A Randomized Controlled Trial of Precision Vestibular Rehabilitation in Adolescents following Concussion: Preliminary Findings

OBJECTIVE

To compare the effectiveness of a 4-week precision vestibular rehabilitation intervention compared with a behavioral management control intervention for adolescents with vestibular symptoms/impairment within 21 days of a concussion.

STUDY DESIGN

This study used double-blind, randomized controlled trial design involving adolescent (12-18 years) patients with a diagnosed sport/recreation-related concussion with vestibular symptoms/impairment from a concussion-specialty clinic between October 2018 and February 2020. Eligible participants were randomized in a 1:1 to either a 4-week vestibular intervention group (VESTIB) or a behavioral management control group (CONTROL). CONTROLS (n = 25) were prescribed behavioral management strategies (eg, physical activity, sleep, hydration, nutrition, stress management) and instructed to perform stretching/physical activity (eg, walking, stationary cycle) 30 minutes/day. VESTIB (n = 25) were prescribed precision vestibular rehabilitation exercises and instructed to perform at-home exercises for 30 minutes/day. Primary outcomes were improvement in Vestibular/Ocular Motor Screening vestibular items (ie, horizontal/vertical vestibular-ocular reflex, visual motion sensitivity) at 4 weeks postenrollment.

RESULTS

We screened 310 and enrolled a total of 55 (18%) adolescent patients who were randomized to one of the interventions. Fifty of fifty-five (91%) participants completed all aspects of the study protocol. Participants in VESTIB improved significantly across the intervention period in horizontal (mean difference-1.628; 95% CI [-3.20, -0.06]; P = .04) and vertical (mean difference-2.24; 95% CI [-4.01, -0.48]; P = .01) vestibular-ocular reflex, but not visual motion sensitivity (mean difference-2.03; 95% CI [-4.26, 0.19]) of the Vestibular/Ocular Motor Screening score compared with CONTROLS.

CONCLUSIONS

Overall, the vestibular intervention group experienced greater clinical improvements in vestibular symptoms/impairment than controls across the 4-week intervention.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03555370.

Update: Interim Guidance for Health Care Providers Caring for Pregnant Women with Possible Zika Virus Exposure - United States (Including U.S. Territories), July 2017

CDC has updated the interim guidance for U.S. health care providers caring for pregnant women with possible Zika virus exposure in response to 1) declining prevalence of Zika virus disease in the World Health Organization's Region of the Americas (Americas) and 2) emerging evidence indicating prolonged detection of Zika virus immunoglobulin M (IgM) antibodies. Zika virus cases were first reported in the Americas during 2015-2016; however, the incidence of Zika virus disease has since declined. As the prevalence of Zika virus disease declines, the likelihood of false-positive test results increases. In addition, emerging epidemiologic and laboratory data indicate that, as is the case with other flaviviruses, Zika virus IgM antibodies can persist beyond 12 weeks after infection. Therefore, IgM test results cannot always reliably distinguish between an infection that occurred during the current pregnancy and one that occurred before the current pregnancy, particularly for women with possible Zika virus exposure before the current pregnancy. These limitations should be considered when counseling pregnant women about the risks and benefits of testing for Zika virus infection during pregnancy. This updated guidance emphasizes a shared decision-making model for testing and screening pregnant women, one in which patients and providers work together to make decisions about testing and care plans based on patient preferences and values, clinical judgment, and a balanced assessment of risks and expected outcomes.

4-Hydroxynonenal and malondialdehyde hepatic protein adducts in rats treated with carbon tetrachloride: immunochemical detection and lobular localization

The metabolism of CCl(4) initiates the peroxidation of polyunsaturated fatty acids producing alpha,beta-unsaturated aldehydes, such as 4-hydroxynonenal (4-HNE) and malondialdehyde (MDA). The facile reactivity of these electrophilic aldehydic products suggests they play a role in the toxicity of compounds like CCl(4). To determine the rate at which CCl(4)-initiated lipid peroxidation results in the formation of 4-HNE and/or MDA hepatic protein adducts, rats were given an intragastric dose of CCl(4) (1.0 ml/kg) and euthanized 0-72 h after administration. Rabbit polyclonal antisera directed toward 4-HNE- or MDA-protein epitopes were employed in immuno-histochemical and immuno-precipitation/Western analyses to detect 4-HNE and MDA-protein adducts in paraffin-embedded liver sections and liver homogenates. As early as 6 h post CCl(4) exposure, 4-HNE and MDA adducts were detected immuno-histochemically in hepatocytes localized to zone 2 of the hepatic acinus. Liver injury was progressive to 24 h as lipid peroxidation and hepatocellular necrosis increased. The hallmark of CCl(4) hepatotoxicity, zone 3 necrosis, was observed 24 h after CCl(4) administration and immuno-positive hepatocytes were observed in zone 2 as well as zone 3. Immuno-positive cells were no longer visible by 36 to 72 h post CCl(4) administration. From 6 to 48 h after CCl(4) administration, at least four adducted proteins were immuno-precipitated from liver homogenates with the anti-MDA or anti-4HNE serum, which corresponded to molecular weights of 80, 150, 205, and greater than 205 kDa. These results demonstrate that 4-HNE and MDA alkylate specific hepatic proteins in a time-dependent manner, which appears to be associated with hepatocellular injury following CCl(4) exposure.