Shirley G. Fitzgerald

Prevalence and risk factors of carotid plaque in women with systemic lupus erythematosus

OBJECTIVE To determine the prevalence of carotid atherosclerosis and associated risk factors in women with systemic lupus erythematosus (SLE). METHODS Carotid plaque and intima-media wall thickness (IMT) were measured by B-mode ultrasound in women with SLE. Risk factors associated with carotid plaque and IMT were determined at the time of the ultrasound scan and included traditional cardiovascular risk factors, SLE-specific variables, and inflammation markers. RESULTS The 175 women with SLE were predominantly white (87%), with a mean age of 44.9 years (SD 11.5). Twenty-six women (15%) had a previous arterial event (10 coronary [myocardial infarction or angina], 11 cerebrovascular [stroke or transient ischemic attack], and 5 both). The mean +/- SD IMT was 0.71 +/- 0.14 mm, and 70 women (40%) had focal plaque. Variables significantly associated with focal plaque (P < 0.05) included age, duration of lupus, systolic, diastolic, and pulse pressure, body mass index, menopausal status, levels of total and low-density lipoprotein (LDL) cholesterol, fibrinogen and C-reactive protein levels, SLE-related disease damage according to the Systemic Lupus International Collaborating Clinics (SLICC) damage index (modified to exclude cardiovascular parameters), and disease activity as determined by the Systemic Lupus Activity Measure. Women with longer duration of prednisone use and a higher cumulative dose of prednisone as well as those with prior coronary events were more likely to have plaque. In logistic regression models, independent determinants of plaque (P < 0.05) were older age, higher systolic blood pressure, higher levels of LDL cholesterol, prolonged treatment with prednisone, and a previous coronary event. Older age, a previous coronary event, and elevated systolic blood pressure were independently associated with increased severity of plaque (P < 0.01). Older age, elevated pulse pressure, a previous coronary event, and a higher SLICC disease damage score were independently related to increased IMT (P < 0.05). CONCLUSION B-mode ultrasound provides a useful noninvasive technique to assess atherosclerosis in women with SLE who are at high risk for cardiovascular disease. Potentially modifiable risk factors were found to be associated with the vascular disease detected using this method.

Vascular Stiffness in Women With Systemic Lupus Erythematosus

Large-vessel manifestations of systemic lupus erythematosus (SLE), a multisystem disease characterized by disturbances in the immune system, include higher than expected rates of hypertension and cardiovascular disease. Reductions in the elasticity of central arteries may act as a marker of early changes that predispose to the development of major vascular disease. This study evaluated risk factors associated with aortic stiffness measured by pulse wave velocity (PWV) in women with SLE. We expected SLE-specific factors, especially variables indicative of inflammation and active disease, to be associated with increasing PWV. The study population included 220 women currently enrolled in the Pittsburgh Lupus Registry. All risk factor data were collected on the day of the ultrasound examinations. PWV waveforms were collected from the right carotid and femoral arteries by Doppler probes. The mean age of the women was 45.5±10.8 years, the median SLE disease duration approximated 9 years, and the mean PWV was 6.1±1.7 m/s. Multiple regression models were stratified by menopausal status. Among postmenopausal women, PWV risk factors were primarily traditional factors and included age, systolic blood pressure, family history of vascular disease, carotid plaque, creatinine, obesity, glucose, white cell count, and cumulative SLE organ damage. Among premenopausal women, PWV risk factors consisted of a mix of SLE-related and traditional variables and included higher C3 levels, presence of ds-DNA antibodies, nonuse of hydroxychloroquine, lower leukocyte count, higher mean arterial pressure, and carotid plaque. SLE-specific variables appeared to be associated with increases in aortic PWV, indicating central artery stiffening. This was seen most clearly among premenopausal women. This finding may partially explain the higher rates of cardiovascular disease and hypertension observed in young women with SLE.

Frequency of fractures in women with systemic lupus erythematosus: Comparison with united states population data

OBJECTIVE To describe the frequency of self-reported fractures in a large population-based cohort of women with lupus, to compare the frequency of self-reported fractures between lupus patients and women of similar age in the general population by use of data from the 1994 National Health Interview Survey (NHIS), and to describe the associated risk factors for fracture in women with lupus. This study is a secondary analysis of data collected to assess cardiovascular risk in women with lupus. METHODS Fractures and associated risk factors were ascertained by self report in this retrospective cohort study of 702 living women with lupus who were followed up for 5,951 person-years. Self-reported fractures were verified in a subset of patients. A Weibull regression model was used to assess risk factors associated with time from lupus diagnosis to fracture in the univariate and multivariate analyses. Age-specific standard morbidity ratios (SMRs) were calculated to determine whether fracture occurrence was greater than expected in women with lupus. RESULTS Eighty-six (12.3%) of 702 women reported at least 1 fracture following the diagnosis of lupus. The sites of the first fracture were the leg (n = 32), foot (n = 16), arm (n = 15), spine (n = 9), rib (n = 7), hip (n = 2), pelvis (n = 2), hand (n = 1), shoulder (n = 1), and finger (n = 1). Fracture risk was increased in the lupus cohort compared with women of similar age from the United States population, using weighted data from the 1994 NHIS (SMR 4.7; 95% confidence interval 3.8, 5.8). Variables in the univariate analysis that were significantly associated (P < 0.05) with time from lupus diagnosis to fracture were older age at lupus diagnosis, longer disease duration, longer duration of corticosteroid use, less use of oral contraceptives, and menopause status. In the multivariate analysis, independent determinants of time from lupus diagnosis to fracture were older age at lupus diagnosis and longer duration of corticosteroid use. CONCLUSION Fractures occurred in 12.3% of lupus patients who were followed up for 5,951 person-years. There was nearly a 5-fold increase in fracture occurrence in the women with lupus compared with women from the US population. Older age at lupus diagnosis and longer use of corticosteroids were associated with time from lupus diagnosis to fracture. With increased life expectancy of lupus patients, fracture occurrence is a major threat to the health of these women. Prevention strategies must be directed toward minimizing the occurrence of fractures in these patients.

Assessing mobility characteristics and activity levels of manual wheelchair users

Although engaging in an active lifestyle is beneficial for maintaining quality of life, a majority of wheelchair users are inactive. This study investigated the mobility characteristics and activity levels of manual wheelchair users in the residential setting and at the National Veterans Wheelchair Games (NVWG). Demographic factors that may have influenced activity in the home environment were also identified. Fifty-two manual wheelchair users completed a brief survey, and their activity was monitored with a custom data logger over a period of 13 or 20 days. We found that they traveled a mean +/- standard deviation of 2,457.0 +/- 1,195.7 m/d at a speed of 0.79 +/- 0.19 m/s for 8.3 +/- 3.3 h/d while using their primary wheelchair in the home environment. No significant differences in mobility characteristics or activity levels were found for level of spinal cord injury or disability. We also found that subjects traveled significantly farther and faster and were active for more hours during an average day at the NVWG than in the home environment (p < 0.001). We found that manual wheelchair users who were employed covered more distance, accumulated more minutes, and traveled a greater average maximum distance between consecutive stops than those who were unemployed. Results from this study provide a better understanding of the activity levels achieved by manual wheelchair users and insight into factors that may influence this activity.

Performance assessment of a pushrim-activated power-assisted wheelchair control system

Wheelchairs are an important form of mobility for people with disabilities. For many years, there have only been three wheelchair varieties: electric-powered wheelchairs, scooters and manual wheelchairs. Recently, wheelchairs have been developed that use a combination of human power and electric power. The human power is delivered by the arms through the pushrims while the electric power is delivered by a battery through two electric motors. The shared control system for a pushrim-activated power-assisted wheelchair (PAPAW) must account for the human behavior and the interaction with the device. The PAPAW uses a form of gain scheduling based upon events recorded from the pushrim torque. The control system significantly altered (p<0.05) selected variables from pushrim torque curves for manual wheelchair propulsion and PAPAW operation as desired. The peak torque was reduced by over 50%, and the time on the rim was nearly doubled with the PAPAW. The PAPAW provided intuitive control and was capable of significantly reducing the strain on the upper extremities commonly associated with secondary disabling conditions among manual wheelchair users.

Isokinetic performance after total hip replacement.

Bertocci GE, Munin MC, Frost KL, Burdett R, Wassinger CA, Fitzgerald SG: Isokinetic performance after total hip replacement. Am J Phys Med Rehabil 2004;83:1–9. ObjectiveTo evaluate differences in isokinetic hip flexion, extension, and abduction muscle performance of operated vs. nonoperated hips in older adults who have undergone elective, unilateral, total hip replacement (THR) surgery and completed rehabilitation. DesignQuasi-experimental study using a nonequivalent posttest-only control group design, comprising 20 unilateral THR patients and a convenience sample of 22 healthy older adults. THR patients participated between 4 and 5 mos after surgery. THR subjects received an average of 13 outpatient or home-based physical therapy sessions. Isokinetic muscle strength and fatigue was assessed through measurement of hip peak torque per body weight, total work, and average power using a robotic dynamometer. ResultsComparisons of THR subjects’ operated vs. nonoperated hips showed no significant differences in isokinetic performance for any of the examined variables. THR subjects’ operated hips generated significantly less peak torque per body weight, total work, and average power across all exercises as compared with a population of healthy subjects. ConclusionsTHR subjects’ operated and nonoperated hips showed similar biomechanical performance. THR patients are not being restored to the same level of strength and muscular endurance as compared with a population of healthy adults. These findings may be useful in providing a preliminary rationale for revising current approaches in THR rehabilitation protocols.

Investigating Neck pain in Wheelchair users

Boninger ML, Cooper RA, Fitzgerald SG, Lin J, Cooper R, Dicianno B, Liu B: Investigating neck pain in wheelchair users. Am J Phys Med Rehabil 2003;82:197–202. Objective Despite the fact that wheelchair users are exposed to risk factors for neck and upper back pain (NP), little is known about the impact and possible diagnoses associated with NP. The purpose of this study was to examine the significance of NP in wheelchair users and to determine if a portion of the NP may be myofascial in origin. Design Cross-sectional cohort study using questionnaires and physical exams to evaluate NP in a convenience sample of wheelchair users from the National Veteran’s Wheelchair Games. Main outcome measures included reported NP, visual analog scale of neck complaints, Neck Disability Index, and physical examination findings of trigger points. Results Sixty-six percent of subjects reported NP since becoming a wheelchair user and, 60% reported pain during the past month. Neither age nor length of time in a wheelchair was significantly different between those subjects who did and those subjects who did not report pain. Of those respondents who reported NP, 60% visited the doctor about the pain and 40% limited their daily activities due to the pain. Trigger-point palpation reproduced pain in 54% of those respondents who experienced pain in the past month (n = 34). Conclusion This study provides a first step in defining the prevalence and significance of NP among wheelchair users. Clinicians who work with this population need to ask subjects about symptoms and consider a myofascial origin for that pain when considering treatment.

Genetic variation in apolipoprotein H (β2-glycoprotein I) affects the occurrence of antiphospholipid antibodies and apolipoprotein H concentrations in systemic lupus erythematosus

Apolipoprotein H (apoH, protein; APOH, gene) is a required cofactor for the production of antiphospholipid antibodies (APA). In this study we have examined whether genetic variation in the APOH gene affects variation in risk for systemic lupus erythematosus (SLE), occurrence of antiphospholipid antibodies (APA), anti-apoH, and plasma apoH concentrations. A total of 222 white SLE women were screened for four APOHpolymorphisms (codons 88, 247, 306, and 316) by polymerase chain reaction, and for plasma apoH concentrations by ELISA. Of these, 29.3% were positive for APA (APA-positive group) and 31.1% for anti-apoH. None of the four APOH polymorphisms were significantly associated with variation in risk for SLE. The codons 306 and 316 polymorphisms showed significant, gene-dosage effects on plasma apoH concentrations (P<0.0001) and explained 30% and 13%, respectively, of the residual variation in apoH concentrations. No significant association was observed between anti-apoH status and APOH polymorphisms or plasma apoH levels. However, plasma apoH concentrations were significantly higher in patients positive for APA than in patients negative for APA (18.5±4.0 mg/dl vs 17.1+3.8 mg/dl; P=0.02). The distribution of the Trp3l6Ser polymorphism was significantly different between the APA-positive and APA-negative groups. The frequency of the mutant allele (Ser316) was significantly lower in the APA-positive group than the APA-negative group (3.1% vs 12.1% P < 0.04), indicating that the Ser316 mutation is protective against the production of phospholipid-apoH dependent APA. Our data indicate that common genetic variation in the APOH gene is a significant determinant of plasma apoH variation in SLE patients, and the Trp3l6Ser polymorphism appears to provide protection against the production of APA in SLE patients.

Engineering Better Wheelchairs to Enhance Community Participation

With about 2.2 million Americans currently using wheeled mobility devices, wheelchairs are frequently provided to people with impaired mobility to provide accessibility to the community. Individuals with spinal cord injuries, arthritis, balance disorders, and other conditions or diseases are typical users of wheelchairs. However, secondary injuries and wheelchair-related accidents are risks introduced by wheelchairs. Research is underway to advance wheelchair design to prevent or accommodate secondary injuries related to propulsion and transfer biomechanics, while improving safe, functional performance and accessibility to the community. This paper summarizes research and development underway aimed at enhancing safety and optimizing wheelchair design

Benefits of assistance dogs: a review

Objective: To review outcome research concerning placement of trained assistance dogs (ADs), focusing primarily on service dogs for people with mobility impairments and hearing dogs for individuals who are deaf or hard of hearing. Design: The authors place the relatively small body of literature on ADs in the context of relevant research on the benefits of human-animal contact and pet ownership. Results: While the research specific to ADs generally shows positive benefits, the small number of studies and methodological limitations of these studies preclude any clear conclusions. Recommendations for future research on ADs include the use of longitudinal designs, matched comparison groups, stan- dardized measures that assess diverse areas of functioning, and behavioral self- monitoring for daily activities. With the passage of the Americans with Disabilities Act(ADA, 1990), there has been an increase in the use of assistance dogs (ADs), which are trained and placed for the purpose of reducing the impact of disabling conditions. While the number of individuals partnered with ADs does not yet represent a substantial