Assessment and screening tools for trauma in children and adolescents: a review

The need for thorough and accurate assessment of trauma in the lives of children and adolescents has become extremely important for the implementation of appropriate interventions. This article reviews 35 measures, 25 in depth and 10 in brief, that are currently available for use by researchers and practitioners. Instruments were divided into four domains: those that screen for (1) both a history of exposure to traumatic events and the presence of symptoms of trauma; (2) only a history of exposure; (3) symptoms of posttraumatic stress disorder (PTSD) or Dissociations; and (4) multiple symptoms of trauma (i.e. depressions, anger, sexual concerns, as well as PTSD). Information about the type of instrument, how trauma is constructed, psychometric properties, and practical issues are addressed for each of the 25 measures. A brief analysis is also provided for each measure.     

Cytomegalovirus hepatitis after bone marrow transplantation: An autopsy study with clinical,histologic and laboratory correlates

Mortality from cytomegalovirus disease after marrow transplantation can be reduced by treatment with antiviral drugs based on the detection of viremia and organ involvement. We examined autopsy liver specimens to determine the frequency, extent and outcome of cytomegalovirus hepatitis and whether cytomegalovirus hepatitis occurred in the absence of cytomegalovirus disease elsewhere. Autopsy specimens from 50 transplant patients were evaluated for cytomegalovirus‐infected cells, in five groups of 10, according to extent of CMV during life and at autopsy. Liver sections were examined by routine light microscopy, immunohistochemistry and in situ DNA hybridization. Clinical and laboratory data collected during the last 30 days of life were analysed as markers of liver cytomegalovirus infection. Cytomegalovirus‐infected cells were detected in the livers of 10/10 patients with cytomegalovirus infection during life and widespread cytomegalovirus at autopsy; in 3/20 livers from patients with cytomegalovirus infection during life but negative liver cultures at autopsy; and in 1/10 livers from cytomegalovirus‐seropositive patients who had been without other evidence of cytomegalovirus infection. Histology detected a lower density of cytomegalovirus‐bearing cells per unit area of liver, compared to immunohistochemistry and in situ hybridization. No cytomegalovirus‐infected cells were detected in livers from cytomegalovirus‐seronegative controls. No distinctive clinical or laboratory findings correlated with liver cytomegalovirus detection. CMV liver disease is common in allografted patients with disseminated CMV but may rarely be isolated to the liver, best demonstrated with IHC and ISH. Massive hepatic necrosis from CMV was not seen in any autopsy liver in this study.     

Insulin resistance is associated with a poor response to intravenous thrombolysis in acute ischemic stroke

OBJECTIVE

Insulin resistance (IR) may not only increase stroke risk, but could also contribute to aggravate stroke prognosis. Mainly through a derangement in endogenous fibrinolysis, IR could affect the response to intravenous thrombolysis, currently the only therapy proved to be efficacious for acute ischemic stroke. We hypothesized that high IR is associated with more persistent arterial occlusions and poorer long-term outcome after stroke thrombolysis.

RESEARCH DESIGN AND METHODS

We performed a prospective, observational, longitudinal study in consecutive acute ischemic stroke patients presenting with middle cerebral artery (MCA) occlusion who received intravenous thrombolysis. Patients with acute hyperglycemia (≥155 mg/dL) receiving insulin were excluded. IR was determined during admission by the homeostatic model assessment index (HOMA-IR). Poor long-term outcome, as defined by a day 90 modified Rankin scale score ≥3, was considered the primary outcome variable. Transcranial Duplex-assessed resistance to MCA recanalization and symptomatic hemorrhagic transformation were considered secondary end points.

RESULTS

A total of 109 thrombolysed MCA ischemic stroke patients were included (43.1% women, mean age 71 years). The HOMA-IR was higher in the group of patients with poor outcome (P = 0.02). The probability of good outcome decreased gradually with increasing HOMA-IR tertiles (80.6%, 1st tertile; 71.4%, 2nd tertile; and 55.3%, upper tertile). A HOMA-IR in the upper tertile was independently associated with poor outcome when compared with the lower tertile (odds ratio [OR] 8.54 [95% CI 1.67–43.55]; P = 0.01) and was associated with more persistent MCA occlusions (OR 8.2 [1.23–54.44]; P = 0.029).

CONCLUSIONS

High IR may be associated with more persistent arterial occlusions and worse long-term outcome after acute ischemic stroke thrombolysis.Stroke is the second most common cause of death and the first leading cause of disability in adults worldwide. Moreover, stroke burden is expected to increase rapidly in the following decades (1). Approximately 85% of all strokes are ischemic, mainly caused by acute thromboembolic occlusion of intracranial arteries. In this context, reperfusion therapies focus on early vessel reopening to save cerebral ischemic tissue at risk, thus reducing final infarct size and neurologic sequelae. Currently, intravenous thrombolysis with tissue plasminogen activator (tPA) remains the only therapy that has proved efficacy for acute ischemic stroke.Insulin resistance (IR), the proposed main pathophysiological mediator of metabolic syndrome (2), may lead to a prothrombotic and proinflammatory state, characterized by a derangement in endogenous fibrinolysis and increased platelet activation (3). These deleterious effects may contribute to explain the well-known association between raised IR and a higher incident or recurrent stroke (4), but whether IR-related metabolic disturbances may also have an impact on the prognosis of acute ischemic stroke once it has occurred and on the response to intravenous thrombolysis remains largely unknown. In this setting, our group previously reported that acute stroke patients fulfilling criteria for metabolic syndrome showed a higher resistance to intravenous thrombolysis (5,6). However, that study was based only on metabolic syndrome clinical criteria and no direct measure to assess IR was performed, thus we could not draw any valid conclusion regarding the relationship between IR and acute stroke outcome. Considering the pathophysiological background and our previous research, we designed a prospective study to test the hypothesis that a high IR is associated with a worse clinical outcome and more persistent arterial occlusions after intravenous thrombolysis for acute ischemic stroke.     

The effect of the administration of human gamma globulins in a model of BCG infection in mice

The effect of the administration of a commercial preparation of human gamma globulins has been evaluated in a mouse model of intranasal infection with BCG. First, we demonstrated the passage of specific antibodies to saliva and lung lavage following the intranasal or intraperitoneal administration to mice of human gamma globulins. This treatment of mice inhibited BCG colonization of the lungs (p < 0.01). A similar inhibitory effect was observed after infection of mice with gamma globulin opsonized BCG organisms (p < 0.01). These results are relevant for the development of new strategies for the control and treatment of tuberculosis.     

Elevated levels of activated CD4 T cells in common variable immunodeficiency: association with clinical findings

BackgroundCommon variable immunodeficiency (CVID) is a very heterogeneous syndrome defined by impaired immunoglobulin production. The primary defect remains unknown, but many reports describe peripheral blood T and B lymphocyte dysfunctions in a substantial proportion of CVID patients. Immunophenotypic alterations on memory B lymphocytes correlate with clinical findings. A B-cell-oriented classification principle of the patients has been proposed.Methods and resultsWe investigated the expression of activation surface molecules on CD4 and CD8 T-cells from 14 patients with CVID, 6 non-CVID hypogammaglobulinemic patients with recurrent infections, 47 asymptomatic HIV-positive patients without AIDS defining conditions and 23 healthy subjects. Lymphocyte subsets were analysed by three-colour flow cytometry. Monoclonal panel: CD38-FITC/HLADR-PE/CD4 or CD8-PerCP. In CVID patients serum levels of CD4 T-cells co-expressing the activation marker HLA-DR [CD4 + DR + (34 %), CD4 + CD38 + DR + (18 %)] were significantly elevated compared with controls. Significant increases in CD8 + DR + (54%), CD8 + CD38 + (43 %) and CD8 + CD38 + DR + (29 %) T-cells were observed in comparison with healthy controls. CVID patients with splenomegaly, lower pre-infusion IgG levels (< 600 mg/dl), autoimmune or lymphoproliferative conditions demonstrated even higher levels of CD4 + CD38 + DR + T cells (22, 22, 21 and 21 % respectively) compared with other CVID patients (13, 13, 15 and 15 % respectively).ConclusionThese findings indicate a state of ongoing T lymphocyte activation which is associated with clinical findings frequently observed in CVID.     

Funktionelle Behandlung bei Humerusschaftfrakturen

Functional bracing of humeral diaphyseal fractures was conceived after initial experiences with a similar method was used in the management of diaphyseal tibial fractures. Over the years, tibial functional bracing underwent major evolutionary changes, and found its indications basically limited to a smaller group of fractures, consisting of closed, axially unstable fractures that experience at the time of the injury an acceptable degree of shortening, and to transverse fracture that are appropriately reduced and rendered stable. On the other hand, functional bracing of diaphyseal humeral fractures has, maintained the initial indications, contraindications and methodology. This article describes the concept, indications and contraindications of functional bracing of humeral diaphyseal fractures and provides results of 620 fractures with complete follow-up. In 97.5% of the patients, the average healing time was 11.5 weeks. 16 patients (2.5%) required operative intervention because of a nonunion and 4 patients (<1 degrees) of the patient had a refracture after brace removal. Nerve function did not return in only one of the 67 patient who had radial nerve palsy.