Comprehensive Systematic Review Update Summary: Disorders of Consciousness: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology; the American Congress of Rehabilitation Medicine; and the National Institute on Disability, Independent Living, and Rehabilitation Research

Publication date: Available online 8 August 2018

Source: Archives of Physical Medicine and Rehabilitation

Author(s): Joseph T. Giacino, Douglas I. Katz, Nicholas D. Schiff, John Whyte, Eric J. Ashman, Stephen Ashwal, Richard Barbano, Flora M. Hammond, Steven Laureys, Geoffrey S.F. Ling, Risa Nakase-Richardson, Ronald T. Seel, Stuart Yablon, Thomas S.D. Getchius, Gary S. Gronseth, Melissa J. Armstrong

Abstract

Objective

To update the 1995 American Academy of Neurology (AAN) practice parameter on persistent vegetative state and the 2002 case definition for the minimally conscious state (MCS) by reviewing the literature on the diagnosis, natural history, prognosis, and treatment of disorders of consciousness lasting at least 28 days.

Methods

Articles were classified per the AAN evidence-based classification system. Evidence synthesis occurred through a modified Grading of Recommendations Assessment, Development and Evaluation process. Recommendations were based on evidence, related evidence, care principles, and inferences according to the AAN 2011 process manual, as amended.

Results

No diagnostic assessment procedure had moderate or strong evidence for use. It is possible that a positive EMG response to command, EEG reactivity to sensory stimuli, laser-evoked potentials, and the Perturbational Complexity Index can distinguish MCS from vegetative state/unresponsive wakefulness syndrome (VS/UWS). The natural history of recovery from prolonged VS/UWS is better in traumatic than nontraumatic cases. MCS is generally associated with a better prognosis than VS (conclusions of low to moderate confidence in adult populations), and traumatic injury is generally associated with a better prognosis than nontraumatic injury (conclusions of low to moderate confidence in adult and pediatric populations). Findings concerning other prognostic features are stratified by etiology of injury (traumatic vs nontraumatic) and diagnosis (VS/UWS vs MCS) with low to moderate degrees of confidence. Therapeutic evidence is sparse. Amantadine probably hastens functional recovery in patients with MCS or VS/UWS secondary to severe traumatic brain injury over 4 weeks of treatment. Recommendations are presented separately.

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Ethical, Palliative, and Policy Considerations in Disorders of Consciousness

Publication date: Available online 8 August 2018

Source: Archives of Physical Medicine and Rehabilitation

Author(s): Joseph J. Fins, James L. Bernat

Abstract

This essay complements the scientific and practice scope of the American Academy of Neurology Guideline on Disorders of Consciousness by providing a discussion of the ethical, palliative, and policy aspects of the management of this group of patients. We endorse the renaming of "permanent" vegetative state to "chronic" vegetative state given the increased frequency of reports of late improvements but suggest that further refinement of this class of patients is necessary to distinguish late recoveries from patients who were misdiagnosed or in cognitive-motor dissociation. Additional nosologic clarity and prognostic refinement is necessary to preclude overestimation of low probability events. We argue that the new descriptor "unaware wakefulness syndrome" is no clearer than "vegetative state" in expressing the mismatch between apparent behavioral unawareness when patients have covert consciousness or cognitive motor dissociation. We advocate routine universal pain precautions as an important element of neuropalliative care for these patients given the risk of covert consciousness. In medical decision-making, we endorse the use of advance directives and the importance of clear and understandable communication with surrogates. We show the value of incorporating a learning health care system so as to promote therapeutic innovation. We support the Guideline's high standard for rehabilitation for these patients but note that those systems of care are neither widely available nor affordable. Finally, we applaud the Guideline authors for this outstanding exemplar of engaged scholarship in the service of a frequently neglected group of brain-injured patients.

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Practice Guideline Update Recommendations Summary: Disorders of Consciousness: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology; the American Congress of Rehabilitation Medicine; and the National Institute on Disability, Independent Living, and Rehabilitation Research

Publication date: Available online 8 August 2018

Source: Archives of Physical Medicine and Rehabilitation

Author(s): Joseph T. Giacino, Douglas I. Katz, Nicholas D. Schiff, John Whyte, Eric J. Ashman, Stephen Ashwal, Richard Barbano, Flora M. Hammond, Steven Laureys, Geoffrey S.F. Ling, Risa Nakase-Richardson, Ronald T. Seel, Stuart Yablon, Thomas S.D. Getchius, Gary S. Gronseth, Melissa J. Armstrong

Abstract

Objective

To update the 1995 American Academy of Neurology (AAN) practice parameter on persistent vegetative state and the 2002 case definition on minimally conscious state (MCS) and provide care recommendations for patients with prolonged disorders of consciousness (DoC).

Methods

Recommendations were based on systematic review evidence, related evidence, care principles, and inferences using a modified Delphi consensus process according to the AAN 2011 process manual, as amended.

Recommendations

Clinicians should identify and treat confounding conditions, optimize arousal, and perform serial standardized assessments to improve diagnostic accuracy in adults and children with prolonged DoC (Level B). Clinicians should counsel families that for adults, MCS (vs vegetative state [VS]/ unresponsive wakefulness syndrome [UWS]) and traumatic (vs nontraumatic) etiology are associated with more favorable outcomes (Level B). When prognosis is poor, long-term care must be discussed (Level A), acknowledging that prognosis is not universally poor (Level B). Structural MRI, SPECT, and the Coma Recovery Scale–Revised can assist prognostication in adults (Level B); no tests are shown to improve prognostic accuracy in children. Pain always should be assessed and treated (Level B) and evidence supporting treatment approaches discussed (Level B). Clinicians should prescribe amantadine (100–200 mg bid) for adults with traumatic VS/UWS or MCS (4–16 weeks post injury) to hasten functional recovery and reduce disability early in recovery (Level B). Family counseling concerning children should acknowledge that natural history of recovery, prognosis, and treatment are not established (Level B). Recent evidence indicates that the term chronic VS/UWS should replace permanent VS, with duration specified (Level B). Additional recommendations are included.

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Is Polonium-210 a Good Indicator for Anthropogenic Radioactivity?

Cancer Biotherapy and Radiopharmaceuticals, Ahead of Print.


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Is Polonium-210 a Good Indicator for Anthropogenic Radioactivity?

Cancer Biotherapy and Radiopharmaceuticals, Ahead of Print.


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Developmental changes in the cortical sources of spontaneous alpha throughout adolescence

Publication date: Available online 8 August 2018

Source: International Journal of Psychophysiology

Author(s): Philippa Howsley, Liat Levita

Abstract

This study investigated age-, gender-, and puberty-related changes in two cortical sources of spontaneous alpha during eyes-open and eyes-closed conditions in a cohort of adolescents aged 9–23 years. In total, 29 preadolescents (9–12 years, 14 females), 29 mid-adolescents (13–17 years, 14 females), and 33 late adolescents (18–23 years, 17 females) had their resting brain activity measured using electroencephalography (EEG) during eyes-open and eyes-closed conditions. Standardised Low Resolution Brain Electromagnetic Tomography (sLORETA) was used to estimate the cortical sources of spontaneous alpha. Two cortical sources were chosen as regions of interest (ROIs): prefrontal cortex and occipital cortex. Significant age-related changes in the cortical sources of alpha were found, particularly in prefrontal regions; prefrontal alpha power was greater during the eyes-open condition compared to the eyes-closed condition for late adolescents, but equivalent across the eyes-open and eyes-closed conditions for both pre- and mid-adolescents. In addition, more advanced pubertal stage predicted reduced alpha power in male, but not female, adolescents aged 9–17 years. This study provides an important initial step towards understanding developmental changes in the cortical sources of spontaneous alpha in the typically developing brain. Moreover, the results from this study underscore the need to tease out the effects of age, gender, and puberty when examining the cortical sources of alpha during the adolescent period.

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Dilation of the dorsal pancreatic duct in an asymptomatic patient with pancreas divisum

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Correction to: Influence of body weight unloading on human gait characteristics: a systematic review

The original article [1] contained a major error whereby Figure 1 mistakenly displayed a duplicate of Figure 5.

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Dilation of the dorsal pancreatic duct in an asymptomatic patient with pancreas divisum

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How much personal liability do individual EMS providers bear?

Our co-hosts discuss a recent article that raises the question of personal liability for EMS workers

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How much personal liability do individual EMS providers bear?

Our co-hosts discuss a recent article that raises the question of personal liability for EMS workers

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Epigenetics: an emerging field in the pathogenesis of nonalcoholic fatty liver disease

Publication date: Available online 8 August 2018

Source: Mutation Research/Reviews in Mutation Research

Author(s): Nissar U. Ashraf, Mohammad Altaf

Abstract

Nonalcoholic fatty liver disease (NAFLD) is a major health concern associated with increased mortality due to cardiovascular disease, type II diabetes, insulin resistance, liver disease, and malignancy. The molecular mechanism underlying these processes is not fully understood but involves hepatic fat accumulation and alteration of energy metabolism and inflammatory signals derived from various cell types including immune cells. During the last two decades, epigenetic mechanisms have emerged as important regulators of chromatin alteration and the reprogramming of gene expression. Recently, epigenetic mechanisms have been implicated in the pathogenesis of NAFLD and nonalcoholic steatohepatitis (NASH) genesis. Epigenetic mechanisms could be used as potential therapeutic targets and as noninvasive diagnostic biomarkers for NAFLD. These mechanisms can determine disease progression and prognosis in NAFLD. In this review, we discuss the role of epigenetic mechanisms in the progression of NAFLD and potential therapeutic targets for the treatment of NAFLD.

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Pulsara launches real-time video call capabilities in version 9.0

BOZEMAN, MT — Pulsara announced today the release of app version 9.0. The full release notes sent out by the company are as follows: Have you ever dreamed of a world in which you could tap a button and get any member of your care team on a video call, just like you do with your grandma, or that friend living abroad in Thailand? Wouldn't it make things so much simpler if medics could...

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Human dignity statement is a good start, but not enough

Position statements from our national leadership are helpful, but we must make culture change ourselves

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3 metrics to track in your EMS operations

EMS, like any other aspect of healthcare, is data driven, and tracking, measuring and reporting the right data can improve operations and patient care

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3 metrics to track in your EMS operations

EMS, like any other aspect of healthcare, is data driven, and tracking, measuring and reporting the right data can improve operations and patient care

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Airway management: Bi-PAP vs. CPAP

While indications for BiPAP and CPAP ventilation differ in the field, both allow EMS to splint broken airways

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Stem cell bioengineering: building from stem cell biology

Stem cell bioengineering: building from stem cell biology

Stem cell bioengineering: building from stem cell biology, Published online: 08 August 2018; doi:10.1038/s41576-018-0040-z

This Review discusses how stem cell bioengineering can advance regenerative medicine by giving insight into the design principles that underlie different levels of stem cell systems — from the inner circuitry in single cells and the stem cell niche to systemic interactions between organs and tissues.

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A novel AXIN2 gene mutation in sagittal synostosis

American Journal of Medical Genetics Part A, EarlyView.


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StatPearls

Related Articles

StatPearls

Book. 2018 01

Authors:

Abstract
Airway control is a critical skill for the prehospital healthcare provider. The prehospital provider must be skilled in various methods of airway support ranging from simple airway positioning to the establishment of a definitive airway with an endotracheal tube. Drug-assisted intubation (DAI) is a term used for any use of medications to facilitate endotracheal intubation (ETI), with or without neuromuscular blocking agents. ETI with the use of neuromuscular blockade is known as rapid-sequence intubation (RSI). ETI without the use of neuromuscular blockade is known as sedation-facilitated or medication-facilitated ETI. RSI is the most common type of prehospital DAI performed. Some studies indicate that RSI is more successful than intubation with sedation alone both in the prehospital setting and the emergency department. The use of DAI by emergency medical services (EMS) systems varies throughout the United States. In general, ETI refers to the placement of an endotracheal tube orally. Although nasotracheal intubation is possible, it has largely fallen out of favor in the urgent care setting. In brief, indications for emergency ETI include: Inability to protect the airway. Inability to maintain oxygenation and/or ventilation. Airway obstruction. Current or expected clinical course concerning for airway compromise.

PMID: 30085511

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Stem cell bioengineering: building from stem cell biology

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Phase II study of trastuzumab with modified docetaxel, cisplatin, and 5 fluorouracil in metastatic HER2-positive gastric cancer

Gastric Cancer

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Previous colonic resection is a risk factor for surgical relapse in Crohn’s disease

Digestive and Liver Diseases

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Incidence and risk factors for dysphagia following non-traumatic subarachnoid hemorrhage: A retrospective cohort study

Dysphagia

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The Oldowan industry from Swartkrans cave, South Africa, and its relevance for the African Oldowan

Publication date: Available online 7 August 2018

Source: Journal of Human Evolution

Author(s): Kathleen Kuman, Morris B. Sutton, Travis Rayne Pickering, Jason L. Heaton

Abstract

The oldest recognized artifacts at the Swartkrans cave hominid-bearing site in South Africa have long been known to occur in the Lower Bank of Member 1, now dated with the cosmogenic nuclide burial method to ca. 1.8–2.19 Ma. However, the affinities of this industry have been debated due to small sample size. In this paper we present newly excavated material from the Lower Bank retrieved since 2005 in the Swartkrans Paleoanthropological Research Project. The sample is now large enough to confirm its affinity with the Oldowan industrial complex. The assemblage is highly expedient and core reduction strategies are largely casual. Although freehand flaking is present, the bipolar technique is most significant, even in non-quartz raw materials. The Swartkrans assemblage shows some significant contrasts with the Sterkfontein Oldowan, ca. 2.18 Ma, which can be explained by its closer proximity to raw material sources, its somewhat different geographic context, and its more expedient nature. The Swartkrans Oldowan now provides us with the first good indication of Oldowan variability in southern Africa, where only two sizeable assemblages have thus far been discovered. Comparisons are made with other sites across Africa that help to place this variability within our overall understanding of the Oldowan industrial complex.

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Presence of 236U and 239,240Pu in soils from Southern Hemisphere

Publication date: December 2018

Source: Journal of Environmental Radioactivity, Volume 192

Author(s): S. Salmani-Ghabeshi, E. Chamizo, M. Christl, C. Miró, E. Pinilla-Gil, F. Cereceda-Balic

Abstract

²³⁶U, ²³⁹Pu and ²⁴⁰Pu are present in soils mainly as a result of the local- and global-fallout from the atmospheric nuclear weapons tests carried out mainly in the 1950's and 1960's. In this work we provide new data on the presence of ²³⁶U and ^239,240Pu in surface soils (i.e. up to 5 cm depth) from Chile and Africa. The results were obtained by low-energy Accelerator Mass Spectrometry (AMS). In the case of the Chilean samples, ²³⁶U/²³⁹Pu atom ratios show a high variability and are in general higher than the reported value for the global fallout in the Northern Hemisphere, ranging from 0.2 to 1.5. The ²³⁶U atomic concentrations range from 3.5 × 10⁶ to 9.1 × 10⁶ atoms/g, and are at least two orders of magnitude lower than the reported values in the Northern Hemisphere. The measured ²⁴⁰Pu/²³⁹Pu atom ratio in soils from South-Africa and Mozambique are of about 0.17, in agreement with the expected one for global-fallout at those coordinates. To best knowledge of the authors the present work is the first publication on ²³⁶U concentrations and ²³⁶U/²³⁹Pu atom ratios in soils from South-America and Africa.

Graphical abstract

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The baseline speed of 10-m gait predicts ambulatory discharge for hospitalized frail elderly after DOPPO rehabilitation

The discharge of elderly patients from hospital on the basis of their independent gait program (DOPPO) is a new rehabilitation strategy for physically frail hospitalized elderly that aims to recover independent gait and to achieve ambulatory discharge. We retrospectively investigated baseline determinants of physical measures associated closely with the 6-min walking distance (6MWD) after DOPPO. Participants were 137 consecutive elderly inpatients, irrespective of the causative disease (mean age: 82±7 years; 76 women), who had a Short Physical Performance Battery (SPPB) score of less than 12 and low independent walking capacity. The rehabilitation comprised muscle stretching, muscle strengthening, balance training, and endurance exercise, including walking. The exercises were gradually increased until the goal of ambulatory discharge was attained. The SPPB, isometric knee-extension muscle strength (IKEMS), functional reach test (FRT), one-leg stance time (OLST), and the 10-m gait speed (TMGS) were measured, before and after the DOPPO intervention, and their association with the 6MWD was evaluated. All participants achieved ambulatory discharge, requiring on average 35±19 hospital days and 32±18 h of rehabilitation. The SPPB, IKEMS, FRT, OLST, and TMGS improved. The SPPB scores increased from 7.1 at baseline to 9.2 at discharge. Eighty-eight patients completed the 6MWD. The SPPB, IKEMS, FRT, OLST, and TMGS were strongly associated with the 6MWD. Only the baseline TMGS and SPPB predicted the 6MWD, with a cut-off TMGS value of 0.84 m/s providing the best prediction of achieving a distance of more than 300 m on the 6MWD. Thus, the baseline TMGS is the best prediction of the ambulatory outcome after the present DOPPO rehabilitation. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. https://ift.tt/1hexVwJ Correspondence to Hiroaki Obata, Division of Rehabilitation and Medicine, Niigata-minami Hospital, 1-7-1, Meike-Shinmei, Chuo-ku, Niigata 950-8601, Japan Tel: +81 252 842 511; fax: +81 252 842 080; e-mail: obata00@gmail.com Received April 5, 2018 Accepted July 13, 2018 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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A comparison of the usability of a standard and an age-friendly smartphone launcher: experimental evidence from usability testing with older adults

Age-friendly smartphone launchers are tools designed to enhance smartphone handling among older adults with cognitive and functional limitations. Although evidence exists about the positive effects of age-friendly smartphone launchers on older adults' usability performance in general, little is known about how the design and interface complexity of these launchers affect their interface usability effectiveness and efficiency compared with standard Android smartphone interfaces. Thus, in this study, a randomized crossover experiment involving 50 older smartphone users, aged 60 years and above, was guided by the principles of summative usability testing to assess whether an age-friendly launcher performs better than a standard Android launcher performs and to investigate the relationship between the user interface complexity and usability performance of launchers. The results of usability tests in which each participant solved 10 tasks on both launchers indicate that the two tested launchers had comparable effectiveness (i.e. completeness with which participants achieved the test tasks' goals), whereas the age-friendly launcher marginally outperformed its standard Android counterpart in terms of efficiency (i.e. the amount of time used by participants to solve the test tasks). The results also demonstrate that lower user interface complexity is associated with higher effectiveness and efficiency, suggesting that age-friendly smartphone launchers might lead to higher adoption rates of smartphones among older adults if interface designers could reduce their cognitive complexity by limiting the number of steps and alternative paths for task completion. Correspondence to Andraž Petrovčič, PhD, Faculty of Social Sciences, University of Ljubljana, Kardeljeva ploščad 5, 1000 Ljubljana, Slovenia Tel: +386 15 805 200; fax: +386 15 805 101; e-mail: andraz.petrovcic@fdv.uni-lj.si Received May 25, 2018 Accepted July 13, 2018 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Therapeutic electrical stimulation and immune status in healthy men

In physical and rehabilitation medicine, there are few reports on the effects of therapeutic low-frequency electrical stimulation on the immune response of the organism, even though electrical stimulation is used widely in clinical practice and sports medicine. The aim of our study was to examine the possible immunological consequences of moderate transcutaneous neuromuscular electrical stimulation (NMES) for quadriceps muscle strengthening in healthy individuals. The study included twelve healthy male adult volunteers (mean age 42 years) without contraindications for electrical stimulation. At the beginning and immediately after a 20-min session of NMES of quadriceps muscles, peripheral blood was collected to analyse the biochemical blood components (creatinine, creatine kinase, estimated glomerular filtration rate, cortisol), differential white blood cell count and immunological parameters. The intensity of NMES was set at maximum tolerance, eliciting on average about one-sixth of the maximum voluntary isometric contraction of the same leg. No statistically significant differences in the average group level were found in any of the measured biochemical blood components, white blood cell count or immunological parameters after the NMES session. On an individual level, the changes in creatine kinase, estimated glomerular filtration rate, basophils and some immunological parameters correlated with changes in the cortisol level. We can conclude that moderate transcutaneous low-frequency electrical stimulation for quadriceps muscle strengthening used in our study did not induce essential changes in immune status in healthy men. Correspondence to Primož Novak, MD, PhD, University Rehabilitation Institute, Linhartova 51, SI-1000 Ljubljana, Slovenia Tel: +386 1475 8207; fax: +386 1437 2070; e-mail: primoz.novak@ir-rs.si Received July 6, 2018 Accepted July 18, 2018 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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