The cost-effectiveness of the diagnosis of renal artery stenosis

Variables were studied which predict at the acute stage the functional and occupational long-term outcome for patients with traumatic brain injury (TBI). Glasgow Coma Scale (GCS) score on hospital admission, length of coma (LOC) and duration of post-traumatic amnesia (PTA) were studied in a group of 508 TBI rehabilitation patients, age 0.8-71, mean age 19, followed up between five and over 20 years, mean of 12 years. Information from hospital charts and all data available before and after the injury were gathered and reviewed. The study was carried out among a consecutive sample of Finnish patients with TBI referred to a rehabilitation programme at the out-patient neurological clinic of Kauniala Hospital, which specializes in brain injuries in Finland. The patients came from various hospital districts in the country for an evaluation of their educational and vocational problems. Main outcome measures were functional outcome, as measured by the Glasgow Outcome Scale (GOS) at the end of follow-up, and post-injury occupational outcome. The patients' reemployment on the open job marklet, subsidized employment or inability to work was noted. The GCS score on hospital admission correlated clearly with the functional outcome of the patients at the end of follow-up. Length of coma and duration of post-traumatic amnesia correlated specifically with the patient's work history after the brain injury and with functional outcome measured by the GOS. Outcomes varied among age groups and seemed to be affected by age at injury. Accordingly, the extent of recovery and quality of life for rehabilitation patients with TBI can be estimated early on by prognostic factors reflecting injury severity in the acute phase. The results suggest that the GCS score, LOC and duration of PTA all have a strong predictive value in assessing functional or occupational outcome for TBI patients.     

Primary traumatic midbrain syndrome--follow-up and prognosis of acute primary brain stem damage

Within 27 months 122 patients with severe head injury were treated at our clinic. Of these patients twelve (9.8%) were categorized as having a primary brain stem lesion (9 male and 3 female, mean age 28.3 years (17 to 73 years). Their injuries were caused primarily by traffic accidents. Initial and follow-up CT ruled out mass lesions or other causes for transtentorial herniation, supporting the diagnosis of primary brain stem lesion. Respiratory insufficiency and control of vegetative function demanded artificial ventilation and analog-sedation for up to 32 days (mean 18 days) on our Intensive Care Unit. In all patients we performed initial and follow-up CT scans, ICP monitoring, evoked potentials (AEP, SSEP) and TCD. MRI was carried out in four patients. One patient died during the acute hospital phase, 7 were transferred in poor and four in good condition. During rehabilitation one patient died, two, one in a vegetative state and one in poor condition were transferred to a caring facility. Eight patients with a good or moderate recovery were dismissed home, subsequently regaining their prior social function. The primary traumatic brain stem lesion presents as a dramatic clinical picture. As shown in our series the prognosis is good independent of the duration of coma. The important prognostic factors were the primary neurological state according to the Gerstenbrand and Luecking classification, the degree of the brain stem lesion in CT scan and MRI, and normal evoked potentials, indicating a favourable outcome.     

A case-mix classification system for medical rehabilitation

Dissatisfaction with Medicare's current system of paying for rehabilitation care has led to proposals for a rehabilitation prospective payment system, but first a classification system for rehabilitation patients must be created. Data for 36,980 patients admitted to and discharged from 125 rehabilitation facilities between January 1, 1990, and April 19, 1991, were provided by the Uniform Data System for Medical Rehabilitation. Classification rules were formed using clinical judgment and a recursive partitioning algorithm. The Functional Independence Measure version of the Function Related Groups (FIM-FRGs) uses four predictor variables: diagnosis leading to disability, admission scores for motor and cognitive functional status subscales as measured by the Functional Independence Measure, and patient age. The system contains 53 FRGs and explains 31.3% of the variance in the natural logarithm length of stay for patients in a validation sample. The FIM-FRG classification system is conceptually simple and stable when tested on a validation sample. The classification system contains a manageable number of groups, and may represent a solution to the problem of classifying medical rehabilitation patients for payment, facility planning, and research on the outcomes, quality, and cost of rehabilitation.     

Reye's syndrome: clinical progression and evaluation of therapy

The hospital course and therapy of 369 patients with Reye's syndrome were evaluated. Eighty-three percent of patients had deepening coma during hospitalization. Stage of coma on admission, evidence of increased intracranial pressure, and blood ammonia levels greater than 300 microgram/100 ml were all significantly associated with increasing mortality. Among survivors of Reye's syndrome, 30% of those who developed either decerebrate posturing or seizures during hospitalization had serious neurologic sequelae upon discharge. When analyzed by (1) stage of coma during admission (2) progression of coma during hospitalization, (3) degree of blood ammonia level elevation, and (4) presence of increased intracranial pressuring, no significant differences were noted between patients receiving intensive supportive care and those receiving exchange transfusions and/or peritoneal dialysis.     

The effect of associated injuries, blood loss, and oxygen debt on death and disability in blunt traumatic brain injury: the need for early physiologic predictors of severity

Studies of 4590 patients with blunt trauma injuries admitted to a Level I Trauma Center, have shown that 37% had a blunt traumatic brain injury (BTBI). Of these brain injured patients 60% has an associated other injury. Examination of mortality has shown that those with an isolated brain injury had an 11% mortality compared with 21.8% in those with an associated systemic injury. Further investigation demonstrated that the cause of the increased mortality was related to the blood loss associated with the injuries and that when hypovolemic shock resulted, mortality rose from 12.8 to 62%. The severity of the associated injuries effect on the brain injured patient could be estimated by a parameter of oxygen debt, the base deficit and this allowed for a quantitative estimate of the probability of death as an index of severity. A combined linear logistic model using the admission Glasgow Coma Score (GCS) as a measure of brain injury and the base deficit as a measure of physiologic injury provides such a predictive score. The effect of associated injuries in patients with moderate brain injury (AIS 2,3) was to increase the average total cost of medical care in the first year of injury by three-fold ($12,489 to $36,177) and for severe brain injury (AIS 4,5) to increase average cost from $59,000 in isolated BTBI to $90,000 in BTBI with associated injury. The high incidence of brain injuries in motor vehicle crashes (MVC) caused by lateral impacts and their association with other side-impact injuries (lungs, spleen, kidney, and pelvic fractures) in which large blood volume losses are common, focuses attention on the need for side impact protection standards that simultaneously protect brain, thoracoabdominal viscera, and pelvis as a means of reducing the severity and cost of lateral impact MVCs.     

Correlates of work injury frequency and duration among firefighters.

This study examined demographic, personality, and economic incentive correlates of workplace injuries suffered by 171 firefighters over a 12-yr period. Results showed that female firefighters experienced more injuries than male firefighters. Several Minnesota Multiphasic Personality Inventory (MMPI) scales (Conversion Hysteria, Psychopathic Deviate, and Social Introversion) were positively related to injury frequency. Regression analyses revealed that age, tenure, gender, marital status, type of injury, and wage variables were significant when predicting the duration of injuries as well as an interaction between marital status and gender. Two MMPI scales (Psychopathic Deviate and Schizophrenia) were also significantly related to injury duration. Indemnity cost estimates were calculated. The results underscore the importance of distinguishing the duration of injury from the occurrence of injury. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Factors associated with rehabilitation outcome in patients with low back pain (LBP): Prediction of employment outcome at 9-month follow-up.

Examined which admission and treatment change variables predicted return to work for 117 male patients (mean age 40.2 yrs) with work-related LBP. Pain and disability perception, coping strategies, depression, and functional status were examined at admission and discharge for Ss who participated in an interdisciplinary work rehabilitation program. Discriminant function analyses, using employment status 9 mo later as the dependent variable, resulted in correct classification rates of 79% when admission and treatment change scores were used as predictors. Psychological factors at admission were the salient variables that predicted employment outcome at follow-up. Of the treatment change variables, physical status and S's perception of his/her disability significantly predicted return to work. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Comparison of two injection techniques using botulinum toxin in spastic hemiplegia

This study sought to test the hypothesis that injections of botulinum toxin type A (BTX-A) at the mid belly of the gastrocnemius muscle in spastic hemiplegic adults produce superior clinical results to proximal injections directed toward the muscular origin. We designed a randomized, double-blind, placebo-controlled intervention study at a university tertiary care setting. Seventeen subjects with chronic spastic hemiplegic gait were enrolled from a volunteer community sample; time range from acute neurologic insult was 0.75 to 31 yr; age range was 19 to 71 yr; gender consisted of 11 men and 4 women; diagnoses were 12 patients with stroke, 2 with traumatic brain injuries, and 1 with a brain tumor. Two subjects were withdrawn from the study because of (1) acute vascular occlusion before intervention and (2) noncompliance with follow-up visits. After baseline measurements, subjects were injected with 50 units of BTX-A (volume, 0.5 cc) into the medial or lateral gastrocnemius: (1) proximally at one site near the muscular origin; (2) distally at three sites along the mid belly. We measured outcome using the Fugl-Meyer score, Ashworth scale, ankle range of motion, and a timed 50-ft fastest walk. No outcome measures showed a significant effect attributable to site of injections. Confounding variables included physical therapy and varying duration of illness in the study cohort. We conclude that the results failed to support the hypothesis that BTX-A injections at the mid belly of the gastrocnemius produced superior functional improvements to injections located near the muscular origin using localization techniques described. Additional research comparing more precise localization methods for BTX-A injections might further establish the importance of electromyographic guidance using BTX-A in management of spasticity.     

Dopamine D2 receptors quantified in vivo in human narcolepsy

The correlation of clinical with psychological and social data is an attempt to find predictors of the definite long-term outcome after brain injury. 34 patients were reexamined 3 to 8 years after the accident using a number of psychological tests. Additionally, life quality was defined and evaluated. Only patients with an initial Glasgow Coma Scale-Score of 3-12, an intracranial traumatic lesion on computertomography and age 16-65 years at the time of accident were included in this study. Patients exhibited a uniform pattern of disturbances in psychosocial long-term outcome. These disturbances were compared with initial clinical data: memory, attention and learning were significantly correlated with the duration of coma and the presence of additional extracerebral injuries. From the initial computerized tomography, the findings 'compression of basal cisterns' and 'intracerebral contusion' showed to be predictors of the cerebral function. Late social status and behavior, defined as quality of life, were clearly related with initial clinical findings. In conclusion, there are early clinical predictors of the long term social and psychological outcome after brain injury.     

Equivalent sensation curves of simultaneous lateral and vertical sinusoidal whole-body vibration

OBJECTIVE: To determine the rates of correct patient disposition after an ED evaluation. METHODS: In a university pediatric hospital, a 25% random sample of ED patients for 4 consecutive months was reviewed, after exclusion of minor injuries and patients triaged to the nonurgent clinic. Patients were categorized into one of 4 outcomes on the basis of inpatient resource use: appropriate admission, inappropriate admission, appropriate release, or inappropriate release. A 10% random sample of released patients was contacted by telephone to detect patients who sought care elsewhere after ED release. RESULTS: 642 of 2,682 ED patients (23.9%) were admitted; 159 (24.7%) were inappropriately admitted, and 26 (1.3%) were inappropriately released. The correct identification of the need for hospitalization (sensitivity) was 94.9%, and for release (specificity) 92.7%. Overall, the correct classification rate was 93.1%. Inappropriate admissions were associated with diagnoses of trauma, seizures, and burns. CONCLUSION: Inappropriate admissions occur at a substantial rate and occur more commonly than inappropriate releases. The correct disposition of patients is a practical and meaningful outcome-based measure of the quality of ED care. This methodology is suitable for use in other EDs.     

Acute myeloid leukemia-type chemotherapy for newly diagnosed patients without antecedent cytopenias having myelodysplastic syndrome as defined by French-American-British criteria: a Cancer and Leukemia Group B Study

PURPOSE: To determine the treatment outcome of standard acute myeloid leukemia (AML)-type chemotherapy in a subset of patients with newly diagnosed myelodysplastic syndromes (MDS) compared with that of patients with de novo AML as defined using French-American-British (FAB) criteria. In addition, to determine the pretreatment variables having prognostic significance for treatment outcome in patients with MDS. PATIENTS AND METHODS: Nine hundred seven newly diagnosed patients with no history of cytopenias having a local institutional de novo AML successfully karyotyped and treated on Cancer and Leukemia Group B (CALGB) protocols for AML from 1984 to 1992. Thirty-three of the 907 patients were reclassified as having MDS on central pathology review using FAB criteria and form the basis of this analysis. RESULTS: The treatment outcomes for patients with MDS and AML were similar; the complete remission (CR) rate was 79% and 68%, respectively (P = .37); median CR duration was 11 and 15 months, respectively (P = .28); and median survival was 13 and 16 months, respectively (P = .72). For the MDS patients, there were no prognostic variables for CR rate identified. For CR duration, only the Sanz classification had prognostic value. The prognostic factors for survival in a univariate analysis included age, WBC count, Sanz classification, and percent blood blasts. In a proportional hazards analysis of survival, age greater than 60 years and WBC less than 2.6 x 10(9)/L were adverse prognostic factors. CONCLUSION: In patients with no known history of cytopenias who are treated intensively at diagnosis, the FAB distinctions between MDS (refractory anemia with excess blasts and refractory anemia with excess blasts in transformation) and AML appear to have little therapeutic relevance.     

The effects of employing different termination classification criteria in dropout research.

Compared differences between therapy terminations categorized by duration and those categorized by therapist judgment in 152 consecutive mental health center outpatient (average age 27 yrs) treatment terminations, in order to demonstrate distinctions between early dropouts and early completers. The sample was first divided based on treatment duration. Terminated Ss who had made 1–5 visits (early terminators) were compared to those with 6 or more visits (late terminators). Early dropouts were then compared to early completers by comparing therapist-classified dropouts who attended 1–2 visits with therapist-classified completers who attended 1–3 visits. Significant differences were found between dropouts and completers on 11 of 18 client and therapist variables when classified by therapist judgments; no differences were found when the groups were classified using duration criteria. Within the therapist-classified groups, low-visit dropouts were found to differ from low-visit completers on 8 of 18 variables. The pattern of results strongly supports the superiority of the therapist classification procedure. It is recommended that duration-based classification not be employed in future investigations of continuance unless investigators explain why such a classification is appropriate for specific variables being investigated and acknowledge the limitations of the approach. (17 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Posttraumatic amnesia: its relation to functional outcome

OBJECTIVE: To investigate the relation between duration of posttraumatic amnesia (PTA) and functional outcome in a traumatically brain injured population. PATIENTS: Two hundred seventy-six patients with traumatic brain injury (TBI) who were admitted to a Level I university trauma center and required inpatient rehabilitation. MEASURES: Duration of PTA was assessed by serial administrations of the Galveston Orientation Amnesia Test (GOAT). Functional Independence Measure (FIM) total scores, FIM cognitive and motor subscores, and Disability Rating Scale (DRS) scores were obtained at admission and discharge from inpatient rehabilitation. RESULTS: Duration of PTA was a significant predictor of all admission and discharge DRS and FIM scores. Duration of PTA and age at the time of injury, in combination, contributed significantly to the prediction of the DRS score and FIM total, cognitive, and motor scores at discharge. CONCLUSION: Duration of PTA appears to be a useful variable in predicting specific functional outcome in the TBI population receiving inpatient rehabilitation services. The use of age as a factor in addition to duration of PTA enhances the prediction of functional outcome.     

Indications for thoracotomy following penetrating thoracic injury

The treatment of penetrating thoracic injuries has been reviewed in both civilian and military series. Although most surgeons agree that closed that closed thoracostomy drainage is the initial treatment of choice, the timing of early thoracotomy and perhaps cardiorrhaphy upon patients with penetrating thoracic injuries remains controversial. The purpose of this study was to determine which patients will require immediate thoractomy or cardiorrhaphy following penetrating chest injury. Over a two-year period 190 patients with penetrating thoracic injuries were treated. Of 53 patients who required immediate thoracotomy, 31 suffered cardiac wounds. Seventy-nine patients required laparotomy for associated intra-abdominal injuries. The mortality rate was related to exsanguinating hemorrhage or postoperative intra-abdominal sepsis. Cardiopulmonary complications were rare in the absence of intra-abdominal sepsis and could not be attributed to the thoracic injury or thoracotomy. Indications for immediate cardiorrhaphy or thoracotomy are: 1) location of the entrance wound (70% in upper mediastinum); 2) blood pressure on admission less than 90; 3) initial thoracostomy blood loss greater than 800 cc; 4) radiographic evidence of retained hemothorax; and/or 5) clinical evidence of pericardial tamponade.     

Serum protein changes in diabetes mellitus

AIM: To evaluate the serum protein pattern in a wide sample of diabetic patients using the simple method of electrophoresis, identifying the characteristics for each condition and correlating the various components. EXPERIMENTAL DESIGN: A retrospective study was made using medical records. SETTING: The Institute of Clinical Medicine I at Palermo University Hospital during the years 1990, 1991 and 1992. PATIENTS: 156 patients suffering from diabetes mellitus, of whom 68 were Type 1 (IDDM) and 88 Type 2 (NIDDM). The latter were divided into non-obese (NO-NIDDM), obese (O-NIDDM) and "secondary failures" (SF-NIDDM) to oral hypoglycemic agents (receiving mixed treatment, TM-NIDDM, or insulin alone, I-NIDDM). PARAMETERS: In addition to personal and anthropometric data and clinical data, in particular dysmetabolic data, an electropherogram was performed in each patient. RESULTS: Higher serum albumin concentrations were found in patients with IDDM, NIDDM compared to I-NIDDM, with an overall inverse correlation between the duration of diabetes and albumin serum levels. On the contrary, serum levels of alpha-2 globulins were higher in I-NIDDM patients compared to IDDM, and directly correlated with the age and duration in the overall series. beta-globulin levels were lower in IDDM patients compared to all other groups, and were directly correlated with age and body mass index (BMI) in the overall series. No statistical significance or correlation was found between the two groups in relation to alpha 1 and gamma-globulins. CONCLUSIONS: The study showed a characteristic serum protein pattern for each group of diabetic patients examined, analysing the role of insulin but also the duration and typical pathological events of the natural history of diabetes on protein metabolism, not only with regard to the amino acid metabolism but also on the distribution of circulating proteins.     

The development of schemes for recognizing additive and alternative effects in a "natural experiment" context.

20 Ss at each of 4 age levels (4th, 6th, and 8th grade and college) were presented a "natural experiment" problem situation in which they were asked to interpret the more complex situations in which (a) either of 2 alternative variables is sufficient to produce an outcome, or (b) 2 variables are additive in their effect on an outcome. Not until adolescence could Ss isolate alternative or additive causes in a multivariable situation, though it is speculated they may comprehend the concept of alternative causes well before this age. Only 65% of college Ss exhibited correct reasoning in one or both situations. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Further examination of post-traumatic amnesia and post-coma disturbance as non-linear predictors of outcome after head injury.

The relationship between early neurological variables and cognitive outcome was investigated in a group of 77 severely head-injured patients following C. Haslam et al (1994). At the time of admission, patients were assessed on 7 neurological indices, including durations of post-traumatic amnesia (PTA) and post-coma disturbance (PCD), the latter defined as the period between emergence from coma and end of PTA. PTA and PCD were transformed to address their non-linearity. Two years later, patients underwent examination on selected psychological measures. Recent memory was best predicted by transformed PTA, and speed of information processing was best predicted by transformed PCD. Prediction of both psychological factors was also improved by taking into account surgical evacuation of an extradural hematoma. Findings are consistent with research demonstrating the utility of transformed variables and PCD in prediction of cognitive outcome. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Prognostic factors of early sequelae and fatal outcome of Japanese encephalitis

A clinical case control study to identify prognostic factors present at hospital admission associated with early sequelae and fatal outcome of acute Japanese encephalitis (JE) was carried out in Gusi county, Henan Province, central China from June to September 1991. A total of 70 patients with laboratory-confirmed acute JE were studied, of whom 3 cases died and 33 cases had neurological or psychiatric sequelae at the end of three months follow-up. The results showed that acute JE at younger age, with higher body temperature, high white cell count in CSF, and deep coma present at hospital admission were markers for unfavorable outcomes (sequelae or fatal). A history of the vaccination was not correlated with the early sequelae and fatal outcome of the disease. The paper suggests that early diagnosis and treatment and universal JE vaccination for all susceptible populations are keys for decreasing incidence of sequelae and fatal outcome of acute JE.     

Chronic pain and depression: role of perceived impact and perceived control in different age cohorts

Chronic pain adversely affects individuals' physical as well as emotional well-being. A cognitive-behavioral model has been proposed to explain the role of cognitive appraisal variables in mediating the development of emotional distress following pain of long duration. There is little evidence linking the prevalence of depression in chronic pain patients to life stage, but there are suggestions in the literature that the link between medical illness and depression may be stronger in elderly patients. One purpose of this study was to replicate the efficacy of a previous study of the cognitive-behavioral mediation model in explaining the association between pain and depressed affect. A second purpose of this study was to extend the cognitive-behavioral model to evaluate relationships among pain, cognitive appraisal variables, and depressive affect in the elderly chronic pain population. One hundred chronic pain patients were divided into two age groups (< or = 69 years and > or = 70 years). A path analysis conducted for the total sample supported the cognitive-behavioral mediation model of depression in chronic pain, in which cognitive appraisal variables mediate the pain-depression relationship. Correlations among variables in each of the two age groups, however, revealed different patterns of association. Consistent with the cognitive-behavioral model, the younger patients demonstrated a low and non-significant correlation between pain severity and depression (r = 0.01). Conversely, a strong direct association was observed in the older patients between these variables (r = 0.51). These results suggest that the relationship between pain and depression varies substantially depending upon age cohort.     

Alpha rhythm during open eye derivation in infantile brain damaged and normal children

1. The behavior of the occipital alpha rhythm during open-eye derivation was studied on nine- to twelve-year-old boys of normal intelligence, of whom ten were free from brain injuries and eleven had been suffering from brain injuries in early childhood. 2. There was observed a marked tendency of the alpha index to differ in dependence upon the time of testing, the cause of which was believed to be a weakness of vigilance on the part of brain-injured children. 3. Application of this simple method of examination to group comparisons makes it possible to neurophysiologically determine an important part of chronic cerebropsychic axis syndromes.