Serum lipase for assessment of pancreatic trauma.

PURPOSE: Pancreatic enzymes are routinely measured during reception of trauma patients to assess for pancreatic injury despite conflicting evidence on their utility. The aim of this study was to investigate the utility of routine initial serum lipase measurement for the diagnosis of acute pancreatic trauma. MATERIALS AND METHODS: Lipase measurements were introduced as part of the trauma pathology panel and requested on all patients who presented to an adult major trauma service and met trauma call-out criteria. Clinical records of these patients were extracted from the trauma registry and retrospectively reviewed. The performance of an initial serum lipase level measured on presentation to detect pancreatic trauma was determined. RESULTS: There were 2,580 patients included in the study, with 17 patients diagnosed with pancreatic trauma. An elevated lipase was recorded in 390 patients. Statistically significant associations were observed for elevated lipase in patients with pancreatic trauma, head injury, acute alcohol ingestion and massive blood transfusion. As a test for pancreatic trauma, an abnormal serum lipase result had a specificity of 85.3 % (95 % CI 83.8-86.6), sensitivity of 76.5 % (95 % CI 49.8-92.2), positive predictive value of 3.3 % (95 % CI 1.8-5.8) and negative predictive value of 99.8 % (95 % CI 99.4-99.9). Higher cut-offs of serum lipase did not result in better performance. CONCLUSIONS: A normal serum lipase result can be a useful adjunct to exclude pancreatic injury. A positive lipase result, regardless of the cut-off used, was not reliably associated with pancreatic trauma, and should not be used to guide further assessment.

The Community Adaptive Planning Assessment: a clinical tool for documenting future planning with clients.

OBJECTIVES: The objectives of this article are to (a) identify features needed in a clinical tool in order to organize collaborative planning for the future between therapist and client; (b) describe the structure and procedures for use of the Community Adaptive Planning Assessment (CAPA), which was developed to meet these needs; (c) summarize research on the usability, trustworthiness, and clinical effectiveness of the CAPA; and (d) consider future work to further evaluate qualitative tools like the CAPA for clinical and research purposes. METHOD: Initial and revised versions of the CAPA were evaluated through several studies. Usability was examined through questionnaires completed by therapists who used the CAPA in acute care, rehabilitation, home health, and community programs with a total of 105 clients who had a variety of acute and chronic disabilities. Trustworthiness was evaluated through comparison of information gathered from 21 clients with that from their family members. Clinical effectiveness was evaluated for discharge planning through content analysis of community outcomes of goals and plans established before discharge. RESULTS: Initial studies indicate that the CAPA has sound usability, trustworthiness, and clinical effectiveness for a variety of service delivery systems and with a variety of clients when used by experienced therapists. Findings support use of these three criteria for evaluation of tools designed to document qualitative consultation-based practice. CONCLUSIONS: Results are related to broader issues in the profession, including a need for further study of collaborative planning for the future between clients and therapists, ways in which qualitative aspects of practice can be documented efficiently, ways in which outcomes of consultation-based practice can be evaluated, and establishment of criteria for evaluation of emerging qualitative assessments and intervention tools.

The ability of children with specific language impairment to access and participate in an ongoing interaction.

This study investigated the ability of 6 children with specific language impairment (SLI), ages 8;10 to 12;5 (years; months), to enter and participate in an ongoing dyadic interaction. Performance was compared to that of 6 chronological age-matched (CA) peers and 6 language-similar (LS) peers. All children in the LS and CA groups successfully accessed the interaction, and most did so quickly. Two children from the SLI group did not access, and the 4 remaining subjects required varying amounts of time to access. Following successful access, the triadic interactions of subjects were examined. The accessing children with SLI talked significantly less, were addressed significantly less, and collaborated less than either of the partners within their triads. Few significant differences were observed between LS or CA children and their partners.

Pregnancy wantedness and adverse pregnancy outcomes: differences by race and Medicaid status.

The relationship between pregnancy wantedness and adverse pregnancy outcomes was studied using data from 2,828 mothers who participated in the Missouri Maternal and Infant Health Survey. The wantedness of a pregnancy was measured using traditional classifications of mistimed and unwanted, as well as additional measures gauging how the woman felt about the pregnancy while she was pregnant. Fifty-eight percent of the very low birth weight infants and 59% of the moderately low birth weight infants resulted from unintended pregnancies, as did 62% of the normal-birth-weight infants. Logistic regression showed that mothers of very low birth weight infants were significantly more likely than those who had a normal-weight baby to report that they had felt unhappy about the pregnancy (odds ratio of 1.53). Very low birth weight was also associated with early denial of the pregnancy (1.54). Odds ratios associating these two unwantedness categories with low-birth-weight babies were higher among Medicaid recipients than among women not receiving Medicaid. Associations between very low birth weight and the denial variable were also significant among white women when very low birth weight outcomes were compared with normal outcomes, but there was no significant association among black women. There were no significant associations between low birth weight and the traditional unwantedness variables.

PIP: This study examines the relationship between pregnancy wantedness and adverse pregnancy outcomes among 2828 mothers who participated in the Missouri Maternal and Infant Health Survey. The survey was designed as a population-based case-control study of very low birth weight infants born to Missouri residents during December 1, 1989, and March 31, 1991. Infants of moderate and normal birth weight were the controls. Stillbirths were included, but multiple pregnancies were excluded. 36% of the sample were in-patients, 38% were Black, 62% were White, 23% were teenagers, 54% were in their 20s, 52% were married, and 52% lived in a major metropolitan area. 45% of mothers qualified for Medicaid. 779 women gave birth to a low birth weight infant, 799 gave birth to a moderately low birth weight infant, and 800 gave birth to a normal birth weight infant. 450 infants were stillbirths. Pregnancy wantedness was defined by traditional measures of mistimed and unwanted pregnancies as used in the NSFG and some newer measures, such as feelings about being pregnant. Six measures were used: unintended (mistimed and unwanted), mistimed, unwanted, unhappy about the pregnancy, unsure about the pregnancy, and denial of the pregnancy. Logistic regression analysis reveals that the odds of a pregnancy being unwanted if the baby was of low birth weight were greater for the following factors: smoking during pregnancy, maternal age, race, education, health status, pre-pregnancy weight-for-height, parity, infant mortality, and in-patient status at the survey date. The sample included 42% of mistimed pregnancies, and 15% each reported the pregnancy as unwanted, unhappy, or a denial. Birth weight outcomes did not vary by age or race. Low birth weight did not differentiate the wantedness of pregnancies using the timing-wantedness scale, but did distinguish on the happiness scale and denial measures.

Continuity and change: past experience as adaptive repertoire in occupational adaptation.

Narratives are gaining recognition as important ways occupational therapists and other clinicians can think about the life stories of clients. The purpose of this article is to examine a conceptualization of how changes from one chapter to another occur in life stories, using the metaphor of an adaptive repertoire, and to consider how this notion can be useful in helping clients maintain continuity and a coherent life story in times of change. Three premises based on the concept of adaptation address (a) configurations of occupational forms embedded in particular local worlds, (b) cumulative development of an adaptive repertoire that allows one to perform both competently and appropriately, and (c) adaptive transitions and application of one's repertoire to new circumstances. Implications for research and clinical practice in occupational therapy also are examined.

Family relationships and adaptation to spinal cord injury: a qualitative study.

To study adaptive processes following spinal cord injury, unstructured audiotaped interviews were conducted on an almost daily basis with a 30-year-old divorced male during the first 3 months of his initial comprehensive inpatient rehabilitation. Analysis of the transcribed tapes identified a number of important themes, including the theme of social relationships, recurring throughout the data. Family relationships are the focus of this article. The role of the rehabilitation nurse in promoting family involvement in the rehabilitation process is discussed.

Assistive technology and the newly disabled adult: adaptation to wheelchair use.

A naturalistic, ethnographic, phenomenological study of adaptation to wheelchair use was conducted with one key informant, a 30-year-old white man with acquired paraplegia who was undergoing acute rehabilitation. Primary staff members served as additional informants. It was found that adaptation to wheelchair use had both pragmatic and emotional components. The latter appeared in alternating phases of resistance and neutrality or detente. Therapist and patient had conflicting goals relative to wheelchair use, which occasioned considerable friction. The patient's initial attitudes regarding wheelchairs were prejudicial, which hampered his ability to see the chair as a useful tool for mobility and independence. Successful pragmatic adaptation hinged in part on emotional acceptance of the wheelchair.

An ethnographic study of independent living alternatives.

The purpose of this ethnographic study was to compare 12 settings in which housing, attendant assistance, and transportation were shared by clusters of young adults with physical disabilities during the early years of the independent living movement. The settings that were studied were (a) a demonstration independent living program established by a medical rehabilitation facility, (b) a university dormitory, (c) four apartment clusters, and (d) six nursing homes. Data were gathered with ethnographic interviews of 109 subjects as well as by participant observation in each setting. Independent living alternatives are compared in terms of their ability to support residents' engagement in school, work, and leisure activities and their social and cultural similarities and differences. Findings are also reported on how residents viewed their experience in clustered living arrangements and how they believe these experiences shaped their future. Implications of the findings are discussed in terms of public policy issues, including the need for community-based support services, alternative models for organizing such services, and better planning of transitions from institutions to the community.

Nonspecific protection of mice against influenza virus infection by local or systemic immunization with Bacille Calmette-Guérin.

Bacille Calmette-Guérin (BCG) has been used effectively to protect nonspecifically against bacterial infections and neoplasms, probably by enhancement of cell-mediated immunity. It has been suggested that cell-mediated immunity plays a role in the host defense against certain viral infections. In recent in vitro studies, macrophages from animals sensitized by BCG were more effective in lowering the titer of influenza virus than were macrophages from control animals. The purpose of this study was to investigate the in vivo effectiveness of nonspecific immune stimulation with BCG on influenza virus infection in mice. Immunization with BCG resulted in significant protection of mice. Also, the local (nasal) route of immunization was more effective than the systemic (intraperitoneal) route against the intranasal inoculum of virus, a finding which suggests that important role of local immunity, i.e., either earlier stimulation of secretory antibody or nonspecific cell-mediated immunity. The time course of the resistance ot infection suggests that interferon was not the protective mechanism.

Amplification of migratory inhibition factor production during the first 48 hours of exposure to antigen.

When lymphocyte-macrophage suspensions from sensitized animals are preincubated with specific antigen for 24 or more h, the following results are observed. (i) In a standard capillary macrophage migration test, there is complete inhibition of migration. (ii) When the preincubated cell suspension is mixed in varying proportions with a similar suspension from nonsensitized animals and a macrophage migration test is performed, there is no linear relationship between the degree of inhibition of migration and the proportion of sensitized lymphocytes initially present. Inhibition thus appears to be an "all-or-none" effect. (iii) In spite of the second observation, increasing periods of preincubation with antigen result in increasing inhibition. (iv) These results suggest the existence of a complex amplifying mechanism operating within the early period of exposure to antigen. (v) To test the possibility that cell proliferation contributes to this amplification, cells from sensitized guinea pigs were irradiated with a dose of 1,000 rads prior to preincubation with antigen. Despite this dose, which virtually abolishes cell division in other systems, no diminution whatever in the amplification of inhibition was observed. These results suggest the existence of an early phase of increased production of migratory inhibition factor that is not dependent on cell division but that may be related to "recruitment" of nonsensitized lymphocytes.