Groupings of Persons With Traumatic Brain Injury: A New Approach to Classifying Traumatic Brain Injury in the Post-Acute Period.

OBJECTIVE: To (1) identify groups of persons with traumatic brain injury (TBI) who differ on 12 dimensions of cognitive function: cognitive, emotional, and physical symptoms; personal strengths; physical functioning; environmental supports; and performance validity; and (2) describe patterns of differences among the groups on these dimensions and on participation outcome. SETTING: Three centers for rehabilitation of persons with TBI. PARTICIPANTS: A total of 504 persons with TBI living in the community who were an average (standard deviation) of 6.3 (6.8) years postinjury and who had capacity to give consent, could be interviewed and tested in English, and were able to participate in an assessment lasting up to 4 hours. DESIGN: Observational study of a convenience sample of persons with TBI. MAIN MEASURES: Selected scales from the Traumatic Brain Injury Quality of Life measures, Neurobehavioral Symptom Inventory, Economic Quality of Life Scale, Family Assessment Device General Functioning Scale, measures of cognitive function, Word Memory Test, and Participation Assessment with Recombined Tools-Objective (PART-O) scale. RESULTS: Cluster analysis identified 5 groups of persons with TBI who differed in clinically meaningful ways on the 12 dimension scores and the PART-O scale. CONCLUSION: Cluster groupings identified in this study could assist clinicians with case conceptualization and treatment planning.

Pediatric Endotracheal Tube Cuff Pressures During Aeromedical Transport.

OBJECTIVES: Cuffed endotracheal tubes (ETTs) are frequently used in children, allowing fewer air leaks and helping prevent ventilator-associated pneumonia. Tracheal mucosal perfusion is compromised at an ETT cuff pressure (ETTCP) of 30 cm H2O with blood flow completely absent above 50 cm H2O. Our objective was to compare multiple pediatric-sized ETTCPs at ground level and various altitudes during aeromedical transport. METHODS: Simulating the transport environment, 4 pediatric-sized mannequin heads were intubated with appropriately sized cuffed ETTs (3.0, 4.0, 5.0, 6.0) and transported by helicopter or nonpressurized fixed-wing aircraft 20 times each. The ETTCP was set to 10 cm H2O before transport, and the pressure was measured with a standard manometer at 1000-ft intervals until reaching peak altitude or CP greater than 60 cm H2O. Ground elevation ranged from 400-650 ft mean sea level (MSL) and peak altitude from 3500 to 5000 ft MSL. RESULTS: Increased altitude caused a significant increase in ETTCP of all ETT sizes (P < 0.001). However, there is no statistical difference in pressures between ETT sizes (P = 0.28). On average, ETTCP in 3.0, 4.0, and 6.0 ETTs surpassed 30 cm H2O at approximately 1500 ft MSL and 50 cm H2O at approximately 2800 ft MSL. In the 5.0 ETT, the CP reached 30 cm H2O at 2000 ft MSL and 50 cm H2O at 3700 ft MSL. CONCLUSIONS: The ETTCP in pediatric-sized ETTs regularly exceed recommended pressure limits at relatively low altitudes. There is no additional pressure increase related to ETT size. This has the potential to decrease mucosal blood flow, possibly increasing risk of subsequent tracheal stenosis, rupture, and other complications.

Key dimensions of impairment, self-report, and environmental supports in persons with traumatic brain injury.

PURPOSE/OBJECTIVES: To determine key dimensions relevant to recovery in the postacute period for persons with traumatic brain injury (TBI) and to determine the ability of scores on these dimensions to predict participation outcomes for persons with TBI. RESEARCH METHOD/DESIGN: This was a prospective cohort, observational study of 504 persons with medically documented TBI. Participants completed a comprehensive battery of measures including cognitive tests; questionnaires assessing self-report of physical, cognitive, and emotional symptoms and strengths; environmental supports; and a measure of participation outcome. RESULTS: Participants were a predominantly male, ethnically/racially diverse sample of persons with complicated mild, moderate, and severe TBI. Variable cluster analysis identified 12 key dimensions of cognitive function, neurobehavioral complaints, personal strengths, physical symptoms and function, environmental supports, and performance validity. In unadjusted analyses, all 12 dimensions were predictive of participation outcome. In multivariable regression analysis with adjustment of all predictors for all other predictors, dimensions measuring memory, independence and self-esteem, resilience, emotional distress, physical functioning, and economic and family support made unique contributions to predicting participation outcome. CONCLUSIONS/IMPLICATIONS: Findings add to our understanding of key aspects of functioning and self-perception for persons with TBI. Knowledge of the profile of an individual patient on these 12 dimensions may assist with development of a treatment approach for the person with TBI. (PsycINFO Database Record

Characteristics and surgical and clinical outcomes of severely obese children with obstructive sleep apnea.

STUDY OBJECTIVES: To describe characteristics and surgical and clinical outcomes of obese children with obstructive sleep apnea (OSA). METHODS: At our institution from 2000 to 2010, 143 obese children with an overnight polysomnography (OPSG) diagnosis of OSA, excluding children with comorbidities, were identified. Relationships between demographics, clinical findings, and the severity of OSA were assessed. Presurgery and postsurgery OPSG indices were compared. We defined cure as an apneahypopnea index (AHI) < 1.5/h on the postsurgery OPSG, and we compared the cure rates of different surgeries. RESULTS: A total of 143 children, median age 12.4 y (interquartile range [IQR] 9.6-14.9) and BMI z-scores 2.8 (IQR 2.6-2.9), were included. Seventy-eight (55%) (Median age 12 y [IQR 9-15]) underwent surgery: 1 had tonsillectomy; 1 tonsillectomy + uvulopharyngopalatoplasty (UPPP); 23 adenotonsillectomy (AT); 27 AT + UPPP; 11 adenoidectomy + UPPP; 8 UPPP; and 7 AT + turbinate trim ± tongue base suspension. Overall, surgery cured 19 children (26%), but AHI improved in the majority of children (p = 0.001). Similarly, the arousal index, PETCO2, and SpO2 nadir improved significantly (p < 0.002, p = 0.019, p < 0.001, respectively). AHI improved significantly in children with mild-to-moderate OSA in comparison to severe OSA (p < 0.001). Children with enlarged tonsils and no history of prior surgery benefitted more often from surgery (p < 0.004 and p = 0.002, respectively). AT was the only surgery reducing the AHI significantly (p = 0.008). Children did not lose weight despite intervention. Adherence with PAP was poor. CONCLUSIONS: Surgery improved OPSG indices in the majority of obese children with OSA.

White matter injury in newborns with congenital heart disease: a diffusion tensor imaging study.

BACKGROUND: Brain injury is observed on cranial magnetic resonance imaging preoperatively in up to 50% of newborns with congenital heart disease. Newer imaging techniques such as diffusion tensor imaging provide sensitive measures of the white matter integrity. The objective of this study was to evaluate the diffusion tensor imaging analysis technique of tract-based spatial statistics in newborns with congenital heart disease. METHODS: Term newborns with congenital heart disease who would require surgery at less than 1 month of age were prospectively enrolled (n = 19). Infants underwent preoperative and postoperative brain magnetic resonance imaging with diffusion tensor imaging. Tract-based spatial statistics, an objective whole-brain diffusion tensor imaging analysis technique, was used to determine differences in white matter fractional anisotropy between infant groups. Term control infants were also compared with congenital heart disease infants. Postmenstrual age was equivalent between congenital heart disease infant groups and between congenital heart disease and control infants. RESULTS: Ten infants had preoperative brain injury, either infarct or white matter injury, by conventional brain magnetic resonance imaging. The technique of tract-based spatial statistics showed significantly lower fractional anisotropy (P < 0.05, corrected) in multiple major white matter tracts in the infants with preoperative brain injury compared with infants without preoperative brain injury. Fractional anisotropy values increased in the white matter tracts from the preoperative to the postoperative brain magnetic resonance imaging correlating with brain maturation. Control infants had higher fractional anisotropy in multiple white matter tracts compared with infants with congenital heart disease. CONCLUSION: Tract-based spatial statistics is a valuable diffusion tensor imaging analysis technique that may have better sensitivity in detecting white matter injury compared with conventional brain magnetic resonance imaging in term newborns with congenital heart disease.

Relationship of preinjury depressive symptoms to outcomes 3 mos after complicated and uncomplicated mild traumatic brain injury.

OBJECTIVE: This study examines the effect of preinjury depressive symptoms on outcomes 3 mos after complicated and uncomplicated cases of mild traumatic brain injury. DESIGN: Preinjury depressive symptoms, experienced in the 30 days before injury, as measured by retrospective self-report, were assessed within the first 2 wks after injury. The outcome measures assessed at 3 mos after injury included affective/behavioral, cognitive, and physical problems and health-related quality-of-life. RESULTS: There were 177 patients who completed both the baseline and 3-mo follow-up interviews. The sample was categorized by severity of depressive symptoms in the month before injury as normal, mild, or moderate-severe. Compared with those reporting no preinjury depressive symptoms, persons reporting moderate-severe depressive symptoms had significantly worse outcomes on the Affective and Behavioral and the Cognitive subscales of the Head Injury-Family Interview Problem Checklist and on the 36-item Short-Form Health Survey Mental Component Summary score. The group reporting mild preinjury depressive symptoms scored worse on a measure of cognitive symptoms compared with those with no preinjury depressive symptoms. There was no interaction between preinjury depressive symptoms and severity of the mild traumatic brain injury (complicated or uncomplicated) for any of the outcomes. CONCLUSION: Moderate to severe depressive symptoms in the month before injury seems to be a possible risk factor for poor affective/behavioral, cognitive, and mental health-related quality-of-life outcomes at 3 mos after mild traumatic brain injury. Clinicians and researchers should consider the impact of preinjury depression on the recovery process to provide at-risk patients adequate treatment soon after injury.

Academic proficiency in children after early congenital heart disease surgery.

Children with early surgery for congenital heart disease (CHD) are known to have impaired neurodevelopment; their performance on school-age achievement tests and their need for special education remains largely unexplored. The study aimed to determine predictors of academic achievement at school age and placement in special education services among early CHD surgery survivors. Children with CHD surgery at <1 year of age from January 1, 1998 to December 31, 2003, at the Arkansas Children's Hospital were identified. Out-of-state births and infants with known genetic and/or neurologic conditions were excluded. Infants were matched to an Arkansas Department of Education database containing standardized assessments at early school age and special-education codes. Predictors for achieving proficiency in literacy and mathematics and the receipt of special education were determined. Two hundred fifty-six children who attended Arkansas public schools and who had surgery as infants were included; 77.7 % had either school-age achievement-test scores or special-education codes of mental retardation or multiple disabilities. Scores on achievement tests for these children were 7-13 % lower than those of Arkansas students (p < 0.01). They had an eightfold increase in receipt of special education due to multiple disabilities [odds ratio (OR) 10.66, 95 % confidence interval (CI) 4.23-22.35] or mental retardation (OR 4.96, 95 % CI 2.6-8.64). Surgery after the neonatal period was associated with decreased literacy proficiency, and cardiopulmonary bypass during the first surgery was associated with decreased mathematics proficiency. Children who had early CHD surgery were less proficient on standardized school assessments, and many received special education. This is concerning because achievement-test scores at school age are "real-world" predictors of long-term outcomes.

Multi-tiered analysis of brain injury in neonates with congenital heart disease.

Early brain injury occurs in newborns with congenital heart disease (CHD) placing them at risk for impaired neurodevelopmental outcomes. Predictors for preoperative brain injury have not been well described in CHD newborns. This study aimed to analyze, retrospectively, brain magnetic resonance imaging (MRI) in a heterogeneous group of newborns who had CHD surgery during the first month of life using a detailed qualitative CHD MRI Injury Score, quantitative imaging assessments (regional apparent diffusion coefficient [ADC] values and brain volumes), and clinical characteristics. Seventy-three newborns who had CHD surgery at 8 ± 5 (mean ± SD) days of life and preoperative brain MRI were included; 38 also had postoperative MRI. Thirty-four (34 of 73, 47 %) had at least one type of preoperative brain injury, and 28 of 38 (74 %) had postoperative brain injury. The 5-min APGAR score was negatively associated with preoperative injury, but there was no difference between CHD types. Infants with intraparenchymal hemorrhage, deep gray matter injury, and/or watershed infarcts had the highest CHD MRI Injury Scores. ADC values and brain volumes were not different in infants with different CHD types or in those with and without brain injury. In a mixed group of CHD newborns, brain injury was found preoperatively on MRI in almost 50 %, and there were no significant baseline characteristic differences to predict this early brain injury except 5-min APGAR score. We conclude that all infants, regardless of CHD type, who require early surgery should be evaluated with MRI because they are all at high risk for brain injury.

High-fidelity hybrid simulation of allergic emergencies demonstrates improved preparedness for office emergencies in pediatric allergy clinics.

BACKGROUND: Simulation models that used high-fidelity mannequins have shown promise in medical education, particularly for cases in which the event is uncommon. Allergy physicians encounter emergencies in their offices, and these can be the source of much trepidation. OBJECTIVE: To determine if case-based simulations with high-fidelity mannequins are effective in teaching and retention of emergency management team skills. METHODS: Allergy clinics were invited to Arkansas Children's Hospital Pediatric Understanding and Learning through Simulation Education center for a 1-day workshop to evaluate skills concerning the management of allergic emergencies. A Clinical Emergency Preparedness Team Performance Evaluation was developed to evaluate the competence of teams in several areas: leadership and/or role clarity, closed-loop communication, team support, situational awareness, and scenario-specific skills. Four cases, which focus on common allergic emergencies, were simulated by using high-fidelity mannequins and standardized patients. Teams were evaluated by multiple reviewers by using video recording and standardized scoring. Ten to 12 months after initial training, an unannounced in situ case was performed to determine retention of the skills training. RESULTS: Clinics showed significant improvements for role clarity, teamwork, situational awareness, and scenario-specific skills during the 1-day workshop (all P < .003). Follow-up in situ scenarios 10-12 months later demonstrated retention of skills training at both clinics (all P ≤ .004). CONCLUSION: Clinical Emergency Preparedness Team Performance Evaluation scores demonstrated improved team management skills with simulation training in office emergencies. Significant recall of team emergency management skills was demonstrated months after the initial training.

Effects of meals high in carbohydrate, protein, and fat on ghrelin and peptide YY secretion in prepubertal children.

CONTEXT: Ghrelin and peptide YY (PYY) are two hormones produced by the gastrointestinal tract that have effects on appetite. However, little is known about their secretion in response to meals high in individual macronutrients in prepubertal children. OBJECTIVE: We sought to understand how meals high in carbohydrate, protein, and fat affect serum concentrations of total ghrelin and total PYY, hypothesizing that these macronutrients would exert differential effects on their secretion. DESIGN AND SETTING: This was a cross-sectional study at one tertiary care center. SUBJECTS: Subjects were 7- to 11-yr-old healthy normal-weight (NW) and obese (OB) volunteers recruited from local advertisements. INTERVENTIONS: After an overnight fast, the subjects were given a breakfast high in carbohydrate, protein, or fat at 0800 h. Blood samples for total ghrelin and total PYY were taken at baseline, 30 min, and hourly from 0900 to 1200 h. MAIN OUTCOME MEASURE: We assessed postprandial ghrelin suppression and PYY elevation, as well as changes in reported hunger and satiety, after the three test meals. RESULTS: After the high-protein meal, ghrelin declined gradually in both groups over the study period without subsequent increase, whereas ghrelin suppressed more rapidly to a nadir at 60 min after the high-carbohydrate meal in both NW and OB children, followed by rebound in ghrelin levels. Similarly, after the high-protein meal, PYY concentrations increased steadily over the course of the morning in both groups without decline, whereas PYY levels peaked 30 min after the high-carbohydrate meal in both NW and OB subjects with significant decline thereafter. Ghrelin and PYY responses to the high-fat meal were somewhat intermediate between that observed with high carbohydrate and high protein. The OB children reported higher hunger and lower satiety after the high-carbohydrate meal compared to the NW subjects, whereas appetite ratings were similar between the groups after the high-protein and high-fat meals. Additionally, within the OB group, area under the curve (AUC) analysis revealed significantly greater PYY response, as well as lower AUC hunger and higher AUC satiety, to the high-protein meal than the high-carbohydrate and high-fat meals. CONCLUSIONS: The patterns of secretion of ghrelin and PYY in our study of prepubertal children suggest that they may play a role in the effectiveness of high-protein/low-carbohydrate diets in promoting weight loss.

Juvenile primary fibromyalgia syndrome in an inpatient adolescent psychiatric population.

UNLABELLED: The purpose of this study was to identify the clinical and demographic characteristics of adolescent females admitted to a psychiatric hospital who meet the criteria for Juvenile Primary Fibromyalgia Syndrome (JPFS). METHODS: Participants (n = 62) were adolescent females, ages 12 to 18 years who were admitted to an inpatient psychiatric unit. The participants completed four questionnaires: The Achenbach Youth Self-Report (YSR), the Children's Somatization Inventory (CSI), the Fibromyalgia Impact Questionnaire modified for children (FIQ-C) and the Pain Symptom Questionnaire (PSQ). Then participants were interviewed to assess the Yunus and Masi JPFS criteria. The interview included an examination of 21 (18 bilateral and 3 control) tender points. RESULTS: Of the 62 adolescent females enrolled, 52% (n = 32) met criteria for JPFS (i.e. JPFS cases). Both the FIQ and CSI scores were significantly elevated for JPFS cases as compared with non-cases (p = .0001 and p = .0012 respectively). Cases of JPFS also scored significantly higher on the anxiety, depression, and conduct disorder scales of the YSR. No between-group differences were found in reports of physical or sexual abuse. However, a consistently higher percentage of JPFS cases reported physical or sexual abuse as a child. CONCLUSIONS: Juvenile primary fibromyalgia is highly prevalent in an adolescent inpatient psychiatric unit. This possibility should be taken into consideration when chronic complaints of pain are expressed by patients in this setting, especially in those who have conduct-related issues. The connection between JPFS and abuse history requires further investigation.