Specialized intensive inpatient rehabilitation is crucial and time-sensitive for functional recovery from disorders of consciousness.

Background: Disorders of consciousness (DoCs) after severe brain injury are considered to be conditions with dire prognosis. Despite the accumulating evidence, inpatient rehabilitation is often denied by payers referring to the Medicare/Medicaid criteria, under the assumption that such patients will not "actively" participate in therapy or make "measurable improvements." Objective: This study aimed to report on the effectiveness and efficiency of a specialized inpatient DoC rehabilitation program based on measurable clinical parameters. Methods: A retrospective cohort study was conducted. The cohort comprised 137 patients with DoC admitted to a specialized acute inpatient rehabilitation program between January 2014 and October 2018. Patients were categorized as having been admitted at the acute stage (<=28 days post-injury), subacute stage (29-365 days following a traumatic brain injury (TBI) or 29-90 days following a non-TBI), or chronic stage (>365 days following a TBI or >90 days following a non-TBI). Outcomes included changes in level of consciousness (based on the Coma Recovery Scale-Revised (CRS-R), while also acknowledging scenarios beyond those captured by the CRS-R via Individualized Qualitative Behavioral Assessment and team consensus); Functional Independence Measure (FIM) levels; achievements in decannulation and initiation of oral diet; and time to those achievements. Results: The rates of emergence from a minimally conscious state were 90, 62, and 18% among patients admitted at the acute, subacute, and chronic stages, respectively. Among patients who emerged, 100, 85, and 67%, respectively, had measurable FIM scores. Approximately 60 and 20% of patients at the acute and subacute stages, respectively, required moderate assistance or less in transfer/communication/eating/grooming/upper body dressing by the time of discharge from Phase I admission. The decannulation rates were 94, 67, and 17%. The oral diet initiation rates were 70, 23, and 6%. The time to reach these achievements lengthened as chronicity increased. There was a weak positive correlation (r s = 0.308) in the case of decannulation and a strong positive correlation (r s = 0.606, both p < 0.01) in the case of oral diet between days since injury on admission and days to the achievement after admission. Patients with TBI and hypoxic brain injury had comparable recovery rates when admitted at the acute and subacute stages. Conclusion: Specialized intensive inpatient rehabilitation is crucial and time-sensitive for functional recovery from DoC caused by TBI and hypoxic-ischemic brain injury. Specific goals and different outcome measures need to be developed to appraise the benefits of acute inpatient rehabilitation for DoC.

Glaucoma in Adults-diagnosis, Management, and Prediagnosis to End-stage, Categorizing Glaucoma's Stages: A Review.

Importance: Most frequent worldwide cause of permanent blindness is glaucoma. Early in the course of the disease, glaucoma affects many patients without any symptoms. In order to examine for indications of glaucoma and to ascertain whether systemic illnesses or drugs can raise a patient's risk of developing glaucoma, primary care practitioners should be aware of which patients to send to an eye care specialist. A review of the pathogenesis, risk factors, screening, disease monitoring, and treatment options for open-angle and narrow-angle glaucoma are included. Observations: The optic nerve and retinal nerve fiber layer (rNFL) are damaged in glaucoma, a chronic, progressive optic neuropathy that can result in a permanent loss of peripheral or central vision. The only risk factor that is known to be controllable is intraocular pressure (IOP). A family history of glaucoma, older age, and non-white race are additional significant risk factors. Numerous systemic diseases and drugs, such as corticosteroids, anticholinergics, certain antidepressants, and topiramate, can put people at risk of developing glaucoma. Open-angle and angle-closure glaucoma are the two main types of disease. Measurement of IOP, perimetry, and optical coherence tomography are diagnostic procedures to evaluate glaucoma and track the course of the condition. In order to treat glaucoma, IOP must be decreased. This is possible with a variety of glaucoma medication classes, laser surgery, and incisional surgery. Verdicts and relevance: By identifying systemic illnesses and drugs that raise a patient's chance of developing glaucoma and referring high-risk individuals for a thorough ophthalmologic examination, vision loss from glaucoma can be reduced. Clinicians should make sure that patients continue taking their glaucoma drugs as prescribed and should keep an eye out for any negative side effects from any medical or surgical procedures used to treat glaucoma. How to cite this article: Joshi P, Dangwal A, Guleria I, et al. Glaucoma in Adults-diagnosis, Management, and Prediagnosis to End-stage, categorizing Glaucoma's Stages: A Review. J Curr Glaucoma Pract 2022;16(3):170-178.

Conceptualizations of consciousness and continuation of care among family members and health professionals caring for patients in a minimally conscious state.

BACKGROUND: The American Academy of Neurology recently emphasized the importance of communicating with patients' families to better reflect patient values in clinical care. However, little is known about how decisions about continuing rehabilitative care made by family caregivers and healthcare providers working with minimally conscious patients are informed by conceptualizations of consciousness and moral status. METHODS: We explored these issues in interviews with 18 family caregivers and 20 healthcare professionals caring for minimally conscious patients. Data were analyzed using thematic content analysis. RESULTS: Results suggest that family members and healthcare professionals share similar views of what consciousness is ("being there") and what it is indicated by ("a look in the eyes," and/or an "ability to do"/agency). They also share a belief that the presence (or "level") of consciousness does not determine whether rehabilitative care should be discontinued. Rather, it should be determined by considerations of suffering and well-being. Providers were more likely to view suffering as rationale for discontinuation of care, while family members viewed suffering as an indicator of and motivator for potential recovery. CONCLUSION: Findings can help optimize family-provider communications about minimally conscious patients by acknowledging shared assumptions and interpretations of consciousness, as well as key areas where perspectives diverge.Implications for rehabilitationFamily and professional caregivers' interpretations of consciousness and suffering are implicated in decisions about continuing rehabilitation for minimally conscious patients.Family members and healthcare providers both rely to some extent on non-observable evidence to evaluate consciousness, which may be an adaptive and philanthropic response to clinical uncertainty.Acknowledging shared assumptions and interpretations of consciousness, as well as diverging perspectives, can help to optimize family-provider communications.

Spasticity Management in Persons with Disorders of Consciousness.

INTRODUCTION: Spasticity is one of the most frequent neurological impairments affecting persons with disorders of consciousness (DoC). If left untreated, it can mask signs of consciousness by inhibiting one's ability to interact with the environment. The lack of information about spasticity specific to patients with DoC may result in insufficient or even inappropriate treatment. OBJECTIVE: To report spasticity characteristics and management in a large dedicated DoC rehabilitation program. DESIGN: Retrospective chart review. SETTING: An inpatient rehabilitation hospital. PARTICIPANTS: Patients admitted to the DoC rehabilitation program from 1 January 2014 to 31 October 2018. MAIN OUTCOME MEASUREMENTS: Spasticity characteristics; impact of interventions on spasticity as well as other clinical measures. RESULTS: A total of 146 patients were included, of whom 95.2% were affected by spasticity; 52.7% had spasticity affecting all four limbs. The most commonly affected muscle groups were shoulder internal rotators (72.6%) in the upper extremity and ankle plantar flexors (59.8%) in the lower extremity. The more commonly affected muscle groups were also more spastic (R = 0.993 and 0.989 in the upper and lower extremity, respectively; P < .01). Atypical posture patterns were also commonly observed, making positioning difficult. Chemoneurolytic injections (botulinum toxin and/or phenol) were performed in over 69.9% patients, and 26.7% had intrathecal baclofen (ITB) pump placement. All patients received individualized physical modalities and therapies. With focal managements, systemic spasmolytic medications, including enteral baclofen, were reduced by at least 50.0%, which appeared to be associated with improvements in the level of consciousness. CONCLUSIONS: Almost all DoC patients were affected by spasticity, often to a moderate or severe degree. Extensive use of focal spasticity interventions allowed for weaning of systemic spasmolytic medications, which seemed to result in improvements in the level of consciousness.

Congenital and acquired brain injury. 3. Spectrum of the acquired brain injury population.

UNLABELLED: This self-directed learning module highlights the subpopulations of traumatic brain injury (TBI) that are treated by the rehabilitation practitioner. It is part of the chapter on TBI in the self-directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. Specifically, this article focuses on the management of patients with mild TBI, children, and individuals with acquired brain injury from other etiologies, such as anoxic events or neoplastic lesions. The clinical spectrum of TBI, from the most severe presentation to the mildest, requires similar clinical skills to evaluate and manage. OVERALL ARTICLE OBJECTIVE: To describe the spectrum of brain injury populations based on age, severity, and etiology.

Congenital and acquired brain injury. 5. Emerging concepts in prognostication, evaluation, and treatment.

UNLABELLED: This self-directed learning module describes recent developments in the field of traumatic brain injury (TBI) rehabilitation. In particular, it focuses on the implications of recent technological advances for evaluation, prognostication, and treatment. It is part of the chapter on TBI medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on neuroplasticity and its implications for rehabilitation interventions, the role of innovative neuroimaging modalities, improvements in our ability to prognosticate made possible by newer technologies, technologically based enhancement of motor rehabilitation, and the role of alternative and complementary medicine in TBI rehabilitation. OVERALL ARTICLE OBJECTIVE: To describe recent advances in our ability to evaluate, prognosticate, and treat traumatic brain injury.

Congenital and acquired brain injury. 4. Outpatient and community reintegration.

UNLABELLED: This self-directed learning module highlights the rehabilitation aspects of care for people with traumatic brain injury (TBI) after the acute phase. It focuses on issues important to community reentry, outpatient care, and return to work. It is part of the chapter on TBI medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on the formulation of rehabilitation plans to address the issues of cognitive dysfunction, behavioral disturbances, and community reintegration. Topics covered include pharmacologic and nonpharmacologic approaches to cognitive and affective disorders, intimacy, social isolation, mobility, and return to work. Finally, the critical issues of legal competency and obtaining informed consent in the population with cognitive impairment are discussed. OVERALL ARTICLE OBJECTIVE: To summarize the issues that affect outpatient care, independence, and community reentry after traumatic brain injury.

Congenital and acquired brain injury. 1. Epidemiology, pathophysiology, prognostication, innovative treatments, and prevention.

UNLABELLED: This self-directed learning module reviews the current epidemiology of traumatic brain injury (TBI), its pathophysiology, prognostication after injury, currently available innovative early approaches to diagnosis and treatment, and effective methods of prevention. It is intended to provide the rehabilitation clinician with current knowledge to accurately inform patients, families, significant others, referring physicians, and payers and to aid in clinical decision making while caring for patients after TBI. OVERALL ARTICLE OBJECTIVE: To describe current knowledge in traumatic brain injury epidemiology, pathophysiology, prognostication, acute treatment, and prevention.

Congenital and acquired brain injury. 2. Medical rehabilitation in acute and subacute settings.

UNLABELLED: This self-directed learning module reviews common clinical problems and issues pertaining to early management of persons with traumatic brain injury (TBI). It is part of the study guide on brain injury medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. Acute TBI is frequently complicated by agitation, dystonia, and numerous orthopedic and neurologic comorbidities, often causing a decrement in function, which requires careful assessment and treatment. Individuals with acute brain injury typically receive rehabilitation in a setting determined by numerous factors, including medical stability and tolerance to rehabilitation interventions. OVERALL ARTICLE OBJECTIVES: To describe (a) common traumatic brain injury-related comorbidities and treatment strategies, (b) potential causes of declining patient performance, and (c) appropriate settings for rehabilitation interventions.

Ingested Foreign Body Causing Duodenal and Colonic Perforations in a Child.

Most ingested foreign bodies usually pass uneventfully through the gastrointestinal tract. Few may cause complications and require surgical interventions. We report a 1.5-year-old child who ingested hair clip and presented with vomiting and obstruction. At operation, we found duodenal and colonic perforations. Hair clip was removed with repair of perforations.

Abandoning the Golden Rule: the problem with "putting ourselves in the patient's place".

A large body of evidence documents the difficulties health care professionals have in predicting their patient's beliefs or wishes. These difficulties extend from the predictions of very specific patient wishes (such as for life-sustaining therapies) to more global assessments of patients' lives as a whole (for instance, their quality of life). Although many explanations have been offered for this phenomenon, we discuss one that has not received as much attention: the conscious or unconscious adoption of what we refer to as Golden Rule thinking. This refers to our attempts to understand another person's situation by imagining what we would believe or want under similar circumstances, in other words, "putting ourselves in the patient's place." Although Golden Rule thinking would seem to be a promising strategy, studies show that it actually results in inaccurate predictions of patients' wishes or beliefs. These mispredictions, in turn, have significant clinical and ethical implications. We review possible reasons why Golden Rule thinking may be of limited utility in understanding our patients' situations and suggest alternate strategies to maximize our understanding of our patient's lives.

Comparison of caudal and intravenous dexamethasone as adjuvants for caudal epidural block: A double blinded randomised controlled trial.

BACKGROUND AND AIMS: Dexamethasone has a powerful anti-inflammatory action with significant analgesic benefits. The aim of this study was to compare the efficacy of dexamethasone administered through intravenous (IV) and caudal route on post-operative analgesia in paediatric inguinal herniotomy patients. METHODS: One hundred and five paediatric patients undergoing inguinal herniotomy were included and divided into three groups. Each patient received a single caudal dose of ropivacaine 0.15%, 1.5 mL/kg combined with either corresponding volume of normal saline (Group 1) or caudal dexamethasone 0.1 mg/kg (Group 2) or IV dexamethasone 0.5 mg/kg (Group 3). Baseline, intra- and post-operative haemodynamic parameters, pain scores, time to rescue analgesia, total analgesic consumption and adverse effects were evaluated for 24 h after surgery. Unpaired Student's t-test and analysis of variance were applied for quantitative data and Chi-square test for qualitative data. Time to first analgesic administration was analysed by Kaplan-Meier survival analysis and log-rank test. RESULTS: Duration of analgesia was significantly longer (P < 0.001), and total consumption of analgesics was significantly lower (P < 0.001) in Group II and III compared to Group I. The incidence of nausea and vomiting was higher in Group I (31.4%) compared to Group II and III (8.6%). CONCLUSIONS: Addition of dexamethasone both caudally or intravenously as an adjuvant to caudal 0.15% ropivacaine significantly reduced the intensity of post-operative pain and prolonged the duration of post-operative analgesia with the significant advantage of caudal over IV route.

Rupture of the right hemidiaphragm due to blunt trauma in children: a diagnostic dilemma.

The diagnosis of right-sided diaphragmatic rupture (RDR) due to blunt abdominal trauma is often missed in the acute setting, especially in the absence of other thoracoabdominal injuries. We describe two such children. The problems associated with the diagnosis and management of RDR are discussed to emphasize the need to have a high index of suspicion for this entity.

Congenital H-type rectourethral fistula.

An H-type rectourethal fistula was seen in a male child. The anus and anterior urethra were normal. The embryology and surgical management of this rare anomaly are discussed.