Functional tremor developing after successful MRI-guided focused ultrasound thalamotomy for essential tremor

OBJECTIVE

To describe a case of functional tremor occurring after a successful MR-guided focused ultrasound thalamotomy (MRgFUS) for essential tremor.

METHODS

A 71-year-old right-handed man with essential tremor was referred to us for consideration of deep brain stimulation surgery for worsening bilateral upper limb tremor after a successful left MRgFUS for essential tremor.

RESULTS

On clinical exam, signs compatible with a functional tremor were noted, including entertainability and suppressibility. Electrophysiological studies were consistent with essential tremor and superimposed tremor fulfilling the laboratory-supported criteria for functional tremor.

DISCUSSION

We describe the first reported case of a functional movement disorder occurring after successful MRgFUS procedure for essential tremor. Recognising this entity and its development after such therapeutic interventions is essential to avoid further unnecessary invasive therapies.

Consumer selection and home health agency quality and patient experience stars

OBJECTIVE

To compare the impact of the introduction of two distinct sets of star ratings, quality of care, and patient experience, on home health agency (HHA) selection.

DATA SOURCES

We utilized 2014-2016 home health Outcome and Assessment Information Set (OASIS) assessments, as well as publicly reported data from the Home Health Compare website.

DATA COLLECTION/EXTRACTION METHODS

We identified a 5% random sample of admissions (186,498 admissions) for new Medicare Fee-for-Service home health users.

STUDY DESIGN

This admission-level assessment compared HHA selection before (July 2014-June 2015) and after (February-December 2016) star ratings were published. We utilized a conditional logit, discrete choice model, which accounted for all HHAs that each patient could have selected (i.e., the choice set) based on ZIP codes. Our explanatory variables of interest were the interactions between star ratings and time period (pre/post stars). We stratified our analyses by race, admission source, and Medicaid eligibility. We adjusted for HHA characteristics and distance between patients' homes and HHAs.

PRINCIPAL FINDINGS

The introduction of star ratings was associated with a 0.88-percentage-point increase in the probability of selecting a high-quality HHA and a 0.81-percentage-point increase in the probability of selecting a highly ranked patient experience HHA. Patients admitted from the community, and black and Medicare-Medicaid dual-eligible beneficiaries experienced larger increases in their likelihood of selecting high-rated agencies than inpatient, white, and nondual beneficiaries.

CONCLUSIONS

The introduction of quality of care and patient experience stars were associated with changes in HHA selection; however, the strength of these relationships was weaker than observed in other health care settings where a single star rating was reported. The introduction of star ratings may mitigate disparities in HHA selection. Our findings highlight the importance of reporting information about quality and satisfaction separately and conducting research to understand the mechanisms driving HHA selection.

The Benefits of Culture Change in Nursing Homes-Obtaining Nationally Representative Evidence

OBJECTIVE

Despite face validity and regulatory support, empirical evidence of the benefit of culture change practices in nursing homes (NHs) has been inconclusive. We used rigorous methods and large resident-level cohorts to determine whether NH increases in culture change practice adoption in the domains of environment, staff empowerment, and resident-centered care are associated with improved resident-level quality outcomes.

DESIGN

We linked national panel 2009-2011 and 2016-2017 survey data to Minimum Data Set assessment data to test the impact of increases in each of the culture change domains on resident quality outcomes.

SETTING AND PARTICIPANTS

The sample included 1584 nationally representative US NHs that responded to both surveys, and more than 188,000 long-stay residents cared for in the pre- and/or postsurvey periods.

METHODS

We used multivariable logistic regression with robust standard errors and a difference-in-differences methodology. Controlling for the endogeneity between increases in culture change adoption and NH characteristics that are also related to quality outcomes, we tested whether pre-post quality outcome differences (ie, improvements in outcomes) were greater for residents in NHs with culture change increases vs in those without such increases.

RESULTS

NH performance on most quality indicators improved, but improvement was not significantly different by whether NHs increased or did not increase their culture change domain practices.

CONCLUSIONS AND IMPLICATIONS

This study found that increases in an NH's culture change domain practices were not significantly associated with improved resident-level quality. It describes a number of potential limitations that may have contributed to the null findings.

Are Patient Experience and Outcomes for Home Health Agencies Related?

To facilitate home health agency (HHA) selection, CMS released patient experience star ratings on the Home Health Compare website in January 2016. Our objective was to understand the relationship between patient experience and outcomes in HHAs. We utilized publicly reported data to evaluate the relationships among patient experience star ratings, summary quality of care star ratings (comprised primarily of outcome measures), and individual outcome measures for 4,249 HHAs. Results indicate a weak correlation between patient experience and quality stars (r = .13, p < .001). The difference between the lowest and highest rated HHAs for patient experience is associated with only a half-star improvement in quality stars. The associations between patient experience and individual outcome measures varied, with functional outcomes most strongly associated with patient experience. Findings highlight the importance of reporting separate quality domains; however, conflicting ratings may complicate the HHA selection process and introduce misaligned incentives for HHAs.

Early Effects of Home Health Value-Based Purchasing on Quality Star Ratings

The Home Health Value-Based Purchasing Model (HHVBP) is a new Medicare model wherein home health agencies compete to achieve higher reimbursements by demonstrating improved value according to clinical and patient experience-related quality measures. Many measures used in HHVBP overlap with measures used in quality star ratings for home health agencies. Thus, improvements in quality measures used in HHVBP may also be reflected in changes in star ratings. However, it is unclear whether agencies competing in HHVBP improve their Centers for Medicare & Medicaid Services star ratings compared with those not competing. Using publicly available data from Centers for Medicare & Medicaid Services, we evaluated the effect of HHVBP on quality of patient care and patient experience composite star ratings over a 2-year period using a difference-in-differences analysis. We found evidence for a small, statistically significant increase in quality of patient care star ratings for agencies participating in HHVBP, and no effect on patient experience ratings.

The Changing Adoption of Culture Change Practices in U.S. Nursing Homes

BACKGROUND AND OBJECTIVES

The study aimed to: (i) describe whether culture change (CC) practice implementation related to physical environment, resident-centered care, and staff empowerment increased within the same nursing homes (NHs) over time; and (ii) identify factors associated with observed increases.

RESEARCH DESIGN AND METHODS

This was a nationally representative panel study of 1,584 U.S. NHs surveyed in 2009/2010 and 2016/2017. Survey data were merged with administrative, NH, and market-level data. Physical environment, staff empowerment, and resident-centered care domain scores were calculated at both time points. Multivariate logistic regression models examined factors associated with domain score increases.

RESULTS

Overall, 22% of NHs increased their physical environment scores over time, 32% their staff empowerment scores, and 44% their resident-centered care scores. However, 32%-68% of NHs with below median baseline scores improved their domain scores over time compared with only 11%-21% of NHs with baseline scores at or above the median. Overall, NHs in states with Medicaid pay-for-performance (with CC components), in community care retirement communities, with special care units and higher occupancy had significantly higher odds of increases in physical environment scores. Only baseline domain scores were associated with increases in staff empowerment and resident-centered care scores.

DISCUSSION AND IMPLICATIONS

This is the first nationally representative panel study to assess NH CC adoption. Many NHs increased their CC practices, though numerous others did not. While financial incentives and indicators of financial resources were associated with increase in physical environment scores, factors associated with staff empowerment and resident-centered care improvements remain unclear. Studies are needed to assess whether the observed increases in CC adoption are associated with greater quality of life and care gains for residents and whether there is a threshold effect beyond which the efficacy of additional practice implementation may be less impactful.

Home Health Use Following a Cancer Diagnosis Among Patients Enrolled in Medicare Advantage and Traditional Medicare: Findings From the Newly Linked SEER-Medicare and Home Health OASIS Data

BACKGROUND

This article describes characteristics of patients receiving home health following an initial cancer diagnosis, comparing those enrolled in Medicare Advantage (MA) and Traditional Medicare (TM), using the newly linked 2010-2014 National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER)-Medicare and home health Outcome and Assessment Information Set (OASIS) data.

METHODS

We identified SEER-Medicare beneficiaries with at least one OASIS assessment within 3 months of cancer diagnosis in 2010-2014, and summarized their demographic and clinical characteristics. Demographic and diagnostic data were obtained from the SEER-Medicare data, while further details about cognitive status, mood, function, and medical history were obtained from OASIS. We assessed differences between MA and TM beneficiaries using chi-square tests for independence, t-tests, and Kruskal-Wallis tests.

RESUTLS

We identified 104 023 patients who received home health within 3 months of cancer diagnosis: 81 587 enrolled in TM and 22 436 enrolled in MA. TM cancer patients had higher unadjusted rates of home health use than MA patients (16.3% vs 10.3%, P < .001). TM cancer patients receiving home health had more limitations in their cognitive function than their MA counterparts and longer lengths of service (mean = 42.2 days vs 39.4 days, P < .001; median = 27 vs 26 days, interquartile range = 42).

CONCLUSION

This study demonstrates the large number of cancer patients in the SEER-Medicare-OASIS data and describes characteristics for TM and MA patients. These newly linked data can be used to assess home health care among older patients with cancer.

THE RELEASE OF TECHNICAL QUALITY AND PATIENT EXPERIENCE STAR-RATINGS FOR HOME HEALTH AGENCIES AND AGENCY SELECTION

To facilitate informed Home Health Agency (HHA) selection for the 3.5 million annual Medicare home health (HH) users, CMS introduced technical quality and patient experience summary star-ratings on the Home Health Compare website in July 2015 and January 2016. There is no information about the relationship between the introduction of these two unique sets of star-ratings and HHA selection. We utilized a conditional logit, discrete choice model, which accounts for all HHAs that each patient could have selected (their “choice-set”) based on ZIP codes, to assess this relationship. We selected a random 5% sample (203,966 admissions) of new Medicare Fee-for-Service HH admissions that occurred in the year before, or the year after star-ratings were released. Star-ratings were obtained from the HH Compare website and categorized as low (=4 stars). We found the introduction of HHA star-ratings was associated with an increased likelihood of selecting an HHA with a high technical quality star-rating, and a decreased likelihood of selecting an HHA with a high patient experience star-rating. After controlling for each patient’s choice-set, patients had 19% increased odds (OR 1.19, 95% CI:1.16,2.23) of selecting a high technical quality HHA and a 12% decreased odds (OR 0.88, 95% CI:0.84,0.92) of selecting a high patient experience HHA, compared to low quality HHAs. Findings suggest patients and referring providers may prioritize technical quality over patient experience. Policy-makers should provide resources to enable HH patients to utilize and interpret the two different HHA star-ratings.

A NATIONAL ASSESSMENT OF THE RELATIONSHIP BETWEEN NURSING HOME CULTURE CHANGE AND RESIDENT OUTCOMES

Literature is mixed regarding the relationship between Nursing Home (NH) culture change and resident outcomes, and the majority of studies are limited to small samples. We evaluated this relationship separately for five unique domains of NH culture change (physical environment, resident care, staff empowerment, leadership, and family and community involvement practices) using a 2016/2017 survey administered to a stratified-random national sample of NHs; 74% of NH administrators responded (n=1,583). We assessed the relationship between each culture change domain and 8 outcomes (calculated with MDS 3.0 and Medicare claims data) using resident-level multivariable logistic regression models, that accounted for resident and NH characteristics, and were weighted by facility-level inverse probability weights (to address NH Selection). We found the relationship between NH culture change and resident outcomes varied by culture change domain. High scores on leadership practices (i.e., two-way communication, staff involvement, education/training, respect for workers, and coaching) were most strongly associated with outcomes. Compared to the lowest quartile, performance in the highest quartile (most implementation of practices) on the leadership domain was associated with 13% lower odds (OR: 0.87, 95%CI: 0.78, 0.96) of urinary tract infections, 15% lower odds (OR: 0.85, 95%CI: 0.80, 0.91) of worsened locomotion, and 41% lower odds (OR: 0.59, 95%CI: 0.42, 0.83) of physical restraint use. For the other domains the estimates (and statistical significance) of the relationship with outcomes varied more than observed for leadership. Our findings emphasize the importance of high-quality NH leadership. Investments in improved leadership practices may result in higher-quality resident outcomes.

Quality of Home Health Agencies Serving Traditional Medicare vs Medicare Advantage Beneficiaries

IMPORTANCE

Medicare Advantage (MA) enrollment is increasing, with one-third of Medicare beneficiaries currently selecting MA. Despite this growth, it is difficult to assess the quality of the health care professionals and organizations that serve MA beneficiaries or to compare them with health care professionals and organizations serving traditional Medicare (TM) beneficiaries. Elderly individuals served by home health agencies (HHAs) may be particularly susceptible to the negative outcomes associated with low-quality care.

OBJECTIVE

To compare the quality of HHAs that serve TM and MA beneficiaries.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional, admission-level analysis used data from 4 391 980 home health admissions identified using the Outcome and Assessment Information Set (most commonly known as OASIS) admission assessments of Medicare beneficiaries in 2015 from Medicare-certified HHAs. A multinomial logistic regression model was used to assess whether an association existed between the Medicare plan type and HHA quality. The model was adjusted for patient demographics, acuity, and characteristics of the zip codes. Sensitivity analyses controlled for zip code fixed effects. The present analysis was conducted between October 2018 and March 2019.

EXPOSURES

Home health users were classified as TM or MA beneficiaries using the Master Beneficiary Summary File. The MA beneficiaries were further classified as enrolled in a high- or low-quality MA plan on the basis of publicly reported MA star ratings.

MAIN OUTCOMES AND MEASURES

Quality of HHA derived from the publicly reported patient care star ratings: low quality (1.0-2.5 stars), average quality (3.0-3.5 stars), or high quality (≥4.0 stars).

RESULTS

Of 4 391 980 admissions, most (75.5%) were for TM beneficiaries (mean [SD] age, 76.1 [12.2] years), with 16.6% of beneficiaries enrolled in high-quality MA plans (mean [SD] age, 77.8 [10.0] years) and 7.9% in low-quality MA plans (mean [SD] age, 74.4 [11.4] years). Individuals enrolled in low-rated MA plans were most likely to be nonwhite (percentages of nonwhite individuals in TM, 14.3%; in high-quality MA, 19.8%; and in low-quality MA, 36.5%) and dual Medicare-Medicaid eligible (percentages for dual eligible in TM, 30.5%; in high-quality MA, 19.5%; and in low-quality MA, 43.3%). Among TM beneficiaries, 30.4% received care from high-quality HHAs, whereas 17.0% received care from low-quality HHAs. Compared with TM beneficiaries, those in a low-quality MA plan were 3.0 percentage points (95% CI, 2.6%-3.4%) more likely to be treated by a low-quality HHA and 4.9 percentage points (95% CI, -5.4% to -4.3%) less likely to be treated by a high-quality HHA. The MA beneficiaries in high-quality plans were also less likely to receive care from high-quality vs low-quality HHAs (-2.8% [95% CI, -3.1% to -2.2%] vs 1.0% [95% CI, 0.7%-1.3%]).

CONCLUSIONS AND RELEVANCE

Compared with TM beneficiaries, MA beneficiaries residing in the same zip code enrolled in either high- or low-quality MA plans may receive treatment from lower-quality HHAs. Policy makers may consider incentivizing MA plans to include higher-quality HHAs in their networks and improving patient education regarding HHA quality.

End-of-Life Culture Change Practices in U.S. Nursing Homes in 2016/2017

CONTEXT

The nursing home (NH) culture change (CC) movement, which emphasizes person-centered care, is particularly relevant to meeting the unique needs of residents near the end of life.

OBJECTIVES

We aimed to evaluate the NH-reported adoption of person-centered end-of-life culture change (EOL-CC) practices and identify NH characteristics associated with greater adoption.

METHODS

We used NH and state policy data for 1358 NHs completing a nationally representative 2016/17 NH Culture Change Survey. An 18-point EOL-CC score was created by summarizing responses from six survey items related to practices for residents who were dying/had died. NHs were divided into quartiles reflecting their EOL-CC score, and multivariable ordered logistic regression was used to identify NH characteristics associated with having higher (quartile) scores.

RESULTS

The mean EOL-CC score was 13.7 (SD = 3.0). Correlates of higher scores differed from those previously found for non-EOL-CC practices. Higher NH leadership scores and nonprofit status were consistently associated with higher EOL-CC scores. For example, a three-point leadership score increase was associated with higher odds of an NH performing in the top EOL-CC quartile (odds ratio [OR] = 2.0, 95% CI: 1.82-2.30), whereas for-profit status was associated with lower odds (OR = 0.7, 95% CI: 0.49-0.90). The availability of palliative care consults was associated with a greater likelihood of EOL-CC scores above the median (OR = 1.5, 95% CI: 1.10-1.93), but not in the top or bottom quartile.

CONCLUSION

NH-reported adoption of EOL-CC practices varies, and the presence of palliative care consults in NHs explains only some of this variation. Findings support the importance of evaluating EOL-CC practices separately from other culture change practices.

Variation in post-adenotonsillectomy admission practices in 24 pediatric hospitals

OBJECTIVES/HYPOTHESIS

There is controversy about which children should be admitted after adenotonsillectomy (T&A) and limited clinical evidence to help with this decision. Current practice has evolved based on empirical or anecdotal evidence. We sought to identify practice variations in postoperative admission after T&A in tertiary care pediatric hospitals.

STUDY DESIGN

Retrospective database study using administrative information stored in the Pediatric Health Information System (PHIS) database.

METHODS

There were 29,920 T&As performed in 24 pediatric hospitals included in the PHIS database between July 1, 2009 and June 30, 2010. Patients were identified as outpatient (discharged the same day) or inpatient (not discharged on the day of surgery). We examined admission rates across different hospitals stratified by age, obstructive sleep apnea (OSA), and other complex chronic conditions.

RESULTS

Younger age, the existence of a complex chronic condition, and OSA were all associated with higher post-T&A admission rates. Admission rates ranged from >94% for children under 2 years of age, with OSA and at least one medical comorbidity, to 14% for children older than 5 years, without OSA and without any medical comorbidities. Between-hospital variability was extreme; for example, for 3 to 5 year olds, the admission rate varied from 5% to 90% between hospitals. Very significant variation remained even after controlling for age, comorbidities, and OSA.

CONCLUSIONS

Post T&A admission rates vary tremendously across comparable tertiary-care pediatric hospitals. There is a crucial need for a better understanding of the risk of complications on the first postoperative night, and the appropriate indications for monitored admission on that night.

LEVEL OF EVIDENCE

4.

Management and clinical outcome of posterior fossa arteriovenous malformations: report on a single-centre 15-year experience

OBJECTIVES

Posterior fossa brain arteriovenous malformations (PFbAVMs) are rare lesions. Management is complicated by eloquence of adjacent neurological structures, multimodality treatment is often necessary, and obliteration is not always possible. We describe a 15-year experience in the management of posterior fossa brain AVMs with a focus on clinical outcome.

METHODS

From 1989 to 2004, prospectively collected information on 106 patients with diagnosis of a PFbAVMs was obtained. Clinical and angioarchitectural characteristics, management options and complications are described and reviewed to evaluate their impact on final outcome as measured by the Modified Rankin Score (mRS).

RESULTS

Ninety-eight patients were followed for an average of 3.3 years (1-14.6). The male-to-female ratio was 1:1. Ninety-five out of 98 patients (96.9%) were symptomatic at presentation, with 61 (62.2%) intracranial haemorrhages. Sixty-two patients were treated (46 cerebellar, 16 brainstem). Ten haemorrhages occurred in follow-up (4.1%/year). The mRS was obtained in 62 patients and was classified as low (good, mRS<or=2) or high (poor, mRS>or=3). Haemorrhage was the only predictor of poor mRS at presentation (p = 0.0229). A poor clinical outcome was correlated with the presence of AA (p = 0.0276), a poor initial mRS (p<0.0001) and the number of treatments needed (p = 0.0434). Patients were significantly more likely to improve than to deteriorate over time (p = 0.0201).

CONCLUSION

The final clinical outcome in PFbAVMs relates directly with the presence of associated aneurysms, number of treatments needed to obliterate the AVM and mRS at presentation. Despite the fact that patients tend to improve after brain AVM haemorrhage, the relationship of MRS at presentation and final outcome suggests that an expedited, more definitive treatment is probably a better choice, especially in patients with good grades after the initial bleeding.

Liquid embolisation material reduces the delivered radiation dose: a physical experiment

OBJECTIVE

To test a new hypothesis that the glue/contrast admixture used for embolisation reduces the dose delivered to AVMs using an experimental model.

METHOD

A model was created using a block of "solid water" (6 x 5 x 2 cm) with twelve wells of different depths. Different concentrations of the glue admixture (Enbucrilate + Lipiodol) were used. The model was irradiated using a 5MV beam with a clinical LINAC system and the dose was checked upstream and downstream. Dose was measured using Kodak XV film, a Vidar 16 bit film scanner and software for therapeutic film dosimetry measurements (RIT software).

RESULTS

The radiation dose varied with the distance beyond the glue solid water interface. For distances of 0, 2 and 5 mm to the film, the mean reduction was 13.65% (SD = 2.94), 6.87% (SD = 1.95) and 1.75% (SD = 1.14), respectively. There was also correlation with the Lipiodol concentration in the mixture. The maximum reductions for 80, 50 and 20% Lipiodol concentrations were 16.1% (SD = 1.32), 14.85% (SD = 0.98) and 10% (SD = 1.21), respectively. There was no correlation between the glue depth and the dose delivered.

CONCLUSION

The hypothesis that the glue mixture used for embolisation reduces the radiation dose delivered was experimentally confirmed with this study.

Chronic hypoxia up-regulates fibroblast growth factor ligands in the perinatal brain and induces fibroblast growth factor-responsive radial glial cells in the sub-ependymal zone

A number of signaling molecules have been implicated in the acute response to hypoxia/ischemia in the adult brain. In contrast, the reaction to chronic hypoxemia is largely unexplored. We used a protocol of chronic hypoxia in rat pups during the first three postnatal weeks, encompassing the period of cellular plasticity in the cerebral cortex. We find that the levels of fibroblast growth factor 1 (FGF1) and FGF2, two members of the FGF family, increase after 2 weeks of chronic hypoxia. In contrast, members of the neurotrophin family are unaffected. FGF2 is normally expressed in the nucleus of mature, glial fibrillary acidic protein (GFAP)-containing astrocytes. Under hypoxia, most FGF2-containing cells do not express detectable levels of GFAP, suggesting that chronic low O(2) induces their transformation into more immature glial phenotypes. Remarkably, hypoxia promotes the appearance of radial glia throughout the sub-ventricular and ependymal zones. Most of these cells express vimentin and brain lipid binding protein. A subset of these radial glial cells expresses FGF receptor 1, and are in close contact with FGF2-positive cells in the sub-ventricular zone. Thus, FGF receptor signaling in radial glia may foster cell genesis after chronic hypoxic damage. From the results of this study we suggest that after the chronic exposure to low levels of oxygen during development, the expression of radial glia increases in the forebrain periventricular region. We envision that astroglia, which are the direct descendants of radial glia, are reverting back to immature glial cells. Alternatively, hypoxia hinders the normal maturation of radial glia into GFAP-expressing astrocytes. Interestingly, hypoxia increases the levels of expression of FGF2, a factor that is essential for neuronal development. Furthermore, chronic hypoxia up-regulated FGF2's major receptor in the periventricular region. Because radial glia have been suggested to play a key role in neurogenesis and cell migration, our data suggests that hypoxia-induced FGF signaling in radial glia may represent part of a conserved program capable of regenerating neurons in the brain after injury.

Predictors of outcome of biventricular repair in infants with multiple left heart obstructive lesions

BACKGROUND

Decisions regarding surgical strategy in patients with multiple left heart obstructive or hypoplastic lesions often must be made in the newborn period and are seldom reversible. Predictors of outcome of biventricular repair have not been well defined in this heterogeneous group of patients, and risk factors described for critical aortic valve stenosis have been shown to be inapplicable to patients with other left heart obstructive lesions. The goal of this study was to identify echocardiographic predictors of outcome of biventricular repair for infants with multiple left heart obstructive lesions.

METHODS AND RESULTS

Patients with >/=2 areas of left heart obstruction or hypoplasia, diagnosed at </=3 months of age, who had not previously undergone surgical or catheter intervention and maintained biventricular physiology were included (n=72). Failure of biventricular repair was defined as takedown to a univentricular repair, cardiac transplantation, and/or death (n=14; 19%). This group was compared with the patients who survived a biventricular approach (n=58). Multiple categorical, morphometric and calculated variables were examined on the basis of the initial echocardiograms. By multivariate analysis, predictors of failure included moderate/large ventricular septal defect (OR=22, P=0.001), unicommissural aortic valve (OR=16, P=0.006), and lower mitral valve dimension z-score (OR=2.2, P=0.02) or lower left ventricular end-diastolic volume z-score (OR=1.9, P=0.03).

CONCLUSIONS

Moderate/large ventricular septal defect, unicommissural aortic valve, and hypoplastic mitral valve or left ventricle are independent risk factors for failure of biventricular repair for infants with multiple left heart obstructive lesions. Combinations of these risk factors may be useful in selecting surgical strategy.

Intracranial arteriovenous malformations: real-time auto-triggered elliptic centric-ordered 3D gadolinium-enhanced MR angiography--initial assessment

Auto-triggered elliptic centric-ordered three-dimensional (3D) gadolinium-enhanced magnetic resonance (MR) angiography was compared with 3D multiple overlapping thin-slab acquisition time-of-flight (TOF) MR angiography in the evaluation of intracranial arteriovenous malformations (AVMs) in 10 patients. Intraarterial digital subtraction angiography (DSA) was the reference standard. Gadolinium-enhanced MR angiograms were found to be equivalent to DSA images in AVM component depiction in 70%--90% of cases and were consistently superior to TOF MR angiograms.

Uterine artery embolization for the treatment of uterine fibroids: an outpatient procedure

OBJECTIVE

Our objectives were to establish an outpatient program for uterine artery embolization of fibroids and to monitor the following: percentage of patients who required immediate hospitalization or admission within 2 weeks, outcomes in terms of the degree of ultrasound regression of the fibroids, patient satisfaction, reduction of pressure symptoms, and reduction of bleeding.

STUDY DESIGN

Patients were screened by a gynecologist with the use of a designed care algorithm; they then underwent uterine embolization, performed by an interventional radiologist. Patients were evaluated at 6 weeks and 6 months after the procedure, and ultrasound studies were performed both before and at 2 to 6 months after the procedure.

RESULTS

Of 35 patients, 29 (83%) went home on the day of the procedure, whereas 6 were observed overnight. Three (9%) patients required admission within 1 week. Of 26 patients, 24 (92%) were satisfied with the reduction of bleeding, and 14 of 18 (78%) were satisfied with the reduction in pressure symptoms. The mean decrease in uterine volume was 36%, and the mean decrease in the size of the dominant fibroid was 49%.

CONCLUSIONS

Uterine artery embolization for the treatment of uterine fibroids might be done on an outpatient basis with a low rate of same-day admissions and delayed admissions. Patient satisfaction was high, and uterine artery embolization might become an accepted option for the treatment of uterine fibroids.

Adding magnesium to the silver-gill binding model for rainbow trout (Oncorhynchus mykiss)

Rainbow trout (Oncorhynchus mykiss; 2-17 g) were exposed to approximately 0.1 microM silver as AgNO3 for 3 to 4 h in synthetic, ion-poor water (20 microM Ca, 100 microM Na, 150 microM Cl, pH 7) to which was added Mg, Ca, or thiosulfate (S2O3). Gills were extracted and assayed for Ag using graphite furnace atomic absorption spectrophotometry. Up to 210 mM Mg (fourfold the concentration of Mg in seawater) did not reduce accumulation of Ag by trout gills. The conditional equilibrium stability constant (K) for Mg at silver-binding sites on the gills was calculated to be log K(Mg-gillAg) = 3.0, or approximately half-as-strong binding as for Ca at these sites. The inclusion of the Mg-gill stability constant into the original Ag-gill binding model increases the flexibility of the model, although the competitive effects of Mg are only important in sodium-poor systems.

DYN 12, a small molecule inhibitor of the enzyme amadorase, lowers plasma 3-deoxyglucosone levels in diabetic rats

3-Deoxyglucosone (3DG) is a highly reactive alpha-dicarbonyl sugar and potent protein cross-linker that is important in the formation of advanced glycation end products (AGEs), which have been postulated to lead to the development of diabetic complications. (1) Reducing 3DG levels in diabetics is a potentially effective therapy to slow the development of diabetic complications. Standard biochemical methods were used to isolate, identify, and characterize the enzyme responsible for the production of 3DG, in order to develop an effective therapeutic agent against this target. We have purified and characterized Amadorase, a fructosamine-3-kinase, and demonstrated both in vitro and in vivo that it is responsible for the production of 3-deoxyglucosone (3DG). A small molecule inhibitor of Amadorase, DYN 12, significantly lowered plasma levels of 3DG in diabetic (by 46%, p = 0.0116) and normal (by 43%, p = 0.0024) rats. These data are the first indications that it is possible to significantly reduce 3DG production in diabetics and thus possibly reduce the development of diabetic complications.

Unruptured intracranial aneurysms: appraisal of the literature and suggested recommendations for surgery, using evidence-based medicine criteria

OBJECTIVE

The literature on unruptured intracranial aneurysms is reviewed, and an attempt is made to stratify it according to the weight of the evidence. Recommendations for surgery are suggested, using evidence-based criteria.

METHODS

A MEDLINE search was performed for 1966 to 1999. The focus was restricted to surgical management rather than other types of management, such as endovascular treatments. Each article was classified as Class I, II, or III according to the weight of the evidence. Some articles, such as literature reviews and data analyses, did not fit this classification and were grouped separately. Recommendations are based on the evidence available.

RESULTS

Forty-five articles were reviewed. Thirteen articles contained information on the natural history, 19 contained data on the risks of surgery, and 2 contained information on both. In addition, 11 contained analyses of costs and benefits. None met the criteria for Class I evidence. Seven articles on the natural history and 7 on the risks of surgery met the criteria for Class II evidence, and 6 and 12, respectively, met those for Class III evidence. The remainder of the articles were analyses or review articles.

CONCLUSION

There is insufficient evidence to recommend a standard of management. As a therapeutic guideline, conservative treatment is recommended for small aneurysms (<10 mm) and asymptomatic nongiant aneurysms in older people, whereas surgery is recommended for larger aneurysms in younger people and symptomatic aneurysms in fit patients. Other recommendations can be justified only as therapeutic options, using evidence-based criteria. Areas for future investigation are discussed.

Heterotopic calcification and tears of the ulnar collateral ligament: radiographic and MR imaging findings

OBJECTIVE

The purpose of this paper is to describe the radiographic and MR imaging appearance of heterotopic calcification in the ulnar collateral ligament.

MATERIALS AND METHODS

Retrospective radiographic review of 710 patients examined for elbow pain yielded 42 individuals (age range, 16-38 years) with heterotopic calcification in the ulnar collateral ligament. Radiographic and MR imaging findings were compared with surgical findings.

RESULTS

Fifty-one heterotopic calcifications were identified in 42 patients; nine patients had two sites of heterotopic calcification. Average initial calcification size in the craniocaudal dimension was 4 mm (range, 1-12 mm) and in the transverse dimension was 1 mm (range, 1-4 mm). Five of 42 patients had enlargement of the calcification on follow-up radiography. The largest heterotopic calcification that was not visualized on MR imaging measured 5 x 4 mm in craniocaudal and transverse dimensions. Of 34 patients with heterotopic calcification who underwent surgery, 26 patients (76%) had either partial or complete tears of the ulnar collateral ligament.

CONCLUSION

Heterotopic calcification in the ulnar collateral ligament may be associated with partial or complete tears. The MR imaging detection of heterotopic calcification is less sensitive than that of radiography of the elbow.

Assessment of strategic self-regulation in traumatic brain injury: its relationship to injury severity and psychosocial outcome

Standard neuropsychological tests administered in a constrained and artificial laboratory environment are often insensitive to the real-life deficits faced by patients with traumatic brain injury (TBI). The Revised Strategy Application Test (R-SAT) creates an unstructured environment in the laboratory in which environmental cues and internal habits oppose the most efficient strategy, thus mimicking the real-life situations that are problematic for patients with TBI. In this study, R-SAT performance was related both to severity of TBI (i.e., depth of coma) sustained 2-3 years earlier and to quality of life outcome as assessed by the Sickness Impact Profile. This relationship held after accounting for variance attributable to TBI-related slowing and inattention. These findings support the validity of the R-SAT and suggest that behavioral correlates of quality of life outcome in TBI can be assessed in the laboratory with unstructured tasks.

Differential modulation of proliferation in the neocortical ventricular and subventricular zones

Recent studies have implicated the classical neurotransmitters GABA and glutamate in the regulation of neural progenitor proliferation. We now show that GABA and glutamate have opposite effects on the two neural progenitor populations in the ventricular zones (VZs) and subventricular zones (SVZs) of the embryonic cerebrum. Application of either molecule to organotypic slice cultures dramatically increases proliferation in the VZ by shortening the cell cycle, whereas proliferation in the SVZ is decreased. These disparate effects, measured both by bromodeoxyuridine uptake and the expansion of retrovirally labeled progenitor clones, are mimicked by the application of specific GABA and glutamate agonists and are blocked by antagonists. Thus, the relative contributions of the VZ and SVZ to neocortical growth may be regulated by differential responsiveness to GABA and glutamate.

Basic fibroblast growth factor (Fgf2) is necessary for cell proliferation and neurogenesis in the developing cerebral cortex

Little is known about regionally specific signals that control the number of neuronal progenitor cells in vivo. We have previously shown that the germline mutation of the basic fibroblast growth factor (Fgf2) gene results in a reduction in the number of cortical neurons in the adult. We show here that Fgf2 is expressed in the pseudostratified ventricular epithelium (PVE) in a dorsoventral gradient and that Fgf2 and its receptor, Fgfr-1, are downregulated by mid to late stages of neurogenesis. In Fgf2 knockout mice, the volume and cell number of the dorsal PVE (the cerebral cortical anlage) are substantially smaller, whereas the volume of the basal PVE is unchanged. The dorsal PVE of Fgf2 knockout mice has a 50% decrease in founder cells and a reduced expansion of the progenitor pool over the first portion of neurogenesis. Despite this reduction, the degree of apoptosis within the PVE is not changed in the Fgf2 knockouts. Cortical neuron number was decreased by 45% in Fgf2 knockout mice by the end of neurogenesis, whereas the number of neurons in the basal ganglia was unaffected. Microscopically, the frontal cerebral cortex of neonatal Fgf2 null mutant mice lacked large neurons in deep cortical layers. We suggest that Fgf2 is required for the generation of a specific class of cortical neurons arising from the dorsal PVE.

Prediction of recovery of continuous memory after traumatic brain injury

OBJECTIVE

To evaluate the ability of measures of initial severity, tests of attention, and demographic characteristics to predict recovery of continuous memory for words over a 24-hour period in patients with acute traumatic brain injury.

METHODS

Recovery of continuous memory was assessed prospectively in 94 patients with nonpenetrating traumatic brain injury. A classification and regression tree analysis identified a hierarchical subset of variables that may be used as a simple guideline for predicting recovery of continuous memory. Weibull regression models evaluated and compared the predictive ability of multiple variables.

RESULTS

Four groups of patients were identified based on measures of severity of injury and demographic characteristics. These four groups had recovery profiles that were more precise than could be obtained by using the Glasgow Coma Scale alone: mild, about 1 week to recovery of continuous memory; moderate, 1 to 4 weeks; severe, 2 to 6 weeks; and extremely severe, 4 to 8 weeks. Regression analysis confirmed that measures of capacity (inherent resources such as indicated by age) and compromise (general functional brain state measured neuropsychologically) improved prediction over models based only on injury severity measures, such as the Glasgow Coma Scale.

CONCLUSIONS

Approaches to predicting recovery of continuous memory in the acute period after traumatic brain injury that take into account multiple measures provide a more sensitive predictive index.

Characteristics of injuries to the cervical spine and spinal cord in polytrauma patient population: experience from a regional trauma unit

STUDY DESIGN

Retrospective analysis of a prospectively collected trauma database of a Level 1 (tertiary) trauma center.

OBJECTIVE

To define the features of the cervical spinal injuries in polytrauma population admitted to the regional trauma unit.

SETTING

Canada, Ontario Province, Toronto, Sunnybrook Health Sciences Center.

METHODS

All trauma admissions between 1987 and 1996 entered prospectively into a trauma registry database were studied for incidence, demographic and epidemiological details of cervical spine (cord and column) injuries.

RESULTS

A total of 468 patients (66% male) with cervical spinal injury (CSI) from 1198 spinal injuries admitted to the regional trauma center were identified. Seventy-five per cent of the CSI involved were aged less than 50 years; nearly 30% were in the third decade alone. Overall, the commonest spinal level injured was C2 (27%) followed by C5 (22%). Older population (above 60 years of age) had C1 + 2 involved more often than the young (P=0.02). Motor vehicular crashes (MVC) accounted for 71%, followed by pedestrian trauma (10%), sport injuries (7%). Spinal cord injury (SCI) was noted in 27%; complete in 16% and incomplete in 11% and more frequently at C4 or C5 level compared with C1, C2 (P<0.00001); the former level had more often a complete SCI (P=0.06). Though MVC produced 74% of SCI, only 27% had neurological deficits. Recreational trauma produced SCI in 45%, motor cycle crashes (MCC) in 37% and a rear passenger in MVC in 34% that was complete in 78%, 71% and 73% respectively. Front seat passenger and driver in MVC had a C5 level injury while a rear seat passenger had at C4 (P<0.001). The C1 level injury had high association with severe and life threatening head and neck and facial injuries compared with the more frequently injured spinal levels; either C2 (P=0.03) or C5 (P=0.004). Similarly C1 injuries had higher ISS compared with C2 (P<0.0001) and C5 (P<0.008).

CONCLUSIONS

C2 was the commonest fractured spine while SCI was more frequent at C5. Older and pedestrian population had higher incidences of injuries at C1 and C2. Sport and MCC resulted in severe SCI. The level of spine injured was different between a front and a rear seat occupant in MVC.

Fibroblast growth factor signaling regulates growth and morphogenesis at multiple steps during brain development

The fibroblast growth factor (FGF) family comprises several members with distinct patterns of expression in the developing central nervous system. FGFs regulate the early specification and the subsequent growth of central nervous system regions. These different actions require the coordinated activation of distinct sets of target genes by FGFs at the appropriate stage of development. The role of FGF2 in the growth and morphogenesis of the cerebral cortex is reviewed in detail. The cellular and molecular mechanisms that underlie the action of FGF2 on cortical development are discussed.

The diagnosis and classification of gestational diabetes mellitus: is it time to change our tune?

OBJECTIVE

This study was designed to determine the impact on our population of adopting the Carpenter and Coustan criteria for gestational diabetes mellitus in place of the currently used National Diabetes Data Group criteria, to review the evidence supporting replacement of the National Diabetes Data Group criteria with the Carpenter and Coustan criteria, and to propose analogous diagnostic criteria for diabetes in pregnant and nonpregnant women.

STUDY DESIGN

The National Diabetes Data Group criteria and the proposed Carpenter and Coustan criteria were both used to retrospectively review medical records of patients screened for gestational diabetes mellitus during 1995 and 1996 in the Kaiser Permanente Northwest Division. Computerized search was performed on automated data systems and software was used for statistical analyses. A MEDLINE review of relevant literature was conducted.

RESULTS

Of 8857 pregnant women screened for gestational diabetes in 1995 and 1996, 284 (3.21%) met the National Diabetes Data Group criteria, whereas 438 (4.95%) met the Carpenter and Coustan criteria. We estimate that in our population use of the Carpenter and Coustan criteria in 1996 could at best have reduced the prevalence of infants weighing >/=4000 g from 17.1% to 16.9% and the prevalence of infants weighing >/=4500 g from 2.95% to 2.91%.

CONCLUSIONS

Replacing the National Diabetes Data Group criteria with the Carpenter and Coustan criteria would increase by 54% the number of pregnant women with a diagnosis of gestational diabetes mellitus and would also increase costs, while only minimally affecting prevalence of infant macrosomia. The medical literature does not provide compelling evidence for adopting the Carpenter and Coustan criteria. Standardization of both measurement of venous plasma glucose level and diagnostic criteria for gestational diabetes mellitus is an important goal. Parallel criteria for diagnosis and classification of diabetes mellitus in pregnant and nonpregnant women should be developed.

Uterine rupture associated with the use of misoprostol in the gravid patient with a previous cesarean section

OBJECTIVE

Our purpose is to report our experience with uterine rupture in patients undergoing a trial of labor after previous cesarean delivery in which labor was induced with misoprostol. The literature on the use of misoprostol in the setting of previous cesarean section is reviewed.

STUDY DESIGN

This report was based on case reports, a computerized search of medical records, and literature review.

RESULTS

Uterine rupture occurred in 5 of 89 patients with previous cesarean delivery who had labor induced with misoprostol. The uterine rupture rate for patients attempting vaginal birth after cesarean section was significantly higher in those who received misoprostol, 5.6%, than in those who did not, 0.2% (1/423, P =.0001). Review of the literature reveals insufficient data to support the use of misoprostol in the patient with a previous cesarean delivery.

CONCLUSION

Misoprostol may increase the risk of uterine rupture in the patient with a scarred uterus. Carefully controlled studies of the risks and benefits of misoprostol are necessary before its widespread use in this setting.

The acute period of recovery from traumatic brain injury: posttraumatic amnesia or posttraumatic confusional state?

OBJECT

The goal of this study was to characterize more fully the cognitive changes that occur during the period of acute recovery after traumatic brain injury (TBI).

METHODS

The pattern of performance recovery on attention and memory tests was compared with the results of the Galveston Orientation and Amnesia Test (GOAT). Tests of memory and attention were administered serially to a hospitalized group of patients with TBI of varying severity. The tests differed in their level of complexity and/or requirement for more effortful or strategic processing. The authors found a regular pattern to recovery. As expected, ability to perform on simpler tests was recovered before performance on more effortful ones. The ability to recall three words freely after a 24-hour delay (the operational definition in this study of return to continuous memory) was recovered last, later than normal performance on the GOAT. Ability to perform simple attentional tasks was recovered before the less demanding memory task (recognition); ability to perform more complex attentional tasks was recovered before the free recall of three words after a 24-hour delay. This recovery of attention before memory was most notable and distinct in the group with mild TBI.

CONCLUSIONS

The period of recovery after TBI, which is currently termed posttraumatic amnesia, appears to be primarily a confusional state and should be labeled as such. The authors propose a new definition for this acute recovery period and argue that the term posttraumatic confusional state should be used, because it more appropriately and completely characterizes the early period of recovery after TBI.

Spinal cord-evoked potentials and muscle responses evoked by transcranial magnetic stimulation in 10 awake human subjects

Transcranial magnetic stimulation (TCMS) causes leg muscle contractions, but the neural structures in the brain that are activated by TCMS and their relationship to these leg muscle responses are not clearly understood. To elucidate this, we concomitantly recorded leg muscle responses and thoracic spinal cord-evoked potentials (SCEPs) after TCMS for the first time in 10 awake, neurologically intact human subjects. In this report we provide evidence of direct and indirect activation of corticospinal neurons after TCMS. In three subjects, SCEP threshold (T) stimulus intensities recruited both the D wave (direct activation of corticospinal neurons) and the first I wave (I1, indirect activation of corticospinal neurons). In one subject, the D, I1, and I2 waves were recruited simultaneously, and in another subject, the I1 and I2 waves were recruited simultaneously. In the remaining five subjects, only the I1 wave was recruited first. More waves were recruited as the stimulus intensity increased. The presence of D and I waves in all subjects at low stimulus intensities verified that TCMS directly and indirectly activated corticospinal neurons supplying the lower extremities. Leg muscle responses were usually contingent on the SCEP containing at least four waves (D, I1, I2, and I3).

Changes in cerebral cortex size are governed by fibroblast growth factor during embryogenesis

We show that fibroblast growth factor 2 (FGF2) and FGF receptors are transiently expressed by cells of the pseudostratified ventricular epithelium (PVE) during early neurogenesis. A single microinjection of FGF2 into cerebral ventricles of rat embryos at E15.5 increased the volume and total number of neurons in the adult cerebral cortex by 18% and 87%, respectively. Microinjection of FGF2 by the end of neurogenesis, at E20.5, selectively increased the number of glia. Mice lacking the FGF2 gene had fewer cortical neurons and glia at maturity. BrdU studies in FGF2-microinjected and FGF2-null animals suggested that FGF2 increases the proportion of dividing cells in the PVE without affecting the cell-cycle length. Thus, FGF2 increases the number of rounds of division of cortical progenitors.

Lower extremity manifestations of vascular disease

All podiatrists are required to know the anatomy and pathophysiology of vascular pathology because it is the leading cause of morbidity and mortality in the western world and a frequent complaint of podiatry patients. Podiatrists have a unique opportunity to reduce the risk of lower extremity vascular pathology, specifically PVD, by encouraging proper diet and exercise in the podiatric patient. Because the next century will bring a population explosion of older people, particular attention must be paid to the multiple and complex disorders that impair functional independence and compromise quality of life--one of the most important disorders being vascular disease. Successful treatment depends on recognition of lower extremity pathology (whether it be arterial, venous, or lymphatic) and the possible suprastructural causes and timely referrals to a vascular specialist when indicated.

Characterization of the mouse neurofilament light (NF-L) gene promoter by in vitro transcription

We have used in vitro transcription to access the basic sequences and factors required for the transcription of the mouse neurofilament light promoter (pNF-L) in the absence of chromatin structure. Deletion from -1.7 to -154 results in little change in NF-L promoter activity using nuclear extracts from either brain (expressing) or liver (non-expressing) tissues. Further deletion to -29 results in a gradual five-fold drop in promoter activity in both extracts. Only replacement of the entire -148 to -29 region results in a drop in NF-L promoter activity to basal levels. Thus, the NF-L promoter differs from the mouse NF heavy (NF-H) and mid-sized (NF-M) promoters in that no specific sequence within the immediate upstream NF-L promoter region (-154 to -29) appears to be responsible for enhancement or brain-specific transcription. We show that the order of strength of the three NF promoters is NF-H>NF-M>NF-L and identify sequences that can increase or reduce transcription when placed in front of heterologous NF promoters. We conclude that the NF-L promoter is a modular, weak and promiscuous promoter whose regulation differs from NF-H or NF-M. Our data suggest that chromatin structure may play an important role in the regulation of the NF-L promoter.

Stability determinants are localized to the 3'-untranslated region and 3'-coding region of the neurofilament light subunit mRNA using a tetracycline-inducible promoter

The tetracycline-responsive expression system of Bujard was used to compare rates of decay of wild-type and mutant neurofilament (NF) light subunit (NF-L) mRNAs. Optimal conditions for activation and inactivation of the target transgene were determined using a luciferase reporter gene. Analyses of mRNA stability were thereupon conducted on cells that were doubly transfected with transactivator and inducible target genes and derived from pooled clones of transfected cells. Rates of mRNA decay were compared upon inactivation of the transgenes after high levels of mRNA had been induced. Deletion of the 445-nucleotide (nt) 3'-untranslated region (3'-UTR) (L/++(+)-) or 527 nt of the 3'-coding region (3'-CR) (L/++-+) increased the stability of NF-L mRNA compared with the full-length (L/++(++)) transcript in neuronal (N2a and P19 cells) and non-neuronal (L cells) lines. Deletion of both the 3'-UTR and 3'-CR (L/++--) led to a further stabilization of the transcript. A major stability determinant was then localized to a 68-nt sequence that forms the junction between the 3'-CR and 3'-UTR of NF-L and is the binding site of a unique ribonucleoprotein complex (Cañete-Soler, R., Schwartz, M. L., Hua, Y., and Schlaepfer, W. W. (1998) J. Biol. Chem. 273, 12655-12661). The studies establish a novel system for mapping determinants of mRNA stability and have applied the system to localize determinants that regulate the stability of the NF-L mRNA.

Characterization of ribonucleoprotein complexes and their binding sites on the neurofilament light subunit mRNA

Levels of neurofilament (NF) gene expression are important determinants of basic neuronal properties, but overexpression can lead to motoneuron degeneration in transgenic mice. In a companion study (Cañete-Soler, R., Schwartz, M. L., Hua, Y., and Schlaepfer, W. W. (1998) J. Biol. Chem. 273, 12650-12654), we show that levels of NF expression are regulated by altering mRNA stability and that stability determinants are present in the 3'-coding region (3'-CR) and 3'-untranslated region (3'-UTR) of the NF light subunit (NF-L) transcript. This study characterizes the ribonucleoprotein complexes that bind to the NF-L mRNA when cytoplasmic brain extracts are incubated with radioactive probes. Gel retardation assays reveal ribonucleoprotein complexes that are selectively competed with poly(C) or poly(U))/poly(A) homoribopolymers and are referred to as C-binding and U/A-binding complexes, respectively. The C-binding complex forms on the proximal 45 nucleotides of 3'-UTR, but its assembly is markedly enhanced by 23 nucleotides of flanking 3'-CR sequence. U/A-binding complexes form at multiple binding sites in the 3'-CR and 3'-UTR. A pattern of reciprocal binding suggests that the C-binding and U/A-binding complexes interact and may compete for common components or binding sites. Cross-linking studies reveal unique polypeptides in the C-binding and U/A-binding complexes. The findings provide the basis for probing mechanisms regulating NF-L mRNA stability and the relationship between NF overexpression and motoneuron degeneration in transgenic mice.

Fatal spontaneous spinal epidural hematoma following thrombolysis for myocardial infarction

BACKGROUND

This is the first communication of a fatal spontaneous spinal epidural hematoma following thrombolysis.

CLINICAL PRESENTATION

Spine pain may precede neurologic deterioration by many hours. The diagnosis can be accurately made with axial computed tomography (CT) of the involved spinal segment.

TREATMENT

Emergency surgery is the treatment for this condition, but conditions such as the acute stage of a myocardial infarction or intraoperative bleeding difficulties due to iatrogenic coagulopathy, the degree of preoperative neurologic deficit, and the timing of surgery must be cautiously considered.

CONCLUSIONS

Neurosurgeons will be faced with another devastating complication of thrombolytic therapy, as long as the available drugs are being used. Early clinical suspicion and availability of CT or magnetic resonance imaging for prompt diagnosis are essential to initiate appropriate medical therapy and timely surgery. New strategies must include the development of completely fibrin-specific thrombolytics and drugs that may rapidly reverse the systemic and local clotting disorder.

The course of post-traumatic amnesia: three little words

OBJECTIVE

To provide a simple means of "real time" recognition of emergence from post-traumatic amnesia (PTA).

METHODS

Ninety-one patients with traumatic brain injury (PBI); 53 minor (GCS 13-15), 19 moderate (GCS 9-12), 18 severe (GCS 3-8). Twenty-seven control subjects treated at two regional trauma units for their acute phase and followed in a hospital-based research institute were studied prospectively. Subjects were examined repeatedly following injury with the Galveston Orientation and Amnesia Test (GOAT) and tests of their ability to learn and retain new information. Word triplets balanced for concreteness and frequency were presented. Immediate and 24-hour recall were tested. If 24-hour recall was imperfect, recognition was tested by presenting the 3 target words and 6 distracters. The target words were then re-presented and recall was tested the next day. The time intervals to first perfect recognition and first free perfect recall were compared with the patients' first GOAT score of 75 or greater on 2 successive days. Simple line drawings of common objects were also presented to the subjects using an identical paradigm. The outcome measures were GOAT, 3-word recognition and recall, 3 picture recognition and recall.

RESULTS

For all categories of head injury severity, the median interval to perfect free recall of words followed the achievement GOAT criterion by a significant interval. The mean GOAT scores for perfect 3-word recall and recognition corresponding to minor, moderate and severe injuries were 97, 90 and 88, and 97, 76 and 68 respectively. The recognition and recall of pictures preceded the recognition and recall of words by approximately 1 day.

CONCLUSIONS

The orientation measures of the GOAT that contain material that the patient knew prior to injury obscure the determination of recovery of continuous memory and should be tested separately. Three-word recall which is simpler to administer than the GOAT is a more reliable measure of emergence from PTA. For patients who are dysphasic or who do not share a common language with the examiner, 3-picture recognition and recall may substitute for word recognition and recall.

Avulsion fracture of the sublime tubercle of the ulna: a newly recognized injury in the throwing athlete

OBJECTIVE

The purpose of this report is to describe the imaging features in three cases of avulsion injury of the sublime tubercle of the ulna that occurred in throwing athletes.

CONCLUSION

Avulsion fracture of the sublime tubercle of the ulna is a potential cause of chronic medial elbow pain in the throwing athlete. This entity is best evaluated with a combination of plain radiographs and coronal MR images, particularly gradient-echo images that show the continuity of the avulsed fragment with the ulnar collateral ligament.

In vitro activation of the mouse mid-sized neurofilament gene by an NF-1-like transcription factor

In vitro transcription using nuclear extracts from rat brain and liver were used to assess the tissue-specific and functional elements of the mouse neurofilament mid-sized gene promoter (pNF-M). Deletion from -2.7 to -103 (relative to the start site of transcription) resulted in a small increase (2-fold) in the activity of the NF-M promoter in both extracts. Promoter strength was slightly higher in brain vs. liver extracts. Deletion to -49 resulted in a 10-fold loss of promoter activity in brain extracts and 6-fold drop in liver. Transcription in both extracts was TATA box-dependent. The region between -65 and -40 was shown to contain sequences responsible for high-level NF-M promoter activity in brain and liver extracts. Within this region are Sp1 and NF-1-like binding sites. Mutation of the NF-1-like site (-53/-39) caused a large drop in the activity of the NF-M promoter while mutation of the Sp1 site (-64/-57) possibly slightly diminished promoter activity in brain and liver extracts. Both the Sp1 and NF-1-like sites were shown by gel shift competition and supershift assays to be able to bind their respective factors. We conclude that the basic mouse NF-M promoter is a promiscuous promoter whose activity is modulated by a NF-1-like transcription factor. The lack of tissue specificity in an in vitro system strongly suggests an important role for chromatin structure in the regulation of the mouse NF-M promoter.

Coordinate induction of the three neurofilament genes by the Brn-3a transcription factor

The POU domain transcription factor Brn-3a is able to stimulate neurite outgrowth when overexpressed in the neuronal ND7 cell line, whereas the closely related Brn-3b factor does not have this effect. We show that Brn-3a overexpression also enhances the expression of the three neurofilament genes at both the mRNA and protein levels, whereas Brn-3b overexpression has no effect. In addition Brn-3a activates the three neurofilament gene promoters in co-transfection assays in both neuronal and non-neuronal cells. As observed for enhanced neurite outgrowth, the stimulation of neurofilament gene expression and activation of the neurofilament gene promoters is observed with the isolated POU domain of Brn-3a. A single amino acid change in the POU homeodomain of Brn-3a to the equivalent amino acid in Brn-3b abolishes its ability to activate the neurofilament promoters, whereas the reciprocal change converts Brn-3b to an activator of these promoters.

Anomalous origin of left coronary artery from pulmonary artery: recovery of left ventricular function after dual coronary repair

OBJECTIVES

We reviewed our institutional experience with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) after dual coronary repair to assess preoperative variables predictive of outcome, the time course for postoperative recovery of cardiac function, the short- and long-term complications and our experience with left ventricular assist devices (LVAD) in these patients.

BACKGROUND

Outcome after surgical repair of ALCAPA remains incompletely defined.

METHODS

The surgical records and echocardiograms of 42 patients were reviewed. Left ventricular function was assessed by fractional shortening z-score (FSz) and stress-velocity index.

RESULTS

The overall survival rate was 86%. All six patients who died were < 1 year old and died within 3 days of the operation. More severe preoperative mitral regurgitation (MR) was associated with increased mortality, but age, body surface area, preoperative FSz and end-diastolic dimension were not. We used an LVAD for 7 of 28 patients who underwent repair for ALCAPA since its introduction at our institution, with a survival of 5 of 7 patients. The degree of MR improved in 62% of patients and remained unchanged in 38%. Complications included supravalvar pulmonary stenosis (16 of 21 patients) and baffle leaks (11 of 21 patients) with the intrapulmonary baffling technique. Supravalvar pulmonary stenosis developed in 1 of 11 patients after direct coronary reimplantation. Left ventricular function became normalized in all 28 patients with follow-up past 1 year, regardless of preoperative FSz. Of 13 patients who underwent serial postoperative echocardiography, the average time to normalization of function was 2 to 7 months.

CONCLUSIONS

The degree of preoperative MR was predictive of outcome, whereas the severity of preoperative cardiac dysfunction and ventricular dilation were not. Mild and moderate MR tended to improve without mitral valvuloplasty. Complete recovery from myocardial dysfunction is expected after dual coronary repair of ALCAPA.

Spontaneous liver hematoma in pregnancy not clearly associated with preeclampsia: a case presentation and literature review

Spontaneous liver hemorrhage with formation of subcapsular hematomas and rupture of Glissan's capsule is a rare but often lethal complication of pregnancy. This entity has usually been associated with severe preeclampsia or the HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome. A case of spontaneous subcapsular hematoma of the liver occurring in the third trimester is presented in which the patient probably had neither preeclampsia nor the HELLP syndrome. The literature on liver hematomas in pregnancy published since 1982 when the term HELLP syndrome was coined is reviewed with a focus on the association of liver hematomas with preeclampsia and the HELLP syndrome. Therapy and maternal and neonatal outcomes for this entity are reassessed.