The relationship between blast-related mild traumatic brain injury and executive function is moderated by white matter integrity.

Blast-related mild traumatic brain injury (BR mTBI) is a critical research area in recent combat veterans due to increased prevalence of survived blasts. Post-BR mTBI outcomes are highly heterogeneous and defining neurological differences may help in discrimination and prediction of cognitive outcomes. This study investigates whether white matter integrity, measured with diffusion tensor imaging (DTI), could influence how remote BR mTBI history is associated with executive control. The sample included 151 Veterans from the Minneapolis Veterans Affairs Medical Center who were administered a clinical/TBI assessment, neuropsychological battery, and DTI scan as part of a larger battery. From previous research, six white matter tracts were identified as having a putative relationship with blast severity: the cingulum, hippocampal cingulum, corticospinal tract, inferior fronto-occipital fasciculus, superior longitudinal fasciculus and uncinate. Fractional anisotropy (FA) of the a priori selected white matter tracts and report of BR mTBI were used as predictors of Trail-Making Test B (TMT-B) performance in a multiple linear regression model. Statistical analysis revealed that FA of the hippocampal cingulum moderated the association between report of at least one BR mTBI and poorer TMT-B performance (p < 0.008), such that lower FA value was associated with worse TMT-B outcomes in individuals with BR mTBI. No significant moderation existed for other selected tracts, and the effect was not observed with predictors aside from history of BR mTBI. Investigation at the individual-tract level may lead to a deeper understanding of neurological differences between blast-related and non-blast related injuries.

The Perceived Impact of Substance Use Education on Social Work Students' Knowledge, Attitudes, and Skills.

BACKGROUND: In 2021, the Substance Abuse and Mental Health Services Administration (SAMHSA) published a report revealing that over 46 million individuals in the United States had a substance use disorder (SUD). In the same year, a record number of drug-related overdose deaths were reported. Social workers play an important role in connecting with people who use substances and providing adequate care and treatment; yet, negative attitudes and lack of holistic knowledge about individuals who use substances create challenges in providing effective care. Social work curricula that integrates substance use content has been identified as one way to address this. METHODS: A 14-week course was introduced in one institution's Master of Social Work curriculum with the goal of providing students with a comprehensive education on SUDs. Foundational knowledge and practical skill development were covered. Seventeen trained instructors taught a total of 1204 students between May 2020 and January 2022. Quantitative and qualitative data were collected to explore changes in student's self-perceived knowledge, attitudes, and skills related to substance use. RESULTS: Among those who completed the survey (N = 553), the majority felt that the course would have a positive impact on their future work and professional development. Specifically, 96.4% reported being satisfied or very satisfied with the course overall. Among those who completed a 30-day follow-up survey (n = 69), data revealed an increase in students' self-perceived knowledge, accompanied by a shift in attitudes and positive changes in self-perceived client-centered care skills. CONCLUSIONS: Findings from this article support the development, implementation, and evaluation of evidence-based substance use content within social work curricula. This has implications for improving knowledge, attitudes, and skills among social workers who work with people who use substances.

Phenylbutazone concentrations in synovial fluid following administration via intravenous regional limb perfusion in the forelimbs of six adult horses.

Background: Pain management is critical to equine welfare with non-steroidal anti-inflammatory drugs (NSAID) commonly used in horses. However, systemic NSAID use is limited by harmful gastrointestinal and renal side effects. Intravenous regional limb perfusion (IVRLP) is a technique used in horses that produces high, local antibiotic concentrations while limiting systemic circulation. NSAID-IVRLP would be a novel method of local pain management while limiting systemic NSAID side effects. To date, NSAID-IVRLP administration has not been reported in horses. This study aimed to identify the pharmacokinetics and local complications associated with using the NSAID phenylbutazone (PBZ) for IVRLP in six standing adult horses. Methods: PBZ-IVRLP, at a dose of 2.2 mg/kg PBZ, was performed in a randomly assigned forelimb cephalic vein in 6 standing, healthy adult horses. A placebo-IVRLP was performed in the contralateral forelimb for comparison. Systemic serum and radiocarpal joint synovial fluid PBZ concentrations were identified at various timepoints (before IVRLP T-0 h, just after tourniquet removal T-0.5, 1.5, 3, 5, 12, 16, and 24 h post IVRLP) for non-compartmental pharmacokinetic analysis and concentration over time curves. Local complications associated with PBZ-IVRP were evaluated for up to 7 days following PBZ-IVRLP using physical and ultrasonographic assessment. On day 7 horses were humanely euthanized with histology performed on both forelimbs at PBZ-IVRLP and placebo-IVRLP administration sites. Results: Non-compartmental pharmacokinetics for PBZ, and its major metabolite oxyphenbutazone (OBZ), were determined for serum and synovial fluid. Synovial PBZ concentrations (mean ± SD; 1.9 ± 2.1 µg/mL) were significantly lower (p = 0.03; CI,0.46-7.36) than serum PBZ concentrations (5.8 ± 5.1 µg/mL) at any time point. Physical and ultrasonographic measurements were not significantly different between PBZ- and placebo-IVRLP forelimbs. The most common histologic findings included focal deep dermal/subcutaneous hemorrhage and edema. Two horses showed perivasculitis and one horse showed a resolving thrombus in the cephalic vein of the PBZ-IVRLP limb. This horse also had severe perivasculitis and fibrinosuppurative dermatitis/panniculitis in the placebo-IVRLP limb. Conclusion: PBZ-IVRLP pharmacokinetics at a 2.2 mg/kg dose showed no benefit compared to systemic PBZ administration in standing adult horses. Local complications associated with PBZ-IVRLP were similar to placebo-IVRLP on physical and ultrasonographic evaluation.

Reconstructing the nasal septum from instrument motion during septoplasty surgery.

Purpose: Surgery involves modifying anatomy to achieve a goal. Reconstructing anatomy can facilitate surgical care through surgical planning, real-time decision support, or anticipating outcomes. Tool motion is a rich source of data that can be used to quantify anatomy. Our work develops and validates a method for reconstructing the nasal septum from unstructured motion of the Cottle elevator during the elevation phase of septoplasty surgery, without need to explicitly delineate the surface of the septum. Approach: The proposed method uses iterative closest point registration to initially register a template septum to the tool motion. Subsequently, statistical shape modeling with iterative most likely oriented point registration is used to fit the reconstructed septum to Cottle tip position and orientation during flap elevation. Regularization of the shape model and transformation is incorporated. The proposed methods were validated on 10 septoplasty surgeries performed on cadavers by operators of varying experience level. Preoperative CT images of the cadaver septums were segmented as ground truth. Results: We estimated reconstruction error as the difference between the projections of the Cottle tip onto the surface of the reconstructed septum and the ground-truth septum segmented from the CT image. We found translational differences of 2.74 ( 2.06 - 2.81 ) mm and a rotational differences of 8.95 ( 7.11 - 10.55 ) deg between the reconstructed septum and the ground-truth septum [median (interquartile range)], given the optimal regularization parameters. Conclusions: Accurate reconstruction of the nasal septum can be achieved from tool tracking data during septoplasty surgery on cadavers. This enables understanding of the septal anatomy without need for traditional medical imaging. This result may be used to facilitate surgical planning, intraoperative care, or skills assessment.

Objective assessment of intraoperative technical skill in capsulorhexis using videos of cataract surgery.

PURPOSE: Objective assessment of intraoperative technical skill is necessary for technology to improve patient care through surgical training. Our objective in this study was to develop and validate deep learning techniques for technical skill assessment using videos of the surgical field. METHODS: We used a data set of 99 videos of capsulorhexis, a critical step in cataract surgery. One expert surgeon annotated each video for technical skill using a standard structured rating scale, the International Council of Ophthalmology's Ophthalmology Surgical Competency Assessment Rubric:phacoemulsification (ICO-OSCAR:phaco). Using two capsulorhexis indices in this scale (commencement of flap and follow-through, formation and completion), we specified an expert performance when at least one of the indices was 5 and the other index was at least 4, and novice otherwise. In addition, we used scores for capsulorhexis commencement and capsulorhexis formation as separate ground truths (Likert scale of 2 to 5; analyzed as 2/3, 4 and 5). We crowdsourced annotations of instrument tips. We separately modeled instrument trajectories and optical flow using temporal convolutional neural networks to predict a skill class (expert/novice) and score on each item for capsulorhexis in ICO-OSCAR:phaco. We evaluated the algorithms in a five-fold cross-validation and computed accuracy and area under the receiver operating characteristics curve (AUC). RESULTS: The accuracy and AUC were 0.848 and 0.863 for instrument tip velocities, and 0.634 and 0.803 for optical flow fields, respectively. CONCLUSIONS: Deep neural networks effectively model surgical technical skill in capsulorhexis given structured representation of intraoperative data such as optical flow fields extracted from video or crowdsourced tool localization information.

Effect of stimulus type and temperature on EEG reactivity in cardiac arrest.

OBJECTIVE: Electroencephalogram (EEG) background reactivity is a reliable outcome predictor in cardiac arrest patients post therapeutic hypothermia. However, there is no consensus on modality testing and prior studies reveal only fair to moderate agreement rates. The aim of this study was to explore different stimulus modalities and report interrater agreements. METHODS: We studied a multicenter, prospectively collected cohort of cardiac arrest patients who underwent therapeutic hypothermia between September 2014 and December 2015. We identified patients with reactivity data and evaluated interrater agreements of different stimulus modalities tested in hypothermia and normothermia. RESULTS: Of the 60 patients studied, agreement rates were moderate to substantial during hypothermia and fair to moderate during normothermia. Bilateral nipple pressure is more sensitive (80%) when compared to other modalities in eliciting a reactive background in hypothermia. Auditory, nasal tickle, nailbed pressure and nipple pressure reactivity were associated with good outcomes in both hypothermia and normothermia. CONCLUSIONS: EEG reactivity varies depending on the stimulus testing modality as well as the temperature during which stimulation is performed, with nipple pressure emerging as the most sensitive during hypothermia for reactivity and outcome determination. SIGNIFICANCE: This highlights the importance of multiple stimulus testing modalities in EEG reactivity determination to reduce false negatives and optimize prognostication.

A liquid chromatography-tandem mass spectrometry assay for the detection and quantification of trehalose in biological samples.

Trehalose is an important disaccharide that is used as a cellular protectant by many different organisms, helping these organisms better survive extreme conditions, such as dehydration, oxidative stress, and freezing temperatures. Methods to detect and accurately measure trehalose from different organisms will help us gain a better understanding of the mechanisms behind trehalose's ability to act as a cellular protectant. A liquid chromatography-tandem mass spectrometry (LC-MS/MS) assay using selected reaction monitoring mode for the detection and quantification of trehalose using maltose as an internal standard has been developed. This assay uses a commercially available LC column for trehalose separation and a standard triple quadrupole mass spectrometer, thus allowing many scientists to take advantage of this simple assay. The calibration curve from 3 to 100µM trehalose was fit best by a single polynomial. This LC-MS/MS assay directly detects and accurately quantifies trehalose, with an instrument limit of detection (LOD) that is 2-1000 times more sensitive than the most commonly-used assays for trehalose detection and quantification. Furthermore, this assay was used to detect and quantify endogenous trehalose produced by Escherichia coli (E. coli) cells, which were found to have an intracellular concentration of 8.5±0.9mM trehalose. This method thus shows promise for the reliable detection and quantification of trehalose from different biological sources.

Outcomes in patients undergoing percutaneous ventricular assist device implantation for cardiogenic shock.

BACKGROUND: Percutaneous ventricular assist devices (PVADs) offer an important but resource-intensive option for management of severe cardiogenic shock (CS). Optimal selection of patients for PVAD support remains undefined. We investigated outcomes, including characteristics associated with in-hospital survival, during PVAD support for CS. METHODS: We established a prospective quality improvement program among patients undergoing TandemHeart PVAD implantation for CS at Brigham and Women's Hospital (Boston, MA). We evaluated 65 consecutive patients between 2006 and 2014, analyzing demographic, clinical, laboratory, hemodynamic, and survival data. RESULTS: Thirty-two patients (49.2%) survived to hospital discharge, of which 12 received destination surgical therapy. Baseline characteristics associated with survival included younger age (47 ± 15 years vs 61 ± 11 years; p<0.001), non-ischemic cardiomyopathy (NICMP) vs ischemic CMP (survival 70.4% vs 34.2%, p=0.004), and, paradoxically, lower presenting left ventricular ejection fraction (LVEF) (survival 66.7% for LVEF ⩽15%, 41.2% for LVEF 16-25%, 25.0% for LVEF >25%; p=0.010). Younger age (p=0.026) and NICMP (p=0.034) remained independent predictors of survival. Twenty-four hours after PVAD placement, a more modest increase in cardiac index (⩽0.75 L/min/m(2)) was associated with higher in-hospital mortality (OR 6.3, 95% CI 1.8-22.1), as was lack of improvement in serum anion gap (⩽2 mEq/L; OR 5.1, 95% CI 1.6-16.6). CONCLUSIONS: Despite intensive care and provision of circulatory support, survival is poor in severe CS. Patients in CS with younger age and NICMP were more likely to survive to hospital discharge. Less robust hemodynamic improvement and persistent acidosis after 24 hours of PVAD support also identified patients less likely to survive.

Continuous electrodermal activity as a potential novel neurophysiological biomarker of prognosis after cardiac arrest--A pilot study.

AIMS: Neurological outcome prognosis remains challenging in patients undergoing therapeutic hypothermia (TH) after cardiac resuscitation. Technological advances allow for a novel wrist-worn device to continuously record electrodermal activity (EDA), a measure of pure sympathetic activity. METHODS: A prospective cohort study was performed to determine the yield of continuous EDA in patients treated with TH for coma after cardiac arrest during hypothermia and normothermia. Association between EDA parameters (event-related and nonspecific electrodermal responses (ER-EDR, NS-EDR)) and outcome measures (cerebral performance category [CPC]) (Full Outline in UnResponsivenss (FOUR) score) were assessed. RESULTS: Eighteen patients were enrolled. Total number of EDR (66.4 vs 12.0/24h, p = 0.02), ER-EDR (39.5 vs 11.2/24h, p = 0.009), median amplitude change of all EDR (0.08 vs 0.03 µSI, p = 0.03) and ER-EDR (0.14 vs 0.05 µSI, p = 0.025) were higher in patients with favorable (CPC 1-2) versus poor outcome (CPC 3-5) during hypothermia. Greater differences in EDA parameters were observed during hypothermia than normothermia. The FOUR score was correlated to the number of all EDR and median amplitudes. CONCLUSIONS: Continuous EDA potentially opens a new avenue for autonomic function monitoring in neurocritically ill patients. It is feasible in the ICU setting, even during hypothermic states. As a measure of a complete neurophysiological circuit, it may be a novel neurophysiologic biomarker of outcome after cardiac resuscitation.

Use of a nursing checklist to facilitate implementation of therapeutic hypothermia after cardiac arrest.

Therapeutic hypothermia has become a widely accepted intervention that is improving neurological outcomes following return of spontaneous circulation after cardiac arrest. This intervention is highly complex but infrequently used, and prompt implementation of the many steps involved, especially achieving the target body temperature, can be difficult. A checklist was introduced to guide nurses in implementing the therapeutic hypothermia protocol during the different phases of the intervention (initiation, maintenance, rewarming, and normothermia) in an intensive care unit. An interprofessional committee began by developing the protocol, a template for an order set, and a shivering algorithm. At first, implementation of the protocol was inconsistent, and a lack of clarity and urgency in managing patients during the different phases of the protocol was apparent. The nursing checklist has provided all of the intensive care nurses with an easy-to-follow reference to facilitate compliance with the required steps in the protocol for therapeutic hypothermia. Observations of practice and feedback from nursing staff in all units confirm the utility of the checklist. Use of the checklist has helped reduce the time from admission to the unit to reaching the target temperature and the time from admission to continuous electroencephalographic monitoring in the cardiac intensive care unit. Evaluation of patients' outcomes as related to compliance with the protocol interventions is ongoing.

Risk factors and outcome of Fontan-associated plastic bronchitis: a case-control study.

BACKGROUND: The onset of plastic bronchitis (PB) can be debilitating in survivors of Fontan surgery. The rarity of this complication makes designing studies to understand risk factors for PB challenging. This 2-center case-control study aimed to describe patient outcomes and to assess the association of antecedent patient factors with PB development. METHODS AND RESULTS: Using center registries, PB patients (n=25) were matched 1:2 to non-PB Fontans (n=43) by date of Fontan surgery and center. The groups were compared for baseline characteristics. Association of patient characteristics with PB was assessed using logistic regression and of potential risk factors with onset of PB using time-to-event analyses. The median time from Fontan to PB diagnosis was 2.5 years. Overall, 12/25 PB patients died or underwent heart transplant; the median transplant-free survival was 8.3 years after diagnosis. Factors associated with developing PB included post-surgical chylothorax (44% PB versus 10% control; odds ratio [OR] 7.3; P=0.003), chest tube (CT) duration at stage 2 (P=0.04) and Fontan (P=0.004), and postoperative ascites (36% PB versus 12% control; OR 4.2; P=0.003). CT drainage >13 days at Fontan was associated with earlier PB onset (P=0.04). Early-onset PB was associated with an increased risk of death (OR 5.0; P=0.002). CONCLUSIONS: PB is a life-threatening disorder. A longer duration of CT drainage after surgery, chylothorax, and development of ascites are all associated with developing PB. Understanding the pathophysiology of peri-operative complications in individual patients and using targeted interventions may delay the onset of the PB phenotype.

Evaluation of a clinical pathway for sedation and analgesia of mechanically ventilated patients in a cardiac intensive care unit (CICU): The Brigham and Women's Hospital Levine CICU sedation pathways.

BACKGROUND: Intravenous sedation and analgesia are important therapies during mechanical ventilation (MV). However, daily interruption of these medications is associated with improved outcomes in mechanically ventilated patients. We tested a clinical pathway for the use of sedation and analgesia during MV in a cardiac intensive care unit (CICU). METHODS AND RESULTS: We evaluated all mechanically ventilated patients in a CICU during two phases: phase 1 prior to pathway implementation (PRE) and phase 2 post-pathway implementation (POST). A total of 198 patients (98 PRE and 100 POST) and 1012 days of intubation (574 PRE and 434 POST) were included in this analysis. We found an increase in the frequency of daily interruptions of sedation post-implementation (49.3% PRE and 58.4% POST, p=0.0041). There was a significant decrease in the mean duration of MV in the POST vs PRE periods (5.0±2.3 vs 6.1±2.8 days, p=0.015). There was also a significant decrease in total neuroimaging studies (9 vs 49, p=0.001) and a trend toward a decrease in tracheostomies (3.0% vs 6.1%, p=0.33). Mean CICU length of stay (LOS) and hospital LOS respectively were 10.4 days and 16.8 days PRE and 10.4 days and 17.9 days POST (p=0.99 and p=0.55). Mortality did not differ (PRE 36.7% vs POST 32.0% p=0.55). CONCLUSIONS: Implementation of a pragmatic pathway for sedation and analgesia in a CICU was associated with an increase in the daily interruption of sedation and a corresponding decrease in the duration of MV days and the need for neuroimaging.

Quality of life of pediatric cardiac patients who previously required extracorporeal membrane oxygenation.

OBJECTIVES: We sought to assess quality of life of pediatric cardiac extracorporeal membrane oxygenation survivors. We hypothesized that these patients would have decreased quality of life when compared to that of a general U.S. population sample. DESIGN: Cross-sectional study. SETTING: Patient homes and Children's Hospital Boston. PATIENTS: Cardiac extracorporeal membrane oxygenation survivors currently 5-18 yrs old. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Quality of life was assessed by parent proxy report using the Child Health Questionnaire Parent Form 50 and was compared to that of a general U.S. population sample and other cardiac populations. Factors associated with lower quality of life were sought. Physical summary scores for 41 cardiac extracorporeal membrane oxygenation survivors were lower than the mean of the general population sample (42.4 ± 16.4 vs. 53.0 ± 8.8; p < .001) but similar to those of children with Fontan physiology or an automatic implantable cardioverter defibrillator. Psychosocial summary scores in extracorporeal membrane oxygenation patients were not different from those of the general population (48.2 ± 11.8 vs. 51.2 ± 9.1; p = .11) or of other cardiac samples. Postcardiotomy extracorporeal membrane oxygenation, more noncardiac operations, total intensive care and hospital days, noncardiac medical conditions, medications, and the need for physical, occupational, or speech therapy were associated with low physical summary scores. More noncardiac operations, noncardiac medical conditions, and the need for special education, physical, occupational, or speech therapy were associated with low psychosocial summary scores. CONCLUSIONS: In pediatric cardiac extracorporeal membrane oxygenation survivors, the physical component of health-related quality of life is lower than that of the general population but similar to that of patients with complex cardiac disease, whereas psychosocial quality of life is similar to that of the general population and of other pediatric cardiac populations.