Adaptation of infant mental health services to preterm infants and their families receiving neonatal intensive care unit services during the COVID-19 pandemic.

Multiple changes and stressors at the family, hospital, and societal levels have resulted from the COVID-19 pandemic that impact the early social environment of infants in Neonatal Intensive Care Unit (NICU) settings. This manuscript reviews these pandemic-related adversities, including hospital-wide visitor restrictions, mask requirements that interfere with caregiver facial expressions, parental anxiety about virus transmission, and reduced support services. We will further describe adaptations to mental health service delivery and approaches to care in the NICU to mitigate increased risk associated with pandemic-related adversities. Adaptations include integration of technology, staff education and support, and delivery of activity kits to encourage parent-infant bonding. Data was collected as part of routine program evaluation of infant mental health services from one 50-bed NICU setting and describes family concerns, barriers to visitation, and utilization of mental health services during the pandemic. Concerns related to COVID-19 rarely emerged as the primary presenting issue by the families referred for infant mental health services from April through December of 2020. However, a number of families indicated that infection concerns and visitation restrictions posed significant challenges to their parenting and/or coping. There were significant discrepancies noted between the visitation patterns of families with public and private insurance. Several adaptations were developed in response to the multiple challenges and threats to infant mental health present during the COVID-19 pandemic.

Múltiples factores de estrés a nivel de la familia, el hospital y la sociedad han resultado de la pandemia del COVID-19, los cuales han tenido un impacto en el temprano ambiente social de los infantes en el ambiente de la Unidad de Cuidados Intensivos Neonatales (NICU). Este artículo revisa estas situaciones adversas relacionadas con la pandemia, incluyendo las restricciones generales de visita al hospital, el requisito de llevar máscara que interfiere con las expresiones faciales de quien presta el cuidado, la ansiedad de los padres acerca de la transmisión del virus y los reducidos servicios de apoyo. Describimos además adaptaciones al ofrecimiento de servicios de salud mental en NICU para mitigar el aumento del riesgo asociado con las situaciones adversas relacionadas con la pandemia. Estas adaptaciones incluyen la integración de tecnología, la educación y el apoyo del personal, así como el ofrecimiento de material para actividades que promueven la unión afectiva entre progenitor e infante. Se recogió información como parte de la evaluación rutinaria del programa sobre los servicios sicosociales en el caso de una unidad NICU de 50 camas y se describen las preocupaciones de la familia, los obstáculos a la visita, así como la utilización de los servicios de salud mental infantil durante la pandemia. El COVID-19 raramente surgió como el principal asunto que enfrentaban las familias que fueron referidas para intervención de abril a diciembre de 2020. Sin embargo, algunas familias indicaron que las preocupaciones de adquirir una infección y las restricciones de visita presentaron retos significativos a la crianza y/o a la manera de arreglárselas. Se notaron discrepancias significativas entre los patrones de visita de familias con seguro público o con seguro privado. Como respuestas a estas amenazas a la salud mental infantil presentes durante la pandemia del COVID-19, se desarrollaron varias adaptaciones.

Des facteurs de stress multiples aux niveaux de la famille, de l'hôpital et de la société ont résulté de la pandémie du COVID-19 qui impacte l'environnement social précoce des nourrissons dans les Unités Néonatales de Soins Intensifs (UNSI). Cet article passe en revue ces adversités liées à la pandémie, y compris les restrictions pour les visiteurs dans les hôpitaux, les obligations de porter le masque qui interfèrent avec les expressions faciales de la personne prenant soin du bébé, l'anxiété parentale à propos de la transmission du virus et des services de soutien réduits. Nous décrivons des adaptations à la prestation de service de santé mentale dans l'UNSI afin de mitiger le risque accru associé aux adversités liées à la pandémie. Des adaptations ont inclus l'intégration de la technologie, la formation et le soutien aux employés, la livraison de kits d'activités afin d'encourager le lien parent-bébé. Des données ont été recueillies comme faisant partie de l'évaluation de routine de services psychosociaux dans le contexte d'une INSI de 50 lits et décrivent les inquiétudes familiales, les barrières aux visites, l'utilisation de services de santé mentale du nourrisson durant la pandémie. Le COVID-19 a rarement émergé comme étant le problème principal présenté par les familles ayant reçu une intervention d'avril à décembre 2020. Cependant certaines familles ont indiqué que les inquiétudes touchant à l'infection et les restrictions des visites ont posé des défis importants à leur parentage et/ou à leur adaptation. Des différences importantes ont été notées entre les patterns de visites des familles ayant une assurance publique et une assurance privée. Plusieurs adaptations ont été développées pour faire face aux dangers pour la santé mentale infantile présents durant la pandémie de COVID-19.

The Effect of the Affordable Care Act on Women's Postpartum Insurance and Depression in 5 States That Did Not Expand Medicaid, 2012-2015.

BACKGROUND: Before the Affordable Care Act (ACA), most women who gained pregnancy-related Medicaid were not eligible for Medicaid as parents postpartum. The ACA aimed to expand health insurance coverage, in part, by expanding Medicaid; introducing mandates; reforming regulations; and establishing exchanges with federal subsidies. Federal subsidies offer a means to coverage for individuals with income at 100%-400% of the federal poverty level who do not qualify for Medicaid. OBJECTIVE: The objective of this study was to identify the effects of the ACA's non-Medicaid provisions on women's postpartum insurance coverage and depressive symptoms in nonexpansion states with low parental Medicaid thresholds. PARTICIPANTS: Women with incomes at 100%-400% of the federal poverty level who had prenatal insurance and completed the Pregnancy Risk Assessment Monitoring System (2012-2015). SETTING: Five non-Medicaid expansion states with Medicaid parental eligibility thresholds below the federal poverty level. DESIGN: Interrupted time-series analyses were conducted to examine changes between pre-ACA (January 2012-November 2013) and post-ACA (December 2013-December 2015) trends for self-reported loss of postpartum insurance and symptoms of postpartum depression. RESULTS: The sample included 9,472 women. Results showed significant post-ACA improvements where the: (1) trend for loss of postpartum insurance reversed (change of -0.26 percentage points per month, P=0.047) and (2) level of postpartum depressive symptoms decreased (change of -3.5 percentage points, P=0.042). CONCLUSIONS: In these 5 states, the ACA's non-Medicaid provisions were associated with large increases in retention of postpartum insurance and reductions in postpartum depressive symptoms, although depressive symptoms findings are sensitive to model specification.

Telehealth adaptation of perinatal mental health mother-infant group programming for the COVID-19 pandemic.

The COVID-19 pandemic and ensuing isolation stressed pregnant and postpartum women and their families pervasively. This necessitated addressing young families' mental health needs while protecting both patients and providers from COVID-19 exposure. Our experience of rapidly adapting Pregnancy, Maternal Postpartum Peer Support, and Mother-Infant Postpartum Group interventions to high-quality telehealth modalities elucidates benefits and challenges of mother-infant dyadic treatment amidst the pandemic. This study compares 2019 in-person and 2020 telehealth services during the period from mid-March through mid-December in each year. Initial program Warmline contacts were similar across years despite pandemic-related restrictions, with 2020 program contacts surpassing the 147 unique patient outreaches during the commensurate 2019 period. Pregnancy Group enrollment remained consistent. Maternal Postpartum Peer Support Group participation increased with transition to telehealth with 27 individuals with over 100 group-based visits in 2020. Twenty-five mother-infant Postpartum pairs initially enrolled in the 12-week multicomponent Mother-Infant Therapy Group (M-ITG) during 2019 in-person services, and 16 completed the program (36% non-completion rate). During 2020 telehealth, 15 of 18 mother-infant pairs completed the program (17% non-completion rate); a greater than 50% reduction in non-completion. We further compare pre-/post-pandemic onset M-ITG participant demographics, enrollment, and Edinburgh Postnatal Depression Scale (EPDS) scores.

La pandemia COVID-19 y el consecuente aislamiento estresó a mujeres embarazadas y en postparto y a sus familias de manera generalizada. Esto requirió abordar asuntos de salud mental de familias jóvenes mientras que se protegía tanto a pacientes como proveedores de estar expuestos al COVID-19. Nuestra experiencia de adaptar rápidamente el Embarazo, el Apoyo entre Iguales al Postparto Materno y las intervenciones de grupo Madre-Infante en Postparto, a modalidades de telesalud de alta calidad, esclarece beneficios y retos del tratamiento a la díada madre-infante en medio de la pandemia. El estudio compara el servicio presencial en 2019 y de telesalud en 2020 durante el período de mitad de marzo a mitad de diciembre en cada año. Los contactos iniciales de programas de apoyo emocional telefónico con alguien en igual circunstancia (Warmline) fueron similares a lo largo de los dos años a pesar de las restricciones de la pandemia, con más contactos de programas de 2020 que las específicas 147 actividades de contacto a pacientes durante el período similar en 2019. La inscripción en grupos de embarazo se mantuvo consistente. La participación en grupos de Apoyo entre Iguales al Postparto Materno aumentó con la transición a la telesalud, con 27 individuos y más de 100 visitas con base en el grupo en 2020. Veinticinco pares de Madre-Infante en Postparto se inscribieron al inicio en el Grupo de Terapia Madre-Infante de 12 semanas y múltiples componentes (M-ITG) durante los servicios en persona de 2019 y 16 completaron el programa (36% tasa de incompletos). Durante la telesalud del 2020, 15 de los 18 pares de madre-infante completaron el programa (17% tasa de incompletos); una reducción de más del 50% en incompletos. Además, comparamos, antes y después de la pandemia, datos demográficos, inscripción y puntajes en la Escala de Edimburgo de Depresión Postnatal de participantes que iniciaron el M-ITG.

La pandémie du COVID-19 et l'isolation qui s'en est suivie a stressé les femmes enceintes et postpartum et leurs familles de façon générale. Il a donc fallu prendre en compte les besoins de santé mentale des jeunes familles tout en protégeant à la fois les patients et les praticiens de toute exposition au COVID-19. Notre expérience d'adaptation rapide du Soutien Maternel par Pair à la Grossesse et Postpartum ainsi que des interventions de groupe Postpartum Mère-Bébé en modalités de télésanté de haute qualité illustrent les bénéfices et les défis du traitement dyadique mère-bébé en pleine pandémie. Cette étude compare l'année 2019 en personne et les services de télésanté de 2020 durant la période de la mi-mars jusqu'à la mi-décembre de chaque année. Les contacts du programme initial Warmline ont été les mêmes au fil de ces deux années en dépit des restrictions liées à la pandémie, avec des contacts du programme de 2020 surpassant la communication à 147 patients uniques durant la même période de 2019. Le groupe de grossesse enregistré est demeuré constant. La participation de groupe de Soutien par Pair Postpartum a augmenté avec la transition à la télésanté avec 27 individus avec plus de 100 visites basées sur le groupe en 2020. Vingt-cinq paires Postpartum Mère-Bébé se sont initialement inscrites dans le Groupe de Thérapie Mère-Bébé de 12 semaines à plusieurs composants (M-ITG) durant les services en personne de 2019 et 16 ont terminé le programme (36% de taux d'inachèvement). Durant la télésanté 2020, 15 des 18 paires mère-bébé ont complété le programme (17% de taux d'inachèvement); un taux de réduction de 50% plus grand pour l'inachèvement). Nous comparons par ailleurs les données démographiques des participants M-ITG avant et après le début de la pandémie, les inscriptions et les scores de l'Echelle de Dépression Postnatale d'Edinbourg.

Ketogenic Diets and Chronic Disease: Weighing the Benefits Against the Risks.

Very-low-carbohydrate ketogenic diets have been long been used to reduce seizure frequency and more recently have been promoted for a variety of health conditions, including obesity, diabetes, and liver disease. Ketogenic diets may provide short-term improvement and aid in symptom management for some chronic diseases. Such diets affect diet quality, typically increasing intake of foods linked to chronic disease risk and decreasing intake of foods found to be protective in epidemiological studies. This review examines the effects of ketogenic diets on common chronic diseases, as well as their impact on diet quality and possible risks associated with their use. Given often-temporary improvements, unfavorable effects on dietary intake, and inadequate data demonstrating long-term safety, for most individuals, the risks of ketogenic diets may outweigh the benefits.

Vegetarian Dietary Patterns and Cognitive Function among Older Adults: The Adventist Health Study-2.

We explored effects on cognitive function of following plant-based vegetarian compared with non-vegetarian dietary patterns in otherwise healthy older community-dwelling members of the Adventist Health Study-2 cohort (n = 132). Cognition was assessed using a comprehensive neuropsychological battery; a principal components analysis derived processing speed, executive function, and memory/language factors. Mild memory impairment (MMI) (n = 26, 19.7%) was identified by memory tests. Vegetarians consumed (a) meats, fish, and dairy <1 time/month, (b) dairy ≥1 time/month and meats, and fish <1 time/month, or (c) fish ≥1 time/month, no limits on dairy, and meats <1 time/month. Dietary patterns were determined at baseline, for each decade, and at cognitive assessment; a diet stability score was calculated. Factor scores were not different between vegetarians and non-vegetarians, nor was dietary pattern associated with a lower odds of MMI. A more stable diet over the life course was associated with better memory/language [ß = 0.021 SE(ß) = 0.008; p = 0.01]. This exploratory study did not support differences in processing speed, executive function, or memory/language abilities between vegetarians and non-vegetarians but did suggest that a more stable dietary pattern which was characteristic of vegetarians was associated with better memory/language abilities.

Novel induction therapy transoral surgery treatment paradigm with risk-adapted adjuvant therapy for squamous cell carcinoma of the head and neck - Mature clinical and functional outcomes.

OBJECTIVE: Induction chemotherapy in head and neck squamous cell carcinoma (HNSCCA) has principally been studied prior to radiation therapy. We evaluated pre-operative induction therapy followed by surgery followed by risk-adapted adjuvant therapy. This report details the mature 5-year survival statistics, clinical and functional outcomes. METHODS: An IRB-approved single institution prospective phase II clinical trial from October 2012 to November 2016 was conducted for patients with transorally-resectable American Joint Committee on Cancer 7th ed. stage III/IV HNSCCA. Patients were treated once weekly for six weeks with a multi-drug induction regimen of carboplatin, paclitaxel and daily lapatinib followed by transoral surgery and neck dissection. Patients were then stratified based on pathologic response to either observation or adjuvant therapy. Survival statistics and functional patient outcomes were analyzed. Specifically, peri-operative outcomes were analyzed and compared to a matched surgical cohort. RESULTS: 38/40 enrolled patients completed trial therapy. Median hospital stay was 3 days with 9/38 patients receiving a PEG (median 46 days). Median NPO status was 1 day, with a median return to a regular diet in 16 days. Mean patient weight was well preserved from pretreatment to 1 year after surgery (85.1 kg (95% CI 79.6-90.7) vs 83.1 kg (95% CI 77.7-88.6 kg) respectively). Of the 38 patients who completed trial therapy; DSS, PFS and OS were 100%, 97% and 97% respectively with median follow up of 4.9 years (3.33-7.25). CONCLUSION: Transoral surgery was feasible following this novel induction regimen with excellent peri-operative, functional and longterm survival outcomes.

Framing Sign Language as a Health Need in Canadian and International Policy.

Although in Canada, hearing screening and early intervention are presented as a health need, we question whether young deaf and hard of hearing children's access to language is adequately supported by public health and children's services. The Ontario Infant Hearing Program has the stated mandate of supporting the language development of deaf and hard of hearing infants and young children. However, this program presents parents with early intervention service options involving either spoken or signed language, but not both together. This policy effectively restricts access to sign language learning for a majority of Ontario's deaf children. Consequently, some deaf children suffer language deprivation and its deleterious effects on cognition and emotional development. In support of our arguments, we refer to Article 25 of the United Nations Convention on the Rights of Persons with Disabilities (CRPD), which Canada has signed and ratified. The CRPD supports recognition of deaf children's right to sign language as a health need because language deprivation occurs in many children who are not offered sign language, and this is a permanent impairment imposed on top of hearing loss. We conclude that in Canada, health services for deaf children do not align with accessibility and human rights legislation, thus creating a policy gap that leaves deaf children vulnerable to additional impairment.

Cognitive Rehabilitation for Individuals With Parkinson's Disease: Developing and Piloting an External Aids Treatment Program.

Purpose Cognitive deficits are common in Parkinson's disease (PD) and can have a detrimental effect on daily activities. To date, most cognitive treatments have had an impairment-based focus with primary outcome measures of formal neuropsychological test scores. Few, if any, studies have focused on functional improvement or patient-centered goals. Method Three individuals with idiopathic PD participated in an 8-week pilot treatment program to train for the use of compensatory external aids to achieve personalized goals. Goal attainment scaling was the primary outcome measure, which was independently judged by multiple raters at baseline, postintervention, and 1 month posttreatment and analyzed via T-score analysis. Descriptive measures, including self-report and spouse-report rating scales of cognitive functioning, were employed. Results All 3 participants improved in the majority of their laboratory and home goals posttreatment, as measured by goal attainment scaling, and maintained gains for the majority of goals 1 month posttreatment. Conclusions This is the 1st known study to implement an external aids treatment program with patient-centered goals for individuals with cognitive deficits from PD. Positive outcomes were likely influenced by 3 factors: (a) a theoretically motivated focus on external aids; (b) a well-documented, systematic approach to instruction; and (c) the personalization of goals. Supplemental Material https://doi.org/10.23641/asha.10093493.

DNA methylome study of human cerebellar tissues identified genes and pathways possibly involved in essential tremor.

BACKGROUND: Essential tremor (ET) is a neurological syndrome of unknown origin with poorly understood etiology and pathogenesis. It is suggested that the cerebellum and its tracts may be involved in the pathophysiology of ET. DNA methylome interrogation of cerebellar tissue may help shine some light on the understanding of the mechanism of the development of ET. Our study used postmortem human cerebellum tissue samples collected from 12 ET patients and 11 matched non-ET controls for DNA methylome study to identify differentially methylated genes in ET. RESULTS: Using Nugen's Ovation reduced representation bisulfite sequencing (RRBS), we identified 753 genes encompassing 938 CpG sites with significant differences in DNA methylation between the ET and the control group. Identified genes were further analyzed with Ingenuity Pathway Analysis (IPA) by which we identified certain significant pathways, upstream regulators, diseases and functions, and networks associated with ET. CONCLUSIONS: Our study provides evidence that there are significant differences in DNA methylation patterns between the ET and control samples, suggesting that the methylation alteration of certain genes in the cerebellum may be associated with ET pathogenesis. The identified genes allude to the GABAergic hypothesis which supports the notation that ET is a neurodegenerative disease, particularly involving the cerebellum.

Phase 2 trial of neoadjuvant chemotherapy and transoral endoscopic surgery with risk-adapted adjuvant therapy for squamous cell carcinoma of the head and neck.

BACKGROUND: The objective of this study was to demonstrate the feasibility and efficacy of induction chemotherapy, surgery, and pathology-guided adjuvant therapy to treat transorally resectable squamous head and neck cancer. METHODS: Patients had squamous head and neck cancer that was resectable by the transoral route and advanced-stage disease (American Joint Committee on Cancer stage III-IV, T3-T4 tumors, and/or positive lymph nodes). They received treatment with weekly carboplatin at an area under the curve of 2, plus paclitaxel 135 mg/m2 , and daily lapatinib 1000mg for 6 weeks followed by surgical resection. Pathology that revealed margins <5 mm, extracapsular extension, N2a of N2b lymph node status, perineural invasion, or lymphovascular space invasion resulted in adjuvant radiotherapy concurrent with weekly cisplatin. Pathology with N2c/N3 lymph node status or positive margins resulted in radiation with bolus cisplatin. The primary endpoint was the clinical response rate to induction chemotherapy, and a key secondary endpoint was feasibility. RESULTS: Toxicity was modest, and 37 of 40 patients completed study procedures as planned. The clinical response rate was 93%, the pathologic complete response rate was 36%, and the clinical response did not predict for a pathologic complete response. No patient on study follow-up has recurred or died. Twenty-nine of 39 patients who underwent surgery avoided radiation. Speech and swallowing function were well preserved. CONCLUSIONS: The study met both its primary efficacy endpoint and the secondary feasibility endpoint. Neoadjuvant, systemic therapy and surgical resection followed by risk-adapted adjuvant therapy resulted in high response rates and excellent long-term outcomes and should be further studied. Cancer 2018;124:2986-92. © 2018 American Cancer Society.

Factors influencing the adoption of telemedicine for treatment of military veterans with post-traumatic stress disorder.

BACKGROUND: Military veterans returning from a combat zone often face mental health challenges as a result of traumatic experiences. The veteran in the United States has been underdiagnosed and underserved. Since its advancement in the 1990s, telemedicine has become a more prevalent means of delivering services for post-traumatic stress disorder among veterans in the United States, but its adoption is not ubiquitous. OBJECTIVE: To clarify the association of telemedicine and the treatment of veterans with post-traumatic stress disorder through identification of facilitators and barriers to the adoption of the modality. METHODS: Reviewers analysed articles from CINAHL and PubMed databases, using relative key words, selecting the 28 most germane to the study objective. RESULTS: The most common adoption facilitators were: improving access to rural populations of veterans (22%), effective treatment outcomes (16%), and decreased costs related to care (13%). The most prevalent barriers were: veterans lacking access to necessary modalities (25%), availability of physicians competent in post-traumatic stress disorder treatment (20%), and complications with technology (20%). Five themes surfaced for facilitators: accessibility, effectiveness, cost reduction, positive patient perception, and supportive community; and 5 themes for barriers: access to technology, technical complications, physician availability, negative patient perception, and uninformed patients. CONCLUSION: This literature review identifies cost and outcomes-effectiveness. The association of telemedicine with the treatment of veterans with post-traumatic stress disorder is feasible, beneficial and effective.

Modification of the BioMedicus centrifugal pump to provide continuous irrigation for neuroendoscopy: technical note.

Continuous irrigation is an important adjunct for successful intraventricular endoscopy, particularly for complex cases. It allows better visualization by washing out blood and debris, improves navigation by expanding the ventricles, and assists with tissue dissection. A method of irrigation delivery using a centrifugal pump designed originally for cardiac surgery is presented. The BioMedicus centrifugal pump has the desirable ability to deliver a continuous laminar flow of fluid that excludes air from the system. A series of modifications to the pump tubing was performed to adapt it to neuroendoscopy. Equipment testing determined flow and pressure responses at various settings and simulated clinical conditions. The pump was then studied clinically in 11 endoscopy cases and eventually used in 310 surgical cases. Modifications of the pump tubing allowed for integration with different endoscopy systems. Constant flow rates were achieved with and without surgical instruments through the working ports. Optimal flow rates ranged between 30 and 100 ml/min depending on endoscope size. Intraoperative use was well tolerated with no permanent morbidity and showed consistent flow rates, minimal air accumulation, and seamless irrigation bag replacement during prolonged surgery. Although the pump is equipped with an internal safety mechanism to protect against pressure buildup when outflow obstructions occur, equipment testing revealed that flow cessation is not instantaneous enough to protect against sudden intracranial pressure elevation. A commonly available cardiac pump system was modified to provide continuous irrigation for intraventricular endoscopy. The system alleviates the problems of inconsistent flow rates, air in the irrigation lines, and delays in changing irrigation bags, thereby optimizing patient safety and surgical efficiency. Safe use of the pump requires good ventricular outflow and, clearly, sound surgical judgment.

YouTube and the single-rod contraceptive implant: a content analysis.

BACKGROUND: Since the internet has become an important source of contraceptive information with YouTube.com as the second most visited site, we analysed contraceptive implant YouTube videos for content and clinical accuracy. METHODS: Using the terms 'contraceptive implant', 'Nexplanon' and 'Implanon', the top 20 results on YouTube by relevance and view count were identified. After excluding duplicates, single-rod implant videos in English were included. Videos were classified as providing a professional or patient perspective. Views, duration and comments were noted. Videos were rated for reliability, global quality scale and whether they were positive or negative about the implant. Inter-rater agreement was measured. RESULTS: A total of 120 videos were retrieved; 52 were eligible for review. Less than 23% were professional videos; the majority reported patient experience (46% testimonials, 27% real-time procedure videos, 4% other). Patient videos had been posted a significantly longer duration of time than professional videos (364 vs 188 days, p=0.02), were less reliable (p≤0.0001) and were of lower global quality (p<0.0001). Some 61% of implant testimonial videos were rated as 'positive experiences' and inter-rater agreement was very good (κ=0.81). All testimonials mentioned side effects, commonly irregular bleeding and discomfort with insertion. A minority (26%) reported misinformation. CONCLUSIONS: This study found that most of the information on YouTube pertaining to contraceptive implants is accurate, is presented from the patient's perspective, and promotes the method's use.

Burn Injuries in Patients with Paralysis: A National Perspective on Injury Patterns and Outcomes.

The affect of paralysis-related comorbidities on outcomes in burn-injured patients has not been explored. We hypothesize that comorbid paralysis is associated with increased morbidity in this population. All burned patients with prior diagnoses of paralysis were identified from the National Burn Repository (Version 8.0). One-to-one matching of nonparalyzed burn-injured patients was performed, and nonparametric analysis was used to compare the groups. We identified 432 paralyzed patients, who were predominantly male (70.6%) and Caucasian (57.6%), with an average age of 40.8 ± 19.0 years. The identified level of disability was distinguished as paraplegia (59.5%), hemiplegia (16.9%), quadriplegia (13.9%), or other (9.8%). A majority of injuries occurred in the home (75.2%), primarily due to scalds (48.1%). More than half sustained small injuries with affected total body surface area <5%. Lower extremities were frequently injured (72.2%), with 41.0% affecting exclusively the lower extremities. While the paralysis population had significantly longer hospital lengths of stay, nonparalyzed patients had longer intensive care unit length of stay and ventilator days (P < .001). There was no statistically significant difference in mortality rate between paralyzed and nonparalyzed patients (4.4% vs 4.9%, P = .550). Patients with paralysis are susceptible to small scald injuries in the home. Comorbid paralysis places patients at risk for longer, more indolent hospital stays, when compared with matched nonparalyzed patients with more critical illness. Further investigation is needed regarding the pathophysiologic mechanisms predisposing paralyzed burn patients to increased morbidity.

Long-distance dispersal and high genetic diversity are implicated in the invasive spread of the common reed, Phragmites australis (Poaceae), in northeastern North America.

PREMISE OF THE STUDY: The Eurasian subspecies of the common reed (Phragmites australis subsp. australis, hereafter abbreviated as P. a. australis) was introduced to North America in the late 18(th) century and rapidly expanded its range, posing an ecological threat to wetlands. In this study, we aimed to determine whether admixture among multiple lineages, dispersal mechanisms, and high genetic diversity have contributed to the invasion of P. a. australis in the northeastern part of its range. Understanding mechanisms of the P. a. australis invasion will 1) contribute to a broader understanding of the factors that facilitate plant invasion, and 2) help us to develop effective management strategies for wetlands threatened by P. a. australis invasion. METHODS: We used a population genetics approach incorporating nine microsatellite loci to study genetic diversity and population structure in relation to biogeography of introduced North American Phragmites a. australis stands in the northeastern continental region. KEY RESULTS: Phragmites a. australis is genetically diverse in the region studied here. Significant population structure exists, and population structure is likely influenced by both long-distance dispersal via major waterways, and short-distance dispersal overland. Different lineages sometimes colonize geographically proximate locations leading to opportunities for admixture. Clonal reproduction likely exaggerates geographical structure among some stands, although high genetic and clonal diversity within some stands implies that sexual reproduction occurs frequently in P. a. australis. CONCLUSIONS: A variety of factors, including admixture among multiple lineages, multiple modes of dispersal, and plasticity in reproductive strategy promote the invasion success of Phragmites a. australis. Wetland managers in the St. Lawrence River/Great Lakes region should focus monitoring efforts on the shores of conservation lands to prevent the establishment of propagules from novel lineages.

Physiological replacement of T3 improves left ventricular function in an animal model of myocardial infarction-induced congestive heart failure.

BACKGROUND: Patients with congestive heart failure (CHF) often have low serum triiodothyronine (T(3)) concentrations. In a rodent model of myocardial infarction-induced CHF and low serum T(3), we hypothesized that replacing T(3) to euthyroid levels would improve left ventricular function without producing untoward signs of thyrotoxicosis. METHODS AND RESULTS: Adult male Sprague-Dawley rats were subjected to left anterior descending coronary artery ligation (myocardial infarction). One week post-myocardial infarction, left ventricular fractional shortening was significantly reduced to 22+/-1% in CHF animals versus 38+/-1% for sham-operated controls (P<0.001). Serum T(3) concentration was also significantly reduced (80+/-3 versus 103+/-6 ng/dL; P<0.001), in CHF animals versus Shams. At 9 weeks post-myocardial infarction, systolic function (+dP/dt max) was significantly attenuated in CHF animals (4773+/-259 versus 6310+/-267 mmHg/s; P<0.001) as well as diastolic function measured by half time to relaxation (15.9+/-1.2 versus 11.1+/-0.3 ms; P<0.001). alpha-myosin heavy chain expression was also significantly reduced by 77% (P<0.001), and beta-myosin heavy chain expression was increased by 21%. Continuous T(3) replacement was initiated 1 week post-myocardial infarction with osmotic mini-pumps (6 microg/kg/d), which returned serum T(3) concentrations to levels similar to Sham controls while resting conscious heart rate, arterial blood pressure and the incidence of arrhythmias were not different. At 9 weeks, systolic function was significantly improved by T(3) replacement (6279+/-347 mmHg/s; P<0.05) and a trend toward improved diastolic function (12.3+/-0.6 ms) was noted. T(3) replacement in CHF animals also significantly increased alpha- and reduced beta-MHC expression, (P<0.05). CONCLUSIONS: These data indicate that T(3) replacement to euthyroid levels improves systolic function and tends to improve diastolic function, potentially through changes in myocardial gene expression.

NCCN Task Force Report: Management of dermatologic and other toxicities associated with EGFR inhibition in patients with cancer.

This NCCN Task Force Report describes the management of dermatologic and ocular toxicities that occur in patients treated with epidermal growth factor receptor (EGFR) inhibitors. Task force members are from NCCN member institutions and include oncologists, dermatologists, an ophthalmologist, and a mid-level oncology provider. This report describes commonly used therapies that the task force agreed are appropriate standards of care for dermatologic and ophthalmologic toxicities associated with EGFR inhibitors, which generally are supported only by anecdotal evidence. Few recommendations are evidence based; however, some commonly used therapies have data supporting their use. Conclusions from completed clinical trials are generally limited by the small numbers of patients enrolled. The information in this report is based on available published data on treating toxicities associated with EGFR inhibitors, data from treatment of clinically similar toxicities from different etiologies, and expert opinion among the NCCN Task Force members.

Delisting publicly funded community-based physical therapy services in Ontario, Canada: a 12-month follow-up study of the perceptions of clients and providers.

Publicly funded community-based physical therapy (PT) services in Canada's most populous province of Ontario were partially delisted, or deinsured, in April 2005. Two previous studies examined the short-term effects from the client and provider perspectives; and in this study, we follow up with participants from these preceding studies to assess long-term consequences of this policy. Sixteen of 18 providers (89%) and 64 of 98 clients (65%) agreed to participate in a follow-up telephone interview. Our results indicate that 12 months following delisting, and despite government assurances that access would be preserved, clients rendered ineligible for publicly funded services report ongoing access barriers across Ontario. Clients in this study also express concern about their overall health and report an increased use of other insured health professionals (e.g., physicians) and services (e.g., hospitals). On the other hand, providers within the network of publicly funded clinics report an important decrease in demand for PT services, whereas those from other settings report little change. We conclude that delisting policies may have long-term consequences on uninsured or underinsured clients and that evidence-based policy planning is warranted to ensure that the goals of reform are aligned with the desired outcomes at the client, provider, and system levels.

Residual language deficits in optimal outcome children with a history of autism.

This study examined whether language deficits persist even in children with optimal outcomes. We examined a group of children with prior diagnoses on the autism spectrum who had IQs in the normal range, were in age-appropriate mainstream classes, and had improved to such an extent that they were considered to be functioning at the level of their typically developing peers. Fourteen such children between the ages of five and nine were matched on age and sex with typically developing children, and were given a battery of 10 language tests to investigate their language abilities. Results indicated that while these children's grammatical capabilities are mostly indistinguishable from their peers, they are still experiencing difficulties in pragmatic and semantic language.