Effect of a pilot gait and balance training program: The importance of fear of falling.

Purpose: To determine the evolution of fear of falling, and its relationship with gait performance after a 10-week gait and balance training program. Population and methods: Participants (N=50) were community-dwelling elderly persons enrolled voluntarily in a 10-week, low intensity, gait and balance training program. At baseline, fear of falling was assessed using a previously validated version of Tinetti's Fall Efficacy Scale (FES, range 0-120, higher score indicating higher confidence), that assesses one's confidence in performing 12 activities of daily life without falling. Gait parameters were measured over a 20m walk at preferred gait speed, using the Physilog system (Aminian K, et al., J Biomechanics, 2002). This system uses 4 kinematics sensors attached to the lower limbs and a data logger carried by the subject. Follow-up data on fear of falling and gait were collected one week after completion of the program. Results: Overall, 43 (86%) of the participants completed the program. Mean age was 78.1 years, 79% were women. At baseline, mean FES score was 98.8 (range 58-120) and mean gait speed was 0.92 m/sec (range 0.43-1.47). At follow-up, participants modestly improved their FES score (98.8±17.0 vs 103.2±16.0, P=.04) and gait speed (0.92±0.27 vs 0.99±0.26 m/sec, P<.01). In secondary analyses stratified by subject's baseline FES, those with lower than average confidence (N=21) improved significantly both FES score (84.4±11.8 vs 94.5±17.9, P<.01) and gait speed (0.79±0.26 vs 0.90±0.28 m/sec, P<.01), while no similar improvement was observed in subjects (N=22) with higher baseline confidence (112.5±6.6 vs 111.5±7.5, P=.56 and 1.03±0.22 vs 1.07±0.21 m/sec, P=.41). After adjustment for age, gender and baseline gait speed, subjects with lower baseline confidence had higher odds than the others to improve their confidence (AdjOR=10.8, 95%CI 1.8- 64.8 P=.01) and gait speed (AdjOR=3.3, 95%CI 0.6-19.7, P=.19) at follow-up. Conclusions: This pilot program of low intensity exercise modestly improved participants' fear of falling and gait speed. Interestingly, subjects with higher baseline fear of falling seemed more likely to benefit. Despite methodological limitations (pre-post comparisons, small sample), these results suggest that measuring fear of falling might be useful to better target subjects most likely to benefit from similar programs.

Additional effect of hypnosis in an in-patient detoxification program: results of a pilot clinical trial

The present study aims to examine the additional effects of hypnosis in the reduction of withdrawal syndrome in an inpatient detoxification treatment program. Thirty-two in-patients aged between 18 and 65 meeting the DSM-IV criteria for multiple substance dependence were randomly assigned to hypnosis condition (two sessions of standardized Ericksonian technique) or control condition (two sessions of standardized support interview). The primary outcome measures were the Short Opiate Withdrawal Scale (SOWS) and Visual Analogue Scales (withdrawal symptoms, craving, depressive mood, anxiety and nervousness). Significant reductions for most outcome measures were found for the total sample. Hypnosis was effective in reducing withdrawal symptoms, however, without significant differences compared to control group.

Methods for the ex vivo characterization of human CD8+ T subsets based on gene expression and replicative history analysis.

The generation of an antigen-specific T-lymphocyte response is a complex multi-step process. Upon T-cell receptor-mediated recognition of antigen presented by activated dendritic cells, naive T-lymphocytes enter a program of proliferation and differentiation, during the course of which they acquire effector functions and may ultimately become memory T-cells. A major goal of modern immunology is to precisely identify and characterize effector and memory T-cell subpopulations that may be most efficient in disease protection. Sensitive methods are required to address these questions in exceedingly low numbers of antigen-specific lymphocytes recovered from clinical samples, and not manipulated in vitro. We have developed new techniques to dissect immune responses against viral or tumor antigens. These allow the isolation of various subsets of antigen-specific T-cells (with major histocompatibility complex [MHC]-peptide multimers and five-color FACS sorting) and the monitoring of gene expression in individual cells (by five-cell reverse transcription-polymerase chain reaction [RT-PCR]). We can also follow their proliferative life history by flow-fluorescence in situ hybridization (FISH) analysis of average telomere length. Recently, using these tools, we have identified subpopulations of CD8+ T-lymphocytes with distinct proliferative history and partial effector-like properties. Our data suggest that these subsets descend from recently activated T-cells and are committed to become differentiated effector T-lymphocytes.

Role of c-Myc in homeostasis of memory CD8 T cells

RESUME La mémoire immunologique est essentielle durant la vie et permet aux lymphocytes de répondre plus rapidement et efficacement lors d'une deuxième rencontre avec un antigène connu. Les facteurs contrôlant l'homéostasie des cellules T CD8 mémoires in vivo ne sont pas encore bien définis. Cependant, la prolifération homéostatique de ces cellules dans un hôte déplété en cellules hématopoietiques nécessite l'intéraction du TCR avec les molecules du MHC de class I du soi. De plus, le rôle de cytokines, telles que 1'IL-15 et l'IL-7, est essentiel dans ce mécanisme, aussi bien que dans la maintenance des cellules T CD8 mémoires. Puisque la protéine c-Myc - impliquée dans des mécanismes tells que la division, la prolifération, l'apoptose et la differentiation - a été définie comme étant impliquée dans la réponse à différentes cytokines, nous nous sommes intéressés à l'analyse de l'homéostasie des lymphocytes T CD8 mémoires dans des souris déficientes en c-Myc (c_rnycΔORF/+), qui expriment un niveau réduit de cette protéine. Bien que le développement des cellules T dans le thymus soit normal dans les souris c_rnycΔORF/+, nous avons observé une réduction de 2 à 3 fois dans la population des cellules T CD8 de phenotype mémoire (CD44+) dans les organes lymphoïdes de la périphérie de ces souris. Cette différence ne correspond pas à une réduction de prolifération ou d'expression de protéines de survie telles que Bel-2. Cependant, la prolifération homéostatique de cellules T CD8 c_rnycΔORF/+, mais pas T CD4 c_rnycΔORF/+, est reduite de manière dramatique lorsqu'elles sont transférées dans un hôte irradié. De plus, le transfert adoptif de lymphocytes T dans des souris irradiées déficientes en l'IL-15 nous a permis de montrer que la prolifération homéostatique dépendante de l'IL-15 des cellules T CD8 nécessite l'expression de c-Myc. De plus, contrairement aux cellules T CD8 CD44+ de type sauvage, nous avons observé que l'expansion induite par l'IL-15 des cellules T CD8 CD44+ c_rnycΔORF/+ est altérée aussi bien in vivo (en réponse à une injection de polyI:C) et in vitro. Par conséquent, nos résultats identifient c-Myc comme une nouvelle protéine régulatrice de la signalisation par l'IL-15 impliquée dans l'homéostasie des cellules T CD8 CD44+. SUMMARY Immunological memory is essential throughout life and allows memory lymphocytes to respond faster and more efficiently upon re-encounter of a known antigen. Factors controlling homeostasis of memory CD8 T cells under steady-state conditions in vivo are currently not well defined. However, the homeostatic proliferation of memory CD8 T cells in lymphopenic hosts requires the interaction of the TCR with self MHC class I molecules. In addition, cytokines, such as IL-15 and to a lesser extent IL-7, are essential for both homeostatic proliferation and maintenance of memory CD8 T cells. Since c-Myc, a proto-oncogene involved in cell division, proliferation, apoptosis and differentiation, has been widely implicated in responsiveness to cytokines, we were interested in analyzing homeostasis of memory CD8 T cells in c-myc hypomorph (c_rnycΔORF/+) mice, which express reduced levels of c-Myc. Although T cell development in the thymus was normal in c_rnycΔORF/+ mice, we found a selective 2- to 3-fold reduction in the memory-phenotype CD44high CD8 T cell population in the periphery. Reduced numbers of CD44high CD8 T cells did not correlate with decreased steady-state turnover rate or low expression of survival factors such as Bcl- 2. However, homeostatic proliferation of c_rnycΔORF/+ CD8 T cells, but not c_rnycΔORF/+ CD4 T cells, was dramatically reduced upon transfer into sublethally irradiated wild-type recipients. In addition, upon transfer of c_rnycΔORF/+ and c-myc WT cells into IL-15-/- mice, we observed that IL-15-induced homeostatic proliferation of CD8 T cells requires c-Myc. Moreover, in contrast to c-myc WT CD44high CD8 T cells, IL-15-induced expansion of c_rnycΔORF/+ CD44high CD8 T cells was strongly impaired both in vivo (in response to polyI:C injection) and in vitro. Collectively, our data identify c-Myc as a novel downstream regulator of IL-15 signaling involved in homeostasis of memory CD8 T cells.

Functional heterogeneity of memory CD4 T cell responses in different conditions of antigen exposure and persistence.

Memory CD4 T cell responses are functionally and phenotypically heterogeneous. In the present study, memory CD4 T cell responses were analyzed in different models of Ag-specific immune responses differing on Ag exposure and/or persistence. Ag-specific CD4 T cell responses for tetanus toxoid, HSV, EBV, CMV, and HIV-1 were compared. Three distinct patterns of T cell response were observed. A dominant single IL-2 CD4 T cell response was associated with the model in which the Ag can be cleared. Polyfunctional (single IL-2 plus IL-2/IFN-gamma plus single IFN-gamma) CD4 T cell responses were associated with Ag persistence and low Ag levels. A dominant single IFN-gamma CD4 T cell response was associated with the model of Ag persistence and high Ag levels. The results obtained supported the hypothesis that the different patterns observed were substantially influenced by different conditions of Ag exposure and persistence.

Investigation of memory, executive functions, and anatomic correlates in asymptomatic FMR1 premutation carriers.

Fragile X-associated tremor/ataxia syndrome (FXTAS) is a late-onset movement disorder associated with FMR1 premutation alleles. Asymptomatic premutation (aPM) carriers have preserved cognitive functions, but they present subtle executive deficits. Current efforts are focusing on the identification of specific cognitive markers that can detect aPM carriers at higher risk of developing FXTAS. This study aims at evaluating verbal memory and executive functions as early markers of disease progression while exploring associated brain structure changes using diffusion tensor imaging. We assessed 30 aPM men and 38 intrafamilial controls. The groups perform similarly in the executive domain except for decreased performance in motor planning in aPM carriers. In the memory domain, aPM carriers present a significant decrease in verbal encoding and retrieval. Retrieval is associated with microstructural changes of the white matter (WM) of the left hippocampal fimbria. Encoding is associated with changes in the WM under the right dorsolateral prefrontal cortex, a region implicated in relational memory encoding. These associations were found in the aPM group only and did not show age-related decline. This may be interpreted as a neurodevelopmental effect of the premutation, and longitudinal studies are required to better understand these mechanisms.

An interdisciplinary HIV-adherence program combining motivational interviewing and electronic antiretroviral drug monitoring.

To ensure successful treatment, HIV patients must maintain a high degree of medication adherence over time. Since August 2004, patients who are (or are at risk of) experiencing problems with their HIV antiretroviral therapy (ART) have been referred by their physicians to an interdisciplinary HIV-adherence program. The program consists of a multifactorial intervention along with electronic drug monitoring (MEMS(TM)). The pharmacists organize individualized semi-structured motivational interviews based on cognitive, emotional, behavioral, and social issues. At the end of each session, the patient brings an adherence report to the physician. This enables the physician to use the adherence results to evaluate the treatment plan. The aim of this study was to retrospectively analyze this on-going interdisciplinary HIV-adherence program. All patients who were included between August 2004 and the end of April 2008 were analyzed. One hundred and four patients were included (59% women, median age 39 (31.0, 46.0) years, 42% black ethnicity). Eighty (77%) patients were ART-experienced patients and 59% had a protease inhibitor-based treatment. The retention rate was high (92%) in the program. Patient inclusion in this HIV-adherence program was determined by patient issues for naive patients and by nonadherence or suboptimal clinical outcomes for ART-experienced patients. The median time spent by a subject at the pharmacy was 35 (25.0, 48.0) minutes, half for the medication handling and half for the interview. The adherence results showed a persistence of 87% and an execution of 88%. Proportion of undetectable subjects increased during study. In conclusion, retention and persistence rates were high in this highly selected problematic population.

Prophylactic isolated limb perfusion for localized, high-risk limb melanoma: results of a multicenter randomized phase III trial. European Organization for Research and Treatment of Cancer Malignant Melanoma Cooperative Group Protocol 18832, the World Health Organization Melanoma Program Trial 15, and the North American Perfusion Group Southwest Oncology Group-8593.

PURPOSE: Patients with primary cutaneous melanoma > or = 1.5 mm in thickness are at high risk of having regional micrometastases at the time of initial surgical treatment. A phase III international study was designed to evaluate whether prophylactic isolated limb perfusion (ILP) could prevent regional recurrence and influence survival. PATIENTS AND METHODS: A total of 832 assessable patients from 16 centers entered the study; 412 were randomized to wide excision (WE) only and 420 to WE plus ILP with melphalan and mild hyperthermia. Median age was 50 years, 68% of patients were female, 79% of melanomas were located on a lower limb, and 47% had a thickness > or = 3 mm. RESULTS: Median follow-up duration is 6.4 years. There was a trend for a longer disease-free interval (DFI) after ILP. The difference was significant for patients who did not undergo elective lymph node dissection (ELND). The impact of ILP was clearly on the occurrence-as first site of progression - of in-transit metastases (ITM), which were reduced from 6.6% to 3.3%, and of regional lymph node (RLN) metastases, with a reduction from 16.7% to 12.6%. There was no benefit from ILP in terms of time to distant metastasis or survival. Side effects were higher after ILP, but transient in most patients. There were two amputations for limb toxicity after ILP. CONCLUSION: Prophylactic ILP with melphalan cannot be recommended as an adjunct to standard surgery in high-risk primary limb melanoma.