Follow-up visits after a concussion in the pediatric population: An integrative review.

BACKGROUND: Concussions are a significant health issue for children and youth. After a concussion diagnosis, follow-up visits with a health care provider are important for reassessment, continued management, and further education. OBJECTIVE: This review aimed to synthesize and analyse the current state of the literature on follow-up visits of children with a concussive injury and examine the factors associated with follow-up visits. METHODS: An integrative review was conducted based on Whittemore and Knafl's framework. Databases searched included PubMed, MEDLINE, CINAHL, PsycINFO, and Google Scholar. RESULTS: Twenty-four articles were reviewed. We identified follow-up visit rates, timing to a first follow-up visit, and factors associated with follow-up visits as common themes. Follow-up visit rates ranged widely, from 13.2 to 99.5%, but time to the first follow-up visit was only reported in eight studies. Three types of factors were associated with attending a follow-up visit: injury-related factors, individual factors, and health service factors. CONCLUSION: Concussed children and youth have varying rates of follow-up care after an initial concussion diagnosis, with little known about the timing of this visit. Diverse factors are associated with the first follow-up visit. Further research on follow-up visits after a concussion in this population is warranted.

The CaT stretcher: An open-source system for delivering uniaxial strain to cells and tissues (CaT).

Integration of mechanical cues in conventional 2D or 3D cell culture platforms is an important consideration for in vivo and ex vivo models of lung health and disease. Available commercial and published custom-made devices are frequently limited in breadth of applications, scalability, and customization. Herein we present a technical report on an open-source, cell and tissue (CaT) stretcher, with modularity for different in vitro and ex vivo systems, that includes the following features: 1) Programmability for modeling different breathing patterns, 2) scalability to support low to high-throughput experimentation, and 3) modularity for submerged cell culture, organ-on-chips, hydrogels, and live tissues. The strategy for connecting the experimental cell or tissue samples to the stretching device were designed to ensure that traditional biomedical outcome measurements including, but not limited to microscopy, soluble mediator measurement, and gene and protein expression remained possible. Lastly, to increase the uptake of the device within the community, the system was built with economically feasible and available components. To accommodate diverse in vitro and ex vivo model systems we developed a variety of chips made of compliant polydimethylsiloxane (PDMS) and optimized coating strategies to increase cell adherence and viability during stretch. The CaT stretcher was validated for studying mechanotransduction pathways in lung cells and tissues, with an increase in alpha smooth muscle actin protein following stretch for 24 h observed in independent submerged monolayer, 3D hydrogel, and live lung tissue experiments. We anticipate that the open-source CaT stretcher design will increase accessibility to studies of the dynamic lung microenvironment through direct implementation by other research groups or custom iterations on our designs.

Is comprehensive geriatric assessment hospital at home a cost-effective alternative to hospital admission for older people?

BACKGROUND: hospital level healthcare in the home guided by comprehensive geriatric assessment (CGA) might provide a less costly alternative to hospitalisation for older people. OBJECTIVE: to determine the cost-effectiveness of CGA admission avoidance hospital at home (HAH) compared with hospital admission. DESIGN/INTERVENTION: a cost-effectiveness study alongside a randomised trial of CGA in an admission avoidance HAH setting, compared with admission to hospital. PARTICIPANTS/SETTING: older people considered for a hospital admission in nine locations across the UK were randomised using a 2:1 randomisation schedule to admission avoidance HAH with CGA (N = 700), or admission to hospital with CGA when available (N = 355). MEASUREMENTS: quality adjusted life years, resource use and costs at baseline and 6 months; incremental cost-effectiveness ratios were calculated. The main analysis used complete cases. RESULTS: adjusting for baseline covariates, HAH was less costly than admission to hospital from a health and social care perspective (mean -£2,265, 95% CI: -4,279 to -252), and remained less costly with the addition of informal care costs (mean difference -£2,840, 95% CI: -5,495 to -185). There was no difference in quality adjusted survival. Using multiple imputation for missing data, the mean difference in health and social care costs widened to -£2,458 (95% CI: -4,977 to 61) and societal costs remained significantly lower (-£3,083, 95% CI: -5,880 to -287). There was little change to quality adjusted survival. CONCLUSIONS: CGA HAH is a cost-effective alternative to admission to hospital for selected older people.

In search of scientific objectivity: Is there such a property for paediatric concussion?

Concussions are a significant public health problem worldwide. This brain injury is problematic in the paediatric population for a variety of reasons; however, the enquiry into these problems has been mainly through the biomedical perspective. This approach has impacted nursing knowledge and practice of children and youth with a concussion, primarily since other perspectives are viewed as not being objective. In this manuscript, I draw on Thomas Kuhn's view of objectivity to evaluate the biomedical perspective of concussion. I utilize current research and clinical examples to illustrate the advantages and drawbacks of this perspective for nursing. From this discussion, I propose an alternative perspective to capture the complexity of paediatric concussions for nursing, a systems perspective. Although I argue for an alternative perspective to approach paediatric concussions for nursing, I maintain that the biomedical perspective can be incorporated as one part of nursing knowledge and practice for paediatric concussion.

Is Comprehensive Geriatric Assessment Admission Avoidance Hospital at Home an Alternative to Hospital Admission for Older Persons? : A Randomized Trial.

BACKGROUND: Delivering hospital-level care with comprehensive geriatric assessment (CGA) in the home is one approach to deal with the increased demand for bed-based hospital care, but clinical effectiveness is uncertain. OBJECTIVE: To assess the clinical effectiveness of admission avoidance hospital at home (HAH) with CGA for older persons. DESIGN: Multisite randomized trial. (ISRCTN registry number: ISRCTN60477865). SETTING: 9 hospital and community sites in the United Kingdom. PATIENTS: 1055 older persons who were medically unwell, were physiologically stable, and were referred for a hospital admission. INTERVENTION: Admission avoidance HAH with CGA versus hospital admission with CGA when available using 2:1 randomization. MEASUREMENTS: The primary outcome of living at home was measured at 6 months. Secondary outcomes were new admission to long-term residential care, death, health status, delirium, and patient satisfaction. RESULTS: Participants had a mean age of 83.3 years (SD, 7.0). At 6-month follow-up, 528 of 672 (78.6%) participants in the CGA HAH group versus 247 of 328 (75.3%) participants in the hospital group were living at home (relative risk [RR], 1.05 [95% CI, 0.95 to 1.15]; P = 0.36); 114 of 673 (16.9%) versus 58 of 328 (17.7%) had died (RR, 0.98 [CI, 0.65 to 1.47]; P = 0.92); and 37 of 646 (5.7%) versus 27 of 311 (8.7%) were in long-term residential care (RR, 0.58 [CI, 0.45 to 0.76]; P < 0.001). LIMITATION: The findings are most applicable to older persons referred from a hospital short-stay acute medical assessment unit; episodes of delirium may have been undetected. CONCLUSION: Admission avoidance HAH with CGA led to similar outcomes as hospital admission in the proportion of older persons living at home as well as a decrease in admissions to long-term residential care at 6 months. This type of service can provide an alternative to hospitalization for selected older persons. PRIMARY FUNDING SOURCE: The National Institute for Health Research Health Services and Delivery Research Programme (12/209/66).

Continent-wide Shifts in Song Dialects of White-Throated Sparrows.

Hypotheses on regional song variation ("dialects") assume that dialects remain stable within regions, are distinct between regions, and persist within populations over extensive periods [1-3]. Theories to explain dialects focus on mechanisms that promote persistence of regional song variants despite gene flow between regions [4-6], such as juveniles settling in non-natal populations retaining only those songs from their repertoires that match neighbors [7, 8]. It would be considered atypical for a novel song variant to invade and replace the established regional variant. Yet some studies have reported song variants shifting rapidly over time within populations [9-11]. White-throated sparrows, Zonotrichia albicolis, for example, traditionally sing a whistled song terminating in a repeated triplet of notes [12], which was the ubiquitous variant in surveys across Canada in the 1960s [13]. However, doublet-ending songs emerged and replaced triplet-ending songs west of the Rocky Mountains sometime between 1960 and 2000 [11] and appeared just east of the Rockies in the 2000s [14]. From recordings collected over two decades across North America, we show that doublet-ending song has now spread at a continental scale. Using geolocator tracking, we confirm that birds from western Canada, where doublet-ending songs originated, overwinter with birds from central Canada, where the song initially spread. This suggests a potential mechanism for spread through song tutoring on wintering grounds. Where the new song variant has spread, it rose from a rare variant to the sole, regional song type, as predicted by the indirect biased transmission hypothesis [10]. VIDEO ABSTRACT.

Concussion Education in Children and Youth: A Scoping Review.

INTRODUCTION: Sports-related concussions in children and youth are a significant health concern. There is increasing literature pertaining to levels of knowledge about concussion and the effects of educational interventions, but the literature has not yet been synthesized for the subpopulation of children and youth. Therefore, the purpose of this review was to identify and summarize the current state of the literature on concussion knowledge, and the effect of concussion education on the knowledge, attitudes, and behaviors of children and youth who engage in sports. METHODS: A scoping review was conducted, guided by Joanna Briggs Institute methodology. Two databases, MEDLINE and CINAHL (Cumulative Index to Nursing and Allied Health Literature), and reference lists were searched to identify relevant studies that focused on children and youth less than 19 years of age who engage in sports. We also searched Google Scholar for gray literature. RESULTS: Of the 21 articles that met inclusion criteria, 15 focused on levels of concussion knowledge, and 6 examined the effects of educational interventions. Children and youths' level of knowledge and exposure to prior concussion education varied, although more of the studies found a lack of concussion knowledge. Educational interventions of various types have been associated with short-term increases in knowledge and intention to report, but few of the studies found sustained effects. CONCLUSIONS: Findings highlight the need for improved concussion education for children and youth engaged in sports. Findings also indicate a need for further research using more rigorous methods, and studies that examine subgroup differences in knowledge and factors that may moderate the effects of educational interventions.

The VAMPIRE challenge: A multi-institutional validation study of CT ventilation imaging.

PURPOSE: CT ventilation imaging (CTVI) is being used to achieve functional avoidance lung cancer radiation therapy in three clinical trials (NCT02528942, NCT02308709, NCT02843568). To address the need for common CTVI validation tools, we have built the Ventilation And Medical Pulmonary Image Registration Evaluation (VAMPIRE) Dataset, and present the results of the first VAMPIRE Challenge to compare relative ventilation distributions between different CTVI algorithms and other established ventilation imaging modalities. METHODS: The VAMPIRE Dataset includes 50 pairs of 4DCT scans and corresponding clinical or experimental ventilation scans, referred to as reference ventilation images (RefVIs). The dataset includes 25 humans imaged with Galligas 4DPET/CT, 21 humans imaged with DTPA-SPECT, and 4 sheep imaged with Xenon-CT. For the VAMPIRE Challenge, 16 subjects were allocated to a training group (with RefVI provided) and 34 subjects were allocated to a validation group (with RefVI blinded). Seven research groups downloaded the Challenge dataset and uploaded CTVIs based on deformable image registration (DIR) between the 4DCT inhale/exhale phases. Participants used DIR methods broadly classified into B-splines, Free-form, Diffeomorphisms, or Biomechanical modeling, with CT ventilation metrics based on the DIR evaluation of volume change, Hounsfield Unit change, or various hybrid approaches. All CTVIs were evaluated against the corresponding RefVI using the voxel-wise Spearman coefficient rS , and Dice similarity coefficients evaluated for low function lung ( DSClow ) and high function lung ( DSChigh ). RESULTS: A total of 37 unique combinations of DIR method and CT ventilation metric were either submitted by participants directly or derived from participant-submitted DIR motion fields using the in-house software, VESPIR. The rS and DSC results reveal a high degree of inter-algorithm and intersubject variability among the validation subjects, with algorithm rankings changing by up to ten positions depending on the choice of evaluation metric. The algorithm with the highest overall cross-modality correlations used a biomechanical model-based DIR with a hybrid ventilation metric, achieving a median (range) of 0.49 (0.27-0.73) for rS , 0.52 (0.36-0.67) for DSClow , and 0.45 (0.28-0.62) for DSChigh . All other algorithms exhibited at least one negative rS value, and/or one DSC value less than 0.5. CONCLUSIONS: The VAMPIRE Challenge results demonstrate that the cross-modality correlation between CTVIs and the RefVIs varies not only with the choice of CTVI algorithm but also with the choice of RefVI modality, imaging subject, and the evaluation metric used to compare relative ventilation distributions. This variability may arise from the fact that each of the different CTVI algorithms and RefVI modalities provides a distinct physiologic measurement. Ultimately this variability, coupled with the lack of a "gold standard," highlights the ongoing importance of further validation studies before CTVI can be widely translated from academic centers to the clinic. It is hoped that the information gleaned from the VAMPIRE Challenge can help inform future validation efforts.

A multi-centre randomised trial to compare the effectiveness of geriatrician-led admission avoidance hospital at home versus inpatient admission.

BACKGROUND: There is concern that existing models of acute hospital care will become unworkable as the health service admits an increasing number of frail older people with complex health needs, and that there is inadequate evidence to guide the planning of acute hospital level services. We aim to evaluate whether geriatrician-led admission avoidance to hospital at home is an effective alternative to hospital admission. METHODS/DESIGN: We are conducting a multi-site randomised open trial of geriatrician-led admission avoidance hospital at home, compared with admission to hospital. We are recruiting older people with markers of frailty or prior dependence who have been referred to admission avoidance hospital at home for an acute medical event. This includes patients presenting with delirium, functional decline, dependence, falls, immobility or a background of dementia presenting with physical disease. Participants are randomised using a computerised random number generator to geriatrician-led admission avoidance hospital at home or a control group of inpatient admission in a 2:1 ratio in favour of the intervention. The primary endpoint 'living at home' (the inverse of death or living in a residential care setting) is measured at 6 months follow-up, and we also collect data on this outcome at 12 months. Secondary outcomes include the incidence of delirium, mortality, new long-term residential care, cognitive impairment, activities of daily living, quality of life and quality-adjusted survival, length of stay, readmission or transfer to hospital. We will conduct a parallel economic evaluation, and a process evaluation that includes an interview study to explore the experiences of patients and carers. DISCUSSION: Health systems around the world are examining how to provide acute hospital-level care to older adults in greater numbers with a fixed or shrinking hospital resource. This trial is the first large multi-site randomised trial of geriatrician-led admission avoidance hospital at home, and will provide evidence on alternative models of healthcare for older people who require hospital admission. TRIAL REGISTRATION: ISRCTN60477865 : Registered on 10 March 2014. Trial Sponsor: University of Oxford. Version 3.1, 14/06/2016.

Insights from the RCPE UK Consensus Conference on approaching the comprehensive management of atrial fibrillation.

This article provides some insights from the Royal College of Physicians of Edinburgh UK Consensus Conference on approaching the comprehensive management of atrial fibrillation. The four key questions addressed by the conference were: how can we best detect atrial fibrillation (AF)? Should the treatment of AF be targeted towards control of rhythm, rate or both? What is the most effective and safest delivery of thromboprophylaxis in AF? And what are the differences between physician and patient expectations with regard to the management of AF? The key recommendations from the consensus conference were that detection of AF must be improved; a national screening programme should be introduced; uptake of oral anticoagulants must be increased and methods of engaging patients in their AF management should be improved; aspirin should not be used for stroke prevention in AF; and in relation to rate and rhythm control for AF, relief of symptoms should be the goal of treatment. The Consensus Statement and its background papers are recommended reading for the development of local guidelines for management, and for the management of individual patients.

Fabrication of a biodegradable calcium polyphosphate/polyvinyl-urethane carbonate composite for high load bearing osteosynthesis applications.

The formation of biodegradable implants for use in osteosynthesis has been a major goal of biomaterials research for the past 2-3 decades. Self-reinforced polylactide systems represent the most significant success of this research to date, however, with elastic constants up to 12-15 GPa at best, they fail to provide the initial stiffness required of devices for stabilizing fractures of major load-bearing bones. Our research has investigated the use of calcium polyphosphate (CPP), an inorganic polymer in combination with polyvinyl-urethane carbonate (PVUC) organic polymers for such applications. Initial studies indicated that composite samples formed as interpenetrating phase composites (IPC) exhibited suitable as-made strength and stiffness, however, they displayed a rapid loss of properties when exposed to in vitro aging. An investigation to determine the mechanism of this accelerated in vitro degradation for the IPCs as well as to identify possible design changes to overcome this drawback was undertaken using a model IPC system. It was found that strong interfacial strength and minimal swelling of the PVUC are very important for obtaining and maintaining appropriate mechanical properties in vitro.

Comprehensive geriatric assessment and home-based rehabilitation for elderly people with a history of recurrent non-elective hospital admissions.

OBJECTIVE: To determine whether a co-ordinated programme of geriatric assessment and multidisciplinary home-based rehabilitation reduces disability and prevents non-elective hospital readmission in high-risk elderly patients. DESIGN: Nested case-control study comparing usual post-discharge care versus usual care plus a comprehensive geriatric assessment and home-based rehabilitation service, comprising nursing, occupational therapy and physiotherapy with geriatric medical review. Patients were >or=65 years with >or=2 non-elective hospital admissions within the previous 12 months. Disability was assessed using the 100-point Barthel index and Nottingham extended activities of daily living (EADL) score. Non-elective hospital admissions were recorded over 1-year follow-up. RESULTS: We studied 84 patients; 56 receiving the new service were matched to 28 controls. Intervention subjects received a median of 19 h [interquartile range (IQR) (7,35)] rehabilitation over 19 [IQR (6,42)] domiciliary visits. At 3 months, there was improvement in median Barthel and Nottingham EADL scores in the intervention group of 3 and 2 points, respectively, compared with reductions in controls of 3 and 6 points (both P<0.001, changes in intervention group versus controls); similar differences persisted in survivors at 12 months. There was a non-significant trend for reduction in the proportion of patients with further non-elective hospital admission in the intervention group (36/56, 64%) compared with controls (21/28, 75%; OR 0.70, 95% CI 0.34, 1.46). CONCLUSIONS: A co-ordinated programme of geriatric assessment and multidisciplinary home-based rehabilitation reduced disability in elderly patients at high risk for non-elective hospital admission. Further research is required to determine whether this approach can reduce the need for hospital admission.