Source:Clinical Neurophysiology, Volume 127, Issue 3
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Πέμπτη 11 Φεβρουαρίου 2016
Editorial Board
Source:Clinical Neurophysiology, Volume 127, Issue 3
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Correlation of tau pathology in eye movement related brainstem nuclei in cases of progressive supranuclear palsy (PSP) and a proposed role of perineuronal nets
Source:Clinical Neurophysiology, Volume 127, Issue 3
Author(s): A. Horn, A. Fröschl, J. Feige, S. Röber, H. Kretzschmar
BackgroundProgressive supranuclear palsy (PSP) is characterized by hyperphosphorylated tau protein (HTP) accumulations in different brain regions. A hallmark of clinical symptoms is a vertical gaze palsy, which may be accompanied by horizontal gaze palsy, whereas the VOR is rather preserved until late in the disease. Based on monkey studies functional cell groups of the oculomotor system including transmitters have been identified in the human brainstem (Büttner-Ennever & Horn, 2010).MethodsTo study the spread of the disease through the oculomotor premotor network sections of 8 archival PSP cases with different eye movement deficits were immunostained for HTP. The analysis involved the glutaminergic rostral interstitial nucleus of the medial longitudinal fascicle (RIMLF) and paramedian pontine reticular formation (PPRF), the glycinergic saccadic omnipause neurons (OPN), the cholinergic oculomotor nucleus (nIII) and the vestibular nuclei (VN). Since the RIMLF and nIII contain well-developed perineuronal nets (PN) (Horn et al., 2003), we further stained sections of the PSP cases for the presence of aggrecan (ACAN) and HTP to prove a possible protective role of PNs as suggested from Alzheimer's disease cases (Morawski et al., 2010).ResultsAll PSP-cases showed HTP-staining in neurons and glia of RIMLF, PPRF and OPNs, in late cases in motonuclei as well. Thereby a correlation between eye movement deficits and degeneration of premotor gaze centers and the complete pathways to motoneurons was found, whereas the VN are less affected. The analysis of PNs revealed that ACAN-based PNs were mainly found around HTP-negative neurons, and only few HTP-positive neurons showed weak ACAN staining.ConclusionsThe early and more severe degeneration of premotor centers compared to nIII support a hypothesis that in PSP the pathology progresses along neuronal chains in an anterograde fashion, and it is not confined to specific transmitters. The severe tau pathology in RIMLF and nIII in late PSP cases implies that the presence of PNs may not protect them from degeneration, but on a cellular basis the integrity of PNs is affected by tau-pathology.Support: BMBF (IFB-01EO0901, Brain-Net-01GI0505).
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Investigation of the brainstem blink reflex circuitry in patients with juvenile myoclonic epilepsy
Source:Clinical Neurophysiology, Volume 127, Issue 3
Author(s): N. Uzun, M. Kandemir, M.E. Kiziltan, A. Gunduz, S.N. Yeni
BackgroundJuvenile myoclonic epilepsy (JME) which is among idiopathic generalized epilepsies presents with myoclonus and/or generalized tonic–clonic seizures during puberty. Electrophysiological studies showed findings at several levels including cortex, thalamus and spinal cord in JME. Given these information, we aimed to analyze electrophysiological findings at the level of brainstem using blink reflex (BR) and blink reflex recovery cycle (BR-RC).MethodsEighteen JME patients and age and sex matched 18 healthy volunteers are included in the study. BR and BR-RC with interstimulus intervals of 200ms and 400ms were recorded over orbicularis oculi on the nondominant side under the same conditions.ResultsJME patients had longer onset latencies (p=0.046) and higher amplitudes (p=0.022) of R2 component of BR. Recovery of responses after double stimulation with interstimulus interval of 400ms was higher in JME patients (p=0.040). Use of valproate did not have an impact on reflex responses.ConclusionOur results support increased excitability of BR pathway in JME without relevant pathological findings regarding BR.
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Somatosensory and auditory startle reflex in patients with stroke and spinal cord injury
Source:Clinical Neurophysiology, Volume 127, Issue 3
Author(s): M.E. Kiziltan, M. Sohtaoglu, A. Gunduz, M. Bozluolçay, N. Uzun
BackgroundSomatosensory startle reflex (SSSR) was recently studied in healthy subjects. Following corticospinal tract lesions caused by stroke or spinal cord injury (SCI), auditory startle reflex (ASR) has been reported to enhance due to reorganization of circuits rostral and caudal to the lesion. To further understand changes in SSSR and ASR, we investigated both responses in patients with spinal cord injury (SCI) and stroke.MethodsWe examined characteristics of ASR and SSSR in 14 SCI and 40 stroke patients (16 brainstem and 24 cerebral hemispheric infarctions) and 39 age and gender matched healthy subjects. ASR was obtained after eight auditory stimuli and SSSR was elicited after median nerve stimulation at the wrist. Surface electromyographic recordings were obtained from orbicularis oculi (O.oc), sternocleidomastoid (SCM), biceps brachii (BB) and abductor pollicis brevis (APB) muscles.ResultsTotal ASR probabilities at distal muscles were significantly higher in patients with SCI and in stroke patients especially with brainstem infarctions. Similarly SSSR rates were increased in both patient groups compared to controls (for APB p<0.05). SSR latency of O.oc in SCI patients were similar to controls whereas it was markedly prolonged in stroke patients (p<0.05).ConclusionsIn conclusion, we have found that SSR and ASR were enhanced in stroke and SCI and this enhancement was more prominent in distal muscles. Secondly, the properties of ASr and SSSR differed according to the lesion site.
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Startle reaction evoked by kinematic stimuli
Source:Clinical Neurophysiology, Volume 127, Issue 3
Author(s): J.M. Castellote, M. Kofler, A. Mayr, L. Saltuari
BackgroundKinematic stimuli are used for both assessment and treatment in neurorehabilitation. A patient's voluntary or reflex response may be affected by a startle reaction. We therefore explored whether certain kinematic stimuli are able to elicit a startle reaction.MethodsEleven healthy subjects were suspended in a Lokomat system and were exposed to unexpected passive left knee flexion at 3 velocities (6, 60, 240°/s). Subjects were asked to perform a right wrist extension as soon as they felt their leg move (conditions: 6-React, 60-React, 240-React, respectively). In some 240°/s trials movement onset was preceded by a low-intensity electrical pre-pulse to the left index finger (240-Prep-React). We recorded EMG activity from right orbicularis oculi and sternocleidomastoid muscles to assess startle responses, from left quadriceps muscle to obtain stretch reflexes, and from right wrist extensors to assess reaction time.ResultsStartle responses were present in most 240-Reacttrials, as evidenced by (1) EMG activity in orbicularis oculi and/or sternocleidomastoid, (2) significant reaction time shortening in wrist extensors, and (3) stretch reflex latency shortening in quadriceps, as compared to responses without startle reaction. Only few trials at lower angular velocities resulted in startle responses. In 240-Prep-React trials no startle responses occurred.ConclusionsKinematic stimuli of high angular velocity, used to assess muscle stiffness, may elicit a generalized startle reaction, which in turn may modulate stretch reflex latencies of the muscle tested in a passive movement paradigm.
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Visualization of human brainstem substructures using gray matter nulling 3D-MPRAGE at 7Tesla
Source:Clinical Neurophysiology, Volume 127, Issue 3
Author(s): B. Daeubler, M. Wyss, M. Bruegger, L. Vionnet, D. Brunner, K. Pruessmann
BackgroundThe human brainstem is one of the most complex neural entities, in both, structural and functional domains. Its plurality of small and densely packed substructures results in demanding settings for in vivo MR visualization. We addressed this issue applying ultra-high field MRI at 7Tesla focusing on enhanced differentiation of brainstem substructures. This approach is an essential prerequisite breaking down the complex brainstem anatomy.MethodsA modified 3D-MPRAGE-sequence in the sagittal and transverse plane was applied in a 7T MR-system. To compensate for B1-inhomogeneities, a highly adiabatic inversion prepulse was implemented. Five healthy volunteers were examined. The resulting images were visually correlated to histological plates and post-mortem MRI images from Duvernoy's Atlas.ResultsWe identified 22 structures (sagittal), clearly assignable to histology data. In the brainstem 12 substructures were manually outlined for all five subjects, also based on histology. Adopting histology nomenclature clearly identifiable structures were labeled.ConclusionsOptimized 3D-MPRAGE-imaging in the gray matter nulling regime at 7Tesla provides enhanced image contrast between substructures in the human brainstem, giving rise to better understanding anatomy and potentially related pathology.
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Optokinetic nystagmus of Chiari Malfromation. The aim of our study is to determine the special characteristics of disorders of the Optokinetic nystagmus in the early stages of Chiari Malformation
Source:Clinical Neurophysiology, Volume 127, Issue 3
Author(s): D. Demidenko, V. Viktor
BackgroundDiagnosis and treatment of cochleovestibular dysfunction becomes complicated in case of genetically based combination of pathology. The Chiari Malformation (CM) is a congenital development defect and associated with the caudal displacement of cerebellum and brain stem.The aim of this study is to determine the special characteristics of disorders of the Optokinetic nystagmus in the early stages of CM.At the otorhinolaryngology department of North-West State Medical University named after I.I.Mechnikov (Russia, St Petersburg), 54 cases (patients aged 16–69 ) were studied. All patients showed the symptoms of cochleovestibular dysfunction.MethodsThe Optokinetic nystagmus was taken in a dark-room using VNGULMAR system manufactured by the German company "Heinemann Medizintechnik GmBH" running software developed by the French company Synapsys. The fixed speed horizontal and vertical Optokinetic stimulus on screen (20 o/s) was applied with distracted and focused attention of the patients.All the studies were conducted before the calloric test (CT) and after CT. The intensity of Optokinetic nystagmus was assessed as per SSC (speed of slow component) of nystagmus. Later on the relative asymmetry in Optokinetic nystagmus was calculated for each same name pair of horizontal and vertical Optokinetic reactions.ResultsThe studies showed that in order to diagnose CM in the early stages it is important not only to identify the asymmetry in horizontal and vertical Optokinetic nystagmus but to mark the value and the sign of asymmetry as well. The sign of asymmetry is especially important after CT. Patients with the low placement of cerebellar tonsil Optokinetic reactions are more susceptible to CT.ConclusionsTherefore, in the early stages of CM and "in the risk group", i.e. the patients with low placement of cerebellar tonsil, before the neurological symptoms have taken place and we have only vestibular dysfunction, the videonystagmography with quantitative evaluation of Optokinetic reaction becomes a voluble source of important diagnostic information and an indication for MRI studies.
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Paired neurophysiological and clinical approach to brainstem assessment in Parkinson’s Disease
Source:Clinical Neurophysiology, Volume 127, Issue 3
Author(s): E.R. de Natale, F. Ginatempo, A. Manca, K.S. Paulus, V. Agnetti, E. Tolu, F. Deriu
BackgroundRecent research has highlighted the role of brainstem (BS) structures in the early spread of Parkinson's Disease (PD) pathological process. Vestibular Evoked Myogenic Potentials (VEMPs) corresponding to the Vestibulo-Ocular (VOR), Vestibulo-Masseteric (VMR) and Vestibulo-Collic (VCR) reflexes can provide information on BS function. Aims: to test the aforesaid set of VEMPs in a cohort of PD patients and healthy controls and to correlate it with presence of symptoms ascribable to BS dysfunction.Methods19 PD patients (age 66.9±5.4years; 12 males; mean disease duration 6.16±3.54years) and 15 age and sex matched controls underwent bilateral recording of VOR, VMR and VCR from inferior oblique, masseter and sternocleidomastoid active muscles, respectively. PD patients were additionally administered a series of clinical scales used for evaluation of brainstem-integrated activities, namely sleep disorders (Epworth Sleepiness Scale, Parkinson's Disease Sleep Scale and REM Sleep Behavior Disorder-Screening Questionnaire or RBD-SQ), postural instability (MiniBESTest) and depression (Geriatric Depression Scale). Groups' comparisons were performed with χ2 test and Mann–Whitney U-test; Sperman's rho test was used for correlation analysis.ResultsVEMPs were significantly impaired in patients compared to controls, absence being the main pattern of alteration. When the set of the 3-VEMP battery was analyzed, both number of altered reflexes (p=0.017) and severity of alteration (p=0.001) were significantly higher in patients than controls. As for each single VEMP, only the VOR and the VMR were significantly altered (VOR: p=0.022; VMR: p=0.005; VCR: p=0.056). Clinical scales revealed the presence of some degree of depression in 36.8% of patients, sleep disturbances in 68.4%, REM sleep disorder in 26.3% and postural instability in 36.8% of PD patients. A significant correlation with VEMP alterations was found only for high scores on RBD-SQ (ρ=0.554; p=0.014).ConclusionsCombined assessment of VOR, VMR and VCR was able to detect BS dysfunction in a rostro-caudal extension in PD. This may prove interesting in the perspective of identifying neurophysiological markers of BS dysfunction in early stages of the disease.
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Radiation dose estimation for marine mussels following exposure to tritium: Best practice for use of the ERICA tool in ecotoxicological studies
Publication date: May 2016
Source:Journal of Environmental Radioactivity, Volumes 155–156
Author(s): Lorna J. Dallas, Alexandre Devos, Bruno Fievet, Andrew Turner, Brett P. Lyons, Awadhesh N. Jha
Accurate dosimetry is critically important for ecotoxicological and radioecological studies on the potential effects of environmentally relevant radionuclides, such as tritium (3H). Previous studies have used basic dosimetric equations to estimate dose from 3H exposure in ecologically important organisms, such as marine mussels. This study compares four different methods of estimating dose to adult mussels exposed to 1 or 15 MBq L−1 tritiated water (HTO) under laboratory conditions. These methods were (1) an equation converting seawater activity concentrations to dose rate with fixed parameters; (2) input into the ERICA tool of seawater activity concentrations only; (3) input into the ERICA tool of estimated whole organism concentrations (woTACs), comprising dry activity plus estimated tissue free water tritium (TFWT) activity (TFWT volume × seawater activity concentration); and (4) input into the ERICA tool of measured whole organism activity concentrations, comprising dry activity plus measured TFWT activity (TFWT volume × TFWT activity concentration). Methods 3 and 4 are recommended for future ecotoxicological experiments as they produce values for individual animals and are not reliant on transfer predictions (estimation of concentration ratio). Method 1 may be suitable if measured whole organism concentrations are not available, as it produced results between 3 and 4. As there are technical complications to accurately measuring TFWT, we recommend that future radiotoxicological studies on mussels or other aquatic invertebrates measure whole organism activity in non-dried tissues (i.e. incorporating TFWT and dry activity as one, rather than as separate fractions) and input this data into the ERICA tool.
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Modulation of force and velocity for accurate tasks by a startle
Source:Clinical Neurophysiology, Volume 127, Issue 3
Author(s): J.M. Castellote, J. Valls-Solé
BackgroundSome skilfulfast activities require control of trajectory and force to fulfill the task. It is known that voluntary reactions can be speeded up by a startling auditory stimulus (SAS) delivered at the same time as the imperative signal (IS), a phenomenon termed Start-React (Valls-Solé et al., 1999). The aim of the present study was to examine how the performance of a task that demands accuracy, mainly in terms of velocity during the trajectory or force control when holding an object, is changed by a SAS timed to occur either at the time of IS or at a pre-determined time interval when movement has already begun and motor control of accurate reaching is expected.MethodsNine subjects performed an accurate elbow extension between two spots placed at an angular distance of 30° when holding with their right hand a pen that monitored, through two strain gauge systems, the force of the subject's fingers during the hold, and the force at which pen-tip was exposed with table contact. According to block of trials, this end spot had three possible diameters: 5, 10, and 20mm. Kinematic and force parameters were measured for three conditions, control, with SAS at IS or SAS delivered when movement has already started.ResultsIn SAS trials, there were no evident differences with respect to control trials in the general outline but there were differences in the timing of the events. In SAS-IS trials time to peak velocity was 166ms (SD=41ms), time to peak force was 95ms (SD=43ms) both shorter than in control or SAS delivered when movement began. Peak velocity (315±56o/s) and peak force (8±2 arbitr. units) were larger for SAS-IS trials than for control or SAS delivered when movement started.ConclusionsStartle can advance a task that requires accuracy with velocity and force modulations, but when task onset is already launched there are not evident changes in velocity or force parameters, that seem already prepared.
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Functional magnetic resonance imaging of pain-related brainstem nuclei in single subjects at 7Tesla
Source:Clinical Neurophysiology, Volume 127, Issue 3
Author(s): F. Beissner, J. Polimeni, J. Kim, M. Bianciardi, V. Renvall, C. Eichner, L. Wald, V. Napadow
BackgroundThe function or dysfunction of pain-related nuclei in the brainstem has only been scarcely studied in humans due to the lack of non-invasive measurement methods. The performance of functional magnetic resonance imaging (fMRI), a standard non-invasive technique, is hampered by the close vicinity of the brainstem to large arteries and ventricles as well as its propensity to spatial distortions caused by the oral cavity. Furthermore, the small average size of brainstem nuclei necessitates higher spatial resolution and accuracy than in studies of the cortex. Here, we present a new approach based on ultra-high field fMRI acquisition at 7Tesla and a brainstem-optimized analysis method (mICA), which we apply to study pain-related activity and connectivity of brainstem nuclei in single subjects.MethodsFollowing a multi-modal imaging approach based entirely on echo-planar imaging, we acquired distortion matched functional, T1-weighted structural as well as diffusion-weighted images at a resolution of 1.2mm isotropic. Five 6min runs of resting-state fMRI were acquired, during two of which subjects received a continuous pressure pain stimulus applied to their lower leg by an inflatable cuff.ResultsPain intensity was percept matched at 50/100 points on a visual analogue scale. Applying our recently developed mICA approach (masked independent component analysis), we were able to detect reproducible resting-state activity for specific brainstem nuclei, like the cuneiform nuclei, periaqueductal grey and as well as brainstem-cortex functional connectivity at the single-subject level. We identified a number of pain-related nuclei that showed distinctive activity changes during pain stimulation.ConclusionsIdentification of nuclei was greatly aided by fractional anisotropy (FA) maps created from the diffusion data. Finally, assessing activity and functional connectivity of brainstem nuclei on the single-subject level may soon give us a deeper understanding of disease subtypes, individual differences in pain processing, as well as other functions localized in the brainstem.
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Caregiver Factors in Stroke: Are they the Missing Piece of the Puzzle?
Publication date: Available online 10 February 2016
Source:Archives of Physical Medicine and Rehabilitation
Author(s): Gerald Choon-Huat Koh, Peck-Hoon Ong
Stroke is a major global health problem and a leading cause of long-term disability. As healthcare professionals working with these patients, we work closely with their caregivers because we recognize the crucial role they play in our patients' recovery. Increasingly, the effect of patient factors on caregiver outcomes is being studied. However, the effect of the reverse relationship of caregiver factors on patient outcomes has received much less attention although there is evidence that social and family support can positively (and sometimes negatively) affect patient outcomes. A better understanding of this relationship may have implications on rehabilitation research, professional practice, and policy directions in terms of resource allocation.
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Somatosensory and auditory startle reaction in patients with movement disorders
Source:Clinical Neurophysiology, Volume 127, Issue 3
Author(s): A. Gunduz, M.E. Kiziltan, G. Kiziltan, D. Yavuz, D. Karadeniz
BackgroundStartle reflex (SR) is a generalized defense reaction which is elicited by unexpected stimuli. To elicit SR, auditory and electrical stimulations are used in electrophysiological investigations. Somatosensory startle reflex (SS-SR) is recently described in healthy volunteers after median and tibial stimulation. Studies in patients with brainstem lesions showed importance of upper brainstem in development of SS-SR. Here, we aim to investigate SS-SR systematically in various movement disorders to address its characteristics in comparison to ASR.MethodsWe have examined ASR and SS-SR in patients with dystonia (n=12), multiple system atrophy (n=8), corticobasal degeneration (n=5), restless legs syndrome (n=14), progressive supranuclear palsy (n=11), essential tremor (n=18) and idiopathic PD (n=16) and healthy volunteers (n=35) under the same conditions. ASR and SS-SR were recorded over orbicularis oculi (o.oc), sternocleidomastoid (SCM), and biceps brachii (BB) after bilateral auditory and median nerve electrical stimulations, respectively.ResultsThe pattern and probability rates over each three muscle of ASR were similar in MSA, RLS, ET, PD and healthy individuals. Probability rates of responses over each muscle and total ASR probability were the highest in dystonia group whereas they were the lowest in CBD and PSP (po.oc=0.016, pscm=0.036, pbb=0.000, ptotal=0.009). Onset latencies of O.oc responses were also longer in CBD and PSP groups (p=0.001). Presence of SSR was also the highest in dystonia and lowest in PSP group similar to ASR. Latency of O.oc response was longest in CBD group. Pattern of SS-SR was similar to healthy individuals in all disease groups except dystonia and MSA in which BB responses were more common than SCM responses.ConclusionsThe findings of ASR parallel the previous findings. Dystonia patients are known to have exaggerated ASRs. The decreased response in PSP was previously suggested as a support to show extent of pathology. Findings regarding SS-SR also parallel ASR. SS-SR is also exaggerated in dystonia. Different pattern of response appears to be a reflection of overflow phenomenon. However, development of withdrawal reaction is a possibility. Shorter onset latencies in dystonia group probably also reflect increased excitability. Absence of SS-SR or longer latencies in PSP reflects impairment of its pathway which supports the opinion that it may share pathway with ASR and its generator is possibly in the upper brainstem.
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Task-dependent bimanual coordination after stroke: Relationship with sensorimotor impairments
Publication date: Available online 10 February 2016
Source:Archives of Physical Medicine and Rehabilitation
Author(s): Shailesh S. Kantak, Nazaneen Zahedi, Robert L. McGRath
ObjectivesTo determine bimanual coordination deficits in patients with stroke using 3-D kinematic analyses as they perform naturalistic tasks requiring collaborative interaction of the two arms. To determine if bimanual coordination deficits are related to clinical measures of sensorimotor impairments and unimanual performance of the paretic arm.DesignCase-control studySettingRehabilitation hospital research InstituteParticipants14 patients with unilateral chronic stroke and 10 age-matched control participantsInterventionsNot applicableMain Outcome measuresTemporal coordination between the two hands as participants performed (1) symmetric task: reach-to-pick up a box using both hands and (2) asymmetric task: open a drawer with one hand to press a button inside with the other hand.ResultsDuring the symmetric task, patients and controls showed preserved temporal coupling while transporting the hands to the box. However, upon reaching the box, patients demonstrated impaired ability to cooperatively interact their two arms for an efficient pick-up. This led to significantly longer pickup times compared to controls. Pickup time positively correlated with proprioceptive deficits of the paretic arm. During the asymmetric task, patients had longer time-delay between drawer opening and button pressing movements than controls. The deficits in asymmetric coordination did not significantly correlate with sensory-motor impairments or unimanual paretic arm performance.ConclusionsBimanual coordination was impaired in patients post-stroke during symmetric and asymmetric bimanual tasks that required cooperative interaction between the two arms. While proprioceptive system contributes to symmetric cooperative coordination, commonly-tested measures of paretic arm impairment and/or performance do not strongly predict deficits in bimanual coordination.
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Startle reflex in neurocritical brainstem patients
Source:Clinical Neurophysiology, Volume 127, Issue 3
Author(s): M. Veciana de las Heras, J. Pedro Perez, H. Kumru, C. Flores, S. Yagüe Jimeno, J. Montero Homs, J. Valls-Solé
BackgroundPatients in a neurocritical condition with lesions involving the brainstem cannot cooperate with electrophysiological examination and, therefore, it may be difficult to determine what are the main functions affected. We have used two tests to characterize the deficit in the motor domain, transcranial magnetic stimulation (TMS) to induce motor evoked potentials (MEPs) and loud auditory stimulation (LAS) to induce the startle reflex (SR).MethodsThe study was done in 5 patients who were in their acute/subacute phase after brainstem involvement because of neoplastic tumors (1 cavernoma and 1 meningioma), vascular lesions (1 ictus and 1 haemorrhage) and meningitis with cranial nerve involvement (1 patient). TMS was applied with a round coil or a double-cone coil over the vertex. LAS was applied by discharging the coil flat on top of a metallic platform.ResultsMEPs were obtained in three patients at normal latency while they were absent in the remaining two patients. Attempts of voluntary contraction to facilitate responses did not change the results. The SR was present in two patients (one of them with normal MEPs). Three patients had no startle response. Normal MEPs and SRs were observed only in the patient with meningitis.ConclusionThere was no clear association between presence or absence of SRs and the standard neurological examination in our patients. Apart from direct lesions in nuclei or tracts, we should also consider alterations in excitability as one of the explanations for absence of SR or MEPs.
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Use of the Houghton Scale to classify community and household walking ability in people with lower limb amputation: criterion-related validity
Publication date: Available online 10 February 2016
Source:Archives of Physical Medicine and Rehabilitation
Author(s): Christopher Kevin Wong, William Gibbs, Elizabeth Sell Chen
ObjectiveTo examine the criterion-related validity of using the self-reported Houghton Scale (HS) to classify community-dwelling people with lower-limb amputations according to the suggested score ranges for independent community (HS≥9), household and limited-community (8≥HS≥6), and limited household (5≥HS) walking ability categories as referenced to performance-based balance ability and walking speed criteria.DesignCross-sectional cohort studySettingCommunity-based wellness-walking programs in 8 Mid-Atlantic, Mid-West, and Southeast statesParticipants180 volunteers (66.5% men, n=118) mean age 55.5±16.0 years, with 7.1±13.1 years since amputation, at the transtibial level in 47.0% (n=79), due to vascular disease in 49.4% of cases (n=89).InterventionsNoneMain Outcome MeasuresSelf-reported data: HS, Prosthetic Evaluation Questionnaire mobility subscale (PEQ-MS), and Activities-specific Balance Confidence (ABC) scale. Clinical performance-based measures: balance ability assessed with 3 Berg Balance Scale (BBS) items, and walking ability assessed with Timed-Up-and-Go (TUG) and 2-Minute-Walk-Test (2MWT). The primary reference criteria were 1) performance-based balance ability measured with the 3 BBS items and 2) gait speed calculated from the 2MWT.Results45.9% (78/170) scored HS≥9, 30.6% (52/170) scored 8≥HS≥6, and 23.5% (40/170) scored 5≥HS. HS correlated with PEQ-MS (r=0.73), ABC (r=0.76), balance ability (r=0.67), TUG (r=-0.67), and 2MWT (r=0.73). The 3 HS ability categories differed significantly from each other (p<0.05) for all outcome measures: PEQ, ABC, balance ability, TUG and 2MWT.ConclusionThe HS demonstrated criterion-related validity by differentiating community-dwelling people with lower-limb amputations into community, limited-community/household, and household ability categories that corresponded to performance-based balance and walking criteria. Average prosthetic walking speeds for each category compared to similar walking ability categories defined in other patient populations.
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An excitatory reflex between R1 and R2 responses of the blink reflex to supraorbital nerve stimuli
Source:Clinical Neurophysiology, Volume 127, Issue 3
Author(s): L. Leon, C. Cabib, M. Cordoso, I. Motta, J. Valls-Solé
BackgroundThe typical pattern of the blink reflex to ipsilateral electrical stimuli to the supraorbital nerve (SN) is composed by an early, short duration, well synchronized, R1 response and a late, long duration, polyphasic R2 response. We examined whether the period between R1 and R2 results from lack of excitatory inputs or active inhibition.MethodsTests were performed in 5 healthy subjects and 10 patients of various disorders affecting blink reflex excitability, including postparalytic facial syndrome and hemifacial spasm. All subjects wore surface electrodes attached to the orbicularis oculi and stimuli were applied to the SN. After obtaining the conventional blink reflex, healthy subjects were requested to close their eyes at various levels of force while applying again the same stimulus.ResultsIn healthy subjects closing the eyes with force, SN stimulation induced a response of smaller amplitude and shorter latency than the R2 (25.2±1.3ms). A short and incomplete silent period emerged after R1 and after R2. Patients with postparalytic facial syndrome and essential hemifacial spasm showed activity interfering with the silence between R1 and R2, with often expanding between the two responses, repeating in successive trials.ConclusionsOur results show that there can be reflex responses between R1 and R2 in healthy subjects during contraction and in patients with abnormal reflex excitability. This suggests that the absence of activity between the two responses in normal conditions is the consequence of an active inhibition that reaches the facial motoneurons at that point.
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Novel myopathy in a newborn with Shwachman–Diamond syndrome and review of neonatal presentation
Shwachman–Diamond–Bodian syndrome (SDS) is a pleiotropic disorder in which the main features are bone marrow dysfunction and pancreatic insufficiency. Skeletal changes can occur, and in rare cases manifest as severe congenital thoracic dystrophy. We report a newborn boy with asphyxia, narrow thorax, and severe hypotonia initially suggesting a neuromuscular disease. The muscle biopsy showed myopathic changes with prominent variability in muscle fiber size and abnormal expression of developmental isoforms of myosin. The myofibrils showed focal loss and disorganization of myofilaments, and thickening of the Z-discs including some abortive nemaline rods. The boy became permanently dependent on assisted ventilation. Pancreatic insufficiency was subsequently diagnosed, explaining the malabsorption and failure to thrive. Except transitory thrombocytopenia and leukopenia, no major hematological abnormalities were noted. He had bilateral nephrocalcinosis with preserved renal function. Transitory liver dysfunction with elevated transaminase levels and parenchymal changes on ultrasound were registered. The clinical diagnosis was confirmed by detection of compound heterozygous mutations in SBDS using whole-exome sequencing: a recurrent intronic mutation causing aberrant splicing (c.258+2T>C) and a novel missense variant in a highly conserved codon (c.41A>G, p.Asn14Ser), considered to be damaging for the protein structure by in silico prediction programs. The carrier status of the parents has been confirmed. This case illustrates the challenges in differential diagnosis of pronounced neonatal hypotonia with asphyxia and highlights the muscular involvement in SDS. To our knowledge, this is the first report of myopathy evidenced in a patient with clinically and molecularly confirmed SDS. © 2016 Wiley Periodicals, Inc.
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2 medics injured when Minn. ambulance rolls over
The ambulance did not have a patient on board at the time of the crash
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Can EMS providers be negligent for not following current AHA guidelines?
What is the clinical obligation vs. legal obligation when the standard of care changes for cardiac arrest treatment?
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Making a difference: Using EMS personnel and vehicles for more than just saving lives
By Matt Zavadsky
Two of the greatest assets EMS providers possess are our education and passion for making a difference. When we marry these two assets with our regular tools of the trade, magic happens that can do even more than resolving a cardiac dysrhythmia.
Consider a small child with a debilitating medical condition who cannot go trick or treating like normal kids. Or, an elderly nursing home resident who has not been home for Thanksgiving in years, and may not ever get to do so. We can help these patients in immeasurable ways by adding a little compassion and innovation to the mix. We can make a difference in each of these patient's lives, and the lives of their family, by using our assets to create events that enhance the lives of special people in our communities and increase employee morale. They are also public relations opportunities for our agencies.
Here's some insight on how to develop and successfully implement special rider or transport programs like these in your local community.
Selecting an event
MedStar and many agencies conduct Home for the Holidays programs, usually occurring on Thanksgiving. These programs transport patients from nursing homes to their local family member homes for the day, using medically trained personnel and equipment to help assure the patient's clinical needs are met during the transport.
We also do a trick or treat event, designed to take medically at-risk kids out trick or treating with their families. Some agencies, like American Medical Response, do a Sentimental Journey program which transports hospice patients to their favorite location one last time.
These programs are designed to be used by patients and families who would not ordinarily have the financial wherewithal to pay for a transport like this, especially since it is not a medically necessary transport and therefore not reimbursable by third party insurers.
We choose Thanksgiving for our Home for the Holidays program for two reasons. First, it is generally a very family gathering type of day and therefore conducive to bringing patients to be with loved ones in one location. Second, it is not a religious holiday which prevents us from having to offer the program on Christmas, Hanukah, Kwanza, or other religious holidays.
Obviously we do the trick or treat event on Halloween, but the neighborhood selection deserves careful consideration. We've been blessed to partner with a wonderful community in Fort Worth for our trick or treat event. The neighborhood goes all out with signs, banners and even designated ambulance parking locations for the families.
Patient nomination and selection
Nomination of patients for the Home for the Holidays program are generally made by the nursing home staff, in consultation with the family that the patient may be visiting. We notify the skilled nursing homes in our service area that the program is available about 30-days before Thanksgiving.
We promote the trick or treat event through our local media outlets and social media, channels, again about 30-days before Halloween. This helps friends and family of the children know about the event and submit nominations.
During our first event, one of the nominations actually came from a local TV reporter and in our second year, one of the families who participated in the previous year nominated a family for the following year.
We create some general parameters for nominations:
- The pick-up and transport destination needs to be within our service area
- Patient is not able to transported by any other means than stretcher/ambulance due to their medical condition
- For the Home for the Holidays program, the family must able to care for the patient while the patient is in the home so the ambulance crew will not have to stay with the patient
- For the trick or treat event, the family must be willing to go trick or treating with the patient
- The patient and/or family members are willing to share their story with the local media outlets
- Crew selection and participation
For most paid agencies, you cannot ask crews to volunteer to participate in these programs off the clock, so we pay the crews the appropriate rate for the hours they will be working the event. We do solicit dedicated crews to sign up for the shift covering the event, that way, the folks working the event are doing so because they want to, not because they were assigned the detail as part of their on-duty shift. Doing this also helps us assure the patient pick-up and return times can be accommodated, regardless of the activity in the rest of the system.
In some cases during the Home for the Holidays event, families have invited the crews to stay and share some of the Thanksgiving dinner with the family. Depending on the transport load of the crews, we have given permission for the crews to go ahead and stay for the meal if invited.
During the Trick or Treat event, the crews stay with the patient, literally taking the child door-to-door on the stretcher to collect their treats. This past year, one of the MedStar crews participating in the Trick or Treat event took the time to actually decorate the ambulance as a haunted ambulance — much to the joy of the patient and family being transported for the event.
Logistics
Once the patients participating in the program have been selected, a representative from your agency should visit the patient and family in advance. During this meeting, you can identify any special medical needs for the patient, discover if there is anything unique about the patient, their family, or the event that you can share with the media; pre-screen the layout of the residence to see if there will be any complicated egress issues; and complete any media releases necessary to meet the guidelines for releasing medical information about the patient to the media.
If there are interesting tidbits about the patient or family, share this with the crew assigned to the transport. We have found that in some cases, the crew will do something special for the patient to make the event even more memorable. For example, one patient in our Home for the Holidays event was 103 years young and a die-hard Texas Rangers baseball fan. The crew arranged for a special Texas Rangers blanket and ball cap the patient wore during the transport and then kept as our gift. This was a huge hit with the local media covering the event.
On one of the Trick or Treat events, the entire family dressed up as characters from Alice in Wonderland. This was shared with the media in advance, and one of the reporters came to the event dressed up as a character from Alice in Wonderland as well!
Media coverage
Programs like this are a huge hit with the media and the local community. If the patient and family agree to media coverage and sign the appropriate releases, prepare a media release describing the basics of the transport, the anticipated date, time and location of the pick-up location, as well as anything unique about the patient or family.
Send this media notice out two days prior to the event, as well as the morning of the event. We generally offer to the families to be the media coordination agency to help prevent too many media representatives converging on one family. As such, we do not release the contact information for the family, nor the address of the residence in the media release. If a media outlet wants to cover the event, we coordinate the arrivals and interview slots for the family and share this information as needed.
We subscribe to a media clipping service called TVEyes. If local media does cover the event, we clip the video or print story and give that to the patient and family as a remembrance of the event.
Cautions
A couple of caution notes for a Home for the Holidays event. Some compliance officers have ruled that doing this type of event may violate Anti-Kick Back rules concerned that this event is providing something of value to a nursing home that may refer Medicare or Medicaid patients to your agency.
Our attorneys have reviewed the Anti-Kick Back statutes and have determined this is a concern for two reasons. First, the facility is not receiving any benefit from this program, the patients are receiving a benefit. Second, we are an exclusive provider market and as such, the facility has to use us for medically necessary ambulance transport regardless. Nonetheless, you should clear this program with your local compliance officer before undertaking the program.
Our compliance officer and legal eagles have not raised any concerns about the Trick or Treat event. We transport these children typically from home and not from a facility.
Another caution is assuring the medical suitability of the patient. Be sure the patient is not so unstable that a trip out of the facility would place the patient at risk for significant harm. We do not enroll patients for this program that are on a ventilator, one or more vasoactive drips, or who have other high-risk medical issues. This helps prevent catastrophe while the patient is out of the facility. We do however take patients on suction, oxygen, or who have issues such as seizures or respiratory difficultly. All these issues can be monitored and mitigated by the crews assigned to the events.
Wonderful for morale and community relations
Above all, have fun! The employee morale and community relations value of these programs cannot be overstated. Each year we have done the Home for the Holidays and Trick or Treat programs, the events have been the lead stories in our local media. We keep in touch with the families, share Christmas cards, stories, joys and sorrows.
When one of the children we took trick or treating passed away a year later, some of us attended the memorial service and cried with the family. The family mentioned that the one time they got to all go trick or treating together was one of their most wonderful memories.
Use the assets you have to make difference for patients, families and your community in innovative ways and trust me, you will get back tenfold what you invest in programs like these.
View media coverage of MedStar's Home for the Holidays and Trick or Treat events.
If you would like more information on how to conduct these types of programs, feel free to contact me.
About the author
Matt Zavadsky, MS-HSA, EMT, is the public affairs director at MedStar Mobile Healthcare, the exclusive emergency and non-emergency EMS/MIH provider for Fort Worth and 14 other cities in North Texas. He has 34 years' experience in EMS and holds a master's degree in Health Service Administration with a Graduate Certificate in Health Care Data Management. Matt is a frequent speaker at national conferences and has done consulting in numerous EMS issues, specializing in mobile integrated healthcare, high performance EMS system operations, public/media relations, public policy, health informatics, costing strategies and EMS research.
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Do Local Social Hierarchies Matter for Mental Health? A Study of Neighborhood Social Status and Depressive Symptoms in Older Adults
Objectives.
Despite a well-established association between relative social position and health, stratification at smaller levels of social organization has received scant attention. Neighborhood is a localized context that has increasing relevance for adults as they age, thus one's relative position within this type of mesolevel group may have an effect on mental health, independent of absolute level of social and economic resources. We examine the relationship between an older adult's relative rank within their neighborhoods on two criteria and depressive symptoms.
Method.Using data from the Chicago Health and Aging Project, neighborhood relative social position was ascertained for two social domains: income and social reputation (number of neighbors one knows well enough to visit). Using multilevel models, we estimated the effect of relative position within the neighborhood on depressive symptoms, net of absolute level for each domain and average neighborhood level.
Results.Higher neighborhood relative rankings on both income and visiting neighbors were associated with fewer depressive symptoms. Although both were modest in effect, the gradient in depressive symptoms was three times steeper for the relative rank of visiting neighbors than for income. Men had steeper gradients than women in both domains, but no race differences were observed.
Discussion.These findings suggest that an older adult's relative position in a local social hierarchy is associated with his/her mental health, net of absolute position.
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Staying on Task: Age-Related Changes in the Relationship Between Executive Functioning and Response Time Consistency
Objective.
Little is known about the relationship of executive functioning with age-related increases in response time (RT) distribution indices (intraindividual standard deviation [ISD], and ex-Gaussian parameters mu, sigma, tau). The goals of this study were to (a) replicate findings of age-related changes in response time distribution indices during an engaging touch-screen RT task and (b) investigate age-related changes in the relationship between executive functioning and RT distribution indices.
Method.Healthy adults (24 young [aged 18–30], 24 young-old [aged 65–74], and 24 old-old [aged 75–85]) completed a touch-screen attention task and a battery of neuropsychological tests. The relationships between RT performance and executive functions were examined with structural equation modeling (SEM).
Results.ISD, mu, and tau, but not sigma, increased with age. SEM revealed tau as the most salient RT index associated with neuropsychological measures of executive functioning. Further analysis demonstrated that correlations between tau and a weighted executive function composite were significant only in the old-old group.
Discussion.Our results replicate findings of greater RT inconsistency in older adults and reveal that executive functioning is related to tau in adults aged 75–85. These results support literature identifying tau as a marker of cognitive control, which deteriorates in old age.
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EMS training: Make the most of every opportunity
When teaching new EMS skills or review old ones, take advantage of the chance to put them in context and reinforce good clinical decision-making
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5 benefits of regionalizing EMS vehicle fleet maintenance
Increasing the number of ambulances in a regionalized fleet maintenance program gives paramedic chiefs more influence with vendors
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Close To You? How Parent-Adult Child Contact Is Influenced by Family Patterns
Objectives.
Intergenerational contacts occur in the context of other family relationships. We examine how in-person contacts among parents and all adult children affect each other, focusing on proximity and other predictors to assess whether and how visiting is correlated across adult children.
Methods.We use a modeling approach derived from an adaptation of multilevel models to provide a convenient mechanism by which to write child-specific equations, each with its own set of predictors, and wherein one child's attribute values can be attached to other children's records.
Results.We find that parent–adult child visiting is positively correlated across siblings, but the frequency of visiting within families is not directly reciprocated. Rather, visiting responds to common family factors. Visiting declines with distance, but there are strong discontinuities in the effect. Distance between parents and a focal child is positively associated with visiting with other children.
Discussion.The empirical patterns we report can be framed within enhancement and compensation models. Positive correlations and cross-sibling interactions that juxtapose levels of visiting against not seeing a child in last 12 months are consistent with the enhancement model. The cross-sibling interaction for distance, whereby one child's farther distance leads to more visits reported with others, provides evidence of a countervailing, though, weaker, pattern of compensation for proximity.
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Mechanisms of xenobiotic receptor activation: Direct vs. Indirect
Publication date: Available online 10 February 2016
Source:Biochimica et Biophysica Acta (BBA) - Gene Regulatory Mechanisms
Author(s): Bryan Mackowiak, Hongbing Wang
The so-called xenobiotic receptors (XRs) have functionally evolved into cellular sensors for both endogenous and exogenous stimuli by regulating the transcription of genes encoding drug-metabolizing enzymes and transporters, as well as those involving energy homeostasis, cell proliferation, and/or immune responses. Unlike prototypical steroid hormone receptors, XRs are activated through both direct ligand-binding and ligand-independent (indirect) mechanisms by a plethora of structurally unrelated chemicals. This review covers research literature that discusses direct vs. indirect activation of XRs. A particular focus is centered on the signaling control of the constitutive androstane receptor (CAR), the pregnane X receptor (PXR) and the aryl hydrocarbon receptor (AhR). We expect that this review will shed light on both the common and distinct mechanisms associated with activation of these three XRs.
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Religious Attendance and Physiological Problems in Late Life
Objectives.
This study queried linkages of older adults' religious attendance with their physiological health.
Method.Data were from the 2005–2006 National Social Life, Health, and Aging Project, nationally representative of U.S. adults aged 57–85 years. Analyses examined associations of religious attendance with biological states, potential gender variations in these linkages, and attenuation by this factor of health effects of spousal loss.
Results.Religious attendance was negatively associated with a system of physiological issues, consistent with mitigation of multisystemic "weathering." Linkages were relatively uniform with inflammatory and cardiovascular but not metabolic states and were not significantly different for women than men. Effects of spousal loss on the 2 former subsystems were attenuated by regular religious attendance—in combined-gender analysis and among women, but not men.
Discussion.Religious attendance may buffer older adults from physiological problems and the health effects of life events such as spousal loss. More intensive analysis is needed to explain differential linkages with specific biological subsystems.
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Age, Rumination, and Emotional Recovery From a Psychosocial Stressor
Objectives.
Exposure to psychosocial stressors often elicits increases in negative affect and blood pressure (BP). Rumination, or thinking about a stressor after it passes, is associated with delayed recovery. Given that older age is associated with greater BP reactivity to psychosocial stressors, rumination may be more detrimental to the recovery of older adults than younger adults. The current study examined this question. We hypothesized that prolonged distress resulting from rumination has greater effects on the recovery of older than younger adults.
Method.Fifty-two older (M = 69 years) and 61 younger (M = 21 years) adults were exposed to a lab stressor. Afterwards, participants were randomly assigned to a rumination condition (n = 58) or a no-instruction control condition (n = 55).
Results.Older participants in the rumination condition had delayed BP recovery relative to those in the control condition and all younger adults. Rumination did not influence affective recovery among any of the groups.
Discussion.Rumination delays BP recovery among older adults, suggesting age-specific risks associated with different types of emotion regulation strategies.
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5 benefits of regionalizing EMS vehicle fleet maintenance
By Jim Woods, NEMSMA
Regionalizing fleet management, maintenance and supply purchasing and stocking is one of the easiest and possibly least controversial regionalization efforts EMS leaders can implement.
The top benefit of increasing vehicle numbers is to buying power. Every EMS organization should take steps to increase their footprint with their vendors to ensure a fair and diligent working relationship. Any organization that has an influence over others through fleet regionalization and central purchasing initiatives, whether it is direct or indirect, becomes a more valued customer by the vendor community. It is for this reason that once regionalization talks have begun, steps to integrate a shared fleet management program and purchasing department should be considered a top priority.
Fleet regionalization does not need to include layoffs and definitely does not include service capacity reduction. Rather the savings of consolidating a fleet operation is the elimination of duplicative training for the staff as well as the duplicated equipment procured for each vehicle maintenance location.
Generally speaking, EMS fleets are over utilized and plagued with significant down time. Every EMS manager has heard excuses from a maintenance vendor or the ambulance manufacture as to why a vehicle is broken and cannot be used. When an EMS operation joins a regionalized fleet operation, they take the wheel on their ambulance issues. A regionalized fleet facility, correctly setup, has purchasing power to reduce parts costs and the volume of vehicles to fund appropriate technician training and advanced equipment diagnostics.
Here are five best practices to implement when regionalizing fleet management and maintenance efforts.
1. Reduce duplicated training efforts
A regional vehicle maintenance shop is capable of having a team of technicians who specialize in different tasks. Just like scope of practice is different for an EMT and a paramedic, mechanics have different competency levels which are closely associated with their hourly rate. A regional fleet maintenance operation has the vehicle volume to maintain appropriate staffing at each mechanic level to ensure technician competence and avoid overpaying redundancies.
This might allow for a diesel engine expert, a body repair and painting expert, and a chassis and tire expert to work side-by-side on the tasks they know and do best. For example, the 2010 EPA standards make a vehicle's exhaust system one of the most troublesome and expensive components to keep in working order. One solution is to have an in-house specialist to repair and update exhaust systems rather than outsourcing the complex diagnostics and repairs that are necessary.
2. Increase the number of vehicles per diagnostic computer
With all of the advanced electronics on board ambulances the computers that technicians use to diagnose problems are extremely expensive. Instead of each local facility owning these expensive computers, the regional facility has the ability to maintain an appropriate ratio of computers to vehicles thus reducing the cost of advanced diagnostics.
These advanced computers also require technicians to master a lot of training. Small-volume ambulance fleet operations are no longer able to make a significant impact in reducing costs when you factor in the additional technician training and equipment that must be purchased in order to work on today's vehicles.
3. Wholesale pricing on parts purchases
A regionalized fleet maintenance operation can bring in the immediate benefit of business-to-business pricing of vehicle OEM parts. Ford and General Motors have extensive business dealership networks that work solely with private repair facilities to streamline parts ordering and delivery, as well as ensuring extremely competitive wholesale pricing.
4. Increase on-hand inventory of critical parts
Along with taking advantage of business-to-business pricing, regional facilities are capable of internally stocking additional volumes of parts. Anything that can be done to reduce vehicle downtime, such as stocking commonly used items or critical to vehicle operation parts, will increase vehicle up time and reduce the need for backup vehicles.
5. Utilize a full-service tire vendor
There are not many things drivers can do to significantly reduce ambulance tire wear which makes it important to get the best price on tires while also assuring the highest level of safety from those tires. To do this many large fleet operations take advantage of tire vendors who supply new heavy-duty tires along with professionally mounting those tires on the wheel. The completed product — tire mounted on the wheel — is delivered to the regional repair facility to be placed on the ambulances.
In this arrangement the tire vendor is responsible for inspecting the tire and wheel and reconditioning the wheel every time a new tire is mounted on it. This greatly assists with the appearance of the vehicle, as the wheels are now freshly painted, and gives you, the customer, exceptional wholesale pricing.
When these five components are put in place it will greatly assist in the reduction of costs and increase the proficiency of the fleet maintenance operation.
About the author
Jim Woods works for a nationwide full-service truck leasing company. He is a Certified Automotive Fleet Manager and holds many ASE certifications. He got his start in EMS as a paramedic in Jersey City, N.J. and then went on to manage fleet operations for two regional, hospital-based EMS agencies in New Jersey.
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EMS training: Make the most of every opportunity
A few months ago, I attended some refresher training on the video laryngoscope that had recently been added to our department's protocols. Apparently a review of the PCR data showed that we weren't using the VLs and that intubation rates had not improved. It was unclear whether or not that was because of an actual problem using the device or documentation errors, but the decision was made — correctly, in my opinion — to provide an in-service VL refresher to every ALS provider.
Unfortunately, this opportunity, like many, was another one wasted.
The paramedic who conducted the training did a good job. It was helpful to practice with the device, become comfortable with how it works, and use it on a manikin a few times. But the training could have been so much more.
After all, how often do we talk to and train every ALS provider in the agency" Besides the regular required continuing education sessions, and an occasional protocol change, it's a rare occasion. And when we do, we often focus solely on a specific skill, like VL intubation. We don't tie the motor skill to the cognitive decision-making process that might be necessary to perform it appropriately, nor did we even train on the other motor skills that often precede or follow intubation.
For example, part of using a video laryngoscope is deciding when to intubate, positioning the patient properly, choosing the right tube, suctioning, and ventilating the patient both before and after intubation. Yet, none of those skills was discussed during this training. Or practiced. We didn't even have a mask, so BVM ventilation prior to intubation couldn't be simulated, even though it's a critical skill that we don't practice enough, especially those of us who are ALS providers.
Contrast this with another training session that I got to teach, but can take none of the credit for, a few months earlier. Another protocol change enabled BLS providers to begin administering intramuscular epinephrine by drawing it into a syringe from a vial. The change was made to save money by no longer purchasing epinephrine auto-injectors.
The slides and other teaching materials, which were provided to me, covered more than the basics of how to draw up and administer the medication. Even though the indications for giving epinephrine had not changed, just the method of administration, we covered how to recognize the signs and symptoms of allergic reactions, what the side effects of epinephrine are, and what other medications and treatments should be considered for those patients. We put the skill into clinical context and took advantage of this opportunity to comprehensively review the topic.
Before implementing any training program, but especially those that are mandatory for every provider, such as the introduction of new equipment or protocols, consider these questions:
1. Am I focusing too much on the motor skill and not the cognitive thinking that should go before, during and after the procedure"
Any training that focuses solely on a single skill creates dangers. Perhaps new caregivers, recently given a new tool, will be in a rush to use it, even at the wrong time. Or maybe, as in the case of drawing up epinephrine, providers will be too hesitant to try something that's new, different, and for years they'd been told they weren't qualified to do.
Others have said more eloquently how focused we are on skills, rather than clinical decision-making, in EMS. Every single time we review a skill we need to also reinforce the thought-process that we use to determine whether or not to perform that procedure.
2. What other skills, tools or equipment should I have personnel use during training"
If a skill is always accompanied by other skills, do them together. This is especially critical in airway training. I remember in paramedic school when we had a long list of skills that were required. Intubation was one. Bag-valve mask ventilation was another. Suctioning was on the list also. But these aren't just three isolated techniques. Each and every time you have a laryngoscope and a manikin, you should have a BVM and suction.
We're really good at saying that "we practice like we fight," but we're not as good at actually doing it. Every time a paramedic starts to intubate and doesn't have suction ready, it's because we often have trained that way.
3. Does this training present a good chance to review a protocol or clinical condition"
Training on how to use a new CPAP machine" Seems like a perfect opportunity to review the pathophysiology and signs and symptoms of congestive heart failure or chronic respiratory ailments. Or perhaps to review the importance of and indications for also giving nitroglycerin to those CHF patients.
Interventions do not exist in a vacuum, but we often teach them like they do, setting up providers to fail and patients to receive potentially dangerous care.
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Can EMS providers be negligent for not following current AHA guidelines?
The American Heart Association updated its Emergency Cardiovascular Care and CPR guidelines in late 2015. For many health care providers, in both the pre-hospital and in-hospital setting, these guidelines are integrated into the daily practices of patient treatment and transportation.
This shapes the AHA ECC and CPR guidelines into the standard of care for patients experiencing acute cardiac, respiratory, and neurological emergencies either in the field, ambulance, or hospital setting. When the guidelines and standard of care change, what must one do to satisfy their clinical and legal obligations when treating patients"
Standard of care
The standard of care is often defined in the context — and as a component to — negligence. Black's Law Dictionary defines negligence as "the failure to exercise the standard of care that a reasonably prudent person would have exercised in a similar situation ... " and defines the standard of care as "the degree of care that a reasonable person should exercise."
If one fails to exercise the standard of care as a reasonably prudent person would, there are potential grounds for a civil lawsuit. However, and as a general statement of law, those persons demonstrating advanced knowledge or skill will be held to the degree that a reasonable person, of that same advanced knowledge or skill, will be held.
This means a layperson will be compared to other lay people and that a paramedic will be compared to a paramedic of similar education, training, and experience. The paramedic won't be compared to the skills of a layperson; they will be held to a higher level standard of care because of their advanced knowledge and skill developed through education, training, and experience. If a paramedic fails to exercise the standard of care, as a reasonably prudent paramedic with similar education, training, and experience, they may be negligent and potentially at fault, or liable, in a civil lawsuit.
Remember, these are general definitions and statements, and each state is free to define negligence and standard of care as it so wishes.
Clinical and legal obligations to the standard of care
Black's Law Dictionary defines an obligation as a "legal or moral duty to do, or, not to do something". EMS providers are given duties to do, or, not do something, via scopes of practice and treatment guidelines or protocols. These governing documents are often populated after much discussion between state government agencies, medical directors, advanced practice individuals, and providers. More and more scopes of practices and guidelines are being updated, on a more frequent basis, to reflect the most current trends and incorporate more evidence based treatments.
Some states even reserve the right to only update a portion of the guidelines or protocols, rather than the entire document, to enact an immediate change in practice when evidence suggests such a change should occur. Essentially, these scopes and guidelines not only create duties, but standardize these duties of care.
The easiest way to answer the question of "what should I do" is to understand the immediate policies, protocols, or guidelines that provide both the scope of practice and the authorization for treatments during patient care. These immediate policies or protocols, listed in ascending order of governance, can be from a service, organization, county, region, and lastly any governmental entity, such as a state. It's these governing documents that create the standards of care and legal duties to which a provider is held accountable and responsible. And it is deviation from these that lay the ground work for civil negligence lawsuits.
When these immediate policies and protocols conflict with additional education and knowledge, such as an update to guidelines or the standard of care, acquired in the course of maintaining licensure or certification, such as BLS, ACLS, or ACLS-EP, it is best to seek additional clarification. This clarification should come from the service, organization, county, region, or governmental entity which governs the scope of practice and treatments. The clarification should be on not only if the new guidelines will be adopted, but if so, what the timeline is for implementation, and the start date of using the new guidelines.
Need to update protocols and policies
It is important to remember that although EMS personnel are guided in the field by protocols and policies, that failure to update protocols and policies when indicated can itself be considered to be negligent. Say, for instance, that a medical director who possesses the authority to update your agency's protocols fails to do so and clings to outdated treatments despite overwhelming clinical evidence that the protocols need to be changed. Although the standard of care would almost always permit a reasonable time to implement new protocols after medical evidence changes, the medical director and the agency could face liability if they negligently fail to implement those changes in a reasonable, timely manner.
When the guidelines and standard of care change, what must one do to satisfy their clinical and legal obligations when treating patients" One must be aware of the governing documents that define scope of practice and treatment guidelines, as these create the standard of care to which one is held responsible and creates the clinical obligation. The legal obligation that must be satisfied is to comply and act as another provider, with similar education, training, and experience, would act under similar circumstances. Deviance from either may result in fault, or liability, in a lawsuit.
A practical test to use in any situation where you are a bit unsure of your actions (or inactions) is to simply ask yourself: Am I about to do what other reasonable EMS providers would do in this situation" If the answer is yes, you are likely on the path to do the right thing for your patient, and with the least amount of risk.
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Making a difference: Using EMS personnel and vehicles for more than just saving lives
Every EMS agency can innovatively use their assets for more than saving lives while making a profound difference for patients and families
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4 ways EMS chiefs can communicate with foreign-language speaking public
The growing number of limited English speakers raises the urgency for managers and chiefs to have a solid plan for communicating with them in times of need
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Health Trajectories of Women in China: The Role of Parental Caregiving
Objectives.
Studies show that caregiving can have negative consequences on the psychological and physical health of its providers. However, few studies have examined the immediate and long-term impact of caregiving on health and none have considered these longitudinal associations among women in a predominately family-care society such as China.
Method.Six waves of data from the Ever-Married Women Survey component of the China Health and Nutrition Survey (n = 6,178) are used for analysis. Multivariate latent growth models are used to examine trajectories of self-rated health associated with providing care to parents (parental caregiving) among young-adult and middle-aged women in China.
Results.Results show that women who are caregivers to their parents have consistently worse self-reported health than women who do not have caregiving responsibilities. We find that caregivers—especially those who provide high-intensity care—exhibit initially low levels of health, followed by a period of health improvement that is comparable to noncaregivers. However, this pattern of role adaptation in women is followed by a precipitous decline in self-rated health in later years.
Discussion.The findings demonstrate the subjective health consequences of caregiving for women in China and provide new evidence to support the life course processes of wear-and-tear and role adaptation.
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Wanting to Get More or Protecting Ones Assets: Age-Differential Effects of Gain Versus Loss Perceptions on the Willingness to Engage in Collective Action
Objectives.
The present research examined motivational differences across adulthood that might contribute to age-related differences in the willingness to engage in collective action. Two experiments addressed the role of gain and loss orientation for age-related differences in the willingness to engage in collective action across adulthood.
Method.In Experiment 1, N = 169 adults (20–85 years) were confronted with a hypothetical scenario that involved either an impending increase or decrease of health insurance costs for their respective age group. In Experiment 2, N = 231 adults (18–83 years) were asked to list an advantage or disadvantage they perceived in being a member of their age group. Subsequently, participants indicated their willingness to engage in collective action on behalf of their age group.
Results.Both experiments suggest that, with increasing age, people are more willing to engage in collective action when they are confronted with the prospect of loss or a disadvantage.
Discussion.The findings highlight the role of motivational processes for involvement in collective action across adulthood. With increasing age, (anticipated) loss or perceived disadvantages become more important for the willingness to participate in collective action.
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The Oct1 transcription factor and epithelial malignancies: Old protein learns new tricks
Publication date: Available online 10 February 2016
Source:Biochimica et Biophysica Acta (BBA) - Gene Regulatory Mechanisms
Author(s): Karina Vázquez-Arreguín, Dean Tantin
The metazoan-specific POU domain transcription factor family comprises activities underpinning developmental processes such as embryonic pluripotency and neuronal specification. Some POU family proteins efficiently bind an 8-bp DNA element known as the octamer motif. These proteins are known as Oct. transcription factors. Oct1/POU2F1 is the only widely expressed POU factor. Unlike other POU factors it controls no specific developmental or organ system. Oct1 was originally described to operate at target genes associated with proliferation and immune modulation, but more recent results additionally identify targets associated with oxidative and cytotoxic stress resistance, metabolic regulation, stem cell function and other unexpected processes. Oct1 is pro-oncogenic in multiple contexts, and several recent reports provide broad evidence that Oct1 has prognostic and therapeutic value in multiple epithelial tumor settings. This review focuses on established and emerging roles of Oct1 in epithelial tumors, with an emphasis on mechanisms of transcription regulation by Oct1 that may underpin these findings.
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Combining Formal and Informal Caregiving Roles: The Psychosocial Implications of Double- and Triple-Duty Care
Objectives.
Women who combine formal and informal caregiving roles represent a unique, understudied population. In the literature, healthcare employees who simultaneously provide unpaid elder care at home have been referred to as double-duty caregivers. The present study broadens this perspective by examining the psychosocial implications of double-duty child care (child care only), double-duty elder care (elder care only), and triple-duty care (both child care and elder care or "sandwiched" care).
Method.Drawing from the Work, Family, and Health Study, we focus on a large sample of women working in nursing homes in the United States (n = 1,399). We use multiple regression analysis and analysis of covariance tests to examine a range of psychosocial implications associated with double- and triple-duty care.
Results.Compared with nonfamily caregivers, double-duty child caregivers indicated greater family-to-work conflict and poorer partner relationship quality. Double-duty elder caregivers reported more family-to-work conflict, perceived stress, and psychological distress, whereas triple-duty caregivers indicated poorer psychosocial functioning overall.
Discussion.Relative to their counterparts without family caregiving roles, women with combined caregiving roles reported poorer psychosocial well-being. Additional research on women with combined caregiving roles, especially triple-duty caregivers, should be a priority amidst an aging population, older workforce, and growing number of working caregivers.
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Cognitive Domains and Health-Related Quality of Life in Alzheimers Disease
Objectives.
The nature of the association between the cognitive decline and quality of life (QoL) during the course of Alzheimer's disease (AD) has not been studied in detail. We designed this study to determine if the association between cognitive domains in AD and health-related quality of life (HRQoL) changed over 18 months.
Methods.We recruited 80 community-dwelling older adults with mild to moderate AD and 61 healthy elderly controls as well as their next-of-kin. The primary outcome measure was the QoL-AD. Specific cognitive functions were assessed with a broad range of neuropsychological measures, which were later grouped into cognitive domains following factor analyses at the baseline and 18-month assessments. Other explanatory variables included demographics, psychopathology, burden of care, and use of medication.
Results.Self-reported QoL-AD scores were not associated with any of the identified cognitive domains at either assessment. The cognitive domains of people with AD changed between baseline and the 18-month assessment, as did the association of these factors with carer-rated HRQoL. The HRQoL scores assigned by the next-of-kin declined alongside a general measure of cognitive function.
Discussion.These results indicate that HRQoL is not consistently associated with specific cognitive domains in AD and that cognitive-enhancing focused therapies may fail to affect the HRQoL of people with AD.
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The Effects of Structural Complexity on Age-Related Deficits in Implicit Probabilistic Sequence Learning
Objective.
The primary objective was to determine whether age deficits in implicit sequence learning occur not only for second-order probabilistic regularities (event n – 2 predicts n), as reported earlier, but also for first-order regularities (event n – 1 predicts event n). A secondary goal was to determine whether age differences in learning vary with level of structure.
Method.Younger and older adults completed a nonmotor sequence learning task containing either a first- or second-order structure. Learning scores were calculated for each subject and compared to address our research objectives.
Results.Age deficits in implicit learning emerged not only for second-order probabilistic structure, but also for simple, first-order structure. In addition, age differences did not vary significantly with structure; both first and second order yielded similar age deficits.
Discussion.These findings are consistent with the view that there is an associative binding deficit in aging and that this deficit occurs for implicit as well as explicit learning and across simple and more complex sequence structures.
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Volunteerism: Social Network Dynamics and Education
Objectives
. We examine how changes in social networks influence volunteerism through bridging (diversity) and bonding (spending time) mechanisms. We further investigate whether social network change substitutes or amplifies the effects of education on volunteerism.
Methods. Data (n = 543) are drawn from a two-wave survey of Social Relations and Health over the Life Course (SRHLC). Zero-inflated negative binomial regressions were conducted to test competing hypotheses about how changes in social network characteristics alone and in conjunction with education level predict likelihood and frequency of volunteering.
Results. Changes in social networks were associated with volunteerism: as the proportion of family members decreased and the average number of network members living within a one-hour drive increased over time, participants reported higher odds of volunteering. The substitution hypothesis was supported: social networks that exhibited more geographic proximity and greater contact frequency over-time compensated for lower levels of education to predict volunteering more hours.
Discussion. The dynamic role of social networks and the ways in which they may work through bridging and bonding to influence both likelihood and frequency of volunteering are discussed. The potential benefits of volunteerism in light of longer life expectancies and smaller families are also considered.
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Tatton–Brown–Rahman syndrome due to 2p23 microdeletion
Tatton–Brown–Rahman syndrome is a new overgrowth syndrome due to DNMT3A (DNA cytosine 5 methyltransferase 3A) mutations. Mutation carriers show a distinctive facial appearance, intellectual disability, and increased height. We report a patient with overgrowth who showed submicroscopic deletion of chromosome 2p23 including DNMT3A. The deletion was detected by array-CGH. He showed moderate ID and distinctive facial gestalt. His clinical features were consistent with those of Tatton–Brown–Rahman syndrome. We suggest that 2p23 microdeletion including DNMT3A may cause similar symptoms in patients with DNMT3A mutations and should be considered in patients with overgrowth. © 2016 Wiley Periodicals, Inc.
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A study to evaluate the effectiveness of first aid training on mothers among under 15 years children in a rural area of South India
2016-02-11T06-56-44Z
Source: International Journal of Community Medicine and Public Health
Rekha S. Sonavane, Aravind Kasthuri, Deepthi Kiran.
Background: Studies done in developed and developing countries have demonstrated deficiencies in knowledge of first aid among caregivers. With nearly 73% of the population of India is residing in rural areas. Thus this study was undertaken to document the effectiveness of first aid training on mothers in a rural area of South India. Methods: A cross sectional study conducted among 140 mothers of under 15 children in a village of South India. For the purpose of assessing the overall knowledge of subjects regarding first aid, 13 questions which assessed different aspects of knowledge regarding first aid were considered. A post training evaluation of the participant women was done to assess a change in their knowledge in comparison to their pre training levels. Results: The mean baseline knowledge score was 2.34±1.98. Fifty six women participated in the training programme on first aid, and the mean knowledge score among these 56 women was 11.64±1.27 immediately following training. There was a significant improvement in the total knowledge scores in the post evaluation as compared to pre evaluation levels (p
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