Assessment of the cutaneous trunci muscle reflex in neurologically abnormal cats.

OBJECTIVES: The aim of this study was to evaluate the presence of the cutaneous trunci reflex (CTR) in a population of neurologically abnormal cats in regard to age, body condition score (BCS), sex, breed, evidence of traumatic injury, pain, known metabolic disease, mentation, neurolocalization and diagnostic classification. METHODS: A retrospective medical record review was performed to identify cats with a history of neurologic disease undergoing a complete neurologic assessment between 24 September 2012 and 20 March 2019. CTR outcome (present, absent), signalment, evidence of traumatic injury, pain, known metabolic disease, mentation, neurolocalization and diagnostic classification were recorded. RESULTS: A total of 182 cats were identified. The CTR was present in 118 cats (64.8%) and absent in 64 cats (35.2%). Statistical analysis revealed no association between CTR outcome and age, BCS, sex, breed, evidence of traumatic injury, non-spinal pain, known metabolic disease, mentation, neurolocalization or diagnostic classification. A significant association was found between spinal pain and CTR outcome (P = 0.037). CONCLUSIONS AND RELEVANCE: These findings suggest that elicitation of the CTR in the cat can be unreliable. Further prospective controlled studies are warranted to determine whether continued inclusion of the CTR in feline neurologic examinations is justified. Consideration of the reliability of the CTR is indicated, particularly in the context of fractious or anxious patients for which only a limited window for examination may be present.

Training needs analysis of Korean nurses' neurological assessment competency.

Despite the importance of neurological assessment, there is a lack of research directed at nurses' competency in performing these assessments. We aimed to identify nurses' competency levels in performing neurological assessments and prioritize their related training needs using importance-performance analysis. This survey research was conducted and reported based on the enhancing the quality and transparency of health research (EQUATOR) guidelines. A total of 213 nurses participated in a descriptive, cross-sectional survey study. Exploratory factor analysis identified seven factors that together accounted for 70.34% of the variance: cerebral function, signs and symptoms, pathologic reflexes, motor strength, assessment of an unconscious patient, reporting and documentation, and neurological assessment scales. [Correction added on 10 February 2020, after first online publication: the value of the variance has been corrected from '7.34%' to '70.34%' in the preceding sentence.] There were significant gaps between importance and performance for all seven factors. The importance-performance matrix identified the neurological assessment scales factor as a high priority for continuing education. Emergency department nurses reported lower neurological assessment competency when compared with ward and intensive care unit nurses. The analysis of training needs is beneficial for developing programs to enhance neurological assessment competency. Training in neurological assessment scales is a priority for nurses, and they prefer simulation- and practicum-based methods.

Dementia assessment and management in primary care settings: a survey of current provider practices in the United States.

BACKGROUND: Primary care providers (PCPs) are typically the first to screen and evaluate patients for neurocognitive disorders (NCDs), including mild cognitive impairment and dementia. However, data on PCP attitudes and evaluation and management practices are sparse. Our objective was to quantify perspectives and behaviors of PCPs and neurologists with respect to NCD evaluation and management. METHODS: A cross-sectional survey with 150 PCPs and 50 neurologists in the United States who evaluated more than 10 patients over age 55 per month. The 51-item survey assessed clinical practice characteristics, and confidence, perceived barriers, and typical practices when diagnosing and managing patients with NCDs. RESULTS: PCPs and neurologists reported similar confidence and approaches to general medical care and laboratory testing. Though over half of PCPs performed cognitive screening or referred patients for cognitive testing in over 50% of their patients, only 20% reported high confidence in interpreting results of cognitive tests. PCPs were more likely to order CT scans than MRIs, and only 14% of PCPs reported high confidence interpreting brain imaging findings, compared to 70% of specialists. Only 21% of PCPs were highly confident that they correctly recognized when a patient had an NCD, and only 13% were highly confident in making a specific NCD diagnosis (compared to 72 and 44% for neurologists, both p < 0.001). A quarter of all providers identified lack of familiarity with diagnostic criteria for NCD syndromes as a barrier to clinical practice. CONCLUSIONS: This study demonstrates how PCPs approach diagnosis and management of patients with NCDs, and identified areas for improvement in regards to cognitive testing and neuroimaging. This study also identified all providers' lack of familiarity with published diagnostic criteria for NCD syndromes. These findings may inform the development of new policies and interventions to help providers improve the efficacy of their decision processes and deliver better quality care to patients with NCDs.

Bedside clinical neurologic assessment utilisation in paediatric cardiac intensive care units.

IntroductionNeurodevelopmental disabilities in children with CHD can result from neurologic injury sustained in the cardiac ICU when children are at high risk of acute neurologic injury. Physicians typically order and specify frequency for serial bedside nursing clinical neurologic assessments to evaluate patients' neurologic status.Materials and methodsWe surveyed cardiac ICU physicians to understand how these assessments are performed, and the attitudes of physicians on the utility of these assessments. The survey contained questions regarding assessment elements, assessment frequency, communication of neurologic status changes, and optimisation of assessments. RESULTS: Surveys were received from 50 institutions, with a response rate of 86%. Routine clinical neurologic assessments were reported to be performed in 94% of institutions and standardised in 56%. Pupillary reflex was the most commonly reported assessment. In all, 77% of institutions used a coma scale, with Glasgow Coma Scale being most common. For patients with acute brain injury, 82% of institutions reported performing assessments hourly, whereas assessment frequency was more variable for low-risk and high-risk patients without overt brain injury. In all, 84% of respondents thought their current practice for assessing and monitoring neurologic status was suboptimal. Only 41% felt that the Glasgow Coma Scale was a valuable tool for assessing neurologic function in the cardiac ICU, and 91% felt that a standardised approach to assessing pre-illness neurologic function would be valuable. CONCLUSIONS: Routine nursing neurologic assessments are conducted in most surveyed paediatric cardiac ICUs, although assessment characteristics vary greatly between institutions. Most clinicians rated current neurologic assessment practices as suboptimal.

Effect of MRI on preterm infants and their families: a randomised trial with nested diagnostic and economic evaluation.

BACKGROUND: We tested the hypothesis that routine MRI would improve the care and well-being of preterm infants and their families. DESIGN: Parallel-group randomised trial (1.1 allocation; intention-to-treat) with nested diagnostic and cost evaluations (EudraCT 2009-011602-42). SETTING: Participants from 14 London hospitals, imaged at a single centre. PATIENTS: 511 infants born before 33 weeks gestation underwent both MRI and ultrasound around term. 255 were randomly allocated (siblings together) to receive only MRI results and 255 only ultrasound from a paediatrician unaware of unallocated results; one withdrew before allocation. MAIN OUTCOME MEASURES: Maternal anxiety, measured by the State-Trait Anxiety inventory (STAI) assessed in 206/214 mothers receiving MRI and 217/220 receiving ultrasound. Secondary outcomes included: prediction of neurodevelopment, health-related costs and quality of life. RESULTS: After MRI, STAI fell from 36.81 (95% CI 35.18 to 38.44) to 32.77 (95% CI 31.54 to 34.01), 31.87 (95% CI 30.63 to 33.12) and 31.82 (95% CI 30.65 to 33.00) at 14 days, 12 and 20 months, respectively. STAI fell less after ultrasound: from 37.59 (95% CI 36.00 to 39.18) to 33.97 (95% CI 32.78 to 35.17), 33.43 (95% CI 32.22 to 34.63) and 33.63 (95% CI 32.49 to 34.77), p=0.02. There were no differences in health-related quality of life. MRI predicted moderate or severe functional motor impairment at 20 months slightly better than ultrasound (area under the receiver operator characteristic curve (CI) 0.74; 0.66 to 0.83 vs 0.64; 0.56 to 0.72, p=0.01) but cost £315 (CI £295-£336) more per infant. CONCLUSIONS: MRI increased costs and provided only modest benefits. TRIAL REGISTRATION: ClinicalTrials.gov NCT01049594 https://clinicaltrials.gov/ct2/show/NCT01049594. EudraCT: EudraCT: 2009-011602-42 (https://www.clinicaltrialsregister.eu/).

Policies, Procedures, and Practices Regarding Sport-Related Concussion in Community College Athletes.

CONTEXT: College sport organizations and associations endorse concussion-management protocols and policies. To date, little information is available on concussion policies and practices at community college institutions. OBJECTIVE: To assess and describe current practices and policies regarding the assessment, management, and return-to-play criteria for sport-related concussion (SRC) among member institutions of the California Community College Athletic Association (CCCAA). DESIGN: Cross-sectional study. SETTING: Web-based survey. PATIENTS OR OTHER PARTICIPANTS: A total of 55 head athletic trainers (ATs) at CCCAA institutions. MAIN OUTCOME MEASURE(S): Data about policies, procedures, and practices regarding SRC were collected over a 3-week period in March 2012 and analyzed using descriptive statistics, the Fisher exact test, and the Spearman test. RESULTS: Almost half (47%) of ATs stated they had a policy for SRC assessment, management, and return to play at their institution. They reported being in compliance with baseline testing guidelines (25%), management guidelines (34.5%), and return-to-play guidelines (30%). Nearly 31% of ATs described having an SRC policy in place for academic accommodations. Conference attendance was positively correlated with institutional use of academic accommodations after SRC (r = 0.44, P = .01). The number of meetings ATs attended and their use of baseline testing were also positively correlated (r = 0.38, P = .01). CONCLUSIONS: At the time of this study, nearly half of CCCAA institutions had concussion policies and 31% had academic-accommodation policies. However, only 18% of ATs at CCCAA institutions were in compliance with all of their concussion policies. Our findings demonstrate improvements in the management of SRCs by ATs at California community colleges compared with previous research but a need for better compliance with SRC policies.

Confidence interval construction for the difference between two correlated proportions with missing observations.

Under the assumption of missing at random, eight confidence intervals (CIs) for the difference between two correlated proportions in the presence of incomplete paired binary data are constructed on the basis of the likelihood ratio statistic, the score statistic, the Wald-type statistic, the hybrid method incorporated with the Wilson score and Agresti-Coull (AC) intervals, and the Bootstrap-resampling method. Extensive simulation studies are conducted to evaluate the performance of the presented CIs in terms of coverage probability and expected interval width. Our empirical results evidence that the Wilson-score-based hybrid CI and the Wald-type CI together with the constrained maximum likelihood estimates perform well for small-to-moderate sample sizes in the sense that (i) their empirical coverage probabilities are quite close to the prespecified confidence level, (ii) their expected interval widths are shorter, and (iii) their ratios of the mesial non-coverage to non-coverage probabilities lie in interval [0.4, 0.6]. An example from a neurological study is used to illustrate the proposed methodologies.

Developmental neuropsychological assessment of 4- to 5-year-old children born following Preimplantation Genetic Diagnosis (PGD): A pilot study.

The purpose of this pilot study was to evaluate developmental neuropsychological profiles of 4- to 5-year-old children born after Preimplantation Genetic Diagnosis (PGD). Twenty-seven participants received a neurological examination and a battery of neuropsychological assessments including Wechsler Preschool & Primary Scale of Intelligence - Third Edition (WPPSI-III; cognitive development), Preschool Language Scale, Fourth Edition (PLS-4; language development), Wide Range Assessment of Visual Motor Abilities (visual motor abilities), Childhood Autism Rating Scales II (a screening test for autistic spectrum disorders), and the Miles ABC Test (ocular dominance). Parental questionnaires included the Behavior Rating Inventory of Executive Function Preschool Version (BRIEF-P; executive function), Child Behavior Checklist (CBCL) and the Carey Temperament Scales Behavioral Style Questionnaire (socioemotional development and temperament), and the Vineland Adaptive Behavior Scales, Interview Edition, Second Edition (general adaptive behavior). Subjects' tests results were compared to each test's norms. Children born after PGD demonstrated scores within the normal or above-normal ranges for all developmental outcomes (mean ± SD): WPPSI-III-VIQ 107.4 ± 14.4 (p = .013), PLS-4-Total 113.2 ± 12.4, p < .001), CBCL-Total 41.1 ± 8.6 (p < .001), BRIEF-P-Global Executive Composite 44.8 ± 9.5 (p = .009). Twelve (44%) of the PGD children had a significant difference between their VIQ and PIQ scores (compared to 27% in the general population). One subject was found to show possible signs of autistic spectrum disorder, although a family history of autism was noted. In conclusion, in this pilot study, children assessed at age 4-5 years and conceived after PGD displayed developmental neuropsychological outcomes within normal limits as compared to their chronologic peers. A larger study is needed to evaluate and follow the neuropsychological development of children born after PGD.

Rasch analysis of the modified version of the postural assessment scale for stroke patients: postural stroke study in Gothenburg (POSTGOT).

BACKGROUND: The modified version of the Postural Assessment Scale for Stroke Patients (SwePASS) is a new ordinal outcome measurement designed to assess postural control in patients with stroke. Before implementation of SwePASS into the clinical setting, it is necessary to know its measurement properties. Thus, the aim of the study was to evaluate the measurement properties of the SwePASS. METHODS: Rasch analysis, based on data of 150 SwePASS assessments was made the first week after stroke onset. The measurement properties referred to were unidimensionality, local independence, invariance, category function, targeting of persons and items and the reliability. RESULTS: The initial analysis showed disordered thresholds in four items. After adjustment of the scoring categories, this was resolved. However, analyses of local dependency revealed correlations between two of the items. These two items were collapsed into one. After adjustments, the person separation index that acts as an indicator of the whole model fit was 0.96. The adjusted SwePASS is a global scale that works the same way regardless of gender, age and location of stroke lesion. Overall, the population had better postural control than was targeted with the items in the scale. CONCLUSIONS: Rasch analysis of the adjusted SwePASS showed that the scale was unidimensional. In SwePASS, equal capacity in postural control provides the same response to an individual item in patients with stroke, regardless of gender, age and location of stroke lesion. Regarding clinical implications, before introducing SwePASS in clinical routine and to confirm the results, further research including a larger sample with poorer postural control is suggested.

Assessment of upper limb capacity in children with unilateral cerebral palsy: construct validity of a Rasch-reduced Modified House Classification.

AIM: The aim of this study was to test and improve the unidimensionality and item hierarchy of the Modified House Classification (MHC) for the assessment of upper limb capacity in children with unilateral cerebral palsy (CP) using Rasch analysis. The construct validity of the Rasch-reduced item set was evaluated. METHOD: Modified House Classification items were scored from 369 videotaped assessments of 159 children with unilateral CP (98 males, 61 females; median age 6y 6mo, range 2y 1mo-17y 5mo). Construct validity was tested in 40 other children with unilateral CP (21 males, 19 females; median age 8y 2mo, range 3y 3mo-17y 6mo) by comparing total scores with the Manual Ability Classification System (MACS) and the ABILHAND-Kids scale. RESULTS: Fifteen MHC items could be included in the Rasch analysis. The excluded items were either too easy or too difficult. Fourteen items fitted the unidimensional model (χ(2) =41.3, df=39, p=0.37). The hierarchy of these items was different from the original MHC. There was a significant correlation with the MACS (r=-0.901, p<0.001) and the ABILHAND-Kids scale (r=0.558, p<0.001). INTERPRETATION: The original item hierarchy of the MHC can be improved in order to use its sum score for the assessment of upper limb capacity in children with unilateral CP. The Rasch-reduced 14-item MHC with weighted sum score shows good construct validity to measure functional capacity of the affected hand in children with unilateral CP.

CT scan utilization patterns in pediatric patients with recurrent headache.

UNLABELLED: Although unnecessary for children with headache and normal history, computed tomography (CT) scans are widely used. This study sought to determine current practice patterns of neuroimaging to diagnose pediatric headache in a variety of treatment settings and to identify factors associated with increased use of neuroimaging. METHODS: This retrospective claims analysis included children (aged 3­17 years) with ≥2 medical claims for headache. The primary outcome was CT scan utilization on or after first presentation with headache in a physician's office or emergency department (ED). RESULTS: Of 15 836 patients, 26% (4034 patients; mean age: 11.8 years) had ≥1 CT scan, 74% within 1 month of index diagnosis. Patients with ED visits were 4 times more likely to undergo a CT scan versus those without ED visits (P < .001 [95% confidence interval: 3.9­4.8]). However, even outside the ED, use of CT scans remained widespread. Two-thirds of patients with CT scans had no ED use.Among patients with no ED utilization, >20% received a CT scan during the study period. Evaluation by a neurologist was strongly associated with a lower likelihood of CT scan compared with other provider specialties (odds ratio: 0.37; P < .01 [95% confidence interval: 0.30­0.46]). CONCLUSIONS: Use of CT scans to diagnose pediatric headache remains high despite existing guidelines, low diagnostic yield, and high potential risk. Implementing quality improvement initiatives to ensure that CT scans in children are performed only when truly indicated will reduce unnecessary exposure to ionizing radiation and associated cancer risks.

The psychometric properties of the McCarron Assessment of Neuromuscular Development as a longitudinal measure with Australian youth.

The importance of considering age and sex differences in the assessment of motor performance has been largely overlooked. This study examines the psychometric properties of the US developed McCarron Assessment of Neuromuscular Development (MAND) using data from a longitudinal sample of 986 Australian youth at 10, 14 and 17 years. A key finding was the sex and age interaction of the Neuromuscular Developmental Index (NDI) (F=121.46, p<.001). Males had a significantly lower mean NDI score at 10 years and the females had a lower score at 17 years. The factor structure differed from the US samples (McCarron, 1997) at each age and between males and females. The sex specific analyses showed that the underlying structure was more complex for younger females. Although the MAND remains a useful test of motor performance for Australian children, further consideration is warranted regarding sex differences, the relevance of the US based normative tables and factor structures.

Further evidence of validity of the Modified Melbourne Assessment for neurologically impaired children aged 2 to 4 years.

AIM: This paper reports the second phase of a study to extend the Melbourne Assessment for use with children with neurological impairment aged 2 to 4 years. The aim was to establish if (1) children's scores on the Modified Melbourne Assessment (MMA) and the Quality of Upper Extremity Skills Test (QUEST) showed a moderate to high, positive relation, (2) children had comparable behaviours for task and time demands on both tools, and (3) scores on the MMA could discriminate between children with mild, moderate, and severe levels of upper limb impairment. METHOD: An observational study of 30 children (19 males, 11 females) with neurological impairment aged 2 to 4 years. Twenty-four children had spasticity (20 with a unilateral and four with a bilateral impairment) and two children presented with athetosis, two with ataxia, and two with hypotonia. RESULTS: A high, positive relation was found between children's scores on the MMA and the QUEST (ρ=0.90; p=0.001). The clinical use of the MMA was comparable to the QUEST. MMA scores were able to discriminate between children's levels of upper limb impairment as determined by clinicians' ratings (F(2,27) =67.76, p=0.001). INTERPRETATION: These findings suggest the MMA can be clinically useful for children as young as 2.5 years and has the advantage of being valid for use with older children. Scores from the tool can also provide therapists with a quantitative means of consistently reporting level of upper limb impairment.

Development of the Hypertonia Assessment Tool (HAT): a discriminative tool for hypertonia in children.

AIM: The aim of this study was to develop a tool to identify paediatric hypertonia subtypes. METHOD: Items generated by experts were subscaled (spasticity, dystonia, rigidity). The tool was administered to 34 children (19 males, 15 females, mean age 8y 2mo, range 2y 5mo-18y 7mo) with hypertonia and cerebral palsy (CP) in Gross Motor Function Classification System (GMFCS) levels: I, n=7; II, n=5; III, n=7 level IV, n=7; and level V, n=8 level. Kuder-Richardson Formula 20 determined internal consistency. To assess reliability, two physicians administered the tool to 25 additional children with CP (15 males, 10 females; mean age 10y 8 mo; GMFCS levels I, n=4; II, n=3; III, n=7; IV, n=4; and V, n=7) on two occasions, 2 weeks apart. To evaluate validity, a third physician diagnosed the hypertonia by neurological examination. RESULTS: The internal consistency of the spasticity items was moderate (alpha = 0.58), and dystonia was high (a=0.79). Item reduction eliminated seven of the 14 original items. The agreement of the spasticity and rigidity subscales was adequate (prevalence-adjusted bias-adjusted kappa [PABAK] ranging from moderate [0.57] to excellent [1.0]) for validity, test-retest reliability, and interrater reliability. For dystonia agreement was lower, with PABAK ranging from fair (0.30) to good (0.65). Eighty-seven per cent had spasticity and 78% had dystonia. INTERPRETATION: The Hypertonia Assessment Tool has good reliability and validity for identifying spasticity and the absence of rigidity, and moderate findings for dystonia.

The assessment of minor neurological dysfunction in infancy using the Touwen Infant Neurological Examination: strengths and limitations.

AIM: Little is known of minor neurological dysfunction (MND) in infancy. This study aimed to evaluate the inter-assessor reliability of the assessment of MND with the Touwen Infant Neurological Examination (TINE) and the construct and predictive validity of MND in infancy. METHOD: Inter-assessor agreement was determined in a sample of 40 infants (24 males, 16 females) aged 3 to 12 months (25 born at term: gestational age 37-41wks, median 39; and 15 born preterm, gestational age 24-35wks, median 32). Thirty typically developing term infants (18 males, 12 females; gestational age 37-42wks, median 40) and 59 preterm infants (34 males, 25 females) born at <35 weeks' gestation (gestational age 25-34wks, median 29) participated in the validity study. They were neurologically assessed with the TINE at the corrected ages of 4, 6, 10, and 12 months and with the Hempel assessment at 18 months. RESULTS: The findings indicated that MND can be assessed reliably (inter-assessor agreement: kappa=0.83). MND during infancy was related to prenatal, perinatal, and social factors, and in particular to preterm birth. Neurological condition during infancy was prone to change, but was related to neurological condition at 18 months at all ages tested. INTERPRETATION: We conclude that MND can be determined reliably in infancy. Important considerations in the construct of MND in infancy are its relation to prenatal and perinatal factors, its limited stability, and its moderate predictive value.

Emergency department assessment of mild traumatic brain injury and the prediction of postconcussive symptoms: a 3-month prospective study.

OBJECTIVE: To investigate the utility of a brief emergency department (ED) bedside screen for the prediction of postconcussive symptoms at 3 months following mild traumatic brain injury (MTBI). PARTICIPANTS: One hundred patients with MTBI (78% men; mean age = 33.6 years); 2 control groups (each n = 100), a "minor nonhead injury" group (77% men; mean age = 32.2 years) and an "uninjured ED visitor" group (78% men; mean age = 33.6 years). MAIN MEASURES: Brief measures of neuropsychological functioning, acute pain, and postural stability were collected in the ED; telephone follow-up at 3 months using the Rivermead Post-Concussion Symptoms Questionnaire was undertaken. RESULTS: Neuropsychological deficits, acute pain, and postural instability in the ED were significantly associated with postconcussive symptoms at 3-month follow-up. A regression formula using 3 easily obtainable measures obtained during acute stage of injury-immediate and delayed memory for 5 words and a visual analog scale score of acute headache-provided 80% sensitivity and 76% specificity for the prediction of clinically significant symptoms at 3 months postinjury. CONCLUSION: A small combination of variables assessable in the ED may predict MTBI patients likely to experience persistent postconcussive symptoms.

Motor assessment of preschool aged children: A preliminary investigation of the validity of the Bruininks-Oseretsky test of motor proficiency - short form.

The aim of this study was to examine the validity of the Bruininks-Oseretsky test of motor proficiency - short form (BOTMP-SF) [Bruininks, R. (1978). Bruininks-Oseretsky test of motor proficiency: Examiners manual. Circle Pines, MN] for the assessment of preschool aged children. Three-hundred and eighteen children 48-71months old (M=58.97months, SD=6.73) participated in the study. For the data analysis both an ANOVA and a MANOVA were applied with the total battery score and the 14 item scores being the dependent variables, respectively. Age was found to have a significant effect on both children's total battery score (F(3, 314)=110.65, p<.001, eta(2)=.68) and 13 item scores (minimum F(3, 314)=8.75, p<.001, minimum eta(2)=.145). Although the aforementioned results represent an evidence for the validity of the BOTMP-SF, a closer study on the score of each item revealed a high percentage of zero scores on four items. Task difficulty has caused a floor effect, constituting a threat to the validity of the preschoolers' motor assessment with the above battery. A modification of the battery items is suggested, so that the BOTMP-SF will give valid results for children 4-6years old.