What influences the functional outcome of children at 6 months post-burn?

The contribution of demographic, injury, pre-morbid, and parent factors to a child's functional outcome at 6 months post-burn injury was examined. Sixty-eight children, aged 5-14 years with percent total body surface area (%TBSA) burns ranging from

Referral to rehabilitation following traumatic brain injury: a model for understanding inequities in access

Identifying inequities in access to health care requires critical scrutiny of the patterns and processes of care decisions. This paper describes a conceptual model. derived from social problems theory. which is proposed as a useful framework for explaining patterns of post-acute care referral and in particular, individual variations in referral to rehabilitation after traumatic brain injury (TBI). The model is based on three main components: (1) characteristics of the individual with TBI, (2) activities of health care professionals and the processes of referral. and (3) the contexts of care. The central argument is that access to rehabilitation following TBI is a dynamic phenomenon concerning the interpretations and negotiations of health care professionals. which in turn are shaped by the organisational and broader health care contexts. The model developed in this paper provides opportunity to develop a complex analysis of post-acute care referral based on patient factors, contextual factors and decision-making processes. It is anticipated that this framework will have utility in other areas examining and understanding patterns of access to health care. (C) 2002 Elsevier Science Ltd. All rights reserved.

Effects of phytase supplementation of diets with two tiers of nutrient specifications on growth performance and protein efficiency ratios of broiler chickens

in two feeding experiments male and mixed-sex broiler chicks were offered diets based on sorghum and a wheat-sorghum blend with two tiers of nutrient specifications, without and with microbial phytase (600 and 800 FTU/kg), from 7-25 and 1-42 days post-hatch, respectively. The nutrient specifications for protein, amino acids, energy density and phosphorus (P) of standard diets were reduced to formulate the modified diets on a least-cost basis. Calculated differences in nutrient specifications between standard and modified diets ranged from 14.3 to 17.1 g/kg crude protein, 0.24 to 0.40 MJ/kg apparent metabolisable energy (AME) and 1.06 to 1.20 g/kg available P. In both experiments, reduced nutrient specifications had a negative impact on growth rates and feed efficiency and phytase supplementation had a positive influence on growth performance and protein efficiency ratios (PER). Phytase addition to the less expensive, modified diets either partially or entirely compensated for reduced growth performance and, consequently, feed costs per kg of live weight gain were reduced. In Experiment 1, phytase increased (p<0.001) nitrogen-corrected AME (AMEn) from 15.39 to 15.89 MJ/kg dry matter. For nitrogen (N) retention there was an interaction (p<0.05) between diet type and phytase as the effects of phytase on N retention were more pronounced in the modified diets, with an increase from 0.512 to 0.561. These results demonstrate the positive effects of phytase on protein and energy utilisation, in addition to its established liberation of phytate-bound P and illustrate the feasibility of assigning nutrient replacement values to the feed enzyme for consideration in least-cost ration formulations. Further work is, however, required to define the most appropriate reductions in nutrient specifications in association with phytase supplementation.

Influence of phytase and xylanase supplementation on growth performance and nutrient utilisation of broilers offered wheat-based diets

Individual and combined supplementation of phosphorus-adequate, wheat-based broiler diets with exogenous phytase and xylanase was evaluated in three experiments. The effects of the enzyme combination in lysine-deficient diets containing wheat and sorghum were more pronounced than those of the individual feed enzymes. The inclusion of phytase plus xylanase improved (p<0.05) weight gains (7.3%) and feed efficiency (7.0%) of broilers (7-28 days post-hatch) and apparent metabolisable energy (AME) by 0.76 MJ/kg DM. Phytase plus xylanase increased (p<0.05) the overall, apparent ileal digestibility of amino acids by 4.5% (0.781 to 0.816); this was greater than the responses to either phytase (3.6%; 0.781 to 0.809) or xylanase (0.7%; 0.781 to 0.784). Absolute increases in amino acid digestibility with the combination exceeded the sum of the individual increases generated by phytase and xylanase for alanine, aspartic acid, glutamic acid, glycine, histidine, isoleucine, phenylalanine, threonine, tyrosine and valine. These synergistic responses may have resulted from phytase and xylanase having complementary modes of action for enhancing amino acid digestibilities and/or facilitating substrate access. The two remaining experiments were almost identical except wheat used in Experiment 2 had a higher phytate concentration and a lower estimated AME content than wheat used in Experiment 3. Individually, phytase and xylanase were generally more effective in Experiment 2, which probably reflects the higher dietary substrate levels present. Phytase plus xylanase increased (p<0.05) gains (15.4%) and feed efficiency (7.0%) of broiler chicks from 4-24 days post-hatch in Experiment 2; whereas, in Experiment 3, the combination increased (p<0.05) growth to a lesser extent (5.6%) and had no effect on feed efficiency. This difference in performance responses appeared to be 'protein driven' as the combination increased (p<0.05) nitrogen retention in Experiment 2 but not in Experiment 3; whereas phytase plus xylanase significantly increased AME in both experiments. In Experiments 2 and 3 the combined inclusion levels of phytase and xylanase were lower that the individual additions, which demonstrates the benefits of simultaneously including phytase and xylanase in wheat-based poultry diets.

Effects of A1 adenosine receptor overexpression on normoxic and post-ischemic gene expression

Objectives: To identify potential molecular genetic determinants of cardiovascular ischemic tolerance in wild-type and transgenic hearts overexpressing A(1) adenosine receptors (A(1)ARs). Methods: cDNA microarrays were used to explore expression of 1824 genes ill wild-type hearts and ischemia-tolerant mouse hearts overexpressing A(1)ARs. Results: Overexpression of A(1)ARs reduced post-ischemic contractile dysfunction, limited arrhythmogenesis, and reduced necrosis by similar to80% in hearts subjected to 30 min global ischemia 60 mill reperfusion. Cardioprotection was abrogated by acute A(1)AR antagonism, and only a small number (19) of genes were modified by A(1)AR overexpression in normoxic hearts. Ischemia-reperfusion significantly altered expression of 75 genes in wild-type hearts (14 induced, 61 down-regulated), including genes for metabolic enzymes, structural/motility proteins, cell signaling proteins, defense/growth proteins, and regulators of transcription and translation. A(1)AR overexpression reversed the majority of gene down-regulation whereas gene induction was generally unaltered. Additionally, genes involved in cell defence, signaling and gene expression were selectively modified by ischemia in transgenic hearts (33 induced, 10 down-regulated), possibly contributing to the protected phenotype. Real-time PCR verified changes in nine selected genes, revealing concordance with array data. Transcription of the A(1)AR gene was also modestly reduced post-ischemia, consistent with impaired functional sensitivity to A(1)AR stimulation Conclusions: Data are presented regarding the early post-ischemic gene profile of intact heart. Reduced A(1)AR transcription is observed which may contribute to poor outcome from ischemia. A(1)AR overexpression selectively modifies post-ischemic gene expression, potentially contributing to ischemic-tolerance. (C) 2003 European Society of Cardiology. Published by Elsevier Science B.V. All rights reserved.

Clinical characteristics of acute dysphagia in pediatric patients following traumatic brain injury

Primary Objective: To document the clinical characteristics of acute dysphagia in a group of pediatric patients after traumatic brain injury (TBI). Research Design: Prospective group study. Methods: Fourteen subjects (7 males, 7 females), aged 4 years 1 month to 15 years, with moderate or severe TBI (Glasgow Coma Scale [GCS] < 12). Subjects were assessed via clinical bedside examination documenting cognitive status, oromotor function, feeding function, dietary recommendations, and an indication of overall feeding severity Results: A pattern of impaired cognition, altered behavior related to feeding, severe tonal and postural deficits, oromotor, respiratory, and laryngeal impairments, and oral sensitivity issues was revealed. Conclusions: Swallowing impairment was affected by multilevel deficits, which both individually and in combination had a negative impact on swallowing competence and safety. In light of deficits identified, which could not be observed on videofluoroscopic investigation alone, this study highlighted the importance of the clinical bedside examination in assessing dysphagia in pediatric patients post-TBI for identifying targets for intervention.

An evaluation of continuous positive airway pressure (CPAP) therapy in the treatment of hypernasality following traumatic brain injury - A report of 3 cases

Objective: To evaluate the effectiveness of continuous positive airway pressure (CPAP) therapy in the treatment of hypernasality following traumatic brain injury (17111). Design: An A-B-A experimental research design. Assessments were conducted prior to commencement of the program, midway, immediately posttreatment, and 1 month after completion of the CPAP therapy program. Participants: Three adults with dysarthria and moderate to severe hypernasality subsequent to TBI. Outcome Measures: Perceptual evaluation using the Frenchay Dysarthria Assessment, the Assessment of Intelligibility of Dysarthric Speech, and a speech sample analysis, and instrumental evaluation using the Nasometer. Results: Between assessment periods, varying degrees of improvement in hypernasality and sentence intelligibility were noted. At the 1-month post-CPAP assessment, all 3 participants demonstrated reduced nasalance values, and 2 exhibited increased sentence intelligibility. Conclusions: CPAP may be a valuable treatment of impaired velopharyngeal function in the TBI population.

Ethics and health systems research in 'post'-conflict situations

Although considerable attention has been given to ethical issues related to clinical research in developing countries, in particular related to HIV therapy, there has been limited focus on health systems research, despite its increasing importance in the light of current trends in development assistance. This paper examines ethical issues related to health systems research in 'post'-conflict situations, addressing both generic issues for developing countries and those issues specific to 'post'-conflict societies, citing examples from the author's Cambodian experience. It argues that the destruction of health infrastructure results in a loss of structures and processes that would otherwise protect prospective research subjects who are part of vulnerable populations. It identifies the growth of health systems research as part of a trend towards sectoral and programmatic development assistance, the emergence of 'knowledge generation' as a form of research linked to development, and the potential for conflict where multilateral and bilateral donors are both primary funders and users of health systems research. It also examines the position of the health system researcher in relation to the sponsors of this research, and the health system being analysed.

Palaeoclimatic implications of the growth history and stable isotope (delta O-18 and delta C-13) geochemistry of a Middle to Late Pleistocene stalagmite from central-western Italy

The age structure and, stable isotope composition of a stalagmite (CC I) from an upland cave in central-western Italy were studied to investigate regional response to global climatic changes. Four growth phases are constrained by 28 thermal ionization and multi-collector inductively coupled plasma mass spectrometry Th-U ages and reveal intermittent deposition through the period between Marine isotope Stage (MIS) 11 and 3 (similar to380 and similar to43 kyr). Most of the growth took place between similar to380 and similar to280 kyr, a period punctuated briefly by a hiatus in deposition through the glacial maximum of MIS 10. Growth was terminated abruptly at 280 kyr just prior to the MIS 8 glacial maximum. With a present-day chamber temperature of 7.5 degreesC, the timing of hiatuses close to these glacial maxima point to freezing conditions at the time. No deposition was recorded through the entirety of MIS 7 and most of MIS 6, whilst two minor growth phases occurred at similar to141-125 and similar to43 kyr. Growth at 141 kyr indicates temperatures >0 degreesC at a time when MIS 6 ice volumes were close to their maximum. High stable carbon isotope (delta(13)C) values (similar to2.8parts per thousand to +3.1parts per thousand) throughout the stalagmite's growth reflect a persistently low input of biogenic CO2, indicating that the steep, barren and alpine-like recharge area of today ha's been in existence for at least the last similar to380 kyr. During MIS 9, the lowest delta(13)C values occur well after maximum interglacial conditions, suggesting a lag in the development of post-glacial soils in this high-altitude karst. The stable oxygen isotope (delta(18)O) trends match the main structural features of the major climate proxy records (SPECMAP, Vostok and Devils Hole), suggesting that the delta(18)O of CC1 has responded to global-scale climate changes, whilst remarkable similarity exists between CC1 delta(18)O and regional sea-surface temperature reconstructions from North Atlantic core ODP980 and southwest Pacific marine core MD97-2120 through the most detailed part of the CC1 record, MIS 9-8. The results suggest that CC1 and other stalagmites from the cave have the potential to capture a long record of regional temperature trends, particularly in regards to the relative severity of Pleistocene glacial stages. (C) 2004 Elsevier B.V. All rights reserved.

Temporal expression of fibroblast growth factor receptors during primary ligament repair

Following injury, it is inherently difficult to completely restore the biomechanical properties of ligaments. Relatively little is known about the cellular mechanisms controlling ligament healing. Numerous studies have implicated fibroblast growth factors (FGFs) as key molecules during the initiation of the cellular proliferation, differentiation, migration and matrix deposition that characterise wound healing. While current surgical emphasis concentrates on growth factor intervention, the role of their cognate receptors (FGFRs) has largely been overlooked. Following transection of the medial collateral ligament (MCL) in rabbits, we examined FGFR expression over a 14-day healing period. Using semiquantitative RT-PCR, we observed a significant upregulation in FGFR2 expression after 3 days. By 7 days post injury, FGFR2 expression fell to basal levels in line with those of FGFR1 and 3, both of which remained unaffected by surgical transection. These results demonstrate a role for FGFR2 in fibroblast and endothelial cell proliferation in damaged ligament, and suggest a window for FGF therapy.

Use of electropalatography in the treatment of disordered articulation following traumatic brain injury: A case study

Electropalatography (EPG) was used as a biofeedback tool in a case study of a 30-year-old male with disordered articulation following traumatic brain injury (TBI). Based on qualitative measures of the participant's intelligibility, improved articulation of the fricatives /s/ and /integral/ were selected as treatment targets. Therapy was administered three times a week for 5 weeks. Results showed that word and sentence intelligibility increased approximately 10%, and error patterns for lingual articulation indicated that fricative -> stop and other fricative errors decreased considerably. EPG measures for /s/ exhibited a significantly more anterior main focus of articulatory contact post therapy. Consonant durations were significantly longer during weeks 3 and 4, and this finding was associated with the emergence of an articulatory contact pattern with a groove rather than complete closure. This articulatory pattern appeared inconsistently and was found to vary across articulations of /s/ but also within a single consonant production. For /integral/, the amount of contact was significantly reduced post therapy and an increase in duration was noted during week 4, similar to that occurring in the production of /s/. Spatial and timing measures were more variable than in normal speakers of English and indicated a general increase in variability across weeks for both /s/ and /integral/. It was concluded that, although the correct fricative patterns appeared only intermittently during production of the consonants, there seemed to be sufficient information for the listener to be able to classify the sound as a fricative. As a part of an intervention program, visual EPG biofeedback therapy would appear to have a definite role in assisting dysarthric speakers exhibiting difficulties with lingual articulation in understanding their errors, learning how to exploit kinesthetic, and acoustic sources of feedback, and how to make appropriate adjustments in tongue articulation to increase the level of speech intelligibility.

Prospective memory rehabilitation for adults with traumatic brain injury: A compensatory training programme

Primary objective: To describe a prospective memory rehabilitation programme based on a compensatory training approach and report the results of three case studies. Research design: Programme evaluation using pre-and post-intervention assessments and telephone follow-up. Methods and procedures: Three participants with traumatic brain injury completed 8 weeks of training with 1 - 2 hour individual sessions. Assessments were formal prospective memory assessment, self-report and measures of diary use. Experimental interventions: Intervention aimed to identify potential barriers, establish self-awareness of memory deficits, introduce a customized compensatory tool, a cueing system and organizational strategies. A significant other was involved in training to assist generalization. Main outcomes and results: All three participants improved on formal prospective memory assessment and demonstrated successful diary use after the programme. Self-report of prospective memory failure fluctuated and may reflect increased self-awareness. Conclusion: A compensatory approach may be useful in improving prospective memory performance following TBI.

Six-month outcome for dysphagia following traumatic brain injury: Radiological assessment

The coexistence of a swallowing impairment, or dysphagia, can severely impact upon the medical condition and recovery of a child with traumatic brain injury (TBI; Logemann, Pepe, & Mackay, 1994). Despite this fact, there is limited data that provide evidence of the progression or outcome of dysphagia in the pediatric population post-TBI (Rowe, 1999). The present study aimed to (1) provide a prospective radiologically based profile of swallowing outcome and (2) determine the clinical significance of any persistent physiological swallowing deficits by investigating the presence/absence of any coexistent respiratory complications. Seven children with moderate/severe TBI were evaluated via an initial videofluoroscopic swallowing assessment (VFSS) at an average of 24.1 days postinjury, during the acute phase of management. A follow-up VFSS was conducted at an average of 7 months, 3 weeks postinjury. The physiological impairment, swallowing safety, swallowing efficiency, and functional swallowing outcomes of the acute phase post-TBI were compared with reassessment results at 6 months post-TBI. The presence/absence of lower respiratory tract infection/respiratory complications in the past 6 months postinjury were recorded.VFSS revealed a number of residual physiological oropharyngeal swallowing impairments and reduced swallowing efficiency. However, all participants presented with clinically safe and functional swallowing outcomes at 6 months post-TBI, with no recent history of respiratory complication. This study indicates good functional swallowing and respiratory outcomes for patients at 6-months post-TBI despite the presence of persistent physiological swallowing impairment.

An Internet training intervention for people with traumatic brain injury: Barriers and outcomes

Primary objective: To test whether people with cognitive-linguistic impairments following traumatic brain injury could learn to use the Internet using specialized training materials. Research design: Pre-post test design. Methods and procedures: Seven participants were each matched with a volunteer tutor. Basic Internet skills were taught over six lessons using a tutor's manual and a student manual. Instructions used simple text and graphics based on Microsoft Internet Explorer 5.5. Students underwent Internet skills assessments and interviews pre- and post-training. Tutors completed a post-training questionnaire. Main outcomes and results: Six of seven participants reached moderate-to-high degrees of independence. Literacy impairment was an expected training barrier; however, cognitive impairments affecting concentration, memory and motivation were more significant. Conclusions: Findings suggest that people with cognitive-linguistic impairments can learn Internet skills using specialized training materials. Participants and their carers also reported positive outcomes beyond the acquisition of Internet skills.

The effects of a song-singing programme on the affective speaking intonation of people with traumatic brain injury

Primary objective: To examine changes in the relationship between intonation, voice range and mood following music therapy programmes in people with traumatic brain injury. Research design: Data from four case studies were pooled and effect size, ANOVA and correlation calculations were performed to evaluate the effectiveness of treatment. Methods and procedures: Subjects sang three self-selected songs for 15 sessions. Speaking fundamental frequency, fundamental frequency variability, slope, voice range and mood were analysed pre- and post-session. Results: Immediate treatment effects were not found. Long-term improvements in affective intonation were found in three subjects, especially in fundamental frequency. Voice range improved over time and was positively correlated with the three intonation components. Mood scale data showed that immediate effects were in the negative direction whereas there weres increases in positive mood state in the longer-term. Conclusions: Findings suggest that, in the long-term, song singing can improve vocal range and mood and enhance the affective intonation styles of people with TBI.