathic disorder as a multifactorial etiology is identified in less than 50% of patients.

As no previous remarks on this matter have been found, we report herein on ten cases of recurrent idiopathic BPPV, occurring in healthy women receiving oral contraceptive treatment, which ceased after treatment suspension.

Case presentation

Between January 2001 and January 2003, 289 patients were diagnosed as having BPPV at the outpatient clinic of the Department of Otolaryngology, University of Rome ‘Tor Vergata.’ Eighty-three patients used oral contraceptives. Among the 83 patients, 22 presented recurrent BPPV, but only in 10 patients the association of oral contraceptives treatment, recurrent BPPV and remission of symptomatology with suspension of treatment was observed.

The latter cohort consisted often young, otherwise healthy women (mean age 32 7 years, range 25-39 years). All of these patients complained of acute onset rotatory vertigo, without any obvious cause, with symptoms and paroxysmal positional nystagmus (PPN) typical for canalithiasis of the posterior semicircular canal (PSC) [10], recurrent over a period of 2-8 months and only partially responsive to ‘repositioning’ maneuvers.

All patients were receiving oral contraceptive therapy: five patients were taking ethinylestradiol/ drospirenone, three were taking ethinylestradiol/levonorgestrel and two ethinylestradiol/ gestodene, for a period of 6-36 months.

The otoneurological examination consisted of:

(1) Obtaining an accurate history.

(2) Pure tone and impedance audiometry.

(3) Vestibular examination with assessment of spontaneous and evoked nystagmus by infrared videonystagmoscopic observation and electronystagmographic recording. The assessment of evoked nystagmus consisted of eliciting nystagmus by head positioning, such as the Dix-Hallpike maneuver [10] for diagnosis of canalithiasis of the PSC and the McClure maneuver [11] for diagnosis of canalithiasis of the lateral semicircular canal.

Table I. Population profile.

(4) During the follow-up period patients were instructed not to avoid movements that may elicit vertigo. Upon the occurrence of relapsing vertigo, the patients were asked to record it and undergo re-examination as soon as possible at the outpatient clinic. The relapses were then defined on the basis of the signs and symptoms recorded.

Hearing was normal in all patients and no patient had a history of labyrinthine or neurological pathology.

The Dix-Hallpike maneuver elicited rotatory vertigo, with intense neurovegetative symptoms, and a nystagmus pattern characteristic of BPPV of the PSC canal in all ten patients (six cases to the left, four cases to the right side). The patients were treated with the Epley repositioning maneuver [12] and rechecked for the presence of vertigo and/or nystagmus after 3 days, 1 month and 3 months.

On the 3-day check-up, all patients reported a subsiding of positional vertigo after the repositioning maneuver, but typical BPPV and PPN were still present after performing the Dix-Hallpike maneuver. At the 1-month check-up, the patients experienced relapses (1-3 episodes) of BPPV with a symptom-free interval of 10-20 days; at the 2-month check-up, all patients experienced at least one episode of BPPV per month. Due to personal previous anecdotical observations of spontaneous resolution of BPPV after discontinuing contraceptive therapy for unrelated causes (unpublished data), all patients were required to discontinue hormonal treatment and monthly examinations were carried out for the next 6 months.

In all cases, the recurrence of BPPV subsided after suspension of oral contraceptives. At the 6-month follow-up no recurrences were reported by patients and no PPN was observed for 6 months after the first episode (Table I).

Discussion

The recurrence of BPPV has been addressed marginally by different authors. Published papers concerning the long-term outcome of different therapeutic strategies report a varied rate of recurrence, which is mainly related to methodological differences between the studies (sample size, follow-up period, type of study, method of analysis). Considering studies with long-term follow-up periods, in which the recurrence rate is determined prospectively, we conclude that the rate of recurrence of BPPV is high, and may exceed 40% [13- 15]. Regarding the factors that may influence a relapse of disease, Dornhoffer and Colvin [16] observed a significant correlation between recurrent BPPV episodes and concomitant Meniere’s disease, while Beynon and colleagues [13] demonstrated a correlation between female gender and recurrent BPPV.

The evaluation of recurrence can also be based on clinical history, identifying elements that characterize the pathologic condition and help solve the etiologic problem. One of the aspects less studied, but certainly fundamental, is the catabolism of otoliths and the genesis of endolabyrinthic bodies of a different nature.

Various hormonal triggers may be released in the premenstrual syndrome, during pregnancy, in premenopausal syndromes and by the use of oral contraceptives [17], which have been associated with neurological symptoms including vertigo. Specifically, the use of oral contraceptives may have multiple metabolic effects. The mechanisms presumed responsible for premenstrual hormonemediated vestibular impairment [18] are as follows:

(1) A sudden fall in blood estrogens and progesterone levels, with a peak in blood aldosterone concentration and subsequent variations of endolymph/perilymph pressures, due to impaired water and electrolyte balance.

(2) secondary hypothyroidism.

(3) Blood hyperviscosity.

It is important to note that the effect of oral contraceptives on vestibular function has not been addressed precisely and seems somehow controversial. The episodic occurrence of vertigo, not better specified, has been described in patients taking these drugs [1921], as well as the absence of negative effects of oral contraceptives on otologic disorders [22]. Furthermore, apart from impacting on the estrogenemia/ progestenemia, oral contraceptives can also induce hyperlipidemia type IV [2\3] and hyperinsulinism with a reduced glucose tolerance [24], similarly to what happens during the ‘premenstrual state’.

Referring to our observations on recurrent and persisting BPPV in young women during contraceptive therapy, it should be emphasized that each systemic disease or condition capable of causing otoconia dislodgement with a partial functional lesion could be responsible for BPPV [9].

Otoconia detachment and formation of highdensity mineralized particles in the semicircular canals are considered the main causes of BPPV, even though the chemical composition of such particles is currently unknown [25]. It has been reported that pH variations and/ or ion deficiencies in the endolymph may alter the structure of the otoconia [26]. A deficit in endolymphatic calcium supply has been suggested to explain senile otoconial demineralization [27,28]; in fact, a possible pathogenesis seems to be related to impaired calcium homeostasis, frequently associated with menopausal hormonal deficiencies or changes. This hypothesis would suggest a higher prevalence of senile otoconial degeneration in females, currently not yet confirmed by histological studies [29].

In the ten described cases of BPPV related to contraceptives assumption, different pathogenetic hormone-mediated mechanisms might be hypothesized:

(1) The variation of endolymphatic pressure, due to alterations of water and electrolyte balance with chronic hydrops, could cause degeneration of the fibers anchoring the otoconia.

(2) Variations of endolymphatic pH, due to a secondary hyperaldosteronism, could cause otoconial degeneration.

(3) A vascular affection of otoconia and macula, due to a secondary impairment of glucose or lipid metabolism, could cause otoconia or otoconial membrane degeneration.

These mechanisms could explain how the mentioned BPPV, recurrent and responsive to the suspension of hormonal treatment, could occur. The rarity of the finding (10/289) could account for the poor attention paid to the hormonal pathogenesis of BPPV.

In conclusion, the effect of hormones on vestibular function appears not completely explored [30], but is worthy of further investigation to clarify clinical entities such as the cases of BPPV reported herein.

References

1. Strupp M, Arbusow V. Acute vestibulopathy. Curr Opin Neurol 2001;14:11-20.

2. Mizukoshi K, Watanabe Y, Shojaku H, Okubo J, Watanabe I. Epidemiological studies on benign paroxysmal positional vertigo in Japan. Acta Otolaryngol Suppl 1988;447:67-72.

3. Froehling DA, Silverstein MD, Mohr DN, Beatty CW, Offord KP, Ballard DJ. Benign positional vertigo: incidence and prognosis in a population-based study in Olmsted County, Minnesota. Mayo Clin Proc 1991;66:596-601.

4. Katsarkas A. Electronystagmographic (ENG) findings in paroxysmal positional vertigo (PPV) as a sign of vestibular dysfunction. Acta Otolaryngol 1991;1H:193-200.

5. Baloh RW, Honrubia V, Jacobson K. Benign positional vertigo: clinical and oculographic features in 240 cases. Neurology 1987;37:371-378.

6. Baloh RW, Jacobson K, Honrubia V. Horizontal semicircular canal variant of benign positional vertigo. Neurology 1994;43: 2542- 2549.

7. Katsarkas A. Benign paroxysmal positional vertigo (BPPV): idiopathic versus post-traumatic. Acta Otolaryngol 1999;119: 745- 749.

8. Schuknecht HF. Cupololithiasis. Adv Otorhinolaryngol 1973; 20:434-443.

9. Karlberg M, Hall K, Quicken N, Hinson J, Halmagyi GM. What inner ear diseases cause benign paroxysmal positional vertigo? Acta Otolaryngol 2000;120:380-385.

10. Dix MR, Hallpike CS. Pathology, symptomatology and diagnosis of certain common disorders of the vestibular system. Ann Otol Rhinol Laryngol 1952;61:987-1016.

11. McClure JA. Horizontal canal BPV. Am J Otolaryngol 1985; 14:30-35.

12. Epley JM Caveats in particle repositioning for treatment of canalithiasis (BPPV). Otolaryngol Head Neck Surg 1997; 8:68-76.

13. Beynon GJ, Baguley DM, da Cruz MJ. Recurrence of symptoms following treatment of posterior semicircular canal benign paroxysmal positional vertigo with a particle repositioning maneuver. J Otolaryngol 2000;29:2-6.

14. Hain TC, Helminski JO, Reis IL, Uddin MK. Vibration does not improve results of the canalith repositioning procedure. Arch Otolaryngol Head Neck Surg 2000;126;617-622.

15. Nunez RA, Cass SP, Furman JM. Short- and long-term outcomes of canalith repositioning for benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 2000;122: 647-652.

16. Dornhoffer JL, Colvin GB. Benign paroxysmal positional vertigo and canalith repositioning: clinical correlations. Am J Otol 2000;21:230-233.

17. Rubin W. Biochemical evaluation of the patient with dizziness. Semin Hearing 1989;10:151-159.

18. Andrews JC, Ator GA, Honrubia V. The exacerbation of symptoms in Meniere’s disease during the premenstrual period. Arch Otolaryngol Head Neck Surg 1992; 118:74-78.

19. Rybak LP. Metabolic disorders of the vestibular system. Otolaryngol Head Neck Surg 1995;112:129-132.

20. Egarter C, Huber J, Leikermoser R, Haidbauer R, Pusch H, Fischl F, Putz M. Tibolone versus conjugated estrogens and sequential progestogen in the treatment of climateric complaints. Maturitas 1996;23:55-62.

21. Brill K, Schnitker J, Albring M. Long-term experience with low dose oral contraceptives. Gynecol Endocrinol 1990;4: 227-286.

22. Vessey M, Painter R. Oral contraception and ear disease: findings in a large cohort study. Contraception 2001;63: 61-63.

23. Stone NJ, Levy RJ. The hyperlipidemias and coronary artery disease. Dis Mon 1972;(Aug):3-35.

24. Godsland IF, Crook D, Wynn V. Low-dose oral contraceptives and carbohydrate metabolism. Am J Obstet Gynecol 1990;163:348-353.

25. Thalmann R, Ignatova E, Kachar B, Ornitz D, Thalmanna I. Development and maintenance of otoconia. Biochemical considerations. Ann N Y Acad Sci 2001;942:162-178.

26. Erway LC, Purichia NA, Netzler ER. Genes, manganese, and zinc in formation of otoconia: labeling, recovery, and maternal effects. Scanning Electron Microsc 1986;4: 1681-1694.

27. Lim DJ. Otoconia in health and disease: a review. Ann Otol Rhinol Laryngol 1983;112(Suppl):12-24.

28. Ross MD, Peacor D, Johnsson LG, Allard LF. Observations on normal and degenerating human otoconia. Ann Otol 1976; 85:310-326.

29. Johnsson LG, Rouse RC, Wright CG, Henry PJ, Hawkins JE Jr. Pathology of neuroepithelial suprastructures of the human inner ear. Am J Otolaryngol 1982;3:77-90.

30. Seemungal BM, Gresty MA, Bronstein AM. The endocrine system, vertigo and balance. Curr Opin Neurol 2001;14: 27-34.

PIER GIORGIO GIACOMINI, BIANCA NAPOLITANO, MARCO ALESSANDRINI, STEFANO DI GIROLAMO, & ANTONIO MAGRINI

Department of Otolaryngology, University of Rome ‘Tor Vergata’, Rome, Italy

(Received 2 March 2005; revised 25 October 2005; accepted 28 October 2005)

Correspondence: P. G. Giacomini, Department of Otolaryngology, Policlinico ‘Tor Vergata’, Viale Oxford 81, 1-00133 Rome, Italy. Tel: +39 06 20902925. Fax: +39 06 20902921. E-mail: [email protected] or [email protected]

Copyright Taylor & Francis Ltd. Jan 2006

By Cocuroccia, Barbara; Gisondi, Paolo; Gubinelli, Emanuela; Girolomoni, Giampiero

Abstract

Autoimmune progesterone dermatitis (APD) is a rare disorder characterized by recurrent polymorphous skin manifestations, which appear or are exacerbated during the Iuteal phase of the menstrual cycle. The hallmarks for diagnosis include premenstrual flare, its prevention with the inhibition of ovulation, and positive skin reaction to intradermal injection of progesterone. The mainstay of treatment is to inhibit the secretion of endogenous progesterone by suppressing ovulation. Bilateral oophorectomy may be necessary in patients with severe and refractory symptoms. We report herein the case of a 38-year-old woman who developed recurrent and cyclic vesiculobullous eruptions clinically suggestive of erythema multiforme or autoimmune bullous diseases. The skin manifestations turned out to be APD. The patient was treated with tamoxifen 20 mg daily with complete symptom remission after 4 months.

Keywords: Autoimmune progesterone dermatitis, hormone-induced dermatitis, progesterone-induced anaphylaxis

Introduction

Autoimmune progesterone dermatitis (APD) is a rare disorder characterized by recurrent cyclic skin eruptions which appear or are exacerbated during the luteal phase of the menstrual cycle and resolve totally or partially after menses [1,2]. The skin manifestations are polymorphous and more commonly include erythematous and eczematous patches and plaques, urticaria, angioedema and erythema multiforme-like eruptions.

Progesterone-induced anaphylaxis has been also reported [3]. APD is considered a hypersensitivity reaction to increased levels of endogenous progesterone during the luteal phase of the menstrual cycle [4]. Exposure to exogenous progesterone may play a role in triggering APD in some patients [5]. Similar eruptions have been reported in relation to exogenous or endogenous estrogens [6]. Positive skin tests to progesterone or its derivatives, reproduction of symptoms with intramuscular hormonal challenges and detection of antibodies to progesterone or its derivatives have suggested an autoimmune basis for the syndrome [3,7].

Case report

A 38-year-old woman presented with a 3-year history of cyclic dermatosis involving the extremities and the oral and genital regions. The eruption usually began approximately 1 week before her menstrual period and improved 2-3 days into the menstrual flow, with some active lesions persisting throughout. The disease was interpreted elsewhere as erythema multiforme. Continuous therapy with oral acyclovir for 6 months was inefficacious. Oral prednisone at high doses (> 1 mg/kg daily) was effective in preventing the manifestations, but the eruption relapsed at daily doses of 0.5 mg/ kg or less, in coincidence with the luteal phase of her menstrual cycle. She had been taking the contraceptive pill for 5 years and denied intake, even occasionally, of other drugs.

At the time of presentation, eroded and crusted lesions were present on the oral mucosa, lips, vulva and perineal area. Moreover, target erythematous plaques with overlying vesiculobullous lesions, symmetrically distributed on the upper and lower extremities, were present (Figure 1). Routine laboratory investigations, as well as serum complement levels and autoantibodies against nuclear antigens, native DNA and extractable nuclear antigens, were normal or absent. A search for serum immunoglobulin M antibodies against herpes simplex virus 1 and 2, Epstein-Barr virus and Mycoplasma pneumoniae was negative. Serum antibodies against the 180-kDa bullous pemphigoid antigen, desmoglein 1 and 3 were absent. Indirect immunofluorescence on normal and salt-split skin was negative. The chest X-ray as well as abdominal and pelvic echo scans did not reveal abnormalities. A biopsy specimen was obtained for histology and direct immunofluorescence studies. Histological examination showed necrotic keratinocytes at the basal layer of the epidermis and upper dermal infiltrates of lymphocytes, neutrophils and rare eosinophils. Moreover, the lymphocytic infiltrate extended into the epidermis in some areas (Figure 2). Direct immunofluorescence test performed on perilesional skin did not reveal deposits of immunoglobulins, complement or fibrinogen. Intradermal testing with progesterone (0.1 ml of an aqueous suspension at 1 mg/ml) on the left forearm resulted in a 10-mm area of erythema and edema 8 h after injection. The control intradermal testing with distillate water was negative. Intradermal testing with estrogen benzoates (0.1 ml of an aqueous suspension at 1 mg/ml) was negative. The contraceptive pill was discontinued without benefit. Therapy with tamoxifen 20 mg daily induced progressive amelioration with complete and durable clearing of the eruption after 3 months. The patient spontaneously discontinued treatment with relapse of the eruption. Further therapy with tamoxifen resulted in complete disease regression after 2 months. At a 6-month follow-up and continuous therapy, the patient was disease-free.

Figure 1. Multiple eroded and crusted elements on the lips (A). Target erythematous and vesiculobullous lesions on the upper arms (B) and knees (C).

Figure 2. Lesional skin showing necrotic keratinocytes at the basal layer of the epidermis and a perivascular infiltrate of lymphocytes, neutrophils and rare eosinophils in the upper dermis. In some areas, lymphocytes emigrate into the epidermis.

Discussion

APD is a rare cyclic reaction to progesterone produced during the luteal phase of a woman’s menstrual cycle which can present with a variety of skin manifestations often resulting in delayed diagnosis. Other than eczematous lesions, urticaria, angioedema and erythema multiforme-like eruptions, vesicular, bullous or papulopustular lesions, deeptype erythema annulare centrifugum-like manifestations and fixed drug eruption have been described [3,8-10]. Moreover, anaphylactic reactions with urticaria, flushing, laryngeal edema, bronchospasm, hypotension and shock have been reported [11-13]. In many cases, APD occurs in women taking or having taken oral contraceptives, which may act as disease trigger [3]. Similar eruptions have been reported in relation to exogenous or endogenous estrogens [6]. The diagnosis of hormone-induced dermatitis in the present case was suspected in view of the premenstrual recurrent cyclic eruptions and previous exposure to exogenous sexual hormones. Physical and histological examination was very suggestive of erythema multiforme, but the absence of recurrent herpes simplex, history of drug intake or associated diseases militated against this diagnosis. Negative skin immunofluorescence and the absence of autoantibodies to skin components excluded an autoimmune bullous disorder. Positive intradermal test with progesterone, but not estrogens, and resolution of the manifestations with tamoxifen confirmed the diagnosis of APD. It is important to suspect the diagnosis of autoimmune hormone dermatitis in women who present with a skin eruption that waxes and wanes in relation to the menstrual cycle. Systemic corticosteroids may temporarily improve symptoms [3,7]. The mainstay of treatment, however, is to inhibit the secretion of endogenous progesterone by the suppression of ovulation and includes gonadotropin-releasing hormone/luteinizing hormone- releasing hormone analogs, danazol, tamoxifen and conjugated estrogens [14-16]. Bilateral salpingo-oophorectomy may be necessary in patients with refractory and severe symptoms [1,17,18].

References

1. Shelley WB, Preucell RW, Spoont SS. Autoimmune progesterone dermatitis. Cure by oophorectomy. JAMA 1964;190:35-38.

2. Herzberg AJ, Strohmeryer CR, Cirillo-Hyland VA. Autoimmune progesterone dermatitis. J Am Acad Dermatol 1995;32:335-338.

3. Snyder JL, Krishnaswamy G. Autoimmune progesterone dermatitis and its manifestation as anaphylaxis: a case report and literature review. Ann Allergy Asthma Immunol 2003;90:469-477.

4. Stephens CJM, Black MM. Perimenstrual eruptions: autoimmune progesterone dermatitis. Semin Dermatol 1989;8:26-29.

5. Osakay T, Kutluay L, Kaptanoglu A, Karabacak O. Autoimmune progesterone dermatitis. Eur J Dermatol 2002;6:589-591.

6. Mutasim DF, Baumbach JL. Bullous autoimmune estrogen dermatitis. J Am Acad Dermatol 2003;49:130-131.

7. Miura T, Matsuda M, Yanbe H, Sugiyama S. Two cases of autoimmune progesterone dermatitis. Immunohistochemical and serological studies. Acta Derm Venereol 1989;69:308-310.

8. Halevey S, Cohen A, Lunenfeld E, Grossman N. Autoimmune progesterone dermatitis manifested as erythema annulare centrifugum: confirmation of progesterone sensitivity by in vitro interferon-y release. J Am Acad Dermatol 2002;47:311-313.

9. Moghadam BK, Hersini S, Barker BF. Autoimmune progesterone dermatitis and stomatits. Oral Surg Oral Med Oral Pathol 1998;85:537- 541.

10. Warin AP. case 2. Diagnosis: erythema multiforme as a presentation of autoimmune progesterone dermatitis. Clin Exp Dermatol 2001;26:107-108.

11. Meggs WJ, Pescovits OH, Metcalfe D, Loriaux DL, Cutler G Jr, Kaliner M. Progesterone sensitivity as a cause of recurrent anaphylaxis. N Engl J Med 1984;311:1236-1238.

12. Slater JE, Kaliner M. Effects of sex hormones on basophil histamine release in recurrent idiopathic anaphylaxis. J Allergy Clinlmmunol 1987;80:285-290.

13. Slater JE, Raphael G, Cutler GB Jr, Loriaux DL, Meggs WJ, Kaliner M. Recurrent anaphylaxis in menstruating women: treat\ment with a luteinizing hormone-releasing agonist-a preliminary report. Obstet Gynecol 1987;70:542-546.

14. Shahar E, Bergman R, Pollack S. Autoimmune progesterone dermatitis: effective prophylactic treatment with danazol. Int J Dermatol 1997;36:708-711.

15. Stephens CJM, Wojnarowska FT, Wilkinson JD. Autoimmune progesterone dermatitis responding to tamoxifen. Br J Dermatol 1989;121:135-137.

16. Yee KC, Cunliffe WJ. Progesterone-induced urticaria: response to buserelin. BrJ Dermatol 1994;130:121-123.

17. Rodanas JM, Herranz MT, Tercedor J. Autoimmune progesterone dermatitis: treatment with oophorectomy. Br J Dermatol 1998; 139:508- 511.

18. Vasconcelos C, Xavier P, Vieira AP, Martinho M, Rodrigues J, Bodas A, Barros MA, Mesquita-Guimaraes J. Autoimmune progesterone urticaria. Gynecol Endocrinol 2000; 14:245-247.

BARBARA COCUROCCIA1, PAOLO GISONDI2, EMANUELA GUBINELLI1, & GIAMPIERO GIROLOMONI2

1 Istituto Dermopatico dell’Immacolata, IRCCS, Rome, Italy, and 2 Department of Biomdical and Surgical Sciences, Section of Dermatology, University of Verona, Verona, Italy

(Received 1 February 2005; revised 1 June 2005; accepted 7 June 2005)

Correspondence: G. Girolomoni, Department of Biomedical and Surgical Sciences, Section of Dermatology, University of Verona, Piazzale A. Stefani 1, 1-37126 Verona, Italy. Tel: 39 45 8072547. Fax: +39 45 8300521. E-mail: [email protected]

Copyright Taylor & Francis Ltd. Jan 2006

By Joe Graedon and Teresa Graedon

Q: I wonder whether some additive to Earl Grey tea might cause muscle pain and cramping. I am a yoga teacher with a generally mobile body. During the past couple of years, I have suffered worsening muscle pain, cramping and restricted movement. Medicine, acupuncture, physical therapy and massage all failed to provide lasting improvement.

When a recent flulike episode caused me stomach distress, I gave up my two cups of Earl Grey with breakfast and switched to regular orange pekoe tea. Within two weeks, all symptoms were gone and mobility was restored.

I am still drinking tea and have made no other conscious changes, so it seems that the Earl Grey tea is somehow the cause of my problems. What is there in Earl Grey that could set up this reaction?

A: A doctor in Austria published a case report on a 44-year-old man who developed severe muscle cramps in his feet and legs after he started drinking a lot of Earl Grey tea (The Lancet, April 27, 2002). The patient also had muscle twitching, but all the tests on the work-up were normal. When he stopped the Earl Grey tea, his symptoms also disappeared.

Earl Grey tea is flavored with bergamot oil, from the citrus fruit bergamot. It contains a compound called bergapten that can block potassium channels. Potassium flow in and out of the cells is crucial for muscle function, and this presumably explains why too much Earl Grey tea could cause muscle cramps.

***

Q: The lady who was concerned about her husband’s hot food causing an ulcer should ease up. My stomach used to bother me until I started using jalapeno peppers, salsa and Tabasco sauce on scrambled eggs, hash browns, pinto beans and spaghetti sauce. I have no more stomach problems.

A: Despite its reputation, spicy food does not necessarily cause ulcers. Animal research suggests that the essence of chili peppers (capsaicin) may even help protect the stomach from aspirin damage.

***

Q: I am concerned about elderly people taking medical advice from their well-intentioned but completely unqualified children. My adult siblings convinced our parents to take herbs and supplements with no comprehension of how these might interact with prescribed medicines. My sibs believe they know as much or more than doctors.

My father died last year with liver complications. I hate to think of all the CoQ-10, echinacea, ginkgo, etc., that went through that vital organ. No amount of reasoning could counteract both my parents’ faith in their children’s advice over their doctors’.

Is there any way to let elderly people know that their prescription drugs might interact with herbs their kids recommend?

A: Your fears are completely justified. Herbs and dietary supplements can interact with many prescription medications. Certain combinations can be lethal. Unfortunately, physicians and pharmacists may not always be aware of such incompatibilities.

People can help prevent such complications by doing their own homework. We have addressed this issue in our 600-page paperback book, “The People’s Pharmacy Guide to Home and Herbal Remedies.” If you would like a copy, please send $6.99 plus $3 postage and handling to: Graedons’ People’s Pharmacy, Dept. HHR, P.O. Box 52027, Durham, NC 27717-2027.

By Kelly Melhart, Fort Worth Star-Telegram, Texas

Mar. 31–LAKE GRAPEVINE — Christopher Constable has walked where giants stood.

The 6-year-old from Fort Worth, his twin sister and his mother drove more than 20 miles to Lake Grapevine to see dinosaur footprints, recently exposed by low water levels.

Christopher, who has a keen interest in dinosaurs, was especially excited.

“They’re cool,” he said Wednesday, then crouched and growled in imitation of a dinosaur.

The tracks — imprints several inches deep in sandstone bedrock — are believed by the U.S. Army Corps of Engineers to be those of the hadrosaur, a duckbilled plant-eating dinosaur that lived about 96 million years ago. Dinosaur tracks were first found at the lake in 1982. The footprints that drew Christopher and dozens of other parents and children to a ledge on the north shore were discovered in 1989.

Tracks from a meat-eating dinosaur and smaller birdlike dinosaur tracks have also been found on the north shore, said Southern Methodist University geology professor Louis Jacobs, who takes his students to see the prints each semester. The three types of dinosaurs left their prints within days of one another, walking along the shore of an ancient ocean, he said.

“You can see how their stride in the mud changes when they walk up over a hill,” Jacobs said.

The prints are “rediscovered” about every six years when lake levels drop significantly, said Dan McGregor, U.S. Army Corps of Engineers archeologist for the Fort Worth district office. Lake Grapevine is currently about 6 feet below normal levels.

Corps spokesman Clay Church asked that their exact location not be published, to help preserve them. However, the area has not been blocked off.

“They are a really significant scientific find, and we don’t want people out there messing with them,” he said.

But any effort to deter tourists was not enough for some curious folks. Most heard about the prints through local news broadcasts.

“They’re learning about dinosaurs in school, and I just thought it was something we should see,” said Lisa Bennett, who brought sons Blaze, 4, and Jett, 3 to the lake.

Christopher’s grandparents, Pat and Jim Constable, spent Wednesday morning driving around the lake, searching for the prehistoric prints. When they finally found the tracks, after asking about them at a local marina, the Constables called Christopher’s mother. She took Christopher and his twin sister, Michelle, out of class at North Riverside Elementary School in far north Fort Worth and drove to the lake.

After more than an hour, the adults sat near the tracks and watched the children play near the water.

“It is amazing that as old as it is, you can still find it here in Texas,” Pat Constable said. “The sad part is we had to go through a drought to be able to see something like this.”

A dinosaur resource guide with findings from Lake Grapevine: www.smu.edu/geology/teacher_resource.htm

————

Kelly Melhart, (817) 685-3854 [email protected]

—–

Copyright (c) 2006, Fort Worth Star-Telegram, Texas

Distributed by Knight Ridder/Tribune Business News.

For information on republishing this content, contact us at (800) 661-2511 (U.S.), (213) 237-4914 (worldwide), fax (213) 237-6515, or e-mail [email protected].

By Darbee, Joan C; Ohtake, Patricia J

INTRODUCTION

Breathlessness is a common complaint of individuals with respiratory disease. The sensation of difficult or uncomfortable breathing is probably the single most important determinant impacting day-to-day function of these patients. Dyspnea can lead to functional limitations and disability, including days lost from employment. The physiologic mechanisms resulting in dyspnea are poorly understood and thus quantification is difficult. Because of the multifactorial nature of dyspnea, it can be difficult to predict the level of breathlessness during activities of daily living using measures of respiratory disease. Therefore, the implementation of a specific measure for the determination of dyspnea is important. Specifically, the quantification of the relationship between dyspnea and physical exertion may be a very useful outcome measure to track the efficacy of interventions aimed at dyspnea reduction, improvements in functional ability, or both.

Objective quantification of disability related to dyspnea can be determined using several health status measures such as the St. George’s Respiratory Questionnaire1 and the Chronic Respiratory Disease Questionnaire.2 However, these questionnaires are complex to administer and score.1,2 The St. George’s Respiratory Questionnaire is a self-report health related quality of life tool that consists of 50 items divided into symptom (scored with a 4 or 5 point Likert scale), activity (scored with a true false format), and psychosocial impact (scored with a true/false format) categories. The questionnaire can be completed in approximately 15 minutes. The score is obtained by calculations involving the patient responses modified by empirically determined weights for each response. Category and total scores range from 100% (highest score-signifying profound impact of respiratory disease on health-related quality of life) to 0% (lowest score-signifying no impact of respiratory disease on health-related quality of life).1 The Chronic Respiratory Disease Questionnaire is also a disease-specific health-related quality of life measurement tool. An interviewer administers the 20- item questionnaire and patients respond using colored card responses. This questionnaire examines the domains of dyspnea, fatigue, emotional function, and mastery and requires approximately 20 minutes to administer. Scoring involves adding the scores together for each domain and dividing by the number of questions asked. The scores will range from 1 (most impact of respiratory disease) to 7 (least impact of respiratory disease).2 An alternative measure is the Medical Research Council (MRC) Dyspnea Scale. This measure is part of a larger measure, the MRC Respiratory Questionnaire,3 and was developed for use in epidemiologic studies to standardize the assessment of patients with occupational respiratory diseases.4

The MRC Dyspnea Scale is a simple, standardized, self- administered scale to quantify the effect of breathlessness on daily activities3 and therefore measures perceived respiratory disability. The original scale3 has been modified to include 55 or 6 categories (Table 1).6 Both the 5-point and the 6-point scales are commonly used, however, the 6-point scale seems to be more prevalent in recent investigations. The purpose of this article is to review the reliability and validity of the MCR Dyspnea Scale and thus determine the usefulness of this instrument to document the impact of dyspnea on a person’s physical functioning.

ADMINISTRATION

The MRC Dyspnea Scale is a questionnaire consisting of 5 or 6 statements about perceived breathlessness (Table 1). The difference between the two scales is that the MODERATE category of the 5-point scale is divided into MODERATE and MODERATELY SEVERE in the 6-point scale to distinguish the functional limitation between “walking slower than people of the same age on the level because of breath lessness” and “having to stop because of breath lessness when walking at own pace on the level.” This measure is a self- administered scale and is available in English. The patient reads the 5 or 6 statements and selects the grade that most closely describes the level of physical activity that precipitates their shortness of breath. The number associated with the selected statement is the score. The MRC Dyspnea Scale takes less than 5 minutes to complete and has been used successfully in patients age 6 to >80 years of age.7,8

Table 1. MRC Dyspnea Scales

PSYCHOMETRIC PROPERTIES

Reliability

To have acceptable reliability, the MRC Dyspnea Scale must provide consistent values with small errors of measurement and be able to differentiate between different clients. Specifically, the test must provide reasonable test-retest reliability and have high interrater reliability. Test-retest reliability, which demonstrates the stability of a patient’s response over time, has not been determined for this measure. Interrater reliability has been shown to be very good with a weighted kappa value (κ^sub w^) of 0.92.9

Validity

A measure is valid to the extent that a useful interpretation can be inferred from the measurement. In order to determine the overall validity of a measurement tool, it is necessary to examine several aspects of validity. Criterion validity is the extent to which the measure provides results that are consistent with a gold standard measurement. However, no gold standard exists for comparison for the MRC Dyspnea Scale therefore evaluation of the criterion validity of this measure is not applicable. However, it is possible to evaluate the MRC Dyspnea Scale utilizing concurrent validity as this validity evaluation is appropriately employed when there is no criterion or gold standard for comparison. Concurrent validity identifies the degree to which the result on the measure of interest agrees with the result of another measure assessing the same attribute when they are measured at the same time.10,11 Since the MRC Dyspnea Scale is intended to assess a person’s dyspnea during physical activity at a single point in time, the MRC Dyspnea score should demonstrate a moderately high correlation with results from other valid dyspnea measurement tools.

The MRC Dyspnea Scale, when compared with other dyspnea evaluation measures, has been shown to have acceptable validity for use with individuals with respiratory disease (Table 2). The MRC Dyspnea Scale and the Oxygen Cost Diagram are one-dimensional measures that detect the threshold of activities that bring physical limitations caused by breathlessness whereas the Baseline Dyspnea Index and the St. George’s Respiratory Questionnaire present questions regarding the level of dyspnea that is provoked by performing activities of daily living.12 Score distributions of the MRC Dyspnea Scale, the Oxygen Cost Diagram, the Baseline Dyspnea Index, and the Activity subscale of the St. George’s Respiratory Questionnaire have been demonstrated to have approximately the same level of discriminatory power in accordance with a wide range of disease severity despite differences in the number of items, grading scales, and scoring.12 Evaluation of patients with a chief complaint of breath lessness [included 153 patients with COPD (n=91), interstitial lung disease (n=23), asthma (n=17), heart disease (n=9), obesity (n=6), and cystic fibrosis, chest wall abnormalities, or respiratory muscle weakness (n=7)] revealed that the MRC Dyspnea Scale scores correlated well with the scores on other dyspnea measurement tools including both the Oxygen Cost Diagram and the Baseline Dyspnea Index.9 For patients with COPD, the MRC Dyspnea Scale correlated well with the Oxygen Cost Diagram,13 the Baseline Dyspnea Index,13 and the total score on the St. George’s Respiratory Questionnaire.14 For patients with asthma, the MRC Dyspnea Scale correlated well with both the Baseline Dyspnea Questionnaire15-17 and the modified (0 – 10 scale) Borg scale.16

The MRC Dyspnea Scale scores demonstrate concurrent validity with measures of pulmonary function. Since many respiratory diseases result in dyspnea, it is plausible that the degree of respiratory impairment may result in breathlessness. Therefore, the relationship between the MRC Dyspnea Scale and measures of pulmonary function has been investigated (Table 3). In patients with a chief complaint of dyspnea as well as those with COPD, measurements of airflow obstruction and respiratory muscle strength demonstrate a fair negative correlation10 with the MRC Dyspnea Scale (Table 3) indicating that the lower the airflow and respiratory muscle strength, the greater the dyspnea score. For patients with asthma, measures of airflow obstruction (FEV^sub 1^) and the degree of hyperinflation (FRC, RV/TLC) have been found to have a fair negative correlation with the MRC Dyspnea Scale. However, unlike patients with COPD and dyspnea, respiratory muscle strength in patients with asthma did not correlate with the MRC Dyspnea Scale. For patients with restrictive lung disease, such as idiopathic pulmonary fibrosis, pulmonary function as well as gas exchange had fair to good negative correlation with the MRC Dyspnea Scale. Partial pressure of arterial carbon dioxide (PaCO^sub 2^) was also found to be \a strong predictor of dyspnea in this patient population suggesting that a reduction in PaCO^sub 2^ may be due to an increase in ventilation in an attempt for these patients to reduce their dyspnea.18 Additionally, the MRC Dyspnea score correlated very highly with the duration of the disease (r = 0.83).19 Finally, for patients with chronic lung infection and mucus production, as occurs with cystic fibrosis and bronchiectasis, a good to excellent correlation10 was observed between airflow obstruction and the MRC Dyspnea Scale.

Table 2. Concurrent Validity of the MRC Dyspnea Scale with Other Dyspnea Measurement Tools

MRC Dyspnea Scale scores demonstrate concurrent validity with measures of functional capacity. Because the MRC Dyspnea Scale measures the level of physical activity necessary to precipitate breathlessness, the degree of correlation of the MRC Dyspnea Scale with functional capacity has been examined. For patients with COPD, the MRC Dyspnea Scale was found to have a good correlation with functional capacity (maximal oxygen consumption; Table 4).12 Additionally, for patients with air flow limitation (COPD and asthma), MRC Dyspnea scores were found to correlate well with six minute walk distance (6MWD), indicating that dyspnea level identified with the MRC Dyspnea scale is a good correlate with distance walked in these patient populations.20-22 Interestingly, although the distance walked was correlated with the MRC Dyspnea score, the degree of oxygen desaturation was not.20 Thus, patients with COPD who indicated that they were severely disabled by breathlessness had the shortest 6MWD but did not necessarily have appreciable oxygen desaturation. However, in another study with patients with asthma, the MRC Dyspnea score did not correlate with 6MWD17 suggesting that more research is needed to determine the association between the MRC Dyspnea Scale and 6MWD for these patients.

Table 3. Concurrent Validity of the MRC Dyspnea Scale with Measures of Pulmonary Function

In patients with cystic fibrosis, the MRC Dyspnea score contributes significantly to the prediction of exercise capacity.7 Dyspnea during activities of daily living, as assessed by the MRC Dyspnea Scale, and the perceived dyspnea during an exercise test, assessed by the Borg scale at 50% of the maximal work rate, were related (Table 4)7 This correlation suggests that moderate exercise work loads might be comparable to the individual’s level of exertion during daily physical activities, and as such, dyspnea scores at moderate work loads might therefore be comparable to dyspnea scores during daily living.

The MRC Dyspnea score correlated strongly with the maximal work rate in individuals with bronchiectasis.23 The slope of the observed relationship indicated that the MRC Dyspnea score (0 – 4 scale) increased by 1 MRC unit for every 16% in the percentage of predicted maximal work rate [WRmax = 100.5 – (15.2 x MRC Dyspnea score)].23 This relationship indicates that it may be possible to use the MRC Dyspnea score to approximate exercise capacity when exercise testing is not available or is not indicated for this patient population.

MRC Dyspnea Scale scores demonstrate concurrent validity with measures of body mass index (BMI) and age. MRC Dyspnea scores are correlated with body mass index (BMI; kg/m^sup 2^) in patients with COPD and asthma. For patients with COPD, the correlation is -0.26 indicating that a lower BMI is associated with a higher MRC Dyspnea score.24 Specifically, in 2 groups of patients with COPD who had similar airways obstruction (FEV^sub 1^ = 46 13 vs. 49 13), the underweight patients had a higher MRC Dyspnea score as compared to normal weight patients (3.1 0.9 vs. 2.5+ 1.2; 0-5 scale).24 Conversely, for patients with asthma, the MRC Dyspnea Scale is positively correlated with BMI (r = 0.34).15 This correlation indicates that for patients with asthma, the heavier the patient, the higher the MRC Dyspnea score. For patients with asthma, age showed good, positive correlation with the MRC Dyspnea scores (r = 0.39 to 0.68), indicating that advancing age is associated with higher MRC Dyspnea scores.15-17 Information on the correlation of age with the MRC Dyspnea Scale is not available for other populations with respiratory disease.

Table 4. Concurrent Validity of the MRC Dyspnea Scale with Measures of Functional Capacity

MRC Dyspnea Scale scores demonstrate concurrent validity with measures of health-related quality of life. The quality of life for individuals with respiratory disease has been shown to be lower than healthy individuals and has been attributed to a limitation in physical functioning.16,25 For individuals with mild to severe asthma, the MRC Dyspnea score correlated well with quality of life as determined by the Quality of Life in Asthma Questionnaire (r = 0.59).16 For patients with cystic fibrosis, limitation in function due to dyspnea was identified to be of greater importance to the quality of life than any other physiological parameter as evidenced by the strong correlation between the MRC Dyspnea scores and scores on the Sickness Impact Profile (overall: r = 0.75; physical: r = 0.64; psychosocial: r = 0.64).25 Thus interventions aimed at reducing dyspnea in this patient population are important and their efficacy can be monitored using the MRC Dyspnea Scale. For patients with idiopathic pulmonary fibrosis, the MRC Dyspnea score correlated well with measurements of health related quality of life (SF-36) subscales of physical functioning (r = -0.75), vitality (r = – 0.44), and social functioning (r = 0.46).26 Since breathlessness scales are usually easier and faster to administer than health- related quality of life tools, the MRC Dyspnea Scale may be a useful surrogate measure of health-related quality of life that is important to monitor in this patient population.

MRC Dyspnea Scale scores demonstrate longitudinal validity in response to therapeutic interventions. Longitudinal validity requires that the measure of interest demonstrate correlation with the results of change from a second measure.10 The MRC Dyspnea Scale has been shown to have longitudinal validity in investigations of the responses to pulmonary rehabilitation programs, lung volume reduction surgery (LVRS) procedures, and pharmacological interventions.

The responsiveness of the MRC Dyspnea Scale to changes in dyspnea following pulmonary rehabilitation has been studied. Pulmonary rehabilitation is known to provide reductions in dyspnea in patients with COPD.27 In patients with severe COPD (FEV^sub 1^

The MRC Dyspnea Scale has been used to quantify dyspnea in patients who are undergoing LVRS. In several studies of patients with severe COPD selected for LVRS, the MRC Dyspnea score decreased approximately 1 to 2 MRC units (Figure 1) within 1 month following the surgery and remained at this level for up to 24 months postoperatively.30-34 This reduction in MRC Dyspnea score was associated with clinically important improvements in average 6MWD (251 190 to 477 189 m) and airway obstruction (FEV^sub 1^; 960 369 to 1438 610 L).34

In patients who have had a pneumonectomy for management of unilateral lung destruction from pulmonary hypertension, the MRC Dyspnea score was found to decrease on average from 4.3 0.5 to 3.0 1.4 indicating that there was a clinically significant improvement in the level of dyspnea associated with physical activity following the pneumonectomy.35 The change in the MRC Dyspnea score was negatively correlated with the change in partial pressure of arterial oxygen (PaO^sub 2^)(r = -0.26), indicating that as PaO^sub 2^ increased, dyspnea decreased.35

Other studies have investigated the change in MRC Dyspnea score following the initiation of pharmacological treatment. In a study of patients with pulmonary hypertension due to chronic pulmonary thromboembolism, the MRC Dyspnea score decreased on average from 5.0 0 to 2.8 0.8 (0 – 5 scale) following administration for 6 weeks of the selective phosphodiesterase-5 inhibitor, sildenafil.36 The reduction in the MRC Dyspnea Score was correlated with an improvement in gas transfer (TL^sub CO^; r = -0.54).36 Other pharmacological trials have used the MRC Dyspnea Scale as an outcome measure. For individuals with COPD taking either theophylline or salbutamol for a 2-week period, there was a reduction in dyspnea with both medications with effect sizes of 0.313 and 0.350, respectively.37

Figure 1. Values are means ( SD) MRC Dyspnea scores observed following lung volume reduction surgery (LVRS). Measurements were made preoperatively and for up to 24 months postoperatively. There was an average reduction of 1 to 2 MRC units following LVRS in every study.

OBSERVED VALUES IN KNOWN POPULATIONS

The MRC Dyspnea Scale has shown good to excellent correlations with FEV^sub 1^ for patients with differing severity of both obstructive and restrictive lung disease (Table 2). Usual values are available for patient populations including COPD, asthma, cystic fibrosis, bronchiectasis, and idiopathic pulmonary fibrosis (Table 5). For all patient p\opulations, a reduction in FEV^sub 1^ is associated with an increase in the MRC Dyspnea score.

For patients with COPD, those with a Global Initiative for Chronic Obstructive Lung Disease (GOLD) score of 2 (FEV^sub 1^/FVC

Predictive equations for MRC Dyspnea score (0 – 5 scale) based on FEV^sub 1^ have been developed for individuals with COPD:

Male (age 70 8) MRC score = 4.1 – 0.04 FEV^sub 1^ 6

Women (age 69 9) MRC Score = 4.6 – 0.04 FEV^sub 1^ 6

The average MRC Dyspnea score for a given FEV^sub 1^ for persons with cystic fibrosis and bronchiectasis is very similar to those observed for patients with COPD (Table 5). In contrast, the average MRC Dyspnea scores for individuals with asthma and idiopathic pulmonary fibrosis are approximately twice that observed for individuals with COPD and cystic fibrosis for the same FEV^sub 1^. This observation suggests that although there are good correlations between MRC Dyspnea score and FEV^sub 1^, the nature of the relationship varies depending on the respiratory disease.

In epidemiological studies of older populations, dyspnea predicts functional deterioration.38 In a recent investigation of community dwelling elderly individuals, the MRC Dyspnea Scale was used to quantify dyspnea related to physical functioning in the elderly (Table 5). In response to a postal survey, 55% of community- dwelling respondents (70 years or older) reported dyspnea on the MRC Dyspnea Scale, with 23% to 35% reporting moderate to severe levels.8,39 This reveals that 1 out of 3 people aged 70 or older who live in their homes experience dyspnea when walking on level ground with people their own age. Dyspnea symptoms were also associated with a hazard ratio for cardiovascular- or pulmonary-related death within 8 years of 1.4 (95% CI: 1.1-1.9) per point increase in the MRC Dyspnea score.8

CLINICAL APPLICATIONS

The MRC Dyspnea Scale is a reliable and valid measure of the level of physical activity that precipitates breathlessness. It is a simple, quick, self-administered tool. The MRC Dyspnea Scale has been used with individuals who have the following respiratory diseases: COPD, asthma, cystic fibrosis, bronchiectais, and idiopathic pulmonary fibrosis. It has been used successfully in patients age 6 to >80 years of age.7,8

Table 5. Average MRC Dyspnea Scores at Different Levels of FEV^sub 1^

This measure performs consistently with other dyspnea measurement tools such as the Oxygen Cost Diagram and the Baseline Dyspnea Index. The MRC Dyspnea Scale has demonstrated fair to excellent correlation with FEV^sub 1^ for all of the obstructive and restrictive respiratory diseases in which it has been studied. The MRC Dyspnea Scale has been shown to have longitudinal validity and thus is a useful measure to document responses to therapeutic interventions. With respect to measures of physical activity, the MRC Dyspnea Scale correlates well with functional measures such as the 6MWD. Thus as the MRC Dyspnea score changes, 6MWD is expected to change as well. Changes in MRC Dyspnea scores have been observed following successful pulmonary rehabilitation as well as surgical and medical interventions. Finally, quality of life has been shown to correlate well with the MRC Dyspnea Scale, indicating that dyspnea has a direct relationship with a person’s well-being.

The MRC Dyspnea Scale is an easy to use tool to document the impact of dyspnea on a person’s physical functioning. It has acceptable reliability and validity for use as a measurement tool and is also sensitive to change. As such, this outcome measure provides clinicians with the ability to quantify dyspnea in a meaningful way and to monitor the change in dyspnea in response to physical therapy interventions. It is recommended that the use of the MRC Dyspnea Scale be considered when evaluating an individual whose history indicates that they experience breathlessness during physical activities.

ACKNOWLEDGEMENTS

PJO is supported by a Research Grant from the American Lung Association.

REFERENCES

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7. de Jong W, van der Schans CP, Mannes GP, van Aalderen WM, Grevink RG, Koeter GH. Relationship between dyspnoea, pulmonary function and exercise capacity in patients with cystic fibrosis. Respir Med. 1997;91:41-46.

8. Huijnen B, van der Horst F, van Amelsvoort L, et al. Dyspnea in elderly family practice patients. Occurrence, severity, quality of life and mortality over an 8-year period. Fam Pract. Aug 22, 2005.

9. Mahler DA, Wells CK. Evaluation of clinical methods for rating dyspnea. Chest. 1988;93:580-586.

10. Portney LG, Watkins MP. Foundations of Clinical Research: Applications to Practice. 2nd ed. Upper Saddle River, NJ: Prentice Hall Health; 2000.

11. Rothstein JM, Echternach JL. Primer on Measurement: An Introductory Guide to Measurement Issues. Alexandria, Va: APTA; 1993.

12. Hajiro T, Nishimura K, Tsukino M, Ikeda A, Koyama H, Izumi T. Analysis of clinical methods used to evaluate dyspnea in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1998;158:1185-1189.

13. Mahler DA, Rosiello RA, Harver A, Lentine T, McGovern JF, Daubenspeck JA. Comparison of clinical dyspnea ratings and psychophysical measurements of respiratory sensation in obstructive airway disease. Am Rev Respir Dis. 1987;135:1229-1233.

14. Hajiro T, Nishimura K, Tsukino M, Ikeda A, Oga T. Stages of disease severity and factors that affect the health status of patients with chronic obstructive pulmonary disease. Respir Med. 2000;94:841-846.

15. Filippelli M, Pacini F, Romagnoli I, et al. Airway obstruction and chronic exertional dyspnoea in patients with persistent bronchial asthma. Respir Med. 2000;94:694-701.

16. Martinez-Moragon E, Perpina M, Belloch A, de Diego A, Martinez-Frances M. Determinants of dyspnea in patients with different grades of stable asthma. J Asthma. 2003;40:375-382.

17. Grazzini M, Scano G, Foglio K, et al. Relevance of dyspnoea and respiratory function measurements in monitoring of asthma: a factor analysis. Respir Med. 2001;95:246-250.

18. Papiris SA, Daniil ZD, Malagari K, et al. The Medical Research Council dyspnea scale in the estimation of disease severity in idiopathic pulmonary fibrosis. Respir Med. 2005;99:755-761.

19. Tzanakis N, Samiou M, Lambiri I, Antoniou K, Siafakas N, Bouros D. Evaluation of health-related quality-of-life and dyspnea scales in patients with idiopathic pulmonary fibrosis. Correlation with pulmonary function tests. Eur J Intern Med. 2005;16:105-112.

20. Mak VH, Bugler JR, Roberts CM, Spiro SG. Effect of arterial oxygen desaturation on six minute walk distance, perceived effort, and perceived breathlessness in patients with airflow limitation. Thorax. 1993;48:33-38.

21. Marin JM, Carrizo SJ, Gascon M, Sanchez A, Gallego B, Celli BR. Inspiratory capacity, dynamic hyperinflation, breathlessness, and exercise performance during the 6-minute-walk test in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2001;163:1395-1399.

22. Wegner RE, Jorres RA, Kirsten DK, Magnussen H. Factor analysis of exercise capacity, dyspnoea ratings and lung function in patients with severe COPD. Eur Respir J. 1994;7:725-729.

23. Koulouris NG, Retsou S, Kosmas E, et al. Tidal expiratory flow limitation, dyspnoea and exercise capacity in patients with bilateral bronchiectasis. Eur Respir J. 2003;21:743-748.

24. Sahebjami H, Sathianpitayakul E. Influence of body weight on the severity of dyspnea in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2000;161(3 Pt 1):886-890.

25. de Jong W, Kaptein AA, van der Schans CP, et al. Quality of life in patients with cystic fibrosis. Pediatr Pulmonol. 1997;23:95- 100.

26. Baddini Martinez JA, Martinez TY, Lovetro Galhardo FP, de Castro Pereira CA. Dyspnea scales as a measure of health-related quality of life in patients with idiopathic pulmonary fibrosis. Med Sci Monit. 2002;8: CR405-410.

27. Lacasse Y, Brosseau L, Milne S, et al. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2002:CD003793.

28. de Torres JP, Pinto-Plata V, Ingenito E, et al. Power of outcome measurements to detect clinically significant changes in pulmonary rehabilitation of patients with COPD. Chest. 2002;121:1092- 1098.

29. Lorenzi CM, Cilione C, Rizzard\i R, et al. Occupational therapy and pulmonary rehabilitation of disabled COPD patients. Respiration. 2004;71:246-251.

30. Stammberger U, Thurnheer R, Bloch KE, et al. Thoracoscopic bilateral lung volume reduction for diffuse pulmonary emphysema. Eur J Cardiothorac Surg. 1997;11:1005-1010.

31. Venuta F, de Giacomo T, Rendina EA, et al. Bronchoscopic lung- volume reduction with one-way valves in patients with heterogenous emphysema. Ann Thorac Surg. 2005;79:411-416; discussion 416-417.

32. Harnacher J, Buchi S, Georgescu CL, et al. Improved quality of life after lung volume reduction surgery. Eur Respir J. 2002;19:54-60.

33. Snell GI, Solin P, Chin W, et al. Lung volume reduction surgery for emphysema. Med J Aust. 1997;167:529-532.

34. Demertzis S, Wilkens H, Lindenmeir M, Graeter T, Schafers HJ. Lung volume reduction surgery for severe emphysema. J Cardiovasc Surg (Torino). 1998;39:843-847.

35. Tanaka H, Matsumura A, Okumura M, Iuchi K. Pneumonectomy for unilateral destroyed lung with pulmonary hypertension due to systemic blood flow through broncho-pulmonary shunts. Eur J Cardiothorac Surg. 2005;28:389-393.

36. Sheth A, Park J, Ong Y, Ho T, Madden B. Early haemodynamic benefit of sildenafil in patients with coexisting chronic thromboembolic pulmonary hypertension and left ventricular dysfunction. Vascular Pharmacology. 2004;42:41-45.

37. Guyatt GH, Townsend M, Keller J, Singer J, Nogradi S. Measuring functional status in chronic lung disease: conclusions from a randomized control trial. Respir Med. 1989;83:293-297.

38. Vestbo J, Knudsen KM, Rasmussen FV. Should we continue using questionnaires on breathlessness in epidemiologic surveys? Am Rev Respir Dis. 1988;137:1114-1118.

39. Ho SF, O’Mahony MS, Steward JA, Breay P, Buchalter M, Burr ML. Dyspnoea and quality of life in older people at home. Age Ageing. 2001;30:155-159.

40. Goetghebeur D, Sarni D, Grossi Y, et al. Tidal expiratory flow limitation and chronic dyspnoea in patients with cystic fibrosis. Eur Respir J. 2002;19:492-498.

Joan C. Darbee, PT, PhD;1 Patricia J. Ohtake, PT, PhD2

1 Assistant Professor, University of Kentucky, College of Health Sciences, Division of Physical Therapy, Lexington, KY

2 Associate Professor, Department of Rehabilitation Science, University at Buffalo, Buffalo, NY

Address correspondence to: Patricia J. Ohtake, PT, PhD, Department of Rehabilitation Science, 515 Kimball Tower, University at Buffalo, Buffalo, NY 14214 ([email protected]).

Copyright Cardiopulmonary Physical Therapy Journal Mar 2006

By Ray, Pallab; Mandal, Jharna; Gautam, Vikas; Singh, Kundan; Gupta, Dheeraj

Sir,

Actinomycosis is a progressive glaucomatous disease with local or systemic manifestations and a tendency to produce draining sinuses. Pulmonary actinomycosis by Actinomyces odontolyticus is a rare but an important and challenging diagnosis to make. Due to highly variable presentation, it is commonly confused with malignancy and other chronic suppurative lung diseases’4. Actinomycotic agents are commensals in the mouth, colon and vagina. The portal of entry is usually a breach in the mucosal integrity or pulmonary aspiration15. Thoracic involvement accounts tor approximately 15 per cent of the cases of actinomycosis. The most common clinical picture is an indolent slowly progressive process that involves some complication of the pulmonary parenchyma and pleural space. The spontaneous drainage of an empyema should raise the suspicion of this disease. It is most commonly mistaken for malignant disease. Tuberculosis, nocardiosis, histoplasmosis, blastomycosis, mixed anaerobic infections, bronchogenic carcinoma, lymphoma. mesothelioma and pulmonary infarction are among the entities confused with pulmonary actinomycosis1. We report here a case of pulmonary actinomycosis due to A. odontolyticus.

A 59 yr old man was admitted to the Department of Pulmonary Medicine Postgraduate Institute of Medical Education & Research, Chandigarh in March 2004 with the complaints of cough and chest pain for four months; fever and moderate (~100 ml/day), foul smelling, mucopurulent expectoration for 15 days prior to hospitalization. He was a treated (details not available) case of pulmonary tuberculosis (16 yr back) and was under treatment for bronchial asthma for the last 10 yr. He was obese, had no pallor, icterus, or cyanosis. The sinuses had no detectable abnormality. Despite poor oral hygiene, most of his teeth were in place and no lesion was present. The patient had generalized lymphadenopathy and was tachypnoeic at rest. Respiratory system examination revealed reduced to absent air entry in right infrascapular area, which was dull on percussion; bilateral rhonchi were present. Provisional diagnosis was empyema of the right lung. Laboratory data included white blood cell count of 20,300 cells/l; 72 neutrophils, 23 lymphocytes, 3 monocytes and 2 per cent eosinophils. Computerised tomography scan revealed loculated collection of fluid in the right infrascapular area. Roentgenogram indicated obliteration of the right costophrenic angle. Pleural fluid was drained and sent for bacteriological examination. Patient was on bronchodilator (metered dose inhaler- salbutamol). and intravenous cefotaxime and clindamycin.

Gram stain of pus revealed branching Grampositive bacilli with an exudative response, predominantly neutrophils. The organism was non acid-fast. Some Gram-positive cocci in chains and Gram-negative bacilli were also seen. On aerobic incubation after 24 h at 37C culture was sterile. Anaerobic incubation for 48 h grew pin-point haemolytic, metronidazole resistant colonies. After 4 days of incubation anaerobically. the colonies developed a red (rust-brown/ burnt-red) pigment. The organism was identified as A. odontolyticus based on standard biochemical tests5. Anaerobic culture also grew Bacteroides spp. and Peptostreptococcus spp. The patient stayed for 4 wk in the hospital and received 10 MU of intravenous penicillin daily and responded well.

Clinical disease produced by A. odontolyticus closely resembles that produced by other actinomyces species. It primarily involves the craniofacial regions, the chest, abdomen and the pelvis with rare involvement of the central nervous system, bones and joints, and affects middle-aged men more frequently than women67. In the present case the patient had a productive cough with associated chest pain. The effusion was an exudate with the presence of A. odontolyticus. No lesions were seen in the oral cavity and sinuses were normal excluding possibility of contamination. Quick resolution of symptoms was noted following the initiation of penicillin therapy.

Pulmonary actinomycosis has not been shown to have increased prevalence among immunocompromised hosts and the manifestations and treatment response are essentially similar to the immunocompetent ones8. Certain contaminants namely species of Bacteroides, Streptococcus and Staphylococcus etc., are usually found in association with the causative actinomycete. These organisms enhance the pathogenicity of actinomycetes by creating an anaerobic milieu in which the actinomyces thrive1. In 1957, Bates and Cruickshank described a fairly dramatic presentation of pulmonary actinomycosis with chest pain and cutaneous fistulae discharging sulphur granules9. In a recent study the commonest presentations were reported to be chest pain, cough, sputum and patch in chest X- ray8.’ Penicillin is the drug of choice. In cases of penicillin allergy alternative therapies include erythromycin, tetracycline, doxycycline or minocycline and clindamycin1.

Since the first isolation from a case of advanced dental caries by Batty in 1958(10), 26 cases of actinomycosis due to A. odontolyticus have been described worldwide47. Of these cases, only 14 cases of pulmonary infection due to A. odontolyticus have been reported world wide and we reported here a case from India.

References

1. Russo TA. Agents of actinomycosis. In: Mandell GL, Bennett JE, Dolin R, editors. Principles and practice of infectious disease. 6th d. USA: Elsevier Churchill Livingstone; 2005 p. 2924-34.

2. Fungi and actinomycetes. In: Fraser RS, Colman N, Muller NL, Par PD, editors. Fraser and Fare’s diagnosis of diseases of the chest. Philadelphia: W.B. Saunders Co.; 1999 p. 952-60.

3. Coodley EL, Yoshinaka R. Pleural effusion as the major manifestation of actinomycosis. Chest 1994; 106 : 1615-7.

4. Takiguchi Y, Terano T, Hirai A. Lung abscess caused by Actinomyces odontolyticus. Intern Med 2003; 42 : 732-5.

5. Goodfellow M. Actinomyecetes: Actinomyces, Actinomadura, Nocardia, Streptomyces and related genera. In: Collee JG, Fraser AG, Marmion BP, Simmons A, editors. Mackie & McCartney: Practical medical microbiology, Edinburgh: Churchill Livingstone; 1999 p. 343- 8.

6. The pathogenic fungi and actinomycetes. In: Wonsiewicz MJ, editor. Rippon JW. Mdical mycology. Philadelphia: WB – Saunders Co.; 1988 p. 30-52.

7. Cone LA, Leung MM, Hirschberg J. Actinomyces odontolvticus bacteremia. Emerg Infect Dis 2003; 9 : 1629-32.

8. Mabeza GF, Macfarlane J. Pulmonary actinomycosis. Ear Respir J 2003; 21 : 545-5 1.

9. Bates M, Cruickshank G. Thoracic actinomycosis. Thorax 1957; 12 : 99-124.

10. Batty I. Actinomyces odontolyticus, a new species of actinomyces regularly isolated from deep carious dentine. J Pathol Bacterial 1958; 75 : 455-9.

Pallab Ray*, Jharna Mandai Vikas Gautam, Kundan Singh & Dheeraj Gupta+

Department of Medical Microbiology & + Pulmonary Medicine, Postgraduate Institute of Medical Education & Research

Chandigarh 160012, India

*Corresponding author:

e-mail: [email protected]

Copyright Indian Council of Medical Research Dec 2005

By Michael Conlon

CHICAGO — A study of more than 1,800 patients who underwent heart bypass surgery has failed to show that prayers specially organized for their recovery had any impact, researchers said on Thursday.

In fact, the study found some of the patients who knew they were being prayed for did worse than others who were only told they might be prayed for — though those who did the study said they could not explain why.

The patients in the study at six U.S. hospitals included 604 who were actually prayed for after being told they might or might not be; another 597 patients who were not prayed for after being told they might or might not be; and a group of 601 who were prayed for and told they would be the subject of such prayer.

The praying was done by members of three Christian groups in monasteries and elsewhere — two Catholic and one Protestant — who were given written prayers and the first name and initial of the last name of the prayer subjects. The prayers started on the eve of or day of surgery and lasted for two weeks.

Among the first group — who were prayed for but only told they might be — 52 percent had post-surgical complications compared to 51 percent in the second group, the ones who were not prayed for though told they might be. In the third group, who knew they were being prayed for, 59 percent had complications.

After 30 days, however, the death rates and incidence of major complications was about the same across all three groups, said the study published in the American Heart Journal.

COMPLICATIONS AFTER SURGERY

“Intercessory prayer itself had no effect on whether complications occurred (and) patients who were certain that intercessors would pray for them had a higher rate of complications than patients who were uncertain but did receive intercessory prayer,” the study said.

There is “no clear explanation” for the latter finding, it added.

The study — called the largest of its kind — was designed only to try to measure the impact of intercessory prayer on heart surgery patients, an intervention that some earlier reports had showed seemed to be beneficial.

“Our study was never intended to address the existence of God or the presence or absence of intelligent design in the universe” or to compare the efficacy of one prayer form over another, said the Rev. Dean Marek, director of chaplain services at the Mayo Clinic, one of the authors.

The patients in the study had similar religious profiles with most believing in spiritual healing and almost all also thinking that friends or relatives would be praying for them as well, he said.

“One caveat is that with so many individuals receiving prayer from friends and family, as well as personal prayer, it may be impossible to disentangle the effects of study prayer from background prayer,” Manoj Jain of Baptist Memorial Hospital, Memphis, Tennessee, another author of the report.

The authors said one possible limitation to their study was that those doing the special praying had no connection or acquaintance with the subjects of their prayer, which would not usually be the norm.

“Private or family prayer is widely believed to influence recovery from illness, and the results of this study do not challenge this belief,” the report concluded.

By Jamie Talan, Newsday, Melville, N.Y.

Mar. 30–Brain development in the smartest kids has a different, slower growth course than that in average children, federal researchers have found.

“This tells us that early growth isn’t necessarily better,” said Dr. Jay Giedd, a scientist at the National Institute of Mental Health and one of the lead investigators of the research. The brain regions used to think, plan and reason mature two years later in those kids with high IQ scores, the research found.

Since 1990, 307 kids between ages 4 to 19 have been scanned with MRIs, many every two years. The scientists also obtained detailed neuropsychological tests, including measurements of intelligence, on the volunteers.

“There is probably an optimal speed of brain development,” Giedd said. He likens it to height, which is also under genetic and environmental control. Some kids who grow faster and reach puberty early may not be as tall in adulthood as a child whose growth is slower.

Giedd says the findings are good news for late bloomers. “A child who is not reading or doing math like his peers may end up doing even better than them years down the road,” he said.

The scanning device measures the thickness of the outer layer of the brain. The latest finding, published in Nature, shows children with the highest IQs – those who were rated as “superior” on intelligence tests with scores from 121-143 – were still undergoing a brain growth spurt when those children of normal (scores of 83-109) or above average intelligence (scores of 110-120) had reached their peak of cortical thickness.

Neurons in the brain grow throughout the early years of life and then prune back. This remodeling is important in strengthening brain connections and making the brain system more efficient. This study has helped dispel myths about brain size, thought to be associated with intelligence.

While the brains of all teenagers eventually thinned out by age 19, the researchers came to understand “it’s the journey and not the final destination that matters.” Those with superior intelligence had a slower developmental curve, but then “showed the highest rates of change throughout the journey,” Giedd said.

The thickness of the cortex (the brain’s gray matter) varies with age, especially in the most advanced part of the brain that helps with cognitive processes like thinking and planning.

In those with average intelligence scores, the thickness of the cortex peaked at age 7, and then gradually thinned. By contrast, the smartest 7-year-olds had a thinner cortex that peaked in thickness by age 11 or 12 before pruning back.

Dr. Judith Rapoport, director of NIMH’s child psychiatry branch and a co-investigator in the study, said this extended time of development may be important in strengthening these high-level cognitive circuits. “If the brain matures later, it might be using more complex environmental stimuli,” she said.

The team has done more than 1,000 scans. They have also observed major developmental differences between boys and girls, with girls’ brains maturing between 8 and 18 months earlier than boys. What they have not done yet is link these neural images back to behavior or performance. The researchers were able to predict a child’s IQ by studying the developmental journey, not by measuring the cortical thickness of the adult brain.

Later but smarter

Growth in the cortex, the thinking part of the brain, is delayed in smarter children, according to a long-term study of 307 children.

7 Years Superior intelligence

9 Years High intelligence

13 Years Average intelligence

SOURCES: National Institute of Mental Health; Nature

—–

Copyright (c) 2006, Newsday, Melville, N.Y.

Distributed by Knight Ridder/Tribune Business News.

For information on republishing this content, contact us at (800) 661-2511 (U.S.), (213) 237-4914 (worldwide), fax (213) 237-6515, or e-mail [email protected].

By Amil Khan

GIZA, Egypt — Balancing on his head in the shadow of the ancient pyramids of Giza, a Dutch visitor tries to connect to the spiritual forces he says are swirling around the monuments during Wednesday’s solar eclipse.

“The eclipse is a special moment in time and the shape of the pyramids attracts a universal energy spiral,” Robin, who did not give his full name, said after meditating at the foot of the largest of the pharaonic mausoleums in the desert outside Cairo.

“We are all made of light. Light is what binds us all and makes all us humans one, so this is a very important time to be here,” said the Dutchman while standing barefoot in a circle of people meant to symbolize the sun.

In the far west of Egypt, thousands of people, including Egyptian President Hosni Mubarak, gathered at the border town of Salloum to witness the full solar eclipse.

At the pyramids, outside the track of the total eclipse, the light dimmed and the air cooled as the moon passed in front of the sun without hiding it completely from view.

“There is a lot of mystery about the pyramids. There are things about the pyramids that the scientists don’t recognize,” said Robin, sitting next to the 4,500-year-old Cheops Pyramid.

PYRAMIDS AND ALIENS

Knowing the prominence of the sun in ancient Egyptian religion, researchers visiting the site said it was exciting to witness the eclipse at the pyramids, which some archaeologists have said may have been aligned to the stars.

“The only thing that would have kept me away was being dead,” Blair Wilkins from Britain said.

Wilkins, a researcher of ancient myths and legends, said he had been waiting 18 years for the event since finding a stone artefact at nearby pyramids depicting an eclipse in the area thousands of years ago.

“I didn’t know what would happen … There are so many unanswered questions. You never know, maybe the pyramids will open up and aliens will come out of them,” he said with a smile.

As the moon passed in front of the sun, Wilkins hushed other onlookers. “Did you hear that subsonic boom?” he asked.

Many visitors had not heard about the eclipse until they were told by hawkers on the pyramid plateau, who were selling special viewing glasses next to their usual stock of plastic pyramids and postcards.

“I don’t know about the special energy stuff but one way or another its a spiritual thing to be here for the eclipse,” said Herve L’Hermitte, a French engineer visiting the pyramids for the first time.

By O’Mahony, C

Summary: Adenoviruses infect mucous membranes, including -on rare occasions the urethra. Adenoviruses should therefore be considered as yet another cause of chlamydia-negative non-gonococcal urethritis. The following case illustrates the dilemma posed in a patient with conjunctivitis and urethritis.

Keywords: adenovirus, conjunctivitis, non-gonococcal urethritis, non-specific urethritis

Introduction

A middle-aged man attended clinic in March 2004. He complained of a 10-day history of intense dysuria, frequency and reddening of the tip of the penis. He also complained that both eyes were feeling gritty the last day. Four days earlier, he had been to his general practitioner who had diagnosed a urinary tract infection and had given him norfloxacin 400 mg twice daily for three days. He was married, but did have occasional oral sex from sex workers. Gram- stained urethral smear showed +++ pus cells. He had the usual swabs for gonorrhoea and chlamydia, and a midstream urine sample sent for analysis. He was given 1 g azithromycin and told to call in 10 days. However, three days later, he re-attended with worsening of symptoms. The urethritis was worse and both eyes were now inflamed. Further discussion elicited a history of possible food poisoning, three months earlier, with diarrhoea for a week; so there was a concern about a Reiter’s type syndrome, although there was no arthritis. He was referred immediately to an ophthalmologist for reassurance about possible uveitis. He was seen straight away and had swabs done, and the ophthalmologist prescribed him two weeks of doxycycline 100 mg twice daily. As this case was unusual, I took photos of the eyes and the penis as there was still considerable urethritis, despite the patient having had norfloxacin, azithromycin and doxycycline (Figures 1, 2 and 3). A week later, he called to say that his wife and child also had conjunctivitis then. One of his eye swabs from ophthalmology was reported as detecting adenovirus. By the time he next attended clinic after four days, his symptoms had started to resolve. On examination, there was no residual urethritis, and a urethral swab for adenovirus at that late stage was negative. His wife was seen, but not treated, as this was assumed to be an adenovirus urethritis.

Discussion

There are many causes of chlamydia-negative non-gonococcal urethritis (NGU). It is not unusual to find herpes virus causing intense dysuria if there happens to be an ulcer in the urethra, and it is no surprise that adenovirus infection is also capable of causing a urethritis. Azariah and Reid1 reviewed the literature and also described six cases. Adenovirus can occasionally be isolated from the urethra of men with no signs or symptoms of urethritis, and many situations can therefore be regarded as simple colonization. Oral sex is an easy way of transmitting respiratory adenovirus to the urethra, and oral sex is a known risk factor for NGU.2 Adenoviral conjunctivitis is highly contagious and it is not surprising that other family members rapidly get infected (hence, the term epidemic keratoconjunctivitis). Swenson et al.3 found urethral adenovirus in 20 male patients, attending an sexually transmitted disease (STD) clinic, of whom, 13 had NGU with no other pathogen found.

Figure 1 Marked inflammation of the meatus with a mucoid discharge

Figure 2 Bilateral conjunctivitis

Figure 3 Obvious conjunctivitis extending right to the corneal margin, so there was a concern about uveitis

A rapid tissue culture test for adenovirus is available – Direct Early Antigen Fixed Focus (DEAFF). A urethral swab is sent in viral transport media for DEAFF and culture. It is necessary to highlight that it is an adenovirus request as there is a risk that the laboratory technicians will assume a urethral viral swab is for herpes culture and may process it inappropriately.

In conclusion, adenovirus as the cause of urethritis should be considered in men with conjunctivitis, intense dysuria, a urethral Gram stain showing inflammation, subsequent negative tests for gonorrhoea and chlamydia, and no response to azithromycin or doxycycline.

References

1 Azariah S, Reid M. Adenovirus and non-gonococcal urethritis. Int J STD AIDS 2000;11:548-50

2 Hernandez-Aguado I, Alvarez-Dardet C, GiIi M, Perea EJ, Camcho F. Oral sex as a risk factor for chlamydia-negative ureaplasm- negative non-gonococcal urethritis. Sex Transm Dis 1987;15:100-2

3 Swenson PD, Lowens MS, Celum CL, Hierholzer JC. Adenovirus types 2, 8 and 37 associated with genital infections in patients attending a sexually transmitted disease clinic. J Clin Microbiol 1995;33:2728-31

(Accepted 26 January 2005)

C O’Mahony MD FRCP

Sexual Health Department, Countess of Chester Hospital, NHS Foundation Trust, Chester CH2 1UL, UK

Copyright Royal Society of Medicine Press Ltd. Mar 2006

By Collins, Cathleen A; Decker, Sharon I; Esquibel, Karen A

OBJECTIVE(S): The purpose of the study was to describe definitions of health in Hispanic and African American elders. METHOD(S): This study employed a qualitative framework conducted through a doctoral-level multicultural nursing course. Quasi- statistics and a semi-structured interview format tabulated a frequency in themes in the sample. Hispanic and African American clients at senior citizen centers comprised the convenience sample. Data collection occurred concurrently and the raw data was then shared throughout the class, which led to the study’s major limitation. RESULT(S): Eight reoccurring themes were identified: spirituality, without pain/feeling good, positive attitude with good mentality, high priority, independent/active, health promotion/ maintenance, socialization, and helping others. CONCLUSION(S): Consistency was found between the existing literature and the results of the study. Differences were discovered between the groups, however more similarities were identified. The study results serve as a reminder to the importance in avoiding stereotypes when caring for individuals from any cultural background.

KEY WORD(S): Culture; Cultural Competence; Cultural Competency Care Model; Definition of Health; Perception; Transcultural Nursing.

The United States is a nation rich in cultural diversity. According to the department of Health and Human Services Administration on Aging (2004), minorities currently comprise 16.1 percent of all Americans 65 years and older. By 2030 the older minority American population is projected to increase by 217 percent compared with 81 percent for the older white population (2004). This increase in the population diversity challenges nurses to explore how culture influences an individual’s definition of health. The purpose of this study was to describe definitions of health in Hispanic and African-American elders.

LITERATURE REVIEW

The World Health Organization (WHO) defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (2003). Purnell and Paulanka (2003) expand on this by defining health as a state of wellness that includes physical, mental, and spiritual states and is defined by individuals within their ethnocultural group. Bonder, Martin, and Miracle (2001) recognize perception of health is influenced by an individual’s culture and can be similar to or different from others from other cultures. Spector (2000) identifies that individuals define health through the use of specific descriptions that can be seen, felt, or touched and are linked to self-care practices. Culture is a learned paradigm of beliefs, values, and behaviors shared by a population or group. These values, beliefs, and behaviors are reflected in the language, dress, food, and in social institutions (Burchum, 2002; Mutha, Alien, & Welch, 2002). Purnell and Paulanka (2003) enhance this definition by stating culture is “the totality of socially transmitted behavioral patterns, arts, beliefs, values, customs, life-ways, and all other products of human work and thought characteristics of a population of people that guide their world view and decision making” (p. 3).

Multiple factors that influence culture include nationality, ethnicity, religion, age, gender, education, occupation, life experiences, and religious affiliation (Purnell & Paulanka). Acknowledging that these multiple factors impact cultural beliefs and thus an individual’s definition of health, nurses need to recognize individuals often embrace more than one culture. Therefore, nurses need to acknowledge each person as an individual who experiences different input and life experiences. This recognition requires nurses to be culturally competent. Leininger (2000) states becoming culturally competent requires commitment, a pursuit of knowledge about others, selfawareness and an open and humble attitude. This self exploration includes acknowledging personal values and beliefs, accepting that one’s culture is not superior to others only unique, and recognizing how personal beliefs can influence relationships with others.

Cultural competence as described by Burchum (2002) is a “nonlinear dynamic process that is never ending and ever expanding” (p. 5). As a dynamic process, cultural awareness integrates an understanding and sensitivity to others with excellent interpersonal skills and knowledge from the humanities, and the physical, biologic and social sciences while avoiding stereotyping (Burchum, 2002; Purnell & Paulanka, 2003). Maintaining cultural competence is a daunting task. It requires life-long learning and unlearning, continuous self-awareness, open discussion with others, and personal and organizational accountability toward achieving identified cultural competence goals. Research conducted by Chevannes (2002) demonstrates that “sustainability of learning to care for ethnic minority patients …is best undertaken in the environment where professionals and patients interact on an on-going basis” (p. 297).

Culturally competent nurses not only need to appreciate the culture of the patient, but need to develop a self awareness of their personal culture. The American Nurses’ Association (ANA) Council on Cultural Diversity in Nursing Practice (1991) states, “It is important the nurse consider specific cultural factors impacting on individual clients and recognize that intra cultural variation means that each client must be assessed for individual cultural differences”( 5). Furthermore, the ANA position statement recognizes that nurse-patient encounters include the interaction of “the culture of the nurse, the culture of the client and the culture of the setting” (U 5). Purnell and Paulanka (2003) challenges that to provide culturally competent health care the provider needs to develop an understanding of “his or her existence, sensations, thoughts, and environment without letting these factors have an undue effect on those for whom care is provided” (p. 193).

THEORETICAL FRAMEWORK

This study used the Cultural Competency Community Care Model (CCCC) as a theoretical framework (Kirn-Godwin, Clarke, & Leslie, 2001). The CCCC (Figure 1) describes the need for culturally competent nursing to bring about positive health outcomes for clients. Cultural competence encompasses the dimensions of cultural sensitivity (being respectful of another’s culture), cultural knowledge (cognitive understanding of another’s culture), cultural skills (methods, such as cultural assessments and communicating in other languages), and caring (Kirn-Godwin, Clarke, & Leslie, 2001). To effectively influence positive outcomes, the nurse should demonstrate all dimensions of cultural competency to ensure that individuals entering the health care system are cared for appropriately. Utilizing this framework, it was the intention of the team that this study would assist us in becoming more culturally knowledgeable and sensitive to the views of health among African- American and Hispanic individuals.

METHODOLOGY

Subjects

Participants in the study were convenience samples of clients at senior citizen centers located in a large metropolitan area of Texas. Subjects were male and female and ranged in age from 65 to 92. Subjects were asked if they would be interested in participating in an interview, and signed informed consent was obtained. Subjects were assured of confidentiality.

Data Collection and Analysis

Subjects were interviewed by students in a doctorallevel multicultural nursing course. Students used a semistructured interview format using questions agreed upon prior to the interviews. Subjects were interviewed one time for approximately 30 minutes. Students then shared their raw data with classmates. Raw data was to be presented in the form of direct quotations to avoid interviewer bias.

This team chose to focus on multicultural definitions of health, and pooled answers to the following questions from the interview tool:

Figure 1 A model for the delivery of culturally competent community care

* “What does health mean to you?”

* “What does a healthy person look like to you?”

* “What makes you a healthy or unhealthy person?”

* “What means you are healthy, or when a person says you are healthy, what does that mean?”

Content analysis was used to analyze answers to the questions. This refers to the process of analyzing the content of the data for recurring themes and patterns (Polit & Hungler, 1993). Themes were identified in terms of recurring descriptions of health from the participants. Quasistatistics, which “involve a tabulation of the frequency with which certain themes, relationships, or insights are supported by the data” (Polit & Hungler, 1993, p. 331), were used to determine the frequency of responses within the themes. This assisted the team in determining differences or similarities of health definitions between Hispanics and African-Americans.

LIMITATIONS

Obviously the major limitations of this study were the sharing of raw data among students and interviewing the subjects only once. The team was not able to interview all subjects and relied on others to share exact quotations wit\h the team. Therefore, the true intent and meaning of the quotations had to be taken at face value without the ability to go back and ask further questions of the subject.

Other limitations included the use of a conveniece sample which may not reflect the viewpoints of elders who do not attend senior citizen centers. The setting was not conducive to open communication because there were multiple interruptions and interviews taking place simultaneously in the same room.

RESULTS

Responses from a total of 45 subjects, 25 Hispanics and 20 African-Americans, were sorted into eight themes: spirituality, without pain/feeling good, positive attitude with good mentality, high priority, independent/active, health promotion/maintenance, socialization, and helping others. Table 1 lists the total number of responses, as well as the frequencies of quotes within the themes from Hispanics and African-Americans.

Health Promotion/Health Maintenance

Thirty two subjects reported health promotion or health maintenance activities as an important way to maintain good health, with a striking 90% of AfricanAmericans mentioning this theme as compared to 56% of Hispanics. Activities included seeing the doctor regularly for checkups (many reported seeing the doctor up to twice a month for checkups) or if they feel sick, eating and sleeping well, exercising, not smoking, and taking prescribed medications (especially those used for chronic illnesses such as hypertension and diabetes).

Table 1 Frequencies of Recurring Theme

Positive Attitude/Good Mentality

Many subjects (N=29, 64%) reported having a positive attitude or a keeping positive outlook or mental state as an important way to maintain good health. Hispanics and African-Americans reported this theme with equal frequency (64% and 65%, respectively). Most statements dealt with happiness and an overall enjoyment of life.

Statements from Hispanics included:

“(Healthy people are) always in a good mood, ” and “happy and active. “

“As long as you are happy and enjoying life (you are healthy).”

While African-Americans stated:

“(Health is) being joyful with a good attitude,” and “being happy daily.”

Maintaining low levels of stress was also reported by both groups as being important.

Statements to this effect included:

“Don’t let things bother you. ” (Hispanic)

“Keep on going, do not give up; everyone has problems.” (Hispanic)

“Take time for yourself; don’t get too tired. ” (AfricanAmerican)

“(Healthy people have) no kinda problems.” (African-American)

“Don’t bemoan fate. ” (African-American)

The groups disagreed, however, as to whether one could tell what a healthy person looked like. Hispanics were more likely to report they could tell if someone was healthy from their outward appearance. One subject commented, “Being healthy shows on your face,” while another stated, “You can see from a person’s complexion they are healthy.”

African-Americans, however, overwhelmingly stated the opposite: “You can’t tell if someone is healthy just by looking. Some people are healthy even if they aren’t walking around.”

Independent/Active

Maintaining independence and activity was considered an important aspect of health to both groups (62% of the total subjects); although the African-American group reported this theme slightly more than the Hispanic group (70% to 56%, respectively).

Independence was verbalized by both groups in the form of being able to do for themselves or not depending on others. Similar statements between groups were noted:

“A person is healthy if they are able to take care of themselves.” (Hispanic)

“Health is being independent and being myself; not what someone else wants me to be or do.” (African-American)

Staying active and being able to get around were often mentioned as an example of one’s independence. Hispanics and African- Americans equally commented that being able to walk, dance, drive, come to the center, or work in the yard defined health.

Without Pain/Feeling Good

Fourteen total subjects (31%), with 40% of the Hispanics and 20% of the African-Americans stated having no pain and feeling good were indicators of good health.

Belief in God

Eleven subjects (24%) reported belief in God as a determination for health. This included 28% of the Hispanics and 20% of the African Americans.

“I go to church everyday. That’s the best medicine.” (Hispanic)

“Prayer and belief in the Lord (make you a healthy person).” (African-American)

Health as a High Priority

Eight subjects (an equal number from each group) reported health as being a high priority in their lives, with Hispanics comprising 16% and African Americans 20%. A common answer to the question “what does health mean to you?” included, “It means everything,” and “Life is not important without it.”

Socialization

Being able to socialize at the senior citizens’ center was important to a small number of subjects (N=6), particularly to the African-American group. One particular subject stated, “This center is a Godsend to me. I can be with these people, play cards, visit, and do whatever.”

Helping Others

Although only a small number of subjects (N=6) reported that being able to help others defined health for them, it was interesting to identify this was a priority for some. Statements to this effect included, “It makes me feel good to know I have helped somebody,” and “(Being healthy means) I can do extra for other people.”

CONCLUSIONS

There is consistency in the results of this qualitative study with research in the existing literature. Hahn (2003), when exploring the definition of health among minority women from Hispanic, Indochinese, and African American heritage, identified similarities between groups were more striking than different. The theme that emerged in the study conducted by Hahn when the individuals’ definitions of health were analyzed was health is “being able to do activities which have meaning” with the most repeated phrase being “staying active” (p. 8-9). According to Spector (2000) and Zoucha (1998), Mexican Americans identify health as a gift from God, a general feeling of well being, to be free of pain, able to work, and spend time with the family.

Other studies exploring definitions of health in the elderly have described the importance of socialization and caring for others as priority. Burbank (1992) found that older adults are more likely to correlate being healthy with maintaining meaningful relationships and helping others. Higgins and Learn (1999) described Hispanic women’s views of health as putting others before themselves.

Additionally, Barrett and Victor (1997) reviewed several health surveys which interestingly enough, appeared to support the major themes identified in this study. Blaxters’s Health and Life Style Survey (as cited in Barrett and Victor, 1997) identified several common perceptions of health: freedom from illness, ability to function, physical fitness, energy or vitality, psychosocial well- being, health as a ‘reserve’, health as an aspect of a healthy lifestyle, and the understanding that health could be present despite a major illness. Another health measurement tool known as the SF36 identified eight dimensions of health: physical functioning, social functioning, role limitations (physical problems), role limitations (emotional problems), mental health, vitality, pain, and overall evaluation of health (Barrett and Victor, 1997). It would seem this study modestly validates these tools’ themes for identifying health.

This study sought to describe the definitions of health for African-American and Hispanic elders. While there were some differences among the groups, there were more similarities in the identified themes. This serves as a reminder to practitioners of the importance in avoiding stereotypes when caring for individuals from any cultural background. This study could also assist nurses to promote health promotion programs based on people’s definitions of health (for example, the centers could include religious or health education programs into their activities for the clients).

Leininger (2000) stresses that a “self and others discovery process” is critical for effective and meaningful transcultural nursing practice (p.313). All practitioners are challenged to provide culturally competent care that is sensitive to differences. In order to provide holistic care, it is important for nurses to recognize everyone has his or her own personal definition of health. Recognizing differences in definitions of health between and within cultures will increase nurses’ cultural knowledge thereby impacting the health care system and promoting positive health outcomes for all individuals, families, and communities.

REFERENCES

American Nurses Association: Nursing World. (1991). Position statement: Cultural diversify in nursing practice. Retrieved January 20, 2004, from http://nursingworld.org/readromoom/position/ethics/ etcldv.htm

Bonder, B., Martin, L. & Miracle, A. (2001). Achieving cultural competence: The challenge for clients and healthcare workers in a multicultural society. Workforce Issues in a Changing Society, 35- 42.

Burbank, R M. (1992). An exploratory study: Assessing meaning of life among older adult clients. Journal of Gerontological Nursing, 18(9), 19-28.

Burchum, J.L. (2002). Cultural competence: An evolutionary perspective. Nursing Forum, 37(4), 5-15.

Chevannes, M. (2002). Issues in educating health professionals to meet the diverse needs f patients and other service users from ethnic minority groups. Journal of Advanced Nursing, 39(3), 290- 298.

Department of Health and Human Services Administration on Health. (2004). Addressing diversity. Retrieved February 8, 2004, from http:/ /www.aoa.gov/prof/adddiv/adddiv.asp

Hahn, K. (2003, July). Older ethnic women of faith communities: Culturally appropriate program planning. Journal of Gerontological Nursing, 5-12.

Higgins, R G., & Learn, C. D. (1999). Health practices of adult Hispanic women. Journal \of Advanced Nursing, 29(5), 1105-1112.

Kim-Godwin, Y. S., Clarke, R N., & Barton, L. (2001). A model for the delivery of culturally competent community care. Journal of Advanced Nursing, 35(6), pp. 918-925.

Leininger, M. (2000). Founder’s focus: Transcultural nursing is discovery of self and the world of others. Journal of Transcultural Nursing, 11(4), 312-313.

Meleis, A.I. (1999). Culturally competent care. Journal of Transcultural Nursing, 10(1), 12.

Mutha, S., Alien, C, and Welch, M. (2002). Toward culturally competent care: A toolbox for teaching communication strategies. San Francisco: Center for the Health Professions, University of California.

Polit, D. F, & Hungler, B. P (1993). Essentials of nursing research: Methods, appraisal, and utilization, (3rd ed.). Philadelphia: J. B. Lippincott Company.

Preamble to the Constitution of the World Health Organization. (2003). WHO defines health. Retrieved January 25, 2004, from http:// www. who. int/about/definitions/en I

Purnell, L.D. and Paulanka, B.J. (2003J. Transcultural health care: A culturally competent approach (2nd ed). Philadelphia: E.A. Davis Company.

Spector, R.E. (2000). Cultural diversity in health and illness (5th ed). Upper Saddle River: Prentice Hall Health.

Zoucha, R.D. (1998). The experience of Mexican Americans receiving professional nursing care: An ethnonursing study. Journal of Transcultural Nursing, 9(2), 34-44.

Reprinted with minor modifications from the Journal of Multicultural Nursing & Health Volume 10, Number 3, Fall 2004

Cathleen A. Collins, RN, MSN, CHPN

Sharon I. Decker, RN, CS, MSN, CCRN

Karen A. Esquibel, RN, MSN

ACKNOWLEDGMENT(S): We acknowledge the assistance of Shirley Hutchinson, RN, DrPH of Texas Woman’s University for her contributions toward the development of this article and study. We are especially thankful to all of the elders who participated in the study. Thank you for sharing your lives with us.

Cathleen A. Collins, RN, MSN, CHPN, Sharon I. Decker, RN, CS, MSN, CCRN and Karen A. Esquibel, RN, MSN. All are doctoral students at Texas Woman’s University, Houston, Texas; and teach at Texas Tech University Health Sciences Center School of Nursing, Lubbock, Texas.

Copyright Riley Publications, Inc. Center for the Study of Multiculturalism and Health Winter 2006

By Gupta, Somesh; Ajith, C; Kanwar, Amrinder J; Sehgal, Virendra N; Et al

Summary: Genital elephantiasis is an important medical problem in the tropics. It usually affects young and productive age group, and is associated with physical disability and extreme mental anguish. The majority of cases are due to filariasis; however, a small but significant proportion of patients develop genital elephantiasis due to bacterial sexually transmitted infections (STIs), mainly lymphogranuloma venereum (LGV) and donovanosis. STI-related genital elephantiasis should be differentiated from elephantiasis due to other causes, including filariasis, tuberculosis, haematological malignancies, iatrogenic, or dermatological diseases. Laboratory investigations like microscopy of tissue smear and nucleic acid amplification test for donovanosis, and serology and polymerase chain reaction for LGV may help in the diagnosis, but in endemic areas, in the absence of laboratory facilities, diagnosis largely depends on clinical characteristics. The causative agent of LGV, Chlamydia trachomatis serovar L1-L3, is a lymphotropic organism which leads to the development of thrombolymphangitis and perilymphangitis, and lymphadenitis. Long-standing oedema, fibrosis and lymphogranulomatous infiltration result in the final picture of elephantiasis. Elephantiasis in donovanosis is mainly due to constriction of the lymphatics which are trapped in the chronic granulomatous inflammatory response generated by the causative agent, Calymmatobacterium (Klebsiella) granulomatis. The LGV- associated genital elephantiasis should be treated with a prolonged course of doxycycline given orally, while donovanosis should be treated with azithromycin or trimethoprimsulphamethoxazole combination given for a minimum of three weeks. Genital elephantiasis is not completely reversible with medical therapy alone and often needs to be reduced surgically.

Keywords: elephantiasis, lymphogranuloma venereum, donovanosis

Introduction

Genital elephantiasis is one of the well-recognized clinical expressions of sexually transmitted infections (STIs), defined as massive enlargement of the genitals. The term ‘elephantiasis’ was originally used to describe the elephant-like appearance of the legs due to grotesque enlargement secondary to mechanical failure of the lymphatic system.1 Subsequently, the term was used to describe the similar enlargement of the arm, chest, breast, penis, scrotum, and vulva.2 Genital elephantiasis may occur due to a variety of infective and non-infective aetiologies causing lymphatic blockage in the genital region3-21 (Table 1).

Genital elephantiasis is unusual in areas where filariasis is not endemic. Bacterial STIs constitute one of the important causes of non-filarial genital elephantiasis in the tropics in particular. Penile venereal oedema, caused by gonococcal/herpes infection or scabies infestation,19 and penile friction oedema23,24 are transient, which resolve completely after treatment of the underlying cause, and may not lead to irreversible huge enlargement. However, the distinction between chronic, persistent, irreversible genital oedema and elephantiasis is arbitrary, and depends only on the subjective perception of size of the enlarged genitalia. Probably patients with long-standing irreversible genital oedema will end up with genital elephantiasis. The prime objective of the current dissertation is to bridge the gap in the contemporary literature pertaining to genital elephantiasis following STIs. Among the STIs, Chlamydia tmchomatis serovar L1-L3, responsible for lymphogranuloma venereum (LGV), and Calymmatobncterium (Klebsiella) granulomatis, a cause of donovanosis, are the most common causes of genital elephantiasis. In addition, genital elephantiasis has also been described as a complication of syphilis and infection with non- LGV strains of C. trachomntis.

Table 1 Genital elephantiasis: incriminating causes

Table 2 Genital elephantiasis: nomenclatures

Various nomenclatures are in use to describe genital elephantiasis based on the morphological appearance of the genitalia secondary to elephantiasis. The term ‘esthiomene’ is derived from a Greek verb which means to eat and carries forth the idea of something gnawed, eroded or ulcerated.25 In clinical terms, it refers to elephantiasic enlargement of the female genitalia along with ulcerations.3,26 Then do we have to look for another term to describe the similar condition in men? The definitions of the various terms used in relation to genital elephantiasis are given in Table 2.

History and epidemiology

Elephantiasis is one of the oldest, most bizarre and crippling diseases, and has a long history of worldwide distribution.28 Genital elephantiasis has been known since antiquity. Benjamin Neisius of the University of Strasburg, Germany in the year 1673, in his inaugural essay had described elephantiasis as an ‘Iliad of diseases’, occurring as complications of several diseases.28 The scientists and doctors, who had accompanied Napoleon to Egypt in the year 1798, described genital elephantiasis in a woman, and elephantiasis of the legs and genitals in a man (Figure 1). Since genital elephantiasis due to filariasis is quite uncommon in women, the case in question might have represented LGV-related elephantiasis.29 DominiqueJean Larrey, one of the French physicians accompanied the Napoleon’s army, had recognized the genital elephantiasis as a disease more of tropical climate than that of temperate climate. He wrote ‘they are endemic in hot climates; at least, they are seldom encountered in cold climates …’.30

Figure 1 A 30-year-old Egyptian woman (left) at the time of Napoleon Bonaparte, who had been afflicted with elephantiasis of external genitalia for several years. (Courtesy: Dr Terence M Russell and Dr Thomas G Russell, reproduced from reference [29])

Furthermore, he also had described the agony of patients due to enormousness of genital elephantiasis: ‘The malady inconveniences [the subject] only by the ponderosity [weight] and embarrassment that it manifests as it progresses – such that it obliges [the subject] to make use of some form of support.’ (From the text provided by Dr Terence M Russell and Dr Thomas G Russell, UK)

Genital elephantiasis due to STIs is an uncommon condition, and there are only sporadic reports that too from the tropical countries. The last large series of STI-related genital elephantiasis was published in early 1980s from India. In this study, 25 female patients with vulvar elephantiasis were described; 13 had LGV-associated elephantiasis and remaining 12 had donovanosis- associated pseudo-elephantiasis.31 LGV is endemic in several tropical and sub-tropical countries including West, Central and East Africa, India, Malaysia, Korea, Vietnam, South America, Papua New Guinea, and the Caribbean Islands32-35 across the globe. The proportion of genital ulcers that might be attributed to LGV varies from 1-10% in these areas. Perhaps, the lack of specific diagnostic criteria and the relatively poor degree of clinical suspicion of this condition might have prejudiced these estimates. HIV epidemic has led to outbreaks of LGV in Western Europe, mostly in men who have sex with men.36 Apparently, LGV occurs six times more frequently in men than in women. It probably remains under- or undiagnosed in women, because of the asymptomatic nature of the early lesions. Esthiomene, one of its late complications, has frequently been reported in women,31 whereas, penile and scrotal elephantiasis has been reported to occur in only 4% of LGV cases.37

While, pseudo-elephantiasis of the genitals, a complication of donovanosis, was first described by Nair and Pandalai38 in Indian patients. Donovanosis was prevalent in many parts of the world in the pre-antibiotic era. It has virtually disappeared from the developed world,39 though increased world travel and migration has resulted in limited outbreaks in industrialized nations.40 Current reports of the disease are only sporadic and largely confined to Papua New Guinea, India,41 South Africa (more common in Zulus), Caribbean islands, remote northern Australia (Aboriginal population), and Brazil. Genital elephantiasis due to donovanosis has largely been reported from India.38,41-43 However, occasional cases have also been reported from Australia44 and Papua New Guinea. 5 Ever since the advent of effective antibiotics, the incidence of elephantiasis due to donovanosis has recorded a perceptible decline from 24% in 1934,38 15-20% in 1954,4311% in 1966(46) and 5% in 1987,42 respectively in studies from India. The current literature seems to have depleted, re-affirming the impression that the disease hardly poses a challenge for the present. Reports of syphilis causing genital elephantiasis mostly appeared in the pre-penicillin era and no such cases have been reported in the indexed literature during the last quarter of the 20th century, though some cases of persistent chronic penile oedema due to syphilis leading to enlargement of the part have been reported recently.47

Pathogenesis

The lymphatic drainage from the anatomical site on the primary lesion probably determines the clinical picture of the disease. It is worthwhile to appreciate that the pathogenesis of elephantiasis caused by LGV and donovanosis are different, the synopsis of which is recounted below:

Lymphogmnuloma v\enereum (LGV)

The causative agent of LGV, C. trachomatis serovars L1-L3, is a lymphotropic organism which initiates the disease process primarily in the lymphatic channels, leading to thrombo-lymphangitis and peri- lymphangitis with an extension of the inflammatory process to the draining lymph nodes. The lymphangitis is marked by proliferation of endothelial cells lining the lymph vessels, and the lymph channels in the lymph nodes. The inflammation around the lymph nodes (peri- adenitis) might cause matting of adjacent lymph nodes. The latter is progressive, and in an untreated case abscesses may coalesce to form fistulae and tracts, confined to lymph nodes draining the site of primary infection. They might rapidly enlarge and undergo necrosis surrounded by densely packed endothelial cells.48 The inflammatory reaction might last for many months, and an eventual healing might take place by fibrosis. This may in turn destroy the normal structure of lymph nodes and obstruct the lymphatics. A combination of chronic oedema, sclerosing fibrosis, and active diffuse lympho- granulomatous infiltration in the subcutaneous tissue results in the final picture of massive enlargement of the genitalia.4 Fibrosis also compromises the blood supply which leads to the surface ulceration.48,51

Donovanosis

The lymphoedema is mainly due to constriction of the lymphatics as they are trapped in the chronic granulomatous inflammatory response in the surrounding tissue.44 Later, healing with fibrosis further constricts the lymphatics and thus interferes with the lymphatic drainage of the area resulting in persistent lymphoedema and enlargement of the involved and dependent tissue. This is

sometimes referred to as ‘pseudo’ elephantiasis, since there is no direct involvement of the lymphatics and lymph nodes by the disease process.42

The lymphoedema associated with syphilis and chlamydial urethritis may be due to ‘scarring’ of the lymphatic channels as a result of persistent lymphatic insult due to a chronic inflammatory response.47

Clinical features

Genital elephantiasis, a physical disability, is a source of extreme mental anguish due to the ugly deformity. Sexual intercourse may not be possible and these morphological changes in the genitals may even interfere with walking.52 Clinical features of elephantiasis related to individual STIs are recounted below in the following text.

Lymphogranuloma venereum

The clinical features of LGV might comprehensively be divided into three stages, namely the primary stage which identifies the site of inoculation, the secondary stage where there is an affliction of regional lymph nodes, and occasionally the anorectum, and the tertiary stage refers to the late complications affecting the rectum and genitalia, including elephantiasis. These late complications in the tertiary stage are frequent in women. Contrary to this, the late manifestations in men, apart from homosexuals, are fairly rare.49 In men, chronic inguinal lymphadenitis leads to penile and scrotal elephantiasis (Figure 2), approximately 1-20 years after infection. It may affect only the prepuce, shaft of the penis, and the scrotum alone or the entire male external genitalia. The genital tissues become woody indurated and often deformed, and the surface may become verrucous due to lymphangiectatic papules. The scrotum may reach a monstrous size.”3″4 The penis may become solidified and may assume the shape of a ‘ramrod’, ‘ram horn’ (Figure 3) or a saxophone.55 Erection is inhibited and sexual intercourse becomes impossible.

Figure 2 Early oedema of external genitalia associated with acute lymphadenitis in inguinal region in lymphogranuloma venereum. (Courtesy: Dr Kamal Aggarwal, Dr Sanjeev Cupta, and Dr Vijay K Jain. Reproduced from Sexually Transmitted Infections, Kumar B, Cupta S, eds. New Delhi: Elsevier, 2005)

In women, chronic progressive lymphangitis, and inguinal and pelvic adenitis may lead to chronic oedema, sclerosing fibrosis of subcutaneous tissue, elephantiasis and chronic genital ulceration, the ‘esthiomene’. It involves the labia, vulva and clitoris which gradually become enlarged. The size may vary from a mere tumefaction of the lips to large, pendulous, multilobed, unsightly masses of hypertrophied tissue hanging down and obstructing the vulval cleft56 (Figure 4). The oedema may extend from the clitoris to anus. The external surface of the labia majora, genitocrural folds, fourchette, urethral orifice, root of clitoris, and perineum may develop ulceration. These ulcers may be localized or they may be large and superficial or perforating. The vascular compromise is secondary to fibrosis, results in large, destructive ulcers or occasionally superficial ulcers with irregular, serrated edges and a shiny yellowish-white base. Genital elephantiasis is often associated with anorectal complications including fistulae and strictures both in men and women.

Donavanosis

It is a chronic, progressively destructive, granulomatous infection of the superficial tissue of the genital region. The initial lesions of donovanosis are single or multiple subcutaneous nodules that erode through skin or mucosa to form an ulcer covered with “beefy’ red granulation tissue. Lymphoedema of the genital region is one of the long-term complications. However, in untreated cases, spontaneous healing may occur, but this is extremely slow with marked fibrosis, scar tissue contractures, and lymphatic obstruction that may produce the consequent elephantiasis like picture.57 As in LGV, elephantiasis in donovanosis is largely seen in women. Clinically, donovanosis-induced elephantiasis in women is characterized by firm, pedunculated, globular swellings with or without verrucous surface and de-pigmentation. It affects predominantly the labia majora (Figure 5) and the clitoris. More than one swelling may be present involving different areas of genitalia. The size of the elephantiasis is apparently not related to the duration of the disease process.41 There may be associated ulceration, especially in intertriginous areas.43 Pseudo- elephantiasis in men is extremely rare. Morphology of pseudo- elephantiasis involving the penis usually has gross, solid enlargement of distal part of the penis with the overlying skin being oedematous and thickened. Phimosis and overlying ulcerations may be present.43

Figure 3 Enlarged curved penis (Ram horn) with lymphagiectatic papules and inguinal scarring and sinuses in a patient with late stage of lymphogranuloma venereum

Figure 4 A huge swelling originating from clitoris in a woman with late stage of lymphogranuloma venereum (reproduced from reference [56])

Figure 5 Genital elephantiasis of labia majora due to donovanosis

Other sexually transmitted infections

A few reports describing syphilis as a cause of genital elephantiasis were the focus of attention in the pre-penicillin era. It is difficult to confirm whether the elephantiasis was due to syphilis itself or due to other co-existing diseases like tuberculosis and LGV. Elsahy5 emphasized that syphilis plays a dominant role in these cases. Recently a case of genital elephantiasis occurring several years after untreated chlamydial urethritis has been reported, which responded to long-term doxycycline therapy.6

Diagnosis and differential diagnoses

Genital elephantiasis is a significant medical problem and persons affected may become a major burden to their family and community, especially when the disease interferes with their economic livelihood. Early diagnosis of the underlying conditions and appropriate management may prevent the development of these deformities. In a patient with genital elephantiasis, importance of a proper history and thorough clinical examination cannot be overemphasized, as it may help to find the cause for the elephantiasis. Computerized tomography may detect pathologies in the anorectum and provide supportive evidence for LGV (Figure 6). When the cause of lymphoedema is suspected to be due to a sexually transmitted pathogen, then patients should be investigated for LGV and donovanosis. Nucleic acid amplification test for donovanosis offers highest sensitivity, but is not commercially available.58 Moreover, its value in late cases of genital elephantiasis is not known. If active granulomatous ulcers are present, demonstration of the donovan bodies with bipolar staining in large foamy mononuclear cells by microscopy from lesion scrapping is the mainstay of diagnosis. The diagnosis of LGV-associated elephantiasis is supported by high titre serology and identification of the organism in pus or bubo fluid by cytology or culture. The pathogen is likely to be isolated from the purulent discharge even in the late cases of LGV-associated elephantiasis.50 Micro-immunofluorescence test is the only serological means of distinguishing LGV strains of C. trachomatis from other serovars,59 though it is still not in routine use as it requires a fluorescent microscope and a trained technician. Only high titres (>1:128) are specific for LGV. Polymerase chain reaction (PCR) amplification and sequence analysis of the omp 1 gene, which encodes the major outer membrane protein (MOMP), has also been found to be useful in identification of LI-L3 serovars.60 Nevertheless, diagnosis of LGV and donovanosis is primarily clinical, more so in endemic areas where diagnostic laboratory facilities are not easily available. Some clinical features may help in differentiating elephantiasis caused by LGV and donovanosis (Table 3).61

Figure 6 Contrast enhanced computerizd tomography scan of the pelvis of a patient with anorectal-genital LCV showing mural thickening of the rectum with presence of perirectal staunching. There is loss of the fat plane between the rectum and the left seminal vesicle. The patient is same as shown in Figure 7. (Reproduced from Sexually Transmitted Infections, Kumar B, Cupta S, eds. New Delhi: Elsevier, 2005).

Table 3 Genital elep\hantiasis: differentiating features between caused by LGV and donovanosis61

Elephantiasis associated with tuberculosis is not uncommon in tropics and may closely resemble elephantiasis due to LGV. Both are associated with inguinal lymphadenitis, though reactive Mantoux test, suggestive histopathology, isolation of Mycobacterium tuberculosis by PCR or culture, and response to anti-tubercular therapy are confirmatory for tuberculosis.7,8 Elephantiasis due to filariasis is seen primarily in men living in endemic areas, but occasional cases in women have been reported.62 Demonstration of peripheral blood eosinophilia, and microfilariae in nocturnal blood samples or lymph node aspirates is diagnostic.62 In the western world, the majority of genital elephantiasis are from trauma or surgery to remove gynaecological, urological, abdominal or prostatic cancers or radiotherapy to the lymph nodes in the groin, and a careful history will help in the diagnosis. Primary lymphoedema affecting only the genitals may be noticed from birth or during the teens. Lymphanogiography is useful to distinguish between primary or secondary lymphoedema. In a minority of patients, the diagnosis of the underlying condition will remain uncertain.63

Treatment modalities

Treatment modalities of genital elephantiasis due to STIs require an interdisciplinary approach involving genitourinary medicine physicians, urologists, and dermatologists. The objectives of treatment are to reduce swelling, restore shape and normal sexual function, and prevent inflammatory episodes, e.g., recurrent cellulitis.64

Genital elephantiasis is usually irreversible. Physical methods (i.e. compression therapy), drugs, and surgery are three mainstays of therapy available for lymphoedema. Compression therapy is not practical for lymphoedema of the genitalia for obvious reasons; however, minor swelling can be treated with support hosiery. Medical therapy should be the first line of treatment and any surgical intervention should be undertaken only under the cover of appropriate antibiotics. In case of genital elephantiasis caused by LGV, doxycycline lOOmg twice daily should be given for prolonged periods (improvement reported with up to 13-month therapy6) (Figures 7a and b). In cases of donovanosis, azithromycin 1 g a day, followed by 500 mg daily or trimethoprim 80 mg and sulphamethoxazole 400 mg two tabs twice a day should be given till ulcerations (if present) heal. If there is no ulceration, a two-week therapy covering surgical reconstruction is recommended.44 Doxycyline 100 mg twice daily, ciprofloxacin 500 mg twice daily, or erythromycin base 500 mg four times daily are other alternatives.

Surgery is the only effective option for a select group of patients in whom the disorder is disabling and persistent. Operations fall into two categories: bypass procedures and reduction procedures.65

Bypass procedures

A number of procedures like omental pedicle, the skin bridge, anastomosing lymph nodes to vein, and more recently, lymphovenous anastomosis with the aid of an operating microscope are described. However, poor long-term results of these technically challenging procedures have made them unpopular worldwide.

Figure 7 (a) Saxophone penis in a homosexual man with tertiary stage of LCV. Prominent lymphangiectatic papules leading to pebbly surface are evident (reproduced from reference [5]). (b) After one- year therapy with doxycycline, there is complete subsidence of scrotal swelling and significant reduction in the swelling of penile shaft, though swelling of prepuce is still persisting due to its dependent position

Reduction procedures

Two types of reduction procedures are commonly performed: (1) removal of the subcutaneous elephantoid tissue with preservation of the overlying skin for covering the penis and denuded testes, and (2) radical excision of the skin and subcutaneous tissue. Following this, scrotal reconstruction can be achieved by free skin graft, positioning a skin flap from between the scrotum and inguinal area using skin of the scrotal neck alone or supplemented with a rotation flap from the skin of the thigh.

Denuded penis is best covered by split thickness skin graft which is sutured to the dorsal, ventral and coronal side of the penis along with fixation to the root of it in the form of a Z to avoid circular contracture and a longitudinal scar on the shaft of the penis.

Labial reduction is easily achieved by wide elliptical excision with a single suture line.31 Recurring swelling in a minority group will be benefited by another similar procedure. Larger labial defects may be covered with myocutaneous, floating island or fasciocutaneous flaps.66

There are no studies available demonstrating the long-term efficacy of reduction procedures in STI-related genital elephantiasis. Chakravarty and Rajagopalan : found no recurrence at two years in 16 women with sexually transmitted disease (STD)- related esthiomene treated with reduction procedures. Burnard et al.65 reported long-term followup of 41 patients (31 male and 10 female) with genital lymphoedema, mostly of filarial origin. They showed complete ‘cure’ lasting at least 10 years in 57% of men and two-thirds of women.65 Dandapat et al.52 reported a recurrence rate of 7.13% in a large series of 350 male patients with genital elephantiasis due to filaria. McDougal20 reported no recurrence after a follow-up of six months to 10 years in male patients with non-STI-related genital lymphoedema treated with reduction procedures.

Erysipelas is a frequent complication in patients with genital elephantiasis, as the defence mechanism of the skin is impaired due to chronic lymphatic obstruction and compromised blood supply. Repeated episodes of erysipelas may further increase the lymphatic obstruction and elephantiasis.10 Such patients often benefit from long-term benzathine penicillin therapy and vaccination against streptococci.10 Meticulous skin care is important to prevent recurrent erysipelas.

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58 Donovan B. Sexually transmissible infections other than HIV. Lancet 2004;363:545-56

59 Clinical Effectiveness Group. National guidelines for the management of lymphogranuloma venereum. Sex Transm Infect 1999;75:S40-2

60 Jurstrand M, FaIk L, et al. Characterization of Chlamydia trachomatis omp 1 genotypes among sexually transmitted disease patients in Sweden. J Clin Microbiol 2001;39: 3915-19

61 Gupta S, Kumar B. Genital elephantiasis/pseudo elephantiasis related to sexually transmitted infections. Poster presented at 8th World Congress of STI/AIDS Congress, 2-5 December 2003, Punta del Este, Uruguay. Final programme and abstract, p. 292.

62 Thami GP, Kaur S, Kanwar AJ. Lymphatic filariasis-lest we forget. Sex Transm Infect 2000;76:321

63 Kos M, Ljubojevic N, Ilic-Forko J, Babic D, Jukic S. Elephantiasis of the vulva of an unclear etiology: case report (Croatian). Lijec Vjesn 1996;118:158-60

64 Mortimer PS. Therapy approaches for lymphoedema. Angiology 1997;48:87-91

65 Burnard K, Mortimer P, Browse N. Management of genital lymphoedema In: Browse N, Burnard KG, Mortimer PS, eds. Diseases of the Lymphatics. London: Arnold, 2003;217-30

66 Prakash S, Radhakrishna K. Problematic ulcerative lesions in sexually transmitted diseases: surgical management. Sex Transm Dis 1986;13:127-33

(Accepted 21 April 2005)

Somesh Cupta MD DNB1 C Ajith MD1, Amrinder J Kanwar MD MNAMS1 Virendra N Sehgal MD FRAS2, Bhushan Kumar MD MNAMS1 and Uttam Mete MS MCh3

1 Department of Dermatology and Venereology, Chandigarh; 2Department of DermatoVenereology (Skin/VD) Centre, Sehgal Nursing Home, Panchwati, Azadpur, Delhi; 3Department of Urology, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Correspondence to: Dr Somesh Cupta, Department of Dermatology and Venereology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India

Email: [email protected]

Copyright Royal Society of Medicine Press Ltd. Mar 2006

By Will Boggs, MD

NEW YORK (Reuters Health) – EMLA, an anesthetic cream, is
effective in treating premature ejaculation, according to a
report by researchers in Turkey.

“Topical EMLA cream alone seems a reasonable, inexpensive,
effective, and easily applicable treatment modality for
premature ejaculation treatment,” co-author Dr. Altug Tuncel
from Ankara Numune Research and Training Hospital, Ankara, told
Reuters Health.

Tuncel and colleagues assigned 84 men with premature
ejaculation to receive sildenafil (Viagra) alone; EMLA alone;
sildenafil plus topical EMLA; or placebo.

The rates of effectiveness were 40 percent for placebo, 55
percent for sildenafil alone, 86.4 percent for the combination
of sildenafil plus EMLA, and 77.3 percent for EMLA alone, the
authors report.

The differences between placebo and sildenafil only and
between the combination of sildenafil plus EMLA and EMLA only
were not statistically significant, the results indicate.
However, the combination treatment and EMLA only were
significantly better than sildenafil alone and placebo alone
according to the study, published in the February issue of
Urology.

Headache and flushing occurred in patients taking
sildenafil as part of their treatment, the researchers note,
but no side effects were reported by patients taking placebo or
EMLA only.

“Topical EMLA cream alone had effectiveness equal to that
of the combination treatment,” the authors note.

SOURCE: Urology, February 2006.

By Mica Rosenberg

EL CERINAL, Guatemala (Reuters) – Every week, Guatemalan
scientists blast 2.7 billion fruit flies with radiation to make
them sterile in a bizarre nuclear war against one of the
world’s most destructive farm pests.

The flies, a threat to the fruit and vegetable industry in
California and Florida, are then dropped from planes to
copulate with fertile females in Guatemala, Mexico and the
United States.

Female medflies only mate once in their month-long lives
but can lay up to 800 eggs so barren procreation with sterile
males denies the chance of life for hundreds of potential
offspring.

As a pest control method, it is easier than killing flies,
which once they infect a crop can reduce yields by over 50
percent.

The MOSCAMED facility in Guatemala, which has a major
medlfy problem, is on the frontline in the fight against the
pest. It is the largest of 25 producers of infertile flies in
the world.

“The irradiation destroys the male reproductive organs;
there’s no sperm,” explained Oscar Zelaya, the director of
MOSCAMED who said the nuclear rays emitted at the plant are
about one-tenth the minimum needed to kill a human.

“The female feels satisfied after copulation but it’s
impossible for her to produce eggs,” he said.

At the plant near the town of El Cerinal, the acrid smell
of fly pheromones wafts through warehouses where millions of
the bugs are bred then heated in a vat.

The female eggs, genetically engineered for sensitivity to
temperature, will die at exactly 93 degrees Fahrenheit (34
degrees Celsius) so only the males remain.

They are grown on trays of sugar cane, wheat and yeast, a
specialized diet that nourishes the eggs to hatch into larvae.

BORN STERILE

In a matter of days, thousands of teeming larva will form a
cocoon called a pupa which is zapped with nuclear radiation to
stunt their sexual development. The flies then hatch sterile.

The medfly originated in sub-Saharan Africa, but in the age
of jet planes it can travel from an infested area like
Guatemala to the United States within a matter of hours.

Medfly outbreaks are now common all over the world, from
Albania to Zambia, but for the United States the biggest threat
comes from Mexico and Guatemala where the pest is more common.

“If we don’t catch them soon enough then an outbreak could
cost us hundreds of millions of dollars,” said Tomas Fasulo an
insect expert at the University of Florida.

The United States is free of largest-scale medfly
infestations but imports the sterile flies to keep the pest’s
population down.

The U.S. Department of Agriculture orders coordinated
fumigations to rid the country of the fly whenever there is
sign of an outbreak.

Although smaller than a housefly, the medfly is known for
particularly aggressive destruction of citrus, mangoes, pears
and other fruits.

Females will lay more than 75 eggs under the skin of a
soft, vulnerable fruit. When the larvae hatch, they burrow deep
into the fleshy interior of their new home, reducing it to an
inedible mass.

The fly then passes from fruit to fruit, tree to tree where
one female medfly can lay up to 22 eggs per day and hundreds in
her entire lifetime.

That is why the U.S. government helps fund Guatemala’s
MOSCAMED facility.

The plant exports about 408 million flies a week to the
United States and 650 million to Mexico, but more than 70
percent of the bugs from the facility are dropped in Guatemala.

The whole operation is funded jointly by the three
governments and MOSCAMED officials say there’s no commercial
profit in the impotent fly business.

Daily flights release bags of the chilled, irradiated pupa
into the wild, but confused farmers who have rarely been told
about the program are often surprised by the unusually large
number of flies falling from the sky.

“The people would say, ‘Before this used to be a clean
area,” said Ana Gonzalez a biologist who worked in Lachua, an
agricultural region in northern Guatemala. “But that was until
the planes came and dropped bags full of worms all over our
crops.”‘

By Valarie Honeycutt Spears and Jim Warren, The Lexington Herald-Leader, Ky.

Mar. 26–Here are some health statistics that might make you a little queasy:

About 2 million Americans get sick each year from infections they acquire while in the hospital, and almost 90,000 die, according to estimates by the federal Centers for Disease Control and Prevention.

Prompted by such numbers, the federal government will make some hospital-infection data public starting next year. And at least six states have passed laws requiring hospitals to make public their rates of nosocomial — or hospital-acquired — infections.

But two bills that would provide for such infection reporting in Kentucky apparently are dead, with the current legislative session set to end this week. A prominent legislator blames hospitals for effectively killing them. Rep. Tom Burch, D-Louisville, who heads the House Health and Welfare Committee, said the measures were strongly opposed by Kentucky hospital administrators.

“I never saw such a smokescreen in my life,” Burch said.

Representatives of all five Lexington acute-care hospitals said in interviews last week that they support the idea of providing hospital-infection data to the public — provided the information is gathered and presented in a standardized, accurate and understandable way. They insisted that the bills being considered in Frankfort wouldn’t do that and instead could result in the release of misleading information that unfairly could put some hospitals in a bad light.

Dr. Mark Dougherty, an epidemiologist at Central Baptist Hospital who also treated Gov. Ernie Fletcher during his recent illness, insisted Friday that infection rates at Lexington’s hospitals are below or significantly below national benchmarks in many categories.

Still, despite several requests over the past month, representatives of Central Baptist Hospital, Samaritan Hospital, St. Joseph Hospital and St. Joseph East declined to provide the Herald-Leader with data on their individual infection rates, arguing that since the hospitals don’t collect infection data in a standardized way, a fair comparison between hospitals would be impossible. They also dispute ratings by a for-profit Internet company that ranks several Lexington hospitals below national averages in infection prevention.

Only the University of Kentucky Hospital was willing to provide some numbers to the Herald-Leader. They showed that, in three specific types of hospital-acquired infections, UK’s infection rates are at or below mean rates at other large centers participating in a national surgical quality improvement program.

‘A sea of bacteria’

No one denies that hospital-acquired infections are a serious health problem. Hospitals are giant repositories for all kinds of infectious organisms that patients bring with them. These bugs can spread to other patients, even though hospitals try to keep that from happening.

“We’re all swimming in a sea of bacteria,” Dougherty says.

But public reporting of hospital infection rates has been a complex, and controversial, proposition in virtually every state that has attempted it.

Pennsylvania began gathering and reporting general hospital infection data on the Internet last summer, though it does not give figures on individual hospitals. Nevertheless, Pennsylvania hospital officials have questioned both the methods and conclusions in the state reports.

In November, Florida became the first state to report infection rates on a hospital-by-hospital basis. Several hospitals that got low marks argued that the reporting system was flawed, although a spokesman for the Florida Hospital Association said last week that initial opposition has eased.

In Florida, Pennsylvania and Kentucky, concerns about infection reporting raised by hospitals and doctors are the same: Reporting could provide useful information to the public, once reporting standards are developed that would put all hospitals on an equal footing. But so far, officials argue, there is no standard system.

Fletcher, a physician, echoed that concern last week in response to inquiries about Kentucky legislation.

“We indeed need transparency, but what is included in ‘hospital-acquired infections’ needs to be clearly defined,” the governor said, speaking through his press secretary Jodi Whitaker.

One of the principal groups pushing for public reporting of hospital infections is Consumers Union, which publishes Consumer Reports magazine. Lisa McGiffert, who runs the organization’s Stop Hospital Infections Project, argues that state laws requiring the reporting of infection rates would force hospitals to do a better job of preventing dangerous, potentially life-threatening infections.

“The public is demanding that hospitals do something about the problem,” McGiffert said. “In the meantime, they’re demanding: ‘Tell us what your results are. We want to know how effectively you’re preventing these infections.'”

McGiffert dismisses hospital officials’ concerns about the potential misinterpretation of infection data.

“I think their concern, justifiably so, is that they are not doing what they should be doing to prevent infections … and they know it,” she said.

‘Apples to apples’

Hospital representatives argue that without a uniform system that also provides interpretation of data, any reporting would be meaningless to the public — and possibly damaging to hospitals.

“Currently there are no agreed-upon definitions,” said Dee Anderson, a certified nurse practitioner who tracks infections at Central Baptist. “It won’t end up apples to apples.”

Many factors could skew a hospital’s infection rates and affect how it looks in any public report, hospital officials contend. A hospital that operates a burn center or organ transplant unit — in which patients often have reduced immunity — could have more infections than hospitals that don’t.

Large medical centers that accept patients referred from other facilities could rack up higher rates if those patients bring infections from other hospitals with them. And a hospital that is aggressive in identifying and reporting infections could come off looking worse than a hospital with a lackadaisical attitude about reporting, officials insist.

“The more honest you are, the more you put yourself in a bad light,” said Dr. John Meek, an epidemiologist for Samaritan Hospital.

Dr. Richard Lofgren, chief medical officer at UK Hospital, says hospital officials nationwide are fearful that without proper interpretation, public reporting of hospital-acquired infections might confuse and frighten the public.

“The debate is whether bad information is worse than no information,” said Lofgren, who helped found a physician-driven infection reporting system in Wisconsin.

Meanwhile, Dougherty suggests that, in the absence of public reporting, patients going into the hospital should ask for details about the facility’s efforts to combat infections and whether it has a paid epidemiologist or certified nurse practitioner tracking infections. Such information could calm concerns, he said.

New standards coming

Some form of public infection reporting is coming. The federal Deficit Reduction Act of 2005, which takes effect in 2007, will require hospitals to provide greater reporting of their infection rates or they will risk reductions in Medicaid payments. That information will be publicly available. Also, the National Quality Forum, a private Washington, D.C.-based health group, is preparing standards for public reporting of hospital infection data. The standards are due next year.

But for now, residents in most states, including Kentucky, have few ways to access information about hospital-acquired infection.

One for-profit health care rating company called Healthgrades does offer hospital quality reports on the Internet at a cost of about $10 per report, but the reports have drawn fire.

Healthgrades’ reports on Lexington’s five major private hospitals show that Samaritan, St. Joseph East, Central Baptist and UK all rate worse than the national average in maintaining a “lack of infections acquired at the hospital.” St. Joseph rated better than the national average in infections acquired at the hospital, but worse in avoiding severe infections following surgery.

Officials at all five Lexington hospitals dispute Healthgrades’ ratings, arguing that it’s unclear how the organization reaches its conclusions.

A 2002 report by Yale University researchers also criticized Healthgrades’ rankings. The report, published in the Journal of the American Medical Association, found that hospitals ranked low by Healthgrades often performed better than higher-rated hospitals.

Meanwhile, Lexington hospitals say they’re working hard to prevent infections by instituting a variety of measures, from redesigning hospital rooms and using sophisticated antibiotic regimens, to emphasizing simple hand washing.

“We want to reassure the public that we are diligent in improving public safety,” Dougherty said.

Still, Dr. Charles Kennedy, epidemiologist at St. Joseph Hospitals, said that despite hospitals’ best efforts, “The risk will never get to zero.”

News researcher Linda Niemi contributed to this report.

—–

Copyright (c) 2006, The Lexington Herald-Leader, Ky.

Distributed by Knight Ridder/Tribune Business News.

For information on republishing this content, contact us at (800) 661-2511 (U.S.), (213) 237-4914 (worldwide), fax (213) 237-6515, or e-mail [email protected].

By Rakita, Steven; Villadolid, Desiree; Thomas, Ashley; Bloomston, Mark; Et al

Nissen fundoplication is applied for patients with gastroesophageal reflux disease (GERD), usually because of symptoms of esophageal injury. When presenting symptoms are extraesophageal, there is less enthusiasm for operative control of reflux because of concerns of etiology and efficacy. This study was undertaken to evaluate the efficacy of laparoscopic Nissen fundoplication in palliating extraesophageal symptoms of GERD. Patients were asked to score their symptoms before and after laparoscopic Nissen fundoplication on a Likert scale (0 = never/none to 5 = always/ every time I eat). A total of 322 patients with extraesophageal symptoms (asthma, cough, gas/bloat, chest pain, and odynophagia) of 4 to 5 were identified and analyzed. After fundoplication, all extraesophageal symptom scores improved (P

GASTROESOPHAGEAL REFLUX DISEASE (GERD) is a common condition in Western society, occurring intermittently in over 40 per cent of the population. Furthermore, 20 per cent of the population is troubled with symptoms on a weekly basis. An evaluation of hospital employees in the United States demonstrated that 7 per cent experienced daily heartburn.1 The efficacy of laparoscopic Nissen fundoplication in alleviating symptoms with high patient satisfaction and improved quality of life is well documented.2-5

A considerable proportion of patients with GERD present with atypical symptoms, such as respiratory or otolaryngological symptoms. The etiology has been thought to be from regurgitation, resultant laryngopharyngeal acid exposure, and microaspiration or perhaps because of a vagally mediated reflex. Remarkably, studies have demonstrated acid reflux is present in 50 per cent to 80 per cent of asthmatic patients, 10 per cent to 20 per cent of patients with chronic cough, up to 80 per cent of patients with intractable hoarseness, and 25 per cent to 50 per cent of patients with globus sensation.6 Often, these patients have no conventional symptoms of GERD, such as heartburn and regurgitation, and they may lack endoscopic evidence of esophagitis, although they can ultimately develop Barrett’s esophagus, though less often than patients with classic GERD. Laryngoscopy may demonstrate laryngeal inflammation, but even this may be absent. The best method of diagnosis for this subset of patients is a dual-channel pH monitoring to determine the occurrence of acid exposure in the proximal and distal esophagus.7, 8 However, some have argued that proximal esophageal monitoring adds little, stating that patients are rarely misdiagnosed with normal distal probe findings and citing inaccuracies inherent in measurement of proximal esophageal acid reflux.9

Symptoms of GERD occur in nearly three-quarters of patients with asthma. Additionally, pathologic GERD has been found to occur in a similar proportion of patients with asthma, independent of classic GERD symptoms, when studied with esophageal pH testing.10

Laryngopharyngeal reflux (LPR) may manifest as head and neck symptoms, such as laryngitis, pharyngitis, sinusitis and/or middle ear disease, hoarseness, and globus sensation. Heartburn can be an uncommon symptom. Furthermore, esophagitis may be uncommon because esophageal motility often remains normal in these patients, and therefore, acid exposure time is minimal because of rapid clearance of refluxed acid. Although esophagitis may be rare, the fragile laryngeal epithelium is easily damaged with even brief periods of exposure to very small amounts of reflux.7, 11 Conversely, many have indicated that LPR is frequently associated with subtle esophageal dysmotility, such as upper esophageal sphincter dysfunction or a generalized nonspecific motility disorder.12 Roughly 40 per cent to 50 per cent of all patients presenting with laryngeal and voice disorders have been found to have abnormal pH studies, prompting the diagnosis of LPR.13

Chest pain of noncardiac etiology is most commonly because of reflux. Similar to other extraesophageal symptoms, approximately 50 per cent to 60 per cent of patients have been found to have refluxinduced pain when studied by endoscopy or 24-hour pH monitoring.14

The majority of patients with extraesophageal symptoms are likely managed by their gastroenterologist or otolaryngologist with proton pump inhibitor (PPI) therapy alone. Because of practical concerns of cost, availability, and patient comfort, many gastroenterologists commonly use a trial of antisecretory therapy as a diagnostic tool. However, alleviation of symptoms does not necessarily imply cessation of esophageal acid exposure, lack of nonacidic or bile reflux, or interruption of the progression to Barrett’s esophagus and ultimately dysplasia. A recent study examined patients with good control of classic GERD symptoms on PPI therapy. Abnormal acid reflux was detected in 45 per cent on ambulatory pH study. Abnormal bile reflux was detected in 60 per cent with Bilitec monitoring, including 55 per cent of patients with normal studies of acid reflux.15

The debate continues whether patients with extraesophageal symptoms of GERD should be treated any differently than those with conventional presentations of GERD. Although they are candidates for antireflux surgery, it is unknown if they will enjoy the same encouraging outcomes as those with classic symptoms of GERD. The indication for fundoplication are similar to those for classic GERD symptoms: persistent symptoms despite maximal medical therapy, complications of continued severe reflux such as Barrett’s esophagus, recurrent aspiration pneumonia, or leukoplakia and laryngeal carcinoma, and the choice of surgery over the need for lifelong medications.

This study was undertaken to determine the efficacy of laparoscopic Nissen fundoplication in palliating extraesophageal symptoms of GERD. Our hypothesis in undertaking this study was that patients with extraesophageal symptoms of GERD would benefit from antireflux surgery similar to patients with classic GERD, experiencing significant improvements in their symptoms and quality of life, and exhibiting significant satisfaction with their outcomes.

Materials and Methods

From a prospectively maintained database of 813 patients that have undergone laparoscopic Nissen fundoplication from 1991 to 2004, patients with extraesophageal symptoms of GERD were identified. Symptoms were scored by patients on a Likert scale (0 = never/none to 5 = every time I eat/always) before and after fundoplication. Patients with preoperative scores of 4 to 5 for extraesophageal symptoms of reflux (asthma, cough, gas/bloat, chest pain, and odynophagia) were identified and changes after fundoplication were noted. Asthmatics were identified if they had symptoms consistent with asthma and had been cared for by a physician because of their asthma. Gas/bloat symptoms included a host of subjective patient symptoms, including postprandial abdominal distention, crampy abdominal discomfort, excessive eructation, and flatulence. Medication requirement was also documented before and after fundoplication pertaining to all symptoms.

Before fundoplication, most patients underwent esophageal manometry and 24-hour pH monitoring. pH monitoring was not undertaken if the predominant presenting symptoms were obstructive (i.e., dysphagia) because of a large hiatal hernia or paraesophageal hernia, which was the case in approximately 10 per cent to 15 per cent of the patients. All patients with manometric dysmotility were further studied with barium-laden food boluses and esophagogram in the prone and 15 degree Trendelenburg position, as has been our practice. Manometry was occasionally supplanted by esophagogram as previously described.16 Esophageal peristalsis was observed first by swallowing a single large bolus of barium thinned with water to a 20 per cent suspension and then with swallowing of barium-laden food boluses. Patients were challenged with first a mechanical soft bolus (marshmallow) and then a solid bolus (bagel). All patients who underwent laparoscopic Nissen fundoplication had normal motility on manometry studies or exhibited adequate clearance of food boluses on esophagogram with two or fewer stripping motions. All patients with GERD symptoms undergoing ambulatory 24-hour pH testing had Demeester scores greater than 14.72.

Our technique of fundoplication has been previously described.3 Briefly, fundoplication was undertaken with five trocars, four 10 mm and one 5 mm. A Hasson cannula was placed in the umbilicus using a cut-down te\chnique and pneumoperitoneum was established. A fan retractor was placed through a trocar along the right anterior axillary line just caudad to the costal margin and was used to retract the left lobe of the liver to expose the gastroesophageal junction. A third trocar was placed near the xyphoid process, just to the left of midline and just below the liver edge. This trocar served as the videoscopic port for the remainder of the procedure. Two operating ports, a 10-mm trocar in the right midclavicular line at the level of the videoscopic port and a 5-mm trocar in the left midclavicular line just below the costal margin, were then placed.

The gastrohepatic omentum was opened in a stellate fashion and the dissection was carried to the right crus using the Ultrasonic Shears(TM) (US Surgical Corporation, Tyco Healthcare, Norwalk, CT). The phrenoesophageal membranes were divided and the esophagus was mobilized from its attachments to the right crus. The short gastric vessels were divided in all patients and the gastric fundus was widely mobilized. The esophagus was completely mobilized from the esophageal hiatus and the dissection continued into the mediastinum for further mobilization, assuring 6 to 8 cm of intra-abdominal esophagus. All of the hiatal hernia was completely reduced. The gastroesophageal fat pad was routinely excised. The sac of the hiatal hernia was routinely excised. The crura were approximated with braided polyester sutures to adequately close the hiatal defect. A floppy 2.5- to 3.0-cm fundoplication was constructed over a 54-60 French bougie using three sutures. The first two sutures incorporated esophagus above the gastroesophageal junction to prevent slippage and to ensure that the fundoplication was above the gastroesophageal junction. The wrap was then secured to the right crus, also incorporating esophagus, to prevent twisting and to minimize tension, which might cause the wrap to come undone. All port sites were closed with nonabsorbale monofilament suture under videoscopic guidance and skin was approximated with absorbable sutures and steristrips.

A liquid diet was started after fundoplication, once patients were awake and alert. Patients were usually discharged home the next day on a liquid diet. They were instructed to slowly advance their diet at home to mechanical soft foods over roughly 2 weeks.

Patients were seen in the clinic within the first 1 to 3 weeks after discharge. They were then seen in clinic as needed in the later postoperative period and followed annually thereafter. At the time of each contact, patients were asked to score their postoperative symptoms. Patients were also asked to grade their overall outcomes as excellent (complete or near complete resolution of symptoms), good (greatly improved symptoms), fair (slightly improved symptoms), or poor (no improvement or worsening of symptoms) relative to before fundoplication. They were also asked to declare if they would again have the operation if necessary after having been through the experience.

Median and mean (SD) symptom scores from before and after fundoplication were calculated for comparison. Dietary and sleeping habit modifications before and after fundoplication were compared. Statistical analysis was undertaken using paired Student’s t test, Wilcoxon matched-pairs test, and χ^sup 2^ analysis, when appropriate. Significance was accepted with 95 per cent confidence. Data are presented as median, mean SD, when appropriate. Of the 813 patients who underwent laparoscopic Nissen fundoplication, 322 patients with severe extraesophageal symptoms were identified and their outcomes analyzed. A subset of 25 patients with isolated extraesophageal symptoms who lacked conventional GERD symptoms, scoring a 0 or 1 for heartburn and regurgitation, were also evaluated.

Results

The patients were 47 per cent male and 53 per cent female. The median age was 52 years, with a mean of 52 15.5 years. Patients have been followed prospectively and data have been entered into our gastroesophageal reflux disease registry. Follow-up was 39 months, with a mean of 50 83.8 months.

Among the 813 patients undergoing laparoscopic Nissen fundoplication, the median length of stay was 1 day, and the mean was 2.7 3.45 days. Major complications were uncommon. Uncomplicated CO2 pneumothoraces occurred in 13 patients. Pneumonia occurred in three patients. Two patients developed small bowel obstruction. Gastrotomy occurred in eight patients and esophagotomy in one. Four of these patients required reoperation, as well as one patient for an enterotomy and another for postoperative bleeding. Cardiac arrest occurred in two patients, and there was one death from postoperative sepsis. Varying degrees of dysphagia were a common complaint, but were usually mild and almost uniformly limited and brief.

One hundred thirty-five patients presented with severe asthma. For these patients, mean symptom scores decreased from 4.7 to 1.7 after fundoplication, with 83 per cent reporting excellent or good outcomes (Table 1). Of the 132 patients with severe cough, only 69 per cent reported excellent or good outcomes, despite a reduction of mean postoperative symptom score 4.3 to 2.0 (Table 1). Still, 81 per cent stated they would still have the operation, after knowing what the process was like and being aware of their outcome. Median symptom scores similarly decreased with fundoplication (Fig. 1).

TABLE 1. Mean SD of Extraesophageal Symptom Scores before and after Fundoplication and Stated Patient Outcomes

Among patients with predominant preoperative symptoms of severe gas/bloat, chest pain, and/or odynophagia, mean and median postoperative scores were significantly reduced (Table 1 and Fig. 1). Excellent or good outcomes were reported to 79 per cent, 81 per cent, and 82 per cent, respectively (Table 1).

Modification of dietary habits diminished from 82 per cent to 50 per cent after fundoplication. Likewise, modification of sleeping habits decreased dramatically from 70 per cent to 28 per cent (Fig. 2).

Poor results were seen in 7 per cent, 11 per cent, 6 per cent, and 8 per cent of patients with predominant symptoms of asthma, gas/ bloat, chest pain, and odynophagia, respectively. Notably, among those with preoperative predominant symptoms of cough, 14 per cent described their outcome as poor. However, all had significant reductions in each of their respective predominant symptom scores after fundoplication (P

Poor outcomes were reported in 11 per cent of all patients after fundoplication. In these patients, analysis demonstrated a significant decrease in symptoms after fundoplication for dysphagia, heartburn, and regurgitation, as well as asthma, cough, gas/bloat, chest pain, and odynophagia (P

FIG. 1. Median extraesophageal symptom scores before and after fundoplication. *P

FIG. 2. Patient modification of dietary and sleeping habits before and after fundoplication. *P

Conversely, 49 per cent of patients reported excellent outcomes, denoting complete or near complete resolution of symptoms. Excellent or good outcomes were reported in 78 per cent of patients.

A subset of 25 patients was identified as having severe extraesophageal symptoms (preoperative symptom scores of 4 or 5) and a lack of classic GERD symptoms (preoperative scores of O or 1 for heartburn and regurgitation). Seventy per cent of these “atypical” patients reported excellent or good outcomes and 80 per cent stated they would undergo the operation again, having been through the experience. Only three patients (12%) described their outcome as poor.

Discussion

Herein, we report the results of laparoscopic Nissen fundoplication on a large and unique group of patients with long- term follow-up. Patients were generally middle-aged. The gender distribution between men and women was nearly equal. The patients focused upon in this report who underwent fundoplication had severe GERD and severe atypical symptoms before fundoplication. This report documents the beneficial impact of fundoplication on patients with GERD and asthma, cough, gas/bloat, chest pain, and odynophagia.

All patients had statistical improvement in their mean atypical symptom scores. Likewise, there was significant reduction in the proportion of patients who continued dietary or sleeping habit modification after fundoplication. Patients presenting with significant gas/bloat had the highest mean score postoperatively, which was likely a consequence of the usual aerophagia occurring with GERD and after fundoplication. It is generally believed that fundoplication causes bloating to be worse postoperatively, yet our patients experienced an improvement after surgery. Those with predominant symptoms of cough had relatively higher postoperative scores than seen with other atypical symptoms. Their outcomes may be attributed to numerous other causes of cough that are not refluxrelated and thus were not resolved with fundoplication. It is important that attention be paid to correlation of all extraesophageal symptoms with pH studies and initial response to PPI therapy, to maximize favorable outcomes. Despite this, all atypical symptoms improved significantly after fundoplication.

Subjective outcomes approached, but did not achieve, the results seen with patients with classic GERD symptoms. A great proportion of patients described their outcome as excellent or good, denoting complete or near complete resolution of symptoms. Few patients felt their outcomes were poor. Approximately 9 of 10 patients would still have had the surgery \again after experiencing it firsthand, and felt it was worthwhile.

It is not fully understood why some patients described their symptoms as poor, despite significant reduction in symptoms, for classic and atypical symptoms. Many patients were upset with issues unrelated to the surgery or their clinical outcomes, i.e., inconvenience, difficulty with insurance companies, miscommunication with the surgical team, etc. There were very few patients who had persistent symptoms despite adequate fundoplication. Patients with unsatisfactory outcomes were not routinely willing to be studied with pH monitoring, particularly if they had resolution of other reflux symptoms. Many atypical symptoms may have a nonreflux induced etiology and therefore are unable to be improved upon with fundoplication.

Patients with true atypical symptoms, that is, patients presenting only with extraesophageal symptoms and lack of classic GERD complaints, had results similar to those presenting with both. Nearly three in four reported their outcome as excellent or good and four in five would undergo the operation again, if necessary.

As we have collected a large database of patients and followed them for an extended period of time, we have been able to determine the time frame and slope relating to improvement of symptoms after fundoplication. Extraesophageal symptoms, as with classic GERD symptoms, improve almost immediately after the operation. Likewise, the results are durable and in the vast majority, long-term outcome approximates early outcome. Those who do not have early improvement are unlikely to achieve excellent results, although nearly all have some degree of improvement.

The efficacy of antireflux surgery in alleviating extraesophageal symptoms has, to date, not been established, and there remains a lack of consensus in the surgical literature. There have been reports of fair to good results after open fundoplication for asthma.17 More recently, small retrospective reports have identified improvements in respiratory symptoms in 58 per cent to 83 per cent.18-20 Surgical intervention has been seen to result in more marked improvement in comparison with medical therapy. The cause and frequency of failures in comparison with the excellent results seen in alleviating classic GERD symptoms have not been identified. It has been thought that esophageal dysmotility may be a factor in continued respiratory symptoms after fundoplication, failing to clear the esophagus or, worse yet, propelling food and saliva to the larynx/pharynx. However, this has not been documented nor does it seem likely. It is generally agreed that patients who initially respond to PPI therapy have the best results with operative intervention, and that although symptoms improve, pulmonary function is usually unaltered.

Laryngeal symptoms have been seen to similarly improve after fundoplication in 78 per cent to 86 per cent.18, 21 Failure to relieve symptoms occurs because of irreversible laryngeal structural damage. As with respiratory symptoms, the patients with the best outcomes after surgery were those who responded to PPI therapy.

Chest pain is reportedly relieved with antireflux surgery in 85 per cent to 96 per cent of patients. Patients who had greater than 40 per cent correlation of chest pain with acid reflux on pH study had the best outcomes as their symptoms were more clearly associated with esophageal acid exposure.22

In this study of a large group of patients with GERD, we have documented relief of extraesophageal symptoms in the majority of patients. This was seen in those who had extraesophageal symptoms in addition to more common classic GERD symptoms, and in patients who had “atypical” extraesophageal symptoms alone.

In summary, laparoscopic Nissen fundoplication is an effective method for palliating classic symptoms of GERD such as heartburn or regurgitation, and for “atypical” extraesophageal symptoms of reflux as well. Outcomes after fundoplication for extraesophageal symptoms, although not quite as favorable as those seen in patients with classic symptoms of GERD, are encouraging.

Extraesophageal symptoms of reflux are well palliated by laparoscopic Nissen fundoplication, and its application for such symptoms that are not amenable to or fail nonoperative therapy is encouraged.

REFERENCES

1. Locke GR III. The epidemiology of functional gastrointestinal disorders in North America. Gastroenterol Clin North Am 1996;25:1- 19.

2. Bloomston M, Zervos E, Gonzalez R, et al. Quality of life and antireflux medication use following laparoscopic Nissen fundoplication. Am Surg 1998;64:509-13, discussion 513-4.

3. Bloomston M, Nields W, Rosemurgy AS. Symptoms and antireflux medication use following laparoscopic Nissen fundoplication: outcome at 1 and 4 years. J Soc Laparoendosc Surg 2003; 7:211-8.

4. Dassinger MS. Laparoscopic fundoplication: 5-year follow-up. Am Surg 2004;70:691-4, discussion 694-5.

5. Lundell L, Miettinen P, Myrvold HE, et al. Continued (5-year) follow-up of a randomized clinical study comparing antireflux surgery and omeprazole in gastroesophageal reflux disease. J Am Coll Surg 2001; 192:172-9, discussion 179-81.

6. Richter JE. Extraesophageal presentations of gastroesophageal reflux disease. Semin Gastrointest Dis 1998;8:75-89.

7. Koufman JA, Belafsky PC, Bach KK, et al. Prevalence of esophagitis in patients with pH-documented laryngopharyngeal reflux. Laryngoscope 2002; 112:1606-9.

8. Nord HJ. Extraesophageal symptoms: what role for the proton pump inhibitors? Am J Med 2004;117:568-625.

9. Wo JM, Hunter JG, Waring JP. Dual-channel ambulatory esophageal pH monitoring. A useful diagnostic tool? Dig Dis Sci 1997;41:2222-6.

10. Harding SM. Gastroesophageal reflux: a potential asthma trigger. Immunol Allergy Clin North Am 2005;25:131-48.

11. Vaezi MF. Gastroesophageal reflux disease and the larynx. J Clin Gastroenterol 2003;36:198-203.

12. Knight RE, Wells JR, Parrish RS. Esophageal dysmotility as an important co-factor in extraesophageal manifestations of gastroesophageal reflux. Laryngoscope 2000; 110:1462-6.

13. Koufman JA, Amin MR, Panetti M. Prevalence of reflux in 113 consecutive patients with laryngeal and voice disorders. Otolaryngol Head Neck Surg 2000;123:385-8.

14. Faybush E. Gastroesophageal reflux disease in noncardiac chest pain. Gastroenterol Clin North Am 2004;33:41.

15. Sarela AI, Verbeke CS, Pring C, Guillou PJ. Is symptom control the correct end point for proton pump inhibitor treatment in Barren’s oesophagus? Gut 2004;53:1387-8.

16. D’Alessio MJ, Rakita S, Bloomston M, et al. Esophagography predicts favorable outcomes after laparoscopic Nissen fundoplication for patients with esophageal dysmotility. J Am Coll Surg 2005;201:335-42.

17. Tardif C, Nouvel G, Denis P. Surgical treatment of gastroesophageal reflux in 10 patients with severe asthma. Respiration (Herrlisheim) 1989;56:110-5.

18. So JBY, Zeitel SM, Rattner DW. Outcome of atypical symptoms attributed to gastroesophageal reflux treated by laparoscopic fundoplication. Surgery 1998; 124:28-32.

19. Patti MG, Arcerito M, Tamburini A. Effect of laparoscopic fundoplication on gastroesophageal reflux disease-induced respiratory symptoms. J Gastrointest Surg 2000;4:143-9.

20. Field SK, Gelfand GA, McFadden SD. The effects of antireflux surgery on asthmatics with gastroesophageal reflux. Chest 1999;116:766-74.

21. Lindstrom DR, Wallace J, Loehrl TA. Nissen fundoplication surgery for extraesophageal manifestations of gastroesophageal reflex (EER). Laryngoscope 2002;112:1762-5.

22. Patti MG, Molena D, Fisichella PM, et al. Gastroesophageal reflux disease (GERD) and chest pain. Results of laparoscopic antireflux surgery. Surg Endosc 2002;16:563-6.

STEVEN RAKITA, M.D., DESIREE VILLADOLID, B.S., ASHLEY THOMAS, MARK BLOOMSTON, M.D., MICHAEL ALBRINK, M.D., STEVEN GOLDIN, M.D., ALEXANDER ROSEMURGY, M.D.

From the Department of Surgery, University of South Florida College of Medicine, Tampa, Florida

Presented at Southeastern Surgical Congress, 2005 Annual Scientific Meeting, February 11-15, 2005, New Orleans, LA.

Address corresponding and reprint requests to Steven Rakita, MD, Department of Surgery, James A. Haley VA Hospital, 13000 Bruce B. Downs Blvd., Tampa, FL 33612.

Copyright The Southeastern Surgical Congress Mar 2006

Moraitis D, Singh P, Jayadevan R, Cayten CG.
Source
Department of Surgery, Our Lady of Mercy Medical Center, New York Medical College, New York, USA.
Abstract
The widespread use of computed tomography (CT) scanning technology frequently leads to the incidental discovery of thickened bowel wall. The clinical significance of such a CT scan finding is largely under-investigated. The purpose of our study was to determine the incidence of significant clinical pathology and, particularly, neoplasia in patients with abnormally thickened bowel on CT scan examination. This is a single institution retrospective analysis of patients that underwent CT scanning of their abdomen. The radiological picture was correlated with colonoscopic findings. A total of 40 consecutive patients with thickened bowel on CT scan that also underwent colonoscopy were identified and their records were reviewed. Thirty-five patients had no history of previous gastrointestinal disorder and form our study group. The median age of the patients was 69 years (range, 24-97 years). There were 26 female and 9 male patients. The incidental CT finding of bowel wall thickening was the only reason for the colonoscopy in 14 (35%) out of the 40 patients. Eight (23%) patients with thick bowel had colonic neoplasia based on pathology. Five (14%) patients had invasive adenocarcinoma of the colon. Four (11%) of the 5 patients with colon adenocarcinoma did not have any associated gastrointestinal symptoms or signs. One (3%) patient had lymphoma of the colon and two (6%) had benign polyps. Colonoscopy was unremarkable in 10 (28%) patients. The incidental finding of colonic thickening on CT imaging could be associated with underlying colonic malignancy and, more importantly, represent the initial disease presentation. Therefore, we propose that these patients should undergo colonoscopy.
More Information
Original Publication

BERLIN — A Chinese teenager whose face was scorched beyond recognition as she lay unconscious on a heater has had it rebuilt by German surgeons.

In December 2001, Xiao Liewen collapsed face down on to the heater while showering, burning a hole in her skull. By the time her father found her half an hour later, she was almost dead. Doctors said it was not clear what had caused her to pass out.

Chinese doctors saved the girl’s life, but she was left with no nose and only one eye, as well as open wounds on her face which would not close properly, putting her at serious risk from infection.

Initial attempts at skin grafts failed, but following a campaign to raise awareness about her plight by a German school in Shanghai, surgeons at the Klinikum Rechts der Isar at Munich’s Technical University have been painstakingly rebuilding Xiao’s face since 2003.

The case contrasts with that of a French woman who last year made headlines after undergoing the world’s first partial face transplant. In Xiao’s instance, only her own tissue was used in the reconstruction.

A team under professor Edgar Biemer gave Xiao a new nose using tissue from her stomach and closed the open sections. Further operations will lend greater symmetry to her face.

Speaking by telephone on Wednesday, Biemer said the surgery had reinvigorated Xiao, who is now 18 years old.

“Before, she totally hid herself — she covered her head, just leaving a tiny gap for her too look out of,” he said.

“That’s all over. Now she goes out quite normally in Shanghai wearing a cap. She no longer has any inhibitions.”

The clinic revealed details of it efforts this week for the first time to coincide with a German television documentary on Xiao which is due to be aired on Thursday evening.

Sticky platelets. They’re a menace.

“Sticky platelets are the equivalent of a cocked gun being held to your head,” said William M. Trolio, Vice President of Bio/Data Corporation, Horsham-based manufacturer, seller and distributor of hemostasis and platelet function medical laboratory products. “Scientists and clinicians around the world are focusing on sticky platelets and the problems they cause.”

When platelets unnecessarily stick together – or aggregate, as it’s called in medical laboratories – they turn into relentless stalkers, ganging up on a vulnerable artery or vein to constrict it from the inside. These clumps of platelets cause blood clots, which result in heart attacks, strokes, pulmonary emboli and deep-vein thromboses.

Three conditions determine when platelets turn lethal, Trolio noted. They are: 1) genetics, 2) an enabling event (usually severe stress) and 3) risk factors, such as smoking or an unhealthy diet. “Put those all together, and the cocked gun discharges,” he said.

Sticky platelet syndrome (“SPS”), which is inherited, was first recognized during a 1983 international conference on stroke and cerebral circulation when 10 young stroke patients were identified with the condition. Subsequently, little reportable testing has occurred about the interrelationship of sticky platelets and blood clots.

Dr. Rodger L. Bick (University of Texas’ Southwestern Medical Center) is one of the exceptions. Over a two-year period prior to 1997, he evaluated 153 patients at the Dallas Thrombosis Hemostasis Clinical Center, Presbyterian Hospital. His findings “strongly suggest SPS to be a common cause of arterial and venous thromboses and a workup for SPS should be considered a routine assay in the workup of individuals with otherwise unexplained arterial or venous thrombotic events. Because treatment with … simple aspirin therapy almost always will correct the defect and protect the individual from second events, it is particularly important to define the presence of this defect.”

In 1998 Dr. Bick discovered that, in a study group of 118 women who suffered recurring miscarriages, over 16 percent had sticky platelet syndrome. Next month (April 2006), Cambridge University Press releases Dr. Bick’s Hematological Complications in Obstetrics, Pregnancy, and Gynecology, described as “the first comprehensive reference on all hematological complications of obstetrics, pregnancy and gynecology.”

“Over the years, we at Bio/Data have admired Dr. Bick’s foresight for insisting upon a correlation between sticky platelets and blood clots,” Trolio said. “Effective drug therapy is readily available, but we need comprehensive studies under controlled laboratory conditions. Sticky platelets should be diagnosed and treated before they kill.”

Bio/Data Corporation’s flagship product is the PAP-8E Platelet Aggregation Profiler(R), an impressive laboratory instrument utilized for testing platelet function. Test results provide a vital pathway enabling medical professionals to diagnose various stages of hemostasis disorders, including von Willebrand Disease, hemophilia and Glanzmann’s disease, or to monitor the use of antiplatelet drugs like Plavix(R) and aspirin. Other Bio/Data products consist of reagents and disposables to augment the variety of platelet testing.

Bio/Data’s web address is www.biodatacorp.com. The company is ISO 9001:2000 registered, and all its aggregation products are CE marked.

Free copies of Bio/Data’s sticky platelet laboratory test procedures are available by calling the company’s U.S. toll-free number at 800-257-3282.

By Cynthia Hubert, The Sacramento Bee, Calif.

Mar. 19–For lawyer Chip Wilkins, springtime means one thing: swirling pollens. And Sacramento in springtime is his version of hell. “I never had allergy problems until I moved to Sacramento,” said Wilkins, reciting a common mantra among Valley dwellers. But does our fair city really deserve its long-standing reputation for being the worst place on the planet for allergy sufferers? Probably not, according to the Asthma and Allergy Foundation of America, which ranks the 320 largest metropolitan areas based on their pollen levels, the number of residents using allergy medications and the number of allergists per capita. By the nonprofit organization’s standards, Sacramento is pretty much middle of the road when it comes to seasonal allergy problems. It ranked 62 last year, up from 73 in 2004, and consistently has landed toward the bottom of the top 100 metro areas, said AAFA spokeswoman Angel Waldron. Cities that ranked far higher than Sacramento last year include: * Lexington, Ky. * Little Rock, Ark.

* Chattanooga, Tenn. * Charlotte, N.C. * St. Louis * And even Washington, D.C. More than 50 million Americans have seasonal allergies, said Waldron. “Of course, everyone thinks that wherever they live is the worst. But if you’re not in the top 10 or 20, you are basically average. I would definitely not say that Sacramento is really, really bad.”

But even if Sacramento cannot claim “worst allergy city” status, it’s still a torturous place for many people, particularly in the spring, according to area specialists. One full week before the official start of spring, things already were busy at allergist Paul Cloninger’s office. “Very busy,” he said. “People are trying to prepare themselves for spring. They want to get a head start.” They will be battling some formidable foes, including geography, weather, air quality and flora and fauna, said Cloninger and others. Our location, in a valley surrounded by agricultural fields, is perhaps the most obvious contributor to making allergy sufferers miserable, they said. “If you’re in San Francisco, you have a large body of water constantly moving pollens toward the east,” said Cloninger. “We don’t have that here.” Tiny pollen particles, when they hit the air in the springtime, can travel for perhaps 20 miles. In Sacramento, they settle in like unwanted houseguests. “We’re like a giant vacuum cleaner bag,” said Eric Gershwin, chief of the division of rheumatology, allergy and immunology in the UC Davis College of Medicine. “Everything gets sucked over here, and it’s trapped.” Grass pollens are the worst offenders, said Robert Watson, an allergist associated with Mercy Medical Group. Our mild, rainy winters allow grasses to grow luxuriantly. When the weather warms and breezes pick up, millions of microscopic pollen grains take to the skies, spreading to other plants as well as our nasal passages. Sacramento’s ubiquitous trees, as well as weeds, including Russian thistle and mugwort, also do their share of pollinating. “I’ve been told that Sacramento is second only to Paris in the number of trees we have,” said Cloninger. “They have to pollinate, too.”

Trees with large blossoms, such as citrus trees, are pollinated by insects “so they don’t affect you,” he explained. But beware of olive trees, ashes, mulberries and many others. Cottonwoods, said Watson, get somewhat of a bad rap. “That fluff that blows around looking like snow in May is seed, not pollen, and we aren’t allergic to it,” he said. The cottonwood tree’s pollens are released well before its fluffy seeds, he noted. Sooner or later, most people develop some type of allergy, regardless of where they live, said Cloninger. “It’s a genetic thing,” he said. “You’re born with it.” You may not have symptoms until adulthood, when you find yourself in the presence of new irritants, the allergists said. It is not uncommon for people to begin sneezing and sniffling when they adopt a cat for the first time, or “move to the Sacramento area from somewhere else,” said Watson. But you cannot necessarily escape allergies by relocating to Minneapolis. “If you move to a climate that’s very cold, you might be less likely to have symptoms in the wintertime because nothing grows,” said Gershwin. But look out when it warms up. “If you go to Miami or New Orleans, you’re more likely to have allergy to mold because those areas have more humidity. You really can’t escape allergies. We don’t recommend moving. It’s silly.” Wilkins and his family moved from California to the desert southwest when he was a boy, in part to relieve his brother’s severe allergies. But for allergy sufferers, “it’s not such a great place anymore,” he noted. Folks from all over the country have brought their native plants to the area, and now Tucson, Ariz., ranks higher than Sacramento for allergy challenges. These days, Wilkins seeks relief on the water. “Anywhere beachy is wonderful,” he said. Candace Hull Taylor, who teaches English at UC Davis and at Sacramento City College, has never seriously considered moving away from the Sacramento area, even though her allergies worsened considerably when she came here from Southern California in 1989. “I moved in August and by December I started seeing an allergist,” she said. “On a scale of 1 to 4 for allergies to pollens, I was a 4-plus.” She also had asthma, which can be worsened by allergens and air pollution. The AAFA places Sacramento 71st on the list of “most challenging places to live” for people with asthma, and medical specialists attribute the ranking to the area’s smog problems. Particles of air pollution can lodge in the lungs to aggravate asthma and worsen respiratory diseases. So what is an allergy sufferer to do, now that spring is on the horizon? “Avoidance of the allergen is the best solution,” said Cloninger, so figuring out exactly what is causing your problems is most important. Close your windows, particularly on warm, breezy days in the spring. Take antihisthamines or steroid nose sprays. Allergy “shots,” reserved for people with the worst symptoms, are a last resort. “Treatment is much better these days,” said Cloninger. “With the advent of so many good new medications, we don’t see as many people suffering.” That is of little comfort to Allie Armstrong, who has battled allergies her whole life. “I’ve had them in Arizona, Oregon, New Mexico and California, but they’re definitely worse here,” said Armstrong, a teacher who lives in Carmichael. “I have pretty much concluded that I am allergic to just about everything.” Both of her children inherited her allergies. Sacramento’s persistent rain of late has, for Armstrong, been a blessing. “When it rains and it’s cold, that’s good for me,” she said. “I am definitely not looking forward to spring. When everything is blooming, I cry.” It’s almost impossible to predict the severity of this year’s spring allergy season, specialists said. But misery is definitely in the forecast for a lot of people. “Every year, someone predicts that ‘This year will be the worst ever,’ ” said Gershwin. “The fact is that every year is bad here. Sacramento always has a very, very busy allergy season.” 2005 WORST CITIES FOR SPRING ALLERGIES 1. Lexington, Ky. 2. Little Rock, Ark. 3. Chattanooga, Tenn. 4. Louisville, Ky. 5.Johnson City, Tenn. 6. Greenville, S.C. 7. Richmond, Va. 8. Charlotte, N.C. 9. Jackson, Miss. 10. St. Louis 16. Washington, D.C. 41. Tucson, Ariz. 62. Sacramento 2005 ASTHMA CAPITALS 1. Knoxville, Tenn. 2. Memphis, Tenn. 3. Louisville, Ky. 4. Toledo, Ohio 5. Washington, D.C. 6. St. Louis 7. Allentown, Pa. 8. Springfield, Mass. 9. Grand Rapids, Mich. 10. Scranton, Pa. 71. Sacramento Source: Asthma and Allergy Foundation of America A-Choo Stuffy nose? Itchy eyes? It’s not in your head, but it is affecting it. If spring’s arrival has you reaching for the tissue, you’re in good company. Americans visited their doctors 15.2 million times for allergies in 2003, the last year for which data are available, according to the National Center for Health Statistics. Seasonal allergies occur during specific flowering periods when plants are shedding their pollen. In general, trees flower in the spring, grasses in the summer and weeds in the fall, according to pollen.com. Pollen (allergen) * Typically a harmless substance, it enters the nose, eyes and/or lungs. The body’s immune system * The immune system overreacts and produces antibodies to defend the body against the pollen, which is seen as a dangerous substance. Types of treatment Proper diagnosis is essential to selecting the proper treatment (see “Identifying allergens,” below). Following are a few categories of allergy treatments. Antihistamine Blocks effect of histamine, reduces symptoms; may not be effective for nasal congestion. May cause dry mouth, dry eyes or drowsiness. Children may experience nightmares, unusual jumpiness, restlessness or irritability. Decongestant Helps clear passageway, congestion produced by allergies. Nasal spray Medication is administered without traveling throughout the body. Steroid sprays reduce inflammation in the nose, preventing sneezing, congestion and runny noses. May cause temporary dryness and irritation of the nose. Immunotherapy Doctor-administered shots that gradually build up resistance to allergens. Allergy information You can check pollen counts and take an allergy quiz at www.pollen.com. Identifying allergens Unsure if you have allergies? A definitive diagnosis requires a doctor’s visit. Tests a doctor might perform: A skin test, in which diluted extracts from allergens are injected under or applied to the skin on a patient’s arm or back. A small, raised, reddened area (called a wheal) with a surrounding flush (called a flare) appears at the site where the allergen was injected or applied. For those with skin conditions (such as eczema), a blood test is used to help determine how much antibody the body produces to a particular allergen. Common myths * “Hay fever” is a term commonly used to describe allergy symptoms, but the allergies aren’t caused by hay at all. The phrase was coined by a British physician in 1828 – because his allergy symptoms worsened during the British haying season. * Allergens such as ragweed or ash trees aren’t readily found in the desert or Southwestern United States, but heading to the desert doesn’t prevent new plant sensitivities and allergies from developing. * Sensitivity to some allergens tends to run in families, but problems can be reduced by avoiding them. Symptoms are more likely to develop as we age and can potentially last a lifetime. Sources: Dr. David L. Patterson; manufacturers’ data; AAO-HNS; www.niaid.nih.gov; www.claritin.com; Surveillance Data Inc., 2001; www.umm.edu/careguides/allergy/

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