Program evaluation of cognitive behavioral therapy in burn survivors.

Mental health is a component of care that should be addressed for burn patients while they are hospitalized. Unfortunately, dedicated burn psychotherapists are rare in burn centers in the United States (US), and it can take months for patients to be seen by a mental health professional after referral. Our burn center has a dedicated licensed clinical social worker who sees patients within two business days of referral. She uses cognitive behavioral therapy (CBT), which is designed to alleviate symptoms of anxiety, depression, and acute stress by modifying the individual's maladaptive thoughts. To evaluate the timely use of CBT as a treatment for depression in burn patients, we measured depressive symptoms before and after psychotherapy. Burn clinic nurses administered the Patient Health Questionnaire (PHQ-9) depression screener as part of standard care. We computed difference scores to determine change in PHQ-9 scores at both group and individual levels. At a group level, psychotherapy significantly improved symptoms of depression, indicated by a decreased mean PHQ-9 score. On an individual level, half of the patients (50.7%) experienced a meaningful improvement in their symptoms, indicated by a change in their PHQ-9 depression category, while 35.6% showed no change. Although it was not an effective solution for all patients in this study, timely use of CBT could be an important component of burn care for many and should be considered as part of standard care in burn centers across the US.

Serum SNTF, a Surrogate Marker of Axonal Injury, Is Prognostic for Lasting Brain Dysfunction in Mild TBI Treated in the Emergency Department.

Mild traumatic brain injury (mTBI) causes persisting post-concussion syndrome for many patients without abnormalities on conventional neuroimaging. Currently, there is no method for identifying at-risk cases at an early stage for directing concussion management and treatment. SNTF is a calpain-derived N-terminal proteolytic fragment of spectrin (αII-spectrin1-1176) generated in damaged axons following mTBI. Preliminary human studies suggest that elevated blood SNTF on the day of mTBI correlates with white matter disruption and lasting brain dysfunction. Here, we further evaluated serum SNTF as a prognostic marker for persistent brain dysfunction in uncomplicated mTBI patients treated in a Level I trauma center emergency department. Compared with healthy controls (n = 40), serum SNTF increased by 92% within 24 h of mTBI (n = 95; p < 0.0001), and as a diagnostic marker exhibited 100% specificity and 37% sensitivity (AUC = 0.87). To determine whether the subset of mTBI cases positive for SNTF preferentially developed lasting brain dysfunction, serum levels on the day of mTBI were compared with multiple measures of brain performance at 90 days post-injury. Elevated serum SNTF correlated significantly with persistent impairments in cognition and sensory-motor integration, and predicted worse performance in each test on a case by case basis (AUC = 0.68 and 0.76, respectively). SNTF also predicted poorer recovery of cognitive stress function from 30 to 90 days (AUC = 0.79-0.90). These results suggest that serum SNTF, a surrogate marker for axonal injury after mTBI, may have potential for the rapid prognosis of lasting post-concussion syndrome and impaired functional recovery following CT-negative mTBI. They provide further evidence linking axonal injury to persisting brain dysfunction after uncomplicated mTBI. A SNTF blood test, either alone or combined with other markers of axonal injury, may have important utilities for research, prognosis, management and treatment of concussion.

Placement of a cervical collar increases the optic nerve sheath diameter in healthy adults.

INTRODUCTION: Blunt head trauma is a common cause of increased intracranial pressure (ICP). Ultrasound measurement of the optic nerve sheath diameter (OSND) is an accurate and non-invasive way to detect increased ICP. Blunt trauma patients are often immobilized in a rigid cervical spine collar. Our objective was to describe the changes in ONSD following the placement of a c-collar and determine if any changes were time-dependent. METHODS: We performed a prospective cohort study measuring the ONSD of healthy volunteers before and after placement of a c-collar. Two physicians obtained the measurements. Each eye was scanned twice using a standardized technique. This was done before c-collar placement, 5min after placement and 20min after placement. A mean of both eyes was calculated and analyzed using descriptive statistics. An intraclass correlation coefficient (ICC) was used to assess inter-rater reliability. RESULTS: Twenty study participants with a mean age of 37.1years old were enrolled. The mean baseline ONSD was 3.77mm (95% CI 3.48-4.07). The mean ONSD 5 min after the c-collar was placed was 4.47 (95% CI 4.17-4.78). The mean ONSD at 20min after c-collar placement was 4.53 (95% CI 4.13-4.92). These changes were statistically significant (p=0.003 and <0.001). Reliability was relatively strong overall (ICC=0.74; 95% CI: 0.65, 0.81). CONCLUSION: The placement of a cervical collar increased the ONSD at 5min and this change remained increased at 20min. Future study should assess whether similar results are found in patients with blunt head trauma.

Intraosseous Pressure Monitoring in Healthy Volunteers.

STUDY OBJECTIVE: Invasively monitoring blood pressure through the IO device has not been thoroughly demonstrated. This study attempted to establish baseline values of IO pressure in a healthy human population. METHODS: This was a prospective, healthy volunteer, observational study. Participants had two IO devices placed (humerus and tibia), and participant IO pressures, vital signs, and pain scores were monitored for up to 60 minutes. Participants were contacted at 24-hours and 7 days post-testing to assess for adverse events. Summary statistics were calculated for systolic, diastolic, and mean humeral and tibial IO pressure. The ratio of IO to non-invasive blood pressure was calculated, and Bland Altman plots were created. The slope (linear) of the mean humeral and the tibial IO pressures were also calculated. RESULTS: Fifteen subjects were enrolled between April and July 2015. Fourteen of 15 humeral IOs were placed successfully (93.3%) and all 15 of the tibial IOs were placed successfully. Mean tibial systolic, diastolic, and mean IO pressure were 55.8 ± 27.9, 49.3 ± 27.1, and 48.4 ± 29.4 mm Hg, respectively. Humeral systolic, diastolic, and mean IO pressure were 32.9 ± 16.0, 27.4 ± 15.2, and 24.5 ± 14.3 mm Hg. The mean tibial IO pressure was 52.5% ± 32.0% of external cuff pressure ratio. The mean humeral IO pressure was 26.5% ± 15.2% of the external mean blood pressure. The Bland Altman plots showed an inconsistent relationship between the systolic and diastolic cuff pressure and the IO pressures. We observed a 1% per minute decrease in IO pressure from the initial placement until the final reading. CONCLUSIONS: Intraosseous pressure readings can be obtained in healthy human volunteers. However, absolute IOP values were not consistent between subjects. Future research may determine how IO pressure can be used to guide therapy in ill and injured patients.

The association of health status and providing consent to continued participation in an out-of-hospital cardiac arrest trial performed under exception from informed consent.

OBJECTIVES: Emergency medical research performed under federal regulation 21 § CFR 50.24 provides a means to protect human subjects and investigate novel time-sensitive treatments. Although prospective individual consent is not required for studies conducted under this regulation, consent from a legally authorized representative (LAR) or the patient at the earliest feasible opportunity is required to obtain short- and long-term outcome data. The objective of this study was to determine which demographic, cardiac arrest, and patient outcome characteristics predicted the likelihood of obtaining informed consent following enrollment under exception from informed consent in a multicenter cardiac arrest study. METHODS: This investigation was an analysis of data collected during a multisite, randomized, controlled, out-of-hospital cardiac arrest clinical trial performed under 21 § CFR 50.24. Research personnel attempted to obtain informed consent from LARs and subjects for medical records review of primary outcome data, as well as consent for neurologic outcome assessments up to 1 year post-cardiac arrest. Hospital discharge and neurologic status were obtained from public records and/or medical records up until the time consent was formally denied, in accordance with federal regulations and guidance. Local institutional review boards also allowed medical records review for cases where consent was neither obtained nor declined despite multiple consent attempts. Patient demographic, cardiac arrest, and clinical outcome characteristics were analyzed in univariate multinomial regression models, with consent status (obtained, denied, neither obtained nor denied) as the dependent variable. A multivariate multinomial logistic regression was then performed. An exploratory secondary analysis following the same process was performed after assigning patients who neither consented nor declined to the declined consent group. RESULTS: Among a total study population of 1,655 cardiac arrest subjects, 457 were transported and had consent attempted (27.6%). The survival status and neurologic function at the time of hospital discharge were known in 440 of 457 (96%) subjects. In the multivariate analysis, initial rhythm of ventricular fibrillation/ventricular tachycardia (VF/VT) and survival with good neurologic outcome were strong predictors of obtaining consent (odds ratio [OR] = 3.15, 95% confidence interval [CI] = 1.73 to 5.75; OR = 7.64, 95% CI = 2.28 to 25.63, respectively). The exploratory secondary analysis also showed initial rhythm of VF/VT and survival with good neurologic outcome as strong predictors of obtaining consent (OR = 1.86, 95% CI = 1.17 to 2.95; OR = 4.52, 95% CI = 2.21 to 9.26, respectively). CONCLUSIONS: Initial arrest rhythm and survival with good neurologic outcome were highly predictive of obtaining consent in this cardiac arrest trial. This phenomenon could result in underrepresentation of outcome data in the study arm with the worse outcome and represents a significant potential confounder in studies performed under 21 § CFR 50.24. Future revisions to the exception from informed consent regulations should allow access to critical survival data recorded as part of standard documentation, regardless of patient consent status.

Evaluation of intraosseous pressure in a hypovolemic animal model.

BACKGROUND: In emergent situations, access to the vascular bed is frequently required for fluid and medication administration. Central venous catheter placement is associated with risk and may slow resuscitation in the unstable patient. The purpose of this study was to determine whether intraosseous pressure (IOP) could be consistently recorded and how similar this pressure was to central venous and arterial pressure in a porcine hemorrhagic shock model. MATERIALS AND METHODS: After sedation, eight female swine had catheters placed in the femoral vein, aorta via femoral artery, and superior vena cava. IOP lines were placed in the proximal humerus, distal femur, and proximal tibia. Pressure readings were recorded continuously through the five stages of progressive hypovolemia. Pressure data were descriptively summarized, with the percent of change of IOP at each stage compared with arterial pressure using a multilevel mixed effects linear model with log transformation. RESULTS: The IOP baseline values were between 16 and 18 mm Hg, approximately 22% of baseline arterial pressure. The intraosseous (IO) waveform mostly closely resembled the arterial pressure waveform, including the presence of a dichroitic notch. Pressure variations caused by ventilation (respiratory variability) were also identified in all the tracings. The rate of pressure change in the humeral IO most closely matched the change in arterial pressure rate. IO blood gas analysis showed gas composition to most closely match venous blood. CONCLUSIONS: IOP was reliably obtained in this porcine model and suggests potential for clinical application in humans.

Debunking three rape myths.

BACKGROUND: Stereotypes and prejudicial misconceptions are prevalent regarding sexual assaults and victims' responses. These are collectively referred to as rape myths. This study examines three rape myths purporting that sexual assault victims (1) immediately report the crime, (2) experience severe physical and/or anogenital injuries, and (3) forcefully resist their assailant. STUDY DESIGN: This is a cross-sectional descriptive study examining presence of physical or anogenital injury, level of physical resistance during a sexual assault, and time to sexual assault report. Study subjects were female sexual assault victims examined by a sexual assault nurse examiner at Regions Hospital in St. Paul, Minnesota, in 2011 and 2012. RESULTS: Sexual assault nurse examiner reports for 317 subjects met the inclusion criteria and were reviewed. Twelve (4%) victims experienced physical injury requiring medical intervention. Thirty-four (11%) sustained anogenital injuries requiring medical intervention. Overall, 253 (81%) victims did not actively resist at some point during the assault, with 178 (57%) victims never actively resisting. Nearly half (129, 43%) did not appear in the emergency department for 12 or more hours from the time of the assault. CONCLUSION: Women who seek emergency department assistance after a sexual assault take a variable amount of time to present to the emergency department, rarely experience moderate or severe physical or anogenital injury, and commonly do not exert strong physical resistance against their attacker during at least part of the assault.

Comparison of success rates between two video laryngoscope systems used in a prehospital clinical trial.

OBJECTIVES: The primary aims of this study were to compare paramedic success rates and complications of two different video laryngoscopes in a prehospital clinical study. METHODS: This study was a multi-agency, prospective, non-randomized, cross over clinical trial involving paramedics from four different EMS agencies. Following completion of training sessions, six Storz CMAC™ video laryngoscopes and six King Vision™ (KV) video laryngoscopes were divided between agencies and placed into service for 6 months. Paramedics were instructed to use the video laryngoscope for all patients estimated to be ≥ 18 years old who required advanced airway management per standard operating procedure. After 6 months, the devices were crossed over for the final 6 months of the study period. Data collection was completed using a telephone data collection system with a member of the research team (available 24/7). First attempt success, overall success, and success by attempt, were compared between treatment groups using exact logistic regression adjusted for call type and user experience. RESULTS: Over a 12-month period, 107 patients (66 CMAC, 41 KV) were treated with a study device. The CMAC had a significantly higher likelihood of first attempt success (OR = 1.85; 95% CI 0.74, 4.62; p = 0.188), overall success (OR = 7.37; 95% CI 1.73, 11.1; p = 0.002), and success by attempt (OR = 3.38; 95% CI 1.67, 6.8; p = 0.007) compared to KV. Providers reverted to direct laryngoscopy in 80% (27/34) of the video laryngoscope failure cases, with the remaining patients having their airways successfully managed with a supraglottic airway in 3 cases and bag-valve mask in 4 cases. The provider-reported complications were similar and none were statistically different between treatment groups. Complication rates were not statistically different between devices. CONCLUSION: The CMAC had a higher likelihood of successful intubation compared to the King Vision. Complication rates were not statistically different between groups. Video laryngoscope placement success rates were not higher than our historical direct laryngoscopy success rates.

Treatment of non-traumatic out-of-hospital cardiac arrest with active compression decompression cardiopulmonary resuscitation plus an impedance threshold device.

BACKGROUND: A recent out-of-hospital cardiac arrest (OHCA) clinical trial showed improved survival to hospital discharge (HD) with favorable neurologic function for patients with cardiac arrest of cardiac origin treated with active compression decompression cardiopulmonary resuscitation (CPR) plus an impedance threshold device (ACD+ICD) versus standard (S) CPR. The current analysis examined whether treatment with ACD+ITD is more effective than standard (S-CPR) for all cardiac arrests of non-traumatic origin, regardless of the etiology. METHODS: This is a secondary analysis of data from a randomized, prospective, multicenter, intention-to-treat, OHCA clinical trial. Adults with presumed non-traumatic cardiac arrest were enrolled and followed for one year post arrest. The primary endpoint was survival to hospital discharge (HD) with favorable neurologic function (Modified Rankin Scale score ≤ 3). RESULTS: Between October 2005 and July 2009, 2738 patients were enrolled (S-CPR=1335; ACD+ITD=1403). Survival to HD with favorable neurologic function was greater with ACD+ITD compared with S-CPR: 7.9% versus 5.7%, (OR 1.42, 95% CI 1.04, 1.95, p=0.027). One-year survival was also greater: 7.9% versus 5.7%, (OR 1.43, 95% CI 1.04, 1.96, p=0.026). Nearly all survivors in both groups had returned to their baseline neurological function by one year. Major adverse event rates were similar between groups. CONCLUSIONS: Treatment of out-of-hospital non-traumatic cardiac arrest patients with ACD+ITD resulted in a significant increase in survival to hospital discharge with favorable neurological function when compared with S-CPR. A significant increase survival rates was observed up to one year after arrest in subjects treated with ACD+ITD, regardless of the etiology of the cardiac arrest.

Supraglottic airway device use as a primary airway during rapid sequence intubation.

INTRODUCTION: This study compared first-attempt placement success rates of the King LTS-D as a primary airway for patients requiring medication-assisted airway management (MAAM) against historical controls. SETTING: Rotor-wing division of a single critical care transportation company METHODS: 53 providers (RNs/EMT-P) consented to participation and were trained in the use of the King LTS-D. All patients in need of MAAM per agency treatment guidelines were screened for inclusion and exclusion criteria. After each placement attempt, providers completed data collection via telephone. The primary endpoint was comparison of first-attempt placement success rate between the King LTS-D and historical control endotracheal intubation (ETI) MAAM patients. Overall placement success, time to placement, pre- and post-placement SaO2, ETCO2 at 2 minutes after placement, and complications were also analyzed. RESULTS: 38 patients received rapid sequence intubation with the King LTS-D by 23 of 58 consented providers. First-attempt success rate was 76% (29/38), with an overall success rate of 84% (32/38). The primary endpoint analysis showed no difference in first-attempt success rate between historical control ETI MAAM data and King LTS-D (71% vs 76%; OR = 0.1.34 [95% CI Intubation time to insertion was 26 seconds (IQR = 12-46). Pre- and post-insertion SaO(1)2 values were 88.9 ± 12.6% and 92.1 ± 12.7%, respectively. Mean ETCO2 at 2 minutes after placement was 34.8 ± 4.0. Vomit in the patient's airway was the most frequently reported complication (46%). CONCLUSION: Success rates with the King LTS-D were not significantly different from historical control ETI data. Time to placement was comparable to previous reports.

Evaluation of the Storz CMAC®, Glidescope® GVL, AirTraq®, King LTS-D™, and direct laryngoscopy in a simulated difficult airway.

OBJECTIVE: The aim of this study was to compare first-attempt and overall success rates and success rates in relation to placement time among 5 different airway management devices: Storz CMAC, Glidescope GVL, AirTraq, King LTS-D, and direct laryngoscopy (DL). METHODS: Emergency medical technician basic (EMT-B), EMT-paramedics (EMT-P), and emergency medicine residents and staff physicians placed each of the 5 devices in a random order into an AirSim (TruCorp, Belfast, UK) part-task training manikin. The difficult airway scenario was created by fixing the manikin head to a stationary object and introducing simulated emesis into the hypopharynx. First-attempt and overall success and success in relation to placement time were compared. Provider feedback about device performance was also evaluated. RESULTS: Ninety-four providers (16 EMT-basics, 54 EMT-paramedics, and 24 emergency department doctors of medicine) consented to participation. First-attempt and overall success rates for DL, King LTS-D, GVL, and CMAC were not statistically different. Compared with DL, the AirTraq was 96% less likely to be placed successfully (odds ratio, 0.04; 95% confidence interval [CI], 0.01-0.14). When time was factored into the model, the odds of successful placement of the King LTS-D were higher compared with DL (hazard ratio [HR], 1.80; 95% CI, 1.34-2.42) and lower for GVL (HR, 0.59; 95% CI, 0.44-0.80) and AirTraq (HR, 0.228; 95% CI, 0.16-0.325). Providers ranked the CMAC first in terms of performance and preference for use in their practice setting. CONCLUSION: Overall success rates for DL, King-LTS-D, and both video laryngoscope systems were not different. When time was factored into the model, the King LTS-D was more likely to be placed successfully.

Comparison of prehospital insertion success rates and time to insertion between standard endotracheal intubation and a supraglottic airway.

OBJECTIVE: To compare paramedic insertion success rates and time to insertion between standard ETI and a supraglottc airway device (King LTS-D™) in patients needing advanced airway management. METHODS: Between June 2008 and June 2009, consented paramedics from 4 EMS systems performed ETI or placed a King LTS-D according to a predetermined randomization calendar. Data collection occurred following each placement via telephone. Placement success (ability to ventilate to chest rise, absence of gastric sounds, presence of bilateral lung sounds, and when applicable, quantitative end-tidal CO(2) reading) was compared between treatment groups. Time to ventilation (time from airway device in hand ready to place to time of first successful ventilation) was also compared. RESULTS: A total of 213 patients in need of advanced airway management were treated during the study period, with 9 patients excluded from the analysis. The remaining 204 placements by 110 of the 272 consented paramedics were analyzed (median placements per paramedic=1; range=1-7). The overall placement success rate was virtually equal across the two groups (ETI=80.2%, King LTS-D=80.5%; p=0.97). The median time to placement between ETI and the King LTS-D was also not significantly different (ETI=19.5s vs. King LTS-D=20.0s; z=-0.25; p=0.80). CONCLUSION: In this study, no differences in placement success rate or time to insertion were detected between the King LTS-D and ETI.

Neurodevelopmental effects of early deprivation in postinstitutionalized children.

The neurodevelopmental sequelae of early deprivation were examined by testing (N = 132) 8- and 9-year-old children who had endured prolonged versus brief institutionalized rearing or rearing in the natal family. Behavioral tasks included measures that permit inferences about underlying neural circuitry. Children raised in institutionalized settings showed neuropsychological deficits on tests of visual memory and attention, as well as visually mediated learning and inhibitory control. Yet, these children performed at developmentally appropriate levels on similar tests where auditory processing was also involved and on tests assessing executive processes such as rule acquisition and planning. These findings suggest that specific aspects of brain-behavioral circuitry may be particularly vulnerable to postnatal experience.

Use of the King LTS-D during medication-assisted airway management.

OBJECTIVE: This case series evaluated provider use of the King LTS-D as a primary airway in patients requiring rapid-sequence intubation (RSI). METHODS: Twenty-seven paramedics completed a one-hour training session on the use of the device. All patients meeting the service's standard criteria for medication-assisted airway management were included in the study. Following each insertion, paramedics contacted a research hotline to complete data collection. The primary endpoint was successful insertion, with secondary endpoints including time from succinylcholine administration to successful ventilation, pre- and post-insertion vital signs (oxygen saturation [SaO(2)], pulse rate, and systolic and diastolic blood pressure), and end-tidal carbon dioxide [ETCO(2)] value 2 minutes after insertion. Analysis between pre- and postinsertion variables was completed using the Wilcoxon signed-rank test. RESULTS: A total of 11 patients met the enrollment criteria and were treated with the device by nine of the 27 paramedics enrolled in the study. All 11 insertions (100%) were successful, with 10 of the 11 (91%) successes achieved on the first insertion attempt. No significant difference existed between pre- and post-insertion pulse rate or blood pressure measures. A significant difference in SaO(2) values was present (p = 0.007). Median ETCO(2) for the study sample was 40 mmHg (interquartile range [IQR] = 33-46 mmHg). Seventy-three percent (8/11) of patients had a time interval of succinylcholine administration to first ventilation of 1 minute or less (range = 1-3 minutes). One case of aspiration was noted on hospital chart review. CONCLUSION: In this case series, paramedics were able to successfully place and use the King LTS-D in patients meeting our emergency medical services (EMS) system indications for RSI.

Use of the pediatric EZ-IO needle by emergency medical services providers.

OBJECTIVE: The aim of this study was to examine emergency medical services providers' use of a new intraosseous needle designed for pediatric patients. METHODS: This prospective pilot study was conducted between May 2006 and October 2007. After completing an initial training session, the EZ-IO PD was deployed for use on patients. Emergency medical services (EMS) providers completed a telephone data collection process after each insertion attempt. Data regarding insertion failure or success (insertion of needle into the bone with subsequent fluid flow), time to fluid flow, provider comfort with the device, device performance assessment, and recommendation for future use were collected. RESULTS: Two hundred forty-six EMS providers (EMT-P and registered nurses) from 14 EMS agencies consented to participation. Nineteen insertions were completed by 19 different providers during the study period. Successful insertion was achieved in 18 (95%) of 19 patients (95% confidence interval [CI], 85%-100%). Successful insertion was achieved in less than 60 seconds by 13 (72%) of 15 providers (95% CI, 60%-94%; 4 providers, no response). Fourteen out of 17 providers (82%) reported feeling very comfortable (59%) or comfortable (23%) with the device (95% CI, 64%-100%; 2 non-responses). Fourteen (82%) of 17 providers (95% CI, 64%-100%) with a successful insertion felt that the device worked very well, and the remaining 3 (18%) felt that it worked well. Thirteen (78%) of 17 providers (95% CI, 56%-96%) recommended future use of the EZ-IO needle over the Illinois needle. Two providers (11%) recommended the use of both needles, and 2 providers (11%) were unsure if they would recommend one of the intraosseous needles over the other. A total of 5 complications were reported by the providers: infiltration during use (2); slow flow rate (2); and needle dislodgement (1) when moving the patient into the ambulance. CONCLUSIONS: This device has a high insertion success rate with our provider group. Most of our EMS providers also felt comfortable using the device and recommend the device for future use.

Moderate versus severe early life stress: associations with stress reactivity and regulation in 10-12-year-old children.

Early life stress (ELS) is expected to increase reactivity of the hypothalamic-pituitary-adrenocortical (HPA) axis; however, several recent studies have shown diminished cortisol reactivity among adults and children with ELS exposure. The goal of this study was to examine cortisol activity in 10-12-year-old internationally adopted children to determine if moderate and severe ELS have different impacts on the HPA axis. Salivary cortisol and two measures of autonomic activity were collected in response to the Trier Social Stress Test for Children (TSST-C). Three groups reflecting moderate, severe, and little ELS were studied: early adopted children who came predominantly from foster care overseas (early adopted/foster care (EA/FC), n=44), later adopted children cared for predominantly in orphanages overseas (late adopted/post-institutionalized (LA/PI), n=42) and non-adopted (NA) children reared continuously by their middle- to upper-income parents in the United States (n=38). Diminished cortisol activity was noted for the EA/FC group (moderate ELS), while the LA/PI group (severe ELS) did not differ from the NA group. Overall, few children showed cortisol elevations to the TSST-C in any group. The presence/absence of severe growth delay at adoption proved to be a critical predictive factor in cortisol activity. Regardless of growth delay, however, LA/PI children exhibited higher sympathetic tone than did NA children. These results suggest that moderate ELS is associated with diminished cortisol activity; however, marked individual differences in cortisol activity among the LA/PI children suggest that child factors modify the impact of severe ELS. Lack of effects of severe ELS even for growth delayed children may reflect the restorative effects of adoption or the generally low responsiveness of this age group to the TSST-C.

Electrophysiologic evidence of impaired cross-modal recognition memory in 8-month-old infants of diabetic mothers.

OBJECTIVES: Previous studies have shown deficits in auditory and visual recognition memory in infants of diabetic mothers. The purpose of this study was to further investigate memory development in infants of diabetic mothers (IDMs) by evaluating cross-modal recognition memory followed by behavioral memory testing at 8 months of age. STUDY DESIGN: Cross-modal (tactile to vision) recognition memory was evaluated using event related potentials. Control and IDMs palpated an object without seeing it and were then tested on their ability to recognize that object visually. Infants were then tested behaviorally on their ability to recognize and discriminate faces. The Bayley Scales of Infant Development was administered at 12 months of age. RESULTS: Control infants showed typical event-related potential patterns indicative of intact cross-modal recognition memory, whereas the IDMs did not show any evidence of recognition of the palpated object. Neither group showed behavioral evidence of visual recognition memory. Both groups had Bayley scores in the normal range, although controls had slightly higher mental development index scores than IDMs. CONCLUSIONS: IDMs showed neurophysiologic evidence of persistent subtle impairments in hippocampally-based recognition memory, despite having normal one-year developmental scores.