Dennis L. Johnson

Intrathecal Baclofen for Management of Spastic Cerebral Palsy: Multicenter Trial

Intrathecal baclofen infusion has demonstrated effectiveness in decreasing spasticity of spinal origin. Oral antispasticity medication is minimally effective or not well tolerated in cerebral palsy. This study assessed the effectiveness of intrathecal baclofen in reducing spasticity in cerebral palsy. Candidates were screened by randomized, double-blind, intrathecal injections of baclofen and placebo. Responders were defined as those who experienced an average reduction of 1.0 in the lower extremities on the Ashworth Scale for spasticity. Responders received intrathecal baclofen via the SynchroMed System and were followed for up to 43 months. Fifty-one patients completed screening and 44 entered open-label trials. Lower-extremity spasticity decreased from an average baseline score of 3.64 to 1.90 at 39 months. A decrease in upper-extremity spasticity was evidenced over the same study period. Forty-two patients reported adverse events. Most common reports were hypotonia, seizures (no new onset), somnolence, and nausea or vomiting. Fifty-nine percent of the patients experienced procedural or system-related events. Spasticity in patients with cerebral palsy can be treated effectively by continuous intrathecal baclofen. Adverse events, although common, were manageable. (J Child Neurol 2000;15:71-77).

Role of apnea in nonaccidental head injury.

We hypothesize that apnea induced by shaking or by shaking combined with impact plays a major role in the pathophysiology of nonaccidental head trauma and accounts for the poor outcome in this subgroup of patients. In a retrospective study of 28 children who suffered significant nonaccidental head injury, 57% had a history of apnea prior to hospitalization, 82% were intubated upon admission, and 71% had early seizures. For further evidence of ischemia and hypoxia, the first recorded blood pressure was < 80 in 50% and the arterial pH < 7.3 in 54%. Seventy-one percent had diffuse brain swelling which is characteristic of cerebral hypoxia and/or ischemia on the first CT scan. None of the children who had clinical evidence of cerebral hypoxia or ischemia had a good outcome. We conclude that trauma-induced apnea causes cerebral hypoxia and/or ischemia which is more fundamental to outcome than the mechanism of injury (shaken vs. shaken with impact), subdural hemorrhage, subarachnoid hemorrhage, diffuse axonal injury, parenchymal shear, or brain contusion.

A spatially distributed hydrologic model utilizing raster data structures

Abstract A distributed hydrologic model, known as the Terrestrial Hydrologic Model or THM was developed for use with rasterized databases to simulate surface runoff. Computations are performed on a pixel-by-pixel basis and all physical drainage basin properties including area, slope, stream length, and stream order are obtained or estimated from a digital elevation model (DEM). Other data sets, such as curve numbers or infiltration rates, are required for estimating the hydrologic abstractions. Precipitation is supplied in the form of gage input, uniform distributions, or raster data. At the present time, hydrologic abstractions can be estimated by any of three methods: a constant infiltration rate, the Soil Conservation Service curve number method, or solution of the more physically based Green-Ampt equation. Overland flow is computed by a kinematic wave approximation and channel routing is performed using the Muskingum-Cunge method.

Depression, anxiety, and asthenia in advanced illness.

Depression, anxiety, and asthenia are frequently experienced by those suffering with an advanced (life-limiting) illness. Many caregivers may feel that it is “normal for patients in this condition to be depressed or anxious,” and this misunderstanding may lead to missed opportunities to address a treatable condition. The role played by the yet more “normal” phenomenon of asthenia (ie, reduced energy or vitality) at the end of life also confounds treatment. Failure to recognize asthenia and to acknowledge depression in this population are exacerbated by the discomfort most physicians experience when they are confronted with a dying patient. A patient’s terminal illness and accompanying psychological distress can remind physicians all too painfully of their treatment “failures” and their own mortality. The objectives of this article are to help readers recognize clinical depression, anxiety, and asthenia in patients with advanced illness; become more aware of the need for active intervention; and gain a knowledge of the pharmacologic and nonpharmacologic approaches to treatment.

Robert Wood Johnson Foundation Office of promoting excellence in end-of-life care: Executive summary of the report from the field

I. BACKGROUND AND CONVENING PROCESS In recognition of a growing interest in palliative care by clinicians, patients, and families, the Promoting Excellence in End-of-Life Care national program of The Robert Wood Johnson Foundation, in conjunction with the American College of Surgeons, created a national Peer Workgroup to facilitate introduction of the precepts and techniques of palliative care to surgical practice and education in the United States and Canada. The World Health Organization has defined palliative care as “The active total care of patients whose disease is not responsive to curative treatment.” The Surgeons Palliative Care Workgroup brought together surgeons with demonstrated interest and experience in palliative care to share resources, strategies, and expertise, and in so doing act as a catalyst for change. This is a summary of their analysis of the current state of palliative care in the surgical field and their recommendations. The full report will be released this summer by the Robert Wood Johnson Foundation. The Workgroup met during a 14-month period from September 2001 through November 2002. The initial Workgroup membership of 20 consisted of 17 surgeons representing 6 subspecialties, representatives of the executive and administrative staff of the American College of Surgeons, two recognized leaders in palliative care research and education, and a representative of the National Program Office of the Robert Wood Johnson Foundation. The Workgroup divided into seven subcommittees and conducted its business at four plenary sessions and periodic teleconferences. The Workgroup adopted the American College of Surgeons’ Statement of Principles Guiding Care at End of Life (1998) as its compass in the execution of its charge. After approval by the American College of Surgeons Board of Regents in October 2002, the Workgroup became integrated into the Division of Education of the American College of Surgeons as the Surgical Palliative Care Task Force.

Development of Regional Rainfall Intensity-Duration-Frequency Estimates for the State of Michigan

Due to the occurrence high-intensity rainfall events more frequently than expected, the Michigan Department of Transportation has deemed it necessary to Update the regional rainfall intensity-duration-frequency (IDF) estimates for the State. Rainfall intensity estimates are to be determined for each of seven durations (1, 2, 3, 6, 12, 18 and 24 hours) and six frequencies (0.5, 0.2, O.1, 0.04, 0.02. and 0.01 per year). Traditionally, method of moments or maximum likelihood procedures have been used to fit a suitable probability distribution to annual maximum or partial duration series data for each gage, and isopluvial maps have been developed from these site-specific IDF estimates using interpolation procedures and judgment. This paper discusses the application of a regional frequency analysis approach based on probability-weighted moments that promises to provide more objective and robust IDF estimates. Definition of homogeneous regions, selection of a distribution, and estimation of parameters are discussed.

Palliative care by the surgeonThe role of tube feeding and total parenteral nutrition in advanced illness1

Consumption of food and drink is a fundamental part of North American culture. “All-you-can-eat” diners and lavish Thanksgiving turkey dinners are as American as Mom and apple pie. Eating and drinking is a valued social activity; we derive our strength from eating, and for many, the ability to eat and drink symbolizes life itself. The development of artificial nutrition has allowed us to feed patients who cannot eat and to continue to feed patients who are dying. It is no wonder that withholding food or withdrawal of artificial feeding may be seen as tantamount to assisted suicide or euthanasia by patients, families, and health professionals. Because placement of a feeding gastrostomy or jejunostomy often falls to the surgeon, the role of tube feeding and total parenteral nutrition (TPN) in advanced illness is an appropriate subject for our review. Two case scenarios help focus the issues at stake.

The role of tube feeding and total parenteral nutrition in advanced illness1 1No competing interests declared.

Consumption of food and drink is a fundamental part of North American culture. “All-you-can-eat” diners and lavish Thanksgiving turkey dinners are as American as Mom and apple pie. Eating and drinking is a valued social activity; we derive our strength from eating, and for many, the ability to eat and drink symbolizes life itself. The development of artificial nutrition has allowed us to feed patients who cannot eat and to continue to feed patients who are dying. It is no wonder that withholding food or withdrawal of artificial feeding may be seen as tantamount to assisted suicide or euthanasia by patients, families, and health professionals. Because placement of a feeding gastrostomy or jejunostomy often falls to the surgeon, the role of tube feeding and total parenteral nutrition (TPN) in advanced illness is an appropriate subject for our review. Two case scenarios help focus the issues at stake.

Mapping Spatial Variation in Rainfall Intensity-Duration-Frequency Estimates Using a Geographical Information System

For hydraulic design purposes, the Michigan Department of Transportation (MDOT) currently uses rainfall intensity-duration-frequency (IDF) estimates for four rainfall zones in Michigan. The delineation of these zones is based on frequency estimates at gage sites and isopluvial maps developed by interpolation procedures and subjective judgment. The objectives of this study are to apply more objective interpolation procedures to regional frequency estimates and to develop an interactive geographic information system (GIS) interface capable of querying and displaying location-specific IDF curves. For each of seven durations (1, 2, 3, 6, 12, 18, and 24 hours), and for each of six event frequencies (0.5, 0.2, O.1, 0.04, 0.02, 0.01 per year), a rainfall intensity grid will be developed using a spatial interpolation procedure available in a commercial geostatistical software package or GIS. An interactive model capable of querying and displaying location-specific rainfall IDF estimates will then be developed to manage the rainfall intensity grid. Through the GIS interface, users will be able to select a specific geographic location within the state of Michigan and display IDF curves and other related information for the selected location. This product will provide water resource professionals with a faster, easier-to-use tool for determining appropriate rainfall intensity values for use in hydrologic engineering design.