Evaluating Injury Severity in Neonatal Encephalopathy Using Automated Quantitative Electroencephalography Analysis: A Pilot Study.

Quantitative analysis of electroencephalography (qEEG) is a potential source of biomarkers for neonatal encephalopathy (NE). However, prior studies using qEEG in NE were limited in their generalizability due to individualized techniques for calculating qEEG features or labor-intensive pre-selection of EEG data. We piloted a fully automated method using commercially available software to calculate the suppression ratio (SR), absolute delta power, and relative delta, theta, alpha, and beta power from EEG of neonates undergoing 72 h of therapeutic hypothermia (TH) for NE between April 20, 2018, and November 4, 2019. We investigated the association of qEEG with degree of encephalopathy (modified Sarnat score), severity of neuroimaging abnormalities following TH (National Institutes of Child Health and Development Neonatal Research Network [NICHD-NRN] score), and presence of seizures. Thirty out of 38 patients met inclusion criteria. A more severe modified Sarnat score was associated with higher SR during all phases of TH, lower absolute delta power during all phases except rewarming, and lower relative delta power during the last 24 h of TH. In 21 patients with neuroimaging data, a worse NICHD-NRN score was associated with higher SR, lower absolute delta power, and higher relative beta power during all phases. QEEG features were not significantly associated with the presence of seizures after correction for multiple comparisons. Our results are consistent with those of prior studies using qEEG in NE and support automated qEEG analysis as an accessible, generalizable method for generating biomarkers of NE and response to TH. Additionally, we found evidence of an immature relative frequency composition in neonates with more severe brain injury, suggesting that automated qEEG analysis may have a use in the assessment of brain maturity.

Tonic Seizures in a Patient With Lennox-Gastaut Syndrome Manifest as "Icicles" Rather Than "Flames" on Quantitative EEG Analysis.

SUMMARY: Quantitative analysis of continuous electroencephalography (QEEG) is increasingly being used to augment seizure detection in critically ill patients. Typically, seizures manifest on QEEG as abrupt increases in power and frequency, a visual pattern often called "flames." Here, we present a case of a 16-year-old patient with intractable Lennox-Gastaut syndrome secondary to a pathogenic variant in the SCN2A gene who had tonic seizures that manifest as abrupt decreases in power on QEEG, a visual pattern we term "icicles." Recognition of QEEG patterns representative of different seizure types is important as QEEG use becomes more widespread including in pediatric populations.

Lifetime Earning Potential and Workforce Distribution in Developmental and Behavioral Pediatrics.

OBJECTIVES: Compare lifetime earning potential (LEP) for developmental and behavioral pediatrics (DBP) to general pediatrics and other pediatric subspecialties. Evaluate association between LEP for DBP and measures of workforce distribution. METHODS: Using compensation and debt data from 2018 to 2019 and a net present value analysis, we estimated LEP for DBP compared to general pediatrics and other pediatric subspecialties. We evaluated potential effects of eliminating educational debt, shortening length of fellowship training, and implementing loan repayment or forgiveness programs for pediatric subspecialists. We evaluated the association between LEP for DBP and measures of workforce distribution, including distance to subspecialists, percentage of hospital referral regions (HRRs) with a subspecialist, ratio of subspecialists to regional child population, and fellowship fill rates. RESULTS: LEP was lower for DBP than for general private practice pediatrics ($1.9 million less), general academic pediatrics ($1.1 million less), and all other pediatric subspecialties. LEP of DBP could be improved by shortening fellowship training or implementing loan repayment or forgiveness programs. LEP for subspecialists, including DBP, was associated with distance to subspecialists (-0.5 miles/$100,000 increase in LEP, 95% confidence interval [CI] -0.98 to -0.08), percentage of HRRs with a subspecialist (+1.1%/$100,000 increase in LEP, 95% CI 0.37-1.83), ratio of subspecialists to regional child population (+0.1 subspecialists/100,000 children/$100,000 increase in LEP, 95% CI 0.04-0.17), and average 2014 to 2018 fellowship fill rates (+1% spots filled/$100,000 increase in LEP, 95% CI 0.25-1.65). CONCLUSIONS: DBP has the lowest LEP of all pediatric fields and this is associated with DBP workforce shortages. Interventions to improve LEP may promote workforce growth.

Development of a composite diffusion tensor imaging score correlating with short-term neurological status in neonatal hypoxic-ischemic encephalopathy.

Hypoxic-ischemic encephalopathy (HIE) is the most common cause of neonatal acquired brain injury. Although conventional MRI may predict neurodevelopmental outcomes, accurate prognostication remains difficult. As diffusion tensor imaging (DTI) may provide an additional diagnostic and prognostic value over conventional MRI, we aimed to develop a composite DTI (cDTI) score to relate to short-term neurological function. Sixty prospective neonates treated with therapeutic hypothermia (TH) for HIE were evaluated with DTI, with a voxel size of 1 × 1 × 2 mm. Fractional anisotropy (FA) and mean diffusivity (MD) from 100 neuroanatomical regions (FA/MD *100 = 200 DTI parameters in total) were quantified using an atlas-based image parcellation technique. A least absolute shrinkage and selection operator (LASSO) regression was applied to the DTI parameters to generate the cDTI score. Time to full oral nutrition [short-term oral feeding (STO) score] was used as a measure of short-term neurological function and was correlated with extracted DTI features. Seventeen DTI parameters were selected with LASSO and built into the final unbiased regression model. The selected factors included FA or MD values of the limbic structures, the corticospinal tract, and the frontotemporal cortices. While the cDTI score strongly correlated with the STO score (rho = 0.83, p = 2.8 × 10-16), it only weakly correlated with the Sarnat score (rho = 0.27, p = 0.035) and moderately with the NICHD-NRN neuroimaging score (rho = 0.43, p = 6.6 × 10-04). In contrast to the cDTI score, the NICHD-NRN score only moderately correlated with the STO score (rho = 0.37, p = 0.0037). Using a mixed-model analysis, interleukin-10 at admission to the NICU (p = 1.5 × 10-13) and tau protein at the end of TH/rewarming (p = 0.036) and after rewarming (p = 0.0015) were significantly associated with higher cDTI scores, suggesting that high cDTI scores were related to the intensity of the early inflammatory response and the severity of neuronal impairment after TH. In conclusion, a data-driven unbiased approach was applied to identify anatomical structures associated with some aspects of neurological function of HIE neonates after cooling and to build a cDTI score, which was correlated with the severity of short-term neurological functions.

Addressing Gender-Based Disparities in Earning Potential in Academic Medicine.

Importance: Gender-based disparities in compensation in academic medicine are recognized, but their estimated impacts on early career earning potential and strategies to mitigate them have not been well studied. Objectives: To compare earning potential between female and male academic physicians in the first 10 years of posttraining employment and to evaluate the estimated impact of promotion timing, starting salary, and salary growth rate on earning potential. Design, Setting, and Participants: Using publicly available mean debt and compensation data for full-time employed academic physicians in the US from 2019 to 2020, starting salary, salary in year 10 of employment, annual salary growth rate, and overall earning potential in the first 10 years of employment were estimated for each gender by subspecialty. The estimated impacts of promotion timing and potential interventions, including equalizing starting salaries and annual salary growth rates, were modeled. Data analysis was performed from March to May 2021. Exposures: Gender and subspecialty. Main Outcomes and Measures: Starting salary, annual salary growth rate, year-10 salary, and earning potential in first 10 years of employment. Results: This cross-sectional study included compensation data from 24 593 female and 29 886 male academic physicians across 45 subspecialties. Women had lower starting salaries in 42 of 45 subspecialties (93%), year-10 salaries in 43 of 45 subspecialties (96%), mean annual salary growth rates in 22 of 45 subspecialties (49%), and earning potential in 43 of 45 subspecialties (96%) (median [IQR], $214 440 [$130 423-$384 954], or 10%, less). A 1-year delay in promotion from assistant to associate professor reduced women's earning potential by a median (IQR) of $26 042 ($19 672-$35 671), but failure to be promoted at all reduced it by a median (IQR) of $218 724 ($176 317-$284 466). Equalizing starting salaries could increase women's earning potential by a median (IQR) of $250 075 ($161 299-$381 799) in the subspecialties for which starting salaries for women were lower than those for men. Equalizing annual salary growth rates could increase women's earning potential by a median (IQR) of $53 661 ($24 258-$102 892) in the subspecialties for which mean annual salary growth rates were lower for women than for men. Conclusions and Relevance: The findings of this study suggest that gender-based disparities in starting salary and early career earning potential are pervasive in academic medicine in the US. Equalizing starting salaries would address the majority of the differences in earning potential.

Association Between Workforce Gender Distribution and Lifetime Earning Potential in the Pediatric Subspecialties.

OBJECTIVE: Examine the relationship between the gender distribution of the pediatric subspecialty workforce and lifetime earning potential. METHODS: We estimated lifetime earning potential for pediatric academic subspecialists using mean debt and compensation data from national physician surveys for 2019 to 2020 and examined the relationship between the workforce gender composition and lifetime earning potential across the pediatric subspecialties using linear regression analysis. RESULTS: Subspecialties with a higher proportion of women had lower lifetime earning potential (-$55,215 in lifetime earning potential/1% increase in the percentage of female subspecialists; P value .002, 95% CI -$24,429 to -$86,000). Similarly, a higher proportion of female first-year fellows was associated with lower lifetime earning potential (-$61,808 in lifetime earning potential/1% increase in the percentage of female first-year fellows; P value .026, 95% CI -$9,210 to -$114,405). CONCLUSIONS: Consistent with patterns seen in other areas of adult medicine and surgery, pediatric subspecialties with higher proportions of women, such as adolescent medicine and endocrinology, tended to have lower lifetime earning potentials than subspecialties with higher proportions of men, such as cardiology and critical care. Lower earning subspecialties also tended to train higher proportions of women, suggesting that this trend may worsen over time as pediatrics in general and individual subspecialties in particular become increasingly female predominant.

Differences in Lifetime Earning Potential Between Pediatric and Adult Physicians.

OBJECTIVES: Compare lifetime earning potential between academic pediatric and adult medicine generalists and subspecialists. Evaluate the effect of decreasing the length of training for pediatric subspecialties whose length of training is longer than that for the adult medicine counterpart. METHODS: Using compensation and debt data from national physician surveys for 2019-2020, we estimated and compared the lifetime earning potential for academic pediatric and adult physicians. RESULTS: Lifetime earning potential was higher for adult physicians than for pediatric physicians across all comparable areas of both general and subspecialty academic practice. The lifetime earning potentials for adult physicians averaged 25% more, or $1.2 million higher, than those of the corresponding pediatric physicians. These differences predominantly were not attributable to unequal training length: when we modeled a shortened length of training for pediatric subspecialists, lifetime earning potential for adult subspecialists still averaged 19% more than that for pediatric subspecialists. For both pediatric and adult medicine, the primarily inpatient, procedure-oriented subspecialties had higher lifetime earning potential than the outpatient, less procedure-oriented subspecialties. CONCLUSIONS: Wide differences in lifetime earning potential between pediatric and adult physicians reflected lower compensation in pediatrics, rather than any differences in training length. Inpatient-based, more procedure-oriented subspecialties had higher lifetime earning potential than outpatient-based, less procedure-oriented subspecialties. Interventions that improve the lifetime earning potential of general pediatrics and the pediatric subspecialties, as well as the less procedure-oriented subspecialties across both pediatric and adult medicine, have the potential to impact both clinical practice and access to care.

Association of Lifetime Earning Potential and Workforce Distribution Among Pediatric Subspecialists.

Importance: Differences in lifetime earning potential between pediatric subspecialties may contribute to shortages in the subspecialty workforce. Objectives: To evaluate the association between lifetime earning potential and workforce distribution and to investigate the potential role of a pediatric subspecialist-specific loan repayment program (LRP) in workforce expansion. Design, Setting, and Participants: This study was performed on publicly available mean debt and compensation data from national physician surveys from 2018 to 2019 of pediatric subspecialists in academic practice. Linear regression analysis was used to evaluate the association between lifetime earning potential and measures of workforce distribution in 2019, including distance to subspecialists, percentage of hospital referral regions with a subspecialist, and ratio of subspecialists to the regional child population as well as between lifetime earning potential in 2018 to 2019 and mean subspecialty fellowship fill rates between 2014 and 2018. The association between the change in lifetime earning potential from 2007 to 2018 and the change in workforce distribution metrics from 2003 to 2019 was also examined. The potential role of a pediatric subspecialist-specific LRP was modeled. Exposures: Lifetime earning potential by subspecialty. Main Outcomes and Measures: Measures of workforce distribution and fellowship fill rates. Results: This study included mean compensation data representing 7539 pediatric subspecialists, workforce distribution data representing 24 375 pediatric subspecialists, and fellowship fill rates representing a mean of 1344 pediatric subspecialty fellows per year. Higher lifetime earning potential was associated with shorter distance to subspecialists (-0.59 miles/$100 000 increase in lifetime earning potential; 95% CI, -1.10 to -0.09), higher percentage of hospital referral regions with a subspecialist (+1.17%/$100 000 increase in lifetime earning potential; 95% CI, 0.34-2.00), and higher ratio of subspecialists to regional child population (+0.11 subspecialists/100 000 children/$100 000 increase in lifetime earning potential; 95% CI, 0.04-0.19). The subspecialties for which lifetime earning potential increased the least between 2007 and 2018 experienced the least growth in the ratio of subspecialists to regional child population from 2003 to 2019 (+0.11 subspecialists/100 000 children/$100 000 increase in lifetime earning potential; 95% CI, 0.07-0.16). Higher lifetime earning potential was associated with higher mean fellowship fill rates (+0.96% spots filled/$100 000 increase in lifetime earning potential; 95% CI, 0.15-1.77). Implementing a pediatric subspecialist-specific LRP could increase fellowship fill rates and improve workforce distribution. Conclusions and Relevance: Lifetime earning potential based on subspecialty may contribute to imbalances in both the current and future pediatric subspecialty workforce. Pediatric subspecialist-specific LRPs, especially for underfilled subspecialties, are potential tools for policy makers to target workforce shortages.

Differences in Lifetime Earning Potential for Pediatric Subspecialists.

OBJECTIVES: Our 2011 report, reflecting data from 2007-2008, demonstrated that, for many pediatric subspecialties, pursuing fellowship training was a negative financial decision when compared with practicing as a general pediatrician. We provide an updated analysis on the financial impact of pediatric fellowship training and model interventions that can influence the results. METHODS: We estimated the financial returns a graduating pediatric resident might anticipate from fellowship training followed by a career as a pediatric subspecialist and compared them with the returns expected from starting a career as a general pediatrician immediately after residency. We evaluated the potential effects of eliminating medical school debt, shortening the length of fellowship training, and implementing a federal loan repayment program for pediatric subspecialists. We compared the financial returns of subspecialty training in 2018-2019 to those from our previous report. RESULTS: Pursuing fellowship training generated widely variable financial returns when compared with general pediatrics that ranged from +$852 129 for cardiology to -$1 594 366 for adolescent medicine. Twelve of 15 subspecialties analyzed yielded negative financial returns. The differences have become more pronounced over time: the spread between the highest and lowest earning subspecialties widened from >$1.4 million in 2007-2008 to >$2.3 million in 2018-2019. The negative financial impact of fellowship training could be partially ameliorated by shortening the length of training or by implementing pediatric subspecialist specific loan repayment programs. CONCLUSIONS: This report can be used to help guide trainees, educators, and policy makers. The interventions discussed could help maintain an adequate and balanced pediatric workforce.

Performance of a Pediatric Stroke Alert Team Within a Comprehensive Stroke Center.

BACKGROUND: Childhood stroke is rare, and diagnosis is frequently delayed. The use of pediatric stroke teams has the potential to decrease time to neurology evaluation and imaging, hastening appropriate diagnosis and treatment for acute neurologic presentations in children. METHODS: We performed a retrospective analysis of our institutional pediatric stroke or "brain attack" team (pedsBAT) activations from October 2014 to July 2017. Clinical characteristics and timing parameters were compared between pedsBAT activations in the inpatient vs emergency department (ED) / outpatient settings as well as between pediatric and adult BAT activations in the same time period. RESULTS: We identified 120 pedsBAT activations (75% in the ED/outpatient setting) during the study time period. Inpatient pedsBAT activations were more likely than outpatient activations to have heart disease as a risk factor for ischemic stroke and presented more frequently with altered mental status, but there were no differences in the proportion of cerebrovascular diagnoses or timing parameters between the 2 groups. When compared with adult BAT activations, outpatient pedsBAT activations had a longer time from symptom discovery to arrival at the ED, and inpatient pedsBAT activations had longer time from symptom discovery to BAT activation. CONCLUSIONS: Compared with adults, the interval leading up to stroke team activation was longer in children, suggesting delays in symptom recognition. Future interventions should be aimed at reducing these delays in presentation to care and stroke alert activation in pediatric patients.

MRI-defined White Matter Microstructural Alteration Associated with Soccer Heading Is More Extensive in Women than Men.

Purpose To examine the role of sex in abnormal white matter microstructure after soccer heading as identified by using the diffusion-tensor imaging (DTI) metric fractional anisotropy (FA). Materials and Methods In this prospective cross-sectional study, 98 individuals who were enrolled in a larger prospective study of amateur soccer players (from 2013 to 2016) were matched 1:1 for age and history of soccer heading in the prior 12 months. Among the subjects, 49 men (mean age, 25.7 years; range, 18-50 years) and 49 women (mean age, 25.8 years; range, 18-50 years) with median total soccer headings per year of 487 and 469, respectively, underwent 3.0-T DTI. Images were registered to the Johns Hopkins University template. A voxelwise linear regression was fitted for FA with terms for the number of headings during the previous 12 months and its interaction with sex after controlling for the following potential confounders: age, years of education, number of lifetime concussions, and handedness. In the resulting statistical maps, P < .01 indicated a statistically significant difference, with a threshold cluster size larger than 100 mm3. Results Among men, three regions were identified in which greater heading exposure was associated with lower FA; eight such regions were identified among women (>100 contiguous voxels, P < .01). In seven of the eight regions identified in women, the association between heading and FA was stronger in women than in men. There was no significant difference of heading with FA between the sexes for any region in which heading was associated with FA among men (P > .01, <100 contiguous voxels). Conclusion With similar exposure to heading, women exhibit more widespread evidence of microstructural white matter alteration than do men, suggesting preliminary support for a biologic divergence of brain response to repetitive trauma. © RSNA, 2018 Online supplemental material is available for this article.

Characterization of Neck Strength in Healthy Young Adults.

BACKGROUND: The role of cervical muscle (neck) strength in traumatic brain and spine injury and chronic neck pain disorders is an area of active research. Characterization of the normal ranges of neck strength in healthy young adults is essential to designing future investigations of how strength may act as a modifier for risk and progression in head and neck disorders. OBJECTIVE: To develop a normative reference database of neck strength in a healthy young adult population, and to evaluate the relationship of neck strength to anthropometric measurements. DESIGN: Cross-sectional. SETTING: An academic medical center research institution. PARTICIPANTS: A total of 157 healthy young adults (18-35 years of age) had their neck strength measured with fixed frame dynamometry (FFD) during 1 visit to establish a normative neck strength database. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASUREMENTS: Peak and average strength of the neck muscles were measured in extension, forward flexion, and right and left lateral flexion using FFD. The ranges of peak and average neck strength were characterized and correlated with anthropometric characteristics. RESULTS: In all, 157 subjects (84 male, 73 female; average age 27 years) were included in the normative sample. Neck strength ranged from 38 to 383 Newtons in men and from 15 to 223 Newtons in women. Normative data are provided for each gender in all 4 directions. Weight, body mass index, neck circumference, and estimated neck muscle volume were modestly correlated with neck strength in multiple directions (correlation coefficients < .4). In a multivariate regression model, weight in women and neck volume in men were significant predictors of neck strength. CONCLUSIONS: Neck strength in healthy young adults exhibits a broad range, is significantly different in men from that in women, and correlates only modestly with anthropometric characteristics. LEVEL OF EVIDENCE: Not applicable.

Neuroimaging in Blast-Related Mild Traumatic Brain Injury.

OBJECTIVE: To summarize imaging findings in blast-related mild traumatic brain injury. DESIGN: Our structured review of the literature yielded 5 structural magnetic resonance imaging (sMRI), 18 diffusion tensor imaging, 9 functional magnetic resonance imaging (fMRI), 3 positron emission tomography, 4 magnetoencephalography, 2 electroencephalography, and 1 single-positron emission computerized tomography studies. RESULTS: Four of the 5 sMRI studies reported decreased cortical thickness and decreased thalamus and amygdala volume. Diffusion tensor imaging studies showed abnormal diffusion within white matter tracts commonly associated with traumatic brain injury, including the corpus callosum (8 of the 18) and superior longitudinal fasciculus (8 of the 18). Resting-state fMRI studies reported a variety of functional network differences. Other functional imaging studies showed diffuse changes in activity, especially in the frontal, parietal, temporal, and cingulate regions. CONCLUSION: Vast variation in the sample, design, and measurement features across studies precludes salient conclusions regarding the effectiveness of neuroimaging to assess outcomes and elucidate pathomechanisms. The inherent spatial heterogeneity of mild traumatic brain injury pathology presents a major challenge to meaningful convergence across and generalizable inferences. Approaches to standardize methodology and facilitate access to data and integration across studies hold promise for enhancing our understanding of this complex brain disorder, but can only bear fruit if they are actually consistently implemented.

Estrogen- and progesterone-mediated structural neuroplasticity in women: evidence from neuroimaging.

There is substantial evidence that the ovarian sex hormones, estrogen and progesterone, which vary considerably over the course of the human female lifetime, contribute to changes in brain structure and function. This structured, quantitative literature reviews aims to summarize neuroimaging literature addressing physiological variation in brain macro- and microstructure across an array of hormonal transitions including the menstrual cycle, use of hormonal contraceptives, pregnancy, and menopause. Twenty-five studies reporting structural neuroimaging of women, addressing variation across hormonal states, were identified from a structured search of PUBMED and were systematically reviewed. Although the studies are heterogenous with regard to methodology, overall the results point to overlapping areas of hormone related effects on brain structure particularly affecting the structures of the limbic system. These findings are in keeping with functional data that point to a role for estrogen and progesterone in mediating emotional processing.

Identification of neural targets for the treatment of psychiatric disorders: the role of functional neuroimaging.

Neurosurgical treatment of psychiatric disorders has been influenced by evolving neurobiological models of symptom generation. The advent of functional neuroimaging and advances in the neurosciences have revolutionized understanding of the functional neuroanatomy of psychiatric disorders. This article reviews neuroimaging studies of depression from the last 3 decades and describes an emerging neurocircuitry model of mood disorders, focusing on critical circuits of cognition and emotion, particularly those networks involved in the regulation of evaluative, expressive and experiential aspects of emotion. The relevance of this model for neurotherapeutics is discussed, as well as the role of functional neuroimaging of psychiatric disorders.