Vestibular Deficits following Youth Concussion Corwin, Daniel J., MD; Wiebe, Douglas J., PhD; Zonfrillo, Mark R., MD, MSCE ...
The Journal of pediatrics,
05/2015, Letnik:
166, Številka:
5
Journal Article
Recenzirano
Odprti dostop
Objective To characterize the prevalence and recovery of pediatric patients with concussion who manifest clinical vestibular deficits and to describe the correlation of these deficits with ...neurocognitive function, based on computerized neurocognitive testing, in a sample of pediatric patients with concussion. Methods This was a retrospective cohort study of patients ages 5-18 years with concussion referred to a tertiary pediatric hospital-affiliated sports medicine clinic from July 1, 2010 to December 31, 2011. A random sample of all eligible patient visits was obtained, and all related visits for those patients were reviewed. Results A total of 247 patients were chosen from 3740 eligible visits for detailed review and abstraction; 81% showed a vestibular abnormality on initial clinical examination. Those patients with vestibular signs on the initial examination took a significantly longer time to return to school (median 59 days vs 6 days, P = .001) or to be fully cleared (median 106 days vs 29 days, P = .001). They additionally scored more poorly on initial computerized neurocognitive testing, and it took longer for them to recover from neurocognitive deficits. Those patients with 3 or more previous concussions had a greater prevalence of vestibular deficits, and it took longer for those deficits to resolve. Conclusion Vestibular deficits in children and adolescents with a history of concussion are highly prevalent. These deficits appear to be associated with extended recovery times and poorer performance on neurocognitive testing. Further studies evaluating the effectiveness of vestibular therapy on improving such deficits are warranted.
Objectives
The most widely used and studied neurostimulation procedure for medically refractory epilepsy is vagus nerve stimulation (VNS) Therapy. The goal of this study was to develop a ...computational model for improved understanding of the anatomy and neurophysiology of the vagus nerve as it pertains to the principles of electrical stimulation, aiming to provide clinicians with a systematic and rational understanding of VNS Therapy.
Materials and methods
Computational modeling allows the study of electrical stimulation of peripheral nerves. We used finite element electric field models of the vagus nerve with VNS Therapy electrodes to calculate the voltage field for several output currents and studied the effects of two programmable parameters (output current and pulse width) on optimal fiber activation.
Results
The mathematical models correlated well with strength–duration curves constructed from actual patient data. In addition, digital constructs of chronic versus acute implant models demonstrated that at a given pulse width and current combination, presence of a 110‐μm fibrotic tissue can decrease fiber activation by 50%. Based on our findings, a range of output current settings between 0.75 and 1.75 mA with pulse width settings of 250 or 500 μs may result in optimal stimulation.
Conclusions
The modeling illustrates how to achieve full or nearly full activation of the myelinated fibers of the vagus nerve through output current and pulse width settings. This knowledge will enable clinicians to apply these principles for optimal vagus nerve activation and proceed to adjust duty cycle and frequency to achieve effectiveness.
Background We sought to determine the prevalence of and clinical variables associated with learned helplessness, a psychologic state characterized by reduced motivation, difficulty in determining ...causality, and depression, in family members of patients admitted to ICUs. Methods We conducted an observational survey study of a prospectively defined cohort of family members, spouses, and partners of patients admitted to surgical, medical, and trauma ICUs at a large academic medical center. Two validated instruments, the Learned Helplessness Scale and the Perceived Stress Scale, were used, and self-report of patient clinical characteristics and subject demographics were collected. Results Four hundred ninety-nine family members were assessed. Of these, 238 of 460 (51.7%) had responses consistent with a significant degree of learned helplessness. Among surrogate decision-makers, this proportion was 50% (92 of 184). Characteristics associated with significant learned helplessness included grade or high school education (OR, 3.27; 95% CI, 1.29-8.27; P = .01) and Perceived Stress Scale score > 18 (OR, 4.15; 95% CI, 2.65-6.50; P < .001). The presence of a patient advance directive or do not resuscitate (DNR) order was associated with reduced odds of significant learned helplessness (OR, 0.56; 95% CI, 0.32-0.98; P = .05). Conclusions The majority of family members of patients in the ICU experience significant learned helplessness. Risk factors for learned helplessness include lower educational levels, absence of an advance directive or DNR order, and higher stress levels among family members. Significant learned helplessness in family members may have negative implications in the collaborative decision-making process.
Abstract Objective To describe the prevalence of breastfeeding and sleep location practices among US mothers and the factors associated with these behaviors, including advice received regarding these ...practices. Methods A nationally representative sample of 3218 mothers who spoke English or Spanish were enrolled at a sample of 32 US birth hospitals between January 2011 and March 2014. Results Exclusive breastfeeding was reported by 30.5% of mothers, while an additional 29.5% reported partial breastfeeding. The majority of mothers, 65.5%, reported usually room sharing without bed sharing, while 20.7% reported bed sharing. Compared to mothers who room shared without bed sharing, mothers who bed shared were more likely to report exclusive breastfeeding (adjusted odds ratio 2.46, 95% confidence interval 1.76, 3.45) or partial breastfeeding (adjusted odds ratio 1.75, 95% confidence interval 1.33, 2.31). The majority of mothers reported usually room sharing without bed sharing regardless of feeding practices, including 58.2% of exclusively breastfeeding mothers and 70.0% of nonbreastfeeding mothers. Receiving advice regarding sleep location or breastfeeding increased adherence to recommendations in a dose response manner (the adjusted odds of room sharing without bed sharing and exclusive breastfeeding increased as the relevant advice score increased); however, receiving advice regarding sleep location did not affect feeding practices. Conclusions Many mothers have not adopted the recommended infant sleep location or feeding practices. Receiving advice from multiple sources appears to promote adherence in a dose response manner. Many women are able to both breastfeed and room share without bed sharing, and advice to adhere to both of these recommendations did not decrease breastfeeding rates.
Gliomas are notoriously aggressive, malignant brain tumors that have variable response to treatment. These patients often have poor prognosis, informed primarily by histopathology. Mathematical ...neuro-oncology (MNO) is a young and burgeoning field that leverages mathematical models to predict and quantify response to therapies. These mathematical models can form the basis of modern "precision medicine" approaches to tailor therapy in a patient-specific manner. Patient-specific models (PSMs) can be used to overcome imaging limitations, improve prognostic predictions, stratify patients, and assess treatment response in silico. The information gleaned from such models can aid in the construction and efficacy of clinical trials and treatment protocols, accelerating the pace of clinical research in the war on cancer. This review focuses on the growing translation of PSM to clinical neuro-oncology. It will also provide a forward-looking view on a new era of patient-specific MNO.
Objective To assess the role of maternal attitudes and other factors associated with infant vaccination status. Study design Data on reported vaccination status were analyzed from a nationally ...representative prospective survey of mothers of 2- to 6-month-old infants. Weighted univariate and multiple logistic regression analyses were conducted. Latent profile analysis of mothers reporting nonimmunized infants identified distinct groups, Results Of 3268 mothers, 2820 (weighted 86.2%), 311 (9.1%), and 137 (4.7%), respectively, reported their infant had received all, some, or no recommended vaccinations for age. Younger infants and infants with younger mothers were more likely to have received no vaccinations. Mothers with neutral and negative attitudes toward vaccination were >3 (aOR 3.66, 95% CI 1.80-7.46) and 43 times (aOR 43.23, 95% CI 20.28-92.16), respectively, more likely than mothers with positive attitudes to report their infants had received no vaccinations. Two subgroups of mothers reporting that their infants had received no vaccinations were identified: group A (52.5%) had less than positive attitudes and less than positive subjective norms about vaccination (ie, perceived social pressure from others); group B (47.5%) had positive attitudes and positive subjective norms. Group A mothers were more likely to be white (76.1% vs 48.3%, P = .002), more educated (43.5% vs 35.4% college or higher, P = .02), and to exclusively breastfeed (74.9% vs. 27.3%, P < .001). Conclusions Although access barriers can result in nonvaccination, less than positive maternal attitude toward vaccination was the strongest predictor. Strategies to improve vaccination rates must focus on both improved access and better understanding of factors underlying maternal attitudes.
Abstract Objective To explore existing barriers and challenges to Early Intervention (EI) referral, enrollment, and service provision for very low birth weight (VLBW; <1500 g) infants. Methods We ...conducted 10 focus groups with parents of VLBW children (n = 44) and 32 interviews with key informants from EI (n = 7), neonatal intensive care units (n = 17), and outpatient clinics (n = 8) at 6 sites in 2 states. We used grounded theory to identify themes about gaps in services. Results Both parents and providers found EI helpful. However, they also identified gaps in the current EI system at the levels of eligibility, referral, family receptivity, and service provision and coordination with medical care. Inadequate funding and variable procedures for evaluation may affect children's eligibility. Referrals can be missed as a result of simple oversight or communication failure among hospitals, EI, and families; referral outcomes often are not formally tracked. Families may not be receptive to services as a result of wariness of home visits, social stressors, denial about potential developmental delays, or lack of understanding of the benefits of EI. Once a child is deemed eligible, services may be delayed or terminated early, and EI providers may have little specialized training. Communication and coordination with the child's medical care team is often limited. Conclusions Systemic barriers, including funding and staffing issues, state and federal regulations, and communication with families and medical providers, have led to gaps in the EI system. The chronic care model may serve as a framework for integrating community-based interventions like EI with medical care for VLBW children and other vulnerable populations.
Abstract Purpose Healthcare-associated infections (HCAIs) impact 10% of hospitalized patients. Some of these infections result from bacterial cross contamination and poor compliance with guidelines ...(Pittet D: Compliance with hand disinfection and its impact on hospital-acquired infections. J HospInfect 48 Suppl A:S40-S46, 2001); (Watanakunakorn C, Wang C, Hazy J: An observational study of hand washing and infection control practices by healthcare workers. Infect Control Hosp Epidemiol 19:858-860, 1998). Contamination of provider hands may be a modifiable risk factor. We instituted a novel multimodal system designed to improve hand hygiene by ICU providers. Materials and Methods A before and after study design was used to evaluate the impact on the incidence of CRBSI and VAP of a multi-modal program incorporating education, performance feedback, and a body worn hand hygiene device. Compliance was communicated quarterly. Primary outcomes were CRBSIs and VAPs per 1,000 line days or per 1,000 ventilator days and compliance rates. Secondary outcomes were hospital length of stay and mortality. Results A total of 1, 262 and 1,331 patients were evaluated during consecutive 12 month periods. VAP per 1000 vent days were significantly reduced after introduction of the program 3.7 vs. 6.9 P < .01. The reduction in CRBSI per 1000 line days was not significant 1.5 vs. 2.6, P = .09. Observed hand hygiene increased during the study period. There was no significant difference in mortality. Conclusions A novel multi-modal hand hygiene system resulted in a reduction in VAP. Provider hand contamination during patient care in the ICU is a modifiable risk factor for reducing ventilator associated pneumonias.
Objective To report longitudinal home recordings of hemoglobin O2 saturation by pulse oximetry (Sp o2 ) during unperturbed sleep in preterm and term infants. Study design We recorded continuous pulse ...oximetry during the first 3 minutes of each hour of monitor use (nonevent epochs) for 103 preterm infants born at <1750 g and ≤34 weeks postmenstrual age (PMA), and 99 healthy term infants. Results Median baseline Sp o2 was approximately 98% for both the preterm and term groups. Episodes of intermittent hypoxemia occurred in 74% of preterm and 62% of term infants. Among infants with intermittent hypoxemia, the number of seconds/hour of monitoring <90% Sp o2 was initially significantly greater in the preterm than the term group and declined with age at a similar rate in both groups. The 75th to 95th percentiles for seconds/hour of Sp o2 <90% in preterm infants were highest at 36 weeks PMA and progressively decreased until 44 weeks PMA, after which time they did not differ from term infants. Conclusions Clinically inapparent intermittent hypoxemia occurs in epochs unperturbed by and temporally unrelated to apnea or bradycardia events, especially in preterm infants at 36 to 44 weeks PMA.
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