Increasing Use of Rapid Magnetic Resonance Imaging for Children with Blunt Head Injury.

OBJECTIVE: To increase the percentage of patients who undergo rapid magnetic resonance imaging (rMRI) rather than computed tomography (CT) for evaluation of mild traumatic brain injury (TBI) from 45% in 2020 to 80% by December 2021. STUDY DESIGN: This was a quality improvement initiative targeted to patients presenting to the pediatric emergency department presenting with mild TBI, with baseline data collected from January 2020 to December 2020. From January 2021 to August 2021, we implemented a series of improvement interventions and tracked the percentage of patients undergoing neuroimaging who received rMRI as their initial study. Balancing measures included proportion of all patients with mild TBI who underwent neuroimaging of any kind, proportion of patients requiring sedation, emergency department length of stay, and percentage with clinically important TBI. RESULTS: The utilization of rMRI increased from a baseline of 45% to a mean of 92% in the intervention period. Overall neuroimaging rates did not change significantly after the intervention (19.8 vs 23.2%, P = .24). There was no difference in need for anxiolysis (12 vs 7%, P = .30) though emergency department length of stay was marginally increased (1.4 vs 1.7 hours, P = < 0.01). CONCLUSION: In this quality improvement initiative, transition to rMRI as the primary imaging modality for the evaluation of minor TBI was achieved at a level 1 pediatric trauma center with no significant increase in overall use of neuroimaging.

Protect Our Kids: a novel program bringing hemorrhage control to schools.

BACKGROUND: Following the shooting at Sandy Hook Elementary School, the Hartford Consensus produced the Stop the Bleed program to train bystanders in hemorrhage control. In our region, the police bureau delivers critical incident training to public schools, offering instruction in responding to violent or dangerous situations. Until now, widespread training in hemorrhage control has been lacking. Our group developed, implemented and evaluated a novel program integrating hemorrhage control into critical incident training for school staff in order to blunt the impact of mass casualty events on children. METHODS: The staff of 25 elementary and middle schools attended a 90-minute course incorporating Stop the Bleed into the critical incident training curriculum, delivered on-site by police officers, nurses and doctors over a three-day period. The joint program was named Protect Our Kids. At the conclusion of the course, hemorrhage control kits and educational materials were provided and a four-question survey to assess the quality of training using a ten-point Likert scale was completed by participants and trainers. RESULTS: One thousand eighteen educators underwent training. A majority were teachers (78.2%), followed by para-educators (5.8%), counselors (4.4%) and principals (2%). Widely covered by local and state media, the Protect Our Kids program was rated as excellent and effective by a majority of trainees and all trainers rated the program as excellent. CONCLUSIONS: Through collaboration between trauma centers, police and school systems, a large-scale training program for hemorrhage control and critical incident response can be effectively delivered to schools.

Linking functional molecular variation with environmental gradients: myosin gene diversity in a crustacean broadly distributed across variable thermal environments.

To investigate the molecular basis of temperature adaptation in natural populations we used the candidate gene approach, targeting the myosin heavy chain (MyHC) gene. The functional effects of genetic variation in MyHC have been well characterised, and changes in the flexibility of the surface loops 1 and 2, caused by modulations in length, amino acid composition and charge can play an important role in thermal acclimation in fish. However, the extent that MyHC diversity is influenced by natural thermal gradients is largely unknown. Sequence variation in MyHC cDNA was examined in 7 species of gammarid amphipod with broad latitudinal distributions and differing intertidal thermal habitats in the NE Atlantic and Arctic Oceans. A high degree of diversity was detected in the loop 1 nucleotide sequences, although not all are likely to be functional transcripts, and their deduced amino acid sequences indicated no differences in the length and charge of loop 1 and associated binding kinetics. Four isoforms for loop 2 were detected which differed in sequence length and charge distribution, suggesting functional differences in sliding velocities and ATPase activities. While all species, and indeed most individuals, expressed multiple loop 2 isoforms, analysis of the two species with the greatest number of sequenced clones revealed that G. duebeni, a high-shore species with the highest thermal tolerance, expressed a greater diversity of forms than G. oceanicus, a low intertidal species more sensitive to temperature change. Latitude further influenced MyHC loop 2 diversity in G. duebeni, as the number of isoforms increased in the northern populations. Species-specific variations in MyHC diversity were observed, irrespective of phylogenetic associations revealed by analysis of the mitochondrial cytochrome oxidase 1 (CO1) gene. Overall, it appears that the temporal temperature variations associated with higher intertidal habitat may be a greater selective agent for MyHC isoform diversity in gammarid muscles than broad spatial changes with latitude.

Influence of beliefs about the consequences of dizziness on handicap in people with dizziness, and the effect of therapy on beliefs.

OBJECTIVE: To determine the longitudinal relationship between beliefs about the consequences of dizziness and handicap levels in dizzy patients, and the effect of therapy on beliefs. METHODS: Symptoms, beliefs, and handicap were assessed at baseline and 6 months follow up in 76 primary care patients complaining of dizziness or vertigo, of whom 33 were assigned to treatment (i.e., vestibular rehabilitation). RESULTS: At baseline most patients believed that dizziness would have negative consequences such as falling, fainting, or losing control. Handicap levels at follow-up were predicted by baseline beliefs that dizziness would have negative consequences. Significant reduction in negative beliefs at follow-up was observed in the patients who received treatment, whereas there was no reduction in negative beliefs in the untreated patients. CONCLUSIONS: Negative beliefs about the consequences of dizziness sustain long-term restriction of activity, and can be modified by therapy.

Developing a dynamic model of treatment perceptions.

A description of factors influencing perceptions of nonpharmacological treatment was derived inductively from interviews with people receiving chiropractic treatment for back pain, using grounded theory analysis. A theoretical model linking these factors was constructed, and was tested using interview data from a longitudinal study of people undertaking exercise therapy for dizziness. The model highlights the potential for reciprocal interactions between abstract beliefs relevant to illness and treatment and concrete experiences of therapy, and for interactions between perceptions of symptom change and of therapist competence. Therapist communication may modify abstract illness/treatment models and symptom perceptions, thus mediating effects of concordance on adherence and placebo effects.

A randomized controlled trial of exercise therapy for dizziness and vertigo in primary care.

BACKGROUND: 'Vestibular rehabilitation' (VR) is an increasingly popular treatment option for patients with persistent dizziness. Previous clinical trials have only evaluated the effects of specialist therapy programmes in small, selective, or uncontrolled patient samples. AIM: To determine the benefits of VR compared with standard medical care, using a brief intervention for dizzy patients in primary care. METHOD: Adults consulting their general practitioner (GP) with dizziness or vertigo were randomly assigned to treatment or control groups. Patients in both groups received the same evaluation at baseline, six-week follow-up, and six-month follow-up, comprising examination of nystagmus, postural control, and movement-provoked dizziness, and a questionnaire assessment of subjective status, symptoms, handicap, anxiety, and depression. At baseline and six weeks later, the treatment group also received an individualized 30-minute therapy session, in which they were taught head, eye, and body exercises designed to promote vestibular compensation and enhance skill and confidence in balance. RESULTS: The treatment group (n = 67) improved on all measures, whereas the control group (n = 76) showed no improvement, resulting in a significant difference between the two groups on physical indices of balance and subjective indices of symptoms and distress. Odds ratios for improvement in treated patients relative to untreated patients were 3.1:1 at six weeks (95% CI = 1.4-6.8) and 3.8:1 at six months (95% CI = 1.6-8.7). CONCLUSION: VR is a simple, inexpensive, and beneficial treatment, and may be an appropriate first stage of management for many dizzy patients in primary care.

Identification of a 57-kilodalton selenoprotein in human thyrocytes as thioredoxin reductase and evidence that its expression is regulated through the calcium-phosphoinositol signaling pathway.

Human thyrocytes incubated with the phorbol ester, phorbol 12-myristate 13-acetate (PMA; 10(-5)-10(-8) mol/L) and the calcium ionophore A23187 (10(-5)-10(-8) mol/L) showed a marked increase in the expression of a 57-kDa selenoprotein identified as thioredoxin reductase (TR). After the addition of A23187 with PMA, a significant induction in TR expression was observed after 6 h, with maximal induction occurring by 24 h. The addition of 8-bromo-cAMP (10(-4) mol/L) or TSH (10 U/L) alone had no effect on TR expression, nor did these agents influence the induction of TR brought about by the addition of A23187 and PMA. These data show that the calcium-phosphoinositol second messenger cascade that controls hydrogen peroxide generation in the human thyrocyte is also an important stimulator of TR expression. The role of TR in the thyrocyte is unclear, but the selenoenzyme has a high capacity to detoxify compounds, such as hydrogen peroxide and lipid hydroperoxides, that are produced in high concentration during thyroid hormone synthesis.

'I'm Not a Doctor': Deconstructing Accounts of Coping, Causes and Control of Dizziness.

This article deconstructs accounts of coping with dizziness and causes of dizziness, using content analysis of interviews with 37 sufferers. Interviewees claimed that they were determined to cope, but were unable to master their illness. They reported attempting to conceal their problem and cope independently, but also admitted to relying on help from others. Most interviewees denied having any idea of what might cause dizziness, but nevertheless suggested several causes. These partly contradictory discourses arise in a context where people with chronic illness must simultaneously demonstrate that they are physically ill but socially responsible. Hence they are prompted to adopt the sanctioned role of a passive patient, rather than engaging actively in the interpretation and management of their symptoms.

Differential control of type-I iodothyronine deiodinase expression by the activation of the cyclic AMP and phosphoinositol signalling pathways in cultured human thyrocytes.

The effects of TSH and the activation of the cyclic AMP (cAMP) and Ca(2+)-phosphatidylinositol (Ca(2+)-PI) cascades on the activity and expression of the selenoenzyme thyroidal type-I iodothyronine deiodinase (ID-I) have been studied using human thyrocytes grown in primary culture. Stimulation of ID-I activity and expression was obtained with TSH and an analogue of cAMP, 8-bromo-cAMP. In the presence or absence of TSH, the addition of the phorbol ester, phorbol 12-myristate 13-acetate (PMA) together with the calcium ionophore A23187, caused a decrease in ID-I activity; a decrease in ID-I expression was also observed as assessed by cell labelling with [75Se]selenite. PMA alone had no effect on ID-I activity in the presence or absence of TSH. A23187 alone produced a small but significant reduction in ID-I activity, but only in TSH-stimulated cells. These data provide evidence that the expression of thyroidal ID-I is negatively regulated by the Ca(2+)-PI cascade, and positively regulated by the cAMP cascade.

Effect of selenium depletion on thyroidal type-I iodothyronine deiodinase activity in isolated human thyrocytes and rat thyroid and liver.

The effects of dietary selenium deficiency on hepatic and thyroidal type I iodothyronine deiodinase (ID-I) and selenium-dependent glutathione peroxidase (GPx) activities have been studied in weanling rats. In selenium-deficient animals hepatic ID-I activity was reduced to 11% of the activity found in the selenium-replete groups, whilst thyroidal ID-I activity increased by 42%. Hepatic and thyroidal GPx activities were also reduced by selenium deficiency to approximately 0.6 and 70%, respectively, of the values found in the selenium-replete animals. We have also studied the effects of thyrotropin (TSH), and selenium supply on the activity of IDI and GPx in human thyrocytes grown in primary culture. When thyrocytes were grown in selenium-deficient (< 1 nmol l-1 Se) medium in the absence of TSH, addition of sodium selenite up to 1000 nmol l-1 had little or no effect on ID-I activity. In the absence of added selenite, TSH addition produced a significant increase in ID-I activity and this stimulation was increased further when selenite was added at concentrations of 50-1000 nmol l-1 with an optimal effect on ID-I activity being observed at a 500 nmol l-1. Selenium content and GPx activity in human thyrocytes grown in selenium-free media (selenium content < 1 nmol l-1) were not significantly lower than the corresponding measurements made in cells grown in media containing selenium at a concentration of 5.4 nmol l-1.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluating the clinical nurse specialist. A review.

This paper reviews evaluative studies on the role of clinical nurse specialists and aims to describe and categorise research according to the methods used. By using the structure, process and outcome framework a clear pattern of research development and evidence emerges. It appears that significant benefits accrue for patients from the contribution of nurse specialists, but more experimental studies with combined methods should now be applied to this area.

The role of thyroidal type-I iodothyronine deiodinase in tri-iodothyronine production by human and sheep thyrocytes in primary culture.

We have studied the origin of tri-iodothyronine (T3) secreted by human and sheep thyrocytes in primary culture and also the expression of type-I thyroidal iodothyronine deiodinase (ID-I) in the thyroid and liver of man and various other animals. Inhibitors of ID-I reduced T3 secretion from human but not sheep thyrocytes. In contrast, inhibitors of de-novo thyroid hormone synthesis reduced both thyroxine (T4) and T3 production in sheep thyrocytes, but had no effect on the T3 secreted by human thyrocytes. Human thyrocytes did not produce T4 under the culture conditions used, although some endogenous T4 was present in the cells following their isolation. Although thyrotrophin (TSH) stimulated T3 production in both human and sheep thyrocytes, iodine in the form of potassium iodide was only essential for T3 and T4 production by the sheep cells. Although 125I from Na125I was incorporated into T3 and T4 in TSH-stimulated sheep thyrocytes, no 125I incorporation into T3 or T4 was detected in TSH-stimulated human thyrocytes. Using activity measurements and affinity labelling, ID-I was present in the livers of all species studied, but ID-I could not be detected in thyroid tissue from cattle, pigs, sheep, goats, rabbits, deer or llamas. In contrast, thyroid tissue from man, mice, guinea-pigs and rats had significant ID-I activity and expressed an affinity-labelled protein with a molecular mass of approximately 28.1 kDa on SDS-PAGE. These data show that under the culture conditions used, sheep thyrocytes produced T3 by de-novo synthesis, whilst human thyrocytes produced T3 by deiodination of endogenous T4. We conclude that thyroidal ID-I shows marked species difference in its expression and that, in those species which express the enzyme (man, mice, guinea-pigs and rats, in this study), it appears that it may make an important contribution to thyroidal T3 production.

Effects of combined iodine and selenium deficiency on thyroid hormone metabolism in rats.

This paper compares the effects of combined iodine and selenium deficiency, of single deficiencies of these trace elements, and of no deficiency on thyroid hormone metabolism in rats. In rats deficient in both trace elements, thyroidal triiodothyronine (T3), thyroidal thyroxin (T4), thyroidal total iodine, hepatic T4, and plasma T4 were significantly lower, and plasma thyroid-stimulating hormone (TSH) and thyroid weight were significantly higher than in rats deficient in iodine alone. Plasma and hepatic T3 concentrations were similar in the dietary groups. Hepatic type I iodothyronine deiodinase (ID-I) activity was inhibited by selenium deficiency irrespective of the iodine status. Type II deiodinase (ID-II) activity in the brain was significantly higher and in pituitary, significantly lower in combined deficiency than in iodine deficiency alone. These data show that selenium can play an important role in determining the severity of the hypothyroidism associated with iodine deficiency.

Utilization of ileal digestible amino acids by growing pigs: threonine.

An experiment was conducted to determine the utilization of ileal digestible threonine by growing pigs. Three threonine-deficient diets (0.22 g ileal digestible threonine/MJ digestible energy (DE] were formulated using cottonseed meal, meat-and-bone meal and soya-bean meal respectively, as the only source of threonine in the diet. An additional three diets were formulated with supplements of threonine to confirm that threonine was limiting in the first three diets. The growth performance and retention of threonine by pigs given the six diets over the 20-45 kg growth phase was then determined. Growth rates (g/d) of the pigs given the three diets formulated to 0.22 g ileal digestible threonine/MJ DE were significantly different (P less than 0.001): cottonseed meal 417, meat-and-bone meal 452, soya-bean meal 524 (SED 13.6). The response of pigs to the addition of threonine confirmed that threonine was limiting in these diets. Crude protein (nitrogen x 6.25) deposited by the pigs (g/d) was significantly higher (P less than 0.001) for those given soya-bean meal (75), relative to meat-and-bone meal (62) and cottonseed meal (47) (SED 3.3). The proportion of ileal digestible threonine retained by pigs given the three protein concentrates was: cottonseed meal 0.44, meat-and-bone meal 0.59, soya-bean meal 0.64 (SED 0.024). These results indicate that values for the ileal digestibility of threonine in protein concentrates are unsuitable in dietary formulations as the assay does not reflect the proportion of threonine that can be utilized by the pig. It appears that, with heat-processed meals, a considerable proportion of the threonine is absorbed in a form(s) that is (are) inefficiently utilized.

Utilization of ileal digestible amino acids by pigs: lysine.

Two experiments were conducted to determine the utilization of ileal digestible lysine by pigs. In the first, the apparent ileal digestibility of amino acids in cottonseed meal, meat-and-bone meal and soya-bean meal was determined in pigs fitted with 'T'-shaped cannulas. In the second experiment, three lysine-deficient diets were formulated to 0.36 g ileal digestible lysine/MJ digestible energy (DE), with lysine contributed from the three protein concentrates as the only source of lysine in sugar-based diets. An additional three diets were formulated with supplements of lysine to verify that lysine was limiting in the first three diets. The growth performance and retention of lysine by pigs given the six diets over the 20-45 kg growth phase were then determined. The apparent ileal digestibility of lysine in the three protein concentrates (proportion of total) was: cottonseed meal 0.74, meat-and-bone meal 0.78, soya-bean meal 0.89. Growth rates (g/d) of the pigs given the three diets formulated to 0.36 g ileal digestible lysine/MJ DE were significantly different (P less than 0.001): cottonseed meal 377, meat-and-bone meal 492, soya-bean meal 541. The response of pigs to the addition of lysine confirmed that lysine was limiting in these diets. Crude protein (nitrogen x 6.25) deposited by the pigs was significantly higher (P less than 0.001) for those given soya-bean meal (77 g/d), relative to meat-and-bone meal (66 g/d) and cottonseed meal (38 g/d). The proportion of ileal digestible lysine retained by pigs given the three protein concentrates was: cottonseed meal 0.36, meat-and-bone meal 0.60, soya-bean meal 0.75. The results indicate that values for the ileal digestibility of lysine in protein concentrates are unsuitable in dietary formulations as the assay does not reflect the proportion of lysine that can be utilized by the pig. It appears that, with heat-processed meals, a considerable proportion of the lysine is absorbed in a form(s) that is (are) inefficiently utilized.

Automatic processing quality assurance program: impact on a radiology department.

A method for evaluating processing variability as well as quantitative data on a quality assurance program tested at a radiology department are presented. Thirty per cent of all retakes due to improper overall density could be attributed to processing variation; these could be prevented through a QA program which is highly cost-effective in both monetary and patient-care terms.