The influence of victim characteristics on potential jurors' perceptions of brain damage in mild traumatic brain injury.

PRIMARY OBJECTIVE: To determine the influence of victim/plaintiff sex, occupation and intoxication status at the time of injury on potential jurors' judgement about the presence of brain damage in mild traumatic brain injury (MTBI). RESEARCH DESIGN: Survey. METHODS AND PROCEDURES: One of eight scenarios describing a MTBI from a motor vehicle accident was presented to 460 participants at a Department of Motor Vehicles. Victim sex, occupation (accountant or cafeteria worker) and alcohol intoxication status at the time of injury (sober or intoxicated) were manipulated across eight scenarios. Participants rated whether the victim's complaints at 6 months post-injury were the result of brain damage. MAIN OUTCOMES AND RESULTS: Ratings were influenced by victim occupation and intoxication status (chi2>5.3, p<0.03), but not the sex of the victim. CONCLUSIONS: The occupational and intoxication status of MTBI victims may influence potential jurors' decision about the presence of brain damage.

Processing of rapid auditory stimuli in school-age children referred for evaluation of learning disorders.

Tallal hypothesized that reading disabled children have a domain-general deficit in processing rapidly occurring auditory stimuli that degrades speech perception, thereby limiting phonologic awareness and thus reading acquisition. She predicted they would be disproportionately affected by rapidly presented auditory stimuli. In this study, one hundred 7- to 11-year-old children with learning impairment (LI) and 243 non-learning impaired (NLI) children were evaluated on a two-tone auditory discrimination paradigm. LI committed more errors, but effects of timing were comparable. The same result was obtained for a subsample of good and poor readers. Task performance predicted reading, spelling, and calculation. Neural processes underlying perception of speech and other auditory stimuli may be less effective in poor readers; however, contrary to Tallal's hypothesis, rate may not be specifically affected.

Sources of poor performance on the Rey-Osterrieth Complex Figure Test among children with learning difficulties: a dynamic assessment approach.

A dynamic assessment approach was used to examine the source of poor performance on the Rey-Osterrieth Complex Figure Test (ROCF) among 202 school-age children referred for learning difficulties. The ROCF was administered in the standard format and then in a structured format that highlighted the design's organizational framework. Manipulating encoding in this way improved recall to at least age-level for the majority of children. Those children who did not benefit from the structured format had relatively poor visual organizational skills. For most children with learning problems, poor ROCF performance stems from metacognitive difficulties; for a minority, the source appears to be more perceptual. A dynamic assessment procedure can enhance the diagnostic utility of the ROCF for children.

Children with adequate academic achievement scores referred for evaluation of school difficulties: information processing deficiencies.

Children (7-11 years old) with standardized academic achievement test scores in the normal range referred for evaluation of learning problems were compared to low-achieving children matched for age, sex, and nonverbal cognitive ability, and to children with no known history of learning difficulty matched for age, sex, and reading (all N = 65) on a battery of computerized tasks of nonverbal information processing. The normally achieving referred children performed similarly to the low-achieving group but worse than reading-matched nonreferred counterparts. These findings suggest that children who struggle in school yet perform adequately on standardized achievement measures can have heightened neurodevelopmental vulnerability. Implications are discussed with respect to the underlying substrate of learning disabilities, as well as their diagnosis, classification, and remediation.

Reliability and validity of a DSM-IV based ADHD screener.

The Diagnostic Rating Scale (DRS) was completed by the parents and teachers of 82 children referred for clinical evaluations, 73 referred children seen twice, and 218 non-referred children from the community. The DRS, which uses a categorical rather than a dimensional rating approach, was 70% to 90% sensitive to diagnoses of Attention Deficit/Hyperactivity Disorder (ADHD) made by blind clinical teams. In research and clinical applications, the DRS could improve screening efficiency, especially in situations where it would be desirable to exclude all children who might have ADHD or identify all children with Hyperactive-Impulsive symptoms. Because of its objectivity and consistency with the Diagnostic and Statistical Manual (DSM)-IV criteria, the DRS could facilitate comparison of participant samples across studies.

Diminished motor timing control in children referred for diagnosis of learning problems.

Disabled readers exhibit motor timing control (MTC) deficits in bimanual coordination relative to average readers. This article evaluates to what extent poor MTC is specific to reading or if it is related to learning problems in general. Children (7 to 11 years of age) referred for learning impairment (LI; n = 100) and same-age children nonlearning impaired (NLI; n = 243) performed a paced finger-tapping task. Greater variability of interresponse intervals was associated with poorer reading, spelling, and arithmetic achievement. The LI group performed more poorly than the NLI group, a difference that persisted even after adjusting for reading skill. Poor MTC is associated with poor reading but may also be a characteristic of children referred for learning problems, possibly signaling increased vulnerability of underlying neural integrative processes relevant to the child's adaptation to academic demands, including reading.

Speed of information processing in children referred for learning problems: performance on a visual filtering test.

Children referred for evaluation of learning impairment (LI, N =100) and a comparison group of nonreferred (NLI, N = 243) children were evaluated on a visual filtering task. The task was designed hierarchically to provide for evaluation of component operations-serial search, parallel search, decision, and response. With each additional processing demand, response times increased disproportionately for the LI group relative to the NLI group. Overall response time reliably predicted academic skills and cognitive ability, but was more strongly related to group membership. Thus, this nonverbal visual task is sensitive to a characteristic of children with learning problems over and above discrete academic and cognitive skills. Children with problems adapting to the demands of schooling may be distinguished by a disproportionate vulnerability to processing load.

Rapid automatized naming in children referred for evaluation of heterogeneous learning problems: how specific are naming speed deficits to reading disability?

Because the Rapid Automatized Naming (RAN) test reliably predicts reading skill, it is typically viewed as a diagnostic indicator of risk for reading disability (RD). Since most of the work on naming speed has been undertaken within the framework of reading research, however, the extent to which poor RAN is specifically associated with RD or with learning impairment (LI) in general is uncertain. We tested the hypothesis that slow naming speed is specific to RD. Participants were 188 children (ages 7 to 11) referred for evaluation of learning problems. Receiver operating characteristic (ROC) analysis was used to evaluate the utility of the RAN task for classifying children in diagnostic groups. RAN was an excellent tool for detecting risk for learning problems in general, but it was much less effective at distinguishing LI children with and without RD from each other.

Processing speed in children with attention deficit/hyperactivity disorder, inattentive type.

Attention Deficit/Hyperactivity Disorder (ADHD) is among the most common and most often reconceptualized neurobehavioral disorders of childhood. In the most recent DSM-IV, a primarily inattentive subtype of ADHD (AD) has again been identified. This study explores the neuropsychological profile of this group of children. Eighty-two children referred for school-related problems participated. Twenty-five met criteria for AD; 52 met criteria for reading disability (RD); 9 were comorbid for RD and AD. AD children performed poorly on measures of information processing speed. Children with comorbid AD/RD were distinguishable from those with RD on speed of processing measures only. Vulnerability to information processing load may be at the root of many of the behavioral manifestations of AD.

Mother and teacher reports of ADHD symptoms: DSM-IV Questionnaire data.

OBJECTIVE: Diagnosis of attention-deficit/hyperactivity disorder (ADHD) is thought to be best accomplished by a multimodal approach. In many research and clinical settings, such extensive procedures may not be feasible. A screening instrument that could identify children meeting necessary (but not sufficient) criteria would permit selection of subgroups for more resource-intensive diagnostic procedures. METHOD: The Diagnostic Rating Scale (DRS) was completed by the mothers and teachers of 124 children referred to hospital-based clinics and 225 nonreferred children. The authors performed principal components analysis (PCA) on the questionnaire, compared the scores obtained by children from the 2 samples, and examined age and gender effects. Diagnoses derived from the DRS were not validated against structured diagnostic interviews. RESULTS: PCAs replicated the DSM-IV symptom combinations. Children from the referred sample exhibited more symptoms (p < .001) than children from the community sample. Boys were overrepresented among the children who received DRS-derived ADHD diagnoses. Girls were more likely (92%) to receive a diagnosis of ADHD, predominantly inattentive subtype, than other ADHD diagnoses. CONCLUSIONS: The results of this study provide preliminary support for the validity of the parent and teacher DRS as time- and resource-efficient screening instruments for examining symptoms associated with ADHD.

Validation of a right hemisphere vigilance system as measured by principal component and factor analyzed quantitative electroencephalogram.

Arruda and colleagues [Arruda, J.E., Weiler, M.D., Valentino, D.A. et al., 1996. A guide for applying principal-component analysis and confirmatory factor analysis to qEEG data. Int. J. Psychophysiol. 23, 63-81.] recently described seven neurophysiological measures that were previously derived and confirmed using factor analytic procedures and the quantitative electroencephalogram (EEG) sampled from 208 normal controls during an auditory continuous performance test (CPT). The purpose of the present investigation was to further test the validity of these empirically derived measures by examining each measure's relationship with CPT-related declines in performance. Participants were 48 right-handed men (n = 13) and women (n = 35) who reported being free of any neurological condition, birthing complications, or loss of consciousness greater than 2 min. After completing an eyes-closed resting condition, participants performed a 23-min CPT while both quantitative EEG and behavioral performance were measured at 45, 405, 765 and 1125 s into the CPT. Bipolar recordings were gathered using the International 10-20 system, from eight sites: frontal, fronto-temporal, temporal and temporal-occipital. Multivariate and follow-up univariate tests suggest the existence of a neurophysiological system located within the right temporal region that appears essential for the maintenance of a sustained attentional state. If confirmed, the further quantification of this neurocognitive system may prove useful as part of a clinical diagnostic workup.

A guide for applying principal-components analysis and confirmatory factor analysis to quantitative electroencephalogram data.

Principal-components analysis (PCA) has been used in quantitative electroencephalogram (qEEG) research to statistically reduce the dimensionality of the original qEEG measures to a smaller set of theoretically meaningful component variables. However, PCAs involving qEEG have frequently been performed with small sample sizes, producing solutions that are highly unstable. Moreover, solutions have not been independently confirmed using an independent sample and the more rigorous confirmatory factor analysis (CFA) procedure. This paper was intended to illustrate, by way of example, the process of applying PCA and CFA to qEEG data. Explicit decision rules pertaining to the application of PCA and CFA to qEEG are discussed. In the first of two experiments, PCAs were performed on qEEG measures collected from 102 healthy individuals as they performed an auditory continuous performance task. Component solutions were then validated in an independent sample of 106 healthy individuals using the CFA procedure. The results of this experiment confirmed the validity of an oblique, seven component solution. Measures of internal consistency and test-retest reliability for the seven component solution were high. These results support the use of qEEG data as a stable and valid measure of neurophysiological functioning. As measures of these neurophysiological processes are easily derived, they may prove useful in discriminating between and among clinical (neurological) and control populations. Future research directions are highlighted.

Prospective, controlled study of vinyl glove use to interrupt Clostridium difficile nosocomial transmission.

PURPOSE: Despite recognition that Clostridium difficile diarrhea/colitis is a nosocomial infection, the manner in which this organism is transmitted is still not clear. Hands of health care workers have been shown to be contaminated with C. difficile and suggested as a vehicle of transmission. Therefore, we conducted a controlled trial of the use of disposable vinyl gloves by hospital personnel for all body substance contact (prior to the institution of universal body substance precautions) to study its effect on the incidence of C. difficile disease. PATIENTS AND METHODS: The incidence of nosocomial C. difficile diarrhea was monitored by active surveillance for six months before and after an intensive education program regarding glove use on two hospital wards. The interventions included initial and periodic in-services, posters, and placement of boxes of gloves at every patient's bedside. Two comparable wards where no special intervention was instituted served as controls. RESULTS: A decrease in the incidence of C. difficile diarrhea from 7.7 cases/1,000 patient discharges during the six months before intervention to 1.5/1,000 during the six months of intervention on the glove wards was observed (p = 0.015). No significant change in incidence was observed on the two control wards during the same period (5.7/1,000 versus 4.2/1,000). Point prevalence of asymptomatic C. difficile carriage was also reduced significantly on the glove wards but not on the control wards after the intervention period (glove wards, 10 of 37 to four of 43, p = 0.029; control wards, five of 30 to five of 49, p = 0.19). The cost of 61,500 gloves (4,505 gloves/100 patients) used was $2,768 on the glove wards, compared with $1,895 (42,100 gloves; 3,532 gloves/100 patients) on the control wards. CONCLUSIONS: Vinyl glove use was associated with a reduced incidence of C. difficile diarrhea and is indirect evidence for hand carriage as a means of nosocomial C. difficile spread.

Nosocomial febrile illnesses in patients on an internal medicine service.

Febrile illnesses commonly arise in hospitalized patients after admission, but most previous studies have been of specific subsets of febrile illnesses. To provide practical information about the problem as a whole, we studied febrile illnesses arising after admission (nosocomial febrile illnesses [NFls]) in 123 inpatients of an internal medicine service who had been afebrile for the preceding week. We compared them with 123 randomly selected patients without NFl. Causes of NFl included infections in 83 cases; noninfectious, inflammatory states in 15; malignancy in 12; ischemia in eight; and procedures in three. Evidence for the cause of the NFl was present at onset in at least 110 of the 123 patients. Despite this, antimicrobial agents were administered to 23 (58%) of 40 patients without infections. Thirty-four patients with NFl died; the NFl contributed to death in 26. In contrast, only eight comparison patients died. "Do not resuscitate" status was present in 32 patients with NFl compared with only 12 comparison patients, and 19 (59%) of the former died. The data from this study provide a comprehensive description of NFl arising in hospitalized internal medicine patients, indicate that the occurrence of a new febrile illness signifies a poor prognosis, and provide a rational basis for management.

Influenza B: hospital activity during a community epidemic.

During a community epidemic of influenza B, surveillance throat cultures for influenza were collected from febrile adult patients and hospital employees on three medical wards to determine the frequency and source of influenza among hospitalized patients. Twenty-five cases of influenza B (18.5% of febrile patients) were identified; no clusters of influenza-like illness occurred. The attack rate on two wards was 4.6%. Peak hospital influenza incidence followed that in the community by 1-2 weeks. Twelve of the cases were community-acquired and 13 were nosocomial. 75% of community-acquired cases had three or more common influenza B symptoms, compared with only 39% of nosocomial cases. A viral etiology of fever was suspected clinically in one-half of the cases, but influenza was specifically suspected in only one case. Two ill culture-positive nurses were identified on the job but no asymptomatic carriers were found among ward personnel. We conclude that influenza B cases were present among hospitalized patients in the absence of recognizable clusters of disease and that patients with community-acquired illness as well as nursing personnel may have introduced influenza into the hospital. Influenza B may be difficult to diagnose clinically in hospitalized patients, but viral throat cultures performed in all suspected cases should identify many infected patients.