Impact of intraoperative wound dressing on post-tracheostomy pressure injuries.

OBJECTIVE: Determine the efficacy of a team-based approach to reduce tracheostomy-related skin breakdown by creating a standardized intraoperative dressing and nursing wound care protocol. METHODS: Prospective data collection of pediatric tracheostomy outcomes before and after interventions consisting of intraoperative wound dressing and standardized nursing wound care bundles. RESULTS: Before intervention, the incidence of skin breakdown within the first-week post-tracheostomy was 52% (13/25). Among patients who received an intraoperative wound dressing and nursing wound care bundles, the incidence of skin breakdown was reduced to 6.1% (3/49). CONCLUSION: The adoption of intraoperative wound dressings and nursing wound care bundles has nearly eliminated the incidence of skin breakdown in the first week post-tracheostomy among patients 0-12 years of age.

Psychobehavioral Treatment Options for Sexual Dysfunction in Multiple Sclerosis: A Systematic Review.

BACKGROUND: Sexual dysfunction in multiple sclerosis (MS) is a significant but overlooked impairment, and treatment options are rare. The aims of this systematic review were to identify psychological interventions used to treat sexual dysfunction in MS, to estimate their benefit, and to note appropriate treatment approaches for research projects and clinical use. METHODS: A systematic review update was conducted to find psychological interventions aiming to improve sexual dysfunction in MS. A comprehensive search and review of MEDLINE, PsycINFO, CINAHL, and PubMed were completed, and the effects and quality of selected studies were reported. RESULTS: Six publications with 295 participants were identified. All selected studies assessed the effectiveness of psychological interventions on sexual dysfunction or sexual satisfaction in people with MS; four studies directly targeted sexual dysfunction in MS, one was a mindfulness yoga program to improve fatigue and quality of life, and one other presented a secondary analysis of a study targeting depression in MS. All six studies reported significant improvements in sexual dysfunction or sexual satisfaction and somewhat in psychological variables. CONCLUSIONS: A pressing need for development and adequate evaluation of psychological interventions for sexual dysfunction in MS remains. In addition, assessment of sexual dysfunction in MS and its treatment should be more focused in clinical care.

What Goes Up Must Come Down: Integrating Air and Water Quality Monitoring for Nutrients.

Excess nitrogen and phosphorus ("nutrients") loadings continue to affect ecosystem function and human health across the U.S. Our ability to connect atmospheric inputs of nutrients to aquatic end points remains limited due to uncoupled air and water quality monitoring. Where connections exist, the information provides insights about source apportionment, trends, risk to sensitive ecosystems, and efficacy of pollution reduction efforts. We examine several issues driving the need for better integrated monitoring, including: coastal eutrophication, urban hotspots of deposition, a shift from oxidized to reduced nitrogen deposition, and the disappearance of pristine lakes. Successful coordination requires consistent data reporting; collocating deposition and water quality monitoring; improving phosphorus deposition measurements; and filling coverage gaps in urban corridors, agricultural areas, undeveloped watersheds, and coastal zones.

Golimumab induction and maintenance for moderate to severe ulcerative colitis: results from GO-COLITIS (Golimumab: a Phase 4, UK, open label, single arm study on its utilization and impact in ulcerative Colitis).

OBJECTIVE: GO-COLITIS aimed to measure the effectiveness of subcutaneous golimumab in tumour necrosis factor-α antagonist-naive patients with moderate to severe ulcerative colitis (UC) despite conventional treatment. DESIGN: GO-COLITIS was an open label, single arm, phase 4 study with a pragmatic design which reflected UK clinical practice. Adult patients were eligible if diagnosed with UC ≥3 months, partial Mayo score (PMS) 4-9. Patients received subcutaneous golimumab induction (200 mg initially and 100 mg at week 2) followed at week 6 by 50 mg or 100 mg (depending on weight) every 4 weeks until week 54 with a 12-week follow-up. Efficacy was measured by PMS at baseline, week 6, 30, 54 and 66. Health-related quality of life (HRQoL; Inflammatory Bowel Disease Questionnaire (IBDQ) and EuroQol Group 5 Dimensions Health Questionnaire (EQ-5D)) was assessed at baseline, week 6 and week 54. All safety adverse events (AEs) were recorded. RESULTS: 207 patients were enrolled and 205 received golimumab (full analysis set (FAS)205). At week 6, 68.8% (95% CI 62.0% to 75.1%) and 38.5% (95% CI 31.8% to 45.6%) of patients were in response and remission, respectively, using PMS. At the end of the induction phase, 140/141 patients in clinical response continued into the maintenance phase (Maintenance FAS). Sustained clinical response through week 54 was achieved in 51/205 (24.9%) of the FAS205 population and 51/140 (36.4%) of the Maintenance FAS population. Statistically significant improvements from baseline to week 6 were observed for the IBDQ total score and for each IBDQ domain score (bowel symptoms, emotional function, systemic symptoms and social function), as well as the EQ-5D index score and associated visual analogue scale score (p<0.0001). Improvement of HRQoL was sustained through week 54. Serious AEs leading to treatment discontinuation occurred in 8.8% of patients. CONCLUSION: In this study measuring patient-reported outcomes in patients with moderate to severe UC, golimumab induced and maintained response as measured by PMS and significantly improved quality of life measures. TRIAL REGISTRATION NUMBER: NCT02092285; 2013-004583-56.

Does a regular Wessex Head Injury Matrix assessment identify early signs of infections in people with Prolonged Disorders of Consciousness?

BACKGROUND & OBJECTIVE: Patients with brain injury are at high risk for infections. Although infection and cognitive deterioration are established for people with dementia, this has not been shown for patients with a prolonged disorder of consciousness (PDOC). This study determines whether regular Wessex Head Injury Matrix (WHIM) assessments can identify early signs of infections in patients with PDOC. METHOD: Retrospective and prospective approaches were used to assess the WHIM scores of patients with a PDOC (N = 21 in the retrospective study and 22 in the prospective study). RESULTS: The WHIM total scores decreased due to infections in 17 of the 21 cases of infection (p < 0.001) in the retrospective study and 15 (p = 0.001) of the 22 prospective cases of infection. Patients in a minimally conscious state (MCS) showed a bigger proportion of change between their baseline score and the scores taken in the pre-infection stage in both the retrospective and prospective studies when compared to patients in a vegetative state (VS). CONCLUSION: The findings suggest the importance of serial WHIM assessments throughout the period of recovery, not only to measure cognitive changes but also to highlight underlying physical changes such as infections that will impact the response to rehabilitation and recovery.

Sexual dysfunctions in MS in relation to neuropsychiatric aspects and its psychological treatment: A scoping review.

OBJECTIVE: Sexual dysfunction in multiple sclerosis (MS) is a significant, but often underestimated and overlooked suffering. Interventions to treat sexual dysfunction in MS are rare. The relation between sexual dysfunction in MS and psychological as well as neuropsychological aspects is evident. However, this field of research remains markedly underdeveloped in this severe chronic illness. The aim of this scoping review is to describe the relevant knowledge in this area and to identify psychological interventions to treat sexual dysfunctions in MS. METHODS: A scoping review was conducted to answer the following questions: (1) Which psychological and neuropsychological factors impact on sexual dysfunction in MS and vice versa? (2) What kind of psychological interventions aiming to improve sexual dysfunctions in MS are available? A comprehensive search and review of MEDLINE, PsycINFO, and CINAHL was completed by using a recent methodological framework for scoping reviews. RESULTS: 23 publications covering a total of 13,259 people with MS and 532 healthy controls were identified. Sexual dysfunction was found to be very common in MS and there is an obvious relation to psychological disorders as e.g. depression and anxiety and also to psychological aspects as partner relationship and quality of life. The relation between sexual dysfunction in MS and neuropsychological impairment has only rarely been studied and no clear results were found. Only two studies were identified, assessing the effectiveness of psychological intervention studies on sexual dysfunction in people with MS, and a third study presenting a secondary analysis of a study targeting depression. All three studies reported significant improvements in sexual dysfunction as well as partly in psychological variables. CONCLUSIONS: There is a pressing need for the development and adequate evaluation of psychological interventions for sexual dysfunctions in MS. In addition, sexual dysfunction and its impact on psychological wellbeing should be more focussed in clinical care. REGISTRATION: This review is registered with PROSPERO; Registration number: CRD42016033066.

Brugada syndrome and the story of Dave.

Brugada syndrome (BrS) is a little known genetic condition that causes severe disturbances in cardiac rhythm and may result in sudden unexpected cardiac death in an apparently healthy person. The heart structure is typically normal but there are problems with electrical activity. The syndrome is named after Spanish brothers who are cardiologists, Pedro and Josep Brugada. BrS is the major cause of sudden unexplained death syndrome (SUDS), also known as sudden arrhythmic death syndrome (SADS). Following a description of the syndrome, including its prevalence and incidence, how it is diagnosed and how it can be treated, we consider those who survive a cardiac arrest and what problems they may face. Most publications focus on the medical aspects of BrS but, of course, cardiac arrest can result in hypoxic brain damage. We conclude with the story of Dave, a 25-year-old man diagnosed with BrS following a nose bleed and subsequent cardiac arrest. He was left with a visual impairment, dystonia, hypersensitivity, and language and cognitive dysfunction. We look at Dave's strengths and weaknesses, his response to offered treatment, and his consequent improvement. We stress the contributions from members of the multidisciplinary team and offer suggestions for the rehabilitation of other survivors of BrS.

Akinetic mutism and the story of David.

Following a description about the characteristics of akinetic mutism (AM) and how it differs from locked-in syndrome (LIS) and a disorder of consciousness (DOC), we present the case of David, a 71-year-old man with AM. David sustained a stroke following a middle cerebral artery (MCA) thrombus. A CT scan at the time detected old ischaemic infarcts affecting the right frontal lobe, the left occipital lobe and the left parietal lobe so David had bilateral brain damage. Initially thought to have a DOC, further neuropsychological assessments administered when David had improved a little, resulted in the diagnosis of AM. Although David spoke little, when he did speak, his words and phrases were well articulated, grammatical and with appropriate intonation. He was alert and visually aware and he was not paralysed. We discuss whether the diagnosis was correct and address the difficulties in assessing such patients.

Sheehan's syndrome and sickle cell disease: the story of Natasha.

Sheehan's syndrome (SS) is one of the pituitary disorders caused by severe blood loss during childbirth leading to necrosis of the pituitary gland. Diagnosis is made following severe haemorrhage, failure to produce milk and failure to menstruate. Rare in countries with good obstetric care, SS is still frequent in those countries with poor healthcare services. The majority of papers published on SS do not mention psychological or neuropsychological sequelae. Of those that do, mood disorders are sometimes reported and occasionally cognitive problems are noted, typically attention, memory or executive deficits. We report on Natasha, a British woman of Caribbean ancestry with sickle cell disease (SCD), diagnosed at age 33 years with SS following the birth of her second child. We know of no reports of a person with both SCD and SS. Natasha has been seen regularly for neuropsychological assessment and treatment for over two years. There has been a slight increase in her cognitive functioning but she remains with Balint's syndrome, so is unable to read. Treatment for this has been partially successful. Natasha presented with psychotic type symptoms when first seen but these have improved to a large extent. We believe that these symptoms are consistent with SS but the severe cognitive problems are more likely to be due to the strokes she suffered at the time of the haemorrhage and, possibly, to hypoxic damage caused by very low blood pressure.

TD: The case of Diogenes Syndrome-deficit or denial?

Diogenes Syndrome (DS) is characterised by extreme self-neglect, domestic squalor, hoarding, social withdrawal, and lack of concern and shame for the individual's residential situation. This paper describes TD who was unable to identify emotional expressions of disgust and was borderline-impaired for facial recognition associated with perceptual difficulties. Problems interpreting expressions of disgust were interesting as TD was living in squalor, neglecting himself, and lacked concern for his circumstances. This led us to question whether the basis of his difficulties were neuropsychological or psychological in nature, which became the objective of this study, with a focus on shame and disgust. TD completed neuropsychological and psychological assessments alongside an experimental task investigating processing of disgust and his living situation. Results highlighted executive dysfunction but understanding of living with the consequences of squalor was spared as was emotion based decision-making. Assessment indicated difficulties with olfactory processing and aspects of interoceptive awareness. TD showed poor awareness of his living conditions and a lack of shame. Disgust sensitivity was unimpaired. It is unclear if TD's difficulties were caused by psychological or neuropsychological impairments, although both likely play a part. Further research is required to understand processes underpinning DS, particularly disgust and shame.

Does Modafinil improve the level of consciousness for people with a prolonged disorder of consciousness? a retrospective pilot study.

BACKGROUND AND AIM: Modafinil is best known as a sleep regulator among healthy individuals, but studies suggest that it reduces excessive daytime sleepiness in patients with brain injury. This retrospective pilot study evaluated the effectiveness of Modafinil for people with a prolonged disorder of consciousness and whether those with a traumatic brain injury did better than those with a non-traumatic brain injury. METHOD: Twenty four prolonged disorder of consciousness patients who were prescribed Modafinil, were assessed at least four times both before and during treatment. The Coma Recovery Scale-Revised was used to determine if patients had a disorder of consciousness and the Wessex Head Injury Matrix was used to monitor behavior during baseline and treatment periods. Patients with a traumatic brain injury (N = 12) were compared with those with non-traumatic brain injury (N = 12). A chi-square test with significance at 0.05 was used and when frequencies were below 5 a Fisher's Exact Test was used. RESULTS: Cognitive improvements were noted in domains of wakefulness, awareness, concentration, tracking and following commands. Significant differences were found for the whole group between baseline and Modafinil (x2 = 9.80; p = 0.002). Eleven of the 12 traumatic brain injury patients had higher Wessex Head Injury Matrix scores when on Modafinil (x2 = 8.33, p < 0.004). Six non-traumatic brain injury patients had higher scores with Modafinil, two had lower scores and four showed no change. There was no significant difference in the number of patients showing an increase compared to those showing a decrease (Fisher's exact test p = 0.29). CONCLUSION: Modafinil appears to be beneficial for enhancing cognition in prolonged disorder of consciousness patients. Traumatic brain injury patients benefited more than non-traumatic brain injury patients. Implications for Rehabilitation People with prolonged disorders of consciousness are those in coma, a vegetative state or a minimally conscious state. Sensorimotor and neuromodulations (pharmacological and brain stimulation) are the available treatment strategies to this group. Modafinil promotes attention, concentration and maintains wakefulness in a patient with narcolepsy, obstructive sleep apnea and shift work sleep disorders. In a relatively small sample, this retrospective pilot study shows the effectiveness of Modafinil in conjunction with good care, suitable medications and multidisciplinary rehabilitation in enhancing arousal in prolonged disorders of consciousness patients.

Seeing red: Relearning to read in a case of Balint's Syndrome.

BACKGROUND AND AIMS: Balint's Syndrome is a rare condition, often associated with hypoxic brain damage. The major characteristic is an inability to localise objects in space, another is simultanagnosia frequently resulting in reading difficulties. We present RN, a 37 year old woman whose major problem with reading was her inability to recognise individual letters correctly in either lower or upper case. We noted, however, that she was better if the letters were shown in red type. The aims were to determine if RN could relearn letters of the alphabet, investigate whether colour affected her ability to learn, and to explore more specifically whether the red type also helped her to read words. METHOD: Using a single case experimental ABA design, we first determined that the optimal font for RN was size 16. In the baseline (A) phase, we assessed her ability to read all lower and upper case letters of the alphabet in black ink. In the intervention (B) phase we used font size 16 in red ink and an errorless learning approach to teaching the letters. Sessions ran 5 times per week (20 minutes per session). The intervention was then applied to picture recognition and word reading with four sets of 10 words and corresponding pictures. RESULTS: A consistent difference was noted between initial baseline and intervention. Improvement carried over when we returned to baseline. CONCLUSION: Using red type and an errorless learning approach enabled RN to re-learn letters of the alphabet and read words she was previously unable to read. This did not however generalise to her everyday life.

The natural history of continuing improvement in an individual after a long period of impaired consciousness: The story of I.J.

AIM: Recovery of consciousness and recovery of function among patients with prolonged disorders of consciousness rarely occur. Those patients who do regain consciousness typically remain with severe disability. The aim of this retrospective study is to suggest that continuing improvement is possible in a survivor of catastrophic brain injury after being in a prolonged state of disordered consciousness. CASE STUDY: This retrospective single case study follows the progress of a 29 year old man, I.J, who sustained a severe traumatic brain injury following an assault in October 2011. He was in a vegetative state for 15 months and in a minimally conscious state for a further 4 months. This was followed by a slow and steady recovery of motor and cognitive functions. At 3 years post-injury I.J is considered to be moderately disabled. He is now living in the community with continuing outpatient support. On the disability rating scale his level of functioning is rated as mildly dependent. CONCLUSION: This study shows that continuing recovery to a level of moderate disability is possible, even after a prolonged disorder of consciousness. Intense multi-disciplinary long-term rehabilitation and cranioplasty may be contributing factors for such an unexpected recovery.

Computerised cognitive behavioural therapy for the treatment of depression in people with multiple sclerosis: external pilot trial.

BACKGROUND: People with multiple sclerosis (MS) are at high risk of depression. We undertook a pilot trial of computerised cognitive behavioural therapy (CCBT) for the treatment of depression in people with MS to test the feasibility of undertaking a full trial. METHODS: Participants with a diagnosis of MS and clinical levels of depression were recruited through out-patient clinics and postal screening questionnaires at two UK centres and randomised to CCBT or usual care. Clinical outcomes included the Beck Depression Inventory (BDI-II) and Multiple Sclerosis Impact Scale (MSIS-29) at baseline, 8 and 21 weeks. Feasibility outcomes included: recruitment rate; reasons for refusal, withdrawal and dropout; feasibility and acceptability of the proposed outcome measures; sample size estimation and variation in and preferences for service delivery. RESULTS: Twenty-four participants were recruited. The recruitment rate, calculated as the proportion of those invited to fill in a screening questionnaire who were consented into the trial, was 4.1%. Recruitment through out-patient clinics was somewhat slower than through screening questionnaire mail-out but the overall recruitment yield was similar. Of the 12 patients in the CCBT arm, 9 (75%) completed at least four, and 6 completed all 8 CCBT sessions. For completers, the median time (IQR) to complete all eight CCBT sessions was 15 (13 to 20) weeks. Participants expressed concern about the face validity of the Beck Depression Inventory II for the measurement of self-reported depression in people with MS. The MSIS-29 was the patient-reported outcome measure which participants felt best reflected their concerns. The estimated sample size for a full trial is between 180 and 390 participants. NHS partners were not delivering CCBT in community facilities and participants preferred to access CCBT at home, with no one expressing a preference for use of CCBT in an alternative location. CONCLUSIONS: A definitive trial, with a recruitment window of one year, would require the participation of around 13 MS centres. This number of centres could be reduced by expanding the eligibility criteria to include either other neurological conditions or people with more severe depression. The MSIS-29 should be used as a patient-important outcome measurement. TRIAL REGISTRATION: ISRCTN: ISRCTN81846800.

The acceptability of computerised cognitive behavioural therapy for the treatment of depression in people with chronic physical disease: a qualitative study of people with multiple sclerosis.

BACKGROUND: People with chronic physical conditions are at elevated risk of depression. Due to a shortage of Cognitive Behavioural Therapy (CBT) practitioners, computerised CBT (CCBT) is recommended for people with mild to moderate depression. We assessed the applicability of CCBT for the treatment of depression in people with multiple sclerosis (MS). METHODS: Depth interviews with 17 people with MS and mild to moderate depression who used one of the two CCBT packages for either eight (Beating the Blues; n = 8) or five (MoodGym; n = 9) weekly sessions were analysed using 'Framework'. RESULTS: Participants found CCBT-use burdensome due to their physical symptoms. In addition to perpetuating social isolation, the lack of human input meant some participants were unable to define problems, set goals or distinguish between events, thoughts and beliefs as required. CCBT did not legitimise their grief over losses concomitant with their MS. They characterised depression symptom inventories as contaminated by somatic symptoms of their MS. One CCBT package (MoodGym) was perceived as using inappropriate case material for people with the symptoms of MS. CONCLUSIONS: It is likely that generic CCBT packages for the treatment of depression will need to be adapted for people with chronic physical conditions to maximise their potential for health benefit.

Is action naming better preserved (than object naming) in Alzheimer's disease and why should we ask?

The present study compared object and action naming in patients with Alzheimer's dementia. We tested the hypothesis put forward in (some) previous studies that in Alzheimer's dementia the production of verbs, that is required in action naming, is better preserved than the production of nouns, that is required in object naming. The possible reason for the dissociation is that verbs are supported predominantly by frontal brain structures that may remain relatively better preserved in early Alzheimer's disease. Objects, on the other hand, are supported by temporal lobe structures that are affected early in the disease. An alternative hypothesis, which is supported by other studies, is that action naming is more impaired than object naming due to verbs being semantically more complex than nouns. In order to test these contrasting hypotheses, the present study used more stringent methodology than previous studies. We used a larger set of stimuli with carefully matched object and action items and we collected not only accuracy data but also naming latencies, a measure that is sensitive to even mild lexical retrieval problems. We compared the performance of 19 patients with mild to moderate Alzheimer's disease with that of 19 healthy age matched participants. We found that both the patients and the comparison group responded faster and made fewer errors on the object pictures than the action pictures. A qualitative analysis of the naming errors indicated that object and action naming pose different demands for the language system. The results overall suggest that the patients' performance is an exaggeration of the pattern present in the comparison participants.