Reconstruction of multiple fingertip crush injuries with full-thickness skin grafting.

Fingertip crush injuries are commonly encountered as a result of workplace accidents causing significant morbidity. The primary goal of reconstruction is to restore function and sensibility, as well as a faster return to work. We reported a patient with multiple fingertip injuries presented 5 days following the initial injury. Copious irrigation and excisional debridement were performed, followed by a full-thickness skin graft harvested from the volar wrist. At the 4-month follow-up, all of the reconstructed fingertips achieved good functionality without any pain or sensory impairment. The length was well preserved and static two-point discrimination was comparable with the contralateral side. Full-thickness skin grafts may provide an excellent alternative reconstruction option in the management of multiple fingertip crush injuries.

A Systematic Review of Scoring System Based on Magnetic Resonance Imaging Parameters to Predict Outcome in Cervical Spinal Cord Injury.

Background: Magnetic resonance imaging (MRI) is a potential tool for the objective assessment of spinal cord injury (SCI) because it correlates well with the spatial and temporal extension of spinal cord pathology. This study aimed to systematically identify currently available scoring system based on MRI parameters, including measurement of the spinal cord lesion length in sagittal view (intramedullary lesion length (IMLL)) and morphology of the lesion in axial view (Brain and Spinal Injury Center (BASIC) score). Methods: A systematic search was conducted using the PubMed/MEDLINE database for English-language studies with the keywords "cervical," "spinal cord injury," "scoring system," "scoring," "classification," and "magnetic resonance imaging" to systematically identify the scoring system based on MRI parameters. The main outcomes of interest are the scoring system's inter- and intraobserver reliabilities and its predictive accuracy of neurological outcome. Results: After assessing the full text and applying the inclusion and exclusion criteria, 13 articles were found to be eligible. The inter- and intraobserver reliabilities were rated as good until perfect for increased signal intensity (ISI), maximum canal compromise (MCC), maximum spinal cord compression (MSCC), BASIC score, cord-canal-area ratio, space available for the cord, and the compression ratio. The weighted mean difference of IML between the group with converted ASIA Impairment Scale (AIS) grade and the group without conversion is 31.79 (I2 =93%, P=0.008). The percentage of agreement between the initial BASIC score of 4 with AIS grade of A at follow-up is 100%. Conclusions: Certain MRI parameters, including IML and BASIC score, have good reliability and correlate well with neurological outcome, making them candidates for building simple and objective scoring system for cervical SCI. Level of Evidence: 2A.

Terapia Ocupacional na Unidade de Terapia Intensiva (UTI) adulto e as percepções da equipe / The Occupational Therapy in adult Intensive Care Unit (ICU) and team perceptions

Introdução: A Agência Nacional de Vigilância Sanitária (ANVISA), em 24 de fevereiro de 2010, aprovou a resolução de número 7, que dispõe sobre a obrigatoriedade do terapeuta ocupacional como profissional integrante da equipe atuante em Unidade de Terapia Intensiva. Acredita-se que, na terapia ocupacional, o âmbito da UTI se constitui como um local de reduzida atuação profissional, visto o escasso número de publicações encontradas na literatura. Objetivo: Descrever a experiência e as ações desenvolvidas pela terapia ocupacional em uma UTI adulto, bem como relatar a percepção da equipe em relação a esta prática realizada em um Hospital Estadual, localizado no interior do Estado de São Paulo. Método: Trata-se de um relato de experiência em que se realizou análise documental para obtenção de dados referentes às ações desenvolvidas pela terapia ocupacional, assim como a aplicação de um questionário à equipe para compreensão das percepções dos profissionais em relação à assistência prestada. Os dados obtidos foram trabalhados por meio de análise de conteúdo temática. Resultados: Como resultado, foi identificado que as intervenções da terapia ocupacional transitaram por aspectos funcionais e de apoio ao enfrentamento, sendo possível constatar reconhecimento dessas ações pela equipe. Conclusão: A atuação descrita consiste em práticas provenientes do processo de inserção da terapia ocupacional em uma UTI adulto e vai ao encontro do desejo de se estimular o desenvolvimento de pesquisas neste âmbito, para o fomento de debates que promovam aprimoramento técnico da profissão na assistência a pacientes críticos.

Introduction: The National Health Surveillance Agency (ANVISA), on 24 February 2010, adopted resolution number 7, which makes mandatory the presence of an occupational therapist as an active member of the Intensive Care Unit professional team. It is believed that the ICU scope is a small professional practice in Occupational Therapy due to the small number of publications in the literature. Objective: To describe the experience and actions developed by occupational therapy in an adult ICU and report the staff awareness reagrding this practice at a state hospital, located in the state of São Paulo. Method: This is an experience report in which we conducted document analysis to obtain data regarding actions taken by occupational therapy, as well as the application of a questionnaire with the team to understand the professionals perceptions regarding the care provided. The data obtained was processed through thematic content analysis. Results: We identified that the occupational therapy intervention transited by functional aspects and support for coping, with the recognition of these actions by the team. Conclusion: The described action consists of practices derived from the occupational therapy insertion process in an adult ICU and meets the desire to encourage the research development in this area for the promotion of debates to promote technical improvement of the profession in the care of critically ill patients.

The Utility of 3D Left Atrial Volume and Mitral Flow Velocities as Guides for Acute Volume Resuscitation.

Left ventricular end-diastolic pressure (LVEDP) is the foundation of cardiac function assessment. Because of difficulties and risks associated with its direct measurement, correlates of LVEDP derived by pulmonary artery (PA) catheterization or transesophageal echocardiography (TEE) are commonly adopted. TEE has the advantage of being less invasive; however TEE-based estimation of LVEDP using correlates such as left ventricular end-diastolic volume (LVEDV) has technical difficulties that limit its clinical usefulness. Using intraoperative acute normovolemic hemodilution (ANH) as a controlled hemorrhagic model, we examined various mitral flow parameters and three-dimensional reconstructions of left atrial volume as surrogates of LVEDP. Our results demonstrate that peak E wave velocity and left atrial end-diastolic volume (LAEDV) correlated with known changes in intravascular volume associated with ANH. Although left atrial volumetric analysis was done offline in our study, recent advances in echocardiographic software may allow for continuous display and real-time calculation of LAEDV. Along with the ease and reproducibility of acquiring Doppler images of flow across the mitral valve, these two correlates of LVEDP may justify a more widespread use of TEE to optimize intraoperative fluid management. The clinical applicability of peak E wave velocity and LAEDV still needs to be validated during uncontrolled resuscitation.

Decreased expression of GGA3 protein in Alzheimer's disease frontal cortex and increased co-distribution of BACE with the amyloid precursor protein.

BACE initiates the amyloidogenic processing of the amyloid precursor protein (APP) that results in the production of Aß peptides associated with Alzheimer's disease (AD). Previous studies have indicated that BACE is elevated in the frontal cortex of AD patients. Golgi-localized γ-ear containing ADP ribosylation factor-binding proteins (GGA) control the cellular trafficking of BACE and may alter its levels. To investigate a link between BACE and GGA expression in AD, frontal cortex samples from AD (N = 20) and healthy, age-matched controls (HC, N =17) were analyzed by immunoblotting. After normalization to the neuronal marker ß-tubulin III, the data indicate an average two-fold increase of BACE protein (p = 0.01) and a 64% decrease of GGA3 in the AD group compared to the HC (p = 0.006). GGA1 levels were also decreased in AD, but a statistical significance was not achieved. qRT-PCR analysis of GGA3 mRNA showed no difference between AD and HC. There was a strong correlation between GGA1 and GGA3 in both AD and HC, but no correlation between BACE and GGA levels. Subcellular fractionation of AD cortex with low levels of GGA proteins showed an alteration of BACE distribution and extensive co-localization with APP. These data suggest that altered compartmentalization of BACE in AD promotes the amyloidogenic processing of APP.

Enhanced creativity in bipolar disorder patients: a controlled study.

OBJECTIVE: Associations between eminent creativity and bipolar disorders have been reported, but there are few data relating non-eminent creativity to bipolar disorders in clinical samples. We assessed non-eminent creativity in euthymic bipolar (BP) and unipolar major depressive disorder (MDD) patients, creative discipline controls (CC), and healthy controls (HC). METHODS: 49 BP, 25 MDD, 32 CC, and 47 HC (all euthymic) completed four creativity measures yielding six parameters: the Barron-Welsh Art Scale (BWAS-Total, and two subscales, BWAS-Dislike and BWAS-Like), the Adjective Check List Creative Personality Scale (ACL-CPS), and the Torrance Tests of Creative Thinking--Figural (TTCT-F) and Verbal (TTCT-V) versions. Mean scores on these instruments were compared across groups. RESULTS: BP and CC (but not MDD) compared to HC scored significantly higher on BWAS-Total (45% and 48% higher, respectively) and BWAS-Dislike (90% and 88% higher, respectively), but not on BWAS-Like. CC compared to MDD scored significantly higher (12% higher) on TTCT-F. For all other comparisons, creativity scores did not differ significantly between groups. CONCLUSIONS: We found BP and CC (but not MDD) had similarly enhanced creativity on the BWAS-Total (driven by an increase on the BWAS-Dislike) compared to HC. Further studies are needed to determine the mechanisms of enhanced creativity and how it relates to clinical (e.g. temperament, mood, and medication status) and preclinical (e.g. visual and affective processing substrates) parameters.

Temperament-creativity relationships in mood disorder patients, healthy controls and highly creative individuals.

OBJECTIVE: To investigate temperament-creativity relationships in euthymic bipolar (BP) and unipolar major depressive (MDD) patients, creative discipline controls (CC), and healthy controls (HC). METHODS: 49 BP, 25 MDD, 32 CC, and 47 HC (all euthymic) completed three self-report temperament/personality measures: the Revised NEO Personality Inventory (NEO-PI-R), the Temperament Evaluation of the Memphis, Pisa, Paris, and San Diego Autoquestionnaire (TEMPS-A), and the Temperament and Character Inventory (TCI); and four creativity measures yielding six parameters: the Barron-Welsh Art Scale (BWAS-Total, BWAS-Like, and BWAS-Dislike), the Adjective Check List Creative Personality Scale (ACL-CPS), and the Torrance Tests of Creative Thinking--Figural (TTCT-F) and Verbal (TTCT-V) versions. Factor analysis was used to consolidate the 16 subscales from the three temperament/personality measures, and the resulting factors were assessed in relationship to the creativity parameters. RESULTS: Five personality/temperament factors emerged. Two of these factors had prominent relationships with creativity measures. A Neuroticism/Cyclothymia/Dysthymia Factor, comprised mostly of NEO-PI-R-Neuroticism and TEMPS-A-Cyclothymia and TEMPS-A-Dysthymia, was related to BWAS-Total scores (r=0.36, p<0.0001) and BWAS-Dislike subscale scores (r=0.39, p<0.0001). An Openness Factor, comprised mostly of NEO-PI-R-Openness, was related to BWAS-Like subscale scores (r=0.28, p=0.0006), and to ACL-CPS scores (r=0.46, p<0.0001). No significant relationship was found between temperament/personality and TTCT-F and TTCT-V scores. CONCLUSIONS: Neuroticism/Cyclothymia/Dysthymia and Openness appear to have differential relationships with creativity. The former could provide affective (Neuroticism, i.e. access to negative affect, and Cyclothymia, i.e. changeability of affect) and the latter cognitive (flexibility) advantages to enhance creativity. Further studies are indicated to clarify mechanisms of creativity and its relationships to affective processes and bipolar disorders.

Temperamental commonalities and differences in euthymic mood disorder patients, creative controls, and healthy controls.

OBJECTIVE: Understanding of mood disorders can be enhanced through assessment of temperamental traits. We explored temperamental commonalities and differences among euthymic bipolar (BP) and unipolar (MDD) mood disorder patients, creative discipline graduate student controls (CC), and healthy controls (HC). METHODS: Forty-nine BP, 25 MDD, 32 CC, and 47 HC completed self-report temperament/personality measures including: The Affective Temperament Evaluation of Memphis, Pisa, Paris and San Diego (TEMPS-A); the Revised NEO Personality Inventory (NEO-PI-R); and the Temperament and Character Inventory (TCI). RESULTS: Euthymic BP, MDD, and CC, compared to HC, had significantly increased cyclothymia, dysthymia and irritability scores on TEMPS-A; increased neuroticism and decreased conscientiousness on NEO-PI-R; and increased harm avoidance and novelty seeking as well as decreased self-directedness on TCI. TEMPS-A cyclothymia scores were significantly higher in BP than in MDD. NEO-PI-R openness was increased in BP and CC, compared to HC, and in CC compared to MDD. TCI self-transcendence scores in BP were significantly higher than in MDD, CC, and HC. LIMITATIONS: Most of the subjects were not professional artists, and represented many fields; temperament might be different in different art fields. CONCLUSIONS: Euthymic BP, MDD, and CC compared to HC, had prominent temperamental commonalities. However, BP and CC had the additional commonality of increased openness compared to HC. BP had particularly high Cyclothymia scores that were significantly higher then those of MDD. The prominent BP-CC overlap suggests underlying neurobiological commonalities between people with mood disorders and individuals involved in creative disciplines, consistent with the notion of a temperamental contribution to enhanced creativity in individuals with bipolar disorders.

Gabapentin augmentation therapy in bipolar depression.

BACKGROUND: Gabapentin (GBP) may be useful in bipolar disorders, including as adjunctive therapy for bipolar depression, although controlled studies suggest inefficacy as primary treatment for mania or treatment-resistant rapid cycling. METHODS: We performed a 12-week trial of open GBP (mean dose 1725 mg/day) added to stable doses of mood stabilizers or atypical antipsychotics in 22 (10 women, mean age 38.4 years) depressed (28-item Hamilton Depression Rating Scale (HDRS) > 18] bipolar (10 bipolar I, 12 bipolar II) disorder outpatients. Mean illness duration was 18.6 years, current depressive episode duration was 18.0 weeks. Prospective 28-item HDRS, Young Mania Rating Scale (YMRS) and Clinical Global Impression-Severity (CGI-S) ratings were obtained. RESULTS: Overall, HDRS ratings decreased 53% from 32.5 +/- 7.7 at baseline to 16.5 +/- 12.8 at week 12 (p < 0.0001). Twelve of 22 (55%) patients had moderate to marked improvement (HDRS decrease = 50%) with HDRS decreasing 78% from 27.9 +/- 6.2 to 6.2 +/- 4.5 (p < 0.0001). Eight of 22 (36%) patients remitted (HDRS > or = 8). In non-responders, HDRS decreased from 38.0 +/- 5.4 to 28.9 +/- 6.7 (p = 0.005). Ten of 13 (77%) mild to moderately depressed (baseline HDRS > 18 and <35) patients responded, while only two of nine patients (22%) with severe depression (HDRS > or = 35) responded (p < 0.03). Both groups, however, had similar, statistically significant HDRS decreases. GBP was well tolerated. CONCLUSION: Open adjunctive GBP was effective and well tolerated in patients with mild to moderate bipolar depression. This open pilot study must be viewed with caution, and randomized controlled studies are warranted.

Olanzapine in diverse syndromal and subsyndromal exacerbations of bipolar disorders.

OBJECTIVE: To evaluate effects of olanzapine in diverse exacerbations of bipolar disorders. METHODS: Twenty-five evaluable bipolar disorder [14 bipolar I (BPI), 10 bipolar II (BPII) and one bipolar disorder not otherwise specified (BP NOS)] outpatients received open olanzapine (15 adjunctive, 10 monotherapy). Thirteen had elevated (11 syndromal, two subsyndromal) and 12 depressed (four syndromal, eight subsyndromal) mood symptoms of at least mild severity, with Clinical Global Impression-Severity (CGI-S) scores of at least 3. Only one had psychotic symptoms. RESULTS: With open olanzapine (15 adjunctive, 10 monotherapy), overall symptom severity (CGI-S) as well as mood elevation (Young Mania Rating Scale), depression (Hamilton and Montgomery-Asberg Depression Rating Scales), and anxiety (Hamilton Anxiety Rating Scale), rapidly decreased (significantly by days 2-3). Patients with the greatest baseline severity (CGI-S) had the greatest improvement. Fifteen of 25 (60%) patients responded. Time to consistent response was bimodal, with five early (by 0.5 +/- 0.3 weeks) and 10 late (by 7.0 +/- 1.9 weeks) responders. Early compared with late responders had 51% lower final olanzapine doses. Olanzapine was generally well tolerated, with sedation and weight gain the most common adverse effects. CONCLUSIONS: Olanzapine was effective in diverse exacerbations of bipolar disorders. The bimodal distribution of time to response and different final doses are consistent with differential mechanisms mediating early compared with late responses. Controlled studies are warranted to further explore these preliminary observations.