Brain drain in pediatric anesthesiology: The geographic and demographic distribution of national origin among pediatric anesthesiologists in the United States.

BACKGROUND: American pediatric anesthesiologists have a long history of international volunteerism. However, the US healthcare system also benefits from the contributions of a large number of physicians who come from other nations to work within its borders. Despite this fact, little is known about the contribution of international medical graduates (IMG) to the pediatric anesthesiology subspecialty. AIMS: To characterize the contribution of IMG to the field of pediatric anesthesiology in the United States, and to elucidate the geographic and demographic distribution of their national origins so as to understand the movement of skilled personnel between countries. METHODS: Online physician directories of American children's hospitals were searched, and anesthesiologists were recorded for their national origin of medical education. International graduates were reported as a percentage of the pediatric anesthesiology workforce. Those attending medical colleges catering to American students ("offshore" medical schools) were analyzed separately from other IMGs. The cohort of non-offshore IMGs were analyzed for national and continental origins, and by national level of economic development. RESULTS: Of 1979 anesthesiologists analyzed, 397 attended medical school outside the United States, with 58 being from offshore schools. The remaining 338 represented 17.1% of the total pediatric anesthesiology workforce. They came from 58 countries on six continents. Of those, 65.1% attended medical school in low- and middle-income countries. CONCLUSIONS: International medical graduates, disproportionately from low- and middle-income countries, compose a large proportion of the US Pediatric Anesthesiology workforce. While these clinicians play a vital role in providing care for American children, the potential impacts of skilled physician loss on their nations of origin must also be considered.

Substance use patterns, quantities, and associated risk factors in women with polysubstance misuse.

Polysubstance use (PSU), the use of two or more substances proximally, is highly prevalent and has amplified the risk for morbidity and mortality. However, PSU patterns and associated risk factors are not well characterized. This may be especially relevant to women who are known to be vulnerable to stress/trauma, craving, pain, and anxious and depressive symptoms as associated risk factors for PSU. A cross-sectional observational study was conducted to characterize substance use patterns in women who regularly used cocaine, opioids, marijuana, alcohol, benzodiazepines and/or nicotine and were being assessed for a placebo-controlled study of guanfacine treatment (n = 94; ages 19-65). Data on stress/traumatic life events, drug cravings for each substance, pain ratings, and anxiety and depressive symptoms were also obtained using standardized well-validated surveys. High use per day of two or more drugs was observed (72.7% ± 33.3%) and opioid amounts were high relative to other drug amounts (p's < 0.001). Notably, higher stress/trauma events and higher cravings are each associated with cumulative PSU days, amounts and probability of an individual PSU day (p's < 0.02). This remained when PSU versus single substance use was compared. Pain, anxiety and depressive symptoms were not associated with PSU metrics. These findings characterize specific patterns of PSU in women and show that average drug craving and stress/trauma events are associated with PSU. Interventions that focus on stress/trauma and craving management could be of benefit in reducing PSU risk in women.

A Descriptive, Retrospective Analysis of COVID-19 Passive Antibody Therapy and Its Effects on Morbidity and Mortality in Patients Receiving B-Cell-Depleting Therapies.

Patients receiving B-cell-depleting therapies (BCDT) are at an increased risk for severe COVID-19. Passive antibody therapy (PAT), including COVID-19 convalescent plasma (CCP) and monoclonal antibodies (mAb), may be an effective treatment in this population. Real-world data on PAT effectiveness are limited. To evaluate response to PAT measured through 90-day all-cause morbidity and mortality, we performed a retrospective review of patients who contracted COVID-19 within a year from the last BCDT. From 64 included patients, the majority were Caucasians (95%), female (56%), vaccinated (67%), treated outpatients (64%), with multiple comorbidities. Examined BCDT were rituximab (55%), obinutuzumab (33%), ocrelizumab (11%) and ofatumumab (1%), used for underlying hematological malignancy (HEM) (40%), multiple sclerosis (34%), and rheumatoid arthritis (16%). Of seven deceased patients, three died from COVID-19. All three were elderly males with multiple comorbidities, treated inpatient for severe COVID-19. Four of 41 patients treated as outpatients were hospitalized for non-COVID-19-related reasons. All deceased and hospitalized patients had an underlying HEM. All but one were on rituximab. PAT may be an effective treatment for patients receiving BCDT, especially if given early for non-severe disease. Patients with underlying HEM may be at increased risk for severe disease compared with others receiving the same BCDT.

Interferon ɛ restricts Zika virus infection in the female reproductive tract.

Interferon ɛ (IFNɛ) is a unique type I IFN that has been implicated in host defense against sexually transmitted infections. Zika virus (ZIKV), an emerging pathogen, can infect the female reproductive tract (FRT) and cause devastating diseases, particularly in pregnant women. How IFNɛ contributes to protection against ZIKV infection in vivo is unknown. In this study, we show that IFNɛ plays a critical role in host protection against vaginal ZIKV infection in mice. We found that IFNɛ was expressed not only by epithelial cells in the FRT but also by immune and stromal cells at baseline or after exposure to viruses or specific Toll-like receptor (TLR) agonists. IFNɛ-deficient mice exhibited abnormalities in the epithelial border and underlying tissue in the cervicovaginal tract, and these defects were associated with increased susceptibility to vaginal but not subcutaneous ZIKV infection. IFNɛ deficiency resulted in an increase in magnitude, duration, and depth of ZIKV infection in the FRT. Critically, intravaginal administration of recombinant IFNɛ protected Ifnɛ-/- mice and highly susceptible Ifnar1-/- mice against vaginal ZIKV infection, indicating that IFNɛ was sufficient to provide protection even in the absence of signals from other type I IFNs and in an IFNAR1-independent manner. Our findings reveal a potentially critical role for IFNɛ in mediating protection against the transmission of ZIKV in the context of sexual contact.

Interferon ε restricts Zika virus infection in the female reproductive tract.

Interferon ε (IFNε) is a unique type I IFN that has been implicated in host defense against sexually transmitted infections (STIs). Zika virus (ZIKV), an emerging pathogen, can infect the female reproductive tract (FRT) and cause devastating diseases, particularly in pregnant women. How IFNε contributes to protection against ZIKV infection in vivo is unknown. Here, we show that IFNε plays a critical role in host protection against vaginal ZIKV infection in mice. We found that IFNε was expressed not only by epithelial cells in the FRT, but also by certain immune and other cells at baseline or after exposure to viruses or specific TLR agonists. IFNε-deficient mice exhibited abnormalities in the epithelial border and underlying tissue in the cervicovaginal tract, and these defects were associated with increased susceptibility to vaginal, but not subcutaneous ZIKV infection. IFNε-deficiency resulted in an increase in magnitude, duration, and depth of ZIKV infection in the FRT. Critically, intravaginal administration of recombinant IFNε protected Ifnε-/- mice and highly susceptible Ifnar1-/- mice against vaginal ZIKV infection, indicating that IFNε was sufficient to provide protection even in the absence of signals from other type I IFNs and in an IFNAR1-independent manner. Our findings reveal a potentially critical role for IFNε in mediating protection against transmission of ZIKV in the context of sexual contact.

Pregnenolone effects on provoked alcohol craving, anxiety, HPA axis, and autonomic arousal in individuals with alcohol use disorder.

RATIONALE: Chronic alcohol intake down-regulates GABAergic transmission and reduces levels of neuroactive steroids. These changes are associated with greater stress dysregulation and high alcohol craving which in turn increases relapse risk. OBJECTIVES: This study tested whether potentiation of the neurosteroid system with pregnenolone (PREG), a precursor to neuroactive steroids and known to increase GABAergic transmission, will normalize chronic alcohol-related stress adaptations in the hypothalamic-pituitary-adrenal (HPA) axis and autonomic responses and reduce alcohol craving to significantly impact relapse risk. METHODS: Forty-three treatment-seeking individuals with alcohol use disorder (AUD) were randomized to placebo (PBO) or supraphysiologic pregnenolone doses of 300 mg or 500 mg treatment using a parallel-between subject design as part of a larger 8-week pilot clinical trial. In week 2, they participated in a 3-day laboratory experiment where on each day they self-administered the assigned study drug in the laboratory and were then exposed to 5-min personalized guided imagery provocation of stress, alcohol, or neutral/relaxing cues, one condition per day on separate days, in a random, counterbalanced order. Repeated assessments of alcohol craving, anxiety, HPA axis, heart rate (HR), systolic (SBP), and diastolic blood pressure (DBP) and serum pregnenolone levels were made on each day. RESULTS: Pregnenolone levels were significantly increased in the PREG groups versus PBO. PREG treatment decreased stress- and alcohol cue- induced craving and dose-specifically reduced stress-induced anxiety in the 300 mg/day group. Both PREG doses compared to PBO also normalized CORT/ACTH and increased stress-induced HR, stress- and cue-induced SBP, and in the 300 mg PREG group cue-induced DBP responses relative to neutral condition. CONCLUSIONS: Findings indicate that pregnenolone decreases stress- and alcohol cue-provoked craving and normalizes HPA axis and autonomic arousal in individuals with AUD, thereby supporting the need for further assessment of pregnenolone in the treatment of AUD.

Powered Knee and Ankle Prosthesis Control for Adaptive Ambulation at Variable Speeds, Inclines, and Uneven Terrains.

Ambulation in everyday life requires walking at variable speeds, variable inclines, and variable terrains. Powered prostheses aim to provide this adaptability through control of the actuated joints. Some powered prosthesis controllers can adapt to discrete changes in speed and incline but require manual tuning to determine the control parameters, leading to poor clinical viability. Other data-driven controllers can continuously adapt to changes in speed and incline but do so by imposing the same non-amputee gait patterns for all amputee subjects, which does not consider subjective preferences and differing clinical needs of users. Here, we present a controller for powered knee and ankle prostheses that can continuously adapt to different walking speeds, inclines, and uneven terrains without enforcing a specific prosthesis position, impedance, or torque. A virtual biarticular muscle connection determines the knee flexion torque, which changes with both speed and slope. Adaptation to inclines and uneven terrains is based solely on the global shank orientation. Continuously variable damping allows for speed adaptation. Minimum-jerk programming defines the prosthesis swing trajectory at variable cadences. Experiments with one individual with an above-knee amputation suggest that the proposed controller can effectively adapt to different walking speeds, inclines, and rough terrains.

A Unified Controller for Natural Ambulation on Stairs and Level Ground with a Powered Robotic Knee Prosthesis.

Powered lower-limb prostheses have the potential to improve amputee mobility by closely imitating the biomechanical function of the missing biological leg. To accomplish this goal, powered prostheses need controllers that can seamlessly adapt to the ambulation activity intended by the user. Most powered prosthesis control architectures address this issue by switching between specific controllers for each activity. This approach requires online classification of the intended ambulation activity. Unfortunately, any misclassification can cause the prosthesis to perform a different movement than the user expects, increasing the likelihood of falls and injuries. Therefore, classification approaches require near-perfect accuracy to be used safely in real life. In this paper, we propose a unified controller for powered knee prostheses which allows for walking, stair ascent, and stair descent without the need for explicit activity classification. Experiments with one individual with an above-knee amputation show that the proposed controller enables seamless transitions between activities. Moreover, transition between activities is possible while leading with either the sound-side or the prosthesis. A controller with these characteristics has the potential to improve amputee mobility.

Volitional EMG Control Enables Stair Climbing with a Robotic Powered Knee Prosthesis.

Existing controllers for robotic powered prostheses regulate the prosthesis speed, timing, and energy generation using predefined position or torque trajectories. This approach enables climbing stairs step-over-step. However, it does not provide amputees with direct volitional control of the robotic prosthesis, a functionality necessary to restore full mobility to the user. Here we show that proportional electromyographic (EMG) control of the prosthesis knee torque enables volitional control of a powered knee prosthesis during stair climbing. The proposed EMG controller continuously regulates knee torque based on activation of the residual hamstrings, measured using a single EMG electrode located within the socket. The EMG signal is mapped to a desired knee flexion/extension torque based on the prosthesis knee position, the residual limb position, and the interaction with the ground. As a result, the proposed EMG controller enabled an above-knee amputee to climb stairs at different speeds, while carrying additional loads, and even backwards. By enabling direct, volitional control of powered robotic knee prostheses, the proposed EMG controller has the potential to improve amputee mobility in the real world.

Acute Postoperative Seizures and Engel Class Outcome at 1 Year Postselective Laser Amygdalohippocampal Ablation for Mesial Temporal Lobe Epilepsy.

BACKGROUND: MRI-guided laser interstitial thermal therapy (MRgLITT) for mesial temporal lobe epilepsy is a safe, minimally invasive alternative to traditional surgical approaches. Prognostic factors associated with efficacy are debated; preoperative epilepsy duration and semiology seem to be important variables. OBJECTIVE: To determine whether acute postoperative seizure (APOS) after MRgLITT for mesial temporal lobe epilepsy is associated with seizure freedom/Engel class outcome at 1 year. METHODS: A single-institution retrospective study including adults undergoing first time MRgLITT for mesial temporal lobe epilepsy (2010-2019) with ≥1-year follow-up. Preoperative data included sex, epilepsy duration, number of antiepileptics attempted, weekly seizure frequency, seizure semiology, and radiographically verified anatomic lesion at seizure focus. Postoperative data included clinical detection of APOS within 7 days postoperatively, and immediate amygdala, hippocampal, entorhinal, and parahippocampal residual volumes determined using quantitative imaging postprocessing. Primary outcome was seizure freedom/Engel classification 1 year postoperatively. RESULTS: Of 116 patients, 53% (n = 61) were female, with an average epilepsy duration of 21 (±14) years, average 6 failed antiepileptics (±3), and weekly seizure frequency of 5. APOS was associated with worse Engel class ( P = .010), conferring 6.3 times greater odds of having no improvement vs achieving seizure freedom at 1 year. Residual amygdala, hippocampal, entorhinal, and parahippocampal volumes were not statistically significant prognostic factors. CONCLUSION: APOS was associated with a lower chance of seizure freedom at 1 year post-MRgLITT for mesial temporal lobe epilepsy. Amygdala, hippocampal, entorhinal, and parahippocampal residual volumes after ablation were not significant prognostic factors.

Distinct features of brain perivascular fibroblasts and mural cells revealed by in vivo two-photon imaging.

Perivascular fibroblasts (PVFs) are recognized for their pro-fibrotic role in many central nervous system disorders. Like mural cells, PVFs surround blood vessels and express Pdgfrß. However, these shared attributes hinder the ability to distinguish PVFs from mural cells. We used in vivo two-photon imaging and transgenic mice with PVF-targeting promoters (Col1a1 or Col1a2) to compare the structure and distribution of PVFs and mural cells in cerebral cortex of healthy, adult mice. We show that PVFs localize to all cortical penetrating arterioles and their offshoots (arteriole-capillary transition zone), as well as the main trunk of only larger ascending venules. However, the capillary zone is devoid of PVF coverage. PVFs display short-range mobility along the vessel wall and exhibit distinct structural features (flattened somata and thin ruffled processes) not seen with smooth muscle cells or pericytes. These findings clarify that PVFs and mural cells are distinct cell types coexisting in a similar perivascular niche.

Development of rearing methodology for the invasive Spotted Lanternfly, Lycorma delicatula (Hemiptera: Fulgoridae).

Lycorma delicatula, White (Hemiptera: Fulgoridae), spotted lanternfly, is a univoltine, phloem-feeding, polyphagous and invasive insect in the USA. Although a primary host for this species is Ailanthus altissima, tree of heaven, L. delicatula also feeds on a wide range of hosts important to the USA including cultivated grapevines. Due to the need for classical or augmentative biological control programs to reduce impacts of L. delicatula across invaded areas, we developed a laboratory-based rearing protocol for this invasive species. Here, we evaluated the use of A. altissima apical meristems, epicormic shoots, and fresh foliage cut from A. altissima as a food source for rearing newly hatched L. delicatula. On these sources of plant material <20% of L. delicatula developed into adults and no oviposition occurred. However, when young, potted A. altissima trees were used as a food source, >50% of L. delicatula nymphs developed to the adult stage under natural daylengths and temperatures ranging from 20-25°C. The addition of wild grapevine, Vitis riparia, did not increase survivorship or reduce development time. To elicit mating and oviposition, adults were provided with A. altissima logs as an oviposition substrate and maintained under shortened daylengths and reduced nighttime temperatures (12L:12D and 24°C:13°C). This resulted in 2.12 egg masses deposited per female, which was 4× more than when adults were maintained in standard rearing conditions (16L:8D and 25°C). Based on these experiments, we present a protocol for reliably rearing L. delicatula under laboratory and/or greenhouse conditions.

The Rare Occurrence of Reoperation After Cervical Laminoplasty: A 14-Year Retrospective Review of Reoperative Rates at a Single Institution.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To determine the rate of recurrent or adjacent-level stenosis requiring reoperation after single-door cervical laminoplasty for spondylotic myelopathy at our institution. SUMMARY OF BACKGROUND DATA: Adjacent-level stenosis requiring reoperation is a commonly evaluated condition for anterior or posterior arthrodesis, however, there are few studies that evaluate adjacent-level stenosis in the case of cervical laminoplasty. METHODS: Retrospective review of adults undergoing cervical laminoplasty for spondylotic myelopathy between January 2005 and May 2018 at our institution. Demographics, symptom duration, stenotic levels, preoperative and postoperative Medical Research Council motor, American Spinal Injury Association, modified Japanese Orthopaedic Association scores, and Nurick grade were obtained. Postoperative data included presence of C5 palsy, infection rate, alleviation or persistence of symptoms, and rate of recurrent or adjacent-level stenosis. RESULTS: A total of 102 patients underwent cervical laminoplasty; mean age was 56.7 years (±12.96). Most were men (n=76, 74.5%), with myelopathy (n=64, 63.4%), C4 (n=94, 93.1%), and C5 (n=92, 91.1%) cervical stenosis; mean symptom duration was 55 days (7 d to 2.8 y). Average follow-up was 6.4 months (±3.4). After surgery, there was statistically significant improvement in Nurick grade (3.1±2.2 vs. 2.7±2.4, P=0.002) and modified Japanese Orthopaedic Association score (11.4±3.7 vs. 13.9±3.6, P<0.001); American Spinal Injury Association scores also improved (P<0.001). Rate of postoperative C5 palsy was 7.8% (n=8); postoperative infection rate was 1.96% (n=2). Reoperation rate was 4.9% (n=5); reoperation for recurrent or adjacent-level stenosis was 1.96% (n=2). CONCLUSIONS: Recurrent or adjacent-level stenosis requiring reoperation after cervical laminoplasty is rare. Longitudinal studies are needed to verify correlation between motion preservation and incidence of adjacent or recurrent stenosis. LEVEL OF EVIDENCE: Level III-treatment benefits: nonrandomized controlled cohort/follow-up study.

Life History and Rearing of Anastatus orientalis (Hymenoptera: Eupelmidae), an Egg Parasitoid of the Spotted Lanternfly (Hemiptera: Fulgoridae).

To support efforts to manage and contain spotted lanternfly (SLF), Lycorma delicatula White (Hemiptera: Fulgoridae), research is being conducted to develop classical biological control methods. To date, two potential biocontrol agents from China have been identified: an egg parasitoid, Anastatus orientalis, and a nymphal parasitoid, Dryinus sinicus Olmi (Hymenoptera: Dryinidae). The research detailed here focuses on investigating the biology and rearing of A. orientalis to assess its potential efficacy in a biocontrol program and optimize its rearing. Female wasps lived significantly longer than male wasps (68 and 23 d, respectively) and females produced an average of 94 total progeny that successfully emerged as adults, with most progeny produced between weeks one and four of the females' lives. The sex ratio of the progeny, with no re-mating, was initially highly female-biased but became progressively more male-biased, likely due to sperm depletion. There was no evidence of additional mortality to SLF eggs from wasp host feeding, but the data were highly variable and the sample size was small. There was high parasitoid emergence when oviposition conditions mimicked mid-September Beijing temperature and photoperiod; however, there was little emergence under 25°C and long-day conditions because most progeny entered a diapause. Storage of parasitized eggs in 5°C chill lowered parasitoid emergence rates. Lastly, there was no evidence that storing field-collected SLF egg masses in 5°C for 10 mo prior to parasitization affected parasitism rates. These findings inform our rearing protocol for A. orientalis and facilitate our testing of this species as a potential biological control agent for SLF.

Stereotactic Brain Biopsy Hemorrhage Risk Factors and Implications for Postoperative Care at a Single Institution: An Argument For Postoperative Imaging.

OBJECTIVE: To determine preoperative factors contributing to postoperative hemorrhage after stereotactic brain biopsy (STB), clinical implications of postoperative hemorrhage, and the role of postoperative imaging in clinical management. METHODS: Retrospective review of STB (2005-2018) across 2 institutions including patients aged >18 years undergoing first STB. Patients with prior craniotomy, open biopsy, or prior STB were excluded. Preoperative variables included age, sex, neurosurgeon seniority, STB method. Postoperative variables included pathology, postoperative hemorrhage on computed tomography, immediate and 30-day postoperative seizure, infection, postoperative hospital stay duration, and 30-day return to operating room (OR). Analysis used the Fisher exact tests for categorical variables. RESULTS: Overall, 410 patients were included. Average age was 56.5 (±16.5) years; 60% (n = 248) were men. The majority of biopsies were performed by senior neurosurgeons (66%, n = 270); frontal lobe (42%, n = 182) and glioblastoma (45%, n = 186) were the most common location and pathology. Postoperative hemorrhage occurred in 28% (114) of patients with 20% <0.05 cm3 and 8% >0.05 cm3. Postoperative hemorrhage of any size was associated with increased rate of postoperative deficit within both 24 hours and 30 days, postoperative seizure, and length of hospital stay when controlling for pathology. Hemorrhages >0.05 cm3 had a 16% higher rate of return to the OR for evacuation, due to clinical deterioration as opposed to radiographic progression. CONCLUSIONS: Postbiopsy hemorrhage was associated with higher risk of immediate and delayed postoperative deficit and seizure. Postoperative computed tomography should be used to determine whether STB patients can be discharged same day or admitted for observation; clinical evaluation should determine return to OR for evacuation.

Building Resources in Caregivers: Feasibility of a Brief Writing Intervention to Increase Benefit Finding in Caregivers.

The Building Resources in Caregivers (BRiC) is a pilot feasibility trial that compared the effects of a 2-week benefit finding writing expressive intervention to a control intervention, who wrote about the weather. Caregivers completed primary (benefit finding) and secondary (quality of life, depression and anxiety) outcome measures at pre (t1), immediately post-test (t2) and 1 month later (t3). They also completed measures relating to trial feasibility, difficulty, and acceptance. Using complete case analysis only, analysis revealed no effect of the intervention for primary or secondary outcomes. Despite this, there were no differences between the intervention and control groups on key feasibility measures. Caregivers in the control condition were less likely to recommend this to other caregivers. Moreover, qualitative commentary provided by caregivers suggested that not everyone enjoyed the writing, some found it stressful, offering up some explanation for our findings. Our pilot trial suggests that any future benefit-finding writing intervention would require several procedure modifications including tailoring to a specific cohort of caregivers, in particular those who like writing, before it has some utility as a psychosocial intervention.

Psychosocial Interventions for Family Carers of People With Dementia: A Systematic Review and Meta-Analysis.

Objective:This study aimed to review and synthesize findings of the effectiveness of psychosocial interventions aimed at improving outcomes for family carers of people with dementia. Method: A systematic review and meta-analysis were conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We systematically searched the following databases: Cochrane, PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycInfo, Excerpta Medica Database (EMBASE), and Applied Social Sciences Index and Abstracts (ASSIA). RevMan 5 software was used to conduct meta-analysis and subgroup analysis using a random-effects model. Results: The search yielded 22 high-quality intervention articles that were suitable for further meta-analysis. Meta-analysis revealed that psychosocial interventions have a small to moderate significant effect on carer burden (standardized mean difference [SMD] = -0.34, confidence interval [CI] = [-0.59, -0.09]), depression (SMD = -0.36, CI = [-0.60, -0.13]), and general health (SMD = 0.34, CI = [0.18, 0.51]). Discussion: Psychosocial interventions had a positive impact on carer outcomes; however, these results should be interpreted with caution, given the significant level of heterogeneity in study designs. Future research could examine contextual and implementation mechanisms underlying psychosocial interventions to develop effective support systems for family carers of people with dementia.

Family Perspectives on Visiting the Pediatric Emergency Department for Migraine: A Qualitative Study.

OBJECTIVE: The aim of this study was to explore the perspectives of families regarding their expectations and experience of visiting the emergency department (ED) for migraine. METHODS: This was a qualitative study involving the families of 25 patients aged 10 to 18 years receiving ED care for acute migraine. Following their visit, independent semistructured telephone interviews were conducted with both the patient and parent or guardian. Questions were designed to explore factors pertaining to the family's perspective regarding their visit to the ED and expectations for the ED visit. RESULTS: Families reported a variety of reasons for visiting the ED. The majority of participants reported that they were worried about their headaches. Families more commonly had expectations for treatment than they did for investigations. As compared with patients, parents more commonly reported specific expectations for investigations and less commonly expressed concerns about intravenous treatments. Expectations for treatment efficacy varied: whereas some parents expected complete pain relief, for others, lesser degrees of relief were considered satisfactory. The experience of treatment efficacy was related to willingness to receive the same treatment again. CONCLUSIONS: Given that a high frequency of families endorsed that they were worried about the headache when presenting to the ED, clinicians should strive to make a diagnosis of migraine in the ED setting and to educate families about this diagnosis. Because of divergent parent and patient perspectives, health care providers should inquire about family expectations, especially in relation to expectations for investigations and concerns surrounding intravenous interventions, and ensure that both the patient's and parent's perspectives are considered when developing a management plan for pediatric migraine.