4-Aminopyridine in pediatric traumatic spinal cord injury: A case report.

CONTEXT: Spinal cord injury (SCI) presents significant challenges due to its debilitating nature and potential complications. While few medications have shown efficacy in improving neurological recovery, 4-Aminopyridine (4-AP), a voltage-gated potassium channel blocker, has been used clinically off-label to improve neurologic function in adults with spinal cord-related paralysis. However, evidence regarding its safety and effectiveness in the pediatric population remains scarce, as it is approved for use in older patients. FINDINGS: This manuscript reports the case of a pediatric patient who sustained a traumatic cervical SCI. Initial neurological assessment indicated a C1 motor complete SCI. Surgical intervention for bullet removal and spinal fusion was carried out, followed by comprehensive inpatient rehabilitation. CONCLUSION/CLINICAL RELEVANCE: 4-AP was introduced three months post-injury and was well-tolerated without obvious adverse effects. Notably, he exhibited neurological and functional improvement after four months of 4-AP use, though his improvement followed the expected trajectory of recovery. To date, this case represents the first case of 4-AP administration in a pediatric SCI patient, and therefore these findings contribute valuable clinical insight. By documenting the clinical trajectory of this case, this manuscript suggests 4-AP may be safe for use in pediatric patients.

Answering the Rehabilitation 2030 Call.

In 2017, the World Health Organization initiated a global effort to improve rehabilitative services by 2030, with the overall goal of helping individuals with disabilities achieve maximal independence and improved well-being. Though more than 1 billion people worldwide live with a disability, a significant portion do not have access to appropriate rehabilitative services. In low-income countries, such as Zambia, where rehabilitative services are greatly lacking, disability can further exacerbate economic disparities in the context of personal, cultural, and environmental factors that limit participation in society. Therefore, expansion of rehabilitative services in low-income countries is a pressing global need, and such efforts must be tailored to the societal and cultural framework in which they are implemented. Community-based rehabilitation programs are uniquely poised to provide services in similar low-to-middle-income countries as they eliminate travel barriers to care, allow for regular follow-up, and address the societal determinants of disability by encouraging greater community engagement and by decreasing cultural stigma around disability. Special Hope Network (SHN), a community-based rehabilitation organization in Lusaka, Zambia that serves families caring for children with physical and cognitive disabilities, represents a cost-effective, sustainable, and culturally practical model to provide rehabilitative care. We propose this organization's model as one that can be reproduced and expanded upon in other low-to-middle-income countries to answer the World Health Organization's call to action.

Actigraphic and nursing sleep log measures in moderate-to-severe traumatic brain injury: Identifying discrepancies in total sleep time.

BACKGROUND: Sleep disturbances are common in patients with traumatic brain injury (TBI). In an inpatient rehabilitation setting, clinicians often use information from sleep logs filled out by trained nurses to identify and treat sleep disturbances. However, there are limited data related to accuracy of sleep logs, and patient-reported sleep diaries are poor predictors of total sleep time, which raises concern about the accuracy of sleep logs filled out by a third party. OBJECTIVE: To examine the reliability of sleep logs for participants with TBI by comparing total sleep time determined by sleep logs versus actigraphy. DESIGN: Prospective, cross-sectional study. SETTING: Free-standing, academic inpatient rehabilitation facility. PARTICIPANTS: Thirty individuals (n = 30) participated in the study. Inclusion criteria were (1) diagnosis of moderate-to-severe TBI; (2) age ≥ 18 years at the time of TBI; and (3) participating in inpatient rehabilitation with no prior inpatient rehabilitation admissions. INTERVENTIONS: Actigraph monitoring using ActiGraph GT9X Link devices was initiated within 72 hours of admission and continued for 7 consecutive days. Sleep logs were concurrently filled out by trained nurses. MAIN OUTCOME MEASURES: Sleep parameter correspondence between actigraphy and sleep logs in moderate-to-severe TBI. RESULTS: Only 51.4% of participants' sleep logs and actigraph total sleep time measurements were within 1 hour of each other, and only 23.8% were within 30 minutes. On average, sleep logs overestimated actigraphy-determined total sleep time by 60 minutes compared to actigraphic measurement. CONCLUSIONS: For those with moderate-to-severe TBI undergoing inpatient rehabilitation, sleep logs are poor predictors of sleep time because they overestimate total sleep time compared to actigraphy. Therefore, clinicians should use caution when using sleep log data to make decisions regarding treatment for sleep disturbances in TBI.

A retrospective analysis of the impact of Michigan's opioid prescribing legislation on discharge opioid prescribing at a single institution.

This study sought to determine if there were any changes in opioid prescribing habits of providers at a single institution after the implementation of legislation to increase opioid prescribing regulations. Our study demonstrated a 39.5 percent decrease in overall morphine milligram equivalent (MME) prescribed the year after the laws took effect when compared with the year prior. It is clear that these laws have been effective in decreasing the number of opioids prescribed at discharge from Mercy Health Grand Rapids. INTRODUCTION: Opioid use disorder has become an epidemic with approximately 130 people dying every day in the United States due to prescription and illegal opioid overdoses. In December 2017, the Michigan legislature ratified a package of 10 acts to address a variety of problems through several layers of regulations including more restrictive prescribing rules, which took effect in June 2018. OBJECTIVE: To evaluate the impact of legislation on the opioid prescribing habits of providers who discharged patients from a community-based academic teaching hospital. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study was performed using data from a community-based academic teaching hospital with 303 beds, a medical ICU, labor and delivery unit, and a 42-room emergency department. All patients discharged from in-patient or observation status in the 12 months before and after June 1, 2018 were included. MAIN OUTCOMES AND MEASURES: The primary outcome was MMEs of opioids prescribed at discharge before (June 1, 2017 to May 31, 2018) and after (June 1, 2018 to May 31, 2019) legislation. Medications included morphine, hydrocodone, oxycodone, fentanyl, methadone, hydromorphone, tramadol, codeine, and meperidine. RESULTS: There were 17,227 patients discharged during the first 12-month period and 15,855 patients discharged in the second 12-month period. There were 14,064 new opioid prescriptions in total during these time periods. Total MME prescribed during the study period showed a 39.5 percent decrease from pre- (2,268,460 MME) to post-legislation (1,372,424 MME), while average MMEs/discharge significantly decreased (135.1 ± 321.2 vs. 87.6 ± 187.4; p < 0.001). Total pill/patch count decreased by almost 40 percent. For patients who were prescribed opioids, average MME/discharge showed significant decline after legislation implementation (309.6 ± 427.1 vs. 212.2 ± 242.1; p < 0.001). Average daily MME/patient prescribed an opioid remained similar between the time periods (52.4 ± 37.0 vs. 51.6 ± 35.0; p = 0.21). Significant reductions (p < 0.05) were seen in MMEs for each individual medication with the exception of acetaminophen-codeine and methadone. CONCLUSIONS AND RELEVANCE: Our results indicate that the legislation implemented in Michigan to regulate opioid prescriptions was associated with a reduction in opioids prescribed to patients discharged from a community-based academic teaching hospital.

Delayed Initiation of Remdesivir in a COVID-19-Positive Patient.

We present a case of late initiation of remdesivir antiviral therapy in the successful treatment of a patient with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in a mixed medical intensive care unit of a community teaching hospital. A previously healthy 40-year-old man was admitted to the hospital 3 days after the onset of coronavirus disease 2019 (COVID-19) symptoms including dry cough, fever, and shortness of breath progressing to intubation and increased mechanical ventilator support. A request for compassionate use remdesivir was submitted on the same hospital day as the positive COVID-19 polymerase chain reaction result. Supportive measures, in addition to a 5-day course of hydroxychloroquine, were maintained until remdesivir could be supplied on day 9 of hospitalization, 13 days after symptom onset. Sixty hours after initiating remdesivir, the patient was successfully extubated and able to transition to room air within 24 hours of extubation. Late initiation of remdesivir may be effective in treating SARS-CoV-2, unlike antivirals utilized for different disease states, such as oseltamivir, that are most effective when started as soon as possible following symptom onset. Urgent action is needed by regulatory agencies to work with drug manufacturers to expedite the study and approval of investigational agents targeting SARS-CoV-2 as well as to meet manufacturing demands.