Relationships between disability measures and nursing effort during medical rehabilitation for patients with traumatic brain and spinal cord injury

OBJECTIVE

The increasing use of disability measures requires that the validity of these instruments be adequately demonstrated. This study sought to evaluate the concurrent validity of one disability measure, the Functional Independence Measure (FIMSM) using minutes of care reported by nursing staff.

STUDY DESIGN

Correlational, cohort design.

SETTING

Eight inpatient medical rehabilitation hospitals that subscribe to the Uniform Data System for Medical Rehabilitation.

PATIENTS OR OTHER PARTICIPANTS

129 patients with traumatic brain injury (TBI) and 53 patients with traumatic spinal cord injury (SCI).

INTERVENTIONS

Routine rehabilitation care.

MAIN OUTCOME MEASURES

Patient-nurse contact times were recorded with a stop watch for a 24-hour period during the first and last weeks of inpatient rehabilitation. The FIM was also completed during the first and last weeks of rehabilitation.

RESULTS

Contact times declined from the first to last weeks of rehabilitation, concurrent with improving scores on motor and cognitive measures derived from the FIM. Statistically significant correlations between contact times and FIM measures were observed for medication dispensing, treatment provision, and teaching/activities of daily living at admission and discharge. Smaller and usually nonsignificant correlations were observed in activities that did not involve direct patient contact. Contact times increased exponentially as disability increased.

CONCLUSIONS

These results support the construct validity of the FIM by demonstrating strong relationships (r values in the range of .40 to .60) between burden of care and a measure of disability.

Impact of the loop electrosurgical excision procedure on future fertility

OBJECTIVE

The loop electrosurgical excision procedure (LEEP) is a popular and effective method of conservatively treating premalignant lesions of the cervix in reproductive-age women. While the safety and effectiveness of LEEP has been documented, few data have been collected on the long-term effect of LEEP of the cervix on subsequent fertility. The purpose of this study was to determine that effect.

STUDY DESIGN

A retrospective, cohort study with chart review and telephone or mail-in survey. One hundred fifty-eight women seen in the colposcopy clinic at New Hanover Regional Medical Center for abnormal cervical cytologic smears from January 1991 through December 1992 were surveyed concerning their reproductive history since undergoing colposcopy. The study group consisted of 79 women who had been treated with LEEP after demonstrating abnormalities on colposcopically directed cervical biopsy. The control group consisted of 79 women who underwent colposcopy and cervical biopsy without subsequent LEEP of the cervix.

RESULTS

One hundred eleven women responded to the survey. In this study group, 11 of the 12 women who desired pregnancy actually became pregnant in the in interval between treatment and completion of the survey. All 17 patients in the control group who desired pregnancy became pregnant.

CONCLUSION

In our patient population there appeared to be no significant detrimental effect of LEEP on future fertility. These preliminary findings are reassuring, however, due to the small sample size, the study lacked sufficient power for us to draw definitive conclusions.

Effect of MgSO4 on heart rate monitoring in the preterm fetus

OBJECTIVE

To evaluate in a controlled, blind fashion, using both subjective and objective criteria, whether MgSO4 is associated with clinically significant changes in fetal heart rate monitoring.

STUDY DESIGN

Fetal heart rate tracings were prospectively collected before and after MgSO4 loading in 50 preterm labor patients. Three obstetricians, blind to treatment status, graded the tracings using both subjective and objective criteria.

RESULTS

The baseline fetal heart rate declined slightly after therapy. Subjective, but not objective, evaluation demonstrated a greater likelihood of decreased variability after MgSO4 loading. There was no difference in periodic changes after MgSO4 loading. Multiple regression analysis showed a greater likelihood of decreased variability at earlier gestational ages but no relationship to the serum magnesium level.

CONCLUSION

Magnesium sulfate tocolysis is associated with a subjective decrease in fetal heart rate variability in the preterm fetus.

Rasch analysis of Visual Analog Scale measurements before and after treatment of Patellofemoral Pain Syndrome in women

The Visual Analog Scale (VAS) can be used to record subjectively experienced pain in different situations (items). By a mathematical method, the Rasch analysis, the original VAS recordings can be converted to an interval scale. Forty women with Patellofemoral Pain Syndrome (PFPS) reported their pain on the VAS from 12 different situations (items) before and after 12 weeks of rehabilitation. The items recorded pain during the last 3 months, during provocation tests, and during activities such as walking up stairs, jumping and strength testing. It was concluded that the items used for the patients with PFPS were hierarchically ordered in a statistically equivalent manner before and after rehabilitation. Subjectively reported pain after 12 weeks of rehabilitation was significantly alleviated for 23 (58%) of the 40 patients, compared with before rehabilitation. The patients with PFPS did not use the VAS as a linear scale over the full range. Rasch analysis of recordings made with the VAS gave a more detailed pain assessment.

Functional status and therapeutic intensity during inpatient rehabilitation

The objective of this study was to describe the relationships between functional status at discharge and intensity of therapies received during inpatient medical rehabilitation. The sample was comprised of 140 patients with traumatic brain injury and 106 patients with spinal cord injury at eight hospitals that subscribe to the Uniform Data System for Medical Rehabilitation. Data included linear measures of motor and cognitive ability derived from the Functional Independence Measure at admission to and discharge from rehabilitation. Multiple regression was used to predict intensity of therapies, discharge motor and cognitive function, the extent to which potential functional gains were achieved, and the efficiency of gains. Intensities of occupational, physical, and speech therapies were not significant predictors of outcomes for either group, controlling linearly for admission function, psychology intensity, length of stay, onset to admission interval, age, and interrupted stays. Only intensity of psychology services seemed to have any relation to functional gain (in cognition for patients with traumatic brain injury). The apparent lack of benefit related to intensity of therapies may be due to factors such as spontaneous recovery, goals not measured by the Functional Independence Measure, limited modulation of therapy intensity according to likely patient responsiveness, or therapies focused on impairment or other goals rather than disability. We suggest that efficiently staged rehabilitation should vary the intensity and nature of services according to patients' functional status, impairments, comorbid conditions, and other clinical factors.

Factors affecting number of prenatal care visits during second pregnancy among adolescents having rapid repeat births

PURPOSE

To examine factors associated with the number of prenatal care visits during second pregnancy for adolescents having a short interval between pregnancies.

METHODS

The sample includes all adolescents aged 13 to 17 years whose first pregnancy resulted in a birth at a regional medical center in southeastern North Carolina from January 1983 to December 1989 and who had a repeat pregnancy within 24 months which resulted in a birth. We abstracted data from medical records and birth certificates. We fit a negative binomial regression model to determine the effects of various factors on the number of prenatal care visits during second pregnancy.

RESULTS

The number of prenatal care visits during the first pregnancy, poor first birth outcome, interval between first and second pregnancy, and care provided by health department staff during first pregnancy were all positively associated with number of prenatal care visits during second pregnancy when controlling for gestation age of second birth. Other independent variables in the model included maternal age, education, black race, and being unmarried at the time of second birth.

CONCLUSIONS

Because prenatal care is important for healthy mothers and babies, adolescents should be encouraged to seek prenatal care early in the first pregnancy. This could be an important time to implement interventions aimed at increasing prenatal care utilization in this and subsequent pregnancies.

Septic abortion with intact fetal membranes caused by Campylobacter fetus subsp. fetus

We report a case of septic abortion with intact fetal membranes caused by Campylobacter fetus subsp. fetus in an 18-year-old woman who was 9 1/2 weeks pregnant.

The structure and stability of the Functional Independence Measure

The Functional Independence Measure (FIM) records the severity of disability of rehabilitation patients. The necessarily curvilinear relationship between the finite range of recorded FIM raw scores and the conceptually infinite range of additive disability measures is resolved through Rasch analysis. The analysis of admission and discharge FIM ratings of 14,799 patients shows that the 18 FIM items define two statistically and clinically different indicators. Thirteen items define disability in motor functions. Five items define disability in cognitive functions. Additive measures for each indicator have the same characteristics at admission and discharge, so that these measures can be used to assess change in patient status.

Prediction of rehabilitation outcomes with disability measures

This study evaluated the extent to which rehabilitation outcomes and resource use can be predicted by functional status measures. Linear measures of motor and cognitive function were derived from the Functional Independence Measure for a sample of 27,699 patients undergoing initial rehabilitation. Admission functional status was consistently related to discharge function and length of stay, though the strength of these associations varied with impairment. Motor function was a stronger predictor of length of stay than was cognitive function for all impairments. However, the unique contribution of cognitive function was apparent for specific impairment groups. The predicted variance at discharge in motor function averaged 55%, 70% in cognitive function, and 20% in length of stay. These results support the use of functional status measures in the development of rehabilitation resource use models. Recommendations for future research are proposed.

Roles of kinesin and kinesin-like proteins in sea urchin embryonic cell division: evaluation using antibody microinjection

Previous studies suggest that kinesin heavy chain (KHC) is associated with ER-derived membranes that accumulate in the mitotic apparatus in cells of early sea urchin embryos (Wright, B. D., J. H. Henson, K. P. Wedaman, P. J. Willy, J. N. Morand, and J. M. Scholey. 1991. J. Cell Biol. 113:817-833). Here, we report that the microinjection of KHC-specific antibodies into these cells has no effect on mitosis or ER membrane organization, even though one such antibody, SUK4, blocks kinesin-driven motility in vitro and in mammalian cells. Microinjected SUK4 was localized to early mitotic figures, suggesting that it is able to access kinesin in spindles. In contrast to KHC-specific antibodies, two antibodies that react with kinesin-like proteins (KLPs), namely CHO1 and HD, disrupted mitosis and prevented subsequent cell division. CHO1 is thought to exert this effect by blocking the activity of a 110-kD KLP. The relevant target of HD, which was raised against the KHC motor domain, is unknown; HD may disrupt mitosis by interfering with an essential spindle KLP but not with KHC itself, as preabsorption of HD with KHC did not alter its ability to block mitosis. These data indicate that some KLPs have essential mitotic functions in early sea urchin embryos but KHC itself does not.

Relationships between impairment and physical disability as measured by the functional independence measure

This study was conducted to scale the Functional Independence Measure (FIM) with Rasch Analysis and to determine the similarity of scaled measures across impairment groups. The results show that the FIM contains two fundamental subsets of items: one measures motor and the second measures cognitive function. Rasch analysis of the Uniform Data System for Medical Rehabilitation patient sample yielded interval measures of motor and cognitive functions. The validity of the FIM was supported by the patterns of item difficulties across impairment groups. Adequate clinical precision of the FIM was demonstrated, though suggestions for improvement emerged. The frequency of misfit between patients and the performance scales varied across impairment groups, but was acceptable. The results of this project will enable clinicians and researchers to plan cost-effective treatment by providing a valid measure of disability.

Performance profiles of the functional independence measure

The functional independence measure (FIM) is used to determine the degree of disability that patients experience and the progress that they make through programs of medical rehabilitation. Rasch analysis is a statistical technique for constructing interval measures from ordinal data that was applied to derive FIM measures. The major factors that are taken into account to produce FIM measures are the relative difficulty in performance of FIM items and the ability of the persons tested. Our analyses showed the relative difficulties that patients experienced in performing items in the FIM. There were two dominant patterns of difficulty, one for motor FIM items and the other for cognitive FIM items. The patterns were consistent across impairment groups, although not identical. Of the motor items, eating and grooming were easiest whereas stair climbing, tub/shower transfers and locomotion were most difficult. Of the cognitive items, expression and comprehension were easiest and problem solving was the most difficult. The patterns of difficulty in performing FIM items are illustrated by analysis of the following impairment groups: for motor items, orthopedic conditions, stroke with left hemiparesis and spinal cord dysfunction; for cognitive items, orthopedic conditions, brain dysfunction, stroke with right hemiparesis and spinal cord dysfunction. By understanding patterns of difficulty in performing FIM items according to types of impairment and levels of function, clinicians may more precisely design treatment programs, use services and predict outcomes of medical rehabilitation.

Immunolocalization of kinesin in sea urchin coelomocytes. Association of kinesin with intracellular organelles

We have recently used domain-specific monoclonal antibodies (mAbs) to immunofluorescently localize kinesin to vesicle-like structures in the cytoplasm of sea urchin coelomocytes. In order to characterize further these localization patterns we have examined the distribution of kinesin with respect to the arrangement of microtubules (MTs) and various organelles. In double-label experiments involving the immunofluorescent staining of kinesin (using a mixture of the mAbs SUK2, 4 and 5), MTs were labeled with an antiserum against sea urchin tubulin, the endoplasmic reticulum (ER) was labeled with an antiserum against a luminal calsequestrin-like protein, the Golgi apparatus was labeled with rhodamine-wheat germ agglutinin (WGA) or NBD-ceramide, mitochondria were labeled with rhodamine 123, endosomes were labeled with Texas Red-ovalbumin, and lysosomes were labeled with Lucifer yellow or acridine orange. Kinesin-labeled vesicle-like structures were found in the same regions of the cells as MTs and the ER, being widely distributed in motile cells, but restricted to the perinuclear regions of stationary cells. There also appeared to be a correlation between the distribution of endosomes and kinesin staining in a subpopulation of cells. The kinesin binding structures were found occasionally to align in linear arrays, consistent with the idea that kinesin may transport ER and endosomes along linear MT tracks. No clear correlations were observed between the kinesin staining and the distribution of mitochondria, the Golgi apparatus or lysosomes, suggesting that kinesin may specifically associate with only a subclass of organelles in coelomocytes.

Exacerbation of akinetic seizures by atropine eye drops

A case is reported where atropine sulphate eye drops increased the frequency of fits in a child suffering regular akinetic seizures. This increase was marked and observed during two separate courses of eye drops. This is discussed with reference to previous reports of central nervous toxicity after the use of topical atropine sulphate.

Microtubule motors in the early sea urchin embryo

Sea urchin gametes and early embryos have proven to be a useful system for studying the roles of microtubule (MT)-associated motors in axonemal motility and cytoplasmic MT-based movements in dividing cells. In this brief article, known and potential sea urchin MT motors are listed and their possible biological functions are discussed.

Subcellular localization and sequence of sea urchin kinesin heavy chain: evidence for its association with membranes in the mitotic apparatus and interphase cytoplasm

Kinesin was previously immunolocalized to mitotic apparatuses (MAs) of early sea urchin blastomeres (Scholey, J.M., M.E. Porter, P.M. Grissom, and J.R. McIntosh. 1985. Nature [Lond.]. 318:483-486). Here we report evidence that this MA-associated motor protein is a conventional membrane-bound kinesin, rather than a kinesin-like protein. Our evidence includes the observation that the deduced amino acid sequence of this sea urchin kinesin heavy chain is characteristic of a conventional kinesin. In addition, immunolocalizations using antibodies that distinguish kinesin from kinesin-like proteins confirm that conventional kinesin is concentrated in MAs. Finally, our immunocytochemical data further suggest that conventional kinesin is associated with membranes which accumulate in MAs and interphase asters of early sea urchin embryos, and with vesicles that are distributed in the perinuclear region of coelomocytes. Thus kinesin may function as a microtubule-based vesicle motor in some MAs, as well as in the interphase cytoplasm.

Observations are always ordinal; measurements, however, must be interval

Quantitative observations are based on counting observed events or levels of performance. Meaningful measurement is based on the arithmetical properties of interval scales. The Rasch measurement model provides the necessary and sufficient means to transform ordinal counts into linear measures. Imperfect unidimensionality and other threats to linear measurement can be assessed by means of fit statistics. The Rasch model is being successfully applied to rating scales.

A hydroponic system for microgravity plant experiments

The construction of a permanently manned space station will provide the opportunity to grow plants for weeks or months in orbit for experiments or food production. With this opportunity comes the need for a method to provide plants with a continuous supply of water and nutrients in microgravity. The Capillary Effect Root Environment System (CERES) uses capillary forces to maintain control of circulating plant nutrient solution in the weightless environment of an orbiting spacecraft. The nutrient solution is maintained at a pressure slightly less than the ambient air pressure while it flows on one side of a porous membrane. The root, on the other side of the membrane, is surrounded by a thin film of nutrient solution where it contacts the moist surface of the membrane. The root is provided with water, nutrients and air simultaneously. Air bubbles in the nutrient solution are removed using a hydrophobic/hydrophilic membrane system. A model scaled to the size necessary for flight hardware to test CERES in the space shuttle was constructed.

Effects of the volatile anesthetic halothane on fertilization and early development in the sea urchin Lytechinus variegatus: evidence that abnormal development is due to polyspermy

The volatile anesthetic halothane, when present at fertilization, dose-dependently increases the incidence of abnormally developing sea urchin embryos at the first cell division. Microscopic examinations of eggs stained with aceto-orcein or the DNA fluorochrome bisbenzimide and direct observations on isolated sperm aster complexes show that halothane induces polyspermy (multiple sperm entry) when present at fertilization. Experimental evidence suggests that anesthetic-induced polyspermy involves impairment of both the fast (electrically mediated) and slow (morphological) blocks to multiple sperm entry. These observations clearly show that relatively brief exposures to halothane at fertilization cause polyspermy and that this effect is almost certainly responsible for the ensuing abnormal development observed at the first cell division.