Brainstem white matter integrity is related to loss of consciousness and postconcussive symptomatology in veterans with chronic mild to moderate traumatic brain injury.

We investigated associations between DTI indices of three brainstem white matter tracts, traumatic brain injury (TBI) injury characteristics, and postconcussive symptomatology (PCS) in a well-characterized sample of veterans with history of mild to moderate TBI (mTBI). 58 military veterans (mTBI: n = 38, mean age = 33.2, mean time since injury = 90.9 months; military controls [MC]; n = 20; mean age = 29.4) were administered 3T DTI scans as well as a comprehensive neuropsychiatric evaluation including evaluation of TBI injury characteristics and PCS symptoms (e.g., negative mood, dizziness, balance and coordination difficulties). Tractography was employed by seeding ROIs along 3 brainstem white matter tracts (i.e., medial lemniscus-central tegmentum tract [ML-CTT]; corticospinal tracts [CST], and pontine tegmentum [PT]), and mean DTI values were derived from fractional anisotropic (FA) maps. Results showed that there were no significant difference in FA between the MC and TBI groups across the 3 regions of interest; however, among the TBI group, CST FA was significantly negatively associated with LOC duration. Additionally, lower FA of certain tracts-most especially the PT-was significantly associated with increased PCS symptoms (i.e., more severe vestibular symptoms, poorer physical functioning, and greater levels of fatigue), even after adjusting for PTSD symptoms. Our findings show that, in our sample of veterans with mTBI, tractography-based DTI indices of brainstem white matter tracts of interest are related to the presence and severity of PCS symptoms. Findings are promising as they show linkages between brainstem white matter integrity and injury severity (LOC), and they raise the possibility that the pontine tegmentum in particular may be a useful marker of PCS symptoms. Collectively, these data point to important neurobiological substrates of the chronic and complex constellation of symptoms following the 'signature injury' of our combat-exposed veterans.

Testing for isoniazid. An evaluation of the Arkansas method.

To better treat and eliminate tuberculosis, patient compliance must be improved. Compliance can be evaluated by measuring a drug or its metabolite in the urine. In Arkansas, a simple colorimetric method of checking the urine for isoniazid (the Potts-Cozart test) has been used for many years, but it is relatively unknown outside that state and its reliability has not been confirmed. To evaluate this test, urine was blindly tested from patients from a tuberculosis clinic. Controls included urine from patients from a substance abuse clinic and Veterans Medical Center. In more than 200 urine samples tested, no false-positives were found. Urinalysis showed normal values for three patients who were supposed to be receiving antituberculosis medication, but it is likely that these patients were noncompliant. A peculiarity of the test was that the color change with positive tests varied. To investigate this variation, absorption spectroscopy of many substances was performed. Nicotine accounted for the different shade of blue associated with the positive test, but the color produced and the absorption spectroscopy were different from isoniazid, so it did not confuse the interpretation of the results. This test for isoniazid in the urine is simple, quick, inexpensive, easy to interpret, and reliable. It also can be used to detect nicotine and its metabolites.

The tuberculosis clinic.

Patient compliance is the major obstacle to successful treatment of tuberculosis. To counter factors of inconstant attention to compliance, inconsistent follow-up, and incomplete documentation, a tuberculosis clinic, managed by nurse specialists, was established. To evaluate this clinic, records of all patients with tuberculosis followed-up there were compared with patients with tuberculosis observed in the other clinics over a nine-year period. Twelve percent of patients in the general clinics group had complete, documented, effective treatment compared with 86 percent in the tuberculosis clinic group. Only 31 percent of the general clinics patients compared with 100 percent of the tuberculosis clinic patients had completely documented follow-up. In hospitals in endemic areas for tuberculosis, a tuberculosis clinic may be superior to general clinics for the care of patients with tuberculosis. Staff of a specialized clinic can quickly identify a break in therapy, provide support necessary for better compliance, lessen the number of incomplete records, and decrease the number of patients who do not receive full therapy.

Treatment of tuberculosis in a nurse-managed clinic.

From July 1982 to January 1986, we saw 86 patients in the tuberculosis clinic; 77 (90%) were alcoholics; all were males, 71 (83%) were black, 14 (16%) were white, and one (1%) was hispanic. Of these, 10 patients (12%) failed to complete therapy and were referred to the Chicago Board of Health. Nine patients (10%) were dropped from the clinic: three moved from the state of Illinois, three died of nontuberculosis causes, and three were transferred to the Chest Clinic for other medical problems. Therefore, 67 patients (78%) successfully completed therapy. Our high rate of success is attributed to constant, high-intensity contact and consistent supervision of these potentially noncompliant patients.