Severe brain injury rehabilitation. What's going to happen after critical care.

Treatment advances and technology will continue to decrease mortality in SBI in the future. A clearer line between lingering death and reasonable potential for recovery will only slowly reveal itself, and prediction will never be an exact science. Concerns about resource utilization and costs will continue to escalate. Critical care, acute care, and rehabilitation nurses will continue to live in this painful haze with the patients and their families. Nevertheless, critical care nurses can help by assisting families to understand the possible outcomes of SBI, the clinical state the patient is experiencing, how diagnosis and prognosis are related and how they are different, the indicators used to establish prognosis early on and then later in the course, and how prognosis is related to treatment decisions. Likewise, the critical care nurses can help the family begin to come to terms with the level of sophistication (or lack of precision, as the case may be) of prognostication, the agonizing time length factor involved, and the demanding prerequisites for level of consciousness assessment in the low functioning clinical states.

Liquid chromatographic-tandem mass spectrometric method for the analysis of a neurokinin-1 antagonist and its metabolite using automated solid-phase sample preparation and automated data handling and reporting.

Pharmacokinetic studies play a vital role during the development of new pharmaceutical substances. Data presented demonstrate an accurate, precise and robust assay for a neurokinin-1 receptor antagonist and its metabolite with HPLC-MS-MS. Sample preparation is performed by solid-phase extraction (SPE) in the 96-well plate format. This process is fully automated with a Tecan Genesis pipetting system using its standard robotic manipulator arm (ROMA). All instruments are fully integrated in a study oriented laboratory information system (LIMS) with an Oracle database that communicates bi-directional with the analytical equipment. Finally, the results are reported by push button operation.

Serum amyloid A--an indicator of inflammation in ankylosing spondylitis.

Biological markers of inflammation are useful for the diagnosis and monitoring of inflammatory rheumatic diseases. The present study tested, whether serum amyloid A (SAA) could be used as a marker of inflammatory disease activity in ankylosing spondylitis (AS). In 72 patients with AS, the two valuable surrogate markers of disease activity, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), and an established clinical activity score (Bath Ankylosing Spondylitis Disease Activity Index, BASDAI) were correlated to the serum levels of SAA. It was found that SAA correlates well with ESR, CRP, and BASDAI. Because of its strong correlation, SAA seems to be an additional very useful disease activity marker. When used in diagnosis, and especially in monitoring of inflammation, further studies are required. Another interesting point of view is the described role of plasma SAA as a precursor of Amyloid A (AA) protein in secondary amyloidosis, a known complication in AS. In all probability, high circulating SAA levels are a predisposing indicator of disease activity.

Dynamic thermography of the knee joints in rheumatoid arthritis (RA) in the course of the first therapy of the patient with methylprednisolone.

Thermography in rheumatology is most often used in a static manner: after having fulfilled the conditions of standardized preparation of the patient in a cold examination room one or more thermograms are taken in standard positions for the respective joints. In our hospital the thermograms are more or less supplementary. The main examination result is a rewarming curve of the skin over the knee joints. The rewarming is provoked by dry cooling of the skin for one minute. Calculation of the slope of the rewarming curve and plotting the slope on a logarithmic scale shows two different rewarming processes in the skin overlying inflamed joints. The faster one is the rewarming by the arterial blood flow in the skin and the slower one is an additional rewarming by a pathological venous skin blood flow originating from deeper tissues under the skin. One has to suppose that the occurrence of excessive nitric oxide production in inflamed tissues is responsible for this pathological venous skin blood flow. Until now only nine patients receiving for the first time methylprednisolone could be included in a therapy study. Therefore only slight indications can be seen in the results. Whereas the erythrocyte sedimentation rate (ESR [mm/h] becomes more homogeneous (lower confidence interval CI 95) over the course of the treatment with decreasing drug dose, the thermal signs of inflammatory activity as measured by dynamic thermography have greater CI 95 values at the end than at the beginning of the treatment under study. This indicates that not all patients had sufficient antiinflammatory medication with the final 6 mg/d of methylprednisolone as measured by dynamic thermography but not by ESR or CRP.

Bone mineral density and biochemical markers of bone metabolism in late onset rheumatoid arthritis and polymyalgia rheumatica--a prospective study on the influence of glucocorticoid therapy.

In the present prospective study, bone metabolism was examined in 51 patients at the time of diagnosis and 6-7 months later: 29 patients had definitive diagnosis of late onset rheumatoid arthritis (LORA) and 22 patients had polymyalgia rheumatica (PMR). At the time of diagnosis, the patients had not received any medication; during the 6-7 months of follow-up they were treated with corticosteroids and nonsteroidal-antirheumatic drugs (NSAIDs). Serum levels of osteocalcin, alkaline phosphatase and ostase, as markers for bone formation, were tested. Bone density was examined by dual x-ray absorption (DEXA) of the lumbar spine and the left ward triangle. At the time of diagnosis, no signs of bone alterations were seen. After 6-7 months, abnormal values of the serum parameters and bone mineral density were found in 16/51 patients (31%): 10/29 patients with LORA and 6/22 with PMR. Thus, our findings suggest that an alteration of bone metabolism could be observed in a minority of patients during the first few months of glucocorticoid medication, but in the majority of patients an osteoprotective effect seems to be worth discussing. The results suggest from a prophylactic and therapeutic point of view that an additional disease-modifying antirheumatic medication should be considered in the early stages of therapy to reduce the osteoporotic risk of a longterm corticoid therapy.

Correlation of IL-6 with the classical humoral disease activity parameters ESR and CRP and with serum cortisol, reflecting the activity of the HPA axis in active rheumatoid arthritis.

Rheumatoid arthritis (RA) is a systemic inflammatory disease with elevated levels of proinflammatory cytokines in peripheral blood, especially IL-6, but also IL-1 alpha and TNF alpha, for example, in different concentrations, depending on disease activity. A disturbed circadian rhythm of cortisol secretion and an overall elevated cortisol release in active RA, depending on disease activity, is known. The presented study examined correlations of IL-6 as the most important systemic mediator of the acute phase response in active RA with classical humoral disease activity parameters, such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), and with serum cortisol. We investigated 64 active RA patients, previously untreated with glucocorticoids. IL-6 was measured by ELISA from Pharmingen (San Diego), ESR by the method of Westergren and CRP by nephelometry (Behring Marburg, Germany). Cortisol was measured in 34 of these patients, using a fluorescence-polarization immunoassay (FPIA) from Abbott. We found correlations of IL-6 with CRP (p < 0.001, Spearman Rank Test, rs = 0.75), with ESR (p < 0.001, rs = 0.62) and with serum cortisol (p = 0.019, rs = 0.401). ESR and CRP correlate (p < 0.001, rs = 0.8) and cortisol also correlates with ESR (p = 0.002, rs = 0.52) and CRP (p < 0.001, rs = 0.57). IL-6 as an important systemic mediator of inflammation in RA correlates closely with CRP, as it induces its production, and with ESR. These three parameters correlate well with serum cortisol, which is increased in active RA, depending on disease activity. Thus, IL-6 is an important disease activity parameter in RA that is closely related to both the classical humoral disease activity and the HPA axis.

Thyroid disorders in female patients with ankylosing spondylitis.

The association between rheumatological and thyroid disorders has long been known, the most common being the association of rheumatoid arthritis and autoimmune thyroiditis. Little is known as to possible thyroid involvement in ankylosing spondylitis (AS). In 22 female patients with AS and 22 healthy age-matched control subjects parameters of thyroid gland function, rheumatic activity, as well as a subtle drug anamnesis of the rheumatic medication, and an ultrasonographic examination of the thyroid gland were determined. Thyroid function was tested by intravenous injection of 400 microg thyrotropin-releasing hormone (TRH). In parallel basal levels of reverse-T3 (rT3), calcium and anti-thyroid antibodies were estimated. In the AS-group an enlarged thyroid volume was seen in 10 cases, basal FT4, FT3 and TT3 were significantly lower, TSH and TT4 were found to be in the normal range and rT3 was significantly increased. The prevalence of anti-thyroid antibodies was significantly higher in the AS-group. The AS-patients responded as well as the controls with thyroid hormone secretion to TRH, within an observation period of 2 hours. No differences were observed in TSH response. Free serum calcium showed in both groups no significant difference. To summarize our results, female patients with AS showed a

Novel 1,3-dioxanes from apple juice and cider.

Extracts obtained by XAD solid-phase extraction of apple juice and cider were separated by liquid chromatography on silica gel. Several new 1,3-dioxanes including the known 2-methyl-4-pentyl-1,3-dioxane and 2-methyl-4-[2'(Z)-pentenyl]-1,3-dioxane, were identified in the nonpolar fractions by GC/MS analysis and confirmed by chemical synthesis. The enantioselective synthesis of the stereoisomers of the 1,3-dioxanes was performed using (R)- and (R,S)-octane-1,3-diol and (R)- and (R,S)-5(Z)-octene-1,3-diol as starting material. Comparison with the isolated products indicated that the natural products consisted of a mixture of (2S,4R) and (2R,4R) stereoisomers in the ratio of approximately 10:1, except for 1,3-dioxanes generated from acetone and 2-butanone. It is assumed that the 1, 3-dioxanes are chemically formed in the apples and cider from the natural apple ingredients (R)-octane-1,3-diol, (R)-5(Z)-octene-1, 3-diol, (3R,7R)- and (3R,7S)-octane-1,3,7-triol, and the appropriate aldehydes and ketones, which are produced either by the apples or by yeast during fermentation of the apple juice.

Pragmatics: right brain communication.

Neuroscience nurses as well as other health care providers are called upon to assess and implement intervention strategies to assist clients and family members and significant others to communicate in the presence of communication deficits. Language, high level language skills and speech are frequently addressed in presentations and in the literature but pragmatics which includes prosody, attitude, emotions and gestural behaviors is rarely addressed. Pragmatic competence mediated by the right hemisphere, is an equally important and essential component of human communication. An understanding of pragmatics permits the neuroscience nurse to identify and evaluate pragmatic deficits so interventions to facilitate communication can be undertaken. Specifically prosody, that is melody, pause, intonation, stresses and accents, affective tone, subtle grades of meaning and varied emphasis; its components; and aprosodia (lack of prosody) will be discussed. Kinesics, that is limb, body and facial movements, and referred to as pantomime and gestures, will be examined also as will facial expression. Suggestions for pragmatic assessment and therapeutic nursing interventions will be given.

A self-care assessment tool (SCAT) for persons with a spinal cord injury: an expanded abstract.

The purpose of this study was to develop a reliable and valid tool that assesses the cognitive and functional skills needed for self-care in persons with spinal cord injury (SCI). The Self-Care Assessment Tool (SCAT) assesses cognitive and functional skills in eight self-care areas: bathing/grooming, nutritional management, medications, mobility/transfers/safety, skin management, bladder management, bowel management and dressing. The tool was carefully developed and has demonstrated content validity. Using two samples of veterans seen in the SCI clinics of two Southern Veterans Affairs Medical Centers, n = 13 and n = 15, interrater reliabilities computed by Pearson product moment correlations for the cognitive, functional and total scores ranged from .69 to .94. Test-retest reliabilities using Pearson product moment correlations for the cognitive, functional and total scores of two groups (n = 14 and n = 15) ranged from -.06 to .86. Regarding predictive validity, R2 was found to be .61 to .90 for the cognitive, functional and total scores. Although continued reliability and validity studies are needed, the SCAT has potential to measure patient rehabilitation outcomes, to evaluate nursing care approaches and to serve as a quality assurance indicator for nursing care.

Self-care competence among persons with spinal cord injury.

The authors of this article report the results of a secondary data analysis which examined the self-care competence of persons with spinal cord injury (SCI) and the retention of cognitive and functional skills following discharge from acute rehabilitation as well as additional learning of self-care following discharge. The sample consisted of 48 persons with SCI from two Veterans Affairs Medical Centers and a state university affiliated rehabilitation program. The data collection tool was the Self-Care Assessment Tool (SCAT) which measures cognitive and functional skills in eight self-care areas: bathing/grooming, nutritional management, taking medications, mobility/transfer/safety, skin management, bladder management, bowel management, and dressing. The overall self-care competence of the participants was high (mean = 78.25) as was their competence in the eight self-care areas. In general, participants retained both the cognitive information and functional skills learned in the acute rehabilitation setting and also continued to learn after discharge in both cognitive information and functional skills.

The influence of donor age on the survival of solid and suspension intraparenchymal human embryonic nigral grafts.

In many species, graft survival and graft-derived behavioral recovery are affected by the embryonic donor age. We compared the ability of solid and suspension grafts of human embryonic mesencephalic dopaminergic (DA) neurons at different embryonic stages to survive intraparenchymal transplantation into 6-OHDA lesioned immunosuppressed rats. Suspension grafts survived best when donor age was between postconception (PC) days 34 and 56. Transplants displayed numerous healthy tyrosine hydroxylase immunoreactive (TH-IR) neurons which sent extensive neuritic processes into the host striatum. Suspension grafts survived poorly when donor age was greater than 65 days. Solid implants displayed comparable viability of TH-IR neurons when donor age was between 44 and 65 days. No solid grafts contained TH-IR cells when donor tissue was older than 72 days. The suspension and solid methods of transplantation resulted in comparable survival of robust grafts, but solid grafts resulted in more intergraft variability than suspension grafts, particularly among the more marginal implants. Our results demonstrate that the upper limit for survival of human embryonic DA suspension grafts correlates well with the period of development of the human nigrostriatal pathway. The "window" for donor age of solid human embryonic DA grafts appears to be extended by about 9 days in comparison to suspension grafts. These data suggest that the upper age limit for grafting human mesencephalic DA neurons should be PC day 56 for suspension grafts, and PC day 65 for solid implants. Older donors are likely to produce grafts with fewer surviving DA neurons.

The neurophysiological basis of learning, Part 2: Concept formation/abstraction, reasoning and executive functions--implications for SCI nurses.

Understanding the neurophysiological basis of learning enables nurses working with spinal cord injured persons to astutely assess potential for learning. This is particularly relevant when head injury or drug effects are influencing neurological systems relevant to learning. The neuroanatomical and neurophysiological bases of learning are related to attention, memory, concept formation/abstraction, reasoning, and executive systems. Concept formation/abstraction, reasoning and executive systems are discussed as they relate to learning in this article. This information is incorporated into expanded assessment. More in-depth nursing assessment related to cognitive systems necessary for learning enables nurses to identify intact and deficit cognitive systems and quantify deficits. Astute assessment is fundamental to planning effective teaching and learning strategies for spinal cord injured persons especially when learning deficits exist, e.g., in head injured persons who have sustained a spinal cord injury. Implications for client and family education derive from an understanding of the normal neurophysiological basis of learning and normal and abnormal assessment findings.

A model three-dimensional culture system for mammalian dopaminergic precursor cells: application for functional intracerebral transplantation.

Grafts of fetal neural tissue, rich in dopamine (DA) neurons, have previously been shown to improve the symptoms of parkinsonism, both in humans and in animal models. In order to circumvent some of the problems associated with cell transplant therapy, such as the limited availability of transplant tissue, we have established a reaggregate (three-dimensional) tissue culture system that can be used to proliferate normal mammalian neuronal precursors. We demonstrate the in vitro growth of DA-neuronal precursors derived from embryonic porcine ventral mesencephalon, Carnegie stages 15-18. Cultures of DA-neuronal precursors were maintained in F12 medium supplemented with Chang C Supplement for 5 days and switched to serum-free N2 medium for an additional 10 days. Cultures labeled with tritiated thymidine on Days 5-7 in vitro revealed that 43.5% of the DA neurons had incorporated the label, indicative of cell division. Histological examination of the cultured cells demonstrated rosette-like structures, similar to developing neuroepithelium in vivo. Neuronal maturation in vitro was stimulated by dibutyryl cyclic AMP (dbcAMP). Exposure to 5 mM dbcAMP for 7 days stimulated tyrosine hydroxylase (TH), neuron-specific enolase, and 200-kDa neurofilament accumulation three- to sixfold above control levels. After 15 days in vitro, cultured cells reversed amphetamine-induced rotation when grafted into the striata of hemiparkinsonian rats. Successful transplants of cultured neurons were dependent upon a minimum density of DA neurons within the graft (greater than 100 DA neurons/mm3 of graft volume). Data suggest that the percentage of TH neurons can be increased about threefold by culturing the aggregates in tyrosine-free medium, which selects for TH-positive cells. The ability to cultivate mammalian neuronal precursor cells in vitro may eventually make graft therapy a more practical approach to treatment of neurological diseases.

The neurophysiological basis of learning: attention and memory implications for SCI nurses.

Understanding the neurophysiological basis of learning enables nurses working with individuals with spinal cord injury to astutely assess potential for learning. This is particularly relevant when head injury or drug effects influence neurological systems relevant to learning. The neuroanatomical and neurophysiological bases of learning are related to attention, memory, concept formation/abstraction, reasoning, and executive systems. Attention and memory are discussed as they relate to learning in this article. This information is incorporated into an expanded assessment (Ciminaro, Calhoun, & Adams, 1977; Gazzaniga 1979; Lezak, 1983: Mesulam, 1985). More in-depth nursing assessment related to cognitive systems necessary for learning enables nurses to identify intact and impaired cognitive systems and to quantify deficits. Astute assessment is fundamental to planning effective teaching and learning strategies for spinal cord injured persons especially when learning deficits exist, e.g., in head injured persons who have sustained a spinal cord injury. Implications for client and family education derive from an understanding of the normal neurophysiological basis of learning and normal and abnormal assessment findings. Learning is dependent on several cognitive systems--attention systems, memory systems, concept formation/abstraction and reasoning systems, and the "executive" system. Attention and memory systems are discussed in this article, the remainder will be discussed in the next issue. The neuroanatomy and neurophysiology, clinical findings associated with normal and abnormal function, and nursing implications for the nurse working with individuals with spinal cord injury will be explored.

Self-care assessment tool for spinal cord injured persons.

The purpose of this study was to develop a reliable and valid tool that assesses the cognitive and functional skills needed for self-care in persons with spinal cord injury (SCI). The Self-Care Assessment Tool (SCAT) assesses cognitive and functional skills in eight self-care areas: bathing/grooming, nutritional management, taking medications, mobility/transfers/safety, skin management, bladder management, bowel management and dressing. The tool was carefully developed and has demonstrated content validity. Interrater reliabilities for the cognitive, functional and total scores ranged from .69 to .94 (n = 10). Test-retest reliabilities for the cognitive, functional and total scores ranged from -.06 to .86 (n = 14, 16). Regarding predictive validity, R2 ranged from .61 to .90 for the cognitive, functional and total scores (n = 18). Although continued reliability and validity studies are needed, the SCAT has potential to measure patient rehabilitation outcomes, to evaluate nursing care approaches and to serve as a quality assurance indicator for nursing care.

Managing communication disorders in stroke.

Dysphasias, dyspraxias, and dysarthrias are communication disorders that may be experienced following a stroke. Nursing assessment of language and speech is based on an understanding of normal language and speech systems. Location of the stroke and clinical assessment findings uncovered through the history and physical examination allow identification of language and speech deficits. Language is examined by assessing spontaneous speech, verbal comprehension, reading, writing, and ability to name and repeat. Speech is examined by testing motor function and reflexes of cranial nerves VII, IX, X, and XII. The identification of intact language and speech functions and language and speech deficits enables the nurse to plan and implement interventions based on the assessment findings in four areas--environmental manipulation, supportive behaviors, behaviors designed to enhance communication, and teaching of the person and family.

Cognitive systems: nursing assessment and management in the critical care environment.

In-depth knowledge of cognitive systems allows the critical care nurse to incorporate that information into an expanded assessment. This in-depth nursing assessment enables the nurse to identify intact and deficient cognitive systems and quantify the deficits. Astute assessment is fundamental to planning appropriate interventions and permits more specific deficit-related interventions by the critical care nurse.