A Descriptive Analysis of Access to Assistive Technology in Children With Acquired Brain Injury: The Right to Assistive Devices.

OBJECTIVE: Pediatric clinicians caring for children with acquired brain injury have noted that many individuals requiring assistive technology (AT) go unserved or face delays until devices are obtained, with potential adverse implications for recovery and development. In this article we map the pathways by which AT is prescribed and assess delays and barriers to access. METHODS: We conducted a retrospective chart review of patients with moderate to severe brain injury admitted to Blythedale Children's Hospital over a 2-year period using a database drawn from the medical record. RESULTS: We identified 72 children diagnosed with brain injury requiring at least 1 device. Devices were used to improve mobility and positioning, self-care, safety, and communication, and enable access to other technologies and foster social integration. We found that 55% of devices were delivered, with most deliveries to home or the hospital's outpatient department for fitting, training, and instruction. Time to delivery ranged from 12 to 250 days with an average of 69.4 days. Twenty percent of nondeliveries were attributable to change in medical status, transfer to a skilled nursing facility, or continued inpatient status, while 31% were canceled by the family. Other nondeliveries were attributed to insurance coverage. We also found that the medical record is not designed for the longitudinal tracking of devices, indicating the need for a prospective process to document the AT trajectory. CONCLUSION: Instead of tolerating delays and denials, there should be a normative expectation that children have a right to medically necessary devices, consistent with disability law. This analysis was undertaken as a step toward formulating a prospective means of tracking AT recommendations, approvals, denials, and/or deliveries. Our findings should be understood as a promissory note toward structural reforms that are reflective of society's responsibility to better meet the needs of vulnerable children and their families.

Cultural Adaptation of a Neurobiologically Informed Intervention in Local and International Contexts.

The relationship between early adversity and numerous negative outcomes across the lifespan is evident in a wide range of societies and cultures (e.g., Pakulak, Stevens, & Neville, 2018). Among the most affected neural systems are those supporting attention, self-regulation, and stress regulation. As such, these systems represent targets for neurobiologically informed interventions addressing early adversity. In prior work with monolingual native English-speaking families, we showed that a two-generation intervention targeting these systems in families improves outcomes across multiple domains including child brain function for selective attention (for detail, see Neville et al., 2013). Here, we discuss the translation and cultural adaptation (CA) of this intervention in local and international contexts, which required systematic consideration of cultural differences that could affect program acceptability. First, we conducted a translation and CA of our program to serve Latino families in the United States using the Cultural Adaptation Process (CAP), a model that works closely with stakeholders in a systematic, iterative process. Second, to implement the adapted program in Medellín, Colombia, we conducted a subsequent adaptation for Colombian culture using the same CAP. Our experience underscores the importance of consideration of cultural differences and a systematic approach to adaptation before assessing the efficacy of neurobiologically informed interventions in different cultural contexts.

Family-based training program improves brain function, cognition, and behavior in lower socioeconomic status preschoolers.

Using information from research on the neuroplasticity of selective attention and on the central role of successful parenting in child development, we developed and rigorously assessed a family-based training program designed to improve brain systems for selective attention in preschool children. One hundred forty-one lower socioeconomic status preschoolers enrolled in a Head Start program were randomly assigned to the training program, Head Start alone, or an active control group. Electrophysiological measures of children's brain functions supporting selective attention, standardized measures of cognition, and parent-reported child behaviors all favored children in the treatment program relative to both control groups. Positive changes were also observed in the parents themselves. Effect sizes ranged from one-quarter to half of a standard deviation. These results lend impetus to the further development and broader implementation of evidence-based education programs that target at-risk families.

Lower extremity compensatory neuromuscular and biomechanical adaptations 2 to 11 years after anterior cruciate ligament reconstruction.

PURPOSE: To determine whether compensatory neuromuscular and biomechanical adaptations exist after successful anterior cruciate ligament reconstruction and rehabilitation. METHODS: Seventy subjects, 5.3 +/- 3 years after surgery, participated in this study. Sagittal-plane lower extremity kinematic, gluteus maximus, vastus medialis, medial hamstring, and gastrocnemius electromyography (EMG) and vertical ground reaction force data were collected during single-leg countermovement jump (CMJ) performance. RESULTS: Women had lower propulsive and landing forces, lower CMJ heights, less hip and knee flexion, and greater angular hip, knee, and ankle velocities than men (P < or = .014). The involved lower extremity of men and women had decreased landing forces (P = .008). During propulsion, men and women had increased involved-lower extremity gluteus maximus (P < .0001) and decreased vastus medialis (P = .013) EMG amplitudes, whereas women had bilaterally increased gastrocnemius EMG amplitudes compared with men (P = .003). During propulsion, men had longer gluteus maximus and vastus medialis EMG durations than women (P < .0001). During landing, both men and women had increased gluteus maximus EMG amplitudes at the involved lower extremity (P < .0001). Women had increased vastus medialis (P = .01) and gastrocnemius (P < .0001) EMG amplitudes compared with men. During landing, men had longer gluteus maximus (P = .004), vastus medialis (P = .012), and gastrocnemius (P = .007) EMG durations than women and the involved-lower extremity vastus medialis EMG durations of both men and women were shorter than at the noninvolved lower extremity (P = .011). CONCLUSIONS: Decreased involved-lower extremity landing forces, decreased vastus medialis activation, and increased gluteus maximus and gastrocnemius activation suggest a protective mechanism to minimize knee loads that increase anterior translatory knee forces during single-leg jumping. Women showed more balanced gluteus maximus, vastus medialis, and gastrocnemius contributions to dynamic knee stability than men during CMJ landings but used shorter activation durations. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Mental health indicators in APEC.

BACKGROUND: The World Economic Forum (2011) concluded that the economic impact of mental illness is the single most important contributor among all non-communicable diseases to loss of productivity. The 21 economies represented by Asia Pacific Economic Cooperation (APEC) responded to that information with efforts to address mental health as an integral component of economic development. AIM: In order to help assess the progress of APEC region compared to other regions of the world, the World Health Organization (WHO) granted us access to a subset of the 2014 Mental Health Atlas database containing health indicators from all 21 APEC economies. METHODS: APEC-specific data were extracted using the same format used by WHO in its Mental Health Atlas to compare/contrast data in APEC versus the six WHO regions of the world. RESULTS: It was observed that mental health workforces in APEC include a higher number of psychiatrist providers compared with WHO regions. Suicide rates reported in three APEC economies are among the highest in the world. All APEC economies continue their individual and coordinated efforts to support their ' APEC Roadmap to Promote Mental Wellness in a Healthy Asia Pacific (2014-2020)'. CONCLUSION: Significant challenges for APEC members exist to coordinate regional efforts to improve mental health due to highly variable income levels, existing health infrastructures and social preferences. The findings in this report may serve as a helpful baseline for measuring success within the APEC region by 2020, the year in which progress in support of economic development will be reassessed.

Evaluation of cruciate and slot auxiliary screw head design modifications for extracting stripped screw heads.

Slotted and cruciate auxiliary screw head design modifications for "salvaging" a stripped hexagonal head screw were studied. Thirty screws were divided into 3 groups: Group 1 = control without modification, Group 2 = auxiliary cruciate design modification and Group 3 = auxiliary slot design modification. Screws were inserted into adhesive filled high-density synthetic bone tunnels using a hexagonal driver. Group 1 screws were removed using a hexagonal driver. Group 2 and group 3 screws were removed using drivers that matched their respective auxiliary design modifications. All group 1 and group 3 screws (100%) were effectively extracted. Three of 10 (30%) group 2 screws could not be effectively extracted. Group 2 screws displayed greater stripping and deformation than the other groups. The auxiliary slot design modification withstood comparable extraction torques as control screws without significant deformation. Screws with a cruciate design modification displayed more frequent failure, greater stripping and deformation.

Peritoneal tuberculosis in a 15-month-old male: surgical diagnosis of an insidious disease.

BACKGROUND: Peritoneal involvement is a relatively rare complication of tuberculosis, accounting for approximately 3.3% of extrapulmonary disease in the United States. Clinical diagnosis relies on a preponderance of indirect evidence and is often delayed. We describe such a patient. METHODS: An otherwise healthy 15-month-old male presented with fever, abdominal distention, vague abdominal pains, and a few episodes of watery diarrhea. Standard laboratory and radiologic work-up was unrevealing, and after a prolonged hospitalization, caseating granulomas were identified at diagnostic laparotomy. RESULTS: Definitive treatment was further delayed pending culture results, and the patient's condition worsened until fulminant cardiovascular collapse led to his demise. CONCLUSIONS: Despite effective chemotherapeutic regimens, the overall mortality of tuberculous peritonitis may be as high as 51%. The diagnosis must be considered and empiric antituberculous treatment started early in the course of the disease, even if definitive diagnosis is still pending.

Influence of thread design on bioabsorbable interference screw insertion torque during retrograde fixation of a soft-tissue graft in synthetic bone.

PURPOSE: Bioabsorbable interference screw design may influence biomechanical characteristics. This study compared the insertion torque and load at failure characteristics of 2 types of screws during retrograde fixation of a soft-tissue graft. TYPE OF STUDY: Biomechanical study. METHODS: Eight matched pairs of doubled 100-mm long tibialis anterior allografts were prepared and fixed in appropriately sized tunnels created in 10 lb/ft 3 (0.16 g/cm3) dense synthetic bone blocks using screws of similar length and root and thread diameter designed with either a large buttress thread with a smaller taper or small buttress thread with a larger taper. Insertion torque was measured at one-third, two-thirds, and full screw insertion. After the graft fixation constructs were mounted in a servohydraulic-testing device with the loading axis aligned directly with the tunnel and preloaded to 25 N, they were cycled 3 times from 0 to 50 N, and then subjected to a 20 mm/minute traction force to failure. RESULTS: All constructs failed by graft slippage past the screw. Mean maximum load at failure (360.5 +/- 68 N v 341.6 +/- 58 N, P = .2) and stiffness (63.6 +/- 16 N/mm 2 v 66.4 +/- 14 N/mm 2 , P = .89) was similar between constructs fixed with a large buttress thread small-taper screw and small buttress thread large-taper screw, respectively. The small buttress thread screw with a large taper displayed greater mean insertion torque at one-third insertion (4.1 +/- 0.57 in-lb v 3.2 +/- 0.49 in-lb, P = .03), whereas the large buttress thread screw with a small taper displayed greater mean insertion torque at full insertion (11.1 +/- 0.74 in-lb v 9.4 +/- 1.3 in-lb, P = .012). Mean differences were not observed at two-thirds screw insertion (P = .12). CONCLUSIONS: Large buttress thread small-taper screws displayed biomechanical fixation characteristics comparable to small buttress thread large-taper screws. CLINICAL RELEVANCE: Given reports of superior screw-graft-bone tunnel contact area, these biomechanical results suggest that use of a large buttress screw with a small taper may be preferable for retrograde soft-tissue graft fixation.

Comparison of intermittent versus continuous infusion of propofol for elective oncology procedures in children.

OBJECTIVE: To compare the effects of administering propofol as a continuous infusion vs. bolus dosing in children undergoing ambulatory oncologic procedures in the pediatric intensive care unit (PICU). DESIGN: Prospective, randomized study. SETTING: Tertiary PICU in a university hospital. PATIENTS: Ambulatory oncology patients scheduled for diagnostic or therapeutic procedures with propofol anesthesia in the PICU were eligible for enrollment. INTERVENTIONS: Patients were randomly assigned to receive either continuous infusion or bolus administration of propofol in a protocol-driven manner. All patients received an initial bolus of 1.5 mg/kg, with additional 0.5 mg/kg doses until complete induction. Continuous infusions were started at 0.1 mg/kg/min and, if needed, increased 20% after a bolus of 0.5 mg/kg. Bolus group patients were given doses of 0.5 mg/kg if needed. Ramsay scores of < 5 were used as criteria for additional dosing. MEASUREMENTS AND MAIN RESULTS: Eighteen patients undergoing 40 separate procedures were enrolled during the study period. Twenty procedures each were performed with continuous or bolus administration of propofol. No differences were present between groups in demographic characteristics, induction dose and time, procedure and recovery times, or adverse events. All patients had adequate anesthesia and favorable satisfaction scores. More boluses were needed in the bolus group (8.5 +/- 4.6 vs. 5.4 +/- 2.9; p < .05). Average systolic blood pressure decreased more in the continuous infusion group (26.4% +/- 12 vs. 19.3% +/- 10; p < .05). Total propofol dose was higher in the continuous infusion group (8.0 mg/kg +/- 3.8 vs. 5.7 mg/kg +/- 2.4; p < .05). CONCLUSION: Both continuous and bolus administration of propofol provided conditions for conducting oncologic procedures that were satisfying to patients, their families, and physicians. Continuous infusions were associated with a larger total dose and greater decreases in systolic blood pressure. Physician preference is likely to dictate which method is used.

The effects of a broad-spectrum matrix metalloproteinase inhibitor on characteristics of wound healing.

This study investigates the effects of a broad-spectrum matrix metalloproteinase inhibitor (MMP-i) on the rate of closure, hydroxyproline deposition, and macrophage infiltration in healing wounds. Full-thickness excisional wounds were created on the dorsal surface of hairless mice. Two experimental groups were used to measure rates of wound closure: (a) MMP-i administration (0.03, 0.3, 3.0, and 30 microg/mL) on days 0-1 postwounding (inflammatory phase) and (b) MMP-i administration (0.03, 0.3, 3.0, and 30 microg/mL) on days 6-8 postwounding (proliferative phase). Additionally, hydroxyproline deposition and percent macrophage infiltration were measured in skin wound margins on days 2, 8, and 16 postwounding. MMP-i administration at concentrations of 0.03, 0.3, and 3.0 microg/mL on days 0-1 postwounding significantly (p <.05) increased the rate of wound closure. No significant effect on the rate of wound closure was observed with MMP-i administration on days 6-8 postwounding. Hydroxyproline deposition was significantly (p <.05) increased on day 8 postwounding, and the percent macrophage infiltration was significantly (p <.05) decreased on day 2 postwounding by MMP-i administration on days 0-1 postwounding. These experiments demonstrate that MMP-i administration during the inflammatory phase significantly affects several characteristics of wound healing. We postulate that these effects may be attributed to decreased degradation of ECM components, increased concentrations of endogenous growth factors, and a shortened inflammatory phase.

Lower extremity neuromuscular compensations during instrumented single leg hop testing 2-10 years following ACL reconstruction.

BACKGROUND: This study compared lower extremity EMG activation and sagittal plane kinematics of subjects at a minimum of 2 years post-successful ACL reconstruction and rehabilitation during instrumented single leg hop testing. METHODS: Comparisons were made based on subject responses to the following question, "compared to prior to your knee injury how capable are you now in performing sports activities"? Group 1=very capable, Group 2=capable, and Group 3=not capable. In addition to EMG (1000 Hz) and kinematic (60 Hz) data, subjective knee function, internal health locus of control, sports activity characteristics (intensity, frequency) pre-knee injury, and at follow-up were also compared. RESULTS: Group 3 had lower perceived knee function, decreased perceived sports intensity, and more subjects with decreased sports activity intensity by two levels compared to pre-injury values. Perceived function scores, anterior laxity measurements and grades were similar between groups. During single leg hop propulsion and landing Group 1 (very capable) had greater involved lower extremity gluteus maximus and medial hamstring activation amplitudes than Group 3 (not capable). Perceived sports capability was related to better subjective knee function, and higher perceived sports activity intensity. CONCLUSION: Neuromuscular compensations suggesting a hip bias with increased gluteus maximus and medial hamstring activation were identified at the involved lower extremity among most subjects who perceived high perceived sports capability compared to pre-injury status. These compensations may be related to a permanent neurosensory deficit, and its influence on afferent pathway changes that influence CNS sensorimotor re-organization.

Five things physicians and patients should question in hospice and palliative medicine.

Overuse or misuse of tests and treatments exposes patients to potential harm. The American Board of Internal Medicine Foundation's Choosing Wisely® campaign is a multiyear effort to encourage physician leadership in reducing harmful or inappropriate resource utilization. Via the campaign, medical societies are asked to identify five tests or procedures commonly used in their field, the routine use of which in specific clinical scenarios should be questioned by both physicians and patients based on the evidence that the test or procedure is ineffective or even harmful. The American Academy of Hospice and Palliative Medicine (AAHPM) was invited, and it agreed to participate in the campaign. The AAHPM Choosing Wisely Task Force, with input from the AAHPM membership, developed the following five recommendations: 1) Don't recommend percutaneous feeding tubes in patients with advanced dementia; instead, offer oral-assisted feeding; 2) Don't delay palliative care for a patient with serious illness who has physical, psychological, social, or spiritual distress because they are pursuing disease-directed treatment; 3) Don't leave an implantable cardioverter-defibrillator activated when it is inconsistent with the patient/family goals of care; 4) Don't recommend more than a single fraction of palliative radiation for an uncomplicated painful bone metastasis; and 5) Don't use topical lorazepam (Ativan®), diphenhydramine (Benadryl®), and haloperidol (Haldol®) (ABH) gel for nausea. These recommendations and their supporting rationale should be considered by physicians, patients, and their caregivers as they collaborate in choosing those treatments that do the most good and avoid the most harm for those living with serious illness.

Moral distress in pediatric palliative care: a case study.

End-of-life decisions for children can be complicated by disagreements between families and health care teams. These conflicts can lead to moral distress in providers. In addition, difficulties in prognostication aggravate the problem. How teams and institutions address potential staff distress is essential to providing effective palliative care for children. Through a case study of a child with a severe life-limiting syndrome, an analysis of both the ethical and legal implications of parental and team conflict are discussed. An ethics team can help provide guidance for teams and help mediate goals of care discussions with families. Palliative care consultation can also be useful, especially in providing support for both the parent and the child.

Comparison of volumetric bone mineral density in the tibial region of interest for ACL reconstruction.

Adequate tibial bone mineral density (BMD) is essential to soft tissue graft fixation during anterior cruciate ligament (ACL) reconstruction. The purpose of this study was to compare volumetric bone plug density measurements at the tibial region of interest for ACL reconstruction using a standardized immersion technique and Archimedes' principle. Cancellous bone cores were harvested from the proximal, middle, and distal metaphyseal regions of the lateral tibia and from the standard tibial tunnel location used for ACL reconstruction of 18 cadaveric specimens. Proximal tibial cores displayed 32.6% greater BMD than middle tibial cores and 31.8% greater BMD than distal tibial cores, but did not differ from the BMD of the tibial tunnel cores. Correlational analysis confirmed that the cancellous BMD in the tibial tunnel related to the cancellous BMD of the proximal and distal lateral tibial metaphysis. In conjunction with its adjacent cortical bone, the cancellous BMD of the region used for standard tibial tunnel placement provides an effective foundation for ACL graft fixation. In tibia with poor BMD, bicortical fixation that incorporates cortical bone from the distal tibial tunnel region is recommended.

Evaluation of the fixation and strength of a "rescue" revision pedicle screw.

One potential complication of pedicle screw instrumentation is long-term nerve root irritation, most commonly resulting from medial or inferior screw malpositioning. This study evaluated the pullout strength and fatigue strength properties of a novel "rescue" revision screw designed to reduce the sequelae of medial screw malpositioning by eliminating threads along the section of the screw corresponding to the pedicular region. The results of this study revealed that a rescue screw with threads eliminated from one half of its circumference provided comparable pullout strength to fully threaded pedicle screws in cadaveric specimens. In addition, mechanical testing of the rescue screw did not show a decrease in fatigue strength characteristics compared with controls. These results suggest that the rescue screw may offer a way to decrease nerve root irritation caused by canal impingement without jeopardizing the overall strength of the spinal construct.

Tendon graft fixation in ACL reconstruction: in vitro evaluation of bioabsorbable tenodesis screw.

BACKGROUND: Conventional ACL reconstruction requires sufficient tibial bone quality for secure graft fixation. We evaluated the mechanical characteristics of a supplemental tenodesis screw in cadaveric specimens. MATERIAL AND METHODS: One group of 7 specimens from 7-paired tibiae was randomly assigned to undergo tibialis anterior tendon graft-bone tunnel fixation with a bioabsorbable interference screw, using conventional ACL reconstruction techniques. The other group of 7 specimens underwent the same procedure supplemented with a bioabsorbable tenodesis screw. All specimens were subjected to pullout testing on a servo hydraulic device. RESULTS: Specimens in the supplemental fixation group had double the load to failure (tenodesis = 467 (SD 184) N, control group = 223 (SD 66) N, p = 0.02) and were also one-third stiffer (tenodesis = 31 (SD 13) N/mm, control group = 21 (SD 6) N/mm, p = 0.03) than the specimens in the conventional fixation group. INTERPRETATION: Supplemental bioabsorbable tenodesis screw fixation may be advantageous for primary reconstruction in patients with low tibial bone mineral density or during revision procedures. By providing secure soft tissue graft-tibia fixation during the early phase after ACL reconstruction, supplemental tenodesis fixation may enable patients to participate safely in more intense, early rehabilitation.

A novel series of potent and selective small molecule inhibitors of the complement component C1s.

Activation of the classical pathway of complement has been implicated in disease states such as hereditary angioedema, ischemia-reperfusion injury and acute transplant rejection. The trypsin-like serine protease C1s represents a pivotal upstream point of control in the classical pathway of complement activation and is therefore likely to be a useful target in the therapeutic intervention of these disease states. A series of thiopheneamidine-based inhibitors of C1s has been optimized to give a 70 nM inhibitor that inhibits the classical pathway of complement activation in vitro.

Optimization of the beta-aminoester class of factor Xa inhibitors. Part 1: P(4) and side-chain modifications for improved in vitro potency.

A systematic modification of the C(3) side-chain of the beta-aminoester class of factor Xa inhibitors and a survey of P(4) variations is described. These changes have resulted in the identification of sub-nanomolar inhibitors with improved selectivity versus related proteases. Coagulation parameters (i.e., APTT doubling concentrations) are also improved.