Collagenous colitis: mucosal biopsies and association with fecal leukocytes

OBJECTIVE: To determine the frequency of patchy colonic involvement, fecal leukocytosis, and association with celiac sprue in a large cohort of patients with collagenous colitis. DESIGN: We conducted a retrospective review of the medical records of 172 consecutive Mayo Clinic patients in whom collagenous colitis had been diagnosed between 1982 and 1993. METHODS: For each of the 172 patients, the medical record was reviewed to determine the frequency of (1) fecal leukocytosis; (2) characteristic histologic findings in the rectum and the sigmoid, descending, and ascending colon; and (3) small bowel biopsy findings consistent with celiac sprue. RESULTS: The presence of fecal leukocytes was noted in 64 of 116 patients (55%) who had undergone assessment for fecal leukocytosis. On analysis of histologic findings, 113 of 123 rectal, 116 of 121 sigmoid, and 68 of 70 descending colon biopsy specimens were diagnostic of collagenous colitis. Small bowel biopsies were performed in 45 patients who did not have a history of small intestinal disease: 1 had celiac sprue and 44 had normal findings. Two other patients had previously diagnosed celiac sprue. CONCLUSION: The finding of fecal leukocytes in 55% of patients with collagenous colitis confirms the inflammatory basis of this disease. Biopsy specimens obtained by flexible sigmoidoscopy seem sufficient to establish the diagnosis in most patients, and colonoscopic biopsy of the more proximal area of the colon is usually unnecessary. Celiac sprue infrequently accompanies collagenous colitis; thus, routine small bowel biopsy is not warranted.     

The effect of traumatic brain injury on children with learning disability

In Argentina, there is rather little information about the natural occurrence of mycotoxins in feedstuffs. The aim of this work was to determine the fungal flora and natural incidence of aflatoxin B1 (AFB1), zearalenone (ZEA) and deoxynivalenol (DON) in poultry feeds from 5 factories of Río Cuarto, Córdoba. Three hundred samples were taken from May 1995 to May 1996. Fungal counts of poultry feeds ranged 10(4) to 10(6) CFU g-1. The lowest counts were obtained on the first months from the sampling (May to September 1995) with mean values significantly different from those found at the last of the sampling (October 1995 to April 1996). The most prevalent species isolated of poultry feed samples belonged to the genera Penicillium that was present in 98% of the samples, Fusarium (87%) and Aspergillus (52%). Fusarium species isolated were: F moniliforme in 73% of the samples, F subglutinans (35%), F graminearum (20%) and within Aspergillus species: A. parasiticus (33%) and A. flavus (8%) were identified. In poultry feeds aflatoxin B1 (AFB1) was the most significant mycotoxin with levels ranging from 17 to 197 ng/g. For deoxynivalenol (DON) the levels ranged from 240 to 410 ng/g. Only three out of 300 samples were contaminated with zearalenone (ZEA) in concentrations of 30, 120 and 280 ng/g. These are preliminary data on this subject in our region.     

The management of severe traumatic brain injury

An approach to the initial evaluation, resuscitation, and treatment of the patient with severe traumatic brain injury is presented in terms of the underlying physiology and literature support. The primary importance of rapid and complete systemic resuscitation in terms of the "ABCs" is stressed, with the goal of optimizing cerebral perfusion and preventing secondary insults to the injured brain. The integration of brain-specific treatments and diagnostic maneuvers into resuscitation protocols is discussed, including the role of mannitol and hyperventilation as well as the prioritization of CT imaging of the brain.     

The effectiveness of computer-assisted cognitive rehabilitation for persons with traumatic brain injury

Electroencephalographic (EEG) findings in syncope are reviewed. There are four major categories of syncope: neurally mediated (neurocardiogenic), neurologic, decreased cardiac output, and orthostatic hypotension. However, regardless of cause, whether the syncope is due to a vasovagal effect, a cardiac arrhythmia, an epileptic seizure, or hypotension, EEG findings are similar and reflect cerebral hypoperfusion. Initially there may be a slowing of background rhythms. This is followed by high amplitude delta activity, maximal anteriorly. If the hypoperfusion persists there is subsequent flattening of the EEG. The EEG returns to normal in the reverse sequence. In cases with severe and prolonged ischemia, convulsive syncope may occur at the time of the EEG flattening. Although not an epileptic phenomena, clinically this is often mistaken for epilepsy. Conversely, epileptic disorders, such as the ictal bradycardia syndrome, may occasionally mimic syncope. Therefore, in patients in whom EEGs are performed for the evaluation of an episode of loss of consciousness, simultaneous ECG should be used.     

The influence of memory beliefs in individuals with traumatic brain injury.

Objective: To explore metamemory (memory beliefs) and affective functioning in individuals with traumatic brain injury (TBI). Participants: Twenty-six individuals with mild TBI (MTBI), 16 individuals with severe TBI (STBI), and 42 uninjured adults. Outcome Measures: Metamemory in Adulthood questionnaire, Postconcussion Syndrome Checklist, Perceived Stress Scale, Beck Depression Inventory (2nd ed.), Beck Anxiety Inventory. Results: The control group endorsed higher memory self-efficacy, fewer depressive symptoms, fewer memory strategies, and fewer postconcussion symptoms than the MTBI or STBI group. The MTBI group placed high importance on success in memory tasks. Memory self-efficacy and memory-strategies use mediated the relation between TBI and depression. Conclusion: Individuals with brain injury hold negative beliefs about their memory functioning, and such beliefs contribute to depression. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Combined therapy affects outcomes differentially after mild traumatic brain injury and secondary forebrain ischemia in rats

Muscarinic and NMDA receptors contribute to post-traumatic hypersensitivity to secondary ischemia. However, the effect of these receptor antagonists on behavior and CA1 neuronal death after traumatic brain injury (TBI) with acute (1 h after TBI) forebrain ischemia has not been systematically assessed. We examined cognitive and motor dysfunction and the relationship of behavior deficits to neuronal death in this model using muscarinic and NMDA antagonists. Three behavioral groups (n=10/group) of Wistar rats were subjected to mild TBI and 6 min of forebrain ischemia imposed 1 h after TBI with 45 days survival. Motor and spatial memory performance were assessed using the rotarod task and Morris water maze. Seven additional groups (n=6/group) were evaluated only for CA1 death after 7 days survival following sham, individual or combined injury with and without drug treatments. Rats were given 0.3 mg/kg MK-801 (M) and 1.0 mg/kg scopolamine (S) alone or combined (M-S) before or 45 min after TBI. Rotarod performance was tested at days 1-5 and maze performance on days 11-15 and 40-44 after M-S treatment. The 7-day studies showed M-S treatment (p<0.01) reduced CA1 neuronal death better than either S or M alone. Behavioral groups had inadvertent post-ischemic hypothermia that decreased CA1 death and likely influenced behavioral morbidity. M-S given before TBI (p<0.01) decreased memory deficits on day 15, while M-S treatment given after TBI was ineffective. Unexpectedly, M-S treatment before or after TBI produced transient motor deficits (p<0. 01). Memory improvement occurred independent of CA1 death.     

Personality disturbances associated with traumatic brain injury.

Personality disturbances associated with traumatic brain injury are reviewed. The varied structural pathology of the brain in this patient group makes it difficult to specify how different brain lesions may result in specific emotional and motivational disturbances. However, an attempt to clarify terms and review empirical findings is made. Longitudinal prospective studies that utilize appropriate control groups are needed. Future research may especially benefit by considering the long-term effects of early agitation following traumatic brain injury as well as the problem of aspontaneity and impairment of self-awareness. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The challenge of unintelligible speech following traumatic brain injury

Management of unintelligible speech following traumatic brain injury is complex. In addition to multiple physiological system deficits, individuals typically present with complicating non-speech factors that impede their progress. The present case study illustrates the influence on outcome of impaired speech physiology, reduced cognitive abilities, pre-morbid personality characteristics, and psychosocial variables such as post-injury psychosis. Highlighted intervention strategies include optimizing the physiological system with a palatal lift prosthesis, reducing speaking rate by pacing, phonetically transcribing words to minimize apraxia of speech, adapting stimuli to optimize auditory comprehension, and providing therapy within functional contexts.     

The enigma of "hidden" traumatic brain injury

OBJECTIVE: To examine individuals with "hidden" traumatic brain injury (TBI), defined in this study as those who sustained a blow to the head, with altered mental status, and experienced a substantial number of the cognitive, behavioral, and emotional sequelae typically associated with brain injury but did not make the causal connection between the injury and its consequences. DESIGN: Comparison of four groups of individuals matched for age, gender, years of education, and duration of loss of consciousness. SETTING: This study of hidden TBI followed the identification of 143 individuals who, within a larger study of people with TBI who live in the community, identified themselves as "nondisabled" (they were to be part of the comparison sample) but who had experienced a blow to the head that left them at minimum dazed and confused. PARTICIPANTS: 21 of these 143 individuals also reported large numbers of symptoms (eg, headaches, memory problems) associated with TBI. This group (Hidden TBI-High Symptoms group) was compared to three other matched samples: one with known TBI (Known Mild TBI group) and one with no disability (No Disability group) (both of which were drawn from the larger study), and one group of individuals who identified themselves as having no disability but who had experienced a blow to the head that resulted in a few symptoms (Head Trauma-Low Symptoms group). MAIN OUTCOME MEASURES: All study participants were administered an interview that incorporated several existing instruments documenting levels of reported symptoms, emotional well-being/distress, and vocational/social handicaps. RESULTS: The Hidden TBI-High Symptoms group was found to be similar to the Known Mild TBI group in terms of the number and types of symptoms experienced, whereas the Head Trauma-Low Symptoms group was similar in this respect to the No Disability group. The two former groups also evidenced high levels of emotional distress, whereas the two latter groups did not. However, on measures of handicap, the Hidden TBI-High Symptoms and Head Trauma-Low Symptoms groups were similar to the No Disability group and dissimilar from the Known Mild TBI group in that the last group experienced vocational handicap, in particular, whereas the other groups did not. Conclusions: We conclude that hidden TBI occurs at a nontrivial level (7% of our nondisabled sample). Also, individuals with hidden TBI (with persistent symptoms), unlike those with known mild TBI, are likely to experience emotional distress but not vocational handicap following injury.     

Management of the patient with minor traumatic brain injury

Staff in the accident and emergency department and critical care unit are often confronted with patients who have sustained life-threatening injuries. In such situations the symptoms of a minor traumatic brain injury (MTBI) may be missed. It is important that, when the physical symptoms begin to subside, nurses are aware of the symptoms of MTBI and respond accordingly. A post-concussion syndrome may develop 2 weeks to 2 months after a MTBI. This syndrome can affect the patient's ability to perform the usual activities of living. This article defines MTBI, describes the symptoms encountered in patients with MTBI, and outlines the pathophysiology, clinical findings, treatment and nursing interventions.     

The validity of the Katz Adjustment Scale among people with traumatic brain injury.

Deficits in self- and social awareness can impair adjustment following traumatic brain injury (TBI) and draw into question the accuracy of self-report measures of adjustment. This study evaluates the validity of Katz Adjustment Scale (KAS) factor components identified by R. J. Fabiano and D. A. Goran (1992). The KAS is an observer rating scale often used to assess the social adjustment of people with traumatic brain injury. The responses of 105 individuals with TBI to the Symptom Checklist 90—Revised (SCL-90–R; L. R. Derogatis, 1983), a self-report measure of distress, were correlated with observer ratings on the KAS. Results support the use of observer ratings and self-report to assess adjustment and social behavior following TBI. Each contributes valuable information that can guide treatment and enhance adaptive functioning. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Perinatal hypoxic-ischemic brain injury

A highly sensitive radioimmunoassay for the measurement of plasma prostaglandins A and B, expressed in equivalents of PGA1, is described. This method was used for the measurement of prostaglandins A and B (PGA/B) in 23 healthy volunteers and 25 hypertensive patients. The PGA/B concentration in peripheral venous plasma of 23 healthy normotensive subjects is 115 +/- 15 pg/ml. The repeated measurement of the same plasma samples kept frozen for 60 days at -20 degrees C shows mean 194% increase of PGA/B concentration. The major site of synthesis of PGA/B seems to be the kidney. However in two patients PGA/B concentration in arterial blood was greater than in venous blood suggesting the possibility of cardio-pulmonary synthesis. The major site of inactivation is the hepatic circulation, as PGA/B concentration in hepatal venous blood is by 30% lower than in vena caval blood. The arterial concentration is 3% lower than venous PGA/B demonstrating very low pulmonary inactivation. Therefore the prostaglandins of the A and B series may represent a "circulating hormone". The plasmatic PGA/B is significantly increased in reno-vascular and essential hypertension.     

Axis I psychopathology in individuals with traumatic brain injury

OBJECTIVES: To assess the incidence, comorbidity, and patterns of resolution of DSM-IV mood, anxiety, and substance use disorders in individuals with traumatic brain injury (TBI). DESIGN: The Structured Clinical Interview for DSM-IV Diagnoses (SCID) was utilized. Diagnoses were determined for three onset points relative to TBI onset: pre-TBI, post-TBI, and current diagnosis. Contrasts of prevalence rates with community-based samples, as well as chi-square analysis and analysis of variance were used. Demographics considered in analyses included gender, marital status, severity of injury, and years since TBI onset. SETTING: Urban, suburban, and rural New York state. PARTICIPANTS: 100 adults with TBI who were between the ages of 18 and 65 years and who were, on average, 8 years post onset at time of interview. MAIN OUTCOME MEASURES: SCID Axis I mood diagnoses of major depression, dysthymia, and bipolar disorder; anxiety diagnoses of panic disorder, obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD), and phobia; and substance use disorders. RESULTS: Prior to TBI, a significant percentage of individuals presented with substance use disorders. After TBI, the most frequent Axis I diagnoses were major depression and select anxiety disorders (ie, PTSD, OCD, and panic disorder). Comorbidity was high, with 44% of individuals presenting with two or more Axis I diagnoses post TBI. Individuals without a pre-TBI Axis I disorder were more likely to develop post-TBI major depression and substance use disorders. Rates of resolution were similar for individuals regardless of previous psychiatric histories. Major depression and substance use disorders were more likely than were anxiety disorders to remit. CONCLUSION: TBI is a risk factor for subsequent psychiatric disabilities. The need for proactive psychiatric assessment and timely interventions in individuals post TBI is indicated.     

Narrative discourse in children with early focal brain injury

Children with early brain damage, unlike adult stroke victims, often go on to develop nearly normal language. However, the route and extent of their linguistic development are still unclear, as is the relationship between lesion site and patterns of delay and recovery. Here we address these questions by examining narratives from children with early brain damage. Thirty children (ages 3:7-10:10) with pre- or perinatal unilateral focal brain damage and their matched controls participated in a storytelling task. Analyses focused on linguistic proficiency and narrative competence. Overall, children with brain damage scored significantly lower than their age-matched controls on both linguistic (morphological and syntactic) indices and those targeting broader narrative qualities. Rather than indicating that children with brain damage fully catch up, these data suggest that deficits in linguistic abilities reassert themselves as children face new linguistic challenges. Interestingly, after age 5, site of lesion does not appear to be a significant factor and the delays we have witnessed do not map onto the lesion profiles observed in adults with analogous brain injuries.     

D2 receptor imaging with iodine-123-iodobenzamide brain SPECT in infants with hypoxic-ischemic brain injury

The purpose of this study was to evaluate the striatal dopamine D2 receptor density in infants with perinatal hypoxic-ischemic brain injury (HIBI) using 123I-iodobenzamide (IBZM) brain SPECT and to correlate the findings with the severity of HIBI and neurologic outcome. METHODS: Twenty infants who were diagnosed to have perinatal HIBI were included in this study. They were classified as having mild (n = 6), moderate (n = 10) or severe (n = 4) HIBI according to their neurologic findings at birth using the criteria of Sarnat and Sarnat. Neurologic outcome of these infants was determined by serial neurologic examinations and the Denver developmental screening test; 10 infants recovered without any deficit and the remaining 10 were affected to a degree varying from motor impairment to cerebral palsy. All 20 infants were examined using 123I-IBZM brain SPECT at age 7.8 +/- 2.3 mo. Transaxial slices were obtained 2 hr after intravenous injection of 300 micro ci (11.1 MBq) 123I-IBZM and the activity ratios of striatal to occipital cortex (ST/OC) were calculated. RESULTS: The mean ST/OC ratios in patients with mild, moderate and severe HIBI (1.219 +/- 0.078, 1.097 +/- 0.069 and 0.813 +/- 0.140, respectively) were significantly different from each other (p = 0.001). The infants who recovered from HIBI without any neurologic sequelae had higher mean ST/OC ratios than the others (1.184 +/- 0.010 versus 0.969 +/- 0.160, p = 0.002). CONCLUSION: The results of this study show that in infants with HIBI, striatal D2 receptor density decreases as the severity of injury increases. The D2 receptor density is higher in infants who recover without neurologic deficits compared to those who are affected neurologically. Dopamine D2 receptor imaging can be used to assess the severity of HIBI in children.     

Association of TAP2 polymorphism with rheumatoid arthritis is secondary to allelic association with HLA-DRB1

OBJECTIVE: To study polymorphisms of the newly described TAP2 locus in rheumatoid arthritis (RA) and to analyze their relationship with HLA-DRB1 alleles previously implicated in the development of the disease. METHODS: TAP2 polymorphic residues at 3 sites, Val/Ile-379, Ala/Thr-565, and Ala/Thr-665, were characterized by amplification refractory mutation system polymerase chain reaction in 185 RA patients and 48 HLA-DR4 positive healthy controls. HLA-DR4 subtypes were determined by sequence-specific priming and oligonucleotide hybridization. RESULTS: The frequencies of Ile-379, Thr-565, and Thr-665 were significantly increased in DR4 positive versus DR4 negative RA patients. TAP2 genotype distributions also differed between the patient groups stratified by DR4 status. However, no significant differences in TAP2 polymorphisms were observed between DR4 positive RA patients and DR4 positive controls, although relationships between specific DR4 subtypes and TAP2 variants were identified. CONCLUSION: Particular TAP2 polymorphisms are associated with distinct HLA-DR specificities in both normal and RA populations. Thus, the prevalence of specific TAP2 residues and genotypes in RA appears to be secondary to the HLA-DR frequencies and genotypic combinations that are typical of RA.