Prevalence of Cardiovascular Conditions After Traumatic Brain Injury: A Comparison Between the Traumatic Brain Injury Model Systems and the National Health and Nutrition Examination Survey

BACKGROUND

The purpose of this study is to compare the prevalence of self-reported cardiovascular conditions among individuals with moderate to severe traumatic brain injury (TBI) to a propensity-matched control cohort.

METHODS AND RESULTS

A cross-sectional study described self-reported cardiovascular conditions (hypertension, congestive heart failure [CHF], myocardial infarction [MI], and stroke) from participants who completed interviews between January 2015 and March 2020 in 2 harmonized large cohort studies, the TBI Model Systems and the National Health and Nutrition Examination Survey. Mixed-effect logistic regression models were used to compare the prevalence of cardiovascular conditions after 1:1 propensity-score matching based on age, sex, race, ethnicity, body mass index, education level, and smoking status. The final sample was 4690 matched pairs. Individuals with TBI were more likely to report hypertension (odds ratio [OR], 1.18 [95% CI, 1.08-1.28]) and stroke (OR, 1.70 [95% CI, 1.56-1.98]) but less likely to report CHF (OR, 0.81 [95% CI, 0.67-0.99]) or MI (OR, 0.66 [95% CI, 0.55-0.79]). There was no difference in rate of CHF or MI for those ≤50 years old; however, rates of CHF and MI were lower in the TBI group for individuals >50 years old. Over 65% of individuals who died before the first follow-up interview at 1 year post-TBI were >50 years old, and those >50 years old were more likely to die of heart disease than those ≤50 years old (17.6% versus 8.6%).

CONCLUSIONS

Individuals with moderate to severe TBI had an increased rate of self-reported hypertension and stroke but lower rate of MI and CHF than uninjured adults, which may be due to survival bias.

An Umbrella Review of Self-Management Interventions for Health Conditions With Symptom Overlap With Traumatic Brain Injury

OBJECTIVE

To synthesize evidence for the effectiveness of self-management interventions for chronic health conditions that have symptom overlap with traumatic brain injury (TBI) in order to extract recommendations for self-management intervention in persons with TBI.

DESIGN

An umbrella review of existing systematic reviews and/or meta-analyses of randomized controlled trials or nonrandomized studies targeting self-management of chronic conditions and specific outcomes relevant to persons with TBI.

METHOD

A comprehensive literature search of 5 databases was conducted using PRISMA guidelines. Two independent reviewers conducted screening and data extraction using the Covidence web-based review platform. Quality assessment was conducted using criteria adapted from the Assessing the Methodological Quality of Systematic Reviews-2 (AMSTAR-2).

RESULTS

A total of 26 reviews met the inclusion criteria, covering a range of chronic conditions and a range of outcomes. Seven reviews were of moderate or high quality and focused on self-management in persons with stroke, chronic pain, and psychiatric disorders with psychotic features. Self-management interventions were found to have positive effects on quality of life, self-efficacy, hope, reduction of disability, pain, relapse and rehospitalization rates, psychiatric symptoms, and occupational and social functioning.

CONCLUSIONS

Findings are encouraging with regard to the effectiveness of self-management interventions in patients with symptoms similar to those of TBI. However, reviews did not address adaptation of self-management interventions for those with cognitive deficits or for populations with greater vulnerabilities, such as low education and older adults. Adaptations for TBI and its intersection with these special groups may be needed.

A - 148 Pre-Injury Personality and Engagement in Inpatient Rehabilitation Following TBI

OBJECTIVE

We sought to evaluate the relationship between pre-injury motivational systems and engagement in inpatient rehabilitation (IR) following moderate-to-severe traumatic brain injury (msTBI).

METHODS

We recruited 20 individuals, aged 18-80 years, from IR with msTBI as evidenced by a GCS score < 13, loss of consciousness ≥60 minutes, post-traumatic amnesia (PTA) of at least 24 hours, and/or positive findings on neuroimaging. After emergence from PTA, participants reported on their general behavior and personality prior to their injury in a verbal interview, which included the 24-item BIS/BAS Scale. This scale measures the behavioral inhibition system (BIS), which motivates avoidance of aversive outcomes, and the behavioral activation system (BAS), which motivates approach to goal-oriented outcomes. Rehabilitation therapists rated participants' engagement in each physical (PT), occupational (OT), and speech therapy (ST) session using the Rehabilitation Intensity of Therapy Scale. We assessed the relationship between BIS/BAS scores and average level of engagement in each rehabilitation discipline using Pearson's correlation.

RESULTS

The sample was 65% male and 65% white with a mean age of 38.95 years (SD = 19.57) and a mean education of 13.45 years (SD = 2.61). Engagement in PT was significantly correlated with BAS Drive, r(18) = -0.55, p = 0.012; BAS Fun-Seeking, r(18) = -0.55, p = 0.013; and BAS Reward Responsiveness, r(18) = -0.56, p = 0.010. There were no significant correlations between the BIS/BAS subscales and engagement in OT or ST.

CONCLUSION

Pre-injury motivation to approach goal-oriented outcomes predicts engagement in inpatient PT following msTBI, which may impact treatment benefit and subsequent functioning.

The Association Between Payer Source and Traumatic Brain Injury Rehabilitation Outcomes: A TBI Model Systems Study

OBJECTIVE

To examine the relationship between payer source for acute rehabilitation, residential median household income (MHI), and outcomes at rehabilitation discharge after traumatic brain injury (TBI).

SETTING

Acute inpatient rehabilitation facilities.

PARTICIPANTS

In total, 8558 individuals enrolled in the Traumatic Brain Injury Model Systems (TBIMS) National Database who were admitted to inpatient rehabilitation between 2006 and 2019 and were younger than 64 years.

DESIGN

Secondary data analysis from a multicenter longitudinal cohort study.

MAIN MEASURES

Payer source was divided into 4 categories: uninsured, public insurance, private insurance, and workers' compensation/auto. Relationships between payer source with residential MHI, rehabilitation length of stay (RLOS), and the FIM Instrument at discharge were examined. Covariates included age, injury severity, FIM at admission, and a number of sociodemographic characteristics including minority status, preinjury limitations, education level, and employment status.

RESULTS

Individuals with workers' compensation/auto or private insurance had longer RLOS than uninsured individuals or those with public insurance after controlling for demographics and injury characteristics. An adjusted model controlling for demographics and injury characteristics showed a significant main effect of payer source on FIM scores at discharge, with the highest scores noted among those with workers' compensation/auto insurance. The main effect of payer source on FIM at discharge became nonsignificant after RLOS was added to the model as a covariate, suggesting a mediating effect of RLOS.

CONCLUSION

Payer source was associated with preinjury residential MHI and predicted RLOS. While prior studies have demonstrated the effect of payer source on long-term outcomes due to lack of inpatient rehabilitation or quality follow-up care, this study demonstrated that individuals with TBI who are uninsured or have public insurance may be at risk for poorer functional status at the point of rehabilitation discharge than those with private insurance, particularly compared with those with workers' compensation/auto insurance. This effect may be largely driven by having a shorter length of stay in acute rehabilitation.

The Utility of the Patient Health Questionnaire (PHQ-9) Sleep Disturbance Item as a Screener for Insomnia in Individuals With Moderate to Severe Traumatic Brain Injury

OBJECTIVE

To examine the utility of the sleep disturbance item of the Patient Health Questionnaire-9 (PHQ-9) as a screening tool for insomnia among individuals with moderate to severe traumatic brain injury (TBI).

SETTING

Telephone interview.

PARTICIPANTS

A sample of 248 individuals with a history of moderate to severe TBI participated in an interview within 2 years of their injury.

DESIGN

Observational, cross-sectional analysis.

MAIN MEASURES

The PHQ-9 was administered along with the Insomnia Severity Index, Pittsburgh Sleep Quality Index, Sleep Hygiene Index, Epworth Sleepiness Scale, and the Insomnia Interview Schedule.

RESULTS

Receiver operating characteristic curve analysis was conducted for the PHQ-9 sleep item rating against a set of insomnia criteria to determine an optimal cutoff score. A cutoff of 2 on the PHQ-9 sleep item maximized sensitivity (76%) and specificity (79%), with an area under the curve of 0.79 (95% CI, 0.70-0.88). The 2 groups formed using this cutoff differed significantly on all sleep measures except the Epworth Sleepiness Scale.

CONCLUSIONS

The PHQ-9 sleep item may serve as a useful screener to allow for detection of potential sleep disturbance among individuals with moderate to severe TBI. Those who screen positive using this item included in a commonly used measure of depression can be prioritized for further and more comprehensive assessment of sleep disorders.

Changes in social participation between 1 and 2 years following moderate-severe traumatic brain injury

Objective

To examine patterns of change in social participation in persons with moderate-severe traumatic brain injury (msTBI) between 1 and 2 years postinjury, and predictors of observed change.

Participants

375 participants with msTBI enrolled in a single TBI Model System site.

Measures and Methods

The dependent variable in a linear regression was a reliable change score for the Social Relations subscale of the Participation Assessment with Recombined Tools-Objective, administered at 1- and 2-year follow-ups. Predictors of change included demographics, injury severity, social and functional status at Year 1, and changes in function and life circumstances between years 1 and 2.

Results

Social participation status did not change substantially for 34 of the sample, while approximately equal proportions of the remainder improved or declined. The regression model was significant (p < 0.001). Improvement was predicted by private vs. public insurance and decline was predicted by a reduction in the FIM functional outcome measure from year 1 to year 2. Marginal predictors included education (higher levels predicting improvement) and year 1 marital status (single status predicting decline).

Conclusions

Longitudinal change in social participation in the chronic phase of msTBI deserves further study, with attention to resource limitations and the impact of changes in functional status.

Participation importance and satisfaction across the lifespan: A traumatic brain injury model systems study

OBJECTIVE

In rehabilitation research and practice, participation is defined as involvement in life situations and most often measured as frequency of engaging in these life situations. This narrow measurement approach overlooks that individuals perceive importance of and satisfaction with participation in activities in various life areas differently. The purpose of this study was to determine differences in meaningful participation (perceived importance and satisfaction) after moderate to severe traumatic brain injury (TBI) across age groups and to identify predictors of participation satisfaction.

METHOD

Secondary data analysis of a TBI Model Systems substudy, including the Participation Assessment with Recombined Tools-Subjective (PART-S) that rates participation importance and satisfaction in 11 life areas that we grouped into three domains (i.e., productivity, social relations, out-and-about). We identified differences across age groups (i.e., 16 to 24 years, 25 to 44 years, 45 to 64 years, and 65 + years) and predictors of participation satisfaction.

RESULTS

Participation satisfaction in and importance of the 11 life areas varied across age groups. In all age groups, participants rated relationships as being of medium or high importance more often than other life areas. Older adults reported the highest participation satisfaction across life areas, despite having the lowest participation frequency. Consistent predictors of participation satisfaction were cognitive functioning and frequency of participation in the domain examined.

CONCLUSION

Participation importance, satisfaction, and frequency are related, yet distinct, dimensions of participation that should all be measured to adequately evaluate meaningful participation. Future research should explore interventions across the lifespan that target modifiable predictors, like functional cognition and access to frequent participation in important life activities. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Neurobehavioral Symptoms and Heart Rate Variability: Feasibility of Remote Collection Using Mobile Health Technology

OBJECTIVES

To determine the covariance of heart rate variability (HRV) and self-reported neurobehavioral symptoms after traumatic brain injury (TBI) collected using mobile health (mHealth) technology.

SETTING

Community.

PARTICIPANTS

Adults with lifetime history of TBI (n = 52) and adults with no history of brain injury (n = 12).

DESIGN

Two-week prospective ecological momentary assessment study.

MAIN MEASURES

Behavioral Assessment Screening Tool (BASTmHealth) subscales (Negative Affect, Fatigue, Executive Dysfunction, Substance Abuse, and Impulsivity) measured frequency of neurobehavioral symptoms via a RedCap link sent by text message. Resting HRV (root mean square of successive R-R interval differences) was measured for 5 minutes every morning upon waking using a commercially available heart rate monitor (Polar H10, paired with Elite HRV app).

RESULTS

Data for n = 48 (n = 38 with TBI; n = 10 without TBI) participants were included in covariance analyses, with average cross-correlation coefficients (0-day lag) varying greatly across participants. We found that the presence and direction of the relationship between HRV and neurobehavioral symptoms varied from person to person. Cross-correlation coefficients r ≤ -0.30, observed in 27.1% to 29.2% of participants for Negative Affect, Executive Dysfunction, and Fatigue, 22.9% of participants for Impulsivity, and only 10.4% of participants for Substance Abuse, supported our hypothesis that lower HRV would covary with more frequent symptoms. However, we also found 2.0% to 20.8% of participants had positive cross-correlations (r ≥ 0.30) across all subscales, indicating that higher HRV may sometimes correlate with more neurobehavioral symptoms, and 54.2% to 87.5% had no significant cross-correlations.

CONCLUSIONS

It is generally feasible for community-dwelling adults with and without TBI to use a commercially available wearable device to capture daily HRV measures and to complete a short, electronic self-reported neurobehavioral symptom measure for a 2-week period. The covariance of HRV and neurobehavioral symptoms over time suggests that HRV could be used as a relevant physiological biomarker of neurobehavioral symptoms, though how it would be interpreted and used in practice would vary on a person-by-person and symptom domain basis and requires further study.

Ecological momentary assessment of affect in context after traumatic brain injury

PURPOSE

To describe where, with whom, and how time was spent daily, and to characterize positive and negative affect, boredom, enjoyment, and perceived accomplishment as a function of time, activity, location, and social context, in people with chronic moderate-severe traumatic brain injury and depression/anxiety.

RESEARCH METHOD

Participants (N = 23) responded to a smartphone app five times daily for approximately 2 weeks prior to treatment in a trial of Behavioral Activation. The app queried activity and physical/social context; concurrent positive and negative affect; and perceived boredom, enjoyment, and accomplishment. Descriptive statistics captured time use, and linear mixed models were used to analyze relations between affect and contextual factors.

RESULTS

Ecological Momentary Assessment (EMA) response rate was positively correlated with integrity of episodic memory and education. Participants spent most time at home versus elsewhere, and alone versus with others. The most frequent activity was watching TV. Mixed model results based on 17 participants with >33% response rate showed that positive affect was associated with being outside of home, and with other people; however, socializing was related to higher negative affect. TV watching was related to lower negative affect but also low accomplishment.

CONCLUSIONS

EMA can provide unique information on the effects of social context and activity on mood in TBI. Clinicians should consider negative as well as positive affect associated with increasing social participation. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Improving communication with patients in post-traumatic amnesia: development and impact of a clinical protocol

OBJECTIVE

To assess the impact of staff training focused on improved treatment and communication with patients in post-traumatic amnesia (PTA) or other disorders of explicit (declarative) memory. A major aim was to minimize questions demanding recall from explicit memory, e.g., orientation quizzing, and personal/medical history questions, which may produce unreliable information and exacerbate patient frustration and anxiety.

METHODS

Mixed-methods design. Inpatients with impairments of explicit memory were observed before (n = 4) and after (n = 4) training, with staff interactions recorded verbatim. Records were coded for types of questions and patient responses. Clinicians who worked before and after training were surveyed regarding perceived changes in practice, team functioning, and patient behavior.

RESULTS

Explicit memory questions decreased significantly, as did irrelevant or "don't know" responses from patients, with large nonparametric effect sizes noted. The frequency of questions not relying on explicit memory remained stable. Most clinicians reported positive effects on their own and others' practice with memory impaired patients, and one-quarter noted less patient frustration or agitation.

CONCLUSIONS

Although questioning patients is a natural part of medical care, targeted staff training can result in positive changes in communication practice and should be considered for facilities treating patients in PTA.

Behavioral Activation Augmented With Mobile Technology for Depression and Anxiety in Chronic Moderate-Severe Traumatic Brain Injury: Protocol for a Randomized Controlled Trial

Objective

To describe and provide the rationale for a randomized controlled trial for depression or anxiety after moderate to severe traumatic brain injury (TBI), which will test 2 treatments based on behavioral activation (BA), a promising model to promote both positive mood and increased activity in this population.

Design

Randomized controlled trial with masked outcome assessment.

Setting

Outpatient catchment area of 1 TBI treatment center.

Participants

Community-dwelling persons (N=60) with moderate-severe TBI at least 6 months prior to enrollment and greater than mild depression or anxiety.

Interventions

Participants will be randomized 2:1 into an 8-session treatment, behavioral activation with technology, consisting of 6 face-to-face sessions and 2 via phone, with mood and activity monitoring conducted via ecological momentary assessment on a smartphone; or a single session incorporating BA principles followed by 8 weeks of activity reminders in the form of implementation intentions, delivered as text messages.

Main Outcome Measures

Brief Symptom Inventory-18 (primary outcome); Environmental Reward Observation Scale, Behavioral Activation for Depression Scale, Participation Assessment with Recombined Tools-Objective, Diener Satisfaction With Life Scale, Quality of Life after Brain Injury scale, Patient Global Impression of Change. Outcomes are measured midway through intervention, after treatment cessation (primary outcome), and at 2-month follow-up. A treatment enactment interview is administered after the follow-up to ascertain to what extent participants continue to engage in activities and use strategies promoted during trial participation.

Results

N/A.

Conclusions

N/A.

Inter-Subject Variability of Axonal Injury in Diffuse Traumatic Brain Injury

Traumatic brain injury (TBI) is a leading cause of cognitive morbidity worldwide for which reliable biomarkers are needed. Diffusion tensor imaging (DTI) is a promising biomarker of traumatic axonal injury (TAI); however, existing studies have been limited by a primary reliance on group-level analytic methods not well suited to account for inter-subject variability. In this study, 42 adults with TBI of at least moderate severity were examined 3 months following injury and compared with 35 healthy controls. DTI data were used for both traditional group-level comparison and subject-specific analysis using the distribution-corrected Z-score (DisCo-Z) approach. Inter-subject variation in TAI was assessed in a threshold-invariant manner using a threshold-weighted overlap map derived from subject-specific analysis. Receiver operator curve analysis was used to examine the ability of subject-specific DTI analysis to identify TBI subjects with significantly impaired processing speed in comparison with region of interest-based fractional anisotropy (FA) measurements and clinical characteristics. Traditional group-wise analysis demonstrated widespread reductions of white matter FA within the TBI group (voxel-wise p < 0.05, corrected), despite relatively low consistency of subject-level effects secondary to widespread variation in the spatial distribution of TAI. Subject-specific mapping of TAI with the DisCo-Z approach was the best predictor of impaired processing speed, achieving high classification accuracy (area under the curve [AUC] = 0.94). In moderate-to-severe TBI, there is substantial inter-subject variation in TAI, with extent strongly correlated to post-traumatic deficits in processing speed. Significant group-level effects do not necessarily represent consistent effects at the individual level. Better accounting for inter-subject variability in neurobiological manifestations of TBI may substantially improve the ability to detect and classify patterns of injury.

Assessing connectivity related injury burden in diffuse traumatic brain injury

Many of the clinical and behavioral manifestations of traumatic brain injury (TBI) are thought to arise from disruption to the structural network of the brain due to diffuse axonal injury (DAI). However, a principled way of summarizing diffuse connectivity alterations to quantify injury burden is lacking. In this study, we developed a connectome injury score, Disruption Index of the Structural Connectome (DISC), which summarizes the cumulative effects of TBI-induced connectivity abnormalities across the entire brain. Forty patients with moderate-to-severe TBI examined at 3 months postinjury and 35 uninjured healthy controls underwent magnetic resonance imaging with diffusion tensor imaging, and completed behavioral assessment including global clinical outcome measures and neuropsychological tests. TBI patients were selected to maximize the likelihood of DAI in the absence of large focal brain lesions. We found that hub-like regions, with high betweenness centrality, were most likely to be impaired as a result of diffuse TBI. Clustering of participants revealed a subgroup of TBI patients with similar connectivity abnormality profiles who exhibited relatively poor cognitive performance. Among TBI patients, DISC was significantly correlated with post-traumatic amnesia, verbal learning, executive function, and processing speed. Our experiments jointly demonstrated that assessing structural connectivity alterations may be useful in development of patient-oriented diagnostic and prognostic tools. Hum Brain Mapp 38:2913-2922, 2017. © 2017 Wiley Periodicals, Inc.

SETD2 loss-of-function promotes renal cancer branched evolution through replication stress and impaired DNA repair

Defining mechanisms that generate intratumour heterogeneity and branched evolution may inspire novel therapeutic approaches to limit tumour diversity and adaptation. SETD2 (Su(var), Enhancer of zeste, Trithorax-domain containing 2) trimethylates histone-3 lysine-36 (H3K36me3) at sites of active transcription and is mutated in diverse tumour types, including clear cell renal carcinomas (ccRCCs). Distinct SETD2 mutations have been identified in spatially separated regions in ccRCC, indicative of intratumour heterogeneity. In this study, we have addressed the consequences of SETD2 loss-of-function through an integrated bioinformatics and functional genomics approach. We find that bi-allelic SETD2 aberrations are not associated with microsatellite instability in ccRCC. SETD2 depletion in ccRCC cells revealed aberrant and reduced nucleosome compaction and chromatin association of the key replication proteins minichromosome maintenance complex component (MCM7) and DNA polymerase δ hindering replication fork progression, and failure to load lens epithelium-derived growth factor and the Rad51 homologous recombination repair factor at DNA breaks. Consistent with these data, we observe chromosomal breakpoint locations are biased away from H3K36me3 sites in SETD2 wild-type ccRCCs relative to tumours with bi-allelic SETD2 aberrations and that H3K36me3-negative ccRCCs display elevated DNA damage in vivo. These data suggest a role for SETD2 in maintaining genome integrity through nucleosome stabilization, suppression of replication stress and the coordination of DNA repair.

Predictors and prevalence of postconcussion depression symptoms in collegiate athletes

CONTEXT

Depression is common after concussion and is associated with functional outcome and quality of life after injury. However, few baseline predictors of postconcussion depressive symptoms (PCDS) have been found.

OBJECTIVE

To describe the prevalence of depressive symptoms in a collegiate athlete sample at baseline and postconcussion, compare these levels of symptoms and change in symptoms with those of a control group with no reported concussions in the past year, and examine the baseline predictors for PCDS.

DESIGN

Case-control study.

SETTING

Undergraduate institution.

PATIENTS OR OTHER PARTICIPANTS

Participants were 84 collegiate athletes (65 men, 19 women) with concussion and 42 individuals (23 men, 21 women) with no history of recent concussion who served as controls.

MAIN OUTCOME MEASURE(S)

The Beck Depression Inventory-Fast Screen was administered to the concussion group at baseline and postconcussion and to the control group at 2 time points.

RESULTS

Seventeen athletes (20%) showed a reliable increase in depression, and more athletes reported clinically important depression postconcussion than at baseline. Only 2 participants (5%) in the control group showed a reliable increase in depression. Concussed athletes were more likely to show a reliable increase in depression symptoms than control participants (χ(2)1 = 5.2, P = .02). We also found several predictors of PCDS in the athletes, including baseline depression symptoms (r = 0.37, P < .001), baseline postconcussion symptoms (r = 0.25, P = .03), estimated premorbid intelligence (full-scale IQ; r = -0.29, P = .009), and age of first participation in organized sport (r = 0.34, P = .002). For the control group, predictors of depression symptoms at time 2 were number of previous head injuries (r = 0.31, P = .05) and baseline depression symptoms (r = 0.80, P < .001).

CONCLUSIONS

A large proportion of athletes showed a reliable increase in depression after concussion, and we identified several baseline predictors. Given that depression affects quality of life and recovery from concussion, more research is necessary to better understand why certain athletes show an increase in PCDS and how these can be better predicted and prevented.

Hypotension during surgery for femoral neck fracture in elderly patients: effect of anaesthetic techniques. A retrospective study

BACKGROUND

The aim of this retrospective study was to compare the incidence of hypotension between different anaesthetic techniques, including general anaesthesia (GA), spinal anaesthesia single injection (SA), continuous spinal anaesthesia with 2.5 mg bolus injections as needed (CSA 2.5) or 5 mg bolus injections as needed (CSA 5) in elderly patients (>75 yrs old) undergoing surgery for femoral neck fractures.

METHODS

Demographic, surgical and hemodynamic data from 333 patients over a four year period within a single hospital were recorded and examined.

RESULTS

Forty-two patients underwent GA, 109 underwent SA, 61 underwent CSA 5, and 121 underwent CSA 2.5. Patients receiving GA, SA or CSA 5 had a higher incidence of hypotension (83%, 68%, and 34%, respectively) than patients who underwent CSA 2.5 (4%; P<0.05). The CSA 2.5 group required less colloid infusion (490+/-50 mL) than the GA and SA groups (810+/-330 and 645+/-230 mL, respectively). The CSA 2.5 group also required less crystalloid infusion volume (760+/-371 mL) than the GA group (1140+/-770 mL). Ephedrine infusion was higher in the GA and SA groups (30+/-10 and 26+/-9 mg, respectively) than the CSA 2.5 (15+/-8 mg; P<0.05).

CONCLUSION

This study demonstrated that CSA 2.5 causes fewer episodes of hypotension than other anaesthetic techniques for surgical repair of hip fracture in elderly patients.

Adverse events associated with balloon rupture during percutaneous coronary intervention

BACKGROUND

Balloon rupture is a potential complication of coronary angioplasty. The literature is inconsistent regarding associated adverse consequences. The experience of St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, with balloon rupture is reviewed.

PATIENTS AND METHODS

All patients who underwent percutaneous coronary intervention complicated by balloon rupture at St Paul's Hospital from April 1992 to March 1996 were identified from the hospital's database (Seattle Systems, Seattle, Washington). Procedural logs, database records, clinical charts and all cineangiograms were reviewed in detail.

RESULTS

A total of 2984 patients had percutaneous coronary revascularization and 110 patients experienced balloon rupture. These occurred in 101 (92%) native coronary arteries and 9 (8%) occurred in saphenous vein grafts. Stents were deployed in 44 (40%) patients; 34 of the stents used were half Johnson & Johnson PS153 stents (Johnson & Johnson Interventinal Systems, Peterborough, Ontario). An event-free postangioplasty course during the index hospitalization was observed in 102 patients (93%); eight patients (7%) had one or more important adverse events postprocedure. These included three deaths (one following a dissection and out-of-catheterization laboratory occlusion, a second following an abrupt occlusion of another target artery and emergency bypass surgery, and another with cardiogenic shock postmyocardial infarction and an unaltered course following angioplasty); one urgent bypass surgery after a left main dissection; and two nonfatal myocardial infarctions (one patient had tamponade and one patient experienced congestive heart failure). Four of the eight events were directly related to the procedure. The rate of death and emergency bypass surgery with balloon rupture did not differ from that of patients without balloon rupture in the authors' centre (1.8% versus 1.4%, not significant).

CONCLUSIONS

The majority of patients did not experience any adverse clinical outcomes and demonstrated good angiographic results after balloon rupture. The data did not detect an excess of major adverse events beyond that expected in a diverse general angioplasty population.

Pullback atherectomy with the Arrow-Fischell atherectomy device

The Arrow-Fischell pullback atherectomy catheter is designed to circumferentially debulk and retrieve coronary atheroma. We performed pullback atherectomy before balloon angioplasty or stenting in 41 patients. The device crossed the target lesion in 38 (93%) and obtained tissue in 36 (88%). All procedures were completed successfully and without myocardial infarction, emergency cardiac surgery, or death. Complications included major spasm in 8 patients, postprocedural abrupt closure in 1, and otherwise uncomplicated arterial perforation in 2. Pullback atherectomy can be performed relatively safely, but is more difficult than balloon angioplasty, obtains less tissue than directional atherectomy, and is associated with significant limitations.

Early and late assessment of the Micro Stent PL coronary stent for restenosis and suboptimal balloon angioplasty

This prospective study represents the initial assessment of the Micro Stent PL (Arterial Vascular Engineering, Inc.) coronary stent. From one to three radiopaque stainless steel stents, each measuring 4 mm long, were premounted onto specially designed balloon catheters. A total of 123 stents were implanted in 41 patients without procedural failure or complications. Stent dislodgment proved a concern, with 7 of 123 stents (5.7%) moving > 3 mm from the site of placement and late downstream migration occurring in an additional patient. Subacute stent thrombosis occurred in two patients (5%). Six-month angiographic follow-up was available in 37 of 41 patients (90%). Minimal lumen diameter at baseline was 0.93 +/- 0.51 mm, increasing to 2.74 +/- 0.49 mm after stenting, and falling to 1.66 +/- 0.89 mm at 6 months; this represents a late loss of 60% of the initial gain. Restenosis, based on a binary definition of > 50% diameter stenosis, was documented in 18 patients (49%). Advantages of the Micro Stent PL include its radiopacity and marked ease of distal delivery. The potential for stent dislodgment has implications for future stent designs. The role of the Micro Stent PL in managing restenosis is unclear, but it appears useful in the management of dissection and threatened closure after balloon angioplasty.

Usefulness of coronary stenting for cardiogenic shock

Coronary stenting was performed in 15 selected patients with cardiogenic shock, with favorable clinical and angiographic outcomes. This experience suggests that coronary stenting may play an important adjunctive role in the management of cardiogenic shock and may improve outcome beyond that achieved with balloon angioplasty alone.

Stenting for treatment of coronary vasospasm

Following an acute anterior myocardial infarction, a 56-yr-old female underwent two balloon angioplasty procedures for a recurrent proximal left anterior descending artery stenosis. She had recurrent angina pectoris. Angiography showed a noncritical restenosis with marked provocable superimposed vasospasm. Despite repeat balloon dilatation and stenting of the lesion, she developed recurrent symptoms. One month later, angiography showed progressive fixed disease and reversible spasm proximal and distal to, but not involving, the stented arterial segment. She underwent single-vessel coronary artery bypass grafting, and is asymptomatic at 6-mo follow-up.

Transfusion practice in medical patients

OBJECTIVE

Blood transfusion raises serious issues of safety and economics. We therefore examined blood usage and its characteristics in medical inpatients, given the relative scarcity of existing data.

DESIGN

During a 1-year period, transfusion episodes on two medical services were reviewed by five specialists for justifiability on the basis of generally agreed on guidelines.

SETTING

The study was conducted at two institutions, a municipal teaching hospital where house staff deliver care and a community hospital where patients are under the direct care of private physicians.

PATIENTS

Four hundred thirty-eight randomly selected transfusion episodes on the medical services of the two institutions were reviewed.

MAIN OUTCOME MEASURES

The prevalence of unjustifiable transfusions based only on the information available to the managing physician at the time of transfusion.

RESULTS

Eighteen percent of the 438 randomly selected transfusion episodes were viewed as not justifiable by at least four of five reviewers; another 17% were classified as equivocal because two or three reviewers judged them to be not justifiable. The most striking observation was the greater prevalence of nonjustifiable transfusion episodes at the community hospital (26% vs 16% at the teaching institution; P = .0121). Other observations included a tendency for physicians to prescribe transfusions by the numbers (at least 11% of nonjustifiable transfusions) and to overtransfuse. The routineness with which transfusion was viewed by managing physicians was also identifiable by the absence of written transfusion notes in 39% of all episodes reviewed, which incidentally raises questions about the adequacy of the medical chart's documentary functions today.

CONCLUSIONS

The rate of nonjustifiable or equivocal transfusion on medical services may be as high as 35%. Reliance on numbers rather than clinical status seems to be a major problem. Education is obviously a critical issue and should also target private practitioners, who seemed to perform less well than physicians in training. Transfusion guidelines that use specific hematocrit values also need to be reexamined.

Racial differences in blood pressure among urban adolescents

The purpose of this study was to determine if there are racial differences in the blood pressure patterns among urban adolescents. Blood pressure (BP) was measured according to Task Force guidelines in health-screening and education sessions conducted in urban public and parochial high schools. The prevalence of BP > or = 95th% (HBP) on initial screening was determined in a population of 3,349 students. Differences in prevalence of HBP among race, sex, and age groups were tested for significance by chi 2 analysis. The overall prevalence of HBP in this urban adolescent population was 8.1%. Significant race differences were present in females (blacks = 6.6% versus non-Hispanics = 2.9%, p < 0.01). Within the black females, HBP occurred more frequently among the girls attending predominantly black public schools (7.7%) compared to an interracial parochial school (2.0%) p < 0.001. This difference could not be explained by weight, height, or the occurrence of obesity. The observed BP differences within black females, by school, may reflect a family-environment effect on cardiovascular risk.

Cerebrospinal fluid beta-endorphin and cortisol study in Rett syndrome

An evaluation of cerebrospinal fluid and plasma beta-endorphin and cortisol levels was performed in 15 girls affected with classic Rett syndrome. There were no differences between the patient group and the control group in plasma cortisol and beta-endorphin levels. But in Rett syndrome, a significant increase in beta-endorphin was noted in the cerebrospinal fluid, with an elevation of the cerebrospinal fluid/plasma beta-endorphin ratio and a decrease in cerebrospinal fluid cortisol. A substantial overlap between patients and control group diminishes the diagnostic value of cerebrospinal fluid beta-endorphin assay in girls suspected of having Rett syndrome.

Detection of occult CNS involvement of follicular small cleaved lymphoma by the polymerase chain reaction

A patient with follicular small cleaved lymphoma presented with an unusual clinical relapse in the central nervous system (CNS) without morphologic evidence of lymphoma cells in the cerebral spinal fluid (CSF). Molecular genetic analysis of the small number of cells in the CSF after in vitro DNA amplification by the polymerase chain reaction demonstrated the presence of an abnormal translocation sequence between chromosomes 14 and 18. A similar translocation could be detected from the original fixed archival lymph node biopsy and from a small proportion of circulating mononuclear cells. These results indicated that occult lymphoma cells were present in the CSF and peripheral blood. Secondary CNS lymphoma involvement was identified at autopsy. This case demonstrates the enhanced sensitivity of lymphoma diagnosis from poorly cellular specimens after in vitro DNA amplification.

Human T-cell lymphotropic virus type I (HTLV-I)-associated adult T-cell leukemia-lymphoma in a patient infected with human immunodeficiency virus type 1 (HIV-1)

A patient had adult T-cell leukemia-lymphoma in the unusual setting of coinfection with human immunodeficiency virus type 1 (HIV-1) and human T-cell lymphotropic virus type I (HTLV-I). The leukemic cells were CD4 positive and showed clonal genetic rearrangement of the T-cell receptor complex. Cytogenetic analysis showed three clonal karyotypic abnormalities: trisomy 3 and two translocations [t(1;15), (X;1)]. The patient was seropositive for HIV and HTLV-I; HTLV-I and HIV-1 DNA sequences were detected in peripheral blood leukocytes by the polymerase chain reaction. The HTLV-I sequences were detected in a relatively high proportion of mononuclear cells (at least 1 in 30 cells), whereas HIV-1 sequences were detected in a smaller proportion of cells (at least 1 in 3000 cells). Clinical remission was achieved after chemotherapy. There was a decrease in the proportion of HTLV-I positive mononuclear cells (at least 1 in 1000 cells), whereas the proportion of HIV-1 positive cells was relatively unchanged (at least 1 in 1000 cells). Adult T-cell leukemia-lymphoma in the setting of HIV coinfection may become increasingly common because asymptomatic retroviral coinfections are frequent.

Molecular cloning and preliminary genetic analysis of the men gene cluster of Bacillus subtilis

The Bacillus subtilis chromosomal locus that contains the genes encoding the menaquinone biosynthetic enzymes (the men genes) was cloned by using an integrable plasmid vector. The men cluster was reconstituted on three overlapping recombinant plasmids, and a tentative gene order was derived. Evaluations of the direction of transcription and of transcriptional boundaries suggested that the men genes are expressed in the form of at least one polycistronic message. In addition, a spectrum of Men phenotypes resulting from the integration of different internal fragments of the cluster indicate transcriptional complexities, possibly including an internal promoter. The size of cloned DNA fragments required to encompass the transcription unit, as well as the locations of known men mutations within these fragments, suggests that a gene(s) not previously identified with the men system is also located within the cluster. The cloned men sequences make available probes to examine the patterns of transcription from the men locus in response to changing environmental conditions and during the developmental sequence represented by endospore formation.

A coprological survey of parasites of wild neotropical felidae

In conjunction with an ecological study of jaguars in the Cockscomb Basin of Belize, Central America, fecal samples from jaguars (Panthera onca), jaguarundis (Felis yagouaroundi), ocelots (Felix pardalis), and pumas (Felix concolor) were examined for parasite products (eggs, larvae, and oocysts). Of the 45 samples examined, 39 (86.7%) were positive for parasite products, 23 of 25 (92%) jaguar samples were positive, as were all of the puma (4/4) and ocelot (8/8) samples. Four of 6 samples from unknown species were positive (66.7%). Two jaguarundis samples were negative. The following were identified in the samples: Paragonimus sp. eggs, Taeniidae eggs, Strongylate eggs, Toxocara cati eggs, Toxascaris sp. eggs, Capillaria sp. eggs, Spiruridae eggs, Aelurostrongylus sp. larvae, Oncicola sp. eggs, Hammondia pardalis oocysts, Isospora sp. oocysts, Toxoplasma gondii-like oocysts and Sarcocystis sp. sporocyst.

Data acquisition using a scintillation detector interfaced to a personal microcomputer

A method is described for interfacing a cadmium telluride semiconductor nonimaging detector to a personal microcomputer in order to store and display nuclear medicine data. There was virtual identity between the count rates stored in the computer and those recorded from the detector's display, demonstrating that the computer accurately acquired data from the probe without erroneous loss or addition of data. Interfacing a nonimaging detector to a microcomputer may provide an extremely versatile method of acquiring, storing, and displaying nuclear medicine data.

Parental influence on adolescents' imagination

It was hypothesized that a permissive democratic parental attitude towards childrearing and favorable accepting attitude towards children's imagination are conducive to the development of their adolescent children's imaginative ability. It was also hypothesized that the mothers' role is more crucial than that of the fathers. The subjects were 104 adolescent Israeli boys and girls and their parents. The subjects were administered four scales of the Imaginal Processes Inventory and the Children's Report of Parental Behavior Inventory. The parents filled out a questionnaire devised to study their attitude to children's imagination. The first two hypotheses were not confirmed. The data point in the opposite direction as regards the first hypothesis. There was partial conformation for the third hypothesis. The data were also discussed in relation to healthy and neurotic daydreaming.

Genetic analysis of bacteriophage P4 using P4-plasmid ColE1 hybrids

A set of plasmids that contain fragments of the bacteriophage P4 genome has been constructed by deleting portions of a P4-ColE1 hybrid. A P4 genetic map has been established and related to the physical map by examining the ability of these plasmids to rescue various P4 mutations. The P4 virl mutation and P4 genes involved in DNA replication (alpha), activation of P2 helper genes (delta and epsilon), polarity suppression (psu) and head size determination (sid) have been mapped, as has the region responsible for synthesis of a nonessential P4 protein. One of the deleted plasmids contains only 5900 base pairs (52%) of P4 but will form plaques if additional DNA is added to increase its total size to near that of P4. This plasmid is also unique in that it will not form stable associations with P2 lysogens of E. coli which are recA+. P4 alpha mutants can be suppressed as a result of replication under control of the ColE1 part of the hybrid.

Locus of control and effects of failure on perfomance and perceived competence

Reactions to related performance feedback of 117 internal and external eighth-grade children were investigated under conditions which made denial of personal responsibility for outcomes difficult. Both internals and externals were equally pleased by success feedback and displeased by failure and their competence judgement was influenced by the feedback received. However, internals exhibited more effective coping with failure than did externals. They improved their performance following failure feedback relatively more than after success and no external feedback conditions, and their percieved competance did not decrease in comparison with externals.