Correlation of quantitative measures with the modified Ashworth scale in the assessment of plantar flexor spasticity in patients with traumatic brain injury

This study of plantar flexor spasticity describes relationships among a traditional qualitative spasticity scale, three potential quantitative spasticity measures and a measure of voluntary ankle muscle function. Thirty-four volunteer adult patients with traumatic brain injuries participated. There were 28 males and 6 females; the mean age was 30.3 years. A battery of five randomly sequenced tests was performed for each subject on one ankle. Tests were: modified Ashworth scale (MAS) scoring; H-reflex testing with and without Achilles tendon vibration; H-reflex testing with and without dorsiflexor contraction; reflex threshold angle and timed toe tapping (TTT). Twenty-six subjects returned to have the second ankle tested, resulting in 60 ankles for the analyses. Spearman's coefficients for correlation of quantitative spasticity measures with MAS scores ranged from 0.39 to 0.49 with associated probabilities 0.002. Pearson coefficients for correlation of quantitative spasticity measures with TTT scores were lower but also significant (P 0.07). Multiple correlation for the set of quantitative measures yieldedR = 0.614 (P < 0.001) with MAS scores andR = 0.365 (P = 0.045) with TTT scores. These findings reveal statistically significant relationships of low to moderate strength among potential quantitative spasticity measures, a traditional qualitative spasticity scale and a simple measure of voluntary ankle muscle function. Understanding these relationships is an essential part of the ongoing search for quantitative spasticity measures.The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.     

Long-term outcome and cost-effectiveness of parenteral nutrition for acute gastrointestinal failure

Although there are several published audits of long-term home parenteral nutrition for chronic gastrointestinal failure, there is little data concerning the long-term outcome following prolonged in-patient parenteral nutrition for an episode of acute gastrointestinal failure. Between 1983 and 1 July 1993, 162 patients received total parenteral nutrition (TPN) in our unit for acute gastrointestinal failure for a total of 4997 patient days and using 192 central venous catheters. Over the 10 years there were 11 mechanical complications resulting in one death. Although the overall catheter infection rate was 5.7%, in the last 4 years it was 0%, associated with a reduction in the frequency of site dressing and change of giving set from three times to once weekly. All patients had lost more than 10% of their body weight before TPN. In the non-malignant group, fed for more than 21 days (mean 50 days), the 10-year survival was 74% at a cost of 4723 pounds sterling per year of life saved. In the malignant group, the 5-year survival was 27% at a cost of 8351 pounds sterling per year of life saved. These costs compare favourably with other technologies, such as dialysis for acute renal failure. Better patient selection, fewer complications and lower costs are obtained when this treatment is carried out by an expert team.     

A hydrophobic oligolamellar lining to the vascular lumen in some organs.

Various endothelial surfaces from sheep and humans have been studied for their hydrophobicity using a standard method based on the angle of contact (theta) of the surface with a droplet of saline placed on it. Most surfaces were relatively hydrophilic (theta less than 25 degrees) but some were distinctly hydrophobic with theta exceeding 65 degrees for sheep pulmonary vein, left ventricle, and aorta, and human umbilical vein. These results are discussed as compatible with the theory that surface-active phospholipid (surfactant) migrates from lung tissue into the pulmonary circulation or reaches intravascular sites from other sources. Transmission electron microscopy of cerebral vessels demonstrated an oligolamellar lining of surfactant on many endothelial surfaces, bridging the "tight" junctions between endothelial cells in many cases. Lamellar bodies were found adjacent to the endothelium. The oligolamellar surfactant lining and lamellar bodies are discussed as potentially very important factors in influencing bubble formation on vessel walls. It is believed to impart hydrophobicity while it could also determine the microgeometry of any crevices vital for bubble formation or retention.     

Dispositional optimism predicts survival status 1 year after diagnosis in head and neck cancer patients.

PURPOSE: The aim of this study was to investigate the hypothesis that, independent of other known prognostic factors, pessimistic head and neck (H&N) cancer patients have a greater risk of being dead 1 year after diagnosis than do optimistic patients. PATIENTS AND METHODS: A prospective observational study design was used with a cohort of H&N cancer patients diagnosed during the period from March 1, 1997, to August 31, 1998, at the Centre Hospitalier Universitaire, Clermont-Ferrand, France. Dispositional optimism (DO) was evaluated at baseline using a French version of the Life Orientation Test translated and validated for this study. One-year survival status was collected on all subjects. The analysis of the hypothesized association between DO and 1-year survival was performed using multiple logistic regression analysis, controlling for other sociodemographic and clinical variables. RESULTS: The sample size was 101 patients, representing all but one of those patients fitting the inclusion criteria who were diagnosed during the recruitment period. Of these, 51 were alive at 1 year after diagnosis, 45 were dead, and five were lost to follow-up. The multivariate analysis was performed on the data from the 96 subjects in whom 1-year survival status was known. Controlling for known predictors of H&N cancer survival, pessimistic subjects (odds ratio [OR], 1.12; 95% confidence interval [CI], 1.01 to 1.24) and those living alone (OR, 4.14; 95% CI, 1.21 to 14.17) were more likely than optimistic subjects and those living with others to be dead at 1 year. CONCLUSION: The results of this study of a cohort of French H&N cancer patients indicate that dispositional optimism predicts 1-year survival independent of other sociodemographic and clinical variables.     

Uterine myomas and factors associated with hysterectomy in premenopausal women

OBJECTIVE: Our purpose was to describe clinical characteristics in premenopausal women with uterine myomas and to identify factors associated with hysterectomy.STUDY DESIGN: Data were collected by chart abstraction in 421 premenopausal women with myomas and analyzed by univariate and multivariable regression.RESULTS: Over a median follow-up period of 29 months, 86% of women had symptoms associated with myomas and 40% had an increase in uterine size of >2 gestational weeks. By multivariable regression, bleeding symptoms at presentation and previous surgical history of cholecystectomy and adhesiolysis were significantly associated with greater odds of hysterectomy. There was a significant interaction between age and uterine size, so that as age increased, uterine size had a greater impact on the likelihood of hysterectomy.CONCLUSIONS: In this cohort of premenopausal women myomas were associated with symptoms in almost all women over the follow-up period. Hysterectomy was performed in 22% of women overall. (Am J Obstet Gynecol 1997;176:1213-9.)     

A comparison of the incidence of the oculocardiac and oculorespiratory reflexes during sevoflurane or halothane anesthesia for strabismus surgery in children

We examined changes in the cardiorespiratory system of small children during surgical correction of strabismus with a laryngeal mask airway and spontaneous respiration with sevoflurane or halothane inhaled anesthesia. Fifty-one children, 1-7 yr old, having outpatient strabismus correction were randomized to sevoflurane (S) or halothane (H) in 66% nitrous oxide at 1.3 minimum alveolar concentration. Children breathed spontaneously through a laryngeal mask airway and were not pretreated with anticholinergics. The oculocardiac reflex (OCR), defined as a 20% decrease in heart rate (HR) from baseline, dysrhythmias, or sinoatrial arrest concomitant with ocular muscle traction occurred less frequently with sevoflurane than with halothane (S 38%, H79%, P = 0.009). The baseline HR was higher with sevoflurane (S 114 +/- 13 bpm, H 101 +/- 15 bpm, P = 0.002). The lowest HR occurred with halothane (S 95 +/- 22 bpm, H 73 +/- 19 bpm, P = 0.001). The incidence of dysrhythmias was higher in the halothane group (S 4%, H 42%, P = 0.004). Reductions in minute ventilation and PETCO(2) accompanied OCRs. Airway irritability was present with halothane only (S 0, H 3). Eleven children, of whom the majority had received halothane, required measures to correct SpO(2) < 95% or PETCO(2) > 60 mm Hg during maintenance anesthesia (S 11%, H 32%). Sevoflurane may be a more suitable anesthetic than halothane for operations involving traction on the ocular muscles with spontaneous respiration in children because of reduced incidence of OCR, airway irritability, and ventilatory disturbances. IMPLICATIONS: Some children experience a sudden slowing of the heart and impaired breathing when the surgeon pulls on the eye muscles during squint operations under anesthesia. Sevoflurane, a recently developed anesthetic vapor, may reduce this problem when compared with the established vapor halothane.     

Adverse effects of amantadine and oseltamivir used during respiratory outbreaks in a center for developmentally disabled adults.

BACKGROUND AND OBJECTIVES: Antiviral prophylaxis is recommended for the control of institutional influenza A outbreaks. In long-term-care institutions other than nursing homes, neither the seriousness of influenza nor the risks and benefits of antiviral prophylaxis is clearly understood. We studied the severity of illness due to influenza among adults residing in a center for the developmentally disabled and assessed adverse reactions to amantadine and oseltamivir prophylaxis. METHODS: Data were collected from the charts of consenting residents. Complications of upper respiratory tract illness were recorded. Potential adverse events were documented during amantadine and oseltamivir therapy, and during a baseline period with neither medication. RESULTS: The median age of the 287 participants was 46.4 years. Only 15 (5%) were older than 65 years, and 69 (24%) had chronic underlying medical illness placing them at high risk for influenza. Of the 122 residents with an upper respiratory tract infection, 16 (13%) developed pneumonia, 12 (9.8%) were hospitalized, and 5 (4%) died. Twenty-eight (25%) of 112 residents had an adverse neurologic event while receiving amantadine prophylaxis, compared with 3 (2.7%) receiving no antiviral medication and 5 (4.5%) receiving oseltamivir (P < .001). Sixteen percent of the residents discontinued amantadine due to adverse events; in contrast, adverse events were identified in 2.9% of the residents prescribed oseltamivir, and none discontinued therapy. CONCLUSIONS: Viral respiratory tract infections are associated with a high risk of complications in this population. The rate of adverse neurologic events associated with amantadine was significantly higher than that associated with oseltamivir.     

Quality improvement in immunization delivery following an unsuccessful immunization recall.

OBJECTIVES: Within a clinic serving disadvantaged children, 1) to evaluate a multifaceted quality improvement (QI) project to improve immunization (IZ) up-to-date (UTD) rates and 2) to assess the efficacy of IZ reminder/recall performed following QI. METHODS: A year-long QI project followed by a trial of reminder/recall. QI interventions were targeted at previously identified barriers to IZ and were designed specifically to improve the efficacy of reminder/recall. QI interventions were designed to 1) increase the use of medical record releases to document IZs received elsewhere; 2) improve the accuracy of parental contact information; and 3) reduce missed opportunities by utilizing chart prompts, provider education, and provider reminders. Following QI, we conducted a randomized trial of reminder/recall. RESULTS: UTD rates for 7-11 month olds increased from 21% before the QI project to 52% after (P <.0001); rates for 12-18 month olds increased from 16% before QI to 44% after (P <.0001); 19-25 month olds 18% before to 33% after (P <.001). After QI, an average of 61 records per month were updated with IZs received elsewhere. However, the accuracy of parental contact information worsened (29% unreachable before QI vs 44% after, P <.001) and missed opportunities did not improve (8% before vs 6% after, P = not significant [NS]). A subsequent trial of reminder/recall did not increase UTD rates, with 17% of recalled children brought UTD vs 16% of controls (P = NS). CONCLUSIONS: Clinic-based QI increased documented UTD rates in a disadvantaged patient population. However, IZ reminder/recall did not further increase UTD rates above the rates achieved by the QI process.