Elizabeth A. Disbrow

Effect of critical injury on plasma antithrombin activity: Low antithrombin levels are associated with thromboembolic complications

OBJECTIVE Determine whether severe injury results in decreased plasma antithrombin (AT) activity and whether this decreased AT activity is associated with thromboembolic complications. DESIGN Prospective observational. SUBJECTS A total of 157 critically injured trauma patients. METHODS Each patient underwent laboratory analysis on arrival to the emergency room at hours 8, 16, 24, and 48, and days 3, 4, 5, and 6. Laboratory analyses included AT, tissue factor pathway inhibitor, protein C, prothrombin fragment 1.2, thrombin-antithrombin complex, and D-dimer. Patients were followed for thromboembolic complications including: deep venous thrombosis (DVT), pulmonary embolus, disseminated intravascular coagulation (DIC) and adult respiratory distress syndrome (ARDS). RESULTS Mean Injury Severity Score was 23 (+/-11). AT activity fell below normal in 95 (61%) patients; AT activity rose to greater than normal in 51 (32%) patients. Nine (6%) patients developed DVT, two (1%) pulmonary embolus, 13 (8%) DIC and 26 (17%) ARDS. Using logistic regression analysis, low AT levels were a significant predictor of DVT, DIC, and ARDS (p < 0.05). Supranormal At levels were associated with closed head injury (p < 0.05). D-dimer levels were inversely correlated with AT (p < 0.05). CONCLUSIONS AT activity was depressed in critically injured patients. Patients with head injury developed supranormal AT activity. The risk factors for AT deficiency mimicked those for thromboembolism. Patients with decreased AT activity were at increased risk for thromboembolic complications. Given heparins dependence on AT, these data call into question the use of unmonitored heparin thromboembolism prophylaxis.

Cognitive and Psychiatric Disturbances in Parkinsonian Syndromes.

Parkinsonian syndromes share clinical signs including akinesia/bradykinesia and rigidity, which are consequences of pathology involving dopaminergic substantia nigra neurons. Yet cognitive and psychiatric disturbances are common, even early in the course of disease. Executive dysfunction is often measurable in newly diagnosed Parkinsons disease. Treatment with dopaminergic medications, particularly dopamine agonists, has been associated with hallucinations and impulse control disorder. Older age, presence of APOE-4 gene, and/or other factors result in amyloid plaque deposition that, in turn, accelerates cortical Lewy body plus tau pathology, linking Dementia with Lewy Bodies and Parkinsons disease with early dementia with Alzheimers disease. Treatments available for cognitive deficits, depression, and psychotic symptoms are discussed.

A pilot study to evaluate multi-dimensional effects of dance for people with Parkinson's disease

Parkinsons disease (PD) is a progressive neurodegenerative disease associated with deficits in motor, cognitive, and emotion/quality of life (QOL) domains, yet most pharmacologic and behavioral interventions focus only on motor function. Our goal was to perform a pilot study of Dance for Parkinsons-a community-based program that is growing in popularity-in order to compare effect sizes across multiple outcomes and to inform selection of primary and secondary outcomes for a larger trial. Study participants were people with PD who self-enrolled in either Dance for Parkinsons classes (intervention group, N=8) or PD support groups (control group, N=7). Assessments of motor function (Timed-Up-and-Go, Gait Speed, Standing Balance Test), cognitive function (Test of Everyday Attention, Verbal Fluency, Alternate Uses, Digit Span Forward and Backward), and emotion/QOL (Geriatric Depression Scale, Falls Efficacy Scale-International, Parkinsons Disease Questionnaire-39 (total score and Activities of Daily Living subscale)) were performed in both groups at baseline and follow-up. Standardized effect sizes were calculated within each group and between groups for all 12 measures. Effect sizes were positive (suggesting improvement) for all 12 measures within the intervention group and 7 of 12 measures within the control group. The largest between-group differences were observed for the Test of Everyday Attention (a measure of cognitive switching), gait speed and falls efficacy. Our findings suggest that dance has potential to improve multiple outcomes in people with PD. Future trials should consider co-primary outcomes given potential benefits in motor, cognitive and emotion/QOL domains.

Effect of Preoperative Suggestion in Postoperative Gastrointestinal Motility

Autonomic behavior is subject to direct suggestion. We found that patients undergoing major operations benefit more from instruction than from information and reassurance. We compared the return of intestinal function after intra-abdominal operations in 2 groups of patients: the suggestion group received specific instructions for the early return of gastrointestinal motility, and the control group received an equal-length interview offering reassurance and nonspecific instructions. The suggestion group had a significantly shorter average time to the return of intestinal motility, 2.6 versus 4.1 days. Time to discharge was 6.5 versus 8.1 days. Covariates including duration of operation, amount of intraoperative bowel manipulation, and amount of postoperative narcotics were also examined using the statistical model analysis of covariance. An average savings of

EFFECT OF PREOPERATIVE SUGGESTION ON POSTOPERATIVE GASTROINTESTINAL MOTILITY

1,200 per patient resulted from this simple 5-minute intervention. In summary, the use of specific physiologically active suggestions given preoperatively in a beleivable manner can reduce the morbidity associated with an intra-abdominal operation by reducing the duration of ileus.