The ability of CNS vital signs to detect coached sandbagging performance during concussion baseline testing: a randomized control trial.

Objective: Despite widespread use of baseline neurocognitive testing in concussion management, suboptimal performance due to sandbagging still readily occurs without detection. The purpose of this study is to determine CNS Vital Signs validity indicator accuracy in detecting coached sandbagging compared to controls.Method: We compared rates of invalidity and domain composite scores for neurocognitive test performance between two groups of twenty-five college-aged students (age = 20.8 ± 1.1 years, range 18-25, 48% female) completing CNS Vital Signs instructed to either 1) give their best effort (control) or, 2) give suboptimal performance (sandbag). The sandbagging group was given standardized instructions on how to sandbag without detection. All participants rated their effort after completing on a Visual Analog Scale (0-100 mm).Results: Built in invalidity indicators successfully identified 68.0% of sandbaggers, while only 12% in the control group presented with invalid scores. Participants in the sandbagging group on average reported significantly lower effort (sandbag: 51.0 ± 21.0, control: 86.0 ± 12.0, p < .001)Conclusions: Built-in CNS Vital Signs validity indicators have an overall high accuracy in identifying those attempting to purposefully sandbag and are comparable to other computerized neurocognitive tests. Given that 32% of intentional sandbaggers went undetected, clinicians should consider additional safeguards to detect these individuals at baseline.

Impact of Factors that Affect Reading Skill Level on King-Devick Baseline Performance Time.

The King-Devick (K-D) test is often used as part of a multimodal assessment to screen for sport-related concussion. However, the test involves reading numbers, and little is known about variation in baseline performance on the K-D by reading skill level. We conducted a cross-sectional study analyzing data from the Concussion Assessment, Research and Education (CARE) Consortium to assess differences in baseline performance on the K-D associated with factors that impact reading skill level (learning disorder [LD] and primary home language other than English [PHLOTE]), while controlling for covariates (gender, type of sport, attentional issues, history of concussion and modality of administration). We had a sample of 2311 student-athletes (47% female), and multivariate regression indicated an average K-D performance time of 40.4 s. Presence of LD was associated with a 3.3 s slower K-D time (95% CI 1.9-4.7, p < 0.001), and PHLOTE was associated with a 2.6 s slower K-D time (95% CI 1.2-4.0, p < 0.001), after controlling for other covariates. These results suggest caution in the use of normative data with the K-D. Future studies should explore the impact of factors associated with reading skill level on sensitivity of the K-D in detecting concussion.

Health-Related Quality of Life Following Concussion in Collegiate Student-Athletes With and Without Concussion History.

The purpose of this study was to compare global and specific health-related quality of life (HRQOL) throughout concussion recovery between those with and without concussion history. Student-athletes diagnosed with concussion completed global (Short Form-12v2; SF-12) and specific (Hospital Anxiety and Depression Scale: HADS) HRQOL assessments at baseline, 24-48 h, asymptomatic, return-to-play, and 6-months post-injury. Baseline scores were compared to post-injury time points for SF-12 subscores (physical and mental; PCS-12, MCS-12) and HADS subscores (depression and anxiety; HADS-D, HADS-A). We conducted a 2 × 5 mixed model ANOVA for group (with and without concussion history) and time (four post-injury assessments compared to baseline). We did not observe interaction or main effects for group, except those with concussion history had worse HADS-D subscores than those without concussion history. PCS-12 subscores were worse at 24-48 h, asymptomatic, and return-to-play compared to baseline, but returned to baseline 6-months post-injury. MCS-12 subscores did not differ at any time points. HADS-D subscores worsened 24-48 h post-injury, but improved for additional assessments compared to baseline. HADS-A improved post-injury compared to baseline at asymptomatic, return-to-play, and 6-month assessments, but was similar to baseline 24-48 h post-injury. HRQOL physical aspects slightly worsened post-injury and restored to baseline after returning to play.

Immune responses to hair dyes containing toluene-2,5-diamine.

BACKGROUND: Toluene-2,5-diamine (PTD) is the most frequently used dye in oxidative hair dyes on the Scandinavian market. However, little is known about immune responses to PTD-containing oxidative hair dyes. OBJECTIVES: To study immune responses induced by PTD-containing hair dyes in mice. METHODS: Immune responses against two different permanent hair dye products containing 1·60% (w/w) and 0·48% (w/w) PTD within the colour gel, and various concentrations of pure PTD were studied. The local inflammatory response was measured by ear swelling and cell infiltration, and T- and B-cell infiltration and proliferation was determined in the draining lymph nodes. RESULTS: Concentration-dependent immune responses were seen to PTD both in the skin and draining lymph nodes. The hair dye containing 1·60% PTD induced strong local inflammation and caused T- and B-cell infiltration and proliferation as well as an increased number of regulatory T cells in the draining lymph nodes. In contrast, the hair dye containing 0·48% PTD induced skin inflammation but only minor responses in the draining lymph nodes. CONCLUSIONS: Consumer-available PTD-containing permanent hair dyes can be potent immune activators inducing both pro- and anti-inflammatory responses. The outcome of the response is dependent on allergen dose, amount of additional allergens and exposure regime.

A geometrical optics polarimetric bidirectional reflectance distribution function for dielectric and metallic surfaces.

A polarimetric bidirectional reflectance distribution function (pBRDF), based on geometrical optics, is presented. The pBRDF incorporates a visibility (shadowing/masking) function and a Lambertian (diffuse) component which distinguishes it from other geometrical optics pBRDFs in literature. It is shown that these additions keep the pBRDF bounded (and thus a more realistic physical model) as the angle of incidence or observation approaches grazing and better able to model the behavior of light scattered from rough, reflective surfaces. In this paper, the theoretical development of the pBRDF is shown and discussed. Simulation results of a rough, perfect reflecting surface obtained using an exact, electromagnetic solution and experimental Mueller matrix results of two, rough metallic samples are presented to validate the pBRDF.

Ferroelectricity in ultrathin BaTiO3 films: probing the size effect by ultraviolet Raman spectroscopy.

We demonstrate the dramatic effect of film thickness on the ferroelectric phase transition temperature Tc in strained BaTiO3 films grown on SrTiO3 substrates. Using variable-temperature ultraviolet Raman spectroscopy enables measuring Tc in films as thin as 1.6 nm, and a film thickness variation from 1.6 to 10 nm leads to Tc tuning from 70 to about 925 K. Raman data are consistent with synchrotron x-ray scattering results, which indicate the presence of 180 degrees domains below Tc, and thermodynamic phase-field model calculations of Tc as a function of thickness.

Esomeprazole induces upper gastrointestinal tract transmucosal permeability increase.

BACKGROUND: Proton pump inhibitors (PPIs) are one of the most widely used drug classes in the US and are now frontline medications for gastro-oesophageal reflux disease (GERD) and dyspepsia. In a previous work, we observed that a transmucosal, upper gastrointestinal (GI) leak exists in Barrett's oesophagus (BO) patients. PPI medications are commonly used by Barrett's patients. AIM: To examine if the PPI, esomeprazole, affects the barrier function of the upper GI tract. METHODS: The sucrose permeability test (SPT) was used to assess the possible effect of the PPI, esomeprazole, on upper GI leak in 37 first-time-presenting GERD patients and 25 healthy controls. RESULTS: Esomeprazole induced a significant transmucosal leak in the upper GI tract of patients taking the drug for the first time. The leak occurred quickly, within days of first taking the drug. The leak was also reversed within days of stopping the medication. CONCLUSIONS: This is the first patient-based study showing that a PPI compromises upper GI barrier function. There are potential implications for transmucosal leak of other medications that a patient on a PPI may be taking, as well as possible leak of endogenous peptides/proteins. The clinical consequences of this phenomenon are currently unknown, but are potentially important.

Transepithelial leak in Barrett's esophagus.

Using orally administered sucrose as a probe of gastrointestinal permeability, this study focused on determining whether Barrett's metaplasia exhibits a paracellular transepithelial leak to small nonelectrolytes. Subjects in five separate classes (nonendoscoped, asymptomatic controls; endoscoped, asymptomatic controls; gastroesophageal reflux disease without mucosal complications; grossly visible esophagitis; and Barrett's esophagus) consumed a sucrose solution at bedtime and collected all overnight urine. Urine volume was measured and sucrose concentration was determined by high-performance liquid chromatography. Patients with Barrett's were observed to exhibit a transepithelial leak to sucrose whose mean value was threefold greater than that seen in healthy control subjects or patients with reflux but without any mucosal defect. A parallel study of claudin tight junction proteins in endoscopy biopsy samples showed that whereas Barrett's metaplasia contains dramatically more claudin-2 and claudin-3 than is found in normal esophageal mucosa, it is markedly lower in claudins 1 and 5, indicating very different tight junction barriers.

Ileal conduit perforation-iatrogenic injury and conservative management.

The ileal conduit was popularized by Bricker in the 1950s. Since then, surveillance of the upper urinary tract has been accomplished with intravenous urography, ultrasonography, or loopography. Loopography is used as an imaging modality at our institution because of its safety and avoidance of intravenous contrast. We report the first case of an iatrogenic rupture of an ileal conduit during loopography.

Cytotoxic T cell immunity against telomerase reverse transcriptase in humans.

Telomerase is a ribonucleoprotein enzyme which has been linked to malignant transformation in human cells. Telomerase activity is increased in the vast majority of human tumors, making its gene product the first molecule common to all human tumors. The generation of endogenously processed telomerase peptides bound to Class I MHC molecules could therefore target cytotoxic T lymphocytes (CTL) to tumors of different origins. This could advance vaccine therapy against cancer provided that precursor CTL recognizing telomerase peptides in normal adults and cancer patients can be expanded through immunization. We demonstrate here that the majority of normal individuals and patients with prostate cancer immunized in vitro against two HLA-A2.1 restricted peptides from telomerase reverse transcriptase (hTRT) develop hTRT-specific CTL. This suggests the existence of precursor CTL for hTRT in the repertoire of normal individuals and in cancer patients. Most importantly, the CTL of cancer patients specifically lysed a variety of HLA-A2(+) cancer cell lines, demonstrating immunological recognition of endogenously processed hTRT peptides. Moreover, in vivo immunization of HLA-A2.1 transgenic mice generated a specific CTL response against both hTRT peptides. Based on the induction of CTL responses in vitro and in vivo, and the susceptibility to lysis of tumor cells of various origins by hTRT CTL, we suggest that hTRT could serve as a universal cancer vaccine for humans.

Proliferative actinic keratosis: three representative cases.

OBJECTIVE: This article describes a new subtype of actinic keratosis that exhibits proliferative characteristics both histologically and clinically. We describe three representative cases occuring in the presence of infiltrative squamous cell carcinoma (SCC) and/or basal cell carcinoma (BCC). METHODS: Histories of each lesion in the three cases discussed were obtained. The lesions were removed by Mohs micrographic surgery. Permanent sections, stained with hematoxylin and eosin, were examined and studied under light microscopy. RESULTS: All three lesions had failed conventional treatment with liquid nitrogen and/or 5-fluorouracil (5-FU). Histologic examination of the lesions revealed sheets of dysplastic cells growing along the basal layer of the epidermis and migrating down hair follicles and sweat ducts. An associated infiltrative SCC and/or BCC was found in each case. CONCLUSIONS: Proliferative actinic keratosis is resistant to standard therapies because of deep migration of abnormal cells along hair follicles and sweat ducts. It has a strong propensity to develop infiltrative SCC and may occur concomitantly with BCC.

New indications for radical prostatectomy.

PURPOSE: Radical prostatectomy is considered the gold standard for treatment of localized prostate cancer, either as primary or salvage therapy. Recently with the advent of increased organ transplantation, use of prostatic specific antigen for cancer detection and cryoablation as an alternative treatment, more men with prostate cancer can be considered for radical surgery. We review these new indications. MATERIALS AND METHODS: Clinically localized untreated prostate cancers were identified in 3 men being considered for cardiac or lung transplantation (group 1), and 4 men originally treated with transperineal cryoablation had local relapse (group 2). All 7 men underwent radical prostatectomy. RESULTS: Organ confined cancer (pT2C) was found in all 3 patients in group 1. All 3 men underwent successful cardiac or lung transplantation 1 to 12 months after radical prostatectomy, and they are disease-free at short-term followup. Of the group 2 patients 2 had organ confined disease (pT2b and c) and 2 had extensive extraprostatic disease (pT3cN1 and pT3cN0). Only 2 patients remain disease-free and do not require adjuvant endocrine therapy. Major perioperative complications of rectotomy and total incontinence occurred only in group 2 patients. CONCLUSIONS: Patients being considered for heart and lung transplantation need to be free of concurrent malignancy because of immunosuppressive therapy. Radical prostatectomy can achieve this goal in select patients. Cases of failed cryoablation can be salvaged with radical prostatectomy but with less chance of success and with greater risk of complications.

Elevated stress protein in transitional cells exposed to urine from interstitial cystitis patients.

BACKGROUND: It has been hypothesized that urine from interstitial cystitis (IC) patients may contain one or more toxic factors not present in "normal" urine. Bladder tissues exposed to these toxic factors could have elevated stress proteins. If this assumption is correct, stress protein levels could be a useful marker for identifying patients at risk for developing this syndrome. METHODS: To experimentally investigate this possibility, a sensitive assay (ELISA) was used to measure levels of the 72 kDa stress protein in urothelial target cells after in vitro exposure to urine from IC patients. RESULTS: We observed a modest 12% increase in 72 kDa stress protein in cells treated with urine from IC patients compared to cells exposed to normal urine (1.12 compared to 0.99 ng/microg extracted protein; P < 0.05). In addition, it was possible to demonstrate the 72 kDa stress protein in histologic sections obtained from mucosal biopsies of IC patients. Stress protein was located primarily in the surface urothelial cells of the mucosa. CONCLUSIONS: These results seem to indicate that stress protein could play an important protective role at this particular site. They further suggest that IC urine is more toxic than normal urine and, in contact with underlying urothelial and deeper bladder tissue, may upregulate genes involved in stress protein responses. This may be an important concept in the etiology of IC.

Prostate cryoablation: update 1998.

Transrectal ultrasound-guided percutaneous transperineal prostate cryoablation has many attractive features both to the patient and to the urologist. The procedure typically can be done in a period of 2 hours or less on an outpatient basis with minimal blood loss and with the patient under regional or general anesthesia. With more experience in using the equipment and the techniques described, urologists can treat all stages of localized prostate cancer with relatively little morbidity. The results of this technique in the treatment of prostate cancer continue to appear promising. With follow-up of 5 years or more available in several series, cryoablation appears to be an effective modality for the eradication of localized prostate cancer, particularly low-volume cancer (PSA less than 10 ng/ml and Gleason score less than 7). Improved results, i.e., undetectable postcryoablation PSA levels and negative biopsies, may occur with modifications such as double freezing and pullback apical freezing. However, the complication rate also may increase with increased tissue destruction. To date, most complications reported have been relatively minor and require limited intervention. Notably, complications, especially incontinence, are significantly greater, in spite of successful eradication of residual tumor, in patients who undergo salvage cryoablation for recurrent disease after radiation therapy. In our experience, transrectal ultrasound-guided prostate cryoablation appears to be effective in controlling local prostate cancer in 81% of patients with minimal morbidity. As with radical prostatectomy and irradiation techniques, longer follow-up is required; however, at this time prostate cryosurgery can be considered in the following situations: as a primary treatment alternative to surgery or irradiation, as salvage treatment for recurrent cancer after irradiation, and for debulking of large symptomatic primary tumors. We look forward to the prospective randomized clinical trial comparing prostate cryoablation with external irradiation.

Globalisation and inequality in urban South-east Asia.

PIP: Malaysia, Singapore, and Vietnam are the only countries in southeast Asia with binding and well-functioning social contracts. The legitimacy of the governments and state bureaucracies in Thailand and Indonesia, and to a certain extent also of those in the Philippines, has been based upon nationalism, high economic growth, and the promotion of social order through coercion or cooptation. However, in order for the management of a city to be successful, its policies need to be conducive to social sustainability, defined as development compatible with the emergence of a social contract which both fosters an environment which will help to harmonize relations between the city's culturally and socially diverse groups, yet encourages social integration and an improvement in the lives of all of its citizens. These concerns are discussed with regard to Jakarta, Bangkok, Manila, and Kuala Lumpur.^ieng

Cryoablation for carcinoma of the prostate.

Percutaneous transperineal cryoablation of the prostate is now available in the armamentarium for treatment of prostate cancer. Technical advances in real-time transrectal imaging of the prostate and improvements in cryosurgical equipment have brought this modality into the limelight of available prostate cancer management. Cryosurgery can be offered to many patients with prostate cancer. However, the main indications for its use include primary treatment for localized disease, salvage therapy after failure of traditional methods, and relief of local symptoms. A historical background, description of the technique, and clinical experience at several medical centers including the University of California San Diego, Allegheny General Hospital, University of Texas M.D. Anderson Cancer Center, and Crittenton Hospital, are presented.