Cognitive symptoms, cervical range of motion and pain as prognostic factors after whiplash trauma.

OBJECTIVES: To evaluate pain, cervical range of motion (CROM) and cognitive symptoms as predictors for poor prognosis defined as sick leave 3 years later. MATERIAL AND METHODS: In 97 patients CROM, pain intensity and cognitive symptoms were measured immediately following trauma, at 6 months and 3 years. Patients were also asked at 3 years if they had been on sick leave the last 6 months. RESULTS: Pain intensity and reduced CROM were not clinically useful as predictors of later sick leave. The best predictors were presence within 96 h after injury of the two cognitive symptoms 'being easily distracted' (odds ratio 8.7-50) and 'easily irritated' (odds ratio 5.3-31). CONCLUSIONS: Initial pain and reduced CROM may be related to minor tissue damage which often heals while late functionality is more dependent on other factors such as cognitive dysfunction. For patients with whiplash-associated disorders two simple questions should be asked; 'Are you currently easily irritated?' and 'Are you currently easily distracted (e.g. is it difficult for you to follow a conversation if several people are talking in the room at the same time)?'. An affirmative answer to any of these questions indicates an increased risk for poor prognosis defined as sick leave 3 years later.

Early intervention in whiplash-associated disorders: a comparison of two treatment protocols.

STUDY DESIGN: A prospective randomized trial in 97 patients with a whiplash injury caused by a motor vehicle collision. OBJECTIVES: The study evaluates early active mobilization versus a standard treatment protocol and the importance of early versus delayed onset of treatment. SUMMARY OF BACKGROUND DATA: There is no compelling evidence to date on the management of acute whiplash-associated disorders. The few studies describing treatment, however, provide evidence to support the recommendation that an active treatment in the acute stage is preferable to rest and a soft collar in most patients. METHODS: Patients were randomized to four groups. Active versus standard treatment and early (within 96 hours) versus delayed (after 2 weeks) treatment. Measures of range of motion and pain were registered initially and at 6 months. RESULTS: Eighty-eight patients (91%) could be followed up at 6 months. Active treatment reduced pain more than standard treatment (P < 0.001). When type and onset of treatment were analyzed, a combined effect was seen. When active treatment was provided, it was better when administered early, and if standard treatment was provided, it was better when administered late for reduction of pain (P = 0.04) and increasing cervical flexion (P = 0.01). CONCLUSIONS: In patients with whiplash-associated disorders caused by a motor vehicle collision treatment with frequently repeated active submaximal movements combined with mechanical diagnosis and therapy is more effective in reducing pain than a standard program of initial rest, recommended use of a soft collar, and gradual self-mobilization. This therapy could be performed as home exercises initiated and supported by a physiotherapist.

Baltimore's consumer ombudsman and assistance program: an emerging public health service in Medicaid Managed Care.

OBJECTIVES: To present Baltimore City Health Department's (BCHD) experience in developing and operating an ombudsprogram for Maryland's Medicaid Managed Care HealthChoice Program as an innovative public health response to its MCH Title V assurance functions. METHODS: This paper presents a case study that 1) describes Baltimore City's Consumer Ombudsman and Assistance Program (COAP) in terms of development, function, structure, and resources; 2) provides a summary of its first 30 months' experiences, both quantitatively and qualitatively; and 3) describes COAP's successes, value, and limitations with respect to its three essential roles--a) conflict resolution for individuals, b) education for consumers, providers and advocates, and c) catalyst for quality improvement. OUTCOMES: Over 1300 cases (involving enrollment, access, billing, and treatment issues) were referred to COAP by the State's Complaint Resolution Section during the first 2 1/2 years of HealthChoice. Ombudsman interventions resulted in conflict resolution for enrollees using a continuum of education, mediation and advocacy, and in generating systematic data for systems change through collaboration with state and community public health, managed care organization, provider, consumer, and advocacy officials and groups. CONCLUSIONS: Public health ombudsprograms can effectively assist and educate enrollees; and provide concurrent, or real-time, information for consumer, provider, health plan, and advocacy groups, as well as public policymakers and legislators to better inform systems improvement and innovation. The community-based ombudsman role is an effective mechanism to ensure appropriate care for MCH populations and others with special needs. Such efforts can be funded by federal/state Medicaid administrative funds and are a sound investment in assuring access to comprehensive care for vulnerable populations.

Prevention and control of epidemic keratoconjunctivitis in a teaching eye institute.

PURPOSE: To determine if an ongoing infection control program is associated with a reduction in rates of nosocomial outbreaks of epidemic keratoconjunctivitis (EKC) and outbreak morbidity from nosocomial EKC in a large teaching eye institute. METHODS: The number of nosocomial EKC outbreaks, the number of affected patients, and the total number of patient visits were collected for each year between 1984 and 1997. An infection control program was implemented in 1992. The program included specified methods of patient screening and isolation, handwashing, instrument disinfection, medication distribution, and furlough of infected employees. The program included two levels of intensity of infection control measures, for non-outbreak and outbreak conditions. We compared rates per 100,000 patient visits of nosocomial outbreaks of EKC and affected patients for the 6-year period after the program was implemented, 1992-1997, with corresponding rates for 1984-1991. RESULTS: One, to three nosocomial outbreaks of EKC occurred annually in the period 1984-1991. After the implementation of the infection control program, no nosocomial outbreaks occurred in three of six years studied. In the pre-infection control years 1984-1991, there were 3.89 outbreaks and 54.09 affected patients per 100,000 visits, respectively. For the post-infection control years 1992-1997, the corresponding rates were 0.54 outbreaks and 5.66 affected patients per 100,000 patient visits. Rates for both outbreaks and affected patients were significantly lower for the post-implementation period (p < 0.005 and p < 0.0005, respectively). CONCLUSIONS: An ongoing infection control program was associated with decreased rates of nosocomial EKC outbreaks and outbreak morbidity from nosocomial EKC in our institute. Although several reports have described infection control measures that terminated individual outbreaks of nosocomial EKC, this study demonstrates that an ongoing infection control program may preemptively reduce nosocomial EKC outbreaks.

Patterns of ICD-9 diagnoses among adolescents using school-based clinics: diagnostic categories by school level and gender.

PURPOSE: Understanding utilization patterns in school clinics is important in discerning potential health outcomes among adolescents. This study reports on high-middle school and gender differences in ICD-9 diagnostic codes for students using Baltimore school clinics in the academic year 1989-90. METHODS: 12,953 visits resulted in 17,241 individual diagnoses. Data were grouped into 17 major diagnostic categories, subcategories for reproductive health and mental health, and 20 sentinel diagnoses. RESULTS: Reproductive health diagnoses were most common for high school clinics (28% of all diagnoses). Mental health (psychosocial) diagnoses were most common for middle school clinics (30%). Adolescent women were much more likely to use clinics for reproductive health care needs than adolescent men. Adolescent men and women used the clinics with equal frequency for mental health, although specific diagnoses varied considerably by gender. CONCLUSIONS: This overview of diagnostic patterns among adolescents using Baltimore's school-based clinics provides a unique view of differences in health care needs between younger and older teens and between male and female teens. These data have meaningful implications for clinic staffing and enhanced outreach efforts.

[Humoral and cellular immunologic reactions in various forms of chronic psychiatric diseases]. / Etude des réactions immunitaires humorales et cellulaires dans diverses formes de pathologies psychiatriques chroniques.

Studies on the status of the immune system in mental disorders have mostly provided contradictory results. For example, some authors have reported dramatic increases of immunoglobulin G in schizophrenic patients, and others a decrease of immunoglobulin G in the same patients. This prompted us to undertake a study on a large cohort of psychiatric patients (120 schizophrenics, 30 manic-depressives, 8 epileptics, 48 cases of Alzheimer and vascular dementia, 23 cases of alcoholic dementia, 14 cases of childhood psychosis, 47 encephalopaths, and 21 chronic alcoholics), all chronically hospitalized. Plasma antitetanus antibodies were assayed in 238 previously immunized patients, the tuberculin test was performed on 302 patients, and the candidine test on 287 patients. Furthermore, 21 patients had an antitetanus vaccine booster injection with antibodies assayed before the injection and one month later, and 31 patients had 2 tuberculin tests with a year or more between them. The results show no major abnormal immune disorders in the patients. Nevertheless some particular features have been found. The first is a very significant relation between the age and the weakness of the immune defences. The second is a large scattering of the blood tetanus antibodies titers in schizophrenic patients, specially in the paranoid subgroup (20.6% of abnormally high or low titers). And the third is the existence of inpredictable variations in the responses when stimulations, or tests, are repeated. These results can raise the hypothesis of a state-dependent component of the immune response in mentally ill patients, but further in, depth studies are needed for better understanding the nature of our findings.

Treatment of neck and shoulder pain in whip-lash syndrome patients with intracutaneous sterile water injections.

Ten whip-lash syndrome patients treated with intracutaneous triggerpoint injections with sterile water for pain relief were followed for 2 months. Pain intensity was evaluated with the Visual Analogue Scale (VAS). Eight patients became free from pain (VAS 0) and two patients improved to VAS 2 immediately after the treatment. Nine patients remained free from pain, three of them after one treatment, while six patients needed 2-4 treatments. One patient responded only a few hours after each of three treatments. Remarkably, with the relief of pain mobility was normalised in all patients. The method is suggested to be a first choice in the treatment of not only whip-lash patients but also for most acute and chronic musculo-skeletal triggerpoint pain syndromes.

An innovative therapeutic program for aphasia patients and their relatives.

Eleven aphasia patients and seven family members participated in a five-day residential course led by a speech pathologist, a psychologist and a neurologist. The aim of the course was to give the aphasics and their relatives information on the etiology, treatment possibilities and prognosis of aphasia; work on personal and interpersonal problems through psychological counseling; improve language function through comprehensive and intensive stimulation; examine the psychological, linguistic and neurological effects of the intensive course. The course participants met again one year after the course and were found to have changed positively both psychologically and interpersonally but, as expected, only to a minor degree linguistically and neurologically. Through this intensive course it was possible to assess the problems of the families more easily than in the hospital. The patients and their relatives reported that they had learnt how to identify and to deal with their psychological problems in a more constructive way. They also felt that they had support from the other families and were able to share their experiences. We found that this type of intervention had many positive effects on the ability of the participants to cope with the chronic disability.

The mesencephalic locomotor region in cat: effects of local applications of diazepam and gamma-aminobutyric acid.

In decorticate unanaesthetized cats, displaying sequences of stereotyped locomotor movements in response to electrical stimulation of their footpad, local injections were made into the mesencephalic locomotor region (MLR). Diazepam (at 10 micrograms) and GABA (at 500 micrograms) induced complete suppression for 5-10 min, followed by partial amplitude recovery. It is suggested that: (i) MLR contains both diazepam and GABA receptors, and (ii) diazepam (and GABA) blockade is only short lasting because of a substitution (vicariancy) process through other structures also involved in locomotion.

Quail fetal antigen (QFA): identification and comparison with chicken fetal antigen.

Quail fetal antigen (QFA), an analogous hematopoietic antigen to chicken fetal antigen (CFA), was identified and shown to be a developmental antigen on the blood cells of Japanese quail and other avian species. Rabbit antiserum against 14-day embryonic quail red blood cells (RBCs) was specifically adsorbed to achieve fetal specificity and to eliminate any cross reactivity with the CFA system. Complement-mediated microcytotoxicity and hemagglutination assays were used to detect the presence of QFA on hematopoietic cells. QFA was found on 100% of the peripheral RBCs from 10-day quail embryos but incidence of the antigen gradually declined with increasing development. Complete loss of QFA from RBCs occurred just prior to sexual maturation between 31 and 42 days of age. No qualitative differences in erythroid expression of QFA were observed during development; however, RBCs from both embryonic duck and interspecific quail- chicken hybrids reacted with R-anti QFA. Like CFA, quail fetal antigen was associated with lymphocytes, particularly those from primary lymphoid organs. Similarities in the developmentally controlled tissue distribution of QFA and CFA suggest that developmental hematopoietic antigens are a common feature of avian species and are useful cell surface markers for studies of development and differentiation.

[The effect of bromocriptine on the course of dementia (author's transl)]. / Contribution a lEtude des syndromes démentiels sous l'action de la bromocriptine

The effect of bromocriptine on the course of dementia in the aged is reported by the authors. This study is based on a protocol taken from genetic psychology and concerns 25 patients. A posology of 5 mg was generally used except in 4 patients who received 10 mg. The clinical results show improvement in the motor, operative and memory functions as well as in affect and behavior. The electroencephalographic results show in 2/3 to 3/4 of the cases, the reappearance of alpha rhythm, an improvement in the arousal reaction and the disappearance of the slow delta rhythms. The comparison between the clinical and the electroencephalographic results shows a remarkable electro-clinical concordance.

[Value of bromocriptine in senile dementia]. / Intérêt de la bromocriptine dans les démences de la vieillesse.

A study concerning the clinical and electroencephalographic effects of bromocriptine, on senile dementia (senile degenerative, vascular and mixed dementia), was carried out on 22 patients. The protocol for this clinical experiment was inspired from genetic psychology. A posology of 5 milligrams was generally used. The clinical results show an improvement in the motor, operative, and memory functions but especially in the sphere of emotion and behaviour. The electroencephalographic results show in 2/3 to 3/4 of the cases, the reappearance of alpha rhythm, an improvement in the arousal reaction and the reduction of the delta rhythms. The comparison between the clinical and the electroencephalographic results shows an appreciable electro-clinical concordance.

[Effects of two drugs substituted o-anisamides: sulpiride and sultopride on the sleep awakening cycle (author's transl)]. / Action sur le cycle veille-sommeil de deux dérivés des o-anisamides substituées: le sulpiride et le sultopride.

The study of the sleep awakening cycle was carried out on implanted cats free of their movements, which received separately each drug in long lasting intake, inorder to differentiate their behavioural and electrophysiological activities. The qualitative and quantitative changes induced by these o-anisamides are reported. Like in man, sulpiride was found to be quite an original substance. It may be distinguished from the other psychotropic drugs studied because it has no effect on the sleep awakening cycle. The effects of sultopride are comparable with those of some neuroleptics, although its both incisive and sedative activity is very special. The neurophysiological results are discussed in the light of other studies and clinical data.

[Benzodiazepines and limbic system. Anxiety and vigilance (author's transl)]. / Benzodiazépines et système limbique. Anxiété et vigilance.

A neurophysiological study of 4 benzodiazepines in the free implanted cat serves as basis to a discussion concerning tranquilizers, anxiety and vigilance. The electrophysiological and behavioural effects of diazepam, nitrazepam, lorazepam and of clorazepate dipotassique are analysed and compared between them and other psychotropic drugs. Their mode of action on the behaviour, on the bioelectric cortical and hippocampal rhythms, is explained according to recent biochemical data. The relations with anxiety, vigilance and neuro-psycho-physiologic mechanisms which subtend them are discussed at the light of clinical effects provoked by substances called tranquillizers.

[Effects of two drugs substituted o-anisamides: sulpiride and sultopride on the sleep awakening cycle (author's transl)]. / Action sur le cycle veille-sommeil de deux dérivés des o-anisamides substituées: le sulpiride et le sultopride.

The study of the sleep awakening cycle was carried out on implanted cats free of their movements, which received separately each drug in long lasting intake, in order to differentiate their behavioural and electrophysiological activities. The qualitative and quantitative changes induced by these o-anisamides are reported. Like in man, sulpride was found to be quite an original substance. It may be distinguished from the other psychotropic drugs studied because it has no effect on the sleep awakening cycle. The effects of sultopride are comparable with those of some neuroleptics, although its both incisive and sedative activity is very special. The neurophysiological results are discussed in the light of other studies and clinical data.

Effects of thioproperazine and sulpiride on the locomotor rhythms in the decorticate cat.

The decorticate cat develops sequences of locomotor movements, especially in the two posterior limbs: those appear either spontaneously, or following a single shock applied to L7 dorsal root. Using this preparation, we tested the effects of two neuroleptic agents, Thioproperazine (TZ) and Sulpiride (S), through either systemic administration or local injection into the lateral-posterior hypothalamus and into the lumbar spinal cord. TZ administered i.v. (0.5 mg/kg) suppressed all locomotor rhythms, while S induced unclear effects. The tested drugs clearly acted at the hypothalamic level, but the effects of the drugs were opposite; TZ (70 microgram) suppressed rhythms, while S (350 microgram) increased or even induced them. T2 (50 microgram) injected at the L7 cord-level abolished rhythms, and S (350 microgram) reduced their amplitude but increased the duration of locomotor sequences. The flexion reflex was never affected by these drugs. The two drugs seem to act at the spinal and the hypothalamic levels. The possible mechanisms involved in their action are discussed.