Development and evaluation of modifications to the Sickness Impact Profile for head injury

Three modifications were made to the Sickness Impact Profile, a behavior-based measure of health status, to improve its sensitivity to the effects of head injury. (1) Additional items were included to capture head injury sequelae and behaviors typical of young adults, the age group to which head injury most frequently occurs. (2) Subjects individually excluded behaviors irrelevant to them, thus allowing the score to better reflect injury-related changes. (3) The different areas of functioning on the Sickness Impact Profile were reweighted to reflect global judgments of the construct's contribution to overall functioning rather than the sum of the item contributions. Only the first modification is head-injury specific. The others, are relevant to any disease or injury. The performance of the modifications was evaluated in a longitudinal study of 102 head injured and 102 comparison subjects tested at 1 and 12 months after injury. The evaluation of the modifications was based on their ability to distinguish head injury from comparison subjects and on the strength of their relationship with measures of brain dysfunction. Despite a few statistically significant improvements in discrimination, differences of a practical degree were not obtained. The standard Sickness Impact Profile performed well and is recommended for evaluation of day-to-day functioning in head injury studies.

Memory and head injury severity

One hundred and two consecutive head injured patients were studied at 1 and 12 months after injury. Their performances were compared with a group of uninjured friends. The results indicate that impairment in memory depends on the type of task used, time from injury to testing, and on the severity of head injury (that is, degree of impaired consciousness). Head injury severity indices are more closely related to behavioural outcome early as compared with later after injury. At 1 year, only those with deep or prolonged impaired consciousness (as represented by greater than 1 day of coma, Glasgow Coma Scale of 8 or less, and post traumatic amnesia of 2 weeks or greater) are performing significantly worse than comparison subjects.

Memory training combined with the use of oral physostigmine

Impaired memory function is one of the most frequent and disabling symptoms observed after brain injury. A number of studies have examined the efficacy of using cholinergic agonists, such as physostigmine, in treating memory impairment resulting from various neurologic conditions. Few studies, however, have either combined the drug treatment with a memory training programme or monitored serum cholinesterase levels to increase the likelihood of achieving a therapeutic dose of the medication. The current study addresses both of these issues. Two single-case studies are reported in this investigation. In each case, a double-blind, placebo-controlled, single-subject, A-B-A design was used with A representing the base-line phases, B constituting the memory training combined with medication phase and A representing the return to base-line condition. Both patients sustained anoxia as a result of carbon monoxide poisoning. In the first case, a clinically significant improvement was seen in the patient's performance of both standardized and non-standardized measures of memory function as a result of the combined treatment regimen. No significant changes, however, were seen in the patient's performance on measures of attention and concentration, cognitive flexibility or motor speed. These findings were then replicated with the second anoxic patient. The results from this study point out the potential benefit of combining cholinergic agonists with specific memory training strategies in improving memory function after brain injury.

Aluminium-related osteomalacia: response to reverse osmosis water treatment

It is generally accepted that aluminium induces osteomalacia in chronic hemodialysis patients by binding to the calcification front, thereby inhibiting mineralization of osteoid. Because this form of osteomalacia is vitamin D resistant, the condition has often been assumed to be irreversible, although promising results have been achieved recently by using a chelating agent for removal of aluminium from the skeleton. In this paper we present four chronic hemodialysis patients with aluminium toxicity and histologic osteomalacia in whom the mineralization defect greatly regressed after the use of reverse osmosis treated-water for dialysis, but without further treatment. In three other patients, also with aluminium toxicity and histologic osteomalacia, similarly treated, the histological severity of the osteomalacia remained static. Those patients in whom bone mineralization status improved developed hyperparathyroidism after reverse osmosis water-treatment, whereas the static patients remained euparathyroid. The results suggest that resolution of aluminium related osteomalacia may occur with reduction in dialysis fluid aluminium, and that parathyroid hormone plays a role in the healing of aluminium related osteomalacia. The therapeutic implications are twofold: attempts to remove all traces of hyperparathyroidism may be detrimental to the bone mineralization status; and stimulation of the parathyroid glands by means of a mild reduction in dialysis fluid calcium may be of value in the management of those cases with persistent osteomalacia and low bone turnover.

Neuropsychological and psychosocial consequences of minor head injury

Twenty subjects with minor head injury were compared to an uninjured group at 1 and 12 months after injury on a battery of neuropsychological and psychosocial measures. The results indicate that single minor head injury in persons with no prior compromising condition is associated with mild but probably clinically non-significant difficulties at 1 month after injury. Disruptions of everyday activities, however, are extensive with other system injuries significantly contributing to these problems. Recent reports in the literature may represent overestimation of head injury related losses due to lack of control for the effects of pre-injury characteristics and other system injuries.

Neuropsychologic outcome at one-month postinjury

Neuropsychologic outcome at one-month postinjury was investigated in a group of 102 adult patients with head injury representing a broad spectrum of severity. A group of friends of the patients with head injury was selected for comparison purposes. A comprehensive battery of measures assessing various abilities determined the adequacy of neuropsychological functions. Results support the following conclusions: head injury is associated with early deficits observable on measures assessing a broad spectrum of functions, ranging from simple to complex and motoric to abstraction skills; use of appropriate control groups is essential for determining head injury related deficits; the degree of neuropsychologic deficits depends on the severity of head injury; and the severity indices of time to following commands and depth of coma relate more closely and systematically to adequacy of one-month neuropsychologic outcome than does retrospectively assessed posttraumatic amnesia.

A diagnostic approach to developmental specific learning disorders

Children and adolescents who are not doing well in school are often referred to physicians for evaluation. Many of these children have average or above-average intelligence but are academically frustrated, low achievers. Parents state that although they are convinced that their child is bright, he or she does not seem to learn, and does not behave acceptably in school and at home. Results of the usual pediatric and neurologic examinations are frequently unrevealing. In evaluating children who are doing poorly in school, the clinician must determine whether the child has a developmental specific learning disorder and whether primary affective illness, disturbed vigilance, or hyperactivity complicates the picture. Children who are intelligent but failing in school frequently manifest either one or several of these conditions. Although there are reasonably well-established criteria for affective illness in children, clinically useful criteria for evaluating the variety of childhood learning problems have not been available. We present criteria for the diagnosis of developmental specific learning disorders and briefly mention some aspects of management and treatment. We also describe a primary disorder of vigilance that becomes manifest in school, worsening the learning and performance process, which is further worsened by affective illness.

Family therapy workshops in the United States: potential abuses in the production of therapy in an advanced capitalist society

A market for family therapy workshops has mushroomed in recent years. Treatment of families by therapists conducting such workshops, however, can be dispassionate and dehumanizing. Using the distinction between curing and healing, I do not question the curative potential of family therapy, but I question whether this kind of doctor/patient interaction promotes healing. Also, by demonstrating how the systems model tends to objectify patients and alienate therapists from those they treat, this paper challenges claims that family therapy recognizes the social nature of illness. The dehumanizing treatment cannot be attributed solely to the therapists, but requires further interpretation by analyzing the biases of the therapy model, the commodified context of the workshops, and epistemological issues arising from the application of general systems theory to a social model of treatment. Family systems therapy shares epistemological features with biomedicine, and like the biomedical model, alienates therapists from patients. This alienation, ironically, can be even greater when the family systems model is used than in biomedical treatment. Finally, I suggest that family therapy workshops have grown in popularity because the mechanistic features of the treatment model, drawn largely from cybernetics, promote the production and reproduction of a form of therapy compatible with the emphasis on 'functional health' favored in an advanced capitalist society.

New method for quantitating the medial component of pulmonary arteries. Factors affecting the measurements

The study objectives were to determine the effect of several factors related to tissue preparation on the relationship between medial area and size of the muscular pulmonary artery (defined in terms of total length of internal elastic lamina). This relationship took the form y = Axb that was linearized by plotting the square root of medial area against artery size. Complete distention of pulmonary arteries by an injection medium caused the internal elastic lamina to stretch by a factor of approximately 1.5. The relationship between medial area and artery size was unaffected by either the pressure method used for lung inflation/fixation or the tissue-embedding medium. Tissue shrinkage was considerable with paraffin embedding and negligible with glycol methacrylate. More arteries were considered measurable in glycol methacrylate-embedded tissue.

Goblet and Clara cells of human distal airways: evidence for smoking induced changes in their numbers

The goblet cell and Clara cell populations of human distal airway epithelium were examined. The bronchioles, terminal bronchioles, and respiratory bronchioles of 16 smokers and four non-smokers were studied by both light and electron microscopy in surgically resected specimens. A very significantly (p less than 0.001) greater number of goblet cells were found in the bronchioles of smokers compared than in those of non-smokers but no such difference was evident in terminal/respiratory bronchioles. Clara cell numbers in contrast were lower in the bronchioles (p less than 0.01) and terminal and respiratory bronchioles of smokers (p less than 0.01). Both of these alterations in cell frequency may adversely affect small airway function in smokers.

Diagnosis of pulmonary emphysema by computerised tomography

Eleven patients with peripheral bronchial carcinoma had computerised tomographic (CT) scans before operation. The resected specimens from six of these patients showed mild centri-acinar emphysema. Preoperatively the two groups had not differed significantly in spirometric findings or lung volumes. The frequency distribution curves of EMI numbers within the lung fields of patients who proved to have centri-acinar emphysema differed significantly from those of the group who did not, there being more pixels in the EMI range -450 to -500 in the emphysematous group (p less than 0.001). Detailed assessment of lung density by CT scanning may be useful in the diagnosis of emphysema in life.

Herpes simplex virus type-2 glycoprotein-subunit vaccine: tolerance and humoral and cellular responses in humans

Twenty-three subjects were administered three doses of inactivated herpes simplex virus (HSV) type 2 (HSV-2) glycoprotein-subunit vaccine, with doses 2 and 3 being given four and 22 weeks after dose 1. Both HSV-neutralizing antibody and antibody effective in antibody-dependent cell-mediated cytotoxicity were detected in serum samples of 12 of the 13 initially seronegative subjects by week 8. The geometric mean titers of both antibody types decreased between weeks 8 and 22 but increased one week after dose 3. HSV-neutralizing antibody remained detectable in serum samples of seven of the 10 initially seronegative subjects assayed seven months after dose 3. Cell-mediated immunity was detected by lymphocyte transformation responses to HSV-2 after vaccine administration in 12 of the 13 initially seronegative subjects. Unlike humoral antibody, which waned over time, in vitro cell-mediated immune responses remained stable over the seven-month follow-up period after dose 3. This HSV-2-subunit vaccine is well tolerated and elicits both humoral and cell-mediated immune responses to HSV.

Psychosocial functioning at 1 month after head injury

The authors examined the psychosocial sequelae of head trauma at 1 month after injury in a group of 102 adult head-injured patients representing a broad range of severity of trauma. One hundred two control subjects selected from friends of the head-injured patients were used for comparison purposes. Outcome was determined with a battery of psychosocial measures assessing a number of different areas of daily functioning. The results support the following conclusions: (a) at 1 month after injury, head-injured patients experience difficulties in a number of areas of psychosocial functioning, especially the resumption of major role activities (i.e., work, school, and home management) and leisure/recreational activities; (b) the relationship between head injury severity level and the adequacy of psychosocial functional differs for the various measures; and (c) in determining the psychosocial consequences of head trauma, the use of an appropriate control group is essential.

A possible molecular basis for strain specific immunity to malaria

A 250 kDa antigen implicated in the induction of protective immunity to Plasmodium chabaudi was examined with a panel of 11 monoclonal antibodies in cloned parasite lines. 2 antibodies cross-reacted with the different parasite lines while 9 were specific for one line. This antigenic diversity was correlated with major differences in one dimensional peptide maps between the purified antigen from different lines of parasites. The peptide maps also revealed some apparently conserved structure which may have been responsible for the antigenic cross reactivity. Using cloned lines of P. falciparum and a second series of monoclonal antibodies, similar antigenic and structural diversity was evident in the equivalent antigen from the important human pathogen. These findings are discussed with relationship to the induction of protective immunity to malaria.

Effect of co-ingestion of fat on the metabolic responses to slowly and rapidly absorbed carbohydrates

The present study examined the acute effects of co-ingestion of fat (37.5 g) on the post-prandial metabolic responses to 75 g of carbohydrate which was either slowly absorbed (lentils) or rapidly absorbed (potatoes). Co-ingestion of fat resulted in a significant flattening of the post-prandial glucose curves, the effect being more pronounced for the rapidly absorbed potatoes. This was probably due to delayed gastric emptying. However, the post-prandial insulin responses to either carbohydrate were not significantly reduced by fat, suggesting that the insulin response to a given glucose concentration was potentiated in the presence of fat. The gastric inhibitory polypeptide (GIP) responses to both carbohydrates were greatly increased in the presence of fat. To investigate further the possible roles of GIP in the entero-insular axis, a 5-g bolus of glucose was injected intravenously 1 h after lentils +/- fat. This was sufficient to raise the glucose levels above the threshold reported for GIP to potentiate insulin secretion. However, despite the large differences in circulating GIP levels, the insulin response to glucose was not affected by the presence of fat. These results suggest that (1) the rate of absorption of carbohydrate is a major determinant of post-prandial metabolic responses even in the presence of fat, (2) fat-stimulated GIP secretion does not potentiate glucose-induced insulin secretion, and (3) the potentiation of the insulin response to glucose when carbohydrate is co-ingested with fat is consistent with the well-documented insulin resistance associated with high fat diets.

The behavioral sequelae of head injury

Twenty patients with mild and, in a few cases, moderately severe head injuries were examined 3 days and 1 month postinjury. The results indicate that these patients, as compared to appropriate controls, show significant neuropsychological difficulties at 3 days, but not at 1 month postinjury. Postconcussional symptoms are endorsed, on the other hand, at both 3 days and 1 month. Absence of significant neuropsychological findings at 1 month is contrary to some of the previous reports. A number of reasons for this discrepancy were discussed. Some of these included: (a) inappropriate controls used in previous research; (2) failure to screen for pre-existing conditions in prior studies, therefore confounding the effects of the injury with pre-injury factors; (3) possible practice effects in our research; and (4) differences in the neuropsychological measures used across different studies.