Treatment methodology Guiding of behaviour through redirection in brain injury rehabilitation

Confusion, agitation, and non-compliance are some of the most common behaviours exhibited by individualswith brain injury. The presence of these behaviours affects their daily functioning and social interactions with others. Management of these behaviours ranges from prevention and total ignoring to restraint, with the strategy of redirection cited most often in the literature. However, few guidelines exist on how to use redirection to manage clients who exhibit confusion and agitation beyond the acute phase of rehabilitation. This paper describes some of the intervention strategies that use guidance and redirection for individuals with brain injury in post-acute rehabilitation. Case examples are used to illustrate the various interventions.     

Quantitation of uterine activity in 100 primiparous patients.

An on-line technique for quantitating uterine activity by measuring the total area under the intrauterine pressure curve was utilized during the labor of 100 primiparous patients. Uterine activity was measured in uterine activity units (1 UAU=1 Torr minute). UAU's were calculated for each patient in both cumulative and noncumulative fashions. The rate of uterine activity (UAU per unit of time) increased as labor progressed, yet the total UAU's expended at each centimeter of dilatation progressively decreased with advancing dilatation. Thus, the rate of cervical dilatation increased faster than could be accounted for by the increase in uterine activity. The implication being that the efficiency of uterine contractions increases with advancing labor. It no longer appears reasonable to refer to labor in terms of elapsed time. Information regarding the "pattern of cervical dilatation" and uterine activity appears to be much more meaningful to the evaluation of progress in labor. Quantitation of uterine activity may provide useful information for the ongoing management of labor. Quantitation of UA does provide a means of evaluating the effects of specific events such as medication, anesthesia, and manipulation on UA.     

Critical airway obstruction, superior vena cava syndrome, and spontaneous cardiac arrest in a child with acute leukemia

We report the unusual presentation of a previously healthy girl with sudden cardiopulmonary arrest caused by acute lymphoblastic leukemia and mediastinal involvement leading to acute tracheal and airway obstruction. Despite active resuscitation and mechanical ventilation, she developed severe cerebral edema as a result of cerebral asphyxia. She also had facial edema caused by superior vena cava obstruction, a high peripheral white cell count with blast differentials, and renal failure. Because of severe asphyxia leading to brain death and renal failure, chemotherapy was withheld. Her white cell count spontaneously reverted to reference range without chemotherapy. This report serves to alert clinicians of the oncological emergency of "superior mediastinal syndrome" causing airway and superior vena cava obstruction leading to death in this potentially curable disease.     

Cardiovascular profile after intravenous injection of Africanized bee venom in awake rats

The manifestations caused by Africanized bee stings depend on the sensitivity of the victim and the toxicity of the venom. Previous studies in our laboratory have demonstrated cardiac changes and acute tubular necrosis (ATN) in the kidney of rats inoculated with Africanized bee venom (ABV). The aim of the present study was to evaluate the changes in mean arterial pressure (MAP) and heart rate (HR) over a period of 24 h after intravenous injection of ABV in awake rats. A significant reduction in basal HR as well as in basal MAP occurred immediately after ABV injection in the experimental animals. HR was back to basal level 2 min after ABV injection and remained normal during the time course of the experiment, while MAP returned to basal level 10 min later and remained at this level for the next 5 h. However, MAP presented again a significant reduction by the 7th and 8th h and returned to the basal level by the 24th h. The fall in MAP may contribute to the pathogenesis of ATN observed. The fall in MAP probably is due to several factors, in addition to the cardiac changes already demonstrated, it is possible that the components of the venom themselves or even substances released in the organism play some role in vascular beds.     

Continuous pulse oximeter monitoring for inapparent hypoxemia after long bone fractures

BACKGROUND: Continuous pulse oximeter monitoring (CPOM) and daily intermittent arterial blood gas (ABG) were used to define the incidence, pattern, and severity of inapparent hypoxemia after long bone fractures. METHOD: Twenty long bone fracture patients and 19 normal control patients were studied. CPOM, daily ABG, hypoxic symptoms, and features of fat embolism syndrome were monitored for 72 hours after fractures and after surgical interventions. RESULTS: CPOM trend curves showed that all fracture patients except one had recurrent desaturations below 90% Sao2 of varying duration and depth. The lowest Sao2 was down to 60% and the longest episode lasted for 1.47 hours. ABG analysis could not show the recurrent phenomena and never detected the corresponding desaturation episodes. Long bone fracture patients had more desaturation episodes, longer total desaturation duration, and larger total area under desaturation curves in both the postfracture and postoperative periods (p < 0.05). The mean Sao2 was significantly lower in the postfracture period. Although most patients remained asymptomatic and recovered spontaneously, two required transient oxygen therapy and one progressed to fat embolism syndrome. CONCLUSION: Inapparent hypoxia with profound desaturation is common after long bone fractures. CPOM of all patients admitted with long bone fractures is recommended for early detection. In patients who develop inapparent hypoxia, additional pulmonary insult should be avoided or undertaken with care and well timed.     

In vitro studies of endophytic fungi from Tripterygium wilfordii with anti-proliferative activity on human peripheral blood mononuclear cells

An array of endophytic fungi which habitat in a Chinese medicinal plant, Tripterygium wilfordii Hook. f., (TWHf) were isolated and tested for their suppressive activity on phytohemaglutinin (PHA) stimulated proliferation of human peripheral blood mononuclear cells (PBMC). Out of the 343 isolates, representing 60 different morphotypes, were screened. Amongst the screened fungi, only 15 isolates showed anti-proliferative activity. Ethyl acetate extracts of Pestalotiopsis leucoth?s, Mucor sp. Verticillium sp. or Pestalotiopsis disseminata, in particular, significantly inhibited the proliferation at doses between 0.12 and 500 microg/ml (stimulation index (S.I.) ranges 0.01-0.70) (P < 0.001-0.05). IC50 values of these four fungal extracts were between 0.75-0.80 +/- 0.12 microg/ml. Trypan blue exclusion test and visual examination of cell morphology demonstrate that the anti-proliferative effect of these extracts was not a sequential consequence of their cytotoxicity. Nevertheless, fungal extracts of Acremonium sp. A and C, Pestalotiopsis suffocata, Morphotype sp. 4 and 5 show a much higher cytotoxic effects on PBMC. Our results indicate that some fungal extracts contain significant amount of immunomodulatory principles.     

Spontaneous multiloculated multiseptated pneumomediastinum in a newborn baby: the spinnaker sail is rigged—CT features with pathologic correlation

The CT appearance of a pathologically proven spontaneous multiloculated multiseptated pneumomediastinum in a newborn baby has not been reported in the English literature. Our baby was delivered vaginally at term and developed mild respiratory distress after birth. The antenatal history was unremarkable apart from borderline oligohydramnios. The multiple septa seen within the pneumomediastinum on CT on day 3 may simulate an underlying 'bubbly' lung lesion like congenital cystadenomatoid malformation or congenital lobar emphysema, but actually represent anatomically known fascia surrounding the thymus. Furthermore, in neonates, air in the mediastinum often loculates locally and tends not to dissect widely as in adults.     

Anticipatory adjustments in the unloading task: is an efference copy necessary for learning?

In the unloading task, a weight is held in the palm of one hand. When an external agent removes the weight, an upward perturbation of the loaded hand is observed. However, when a person removes the weight by lifting it with their own hand, the perturbation is attenuated due to an anticipatory adjustment of the flexor muscles in the load-bearing arm. An experiment was conducted to examine conditions under which this anticipatory response could be learned. Using a virtual reality system with force-feedback robotic arms, normal subjects performed the unloading task under one of four learning conditions: (a) the participant initiated the unloading by pressing a button, (b) the unloading was cued by a brief visual stimulus, (c) the unloading was performed by a virtual "hand" that moved smoothly towards the object, and (d) the unloading followed three rhythmic force-pulses applied to the finger of the participant. After extended practice (192 trials) we found a significant reduction of the upward perturbation only in the button pressing condition. Control conditions indicated that the acquired response was due to an anticipatory feedforward response rather than due to a change in tonic state such as an increase in arm stiffness. These results indicate that a voluntary action is necessary to acquire an anticipatory adjustment in the unloading task. Electronic Publication