bluuebunny/crossref_metadata_2025 huggingface dataset:
Screening of Laccase Producing Fungi Using Agro-Wastes under Different Cultural Conditions
Authors: Ndochinwa O. G. , Amadi O. C. , Nwagu T. N. , Okpala G. N. , Nnamchi C. I. , Moneke A. N.
Published: December 2020

This study evaluated the potential of fungal isolates for laccase production. Fungi cultures were screened for laccase production on plate assay using 2’ 2’ – azinobis-(-3-ethyl benzthiazoline -6- suphonate) (ABTS), and by submerged fermentation. Result obtained from the plate assay showed the formation of green halo after 2-4 days of incubation due to oxidation of 2’ 2’ – azinobis-(-3-ethyl benzthiazoline -6- suphonate) (ABTS) which is as a result of lignolytic enzymes production Utilization of selected agro-wastes residues (sawdust, plantain and banana peels) for laccase production was evaluated. Fungal isolates were identified based on their cultural characteristics according to standard mycology methods. Light microscopy was performed on cultures and the fungal isolates were identified by their different morphological and colonial characteristics after which they were confirmed using fungal atlas. Total protein content was also determined using the Bradford method Five out of twelve isolates were positive for oxidation of 2’ 2’ – azinobis-(-3-ethyl benzthiazoline -6- suphonate) (ABTS) which signifies laccase enzyme activity and identified as Geotrichum spp, Cephalosporium spp, Trichoderma spp, Trametes spp and Fusarium sppThe highest enzyme activity was observed using Trichoderma spp at 57.1U/l, Trametes spp 51.99 U/l, Fusarium spp had 29.2 U/l. Geotrichum spp and Cephalosporium spp were least at 28.04 U/l and 9.72 U/l respectively. Trichoderma spp was used for further studies. Effect of carbon sources, inoculum size, pH, total protein and shaker speed on laccase production was evaluated. Sawdust gave the highest yield of laccase enzyme 151.17U /l, followed by plantain peel with 62.49U/l of enzyme, banana peel recorded the least of laccase enzyme 54.94 U /l. Protein content obtained from sawdust medium was 45.8mg/ml, plantain peel medium had 29.2 mg/ml while banana peel was the lowest with 16.8mg/ml all at the sixth day of the fermentation process. Optimum pH for sawdust, banana peel and plantain peel was 5.95, 5.94, and 5.83 respectively. Using shaker incubator (150 rpm) with sawdust as carbon source, laccase yield of (310.45U/l) was obtained at pH 6, temperature 25°C and inoculum size of 105 spores per ml. Thus, sawdust can be categorically stated to be safe, cheap and could be suggested for prospective application of higher production of laccase enzyme in various industries.
Fluctuational Dynamics of Extended Systems: Activation-Tunnel Frontier
Authors: Petukhov Boris
Published: December 2020

The dynamics of systems in barrier structures is determined by the rate of the fluctuational decay of metastable states in a potential relief. The nature of the decay undergoes a qualitative change with a variation of the temperature. As the temperature decreases, thermal fluctuations freeze out and are replaced by quantum ones, which leads to a kind of phase transition in the dynamics. The transition temperature depends on the degree of metastability and can be controlled by an external load. This dependence is calculated for an extended nanosystem in an inclined periodic relief of the "washboard" type in a wide range of load changes. The obtained dependence generalizes the previously known results and can serve as the phase diagram of various dynamics mechanisms.
Total Amylase Value in Drains After Gastrectomy for Predicting Postoperative Pancreatic Fistula
Authors: Sugawara Toshitaka , Shinohara Hisashi , Haruta Shusuke , Shindoh Junichi , Ueno Masaki , Udagawa Harushi
Published: December 2020

Objective

Postoperative pancreatic fistula (POPF) is defined using the ratio of the amylase concentration in abdominal drainage fluid to the upper normal range of serum amylase level. However, we hypothesized that the total amylase value in discharge (AVD) on postoperative day (POD) 3 may be more sensitive for predicting grade II or higher severe POPF (sPOPF) and compared the predictive power of the conventional definition of POPF and AVD for sPOPF.

Methods

One hundred fifty-one patients who underwent gastrectomy between October 2011 and February 2013 were analyzed. A drainage tube was placed in all the cases through the stump of the right gastroepiploic vein and the front of the pancreas to the back of the anastomotic site. The drainage volume and amylase concentration in the discharge were examined on POD 1, 3, and 5. AVD was calculated by multiplying the volume by the amylase concentration.

Results

Eight patients (5.3%) developed sPOPF. In univariate analysis, both AVD and the amylase concentration ratio was significantly correlated with sPOPF (P = 0.002 and 0.007, respectively). AVD on POD 3 showed the best predictive performance compared with the amylase concentration ratio on POD 3 (area under the curve 0.876 versus 0.844). Based on the cutoff values calculated from the receiver operating characteristic curves, AVD was more specific than amylase concentration ratio in predicting sPOPF (specificity: 97.6% versus 86.0%; positive predictive value: 62.5% vs. 23.1%).

Conclusion

AVD on POD 3 is a more specific parameter than conventional amylase concentration ratio in predicting sPOPF.
Breast Cancer Metastasis to the Colon and Rectum: Review of Current Status on Diagnosis and Management
Authors: Hani Murad Bani , Attuwaybi Bashir , Butler Bryan
Published: December 2020

Approximately 5% to 10% of patients will harbor distant metastasis at the time of breast cancer diagnosis, with about a third of these patients developing distant recurrence after optimal therapy. Breast cancer has an unusual metastatic pattern to the colon and rectum with incidence that may be underappreciated. Lobular breast cancer has a higher preponderance to this unusual metastatic pattern. Clinical manifestation is nonspecific with a long latency period, and diagnosis requires a high index of suspicion. The management is not clearly defined. However, medical management with chemo and hormonal therapy seem to be favored, likely because of overall metastatic burden at time of diagnosis. Radical colonic resection in selected patients with isolated colorectal metastasis has been well tolerated and may influence survival. A regimented screening colonoscopy in breast cancer patients with high-risk features may offer early diagnosis and management.
Literature Review: Disability Evaluation
Authors: Talmage James B.
Published: December 2020

The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Third Edition, exclusively used the Range of Motion (ROM) Model to rate motion of the spine. The fourth edition requires the additional use of an inclinometer and also indicates that the Injury Model is the primary method for evaluating the spine; the ROM Model can be used as the differentiator or tie breaker. The ROM and the Injury Models cannot be used interchangeably, and the final rating always should be based on the Injury Model, not the ROM Model. One of the goals of changing the evaluation method is to create a more reproducible rating system. Because the Injury Model uses only objective findings present at the time of examination or found in the record, it is more reproducible. A further difference between the Injury and ROM Models is that in the former the examining physician rates the results of the injury, not the results of the treatment. The AMA Guides also requires that the patient's condition be stable—ie, not likely to change for one year. In the spine, the results of the injury, not the treatment, are rated, and often this can be done within several days of the injury.
Impairment Tutorial: Rating Cranial Nerve and Spinal Cord Disorders
Authors: Direnfeld Lorne
Published: December 2020

The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth Edition, discusses rating cranial nerve and spinal cord impairments. Evaluation of impairment of the cranial nerves is based on clinical neurological assessment, and many cranial nerves also are addressed in other chapters of the AMA Guides (eg, the visual system or the ear, nose, and throat). With respect to cranial nerve I, an impairment estimate associated with anosmia or parosmia should be given only if this significantly interferes with daily activities. For cranial nerve II, the AMA Guides recommends ophthalmologic testing of visual fields and best correction. For cranial nerves III, IV, and VI, the reader is referred to section 8.3, and, for cranial nerve V, the AMA Guides provides a method of determining impairment associated with trigeminal neuralgia. A table provides data regarding impairment for conditions that affect the seventh cranial (facial) nerve; sensory loss related to the facial nerve does not interfere with activities of daily living. Auditory impairment (cranial nerve VIII) is rated according to criteria in the ear, nose, throat, and related structures chapter, including tinnitus. Cranial nerves IX, X, XI, and XII are involved in breathing, swallowing, speaking, and some visceral functions, and ratings criteria are presented. In terms of spinal cord impairments, the AMA Guides divides pathology into six categories: station and gait; use of the upper extremities; respiration; urinary bladder function; anorectal function; and sexual function.
Literature Review
Authors: Talmage James B.
Published: December 2020

Functional capacity testing typically involves musculoskeletal evaluations using instruments such as inclinometers, goniometers, range-of-motion machines, and strength analyzers. Depending on the organ system to be tested, a variety of tests are available to assess physiological competency (eg, liver function or renal function tests). The cardiopulmonary exercise test (CP Ex test) is one test that defines work capacity and addresses the two primary issues necessary for muscle movement: the adequacy of the cardiac output and that of the lungs to acquire oxygen and excrete carbon dioxide. A normal test requires correct functioning in five organ systems: the heart, the lungs, the hematopoietic system, the vascular system, and the muscles. The CP Ex test can discriminate between individuals with poor exercise capacity caused by hyperventilation, obesity, or malingering. The CP Ex test is not required when one is rating impairments according the AMA Guides to the Evaluation of Permanent Impairment, but the test may help physicians understand the basis for decreased exercise tolerance, thereby facilitating the impairment rating process. Finally, the CP Ex text is useful for assessing functional capacity but does not address all the physiologic, anatomic, and functional issues—no single test can do so—but the CP Ex test provides a very adequate way to address an individual's functional capacity.
Post-Operative Backs: Common Impairment Rating Scenarios (Part II)
Authors: Talmage James B.
Published: December 2020

This article continues the discussion from the previous issue regarding common impairment rating scenarios for individuals who have had back surgery: Scenario 6) What is the impairment rating for an individual who has had a spinal fusion operation? 7) What is the impairment rating for an individual who has pre-existing spondylolisthesis, has a back strain injury, and undergoes a spinal fusion operation? 8) What is the impairment rating of an individual with spinal fracture(s) who has been treated by spinal fusion? 9) What about surgical complications? The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) notes that, following the Injury Model, surgery to treat an impairment does not modify the original impairment estimate. Major postoperative complications such as myocardial infarction and deep venous thrombosis are covered by most workers’ compensation systems; thus they should be rated, and the rating should be combined with the rating for the injury. The article discusses ratings for arachnoiditis; discitis; bowel, bladder, and sexual impairment; pseudarthrosis following attempted fusion; and chronic pain syndrome (note that it is never appropriate to rate an individual for both a spinal injury and chronic pain syndrome). The AMA Guides recognizes that rating spinal impairment is challenging and may change over time.
Tools and Resources: Lower Extremity Conditions: Combination vs Duplication
Authors: Lea Randall , Shaw William
Published: December 2020

This article discusses uses of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) in Australia and New Zealand. In addition to its use in the United States, the AMA Guides also is used in Australia, New Zealand, Canada, and some European countries such as Ireland, the Netherlands, and Norway. Use of the AMA Guides varies from country to country, depending on local workers’ compensation or personal injury legislation. In Australia, the AMA Guides is used in various state systems, but the editions used or recommended may differ. Often, cases in which the impairment predates December 1988 (when the current Commonwealth Workers’ Compensation Act became effective) are assessed in terms of the AMA Guides, Fourth Edition. Although many physicians use the Fourth Edition, others refer to the Table of Disabilities (Div 4/S66 of the New South Wales Workers’ Compensation Act) and Victoria prefers the AMA Guides, Second Edition. At the federal level, Australia has adopted the Guide to the Assessment of the Degree of Permanent Impairment (1989 but under revision at the time of writing). In New Zealand, the Accident Compensation Commission officially adopted use of the AMA Guides, Fourth Edition, in 1997.
Instability of the Wrist
Authors: Cohen Mark S.
Published: December 2020

Wrist trauma can disrupt the ligamentous support between the carpal bones, leading to instability of the carpus and pain, loss of motion, and loss of function. The most common patter of wrist instability is scapholunate instability that results from a fall on the outstretched hand, possibly with twisting motion. The second most common carpal instability pattern is that between the triquetrum and the lunate, termed lunotriquetral instability. The AMA Guides to the Evaluation of Permanent Impairment directs physicians to use frontal and lateral roentgenographic projections of the wrist to evaluate carpal instabilities and to rate impairment as mild, moderate, or severe. Carpal height can be used to assess impairment. Carpal translation is a medial or lateral translation of the entire carpus on the forearm (radius and ulna). Arthritic changes also can impair wrist stability and are seen roentgenographically as loss of joint space in the wrist. The degree of carpal instability lies on a continuum of loss of carpal bone support and amount of collapse, and, although little absolute difference exists between a 28-degree radiolunate angle and a 31-degree measurement, these two measurements yield different impairment ratings. Also, some forms of instability (eg, dynamic carpal instability) appear roentgenographically if the wrist is stressed, and examiners have freedom to assign impairment without reproducible, objective measures.
Impairment Tutorial: The Combined Values Chart
Authors: Brigham Christopher R.
Published: December 2020

Impairment values are more often combined than added, and the Combined Values Chart in the AMA Guides to the Evaluation of Permanent Impairment can be used to calculate the combined value of two numbers. The values are derived from the formula A + B(1 – A) = the combined value of A and B, where A and B are the decimal equivalents of the impairment ratings. This mathematically prevents an estimate of impairment greater than 100%. With smaller numbers, the combined value may equal the arithmetic sum of the 2 numbers. Impairments of different organ systems are converted to whole person impairment ratings before combining. In most lower extremity impairment cases only one evaluation method is used, but certain circumstances justify combining impairments. Examples in the lower extremity include diagnosis-based estimates with short leg, degenerative joint disease (in the case of fractures in and about joints), and neurologic loss. Combining vs adding can be confusing, but one can nearly always combine, with the following exceptions for the musculoskeletal system: range of motion (ROM) deficits within an upper extremity; ROM deficits of the thumb; total hand impairment; rating hip or knee replacement results; and ROM deficits of the spine at a specific level.
Clinical Update: Measuring Shoulder Joint Motion
Authors: Brigham Christopher R.
Published: December 2020

Accurate measurement of shoulder motion is critical in assessing impairment following shoulder disorders. To this end, measuring and recording joint motion are important steps in diagnosing, determining the severity and progression of a disorder, assessing the results of treatment, and evaluating impairment. Shoulder movement usually is composite rather than in a single plane, so isolating single movements is challenging. Universal goniometers with long arms are used to measure shoulder motion, and testing must be performed and recorded consistently. Passive motion may be carried out cautiously by the examiner; two measurements of the same patient by the same examiner should lie within 10° of each other. Shoulder extension and flexion are illustrated. Maximal flexion of the shoulder also includes slight external rotation and abduction, and controlling or eliminating these components during evaluation is challenging. Abduction and adduction are illustrated. Deficits in external rotation may occur in patients who have undergone reconstructive procedures with an anterior approach; deficits in internal rotation may result from issues with shoulder instability. The authors recommend recording the shoulder's range of motion measurements according to the Upper Extremity Impairment Evaluation Record in the AMA Guides to the Evaluation of Permanent Impairment, Fourth Edition.
Letter to the Editor: The Continuing Challenge of Evaluating RSD Impairment and Disability
Authors: Knobler Robert L. , Brooks Charles N. , Ensalada Leon H. , Talmage James B. , Brigham Christopher R.
Published: December 2020

The author of the two-part article about evaluating reflex sympathetic dystrophy (RSD) responds to criticisms that a percentage impairment score may not adequately reflect the disability of an individual with RSD. The author highlights the importance of recognizing the difference between impairment and disability in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides): impairment is the loss, loss of use, or derangement of any body part, system, or function; disability is a decrease in or the loss or absence of the capacity to meet personal, social, or occupational demands or to meet statutory or regulatory requirements because of an impairment. The disparity between impairment and disability can be encountered in diverse clinical scenarios. For example, a person's ability to resume occupational activities following a major cardiac event depends on medical, social, and psychological factors, but nonmedical factors appear to present the greatest impediment and many persons do not resume work despite significant improvements in functional capacity. A key requirement according to the AMA Guides is objective documentation, and the author agrees that when physicians consider the disability evaluation of people, more issues than those relating to the percentage loss of function should be considered. More study of the relationships among impairment, disability, and quality of life in patients with RSD are required.
Letter to the Editor: Assessing Mild Traumatic Brain Injury
Authors: Mandel Steven , Maitz Edward A. , Gordon John E. , Massari David , Esposito Joely , Mandel Heidi
Published: December 2020

The authors respond to an article, Assessing Mild Traumatic Brain Injury, that appeared in the November/December 1998 issue of the Guides Newsletter. The authors of the article referred to several shortcomings of neuropsychological assessment; specifically, they questioned the ecological (real-world) validity of such testing for less severely impaired individuals. The authors of the letter agree that neuropsychological testing may underestimate problems with attention, concentration, and memory that patients experience in real-world settings. The letter writers identify research that indicates a correlation between neuropsychological test findings and an individual's ability to perform in a work environment, and they emphasize the need to consider the individual's environment before determining the degree of functional impairment based on neuropsychological test findings. The letter writers also suggest that evaluators use recently developed measures of malingering in test batteries, and they dispute the existence of an “overreliance on technicians for test administration.” The authors of the original article respond that questions of ecological validity are less relevant when neuropsychologists do not generalize from test scores to real-world performance. The authors of the article mention their work in detecting malingering and report only preliminary and variable success. Finally, the authors of the original article note that limited space precluded discussion of all the issues raised by the letter's authors.
Challenge of Evaluating Multiple Chemical Sensitivity
Authors: Ranavaya Mohammed I.
Published: December 2020

Impairment and disability resulting from claims of multiple chemical sensitivity (MCS) challenge independent medical examiners because of polemics associated with the syndrome, and the mainstream medical community has questioned its very existence as a medical disease entity. Since the syndrome was described in 1952, MCS has had many names, including universal allergy, total allergy syndrome, ecologic illness, 20th century disease, and chemical AIDS. Epidemiologic data show that a higher proportion of females (up to 88%) suffer from MCS, and the percentage of unemployment among MCS sufferers may be as high as 85%. The best explanation to date for MCS is that it is an illness belief system manifested by culturally shaped illness behavior. Several distinguished scientific organizations, including the AMA, conclude that there is no scientific evidence to support the MCS concept of a physiologic exposure–disease relationship; the proposed diagnostic tests and treatments have not been shown to have value; and MCS should not be a recognized clinical syndrome. Impairment evaluations should follow the guidelines in Chapters 1 and 2 of the AMA Guides to the Evaluation of Permanent Impairment. Evaluators must recognize that MCS claimants often present with comorbid psychiatric conditions, and iatrogenic disability also is a concern among MCS patients.
Upper Extremity Impairment Evaluation: Fifth Edition Revisions
Authors: Brigham Christopher R. , Brooks Charles N.
Published: December 2020

Chapter 16, The Upper Extremities, in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, presents several changes from the Fourth Edition. The changes are minor compared to those in Chapter 15, The Spine, but are more significant than those in Chapter 17, The Lower Extremities. This article examines some of the most important revisions, notably the more rigorous standards for upper extremity evaluation, the requirement to compare motion findings to those of the contralateral extremity, entrapment neuropathies evaluation, and strength assessment. The principles of assessment are essentially unchanged in the AMA Guides, Fifth Edition, and Section 16.1c now clarifies the process of combining assessments. The Fifth Edition provides more direction about how to measure motion, but the values for motion deficits remain the same as in the Fourth Edition. Among important changes in the Fifth Edition regarding rating peripheral nerve impairment are: grading sensory deficits, rating entrapment neuropathies, and evaluating complex regional pain syndrome. The most noteworthy changes in assessing impairment due to other disorders are the following: explicit directions about how to rate these other disorders; elimination of rating for joint crepitation; inclusion of new radiographic criteria for rating carpal instability, and introduction of a new process for rating shoulder instability. The discussion of strength is expanded in the Fifth Edition of the AMA Guides.
Sexual Dysfunction Impairment
Authors: Hirsch Irvin H. , Mandel Steven , Brigham Christopher R.
Published: December 2020

Male sexual dysfunction (MSD) and female sexual dysfunction (FSD) may be of multifactorial etiology; rating these disorders heretofore has been based on subjective, patient-reported criteria. This article discusses the process of determining sexual disability by incorporating objective, laboratory-based data in order to render more reliable and valid determinations, including whether the patient has received appropriate treatment and is at maximum medical improvement. MSD is of organic, psychogenic, mixed, or indeterminate cause, and identification of specific MSD etiology can be made via a thorough sexual and medical history, physical examination, and tailored laboratory testing. Routine laboratory studies should include complete blood count, serum chemistry, lipid profile, and serum free/total testosterone and prolactin levels. Using the history and physical examination and laboratory studies, evaluators can differentially diagnose more than 80% of patients as having either organic or psychogenic MSD. Objective laboratory studies for MSD include nocturnal penile tumescence, duplex Doppler ultrasound, and neurosensory testing. FSD is a prevalent, age-related women's health issue that reportedly affects up to half of women older than 50. FSD evaluation requires a comprehensive sexual and medical history as well as physical examination, pelvic examination, hormonal profile, and an evaluation by a sex therapist. Laboratory testing is not yet fully defined but may include measurements of genital blood flow, vaginal pH and compliance, and genital vibratory sensory threshold determination.
Combining Values
Authors: Brigham Christopher R.
Published: December 2020

To account for the effects of multiple impairments, evaluating physicians must provide a summary value that combines multiple impairments so the whole person impairment is equal to or less than the sum of all the individual impairment values. A common error is to add values that should be combined and typically results in an inflated rating. The Combined Values Chart in the AMA Guides to the Evaluation of Permanent Impairment, Fifth Edition, includes instructions that guide physicians about combining impairment ratings. For example, impairment values within a region generally are combined and converted to a whole person permanent impairment before combination with the results from other regions (exceptions include certain impairments of the spine and extremities). When they combine three or more values, physicians should select and combine the two lowest values; this value is combined with the third value to yield the total value. Upper extremity impairment ratings are combined based on the principle that a second and each succeeding impairment applies not to the whole unit (eg, whole finger) but only to the part that remains (eg, proximal phalanx). Physicians who combine lower extremity impairments usually use only one evaluation method, but, if more than one method is used, the physician should use the Combined Values Chart.
Legal Update: Rating Pain: Rating Pain: Chapter 18 and Workers’ Compensation
Authors: Mueller Kathryn
Published: December 2020

The first four editions of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) used the range of motion (ROM) method and derived impairment percentages. This method is reliable and works well to rate finger joint injuries such as fractures or sprains that cause reduced finger joint ROM, but it frequently underestimates the functional difficulty (impairment) caused by tendon injuries that restrict the excursion of tendons. For this reason, the AMA Guides, Fifth Edition, introduced a second method to rate ROM in fingers, the total active motion (TAM) method. When an evaluator calculates the patient's impairment using the traditional method from the first four editions of the AMA Guides, the impairment percentage is likely to underestimate the patient's “real world” difficulty or function; the TAM method measures flexion when the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints are in full simultaneous flexion, and it measures extension when all three joints are in full simultaneous extension. Based on an example and using the Combined Values Chart in the Fifth Edition and the traditional method (the only method allowed in the first four editions), one would assess a 16% impairment of the digit; using the TAM method now available in the Fifth Edition, the impairment is more appropriately estimated at 61%.
Natural Rubber Latex Allergy
Authors: Musmand Jon , Brigham Christopher R.
Published: December 2020

Natural rubber latex (NRL) allergy is discussed in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, in Section 8.5, Natural Rubber Latex Allergy, and refers to an IgE-mediated immediate hypersensitivity reaction to one or more protein allergens in latex devices, especially gloves. Among health care workers, NRL allergy is the most common cause of occupationally induced rhinoconjunctivitis and asthma, and clinical manifestations range from dermatitis and contact urticaria, allergic rhinoconjunctivitis, and asthma, to anaphylaxis. Evaluating physicians must be cognizant that a suggestive clinical history is necessary but not sufficient to diagnose NRL allergy, and FDA-approved NRL-specific IgE serum tests may have sensitivity as low as 75% and up to 27% false-positive results. No FDA-approved skin test reagent is available for testing. In evaluating impairment due to NRL allergy, evaluators should determine if the individual's problem can be resolved by avoidance of wearing latex gloves. Most patients who have asthma or air passage disruption impairment due to NRL have problems with bronchospasm only when they are exposed, and these patients may not necessarily have any ratable impairment due to NRL (but individuals who have atopic dermatitis may have ongoing symptoms due to pre-existing allergic rhinitis). Efforts to decrease the incidence of NRL allergy have been encouraging, and some patients diagnosed with NRL allergy may return to work in a latex-safe environment.
Lumbosacral Corticospinal and Cauda Equina Injuries
Authors: Brigham Christopher R.
Published: December 2020

Spinal cord injuries can affect many functions, interfere with the activities of daily living, and result in significant impairment. This article reviews cauda equina and conus medullaris syndromes, examines the process of rating corticospinal tract damage, and provides a case example. In the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), cauda equina syndrome refers to the polyradicular symptomatology resulting from single- or double-level compression of the lumbosacral nerve roots in the dural sac and may include low-back pain, saddle anesthesia, sciatica, motor weakness of the lower extremities, chronic paraplegia, and bladder, bowel, or sexual dysfunction. Conus medullaris syndrome is caused by a compression injury at T12 or L1, and flaccid paralysis of the legs and anal sphincter with variable sensory deficits may be present. The AMA Guides, Fifth Edition, includes Table 15-6, Rating Corticospinal Tract Impairment, which presents criteria for rating the neurological impairment. The physician must determine which systems are impaired, then which categories are appropriate and what value within a range should be selected. This requires the use of judgment because large ranges are provided. Spinal injuries that involve corticospinal tract damage are assessed using the Diagnosis-related estimate (DRE) method, but the range-of-motion method can be used in specified situations. A case example demonstrates how to assess neurological impairment.
Impairment Rating in Traumatic Brain Injury
Authors: Zasler Nathan D. , Martelli Michael F. , Bender Mark C.
Published: December 2020

Traumatic brain injury (TBI) usually is described in terms of the severity of the initial neurologic insult and is defined by the Glasgow Coma Scale (GCS) score; the presence and duration of amnesia (retrograde and anterograde); and the presence and duration of alteration in or loss of consciousness. According to the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), the evaluating physician should consider the following: narrative history; most recent clinical evaluation; assessment of current clinical status; plans for future treatment; diagnosis and clinical impressions; and estimated time for full or partial recovery. Individuals who present with brain disease or damage also may experience impairments in several parts of the body or nervous system. Physicians who evaluate TBI must be familiar with numerous relevant sections in Chapter 13, The Central and Peripheral Nervous System, as shown in a table in the article. Individual impairments can be combined using the Combined Values Chart in the AMA Guides. Also, the AMA Guides requires the examiner to grade mental status impairment based on the individual's ability to perform activities of daily living and may require neuropsychological testing. The evaluation of TBI impairment and disability is by no means a simple undertaking for any clinician, and evaluators must familiarize themselves with disability and impairment evaluation protocols and their limitations.
Apportionment Analysis
Authors: Brigham Christopher R. , Roth Henry J.
Published: December 2020

In the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, apportionment refers to the “distribution or allocation of causation among multiple factors that caused or significantly contributed to the injury or disease and existing impairment,” and causation is the process of determining “an identifiable factor (eg, accident or exposure to hazards) that results in a medically identifiable condition.” Causality assessment requires a clear understanding and discussion of causal relationships; apportionment analysis refers to the extent to which factors may have contributed to a particular effect or impairment. A causal relationship requires three elements—a cause, an effect, and a specific relationship between them—the absence of any one of which disqualifies causality. Apportionment is an estimate of the degree to which each of various medically probable occupational or nonoccupational factors contributed to a particular impairment. The unique legal standards of compensability and apportionment vary by locality, and the apportionment of disability involves assessing the functional effects of different injuries over time. Evaluators should consider the effect of using the Combined Values Chart on the final assessment and must carefully distinguish factors that are combined vs those that are added or subtracted. A sidebar discusses important changes to the State of California's Workers’ Compensation.
Permanent Impairment—Disability Rating Study: Impact of the AMA Guides on Permanent Disability Ratings in the State of California
Authors: Brigham Christopher R , Bellusci Dave , Beuret Terry
Published: December 2020

Following passage of California Senate Bill No. 899 (SB 899) in 2005, disability in California is rated using the AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides), Fifth Edition. The authors compare the disability ratings under the new law to those under the pre-2005 California Permanent Disability Rating Schedule. The authors reviewed 267 cases, of which 250 were ratable, and the ratings of expert reviewers who used the AMA Guides were compared with the ratings of the pre-2005 evaluations (the reviewers who used the AMA Guides to examine the earlier evaluations were blinded to the results of the earlier evaluations). The average permanent disability ratings were 22% under the old schedule and 6.4% under the new schedule, possibly because the current AMA Guides bases impairment primarily on objective data, not subjective complaints and opinions regarding work restrictions. The AMA Guides also has changed certain tests and minimized others (eg, range of motion and grip, respectively). Study limitations include sample selection and differences between pre-2005 evaluators and the highly proficient experts who used the AMA Guides for the present study. The authors conclude that this study shows ratings that are lower than those typically given by treating physicians and other examiners, and they note potential causes of the discrepancies, including evaluation by physicians who are not yet expert and experienced in using the AMA Guides.
Questions and Answers
Authors: Talmage James B. , Melhorn J. Mark , Brigham Christopher
Published: December 2020

This Case Exercise presents and critiques the case of a 52-year-old right hand dominant male who received a Qualified Medical Evaluation regarding his right wrist injury; the examination report includes several erroneous conclusions that are discussed following the case presentation: The examinee is a retail clerk at a liquor store who complained of progressive right hand pain and numbness in 2004; the examination took place in 2006, and the examiner reports an extensive list of relevant reports reviewed. Because the patient declines a carpal tunnel release procedure, the physician declares the patient to be at maximum medical improvement and uses tables in the AMA Guides to the Evaluation of Permanent Impairment, Fifth Edition, to rate 19% whole person impairment and to apportion 90% to work activities. Readers can pause at this point to evaluate the case and then compare their results with the analysis. The author notes that the report does not discuss activities of daily living and does not report in detail the results of physical testing. Nor does the written report correctly explain how the rating was performed, with a detailed discussion of the rating process with reference to specific criteria and to specific tables, figures, and page numbers. As written, the report provides inadequate information to grade sensory or motor deficits and suggests the use of subjective reports, not objective findings.
Impairment Tutorial: Neurological Impairment Evaluation: Overview of Sixth Edition Approaches
Authors: Direnfeld Lorne , Brigham Christopher R. , Genovese Elizabeth
Published: December 2020

The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), does not provide a Diagnosis-based estimate of impairment due to syringomyelia, a disorder in which a cyst (syrinx), develops within the central spinal cord and destroys neural tissue as it expands. The AMA Guides, however, does provide an approach to rating a syringomyelia based on objective findings of neurological deficits identified during a neurological examination and demonstrated by standard diagnostic techniques. Syringomelia may occur after spinal cord trauma, including a contusion of the cord. A case study illustrates the rating process: The case patient is a 46-year-old male who fell backwards, landing on his upper back and head; over a five-year period he received a T5-6 laminectomy and later partial corpectomies of C5, C6, and C7, cervical discectomy C5-6 and C6-7; iliac crest strut graft fusion of C5-6 and C6-7; and anterior cervical plating of C5 to C7 for treatment of myelopathy; postoperatively, the patient developed dysphagia. The evaluating physician should determine which conditions are ratable, rate each of these components, and combine the resulting whole person impairments without omission or duplication of a ratable impairment. The article includes a pain disability questionnaire that can be used in conjunction with evaluations conducted according to Chapter 3, Pain, and Chapter 17, The Spine.
Impairment Ratings: Observations Based on Review of More Than 6,000 Cases
Authors: Brigham Christopher R. , Uejo Craig , Dilbeck Leslie , Uehlein W. Frederick
Published: December 2020

The goal of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) is “to provide a standardized, objective approach to evaluating medical impairment,” resulting in reliable, reproducible impairment ratings with high levels of interrater consistency. The authors reviewed 6233 impairment ratings that took place between July 2006 and January 2010 that reflected 11991 ratable diagnoses and found poor interrater reliability (78% disagreement rate). A previous study conducted in 2005 was published in The Guides Newsletter (May/June and July/August 2006 issues) and evaluated 2100 cases for impairment rating review and found that 80% of ratings resulted in different outcomes when reviewed by an expert reviewer. The current study found an average difference of 10.0% whole person permanent impairment (WPI) between the original WPI ratings calculated with the fifth edition and the revised ratings after expert review; the 2005 study found a similar difference, 9.9% WPI. The reasons for poor interrater reliability with fifth edition ratings are many and include inaccurate clinical and causation analysis, failure to use the AMA Guides appropriately, and bias. The error rate in this study was lowest for patients in Hawaii, where the AMA Guides, Fifth Edition, has been used since 2001, only a relatively small number of authors who have been trained in the use of the AMA Guides perform the evaluations, there is no systematic coaching by attorneys about how to use the AMA Guides, and impairment ratings are routinely reviewed to determine their accuracy.
Causes of Erroneous Fifth Edition Ratings
Authors: Brigham Christopher R. , Auerbach Marjorie Eskay , Talmage James B. , Barth Robert , Uejo Craig , Melhorn Mark , Dilbeck Leslie
Published: December 2020

The application of the processes defined in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) should result in reliable impairment ratings, ie, reproducible impairment ratings when the AMA Guides is applied appropriately. This article reviews some of the causes of erroneous impairment ratings based on misapplication of the fifth edition. The first two chapters of the AMA Guides provide the principles of assessing impairment, a key of which is that physicians must be independent and unbiased. Treating physicians cannot be unbiased because they inherently have a patient advocacy role, and they may use approaches that will increase the patient's impairment rating. Clinical and causation errors are common in evaluations; the greatest source of error is examiner inexperience. Evaluations should take place only when the patient is at maximum medical improvement, and evaluators must distinguish between impairment related to the alleged injury and that due to other injury, degenerative disease, or illness, not self-reports. A box shows common causes of erroneous impairment ratings based on the fifth edition. Both the rating physician and the party requesting the rating should recognize the high likelihood of error and should become knowledgeable about the AMA Guides, and the evaluating physician should have had formal training regarding use of the AMA Guides and should possess demonstrated competency in assessing impairment.
Case Example: Spinal Impairment: California Case
Authors: Brigham Christopher R. , Talmage James , Eskay-Auerbach Marjorie , Stevens Patty
Published: December 2020

Accurate, unbiased impairment ratings must follow the procedures and processes defined in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). This Case Example from California in 2010 illustrates some problems that result from rating a lumbar injury as if it were an inguinal hernia. At critical issue in this case is whether sufficient clinical findings were available to support a rating for lumbar radiculopathy; the evaluating (and also, treating) physician gave the patient the benefit of doubt with a rating of “nonverifiable radicular (nerve root) pain” but did not address the patient's ability to perform activities of daily living (ADLs). The State of California Workers’ Compensation Appeals Board (WCAB) affirmed on August 20, 2010, that the State relies on the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, to determine impairment. WCAB noted that “medical opinion that departs unreasonably from a strict application of the [AMA] Guides can be challenged, and it would not be acceptable as substantial evidence.” In the present case, the rating provided by the evaluating physician was based on an obviously inapplicable section of the AMA Guides and is not appropriate. Evaluators must use the procedures defined in the AMA Guides, perform evaluations according to the standards in the AMA Guides, and do so without bias.
Prescription Narcotics: An Obstacle to Maximum Medical Improvement
Authors: Barth Robert J.
Published: December 2020

The increasingly severe epidemic of overuse, abuse, and death involving prescription narcotics is of specific relevance to workers’ compensation, which is the primary venue for use of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). Because of the scientific knowledge base regarding prescription narcotics for chronic benign pain, evaluators may question how any patient could credibly be considered to have reached maximum medical improvement (MMI) if that patient has a prescription for a narcotic. Hyperalgesia associated with narcotics does not appear to be permanent, but evidence indicates that prescription narcotics cause significant problems in addition to worsening pain: endocrine disruption, sleep abnormalities, immune system compromise, cognitive impairment, substance abuse, and generalized ill health and disability, among others. Evaluators may worry that refusing to evaluate a person who is not at MMI because they are receiving a prescription narcotic may unintentionally delay resolution of the person's claim. In a more efficient approach, an evaluator could undertake the complete evaluation process, including creating an impairment rating, and document in the evaluation report that the rating is being provided despite reasons to be concerned that the impairment is artificially inflated in a nonpermanent way by the unjustifiable narcotic prescription. Evaluators should not state that the impairment from side effects of the opioids is permanent.
Case Example: Rating Lower Extremity Injuries Involving Multiple Diagnoses in One Region Using the AMA Guides, Sixth Edition
Authors: Uejo Craig , Brooks Charles N.
Published: December 2020

Injuries to a specific region can result in more than one diagnosis. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, states that, in most cases, only one diagnosis in a region (eg, hip, knee, or foot/ankle) is appropriate. If a patient has two significant diagnoses (eg, ankle instability and posterior tibial tendonitis), the examiner should use the diagnosis with the highest impairment rating in that region that is causally related. The rationale for this principle is that the rating for the diagnosis with the highest impairment also encompasses the functional loss of diagnoses with lesser impairment; it also attempts to prevent the use of multiple diagnoses to inflate the impairment rating. In the Case Example, a 62-year-old female teacher was tripped and fell on her left knee at work; the diagnoses were osteoarthritis and medial collateral ligament sprain. Despite activity modification and extensive treatment, she reported only moderate improvement; an orthopedic surgeon was consulted and recommended total knee replacement (TKR), but the patient declined and decided to retire with the option to consider TKR later, if necessary. Causation is an issue because tricompartmental arthritis clearly was not caused by the fall, but one wonders about the role of the individual's arthritis is unclear. Evaluators should be aware that such apportionment varies by jurisdiction.