Discriminating Mild Traumatic Brain Injury and Posttraumatic Stress Disorder Using Latent Neuroimaging and Neuropsychological Profiles in Active-Duty Military Service Members

OBJECTIVE

Mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD) commonly occur among military Service Members and Veterans and have heterogenous, but also overlapping symptom presentations, which often complicate the diagnoses of underlying impairments and development of effective treatment plans. Thus, we sought to examine whether the combination of whole brain gray matter (GM) and white matter (WM) structural measures with neuropsychological performance can aid in the classification of military personnel with mTBI and PTSD.

METHODS

Active-Duty US Service Members ( n = 156; 87.8% male) with a history of mTBI, PTSD, combined mTBI+PTSD, or orthopedic injury completed a neuropsychological battery and T1- and diffusion-weighted structural neuroimaging. Cortical, subcortical, ventricular, and WM volumes and whole brain fractional anisotropy (FA), mean diffusivity (MD), radial diffusivity (RD), and axial diffusivity (AD) were calculated. Latent profile analyses were performed to determine how the GM and WM indicators, together with neuropsychological indicators, classified individuals.

RESULTS

For both GM and WM, respectively, a 4-profile model was the best fit. The GM model identified greater ventricular volumes in Service Members with cognitive symptoms, including those with a diagnosis of mTBI, either alone or with PTSD. The WM model identified reduced FA and elevated RD in those with psychological symptoms, including those with PTSD or mTBI and comorbid PTSD. However, contrary to expectation, a global neural signature unique to those with comorbid mTBI and PTSD was not identified.

CONCLUSIONS

The findings demonstrate that neuropsychological performance alone is more robust in differentiating Active-Duty Service Members with mTBI and PTSD, whereas global neuroimaging measures do not reliably differentiate between these groups.

Treatment of femoral neck fracture with a minimal invasive surgical approach for hemiarthroplasty - clinical and radiological results in 180 geriatric patients

Purpose :

The Direct Anterior Approach (DAA) is well established as a minimal access approach in elective orthopaedic hip surgery. For the growing number of elderly patients with femoral neck fractures treated with Bipolar Hip Hemiarthroplasty (BHH), only a few results do exist. The study shows the clinical and radiological outcome for 180 patients treated by a modified DAA with BHH.

Materials and Methods :

The data of 180 geriatric patients with medial femoral neck fractures were evaluated retrospectively. The general and surgical complications, mobilisation using the Timed Up and Go test (TUG), the social environment pre- and postoperative and the radiological results have been compared with established approaches for geriatric hip surgery.

Results :

After joint replacement, 18 (10%) patients were developed pneumonia, of which 3 (1.7%) died during hospitalisation. In 7 cases (4%), surgical revision had to be carried out: three times (1.7%) because of a seroma, three times (1.7%) because of subcutaneous infection, and one time (0.6%) because the BHH was removed, owing to deep wound infection. One dislocation (0.6%) occurred, as well as one femoral nerve lesion (0.6%) occured. 88.3% of patients were mobilised on walkers or crutches; the Timed Up and Go Test showed a significant improvement during inpatient rehabilitation. 83% were discharged to their usual social environment, 10% were transferred to a short-term care facility and 7% were relocated permanently to a nursing home. 3/4 of patients had a cemented stem alignment in the range between -5° and 5°, while 2/3 of patients had a maximum difference of 1 cm in leg length.

Conclusion :

Using the modified DAA, a high patient satisfaction is achieved after implantation of a BHH. The rate of major complications is just as low as in conventional approaches, and rapid mobilisation is possible.

Biopolymer augmentation of the lag screw in the treatment of femoral neck fractures--a biomechanical in-vitro study

The cut-out of the sliding screw is one of the most common complications in the treatment of intertrochanteric fractures. The reasons for the cut-out are: a suboptimal position of the hip-screw in the femoral head, the type of fracture and poor bone quality. The aim of this study was to reproduce the cut-out event biomechanically and to evaluate the possible prevention of this event by the use of a biopolymer augmentation of the hip screw. Concerning the density and compression force of osteoporotic femoral bone polyurethane foam according to the terms of the Association for Standard Testing Material (ASTMF 1839-97) was used as test material. The polyurethane foam Lumoltan 200 with a compression force of 3.3 Mpa and a density of 0.192 g/cm(3) was used to reproduce the osteoporotic bone of the femoral fragment (density 12 lbm/ft(3)). A cylinder of 50 mm of length and 50 mm of width was produced by a rotary splint raising procedure with planar contact. The axial load of the system was performed by a hydraulic force cylinder of a universal test machine type Zwick 1455, Ulm, Germany. The CCD-angle of the used TGN-System was preset at 130 degrees. The migration pattern of the hip screw in the polyurethane foam was measured and expressed as a curve of the distance in millimeter (mm) against the applied load in Newton (N) up to the cut-out point. During the tests the implants reached a critical changing point from stable to unstable with an increased load progression of steps of 50 Newton. This unstable point was characterized by an increased migration speed in millimeters and higher descending gradient in the migration curve. This peak of the migration curve served as an indicator for the change of the hip screw position in the simulated bone material. The applied load in the non-augmented implant showed that in this group for a density degree of 12 (0,192 g/cm(3)) the mean force at the failure point was 1431 Newton (+/- 52 Newton). In the augmented implant we found that the mean force at the failure point was 1987 Newton (+/- 84 Newton). This difference was statistically significant. In conclusion, the bone density is a significant factor for the stability of the hip screw implant. The osteosynthesis with screws in material with low density increases the chance for cut-out. A biopolymer augmented hip screw could significantly improve the stability of the fixation. The use of augmentation with a fast hardening bone replacement material containing polymer-ceramic changes the point of failure under axial load in the osteoporotic bone model and could significantly improve the failure point. Our study results indicate, that a decrease of failure in terms of cut-out can be achieved with polymer augmentation of hip screws in osteoporotic bones.

Clostridium pascui sp. nov., a new glutamate-fermenting sporeformer from a pasture in Pakistan

Four strains of an obligately anaerobic spore-forming bacterium were isolated from soil samples from a donkey pasture in Pakistan. Comparative 16S rRNA sequence analysis demonstrated that the strains are members of phylogenetic cluster I of the genus Clostridium (Collins et al. 1994). The strains are mesophilic, nonsaccharolytic, and nonproteolytic, utilize glutamate and histidine, and produce indole. Acetate, butyrate, ethanol, hydrogen, and carbon dioxide are the products of fermentation. Although the strains phenotypically resemble the classical glutamate-fermenting clostridia, such as Clostridium cochlearium, Clostridium tetanomorphum, Clostridium tetani, and especially Clostridium malenominatum, they differ from these organisms in sugar utilization, cellular fatty acid composition, and cellular protein pattern and by a 16S rRNA sequence divergence value of approximately 4 to 8%. Phylogenetically, the strains are more closely related to Clostridium estertheticum (sequence divergence, approximately 5%) and Clostridium subterminale (sequence divergence, approximately 5%) but are phenotypically readily distinguished from these species. On the basis of phenotypic and genotypic criteria, we conclude that the four strains are members of a new species of the genus Clostridium, for which the name Clostridium pascui is proposed. The type strain is strain Cm19 (= DSM 10365).

Bronchogenic squamous cell carcinoma complicating localized recurrent respiratory papillomatosis

Bronchogenic squamous cell carcinoma has been reported in patients with recurrent respiratory papillomatosis (RRP) extending into the tracheobronchial tree even in the absence of a history of radiation therapy or smoking. We present a case of bronchogenic squamous cell carcinoma developing in a patient with RRP localized to the larynx for 45 years.

Multicentric quality assurance in cardiac surgery. QUADRA study of the German Society for Thoracic and Cardiovascular Surgery (QUADRA: quality data retrospective analysis)

A method for initiating quality assurance in cardiac surgery was developed multicentrically by a commission of the German Society for Thoracic and Cardiovascular Surgery (QUADRA Study). To appraise the quality of cardiosurgical action, variables were compiled from the preoperative, intraoperative, and postoperative treatment course. The data collection was carried out at the same time as treatment. On the basis of unicentric data profiles, multicentric hospital profiles, and problem profiles, a quality comparison could be carried out and the variability of cardiosurgical action which may occasion interventions could be identified. A reduction of perioperative blood consumption during the study period could be observed in four out of five hospitals as the first result. The data collection also revealed epidemiological features. On average, women were older than men at the time of the heart-valve and coronary operations. To ensure data validity and the organization of quality assurance, a documentation assistant and a specially trained physician are necessary at every cardiovascular surgery center. The multicentric external comparison is indispensable and must be carried out by means of a central data collection, for which intrumental and staff capacities are also to be provided. With modern methods of data processing, an additional and new approach to the improvement of quality in cardiac surgery can thus be made.

Development and application of a quality assurance information system in cardiac surgery (QUADRA study)

Preventive measures for quality in cadiac surgery which are based on electronic data processing initially have to overcome a variety of obstacles. Some of the most serious encountered are the need for more extensive but more precise and correct documentation, the definition of quality and the identification of parameters to assess it, fears that means to check everything and everybody are being installed, and finding ways to found the measures. The measures have two aims at least: ensuring a broad general standard of treatment which every patient can expect, and supporting efforts at a continuous improvement of treatment methods and thus of the results. These aims dictate that any measures instituted have to be of a permanent nature: they cannot be reached in the long term by a simple supplementary activity such as a research project. On the contrary, a complete integration in the general hospital routine and in the standard documentation and information processes is necessary. As these today still are not usually based on clinical progress reports which are formally suitable for data processing, reorganisation to achieve this is a prerequisite for successful quality assurance. This means, however, that those responsible for quality must help in the reorganisation.

Pilot study on quality assurance in cardiac surgery

In 1986 development, testing and improvement of a multi-center based quality assurance procedure has been started by the German Society for Thoracic and Cardiovascular Surgery supplied by a research fund of the Federal Ministry of Research and Technology. Initially five cardiac surgery units took part in defining quality related items, collecting associated data and establishing a common data base. In the first year of its existence this data base received about 3800 records of patients undergoing cardiac surgery procedures using ECC. Preoperative clinical state, intraoperative actions and postoperative results including unexpected events sum up to an average record length of 300 items per procedure. Evaluation and representation of quality related data ist done in two ways: an overall quality profile consisting of 17 so called quality indicators accompanied by six patient-mix indicators enables each cardiac surgeon to get a quick global reference within the multicentrical data context, and several problem oriented profiles assist building and testing of special quality-related hypotheses towards improvement of procedure standards and performance.

[Examination and patient management in x-ray diagnosis using a computerized hospital communication system]

Concept, realization and our 2-year experiences in the routine use of a computerized data-processing communications system supporting the central radiology department in a 1,625-bed, municipal hospital are discussed. Via the hospital ward-linked terminal network, routine X-ray examination is so ordered that individual medical case information is provided, which certifies qualified clinical and diagnostic procedure along with good patient preparation and transportation. Complete information and documentation are also ensured. It was shown that good motivation among involved radiologists and their close working-association with other departments are mandatory from the start to maintain exact time schedules and satisfactory completion of ordered X-ray procedures. Subsequently, the assistence of computerized data processing is accepted for routine use, as time goes by, insofar as it is appropriate by used.

Oxygen tolerance of strictly aerobic hydrogen-oxidizing bacteria

Growth of various bacteria, especially aerobic hydrogen-oxidizing bacteria, in the presence of 2 to 100% (v/v) oxygen in the gas atmosphere was evaluated. The bacterial strains included Alcaligenes eutrophus, A. paradoxus, Aquaspirillum autotrophicum, Arthrobacter spec. strain 11 X, Escherichia coli, Arthrobacter globiformis, Nocardia opaca, N. autotrophica, Paracoccus denitrificans, Pseudomonas facilis, P. putida, and Xanthobacter autotrophicus. Under heterotrophic conditions with fructose or gluconate as substrates neither colony formation on solid medium nor the growth rates in liquid media were drastically impaired by up to 100% oxygen. In contrast, autotrophic growth--with hydrogen, carbon dioxide and up to 80% oxygen in the gas atmosphere--was strongly depressed by high oxygen concentrations. However, only the growth rate, not the viability of the cells, was decreased. Growth retardation was accompanied by a decrease of hydrogenase activity.