Cardiac and vascular metal deposition with high mortality in nephrogenic systemic fibrosis.

Nephrogenic systemic fibrosis is a severe disabling disease that can follow gadolinium-based contrast exposure. In this study we analyzed the clinical and laboratory records of patients with nephrogenic systemic fibrosis who had a history of exposure to gadolinium-based contrast media and identified their cardiac and vascular events. At autopsy, we found that the heart, blood vessels, and skin of three patients who died of cardiac and/or vascular complications had appreciable amounts of gadolinium, iron, and aluminum as measured by inductively coupled plasma-mass spectrometry and confirmed by x-ray fluorescence. Of the 32 patients with nephrogenic systemic fibrosis studied, 10 died at a median of 112 days after diagnosis. Cardiovascular events contributed to the mortality of 9 patients and included congestive heart failure, recurrent arrhythmias, hypotension, stroke, limb ischemia, posterior ischemic optic neuropathy and sudden death. Our results show that increased cardiac and vascular complications along with short survival in nephrogenic systemic fibrosis are associated with metal accumulation in the heart, blood vessels, and skin of these patients.

Neuropsychological outcome and community re-integration following traumatic brain injury: the impact of frontal and non-frontal lesions.

PRIMARY OBJECTIVE: To examine the relationship between cortical lesion location and brain injury outcome. It was hypothesized that focal frontal lesions after traumatic brain injury (TBI) would result in decreased executive and memory functioning and poor community participation outcome. RESEARCH DESIGN: Three quasi-experimental, prospective studies employed a total of 643 patients with focal frontal, fronto-temporal, non-frontal or no lesions in CT scans. METHODS AND PROCEDURES: CT scan analysis, neuropsychological assessment, the Neurobehavioural Functioning Inventory (NFI), the Community Integration Questionnaire (CIQ). MAIN RESULTS: In study 1, frontal and fronto-temporal groups performed worse in executive functioning and better in constructional ability. Study 2 found no differences in neuropsychological and community re-integration measures at 1-year follow-up. Study 3 found comparable neuropsychological test score improvement across groups over 1 year. CONCLUSIONS: Results are consistent with previous findings and document the potential for test score improvement with rehabilitation and suggest that lesion location needs to be considered when individual rehabilitation plans are being implemented in the post-acute stage of TBI.

Charges and lengths of stay for acute and inpatient rehabilitation treatment of traumatic brain injury 1990-1996.

This investigation evaluated yearly trends in charges and lengths of stay for patients with brain injury in acute care and rehabilitation settings over a 7 year period. Data was collected from 800 consecutive patients enrolled in four NIDRR Model Systems Traumatic Brain Injury programmes. Acute care daily charges showed almost routine increases, averaging nearly $550 per year. Conversely, lengths of stay generally showed a downward trend, with annual reductions averaging 2.25 days. Admission lengths of stay averaged 22-29 days between 1990-1994. Admissions averaged less than 20 days beginning in 1995, with the 1996 average of 16 days, nearly half that of the 1993 average. Between 1990-1996, average daily rehabilitation charges increased each year, with the rise averaging $83 or 7%. The rise in daily rehabilitation charges was offset by corresponding decreases in lengths of stay averaging 3.65 days or 8% annually. Increases in daily charges for brain injury rehabilitation care were roughly comparable to those for general medical care prices. However, the rate of change in acute care charges was substantially greater, with annual increases averaging 10% more than national medical care prices. The steady downward trend in lengths of stay raises serious concerns about the future availability of health care services to persons with brain injury.

A multi-center analysis of rehospitalizations five years after brain injury.

OBJECTIVE: To investigate the incidence and cause of rehospitalizations 1 and 5 years after traumatic brain injury. DESIGN: Descriptive statistics were computed in a prospective study of the cause and incidence of rehospitalizations at years 1 and 5 after injury. Analysis of variance and chi-square tests were used to identify factors relating to rehospitalization; factors included length of stay, admission and discharge functional status, payer source, medical complications, injury severity, and demographics. SETTING: Seventeen medical centers in the federally sponsored Traumatic Brain Injury Model Systems. In each setting, the continuum of care includes emergency medical services, intensive and acute medical care, inpatient rehabilitation, and a spectrum of community rehabilitation services. PARTICIPANTS: Eight hundred ninety-five rehabilitation patients admitted to acute care within 24 hours of traumatic brain injury between 1989 and 1999 were examined at 1-year follow-up. MAIN OUTCOME MEASURES: Incidence and cause of rehospitalization at 1 and 5 years after injury. RESULTS: The incidence of rehospitalization ranged from 22.9% 1 year after injury to 17.0% at 5 years after injury. At 1 year after injury, a third of the rehospitalizations were for elective reasons. At 5 years after injury, the incidence of readmissions for seizures and psychiatric difficulties and general health maintenance increased substantially. T-tests and chi-square analyses were performed on the 5-year follow-up data to compare those rehospitalized for unplanned reasons with those not rehospitalized. CONCLUSIONS: There remains a relatively high rate of rehospitalization in the long term after traumatic brain injury. The costs of rehospitalization should be considered when evaluating the long-term consequences of injury.

Long-term neuropsychological outcome after traumatic brain injury.

OBJECTIVE: To describe neuropsychological outcome 5 years after injury in persons with traumatic brain injury (TBI) who received inpatient medical rehabilitation. To determine the magnitude and pattern neuropsychological recovery from 1 year to 5 years after injury. DESIGN: Longitudinal cohort study with inclusion based on the availability of neuropsychological data at 1 year and 5 years after injury. SETTING: National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems of Care. PARTICIPANTS: One hundred eighty-two persons with complicated mild to severe traumatic brain injury. PRIMARY OUTCOME MEASURES: Digits Forward and Backward, Logical Memory I and II, Token Test, Controlled Oral Word Association Test, Symbol Digit Modalities Test, Trail Making Test, Rey Auditory Verbal Learning Test, Visual Form Discrimination, Block Design, Wisconsin Card Sorting Test, and Grooved Pegboard. RESULTS: Significant variability in outcome was found 5 years after TBI, ranging from no measurable impairment to severe impairment on neuropsychological tests. Improvement from 1 year after injury to 5 years was also variable. Using the Reliable Change Index, 22.2% improved, 15.2% declined, and 62.6% were unchanged on test measures. CONCLUSIONS: Neuropsychological recovery after TBI is not uniform across individuals and neuropsychological domains. For a subset of persons with moderate to severe TBI, neuropsychological recovery may continue several years after injury with substantial recovery. For other persons, measurable impairment remains 5 years after injury. Improvement was most apparent on measures of cognitive speed, visuoconstruction, and verbal memory.

Long-term maintenance of gains obtained in postacute rehabilitation by persons with traumatic brain injury.

OBJECTIVE: To investigate maintenance of gains after discharge from a postacute rehabilitation program. DESIGN: Longitudinal cohort study, with inclusion based on availability of subjects at three time points. SETTING: Comprehensive postacute rehabilitation program in the Southern United States. PARTICIPANTS: Thirty-four persons with medically documented complicated mild to severe traumatic brain injury; primarily male Caucasians with some college. MAIN OUTCOME MEASURES: Disability Rating Scale and the Community Integration Questionnaire completed at admission, discharge, and two follow-up time points. RESULTS: Repeated measures analyses, using time from injury to discharge as a covariate, revealed significant improvements on all measures from admission to discharge, with no significant change from discharge to either of the follow-up periods. However, substantial changes were noted in individual cases. CONCLUSIONS: The results indicate that gains made by persons with traumatic brain injury during postacute rehabilitation are generally maintained at long-term follow-up, but changes occur in individual cases. Long-term services may help prevent decline in individual cases.

Using early neuropsychologic testing to predict long-term productivity outcome from traumatic brain injury.

OBJECTIVE: To evaluate whether early neuropsychologic testing is useful in predicting long-term productivity outcome after traumatic brain injury (TBI). DESIGN: Validation cohort prediction study. SETTING: Four inpatient brain injury rehabilitation programs participating in the Traumatic Brain Injury Model Systems project. PARTICIPANTS: A total of 293 adults with nonpenetrating TBI. MAIN OUTCOME MEASURES: Fifteen neuropsychologic tests were administered to patients who emerged from posttraumatic amnesia before rehabilitation discharge. Test scores were classified in the normal range or impaired range, using objective criteria. Outcome was defined as productive if the patient was competitively employed or enrolled full time in regular education. RESULTS: Productivity at follow-up was predicted by completion of at least 1 neuropsychologic test before discharge, by an injury-test interval of less than 2 months, and by normal range scores on 10 of the 15 neuropsychologic tests. Normal range scores on these tests increased the probability of a productive outcome by 40% to 130%. CONCLUSIONS: Neuropsychologic testing can help predict long-term productivity even when performed before discharge from inpatient rehabilitation and at variable injury-test intervals. Early testing should be interpreted in relation to injury-test interval. Because tests of multiple neuropsychologic domains predicted outcome, comprehensive evaluations might be more useful in predicting outcome.

Neuropsychological assessment and the Disability Rating Scale (DRS): a concurrent validity study.

Assessment of current level of functioning among clients with traumatic brain injury (TBI) often guides the establishment of realistic outcome goals for post-acute rehabilitation. Further, data generated from neuropsychological testing provide a clinician with a better understanding of a client's pattern of cognitive strengths and weaknesses. The Disability Rating Scale (DRS) is commonly used by TBI rehabilitation facilities to assess a client's general level of functioning in terms of impairment, disability, and handicap. Previous studies have used clients' neuropsychological test results to predict future level of functioning. These studies have shown mixed results regarding the predictive validity of the test findings; however, they usually employ only a limited number of tests for prediction representing a limited number of cognitive domains. Using a concurrent validity design, the present study investigated the bivariate associations between various neuropsychological testing domains (i.e. intellectual, academic, language, visuoperceptual, memory, and executive functioning) and level of functioning as indexed by the DRS. Participants were administered the DRS and the neuropsychological evaluation during the initial part of post-acute rehabilitation. Composite scores were derived for each of the neuropsychological domains. Most participants were categorized as sustaining a severe TBI. The mean age and education of this predominately male sample was 28.84 years (SD = 9.13) and 11.83 years (SD = 1.7), respectively. Results revealed a significant positive relationship between performances in intellectual, executive, academic, and visuoperceptual domains and level of functioning.

Subchronic in vivo effects of a high static magnetic field (9.4 T) in rats.

The potential adverse biologic effects of sub chronic (cumulatively 10 weeks) exposure to a high magnetic field (9.4 T) were evaluated in young adult male and female Fischer rats as well as in their progeny. Biologic end points in adult rats included changes in daily clinical observations; spatial memory tests; weekly heart rates, body weights, food and water consumption, and the feed efficiency ratio; terminal hematologic, blood biochemical and urinary parameter changes; gross pathologic findings; and major organ weights. In offspring, biologic end points included the gestation period, number of live births, number of pups, ratio of male to female pups/litter; postnatal time period of eye opening; birth and weekly body weights, behavioral changes, central nervous system responses, as well as hematologic, blood biochemistry, and urinary parameter changes; and gross pathologic findings. Findings from this study showed that there were no adverse biologic effects in male and female adult rats or their progeny that could be attributed to 10-week exposure to a 9.4-T static magnetic field.

Assessment of the accuracy of low-cost store-and-forward teledermatology consultation.

BACKGROUND: Telemedicine has the potential to revolutionize the delivery of dermatologic care to underserved areas. OBJECTIVE: Our purpose was to compare diagnoses from two types of dermatology consultations: telemedicine using store-and-forward (SAF) technology, and traditional face-to-face (FTF) office visits. METHODS: Skin conditions were imaged with a consumer-grade digital camera. A standardized template was used to collect historical data. Information was stored in a secured database for access by 2 or 3 board-certified dermatologists. Results from the FTF visit were used to assess the accuracy of the SAF diagnoses. RESULTS: A total of 106 dermatologic conditions in 92 patients were included. Concordance between FTF and SAF diagnoses was high, ranging from 81% to 89% for all 3 dermatologists. Clinically relevant disagreement occurred in only 4% to 8% of cases. Remaining disagreements did not affect patient care. Diagnostic confidence and image quality affected agreement. When cases of high confidence were analyzed separately, agreement increased to 88% to 100%. This increase was substantiated by means of a chi-square test between the high confidence and low confidence groups, which demonstrated statistical significance (P <. 005) for all dermatologists. Similarly, when cases of above average image quality were considered, agreement increased to 84% to 98%. Again this difference was substantiated by means of a chi-square test between adequate and poor images, with statistical significance for two dermatologists (P <.001). Accuracy was comparable between disease types with the exception of benign neoplasms, which demonstrated agreement of 22% to 46%. CONCLUSION: These data support the use of existing digital technology to construct an accurate SAF teledermatology system. The inexpensive camera and widely available computer equipment make this an extremely affordable system. Furthermore, participating dermatologists appear well aware of system limitations, as reflected in the increased agreement for high confidence cases. Additional investigation of the accuracy of teledermatology for benign neoplasms is warranted.

Predictive validity of the Neurobehavioural Cognitive Status Examination (NCSE) in a post-acute rehabilitation setting.

Within the context of a post-acute rehabilitation setting, association and agreement between results from the Neurobehavioural Cognitive Status Examination (NCSE) and from the neuropsychological (NP) evaluation are examined. All participants (n = 48) had sustained a severe traumatic brain injury and NCSE testing preceded NP testing by an average of 1 month. A significant relationship and fair classification agreement (i.e. presence or absence of cognitive impairment) was found between the overall results from NCSE and NP evaluation. Significant relationships were also observed between most NCSE subtests and paired NP tests thought to be assessing the same cognitive domains. However, the classification agreement (i.e. the presence or absence of deficient performance) between most NCSE subtests and paired NP tests was poor. The findings are discussed from the standpoint of individual treatment planning.

Extensor triggering in de Quervain's stenosing tenosynovitis.

Extensor triggering is an uncommon but recognized component of de Quervain's stenosing tenosynovitis. In a retrospective review of 827 patients with the diagnosis of de Quervain's disease over a 5-year period, 11 patients with 13 affected wrists were identified who had demonstrable triggering by both history and physical examination (prevalence of 1.3%). One wrist underwent surgical release without conservative treatment. The remaining 12 wrists were initially treated with nonoperative modalities. Failure of conservative treatment as defined by recurrent triggering and pain occurred in 7 wrists, of which 5 underwent surgical release. At the time of surgery, all wrists were noted to have synovitis, separate compartments for the extensor pollicis brevis and abductor pollicis longus tendons, and no intratendinous nodules. After an average follow-up period of 42 months (range, 5.7-94.5 months) there were no recurrences of triggering after surgical treatment. Seven of 12 wrists with triggering de Quervain's stenosing tenosynovitis failed nonoperative treatment. Triggering or locking in extension is an uncommon symptom in de Quervain's stenosing tenosynovitis and demonstrates a more recalcitrant course when treated nonoperatively.

The Community Integration Questionnaire revisited: an assessment of factor structure and validity.

OBJECTIVE: To investigate the factor structure and concurrent validity of the Community Integration Questionnaire (CIQ), using a large sample of persons with traumatic brain injury (TBI). DESIGN: Principal components analysis with varimax rotation was performed on CIQ items completed through interview with patients at 1 year after injury. Correlational analyses compared CIQ scores to scores on other widely used outcome measures. SETTING: Outpatient clinics affiliated with four TBI Model System rehabilitation centers funded by the National Institute on Disability and Rehabilitation Research. PARTICIPANTS: Three hundred twelve patients with medically documented TBI who were enrolled in the TBI Model Systems Project. The majority of patients were Caucasian males with severe TBI. MAIN OUTCOME MEASURES: CIQ; Functional Independence Measure (FIM); Functional Assessment Measure (FAM); Disability Rating Scale (DRS). RESULTS: Three factors emerged: Home Competency, Social Integration, and Productive Activity. The financial management item was moved from Social Integration to Home Competency, and the travel item was moved from Productive Activity to Social Integration. Each CIQ scale score showed significant correlations in the expected direction with the FIM+FAM and DRS items. CONCLUSIONS: The results provide further evidence for the validity of the CIQ and improve the scoring system. The factor structure is clinically and theoretically meaningful. The subscale and total scores show significant relationships with other widely used measures of outcome. Future research should focus on increasing the range of questions, accounting for changes from preinjury functioning, and obtaining normative data on the new factors.

Search for the trematode Prouterina wescotti in black bears in Oregon.

Forty-six heads of free-ranging black bears (Ursus americanus) collected in May and June of 1995 and 1996 from Oregon (USA) were examined for the trematode Prouterina wescotti and other parasites. Only Sarcocystis sp. was detected in two adult male bears. Prouterina wescotti has been found only once previously in one black bear from Idaho (USA); its normal definitive host remains unknown.

Etiology and incidence of rehospitalization after traumatic brain injury: a multicenter analysis.

OBJECTIVE: To investigate incidence and etiology of rehospitalizations at 1, 2, and 3 years after traumatic brain injury. DESIGN: Descriptive statistics were computed in a prospective study of etiology and incidence of rehospitalization at years 1, 2, and 3 postinjury. Analysis of variance (ANOVA) and chi2 were used to identify factors relating to rehospitalization; factors included length of stay, admission and discharge functional status, payer source, medical complications, injury severity, and demographics. SETTING: Four medical centers in the federally sponsored Traumatic Brain Injury Model Systems. In each setting, the continuum of care includes emergency medical services, intensive and acute medical care, inpatient rehabilitation, and a spectrum of community rehabilitation services. PARTICIPANTS: Six hundred sixty-five rehabilitation patients admitted to acute care within 24 hours of traumatic brain injury between 1989 and 1996. MAIN OUTCOME MEASURES: Annual incidence and etiology of rehospitalization. RESULTS: The annual incidence of rehospitalization ranged from 20% to 22.5%. Approximately half the rehospitalizations were for elective reasons. The most common reason for rehospitalization was for orthopedic or reconstructive surgery, followed by infectious disorders and general health maintenance. After the first year, the incidence of readmissions for seizures and psychiatric difficulties increased substantially. ANOVA and chi2 analyses were performed on data from the first year postinjury. No statistically significant associations were noted between incidence and etiology of rehospitalization and: demographics; injury severity; payer source for rehabilitation; concurrent injuries; acute care and rehabilitation length of stays; discharge Functional Assessment Measure; and discharge residence (p > .05). CONCLUSIONS: There is a relatively stable but high rate of rehospitalization for at least 3 years after injury. The costs of rehospitalization should be considered when evaluating the long-term consequences of injury.

Contribution of functional ratings to prediction of longterm employment outcome after traumatic brain injury.

The present study investigated the contribution of functional ratings to prediction of employment outcome after traumatic brain injury (TBI). Previous studies have suggested that functional ratings obtained at a significant time post-injury can supplement neurologic, pre-injury, neuropsychologic, and other post-injury variables in predicting long-term employment outcome. Functional ratings studied were patients' needs for physical, cognitive, and behavioural supervision. This investigation also addressed the issue of predicting long-term outcome for the select group of TBI patients who receive post-acute brain injury rehabilitation. Subjects were 76 patients with TBI. The mean age (25th, 50th, and 75th percentiles) was 32 (22, 28, 39) years and mean premorbid education level was 13 (12, 12, 14) years. Predictors studied were severity of injury, premorbid education level, pre-injury substance use, and needs for physical, cognitive and behavioural supervision at discharge from post-acute rehabilitation. Supervision needs ratings were obtained an average of 9.6 (4.2, 5.9, 11.2) months post-injury. Productivity status was assessed an average of 22.5 (12.6, 20.7, 30.5) months post-injury and 12.9 (4.9, 12.4, 16.6) months post-discharge from treatment. Spearman correlation coefficients revealed that premorbid educational level, pre-injury substance use, and needs for physical and behavioural supervision were related to long-term functional outcome (p < 0.05). However, multiple logistic regression analysis revealed that only level of pre-injury substance use was predictive of long-term productivity outcome once adjusted for the effects of the other predictors. Patients with no history of pre-injury substance use were more than eight times as likely to be employed at follow-up as those with a history of pre-injury substance abuse (p < 0.01).

Lactate turnover in rat glioma measured by in vivo nuclear magnetic resonance spectroscopy.

Elevated tissue lactate concentrations typically found in tumors can be measured by in vivo nuclear magnetic resonance (NMR) spectroscopy. In this study, lactate turnover in rat C6 glioma was determined from in vivo 1H NMR measurements of [3-13C]lactate buildup during steady-state hyperglycemia with [1-13C]glucose. With this tumor model, a narrow range of values was observed for the first-order rate constant that describes lactate efflux, k2 = 0.043 +/- 0.007 (n = 12) SD min-1. For individual animals, the standard error in k2 was small (< 18%), which indicated that the NMR data fit the kinetic model well. Lactate measurements before and after infusing [1-13C]glucose showed that the majority of the tumor lactate pool was metabolically active. Signals from 13C-labeled glutamate in tumors were at least 10-fold smaller than the [3-13C]lactate signal, whereas spectra of the contralateral hemispheres revealed the expected labeling of [4-13C]glutamate, as well as [2-13C] and [3-13C]glutamate, which indicates that label cycled through the tricarboxylic acid cycle in the brain tissue. Lack of significant 13C labeling of glutamate was consistent with low respiratory metabolism in this glioma. It is concluded that lactate in rat C6 glioma is actively turning over and that the kinetics of lactate efflux can be quantified noninvasively by 1H NMR detection of 13C label. This noninvasive NMR approach may offer a valuable tool to help evaluate tumor growth and metabolic responsiveness to therapies.