Problem-solving in real-life-type situations: the effects of anterior and posterior lesions on performance

Clinical studies have described patients who show marked impairments in everyday life, including planning, problem-solving and decision-making. Several factors potentially contribute to such impairments, including difficulties in generating possible problem solutions, and difficulties in selecting an appropriate solution. The present study describes the performance of participants with unilateral anterior or posterior lesions compared to healthy controls in ability to solve real-life-type problems. These covered a range of everyday interpersonal situations, and were presented both in video and story format. Participants also carried out a set of more abstract neuropsychological tests. Those with brain lesions showed impairment relative to controls in both everyday problem-solving and on more abstract tests involving executive function and memory. The anterior group was impaired on more aspects of everyday problem-solving than the posterior group, showing reduced fluency in generating possible solutions, and also impairment in selecting appropriate problem solutions. The implications of the findings for our understanding of impairments in everyday life problem-solving after brain injury are discussed.

Biochemical and immunologic comparison of virus-like particles for a rotavirus subunit vaccine

A parenterally administered rotavirus vaccine composed of virus-like particles (VLPs) is being evaluated for human use. VLPs composed of bovine VP6 and simian VP7 (SA11, G3) proteins (6/7-VLPs) or of bovine VP2, bovine VP6, and simian VP7 (SA11, G3) proteins (2/6/7-VLPs) were synthesized and purified from Sf9 insect cells co-infected with recombinant baculoviruses. 6/7- and 2/6/7-VLP administered parenterally (i.m.) in mice had comparable immunogenicity, but the 2/6/7-VLPs were more homogeneous and stable. The inclusion of the VP2 capsid contributed to particle formation and stability. The adjuvant QS-21 significantly enhanced the immunogenicity of 2/6/7-VLPs over A10H or saline alone. Equivalent serum neutralizing antibody responses were induced over the range of 1-15 microg/dose of 2/6/7-VLPs administered with the range of 5-20 microg/dose of QS-21. The immunogenicity of 2/6/7-VLPs and inactivated SA11 virus were comparable. 2/6/7-VLPs are a promising candidate for a parenterally delivered rotavirus subunit vaccine.

Early prediction of persisting post-concussion symptoms following mild and moderate head injuries

OBJECTIVES

King (1996) reported that a combination of emotional, organic and neuropsychological measures taken at 7-10 days following mild and moderate head injury may significantly help predict patients most likely to suffer persisting post-concussion symptoms (PCS) at three months post-injury. This study investigated a cross-validation sample (N = 57) to determine whether the results would be replicated for the early prediction of longer-term sufferers (i.e. those with persisting symptoms at 6 months post-injury).

DESIGN

Multiple regression analyses were used in which scores on the Hospital Anxiety and Depression Scale, Impact of Event Scale, Short Orientation Memory and Concentration Test, Rivermead Post-Concussion Symptoms Questionnaire and Post-Traumatic Amnesia taken at 7-10 days post-injury were the independent measures. Scoring on the Rivermead Post-Concussion Symptoms Questionnaire taken at 6 months post-injury was the dependent measure.

METHODS

Sixty-six consecutive patients admitted to any trauma ward in Oxfordshire with a mild or moderate head injury were recruited from a largescale randomized controlled sample. The assessment measures were administered at 7-10 days post-injury and the Rivermead Post-Concussion Symptoms Questionnaire at 6 months post-injury. Nine patients were unable to be followed up, leaving an active sample of 57.

RESULTS

The cross-validation data confirmed that a similar combination of measures to that found in the original study best predicted persisting PCS but that the strength of prediction diminished for the longer term prediction (i.e. 6 months post-injury).

CONCLUSIONS

The Hospital Anxiety and Depression Scale, Impact of Even Scale and Post-Traumatic Amnesia in combination are recommended as useful prognostic screening instruments for predicting persisting PCS, but great caution is required if they are used to aid predictions beyond 3 months post-injury.

High angiogenic activity in cells isolated from cystic hygroma: role of bFGF

BACKGROUND

Cystic hygromas are characterized by a proliferation of small vessels and lymphatics with intervening fibrous tissue. Studies have shown malignant tumors and some benign neoplasms are dependent on angiogenesis, the induction of new capillaries from preexisting vessels. Growth and progression of these tumors are associated with a disturbance in the balance of angiogenic inducers and inhibitors. We have postulated that cells derived from cystic hygromas are angiogenic due to secretion of higher levels of angiogenic inducers that promote vascular proliferation.

DESIGN

A large cystic mass was surgically removed and a portion of the sterile tumor was immediately placed in the medium. The tissue was minced, washed in phosphate-buffered saline, and grown to near confluence. Conditioned medium was collected under serum-free conditions after 48 hours. Secreted proteins were concentrated, quantitated, and analyzed in an in vitro endothelial cell migration assay and by Western blot. Antibody to factor VIII-related antigen was performed to confirm endothelial cell origin of the cultured cells.

MAIN OUTCOME MEASURES

In vitro angiogenic activity of secreted proteins in a capillary endothelial migration assay was tested by using blocking antibodies to angiogenic inducer, basic fibroblast growth factor, and angiogenic inhibitor, thrombospondin-1. Total protein levels of thrombospondin-1 were determined by Western blot.

RESULTS

Cells isolated from cystic hygroma are angiogenic in vitro and this angiogenic activity is due to secretion of high levels of angiogenic inducer, basic fibroblast growth factor, and lower levels of naturally occurring angiogenic inhibitor, thrombospondin-1.

CONCLUSIONS

Cystic hygromas may represent another neoplasm dependent on angiogenesis. The angiogenic activity is due in part to elevated levels of potent angiogenic inducer, basic fibroblast growth factor. Antiangiogenic therapy directed at the endothelial cell may help suppress the growth of cystic hygromas.

Covert fears, anxiety and depression in congenital heart disease

This study compared anxiety, fears, depression and behavioural problems as occurring in children with congenital heart disease, comparing them with samples of normal children. It further considered the influence of maternal anxiety, as well as analyzing a subgroup of children with cyanotic forms of congenital heart disease to determine if they were at higher risk than acyanotic children for the problems identified.

METHOD

We recruited 40 consecutive children with congenital heart disease without obvious psychosocial problems from the Cardiology clinic at the Alberta Children's Hospital. Of the 40 children, 39 families consented to have the children participate, of which 24 were cyanotic and 15 acyanotic. Children completed the revised versions of the Fear Survey Scale-Revised and the Child Manifest Anxiety Scale as well as the Child Depression Inventory. Mothers completed the Child Behaviour Checklist, and the State Trait Anxiety Scale.

RESULTS

Children with congenital heart diseases demonstrated more medical fears, and more physiological anxiety, than the normative samples. More specifically, children with cyanotic forms of congenital heart disease demonstrated more fears of the unknown, physiological anxiety, depression, and delinquent behaviors than the acyanotic children with congenital heart disease. Mothers of the children with cyanotic forms of congenital heart disease scored higher on both the state and trait scales, with higher maternal anxiety correlating with higher anxiety, medical fears and behavioral problems in the child.

CONCLUSION

In a clinical setting, children with congenital heart diseases who do not present with psychological adjustment problems are still at risk for covert physiological anxiety, medical fears, depression and behavioral problems. The children with cyanotic malformations represent a subgroup at higher risk for these problems, which may be further exacerbated by increased maternal anxiety.

Interrelationships among disablement concepts

BACKGROUND

Understanding interrelationships among disablement concepts is critical to the design of future disability treatment and prevention interventions.

METHODS

This study uses cross-sectional data to examine the relationships among physiologic impairments, functional limitations, and disability in a moderately disabled sample of 207 community-dwelling older adults.

RESULTS

As hypothesized, the data revealed statistically significant curvilinear relationships of upper and lower extremity strength and balance with mobility in this older sample. Multivariate analyses further clarified the hypothesized causal mechanism among the disablement concepts by demonstrating that most of the association of muscle strength and balance with disability was through the intermediary role of mobility limitations.

CONCLUSIONS

The findings from this study highlight the value of clinical trials that focus on prevention or treatment of mobility limitations as a means of preventing disability; our findings underscore the need for future research that examines the effects of other variables believed to influence disablement in late life.

Routine follow up after head injury: a second randomised controlled trial

OBJECTIVE

To confirm that patients admitted to hospital with a head injury benefit from a routinely offered early intervention service.

PATIENTS AND METHODS

A mixed rural and urban Health District of 560000 people with two accident and emergency departments provided the setting. Existing routine services for most patients with head injury are minimal. All patients aged 16-65 years admitted to hospital after a head injury of any severity, with or without other injuries entered the trial. Prospective randomisation, with a block randomisation procedure was used to allocate all eligible patients to either: a group offered an additional service by a specialist team; or a group receiving existing standard services. Patients were assessed at follow up six months after injury. The primary outcome measure was the Rivermead head injury follow up questionnaire, a validated and reliable measure of social disability. The Rivermead post-concussion symptoms questionnaire was used to estimate severity of post-concussion symptoms. Each patient in the trial group was contacted 7-10 days after injury, and offered assessment and interventions as needed. These initially focused on the provision of information, support, and advice. Forty six per cent of patients in the trial group also received further outpatient intervention or additional support by telephone.

RESULTS

314 patients were registered: 184 were randomised into the trial group, 130 into the control group. For prognostic data, the groups were comparable at randomisation, and remained comparable when assessed at six months. 132 trial and 86 control patients were followed up at six months after injury. Patients' posttraumatic amnesia ranged from mild (n=79, 40%), and moderate (n=62, 32%), to severe (n=38, 19%) and very severe (n=17, 9%). The trial group patients had significantly less social disability (p=0.01) and significantly less severe post-concussion symptoms (p=0.02) at follow up at six months after injury than the control group patients.

CONCLUSIONS

The early interventions offered by a specialist service significantly reduced social morbidity and severity of post-concussion symptoms in trial group patients at six months after head injury. Recommendations about how specialist services should be targeted are made both in the light of these results and those from a previous randomised controlled trial.

Assault, post-traumatic amnesia and other variables related to outcome following head injury

OBJECTIVE

To estimate how many patients who sustain a head injury might benefit from intervention and support each year and to consider whether relationships can be found between demographic data relating to patients' circumstances at the time of head injury, and their outcomes six months later.

DESIGN

Data collected on 625 patients through follow-up interviews and assessments by the Oxford Head Injury Service for a randomized controlled trial of intervention conducted in 1993-94.

SETTING

A mixed rural and urban Health District with a population of approximately 560,000.

PATIENTS

Patients were aged between 16 and 65 years and resident in Oxfordshire. They presented over 13 months to accident and emergency departments, or were admitted to hospital. All were diagnosed as having suffered a head injury.

OUTCOME MEASURES

The Rivermead Head Injury Follow Up Questionnaire and the Rivermead Post Concussion Symptoms Questionnaire.

RESULTS

Data are given on age, sex, social circumstances, employment, cause of injury, severity of associated injuries, post-traumatic amnesia (PTA), anticonvulsants, postconcussion symptoms and activities of everyday life. Outcome at six months was significantly worse for those who had been assaulted as against all other causes of injury combined (p = 0.0001); and/or had been admitted to hospital (p = 0.0001)l and/or had sustained more severe additional injuries (p = 0.04); and/or had experienced any PTA (p = 0.00001). The minimum incidence of such injuries in those aged 16-65, calculated for Oxfordshire, is 292 per annum (74/100,000 aged 16-65 per year).

CONCLUSIONS

In the general population 52/100,000 patients per annum will experience more serious head injuries as indicated by hospital admission and/or one or more fractures and/or any length of PTA and/or having been assaulted. This group may benefit from monitoring and support and their needs should be considered when planning services.

Lymph node human immunodeficiency virus RNA levels and resistance mutations in patients receiving high-dose saquinavir

The development of resistance mutations and human immunodeficiency virus (HIV) RNA levels were compared in lymph nodes and plasma of patients receiving antiretroviral therapy. Ten HIV-positive patients receiving high-dose saquinavir monotherapy (3600 or 7200 mg/day) underwent 14 lymph node biopsies before and during therapy. HIV RNA levels and appearance of resistance mutations to saquinavir were determined in simultaneous lymph node and plasma samples. HIV RNA levels were found to be consistently higher (mean, 3.16 log RNA copies; SD, 1.04; range, 2.23-5.59) in lymph nodes than in simultaneous plasma samples. Saquinavir therapy resulted in a reduction in HIV RNA levels in both plasma and lymph nodes. The presence or absence of a resistance mutation to saquinavir at codons 48 or 90 of the HIV-1 protease gene was identical in 13 of 14 biopsies, suggesting that resistance mutations to saquinavir appear within close temporal proximity in lymph nodes and plasma.

Sexual abuse and bulimia: response to inpatient treatment and preliminary outcome

The purpose of this study was to explore the clinical impact of child sex abuse on bulimic patients. Specifically, differences in treatment response and preliminary treatment outcome between hospitalized bulimic patients with and without a reported history of sexual abuse were examined. The patients were evaluated for past history of alleged sexual abuse by investigator-based interview and ratings of severity of sexual abuse were made. Assessments of mood, eating disordered-related attitudes, and eating behaviors were conducted at the start of treatment, weekly during treatment, and three months post discharge. Sixty-one per cent (45) of the 74 patients enrolled in the study reported a history of child sexual abuse. The majority of such events constituted serious and very serious abuse by this study's criteria. The abused subjects exhibited higher levels of depression, anxiety, and eating disordered attitudes at each assessment point relative to nonabused subjects. In addition, abused subjects were more likely to be re-hospitalized in the 3 month post-discharge period. Significant differences in the extent of actual bulimic behaviors were not detected. Both the abused and nonabused bulimic patients demonstrated significant reductions in psychiatric symptomatology from pretreatment to posttreatment, and from posttreatment to follow-up. Contrary to prediction, differences in symptomatology between the very serious, serious, and least serious abused groups were not detected. Results suggest that bulimic patients with reported histories of sexual abuse can be effectively engaged in a conventional eating disorder treatment program, but that such abuse may place patients at a disadvantage owing to higher levels of pretreatment symptom severity. Findings suggest that extended and/or more specific intervention may be warranted for the abused bulimic patient.

The effects of health care reforms on job satisfaction and voluntary turnover among hospital-based nurses

OBJECTIVES

Among the consequences of downsizing and cost containment in hospitals are major changes in the work life of nurses. As hospitals become smaller, patient acuity rises, and the job of nursing becomes more technical and difficult. This article examines the effects of changes in the hospital environment on nurses' job satisfaction and voluntary turnover between 1993 and 1994.

METHODS

Data were collected in a longitudinal survey of 736 hospital nurses in one hospital to examine correlates of change in aspects of job satisfaction and predictors of leaving among nurses who terminated in that period.

RESULTS

Unadjusted results showed decline in most aspects of satisfaction as measured by Hinshaw and Atwood's and Price and Mueller's scales. Multivariate analysis indicated that the most important determinants of low satisfaction were poor instrumental communication within the organization and too great a workload. Intent to leave was predicted by the perception of little promotional opportunity, high routinization, low decision latitude, and poor communication. Predictors of turnover were fewer years on the job, expressed intent to leave, and not enough time to do the job well.

CONCLUSIONS

The authors conclude that although many aspects of job satisfaction are diminished, some factors predicting low satisfaction and turnover may be amenable to change by hospital administrators.

Does routine follow up after head injury help? A randomised controlled trial

OBJECTIVE

To evaluate the Medical Disability Society's 1988 recommendation that "every patient attending hospital after a head injury should be registered and offered an outpatient follow up appointment" by determining whether offering a routine follow up service to patients presenting to hospital with a head injury of any severity affects outcome six months later.

DESIGN

A randomised controlled trial design with masked assessment of outcome.

SETTING

A mixed rural and urban health district with a population of about 560000.

PATIENTS

1156 consecutive patients resident in Oxfordshire aged between 16 and 65 years presenting over 13 months to accident and emergency departments or admitted to hospital and diagnosed as having a head injury of any severity, including those with other injuries.

INTERVENTIONS

Patients were registered and randomised to one of two groups. Both groups continued to receive the standard service offered by the hospitals. The early follow up group were approached at 7-10 days after injury and offered additional information, advice, support, and further intervention as needed. All randomised patients were approached for follow up assessment six months after injury by independent clinicians blind to their group.

MAIN OUTCOME MEASURES

Validated questionnaires were used to elicit ratings of post-concussion symptoms (the Rivermead postconcussion symptoms questionnaire), and changes in work, relationships, leisure, social, and domestic activities (the Rivermead head injury follow up questionnaire).

RESULTS

The two groups were comparable at randomisation. Data was obtained at six months on 226 of 577 "control" patients and 252 of 579 "trial" patients (59% were lost to follow up). There were no significant differences overall between the trial and control groups at follow up, but subgroup analysis of the patients with moderate or severe head injuries (posttraumatic amnesia > or = one hour, or admitted to hospital), showed that those in the early intervention group had significantly fewer difficulties with everyday activities (P = 0.03).

CONCLUSIONS

The results from the 41% of patients followed up do not support the recommendation of offering a routine follow up to all patients with head injury, but they do suggest that routine follow up is most likely to be beneficial to patients with moderate or severe head injuries. Some of those with less severe injuries do continue to experience difficulties and need access to services. A further trial is under way to test these conclusions.

Interventions and service need following mild and moderate head injury: the Oxford Head Injury Service

OBJECTIVE

To describe the interventions given by the Oxford Head Injury Service (OXHIS) to patients seen after head injury, predominantly mild or moderate, over the first six months after their injuries.

DESIGN

Descriptive data of the amounts of early intervention provided by OXHIS in relation to severity of head injury and the amount of service need identified at six month follow-up.

SETTING

OXHIS aimed to register all patients aged 16-65 with a head injury of any severity, resident in Oxfordshire. It contacted and provided interventions for a random half of those registered at 7-10 days post-injury as part of a randomized controlled trial to investigate the effectiveness of early follow-up. At six months post-injury, independent assessment of all those registered was undertaken to evaluate outcome and identify continuing service needs.

SUBJECTS

The data come from the 579 patients (of the 1156 registered), randomized to receive the new service at 7-10 days post-injury. All but eight of these received some form of service, and 252 of the randomized patients were available for interview at six months post-injury to assess their continuing service need.

RESULTS

In the first five months after head injury: 240 patients received postal information alone and were not otherwise in contact with the service; 127 had telephone contact, advice and information; 93 were seen in person, assessed and given advice and information; 78 needed more help and support from the OXHIS team over the telephone; and 33 required further face-to-face contact either from OXHIS or other services. Extensive use was made of standardized leaflets but only accompanied by individualized assessment and advice. At six months 252 of the 579 patients were interviewed: 101 had no problems; 136 needed further reassurance; and 15 required further intervention. Patients with longer periods of post-traumatic amnesia (PTA) were more likely to receive a higher level of service, but the majority of patients who received the more extensive services were those with 'mild' and 'moderate' head injuries.

CONCLUSIONS

Although the amount of service provided at 7-10 days post-injury increased with severity of head injury, most service was in fact given to patients with milder head injuries which were much more common. The majority of patients seen at six months post-injury needed reassurance, advice or other services, and monitoring of patients for some time after their head injuries does seem warranted. A population of 560,000 people could receive service from three whole-time equivalent (WTE) staff using these assessment and management protocols.

Measurement of post-traumatic amnesia: how reliable is it?

OBJECTIVE

To develop and test a clinical protocol for determining post-traumatic amnesia by retrospective questioning. To establish its limits and factors which influence reliability.

DESIGN

Two independent assessments using the Rivermead post-traumatic amnesia protocol were undertaken by separate observers on various groups of patients at various time intervals. Analysis investigated the correlations between assessments, the percentage difference between assessments, the number of patients changing category, and the differences between these analyses in the different patient subgroups. Assessments were undertaken both in hospital and in the patients' homes. Four different patient groups were studied. These were group A: 12 inpatients with very severe head injury late after injury; Group B: 40 patients interviewed at home six months after injury; group C: 22 patients interviewed within a few weeks of injury at home; group D: 116 patients interviewed initially within a few weeks and then at six months, on both occasions at home. The Rivermead post-traumatic amnesia protocol involved clinical questioning of the patient to establish how long after injury (in hours/days/weeks) the patient regained continuous day to day memory. All periods of coma were included. Severity was categorised with standard criteria.

RESULTS

Overall correlation was good (Spearman's r 0.79), but the correlation was lower for patients with post-traumatic amnesia < 24 hours and when there was a long delay between assessments. In all groups 19%-25% of patients changed categories between assessments, but only 2% changed by two categories.

CONCLUSIONS

The assessment of post-traumatic amnesia with the Rivermead post-traumatic amnesia protocol is reasonably reliable. The misclassification rate however, is significant enough that some caution should be taken in individual cases. Other evidence does show post-traumatic amnesia to be valid, and it probably remains the best simple prognostic item available. In clinical practice one should avoid placing too much weight on post-traumatic amnesia alone.

The relationship between hepatic copper content and morphologic changes in the liver of West Highland White Terriers

Liver tissue from 17 West Highland White Terriers (WHWTs) with cirrhosis, subacute bridging necrosis, hepatitis, or massive necrosis were examined for the presence, composition, and distribution of inflammatory foci. Copper analysis was performed on the specimens. The foci of inflammation and necrosis composed a significant part of the lesion in 15 of the samples. The foci were of two types. One, characteristic of idiopathic chronic active hepatitis, consisted of one or two apoptotic hepatocytes attended by lymphocytes and plasma cells. These foci were found primarily in the vicinity of the portal tracts, not associated with centrolobular copper-laden hepatocytes. The other type of focus was characteristic of copper toxicosis. These foci were larger and composed of debris-filled macrophages, lymphocytes, plasma cells, and scattered neutrophils, and on occasion apoptotic hepatocytes were found at the periphery. These foci were always found around the central vein among the copper-laden hepatocytes. Such foci were found only in dogs with copper concentration > 2,000 parts/million on a dry weight basis. These morphologic studies show that clinical liver disease in WHWTs is caused by more than one etiologic agent. Among 17 WHWTs with clinical liver disease, two had copper toxicosis, five had idiopathic chronic active hepatitis, and 10 had hepatic disease of undetermined type.

Virus-like particles as a rotavirus subunit vaccine

Rotavirus subunit vaccines are being evaluated for use in humans. The virus-like particles (VLPs) for these vaccines are produced in insect cells coinfected with combinations of baculovirus recombinants expressing bovine RIF VP2 and simian SA11, VP4, VP6, or VP7 rotavirus proteins. VLPs were administered parenterally to mice and rabbits, and the immunogenicity and protective efficacy of the vaccines were evaluated. Rabbits vaccinated with VP2/4/6/7 or VP2/6/7 VLP combinations developed high levels of rotavirus-specific serum antibody and fecal IgG but not fecal IgA. The induction of fecal IgG was associated with total or partial protection from oral challenge with ALA rotavirus. Heterotypic serum and fecal neutralizing antibody was induced in mice vaccinated parenterally with G1 VP2/6/7 or VP2/4/6n VLPs. VLPs were highly immunogenic when administered in QS21 adjuvant, inducing serum neutralizing antibody titers comparable to those induced by SA11 virus. VLPs are effective immunogens when administered parenterally and may be an effective subunit vaccine.

Prevention of youth violence: rationale and characteristics of 15 evaluation projects

Interpersonal violence is a major cause of injury, disability, and death, especially among youth. Evaluations of 15 youth violence-prevention projects are under way. Public health is concerned about health problems that need to be addressed via collective action. Public health involvement in addressing interpersonal violence among youths brings an emphasis on primary prevention, a systematic and scientific process, and integrative leadership. Few quantitative evaluations of violence-prevention projects have been done. The interventions are scientifically based and use a spectrum of strategies. Individually oriented strategies are more common than those directed toward peers, families, schools, or communities. Each project has a rigorous evaluation design. Twelve are randomized. Sample sizes range from 180 to 10,000. Participants range in age from 5 to 18 years, although most are in the middle-school years (11-14 years). At baseline, intervention and comparison groups are similar. Baseline data demonstrate high frequency of violent behavior, weapon carrying, and exposure to violence among the youthful participants. Field intervention and evaluation research is difficult and expensive. Difficulties encompass organizational programatic, and scientific issues; these difficulties reduce scientific interest and financial support for projects such as these. Public health has an important role to play in reducing violence. These projects will make important contributions to that task.

Naomi C. Broering Medical Library Association President 1996-1997

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The Rivermead head injury follow up questionnaire: a study of a new rating scale and other measures to evaluate outcome after head injury

OBJECTIVE

To develop and evaluate a short (10 item) simple measure of outcome mainly for use with patients with mild to moderate head injuries.

DESIGN

Two studies on patients at three and six months after injury, comparing different methods of administration (two raters and postal questionnaire), and comparing ratings with other assessments.

SUBJECTS

Forty three patients seen three months after injury and 46 seen six months after injury; both groups had head injuries covering a range of severity from minor to severe.

MAIN OUTCOME MEASURES

Differences between ratings in different groups of patients (Mann-Whitney U test); differences in ratings used different methods of administration (Wilcoxon signed rank test); and correlation between ratings from the same patient (Spearman r).

RESULTS

The sum total ratings were consistent between raters and between methods (postal questionnaire v face to face interview) with no evidence of selective bias between rates or methods. Ratings on individual items were also reasonably consistent. The sum total rating varied as anticipated between groups divided by clinical judgement of recovery and patient assessment of recovery, and related as expected to the extent of post-concussion symptomatology. The 10 items included covered the most important problem areas reported by patients.

CONCLUSION

The Rivermead head injury follow up questionnaire (RHFUQ) is a short, simple, adequately reliable, and valid measure of outcome, across the entire range of severity, but particularly after mild to moderate head injury.

Informal care vs. formal services: changes in patterns of care over time

Longitudinal data from a representative sample of community-residing older persons were used to document changes in patterns and costs of care, both informal and formal. It was found that use of formal services was usually in conjunction with, and secondary to, informal care. Limited availability of informal care as well as increased disability raised the odds of using services. Substitution of formal services for informal care was limited and usually temporary. Total costs of community care, including living expenses, were generally less than the cost of nursing home care.

The Rivermead Post Concussion Symptoms Questionnaire: a measure of symptoms commonly experienced after head injury and its reliability

After head injuries, particularly mild or moderate ones, a range of post-concussion symptoms (PCS) are often reported by patients. Such symptoms may significantly affect patients' psychosocial functioning. To date, no measure of the severity of PCS has been developed. This study presents the Rivermead Post Concussion Symptoms Questionnaire (RPQ) as such a measure, derived from published material, and investigates its reliability. The RPQ's reliability was investigated under two experimental conditions. Study 1 examined its test-retest reliability when used as a self-report questionnaire at 7-10 days after injury. Forty-one head-injured patients completed an RPQ at 7-10 days following their head injury and again approximately 24 h later. Study 2 examined the questionnaire's inter-rater reliability when used as a measure administered by two separate investigators. Forty-six head-injured patients had an RPQ administered by an investigator at 6 months after injury. A second investigator readministered the questionnaire approximately 7 days later. Spearman rank correlation coefficients were calculated for ratings on the total symptom scores, and for individual items. High reliability was found for the total PCS scores under both experimental conditions (Rs = + 0.91 in study 1 and Rs = + 0.87 in study 2). Good reliability was also found for individual PCS items generally, although with some variation between different symptoms. The results are discussed in relation to the major difficulties involved when looking for appropriate experimental criteria against which measures of PCS can be validated.

Detection of mycobacteria in bone marrow biopsy specimens taken to investigate pyrexia of unknown origin

AIMS

To investigate the value of bone marrow biopsy in the diagnosis of mycobacterial infection.

METHODS

The culture results of 433 bone marrow samples taken between 1983 and 1992 were reviewed. The histopathology reports on bone marrow trephine specimens of culture positive samples and all those on HIV positive patients sent in 1992 were also reviewed.

RESULTS

Fifty one specimens yielded Mycobacterium spp, 47 were obtained from HIV positive patients. Of the isolates, 42 were Mycobacterium avium-intracellulare (MAI), five were M tuberculosis (MTB), and the remaining four comprised a variety of atypical mycobacteria. All MAI positive samples were obtained from HIV positive patients, with the bone marrow being the only culture positive specimen in one third. Bone marrow yielded MTB only in patients from whom it was also isolated in other specimens. Eleven of 47 trephine specimens from positive bone marrow showed granulomata and nine showed acid-fast bacilli. No acid-fast bacilli were seen in the absence of granulomata.

CONCLUSION

Bone marrow biopsy for mycobacterial culture should be reserved for severely immunosuppressed patients and should not be advocated for immunocompetent patients with suspected tuberculosis. Bone marrow biopsy still has a role in the investigation of pyrexia of unknown origin in HIV positive patients, despite the advent of mycobacterial blood culture techniques, particularly if these can be processed safely in automated systems.

How does formal and informal community care affect nursing home use?

We examined the effects of informal and formal community care on the 6-year risk of nursing home use in a representative sample of disabled elders. Increased risk was associated with receiving formal community services and with caregiver burnout. There was a modest reduction in risk of using a nursing home among those receiving greater amounts of informal care. Elders with male caregivers were at over twice the risk of using a nursing home than those with female caregivers, while those who lived with their primary caregiver were at reduced risk. Increasing amount of formal services was associated with reduced risk of nursing home use for cognitively impaired older persons. Formal community services did not buffer the effects of severity of disability on nursing home use. Supplementing informal services with formal care was associated with greater risk of using a nursing home. Future research should move beyond testing global hypotheses regarding the protective effects of informal and formal community care and examine the impact of specific types of community care for specific subgroups of older persons on subsequent nursing home use.

Promoting dietary change

The discouraging failure rate of counselling patients for dietary change suggests that traditional methods require some reconsideration. These have been frequently based on generalized assumptions regarding patients' health values, their need for knowledge, level of literacy, and ability to translate abstract concepts into daily food. Similarly, both patient and counsellor often insufficiently examine the environmental context of the dietary changes to determine whether or not they are feasible. This brief overview examines ways in which nutrition counselling can be enhanced to ensure that patients are enabled to develop a heart-healthy diet through active problem solving and directed development of self-efficacy in the skills they will need for lasting change.

Measuring depressive symptoms in the frail elderly

To determine the usefulness of the Center for Epidemiological Studies Depression Scale (CES-D) as a measure of depressive symptoms among frail and disabled elderly, we conducted a first- and second-order confirmatory factor analysis testing the four-factor structure of the CES-D and the existence of a single underlying second-order factor. We also examined the relative contribution of the somatic factor of the total symptom score, and relationships of age, race, functional status, and health with the four factors. We found that the factor structure is replicated when used with frail elderly, and scores are not distorted by the disproportionate influence of somatic items. Age and health do not affect the somatic subscale more than the other three subscales. Functional limitations are associated with higher somatic scores. We conclude that the CES-D is an appropriate tool to measure depressive symptoms in frail elderly.

Role of endomyocardial biopsy in rejection surveillance after heart transplantation in neonates and children

OBJECTIVES

The aim of this study was to retrospectively evaluate the sensitivity of noninvasive surveillance (physical examination, echocardiography) of rejection in accurately predicting histologically documented rejection episodes. Additionally, the usefulness of routine scheduled biopsy and its safety in pediatric patients was explored.

BACKGROUND

Endomyocardial biopsy has been utilized as the standard for rejection surveillance after heart transplantation in adults, but its role in documenting clinically suspected rejection and in routine surveillance of pediatric patients has not been agreed upon.

METHODS

Heart transplantation was performed in 14 neonates and 21 children. The immunosuppressive regimen consisted of cyclosporine, azathioprine and prednisone. All patients underwent routine noninvasive rejection surveillance that included clinical examination and echocardiography. In the neonates, biopsy was performed quarterly beginning 6 months after transplantation, after cessation of prednisone therapy. In the children, biopsy was performed 15 times in the 1st year. A minimum of five biopsy samples were interpreted using the Working Formulation for Heart Transplant Rejection.

RESULTS

In the neonates, 37 biopsies were performed. Evidence of rejection was present in only three biopsy samples obtained during eight episodes (38%) of clinically suspected rejection. In 29 biopsies performed when rejection was not clinically suspected, each biopsy was free of cellular infiltrate. In the children, 291 biopsies were performed. Evidence of rejection was present in only seven biopsies (41%) from 17 episodes of clinically suspected rejection. Cellular rejection was discovered during routine rejection surveillance biopsies in asymptomatic patients in 23 (8.4%) of 274 biopsies.

CONCLUSIONS

In neonates with clinically suspected rejection, endomyocardial biopsy identified which patients did not require rejection therapy. Endomyocardial biopsy surveillance did not detect any unsuspected cases of rejection. In children, noninvasive rejection surveillance was less reliable even in asymptomatic patients, suggesting that periodic endomyocardial biopsy should be utilized.

Pharmacologic reduction of pretransplantation pulmonary vascular resistance predicts outcome after pediatric heart transplantation

Pulmonary hypertension leading to donor right ventricular dysfunction remains a major risk factor associated with poor outcome after heart transplantation. This study evaluated a pretransplantation protocol to assess pulmonary vascular resistance index and its response to pharmacologic modulation. Cardiac catheterization was performed in 25 patients (mean age, 8.6 years [range, 1 to 17 years]; mean weight, 27.3 kg [range, 8.1 to 54 kg]) with end-stage heart failure. Mean pulmonary artery and capillary wedge pressures and cardiac index were measured in the baseline state and during administration of 100% oxygen, dobutamine at 10 micrograms/kg/min, and nitroprusside at 1 to 4 micrograms/kg/min. Transpulmonary pressure gradient and pulmonary vascular resistance index were calculated. In 22 survivors, hemodynamics were reassessed 1 and 4 weeks after transplantation. The mean cardiac index significantly increased (2.2 to 3.2 L/min/m2); transpulmonary pressure gradient (12.7 to 9.6 mm Hg) and pulmonary vascular resistance index (6.2 to 3.0 units/m2) decreased during the drug study. In 12 patients with a baseline pulmonary vascular resistance index of more than 6 units/m2, 10 survived heart transplantation. This study shows that pharmacologic reduction of the pulmonary vascular resistance index in the pretransplantation protocol predicts reduced pulmonary vascular resistance index and a favorable outcome after heart transplantation.

Spectrum of humoral rejection after pediatric heart transplantation

The deposition of immunoglobulin and complement 3 in the coronary microvasculature (humoral rejection) has been associated with poor outcome after heart transplantation. The purpose of this study is to relate the incidence of immunoglobulin and complement 3 myocardial deposition to the clinical course of pediatric heart transplant patients. One hundred thirty-one biopsy specimens from 30 patients, whose mean age at transplantation was 4.9 years (range, 2 days to 17 years), were processed for light microscopy and immunofluorescence. The mean follow-up was 25 months (range, 6 to 63 months). All patients underwent annual selective coronary artery angiography. No cellular or humoral rejection was seen in 97 biopsy specimens. Humoral rejection without cellular infiltrate was found in eight biopsy specimens from four patients (13%). Of 19 grade 1A, B (mild) biopsy specimens, 17 showed only cellular rejection, and two showed a mixed pattern of cellular and humoral rejection. Of six grade 2,3 (moderate) biopsy specimens, four showed only cellular rejection, and two showed a mixed pattern. The only grade 4 (severe) biopsy specimen revealed a mixed pattern. Three patients have had persistent immunoglobulin M and complement 3 deposits. One of these had angiographic evidence of accelerated graft coronary artery disease 2 years after transplantation, which was later confirmed at autopsy. Coronary artery disease has not been detected by serial angiography at 1 year (28 patients), 2 years (18 patients), 3 years (15 patients), 4 years (five patients), and 5 years (one patient). Humorally mediated rejection occurs with and without cellular rejection after pediatric heart transplantation. Humoral rejection may persist after treatment and resolution of severe cellular rejection episodes.(ABSTRACT TRUNCATED AT 250 WORDS)

Cranial magnetic resonance imaging in severe preeclampsia vs eclampsia

OBJECTIVE

This study was undertaken to evaluate the hypothesis that severe preeclampsia and eclampsia are associated with unique cranial magnetic resonance images.

DESIGN

Case series of women with severe preeclampsia and eclampsia.

SETTING

Referral center.

PATIENTS

Sixteen women with severe preeclampsia and 10 women with eclampsia.

RESULTS

Half of the women with severe preeclampsia had abnormal scans with nonspecific foci of increased signal in the deep cerebral white matter on T2-weighted images. However, women with eclampsia had either a multifocal area of increased signal at the gray-white matter junction on T2-weighted images or cortical edema and hemorrhage. These findings are consistent with necropsy descriptions of cortical edema and petechial hemorrhage. Basal ganglion lesions were also common.

CONCLUSIONS

These findings appear to be unique to eclamptic women and should be considered of diagnostic significance in contrast to the nonspecific changes in patients with severe preeclampsia. Cranial magnetic resonance imaging may, thus, be of value in cases with diagnostic uncertainty, atypical presentation, or focal neurologic deficit.

Mononuclear cell reconstitution in the lung after marrow transplantation. Lack of influence of cytomegalovirus pneumonia, irradiation, and graft-versus-host disease

The number and types of mononuclear cells obtained by bronchoalveolar lavage from 105 marrow transplant patients with and without cytomegalovirus pneumonia were studied to determine whether: (1) CMV pneumonia was associated with local recruitment of lymphocytes and lymphocytes of particular subtypes to the lung, and (2) whether local recruitment was affected by the known risk factors for the development of CMV pneumonia, namely acute graft-versus-host disease and total body irradiation. Results showed a significant increase in the number of lymphocytes (P = 0.014) and in the number of lymphocytes marking for CD8 (P = 0.0045) and CD16 (P = 0.052) in BAL from all patients compared with BAL from normal subjects. However, no significant differences were observed in BAL cellular characteristics between patients with and without pneumonia nor between patients with CMV or other etiologies of pneumonia. There were also no significant differences in BAL characteristics when patients were analyzed for the presence of acute GVHD, the use of TBI, or the type of transplant. These results do not provide evidence for local recruitment of lymphocytes to the lung unique of patients with CMV pneumonia nor to patients with GVHD and CMV pneumonia, in contrast to what is observed in murine CMV pneumonia.

Determining the pattern of community care: is coresidence more important than caregiver relationship?

Researchers have previously emphasized the importance of kinship tie to explaining the pattern of care received by a disabled elder. For example, it has been argued that spouses are a distinct group of caregivers, i.e., they provide more care with less help from others and experience more stress. However, based on the theory of primary group structures and functions, this study hypothesized that coresidence rather than the kinship tie is more important in determining the pattern of caregiving. When spouses are compared to other coresiding caregivers, patterns of informal care and use of formal services are similar. Variance in amounts of informal care is explained by elder gender and frailty level rather than by caregiver relationship. Similarly, level of frailty was the only important predictor of use of formal services.

Interleukin-2, interferon-gamma and natural killer cell activity in bronchoalveolar lavage fluid from marrow transplant recipients with cytomegalovirus pneumonia

Cytokines interleukin-2 (IL-2) and interferon-gamma (IFN-gamma) were measured from bronchoalveolar lavage (BAL) fluid and sera of 41 marrow transplant recipients and eight healthy volunteers as controls. Although IL-2 and IFN-gamma were detected in 32 and 10 patient sera respectively, IL-2 or IFN-gamma was detected in BAL of only five patients. There was no correlation of the presence of either cytokine with cytomegalovirus pneumonia, pneumonia of other etiology or absence of pneumonia. Local lung production of IL-2 and IFN-gamma as measured in BAL did not correlate with natural-killer cell activity and had no apparent role in the pathogenesis of lung disease after marrow transplant.

Computer-aided treatment design of a distal upper extremity soft tissue tumor with electron beam radiotherapy

We present here a novel approach for the planning and treatment of a distal upper extremity soft tissue tumor. Utilizing computed tomography (CT) based electron dose calculations, a customized compensating wax bolus was designed in order to deliver sufficient dose coverage to the tumor volume while sparing the draining lymphatics of the patient's hand and digits. A clinical case is presented as well as the design and construction of the compensator. Outcome and clinical implications are discussed.

Naomi C. Broering, twenty-first editor of the Bulletin

Images

Heart transplantation in neonates and in children

Between May 1988 and July 1991, 28 neonates and children underwent orthotopic heart transplantation at Children's Memorial Hospital in Chicago. Indications for heart transplantation were hypoplastic left heart syndrome (10), dilated cardiomyopathy (13), aortic stenosis with endocardial fibroelastosis (1), complex D-transposition of the great arteries after Senning repair (1), L-transposition of the great arteries with single ventricle after shunt (1), cor biloculare, pulmonary atresia, and situs inversus after Fontan (1), and chronic rejection after heart transplantation for hypoplastic left heart syndrome (1). The age at time of transplantation ranged from 2 days to 17 years (mean, 5.3 +/- 6.1 years). Early deaths were from intraoperative donor right ventricular failure (2) and acute rejection after a second transplant procedure at 21 days (1), for an in-hospital mortality rate of 10.7%. Immunosuppression was with cyclosporine, azathioprine, and prednisone, with an attempt to discontinue the prednisone in neonates at age 6 months as guided by endomyocardial biopsy. Rejection episodes were treated with methylprednisolone pulse (34) or with OKT3 (4). Endomyocardial biopsy (in patients older than 6 months) was used extensively, and acute rejection was diagnosed in 29 of 301 biopsies. Three late deaths occurred (mean follow-up, 16.3 +/- 11.8 months): one of acute rejection at 13 months, one of viral pneumonia at 7 months, and one of intraabdominal sepsis as a complication of peritoneal dialysis at 5 months. Actuarial survival at 2 years is 77% +/- 9% (standard error of the estimate). Heart transplantation for neonates and for children can be performed with acceptable operative mortality. Intermediate results with triple therapy immunosuppression and an intensive rejection surveillance regimen relying on endomyocardial biopsy are encouraging.

A novel 110-kDa maternal CAAX box-containing protein from Xenopus is palmitoylated and isoprenylated when expressed in baculovirus

We describe a unique 110-kDa protein, xlcaax-1, that is a member of a group of membrane-associated proteins such as the ras and ras-related proteins and nuclear lamins. Many of these proteins are involved in signal transduction or cell signaling, possess a C-terminal CAAX box, and undergo fatty acid acylation (Glomset, J. A., Gelb, M. H., and Farnsworth, C. C. (1990) Trends Biochem. Sci. 15, 139-142). The ras and ras-related proteins bind GTP and in most cases are both isoprenylated and palmitoylated. The xlcaax-1 protein possesses a C-terminal CAAX sequence that is identical to the N-ras protein. In addition to the CAAX box, xlcaax-1 contains a series of basic amino acids upstream of the CAAX sequence similar to several nonpalmitoylated forms of the ras-related proteins. When the xlcaax-1 cDNA is expressed in a baculovirus expression system, the product undergoes isoprenylation and palmitoylation utilizing a mechanism similar to that of the ras proteins. In addition, the xlcaax-1 protein is isoprenylated, and a minor fraction is palmitoylated in Xenopus XTC tissue culture cells. We have also demonstrated that the protein is associated with membrane fractions in full-grown Xenopus oocytes and in Xenopus XTC tissue culture cells and that membrane association is isoprenylation-dependent. The presence of maternal molecules possessing signal transduction potential is an attractive mechanism for modulating the effects of growth factors and other signal molecules during development.

Comparison of heterotypic protection against influenza A/Taiwan/86 (H1N1) by attenuated and inactivated vaccines to A/Chile/83-like viruses

Children (n = 192) aged 3-19 years from 98 families completed this double-blind, placebo-controlled study comparing the efficacy of a bivalent attenuated (CR) vaccine with trivalent inactivated (TI) vaccine. Both vaccines contained A/Chile/83 (H1N1)-like antigens. After vaccination the geometric mean titer to A/Taiwan/86 (H1N1) was 1:36 in the CR group, 1:92 in the TI group, and 1:5 in the placebo group. During the influenza A/Taiwan/86 (H1N1) epidemic, 21.4% of CR recipients, 16.7% of TI recipients, and 43.9% of placebo recipients were infected with influenza A/Taiwan. TI vaccine provided better heterotypic protection than did CR vaccine for children aged 10-18 years (infection rate, 0 vs. 24%, respectively; P less than .025); in contrast, in the younger children (3-9 years), CR vaccine tended to be more protective (19% vs. 26% for TI).

Spinal cord ischemia after resection of thoracoabdominal aortic aneurysms: MR findings in 24 patients

MR images of the thoracic spinal cord were made in 24 patients who developed signs and symptoms of spinal cord ischemia or infarction following surgery for a thoracoabdominal aortic aneurysm. Findings consisted primarily of four different patterns of signal abnormalities in the distribution of the anterior spinal artery. These abnormalities were identified as types A-D, depending on the degree of involvement of the gray matter and surrounding white matter. We found good correlation between the distribution of the signal abnormalities in the cord, the severity of the neurologic deficits, and the clinical outcome. MR is the imaging method of choice for diagnosing spinal cord ischemia or infarction. A thorough knowledge of the spinal cord arterial territories is crucial for characterizing ischemic MR signal abnormalities and for differentiating them from other causes of myelopathy.

Planning a new library in an age of transition: the Washington University School of Medicine Library and Biomedical Communications Center

In an era of great technological and socioeconomic changes, the Washington University School of Medicine conceptualized and built its first Library and Biomedical Communications Center in seventy-eight years. The planning process, evolution of the electronic library, and translation of functions into operating spaces are discussed. Since 1983, when the project was approved, a whole range of information technologies and services have emerged. The authors consider the kind of library that would operate in a setting where people can do their own searches, order data and materials through an electronic network, analyze and manage information, and use software to create their own publications.