Sleep Dysfunction in Adolescents With Prolonged Postconcussion Symptoms: A Reciprocal Coupling of Traumatic Brain Injury and Sleep-Related Problems.

CLINICAL SCENARIO: Concussions are often neglected injuries that affect children and adolescents. Two physiological responses to a concussion are an ionic flux and an increased indiscriminate release of glutamate, which leads to an increase of intracellular calcium and extracellular potassium. This can ultimately result in sleep dysfunction, which often occurs after concussion and has long been thought of as simply another concussion symptom. FOCUSED CLINICAL QUESTION: Does the likelihood of prolonged postconcussion symptoms increase with reported sleep-related problems (SRPs) in young athletes (8-18 y) compared to concussed young athletes without SRPs and healthy controls? SUMMARY OF KEY FINDINGS: Four cohort studies with level 2/3 evidence measured subjective and objective sleep dysregulations in concussed and healthy populations. Overall, there was a difference in subjective SRPs between concussed and healthy patients. This correlated with other studies where worse sleep scores during the acute phase of concussion and increased SRPs led to worse ImPACT scores in patients 3 to 12 months postconcussion and longer overall recovery. Objective sleep dysfunction measures were significantly worse in concussed patients than in healthy controls, but no significant difference existed in melatonin measures. CLINICAL BOTTOM LINE: There is strong evidence that sleep dysfunction is both a symptom of concussion as well as a causal factor of prolonged postconcussion symptoms. These studies show that sleep dysregulation is not always evident in objective measurements, leading to the strong possibility of a functional dysregulation of the sleep-wake cycle that is evident solely from subjective reports. STRENGTH OF RECOMMENDATION: While there are strong cohort studies researching the role of sleep in those with postconcussion symptoms, the nature of sleep studies prevents the production of strong, high-level evidence studies such as randomized control trials. Thus, there is level B evidence that the likelihood of prolonged postconcussion symptoms is increased by a higher amount of SRPs.

Screening for diabetic kidney disease in primary care for the underinsured: A quality improvement initiative.

PURPOSE: Screening rates for DKD in primary care are low, even though diabetes accounts for 44% of all new kidney disease cases. The purpose of this project was to determine if a primary care team for the underinsured improved screening and diagnosis of diabetic kidney disease (DKD) after initiating a quality improvement (QI) process. METHODS: A chart audit with feedback, provider education of clinical practice guidelines, and strategies from TeamSTEPPS™ were implemented with the inter-professional primary care team. RESULTS: Pre/post-intervention chart audit analysis showed the frequency of ordering microalbumin increased from 50.3% (n=148) to 75% (n=148), and diagnosing DKD rose from 3.3% (n=10) to 10.7% (n=21) over three months (P=.000). CONCLUSION: Implementing a QI process in underinsured primary care centers improved the compliance of proper screening and diagnosing DKD AND introduced inter-professional practice competencies and teamwork strategies not previously recognized at the centers.