Identification of patients with cervical SCI suitable for early nerve transfer to achieve hand opening.

STUDY DESIGN: Retrospective audit. OBJECTIVES: The objective of this study was to identify the proportion of patients with cervical spinal cord injury who would potentially benefit from nerve transfer surgery to gain active hand opening, and to determine when a safe nerve transfer decision can be made. SETTING: Christchurch, New Zealand. METHODS: Case note review of the first 12 months following acute cervical spinal cord injury (2007-2012). Neurological assessment at 6 weeks, 12 weeks and 1 year following injury. RESULTS: Fifty-three patients had complete assessments and showed changes in the level of injury and severity of neurological injury between assessments. Forty-two percent of patients had motor complete C5-7 level injuries 12 weeks following injury and would benefit from consideration for nerve transfer to improve hand opening. Fewer (26%) would benefit 1 year following injury owing to a change in the neurological level of injury. CONCLUSIONS: Twelve-week neurological assessment identifies patients who may benefit from nerve transfer surgery. This enables referral for comprehensive upper limb assessment and reassessment of motor function to determine suitability for surgical intervention. Nerve transfer within the window of opportunity provides active hand opening for patients following cervical spinal cord injury.

Intergenerational transmission of post-traumatic stress disorder in Australian Vietnam veterans' families.

OBJECTIVE: To assess the association between parental post-traumatic stress disorder (PTSD) and offspring PTSD and its specificity for other disorders in a non-clinical epidemiological cohort of Australian Vietnam veterans, their partners and their sons and daughters. METHOD: Veterans were interviewed twice, in 1992-1994 and 2005-2006; partners were interviewed in 2006-2007, and their offspring in 2012-2014. A total of 125 sons and 168 daughters were interviewed from 197 families, 137 of which also included partners who were the mothers of the children. Statistical analysis used multi-level modelling to compute odds ratios and 95% confidence intervals while controlling for clustering effects within families. Parent PTSD diagnoses were examined for associations with offspring trauma exposure, PTSD and other psychiatric diagnoses. RESULTS: Veteran PTSD increased the risk of PTSD and no other disorder in both sons and daughters; partner PTSD did not. Veteran depression was also a risk factor for sons' PTSD, and alcohol disorder was linked to alcohol dependence in sons and PTSD in daughters, but not when controlling for veteran PTSD. CONCLUSION: We conclude that PTSD in a Vietnam veteran father increases the risk specifically for PTSD in his sons and daughters.

Perioperative mortality in New Zealand related to hip and knee replacement surgery: comparing administrative and registry data.

INTRODUCTION: Perioperative mortality is of considerable importance, but few national assessments are available. New Zealand has a clinical registry and an administrative dataset that both capture national information about hip and knee arthroplasties. National perioperative mortality rates were compared between the two data sources. METHOD: Data related to all patients undergoing an elective hip or knee replacement procedure (primary or revision) between 1 January 2007 and 31 December 2011 were separately extracted from the New Zealand Joint Registry and the National Minimum Dataset. The procedure date was used to define the occurrence of an event and dates were compared between datasets plus or minus 3 days. Date of death information was obtained from the National Mortality Collection and used to estimate 30 day mortality rates. RESULTS: No statistically significant differences in perioperative mortality were evident between comparisons from the two data sources although more deaths were recorded among Registry-only procedures. CONCLUSIONS: Estimates of 30 day perioperative mortality related to hip and knee arthroplasty procedures in New Zealand 2007-2011 are very similar regardless of data source. These data, coupled with perioperative mortality review using structured reports obtained from clinicians, could be used to develop a surveillance system to promote surgical safety.

The development of the NZ-based international upper limb surgery registry.

STUDY DESIGN: Implementation study. OBJECTIVES: To describe the development and potential value of the New Zealand (NZ) upper limb surgery registry and report the demographic and spinal cord injury characteristics of individuals with tetraplegia collated to date. SETTING: Multi Center-coordinated from Burwood Spinal Unit, NZ. METHODS: Following discussions with eight international units, clinical information and outcomes measures were agreed upon for use in this specific population. To implement this consensus, a web-based upper limb surgery registry was developed in NZ. Inclusion criteria included referral to a hand clinic for clinical assessment for suitability for tendon transfer surgery. Clinical data were collected regardless of acceptance of surgery thereby creating a self-selected control group. Twenty-eight years of retrospective NZ data was entered into the registry, as well as 3 years of prospective data collected in NZ. RESULTS: From 1982 to 2013, a total of 357 persons with tetraplegia were assessed as suitable for surgery. Of those, 223 individuals underwent surgery and 134 declined the intervention(s). The prospective group currently comprises 55 assessments with 23 surgery individuals and 32 who have declined surgery to date. CONCLUSION: Clinical information is now available within a web-based registry for all individuals reviewed in hand clinics from when upper limb surgery was first introduced. A broad range of outcomes of interest can easily be reported directly from the registry. The self-selected control group will allow comparative studies to be explicitly linked to the specific interventions of interest.

Altered cortical activation patterns associated with baroreflex unloading following 24 h of physical deconditioning.

Cardiovascular arousal is associated with patterned cortical activity changes. Head-down-tilt bed rest (HDBR) dimishes the baroreflex-mediated cardiac control. The present study tested the hypothesis that HDBR deconditioning would modify the forebrain organization for heart rate (HR) control during baroreflex unloading. Heart rate variability (HRV), blood pressure and plasma hormones were analysed at rest, whereas HR and cortical autonomic activation patterns (functional magnetic resonance imaging) were measured during graded and randomly assigned lower body negative pressure treatments (LBNP, -15 and -35 mmHg) both before (Pre) and after (Post) a 24 h HDBR protocol (study 1; n = 8). An additional group was tested before and following diuretic-induced hypovolaemia (study 2; n = 9; spironolactone, 100 mg day(-1) for 3 days) that mimicked the plasma volume lost during HDBR (-15% in both studies; P < 0.05). Head-down bed rest with hypovolaemia did not affect baseline HR, mean arterial pressure, HRV or plasma catecholamines. Head-down bed rest augmented the LBNP-induced HR response (P < 0.05), and this was associated with bed-rest-induced development of the following changes: (i) enhanced activation within the genual anterior cingulate cortex and the right anterior insular cortex; and (ii) deactivation patterns within the subgenual regions of the anterior cingulate cortex. Diuretic treatment (without HDBR) did not affect baseline HR and mean arterial pressure, but did reduce resting HRV and elevated circulating noradrenaline and plasma renin activity (P < 0.05). The greater HR response to LBNP following diuretic (P < 0.05) was associated with diminished activation of the right anterior insula. Our findings indicate that 24 h of HDBR minimized the impact of diuretic treatment on baseline autonomic and cardiovascular variables. The findings also indicate that despite the similar augmentation of HR responses to LBNP and despite similar pre-intervention cortical activation patterns, HDBR and diuretic treatment produced different effects on the cortical responses, with HDBR affecting anterior cingulate cortex and right insula regions, whereas diuretic treatment affected primarily the right insula alone, but in a direction that was opposite to HDBR. The data indicate that physical deconditioning can induce rapid functional changes within the cortical circuitry associated with baroreflex unloading, changes that are distinct from diuretic-induced hypovolaemia. The results suggest that physical activity patterns exert a rapid and notable impact on the cortical circuitry associated with cardiovascular control.

Does the use of laminar flow and space suits reduce early deep infection after total hip and knee replacement?: the ten-year results of the New Zealand Joint Registry.

We have investigated whether the use of laminar-flow theatres and space suits reduced the rate of revision for early deep infection after total hip (THR) and knee (TKR) replacement by reviewing the results of the New Zealand Joint Registry at ten years. Of the 51 485 primary THRs and 36 826 primary TKRs analysed, laminar-flow theatres were used in 35.5% and space suits in 23.5%. For THR there was a significant increase in early infection in those procedures performed with the use of a space suit compared with those without (p < 0.0001), in those carried out in a laminar-flow theatre compared with a conventional theatre (p < 0.003) and in those undertaken in a laminar-flow theatre with a space suit (p < 0.001) when compared with conventional theatres without such a suit. The results were similar for TKR with the use of a space suit (p < 0.001), in laminar-flow theatres (p < 0.019) and when space suits were used in those theatres (p < 0.001). These findings were independent of age, disease and operating time and were unchanged when the surgeons and hospital were analysed individually. The rate of revision for early deep infection has not been reduced by using laminar flow and space suits. Our results question the rationale for their increasing use in routine joint replacement, where the added cost to the health system seems to be unjustified.

Survival and functional outcome after revision of a unicompartmental to a total knee replacement: the New Zealand National Joint Registry.

We reviewed the rate of revision of unicompartmental knee replacements (UKR) from the New Zealand Joint Registry between 1999 and 2008. There were 4284 UKRs, of which 236 required revision, 205 to a total knee replacement (U2T) and 31 to a further unicompartmental knee replacement (U2U). We used these data to establish whether the survival and functional outcome for revised UKRs were comparable with those of primary total knee replacement (TKR). The rate of revision for the U2T cohort was four times higher than that for a primary TKR (1.97 vs 0.48; p < 0.05). The mean Oxford Knee Score was also significantly worse in the U2T group than that of the primary TKR group (30.02 vs 37.16; p < 0.01). The rate of revision for conversion of a failed UKR to a further UKR (U2U cohort) was 13 times higher than that for a primary TKR. The poor outcome of a UKR converted to a primary TKR compared with a primary TKR should contra-indicate the use of a UKR as a more conservative procedure in the younger patient.

An analysis of the Oxford hip and knee scores and their relationship to early joint revision in the New Zealand Joint Registry.

We analysed data from the Oxford hip and knee questionnaires collected by the New Zealand Joint Registry at six months and five years after joint replacement, to determine if there was any relationship between the scores and the risk of early revision. Logistic regression of the six-month scores indicated that for every one-unit decrease in the Oxford score, the risk of revision within two years increased by 9.7% for total hip replacement (THR), 9.9% for total knee replacement (TKR) and 12.0% for unicompartmental knee replacement (UKR). Our findings showed that 70% of the revisions within two years for TKR and 67% for THR and UKR would have been captured by monitoring the lowest 22%, 28% and 28%, respectively, of the Oxford scores. When analysed using the Kalairajah classification a score of < 27 (poor) was associated with a risk of revision within two years of 7.6% for THR, 7.0% for TKR and 24.3% for UKR, compared with risks of 0.7%, 0.7% and 1.8%, respectively, for scores > 34 (good or excellent). Our study confirms that the Oxford hip and knee scores at six months are useful predictors of early revision after THR and TKR and we recommend their use for the monitoring of the outcome and potential failure in these patients.

Upper limb reconstructive surgery uptake for persons with tetraplegia in New Zealand: a retrospective case review 2001-2005.

STUDY DESIGN: Retrospective case series. OBJECTIVE: To describe the uptake of upper limb surgery by individuals with tetraplegia in New Zealand (NZ). SETTING: New Zealand. METHODS: The clinical notes of all individuals who sustained a cervical spinal cord injury between 1 January 2001 and 31 December 2005 were retrospectively reviewed for those who met the clinical criteria to undergo upper limb surgery. Cases were cross-referenced to the hand surgery record to determine the uptake of upper limb surgery in this cohort. RESULTS: The uptake of upper limb surgery for people with tetraplegia in NZ was 44% of the eligible cohort and 59% of those assessed for surgery. This is notably higher than the reported proportion in other developed countries. The data also suggested that women and those who identified as NZ Maori were less likely to undergo upper limb surgery than were men and those of NZ European ethnicity. CONCLUSION: Utilization of upper limb surgery in the eligible tetraplegic population in NZ was high. However, it seemed that some groups were less likely to undergo surgery. Further research into the factors that affect an individual's decision to undergo upper limb surgery could explain the observed pattern.

Revision following cemented and uncemented primary total hip replacement: a seven-year analysis from the New Zealand Joint Registry.

We have reviewed the rate of revision of fully cemented, hybrid and uncemented primary total hip replacements (THRs) registered in the New Zealand Joint Registry between 1999 and December 2006 to determine whether there was any statistically significant difference in the early survival and reason for revision in these different types of fixation. The percentage rate of revision was calculated per 100 component years and compared with the reason for revision, the type of fixation and the age of the patients. Of the 42 665 primary THRs registered, 920 (2.16%) underwent revision requiring change of at least one component. Fully-cemented THRs had a lower rate of revision when considering all causes for failure (p < 0.001), but below the age of 65 years uncemented THRs had a lower rate (p < 0.01). The rate of revision of the acetabular component for aseptic loosening was less in the uncemented and hybrid groups compared with that in the fully cemented group (p < 0.001), and the rate of revision of cemented and uncemented femoral components was similar, except in patients over 75 years of age in whom revision of cemented femoral components was significantly less frequent (p < 0.02). Revision for infection was more common in patients aged below 65 years and in cemented and hybrid THRs compared with cementless THRs (p < 0.001). Dislocation was the most common cause of revision for all types of fixation and was more frequent in both uncemented acetabular groups (p < 0.001). The experience of the surgeon did not affect the findings. Although cemented THR had the lowest rate of revision for all causes in the short term (90 days), uncemented THR had the lowest rate of aseptic loosening in patients under 65 years of age and had rates comparable with international rates of aseptic loosening in those over 65 years.

The low contact stress mobile-bearing total knee replacement: a prospective study with a minimum follow-up of ten years.

We have examined the outcome of 400 consecutive patients who underwent total knee replacement with the Low Contact Stress mobile-bearing system between 1993 and 1994 and were followed up for a minimum of ten years. All operations were performed by surgeons in Christchurch, New Zealand, who used no other knee prosthesis during the study time. At ten years after operation 238 patients (244 knees) remained for independent clinical and radiological assessment. There was a significant improvement (p < 0.001) in the postoperative knee scores at one, three, seven and ten years, although a slight deterioration in the score occurred between seven and ten years which did not reach statistical significance. The survival for polyethylene wear or loosening was 97% (95% CI 96 to 98) and survival using reoperation for any cause was 92% (95% CI 90 to 94) at 12 years. Polyethylene wear was more common in the meniscal-bearing component, with five knees requiring revision and a further eight demonstrating early wear. Osteolysis was not seen in the rotating platform component, but was present in three of the meniscal-bearing knees. There was no association between the radiological alignment at one year and those knees that subsequently required revision. However, there was an association between the overall limb alignment and the Western Ontario McMasters University score (p < 0.001). The Low Contact Stress mobile-bearing total knee replacement has proved to be a reliable implant at ten years when used in primary knee replacement irrespective of the deformity and diagnosis.

Subtle metabolic and liver gene transcriptional changes underlie diet-induced fatty liver susceptibility in insulin-resistant mice.

AIMS/HYPOTHESIS: Complex changes in gene expression are associated with insulin resistance and non-alcoholic fatty liver disease (NAFLD) promoted by feeding a high-fat diet (HFD). We used functional genomic technologies to document molecular mechanisms associated with diet-induced NAFLD. MATERIALS AND METHODS: Male 129S6 mice were fed a diet containing 40% fat (high-fat diet, HFD) for 15 weeks. Glucose tolerance, in vivo insulin secretion, plasma lipid profile and adiposity were determined. Plasma metabonomics and liver transcriptomics were used to identify changes in gene expression associated with HFD-induced NAFLD. RESULTS: In HFD-fed mice, NAFLD and impaired glucose and lipid homeostasis were associated with increased hepatic transcription of genes involved in fatty acid uptake, intracellular transport, modification and elongation, whilst genes involved in beta-oxidation and lipoprotein secretion were, paradoxically, also upregulated. NAFLD developed despite strong and sustained downregulation of transcription of the gene encoding stearoyl-coenzyme A desaturase 1 (Scd1) and uncoordinated regulation of transcription of Scd1 and the gene encoding sterol regulatory element binding factor 1c (Srebf1c) transcription. Inflammatory mechanisms appeared to be stimulated by HFD. CONCLUSIONS/INTERPRETATION: Our results provide an accurate representation of subtle changes in metabolic and gene expression regulation underlying disease-promoting and compensatory mechanisms, collectively contributing to diet-induced insulin resistance and NAFLD. They suggest that proposed models of NAFLD pathogenesis can be enriched with novel diet-reactive genes and disease mechanisms.

Levels of the soluble forms of CD80, CD86, and CD83 are elevated in the synovial fluid of rheumatoid arthritis patients.

The release of soluble forms of CD80 (sCD80), CD86 (sCD86), and CD83 (sCD83) provide a potentially powerful immunoregulatory mechanism. We therefore investigated the potential presence and relative levels of these molecules in the synovial fluid (SF) and serum of patients with rheumatoid arthritis (RA) and osteoarthritis (OA). Serum and SF levels were measured by enzyme-linked immunosorbent assay. Serum levels of sCD80, sCD86, and sCD83 in RA and OA patients were similar to those present in normal donor serum (NDS) and the SF of OA patients. In contrast, when compared with NDS and OA SF levels, almost all RA SF samples had elevated sCD83 levels (32/35, >0.63 ng/ml) and a substantial proportion had elevated sCD80 (13/29, >0.22 ng/ml) or sCD86 (16/33, >2.31 ng/ml) levels. Analysis of matched pairs of serum and SF from RA patients demonstrated that the SF/serum ratio for sCD80 (95% CI = 1.7-3), sCD86 (95% CI = 1.5-3.1), and sCD83 (95% CI = 3.6-7.8) levels was >1 in almost all patients. In conclusion, this study shows that the SF from almost all RA patients contain elevated levels of sCD83 and the majority of these samples also contain elevated levels of sCD80 and/or sCD86. These molecules may play a role in modulating immune responses within the rheumatoid joint.

Use of the ICF conceptual framework to interpret hand function outcomes following tendon transfer surgery for tetraplegia.

STUDY DESIGN: Clinical commentary OBJECTIVE AND SETTING: This paper is a clinical commentary based on the Round Table discussion on Assessment and Outcomes at the 7th International Conference on Tetraplegia: Surgery and Rehabilitation, Bologna, Italy 6-8 June, 2001. It refers specifically to the 10-year re-review undertaken in 2001 at the Spinal Unit, Burwood Hospital, Christchurch, New Zealand. SUBJECTS: In all, 24 tetraplegic persons at a minimum of 12 years and up to 18 years following bilateral forearm tendon transfer surgery. METHOD: The data were interpreted using the International Classification of Functioning, Disability, and Health (ICF) conceptual framework as the basis of interdisciplinary understanding of the participation dimension. RESULTS: The results of the study outlined confirm that outcome measurement at more than one level of functioning is desirable to determine the functional effects beyond grip strength levels and activities of daily living, to consider the dimension of participation. CONCLUSIONS: Use of the ICF as a theoretical framework for interpretation of the results enhanced the clinical applicability of the outcome measures used in the 10-year re-review undertaken in New Zealand in 2001.

Impact of early intervention on outcome following mild head injury in adults.

BACKGROUND: The impact of mild head injury is variable and determinants of outcome remain poorly understood. Results of previous intervention studies have been mixed. OBJECTIVES: To evaluate the impact on outcome of the provision of information, measured in terms of reported symptoms, cognitive performance, and psychological adjustment three months postinjury. METHODS: 202 adults with mild head injury were studied: 79 were assigned to an intervention group and were assessed one week and three months after injury; 123 were assigned to a non-intervention control group and were seen at three months only. Participants completed measures of preinjury psychological adjustment, concurrent life stresses, post-concussion symptoms, and tests of attention, speed of information processing, and memory. Subjects seen at one week were given an information booklet outlining the symptoms associated with mild head injury and suggested coping strategies. Those seen only at three months after injury did not receive this booklet. RESULTS: Patients in the intervention group who were seen at one week and given the information booklet reported fewer symptoms overall and were significantly less stressed at three months after the injury. CONCLUSIONS: The provision of an information booklet reduces anxiety and reporting of ongoing problems.

Impact of early intervention on outcome after mild traumatic brain injury in children.

OBJECTIVE: The impact of mild head injury or mild traumatic brain injury (TBI) in children is variable, and determinants of outcome remain poorly understood. There have been no previous attempts to evaluate the impact of interventions to improve outcome. Results of previous intervention studies in adults have been mixed. This study aimed to evaluate the impact of providing information on outcome measured in terms of reported symptoms, cognitive performance, and psychological adjustment in children 3 months after injury. METHODS: A total of 61 children with mild TBI were assessed 1 week and 3 months after injury, and 58 children with mild TBI were assessed 3 months after injury only. They were compared with 2 control groups (N = 45 and 47) of children with minor injuries not involving the head. Participants completed measures of preinjury behavior and psychological adjustment, postconcussion symptoms, and tests of attention, speed of information processing, and memory. Children with mild TBI seen at 1 week were also given an information booklet outlining symptoms associated with mild TBI and suggested coping strategies. Those seen 3 months after injury only did not receive this booklet. RESULTS: Children with mild TBI reported more symptoms than controls at 1 week but demonstrated no impairment on neuropsychological measures. Initial symptoms had resolved for most children by 3 months after injury, but a small group of children who had previous head injury or a history of learning or behavioral difficulties reported ongoing problems. The group not seen at 1 week and not given the information booklet reported more symptoms overall and was more stressed 3 months after injury. CONCLUSIONS: Providing an information booklet reduces anxiety and thereby lowers the incidence of ongoing problems.

Factors influencing outcome following mild traumatic brain injury in adults.

This study aimed to investigate outcome in adults with mild traumatic brain injury (TBI) at 1 week and 3 months postinjury and to identify factors associated with persisting problems. A total of 84 adults with mild TBI were compared with 53 adults with other minor injuries as controls in terms of postconcussional symptomatology, behavior, and cognitive performance at 1 week and 3 months postinjury. At 1 week postinjury, adults with mild TBI were reporting symptoms, particularly headaches, dizziness, fatigue, visual disturbance, and memory difficulties. They exhibited slowing of information processing on neuropsychological measures, namely the WAIS-R Digit Symbol subtest and the Speed of Comprehension Test. By 3 months postinjury, the symptoms reported at 1 week had largely resolved, and no impairments were evident on neuropsychological measures. However, there was a subgroup of 24% of participants who were still suffering many symptoms, who were highly distressed, and whose lives were still significantly disrupted. These individuals did not have longer posttraumatic amnesia (PTA) duration. They were more likely to have a history of previous head injury, neurological or psychiatric problems, to be students, females, and to have been injured in a motor vehicle accident. The majority were showing significant levels of psychopathology. A range of factors, other than those directly reflecting the severity of injury, appear to be associated with outcome following mild TBI.

Iliopsoas haemophiliac pseudotumours with bowel fistulation.

Two cases of iliopsoas haemophilic pseudotumours are presented. In one patient a fistula developed between a pseudotumour and the large bowel. This resulted in an abscess involving the pseudotumour and adjacent tissues. It resolved after 5 years of therapy involving percutaneous drainage and closure of the fistula. The second patient had a massive pseudotumour that had obstructed both ureters. Later he suffered a fatal mixed Gram negative septicaemia probably related to erosion into the colon.

Prefrontal neuropsychological effects of sleep deprivation in young adults--a model for healthy aging?

Neuropsychological testing and brain imaging show that healthy aging leads to a preferential impairment of the prefrontal cortex (PFC). Interestingly, in young adults sleep deprivation (SD) has similar effects. Psychological tasks not so oriented to the PFC are less sensitive both to SD and aging. The PFC is a cortical region working particularly hard during wakefulness, which may make it more vulnerable to "deterioration," whether this is through aging or SD. In these respects SD in young adults may offer a model for aging. No study has directly compared aging with SD. We compared groups comprising (equal sexes): YOUNG (av. 23y), MIDDLE AGED (av. 60y) and OLD (av. 73y). Young were subdivided into SD and non-sleep deprived groups. All participants were carefully screened, were healthy, good sleepers and with a similar educational background. A battery of PFC-oriented, short and straightforward neuropsychological tests was used to compare the effects of 36h of SD in the young group, with findings from the healthy, alert, non-sleep deprived groups. Tests relied on accuracy rather than speed (which took into account the problem of "global slowing" in the older participants), and were administered once (i.e., were novel). Test outcomes were significantly affected by: (1) SD in the young groups, and (2) by age. A non-PFC component of one test was not affected by SD or by age. It was concluded that 36h SD in young adults produces effects on the PFC similar to those found in normal, alert people aged about 60 years. However, it can not be concluded that an aged brain is a sleep-deprived brain.