A Novel Neuropsychological Tool for Immersive Assessment of Concussion and Correlation with Subclinical Head Impacts.

Mild traumatic brain injury (mTBI) remains a diagnostic challenge and therefore strategies for objective assessment of neurological function are key to limiting long-term sequelae. Current assessment methods are not optimal in austere environments such as athletic fields; therefore, we developed an immersive tool, the Display Enhanced Testing for Cognitive Impairment and mTBI (DETECT) platform, for rapid objective neuropsychological (NP) testing. The objectives of this study were to assess the ability of DETECT to accurately identify neurocognitive deficits associated with concussion and evaluate the relationship between neurocognitive measures and subconcussive head impacts. DETECT was used over a single season of two high school and two college football teams. Study participants were instrumented with Riddell Head Impact Telemetry (HIT) sensors and a subset tested with DETECT immediately after confirmed impacts for different combinations of linear and rotational acceleration. A total of 123 athletes were enrolled and completed baseline testing. Twenty-one players were pulled from play for suspected concussion and tested with DETECT. DETECT was 86.7% sensitive (95% confidence interval [CI]: 59.5%, 98.3%) and 66.7% specific (95% CI: 22.3%, 95.7%) in correctly identifying athletes with concussions (15 of 21). Weak but significant correlations were found between complex choice response time (processing speed and divided attention) and both linear (Spearman rank correlation coefficient 0.262, p = 0.02) and rotational (Spearman coefficient 0.254, p = 0.03) acceleration on a subset of 76 players (113 DETECT tests) with no concussion symptoms. This study demonstrates that DETECT confers moderate to high sensitivity in identifying acute cognitive impairment and suggests that football impacts that do not result in concussion may negatively affect cognitive performance immediately following an impact. Specificity, however, was not optimal and points to the need for additional studies across multiple neurological domains. Given the need for more objective concussion screening in triage situations, DETECT may provide a solution for mTBI assessment.

Application of the RE-AIM Framework for the Pediatric Mild Traumatic Brain Injury Evaluation and Management Intervention: A Study Protocol for Program Evaluation.

BACKGROUND: Children who experience a mild Traumatic Brain Injury (mTBI) may encounter cognitive and behavioral changes that often negatively impact school performance. Communication linkages between the various healthcare systems and school systems are rarely well-coordinated, placing children with an mTBI at risk for prolonged recovery, adverse impact on learning, and mTBI re-exposure. The objective of this study is to rigorously appraise the pediatric Mild Traumatic Brain Injury Evaluation and Management (TEaM) Intervention that was designed to enhance diagnosis and management of pediatric mTBI through enhanced patient discharge instructions and communication linkages between school and primary care providers. METHODS: This is a combined randomized and 2 × 2 quasi-experimental study design with educational and technology interventions occurring at the clinician level with patient and school outcomes as key endpoints. The RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework will be utilized as a mix methods approach to appraise a multi-disciplinary, multi-setting intervention with the intent of improving outcomes for children who have experienced mTBI. DISCUSSION: Utilization of the RE-AIM framework complemented with qualitative inquiry is suitable for evaluating effectiveness of the TEaM Intervention with the aim of emphasizing priorities regarding pediatric mTBI. This program evaluation has the potential to support the knowledge needed to critically appraise the impact of mTBI recovery interventions across multiple settings, enabling uptake of the best-available evidence within clinical practice.

Preparedness, Adaptation, and Innovation: Approach to the COVID-19 Pandemic at a Decentralized, Quaternary Care Department of Emergency Medicine.

The COVID-19 pandemic has required healthcare systems to be creative and adaptable in response to an unprecedented crisis. Below we describe how we prepared for and adapted to this pandemic at our decentralized, quaternary-care department of emergency medicine, with specific recommendations from our experience. We discuss our longstanding history of institutional preparedness, as well as adaptations in triage, staffing, workflow, and communications. We also discuss innovation through working with industry on solutions in personal protective equipment, as well as telemedicine and methods for improving morale. These preparedness and response solutions and recommendations may be useful moving forward as we transition between response and recovery in this pandemic as well as future pandemics.

A cross-sectional exploratory study of knowledge, attitudes, and practices of emergency health care providers in the assessment of child maltreatment in Maputo, Mozambique.

BACKGROUND: In Mozambique, and other low-income countries (LICs), there is little information on the burden of child maltreatment (CM). Emergency care services (ECS) play an important role in recognizing, treating, and intervening in situations of CM. We aim to identify knowledge, attitudes, and practices regarding CM among health care providers in ECS at Mavalane General Hospital in Maputo, Mozambique. METHODS: This exploratory cross-sectional study evaluates the knowledge, attitudes, and practices of health care providers to diagnose and treat cases of CM. A 25 min, pilot-tested verbal interview questionnaire was administered to 49 physicians and nurses working in ECS at Mavalane General Hospital. Interviews were completed between October-November 2010. Data were managed and analyzed in SPSS 14.0 and descriptive statistics were generated. RESULTS: Of 49 health care providers, 83.6% reporting receiving no, or very little CM education or training. Only 61.2% had knowledge of physical abuse as a main form of child maltreatment and 38.8% were able to identify corresponding symptoms of physical abuse. Sexual abuse as a main form of CM was mentioned by 26.5 and 2% cited its symptoms. While 87.7% of health care providers strongly agreed or agreed that they hold an important role in preventing CM, 51.1% also strongly disagreed or disagreed that they feel confident diagnosing and treating CM cases. In regards to follow-up, 14.3% strongly disagreed or disagreed that they know where to refer victims for further follow-up and an additional 14.3% did not know whether they agreed or disagreed. CONCLUSION: This study revealed knowledge gaps in emergency health care provider knowledge of the main forms of CM and their symptoms. The fact that a majority of health care providers in our sample did not receive information specific to CM in their medical education and training could explain this gap, as well as their unawareness of where to refer victims. Given that health care providers believe they play an important role in identifying and treating CM, future research should focus on raising physician awareness of CM and developing education and training materials grounded in cultural contexts to build response capacity in Mozambique and other LICs.

Effect of clinical decision rules, patient cost and malpractice information on clinician brain CT image ordering: a randomized controlled trial.

BACKGROUND: The frequency of head computed tomography (CT) imaging for mild head trauma patients has raised safety and cost concerns. Validated clinical decision rules exist in the published literature and on-line sources to guide medical image ordering but are often not used by emergency department (ED) clinicians. Using simulation, we explored whether the presentation of a clinical decision rule (i.e. Canadian CT Head Rule - CCHR), findings from malpractice cases related to clinicians not ordering CT imaging in mild head trauma cases, and estimated patient out-of-pocket cost might influence clinician brain CT ordering. Understanding what type and how information may influence clinical decision making in the ordering advanced medical imaging is important in shaping the optimal design and implementation of related clinical decision support systems. METHODS: Multi-center, double-blinded simulation-based randomized controlled trial. Following standardized clinical vignette presentation, clinicians made an initial imaging decision for the patient. This was followed by additional information on decision support rules, malpractice outcome review, and patient cost; each with opportunity to modify their initial order. The malpractice and cost information differed by assigned group to test the any temporal relationship. The simulation closed with a second vignette and an imaging decision. RESULTS: One hundred sixteen of the 167 participants (66.9%) initially ordered a brain CT scan. After CCHR presentation, the number of clinicians ordering a CT dropped to 76 (45.8%), representing a 21.1% reduction in CT ordering (P = 0.002). This reduction in CT ordering was maintained, in comparison to initial imaging orders, when presented with malpractice review information (p = 0.002) and patient cost information (p = 0.002). About 57% of clinicians changed their order during study, while 43% never modified their imaging order. CONCLUSION: This study suggests that ED clinician brain CT imaging decisions may be influenced by clinical decision support rules, patient out-of-pocket cost information and findings from malpractice case review. TRIAL REGISTRATION: NCT03449862 , February 27, 2018, Retrospectively registered.

Intracranial Pathology (CT+) in Emergency Department Patients With High GCS and High Standard Assessment of Concussion (SAC) Scores.

OBJECTIVE: To demonstrate that a subpopulation of patients with mild/moderate traumatic brain injury (TBI) had intracranial pathology despite having a Glasgow Coma Scale (GCS) score of 15 and a Standardized Assessment of Concussion (SAC) score of 25 or higher. SETTING: A network of 11 US emergency departments (ED) enrolling patients in a multisite study of TBI. PARTICIPANTS: Men and women between the ages of 18 and 85 years admitted to a participating ED having sustained a closed head injury within the prior 72 hours and a GCS score of 13 to 15 at the time of enrollment. DESIGN: Prospective observational study. MAIN MEASURES: GCS, SAC, computed tomography (CT) positive or negative for intracranial pathology, Marshall scoring of CT scans. RESULTS: Of 191 patients with intracranial pathology (CT+) and having a SAC score recorded, 24% (46/191) had a SAC score in the normal range (≥25) as well as a GCS score of 15. All causes of CT+ brain injury were present in both SAC groups. CONCLUSION: A normal GCS score and a SAC score do not exclude the possibility of significant intracranial injury.

Combined Monte Carlo/torsion-angle molecular dynamics for ensemble modeling of proteins, nucleic acids and carbohydrates.

We describe a general method to use Monte Carlo simulation followed by torsion-angle molecular dynamics simulations to create ensembles of structures to model a wide variety of soft-matter biological systems. Our particular emphasis is focused on modeling low-resolution small-angle scattering and reflectivity structural data. We provide examples of this method applied to HIV-1 Gag protein and derived fragment proteins, TraI protein, linear B-DNA, a nucleosome core particle, and a glycosylated monoclonal antibody. This procedure will enable a large community of researchers to model low-resolution experimental data with greater accuracy by using robust physics based simulation and sampling methods which are a significant improvement over traditional methods used to interpret such data.

Immunomagnetic capture and colorimetric detection of malarial biomarker Plasmodium falciparum lactate dehydrogenase.

We report a sensitive, magnetic bead-based colorimetric assay for Plasmodium falciparum lactate dehydrogenase (PfLDH) in which the biomarker is extracted from parasitized whole blood and purified based on antigen binding to antibody-functionalized magnetic particles. Antigen-bound particles are washed, and PfLDH activity is measured on-bead using an optimized colorimetric enzyme reaction (limit of detection [LOD] = 21.1 ± 0.4 parasites/µl). Enhanced analytical sensitivity is achieved by removal of PfLDH from the sample matrix before detection and elimination of nonspecific reductases and species that interfere with the optimal detection wavelength for measuring assay development. The optimized assay represents a simple and effective diagnostic strategy for P. falciparum malaria with time-to-result of 45 min and detection limits similar to those of commercial enzyme-linked immunosorbent assay (ELISA) kits, which can take 4-6 h. This method could be expanded to detect all species of malaria by switching the capture antibody on the magnetic particles to a pan-specific Plasmodium LDH antibody.

Gender-specific Regulatory Challenges to Product Approval: a panel discussion.

On May 13, 2014, a 1-hour panel discussion session titled "Gender-specific Regulatory Challenges to Product Approval" was held during the Academic Emergency Medicine consensus conference, "Gender-specific Research in Emergency Medicine: Investigate, Understand, and Translate How Gender Affects Patient Outcomes." The session sought to bring together leaders in emergency medicine (EM) research, authors, and reviewers in EM research publications, as well as faculty, fellows, residents, and students engaged in research and clinical practice. A panel was convened involving a representative from the Office of Women's Health of the U.S. Food and Drug Administration, two pharmaceutical executives, and a clinical EM researcher. The moderated discussion also involved audience members who contributed significantly to the dialogue. Historical background leading up to the session along with the main themes of the discussion are reproduced in this article. These revolve around sex- and gender-specific research, statistical analysis of sex and gender, clinical practice, financial costs associated with pharmaceutical development, adaptive design, and specific recommendations on the regulatory process as it affects the specialty of EM.

Progress in sexual counseling by cardiac nurses, 1994 to 2009.

OBJECTIVE: To examine trends in the practice of sexual counseling by cardiac nurses. METHODS: A non-experimental descriptive design was used to analyze survey data collected at 2 time points: 1994 (n = 171) and 2009 (n = 288). RESULTS: Nurses in the 2009 sample reported more conservative values (P < .001) and greater sense of responsibility for providing sexual counseling (P < .0001) than those in the 1994 sample. Although sexual activities (cuddling, kissing, fondling, masturbation, oral sex) were discussed more frequently by nurses in the 1994 survey (P < .001), improvements in the specific discussion of myocardial infarction-related sexual activity and counseling were noted in the 2009 sample, including by patient age and gender (P < .0001). CONCLUSION: Comparison of the 2 data samples suggests an improving trend in provision of sexual counseling by cardiac nurses, which can be reinforced by including sexual counseling information and role-play opportunities in continuing education courses.

Common data elements for traumatic brain injury: recommendations from the interagency working group on demographics and clinical assessment.

Comparing results across studies in traumatic brain injury (TBI) has been difficult because of the variability in data coding, definitions, and collection procedures. The global aim of the Working Group on Demographics and Clinical Assessment was to develop recommendations on the coding of clinical and demographic variables for TBI studies applicable across the broad spectrum of TBI, and to classify these as core, supplemental, or emerging. The process was consensus driven, with input from experts over a broad range of disciplines. Special consideration was given to military and pediatric TBI. Categorizing clinical elements as core versus supplemental proved difficult, given the great variation in types of studies and their interests. The data elements are contained in modules, which are grouped together in categories. Three levels of detail for coding data elements were developed: basic, intermediate, and advanced, with the greatest level of detail in the advanced version. In every case, the more detailed coding can be collapsed into the basic version. Templates were produced to summarize coding formats, motivation of choices, and recommendations for procedures. Work is ongoing to include more international participation and to provide an electronic data entry format with pull-down menus and automated data checks. This proposed standardization will facilitate comparison of research findings across studies and encourage high-quality meta-analysis of individual patient data.

Prescription for trouble: Medicare Part D and patterns of computer and internet access among the elderly.

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 specifically encourages Medicare enrollees to use the Internet to obtain information regarding the new prescription drug insurance plans and to enroll in a plan. This reliance on computer technology and the Internet leads to practical questions regarding implementation of the insurance coverage. For example, it seems unlikely that all Medicare enrollees have access to computers and the Internet or that they are all computer literate. This study uses the 2003 Current Population Survey to examine the effects of disability and income on computer access and Internet use among the elderly. Internet access declines with age and is exacerbated by disabilities. Also, decreases in income lead to decreases in computer ownership and use. Therefore, providing prescription drug coverage primarily through the Internet seems likely to maintain or increase stratification of access to health care, especially for low-income, disabled elderly, who are also a group most in need of health care access.

Clinical policy: neuroimaging and decisionmaking in adult mild traumatic brain injury in the acute setting.

This clinical policy provides evidence-based recommendations on select issues in the management of adult patients with mild traumatic brain injury (TBI) in the acute setting. It is the result of joint efforts between the American College of Emergency Physicians and the Centers for Disease Control and Prevention and was developed by a multidisciplinary panel. The critical questions addressed in this clinical policy are: (1) Which patients with mild TBI should have a noncontrast head computed tomography (CT) scan in the emergency department (ED)? (2) Is there a role for head magnetic resonance imaging over noncontrast CT in the ED evaluation of a patient with acute mild TBI? (3) In patients with mild TBI, are brain specific serum biomarkers predictive of an acute traumatic intracranial injury? (4) Can a patient with an isolated mild TBI and a normal neurologic evaluation result be safely discharged from the ED if a noncontrast head CT scan shows no evidence of intracranial injury? Inclusion criteria for application of this clinical policy's recommendations are nonpenetrating trauma to the head, presentation to the ED within 24 hours of injury, a Glasgow Coma Scale score of 14 or 15 on initial evaluation in the ED, and aged 16 years or greater. The primary outcome measure for questions 1, 2, and 3 is the presence of an acute intracranial injury on noncontrast head CT scan; the primary outcome measure for question 4 is the occurrence of neurologic deterioration.

Effects of attending phase II cardiac rehabilitation on patient versus spouse (proxy) quality-of-life perceptions.

PURPOSE: Little has been published about the differences or similarities in patient and spouse views of the patient's health-related quality of life (HRQL) related to cardiac rehabilitation (CR) participation. This study described patient versus spouse (proxy) ratings of patient HRQL prior to (T1) and after 6 weeks (T2) of phase II CR. METHODS: A nonprobability sample of patients referred to phase II CR and their spouses were recruited (42 pairs). The Short Form 36 v.2 (SF-36) instrument was used to measure HRQL. Differences between group means were tested with paired-samples t tests (P < .05). RESULTS: Improvements in patient self-report of HRQL from T1 to T2 were noted in physical functioning, role-physical, bodily pain, vitality, social functioning, role-emotional (all P <.001), mental health (P < .01), and both physical and mental component summary (P < .001). Spouse reports of patient HRQL improved in physical functioning, role-physical, bodily pain, vitality, social functioning, mental health (all P < .001), role-emotional (P < .01), and the physical (P < .001) and mental component summary (P < .01). Differences between patient and spouse were found at T1 in vitality and mental health (both P < .01). At T2, differences between patient and spouse were found in vitality (P < .001), physical functioning, mental health (both P < .05), and the mental component summary (P < .05). CONCLUSIONS: Improvement of patient HRQL is mirrored by spouse viewpoint of patient HRQL. This unique finding has not previously been reported in the literature.

The role of sexual satisfaction, age, and cardiac risk factors in the reduction of post-MI anxiety.

BACKGROUND: Anxiety is common after myocardial infarction (MI); however, little is known about the role of sexual satisfaction and return to sexual activity on anxiety post-MI. AIM: To examine the role of sexual satisfaction in reducing anxiety post-MI. METHODS: Patients with acute myocardial infarction (MI) recruited from one U.S. medical center completed questionnaires at baseline while hospitalized and at 1, 3, and 5 months post-MI. This analysis includes 64 patients compared on low or high anxiety at 5 months post-MI using sexual satisfaction and selected demographic and clinical variables in the analysis. RESULTS: Patients with high anxiety scores reported lower sexual satisfaction (p < .001) and a higher percentage of coronary risk factors (p < .01). The OLS regression model provided similar results with an adjusted R-square of .422, accounting for approximately 42% of anxiety (p < .001). Sexual satisfaction accounted for the most variance in the model, showing an inverse relationship between sexual satisfaction and anxiety. An inverse relationship also existed between age and anxiety. CONCLUSIONS: Anxiety is common after MI, and decreased sexual satisfaction appears to contribute to heightened anxiety. Attention to sexual concerns of MI patients before and after hospital discharge may improve psychosocial outcomes.

National practice guidelines for mental health care: a comparative policy analysis of the United kingdom and the United States.

Mental disorders are the leading cause of disability worldwide, according to the World Health Organization (WHO, 1996). In a report on health indicators of premature death and disability, the World Bank concluded that mental health problems account for 8.1% of the global burden of disease (GBD). Industrialized nations have taken different approaches in applying innovations to mental health care and mental health care policy. This paper uses the K. McInnis-Dittrich model of policy analysis (Ginsberg, 1994) to analyze the approaches of the United Kingdom (U.K.) and the United States (U.S.) to mental health treatment, specifically examining the effects of the U.K.'s national practice guidelines and the U.S.'s lack of similar guidelines. Recommendations for changes in current U.S. mental health policy are presented.