Self-awareness and psychosocial functioning following acquired brain injury: An evaluation of a group support programme

This study investigated a group support programme designed to improve self-awareness deficits and psychosocial functioning in a group of chronic patients (N = 21) with acquired brain injury (ABI). The participants were on average 8.6 years (range: 1-36 years) post-injury and were seen at the Brain Injury Association of Queensland, Australia. The assessment of participants involved two standardised measures of intellectual self-awareness with collateral reports from relatives. The present study introduced a new measure called the Self-Regulation Skills Interview (SRSI) which assessed higher levels of self awareness and self-regulation skills. Psychosocial functioning was assessed using a standardised self-report measure. At baseline the group had a relatively high level of intellectual self-awareness regarding their deficits, a low to moderate level of self-regulation skills, and significant psychosocial impairment. The participants were involved in a 16-week group programme which involved components of cognitive rehabilitation, cognitive-behavioural therapy, and social skills training. A post-intervention assessment indicated that participants had significantly improved levels of self-regulation skills and psychosocial functioning. A 6-month follow-up assessment indicated that overall, participants had maintained the gains made during the programme. The important role of self-regulation skills is emphasised as the principle factor contributing to the maintenance of the gains observed.

Referral to post-acute care following traumatic brain injury (TBI) in the Australian context

The study aimed to describe the types of care allocated at the end of acute care to people diagnosed with TBI and to identify the factors associated with variations in referral to care. A retrospective analysis of medical records of 61 patients was conducted based on a sample from two hospitals. While 60.7% of the study sample were referred to formal rehabilitation care, this was primarily non-inpatient rehabilitation care (32.8%). Discriminant analysis was used to determine medical and non-medical predictors of referral. Results indicated that place of treatment and age contribute to group differences and were significant in separating the inpatient rehabilitation group from the non-inpatient and no rehabilitation groups. Review by a rehabilitation physician was associated with referral to inpatient rehabilitation but was not adequate to explain referral to non-inpatient rehabilitation. An in-depth exploration of post-acute referral is warranted to improve policy and practice in relation to continuity of care following TBI.

Human cyclophilin 40 is a heat shock protein that exhibits altered intracellular localization following heat shock

The unactivated steroid receptors are chaperoned into a conformation that is optimal for binding hormone by a number of heat shock proteins, including Hsp90, Hsp70, Hsp40, and the immunophilin, FKBP52 (Hsp56). Together with its partner cochaperones, cyclophilin 40 (CyP40) and FKBP51, FKBP52 belongs to a distinct group of structurally related immunophilins that modulate steroid receptor function through their association with Hsp90. Due to the structural similarity between the component immunophilins, FKBP52 and cyclophilin 40, we decided to investigate whether CyP40 is also a heat shock protein. Exposure of MCF-7 breast cancer cells to elevated temperatures (42 degreesC for 3 hours) resulted in a 75-fold increase in CyP40 mRNA levels, but no corresponding increase in CyP40 protein expression, even after 7 hours of heat stress. The use of cycloheximide to inhibit protein synthesis revealed that in comparison to MCF-7 cells cultured at 37 degreesC, those exposed to heat stress (42 degreesC for 3 hours) displayed an elevated rate of degradation of both CyP40 and FKBP52 proteins. Concomitantly, the half-life of the CyP40 protein was reduced from more than 24 hours to just over 8 hours following heat shock. As no alteration in CyP40 protein levels occurred in cells exposed to heat shock, an elevated rate of degradation would imply that CyP40 protein was synthesized at an increased rate. hence the designation of human CyP40 as a heat shock protein. Application of heat stress elicited a marked redistribution of CyP40 protein in MCF-7 cells from a predominantly nucleolar localization, with some nuclear and cytoplasmic staining, to a pattern characterized by a pronounced nuclear accumulation of CyP40, with no distinguishable nucleolar staining. This increase in nuclear CyP40 possibly resulted from a redistribution of cytoplasmic and nucleolar CyP40, as no net increase in CyP40 expression levels occurred in response to stress. Exposure of MCF-7 cells to actinomycin D for 4 hours resulted in the translocation of the nucleolar marker protein, B23, from the nucleolus, with only a small reduction in nucleolar CyP40 levels. Under normal growth conditions, MCF-7 cells exhibited an apparent colocalization of CyP40 and FKBP52 within the nucleolus.

Residues of zeta-cypermethrin in bovine tissues and milk following pour-on and spray application

The depletion of zeta-cypermethrin residues in bovine tissues and milk was studied. Beef cattle were treated three times at 3-week intervals with 1 ml 10 kg(-1) body weight of a 25 g litre(-1) or 50 g litre(-1) pour-on formulation (2.5 and 5.0 mg zeta-cypermethrin kg(-1) body weight) or 100 mg kg(-1) spray to simulate a likely worst-case treatment regime. Friesian and Jersey dairy cows were treated once with 2.5 mg zeta-cypermethrin kg(-1) in a pour-on formulation. Muscle, liver and kidney residue concentrations were generally less than the limit of detection (LOD = 0.01 mg kg(-1)). Residues in renal-fat and back-fat samples from animals treated with 2.5 mg kg(-1) all exceeded the limit of quantitation (LOQ = 0.05 mg kg(-1)), peaking at 10 days after treatment. Only two of five kidney fat samples were above the LOQ after 34 days, but none of the back-fat samples exceeded the LOQ at 28 days after treatment. Following spray treatments, fat residues were detectable in some animals but were below the LOQ at all sampling intervals. Zeta-cypermethrin was quantifiable (LOQ = 0.01 mg kg(-1)) in only one whole-milk sample from the Friesian cows (0.015 mg kg(-1), 2 days after treatment). In whole milk from Jersey cows, the mean concentration of zeta-cypermethrin peaked 1 day after treatment, at 0.015 mg kg(-1), and the highest individual sample concentration was 0.025 mg kg(-1) at 3 days after treatment. Residues in milk were not quantifiable beginning 4 days after treatment. The mean concentrations of zeta-cypermethrin in milk fat from Friesian and Jersey cows peaked two days after treatment at 0.197 mg kg(-1) and 0.377 mg kg(-1), respectively, and the highest individual sample concentrations were 2 days after treatment at 0.47 mg kg(-1) and 0.98 mg kg(-1), respectively. (C) 2001 Society of Chemical Industry.

Prior calcium channel blockade and short-term survival following acute myocardial infarction

There is concern over the safety of calcium channel blockers (CCBs) in acute coronary disease. We sought to determine if patients taking calcium channel blockers (CCBs) at the time of admission with acute myocardial infarction (AMI) had a higher case-fatality compared with those taking beta-blockers or neither medication. Clinical and drug treatment variables at the time of hospital admission predictive of survival at 28 days were examined in a community-based registry of patients aged under 65 years admitted to hospital for suspected AMI in Perth, Australia, between 1984 and 1993. Among 7766 patients, 1291 (16.6%) were taking a CCB and 1259 (16.2%) a betablocker alone at hospital admission. Patients taking CCBs had a worse clinical profile than those taking a beta-blocker alone or neither drug (control group), and a higher unadjusted 28-day mortality (17.6% versus 9.3% and 11.1% respectively, both P < 0.001). There was no significant heterogeneity with respect to mortality between nifedipine, diltiazem, or verapamil when used alone, or with a beta-blocker. After adjustment for factors predictive of death at 28 days, patients taking a CCB were found not to have an excess chance of death compared with the control group (odds ratio [OR] 1.06, 95% confidence interval [CI]; 0.87, 1.30), whereas those taking a beta-blocker alone had a lower odds of death (OR 0.75, 95% CI; 0.59, 0.94). These results indicate that established calcium channel blockade is not associated with an excess risk of death following AMI once other differences between patients are taken into account, but neither does it have the survival advantage seen with prior beta-blocker therapy.

Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial

Background Epidural block is widely used to manage major abdominal surgery and postoperative analgesia, but its risks. and benefits are uncertain. We compared adverse outcomes in high-risk patients managed for major surgery with epidural block or alternative analgesic regimens with general anaesthesia in a multicentre randomised trial. Methods 915 patients undergoing major abdominal surgery with one of nine defined comorbid states to identify high-risk status were randomly assigned intraoperative epidural anaesthesia and postoperative epidural analgesia for 72 h with general anaesthesia (site of epidural selected to provide optimum block) or control. The primary endpoint was death at 30 days or major postsurgical morbidity. Analysis by intention to treat involved 447 patients assigned epidural and 441 control. Findings 255 patients (57.1%) in the epidural group and 268 (60.7%) in the control group had at least one morbidity endpoint or died (p=0.29). Mortality at 30 days was low in both groups (epidural 23 [5.1%], control 19 [4.3%], p=0.67). Only one of eight categories of morbid endpoints in individual systems (respiratory failure) occurred less frequently in patients managed with epidural techniques (23% vs 30%, p=0.02). Postoperative epidural analgesia was associated with lower pain scores during the first 3 postoperative days. There were no major adverse consequences of epidural-catheter insertion. Interpretation Most adverse morbid outcomes in high-risk patients undergoing major abdominal surgery are not reduced by use of combined epidural and general anaesthesia and postoperative epidural analgesia. However, the improvement in analgesia, reduction in respiratory failure, and the low risk of serious adverse consequences suggest that many high-risk patients undergoing major intra-abdominal surgery will receive substantial benefit from combined general and epidural anaesthesia intraoperatively with continuing postoperative epidural analgesia.

Mortality and recurrent cardiac events after coronary artery bypass graft: long term outcomes in a population study

Objective: To determine 30 day mortality, long term survival, and recurrent cardiac events after coronary artery bypass graft (CABG) in a population. Design: Follow up study of patients prospectively entered on to a cardiothoracic surgical database. Record linkages were used to obtain data on readmissions and deaths. Patients: 8910 patients undergoing isolated first CABG between 1980 and 1993 in Western Australia. Main outcome measures: 30 day and long term survival, readmission for cardiac event (acute myocardial infarction, unstable angina, percutaneous transluminal coronary angioplasty or reoperative CABG). Results: There were 3072 deaths to mid 1999. 30 day and long term survival were significantly better in patients treated in the first five years than during the following decade. The age of the patients, proportion of female patients, and number of grafts increased over time. An urgent procedure (odds ratio 3.3), older age (9% per year) and female sex (odds ratio 1.5) were associated with increased risk for 30 day mortality, while age (7% per year) and a recent myocardial infarction (odds ratio 1.16) influenced long term survival. Internal mammary artery grafts were followed by better short and long term survival, though there was an obvious selection bias in favour of younger male patients. Conclusions: This study shows worsening crude mortality at 30 days after CABG from the mid 1980s, associated with the inclusion of higher risk patients. Older age, an acute myocardial infarction in the year before surgery, and the use of sephenous vein grafts only were associated with poorer long term survival and greater risk of a recurrent cardiac event. Female sex predicted recurrent events but not long term survival.

Plant growth limitation and nutrient loss following piled burning in slash and burn agriculture

In the forest zone of Cameroon, small-scale family farmers practicing traditional slash and burn practices achieve a clear field by piled burning of the branches and trunks of cleared vegetation. Plant growth inhibition on ash patches, and the risk of nutrient loss from these areas, was evaluated on field plots on which 0.5 t m(-2) or 1.0 t m(-2) of wood was piled and burnt, and in laboratory studies. The ash produced by burning was strongly alkaline, and laboratory bio-assessment studies showed that the saline, high pH conditions produced in ash patches prevented germination and plant growth for up to two wet seasons, as is observed in the field. Field and laboratory studies demonstrated rapid release (1 wet season) of K and S from the ash and the loss of a substantial portion of these nutrients from the soil profile by leaching. In contrast, leaching carries Mg from the ash gradually (3 to 4 wet seasons), while Ca, Cu, Zn and P are leached slowly. The nutrients contained in ash patches are considered at risk of loss both through leaching (K and S) and by erosion of ash (Ca, Mg, Cu, Zn and P). Farmers should be encouraged to spread ash patches prior to cultivation in order to exploit the nutrient content of ash and to lessen the risk of nutrient loss.

Perioperative epidural analgesia and outcome after major abdominal surgery in high-risk patients

In a primary analysis of a large recently completed randomized trial in 915 high-risk patients undergoing major abdominal surgery, we found no difference in outcome between patients receiving perioperative epidural analgesia and those receiving IV opioids, apart from the incidence of respiratory failure. Therefore, we performed a selected number of predetermined subgroup analyses to identify specific types of patients who may have derived benefit from epidural analgesia. We found no difference in outcome between epidural and control groups in subgroups at increased risk of respiratory or cardiac complications or undergoing aortic surgery, nor in a subgroup with failed epidural block (all P > 0.05). There was a small reduction in the duration of postoperative ventilation (geometric mean [SD]: control group, 0.3 [6.5] h, versus epidural group, 0.2 [4.8] h, P = 0.048). No differences were found in length of stay in intensive care or in the hospital. There was no relationship between frequency of use of epidural analgesia in routine practice outside the trial and benefit from epidural analgesia in the trial. We found no evidence that perioperative epidural analgesia significantly influences major morbidity or mortality after major abdominal surgery.

Response to The quality of epidural Anesthesia is crucial in the assessment of periciperative outcome

In their letter, Gogarten et al. question the effectiveness of the epidural regimens across the trial centers. In our original publication (1), we clearly demonstrated that patients in the epidural group had a working epidural block intraoperatively (evidenced by significantly more hypotension) and postoperatively (evidenced by significantly improved pain scores for 3 days).