Hospitalized Infants With Medical Complexity Experience Slow Acquisition of Gross Motor Skills

OBJECTIVES

The progression of infant gross motor development during an acute hospitalization is unknown. Understanding gross motor skill acquisition in hospitalized infants with complex medical conditions is necessary to develop and evaluate interventions that may lessen delays. Establishing a baseline of gross motor abilities and skill development for these infants will guide future research. The primary purposes of this observational study were to: (1) describe gross motor skills of infants with complex medical conditions (n = 143) during an acute hospitalization and (2) evaluate the rate of change in gross motor skill development in a heterogenous group of hospitalized infants with prolonged length of stay (n = 45).

METHODS

Gross motor skills in hospitalized infants aged birth to 18 months receiving physical therapy were evaluated monthly using the Alberta Infant Motor Scale. Regression analysis was completed to assess rate of change in gross motor skills.

RESULTS

Of the 143 participants, 91 (64%) demonstrated significant motor delay at initial evaluation. Infants with prolonged hospitalization (mean 26.9 ± 17.5 weeks) gained new gross motor skills at a significant rate of 1.4 points per month in Alberta Infant Motor Scale raw scores; however, most (76%) continued with gross motor delays.

CONCLUSIONS

Infants with complex medical conditions admitted for prolonged hospitalization frequently have delayed gross motor development at baseline and have slower than typical acquisition of gross motor skills during hospitalization, gaining 1.4 new skills per month compared with peers acquiring 5 to 8 new skills monthly. Further research is needed to determine effectiveness of interventions designed to mitigate gross motor delay in hospitalized infants.

Clinical Assessment of Mechanical Allodynia in Youth With Complex Regional Pain Syndrome: Development and Preliminary Validation of the Pediatric Tactile Sensitivity Test of Allodynia (Pedi-Sense)

Youth with complex regional pain syndrome (CRPS) commonly experience mechanical allodynia and disability. Assessment of mechanical allodynia is typically binary (present or absent), making it difficult to assess the quality and degree of mechanical allodynia before and after treatment. This study developed and validated the Pediatric Tactile Sensitivity Test of Allodynia (Pedi-Sense) to provide an easy way for rehabilitation clinicians to evaluate mechanical allodynia before and after intensive interdisciplinary pain treatment. The 6 Pedi-Sense items demonstrated adequate internal consistency reliability (CR) at admission (CR = .956) and discharge (CR = .973), reasonably fit the hypothesized linear model of stimulus intensity (P < .0001), and significantly loaded onto a single latent factor, mechanical allodynia (P < .0001), at admission and discharge. Pedi-Sense scores significantly correlated with disability (r_s = .40; P = .004) and pain catastrophizing (r_s = .33; P = .017) at admission. The Pedi-Sense appeared responsive to intervention as participants' total scores improved by 1.44 points (95% CI: .72, 2.15) after IIPT interventions that included daily tactile desensitization. However, test-retest and interrater reliability and the specific contribution of desensitization treatment to the overall success of multi-modal pain rehabilitation still needs to be evaluated. PERSPECTIVE: This article presents the development and preliminary validation of a novel clinical assessment of static and dynamic mechanical allodynia. The Pediatric Tactile Sensitivity Test of Allodynia (Pedi-Sense) allows rehabilitation clinicians to easily evaluate mechanical allodynia at the bedside with minimal training and simple equipment to guide desensitization treatment in clinical settings.

Reversible Cerebral Vasoconstriction Syndrome in Patients with Coronavirus Disease: A Multicenter Case Series

BACKGROUND AND OBJECTIVES

RCVS (Reversible Cerebral Vasoconstrictive Syndrome) is a condition associated with vasoactive agents that alter endothelial function. There is growing evidence that endothelial inflammation contributes to cerebrovascular disease in patients with coronavirus disease 2019 (COVID-19). In our study, we describe the clinical features, risk factors, and outcomes of RCVS in a multicenter case series of patients with COVID-19.

MATERIALS AND METHODS

Multicenter retrospective case series. We collected clinical characteristics, imaging, and outcomes of patients with RCVS and COVID-19 identified at each participating site.

RESULTS

Ten patients were identified, 7 women, ages 21 - 62 years. Risk factors included use of vasoconstrictive agents in 7 and history of migraine in 2. Presenting symptoms included thunderclap headache in 5 patients with recurrent headaches in 4. Eight were hypertensive on arrival to the hospital. Symptoms of COVID-19 included fever in 2, respiratory symptoms in 8, and gastrointestinal symptoms in 1. One patient did not have systemic COVID-19 symptoms. MRI showed subarachnoid hemorrhage in 3 cases, intraparenchymal hemorrhage in 2, acute ischemic stroke in 4, FLAIR hyperintensities in 2, and no abnormalities in 1 case. Neurovascular imaging showed focal segment irregularity and narrowing concerning for vasospasm of the left MCA in 4 cases and diffuse, multifocal narrowing of the intracranial vasculature in 6 cases. Outcomes varied, with 2 deaths, 2 remaining in the ICU, and 6 surviving to discharge with modified Rankin scale (mRS) scores of 0 (n=3), 2 (n=2), and 3 (n=1).

CONCLUSIONS

Our series suggests that patients with COVID-19 may be at risk for RCVS, particularly in the setting of additional risk factors such as exposure to vasoactive agents. There was variability in the symptoms and severity of COVID-19, clinical characteristics, abnormalities on imaging, and mRS scores. However, a larger study is needed to validate a causal relationship between RCVS and COVID-19.

Offset analgesia identifies impaired endogenous pain modulation in pediatric chronic pain disorders

Offset analgesia (OA), a psychophysical test of endogenous pain inhibition, is diminished in many adult chronic pain disorders but OA has not been investigated in youth with chronic pain disorders. This study assessed OA responses in 30 youth with chronic primary and secondary pain disorders and 32 healthy controls. The OA, control, and constant thermal tests were evoked with an individualized noxious heat stimulus of approximately 50/100 mm on a visual analogue scale followed by 1°C offset temperature. This study also examined the association of OA responses with 2 self-report measures of pain sensitivity, the Central Sensitization Inventory (CSI) and Pain Sensitivity Questionnaire. Patients exhibited diminished capacity to activate OA with a reduction in ΔeVASc of 53 ± 29% vs controls 74 ± 24% (P = 0.003) even after multivariate regression adjusting for age, sex, and body mass index. Patients also showed decreased ability to habituate to a constant noxious heat stimulus compared to controls (P = 0.021). Central Sensitization Inventory scores showed excellent predictive accuracy in differentiating patients from controls (area under the curve = 0.95; 95% CI: 0.91-0.99) and CSI score ≥30 was identified as an optimal cutoff value. Pain Sensitivity Questionnaire scores did not differentiate patients from controls nor correlate with OA. In this study, 60% of youth with chronic pain showed reduced capacity for endogenous pain inhibition.

Intravenous tPA for Acute Ischemic Stroke in Patients with COVID-19

BACKGROUND/PURPOSE

Coronavirus disease 2019 (COVID-19) is associated with increased risk of acute ischemic stroke (AIS), however, there is a paucity of data regarding outcomes after administration of intravenous tissue plasminogen activator (IV tPA) for stroke in patients with COVID-19.

METHODS

We present a multicenter case series from 9 centers in the United States of patients with acute neurological deficits consistent with AIS and COVID-19 who were treated with IV tPA.

RESULTS

We identified 13 patients (mean age 62 (±9.8) years, 9 (69.2%) male). All received IV tPA and 3 cases also underwent mechanical thrombectomy. All patients had systemic symptoms consistent with COVID-19 at the time of admission: fever (5 patients), cough (7 patients), and dyspnea (8 patients). The median admission NIH stroke scale (NIHSS) score was 14.5 (range 3-26) and most patients (61.5%) improved at follow up (median NIHSS score 7.5, range 0-25). No systemic or symptomatic intracranial hemorrhages were seen. Stroke mechanisms included cardioembolic (3 patients), large artery atherosclerosis (2 patients), small vessel disease (1 patient), embolic stroke of undetermined source (3 patients), and cryptogenic with incomplete investigation (1 patient). Three patients were determined to have transient ischemic attacks or aborted strokes. Two out of 12 (16.6%) patients had elevated fibrinogen levels on admission (mean 262.2 ± 87.5 mg/dl), and 7 out of 11 (63.6%) patients had an elevated D-dimer level (mean 4284.6 ±3368.9 ng/ml).

CONCLUSIONS

IV tPA may be safe and efficacious in COVID-19, but larger studies are needed to validate these results.

Chronic Kidney Disease as Risk Factor for Enlarged Perivascular Spaces in Patients With Stroke and Relation to Racial Group

BACKGROUND AND PURPOSE

Enlarged perivascular spaces (EPVS) are considered subclinical markers of small vessel disease, associated with increased risk of stroke and dementia. Increasing evidence links chronic kidney disease (CKD) to small vessel disease. We explored the relationship between CKD and EPVS burden and the influence of racial group in this relation.

METHODS

Consecutive patients with stroke who underwent brain magnetic resonance imaging were included (n=894). Racial group was categorized as White, Black, or other (other racial groups). CKD was defined by glomerular filtration rate <60 mL/minute per 1.73 m² for >3 months. EPVS were rated following a standardized method, dichotomized for analyses (mild [<20] versus severe [≥20]), and stratified by brain region (basal ganglia and centrum semiovale).

RESULTS

In multivariable-adjusted analysis, the association of CKD with severe EPVS varied across racial groups. Comparing patients with and without CKD within racial groups, we found that Whites with CKD had higher odds of severe centrum semiovale EPVS (odds ratio [OR], 2.41 [95% CI, 0.98-5.88]). Among patients with CKD, Black patients had higher odds of severe EPVS in the basal ganglia and centrum semiovale compared with Whites (OR, 1.93 [95% CI, 1.18-3.16] and OR, 1.90 [95% CI, 1.16-3.11], respectively) and other racial groups (OR, 2.03 [95% CI, 1.23-3.36] and OR, 2.02 [95% CI, 1.22-3.34], respectively).

CONCLUSIONS

CKD was more prevalent in our sample of patients with stroke with severe EPVS in the centrum semiovale. The relation differed when stratified by racial group and brain topography. Further studies are needed to confirm that CKD may relate differently to subclinical measures of small vessel disease according to race.

Does intensive interdisciplinary pain treatment improve pediatric headache-related disability?

Purpose: To examine the effectiveness of intensive interdisciplinary pain treatment for improving disability in children with chronic headache using the International Classification of Functioning, Disability and Health model as a conceptual framework for disability assessment.Materials and methods: Children with chronic headache (n = 50; ages 10-19 years; 62% female) attended an intensive interdisciplinary pain treatment program 8 h/day, 5 times/week for 2-7 weeks. Disability measures were administered at admission, discharge, and 6-8 week follow-up. Disability outcomes were analyzed retrospectively. Wilcoxon signed rank tests and Friedman's analyses of variance were used to compare scores across two and three longitudinal time points, respectively.Results: After rehabilitation, disability reduced on the Headache Impact Test-6 from severe impact at admission to some impact at follow-up (p < 0.001). Median time on the modified Bruce protocol increased from 13.1 min (interquartile range = 12.6-14.1) to 14.4 min (interquartile range = 12.9-16.3), p < 0.001, with gains maintained at follow-up. Improvements in pain and disability were associated with improvements in school participation.Conclusions: Findings of this study support the effectiveness of intensive interdisciplinary pain treatment for improving disability in children with chronic headache.Implication for rehabilitationIntensive interdisciplinary pain treatment is effective for improving pain and disability in children with chronic headaches.Application of the ICF model to disability assessment suggests that children with chronic headaches may experience significant disability, even when standardized assessments of physical capacity are normal.The modified Bruce protocol, Pediatric Evaluation of Disability Inventory - Computerized Adaptive Tests, and Headache Impact Test-6 appear particularly valuable in understanding the nature of disability in children with chronic headaches.

Abstract WP189: Prevalence and Risk Factors for Cerebral Enlarged Perivascular Spaces in Relation to Race and Stroke Severity

Purpose: Racial minorities have a higher prevalence of vascular risk factors (VRF), as well as higher incidence and greater severity of stroke. Enlarged perivascular spaces (EPVS) are considered a marker of small vessel disease reflecting the long term effect of VRF. We aim to determine the prevalence and burden of EPVS in racial minorities, and examine their association with VRF and stroke severity.

Methods: We included 894 consecutive stroke patients who underwent brain MRI admitted to an academic stroke center. EPVS were rated in the basal ganglia (BG), centrum semiovale (CSO) and midbrain (MB) following a standardized method, and dichotomized for analyses (mild <20 vs severe ≥20). Race was assessed based on US census procedures and categorized as White, Black or Other racial groups (ORG). Stroke severity was determined at time of admission using the NIH stroke scale. We used univariate analysis to assess the relation of VRF and EPVS severity, and multivariable logistic regression analysis to relate EPVS and stroke severity.

Results: EPVS were present in the entire sample (219 White, 455 Black, 220 ORG). Severe EPVS prevalence for Whites, Blacks and ORG was for BG 19.6%, 18%, and 15.4%; for CSO, 38.8%, 42.6%, and 33.6%; and for MB, 88.6%, 84.8%, and 84.1%, respectively. In univariate analyses, increasing age was associated with severe EPVS in the BG and CSO in all racial groups (p=< .0001); White and Black women were more likely to have severe EPVS in the BG and CSO (p<0.05). Hypertension was associated with EPVS severity in the BG in the entire sample (p=0.0004), with severe EPVS in MB and BG among Blacks, and with severe EPVS in BG and CSO in ORG (p<0.0001). Dyslipidemia was associated with severity of EPVS in BG only in ORG (p=0.01), while diabetes showed an inverse relation with EPVS severity in BG among Blacks only (p=0.003). EPVS severity was not associated with stroke severity when evaluating different NIHSS thresholds.

Conclusion: Race was not related to EPVS severity in our study, but traditional risk factors were, supporting their role as markers of small vessel disease. Severe EPVS were more frequent in MB, CSO and less common in BG. Further studies are required to clarify the relation of EPVS with stroke severity, assessing other measures and functional outcomes.

Children With Chronic Pain: Response Trajectories After Intensive Pain Rehabilitation Treatment

Intensive pain rehabilitation programs for children with chronic pain are effective for many patients. However, characteristics associated with treatment response have not been well documented. In this article we report trajectories of pain and functional impairment in patients with chronic pain up to 1 year after intensive pain rehabilitation and examine baseline factors associated with treatment response. Patients (n = 253) with chronic pain and functional disability were assessed at 5 time points (admission, discharge, 1-month, 4-month, and 12-month follow-ups). Individual trajectories were empirically grouped using SAS PROC TRAJ. For functional disability, 2 groups emerged: treatment responders (88%) and nonresponders (12%). Using a binomial logistic regression model to predict disability trajectory group, no baseline variables were significant predictors for the disability trajectory group. For pain, 3 groups emerged: early treatment responders (35%), late treatment responders (38%), and nonresponders (27%). Using multinomial regression analyses to predict pain trajectory group, older age, higher pain scores, fewer social difficulties, higher anxiety levels, and lower readiness to change were characteristics that distinguished nonresponders from responders; no significant predictors distinguished the late responders from the early responders. These results provide key information on the baseline factors that influence intensive pain rehabilitation outcomes, including risk factors that predict treatment nonresponse. Our findings have implications for developing more targeted treatment interventions.

PERSPECTIVE

Deriving groups of individuals with differing treatment response trajectories stimulates new thinking regarding potential mechanisms that may be driving these outcomes.

Predictors of Sexual Minority Youth's Reported Suicide Attempts and Mental Health

Lesbian, gay, and bisexual youth (LGBY) report higher rates of mental health concerns compared to heterosexual youth due to minority stressors. This study examined the interpersonal and intrapersonal variables that predict psychological distress and self-reported suicide attempts in a sample of 61 LGBY in the Mid-South, which is a highly overlooked regional area for LGBY research. Youth who lost friends when coming out were 29 times more likely to report suicide attempts, and those who experienced psychological maltreatment from caregivers were 9.5 times more likely to report a suicide attempt. Internalized heterosexism, feelings of guilt or shame, and psychological maltreatment from caregivers were significant predictors of depression and anxiety symptoms. This study highlights the importance of creating affirming spaces for LGBY, particularly in areas of the country that experience greater political oppression of sexual minorities, such as the Mid-South.

The Ordinary Conception of Race in the United States and Its Relation to Racial Attitudes: A New Approach

Abstract

Many hold that ordinary race-thinking in the USA is committed to the 'one-drop rule', that race is ordinarily represented in terms of essences, and that race is ordinarily represented as a biological (phenotype- and/or ancestry-based, non-social) kind. This study investigated the extent to which ordinary race-thinking subscribes to these commitments. It also investigated the relationship between different conceptions of race and racial attitudes. Participants included 449 USA adults who completed an Internet survey. Unlike previous research, conceptions of race were assessed using concrete vignettes. Results indicate widespread rejection of the one-drop rule, as well as the use of a complex combination of ancestral, phenotypic, and social (and, therefore, non-essentialist) criteria for racial classification. No relationship was found between racial attitudes and essentialism, the one-drop rule, or social race-thinking; however, ancestry-based and phenotype-based classification criteria were associated with racial attitudes. These results suggest a complicated relationship between conceptions of race and racial attitudes.

The shc adaptor protein forms interdependent phosphotyrosine-mediated protein complexes in mast cells stimulated with interleukin 3

The Shc adaptor protein possesses 2 distinct phosphotyrosine (pTyr) recognition modules-the pTyr binding (PTB) domain and the Src homology 2 (SH2) domain-and multiple potential sites for tyrosine (Tyr) phosphorylation (Tyr residues 239, 240, and 317). On stimulation of hematopoietic cells with interleukin 3 (IL-3), Shc becomes phosphorylated and may therefore contribute to IL-3 signaling. We investigated the interactions mediated by the Shc modular domains and pTyr sites in IL-3-dependent IC2 premast cells. The Shc PTB domain, rather than the SH2 domain, associated both in vitro and in vivo with the Tyr-phosphorylated beta subunit of the IL-3 receptor and with the SH2-containing 5' inositol phosphatase (SHIP), and it recognized specific NXXpY phosphopeptides from these binding partners. In IL-3-stimulated mast cells, Shc phosphorylation occurred primarily on Tyr239 and 317 and was dependent on a functional PTB domain. Phosphorylated Tyr317, and to a lesser extent, Tyr239, bound the Grb2 adaptor and SHIP. Furthermore, a pTyr317 Shc phosphopeptide selectively recognized Grb2, Sos1, SHIP, and the p85 subunit of phosphatidylinositol 3' kinase from mast cells, as characterized by mass spectrometry. These results indicate that Shc undergoes an interdependent series of pTyr-mediated interactions in IL-3-stimulated mast cells, resulting in the recruitment of proteins that regulate the Ras pathway and phospholipid metabolism.

A previously unreported surgical technique utilizing five different grafting materials to successfully achieve simultaneous alveolar regeneration and closure of a large oronasal defect

This case report describes the successful surgical and restorative management of an unusual cyst-granuloma combination that had expanded to perforate the labial and nasal parts of the maxillary bone. Enucleation and curettage of the lesions resulted in a large oronasal communication that presented a reconstructive challenge. Five different graft and/or barrier materials were used to close the oral and nasal openings and to regenerate the alveolus for implant placement and for aesthetic prosthetic restoration.

Motivation for rhinoplasty: changes in 5970 cases, in three groups, 1964 to 1997

The motivational factors were divided into three categories: (1) independent decision, (2) observation of previous patients, and (3) external influences. The results of the percentage breakdown of the patients in our present study are compared with previous results are presented in 1983 in this journal. Once again, the independent decision of the patient was the most important factor in deciding to have cosmetic rhinoplasty, followed by their observation of results in other patients. These two factors have been the motivation in approximately 80% of all the patients in all three studies. The age breakdown of cosmetic rhinoplasty patients shows that after the age of 21, as patients get older, a smaller and smaller percentage of patients was motivated for surgery by independent decision alone. These older patients need external influences to motivate them to have surgery. In most cases, the desire for surgery had smoldered in them since adolescence, and they needed an external "OK" to have it done.

Clinical evaluation of an acellular dermal allograft for increasing the zone of attached gingiva

Grafting with autogenous tissue or freeze-dried skin is the generally accepted method for increasing and/or restoring the width of attached gingiva. This article describes the periodontal use of an acellular dermal allograft previously available for treating burn patients. When used as a gingival graft, this new dermal allograft has major potential advantages over the previously available periodontal graft materials, including improved color and contour match, elimination of multiple surgeries, and unlimited availability. The technique and results of acellular dermal grafting are presented and discussed. The learning objective of this article is to describe the principles and the clinical procedure of this technique. Several cases are used to illustrate this technique.

A new technique for making occlusal devices

This procedure has an application to all types of occlusal devices. It is a novel combination of hard and soft acrylic resin. The outer shell of hard resin takes the abuse of the opposing occlusion. The thin well-controlled lining of soft resin makes it easier to seat and more comfortable to wear yet is thin enough that the entire device serves as if it were made entirely of hard acrylic resin. The detailed directions for the entire procedure make it possible to fabricate these novel devices without error.

Rhinoplasty update: preoperative evaluation of 4,040 cases

A total of 4,040 cases of cosmetic rhinoplasty surgery was evaluated in terms of sex distribution, age, marital status, and motivating factors. There was a male to female ratio of 1:15.9. Of the 1,880 patients operated on between 1975 and 1980, there were 40.2% females and 33.3% males over the age of 24 years. This is an increase over a previous patient group of 2,160 patients treated between 1964 and 1974, in which older women comprised 26.8% and older men 24% of those treated. The proportion of married patients has increased since 1975, with 29.1% of the women married and 11.4% of the men (versus 18.6% and 4.8%, respectively, for the earlier period). Motivating factors included the patient's own desire for a change, external influences such as advice from family or friends, and observation of someone who had undergone rhinoplasty successfully.

A practical approach to the treatment of burn shock in childhood

A simple method of evaluating and treating burn shock has been used with very good results and low mortality. The amounts of fluids given in a specific time and the type of fluids given are dependent upon the evaluation of a few simple observations. We believe that shock is a treatable condition and that 'shock kidney' is preventable. We stress the difficulty of trying to compare the results of two different burn units.