Discharge destination and motor function outcome in severe stroke as measured by the functional independence measure/function-related group classification system

OBJECTIVES: Function-related groups based on the Functional Independence Measure have been proposed as a model for a prospective payment system for medical rehabilitation. This study describes discharge destination and motor function outcomes in a sample of patients with stroke from the FIM-FRG STR1 classification. STUDY DESIGN: A retrospective review of 293 cases of stroke from the years 1993 to 1995. The demographic and outcome characteristics of this sample were described. RESULTS/CONCLUSIONS: Forty-five percent of the patients were discharged to home after a mean length of stay of 23.8 days in acute medical rehabilitation. Patients who were discharged home had higher admission and discharge motor FIM scores than those discharged to a subacute facility or long-term care facility, although the correlation between motor FIM score and discharge destination was low to moderate. Median discharge motor FIM scores indicate considerable residual disability in this classification after rehabilitation. Research problems that address methods to improve the usefulness of the FIM-FRG system in a prospective payment system are discussed.     

Differences in the retinal GABA system among control, spastic mutant and retinal degeneration mutant mice

Immunocytochemical methods were used to compare the GABA system in control mice and two mutant strains: spastic which has reduced glycine receptors and retinal degeneration mutant in which the photoreceptors degenerate and reportedly have increased GABA and GAD levels. We found that the spastic mutant retina had reduced GABA-immunoreactivity (IR) in the proximal retina, reduced staining for GAD-1440 in the OPL, and reduced GABAA receptor staining in the OPL, compared to control. The retinal degeneration mutant retinas had enhanced GABA-IR throughout the retina, particularly in Müller cells, bipolar cells and IPL, and enhancement of GABAA receptor staining in the OPL, compared to control. The distributions of GABA-IR, GAD-1440-IR and GABAA receptor-IR in retinas of spastic mutant mice that also expressed the retinal degeneration phenotype resembled those found in retinas of mice that expressed only the retinal degeneration phenotype rather than those that expressed only the spastic mutation. No differences were observed among the conditions for GAD-65, GAD-67 or GABA-T. Our results with the spastic and retinal degeneration mutant mice demonstrate that attenuation in the glycinergic system and photoreceptor degeneration, respectively, is accompanied by alterations in different aspects of the GABA system, giving impetus for caution in the interpretation of experiments involving genetic manipulation of complex phenotypes.     

Effects of hypervolemia on interdialytic hemodynamics and blood pressure control in hemodialysis patients

The influence of hypervolemia on hemodynamics and interdialytic blood pressure, as well as in relation to vascular compliance, was investigated in 10 hemodialysis patients who were not receiving vasoactive medication. All subjects were studied during a relative normovolemic interdialytic period (from 1 kg below dry weight postdialytic until dry weight predialytic) and a hypervolemic interdialytic period (from 1 kg above dry weight postdialytic until 3 kg above dry weight predialytic). Interdialytic blood pressure was measured with an ambulatory blood pressure monitor. Cardiac output was echographically measured and total peripheral resistance calculated postdialytic, mid-interdialytic, and predialytic. At the same time, a blood sample was drawn for analyzing vasoactive hormones, sodium, and hematocrit. In all patients, ideal dry weight was estimated by echography of the caval vein. Arterial and venous compliance were measured with an ultrasound vessel wall movement detector system and a strain-gauge plethysmograph. After fluid load, an increase in intravascular volume, an increase in caval vein diameter and cardiac output, and a decrease in peripheral resistance was observed. No significant influence of a 3-L fluid load was found on interdialytic blood pressure course (153+/-24 mm Hg/90+/-19 mm Hg in the hypervolemic period and 146+/-27 mm Hg/89+/-22 mm Hg in the normovolemic period). Sodium and osmolality were similar in the hypervolemic and normovolemic interdialytic periods. After fluid load, a decrease in arginine vasopressin and angiotensin II was observed, which probably contributed to the decreased systemic vascular resistance. Catecholamines were not influenced by fluid load, but increased during the interdialytic period, suggesting accumulation after dialysis. Three of the 10 patients had higher systolic but not diastolic blood pressures after fluid load (159+/-13 mm Hg/81+/-22 mm Hg in the hypervolemic period and 135+/-16 mm Hg/81+/-22 mm Hg in the normovolemic period). No correlation could be found between arterial or venous compliance and blood pressure changes. We concluded that a 3-L interdialytic fluid load does not result in higher blood pressure in most hemodialysis patients.     

Immunoaffinity resin for purification of urinary leukotriene E4

Urinary leukotriene E4 (LTE4) has been used as an index of total leukotriene synthesis. A wide variety of methods have been applied to measure LTE4 which has made direct comparison of urinary levels reported by different laboratories difficult. A new peptidoleukotriene immunoaffinity resin was utilized for urinary LTE4 purification in a method that is easy and inexpensive, utilizing commercially available reagents. This method is described and compared to other methods. LTE4 (50-250 pg/mL) added to a urine extract was quantitatively recovered using the immunoaffinity resin. Similarly, LTE4 (50-400 pg/mL) added to urine was recovered between 63 and 76%. The coefficient of variation of samples purified and quantified on the same or on different days ranged from 8-10%. There was a strong correlation (r2 = 0.95) between LTE4 concentrations determined after immunofiltration and immunoaffinity purification. Although there was a good correlation between urinary LTE4 levels measured without purification compared to after immunoaffinity purification, the high y-intercept of 179 indicates the presence of interfering substances in unpurified urine. Urinary LTE4 in normal healthy adults was 80 +/- 7 pg/mg creatinine, similar to that previously reported following HPLC or immunofiltration purification. Urinary LTE4 was also measured in healthy children (age 3-12) and found to be 103 +/- 9.     

Survival and vasculitis activity in patients with end-stage renal disease due to Wegener's granulomatosis

BACKGROUND: In patients with end-stage renal disease (ESRD) due to Wegener's granulomatosis, a decrease in vasculitis activity after the development of ESRD, as described in other autoimmune diseases, has been postulated. However, up to now no data in a larger group of patients with Wegener's granulomatosis on chronic dialysis have been available. METHODS: We retrospectively analysed the clinical course of 35 patients with Wegener's granulomatosis and ESRD during chronic dialysis treatment. Diagnosis was based on clinical manifestation, antineutrophil cytoplasmic antibodies and/or histology. RESULTS: During a mean follow-up of 43 months (5-113 months), six patients died, three related to treatment toxicity. The patient survival rates (according to Kaplan-Meier calculation) were 93% after 2 years and 79% after 5 years. Twenty-nine relapses of Wegener's granulomatosis occurred in 17 patients (relapse rate 0.24/patient/year); 2/3 of the relapses were seen during treatment with steroids, 1/6 during cyclophosphamide therapy. The relapses were not related to the dialysis membrane used. Remission or partial remission could be achieved in 93% of the relapses. CONCLUSIONS: The survival of patients on chronic dialysis treatment due to Wegener's granulomatosis was comparable to that of other patient groups with ESRD. The relapse rate was not different from that of non-dialysed patients with Wegener's granulomatosis, and this finding underlines the need for a therapeutic strategy to maintain long-term remission in dialysis-dependent patients, too.     

Replacement of linoleic acid with alpha-linolenic acid does not alter blood lipids in normolipidaemic men

A retrospective immunohistochemical study of 33 cases of primary thyroid carcinomas and 5 cases of metastases to thyroid was carried out. The immunostaining for thyroglobulin and calcitonin was done by peroxidase-anti-peroxidase (PAP) technique. The optimum staining results were obtained by proper standardisation of the staining procedure and reagents. The sections were systematically evaluated for immunostaining intensity and distribution. The observations revealed that thyroglobulin and calcitonin could be useful as sensitive and specific histogenetic markers for follicular and parafollicular cell derived thyroid carcinomas respectively. However, there was no absolute correlation between thyroglobulin positivity and grade of differentiation. The immunostaining could not differentiate follicular adenoma from follicular carcinoma. More extensive study using other markers may be useful for better patient management.     

Neuropsychological symptom presentation after electrical injury

OBJECTIVE: This study explored the relationship of neuropsychological complaints to accident- and injury-related characteristics, affective state, and work status in a group of electrical injury (EI) patients. METHODS: Sixty-three EI patients and 22 electricians with no history of electrical shock completed the Neuropsychological Symptom Checklist and the Beck Depression Inventory as part of an extensive neuropsychological evaluation. RESULTS: The EI group endorsed significantly more physical, cognitive, and emotional symptoms than did the controls. Symptom complaints were not related to injury parameters or litigation status. Only the time interval between injury and assessment accounted for differences in symptom presentation, with patients in the postacute stages of recovery showing the most cognitive and emotional complaints. CONCLUSION: The neuropsychological syndrome of electrical injury survival includes physical, cognitive, and emotional complaints. Considering that most electrically injured patients are treated within the acute medical setting, greater attention needs to be directed early in the course of treatment toward addressing neuropsychologic and psychiatric issues.     

Pharmacologic management of depression in the elderly

Depression, the most common geriatric psychiatric disorder, is a disabling mood disorder that impairs one's well-being and may even threaten a sufferer's life. Severely depressed elderly persons are more likely to kill themselves than individuals in any other age group. However, geriatric depression is, for the most part, a treatable and manageable illness. Antidepressant medication can be very effective in treating major depressive disorder (MDD). Because age-related physical changes in the elderly produce pharmacokinetics that are often different than that experienced by younger adults, different doses are often necessary. This article summarizes recommendations for selecting and initiating appropriate antidepressant therapy in elderly persons suffering from MDD. The benefits and drawbacks of tricyclic antidepressant agents, and other atypical antidepressant agents are discussed. Phases of treatment, drug selection, dosing, and educational tips for pharmacotherapy are presented.     

Use of an ultrasensitive recombinant cell bioassay to determine estrogen levels in girls with precocious puberty treated with a luteinizing hormone-releasing hormone agonist

Although treatment of girls with precocious puberty should ideally restore estradiol levels to the normal prepubertal range, treatment effectiveness has usually been monitored by gonadotropin levels because estradiol RIAs have lacked sufficient sensitivity to monitor treatment effectiveness. We hypothesized that a recently developed ultrasensitive recombinant cell bioassay for estradiol would have sufficient sensitivity to demonstrate a dose-dependent suppression of estradiol during LH-releasing hormone agonist treatment and to determine whether currently used doses are able to suppress estradiol levels to the normal prepubertal range. Twenty girls with central precocious puberty were assigned randomly to receive deslorelin for 9 months at a dose of 1, 2, or 4 micrograms/ kg.day. A significant dose-response relationship was observed, with mean +/- SD estradiol levels of 16.7 +/- 6.1, 7.9 +/- 1.6, and 6.5 +/- 0.7 pmol/L at the doses of 1, 2, and 4 micrograms/kg.day, respectively (P < 0.01). The highest dose suppressed estradiol levels to just above the 95% confidence limits for normal prepubertal girls (< 0.07-6.3 pmol/L). We conclude that the ultrasensitive bioassay for estradiol has sufficient sensitivity for monitoring the response to LH-releasing hormone agonist treatment of central precocious puberty. Additionally, the observation that the deslorelin dose of 4 micrograms/kg.day did not fully restore estradiol levels to the normal prepubertal range suggests that some girls with precocious puberty may require higher doses to receive the maximal benefit of treatment. We suggest that restoration of estradiol levels to the normal prepubertal range should be the ultimate biochemical measure of efficacy, as estradiol is the key hormone that accelerates growth rate, bone maturation rate, and breast development in girls with precocious puberty.