Bihemispheric Cerebral Oximetry Monitoring's Functionality in Suspected Cerebral Edema Diabetic Ketoacidosis With Therapeutic 3% Hyperosmolar Therapy in a Pediatric Emergency Department.

BACKGROUND: Suspected cerebral edema diabetic ketoacidosis (SCEDKA) is more common than perceived with symptoms including altered mentation, headache with vomiting, depressed Glasgow coma scale (GCS), abnormal motor or verbal responses, combativeness, and neurological depression. Suspected cerebral edema diabetic ketoacidosis has been associated with initial diabetic ketoacidosis (DKA) presentation and at start of DKA therapy.Cerebral oximetry (bihemispheric regional cerebral oxygen saturation [rcSO2] and cerebral blood volume index [CBVI]) can detect increased intracranial pressure (ICP)-induced altered bihemispheric cerebral physiology (rcSO2) (Crit Care Med 2006;34:2217-2223, J Pediatr 2013;163: 1111-1116, Curr Med Chem 2009;16:94-112, Diabetologia 1985;28:739-742, Pediatr Crit Care Med 2013;14:694-700). In pediatrics, rcSO2 of less than 60% or rcSO2 of greater than 85% reflects increased ICP and cerebral edema (Crit Care Med 2006;34:2217-2223, J Pediatr 2013;163: 1111-1116, Curr Med Chem 2009;16:94-112, Diabetologia 1985;28:739-742, Pediatr Crit Care Med 2013;14:694-700). Cerebral oximetry can detect increased ICP-induced altered bihemispheric cerebral physiology (rcSO2, CBVI) and cerebral physiological changes (rcSO2, CBVI changes) during therapeutic mechanical cerebral spinal fluid removal to decrease increased ICP (Crit Care Med 2006;34:2217-2223, J Pediatr 2013;163: 1111-1116, Curr Med Chem 2009;16:94-112, Diabetologia 1985;28:739-742, Pediatr Crit Care Med 2013;14:694-700).In the pediatric intensive care units, SCEDKA patients with nonbihemispheric cerebral oximetry showed an initial rcSO2 of greater than 90%. Bihemispheric rcSO2 with CBVI in SCEDKA patients has the potential to detect the abnormal cerebral physiology and disruptive autoregulation while detecting 3% hypertonic saline solution (HTS) effects on the SCEDKA altered cerebral physiology (rcSO2). PURPOSE: The purposes of this study were to analyze and compare 3% HTS effect on bihemispheric rcSO2 readings, neurological and biochemical parameters in SCEDKA with 3% HTS infusion to non-SCEDKA patients in pediatric emergency department (PED). METHODS: An observational retrospective comparative analysis study of bihemispheric rcSO2 readings, neurological and biochemical parameters in 2 groups of PED DKA patients were performed: PED DKA patients with SCEDKA +3% HTS infusions versus non-SCEDKA without 3% HTS infusions. RESULTS: From 2008 to 2013, of the 1899 PED DKA patients, 60 SCEDKA patients received 3% HTS (5 mL/kg via peripheral intravenous) infusion (median age of 5 years [range, 3.7-7 years]), with 42 new DKA insulin dependent diabetes mellitus onset. Suspected cerebral edema diabetic ketoacidosis patients had GCS of 11 (range, 11-12), with consistent SCEDKA signs and symptoms (severe headaches with vomiting, confusion, blurred vision, altered speech, lethargy, and combativeness). Suspected cerebral edema diabetic ketoacidosis patients' initial (0-5 minutes) left rcSO2 readings were 91.4% (range, 88.4%-94.1%) and right was 90.3% (range, 88.6%-94.1%) compared with non-SCEDKA patients' left rcSO2 readings of 73.2% (range, 69.7%-77.8%) and right of 73.2% (range, 67.6%-77%) (P < 0.0001). The rcSO2 monitoring time before 3% HTS infusion was 54.9 minutes (range, 48.3-66.8 minutes) with 3% HTS time effect change: pre-3% HTS (54.9 minutes [range, 48.3-66.8 minutes]). Before 3% HTS infusion, the left rcSO2 readings were 90.0% (range, 89%-95%) and right was 91% (range, 86%-95%). The 30 to 45 minutes post-3% HTS showed that left was 64% (range, 62%-69%) and right was 65.4% (range, 63%-70%) (P < 0.0001). rcSO2 Δ change for post-3% HTS (0-20 minutes) to pre-3% HTS was as follows: left, -26.58 (-29.5 to -23.7) (P < 0.0001); right, -25.2 (-27.7 to -22.6) (P < 0.0001). Post-3% HTS GCS (14,15) and biochemistry compared with pre-3% HTS infusions all improved (P < 0.001). CONCLUSIONS: In PED SCEDKA patients, the pre-3% HTS bihemispheric rcSO2 readings were greater than 90% and had lower GCS than non-SCEDKA patients. The post-3% HTS infusion rcSO2 readings showed within minutes a substantial reduction compared with non-SCEDKA patients, with no complications. Changes in rcSO2 readings after 3% HTS correlated with improved SCEDKA indicators (improved mental status, headache, and GCS) without any complications. We showed that cerebral oximetry in PED SCEDKA patients has shown an initial bihemispheric of greater than 90% readings signifying abnormal bihemispheric cerebral physiology. We also showed the cerebral oximetry's functionality in detecting 3% HTS therapeutic effects on SCEDKA's abnormal cerebral physiology and the beneficial therapeutic effects of 3% HTS infusion in SCEDKA patients. Using cerebral oximetry in pediatric DKA patients' initial cerebral assessment could have a significant impact in detecting SCEDKA patients. Further SCEDKA research using cerebral oximetry should be considered.

Sluggish Cognitive Tempo as a Possible Predictor of Methylphenidate Response in Children With ADHD: A Randomized Controlled Trial.

OBJECTIVE: To examine whether sluggish cognitive tempo (SCT) symptomatology moderates dose response to methylphenidate and whether the impact of SCT on medication response is distinct from attention-deficit/hyperactivity disorder (ADHD) subtype effects. METHODS: Stimulant-naive children with ADHD predominantly inattentive type (ADHD-I; n = 126) or ADHD combined type (ADHD-C; n = 45) aged 7-11 years were recruited from the community from September 2006 to June 2013 to participate in a prospective, randomized, double-blind, 4-week crossover trial of long-acting methylphenidate. ADHD diagnosis and subtype were established according to DSM-IV criteria using a structured interview and teacher ADHD symptom ratings. SCT symptoms were assessed using a teacher-rated scale with 2 factors (Sluggish/Sleepy and Daydreamy). Primary outcomes included (1) categorization of children as methylphenidate responders, methylphenidate nonresponders, or placebo responders by 2 blinded physicians and (2) parent and teacher ratings of child behavior on the Vanderbilt ADHD Diagnostic Rating Scales while subjects were on treatment with placebo or 1 of 3 methylphenidate dosages (low, medium, high). RESULTS: Increased SCT Sluggish/Sleepy factor scores were associated with being a methylphenidate nonresponder or placebo responder rather than a methylphenidate responder (P = .04). Sluggish/Sleepy factor scores were also linked to diminished methylphenidate dose response for parent- and teacher-rated inattention symptoms (Sluggish/Sleepy factor × dose P = .004). SCT Daydreamy symptoms and ADHD subtype (ADHD-I vs ADHD-C) were not associated with methylphenidate responder status and did not moderate methylphenidate dose response for inattention symptoms. CONCLUSIONS: SCT Sluggish/Sleepy symptoms, but not SCT Daydreamy symptoms or ADHD subtype, predicted methylphenidate nonresponse. This novel finding, if replicated, may have important implications for assessing SCT as part of ADHD care. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01727414.

Impact of Degree of Obesity on Sleep, Quality of Life, and Depression in Youth.

OBJECTIVE: Obese youth are more likely to report difficulties with sleep, depression, and quality of life (QOL). This study aims to characterize sleep problems, QOL, and symptoms of depression by degree of obesity. METHOD: The cross-sectional study was conducted in a specialized obesity clinic. Obese youth and their caregivers (N = 150) were evaluated with the Child Sleep Habits Questionnaire and Pediatric Quality of Life. Youth completed the Children's Depression Inventory. Regression models and correlations were calculated. RESULTS: Degree of obesity was predictive of increased sleep difficulties and decreased QOL scores. Children's Depression Inventory scores showed that children with more symptoms of depression had more sleep problems, and these were not associated with the degree of obesity. Adolescents with more difficulties sleeping also reported more symptoms of depression and lower QOL. CONCLUSIONS: Degree of obesity negatively affected QOL and sleep variables. Patients with greater sleeping difficulties reported more symptoms of depression.

Paediatric ED BiPAP continuous quality improvement programme with patient analysis: 2005-2013.

OBJECTIVE: In paediatric moderate-to-severe asthmatics, there is significant bronchospasm, airway obstruction, air trapping causing severe hyperinflation with more positive intraplural pressure preventing passive air movement. These effects cause an increased respiratory rate (RR), less airflow and shortened inspiratory breath time. In certain asthmatics, aerosols are ineffective due to their inadequate ventilation. Bilevel positive airway pressure (BiPAP) in acute paediatric asthmatics can be an effective treatment. BiPAP works by unloading fatigued inspiratory muscles, a direct bronchodilation effect, offsetting intrinsic PEEP and recruiting collapsed alveoli that reduces the patient's work of breathing and achieves their total lung capacity quicker. Unfortunately, paediatric emergency department (PED) BiPAP is underused and quality analysis is non-existent. A PED BiPAP Continuous Quality Improvement Program (CQIP) from 2005 to 2013 was evaluated using descriptive analytics for the primary outcomes of usage, safety, BiPAP settings, therapeutics and patient disposition. INTERVENTIONS: PED BiPAP CQIP descriptive analytics. SETTING: Academic PED. PARTICIPANTS: 1157 patients. INTERVENTIONS: A PED BiPAP CQIP from 2005 to 2013 for the usage, safety, BiPAP settings, therapeutic response parameters and patient disposition was evaluated using descriptive analytics. PRIMARY AND SECONDARY OUTCOMES: Safety, usage, compliance, therapeutic response parameters, BiPAP settings and patient disposition. RESULTS: 1157 patients had excellent compliance without complications. Only 6 (0.5%) BiPAP patients were intubated. BiPAP median settings: IPAP 18 (16,20) cm H2O range 12-28; EPAP 8 cmH2O (8,8) range 6-10; inspiratory-to-expiratory time (I:E) ratio 1.75 (1.5,1.75). Pediatric Asthma Severity score and RR decreased (p<0.001) while tidal volume increased (p<0.001). Patient disposition: 325 paediatric intensive care units (PICU), 832 wards, with 52 of these PED ward patients were discharged home with only 2 hours of PED BiPAP with no returning to the PED within 72 hours. CONCLUSIONS: BiPAP is a safe and effective therapeutic option for paediatric patients with asthma presenting to a PED or emergency department. This BiPAP CQIP showed significant patient compliance, no complications, improved therapeutics times, very low intubations and decreased PICU admissions. CQIP analysis demonstrated that using a higher IPAP, low EPAP with longer I:E optimises the patient's BiPAP settings and showed a significant improvement in PAS, RR and tidal volume. BiPAP should be considered as an early treatment in the PED severe or non-responsive moderate asthmatics.

Groupings of Persons With Traumatic Brain Injury: A New Approach to Classifying Traumatic Brain Injury in the Post-Acute Period.

OBJECTIVE: To (1) identify groups of persons with traumatic brain injury (TBI) who differ on 12 dimensions of cognitive function: cognitive, emotional, and physical symptoms; personal strengths; physical functioning; environmental supports; and performance validity; and (2) describe patterns of differences among the groups on these dimensions and on participation outcome. SETTING: Three centers for rehabilitation of persons with TBI. PARTICIPANTS: A total of 504 persons with TBI living in the community who were an average (standard deviation) of 6.3 (6.8) years postinjury and who had capacity to give consent, could be interviewed and tested in English, and were able to participate in an assessment lasting up to 4 hours. DESIGN: Observational study of a convenience sample of persons with TBI. MAIN MEASURES: Selected scales from the Traumatic Brain Injury Quality of Life measures, Neurobehavioral Symptom Inventory, Economic Quality of Life Scale, Family Assessment Device General Functioning Scale, measures of cognitive function, Word Memory Test, and Participation Assessment with Recombined Tools-Objective (PART-O) scale. RESULTS: Cluster analysis identified 5 groups of persons with TBI who differed in clinically meaningful ways on the 12 dimension scores and the PART-O scale. CONCLUSION: Cluster groupings identified in this study could assist clinicians with case conceptualization and treatment planning.

Disaster Preparedness in Families With Children With Special Health Care Needs.

Children with special health care needs (CSHCN) may present unique challenges for disaster preparedness. This study's objective was to determine the impact of a disaster supply starter kit intervention on preparedness for families of CSHCN. The study was a 1-group pre-post cohort design with consecutive enrollment at the Arkansas Children's Hospital Medical Home Clinic. Pre- and postintervention survey findings were compared using McNemar's test. Of the 249 enrolled, 223 completed the postsurvey. At presurvey, 43% had an Emergency Information Form, compared with 79% at postsurvey (P < .001). At presurvey, 18% had a disaster kit, compared with 99.6% at postsurvey, and 44% added items. Of the 183 respondents who did not have a disaster kit at presurvey, 99% (n = 182) had a disaster kit on postsurvey, and 38% (n = 70) added items. An inexpensive educational disaster supply starter kit may increase preparedness. Further investigation on sustainability and dissemination to other populations is needed.

Evaluation of Anaphylaxis Management in a Pediatric Emergency Department.

OBJECTIVE: In 2006, the National Institute of Allergy and Infectious Disease established evidence-based treatment guidelines for anaphylaxis. The purpose of our study was to evaluate provider adherence to guidelines-based management for anaphylaxis in a tertiary care pediatric emergency department (ED). METHODS: Retrospective chart review was conducted of patients (0-18 years) presenting to the Arkansas Children Hospital ED from 2004 to 2011 for the treatment of anaphylaxis using International Classification of Diseases, Ninth Edition, codes. Multiple characteristics including demographics, clinical features, allergen source, and anaphylaxis management were collected. Fisher exact or χ tests were used to compare proportion of patients treated with intramuscular (IM) epinephrine in the preguideline versus postguideline period. Relative risk (RR) statistics were computed to estimate the ratio of patients who received self-injectable epinephrine prescription and allergy follow-up in the preguideline and postguideline groups. RESULTS: A total of 187 patients (median [range] age, 7 [1-18] years; 67% male; 48% African American) were evaluated. Food (44%) and hymenoptera stings (22%) were commonly described culprit allergens, whereas 29% had no identifiable allergen. Only 47% (n = 87) received epinephrine in the ED and 31% (n = 27) via the preferred IM route. Comparing postguideline (n = 126) versus preguideline (n = 61) periods demonstrated increase in the usage of the IM route (46% postguideline vs 6% preguideline; risk ratio (RR), 7.64; 95% confidence interval [CI], 2.04-46.0; P < 0.001). Overall, 61% (n = 115) of the patients received self-injectable epinephrine upon discharge, and there were no significant differences between the groups (64% postguideline vs 56% preguideline, P = 0.30). Postguideline patients were more likely to receive a prescription compared with preguideline patients (64% postguideline vs 56% preguideline; RR, 1.15; 95% CI, 0.89-1.55; P = 0.30). Only 45% (n = 85) received an allergy referral. Postguideline patients were more likely to receive an allergy referral than preguideline patients (48% postguideline vs 41% preguideline; RR, 1.16; 95% CI, 0.81-1.73; P = 0.40). CONCLUSIONS: Provider use of IM epinephrine has improved since anaphylaxis guidelines were published. However, more provider education is needed to improve overall adherence of guidelines in a tertiary care pediatric ED.

Cerebral oximetry with blood volume index and capnography in intubated and hyperventilated patients.

OBJECTIVE: Hyperventilation-induced hypocapnia leads to cerebral vasoconstriction and hypoperfusion. Intubated patients are often inadvertently hyperventilated during resuscitations, causing theoretical risk for ischemic brain injury. Current emergency department monitoring systems do not detect these changes. The purpose of this study was to determine if cerebral oximetry (rcSo2) with blood volume index (CBVI) would detect hypocapnia-induced cerebral tissue hypoxia and hypoperfusion. METHODS: Patients requiring mechanical ventilation underwent end-tidal CO2 (ETco2), rcSo2, and CBVI monitoring. Baseline data was analyzed and then the effect of varying ETco2 on rcSo2 and CBVI readings was analyzed. Median rcSo2 and CBVI values were compared when above and below the ETco2 30 mmHg threshold. Subgroup analysis and descriptive statistics were also calculated. RESULTS: Thirty-two patients with neurologic emergencies and potential increased intracranial pressure were included. Age ranged from 6 days to 15 years (mean age, 3.1 years; SD, 3.9 years; median age, 1.5 years: 0.46-4.94 years). Diagnoses included bacterial meningitis, viral meningitis, and seizures. ETco2 crossed 30 mm Hg 80 times. Median left and right rcSO2 when ETCO2 was below 30 mmhg was 40.98 (35.3, 45.04) and 39.84 (34.64, 41) respectively. Median left and right CBVI when ETCO2 was below 30 mmhg was -24.86 (-29.92, -19.71) and -22.74 (-27.23, - 13.55) respectively. Median left and right CBVI when ETCO2 was below 30 mmHg was -24.86 (-29.92, -19.71) and -22.74 (-27.23, -13.55) respectively. Median left and right rcSO2 when ETCO2 was above 30 mmHg was 63.53 (61.41, 66.92) and 63.95 (60.23, 67.58) respectively. Median left and right CBVI when ETCO2 was above 30 mmHg was 12.26 (0.97, 20.16) and 8.11 (-0.2, 21.09) respectively. Median duration ETco2 was below 30 mmHg was 17.9 minutes (11.4, 26.59). Each time ETco2 fell below the threshold, there was a significant decrease in rcSo2 and CBVI consistent with decreased cerebral blood flow. While left and right rcSO2 and CBVI decreased quickly once ETCO2​ was below 30 mmHg, increase once ETCO2​ was above 30 mmHg was much slower. CONCLUSION: This preliminary study has demonstrated the ability of rcSo2 with CBVI to noninvasively detect the real-time effects of excessive hyperventilation producing ETco2 < 30 mmHg on cerebral physiology in an emergency department. We have demonstrated in patients with suspected increased intracranial pressure that ETco2 < 30 mmHg causes a significant decrease in cerebral blood flow and regional tissue oxygenation.

Grandmothers' Beliefs and Practices in Infant Safe Sleep.

Background Sudden infant death syndrome (SIDS) and suffocation are leading causes of infant mortality. Supine sleep position and use of appropriate sleep surfaces reduce SIDS risk but are not universally practiced. Mothers' decisions about sleep position and environment may be influenced by guidance provided by infants' grandmothers and other caregivers. Methods A survey was conducted of a convenience sample of grandmothers aged 30-70 years who provide care at least weekly for an infant grandchild <6 months old. The survey was distributed through community partners of a university-based research team. Respondents received home safety items as compensation. Analyses focused on the relationship of grandmother demographic characteristics and beliefs on their reported practices related to infant sleep. Results Among the 239 grandmothers, 45 % reported placing infants to sleep supine on an appropriate sleep surface at the grandmother's house, while 58 % reported doing so when the infant was sleeping in the mother's house. After adjusting for other factors, respondents were less likely to adhere to recommended guidelines when they believed supine position increased choking risk (OR 0.34, 95 % CI 0.18-0.62) or believed infants are more comfortable or sleep longer when on their stomachs (OR 0.51, 95 % CI 0.28-0.93). Discussion Grandmothers do not universally observe evidence-based safe sleep practices, particularly if the infant is not sleeping in the home of the parent. Interventions for senior caregivers focused on perceived choking risk, infant comfort in the supine position, and other recent changes in recommended safety practices are warranted.

Pediatric Endotracheal Tube Cuff Pressures During Aeromedical Transport.

OBJECTIVES: Cuffed endotracheal tubes (ETTs) are frequently used in children, allowing fewer air leaks and helping prevent ventilator-associated pneumonia. Tracheal mucosal perfusion is compromised at an ETT cuff pressure (ETTCP) of 30 cm H2O with blood flow completely absent above 50 cm H2O. Our objective was to compare multiple pediatric-sized ETTCPs at ground level and various altitudes during aeromedical transport. METHODS: Simulating the transport environment, 4 pediatric-sized mannequin heads were intubated with appropriately sized cuffed ETTs (3.0, 4.0, 5.0, 6.0) and transported by helicopter or nonpressurized fixed-wing aircraft 20 times each. The ETTCP was set to 10 cm H2O before transport, and the pressure was measured with a standard manometer at 1000-ft intervals until reaching peak altitude or CP greater than 60 cm H2O. Ground elevation ranged from 400-650 ft mean sea level (MSL) and peak altitude from 3500 to 5000 ft MSL. RESULTS: Increased altitude caused a significant increase in ETTCP of all ETT sizes (P < 0.001). However, there is no statistical difference in pressures between ETT sizes (P = 0.28). On average, ETTCP in 3.0, 4.0, and 6.0 ETTs surpassed 30 cm H2O at approximately 1500 ft MSL and 50 cm H2O at approximately 2800 ft MSL. In the 5.0 ETT, the CP reached 30 cm H2O at 2000 ft MSL and 50 cm H2O at 3700 ft MSL. CONCLUSIONS: The ETTCP in pediatric-sized ETTs regularly exceed recommended pressure limits at relatively low altitudes. There is no additional pressure increase related to ETT size. This has the potential to decrease mucosal blood flow, possibly increasing risk of subsequent tracheal stenosis, rupture, and other complications.

Cerebral oximetry with cerebral blood volume index in detecting pediatric stroke in a pediatric ED.

BACKGROUND: Despite pediatric stroke awareness and pediatric stroke activation systems, recognition and imaging delays along with activation inconsistency still occur. Reliable objective pediatric stroke detection tools are needed to improve detection and activations. Regional cerebral oxygen saturation (rcso2) with cerebral blood volume index (CBVI) can detect abnormal cerebral physiology. OBJECTIVE: To determine cerebral oximetry in detecting strokes in stroke alert and overall stroke patients. METHOD: Left rcso2, right rcso2, and rcso2 side differences for stroke, location, and types were analyzed. RESULTS: Compared with stroke alert (n = 25) and overall strokes (n = 52), rcso2 and CBVI were less than those in nonstrokes (n = 133; P < .0001). Rcso2 side differences in stroke alert and overall strokes were greater than in nonstrokes (P < .0001). Lower rcso2 and CBVI correlated with both groups' stroke location, left (P < .0001) and right rcso2 (P = .004). Rcso2 differences greater than 10 had a 100% positive predictive value for stroke. Both groups' rcso2 and CBVI side differences were consistent for stroke location and type (P < .0001). For both groups, left rcso2 and CBVI were greater than those of the right (P < .0001). Hemorrhagic strokes had lower bilateral rcso2 and CBVI than did ischemic strokes (P < .001). CONCLUSIONS: Cerebral oximetry and CBVI detected abnormal cerebral physiology, stroke location, and type (hemorrhagic or ischemic). Rcso2 side differences greater than 10 or rcso2 readings less than 50% had a 100% positive predictive value for stroke. Cerebral oximetry has shown potential as a detection tool for stroke location and type in a pediatric stroke alert and nonalert stroke patients. Using cerebral oximetry by the nonneurologist, we found that the patient's rcso2 side difference greater than 10 or one or both sides having less than 50% rcso2 readings suggests abnormal hemispheric pathology and expedites the patient's diagnosis, neuroresuscitation, and radiologic imaging.

Key dimensions of impairment, self-report, and environmental supports in persons with traumatic brain injury.

PURPOSE/OBJECTIVES: To determine key dimensions relevant to recovery in the postacute period for persons with traumatic brain injury (TBI) and to determine the ability of scores on these dimensions to predict participation outcomes for persons with TBI. RESEARCH METHOD/DESIGN: This was a prospective cohort, observational study of 504 persons with medically documented TBI. Participants completed a comprehensive battery of measures including cognitive tests; questionnaires assessing self-report of physical, cognitive, and emotional symptoms and strengths; environmental supports; and a measure of participation outcome. RESULTS: Participants were a predominantly male, ethnically/racially diverse sample of persons with complicated mild, moderate, and severe TBI. Variable cluster analysis identified 12 key dimensions of cognitive function, neurobehavioral complaints, personal strengths, physical symptoms and function, environmental supports, and performance validity. In unadjusted analyses, all 12 dimensions were predictive of participation outcome. In multivariable regression analysis with adjustment of all predictors for all other predictors, dimensions measuring memory, independence and self-esteem, resilience, emotional distress, physical functioning, and economic and family support made unique contributions to predicting participation outcome. CONCLUSIONS/IMPLICATIONS: Findings add to our understanding of key aspects of functioning and self-perception for persons with TBI. Knowledge of the profile of an individual patient on these 12 dimensions may assist with development of a treatment approach for the person with TBI. (PsycINFO Database Record

Factors Associated with Word Memory Test Performance in Persons with Medically Documented Traumatic Brain Injury.

OBJECTIVES: (1) To examine the rate of poor performance validity in a large, multicenter, prospectively accrued cohort of community dwelling persons with medically documented traumatic brain injury (TBI), (2) to identify factors associated with Word Memory Test (WMT) performance in persons with TBI. METHOD: This was a prospective cohort, observational study of 491 persons with medically documented TBI. Participants were administered a battery of cognitive tests, questionnaires on emotional distress and post-concussive symptoms, and a performance validity test (WMT). Additional data were collected by interview and review of medical records. RESULTS: One hundred and seventeen participants showed poor performance validity using the standard cutoff. Variable cluster analysis was conducted as a data reduction strategy. Findings revealed that the 10 cognitive tests and questionnaires could be summarized as 4 indices of emotional distress, speed of cognitive processing, verbal memory, and verbal fluency. Regression models revealed that verbal memory, emotional distress, age, and injury severity (time to follow commands) made unique contribution to prediction of poor performance validity. CONCLUSIONS: Poor performance validity was common in a research sample of persons with medically documented TBI who were not evaluated in conjunction with litigation, compensation claims, or current report of symptoms. Poor performance validity was associated with poor performance on cognitive tests, greater emotional distress, lower injury severity, and greater age. Many participants expected to have residual deficits based on initial injury severity showed poor performance validity.

Goal-Directed Resuscitative Interventions During Pediatric Interfacility Transport.

OBJECTIVES: This article reports results of the first National Institutes of Health-funded prospective interfacility transport study to determine the effect of goal-directed therapy administered by a specialized pediatric team to critically ill children with the systemic inflammatory response syndrome. We hypothesized that goal-directed therapy during interfacility transport would decrease hospital length of stay, prevent multiple organ dysfunction, and reduce subsequent ICU interventions. DESIGN: Before-and-after intervention trial. SETTING: During interfacility transport of critically ill patients by a specialized pediatric transport team, back to a tertiary care children's hospital. PATIENTS: Before-and-after intervention trial. DESIGN: Interfacility pediatric transport patients, age 1 month to 17 years, with systemic inflammatory response syndrome. INTERVENTIONS: Prospective data were collected on all pediatric interfacility transport patients with systemic inflammatory response syndrome transported by the Angel One Transport team at Arkansas Children's Hospital. A 10-month data collection period was followed by institution of a goal-directed resuscitation protocol. Data were subsequently collected for 10 additional months followed by comparison of pre- and postintervention groups. All transport personnel underwent training with didactics and high-fidelity simulation until mastery with goal-directed resuscitation was achieved. MEASUREMENTS AND MAIN RESULTS: All transport patients were screened for systemic inflammatory response syndrome using established variables and 235 (123 preintervention and 112 postintervention) were enrolled. Univariate analysis revealed shorter hospital stay (11 ± 15 d vs 7 ± 10 d; p = 0.02) and fewer required therapeutic ICU interventions in the postintervention group (Therapeutic Intervention Scoring System-28 Scores, 19.4 ± 6.8 vs 17.3 ± 6.6; p = 0.04). ICU stay and prevalence of organ dysfunction were not statistically different. Multivariable analysis showed a 1.6-day (95% CI, 1.3-2.03; p = 0.02) decrease in hospital stay in the postintervention group. CONCLUSIONS: This study suggests that goal-directed therapy administered by a specialized pediatric transport team has the potential to impact the outcomes of critically ill children. Findings from this study should be confirmed across multiple institutions, but have the potential to impact the clinical outcomes of critically ill children with systemic inflammatory response syndrome.

Obstructive heart defects associated with candidate genes, maternal obesity, and folic acid supplementation.

Right-sided and left-sided obstructive heart defects (OHDs) are subtypes of congenital heart defects, in which the heart valves, arteries, or veins are abnormally narrow or blocked. Previous studies have suggested that the development of OHDs involved a complex interplay between genetic variants and maternal factors. Using the data from 569 OHD case families and 1,644 control families enrolled in the National Birth Defects Prevention Study (NBDPS) between 1997 and 2008, we conducted an analysis to investigate the genetic effects of 877 single nucleotide polymorphisms (SNPs) in 60 candidate genes for association with the risk of OHDs, and their interactions with maternal use of folic acid supplements, and pre-pregnancy obesity. Applying log-linear models based on the hybrid design, we identified a SNP in methylenetetrahydrofolate reductase (MTHFR) gene (C677T polymorphism) with a main genetic effect on the occurrence of OHDs. In addition, multiple SNPs in betaine-homocysteine methyltransferase (BHMT and BHMT2) were also identified to be associated with the occurrence of OHDs through significant main infant genetic effects and interaction effects with maternal use of folic acid supplements. We also identified multiple SNPs in glutamate-cysteine ligase, catalytic subunit (GCLC) and DNA (cytosine-5-)-methyltransferase 3 beta (DNMT3B) that were associated with elevated risk of OHDs among obese women. Our findings suggested that the risk of OHDs was closely related to a combined effect of variations in genes in the folate, homocysteine, or glutathione/transsulfuration pathways, maternal use of folic acid supplements and pre-pregnancy obesity.

A powerful nonparametric statistical framework for family-based association analyses.

Family-based study design is commonly used in genetic research. It has many ideal features, including being robust to population stratification (PS). With the advance of high-throughput technologies and ever-decreasing genotyping cost, it has become common for family studies to examine a large number of variants for their associations with disease phenotypes. The yield from the analysis of these family-based genetic data can be enhanced by adopting computationally efficient and powerful statistical methods. We propose a general framework of a family-based U-statistic, referred to as family-U, for family-based association studies. Unlike existing parametric-based methods, the proposed method makes no assumption of the underlying disease models and can be applied to various phenotypes (e.g., binary and quantitative phenotypes) and pedigree structures (e.g., nuclear families and extended pedigrees). By using only within-family information, it can offer robust protection against PS. In the absence of PS, it can also utilize additional information (i.e., between-family information) for power improvement. Through simulations, we demonstrated that family-U attained higher power over a commonly used method, family-based association tests, under various disease scenarios. We further illustrated the new method with an application to large-scale family data from the Framingham Heart Study. By utilizing additional information (i.e., between-family information), family-U confirmed a previous association of CHRNA5 with nicotine dependence.

Accuracy of self-reported length of coma and posttraumatic amnesia in persons with medically verified traumatic brain injury.

OBJECTIVE: To determine the accuracy of self-reported length of coma and posttraumatic amnesia (PTA) in persons with medically verified traumatic brain injury (TBI) and to investigate factors that affect self-report of length of coma and PTA duration. DESIGN: Prospective cohort study. SETTING: Specialized rehabilitation center with inpatient and outpatient programs. PARTICIPANTS: Persons (N=242) with medically verified TBI who were identified from a registry of persons who had previously participated in TBI-related research. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Self-reported length of coma and self-reported PTA duration. RESULTS: Review of medical records revealed that the mean medically documented length of coma and PTA duration was 6.9±12 and 19.2±22 days, respectively, and the mean self-reported length of coma and PTA duration was 16.7±22 and 106±194 days, respectively. The average discrepancy between self-report and medical record for length of coma and PTA duration was 8.2±21 and 64±176 days, respectively. Multivariable regression models revealed that time since injury, performance on cognitive tests, and medical record values were associated with self-reported values for both length of coma and PTA duration. CONCLUSIONS: In this investigation, persons with medically verified TBI showed poor accuracy in their self-report of length of coma and PTA duration. Discrepancies were large enough to affect injury severity classification. Caution should be exercised when considering self-report of length of coma and PTA duration.

Variation in child health care utilization by medical complexity.

Children with medical complexity (CMC) have multiple specialty need, technology dependence, and high health care utilization. The objective of this study is to profile types of pediatric health care utilization and costs by increasing levels of medical complexity. This is a cross-sectional study of the 2007, 2008 and 2009 Full-Year Data Sets from the Medical Expenditure Panel Survey. Medical complexity was defined by a higher number of positive items from the five question children with special health care needs (CSHCN) Screener. CMC were defined by ≥ 4 positive screener items. Outcomes included the number of inpatient, outpatient, and emergency department visits, associated costs and diagnoses, and reported satisfaction. ICD-9 codes were grouped by Clinical Classifications Software. Of 27,755 total study subjects ≤ 17 years, 4,851 had special needs and 541 were CMC. Older age, male gender, white/non-Hispanic race/ethnicity, and public insurance were all associated with medical complexity (all p < 0.001). CMC had an annual mean of 19 annual outpatient visits ($616) and 0.26 inpatient visits ($3,308), with other significant cost drivers including home health ($2,957) and prescriptions ($2,182). The most common reasons for non-CSHCN and less-complex CSHCN outpatient visits were viral illnesses, while the main reasons for CMC visits were for mental health. Compared to families without CSHCN, those with CMC have, on average, lower satisfaction with health care (8.4 vs. 8.9 out of 10, p < 0.001). Health care models for CMC should account for mental health conditions that may be driving high numbers of outpatient encounters.

Maternal obesity and tobacco use modify the impact of genetic variants on the occurrence of conotruncal heart defects.

Conotruncal heart defects (CTDs) are among the most severe birth defects worldwide. Studies of CTDs indicate both lifestyle behaviors and genetic variation contribute to the risk of CTDs. Based on a hybrid design using data from 616 case-parental and 1645 control-parental triads recruited for the National Birth Defects Prevention Study between 1997 and 2008, we investigated whether the occurrence of CTDs is associated with interactions between 921 maternal and/or fetal single nucleotide polymorphisms (SNPs) and maternal obesity and tobacco use. The maternal genotypes of the variants in the glutamate-cysteine ligase, catalytic subunit (GCLC) gene and the fetal genotypes of the variants in the glutathione S-transferase alpha 3 (GSTA3) gene were associated with an elevated risk of CTDs among obese mothers. The risk of delivering infants with CTDs among obese mothers carrying AC genotype for a variant in the GCLC gene (rs6458939) was 2.00 times the risk among those carrying CC genotype (95% confidence interval: 1.41, 2.38). The maternal genotypes of several variants in the glutathione-S-transferase (GST) family of genes and the fetal genotypes of the variants in the GCLC gene interacted with tobacco exposures to increase the risk of CTDs. Our study suggests that the genetic basis underlying susceptibility of the developing heart to the adverse effects of maternal obesity and tobacco use involve both maternal and embryonic genetic variants. These results may provide insights into the underlying pathophysiology of CTDs, and ultimately lead to novel prevention strategies.

Evaluating community ED crowding: the Community ED Overcrowding Scale study.

OBJECTIVES: The goals of this study were to (1) identify valid variables that correlate with emergency department (ED) crowding and (2) determine a model that could be used to accurately reflect the degree of ED crowding. METHODS: A site sampling form was applied to convenience sampling of 13 community hospitals in California between April 6, 2011, and May 1, 2011. The outcome variable was average perception of crowding by the ED physician and charge nurse on a 100-mm visual analog scale. We focused on 20 candidate predictor variables that represented counts and times in the ED that were collected every 4 hours. A prediction model was developed using multivariable linear regression to determine the measures that predicted ED crowding. A parsimonious model was developed to allow for a clinical useful tool that that explained a significant amount of variability predicted by the full ED crowding model. RESULTS: A total of 2006 data sets were collected for each of the participating hospitals. A total of 1628 time entries for the hospitals were included in the study. Hospital EDs had censuses ranging from 18 000 to 98 000. Full evaluation was completed on 1489 data sets. Twenty variables were considered for the full model with 7 removed due to multicollinearity. The remaining 13 variables constituted the full model and explained 50.5% of the variability in the outcome variable. Five predictors were found to represent 92% of the variability represented by the full model. CONCLUSIONS: Five variables were highly correlated with community ED crowding and could be used to model the full set of all variables in explaining ED crowding.