B-65 Systematic Review of Pre-Injury Mental Health Problems as a Vulnerability Factor for Worse Outcome Following Sport-Related Concussion

Objective

A systematic review of the extent to which pre-injury mental health problems are a vulnerability factor for slower clinical recovery from sport-related concussion, defined as recovery from symptoms or a return to normal activities, including school and sports, following injury.

Data Selection

We conducted a search using (i) concussion-related terms, (ii) sport/athlete-related terms, and (iii) diverse predictor/modifier terms in the following databases: PubMed, PsycINFO®, MEDLINE®, CINAHL, Cochrane Library, EMBASE, SPORTDiscus, Scopus, and Web of Science. Studies published by February 2019 that examined pre-injury mental health problems as a possible predictor of clinical recovery from concussion were included. A total of 4,013 articles were screened. A full-text review was conducted on 358 articles, and 12 articles were ultimately included.

Data Synthesis

Those with a preinjury history of mental health problems were at greater risk for having persistent symptoms. There are major methodological differences across the studies. Most of the articles were not focused on mental health as a primary predictor, and the sample sizes in most studies were small. The type of preinjury mental health problems were inconsistently defined. The age of onset, course, severity, and duration of mental health problems were not defined. The extent to which the mental health problems were present prior to the season, during baseline testing, was not reported.

Conclusions

Pre-injury mental health difficulties predict prolonged recovery from concussion, but much more research is needed to understand the mechanisms and the magnitude of the effect.

B-64 Symptom Reporting and Cognitive Functioning in Middle School Athletes with Past Concussions

Objective

We examined the association between past concussions and current preseason symptom reporting and cognitive performance in boys participating in school sports.

Method

A sample of 2,582 boys ages 11-13 completed neurocognitive testing prior to participating in a school sport, using ImPACT®, between 2009-2015. A minority reported prior concussions: 0 (n = 2,244, 86.9%), 1 (n = 261, 10.1%), and ≥2 (n = 77, 3.0%).

Results

There was a significant difference in total symptom scores across groups (Kruskall-Wallis = 10.75, p = .005). Those with ≥2 prior concussions reported more symptoms than those with 0 concussions (p = .004, Cohen’s d = 0.41). A multivariate regression examining the contribution of concussion history and developmental/health history to symptom reporting was significant [F(7, 2,267) = 16.80, p < .001]. The following were independent predictors of symptoms scores (in descending order of strength): treatment for a psychiatric condition, treatment for headaches, history of learning disability, age, and history of ADHD. Prior concussion history was not a significant independent predictor in this multivariate model. There was a very small omnibus difference in visual motor speed (ANOVA, F = 4.10, p = .02); athletes with 1 prior concussion performed worse than those with no prior concussions (Tukey p = .01; d = 0.19). There were no significant differences on the other cognitive variables.

Conclusions

Boys with two or more prior concussions reported more symptoms than those with no prior concussions, but performed similarly on cognitive testing. The strongest predictors of current symptom reporting were a prior history of treatment for mental health problems or headaches, and a personal history of learning disability.

Best practice recommendations for bladder management in spinal cord-afflicted patients in South Africa

Recent research on the standard of care and related quality of life of the spinal cord-afflicted community in South Africa (SA) has revealed significant gaps in practice, and challenges regarding levels of care and access to services and supplies specifically related to the neurogenic bladder.

In Vivo Validation of the M-COVX® Metabolic Monitor in Patients under Anaesthesia

A practical method of breath-by-breath monitoring of metabolic gas exchange has been developed by GE Healthcare/Datex Ohmeda and incorporated into existing anaesthetic and critical care monitoring systems (M-COVX®). This device relates flow measurements made at the mouth by pneumotachograph to measurements of inspired and expired gas composition by matching the two waveforms thereby allowing continuous, breath-by-breath monitoring of an intubated patient's oxygen uptake and carbon dioxide production. Given that there is a paucity of data comparing this new device against methods more widely used clinically, we tested the device on 11 patients undergoing cardiopulmonary bypass surgery. Using a standard anaesthetic machine (Datex Ohmeda Excel 210 SE) with a semi-closed circle absorber system, oxygen uptake was measured at the mouth continuously throughout the operation at approximately six-second intervals. The data were compared against the reverse Fick method and against standard indirect calorimetry using the Haldane transformation. When compared to the calculated reverse Fick oxygen uptake, a mean difference of +16.5% was found pre-bypass and +9.9% post-bypass, consistent with uptake of oxygen by lung tissue, which is not taken into account by the reverse Fick method. Measurements made comparing the M-COVX metabolic monitor against standard Haldane showed a mean difference of +5.1% pre-bypass and –2.1% post-bypass. Given the ease with which this device can be incorporated into existing anaesthetic monitoring systems and its accuracy in measuring oxygen uptake, the M-COVX module is an attractive addition to existing perioperative monitoring.

On site remediation of a fuel spill and soil reuse in Antarctica

The first large-scale remediation of fuel contamination in Antarctica treated 10000L of diesel dispersed in 1700t of soil, and demonstrated the efficacy of on-site bioremediation. The project progressed through initial site assessment and natural attenuation, passive groundwater management, then active remediation and the managed reuse of soil. Monitoring natural attenuation for the first 12years showed contaminant levels in surface soil remained elevated, averaging 5000mg/kg. By contrast, in five years of active remediation (excavation and biopile treatment) contaminant levels decreased by a factor of four. Chemical indicators showed hydrocarbon loss was apportioned to both biodegradation and evaporative processes. Hydrocarbon degradation rates were assessed against biopile soil temperatures, showing a phase of rapid degradation (first 100days above soil temperature threshold of 0°C) followed by slower degradation (beyond 100days above threshold). The biopiles operated successfully within constraints typical of harsh climates and remote sites, including limitations on resources, no external energy inputs and short field seasons. Non-native microorganisms (e.g. inoculations) and other organic materials (e.g. bulking agents) are prohibited in Antarctica making this cold region more challenging for remediation than the Arctic. Biopile operations included an initial fertiliser application, biannual mechanical turning of the soil and minimal leachate recirculation. The biopiles are a practical approach to remediate large quantities of contaminated soil in the Antarctic and already 370t have been reused in a building foundation. The findings presented demonstrate that bioremediation is a viable strategy for Antarctica and other cold regions. Operators can potentially use the modelled relationship between days above 0°C (threshold temperature) and the change in degradation rates to estimate how long it would take to remediate other sites using the biopile technology with similar soil and contaminant types.

Survivin as a therapeutic target in Sonic hedgehog-driven medulloblastoma

Medulloblastoma (MB) is a highly malignant brain tumor that occurs primarily in children. Although surgery, radiation and high-dose chemotherapy have led to increased survival, many MB patients still die from their disease, and patients who survive suffer severe long-term side effects as a consequence of treatment. Thus, more effective and less toxic therapies for MB are critically important. Development of such therapies depends in part on identification of genes that are necessary for growth and survival of tumor cells. Survivin is an inhibitor of apoptosis protein that regulates cell cycle progression and resistance to apoptosis, is frequently expressed in human MB and when expressed at high levels predicts poor clinical outcome. Therefore, we hypothesized that Survivin may have a critical role in growth and survival of MB cells and that targeting it may enhance MB therapy. Here we show that Survivin is overexpressed in tumors from patched (Ptch) mutant mice, a model of Sonic hedgehog (SHH)-driven MB. Genetic deletion of survivin in Ptch mutant tumor cells significantly inhibits proliferation and causes cell cycle arrest. Treatment with small-molecule antagonists of Survivin impairs proliferation and survival of both murine and human MB cells. Finally, Survivin antagonists impede growth of MB cells in vivo. These studies highlight the importance of Survivin in SHH-driven MB, and suggest that it may represent a novel therapeutic target in patients with this disease.

Diffusion tensor imaging study of the fornix in first episode schizophrenia and in healthy controls

BACKGROUND

The fornix is a compact bundle of white matter fibers that project from the hippocampus to the mamillary bodies and septal nuclei. Its association with memory, as well as with symptoms in schizophrenia, has been reported in chronic schizophrenia. The purpose of this study is to determine whether or not fornix abnormalities are evident at the onset of schizophrenia.

METHODS

Diffusion tensor imaging (DTI) and DT tractography were used to evaluate the fornix in 21 patients with first episode schizophrenia (16 males/5 females) and 22 healthy controls (13 males/9 females). Groups were matched on age, gender, parental socioeconomic status, education and handedness. Fractional anisotropy (FA), a measure of white matter integrity, radial diffusivity (RD), thought to reflect myelin integrity, trace, a possible marker of atrophy or cell loss, and axial diffusivity (AD), thought to reflect axonal integrity, were averaged over the entire tract extracted by means of DT tractography, and used to investigate fornix abnormalities in first episode schizophrenia compared with healthy controls.

RESULTS

Significant group differences were found between first episode patients and controls for FA (p=0.0001), RD (p=0.001) and trace (p=0.006).

CONCLUSION

These findings suggest abnormalities in the fornix in the early stages of schizophrenia, and further suggest that white matter abnormalities, which are apparent in the early course of the disease, may reflect myelin disturbances.

Non-invasive metabolic monitoring of patients under anaesthesia by continuous indirect calorimetry—an in vivo trial of a new method

BACKGROUND

Oxygen uptake is an important form of metabolic monitoring for patients under anaesthesia. In critically ill patients oxygen uptake has been shown to provide valuable clinical information in directed therapy and acts as a useful monitor of cardiovascular dysfunction. A new method of continuous real time monitoring of metabolic gas exchange was tested in patients during anaesthesia.

METHODS

Using a standard anaesthetic machine with attached semi-closed circle absorber system, oxygen uptake was measured continuously throughout surgery in 30 patients undergoing cardiopulmonary bypass surgery and compared with paired measurements made with the reverse Fick method. The method is an indirect calorimetry technique which uses fresh gas rotameters for control, regulation and measurement of the gas flows into the system, with continuous sampling of mixed exhaust gas.

RESULTS

When compared with the reverse Fick method the oxygen uptake showed a mean difference (and sd) of 20.7 ml min(-1) or 12.1% (25.3 ml min(-1)) pre-bypass and 13.9 ml min(-1) or 8.1% (27.0 ml min(-1)) post-bypass. This bias is consistent with previous studies comparing oxygen uptake measured at the mouth against oxygen uptake by reverse Fick, which have shown a difference of approximately 10-15% accounted for by the consumption of oxygen by lung tissue.

CONCLUSIONS

As the method allows continuous measurement of gas exchange and can be adapted to a modern anaesthetic workstation it is an attractive method for use in clinical setting.

A phase II study of carboplatin and paclitaxel in esophageal cancer

BACKGROUND

This study was conducted to evaluate the efficacy and toxicity of combination carboplatin and paclitaxel in patients with esophageal cancer.

MATERIALS AND METHODS

Thirty-five patients were enrolled. Patients were treated with paclitaxel 200 mg/m(2) intravenously (i.v.) over 3 h and carboplatin i.v. at an AUC of 5 mg/h/ml. Thirty-three patients were assessable for toxicity and objective response.

RESULTS

A total of 166 treatment courses were administered with a median of five courses per patient. The objective response rate was 43% [90% confidence interval (CI) 0.3-0.58] by the intention-to-treat analysis. The median response duration was 2.8 months (90% CI 2.1-5.4). The median survival time was 9 months (90% CI 7-13.8) and the 1-year survival rate was 43% (90% CI 0.29-0.57). The major grade 3-4 toxicity observed was neutropenia, occurring in 17 patients (52%). There were no treatment-related deaths.

CONCLUSIONS

The combination of carboplatin and paclitaxel is an moderately active and tolerable regimen in advanced esophageal cancer.

Effects of megakaryocyte growth and development factor on platelet production, platelet life span, and platelet function in healthy human volunteers

The effects of thrombopoietic stimulation on megakaryocytopoiesis, platelet production, and platelet viability and function were examined in normal volunteers randomized to receive single bolus subcutaneous injections of 3 microg/kg pegylated recombinant megakaryocyte growth and development factor (PEG-rHuMGDF) or placebo in a 3:1 ratio. PEG-rHuMGDF transiently doubled circulating platelet counts, from 237 +/- 41 x 10(3)/microL to 522 +/- 90 x 10(3)/microL (P <.0001), peaking on day 12. Baseline and day-12 samples showed no differences in responsiveness of platelets to adenosine diphosphate or thrombin receptor agonist peptide (P >.4 in all cases); expression of platelet ligand-induced binding sites or annexin V binding sites (P >.6 in both cases); or density of platelet TPO-receptors (P >.5). Platelet counts normalized by day 28. The life span of autologous (111)In-labeled platelets increased from 205 +/- 18 hours (baseline) to 226 +/- 22 hours (P <.01) on day 8. Platelet life span decreased from 226 +/- 22 hours (day 8) to 178 +/- 53 hours (P <.05) on day 18. The theoretical basis for senescent changes in mean platelet life span was illustrated by biomathematical modeling. Platelet turnover increased from 43.9 +/- 11.9 x 10(3) platelets/microL/d (baseline) to 101 +/- 27.6 x 10(3) platelets/microL/d (P =.0009), and marrow megakaryocyte mass expanded from 37.4 +/- 18.5 fL/kg to 62 +/- 17 x 10(10) fL/kg (P =. 015). Although PEG-rHuMGDF initially increased megakaryocyte volume and ploidy, subsequently ploidy showed a transient reciprocal decrease when the platelet counts exceeded placebo values. In healthy human volunteers PEG-rHuMGDF transiently increases megakaryocytopoiesis 2-fold. Additionally, peripheral platelets expand correspondingly and exhibit normal function and viability during the ensuing 10 days. The induced perturbation in steady state thrombopoiesis resolves by 4 weeks. (Blood. 2000;95:2514-2522)

Effective employee relations in reengineered organizations

The degree to which a healthcare organization can effectively respond to changes that are brought about by managed care is often the result of how well the organization engages the workforce in the changes. The goal of a process-centered healthcare organization is to deliver service that is truly patient-centered. Successful organizations understand that the actualization of this goal begins with the decision to engage in an employee-guided approach to reengineering. This article describes issues of effective employee relations in the postreengineering era. Strategies for dealing effectively with labor unions or for preventing unionization are also discussed.

Quality of life in chronic fatigue syndrome

Whilst the debilitating fatigue experienced in patients suffering from Chronic Fatigue Syndrome (CFS) results in a subjective marked impairment in functioning, little research has investigated the impact of this disorder on quality of life. Forty-seven subjects with a confirmed diagnosis of CFS and 30 healthy controls were compared using the Sickness Impact Profile (SIP). A subgroup of subjects were interviewed regarding the impact CFS has had on their social and family relationships, work and recreational activities. Results from both the SIP and the interview revealed that CFS subjects had significantly impaired quality of life, especially in areas of social functioning. These findings highlight the importance of addressing the social isolation and loss of role functioning experienced by CFS sufferers.

Integrated health care in California's managed care capital

Sacramento, California's capital, represents the nation's most competitive managed care marketplace. The Sutter Health organization represents a significant force in this marketplace and surrounding regions of Northern California. Sutter has created an integrated regional health care network capable of delivering a full continuum of care through appropriate community-based facilities, a variety of physician relationships, and both owned and aligned managed care structures. The overall Sutter Health strategy that incorporates facilities, physician partnerships, and patient care financing is described. The article identifies six key lessons learned during this period of growth.

Ventriculoperitoneal shunt dysfunction and constipation: a chart review

Children treated for hydrocephalus frequently experience chronic constipation. A retrospective chart review was conducted to determine if there is a population of children with ventriculoperitoneal (VP) shunt dysfunction in whom constipation might be a factor in the shunt dysfunction. Of 51 cases reviewed, 19 had documented constipation, such as no bowel movement for 2 or more days, small hard ball-like stools or fullness of the colon noted on physical examination or abdominal radiographs. In 6 cases, a bowel cleansing was performed and signs and symptoms of shunt dysfunction resolved without shunt revision. This review suggests that constipation may affect the fluid or pressure dynamics of the VP shunt and contribute to shunt dysfunction.

Shunt dysfunction and constipation: could there be a link?

A ventriculoperitoneal (VP) shunt is the treatment of choice for hydrocephalus, functioning by means of a pressure differential between the ventricular system and peritoneal cavity. Constipation is frequently a concomitant problem in children with VP shunts. A case study is reported in which signs and symptoms of shunt dysfunction appear to have developed as a result of constipation. Nurses and physicians must address the need for preventing constipation much more aggressively in the population requiring shunts.

Comparison of Texas Liquid Sampler with Missouri Bottle for Sampling Liquid Fertilizers: Collaborative Study

Six laboratories participated in a collaborative study designed to qualify the Texas liquid sampling tube as a device for sampling liquid fertilizers. The Texas sampler is a polyethylene tube with a stainless steel check valve on one end. The tube, which is threaded so that it can be expanded in length, enables acquisition of a uniform profile across a liquid sample. The 6 collaborators sampled 33 loads of fertilizer, 8 of which were slurries, using both the Texas tube and the Missouri bottle (AOAC 969.01). The resulting subsamples were analyzed for total nitrogen, available phosphorus, and soluble potash. Analysis of the data showed no significant (p &lt; 0.05) difference in results. This sampling procedure, using the Texas liquid sampler, was adopted first action by AOAC International as a suitable means of sampling liquid fertilizers.

Nursing care of the child with external ventricular drainage

External ventricular drainage (EVD) is used in children who have hydrocephalus, usually for shunt infection. Several complications, including increased intracranial pressure, hemorrhage, brain injury and infection, can occur in children with EVD. Nursing care for these children involves interventions to prevent complications and promote the well-being of children and their families.

Use of low-dose trimethoprim-sulfamethoxazole thrice weekly for primary and secondary prophylaxis of Pneumocystis carinii pneumonia in human immunodeficiency virus-infected patients

We conducted an open prospective clinical trial to evaluate the efficacy and toxicity of trimethoprim-sulfamethoxazole given as one double-strength tablet thrice weekly for primary and secondary prophylaxis of Pneumocystis carinii pneumonia (PCP) in human immunodeficiency virus-infected (HIV+) patients. A total of 104 HIV+ patients were evaluated, with 74 being in the primary prophylaxis group and 30 being in the secondary prophylaxis group. All except six patients received concomitant zidovudine; five patients on primary prophylaxis and one patient on secondary prophylaxis refused zidovudine. There were 70 patients evaluated for the efficacy of primary prophylaxis. The mean CD4 count was 124.4 +/- 110.1 cells per microliter. The mean follow-up time was 11.8 +/- 5.8 months (median, 12 months; range, 1 to 32 months). Two noncompliant patients developed PCP after 1 and 3 months of chemoprophylaxis. The failure rate (under the intention to treat principle) was 2 of 70 patients (2.9%; 95% confidence interval, 0.35 to 10%), or 1 per 413 patient-months of observation. There were 27 patients evaluated for the efficacy of secondary prophylaxis. The mean follow-up time was 12.4 +/- 7.2 months (median, 11 months; range, 1 to 29 months). Two patients, one of whom was noncompliant, were treatment failures, developing PCP after 14 and 15 months of chemoprophylaxis; this gave a failure rate of 2 of 27 patients (7.4%; 95% confidence interval, 0.9 to 24.3%), or 1 per 167 patient-months of observation. Adverse reactions sufficient to permanently terminate therapy occurred in 9 of 104 patients (8.7%; 95% confidence interval, 4 to 15.7%) overall. The serum trimethoprim, sulfamethoxazole, and N4-acetyl-sulfamethoxazole concentrations measured by high-pressure liquid chromatography were uniformly low. One double-strength tablet of trimethoprim-sulfamethoxazole taken weekly on Monday, Wednesday, and Friday appeared to be well tolerated and efficacious for the prophylaxis of PCP in HIV+ patients at high risk and deserves further investigation.