International study of the Complex Stress Reaction Syndrome: Implications for transdiagnostic clinical practice

BACKGROUND

The debate regarding diagnostic classification systems in psychiatry (categorial vs dimensional systems) has essential implications for the diagnosis, prevention and treatment of stress reactions. We previously found a unique pattern of stress reaction in a study executed during the coronavirus disease 2019 pandemic using large representative samples in two countries, and termed it the Complex Stress Reaction Syndrome (CSRS).

AIM

To investigate CSRS, Type A (psychiatric symptoms, spanning anxiety, depression, stress symptoms, and post-traumatic stress disorder (PTSD)), with or without long-coronavirus disease (COVID) residuals (CSRS, Type B, neuropsychiatric symptoms spanning cognitive deficits and fatigue, excluding systemic symptoms). Our two-tailed hypothesis was that CSRS is a condition related to an unrecognized type of stress reaction in daily life in the general population (Type A) or that it is related to the severe acute respiratory syndrome coronavirus 2 infection and its long-COVID residuals (Type B).

METHODS

977 individuals in four continents (North America, Europe, Australia and the Middle East) completed the online study questionnaire in six languages using the Qualtrics platform. The study was managed by six teams in six countries that promoted the study on social media. The questionnaire assessed anxiety, depression, stress symptoms and PTSD (CSRS, Type A), cognitive deficits and fatigue (CSRS, Type B). The data were analyzed using Proportion Analyses, Multivariate Analysis of Co-Variance (MANCOVA), linear regression analyses and validated clinical cutoff points.

RESULTS

The results of the Proportion Analyses showed that the prevalence of 4 symptoms spanning anxiety, depression, stress symptoms, and PTSD was significantly higher than the most prevalent combinations of fewer symptoms across 4 continents, age groups, and gender. This supports the transdiagnostic argument embedded in the CSRS (Type A). The same pattern of results was found in infected/recovered individuals. The prevalence of the 4 psychiatric symptoms combination was significantly greater than that of 5 and 6 symptoms, when adding cognitive deficits and fatigue, respectively. MANCOVA showed a significant three-way interaction (age × gender × continent). Further analyses showed that the sources of this three-way interaction were threefold relating to two sub-populations at-risk: (1) Individuals that self-identified as non-binary gender scored significantly higher on all 4 psychiatric symptoms of the CSRS, Type A at young age groups (< 50 years old) in North America compared to (self-identified) women and men located in the 4 continents studied, and to other ages across the adult life span; and (2) This pattern of results (CSRS, Type A) was found also in women at young ages (< 40 years old) in North America who scored higher compared to men and women in other continents and other ages. Linear regression analyses confirmed the MANCOVA results.

CONCLUSION

These results show a combined mental health risk factor related to stress reactivity, suggesting that the CSRS is sensitive to populations at risk and may be applied to future identification of other vulnerable sub-populations. It also supports the transdiagnostic approach for more accurate prevention and treatment. Time will tell if such transdiagnostic syndromes will be part of the discussions on the next revisions of the traditional classification systems or whether the crisis in psychiatry further evolves.

Analysis of historical negative control group data from the rat in vivo micronucleus assay

A database of micronuclei counts for historical negative control data from rat in vivo micronuclei tests performed in 10 different laboratories was established. Data were available from over 4000 negative control rats from 10 laboratories. The mean frequency of micronucleated cells (MN)/1000 cells ranged from 0.44 to 2.22, a 5-fold range. Overall there were no major sex or strain differences in frequency, although there were some small but statistically significant differences within laboratories. There was appreciable variability between experiments compared with variability within experiments in some laboratories. No specific factor was identified which could explain this variability although it was noted that many different vehicles were used in the experiments. It is hoped that these data will help laboratories beginning studies with the rat micronucleus assay and those involved in the assessment of micronucleus assay results.

[Determination of renal function in clinical routine: which is the best method?]

BACKGROUND AND OBJECTIVE

Accurate quantification of renal function is important for diagnosing and monitoring progression of renal diseases and for calculating adequate doses of drugs that are excreted by the kidneys. Gold-standard procedures are too complex for routine clinical use. At the moment there are several formulae to choose from, all said to estimate renal function precisely enough for clinical purposes. It was the aim of this study to compare the accuracy of several of these in clinical routine.

PATIENTS AND METHODS

The results of inulin clearance were compared with those calculated by the Cockcroft-Gault formula (CGF), abbreviated diet modification of renal disease (MDRD) formula, the Mayo formula and the cystatin C-based formula as proposed by Larsson et al. Included were 189 in-patients (aged 20-87, 40% of them women, range of inulin clearance 8-244 ml/min/1,73m). In addition, inulin clearance was compared with creatinine clearance in 142 patients (aged 20-87 years, 42% women. Inulin clearance 13-244 ml/min/1,73m). Bland-Altman diagrams were drawn and mean bias and standard deviation of the formulae were compared with inulin clearance, as were sensitivity and specifity for diagnosing reduced renal function.

RESULTS

All formulae underestimated glomerular filtration rate (GFR), with CGF and MDRD formulas giving the best results. These formulae had a mean bias of -16.2 (SD 24.8) and -18.2 (SD 25.6) ml/min/1,73m (2) , respectively. All creatinine-based formulae showed a high sensitivity and specifity for diagnosing a GFR below 60 ml/min/1,73m (2).

CONCLUSION

None of the estimating formulae can replace inulin clearance with adequate accuracy. In our patients the cystatin C formula of Larsson et al showed no advantage. But the MDRD formula, which can be calculated without knowing body weight, is as accurate and precise as CGF.

Ovarian cancer identification based on dimensionality reduction for high-throughput mass spectrometry data

MOTIVATION

High-throughput and high-resolution mass spectrometry instruments are increasingly used for disease classification and therapeutic guidance. However, the analysis of immense amount of data poses considerable challenges. We have therefore developed a novel method for dimensionality reduction and tested on a published ovarian high-resolution SELDI-TOF dataset.

RESULTS

We have developed a four-step strategy for data preprocessing based on: (1) binning, (2) Kolmogorov-Smirnov test, (3) restriction of coefficient of variation and (4) wavelet analysis. Subsequently, support vector machines were used for classification. The developed method achieves an average sensitivity of 97.38% (sd = 0.0125) and an average specificity of 93.30% (sd = 0.0174) in 1000 independent k-fold cross-validations, where k = 2, ..., 10.

AVAILABILITY

The software is available for academic and non-commercial institutions.

[Reconstructive foot surgery in cases of diabetic-neuropathic osteoarthropathy]

QUESTION

Neurogenic osteoarthropathy often results in a debilitating deformity of the foot which can not be handled conservatively. Indications for surgery are recurrent ulcers, deep tissue infection and decompensated statics with progressing deformity. External fixation as a possible method of correction has to show its efficiency and methods.

METHODS

Between 1997 and 2003, 65 feet which could be examined retrospectively, were operated for neuroarthropathy in 21 women and 43 men. A diabetic polyneuropathy was present in 56 patients. In 59 cases, an external fixation was used while in nine cases Steinmann pins were used. Follow-up treatment consisted of mobilisation in a ankle-foot-orthosis (AFO) for up to a year.

RESULTS

For diabetics, the mean duration of illness was 24.8 years (Type 1) and 13.7 years (Type 2). All feet were Levin stage 3 or 4 and for the classification types II-V. In five cases there was only luxation, another nine had a combination of luxation and osseous changes. Surgical revision was necessary in seven cases, sometimes more than once. Additional operations as the illness progressed were necessary 13 times, in six cases due to loss of correction. The application of a prosthesis was necessary in three cases following amputations in two patients after an average of 752 days. Pin infections and disturbances in healing wound were common but could be successfully treated conservatively and were independent of previous ulceration or infection. Within the first year after operation, 13.9% of the feet developed an ulcer. All of the patients could be mobilised with the help of an orthosis (47 cases) or orthopedic shoes (15 cases)

CONCLUSIONS

External fixation is a suitable and variable method for correcting malalignment of the foot in cases of neuroarthropathy. It has a low complication rate and can be used for rapidly developing as well as non-progressing osteoarthropathies. In general, a fibrous ankylosis is the result of treatment, which allows pain free mobilisation under full weight bearing. In suitable cases, with a good alignment of the foot and good patient cooperation, the use of the AFO can be changed to orthopedic shoes after about 12 months.

Die fu�entlastende Unterschenkelorthese und ihre klinische Anwendung bei Patienten mit diabetisch-neuropathischer Osteoarthropathie

In the daily routine of treating patients with diabetic neuropathic osteoarthropathy (DNOAP), their history often reveals a prolonged course of therapy caused in part by incorrect diagnosis but also by inadequate provision of orthopedic devices. A "classic" case is that of undetected osteoarthropathy, which is erroneously interpreted as osteomyelitis. Thus, subsequent to frustrating attempts at therapy and persistence of the clinical symptoms, patients are not infrequently "offered" the option of amputation, which is performed quite proximal to the osseous lesion to "ensure treatment success." The fact that major amputations lead to a statistically significant decrease of the patient's life span is usually not taken into consideration during the decision making process for amputation. Orthopedic surgical procedures to preserve the leg should be given precedence for the sake of maintaining quality of life just as orthopedic devices and orthopedic shoes should be preferred to retain mobility before amputation is indicated in patients with DNOAP. The cases reports presented here should encourage others to implement treatment concepts with the aim of avoiding unnecessary amputations.

[First clinical experience with a full-size, flat-panel detector for imaging the peripheral skeleton - Part II: Post-processing with a newly developed adaptive autowindow algorithm]

PURPOSE

of the second part of the investigation was the evaluation of a newly developed adaptive autowindow algorithm in comparison to the system processing radiographs of the wrist and ankle to further optimize the image quality with softcopy reading.

MATERIAL AND METHODS

All 120 radiographs of the wrist and all 100 radiographs of the ankle used in the 1st part of this paper were processed with the adaptive autowindow algorithm. The evaluation was again performed by 5 radiologists with softcopy reading. For the data analysis a variation of the Visual Grading Analysis (VGA) was used.

RESULTS

Up to 19 % of the wrist radiographs and 2 % of the ankle radiographs processed with the system software had to be processed manually afterwards to get acceptable results. By the application of the adaptive autowindow algorithm a manual post-processing was no longer necessary. Highly significant (p less-than-or-equal 0.001) differences for all criteria to be evaluated were found for the wrist radiographs and in the case of the ankle radiographs for the bone contrast, the contrast in soft-tissue regions, the fine details in the bone and the artifacts, the adaptive autowindow algorithm performed always better than the system software.

CONCLUSION

Using half of the exposition dose on a flat-panel detector, an optimized post-processing leads to comparable or better results compared to the conventional film-screen-system concerning the image quality.

Is interleukin-6 concentration in the dialysate of continuous ambulatory peritoneal dialysis patients a prognostic parameter in peritonitis?

In continuous ambulatory peritoneal dialysis (CAPD) patients, peritonitis is a dangerous complication. Chemical examinations in the dialysate can be successfully used to assess permeability disturbances, hemostatic balance, and (for early detection and follow-up) cellular inflammatory reaction. In 7 CAPD patients (age: 50 +/- 15 years; dialysis duration: 40 +/- 24 months) with peritonitis episodes, and in 17 age-matched CAPD patients (age: 50 +/- 13 years; dialysis duration: 29 +/- 18 months) without peritonitis, we examined daily dialysate cell count (CC) and concentrations of albumin (ALB), immunoglobulin G (IgG), thrombin-antithrombin III complex (TAT), D-dimer (DD), and interleukin-6 (IL-6) after the long dwell (8-10 hours) over an interval of at least 14 days. In CAPD patients with peritonitis episodes, all parameters (CC, ALB, IgG, TAT, DD, IL-6) were significantly increased in the first days [IL-6 mean: 25,190 pg/mL (range: 2560-52,708 pg/mL) vs 66 pg/mL (range: 21-163 pg/mL)]; then, up to day 14 after successful therapy with antibiotics, the levels showed no differences as compared with CAPD patients without peritonitis. In the case of relapse of peritonitis (4 cases), concentration of IL-6 rose again on day 14, 1 day earlier than did the other parameters. Determination of IL-6 in the dialysate is a reliable prognostic parameter for the course of peritonitis (start, end, relapse) in CAPD patients.

[First clinical experience with a full-size, flat-panel detector for imaging the peripheral skeletal system]

PURPOSE

This investigation was intended to show that exposures of the peripheral skeleton system can be done with half of the dose used for conventional screen-film systems with a full-size CsI/a-Si flat panel detector. MATERIAL AN METHODS: 120 exposures of the wrist and 100 exposures of the ankle have been made on a full-size flat panel detector system (43 x 43 cm). The patient dose has been reduced by a factor of two compared to conventional images. Five radiologists evaluated every image as a softcopy and a hardcopy image. For the evaluation, a variation of the Visual Grading Analysis (VGA) without reference images was used. For the determination of the patient entrance dose, measurement of a phantom were performed.

RESULTS

A dose reduction of about 50 % is possible with the same or even better image quality in routine diagnostics. Only 3 % of the ankle and approx. 21 % of the wrist exposures required a postprocessing. Exposures with implants did not show any artifacts and some of the those achieved better evaluation results compared with exposures without implants.

CONCLUSION

A halving of the patient dose is possible with acceptable results for the image quality. The effect of an improved image processing remains to be evaluated. The patient entrance dose is suitable for an evaluation of a radiographic detector and especially for a dose-referred comparison of digital X-ray units.

Reestablishment of foot-stability with external fixation in cases of neurogenic osteoarthropathy

The localization of neurogenic osteopathy in the hindfoot often results in deformities which cannot be corrected by conservative methods. Indications for operation are recurring ulcers, deep infection, and reduced stability with progressive deformity. The aim of this study was to ascertain whether external fixation enables reestablishment of foot stability even when the osteoarthropathic processes have not entirely ceased. A bilaterally mounted Hoffman 2 fixator was used for open repositioning and restabilization on 14 patients with osteoarthropathy of the hindfoot: 12 had diabetes mellitus and 13 had florid processes. Revision with axial correction was necessary in 2 patients. One underwent amputation according to Syme and received a prosthesis. Thirteen were completely remobilized: ten were fitted with an orthosis and three with a rigid orthopedic shoe. Complicated deformities of the hindfoot from neurogenic arthropathy can be satisfactorily restabilized in the edematous and demineralizing stages by surgery and the application of external fixation.

An electrophysiological study of the insertion of overt response choice

Using electrophysiological measures, the authors studied changes in prestimulus state, stimulus identification, and response-related processing when, in a go/no-go task, forced choice between 2 overt go responses was inserted. The authors observed decreased prestimulus motor preparation (electromyogram), no change in stimulus identification time (selection negativity), a minor increase in response selection time (lateralized readiness potential), a large increase in response preparation time (lateralized readiness potential), a minor effect on response execution time (electromyogram), and a decrease in the activation of a response-inhibition process on no-go trials (frontal event-related potential). The existence of the response-inhibition process was verified by the presence of inverted lateralized readiness potentials on no-go trials. Pure insertion of response choice in a task seems impossible because the choice between activation and inhibition (go/no-go) always seems already present.

An electrophysiological study of the insertion of overt response choice

Using electrophysiological measures, the authors studied changes in prestimulus state, stimulus identification, and response-related processing when, in a go/no-go task, forced choice between 2 overt go responses was inserted. The authors observed decreased prestimulus motor preparation (electromyogram), no change in stimulus identification time (selection negativity), a minor increase in response selection time (lateralized readiness potential), a large increase in response preparation time (lateralized readiness potential), a minor effect on response execution time (electromyogram), and a decrease in the activation of a response-inhibition process on no-go trials (frontal event-related potential). The existence of the response-inhibition process was verified by the presence of inverted lateralized readiness potentials on no-go trials. Pure insertion of response choice in a task seems impossible because the choice between activation and inhibition (go/no-go) always seems already present.

Preparing Nursing Students for Contemporary Practice: Restructuring the Psychomotor Skills Laboratory

The restructured laboratory experience offered a safe environment that supported student experimentation with psychomotor skills and self-initiated approaches to problem solving. Restructuring psychomotor laboratory experiences with emphasis on communication and conceptualization of principles supported students to begin addressing clinical problems with flexibility, creativity, and the premise for lifelong skill acquisition. Students who have skills that extend beyond technique will inevitably be better prepared to meet the demands of health care systems and patients now and in the future.

Insulin-like growth factor system components in hyperparathyroidism and renal osteodystrophy

BACKGROUND

The insulin-like growth factor (IGF) system plays a key role in regulation of bone formation. In patients with renal osteodystrophy, an elevation of some IGF binding proteins (IGFBPs) has been described, but there is no study measuring serum levels of both IGF-I and IGF-II as well as IGFBP-1 to -6 in different forms of renal osteodystrophy and hyperparathyroidism.

METHODS

In a cross-sectional study, we investigated 319 patients with mild (N = 29), moderate (N = 48), preuremic (N = 37), and end-stage renal failure (ESRF; N = 205). The ESRF group was treated by hemodialysis (HD; N = 148), peritoneal dialysis (PD; N = 27), or renal transplantation (RTX; N = 30). As controls without renal failure, we recruited age-matched healthy subjects (N = 87) and patients with primary hyperparathyroidism (pHPT; N = 25). Serum levels of total and free IGF-I, IGF-II, IGFBP-1 to -6, and biochemical bone markers including intact parathyroid hormone (PTH), bone alkaline phosphatase (B-ALP), and osteocalcin (OSC) were measured by specific immunometric assays. IGF system components and bone markers were correlated with clinical and bone histologic findings. Mean values +/- SEM are given.

RESULTS

With declining renal function a significant increase was measured for IGFBP-1 (range 7- to 14-fold), IGFBP-2 (3- to 8-fold), IGFBP-3 (1.5- to 3-fold), IGFBP-4 (3- to 19-fold), and IGFBP-6 (8- to 25-fold), whereas IGFBP-5 levels tended to decrease (1.3- to 1. 6-fold). In contrast, serum levels of IGF-I, free IGF-I, and IGF-II remained constant in most patients. Compared with renal failure patients, pHPT patients showed a similar decline in IGFBP-5 levels and less elevated levels of IGFBP-1 (3.5-fold), IGFBP-2 (2-fold), IGFBP-3 (1.2-fold), and IGFBP-6 (4-fold) but no elevation of IGFBP-4 levels. In all subjects, free and total IGF-I levels showed significant negative correlations with IGFBP-1, IGFBP-2, and IGFBP-4 (that is, inhibitory IGF system components) and significant positive correlations with IGFBP-3 and IGFBP-5 (that is, stimulatory IGF system components). A positive correlation was observed between IGF-II and IGFBP-6. ESRF patients with mixed uremic bone disease and histologic evidence for osteopenia revealed significantly (P < 0.05) higher levels of IGFBP-2 and IGFBP-4 but lower IGFBP-5 levels. Histologic parameters of bone formation showed significant positive correlations with serum levels of IGF-I, IGF-II, and IGFBP-5. In contrast, IGFBP-2 and IGFBP-4 correlated positively with indices of bone loss. Moreover, dialysis patients with low bone turnover (N = 24) showed significantly (P < 0.05) lower levels of IGFBP-5, PTH, B-ALP, and OSC than patients with high bone turnover.

CONCLUSION

Patients with primary and secondary hyperparathyroidism showed lower levels of the putative stimulatory IGFBP-5 but higher levels of IGFBP-1, -2, -3, and -6, whereas total IGF-I and IGF-II levels were not or only moderately increased. The marked increase in serum levels of IGFBP-4 appeared to be characteristic for chronic renal failure. IGFBP-5 correlated with biochemical markers and histologic indices of bone formation in renal osteodystrophy patients and was not influenced by renal function. Therefore, IGFBP-5 may gain significance as a serological marker for osteopenia and low bone turnover in long-term dialysis patients.

[Functional outcome and quality of life at least 6 months after pneumonectomy--effect of operation, adjuvant therapy, tumor stage, sex, type of pneumonia and recurrence]

This study reports on the results of a checkup carried out on 38 patients subjected to an extended cancer aftercare examination at least 6 months after pneumectomy because of bronchial carcinoma, 12 of these patients receiving adjuvant chemotherapy and/or radiotherapy. Lung function data determined by body plethysmography were measured, as well as the quality of life, using the Karnofsky and Spitzer indices as well as QLQ-C30 of the EORTC. In addition, anamnestic data and postoperative ECG and blood gas analysis results were recorded. The most important findings concern restricted lung function due to pneumectomy, an IVC decrease by 33.3%, a drop in FEV1 by 27.3% and a reduction of the total lung capacity (TLC) by 14%. Moreover, a distinctly increased right heart load was seen in 23.4% of all patients. The quality of life tests revealed a slightly reduced quality of life in the external assessment indices according to Karnofsky (86 +/- 11%) and Spitzer (8.6 +/- 1.2). Self-assessment by QLQ-C30 of the EORTC, however, evidenced a clear reduction of the global quality of life (54.2 +/- 15.6) and role function, a moderate decrease of physical, emotional, cognitive and social functioning as well as a greatly increased incidence of the symptoms fatigue, dyspnea, sleep disturbances and pain after surgery. Adjuvant therapy applied in 12 patients had no significant influence, neither on lung function parameters nor on the quality of life. A more advanced tumour stage or a relapse, however, will adversely affect the quality of life.

Comparing consumer and clinician values for alternative functional states: application of a new feature trade-off consensus building tool

OBJECTIVE

To present the Features-Resource Trade-Off Game (Features Game) as a new method for comparing preferences for alternative outcomes among different groups of people.

DESIGN

The Features Game is illustrated by comparing preferences for recovery among the 18 functional status items making up the Functional Independence Measure. Methods involved trading levels of independence (resources) across the different items (features).

SETTING

Ten community-dwelling consumers with physical disabilities and 10 rehabilitation clinicians participated in four separate expert panels-two in Houston and two in Philadelphia.

MAIN OUTCOME MEASURES

Five sets of hierarchical stages defined by the four separate panels specifying the profiles of function believed to most foster independent living.

RESULTS

Cognitive and communication skills were selected preferentially over the recovery of physical tasks by all panels, but, in comparison to clinicians, consumers were more willing to accept mild deficits in cognitive skills as trade for realizing earlier recovery of physical abilities.

CONCLUSION

The overwhelming choice of cognitive and communication abilities over physical abilities suggests a need to enhance therapeutic efforts in those areas. More subtle differences in consumer and clinician preferences emphasize the importance of establishing consumer-oriented goals.

[Mutilating complex trauma of the pelvis]

Traumatic hemipelvectomy is a rare, but devastating pelvic injury with few survivors reported in the literature. We report on a 19-year-old motorcyclist with a near-total hemipelvectomy. After a complicated course, the patient survived with good potential for a functional level of activity. We review the experience of other authors and give details on the management of one of the most challenging injuries confronting surgeons. Successful treatment requires extraordinary efforts and multidisciplinary team cooperation.

Liver biopsy is a useful predictor of response to interferon therapy in chronic hepatitis C

AIM

To evaluate the usefulness of easily assessable morphological parameters in liver biopsies in order to predict efficacy of interferon-alpha (IFN) treatment in patients with chronic hepatitis C.

METHODS AND RESULTS

Inflammatory activity and fibrosis (according to Scheuer), and the hepatic iron content (according to Rowe and DiBisceglie) were assessed in pre-treatment liver biopsies of 73 de novo patients with chronic hepatitis C. Furthermore the presence of fat, lymphoid aggregates, and bile duct lesions was evaluated. With respect to IFN therapy patients were classified as responders alanine aminotransferase (ALT) normal and negative hepatitis C virus (HCV) RNA in serum at the end of treatment, n = 33) or non-responders (n = 40). Non-responders had more advanced fibrosis (P = 0.0001) and more extensive iron storage (P = 0.0008) than responders. In contrast absence of stainable iron was frequently (46%) associated with sustained response. Absence of fat droplets in hepatocytes was associated with response (P = 0.0001). Stepwise logistic regression analysis indicated that the stage of fibrosis, the hepatic iron grade, and the presence or absence of fat were independent predictors of response.

CONCLUSIONS

Liver biopsy provides useful information for selection of patients with hepatitis C for IFN therapy.

[Quality of life after pneumonectomy for bronchial carcinoma]

Quality of life measurements gained increasing importance in the last years. After lung tissue reducing interventions for bronchogenic carcinoma quality of life measurements play an important role, since quality of life can be decisively influenced by post-operative reduced lung function. On the basis of postoperative physical symptoms and lung function the restriction of quality of life after pneumonectomy should be analyzed with respect to intervention and adjuvant therapy, 36 patients with an average age of 61 years were followed up by ambulatory oncological care for 40 months (median) after operation and lung function as well as quality of life were measured by self assessment index QLQ- C 30 of EORTC.

RESULTS

Beside physical symptoms (increasing of dyspnea by 61.1% and pain by 30.6% after pneumonectomy as compared to preoperative values) the significant reduced lung function (IVC by 33.5%, FEV 1 by 27.1%) and the QL-measurement showed the greatest restrictions, latter in "Physical functioning" by 27.2%, in "Role functioning" by 45.8% and in "Global health status/ Quality of life" by 45.6%. The symptoms "Fatigue" (Score 39.8), "Dyspnea" (50,9), "Pain" (29.6) and "Sleep disturbance" (35.2; max. score 100 = high frequency) were most often found. Further adjuvant therapy (at least 6 months after completion) in 11 patients and the type of pneumonectomy (right-side: n = 11, left-side: n = 25) did not result in additional significant reduction of lung function and of single quality of life dimensions, except that "Dyspnea" in patients with right-sided pneumonectomy (66.7) was significantly more frequent than in patients with left-sided pneumonectomy (44.0).

CONCLUSIONS

In this study the restricted quality of life after pneumonectomy was mainly caused by reduction of cardiopulmonary function (reduced lung function by loss of parenchyma). Adjuvant therapy reduced neither lung function nor quality of life. Compared to quality of life measurements after lung resection [17] quality of life after pneumonectomy didn't worse.

Discharge motor FIM-function related groups

OBJECTIVE

To develop a patient classification system that groups patients achieving similar functional outcome scores by discharge from medical rehabilitation.

DESIGN

Patient groups were developed using a recursive partitioning algorithm and clinical input. Results were validated in a separate set of patient records.

SETTING

Two hundred fifty-two free-standing rehabilitation hospitals and distinct part units that participate in the Uniform Data System for Medical Rehabilitation.

PATIENTS

The 84,492 rehabilitation inpatients discharged in 1992 were grouped into 20 impairment categories.

MAIN OUTCOME MEASURE

Discharge score on the motor subscale of the Functional Independence Measure (FIM).

RESULTS

In the Discharge Motor FIM-Function Related Groups (DMF-FRGs) system, patients are first classified into one of 20 impairment categories and then into FRGs by their admission motor FIM scores. Some FRGs are also subdivided on the basis of admission cognitive FIM scores and age. The entire system consists of 139 patient groups that explain 63% of the variation in motor FIM discharge scores in the validation data set. Nontraumatic brain injury and joint replacement DMF-FRGs are provided as examples.

CONCLUSION

Clinicians can use the DMF-FRGs to identify groups of patients whose motor FIM scores at discharge are below, within, or above nationally established ranges of values for the purpose of outcomes management, guideline development, and quality improvement. The DMF-FRGs can also be considered in the design of an outcome-based payment system for medical rehabilitation.

Impairment-specific dimensions within the Functional Independence Measure

OBJECTIVE

The analyses presented in this article were intended to seek more fine-grained impairment-specific dimensions beyond the motor and cognitive dimensions of the Functional Independence Measure (FIMSM).

DESIGN

The study used factor analysis within 20 categories of impairment to test the hypotheses that FIM items can be grouped according to functional areas of the body and that these item groupings differ depending on the patient's impairment.

PATIENTS

Data from 93,829 patients discharged in 1992 from 252 free-standing rehabilitation hospitals and units were obtained from the Uniform Data System for Medical Rehabilitation.

RESULTS

In 18 of 20 impairment categories, factor analyses of patients admission FIM scores showed impairment-specific FIM dimensions. Four impairments had a 3-dimensional factor structure, and 14 had a 4-dimensional structure. The impairment-specific dimensions were always nested within the motor-FIM subscale. Reliability coefficients for subscales based on these dimensions ranged from .74 to .97. The subscales appear to cluster FIM items by the area of body involved, neurological level, or relative energy consumption.

CONCLUSION

The FIM can be viewed as a multilayered multidimensional measure of human function. The impairment-specific dimensions, at an intermediate layer, provide insight about the causal linkage between the impairment and resultant patterns of disability. Impairment-specific subscales are relevant to those clinical or research applications where the type of disability needs to be more closely related to impairment.

Rational use of polymerase chain reaction--based detection of viral genomes in patients with serologic markers of hepatitis B or C virus infection

We studied the value of additional diagnostic information obtained by detection of hepatitis B virus (HBV) DNA or hepatitis C virus (HCV) RNA using the qualitative polymerase chain reaction (PCR) in patients with serologic markers of hepatitis B or hepatitis C virus infection. In HBV infection, all HBsAg+HBeAg+ patients and all HBsAg+HBeAg- patients with alanine aminotransferase (ALT) levels > 100 U/L were positive for HBV-DNA by PCR, whereas in HBsAg+HBeAg- patients with ALT < 100 U/L 58% and in HBsAg+HBeAg- patients with normal aminotransferase 45% were found to be positive. In HBsAg+ patients no further clinically useful information can be obtained by PCR as the presence of HBsAg proves infection. However in three of 42 (7%) patients with markers of past HBV infection (antiHBs and/or antiHBc+) HBV-DNA was detected in the serum. Similarly, in some patients with acute hepatitis B HBV-DNA was demonstrable up to four months after the disappearance of HBsAg from serum, pointing to persistence of viremia despite the loss of serological markers of ongoing HBV infection. Demonstrating ongoing HBV infection in patients with serological markers of past infection is valuable additional information in only selected patients. In HCV infection, 10% of anti-HCV+ patients with increased ALT levels had a negative serum HCV-RNA. However, in 20% of those patients HCV-RNA was demonstrated in a serum sample collected later during follow-up, indicating that a single negative HCV-RNA determination cannot be taken as evidence for the resolution of infection.

Psychiatric home care for the elderly

This study summarizes descriptive information concerning an existing psychiatric home care service and lays the foundation for more sophisticated studies of elderly depressed persons who receive this type of long term care. Using existing medical record data, the demographic and clinical characteristics of the elderly patients using a multi-site home health care service are summarized, including: (1) their functional/psychiatric status, (2) their length of stay, (3) caregiver availability, (4) scope of multidisciplinary interventions provided, and (5) reasons for discharge. Prospective research of elderly persons receiving psychiatric home care is needed in the future.

Dose increase augments response rate to interferon-alpha in chronic hepatitis C

Approximately 50% of patients with chronic hepatitis C respond to treatment with interferon-alpha. The aim of this randomized controlled trial was to evaluate whether an increase in dose of interferon-alpha augments response rate. One hundred thirty-eight patients with newly diagnosed chronic hepatitis C received a three-month course of 3 MU IFN-alpha2b administered every two days. All patients were anti-HCV and HCV-RNA (PCR) positive. Prior to treatment, a liver biopsy was performed. Complete response was defined by normal serum ALT concentrations and disappearance of HCV-RNA. After three months, 60 nonresponders were randomized (stratified according to histology) either to continue 3 MU interferon-alpha2b every two days for another six months (group A, total dose: 410 MU) or to receive increasing doses of interferon-alpha2b (6 MU every two days for three months, followed by 10 MU every two days for three months) (group B, total dose: 870 MU). Serum ALT concentrations were measured monthly and HCV-RNA at three-month intervals. Liver biopsy was repeated six months after end of treatment. Pretreatment characteristics of the randomized patients were: group A: N = 30; male/female: 20/10; age: 54 +/- 10 years; CPH 9, CAH 8, cirrhosis 13; mean ALT 108 +/- 98 units/liter; group B: N = 30; male/female: 21/9; age: 57 +/- 15 years; CPH 10, CAH 9, cirrhosis 11; mean ALT 90 +/- 40 units/liter. At the end of treatment six patients in group B but none in group A became responders [P = 0.011 (Fisher's exact test), intent-to-treat analysis]. All six responders were noncirrhotics. High-dose interferon was not tolerated by six patients in group B. Noncompliance resulted in five dropouts in group A and one in group B. During the six-month follow-up, four of the six responders relapsed. A patient in group A with increased serum ALT concentration but negative HCV-RNA at the end of treatment became a full responder after six months. Of nonresponders to 3 MU interferon alpha2b every two days for three months, 20% responded to higher interferon doses, but none to continued standard dose. Prolonged treatment with interferon may be necessary to obtain a sustained response. However, treatment with higher-dose interferon was not tolerated in 20% of the patients.

The Functional Independence Measure: tests of scaling assumptions, structure, and reliability across 20 diverse impairment categories

OBJECTIVE

The analysis presented here evaluated the psychometric properties of the Functional Independence Measure (FIM) as a summated rating scale within context of the 20 impairment categories of the FIM-Function Related Group (FIM-FRG) system.

DESIGN

This study involved a cross-sectional analysis of patient records, utilizing factor analysis and techniques of multitrait scaling to verify the summative properties of the motor and cognitive dimensions of the FIM and to study the statistical properties of admission FIM scores.

PATIENTS

Included were a total of 93.829 patients discharged from 252 freestanding rehabilitation hospitals and units during calendar year 1992. Cases were excluded that had missing or out-of-range values or atypical lengths of stay. These criteria were developed previously in conjunction with an expert clinical panel and confirmed through statistical analyses.

RESULTS

Factor analyses supported the motor and cognitive dimensions across all 20 impairment categories. The resulting subscales exceeded minimum criteria for item internal consistency in 96.9% of tests and item discriminant validity in 100% of tests. Reliability coefficients for each impairment category for both subscales ranged from .86 to .97. There were no major ceiling effects, but patients in certain impairment categories were unable to climb stairs at admission.

CONCLUSION

The psychometric properties of the summated FIM compare favorably to most standardized health measures used in medical practice. Findings provide support for the motor and cognitive subscales as used in the FIM-FRGs. As a unidimensional scale, the FIM quantifies care burden. Split into the motor and cognitive (as used in the FIM-FRGs) it distinguishes physical disabilities from those arising from communication or cognitive difficulties.

Minimal chronic inactive gastritis: indicator of pre-existing helicobacter pylori gastritis?

Minimal chronic inactive gastritis is regularly observed in routine histopathology. Presently, it is not clear whether this type of gastritis should be regarded as a histopathological entity or a normal variant. The similarity to lesions observed after H.pylori eradication prompted us to look for an association between minimal chronic inactive gastritis and status post H.pylori eradication. In a prospective study of 110 consecutive patients undergoing upper gastrointestinal endoscopy, at least two mucosal biopsies were taken from the gastric antrum and body. Gastritis was classified according to the Sydney System. Antibodies to H.pylori were determined serologically by immunofluorescence test, ELISA, and complement binding reaction. A status post eradication of H.pylori was revealed by medical history and/or positive serology; H.pylori gastritis was found in 39.1%, reactive gastritis in 12.7%, and minimal chronic inactive gastritis in 29.1%. In 19.1% a combination of reactive/ minimal chronic gastritis was diagnosed according to morphology. Status post eradication was observed significantly more often in cases with minimal chronic inactive gastritis (43.8%) than in cases with reactive gastritis (7.1%, p < 0.004). Furthermore, positive ELISA and/or status after eradication was found in 50% of the cases with minimal chronic inactive gastritis (p < 0.005 vs reactive gastritis), in 42.9% of the cases with mixed reactive/chronic inactive gastritis (p < 0.03 vs reactive gastritis), and in 7.1% of the cases with reactive gastritis. Lymphoid aggregates, considered another sign of former H.pylori presence, were found significantly more often in minimal chronic inactive gastritis than in reactive gastritis (50% versus 7.1%, p < 0.005). Minimal chronic inactive gastritis is significantly associated with both positive H.pylori serology and status post eradication and is, therefore, an indicator of pre-existing H.pylori gastritis.

[The diabetic foot]

Foot disease in patients with diabetes mellitus is multifactorial and results from a combination of peripheral neuropathy, vascular compromise and superimposed infection. Foot complications in diabetic patients are common and account for more hospital days than any other aspects of their disease. Therefore, familiarity with the spectrum of findings in the different imaging modalities appears essential. Radiographically, significant changes include Charcot joints of the tarsus (destructive type) and bone absorption of the forefoot (mutilating type). In diabetic foot problems, magnetic resonance imaging and leukocyte scintigraphy appear to be the most effective tools for detection of osteomyelitis, and a negative study makes osteomyelitis unlikely. However, the findings of both techniques in active, noninfected neuropathic osteoarthropathy may be indistinguishable from those of osteomyelitis.

[HIV-screening in bone transplantation]

Tissue transplantation obviously always involves the risk of HIV transmission. Since 1980, the Orthopaedic University of Muenster has conducted careful anamnestic and laboratory screening in 62 donors. Epidemiological investigations show that 90.1% of HIV-positive people in Germany are between 20 and 50 years old. For 25 donors (40%) the results of the HIV antigen test performed in the recipients of the other organs guaranteed HIV negativity. A further 17 donors (28%) were outside the epidemiologic risk group aged between 20 and 50 years. Tissue from all 20 other donors (32%) was subjected to a secondary sterilization method, e.g. fumigation with ethylene oxide or irradiation with 25 kGy.

Simultaneous evaluation of clastogenicity, aneugenicity and toxicity in the mouse micronucleus assay using immunofluorescence

An improved antikinetochore antibody technique was established in the mouse micronucleus assay to simultaneously evaluate toxicity, clastogenicity and aneugenicity induced by various test agents. The procedure involved the use of cellulose column fractionated cytospun slides for analysis. The staining method consisted of sequential treatment of slides with crest serum, fluorosceinated goat-antihuman and swine-antigoat antibodies, and propidium iodide. In this method, polychromatic erythrocytes (PCEs, dark red), normochromatic erythrocytes (NCEs, green), chromosome(s)/fragments/micronuclei (orange), and kinetochores (yellow), are identified using the same filter setting under blue excitation (440-490 nm) with a barrier filter at 520 nm. Using this method, three agents, cyclophosphamide, X-rays and vincristine were tested for micronucleus/aneuploidy induction and bone marrow toxicity. The aneugen, vincristine, and clastogens, X-rays and cyclophosphamide, induced predominantly kinetochore positive (K+) and negative (K-) micronucleated PCEs, respectively. At the doses tested, cyclophosphamide caused a slight but statistically significant decrease in PCEs in females, and other agents did not produce any severe bone-marrow toxicity in either male or female mice. These results are comparable with the results reported in the literature on these compounds with various methods and thus demonstrate the usefulness of this assay in distinguishing clastogenicity from aneugenicity and in evaluating toxicity.

Simultaneous analysis of chromosome damage and aneuploidy in cytokinesis-blocked V79 Chinese hamster lung cells using an antikinetochore antibody

A modified antikinetochore antibody technique was established in the V79 Chinese hamster lung cells to simultaneously analyze chromosome damage and aneuploidy induced by various agents. The method involved sequential treatment of slides with crest serum, fluoresceinated goat-antihuman and swine-antigoat antibodies, and propidium iodide. In this method, cytoplasm (green), nuclei or micronuclei (red), and kinetochores (yellow), are identified using the same filter setting under blue excitation (440-490 nm) with a barrier filter at 520 nm. Using this method, three agents, vinblastine (VB), X-rays, and methyl methanesulfonate (MMS) were tested for micronucleus/aneuploidy induction. An aneugen, VB and a clastogen, X-rays, induced predominantly kinetochore positive (K+) and negative (K-) micronucleated binucleate (MNBN) cells, respectively, in a dose-dependent fashion. An alkylating agent, MMS, produced both K+ and K- MNBN cells. These results are comparable with the results reported in the literature on these compounds using various methods and thus demonstrate the usefulness of this assay in distinguishing clastogenicity from aneugenicity.

Ruptured abdominal aortic aneurysms: factors affecting mortality rates

Outcome of 113 operations for ruptured abdominal aortic aneurysms were reviewed to determine the contribution of perioperative events to mortality rates. Preoperative, intraoperative, and postoperative factors were examined with regard to their influence on early and late deaths. A mortality rate of 64% (72/113) was unrelated to age, gender, and preexistent medical conditions. Death within 48 hours occurred in 42 of 72 patients (58%). Preoperative status, including cardiac arrest, loss of consciousness, and acidosis influenced early deaths (less than 48 hours) but not late deaths. Early deaths were also influenced by severe operative hypotension and excessive transfusion requirements. Late deaths (greater than 48 hours) occurred in 30/72 cases (42%) at a mean of 24.6 +/- 22.9 days. Late death was related to postoperative organ system failure, specifically renal and respiratory failure, and the need for reoperation. The overall mortality rate was influenced by preoperative, intraoperative, and postoperative factors. Postoperative renal failure was the strongest predictor of overall deaths. Survival after ruptured abdominal aortic aneurysm depends on intraoperative and postoperative complications as well as preoperative conditions. Late death, the greatest strain on resources, is independent of preoperative status. The thesis that some patients with ruptured abdominal aortic aneurysm should be denied operation to conserve resources is not supported by these data. Efforts to improve survival should focus on reducing intraoperative complications and improving management of postoperative organ failure.

Research skills for medical students: a summer assistantship in family medicine

This report presents a description of a summer research assistantship program for first- and second-year medical students. The program's goals are to develop and enhance students' research capabilities and to familiarize students with clinical research in family practice. The program provides sponsorship of a student by a faculty member, with a $1,120 stipend for students, as well as seminars on research skills. A pre- and post-program questionnaire and test documented significant improvements in students' perceived knowledge of research methodology. This structured summer research program is an effective way to introduce and emphasize essential research skills.

Monoclonal antibodies to human chorionic gonadotropin and certain human and animal hormones of the adenohypophysis

As a result of cell fusion between myeloma cell line X63.Ag8.653 and lymphocytes of BALB/c mice immunized with chorionic gonadotropin, growth hormone, prolactin, luteinizing hormone, and follicle-stimulating hormone from humans and various farm animals, 148 primary cultures of hybridoma cells were obtained. These hybridomas produced antibodies against the corresponding hormones. The specificities of the resultant monoclonal antibodies, and, in the case of monoclonal antibodies to human chorionic gonadotropin, targeting to certain antigenic regions within the hormone molecule, were characterized in detail. Monoclonal antibodies with specificities different from those previously described were identified.

A study of benefits offered volunteer clinical faculty

The School of Health Related Professions (HRP) at State University of New York at Buffalo offers its volunteer clinical faculty (VCF) a number of benefits and privileges. These VCF are professionals who train students but do not receive monetary compensation for doing so. A study was conducted to determine what benefits/privileges are valued and used most, the impact and use of tuition waivers (TWs), and other benefits the VCF would desire. A survey was sent to 383 VCF, and 233 (61%) responded. The results showed that VCF valued, in order of priority: TWs, University library privileges, faculty parking, photocopying service, clinical faculty awards, use of recreational facilities, and faculty discounts. The data revealed that 42% of the respondents had used TWs, and the study demonstrated that TWs promote the University's graduate programs. The data supported the contention that TWs play a significant role in recruiting and rewarding VCF. As a result, University financial support for TWs was not eliminated. The feasibility and cost of implementing other incentives for VCF participation, suggested by the VCF, will be investigated by the School of HRP in the future.