Percutaneous ethanol injection and radio-frequency ablation for the treatment of nonresectable colorectal liver metastases - techniques and results

BACKGROUND

Percutaneous ethanol injection (PEI) and radio-frequency (RF) ablation are possible palliative treatment modalities for patients with non-resectable liver metastases of colorectal carcinomas. The different techniques are explained and reviewed.

RESULTS

PEI did not show promising results for the treatment of liver metastases. RF results were more encouraging; some studies showed improved mean survival times for patients when a complete necrosis of the metastases could be achieved. The maximum diameter of the necrotic area possible in a single session is about 5 cm.

CONCLUSION

PEI and RF are palliative last-line treatment strategies for patients with non-resectable liver metastases and should only be applied if chemotherapy is not sufficient or not possible. The long-term efficacy of RF ablation in this group of patients has to be evaluated.

Improved glycemic control reduces the impact of weight gain on cardiovascular risk factors in type 1 diabetes. The Epidemiology of Diabetes Complications Study

OBJECTIVE

To assess the prevalence and incidence of being overweight in type 1 diabetes, to identify factors associated with weight gain and improved glycemic control, and to examine relationships among weight gain, glycemic control, and cardiovascular risk factors.

RESEARCH DESIGN AND METHODS

The prevalence and incidence of being overweight in the Pittsburgh Epidemiology of Diabetes Complications (EDC) cohort (n = 441) were compared with the general population (National Health and Nutrition Examination Survey [NHANES]). Factors associated with weight gain and improved glycemic control were identified, and relationships among weight gain, glycemic control, and cardiovascular risk factors were examined over a 6.9 +/- 2.2-year period.

RESULTS

At baseline, the prevalence of being overweight (BMI > 27.8 kg/m2 for men and > 27.3 kg/m2 for women) was 10.4 and 11.4%, respectively, and was lower than the age- and sex-specific estimate for the general population (P < 0.05). The incidence of being overweight was comparable in men (12.6%) and women (11.8%) and did not differ from the general population (P = 0.98). Weight gain correlated with improvements in HbA1c (r = -0.21, P < 0.001). Patients with the highest baseline HbA1c levels gained the most weight and had the greatest improvement in glycemic control. A lower baseline BMI was also associated with a greater improvement in glycemic control. Weight gain favorably influenced the lipid profile in the setting of improved glycemic control, but adversely influenced the lipid profile in the absence of improved glycemic control. Weight change was directly associated with blood pressure change, but the incidence of hypertension was more strongly influenced by the development of nephropathy.

CONCLUSIONS

The prevalence of being overweight in type 1 diabetes remains lower than that in the general population. Moderate weight gain did not adversely affect the cardiovascular risk profile in the setting of improved glycemic control.

The significance of high levels of lipoprotein (a) compared with established risk factors in premature coronary artery disease: differences between men and women

It was shown in a series of studies that increased lipoprotein (a) concentration is a strong and independent risk factor for coronary artery disease. The goal of this study was to determine the significance of elevated lipoprotein (a) levels for the existence and the early manifestation of coronary artery disease by systematically recording cardiovascular risk factors in diagnostic coronary angiographies in a larger group of patients, whereby particular attention was paid to sex-specific differences. In 1011 consecutive patients who underwent coronary angiography (731 men, 280 women, mean age 59 +/- 10 years), fasting blood samples were taken immediately before the angiographies to determine the levels of cholesterol, low density lipoprotein-, high density lipoprotein-cholesterol, triglycerides and lipoprotein (a). In addition, further risk factors were qualitatively recorded. The data evaluation was carried out using the SPSSx software package univariately and multivariately with stepwise discriminant analysis. In 231 patients (144 men, 87 women) either no or only discrete coronary findings appeared, while in 780 cases (587 men, 193 women) coronary artery disease with stenoses > 50% were found. Women with coronary artery disease were significantly older than men and demonstrated higher lipoprotein levels. Women as well as men with coronary artery disease differed from healthy controls by having higher levels of lipoprotein (a) and other lipoproteins, lipoprotein (a) having the smallest error probability (P < 0.0005). The early manifestation of coronary artery disease (below the 18th age percentile) in men (< 50 years) was connected with significantly higher levels of cholesterol, triglycerides and lipoprotein (a), which emphasized their atherogenic significance in the general view. The most striking finding was that in young women (< 53 years), compared to older women with coronary artery disease--corresponding to the age-determined prevalence--significantly lower concentrations of cholesterol, triglycerides and lipoprotein (a) were found. Possible explanations include later manifestation of coronary artery disease, a steeper increase of the lipids with age, particularly of lipoprotein (a), but also a different valence of the risk factors in women.

Gap junctions and connexin expression in the inner ear

Several different recessive mutations in the connexin26 (Cx26; beta 2) gene have been associated with non-syndromic hereditary deafness. This suggests gap junctions are important to cochlear function. Numerous large gap junctions are present between adjacent supporting cells in both the vestibular and auditory sensory epithelia of the mature inner ear. In vestibular organs, Cx26 is highly expressed, but antibodies of Cx32 (beta 1) also label the supporting cells. In the organ of Corti of the cochlea, Cx26 is the predominant connexin isoform; neither Cx32 nor Cx43 (alpha 1) can be detected by immunohistochemistry. One role for gap junctions between supporting cells may be to provide a pathway for the rapid removal of ions away from the region of the sensory cells during transduction in order to maintain sensitivity. In the cochlea gap junctions are also associated with the basal cells of the stria vascularis, an ion-transporting epithelium that maintains a positive electrical potential in the potassium-rich endolymph fluid which bathes the apical surfaces of the sensory 'hair' cells and which is crucial for auditory transduction. Gap junctions are present between fibrocytes in the spiral ligament that underlies the stria vascularis, and between these fibrocytes and strial basal cells. During cochlear development, the initial formation and subsequent increase in size and number of gap junctions in the stria vascularis coincides with the initial generation and rise of the endocochlear potential. This and other evidence suggests that one role of gap junctions in the cochlea is to provide a pathway for passage of ions to maintain endolymph and, thus, auditory acuity. Mutations to Cx26 could, therefore, disrupt this ion circulation, resulting in deafness.

[Color doppler ultrasonographic detection of focal thyroid nodules]

AIM

To determine if colour Doppler sonography is a sensitive tool to detect solitary hot thyroid nodules.

METHODS

All patients evaluated in our ultrasound laboratory during study period also underwent thyroid sonography. If one or more nodules with a diameter of at least 8 mm were present, thyroid scientigraphy was performed. Hyperperfusion within the nodule compared to the surrounding tissue indicated autonomy according to the study protocol.

RESULTS

1010 patients were screened. 385 had one or more nodules, 309 of them with a diameter of more than 8 mm. Among these patients a hot nodule was proved with scintigraphy in 120 cases. 116 of these 120 patients were correctly identified with colour Doppler sonography.

CONCLUSION

Colour Doppler sonography is a reliable method to detect solitary hot or hyperperfused thyroid nodules and to identify a risk group of patients prior to the administration of x-ray contrast media.

Channel-mediated high-affinity K+ uptake into guard cells from Arabidopsis

Potassium uptake by higher plants is the result of high- or low-affinity transport accomplished by different sets of transporters. Although K+ channels were thought to mediate low-affinity uptake only, the molecular mechanism of the high-affinity, proton-dependent K+ uptake system is still scant. Taking advantage of the high-current resolution of the patch-clamp technique when applied to the small Arabidopsis thaliana guard cells densely packed with voltage-dependent K+ channels, we could directly record channels working in the concentration range of high-affinity K+ uptake systems. Here we show that the K+ channel KAT1 expressed in Arabidopsis guard cells and yeast is capable of mediating potassium uptake from media containing as little as 10 microM of external K+. Upon reduction of the external K+ content to the micromolar level the voltage dependence of the channel remained unaffected, indicating that this channel type represents a voltage sensor rather than a K+-sensing valve. This behavior results in K+ release through K+ uptake channels whenever the Nernst potential is negative to the activation threshold of the channel. In contrast to the H+-coupled K+ symport shown to account for high-affinity K+ uptake in roots, pH-dependent K+ uptake into guard cells is a result of a shift in the voltage dependence of the K+ channel. We conclude that plant K+ channels activated by acid pH may play an essential role in K+ uptake even from dilute solutions.

Absorbable fasteners for the fixation of ankle fractures

Bioabsorbable materials have been used for the treatment of fractures for more than a century. We reviewed the results of a combined series of 30 ankle fractures from Bad Hersfeld, Germany, and Louisville, Kentucky, using initially polyglycolide and more recently poly-L-lactide screws and rods. The results were comparable to treatment with metal screws. The advantage of bioabsorbable implants is they do not need operations to take them out. There was a low incidence of reaction around the screw heads, which was reduced further with the use of the newer self-reinforced poly-L-lactate screws. The technique for use of plastics is different than the methods for placement of metal screws. Bioabsorbables will have an increasing role in fracture fixation in the future.

On the accuracy of a new displacement instrumentation for rotary tablet presses

The Portable Press Analyzer (PPA; Puuman Oy, Finland), a commercially available instrumentation for rotary tablet presses, was tested for accuracy of determination of force and displacement. The calibration of the force transducers (strain gauges) was tested under a static condition. The calibration of the displacement transducers (plastic film potentiometer) was compared for static and dynamic recordings. Force measurement was found precise (deviation < 1.1%) after alterations in the calibration procedure. Displacement measurement was affected by punch tilting and the application of the transducers. If tilting of punches was not considered, the deviation of displacement measurement from the true value (using steel tablets as a reference) was found up to 110 microns. By modifying the original PPA system by supplementing additional displacement transducers in the adjacent turret positions of the punches and adding a custom electronic device (Tilting Compensation Device), the accuracy of distance measurement was improved to 18.1 microns (+/- 3.64). Furthermore, machine and tooling deformation were recorded and found different under static and dynamic conditions. Correction of punch displacement for elastic deformation therefore should preferably be made from dynamic recordings.

Detection of increased tyrosine phosphorylation in murine Langerhans cells after stimulation with contact sensitizers

The signalling pathways in epidermal Langerhans cells (LC) during activation by contact sensitizers are poorly understood. Recently, we have described an increased phosphorylation of tyrosine residues in human MHC class II-positive cells in vitro following stimulation with contact sensitizers. In the study reported here the formation of phosphotyrosine (p-tyr) in murine epidermal LC upon stimulation with contact sensitizers was examined. By the use of a flow cytometric technique a significant increase in p-tyr was demonstrated in LC stimulated in vitro with the strong contact sensitizers TNCB (2,4,6-trinitro-chlorobenzene) and MCI/MI (5-chloro-2-methylisothiazolinone plus 2-methylisothiazolinone) but not after treatment with the irritants sodium lauryl sulphate or benzoic acid. The protein tyrosine kinase inhibitors genistein and tyrphostin A9, but not tyrphostin AG 1288, were able to block this process significantly. Similar results were obtained using the LC-like dendritic cell line XS52. In addition, Western blot analysis on XS52 cells revealed a selective phosphorylation of two protein bands with a molecular weight between 50 and 60 kDa following stimulation with TNCB. These results demonstrate that contact sensitizers induce an increased phosphorylation of tyrosine residues in murine LC and can be used as the basis for in vivo studies using inhibitors for signal transduction pathways for prevention of primary sensitization to contact sensitizers.

Systemic interferon-alpha (IFN-alpha) treatment leads to Stat3 inactivation in melanoma precursor lesions

BACKGROUND

In the setting of familial melanoma, the presence of atypical nevi, which are the precursors of melanoma, is associated with a nearly 100% risk of developing primary melanoma by age 70. In patients with sporadic melanoma, it is estimated that 40-60% of melanomas develop in contiguous association with atypical nevi. Currently, the only way to prevent atypical nevi from progressing to melanoma is to monitor and excise them as soon as they exhibit changes in their clinical features. Activation of the transcription factor, Stat3, has been linked to abnormal cell growth and transformation as well as to interferon alpha (IFN-alpha)-mediated growth suppression in vitro.

MATERIALS AND METHODS

To determine whether IFN-alpha, used for adjuvant therapy of high-risk, resected melanoma, induces changes in Stat3 in atypical nevi, patients with a clinical history of melanoma who have multiple atypical nevi were treated for 3 months with low-dose IFN-alpha. Thereupon, the new technology of microscopic spectral imaging and biochemical assays such as electrophoretic mobility shift assays (EMSAs) and immunoblot analysis were used for the study of atypical nevi, obtained before and after IFN-alpha treatment.

RESULTS

The results of the investigations provided evidence that, as a result of systemic IFN-alpha treatment, Stat1 and Stat3, which are constitutively activated in melanoma precursor lesions, lose their ability to bind DNA, and as shown in the case of Stat3, become dephosphorylated.

CONCLUSIONS

Unlike primary and metastatic melanomas, melanoma precursor lesions cannot be established as cell cultures. Thus, the only way to explore pathways and treatment regimens that might help prevent progression to melanoma is within the context of a melanoma precursor lesion study conducted prospectively. The findings presented here suggest that down-regulation of the transcription factors Stat1 and Stat3 by systemic IFN-alpha treatment may represent a potential pathway to prevent the activation of gene(s) whose expression may be required for atypical nevus cells to progress to melanoma.

Islet cell autoimmunity in white and black children and adolescents with IDDM

OBJECTIVE

To compare the frequency of islet cell antibodies (ICA) and antibodies to GAD65 and IA-2(ICA512) between black and white children and adolescents at the diagnosis of IDDM in a large consecutive series of cases from Children's Hospital of Pittsburgh.

RESEARCH DESIGN AND METHODS

ICA and antibodies to GAD65 and IA-2 were measured in 437 white and black children and adolescents who were diagnosed with IDDM at < 19 years of age at Children's Hospital of Pittsburgh from January 1983 to December 1985, from January to December 1989, and from January 1996 to December 1997.

RESULTS

The prevalence of ICA(H), GAD65, and IA-2 antibodies was significantly lower in blacks than whites at onset of the disease. In contrast, the prevalence of ICA(R) alone was higher in blacks. None of the antibodies were present in 12% of the blacks compared with 4% in whites. The same pattern was seen in both sexes. The prevalence of antibodies in white patients with onset of IDDM at <11 years of age was no different than in those who developed IDDM during adolescence. In contrast, black patients showed a significantly lower prevalence of almost all antibodies in the adolescent group.

CONCLUSIONS

Black adolescents were more likely to not have antibodies, suggesting either that they have a nonautoimmune type of diabetes or that antibodies are not being detected by these assays.

TGF-beta and its receptor complex in leukemic B-cell precursors

Transforming growth factor beta (TGF-beta) is a highly conserved peptide with growth-inhibitory activity in multiple normal and transformed cell types. Signal transduction is mediated through the receptor complex, consisting of two active seronine or threonine kinases (TGF-beta-receptor I and II) and the receptor-associated proteins betaglycan (TGF-beta-receptor III) and endoglin. In this study, we assessed the analysis of the role of TGF-beta and the transcription of the genes for TGF-beta and its receptor in highly purified leukemic B-cell precursors (BCPs) of patients with common acute lymphoblastic leukemia (cALL). Leukemic BCPs were positive for gene transcription of TGF-beta (9/9), the TGF-beta-receptor I (9/9), the TGF-beta-receptor II (6/6), betaglycan (5/6), and endoglin (6/6). Incubation with TGF-beta significantly reduced the cell viability of leukemic BCPs by a mean of 45% (p = 0.0009). The reduction of cell viability was associated with the induction of apoptosis by a mean of 31%. TGF-beta caused significant suppression of the S phase (p = 0.002) and accumulation in the G0/G1 phase (p = 0.0005). It also reduced expression of the adhesion surface receptor CD18 and the Fas antigen CD95 from 58% to 40% and from 48% to 27%, respectively. The data indicate that TGF-beta is a negative growth signal in leukemic BCPs and point to an additional role of TGF-beta as an immunomodulatory cytokine, suggesting a complex role of TGF-beta in the leukemogenesis of cALL.

Cell coupling in the retina: patterns and purpose

Gap junction channels (electrical synapses) are a major component of the central nervous system mediating both electrical and metabolic coupling between neurons and glia. Their roles are as diverse as the cell types in which they are expressed and only some of these are reviewed here. In the adult the plastic nature of the gap junction channel allows for changes in the writing of the retinal circuitry that optimize visual processing to suit ambient lighting conditions. Gap junctional communication has been proposed to play a key role in embryonic development in general and in particular during the development of the retina where its roles may include control of neurogenesis, cell specification, synaptogenesis, and the synchronization of the spontaneous electrical activity required for the sharpening of central visual projections. Here we review gap junctional coupling within the retina and present data correlating gap junction expression with development events in the chick retina.

2-Phenyl-4-hydroxyphthalazin-1-one: A Benzoannelated Derivative of Maleic Hydrazide

The monoclinic crystals (space group P21/a, Z = 8) of 2-phenyl-4-hydroxyphthalazin-1-one, C14H10N2O2, have two independent molecules (A and B) in the asymmetric unit. Both occur as the lactim–lactam (hydroxy–one) structure, which is also found in the parent molecule maleic hydrazide (both triclinic and monoclinic polymorphs), dichloromaleic hydrazide and luminol (3-aminophthalhydrazide). The molecular arrangement is based on strings of alternating A and B molecules linked by hydroxyl...carbonyl hydrogen bonds, with only van der Waals interactions between adjacent strings. Comparison is made of the measured bond lengths for (monoclinic) maleic hydrazide and values from high-level ab initio calculations, and reasonably good agreement is obtained, with indications of improvements when allowance is made for electron correlation and hydrogen bonding.

[Flow quantification of intracardiac shunt volumes using MR phase contrast technique in the breath holding phase]

PURPOSE

Comparison of a breath-hold, velocity-encoded, phase-difference magnetic resonance (MR) sequence for intracardiac shunt flow measurement with the invasive shunt size determination by oximetry.

PATIENTS AND METHODS

10 patients with different cardiac shunts (6 ASD/3 VSD/1 PDA) and four healthy individuals were investigated using a 1.5 Tesla Siemens Vision system. For flow measurements a breath-hold, velocity-encoded, phase-difference magnetic resonance (MR) sequence was used ('through plane', FLASH 2D-sequence, TR/TE 110/5 ms, 'velocity encoding' 250 cm/s). Mean flow (ml/R-R interval) in the ascending aorta, the pulmonary trunk, and the right and left pulmonary arteries was determined. The ratio of the mean flow in the pulmonary circulation (Qp: sum of the mean flows in the right and left pulmonary arteries) and the systemic circulation (Qs: mean flow in the proximal aorta) was compared with the Qp/Qs ratios determined by the invasive oxymetric technique. Oximetry was performed within 24 hours after MR imaging.

RESULTS

In the 4 healthy individuals MR flow measurement yielded a Qp/Qs ratio of 0.96 +/- 0.15. In the 10 patients with the various shunt defects, the non-invasive shunt determination by MR gave a Qp/Qs ratio of 2.09 +/- 0.67. The percentage of the calculated shunt sizes was 47.05 +/- 17.45%. In the comparison with the results determined by the invasive oxymetric technique, the MR data showed a strong correlation of r = 0.87.

CONCLUSIONS

Breath-hold, velocity-encoded, phase-difference MR-technique enables a reliable quantification of cardiac shunts within a short acquisition time.

Individualized insulin therapy in children and adolescents with type 1 diabetes

The most important point about individualized therapy is to make it flexible to fit the needs of the patient. These needs are determined by age, pubertal status, treatment schedule, exercise, intelligence, education and socioeconomic status. In addition, major emphasis should be placed on the dietary needs, attitude and ability of the patient. Aspects of insulin regimens that can be adjusted include number of injections per day, timing of injections and the type of insulin used. Several factors that affect insulin action should also be considered, including the presence of insulin antibodies, the amount of subcutaneous fat, injection technique and muscular activity. Insulin pump therapy in childhood and adolescence may also be considered in certain cases. Controversial areas in childhood diabetes therapy include the number of daily injections, whether porcine insulin has any advantages, use of multiple doses of intermediate- and long-acting insulin, mixing regular insulin and short-acting insulin analogues, strategies to prevent hypoglycaemia and the importance of choice of injection sites in childhood.

Was there an epidemic of diabetes in nonwhite adolescents in Allegheny County, Pennsylvania?

OBJECTIVE

To determine the incidence of IDDM in children aged < 20 years at diagnosis in Allegheny County, Pennsylvania, for the period from 1 January 1990 to 31 December 1994 and to compare the incidence between whites and nonwhites in the same area and for the same time period.

RESEARCH DESIGN AND METHODS

All new patients diagnosed between January 1990 and December 1994 who were aged < 20 years, on insulin, and residents of Allegheny County at diagnosis were identified from medical records of 23 hospitals in the Allegheny County area. To verify the completeness of the hospitals using the capture-recapture method, pediatricians and diabetologists were used as a secondary source.

RESULTS

A total number of 257 patients were identified. The overall age-standardized incidence rate was 16.7/100,000. Nonwhites had a slightly higher incidence (17.6/100,000) than whites (16.5/100,000). In the 15-19 years age-group, the incidence in nonwhites (30.4/100,000) was almost three times higher than that in white (11.2/100,000) and more than two times higher than that in the previous period (from 1985 to 1989) (13.8/100,000).

CONCLUSIONS

For the first time in the Allegheny County registry, and in any other registry, nonwhites showed a higher incidence of IDDM than whites. The high incidence in the 15-19 years age-group was responsible for this phenomenon. This epidemic of diabetes in adolescent nonwhites may be the result of a rising incidence of classical IDDM or another type of diabetes. Further studies using population-based registries are needed to determine whether this increase is being seen in other areas and other ethnic groups and to clarify the reasons for the increase in IDDM among blacks.

Single mutations strongly alter the K+-selective pore of the K(in) channel KAT1

Voltage-dependent potassium uptake channels represent the major pathway for K+ accumulation underlying guard cell swelling and stomatal opening. The core structure of these Shaker-like channels is represented by six transmembrane domains and an amphiphilic pore-forming region between the fifth and sixth domain. To explore the effect of point mutations within the stretch of amino acids lining the K+ conducting pore of KAT1, an Arabidopsis thaliana guard cell K(in) channel, we selected residues deep inside and in the periphery of the pore. The mutations on positions 256 and 267 strongly altered the interaction of the permeation pathway with external Ca2+ ions. Point mutations on position 256 in KAT1 affected the affinity towards Ca2+, the voltage dependence as well as kinetics of the Ca2+ blocking reaction. Among these T256S showed a Ca2+ phenotype reminiscent of an inactivation-like process, a phenomenon unknown for K(in) channels so far. Mutating histidine 267 to alanine, a substitution strongly affecting C-type inactivation in Shaker, this apparent inactivation could be linked to a very slow calcium block. The mutation H267A did not affect gating but hastened the Ca2+ block/unblock kinetics and increased the Ca2+ affinity of KAT1. From the analysis of the presented data we conclude that even moderate point mutations in the pore of KAT1 seem to affect the pore geometry rather than channel gating.

Depression, cognition, and functional correlates of recovery outcome after traumatic brain injury

The present study investigated the prevalence and magnitude of depressive symptomatology in a sample of patients who had sustained traumatic brain injury (TBI) six months earlier. Depression was examined as a function of recovery outcome status, and its association with neuropsychological functioning, personal competency, and employability was also explored. Subjects were 100 patients who had previously sustained moderate-to-severe TBI who were enrolled as research subjects in the UCLA Brain Injury Research Center, and 30 matched control subjects who had sustained traumatic injuries other than to the head six months prior to evaluation. The results showed a significant association between depression and recovery status as measured by the Glasgow Outcome Scale (GOS). A significant majority of depressed subjects were found in the poorer GOS outcome groups (severe and moderate disability), compared to TBI subjects who had good GOS outcomes, and control subjects. This association was also reflected in the magnitude of the mean depression scores on two self-report measures of depression. However, no association was found between depression status and performance on the neuropsychological measures. Effects of depression were found only on an examiner-rated Patient Competency scale, and a metacognition measure based on self-report. These results are discussed in terms of brain injury severity, recovery status, and metacognition issues in TBI and other disorders.

Neuropsychological, psychosocial and vocational correlates of the Glasgow Outcome Scale at 6 months post-injury: a study of moderate to severe traumatic brain injury patients

Traumatic brain injury (TBI) subjects at Glasgow Outcome Scale levels 3 (severe disability), 4 (moderate disability), 5 (good recovery), and an other-injury control group (OIC) were compared in terms of neuropsychological, psychosocial, and vocational functioning 6 months after injury. Subjects were a sample of 100 patients with a moderate to severe traumatic brain injury (TBI) and a matched sample of 30 other-injury control subjects (OIC) enrolled in the UCLA Brain Injury Research Center study of TBI outcome. Overall, the results showed a systematic decrease in mean neuropsychological test performance as a function of increasing GOS severity, as well as an increased prevalence of symptoms of depression and lower ratings on measures assessing employability and capacity for self care. TBI patients in the 'severe' and 'moderate disability' groups were distinctly inferior to the 'good recovery' and 'OIC' groups, who were quite similar to each other in terms of cognitive, psychosocial, and vocational outcomes. The results demonstrate overall support for the predictive and concurrent validity of the GOS 6 months post injury. Despite these results, which strengthen the utility and appeal of the GOS for multicentre studies, concerns still remain regarding GOS category 4 (moderate disability), which was shown to lack sufficient discriminability in this study.