Adolescent musculoskeletal injuries in a football academy

Interest in football continues to increase, with ever younger age groups participating at a competitive level. Football academies have sprung up under the umbrella of professional clubs in an attempt to nurture and develop such talent in a safe manner. However, increased participation predisposes the immature skeleton to injury. Over a five-year period we have prospectively collected data concerning all injuries presenting to the medical team at Newcastle United football academy. We identified 685 injuries in our cohort of 210 players with a mean age of 13.5 years (9 to 18). The majority of injuries (542;79%) were to the lower limb. A total of 20 surgical procedures were performed. Contact injuries accounted for 31% (210) of all injuries and non-contact for 69% (475). The peaks of injury occurred in early September and March. The 15- and 16-year-old age group appeared most at risk, independent of hours of participation. Strategies to minimise injury may be applicable in both the academy setting and the wider general community.

Odour emissions from anaerobic piggery ponds. 2: improving estimates of emission rate through recognition of spatial variability

Odour emission rates were measured for seven different anaerobic ponds treating piggery wastes at six to nine discrete locations across the surface of each pond on each sampling occasion over a thirteen month period. Significant variability in emission rates were observed for each pond. Measurement of a number of water quality variables in pond liquor samples collected at the same time and from the same locations as the odour samples indicated that the composition of the pond liquor was also variable. The results indicated that spatial variability was a real phenomenon and could have a significant impact on odour assessment practices. Considerably more odour samples would be required to characterise pond emissions than currently recommended by most practitioners, or regulatory agencies.

Impairment of nonverbal recognition in Alzheimer disease: a PET O-15 study

OBJECTIVE

To characterize deficits in nonverbal recognition memory and functional brain changes associated with these deficits in Alzheimer disease (AD).

METHODS

Using O-15 PET, we studied 11 patients with AD and 17 cognitively intact elders during the combined encoding and retrieval periods of a nonverbal recognition task. Both task conditions involved recognition of line drawings of abstract shapes. In both conditions, subjects were first presented a list of shapes as study items, and then a list as test items, containing items from the study list and foils. In the titrated demand condition, the shape study list size (SLS) was adjusted prior to imaging so that each subject performed at approximately 75% recognition accuracy; difficulty during PET scanning in this condition was approximately matched across subjects. A control task was used in which SLS = 1 shape.

RESULTS

During performance of the titrated demand condition, SLS averaged 4.55 (+/-1.86) shapes for patients with AD and 7.53 (+/-4.81) for healthy elderly subjects (p = 0.031). However, both groups of subjects were closely matched on performance in the titrated demand condition during PET scanning with 72.17% (+/-7.98%) correct for patients with AD and 72.25% (+/-7.03%) for elders (p = 0.979). PET results demonstrated that patients with AD showed greater mean differences between the titrated demand condition and control in areas including the left fusiform and inferior frontal regions (Brodmann areas 19 and 45).

CONCLUSIONS

Relative fusiform and inferior frontal differences may reflect the Alzheimer disease (AD) patients' compensatory engagement of alternate brain regions. The strategy used by patients with AD is likely to be a general mechanism of compensation, rather than task-specific.

Managing peripherally inserted central catheter-related venous thrombosis: How I do it

Imaging-guided insertion of central venous catheters, either in the form of a peripherally inserted central catheter (PICC) or through a subclavian or a jugular approach, is becoming the preferred method of acquiring long-term venous access for a variety of therapeutic purposes. The most significant complication from central venous catheters is thrombosis of the catheterized vein. Venous thrombosis related to the insertion of PICC lines is conventionally treated with line removal followed by anticoagulation. Direct thrombolysis with urokinase, using the lumen of the PICC line to facilitate the insertion of the infusion catheter is a simple, safe and effective treatment option. In this article, we describe our experience with this procedure and the technique used.

Motor signs predict poor outcomes in Alzheimer disease

OBJECTIVE

To examine whether the presence of motor signs has predictive value for important outcomes in Alzheimer disease (AD).

METHODS

A total of 533 patients with AD at early stages (mean Folstein Mini-Mental State Examination [MMSE] 21/30 at entry) were recruited and followed semiannually for up to 13.1 years (mean 3) in five University-based AD centers in the United States and European Union. Four outcomes, assessed every 6 months, were used in Cox models: cognitive endpoint (Columbia Mini-Mental State Examination < or = 20/57 [ approximately MMSE < or = 10/30]), functional endpoint (Blessed Dementia Rating Scale > or = 10), institutionalization equivalent index, and death. Using a standardized portion of the Unified PD Rating Scale (administered every 6 months for a total of 3,149 visit-assessments, average 5.9 per patient), the presence of motor signs, as well as of individual motor sign domains, was examined as time-dependent predictor. The models controlled for cohort, recruitment center, sex, age, education, a comorbidity index, and baseline cognitive and functional performance.

RESULTS

A total of 39% of the patients reached the cognitive, 41% the functional, 54% the institutionalization, and 47% the mortality endpoint. Motor signs were noted for 14% of patients at baseline and for 45% at any evaluation. Their presence was associated with increased risk for cognitive decline (RR, 1.72; 95% CI, 1.24 to 2.38), functional decline (1.80 [1.33 to 2.45]), institutionalization (1.68 [1.26 to 2.25]), and death (1.38 [1.05 to 1.82]). Tremor was associated with increased risk for reaching the cognitive and bradykinesia for reaching the functional endpoints. Postural-gait abnormalities carried increased risk for institutionalization and mortality. Faster rates of motor sign accumulation were associated with increased risk for all outcomes.

CONCLUSIONS

Motor signs predict cognitive and functional decline, institutionalization, and mortality in Alzheimer disease. Different motor sign domains predict different outcomes.

Use of re-transfusion versus vacuum drains in primary total hip replacement

Whilst the use of re-transfusion drains in primary knee arthroplasty has gained acceptance in reducing the requirement for donor blood products postoperatively, their use in total hip arthroplasty remains uncertain. Using two groups of 32 patients, a comparison was made between re-transfusion drains and vacuum drains in primary total hip arthroplasty in one centre and the requirement for postoperative donor blood. No statistically significant difference was found between the groups in terms of blood loss (p=0.51) or requirements for postoperative blood transfusion (p=0.12). The use of re-transfusion drains in primary total hip arthroplasty did not alter the rate of postoperative blood transfusion. (Hip International 2005; 15: 223-5).

Effect of awake Carotid Endarterectomy under local anaesthesia on peri-operative blood pressure: blood pressure is normalised when carotid stenosis is treated under local anaesthesia

BACKGROUND

Carotid Endarterectomy can be performed under local, regional or general anaesthesia. One of the most important effects of the type of anaesthetic used is on the systemic blood pressure. Although variations in blood pressure during and following carotid endarterectomy have been studied previously, the effects of awake carotid endarterectomy under local anaesthesia on blood pressure and its comparison with similar procedures under similar types of anaesthesia have not.

METHODS

Peri-operative blood pressure measurements were collected from the records of 25 consecutive patients for each of the following five procedures; Carotid Endarterectomy under general anaesthesia (CEAGA), Anterior Cervical Discectomy and Fusion under general anaesthesia (ACDF), Cerebral Angiography under local anaesthesia (ANG), Carotid Endarterectomy patients under local anaesthesia who were symptomatic (CEALAS) and Carotid Endarterectomy patients under local anaesthesia who were asymptomatic (CEALAA). The recordings were then analysed to find out if there were any clinically significant variations in peri-operative blood pressure.

FINDINGS

There is a significant and consistent difference when the pre-operative value was compared with the 4 hour and 24 hour post-operative recordings between the local and general anaesthetic groups for carotid endarterectomy. Carotid endarterectomy reduces the systolic and diastolic blood pressures post-operatively when performed under local anaesthesia and only the diastolic pressure was reduced when performed under general anaesthesia.

CONCLUSION

The study provides evidence about the effect of carotid endarterectomy on the systemic blood pressure and its variations when performed under different types of anaesthesia. There is significant post-operative reduction in both the systolic and diastolic blood pressure values and the intraoperative fluctuation is minimal when local anaesthesia is used. Further studies are required to find out how this affects the long-term blood pressure and clinical outcome of the patient.

MRSA-free elective orthopaedic surgery.A dedicated elective orthopaedic ward free from MRSA Alexandra Hospital, Redditch, UK

Deep infection complicating arthroplasty surgery carries a heavy financial and emotional burden on any orthopaedic service. The cost of hospital acquired infection is estimated at 1 billion per year by the National Audit Office. Healthcare associated infection is an area currently under great scrutiny. The Alexandra Hospital, Redditch, has developed a dedicated elective orthopaedic ward free from methicillin-resistant Staphylococcus aureus (MRSA) that delivers high quality and high volume major joint replacement surgery through rigorous infection control. Between October 2001 and December 2002, the Alexandra Hospital had an infection rate of 0.21% for total knee replacements compared to the national rate of 2.1% p= 0.002 (CI 0.00005-0.01) The infection rate for total hip replacements was 1.31% compared to 3.8% nationwide. p= 0.01 (CI 0.004- 0.03). The total number of joint replacements performed per year, utilising the same number of elective beds, increased from 482 in 2001 to 629 in 2002. We believe that the MRSA screening policy and subsequent altered bed utilisation have contributed to lowering the rate of infection and improved efficiency. We have developed a safe, effective and efficient orthopaedic unit within the framework of an acute NHS trust. We believe the practical changes and modest investment that have been made within our department can be repeated in other units around the country with relative ease. (Hip International 2005; 15: 171-6).

Motor signs during the course of Alzheimer disease

BACKGROUND

Motor signs (MOSIs) are common in Alzheimer disease (AD) and may be associated with rates of cognitive decline, mortality, and cost of care.

OBJECTIVE

To describe the progression and identify predictors of individual MOSIs in AD.

METHODS

A cohort of 474 patients with AD at early stages was followed semiannually for up to 13.1 years (mean 3.6 years) in five centers in Europe and the United States. MOSIs were rated using a standardized portion of the Unified Parkinson's Disease Rating Scale. Overall, 3,030 visits/assessments of MOSIs (average 6.4/patient) were performed. Prevalence and incidence rates were calculated, and cumulative risk graphs were plotted for individual non-drug-induced MOSI domains. Rates of change over time taking into account potential covariates were also estimated. With use of each MOSI domain as outcome in Cox models, predictors of MOSI incidence were identified.

RESULTS

At least one MOSI was detected in 13% of patients at first examination and in 36% for the last evaluation. Total MOSI score increased at an annual rate of 3% of total possible score. Rates of annual change for speech/facial expression (4%), rigidity (2.45%), posture/gait (3.9%), and bradykinesia (3.75%) were of similar magnitude, and their occurrence increased from first (3 to 6%) to last (22 to 29%) evaluation. Tremor was less frequent throughout the course of the disease (4% at first and 7% at last evaluation) and worsened less (0.75% increase/year).

CONCLUSIONS

Most motor signs occur frequently and progress rapidly in Alzheimer disease. Tremor is an exception in that it occurs less frequently and advances at slower rates.

The prevalence of feline A/B blood types in the Sydney region

OBJECTIVE

To determine the distribution of A/B blood types in pedigree and crossbred cats in the Sydney region, and to estimate the associated risk of administering incompatible blood in an unmatched random transfusion.

DESIGN

A prospective/retrospective study of blood specimens collected from both sick and healthy cats.

MATERIALS AND METHODS

Blood was collected from 355 cats from the Sydney region over a 12-year period from 1992 to 2003. Specimens were obtained from 187 domestic crossbred cats (short and long-haired) and 168 pedigree cats. The blood type of each cat was determined by one of three different laboratories using standard methods that varied over the duration of the survey.

RESULTS

The distributions of blood types obtained by the three laboratories were not significantly different. The prevalence of type-A, type-B and type-AB blood types in crossbred cats was 62%, 36% and 1.6%, respectively. This is the highest percentage of type-B cats so far reported for an outbred population of domestic cats, and is significantly higher than the 26% reported previously for cats in the Brisbane region. The calculated frequency for the type-B allele assuming Hardy-Weinberg equilibrium for this feline population is 0.60; the corresponding frequency of the type-A allele is thus approximately 0.40. The calculated proportion of random transfusions from this population giving rise to an incompatible blood transfusion is 46%, with half of these being life-threatening events. The calculated proportion of random matings from this population at risk for developing neonatal isoerythrolysis is 23%. The distribution of A and B blood types for pedigree cats was in general agreement with data reported previously for cats in North America and Europe, suggesting that the distribution of blood types in these purebred populations is relatively consistent throughout the world.

CONCLUSIONS

The prevalence of type B cats in the owned domestic and pedigree cat population is so high that blood typing or cross matching prior to transfusion should be mandatory, except in Siamese/Oriental cats.

Molecular TCR diagnostics can be used to identify shared clonotypes after allogeneic hematopoietic stem cell transplantation

OBJECTIVE

In allogeneic hematopoietic stem cell (HSCT) transplantation, recovery of the T cell receptor (TCR) repertoire depends upon the composition of the graft and is modulated by peri-transplant immunosuppression, viral infections, and graft-vs-host disease (GVHD). We hypothesized that after allogeneic HSCT, molecular analysis of the TCR repertoire can be used to identify and quantitate immunodominant T cell clones that may play a role in GVHD or other clinical events.

METHODS

We utilized a rational strategy for the analysis of the expanded CTL clones. First, we studied the VB spectrum in a cohort of patients who had received either matched sibling or unrelated donor grafts. The CDR3 sequences of immunodominant clones were identified and clonotypic PCR and sequencing was applied to determine the level of clonotype sharing.

RESULTS

Significant expansions of VB families were observed following transplantations; 61% were oligo/monoclonal. Immunodeficiency was reflected by depletion of multiple VB families from both the CD8 and CD4 repertoires. The level of sharing varied between clonotypes, suggesting that some antigens have a more "public" spectrum while others are restricted to specific patients. Immunodominant CDR3 sequences common to allogeneic HSCT, healthy controls, and other conditions were identified.

CONCLUSION

The clonotypes of expanded CTL clones may reflect responses to alloantigens (e.g., in correlation with clinical GVHD) or pathogens. In the future, molecular T cell diagnostics may become a powerful clinical tool in transplantation to monitor disease and to direct treatment.

Localised genital Norwegian scabies in an AIDS patient

OBJECTIVES

We present a case of an AIDS patient with Norwegian scabies manifest by a single, crusted plaque localised to the glans penis.

METHODS

A 45 year old man with AIDS presented to our clinic complaining of a red papular pruritic rash on his abdomen and anterior thighs and a single, thick, crusted, non-pruritic lesion on the penis. He had been treated with lindane topically prior to the development of the penile lesion without resolution of the pruritus or red papular lesions. A mineral oil preparation was obtained from the hyperkeratotic penile lesion and revealed numerous mite eggs and faeces.

RESULTS

The diagnosis of localised, genital Norwegian scabies was made. The patient was treated with ivermectin 200 micro g/kg per dose taken as two doses, 14 days apart, with complete resolution of both pruritus and skin lesions.

CONCLUSIONS

This patient is the first known report of Norwegian scabies localised as a single lesion on the penis. He was successfully treated with oral ivermectin monotherapy.

Harm avoidance, anxiety, and response to novelty in the adolescent S-100beta transgenic mouse: role of serotonin and relevance to Down syndrome

S-100beta is an astroglial-derived protein, which plays a role in brain development and maintenance, and is known to play a specific role in the regulation of growth of the serotonergic neuronal system. In humans, the gene for S-100beta is found on chromosome 21, within the region that is considered important for the phenotype of Down syndrome (DS). Thus, we have been studying a model of DS, the S-100beta transgenic mouse. In the current study, we have examined anxiety and responses to novelty in adolescent (60-90 days) animals, at a time when we have shown the animals to be relatively lacking in serotonin innervation, compared to their CD-1 nontransgenic controls. In a test for approach/avoidance, the light/dark test, the S-100beta transgenic mice animals showed no differences from control CD-1 mice. However, in the hole-board test for exploratory behavior, the S-100beta animals were found to be less responsive to the inhibiting effects of the serotonin receptor 5-HT1A agonist, buspirone. Three tests were used to measure response to novelty. In the open field, the S-100beta animals showed greater activity longer than the control animals, and in the Y-maze test, the S-100beta animals spent more time in the novel arm. In a test for novelty-induced gnawing, the S-100beta animals were also more active than control animals. All of these suggest that the S-100beta transgenic mice are slower to habituate to novelty than control animals. Finally, we tested the animals in a new procedure that we are proposing as a test for harm avoidance. In this apparatus, the S-100beta animals showed more approaches to a novel and potentially harmful object than the control mice did. These results are discussed in reference to the known lack of serotonin in the animals, and to the behavioral phenotype of DS.

The serum concentration of estradiol after embryo transfer and the decline from preovulatory levels may influence the success of IVF treatment

AIM

To establish the influence that serum estradiol concentrations prior to oocyte retrieval and 3 days after embryo transfer have on the establishment of in vitro fertilization (IVF) pregnancy.

METHOD

Preovulatory (day-0) and luteal-phase (day-6) estradiol concentrations were retrospectively analyzed in 310 infertile patients, undertaking 1st-cycle conventional IVF or intracytoplasmic sperm injection.

RESULTS

The IVF treatment success is significantly reduced in patients with an estradiol level <600 pg/ml and also when a rapid decline in luteal-phase estradiol concentrations from preovulatory concentrations (day 0:day 6 ratio) was exhibited.

CONCLUSION

A day 0:day 6 estradiol ratio >5 and a serum estradiol concentration <600 pg/ml may adversely impact on the establishment of pregnancy in IVF.

The second generation of the International Equine Gene Mapping Workshop half-sibling linkage map

A low-density, male-based linkage map was constructed as one of the objectives of the International Equine Gene Mapping Workshop. Here we report the second generation map based on testing 503 half-sibling offspring from 13 sire families for 344 informative markers using the CRIMAP program. The multipoint linkage analysis localized 310 markers (90%) with 257 markers being linearly ordered. The map included 34 linkage groups representing all 31 autosomes and spanning 2262 cM with an average interval between loci of 10.1 cM. This map is a milestone in that it is the first map with linkage groups assigned to each of the 31 automosomes and a single linkage group to all but three chromosomes.

Delivery of an adenoviral vector to the crushed recurrent laryngeal nerve

OBJECTIVES

Objectives were to create a model of recurrent laryngeal nerve injury for testing the efficacy of potential therapeutic viral gene therapy vectors and to demonstrate that remote injection of a viral vector does not cause significant additional neuronal injury.

STUDY DESIGN

Animal model.

METHODS

Rats were randomly assigned to three groups of 10 animals each. In group I, the recurrent laryngeal nerve was crushed. In group II, the nerve was crushed and then injected with an adenoviral vector containing no transgene. In group III, the nerve was identified but was not crushed. Rats were killed at 1 week, and their larynges and brainstems were cryosectioned in 15-microm sections. Laryngeal cryosections were processed for acetylcholine histochemical analysis (motor endplates) followed by neurofilament immunoperoxidase (nerve fibers). Percentage of nerve-endplate contact was determined and compared between groups. Fluorescent in situ hybridization was performed on brainstem sections from rats in group II to confirm the presence of virus.

RESULTS

No significant difference in percentage of nerve-endplate contact exists between the two crushed-nerve groups (groups I and II) (P =.88). The difference between both crushed-nerve groups and the group with noncrushed nerves (group III) was highly significant (P <.0001). The presence of virus was confirmed in group II rats.

CONCLUSIONS

Crush provides a significant measurable injury to the recurrent laryngeal nerve and may be used as a model to explore therapeutic interventions for nerve injury. The remote injection of viral vector did not cause significant additional neuronal injury. Remote delivery of viral vectors to the central nervous system holds promise in the treatment of recurrent laryngeal nerve injury and central nervous system diseases.

Association between the APOE genotype and psychopathologic symptoms in Alzheimer's disease

BACKGROUND

Psychiatric symptoms occur frequently in the course of AD, are a frequent contributor to institutionalization, predict cognitive decline and death, and often require treatment with psychotropic medications. Previous studies investigating the association between APOE genotype and psychiatric symptomatology in AD have reported contradictory results.

OBJECTIVE

To determine whether APOE genotype predicts incident psychiatric symptomatology in patients with AD.

METHODS

Eighty-seven patients with AD at early stages and no psychiatric history were followed semiannually for up to 9.3 years (mean 5.5 years) for development of delusions, illusions, hallucinations, behavioral symptoms, and depression. Cox proportional hazards models were used to examine the relative risk for incident psychiatric symptomatology (outcome) in relation to APOE genotype (predictor).

RESULTS

The presence of one epsilon4 allele carried a 2.5-fold risk, whereas the presence of two epsilon4 alleles carried a 5.6-fold risk for development of delusions. The associations remained significant even when age, ethnicity, sex, education, duration of disease, and cognitive and functional performance were controlled for. The presence of two epsilon4 alleles was associated with reduced risk for developing hallucinations in the adjusted analysis only. No significant associations were detected between APOE genotype and the incidence of illusions, behavioral symptoms, or depression.

CONCLUSION

The presence of one or more epsilon4 alleles is a significant predictor for the incidence of delusions in the course of AD.

Persistent mobility deficit in the absence of deficits in activities of daily living: a risk factor for mortality

OBJECTIVES

To investigate the extent to which self-reported mobility deficit in the absence of impairment in activities of daily living (ADL) is associated with elevated mortality risk.

DESIGN

Prospective cohort study, with annual assessments of mobility and ADL status and ongoing monitoring of vital status.

SETTING

Population-based cohort drawn from Medicare enrollees in New York City.

PARTICIPANTS

One thousand two hundred ninety-eight older adults reporting functional status at baseline (1992-1994) and 2 years later.

MEASUREMENTS

Subjects reported mobility (e.g., walking, climbing stairs, and rising from a chair) and ADL (e.g., bathing, toilet use, dressing, grooming, and feeding) limitations. Two-year functional status trajectories were noted. We used two additional follow-up periods, at 2 and 4 years, to examine the likelihood that older people with mobility deficit may face an increased risk of death without first passing through a state of enduring ADL disability.

RESULTS

At 2 years, 12.7% had incident mobility deficit without ADL disability, and 21.3% were persistently disabled in mobility without ADL disability. Relative to subjects free of disability at baseline and follow-up, risk of mortality in the incident mobility deficit group was elevated at 2 and 4 years but did not achieve statistical significance. By contrast, for subjects with persistent mobility impairment who did not report ADL impairment, the mortality risk was significantly elevated both at 2 years (relative risk (RR) = 2.5; 95% confidence interval (CI) = 1.1-5.7)) and 4 years (RR = 2.9; 95% CI = 1.7-4.9)) of follow-up. Mortality was significantly elevated in this group in analyses restricted to respondents with no or only one comorbid condition.

CONCLUSION

Continuing, self-reported mobility impairment in the absence of ADL deficit is a risk factor for mortality. Older people with self-reported mobility deficit face an increased risk of mortality without first passing through enduring states of ADL disability.

Principles for the use of macrocyclic lactones to minimise selection for resistance

OBJECTIVE

To provide principles for the appropriate use of avermectin/milbemycin or macrocyclic lactone (ML) anthelmintics in sheep, to ensure effective worm control and to minimise selection for ML resistance.

STRATEGY

The principles were based on an assessment of the information currently available. The MLs were categorised into three groups (ivermectin [IVM], abamectin [ABA] and moxidectin [MOX]) based on structural differences, persistence and efficacy against ML resistant strains. The reported order of activity or efficacy against ML resistant worm strains was IVM<ABA<MOX. General treatment schemes were considered for Australian conditions and were divided into the following situations: 1. quarantine treatment, 2. treatment on/to clean pasture, 3. treatment on/to safe pasture, 4. treatment on/to moderate/heavily contaminated pasture. For each of these situations a strategy was considered for farms where ML resistance was present or absent. It was assumed that resistance commonly occurs in some or all other broad spectrum anthelmintics, and even where ML resistance has been detected, the ML group remains the most effective. The guidelines provided are general and it is expected that state agencies and sheep/veterinary advisers would give specific advice to suit their environments and drug resistance/worm problems.

CONCLUSIONS

The primary recommendation is to use a mixture of effective drugs when treating sheep. However, unless the combination treatment is highly effective it is unlikely to delay selection for ML resistance if sheep are being treated and moved to a clean or safe pasture. Where possible, reliance on the ML anthelmintics should be reduced by not using them every year, not using them in low risk stock or by using narrow spectrum and low efficacy drugs such as naphthalophos when appropriate. Anthelmintic treatment should be given as part of a strategic worm control program. It is suggested that IVM-oral and IVM-capsules should not be used when ML resistance is present. In this situation MOX or ABA should be used in combination with other drugs, provided that the chosen ML is effective against the resistant parasite. It is essential to monitor the efficacy of ML and drug combinations by post-treatment worm egg counts, particularly when ML resistance has been detected.

Provision of MRI can significantly reduce CT collective dose

The purpose of this study was to investigate the proportion of patients currently being investigated by CT that could be investigated by MRI with a potential reduction in exposure to ionizing radiation. The health detriment arising from the radiation dose associated with CT has been quantified in terms of the number of likely cases of serious health effects. The results show that a significant saving in the collective radiation dose is possible, with an associated detriment of between 0.23 and 0.33 cases of cancer or severe hereditary effects averted in one imaging department every year. In selecting the balance of provision of MRI and CT facilities, the health detriment associated with the radiation dose from CT should be considered.

Discharge disposition from acute care after traumatic brain injury: the effect of insurance type

OBJECTIVE

To determine if persons with traumatic brain injury (TBI) who are insured by Medicaid or health maintenance organizations (HMOs) are more likely to receive postacute care in skilled nursing facilities (SNFs) than in rehabilitation facilities, compared with persons insured by commercial fee-for-service (FFS) plans.

DESIGN

Retrospective cohort study.

SETTING

County hospital admitting 30% of all Washington State TBI patients.

PATIENTS

Patients with moderate to severe TBI discharged to rehabilitation facilities or SNFs between 1992 and 1997 (n = 1271); 56.3% were insured by Medicaid, 26.1% by FFS plans, and 17.6% by HMOs.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Disposition on discharge from acute care (rehabilitation facilities vs SNF); adjusted relative risk (RR) and confidence interval (CI) for different insurance types.

RESULTS

After accounting for confounding factors, Medicaid patients were 68% more likely (RR = 1.68, 95% CI = 1.34-2.11) and HMO patients were 23% more likely (RR = 1.23, 95% CI =.90-1.68) to go to a SNF than FFS patients. However, the latter difference was not statistically significant.

CONCLUSIONS

An association exists between insurance type and postacute care site. Efforts should be made to determine the effect this relationship has on the cost and outcomes for TBI patients.