Causes and outcomes of mild traumatic brain injury: an analysis of CIREN data

Approximately one-half of vehicle occupants with traumatic brain injury (TBI) have a mild TBI (admission Glasgow Coma Scale (GCS) score of 13-15 with transient loss of consciousness). However, despite the label of "mild", many of these injuries result in long-term consequences; frequently these sequelae go unrecognized, as the patients are lost to medical follow-up. The Crash Injury Research Engineering Network (CIREN) project affords us the opportunity to examine the crash circumstances, injury sources and outcomes of mild TBI cases in greater detail.

Sixteen-year experience with 1,000 heart transplants at UCLA

1. The consecutive pre- and post-1994 eras have demonstrated improved survival for all age groups. This is linked to improved preservation methods, surgical technique and immunosuppression agents. 2. The use of marginal donor hearts for Status I and alternate elderly patients has followed the model of matching donor and recipient risk without affecting patient outcome and minimized the use of implantable assist devices. 3. A donor history of systemic gram-negative infection, hypertension, or traumatic intracranial bleeds was an important marker for risk. Younger age and shorter ischemia time could compensate for other hazards. 4. Heart transplantation in carefully selected elderly recipients yielded clinical results similar to those of younger patients with less rejection. 5. An adult alternate recipient list proved useful to prevent diversion of standard donors away from younger recipients. 6. Retransplantation for TCAD is acceptable but much less satisfactory for acute graft failure. 7. Trends show an increase in the use of implantable devices; refinement in technology for mechanical assist and replacement is forthcoming.

Use of OKT3 for acute myocarditis in infants and children

Acute viral myocarditis triggers an autoimmune phenomenon that aggressive immunosuppressive therapy with monoclonal OKT3 may suppress. We treated 5 patients, aged 15 months to 16.5 years, who had acute viral myocarditis and left ventricular ejection fraction (LVEF) of 5% to 20%, with a combination immunosuppressive regimen that included OKT3, intravenous immunoglobulin, methylprednisone, cyclosporine, and azathioprine. Within 2 weeks of therapy, all patients demonstrated normalization of LVEF to 50% to 74%, and on mid-term follow-up, we have found no recurrence of heart failure or progression to dilated cardiomyopathy. In patients with severe acute myocarditis, aggressive immunosuppressive regimen based on OKT3 is safe and may inhibit or reverse the immune response, resulting in dramatic improvement in myocardial function.

Drug utilization review of sedative/hypnotic agents in Texas Medicaid patients. Texas Medicaid Vendor Drug Program Drug Utilization Review Board

OBJECTIVE

To assess use of sedative/hypnotic agents in Texas Medicaid patients and evaluate practitioner receptiveness to intervention letters concerning sedative/hypnotic prescribing generated by the Texas Medicaid Drug Utilization Review (DUR) Board.

DESIGN

Retrospective DUR.

SETTING

Texas Medicaid retrospective DUR program.

PATIENTS OR OTHER PARTICIPANTS

244 Texas Medicaid patients and 291 Texas physicians.

INTERVENTION

Patient profiles for Texas Medicaid patients were reviewed retrospectively to quantify sedative/hypnotic prescribing practices. Intervention letters were prepared and sent to physicians directly involved in the care of patients receiving excessive sedative/hypnotic therapy. Physician responses were categorized based on information presented in the intervention letter and circumstances surrounding the identified patient. Prescribing practices were assessed approximately 1 year after the intervention to determine the impact of intervention letters on prescribing.

MAIN OUTCOME MEASURE

Physician response to intervention letter.

RESULTS

Responses were received from 208 of 291 physicians (71.5%). Approximately 40% of physicians agreed in principle with the suggestions offered by the Texas Medicaid DUR Board to minimize chronic sedative/hypnotic use. Almost one-half of these physicians had discontinued sedative/hypnotic therapy for the identified patients 1 year after the intervention. Approximately 9% justified continued sedative/hypnotic use based on patient diagnosis or refractory response to treatment, and 55 physicians (26.4%) were unwilling to alter therapy because of patient-specific factors.

CONCLUSION

Through the use of retrospective DUR, Texas Medicaid patients receiving excessive amounts of sedative/hypnotic agents were identified and improvements in sedative/hypnotic therapy were initiated. DUR can be useful not only in identifying problem areas, but also in encouraging physicians to modify prescribing practices through educational means.

Transplantation for congenital heart disease

Refinements in surgical technique, donor and recipient myocardial preservation, and immunosuppression have brought pediatric heart transplantation for end-stage heart failure (whatever the cause) from the heyday of clinical experimentation to the realm of a viable therapeutic. Heart transplantation in this subpopulation yields excellent early and midterm survival. Acute rejection remains an important cause of morbidity and mortality after heart transplantation in children. Future improvement in quality of life for these patients calls for newer immunosuppressive strategies to reduce acute rejection episodes and ultimately improve long-term graft survival.

Peer evaluation. A visual picture

To meet the criteria of role accountability, nursing competence and ongoing staff development, an improved peer-evaluation system was designed to continuously monitor these new roles. This peer-evaluation process converts evaluation input into data, giving staff a visual picture of how their performance compares within their peer group. This peer-evaluation process was designed as a tool to assist in staff growth and development, not as a punitive system.

Evaluation of physician intervention letters

OBJECTIVES

The Omnibus Budget Reconciliation Act of 1990 requires that Medicaid Agencies perform drug utilization review (DUR). The Texas Medicaid Agency, in cooperation with the Texas DUR Board, have chosen to mail intervention letters to physicians with patient profiles that indicate possible inappropriate use of medications. The objective of this study was to assess the effect of intervention letters indicating duplicative anti-ulcer medications.

METHODS

Analysis of Medicaid prescription claims produced 335 patient profiles involving concurrent therapy. Physicians for 174 patients were selected randomly to receive an intervention letter, a response form, and a stamped envelope. The remaining patients served as a control group.

RESULTS

A 71.2% response rate was obtained. Of these responses, 48.9% agreed with the letter and 19.1% disagreed with the letter. Profiles generated 6 months after the letters were sent indicated that 47.7% of the patients in the experimental group were still on concurrent therapy compared with 64.4% of patients in the control group (P = 0.007).

CONCLUSIONS

The high response rate to the letter, the moderately high agreement with the letters, and the statistically significant reduction of duplicative therapy in the experimental group indicate that intervention letters can be an effective way to change prescribing. Future research is needed to assess the effects of educational intervention letters for other drug categories, for other populations, and for longer periods of time; and the effect these changes may have on true patient outcomes.

Closed loop television tracking of beating heart cells in vitro

The motion of beating heart cells in vitro has been used as a sensitive indicator of the presence of drugs. The combination of closed loop television video tracking and latex microspheres placed on the cells as markers results in an improved measurement of cell motion. Latex microspheres, 5.2 micrometers, are allowed to settle onto beating myocardial heart cells in vitro, where they move in concert with the cell motion. These microspheres, when viewed by televised transmission microscopy with normal optics, present high contrast circular targets that are excellent for closed loop television video tracking techniques. With video tracking, an analog voltage is generated proportional to the horizontal center of intensity of the target being tracked. This signal represents the location of a video demodulator gate that is maintained centered over the video target by feedback control.

Adult respiratory distress syndrome in patients with severe neutropenia

Most investigators believe that the pulmonary endothelial damage that is characteristic of the adult respiratory distress syndrome (ARDS) requires the action of neutrophils. In a retrospective review of patients with ARDS, we looked for cases that had developed in patients who already had neutropenia. Four clinical criteria were required for the diagnosis of ARDS: the occurrence of a precipitating event, diffuse bilateral pulmonary infiltrates on a chest x-ray film, a normal intravascular volume (as reflected by a wedge pressure of less than 18 mm Hg), and arterial hypoxemia. During 2 1/2 years, 11 patients fulfilled these clinical criteria, had severe neutropenia that antedated the onset of ARDS, and had pulmonary histologic specimens obtained during the early stages (less than seven days) of clinical respiratory distress. Five of these specimens showed diffuse alveolar damage without evidence of infectious pneumonitis (the histopathological finding characteristic of ARDS), and none had a neutrophil infiltrate. We conclude that ARDS can occur in the setting of severe neutropenia, without pulmonary neutrophil infiltration.

A circulating myocardial depressant substance in humans with septic shock. Septic shock patients with a reduced ejection fraction have a circulating factor that depresses in vitro myocardial cell performance

We have previously described a subpopulation of patients with septic shock who had a reversible depression of radionuclide-determined left ventricular ejection fraction (EF). To investigate the mechanism of this myocardial depression, an in vitro model of mammalian myocardial cell performance was established employing primary spontaneously beating rat myocardial cells. The contraction of a single cardiac cell was quantitated by recording the changes in area occupied by the cell during contraction and relaxation. In 20 septic shock patients during the acute phase, the mean left ventricular EF was decreased (mean = 0.33, normal mean = 0.50), and serum obtained during this acute phase induced a mean (+/- standard error of the mean) 33 +/- 4% decrease in extent and 25 +/- 4% decrease in velocity of myocardial cell shortening during contraction (P less than 0.001). In contrast, serum obtained from 11 of these same patients before shock (n = 2) or after recovery (n = 9) of the left ventricular EF (mean = 0.50) showed a return toward normal in extent and velocity of shortening (P less than 0.001). Sera from 17 critically ill nonseptic patients, from 10 patients with structural heart disease as a cause for a depressed EF, and from 12 healthy laboratory personnel, induced no significant changes in in vitro myocardial cell performance. In 20 patients during the acute phase of septic shock, the decreased EF in vivo demonstrated a significant correlation (r = +0.52, P less than 0.01) with a decrease in the extent of myocardial cell shortening in vitro. The quantitative and temporal correlation between the decreased left ventricular EF and this serum myocardial depressant substance argues for a pathophysiologic role for this depressant substance in producing the reversible cardiomyopathy seen during septic shock in humans.

Activation of human B lymphocytes. XV. Spontaneously occurring and mitogen-induced indirect anti-sheep red blood cell plaque-forming cells in normal human peripheral blood

A system for the development of indirect (IgG, IgA, and IgM) anti-SRBC plaque-forming cells (PFC) after polyclonal stimulation of human peripheral blood lymphocytes with pokeweed mitogen (PWM) is described. Rabbit anti-human polyvalent Ig or Ig class-specific antisera were employed. Most of the indirect PFC were IgG with less being IgM and IgA. The finding of significantly more indirect IgM PFC than direct PFC suggests that many IgM PFC are producing low efficiency hemolysin that requires an anti-globulin to produce lysis. The system is T cell dependent and cultures require selected batches of supplemented fetal calf serum that preferentially yield indirect (1527 +/- 243 PFC/10(6) lymphocytes) as opposed to direct (36 +/- 11 PFC/10(6) lymphocytes) PFC. Batches of human AB sera that were previously chosen to yield optimal direct PFC (approximately 200 to 300 PFC/10(6) lymphocytes) did not yield indirect PFC. Hence, depending on culture conditions, polyclonal stimulation of human lymphocytes can yield antigen-specific direct and indirect hemolytic PFC.

Activation of human B lymphocytes. XV. Spontaneously occurring and mitogen-induced indirect anti-sheep red blood cell plaque-forming cells in normal human peripheral blood

A system for the development of indirect (IgG, IgA, and IgM) anti-SRBC plaque-forming cells (PFC) after polyclonal stimulation of human peripheral blood lymphocytes with pokeweed mitogen (PWM) is described. Rabbit anti-human polyvalent Ig or Ig class-specific antisera were employed. Most of the indirect PFC were IgG with less being IgM and IgA. The finding of significantly more indirect IgM PFC than direct PFC suggests that many IgM PFC are producing low efficiency hemolysin that requires an anti-globulin to produce lysis. The system is T cell dependent and cultures require selected batches of supplemented fetal calf serum that preferentially yield indirect (1527 +/- 243 PFC/10(6) lymphocytes) as opposed to direct (36 +/- 11 PFC/10(6) lymphocytes) PFC. Batches of human AB sera that were previously chosen to yield optimal direct PFC (approximately 200 to 300 PFC/10(6) lymphocytes) did not yield indirect PFC. Hence, depending on culture conditions, polyclonal stimulation of human lymphocytes can yield antigen-specific direct and indirect hemolytic PFC.