Current status of pediatric neurocritical care in Argentina. / Estado actual del soporte neurológico crítico en pediatría en la Argentina.

INTRODUCTION: Patients with neurocritical injuries account for 10-16 % of pediatric intensive care unit (PICU) admissions and frequently require neuromonitoring. OBJECTIVE: To describe the current status of neuromonitoring in Argentina. METHODS: Survey with 37 questions about neuromonitoring without including patients' data. Period: April-June 2017. RESULTS: Thirty-eight responses were received out of 71 requests (14 districts with 11 498 annual discharges). The PICU/hospital bed ratio was 21.9 (range: 4.2-66.7). Seventy-four percent of PICUs were public; 61 %, university-affiliated; and 71 %, level I. The availability of monitoring techniques was similar between public and private (percentages): intracranial pressure (95), electroencephalography (92), transcranial Doppler (53), evoked potentials (50), jugular saturation (47), and bispectral index (11). Trauma was the main reason for monitoring. CONCLUSION: Except for intracranial pressure and electroencephalography, neuromonitoring resources are scarce and active neurosurgery availability is minimal. A PICU national registry is required.

Introducción. Los pacientes con lesiones neurocríticas representan el 10-16 % de los ingresos a unidades de cuidados intensivos pediátricas (UCIP) y, frecuentemente, requieren neuromonitoreo. Objetivo. Describir el estado actual del neuromonitoreo en la Argentina. Métodos. Encuesta con 37 preguntas sobre neuromonitoreo sin incluir datos de pacientes. Período: abril-junio, 2017. Resultados. Se recibieron 38 respuestas a 71 solicitudes (14 distritos con 11 498 egresos anuales). La relación camas de UCIP/hospitalarias fue 21,9 (rango: 4,2-66,7). El 74 % fueron públicas; el 61 %, universitarias, y el 71 %, nivel 1. La disponibilidad fue similar entre públicas y privadas (porcentajes): presión intracraneana (95), electroencefalografía (92), doppler transcraneano (53), potenciales evocados (50), saturación yugular (47) e índice bispectral (11). El principal motivo de monitoreo fue trauma. Conclusión. Excepto la presión intracraneana y la electroencefalografía, los recursos de neuromonitoreo son escasos y la disponibilidad de neurocirugía activa es mínima. Se necesita un registro nacional de UCIP.

Developing a Guideline for Neurotrauma in Nigeria.

BACKGROUND: The Nigerian Academy of Neurological Surgeons in 2019 resolved to standardize the practice of neurosurgery in Nigeria. It set up committees to standardize the various aspects of neurosurgery, such as neurotrauma, pediatrics, functional, vascular, skull base, brain tumor, and spine. The Committee on Neurotrauma convened and resolved to study most of the available protocols and guidelines in use in different parts of the world. OBJECTIVE: To formulate a standard protocol for the practice of neurotrauma care within the Nigerian locality. METHODS: The Committee split its membership into 3 subcommittees to cover the various aspects of the Neurotrauma Guidelines, such as neurotrauma curriculum, standard neurotrauma management protocols, and neurotrauma registry. Each subcommittee was to research on available models and formulate a draft for Nigerian neurotrauma. RESULTS: All the 3 subcommittees had their reports ready on schedule. Each concurred that neurotrauma is a major public health challenge in Nigeria. They produced 3 different drafts on the 3 thematic areas of the project. The subcommittees are: 1. Subcommittee on Fellowship, Training and Research Curriculum; 2. Subcommittee on Standard Protocols and Management Guidelines; and 3. Subcommittee of the Nigerian Neurotrauma Registry. CONCLUSION: The committee concluded that a formal protocol for neurotrauma care is long overdue in Nigeria for the standardization of all aspects of neurotrauma. It then recommended the adoption of these guidelines by all institutions offering services in Nigeria using the management protocols, opening a registry, and mounting researches on the various aspects of neurotrauma.

Assessment of Acute Kidney Injury in Neurologically Injured Patients Receiving Hypertonic Sodium Chloride: Does Chloride Load Matter?

Background: Increasing evidence suggests that large-volume infusions of 0.9% sodium chloride (NaCl) for resuscitation are associated with hyperchloremic metabolic acidosis, renal vasoconstriction, and increased risk of acute kidney injury (AKI). Patients with neurological injury may require hypertonic NaCl for therapeutic hypernatremia, treatment of cerebral salt wasting, hyponatremia, or elevated intracranial pressure. Consequently, this increased exposure to chloride may result in an increased risk for development of AKI. Objective: The primary aim of this study was to describe the risk for development of AKI in neurologically injured patients receiving large volumes of intravenous hypertonic NaCl. Methods: This single-center, retrospective study looked at neurologically injured patients who received hypertonic NaCl and sodium acetate. Data were collected to assess renal function, hyperchloremia, and acidemia. Receiver operating characteristic (ROC) curve analysis was used to determine the predictive association between the amount of daily and overall chloride exposure and development of AKI. Results: A total of 301 patients were screened, and of those, 142 were included. Of the 142 patients included, 13% developed AKI, and 38% developed hyperchloremia. Additionally, 32% of patients were switched from NaCl to sodium acetate after an average of 3.4 ± 1.5 days of NaCl therapy. The ROC curve demonstrated that if patients received greater than 2055 mEq of chloride over 7 days, they were more likely to develop AKI (sensitivity 72%, specificity 70%; P = 0.002; area under the curve = 0.7). Conclusion and Relevance: Neurologically injured patients receiving hypertonic sodium therapy with a high chloride load are at risk of developing hyperchloremia and AKI.

Stress Ulcer Prophylaxis in Neurocritical Care.

Stress ulcer prophylaxis (SUP) with acid-suppressive drug therapy is widely utilized in critically ill patients following neurologic injury for the prevention of clinically important stress-related gastrointestinal bleeding (CIB). Data supporting SUP, however, largely originates from studies conducted during an era where practices were vastly different than what is considered routine by today's standard. This is particularly true in neurocritical care patients. In fact, the routine provision of SUP has been challenged due to an increasing prevalence of adverse drug events with acid-suppressive therapy and the perception that CIB rates are sparse. This narrative review will discuss current controversies with SUP as they apply to neurocritical care patients. Specifically, the pathophysiology, prevalence, and risk factors for CIB along with the comparative efficacy, safety, and cost-effectiveness of acid-suppressive therapy will be described.

Palliative Care Needs Assessment in the Neuro-ICU: Effect on Family.

BACKGROUND: Examine the association of a daily palliative care needs checklist on outcomes for family members of patients discharged from the neurosciences intensive care unit (neuro-ICU). METHODS: We conducted a prospective, longitudinal cohort study in a single, thirty-bed neuro-ICU in a regional comprehensive stroke and level 1 trauma center. One of two neuro-ICU services that admit patients to the same ICU on alternating days used a palliative care needs checklist during morning work rounds. Between March and October, 2015, surveys were mailed to family members of patients discharged from the neuro-ICU. RESULTS: Nearly half of surveys (n = 91, 48.1%) were returned at a median of 4.7 months. At the time of survey completion, mean Modified rankin scale score (mRS) of neuro-ICU patients was 3.1 (SD 2). Overall ratings of quality of care were relatively high (82.2 on a 0-100 scale) with 32% of family members meeting screening criteria for depressive syndrome. The primary outcome measuring family satisfaction, consisting of eight items from the Family Satisfaction in the ICU questionnaire, did not differ significantly between families of patients from either ICU service nor did family ratings of depression (PHQ-8) and post-traumatic stress (PCL-17). CONCLUSIONS: Among families of patients discharged from the neuro-ICU, the daily use of a palliative care needs checklist had no measurable effect on family satisfaction scores or long-term psychological outcomes. Further research is needed to identify optimal interventions to meet the palliative care needs specific to family members of patients treated in the neuro-ICU.

Introduction of a simple guideline to improve neurological assessment in paediatric patients presenting with upper limb fractures.

BACKGROUND: Neurological examination in children presenting with upper limb fractures is often poorly performed in the Emergency Department (ED). We aimed to assess the improvement in documented neurological examination for children presenting with upper limb fractures following introduction of a simple guideline. METHODS: We developed and introduced a simple guideline for upper limb neurological assessment in children ('rock, paper, scissors, OK'). We compared documentation of neurological examination and nerve injury detection at our hospital before and after introduction of this guideline, as well as for children admitted from external hospitals (where the guideline had not been introduced). RESULTS: In the period following guideline introduction, 97 children with upper limb fractures were admitted (46% presenting directly to our ED and 54% admitted from external hospitals). This cohort was similar in number and distribution to the cohort reviewed prior to the guideline. Documentation of neurological examination in our ED increased from 92% to 98% after guideline introduction. Documented information on nerves examined also increased from 2% to 68% (p<0.01). Prior to the guideline, there were six nerve injuries, all of which were missed in our ED. After guideline introduction, there were four nerve injuries, all of which were detected in our ED. Documentation and nerve injury detection at external hospitals over the same time period showed no improvement. CONCLUSIONS: A simple guideline to assist neurological examination in children with upper limb fractures can significantly improve the quality of documented neurological assessment and nerve injury detection.

Prospective assessment of time-dependent changes in quality of life of Japanese patients with prostate cancer following robot-assisted radical prostatectomy.

The objective of this study was to characterize changes in the quality of life (QOL) of Japanese patients following robot-assisted radical prostatectomy (RARP). This study included 298 consecutive localized prostate cancer (PC) patients undergoing RARP. The health-related QOL and disease-specific QOL were assessed using The Medical Outcomes Study 8-Item Short Form (SF-8) and The Extended Prostate Cancer Index Composite (EPIC), respectively, before and 1, 3, 6, 12 and 24 months after RARP. At 1 month after RARP, four (physical function, role limitations because of physical health problems, social function and role limitations because of emotional problems) of the eight scores in SF-8 were significantly impaired compared with those of baseline scores. However, all eight scores on all postoperative assessments, except for at 1 month after RARP, showed no significant differences from baseline scores. Although there were no significant differences in the bowel function, bowel bother, sexual bother, hormonal function or hormonal bother between baseline and postoperative assessments of EPIC at all time points, the urinary function, urinary incontinence and sexual function scores at 1, 3 and 6 months after RARP were significantly inferior to those of baseline scores, and urinary bother and urinary irritation/obstruction scores at 1 month after RARP were significantly impaired compared with those of baseline scores. These findings suggest that the health-related QOL of Japanese PC patients undergoing RARP may not be markedly deteriorated following RARP; however, as for the disease-specific QOL, urinary and sexual functions, particularly those early after RARP, appeared to be significantly impaired.

Complications Following Direct Anterior Hip Procedures: Costs to Both Patients and Surgeons.

A systematic review of the literature on clinical outcomes following direct anterior approach (DAA) hip arthroplasty was performed. An aggregated 11,810 hip procedures were analyzed for intraoperative and early postoperative complications. The most common complication following DAA hip arthroplasty was nerve dysfunction (2.8%) followed by intraoperative fractures (2.3%). Postoperative dislocation, wound complications, and revision THA within the first 12 months were reported in 1.2% of cases. Thus, while DAA hip arthroplasty can be successfully performed, it is not without complications. Without definitive evidence of clinical superiority, surgeons considering switching to DAA should benchmark their personal complication rates against published reports.

A nine-year review of medicolegal claims in neurosurgery.

INTRODUCTION: Neurosurgery remains among the highest malpractice risk specialties. This study aimed to identify areas in neurosurgery associated with litigation, attendant causes and costs. METHODS: Retrospective analysis was conducted of 42 closed litigation cases treated by neurosurgeons at one hospital between March 2004 and March 2013. Data included clinical event, timing and reason for claim, operative course and legal outcome. RESULTS: Twenty-nine claims were defended out of court and twelve were settled out of court. One case required court attendance and was defended. Of the 42 claims, 28, 13 and 1 related to spinal (0.3% of caseload), cranial (0.1% of caseload) and peripheral nerve (0.07% of caseload) surgery respectively. The most common causes of claims were faulty surgical technique (43%), delayed diagnosis/misdiagnosis (17%), lack of information (14%) and delayed treatment (12%), with a likelihood of success of 39%, 29%, 17% and 20% respectively. The highest median payouts were for claims against faulty surgical technique (£230,000) and delayed diagnosis/misdiagnosis (£212,650). The mean delay between clinical event and claim was 664 days. CONCLUSIONS: Spinal surgery carries the highest litigation risk versus cranial and peripheral nerve surgery. Claims are most commonly against faulty surgical technique and delayed diagnosis/misdiagnosis, which have the highest success rates and payouts. In spinal surgery, the most common cause of claims is faulty surgical technique. In cranial surgery, the most common cause is lack of information. Claims may occur years after the clinical event, necessitating thorough contemporaneous documentation for adequate future defence. We emphasise thorough patient consultation and meticulous surgical technique to minimise litigation in neurosurgical practice.

Death or neurologic injury after tonsillectomy in children with a focus on obstructive sleep apnea: houston, we have a problem!

BACKGROUND: Obesity is epidemic in the United States and with it comes an increased incidence of obstructive sleep apnea (OSA). Evidence regarding opioid sensitivity as well as recent descriptions of deaths after tonsillectomy prompted a survey of all members of the Society for Pediatric Anesthesia regarding adverse events in children undergoing tonsillectomy. METHODS: An electronic survey was sent to 2377 members of the Society for Pediatric Anesthesia. Additionally, data from the American Society of Anesthesiologists Closed Claims Project were obtained. Adverse events during or after tonsillectomy with or without adenoidectomy in children were included. Children at risk for OSA were identified as either having a positive history for OSA or a post hoc application of the American Society of Anesthesiologists OSA practice guidelines. These children were compared with all other children by Fisher exact test for proportions and t test for continuous variables. RESULTS: A total of 129 cases were identified from the 731 replies to the survey, with 92 meeting inclusion criteria for having adequate data. Another 19 cases with adequate data were identified from the 45 from the American Society of Anesthesiologists Closed Claims Project. A total of 111 cases were included in the final analysis. Death and permanent neurologic injury occurred in 86 (77%) cases and were reported in the operating room, postanesthesia care unit, on the ward, and at home. Sixty-three (57%) children fulfilled American Society of Anesthesiologists criteria to be at risk for OSA. Children categorized as at risk for OSA were more likely than other children to be obese and to have comorbidities (P < 0.0001). A larger proportion of at risk children had the event attributed to apnea (P = 0.016), whereas all others had a larger proportion of events attributed to hemorrhage (P = 0.006). CONCLUSIONS: Deaths or neurologic injury after tonsillectomy due to apparent apnea in children suggest that at least 16 children could have been rescued had respiratory monitoring been continued throughout first- and second-stage recovery, as well as on the ward during the first postoperative night. A validated pediatric-specific risk assessment scoring system is needed to assist with identifying children at risk for OSA who are not appropriate to be cared for on an outpatient basis.

Costs and outcome for serious hand and arm injuries during the first year after trauma - a prospective study.

BACKGROUND: To study costs and outcome for serious hand and arm injuries during the first year after the trauma. METHODS: In patients with a Hand Injury Severity Score (HISS) > 50, DASH and EQ-5D scores as well as factors related to costs within the health care sector, costs due to lost production and total costs were evaluated. Cox-regression analysis stratifying for mechanism of injury was used to analyse return to work. RESULTS: The majority of the 45 included patients (median 42 years 16-64) were men with severe (n = 9) or major (n = 36) injuries with different type of injuries (amputations n = 13; complex injuries n = 18; major nerve injuries/full house n = 13; burn injury n = 1). DASH and EQ-5D decreased and increased, respectively, significantly over time during one year. Total costs (+34%) and costs of lost production were highest for persons injured at work. Factors associated with higher health care costs were age >50 years (+52%), injury at work (+40%) and partial labour market activity (+66%). Costs of lost production had a significant role in total costs of injury. Patients with major injuries had longer duration of sick leave. Patients with severe injuries were more likely to return to work [(RR 3.76 (95% CI 1.38-10.22) from Cox regression, controlling for age, gender and presence of nerve injury]. CONCLUSIONS: Despite the fact that work environments have constantly improved over the last decades, we found that hand injuries at work were most costly both in terms of health care and costs of lost production, although the severity, i.e. HISS, did not differ from injuries occurring at home or during leisure.

Anthropometric assessment of cervical neurovascular structures using CTA to determine zone-specific vulnerability to penetrating fragmentation injuries.

AIM: To determine military-specific cervical neurovascular and external anthropometric data to scale future numerical injury models of the neck and improve body armour design with a view to prevention or mitigation of combat neck injury. MATERIALS AND METHODS: Contrast-enhanced computed tomography (CT) angiograms of 50 UK servicemen were analysed. Mean diameters and distances from the skin surface were determined for the carotid artery (CA), internal jugular vein (IJV), vertebral artery (VA) and spinal cord (SC) at the three surgical neck zones. Horizontal neck circumference at C6 and three potential vertical cervical anthropometric measurements were analysed to determine which had the least variability between subjects. RESULTS: The diameters of cervical vascular structures are greater and the vessels more superficial as the anatomical plane moves caudally. The SC and VA are better protected than the IJV and CA due to their greater depth and bony coverage, except for the VA in zone 1. CONCLUSION: Future cervical anthropometric assessments should use the vertical angle of mandible to mid-claviclular distance in combination with the horizontal neck circumference as these demonstrated the least variability. Cervical neurovascular structures are least vulnerable posterosuperiorly and therefore extending the posterior aspect of a ballistic helmet inferiorly or adding a nape protector would appear to be less justified. Cervical vessels are most vulnerable in zone 1 and a circumferential collar of ballistic material at least 75 mm high would cover this area in 95% of this population.

Bad medicine: prescription drugs, preemption, and the potential for a no-fault fix.

For decades, federal regulation of pharmaceutical drugs and medical devices has worked hand in hand with state tort claims to protect the health and safety of the American public. Now, a new trend toward preemption endangers this scheme. In recent years, the Supreme Court has given increasing deference to agency assertions about their preemptive authority and has found preemption in an increasing number of cases. In the process, the Supreme Court has preempted claims for medical device injuries and left claims for pharmaceutical harms in a precarious position. The elimination of common law claims for drug and device harms will leave holes in the FDA's regulatory scheme, endangering the health and safety of Americans. It will also prevent ordinary Americans from seeking compensation for their injuries--even those injuries caused by manufacturer malfeasance. This Article proposes that Congress create a no-fault compensation scheme for drugs and medical devices to close these gaps. Such a scheme could be both practical and politically possible, satisfying manufacturers, tort reformers, patients, and plaintiffs' lawyers alike.

Iatrogenic nerve injury in a national no-fault compensation scheme: an observational cohort study.

BACKGROUND: Iatrogenic nerve injury causes distress and disability, and often leads to litigation. The scale and profile of these injuries has only be estimated from published case reports/series and analyses of medicolegal claims. AIM: To determine the current spectrum of iatrogenic nerve injury in New Zealand by analysing treatment injury claims accepted by a national no-fault compensation scheme. METHODS: The Accident Compensation Corporation (ACC) provides national no-fault personal accident insurance cover, which extends to patients who have sustained a treatment injury from a registered healthcare professional. Nerve injury claims identified from 5227 treatment injury claims accepted by the ACC in 2009 were analysed. RESULTS: From 327 claims, 292 (89.3%) documenting 313 iatrogenic nerve injuries contained sufficient information for analysis. Of these, 211 (67.4%) occurred in 11 surgical specialties, particularly orthopaedics and general surgery; the remainder involved phlebotomy services, anaesthesia and various medical specialties. The commonest causes of injury were malpositioning (n = 40), venepuncture (n = 26), intravenous cannulation (n = 21) and hip arthroplasty (n = 21). Most commonly injured were the median nerve and nerve roots (n = 32 each), brachial plexus (n = 26), and the ulnar nerve (n = 25). At least 34 (11.6%) patients were referred for surgical management of their nerve injury. CONCLUSIONS: Iatrogenic nerve injuries are not rare and occur in almost all branches of medicine, with malpositioning under general anaesthesia and venepuncture as leading causes. Some of these injuries are probably unavoidable, but greater awareness of which nerves are at risk and in what context should facilitate the development and/or wider implementation of preventive strategies.

Análise dos acidentes motociclísticos no Centro de Reabilitação e Readaptação Dr. Henrique Santillo (CRER) / Analysis of motorcycle accidents at the Dr. Henrique Santillo Rehabilitation and Readaptation Center (CRER)

Introdução: na última década, dentre os acidentes automobilísticos, observa-se um número crescente envolvendo motocicletas, veículo que ganha cada vez mais aceitação e aprovação da população. Nestes acidentes, as lesões neurológicas mais freqüentes são o traumatismo cranioencefálico (TCE), seguido de lesão medular (LM), ambas de grande importância devido à gravidade das seqüelas que provocam. Objetivos: identificar o perfil dos pacientes vítimas de acidentes de tráfego com motocicletas no Centro de Reabilitação e Readaptação Dr. Henrique Santillo (CRER), tipo de lesão neurológica, incapacidades adquiridas, reinserção laboral e capacidade para conduzir veículos após o trauma. Pacientes e métodos: realizou-se uma análise descritiva dos prontuários dos pacientes internados no CRER, no período de 2007 a 2010, selecionando apenas as vítimas de acidente motociclístico, assim como da atual situação produtiva dos mesmos através de contato telefônico no período de 01-07-2011 a 20-07-2011, utilizando formulário previamente elaborado. Resultados: houve predomínio de homens jovens economicamente ativos, sendo que a maioria não retornou sua vida laboral (86%) e está usufruindo de benefício previdenciário (79,6%). Conclusão: faz-se primordial a elaboração de estratégias para prevenção e controle dos traumas por motos, assim como medidas que estimulem a reinserção desses indivíduos incapacitados.

Introduction: in the last decade, among automobile accidents, it was observed that a growing number involved motorcycles, a vehicle that is beingmore and more accepted and approved by the population. In these accidentsthe most frequent neurological lesions are cranioencephalic trauma (CET), followed by medullary lesion (ML), both of great importance due to the gravity of their after-effects. Objectives: to identify the profile of the patients who are victims of motorcycle accidents at the Dr. Henrique Santillo Rehabilitation and Readaptation Center (CRER), their type of neurologicallesion, any acquired disabilities, their reinsertion into the job market, andtheir capacity to drive vehicles after the trauma. Patients and methods: a descriptive analysis of the medical history forms of patients admitted at CRER, from 2007 to 2010, selecting only the victims of motorcycle accidents, as well as the current productive situation of these victims through telephone contact between July 1st, 2011 and July 20th, 2011, utilizing apreviously-prepared form. Results: there was a predominance of youngmales economically active, the majority of whom did not return to work (86%) and are enjoying social welfare benefits (79.6%). Conclusion: The need to prepare strategies to prevent and control motorcycle traumas is evident, as well as measures that stimulate the reinsertion of these disabled individuals into the work market.

Physically interactive robotic technology for neuromotor rehabilitation.

Robotic technology can provide innovative responses to the severe challenges of providing cost-effective care to restore sensory-motor function following neurological and biomechanical injury. It may be deployed at several points on a continuum of care, to provide precisely controlled sensory-motor therapy to ameliorate disability and promote recovery of function, or to provide assistance to compensate for functions that cannot be recovered, or to replace limbs lost irretrievably. This chapter reviews recent progress using robotic technology to capitalize on neural plasticity and promote recovery after neurological injury such as stroke (cerebral vascular accident), research on brain-computer interfaces as a source of control signals for assistive technologies, and research on high-performance multiple-degree-of-freedom upper-extremity prosthetic limbs.

Repair of complete nerve lacerations at the forearm: an outcome study using Rosén-Lundborg protocol.

A comparison of outcomes based on a scoring system for assessments, described by Rosén and Lundborg, after sharp complete laceration of median and/or ulnar nerves at various levels in the forearm was carried out. There were 66 males (90.4%) and 7 females (9.6%), with a mean age of 31 years (range: 14-62 years). The patients were categorized into three groups according to the type of nerve injury. The median nerve was injured in 25 cases (group M, 34.3%), the ulnar in 27 (group U, 36.9%), and both the nerves in 21 (group MU, 28.8%). The demographic data of the patients and the mechanism of injury were recorded. We also examined the employment status at the time of the injury and we estimated the percentage of patients who returned to their work after trauma. In all cases, a primary epineural repair was performed. Concomitant injuries were repaired in the same setting. The mean period of time between injury and surgery was 5.3 hours (range: 2-120 hours). A rehabilitation protocol and a reeducation program were followed in all cases. The mean follow-up was 3 years (range: 2-6 years), with more distal injuries having a shorter follow-up period. The total score was 2.71 in group M (range: 0.79-2.99) and 2.63 in group U (range: 0.63-3), with no significant differences observed. There was a significant difference between these two groups and group MU (total score 2.03, range: 0.49-2.76, P = 0.02). Up to the last follow-up, 61 patients (83.5%) had returned to their previous work. The Rosén-Lundborg model can be a useful and simple tool for the evaluation of the functional outcome after nerve injury and repair temporally reflecting the processes of regeneration and reinnervation.

Diagnosis of abnormal diaphragm motion after cardiothoracic surgery: ultrasound performed by a cardiac intensivist vs. fluoroscopy.

OBJECTIVES: Abnormal diaphragmatic motion secondary to phrenic nerve injury is not uncommon after pediatric cardiothoracic surgery. Fluoroscopy is the most frequent method of diagnosis but it carries risks associated with transportation of critically ill children and exposure to ionizing radiation. Ultrasonography, a reliable diagnostic method in adults, eliminates both concerns. Since most cardiac intensivists are trained in echocardiography, we tested the hypothesis that chest ultrasound performed by a cardiac intensivist is faster than fluoroscopy, and is highly accurate in predicting fluoroscopy results, therefore serving as an equally useful diagnostic test. DESIGN: Prospective study in consecutive pediatric patients with suspected abnormal diaphragmatic motion after cardiothoracic surgery. All patients underwent fluoroscopy and ultrasound study of the diaphragm. Ultrasound was performed by a pediatric cardiac intensivist and a trainee. Kappa statistic was calculated to assess concordance between both ultrasound readings. Sensitivity, specificity, and positive and negative predictive values (PPV and NPV) were calculated to assess accuracy of each ultrasound test in predicting fluoroscopy results. RESULTS: Twenty-five patients with median age 3 months (12 days-11 years) and median weight of 3.8 kg (2.5-29 kg) were included. The ultrasound diagnosis of the cardiac intensivist was perfectly accurate (100% sensitivity, specificity, and PPV and NPV) in predicting fluoroscopy results. The ultrasound performed by the trainee achieved 85.7% sensitivity, 94.4% NPV, and 100% specificity relative to fluoroscopy. The interoperator reliability of chest ultrasound was 0.89 (95% confidence interval 0.69-1). Delay between clinical suspicion and the diagnostic tests was 15 minutes (5 minutes-2.5 hours) for ultrasound and 17 hours (60 minutes-82 hours) for fluoroscopy (P < 0.001). CONCLUSIONS: Chest ultrasound performed by cardiac intensivists allows for an early and accurate diagnosis of abnormal diaphragmatic motion, as evidenced by their ability to predict fluoroscopy findings in pediatric cardiothoracic patients. Training in ultrasound-guided assessment of diaphragmatic motion should be reinforced during pediatric cardiac intensive care fellowship.

"Mood rings": a new method of objective clinical assessment of peripheral nerve injuries.

The clinical assessment of patients with peripheral nerve injury is primarily dependent on subjective clinical examination. We aimed to assess whether a thermotropic liquid crystal ring (TLC-ring) could provide the basis for an objective assessment of peripheral nerve injury by detecting temperature changes in the digits innervated by the damaged nerve. A group of patients with known median, ulnar or both digital nerve injuries were compared against a control group. TLC-rings, marketed to the general public as "mood rings", were applied to the affected and unaffected digits and the colour change recorded. Areas with nerve damage showed a statistically significant difference in colour response to those without damage. This study establishes the ability of TLCs to detect cutaneous temperature changes associated with peripheral nerve injuries. Further studies and improvements are needed to refine TLC as an acute assessment tool for peripheral nerve injuries.