Rehabilitation outcomes of terror victims with multiple traumas

OBJECTIVES: To describe the rehabilitation outcomes of terror victims with multiple traumas, and to compare those outcomes with those of patients with nonterror-related multiple traumas treated in the same rehabilitation facility over the same time period. DESIGN: Retrospective chart reviews. SETTING: Rehabilitation department in a university hospital in Jerusalem, Israel. PARTICIPANTS: Between September 2000 and September 2004, we treated 72 victims of terrorist attacks who had multiple traumas. Among them, 47 (65%) had multiple traumas without central nervous system involvement (MT subgroup), 19 (26%) had multiple traumas with traumatic brain injury (TBI subgroup), and 6 (8%) had multiple traumas with spinal cord injury (SCI subgroup). We matched, according to their types of injury and demographic data, each terror victim with a control patient treated in the same period in our rehabilitation department. INTERVENTION: Interdisciplinary inpatient and outpatient rehabilitation. MAIN OUTCOME MEASURES: Hospital length of stay (LOS) in acute care departments, inpatient and outpatient rehabilitation departments, functional outcome (FIM instrument score), occupational outcome (returning to previous occupation), and psychologic outcome (Solomon PTSD [post-traumatic stress disorder] Inventory). RESULTS: The mean LOS of terror victims was 218+/-131 days; for the nonterror group it was 152+/-114 days (P<.01). In comparison with the control subgroups, the MT subgroup of terrorist victims had significantly longer LOS in the acute care and outpatient rehabilitation departments (P=.06) and the terror TBI subgroup had a longer LOS in outpatient department only (P<.05). The LOS of the SCI patients, both terror victims and control patients, was significantly longer than that of the other 2 subgroups. The difference between FIM value at entry and discharge (DeltaFIM) was significantly higher for terror victims than for the controls (41.1+/-21.6 vs 30.8+/-21.8, P=.002). This difference was mainly the result of the significantly higher DeltaFIM achieved by the terror MT subgroup than by the MT controls. The rate of PTSD was higher among terror victims than among controls (40.9% vs 24.2%, P=.04). The rate of return to previous occupations was similar between terror victims and nonterror patients (53% vs 46.9%, respectively). CONCLUSIONS: Victims of terror spent longer periods in rehabilitation than the nonterror group; however, they regained most activity of daily living functions similar to the nonterror group. Despite the higher rate of PTSD, terror victims succeeded in returning to their previous occupations at a similar rate to that of the nonterror group.     

A structural basis for antigen recognition by the T cell-like lymphocytes of sea lamprey

Adaptive immunity in jawless vertebrates is mediated by leucine-rich repeat proteins called “variable lymphocyte receptors” (VLRs). Two types of VLR (A and B) are expressed by mutually exclusive lymphocyte populations in lamprey. VLRB lymphocytes resemble the B cells of jawed vertebrates; VLRA lymphocytes are similar to T cells. We determined the structure of a high-affinity VLRA isolated from lamprey immunized with hen egg white lysozyme (HEL) in unbound and antigen-bound forms. The VLRA–HEL complex demonstrates that certain VLRAs, like γδ T-cell receptors (TCRs) but unlike αβ TCRs, can recognize antigens directly, without a requirement for processing or antigen-presenting molecules. Thus, these VLRAs feature the nanomolar affinities of antibodies, the direct recognition of unprocessed antigens of both antibodies and γδ TCRs, and the exclusive expression on the lymphocyte surface that is unique to αβ and γδ TCRs.     

Protein synthesis inhibition before or after stress exposure results in divergent endocrine and BDNF responses disassociated from behavioral responses

This study aimed to assess the effects of anisomycin, a protein synthesis inhibitor, on behavioral responses, brain-derived neurotrophic factor (BDNF) and TrkB mRNA levels, and circulating corticosterone in rats-when administered before or after initial exposure to a predator scent stress stimulus. Magnitude of changes in prevalence of anxiety-like behaviors on the elevated plus-maze and exaggerated startle reaction as well as corticosterone levels and mRNA BDNF and TrkB were compared in rats exposed to predator stress, microinjected with anisomycin before or after stress exposure. Administration of anisomycin before or after stress exposure reduced anxiety-like behavior in the elevated plus-maze and reduced the mean startle amplitude 7 days postexposure. Although the behavioral responses were similar when anisomycin was microinjected before or after stress exposure, the levels of mRNAs for BDNF and TrkB, which play a role in modulation of synaptic plasticity and the consolidation process, showed varying responses.     

Biphenotypic acute leukaemia: a case series

Biphenotypic acute leukaemia (BAL) is a rare type of leukaemia. Whether patients with BAL should be treated with regimens designed for acute myeloid leukaemia (AML), acute lymphocytic leukaemia (ALL) or both remain unclear. We have reviewed the clinical data for 31 BAL patients. Most patients co-expressed B-lymphoid and myeloid markers. No specific chromosomal abnormality was identified. The majority of the patients were treated with regimens devised for treating ALL. Seven patients were treated with regimens designed for AML. Complete remission (CR) rates of 78% and 57% were noted respectively. The overall survival probability at 2 years was 60%.     

Vagal damage enhances polyneuropathy pain: additive effect of two algogenic mechanisms

While the major pain generation in polyneuropathy is in the somatic peripheral nerves, pathologies at visceral nerves might be involved as well. Decreased vagal afferent activity is known to disinhibit pain perception, and therefore might contribute to pain in polyneuropathy. In this study we explored this potential contribution by employing a rat model of vincristine (VCR)-induced pain after sub-diaphragmatic vagotomy (SDV). Forty rats were divided into 4 groups: VCR, SDV, VCR + SDV and controls. Each rat underwent a variety of pain-related behavioral tests including assessment of spontaneous pain, allodynia and hyperalgesia to thermal and mechanical stimuli. We found that VCR + SDV rats had enhanced painful neuropathy compared to VCR alone, expressed as: (1) earlier development of central sensitization: at the first week in rats that underwent SDV + VCR (p < 0.0001) and only at the second week in rats injected with VCR alone (p < 0.0001), (2) increased incidence of spontaneous pain behavior (p = 0.0036), (3) spreading of the spontaneous pain behavior to the forelimbs, (4) higher mechanical dynamic allodynia (tendency, p = 0.08) and (5) augmentation of the response to repetitive painful and non-painful mechanical stimuli (p < 0.001). Thus, decreased vagal activity aggravates both the severity and the time course of painful polyneuropathy. Therefore, the two mechanisms add to each other in generating the pain picture.     

Acute disseminating encephalomyelitis in neuromyelitis optica: closing the floodgates

OBJECTIVE: To report the clinical and radiological features of 2 patients with neuromyelitis optica (NMO) associated with severe acute disseminating encephalomyelitis. The first patient had anti-aquaporin 4 antibodies (NMO-IgG) but no lesion enhancement, in contrast to the second patient who was seronegative for NMO-IgG but had clear lesion enhancement on magnetic resonance imaging. DESIGN: Clinical, laboratory, and radiological analysis of 10 patients presenting with features compatible with an NMO-spectrum disorder, 2 of whom developed acute disseminating encephalomyelitis. SETTING: Inpatient ward at the Department of Neurology, Hadassah University. PATIENTS: Patients admitted during a 1-year period with features compatible with an NMO-spectrum disorder. INTERVENTIONS: Medical histories and imaging data were reviewed and serum samples were analyzed for the presence of NMO-IgG. MAIN OUTCOME MEASURES: Clinical and paraclinical evidence of brain involvement. RESULTS: Of 10 patients tested, 5 were positive for NMO-IgG. One seropositive and 1 seronegative patient had an acute disseminating encephalomyelitis-like episode. In both cases, the clinical, laboratory, and electroencephalographic findings supported a diagnosis of acute disseminating encephalomyelitis. Magnetic resonance imaging demonstrated extensive bilateral white matter lesions in both patients. Lesions in the seropositive patient were notably lacking in enhancement following gadolinium injection, whereas robust lesion enhancement was observed in the seronegative patient. CONCLUSIONS: Acute disseminating encephalomyelitis without lesion enhancement on magnetic resonance imaging may represent a childhood manifestation of seropositive NMO. The lack of enhancement suggests an intact blood-brain barrier and supports a unique mechanism of edema induction due to dysfunction of water channels.     

Cognitive and functional outcomes of terror victims who suffered from traumatic brain injury

Primary objective: To describe the outcomes of terror victims suffered from traumatic brain injury (TBI).

Research design: Retrospective chart review of 17 terror and 39 non-terror TBI patients treated in a rehabilitation department during the same period.

Methods and procedure: Variables include demographic data, Injury Severity Scale (ISS), length of stay (LOS) and imaging results. ADL was measured using the Functional Independence Measurement (FIM), cognitive and memory functions were measured using the Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) battery and the Rivermead Battery Memory Test (RBMT), respectively.

Main outcome and results: Terror TBI patients were significantly younger, had higher ISS score and higher rates of intracerebral haemorrhage (ICH), brain surgery and penetrating brain injuries than the non-terror TBI group. There was no difference in mean LOS, mean FIM values, mean FIM gain and mean cognitive and memory improvement between groups. Terror victims suffered from a higher percentage of post-traumatic epilepsy (35% vs. 10%, p = 0.05), whereas the rate of PTSD and the rate of return to previous occupation were similar between groups.

Conclusions: Although TBI terror victims had more severe injury, they gained most of ADL functions and their rehabilitation outcomes were similar to non-terror TBI patients. These favourable results were achieved due to a comprehensive interdisciplinary approach to terror victims and also by national support which allowed an adequate period of treatment and sufficient resources as needed.