Current evidence for pharmacological management of pediatric concussion: a systematic review.

PURPOSE: Mild traumatic brain injury (mTBI) is a global public health problem and its current management is limited to rest and symptom management. Despite frequent use of drugs for symptom control, there is a lack of consensus on the optimal pharmacological management of post-concussive symptoms. We reviewed the relevant literature to compile the evidence about the pharmaceutical management of pediatric mTBI. METHODS: We performed a systematic review of the literature available in PubMed, Cochrane CENTRAL, and ClinicalTrials.Gov as well as through citation tracing. A modified PICO framework was used for the construction of search strategy and eligibility criteria. Risk of bias was assessed using RoB-2 tool for randomized and ROBINS-I for non-randomized studies. RESULTS: A total of 6260 articles were screened for eligibility. After exclusions, a total of 88 articles received full text review. A total of 15 reports representing 13 studies (5 randomized clinical trials, 1 prospective randomized cohort study, 1 prospective cohort study, and 6 retrospective cohort studies) met the eligibility criteria and were included in the review. We identified 16 pharmacological interventions in a total of 931 pediatric patients with mTBI. Amytriptiline (n = 4), ondansetron (n = 3), melatonin (n = 3), metoclopramide (n = 2), magnesium (n = 2), and topiramate (n = 2) were investigated in multiple studies. All RCTs were relatively of small size (n ≤ 33/group). CONCLUSION: The available evidence supporting pharmacological intervention in pediatric mild traumatic brain injury is scarce. We propose a framework to facilitate future collaborative research efforts to test and validate various pharmacological interventions for acute and persistent post-concussive symptoms in children.

Automatic Detection of Focal Cortical Dysplasia Using MRI: A Systematic Review.

Focal cortical dysplasia (FCD) is a congenital brain malformation that is closely associated with epilepsy. Early and accurate diagnosis is essential for effectively treating and managing FCD. Magnetic resonance imaging (MRI)-one of the most commonly used non-invasive neuroimaging methods for evaluating the structure of the brain-is often implemented along with automatic methods to diagnose FCD. In this review, we define three categories for FCD identification based on MRI: visual, semi-automatic, and fully automatic methods. By conducting a systematic review following the PRISMA statement, we identified 65 relevant papers that have contributed to our understanding of automatic FCD identification techniques. The results of this review present a comprehensive overview of the current state-of-the-art in the field of automatic FCD identification and highlight the progress made and challenges ahead in developing reliable, efficient methods for automatic FCD diagnosis using MRI images. Future developments in this area will most likely lead to the integration of these automatic identification tools into medical image-viewing software, providing neurologists and radiologists with enhanced diagnostic capabilities. Moreover, new MRI sequences and higher-field-strength scanners will offer improved resolution and anatomical detail for precise FCD characterization. This review summarizes the current state of automatic FCD identification, thereby contributing to a deeper understanding and the advancement of FCD diagnosis and management.

Responsive neurostimulation in pediatric patients with drug-resistant epilepsy.

OBJECTIVE: Medically refractory epilepsy remains a therapeutic challenge when resective surgery is not a practical option and indirect neurostimulation efficacy may be limited. In these instances responsive neurostimulation (RNS) has been used in adults, with good outcomes in most patients. However, the utility of RNS in children and young adults has not been systematically explored. In this study, the authors present a single institution's experience with RNS in pediatric patients. METHODS: A single-center retrospective chart review of patients who underwent RNS implantation at Phoenix Children's Hospital during the 4-year period between January 2018 and December 2021 was performed. RESULTS: Following evaluation for epilepsy surgery, 22 patients underwent RNS implantation using different anatomical targets depending on the predetermined epileptic focus/network. In the cohort, 59% of patients were male, the mean age at implantation was 16.4 years (range 6-22 years), and the mean follow-up time was 2.7 years (range 1.0-4.3 years). All patients had a preoperative noninvasive evaluation that included MRI, video-electroencephalography, and resting-state functional MRI. Additionally, 13 patients underwent invasive monitoring with stereo-electroencephalography to help determine RNS targets. All patients had variable positive responses with reduction of seizure frequency and/or intensity. Overall, seizure frequency reduction of > 50% was seen in the majority (86%) of patients. There were two complications: one patient experienced transitory weakness and one generator failed, requiring replacement. A patient died of sudden unexpected death in epilepsy 3 years after implantation despite being seizure free during the previous year. CONCLUSIONS: RNS used in children with medically refractory epilepsy improved seizure control after implantation, with decreases in seizure frequency > 50% from preoperative baseline in the majority of patients. Preliminary findings indicate that functional MRI and stereo-electroencephalography were helpful for RNS targeting and that RNS can be used safely even in young children.

Bovine leptospirosis: effects on reproduction and an approach to research in Colombia.

Leptospirosis is the most widespread zoonosis worldwide, causing severe effects on beef and dairy cattle farming and other livestock. Colombia geographical location in the tropical zone, high biodiversity, and climatic conditions promote Leptospira growth and prevalence. This review article presents state-of-the-art knowledge about the effects of leptospirosis on bovine reproduction and a critical analysis of the research carried out in Colombia. The analysis of the information allows us to infer a sustained increase in prevalence over the last decade in the densest livestock production areas and a high serovar diversity of circulating pathogenic Leptospira. Given the zoonotic nature of leptospirosis, an inter-institutional effort is required to implement prevention, control, and monitoring programs under one-health concept.

Changes in attentional processing following neurofeedback in patients with persistent post-concussive symptoms: a pilot study.

OBJECTIVE: Persistent post-concussive symptoms (PPCS) often include attention deficits, particularly orienting and executive attention. Research in other clinical populations has demonstrated that neurofeedback therapy (NFT) is effective at improving orienting and executive attention, although its effects on attentional networks in patients with PPCS are unknown. METHOD: In this single-group pilot study, we examined attention-related event-related potentials (ERPs) - N1 and P3 - and cognitive outcomes following Live Z-score training (LZT), a variant of NFT. RESULTS: No changes in early selective attention, as indexed by N1 amplitude, were observed; however, P3 amplitude, which indexes neural resource allocation, increased following LZT and returned to baseline by 3 months. Cognitive performance improved following treatment, which was sustained at 3 months. The magnitude of change in P3 and ANT performance did not differ between orienting or executive attention, suggesting LZT improved general attentional processing efficiency. CONCLUSION: Our results suggest that LZT may positively affect attention globally, but does not target specific attention networks. These pilot data warrant the initiation of a clinical trial evaluating the effectiveness of LZT for treating attention deficits in patients with PPCS.

[Profile of antimicrobial resistance in isolates of Staphylococcus spp. obtained from bovine milk in Colombia]. / Perfil de resistencia antimicrobiana en aislamientos de Staphylococcus spp. obtenidos de leche bovina en Colombia.

Staphylococcus spp. is one of the pathogens that cause bovine mastitis and may present multiple resistance to different antimicrobial groups. The aim of this study was to phenotypically identify Staphylococcus spp. isolates obtained from bovine milk and to characterize their antimicrobial resistance profile. The 101 strains were classified by phenotypic tests, their resistance to oxacillin, cefoxitin, penicillin, ampicillin, tetracycline, kanamycin, sulfamethoxazole / trimethoprim, clindamycin and erythromycin was determined by the Kirby-Bauer technique and the presence of resistance genes by PCR. A total of 65 strains was S. aureus and 36 strains were coagulase-negative staphylococci (CoNS). We found different patterns of resistance to antibiotics evaluated in strains of S. aureus and CoNS, only the resistance to ampicillin was found associated with the species (p<0.005). In the 101 strains, the mecA gene was detected in 27%, aph(3')-IIIa in 75.2%, aac(6')/aph(2")-3 in 47.4%, ant(4')-Ia in 32.7%, tetM in 63% and tetK in 43.6%; however, no association was found with the resistance to penicillin, ampicillin, cefoxitin, kanamycin and tetracycline, respectively (p>0.05). On the other hand, the blaZ gene was found in 59.4% of the 101 strains and the ermCgene in 62.3%, which was associated with resistance to ß-lactams and macrolides, respectively (p<0.001). In this study, antimicrobial multiresistance was found in S. aureus and CoNS strains. This finding impacts on the dairy industry, representing a risk to public health.

Guillain-Barré Syndrome Associated with Zika Virus Infection in Colombia.

BACKGROUND: Zika virus (ZIKV) infection has been linked to the Guillain-Barré syndrome. From November 2015 through March 2016, clusters of cases of the Guillain-Barré syndrome were observed during the outbreak of ZIKV infection in Colombia. We characterized the clinical features of cases of Guillain-Barré syndrome in the context of this ZIKV infection outbreak and investigated their relationship with ZIKV infection. METHODS: A total of 68 patients with the Guillain-Barré syndrome at six Colombian hospitals were evaluated clinically, and virologic studies were completed for 42 of the patients. We performed reverse-transcriptase-polymerase-chain-reaction (RT-PCR) assays for ZIKV in blood, cerebrospinal fluid, and urine, as well as antiflavivirus antibody assays. RESULTS: A total of 66 patients (97%) had symptoms compatible with ZIKV infection before the onset of the Guillain-Barré syndrome. The median period between the onset of symptoms of ZIKV infection and symptoms of the Guillain-Barré syndrome was 7 days (interquartile range, 3 to 10). Among the 68 patients with the Guillain-Barré syndrome, 50% were found to have bilateral facial paralysis on examination. Among 46 patients in whom nerve-conduction studies and electromyography were performed, the results in 36 patients (78%) were consistent with the acute inflammatory demyelinating polyneuropathy subtype of the Guillain-Barré syndrome. Among the 42 patients who had samples tested for ZIKV by RT-PCR, the results were positive in 17 patients (40%). Most of the positive RT-PCR results were in urine samples (in 16 of the 17 patients with positive RT-PCR results), although 3 samples of cerebrospinal fluid were also positive. In 18 of 42 patients (43%) with the Guillain-Barré syndrome who underwent laboratory testing, the presence of ZIKV infection was supported by clinical and immunologic findings. In 20 of these 42 patients (48%), the Guillain-Barré syndrome had a parainfectious onset. All patients tested were negative for dengue virus infection as assessed by RT-PCR. CONCLUSIONS: The evidence of ZIKV infection documented by RT-PCR among patients with the Guillain-Barré syndrome during the outbreak of ZIKV infection in Colombia lends support to the role of the infection in the development of the Guillain-Barré syndrome. (Funded by the Bart McLean Fund for Neuroimmunology Research and others.).

Aquaporin-4 serostatus does not predict response to immunotherapy in neuromyelitis optica spectrum disorders.

BACKGROUND: Debate exists about whether neuromyelitis optica spectrum disorder seronegative disease represents the same immune-mediated attack on astrocytic aquaporin-4 as in seropositive disease. OBJECTIVE: We investigated whether response to common treatments for neuromyelitis optica spectrum disorder differed by serostatus, as assessed by change in annualized relapse rate. METHODS: We performed a multicenter retrospective analysis of 245 patients with neuromyelitis optica spectrum disorder who were treated with either rituximab or mycophenolate mofetil as their first-line immunosuppressive treatment for disease prevention. Patients were followed for a minimum of 6 months following treatment initiation. RESULTS: In those started on rituximab, the pre-treatment annualized relapse rates for seropositive and seronegative patients were 1.81 and 1.93, respectively. On-treatment annualized relapse rates significantly declined to 0.32 (seropositive; p < 0.0001) and 0.12 (seronegative; p = 0.0001). In those started on mycophenolate mofetil, the pre-treatment annualized relapse rates for seropositive and seronegative patients were 1.79 and 1.45, respectively. On-treatment annualized relapse rates declined to 0.29 (seropositive; p < 0.0001) and 0.30 (seronegative; p < 0.005). CONCLUSION: In this international collaboration involving a large number of neuromyelitis optica spectrum disorder patients, treatment was effective regardless of serostatus. This suggests that treatment should not differ when considering these treatments.

Development and validation of a stakeholder-driven, self-contained electronic informed consent platform for trio-based genomic research studies.

Increasingly long and complex informed consents have yielded studies demonstrating comparatively low participant comprehension and satisfaction with traditional face-to-face approaches. In parallel, interest in electronic consents for clinical and research genomics has steadily increased, yet limited data are available for trio-based genomic discovery studies. We describe the design, development, implementation, and validation of an electronic iConsent application for trio-based genomic research deployed to support genomic studies of cerebral palsy. iConsent development incorporated stakeholder perspectives including researchers, patient advocates, institutional review board members, and genomic data-sharing considerations. The iConsent platform integrated principles derived from prior electronic consenting research and elements of multimedia learning theory. Participant comprehension was assessed in an interactive teachback format. The iConsent application achieved nine of ten proposed desiderata for effective patient-focused electronic consenting for genomic research. Overall, participants demonstrated high comprehension and retention of key human subjects' considerations. Enrollees reported high levels of satisfaction with the iConsent, and we found that participant comprehension, iConsent clarity, privacy protections, and study goal explanations were associated with overall satisfaction. Although opportunities exist to optimize iConsent, we show that such an approach is feasible, can satisfy multiple stakeholder requirements, and can realize high participant satisfaction and comprehension while increasing study reach.

Long-term outcomes of patients affected by Guillain-Barré syndrome in Colombia after the Zika virus epidemic.

BACKGROUND: Guillain-Barré Syndrome (GBS) can lead to significant functional impairments, yet little is understood about the recovery phase and long-term consequences for patients in low- and medium-income countries. OBJECTIVE: To evaluate the functional status and identify factors influencing outcomes among patients with GBS in Colombia. METHODS: Telephone interviews were conducted with GBS patients enrolled in the Neuroviruses Emerging in the Americas Study between 2016 and 2020. The investigation encompassed access to health services and functional status assessments, utilizing the modified Rankin Scale (mRS), GBS Disability Score (GDS), Barthel Index (BI), and International Classification of Functioning (ICF). Univariate analysis, principal component analysis, linear discriminant analysis, and linear regression were employed to explore factors influencing functional status. RESULTS: Forty-five patients (mean age = 50[±22] years) with a median time from diagnosis of 28 months (IQR = 9-34) were included. Notably, 22% and 16% of patients did not receive rehabilitation services during the acute episode and post-discharge, respectively. Most patients demonstrated independence in basic daily activities (median BI = 100, IQR = 77.5-100), improvement in disability as the median mRS at follow-up was lower than at onset (1 [IQR = 0-3] vs. 4.5 [IQR = 4-5], p < 0.001), and most were able to walk without assistance (median GDS = 2, IQR = 0-2). A shorter period from disease onset to interview was associated with worse mRS (p = 0.015) and ICF (p = 0.019). Negative outcomes on GDS and ICF were linked to low socioeconomic status, ICF to the severity of weakness at onset, and BI to an older age. CONCLUSIONS: This study underscores that the functional recovery of GBS patients in Colombia is influenced not only by the natural course of the disease but also by socioeconomic factors, emphasizing the crucial role of social determinants of health.

Posttraumatic seizures in children with severe traumatic brain injury.

PURPOSE: Traumatic brain injury (TBI) remains a leading cause of childhood death and disability worldwide. Seizures are a common complication of TBI and they are particularly common in pediatric populations. The proper management of children sustaining severe TBI is still controversial. Our study aims to share our experience contributing to build evidence for better care. METHODS: Retrospective chart review was performed on individuals ages 0 to <18 who presented to a level 1 trauma center during a 10-year period with the diagnosis of severe TBI. Data analyzed included patient's demographics, event information, clinical and radiological presentation, management, and midterm follow-up. Presence of seizures was tracked through EEG monitoring, staff witnessing, or guardian referral. RESULTS: The incidence of early posttraumatic seizures (EPTS) observed in our population (19 %) exceeds those previously reported. Such findings likely reflect the importance of close monitoring including EEG. An association between the presence of EPTS and the development of late posttraumatic seizures (LPTS) was evidenced (p=0.001; 95 % CI 2.2, 16.5), while this association should not be assumed as a measure of causality, it should be considered for the management of patients presenting EPTS. Non-accidental trauma and young age were identified as independent predictors for the development of seizures. CONCLUSIONS: Seizures are a common complication of severe TBI among children aged 0-3 years. Given the detrimental effects that seizures produce on the injured brain, close observation and appropriate monitoring with EEG are essential for the management of children sustaining severe TBI.

Seroprevalence of antibodies to Chlamydia abortus and risk factors in cattle from Villavicencio, Colombia.

Chlamydia abortus is a Gram-negative obligate intracellular bacterium, responsible for abortions and reproductive problems. The disease has a high zoonotic potential and causes great economic losses in ruminant farmers. A cross-sectional study was carried out with 514 cattle from 24 farms of Villavicencio, Colombia. The blood samples were collected from each individual animal and analyzed by Indirect Elisa for immunoglobulin G (IgG) in blood serum (Idexx Chlamydiosis total Ab test). A serum was considered positive when the optical density (OD) of the sample was ≥30% of that of the positive control serum. Data on potential risk factors associated with the disease were collected through a questionnaire in each farm and analyzed. The individual and herd prevalence was estimated. A risk factors analysis was performed through univariate and multivariable using the software SPSS version 20. The animal level seroprevalence was found to be 47.1% and the herd 91.6%. The prevalence in cattle aged 0-1, 1-3 and >4 years was 23.8%; 31.4% and 51.4% respectively. The risk factors associated with the prevalence of disease were female sex (OR = 2.102 CI: 1.066-4.144), age older than 4 years (OR = 2.707 CI: 1.667-4.394), presence of canines on the farm (OR = 2.556 CI: 1.560-4.189) and retention of placenta (OR = 2.678 CI: 1.670-4.295). A high prevalence was identified, suggesting natural infection where the pathogen could be transmitted to humans at the animal-human interface.

Prevalence of neuromyelitis optica spectrum disorder in antioquia between 2016 and 2018.

BACKGROUND: There are few epidemiological studies published in the world evaluating the prevalence of Neuromyelitis Optica Spectrum Disorder (NMOSD). The true prevalence of the disease is not known and the studies carried out are based on the diagnostic criteria used prior to 2015. OBJECTIVE: To determine the prevalence of NMOSD in Antioquia, from January 2016 to December 2018. METHODS: The prevalence of NMOSD in Antioquia was determined using the Capture-Recapture Method. Eight centers in the Department of Antioquia for the care of patients with neurological diseases were included. The data was collected between 2016 and 2018. RESULTS: A total of 221 consultation histories, 169 patients with a diagnosis of NMOSD were identified. The prevalence was 4.03 cases/100,000 inhabitants (95% confidence interval (CI) 3.3-4.8) of whom (87.5%), were women and the predominant race was Mestizo (81.6%). The most frequent initial presentation was optic neuritis (ON) (50.9%). Most of the patients had motor or visual disability (86.4%) and the treatment most used was Rituximab (47.9%). CONCLUSION: The prevalence of NMOSD in Antioquia is one of the highest reported in the world, except for the French Antilles. More studies are required to know the prevalence of this disease in the Colombian population.

Central Nervous System Metabolism in Autism, Epilepsy and Developmental Delays: A Cerebrospinal Fluid Analysis.

Neurodevelopmental disorders are associated with metabolic pathway imbalances; however, most metabolic measurements are made peripherally, leaving central metabolic disturbances under-investigated. Cerebrospinal fluid obtained intraoperatively from children with autism spectrum disorder (ASD, n = 34), developmental delays (DD, n = 20), and those without known DD/ASD (n = 34) was analyzed using large-scale targeted mass spectrometry. Eighteen also had epilepsy (EPI). Metabolites significantly related to ASD, DD and EPI were identified by linear models and entered into metabolite-metabolite network pathway analysis. Common disrupted pathways were analyzed for each group of interest. Central metabolites most involved in metabolic pathways were L-cysteine, adenine, and dodecanoic acid for ASD; nicotinamide adenine dinucleotide phosphate, L-aspartic acid, and glycine for EPI; and adenosine triphosphate, L-glutamine, ornithine, L-arginine, L-lysine, citrulline, and L-homoserine for DD. Amino acid and energy metabolism pathways were most disrupted in all disorders, but the source of the disruption was different for each disorder. Disruption in vitamin and one-carbon metabolism was associated with DD and EPI, lipid pathway disruption was associated with EPI and redox metabolism disruption was related to ASD. Two microbiome metabolites were also detected in the CSF: shikimic and cis-cis-muconic acid. Overall, this study provides increased insight into unique metabolic disruptions in distinct but overlapping neurodevelopmental disorders.

[A growth study of Prioria copaifera (Caesalpinaceae) using dendrochronological techniques]. / Estudio del crecimiento de Prioria copaifera (Caesalpinaceae) mediante técnicas dendrocronológicas.

The Cativo (Prioria copaifera) forms very homogeneous forests called cativales in the flooded plains of some rivers from Costa Rica to Colombia. For over 70 years Cativo has been the main base of the timber industry in the Colombian Darien area. Because of high productivity and high-dominance of Cativo trees, they represent one of the most prone tropical forests for sustainable forest management. The objective of this research is to model diameter and timber volume growth and growth rates (absolute, mean and relative) of Cativo as a function of age, using tree ring data derived from dendrochronologycal techniques. We evaluated the annual nature of the tree rings by radiocarbon analysis and crossdating techniques. Besides, the diameter and volume growth was modeled using von Bertalanffy's model. As of our results, we estimated the life span of Cativo in 614 years as the time required to reach 99% of the asymptotic diameter. By the mean value we have found that the mean rate of diameter growth is 0.31cm/y. The species requires 90 years to reach 40cm in diameter, the regulated cut diameter in Colombia. We find that Cativo reaches maximum current annual increment (ICA) in diameter at 40 years and in volume at 90 years with rates of 0.5cm/y and 0.032m3/y per tree, respectively. The maximum diameter mean annual increments (MAI) are achieved at 80 years and for the volume at 140 year, with growth rates of 0.45cm/y and 0.018m3/y per tree, respectively. The generated information is useful for the sustainable management of Cativò forests.

Mild Traumatic Brain Injury and Postconcussive Symptom Endorsement: A Parallel Comparison Between Two Nonclinical Cohorts.

INTRODUCTION: The prevalence of mild traumatic brain injury (mTBI) is commonly estimated based on indirect metrics such as emergency department visits and self-reporting tools. The study of postconcussive symptoms faces similar challenges because of their unspecific character and indistinct causality. In this article, we compare two nonclinical, epidemiological studies that addressed these two elements and were performed within a relatively narrow period in the state of Colorado. MATERIALS AND METHODS: De-identified datasets were obtained from a random digit-dialed survey study conducted by the Craig Hospital and a study surveying soldiers returning from deployment by Defense and Veteran Traumatic Brain Injury Center. Information pertinent to participants' demographics, a history of mTBI, and symptom endorsement was extracted and homogenized in order to establish a parallel comparison between the populations of the two studies. RESULTS: From the 1,558 (Warrior Strong, 679; Craig Hospital, 879) records selected for analysis, 43% reported a history of at least one mTBI. The prevalence was significantly higher among individuals from the Defense and Veteran Traumatic Brain Injury Center study independent of gender or race. Repetitive injuries were reported by 15% of the total combined cohort and were more prevalent among males. Symptom endorsement was significantly higher in individuals with a positive history of mTBI, but over 80% of those with a negative history of mTBI endorsed at least one of the symptoms interrogated. Significant differences were observed between the military and the civilian populations in terms of the types and frequencies of the symptoms endorsed. CONCLUSIONS: The prevalence of mTBI and associated symptoms identified in the two study populations is higher than that of previously reported. This suggests that not all individuals sustaining concussion seek medical care and highlights the limitations of using clinical reports to assess such estimates. The lack of appropriate mechanisms to determine symptom presence and causality remains a challenge. However, the differences observed in symptom reporting between cohorts raise questions about the nature of the symptoms, the impact on the quality of life for different individuals, and the effects on military health and force readiness.

Severe Pediatric TBI Management in a Middle-Income Country and a High-Income Country: A Comparative Assessment of Two Centers.

Background: Traumatic brain injury (TBI) is a global public health issue with over 10 million deaths or hospitalizations each year. However, access to specialized care is dependent on institutional resources and public health policy. Phoenix Children's Hospital USA (PCH) and the Neiva University Hospital, Colombia (NUH) compared the management and outcomes of pediatric patients with severe TBI over 5 years to establish differences between outcomes of patients managed in countries of varying resources availability. Methods: We conducted a retrospective review of individuals between 0 and 17 years of age, with a diagnosis of severe TBI and admitted to PCH and NUH between 2010 and 2015. Data collected included Glasgow coma scores, intensive care unit monitoring, and Glasgow outcome scores. Pearson Chi-square, Fisher exact, T-test, or Wilcoxon-rank sum test was used to compare outcomes. Results: One hundred and one subjects met the inclusion criteria. NUH employed intracranial pressure monitoring less frequently than PCH (p = 0.000), but surgical decompression and subdural evacuation were higher at PCH (p = 0.031 and p = 0.003). Mortality rates were similar between the institutions (15% PCH, 17% NUH) as were functional outcomes (52% PCH, 54% NUH). Conclusions: Differences between centers included time to specialized care and utilization of monitoring. No significant differences were evidenced in survival and the overall functional outcomes.

Diaphragmatic injuries: what has changed over a 20-year period?

Traumatic diaphragmatic injuries are uncommon events but are associated with a high mortality. We hypothesize that injury pattern has changed over time with increasing prevalence of blunt injuries. A retrospective chart review was performed of 124 patients who sustained traumatic diaphragmatic injuries over the 20-year period between January 1, 1986 and December 31, 2005. Penetrating trauma accounted for 65 per cent (80/124) of all diaphragm injuries, and blunt trauma for 35 per cent (44/124). Mean Injury Severity Scores of 19 +/- 9 and 34 +/- 13 were observed for the penetrating and blunt trauma groups, respectively (P = 0.001). Blunt traumatic diaphragm injuries increased from 13 per cent in the first 10-year period to 66 per cent in the second 10-year period (P = 0.001). The overall mortality was 9 per cent (11/124) with 10 deaths resulting from blunt trauma and one resulting from penetrating trauma (P < 0.001). The mortality rate increased from 3 to 17 per cent over the two decades (P = 0.007). Our data suggests that over the last 20 years, the increase in mortality associated with traumatic diaphragmatic injury is primarily related to an increase in the proportion of patients with blunt trauma as a cause of their diaphragmatic injury and associated injuries.

Comparison of autograft versus allograft in the surgical repair of pediatric obstetrical brachial plexus injuries.

OBJECTIVE: The goal of this study was to determine the functional efficacy of acellular processed nerve allograft (ALG) as compared to sural nerve autograft (AUG) harvested at time of surgery for children with obstetrical brachial plexus injury (OBPI). METHODS: A retrospective review of records was performed in patients who underwent surgical repair of OBPI between 2009 and 2015 at Phoenix Children's Hospital. Patients were grouped based on the type of nerve graft used (AUG using the patient's own sural nerve or decellularized processed cadaveric nerve ALG) and compared in terms of motor strength, British Medical Research Council score, functionality (Mallet scale score), surgical time, rate of complications, and need for further intervention. RESULTS: A total of 52 records were identified meeting study criteria. Sural nerve AUG was used in 22 cases and ALG in 30 cases. Changes from pre- to postsurgical assessment of motor strength were significant for all muscle groups measured except for elbow extension for both groups. All Mallet scores increased significantly. No significant differences were observed in motor strength and functional components between groups. Interventions using ALG had shorter operative times than those performed using AUG. No significant difference was observed in terms of need for further intervention. Two patients (9%) in the AUG group developed stitch abscesses at the harvest site, whereas there were no infectious complications reported in the ALG group. CONCLUSIONS: These findings suggest equivalence in terms of muscle strength and functional outcomes between the use of AUG and ALG for patients with OBPI. However, the less invasive character of ALG repair decreases surgical time and risk of complications.

Implementation of a Generalized Vestibular Rehabilitation Approach.

INTRODUCTION: Vestibular dysfunction is common in military populations as the result of traumatic brain injury, blast exposure, and/or repetitive acoustic insult. Vestibular rehabilitation (VR) has been proven to be an effective approach in the treatment of vestibular dysfunction. VR consists of a series of exercises prescribed on the basis of individual patient needs by a vestibular trained physical therapist (PT). A generalized approach to VR in a military setting could help widen the system capacity to take care of patients with vestibular symptoms, shorten waiting times for patients without impacting the burden on PTs. The rehabilitation team at the Warrior Recovery Center on Fort Carson, Colorado, developed a generalized approach in which a series of exercises were administered to individuals with vestibular dysfunction. The implementation of this approach was evaluated for quality improvement purposes and is presented below. MATERIALS AND METHODS: We utilized a combined observational/survey approach to evaluate the patients' tolerance to a variety of exercises provocative of dizziness symptoms, their overall satisfaction with the intervention, the appropriateness of the allocated resources, and the providers' confidence with the treatment and its administration. Research staff members were present as observers in all therapy sessions during the 3-month implementation period and administered surveys to patients and clinical staff at pre-established time points. Descriptive analysis was performed to summarize observations and responses to surveys. Linear regression was utilized to evaluate if a reduction in the number of patient:provider interactions occurred over the course of the implementation period. RESULTS: A total of 25 therapy sessions took place during the implementation period. Each visit lasted an average of 56 minutes with 6 minutes allocated for set up, 45 minutes for intervention and 5 minutes for cleanup. The mean number of patients per session was 3 (Max 6, Min 1) with one staff member running the intervention 56% of the time and two staff members running the intervention 44% of the time. Exercise tolerance was at 99% and the need for one-on-one interactions between providers and patients was easily attained at a 3:1 patient:provider rate. Survey assessment demonstrated 100% patient satisfaction with the program and 100% provider confidence with treatment delivery. CONCLUSION: Generalized Vestibular Rehabilitation Treatment (GVRT) was successfully implemented at the Warrior Recovery Center at Fort Carson, Colorado. The individual exercises used during the interventions were challenging to patients yet well tolerated. Resource allocation was appropriate in terms of personnel, time, and equipment. Both the clinical staff and the patients felt comfortable with the therapy and subjectively found it to be effective. The project provided valuable information to clinical staff, administrators, and the organization.