Anatomy of Soft Tissues of the Spinal Canal

Background and Objectives. Important issues regarding the spread of solutions in the epidural space and the anatomy of the site of action of spinal and epidural injections are unresolved. However, the detailed anatomy of the spinal canal has been incompletely determined. We therefore examined the microscopic anatomy of the spinal canal soft tissues, including relationships to the canal walls. Methods. Whole mounts were prepared of decalcified vertebral columns with undisturbed contents from three adult humans. Similar material was prepared from a macaque and baboon immediately on death to control for artifact of tissue change after death. Other tissues examined included nerve root and proximal spinal nerve complex and dorsal epidural fat obtained during surgery. Slides were examined by light microscopy at magnifications of 10-40×. Results. There is no fibrous tissue in the epidural space. The epidural fat is composed of uniform cells enclosed in a fine membrane. The dorsal fat is only attached to the canal wall in the dorsal midline and is often tenuously attached to the dura. The dura is joined to the canal wall only ventrally at the discs. Veins are evident predominantly in the ventral epidural space. Nerve roots are composed of multiple fascicles which disperse as they approach the dorsal root ganglion. An envelope of arachnoid encloses the roots near the site of exit from the dura. Conclusions. These features of the fat explain its semifluid consistency. Lack of substantial attachments to the dura facilitate movement of the dura relative to the canal wall and allow distribution of injected solution. Fibrous barriers are an unlikely explanation for asymmetric epidural anesthesia, but the midline fat could impede solution spread. Details of nerve-root structure and their envelope of pia-arachnoid membrane may be relevant to anesthetic action

Loop algebras, gauge invariants and a new completely integrable system

One fruitful motivating principle of much research on the family of integrable systems known as ``Toda lattices'' has been the heuristic assumption that the periodic Toda lattice in an affine Lie algebra is directly analogous to the nonperiodic Toda lattice in a finite-dimensional Lie algebra. This paper shows that the analogy is not perfect. A discrepancy arises because the natural generalization of the structure theory of finite-dimensional simple Lie algebras is not the structure theory of loop algebras but the structure theory of affine Kac-Moody algebras. In this paper we use this natural generalization to construct the natural analog of the nonperiodic Toda lattice. Surprisingly, the result is not the periodic Toda lattice but a new completely integrable system on the periodic Toda lattice phase space. This integrable system is prescribed purely in terms of Lie-theoretic data. The commuting functions are precisely the gauge-invariant functions one obtains by viewing elements of the loop algebra as connections on a bundle over $S^1$

Litigating State Interests: Attorneys General as Amici

An important strain of federalism scholarship locates the primary value of federalism in how it carves up the political landscape, allowing groups that are out of power at the national level to flourish—and, significantly, to govern—in the states. On that account, partisanship, rather than a commitment to state authority as such, motivates state actors to act as checks on federal power. Our study examines partisan motivation in one area where state actors can, and do, advocate on behalf of state power: the Supreme Court. We compiled data on state amicus filings in Supreme Court cases from the 1979–2013 Terms and linked it up with data on the partisanship of state attorneys general (AGs). Focusing only on merits-stage briefs, we looked at each AG’s partisan affiliation and the partisanship of the AGs who either joined, or explicitly opposed, her briefs. If partisanship drives amicus activity, then we should see a strong negative relationship between the partisanship of AGs opposing each other and a strong positive relationship between those who cosign briefs. What we found was somewhat surprising. States agreed far more often than they disagreed, and—until recently—most multistate briefs represented bipartisan, not partisan, coalitions of AGs. Indeed, for the first twenty years of our study, the cosigners of these briefs were generally indistinguishable from a random sampling of AGs then in office. The picture changes after 2000, when the coalitions of cosigners become decidedly more partisan, particularly among Republican AGs. The partisanship picture is also different for the 6% of cases in which different states square off in opposing briefs. In those cases, AGs do tend to join together in partisan clusters. Here, too, the appearance of partisanship becomes stronger after the mid-1990s

Exit polling and racial bloc voting: Combining individual-level and R×\timesC ecological data

Despite its shortcomings, cross-level or ecological inference remains a necessary part of some areas of quantitative inference, including in United States voting rights litigation. Ecological inference suffers from a lack of identification that, most agree, is best addressed by incorporating individual-level data into the model. In this paper we test the limits of such an incorporation by attempting it in the context of drawing inferences about racial voting patterns using a combination of an exit poll and precinct-level ecological data; accurate information about racial voting patterns is needed to assess triggers in voting rights laws that can determine the composition of United States legislative bodies. Specifically, we extend and study a hybrid model that addresses two-way tables of arbitrary dimension. We apply the hybrid model to an exit poll we administered in the City of Boston in 2008. Using the resulting data as well as simulation, we compare the performance of a pure ecological estimator, pure survey estimators using various sampling schemes and our hybrid. We conclude that the hybrid estimator offers substantial benefits by enabling substantive inferences about voting patterns not practicably available without its use.Comment: Published in at http://dx.doi.org/10.1214/10-AOAS353 the Annals of Applied Statistics (http://www.imstat.org/aoas/) by the Institute of Mathematical Statistics (http://www.imstat.org

What contributes to depression in Parkinson's disease?

Background: Depression is a common problem in patients with Parkinson's disease, but its mechanism is poorly understood. It is thought that neurochemical changes contribute to its occurrence, but it is unclear why some patients develop depression and others do not. Using a community-based sample of patients with Parkinson's disease, we investigated the contributions of impairment, disability and handicap to depression in Parkinson's disease. Methods: Ninety-seven patients seen in a population-based study on the prevalence of Parkinson's disease completed the Beck Depression Inventory (BDI). Clinical and historical information on symptoms and complications of Parkinson's disease were obtained from the patients by a neurologist. In addition, clinician and patient ratings of disability on the Schwab and England scale were obtained and a quality of life questionnaire was completed. Results: Moderate to severe depression (BDI [gt-or-equal, slanted] 18) was reported by 19·6% of the patients. Higher depression scores were associated with advancing disease severity, recent self-reported deterioration, higher akinesia scores, a mini-mental score of 50% of the variance of depression scores. Conclusions: Depression in patients with Parkinson's disease is associated with advancing disease severity, recent disease deterioration and occurrence of falls. Regression analysis suggests that depression in Parkinson's disease is more strongly influenced by the patients' perceptions of handicap than by actual disability. The treatment of depression should therefore be targeted independently of treatment of the motor symptoms of Parkinson's disease, and consider the patients' own perception of their disease

Reliability of the modified Rankin Scale: a systematic review

<p><b>Background and Purpose:</b> A perceived weakness of the modified Rankin Scale is potential for interobserver variability. We undertook a systematic review of modified Rankin Scale reliability studies.</p> <p><b>Methods:</b> Two researchers independently reviewed the literature. Crossdisciplinary electronic databases were interrogated using the following key words: Stroke*; Cerebrovasc*; Modified Rankin*; Rankin Scale*; Oxford Handicap*; Observer variation*. Data were extracted according to prespecified criteria with decisions on inclusion by consensus.</p> <p><b>Results:</b> From 3461 titles, 10 studies (587 patients) were included. Reliability of modified Rankin Scale varied from weighted κ=0.95 to κ=0.25. Overall reliability of mRS was κ=0.46; weighted κ=0.90 (traditional modified Rankin Scale) and κ=0.62; weighted κ=0.87 (structured interview).</p> <p><b>Conclusion:</b> There remains uncertainty regarding modified Rankin Scale reliability. Interobserver studies closest in design to large-scale clinical trials demonstrate potentially significant interobserver variability.</p&gt

Exploring the reliability of the modified Rankin Scale

<p><b>Background and Purpose:</b> The modified Rankin Scale (mRS) is the most prevalent outcome measure in stroke trials. Use of the mRS may be hampered by variability in grading. Previous estimates of the properties of the mRS have used diverse methodologies and may not apply to contemporary trial populations. We used a mock clinical trial design to explore inter- and intraobserver variability of the mRS.</p> <p><b>Methods:</b> Consenting patients with stroke attending for outpatient review had the mRS performed by 2 independent assessors with pairs of assessors selected from a team of 3 research nurses and 4 stroke physicians. Before formal assessment, interviewers estimated disability based only on initial patient observation. Each patient was then randomized to undergo the mRS using standard assessment or a prespecified structured interview. The second interviewer in the pair reassessed the patient using the same method blinded to the colleague’s score. For each patient assessed, one rater was randomly assigned to video record their interview. After 3 months, this interviewer reviewed and regraded their original video assessment.</p> <p><b>Results:</b> Across 100 paired assessments, interobserver agreement was moderate (k=0.57). Intraobserver variability was good (k=0.72) but less than would be expected from previous literature. Forty-nine assessments were performed using the structured interview approach with no significant difference between structured and standard mRS. Researchers were unable to reliably predict mRS from initial limited patient assessment (k=0.16).</p> <p><b>Conclusions:</b> Despite availability of training and structured interview, there remains substantial interobserver variability in mRS grades awarded even by experienced researchers. Additional methods to improve mRS reliability are required.</p&gt