Does lower extremity fracture fixation technique influence neurologic outcomes in patients with traumatic brain injury? The EAST Brain vs. Bone multicenter trial

OBJECTIVE

This study aimed to determine whether lower extremity fracture fixation technique and timing (≤24 vs. >24 hours) impact neurologic outcomes in TBI patients.

METHODS

A prospective observational study was conducted across 30 trauma centers. Inclusion criteria were age 18 years and older, head Abbreviated Injury Scale (AIS) score of >2, and a diaphyseal femur or tibia fracture requiring external fixation (Ex-Fix), intramedullary nailing (IMN), or open reduction and internal fixation (ORIF). The analysis was conducted using analysis of variamce, Kruskal-Wallis, and multivariable regression models. Neurologic outcomes were measured by discharge Ranchos Los Amigos Revised Scale (RLAS-R).

RESULTS

Of the 520 patients enrolled, 358 underwent Ex-Fix, IMN, or ORIF as definitive management. Head AIS was similar among cohorts. The Ex-Fix group experienced more severe lower extremity injuries (AIS score, 4-5) compared with the IMN group (16% vs. 3%, p = 0.01) but not the ORIF group (16% vs. 6%, p = 0.1). Time to operative intervention varied between the cohorts with the longest time to intervention for the IMN group (median hours: Ex-Fix, 15 [8-24] vs. ORIF, 26 [12-85] vs. IMN, 31 [12-70]; p < 0.001). The discharge RLAS-R score distribution was similar across the groups. After adjusting for confounders, neither method nor timing of lower extremity fixation influenced the discharge RLAS-R. Instead, increasing age and head AIS score were associated with a lower discharge RLAS-R score (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.002-1.03 and OR, 2.37; 95% CI, 1.75-3.22), and a higher Glasgow Coma Scale motor score on admission (OR, 0.84; 95% CI, 0.73-0.97) was associated with higher RLAS-R score at discharge.

CONCLUSION

Neurologic outcomes in TBI are impacted by severity of the head injury and not the fracture fixation technique or timing. Therefore, the strategy of definitive fixation of lower extremity fractures should be dictated by patient physiology and the anatomy of the injured extremity and not by the concern for worsening neurologic outcomes in TBI patients.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Hematopoietic stem and progenitor cell mobilization in mice and humans by a first-in-class mirror-image oligonucleotide inhibitor of CXCL12

NOX-A12 is a PEGylated mirror-image oligonucleotide (a so-called Spiegelmer) that binds to CXCL12 (stromal cell-derived factor-1, SDF-1) with high affinity thereby inhibiting CXCL12 signaling on both its receptors, CXCR4 and CXCR7. In animals, NOX-A12 mobilized white blood cells (WBCs) and hematopoietic stem and progenitor cells (HSCs) into peripheral blood (PB). In healthy volunteers, single doses of NOX-A12 had a benign safety profile and also dose-dependently mobilized WBCs and HSCs into PB. HSC peak mobilization reached a plateau at five times the baseline level at an i.v. dose of 5.4 mg/kg. In accordance with the plasma half-life of 38 h, the duration of the WBC and HSC mobilization was long lasting and increased dose-dependently to more than 4 days at the highest dose (10.8 mg/kg). In conclusion, NOX-A12 may be appropriate for therapeutic use in and beyond mobilization of HSCs, e.g., in long-lasting mobilization and chemosensitization of hematological cancer cells.

Region-dependent modulation of intestinal permeability by drug efflux transporters: in vitro studies in mdr1a(-/-) mouse intestine

Information on the extent to which xenobiotics interact with P-glycoprotein (PGP) during transit through the intestine is crucial in determining the influence of PGP on oral drug absorption. We have recently described a novel use of isolated ileum from PGP-deficient mdr1a(-/-) mice to resolve PGP- and non-PGP-dependent drug efflux and provide a definitive measure of intrinsic drug permeability without recourse to inhibitors. The present study uses this approach to investigate the impact of PGP on intestinal permeability of paclitaxel and digoxin in different regions of the mouse intestine (jejunum, ileum, and proximal and distal colon). Absorption of paclitaxel and digoxin in tissues from wild-type mice was low and showed little regional variation. In contrast, absorption of both drugs was markedly higher in mdr1a(-/-) intestine, although the increase was highly region-dependent, with the ileum and distal colon showing the greatest effect and much smaller changes in the jejunum and proximal colon. These effects were accompanied by the abolition of paclitaxel and digoxin secretion in mdr1a(-/-) mice, suggesting that regional variations in intestinal permeability are masked by differential PGP expression, confirmed by immunoblotting studies. Propranolol permeability, which is not influenced by PGP, showed similar regional variation in both wild-type and mdr1a(-/-) tissues, suggesting that differences are at the level of transcellular permeability. These data suggest that the ileum and the distal colon are regions of relatively high transcellular permeability for xenobiotics that are compensated by enhanced expression of PGP.

The changing role of Asian labour migration in the Middle East

"The paper explores the changing role and origins of foreign labour in two labour importing states, Kuwait and Jordan.... Because Asian labour is cheaper, politically quiescent and more readily reexportable than Arab labour migrants it has become an increasingly important element of these labour forces.... The paper argues that the strategy of dependent development based on the state's import of large amounts of capital, labour and technology has emphasised specific national identities over a regional pan-Arab one." (SUMMARY IN FRE AND SPA)

Resolution of P-glycoprotein and non-P-glycoprotein effects on drug permeability using intestinal tissues from mdr1a (-/-) mice

1. Intestinal xenobiotic transporters are a significant barrier to the absorption of many orally administered drugs. P-glycoprotein (PGP) is the best known, but several others, including members of the multidrug resistance-associated protein (MRP) family, are also expressed. Definitive information on their precise effect on intestinal drug permeability is scarce due to a lack of specific inhibitors and the difficulty of studying non-PGP activity in the presence of high PGP expression. 2. We have investigated the in vitro use of intestinal tissues from PGP knockout (mdr1a (-/-)) mice as a tool for dissecting the mechanisms of intestinal drug efflux. The permeability characteristics of digoxin (DIG), paclitaxel (TAX) and etoposide (ETOP) were measured in ileum from mdr1a (-/-) and wild-type (FVB) mice mounted in Ussing chambers. 3. DIG and TAX exhibited marked efflux across FVB tissues (B-A : A-B apparent permeability (P(app)) ratio 10 and 17 respectively) which was absent in mdr1a (-/-) tissues, confirming that PGP is the sole route of intestinal efflux for these compounds. The A-B P(app) of both compounds was 3 - 5 fold higher in mdr1a (-/-) than in FVB. 4. Polarized transport of ETOP in FVB tissues was reduced but not abolished in mdr1a (-/-) tissues. Residual ETOP efflux in mdr1a (-/-) tissues was abolished by the MRP inhibitor MK571, indicating involvement of both PGP and MRP. 5. MK571 abolished calcein efflux in mdr1a (-/-) tissues, while quinidine had no parallel effect in FVB tissues, suggesting involvement of MRP but not PGP. 6. Tissues from mdr1a (-/-) mice provide a novel approach for investigating the influence of PGP ablation on intestinal permeability and for resolving PGP and non-PGP mechanisms that modulate drug permeability.

Evaluation of the Intelisite capsule to deliver theophylline and frusemide tablets to the small intestine and colon

The objective of the research was to establish the capability of the Intelisite capsule to deliver the probe drugs, theophylline and frusemide, in the form of split immediate release (IR) tablets, to the small intestine and colon. The two probe drugs were administered together in an open, random, three-way crossover study in eight healthy volunteers, comparing absorption following Intelisite delivery in the small bowel and colon to conventional IR dosing. Gamma scintigraphy was employed to monitor the gastrointestinal transit and activation of the Intelisite capsule. Standard pharmacokinetic parameters, and the percentage remaining in the capsules post defecation were determined. The Intelisite capsule was well tolerated in human volunteers and successfully activated on 15/16 occasions. Pharmacoscintigraphy showed internal marker release from the Intelisite capsule to be approximately 10-fold faster in the small intestine than in the colon. Theophylline and frusemide were both well absorbed following Intelisite activation in the small intestine, whereas complete colonic absorption was only observed in 1/7 subjects for theophylline, and 0/7 subjects for frusemide. The probe drugs were successfully delivered in particulate form from the Intelisite capsule in the small intestine and produced expected pharmacokinetic profiles. However drug release in the colon was incomplete and variable possibly due to: low water content, poor mixing, and a high loading dose.

Fetal growth charts for Aboriginal fetuses

The study aimed to determine whether fetal growth parameters in Aboriginal pregnancies are such that separate fetal growth charts are necessary for their appropriate care. We designed a prospective study of a cohort of Aboriginal women presenting for antenatal care before 20 weeks gestation (ultrasound proven) and a reference cohort of Caucasian women. Four remote North Queensland communities served by the Far North Regional Obstetric and Gynaecological Service (FROGS) and the antenatal clinic at Cairns Base Hospital took part in the survey One hundred and four Aboriginal and 101 Caucasian women with no known medical factors affecting fetal growth or gestation were recruited, and 96 Aboriginal and 96 Caucasian women completed the study Measurements took the form of longitudinal percentile charts of fetal biparietal diameter, abdominal circumference and femur length. Ultrasound measurements of fetal biparietal diameter, abdominal circumference and femur length were obtained 3 to 5 times during Aboriginal and Caucasian pregnancies, where the gestation was established by ultrasound before 20 weeks gestation, and no known medical conditions which affect fetal growth were present in the mother. There were no statistical or clinically important differences in biparietal diameter, femur length and abdominal circumference of Aboriginal and Caucasian fetuses. We concluded that there is no reason to use separate fetal growth charts when examining Aboriginal fetal growth.

A prospective study of gestation and birthweight in Aboriginal pregnancies in far north Queensland

This study aimed to determine the cause(s) of the increased incidence of low birthweight birth in Aboriginal pregnancies. The study prospectively examined a cohort of Aboriginal women presenting for antenatal care before 20 weeks gestation (ultrasound proven) and a reference cohort of Caucasian women in four remote North Queensland communities served by the Far North Regional Obstetric and Gynaecological Service (FROGS) and the antenatal clinic at Cairns Base Hospital. Women with no known medical factors affecting fetal growth or gestation were recruited. Of the 102 Aboriginal and 101 Caucasian women recruited, 96 Aboriginal and 96 Caucasian women completed the study, providing groups of sufficient size to allow statistical assessment at 80% power and 95% significance. Outcomes measured were gestation at delivery, planned or spontaneous birth, neonatal anthropometric measurements and Dubowitz score. The phenotypic and demographic characteristics of the women, their pregnancies, and their babies were also compared to understand the major associations with low birthweight birth in the Aboriginal women. Apart from Aboriginal ethnicity, excessive alcohol use in pregnancy, low maternal body mass index (BMI), and low maternal age had significant negative correlations with birthweight, and excessive tobacco use in pregnancy and high maternal gravidity showed strong similar trends. Culturally appropriate programs need to be funded and developed to reduce the incidence of low birthweight Aboriginal birth, rather than medical programs primarily aimed at the reduction of the incidence of preterm labour.

Specificity of TLS-CHOP rearrangement for classic myxoid/round cell liposarcoma: absence in predominantly myxoid well-differentiated liposarcomas

Myxoid liposarcoma (LS), the most common subtype of LS, is known to be characterized by the specific t(12;16) resulting in a TLS-CHOP fusion in almost all cases. We wished to address the following questions: (i) Is this genetic hallmark also present in other types of LS with predominant myxoid change? (ii) What is the proportion of cases with the variant EWS-CHOP fusion? (iii) What is the optimal approach for Southern blot detection of TLS breakpoints? We identified 59 LS characterized histologically by >90% myxoid component, in which frozen tissue tumor was available for DNA extraction. These 59 LS with myxoid features were divided into 2 groups: 42 LS with classic myxoid/round cell appearance (myxoid LS) and 17 well-differentiated LS (WDLS) with a predominant (>90%) myxoid component. Within the myxoid LS group, 29 tumors were low grade and 13 high grade (>20% round cell component). Among the 17 predominantly myxoid WDLS, there were 15 low grade and 2 focally high grade tumors. In addition, we selected as control group, 20 LS of other histological types with minimal or no myxoid change (17 WDLS and 3 pleomorphic LS) and 13 myxofibrosarcomas. Southern blot analysis was performed in all cases using a CHOP cDNA probe, and in all CHOP rearranged cases using a TLS cDNA probe. Probe/enzyme combinations for Southern blot analysis were CHOP exon 3-4 cDNA probe with BamHI or SacI, TLS exon 3-6 cDNA probe with BclI. All 42 cases of myxoid LS showed a CHOP rearrangement and 38 of them also had a TLS rearrangement. Among the 4 myxoid LS without Southern blot evidence of TLS rearrangement, 1 showed an EWS-CHOP fusion by Southern blotting and reverse transcriptase-polymerase chain reaction and in another case, reverse transcriptase-polymerase chain reaction detected a TLS-CHOP fusion transcript. None of the predominantly myxoid WDLS and none of the tumors included in the control group showed rearranegements with CHOP probe. In addition, 12 predominantly myxoid WDLS, 10 other LS, and 5 myxofibrosarcoma from the control group were also tested for TLS rearrangement; all were negative. The TLS-CHOP fusion is highly sensitive and specific for the entity of classic myxoid/round cell LS. Other types of LS, even with a predominant myxoid component, lack the TLS-CHOP rearrangement, confirming that they represent a genetically distinct group of LS. The prevalence of the EWS-CHOP variant fusion was approximately 2% in this series. The optimal enzyme for TLS genomic breakpoint detection is BclI.

Breast-feeding and weight change in newborns in Jamaica

This study was conducted to examine weight change of exclusively breast-fed infants during the first week and through the first 24 days of life, and to evaluate the effect of breast-feeding factors and maternal characteristics on early weight change in the infants. The weights of 21 infants were recorded on day 1 (day of birth), and on days 3, 7, 10, 17, and 24, and the data analysed to evaluate weight change over the period. Multiple regression analysis was used to assess whether birth weight as well as maternal and breast-feeding factors were significant predictors of weight on day 24. Nineteen of the 21 infants gained weight between days 1 and 3, and 20 infants gained weight between days 3 and 7. All infants gained weight over the 24-day period and their weights at day 7 and day 24 were significantly different (P < 0.05 and P < 0.01, respectively) from their birth weights. Multiple linear regression analysis showed that significant (P < 0.01) predictors of weight gain by day 24 included birth weight, mother's educational level, whether the baby cried before feeding, and length of feeding time periods. This is the first study of weight change in the early days and weeks of life of exclusively breast-fed newborn infants in Jamaica. The infants showed significant weight gain during the study period and weight gain was affected by certain maternal and breast-feeding factors.

The cell-surface proteoglycan Dally regulates Wingless signalling in Drosophila

Wingless (Wg) is a member of the Wnt family of growth factors, secreted proteins that control proliferation and differentiation during development. Studies in Drosophila have shown that responses to Wg require cell-surface heparan sulphate, a glycosaminoglycan component of proteoglycans. These findings suggest that a cell-surface proteoglycan is a component of a Wg/Wnt receptor complex. We demonstrate here that the protein encoded by the division abnormally delayed (dally) gene is a cell-surface, heparan-sulphate-modified proteoglycan. dally partial loss-of-function mutations compromise Wg-directed events, and disruption of dally function with RNA interference produces phenotypes comparable to those found with RNA interference of wg or frizzled (fz)/Dfz2. Ectopic expression of Dally potentiates Wg signalling without altering levels of Wg and can rescue a wg partial loss-of-function mutant. We also show that dally, a regulator of Decapentaplegic (Dpp) signalling during post-embryonic development, has tissue-specific effects on Wg and Dpp signalling. Dally can therefore differentially influence signalling mediated by two growth factors, and may form a regulatory component of both Wg and Dpp receptor complexes.

Creating the "spirit of service"

What does it take for a hospital to achieve excellence in the area of customer service? How can customer service be improved within a large and complex healthcare facility? Many hospitals are currently seeking answers to these questions.

Screening for important base identities in the hairpin ribozyme by in vitro selection for cleavage

Random mutagenesis followed by an in vitro selection procedure was shown to be capable of identifying important bases of the hairpin ribozyme for cleavage of an RNA target sequence. The selection scheme enriched the RNA population for those molecules capable of efficient site-specific self-cleavage in the absence of ligation. Cleavable mutants were selected for all positions in loop 4 except for position A38, supporting the notion that A38 is an important base in the hairpin ribozyme. This has been confirmed by direct mutagenesis, validating the utility of this procedure. Thus, the method developed and reported here has utility for the selection of efficient hairpin ribozymes capable of highly efficient cleavage of a substrate RNA without a requirement for ribozyme-catalyzed ligation, conditions desired for many applications of catalytic RNA such as gene therapy.

The meaning of parenthood and couples' reactions to male infertility

This paper reports findings from a postal survey of 205 couples belonging to the National Association for the Childless who saw their infertility as due to the male partner. Two self-report scales used in previous studies were administered to measure personal and social identity needs as a basis for parenthood (the Meaning of Parenthood scale), and emotional distress and marital problems. Endorsement of items on the Meaning of Parenthood (MOP) scale showed only small mean gender differences for each item and a consistent item rank order for men and women. Factor analysis confirmed that the scale tapped dimensions pertaining to social and personal identity needs. For women, distress was associated with ratings on the MOP scale which emphasized the link between femininity and motherhood, while for men distress was associated with ratings which emphasized masculinity and fatherhood. Implications of the results for further research and counselling in relation to male infertility are discussed.

Vasectomy as a reason for donor insemination

Among 200 couples referred for counselling with a view to donor insemination (DI) were 21 whose request arose from an earlier vasectomy. This had been judged irreversible, apart from one case where the man had been sterilised for genetic reasons and therefore had not sought reversal. An overall incidence of 10.5% indicates that vasectomy may lead to fertility problems in the event of remarriage, which has become more common with an increasing divorce rate. All 21 husbands but only 3 wives had been previously married; 3 former wives had died, otherwise all previous marriages had ended in divorce. Most husbands were considerably older than their second wives, especially as compared with the majority of men in the larger series who were still in a first marriage. Their relative maturity may have helped them to respond more sensitively to their wives' maternal needs when they already had children of their own. During a follow-up interval of up to 8 years, 2 couples had separated after a brief relationship but 9 of the other 12 contacted had become parents by DI. The 3 remaining couples included a wife who at the latest report was 5 months pregnant, and 2 who were still pursuing treatment. Despite the low failure rate in this small series we should bear in mind that DI is not an ideal solution to the problem of male infertility, nor always even acceptable.(ABSTRACT TRUNCATED AT 250 WORDS)

Migrants, workers and refugees: the political economy of population movements in the Middle East

The author investigates causes and consequences of migratory movements in the Middle East. "Two factors--integration into the world labor market and the fragility of integration within the separate states--largely explain why conflicts in the Middle East have in recent years produced the greatest refugee flows of any region in the world.... The crisis of the secular nation-state in the Middle East will continue as states become either politically or economically more dependent on outside protection or assistance. The challenge by Islamist movements is also likely to undermine national cohesion by politicizing religious identity."

Assessments of personal and general risks of HIV and AIDS in Harare, Zimbabwe

This study examines the relationship between perceptions of personal risk and perceptions of general risk of HIV infection. It relates these perceptions to the likelihood of behavioural change, and to the health belief model. It is argued that as part of the education campaign concerning HIV and AIDS it is important to present images and messages which can be personalized by different sections of the community.

Absence of retroviral sequences in Graves' disease

An earlier report of HIV-1 gene sequences in thyroid cell genomic DNA from patients with Graves' disease prompted use of the polymerase chain reaction technique to identify such sequences in Graves' disease thyroid tissue and in white blood-cells from these patients. We were unable to confirm the existence of HIV-1-related DNA sequences in Graves' specimens.

Screening couples for parenthood by donor insemination

Traditionally the selection of applicants for donor insemination (DI) has been governed by technical considerations relating to the fertility of the female and infertility of the male partner. In contrast, adoptive applicants have been carefully appraised in terms of their social and psychological fitness for parenthood. Despite easily recognisable differences between the two situations, we propose that DI candidates should be expected to satisfy minimal criteria regarding their marital relationship, health and social adjustment. The case for screening (as opposed to 'vetting', which implies a more searching examination) is argued with reference to a series of almost 200 couples referred from a hospital infertility clinic. In the absence of scientific validation the pursuit of more stringent criteria would be unwarranted, and in the event only a few couples were regarded as totally unsuitable on account of serious personal and marital problems. Others may have benefited from the opportunity to explore some of the delicate issues involved, although the value of independent counselling has yet to be established.

Damaged identity and the search for kinship in adult adoptees

A postal questionnaire was sent to 100 members of an organization for helping adopted individuals to trace their origins. Replies were received from 42 women and 34 men, some of whom were interviewed in person or more often by telephone. The voyage of self-discovery was evidently more crucial for women, whose need for a stronger sense of identity had been enhanced by marriage and motherhood. Relatively more men than women had sought help for personal problems in adulthood, although paradoxically more women reported an unhappy experience of adoption and a damaged sense of identity. Predictably, mother-child reunions had often proved disappointing and occasionally distressing for both parties. In contrast, the discovery of lost siblings had usually brought more reward. This aspect of the search for biological relatives deserves more emphasis, in case adoptees (especially when reared as only children and/or when psychologically disturbed) might have more to gain from meeting a sibling than from meeting a parent.

Marital relationships in couples seeking donor insemination

Findings are reported on 100 couples who had requested donor insemination as a means of circumventing male infertility. Twelve couples dropped out, but the remainder were graded for personal acceptability. Forty-six couples were recommended with only minor reservations if any, 40 were seen as unsatisfactory in varying degree, and two were rejected owing to gross marital and sexual problems. In one couple, early marital breakdown after childbirth occurred.

A strong sense of mutual commitment may be the norm in such couples but exchange of affection between partners, as measured by the Ryle marital patterns test, was less vivid than in an earlier study of childless couples waiting to adopt. The infertile husband may be in particular need of emotional support from his wife, and a careful appraisal of the marriage seems warranted before treatment.

Summary of labour and obstetric audit by microcomputer

A microcomputer is used directly by the clinician, immediately after delivering a baby, to produce a summary letter to the referring physician and for the case notes. The programme is easy to use, and accepted by a wide range of medical users. In addition to producing a summary, the information is added to the obstetric data base, which may be interrogated by a computer novice. The system is now used to produce yearly obstetric audits of the Queen Victoria Medical Centre.

A fresh look at genealogical bewilderment

The concept of genealogical bewilderment is re-examined in the light of empirical evidence gathered over the past 20 years. It is concluded that, where the quality of surrogate family relationships is sufficient to meet the child's emotional needs, then there is no reason why ancestral knowledge should be a prerequisite of mental health. It would appear that individuals with a spontaneous urge or sometimes even a compulsion to search for their biological relatives are not uncommonly suffering from emotional deprivation. However, this is not to deny the reality of healthy genetic curiosity in children cut off from their roots.

Cognitive methods of preparing women for hysterectomy: does a booklet help?

Thirty women about to undergo hysterectomy were sequentially assigned to three equal groups. The first two groups were taught methods of cognitive control over anxiety, either through a detailed booklet (group 1) or orally (group 2). The third group served as attention-placebo controls. The two experimental groups reported less pain and distress than the control group, who spent longer in hospital and were more prone to post-operative vomiting. The booklet proved neither more nor less beneficial than oral teaching on the criteria adopted, and is therefore seen as more cost effective.

Number and distribution of putative cholinergic neurons in the cat retina

The number and distribution of putative cholinergic amacrine cells in cat retina was demonstrated by immunocytochemical localization of choline acetyltransferase (ChAT), the synthesizing enzyme for acetylcholine. In whole mount preparations of the cat retina ChAT-immunoreactive neurons were found in the inner nuclear layer (presumably amacrine cells) and in the ganglion cell layer (presumably displaced amacrine cells). The density of ChAT-labelled neurons increased from about 280 cells/mm2 in peripheral retina, to about 2750 cells/mm2 in the central area. There were always more ChAT-positive cells in the ganglion cell layer (50-70%) than in the amacrine cell layer. Two narrow dendritic strata were labelled in the inner plexiform layer.

Adolescent fantasy and self-fulfillment: the problem of female passivity

A detailed analysis is reported of essays written by teenagers from two independent schools (120 of each sex) in response to the opening sentence: "Today is my eightieth birthday and I look back to the day I left school." Predictably the girls were orientated toward marriage and family life, and were somewhat less career-minded than the boys. They were also less politically aware, and saw hobbies as a luxury for their retirement and not as an integral part of life. Essentially they differed from the boys in being ready to live through others rather than on their own terms. These findings are interpreted in the light of Freud's distinction between passivity and the pursuit of a passive aim, which may call for well directed activity.

Changes in self-concept following severe head injury

Twenty five severely head injured patients from two specialist neurological rehabilitation centres were interviewed on average seven months post-injury. Changes in self-concept were investigated through the completion of scales of anxiety and depression, an attitude questionnaire relating to physical disability and semantic differential ratings of Present Self, Past (pre-morbid) Self, Future Self, a Typical Person and a Typical Head Injured Person. Psychological distress in terms of anxiety and depressions was common. Patients viewed themselves as having changed substantially as a result of their head injury on a wide range of constructs, yet confidently anticipated a return to Past (pre-morbid) Self within a year, even though Past Self was rated more positively overall than a Typical Person. While differing dramatically from Past Self, Present Self was rated more positively in some respects than the concept of a Typical Head Injured Person, which was perceived as markedly different from that of a Typical Person. Whilst unrealistic expectations may initially serve to protect the profoundly disabled individual and even motivate him towards recovery, in the long run they are more likely to hamper rehabilitation and adjustment. Effective intervention calls for awareness of the patient's own perspective as well as the relatives' reactions to the overt disabilities.

Coping with the loss of a leg

This study sets out to examine the physical and psychological effects of amputation on marriage and family life; assess the extent to which the needs of the younger amputee are being met from current rehabilitation resources, and to ascertain how the non-disabled regard amputation and its consequences. Interviews were conducted with a group of 19 amputees and a group of 40 non-disabled individuals within the same age range and the results are reported.

The role of the regional lymph node in breast cancer: a comparison between nodal and systemic reactivity

Confusion remains concerning the role of the regional lymph node in the containment of cancer. Numerous investigators using a variety of assays have reported often conflicting results concerning the immunocompetency of lymphocytes residing in regional nodes. Forty-two axillary lymph nodes from ten stage I and stage II breast cancer patients were studied in lymphocyte blast assays using mitogens and breast cancer antigen (BCA). Three general response patterns to BCA were identified which were related primarily to tumor size. In the patients with the smallest primary tumor (0.5 cm), lymphocytes in the nodes reacted to a much greater extent than peripheral blood lymphocytes (PBL). In two of three patients with intermediate-size tumor (1.0 to 1.5 cm), a mixed pattern of responses was seen with both stimulation suppression occurring within the nodes of the same patient. In the four patients with the largest tumors (2.0 to 3.0 cm), 15 of 19 nodes had a lower stimulation index (SI) than the corresponding PBL. From the results of this study it appears that regional lymph nodes are dynamic immunologic structures which regress in responsiveness as tumor burden increases.

Presenile stroke: long-term outcome for patients and their families

Postal questionnaires were completed by the spouses of 170 surviving stroke patients who had attended a medical rehabilitation centre up to eight years earlier. Problems of self-care were reported as persisting in two thirds and restricted mobility in almost half of the patients. Outcome here was influenced by presence or absence rather than by side of hemiplegia. However, return to work was significantly more common with left hemiplegia. Memory defects were said to be displayed by one patient in three, communication loss and marked personality change by one in four. A third of both patients and spouses had received treatment for tension or depression, which points to a need for improved after-care facilities.