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Purpose To evaluate how the COVID-19 pandemic affected the imaging utilization patterns for non-COVID-19-related illness in a pediatric emergency department (ED). Methods We retrospectively reviewed radiology reports for ultrasound, CT, MRI, and fluoroscopy studies performed at a pediatric ED in April from 2017 to 2021, excluding studies for respiratory symptoms and trauma. Radiology reports and medical records were reviewed to determine if patients had a positive radiology diagnosis, the type of diagnosis, and whether it required hospital admission. Results from during the pandemic were compared to predicted rates based on pre-pandemic years. Results A total of 2198 imaging studies were included. During the COVID-19 pandemic, fewer ED imaging studies were performed compared to predicted. The decrease was greater in April 2020 (RR = 0.56, p

To assess the degree of narrowing of the popliteal artery during active ankle plantar flexion in healthy volunteers using a non-contrast quiescent-interval single-shot (QISS) magnetic resonance angiography (MRA) technique. Following IRB approval, 10 healthy volunteers were recruited and following informed consent underwent QISS MRA of the lower extremity at rest and during ankle plantarflexion. Two pediatric musculoskeletal radiologists independently reviewed MR images in random order and recorded a number of subjective and objective anatomic variables including branch pattern, proximity of vessel to bony structures, gastrocnemius bulk, and presence of accessory muscle. Arterial narrowing with plantarflexion was recorded by a subjective assessment of 3D reconstructions (negligible or non-negligible) and objectively by measuring the narrowest diameter during plantarflexion and at rest. Agreement between reader scores was assessed using the concordance correlation coefficient (CCC) for continuous variables, and kappa and the proportion of agreement for categorical variables. Mean reduction in arterial diameter during plantar flexion was 17.1% (min 1.9%, max 64.1%, SD 16.7%) for reader 1 and 17.2% (min 1.7%, max 50.0%, SD 14.3%.) for reader 2 with high agreement between readers: CCC = 0.92 and CI = 0.82, 0.96. Arterial narrowing was described subjectively as “non-negligible” in 7/20 legs by reader 1 and 5/20 legs by reader 2 with proportion of agreement = 0.90, CI (0.77, 1.00). We observed a wide range of popliteal arterial narrowing with plantarflexion in asymptomatic volunteers. Larger studies, for which QISS is well suited, may be invaluable for distinguishing physiologic from pathologic arterial narrowing in patients with suspected popliteal artery entrapment syndrome (PAES).

OBJECTIVE. The purpose of this study was to compare radiology trainees' perceptions of the culture regarding speaking up about patient safety and unprofessional behavior in the clinical environment and to assess the likelihood that they will speak up in the presence of a medical hierarchy. MATERIALS AND METHODS. The study included radiology trainees from nine hospitals who attended a communication workshop. Trainees completed questionnaires assessing their perceptions of the support provided by their clinical environment regarding speaking up about patient safety and unprofessional behavior. We also queried their likelihood of speaking up within a team hierarchy about an error presented in a hypothetical clinical vignette. RESULTS. Of 61 participants, 58 (95%) completed questionnaires. Of these 58 participants, 84% felt encouraged by colleagues to speak up about safety concerns, and 57% felt encouraged to speak up about unprofessional behavior (p < .001). Moreover, 17% and 34% thought speaking up about safety concerns and unprofessional behavior, respectively, was difficult (p < .02). Trainees were less likely to agree that speaking up about unprofessional behavior (compared with speaking up about safety concerns) resulted in meaningful change (66% vs 95%; p < .001). In a vignette describing a sterile technique error, respondents were less likely to speak up to an attending radiologist (48%) versus a nurse, intern, or resident (79%, 84%, and 81%, respectively; p < .001). Significant predictors of the likelihood of trainees speaking up to an attending radiologist included perceived potential for patient harm as a result of the error (odds ratio [OR], 6.7; p < .001), perceptions of safety culture in the clinical environment (OR, 5.0; p = .03), and race or ethnicity (OR, 3.1; p = .03). CONCLUSION. Radiology trainees indicate gaps in workplace cultures regarding speaking up, particularly concerning unprofessional behavior and team hierarchy.

Hutchinson-Gilford progeria syndrome (termed progeria in this Article) is a rare sporadic genetic disorder. One early clinical manifestation of progeria is abnormal skeletal growth, yet this growth has not been fully characterised. We aimed to characterise the skeletal maturation and long-bone growth patterns of patients with the clinical phenotype of progeria.For this retrospective study, we reviewed skeletal surveys of patients (aged20 years) with progeria obtained over a 9·5-year period. Most surveys included radiographs of the hands and long bones (humeri, radii, ulnas, tibias, and fibulas). Bone ages of these patients were estimated by the standards of Greulich and Pyle. Following the established methods for studying long-bone growth, the study cohort was separated into two overlapping age groups: longitudinal bone length measurements were made between physes for the childhood group (aged 12 years or younger) and from the upper margins of the proximal to the lower margin of the distal ossified epiphyses for the adolescent group (aged 10 years or older). Bone age estimates and bone length measurements were plotted against the chronological age of patients and compared with reference standards. Statistical analyses were based on mixed models.85 patients with progeria and 250 skeletal surveys were included in our study. For both sexes, bone age estimates showed a more advanced skeletal maturation rate throughout all chronological ages than the normal rate of 1 (p0·0001), with the rate of maturation being 1·09 (SE 0·02) for boys and 1·14 (0·02) for girls. Longitudinal long-bone lengths began to deviate from normal standards by age 1-2 years. Growth curves for these long bones plateaued at about half the normal eventual bone length, and the half-life (the time taken to grow to half the eventual bone length) was also about half the time compared with normal standards.Our study established growth curves that might serve as reference standards for skeletal maturation and long-bone growth of patients with the clinical phenotype of progeria.The Progeria Research Foundation, the US National Heart, Lung and Blood Institute, the Dana-Farber Cancer Institute StopShop Pediatric Brain Tumor Program, the US National Center for Research Resources, US National Institutes of Health.

The classic metaphyseal lesion (CML) is a strong indicator of infant abuse, and the distal tibia is one of the most common sites for this injury. To determine the prevalence of subperiosteal new bone formation accompanying the distal tibial CMLs identified on infant skeletal surveys. Skeletal surveys performed for suspected infant abuse (2005–2017) were reviewed. Inclusion criteria were 1) anteroposterior (AP) and lateral radiographs of a distal tibial CML from the initial survey, 2) AP radiograph from the 2-week follow-up survey, 3) additional fractures, 4) child protection team consults and 5) mandated report filing for suspected abuse. We identified 22 distal tibial CMLs from 16 infants. Radiographs of these lesions were shown on the picture archiving and communication system to two blinded pediatric radiologists. Readers indicated the presence/absence of subperiosteal new bone formation on individual and combinations of images. Inter-reader agreements were fair (kappa=0.47). The prevalence of subperiosteal new bone formation on initial AP radiograph was 34%. Significant increases in the prevalence were found with the addition of follow-up AP radiograph (57%; P

OBJECTIVE. Intussusception is the most common cause of intestinal obstruction in young children. Radiology has a key role in its diagnosis and treatment. This systematic review summarizes the currently available evidence for best practices in radiologic management of pediatric intussusception. CONCLUSION. High diagnostic accuracy and lack of ionizing radiation make ultrasound (US) the preferred imaging modality for diagnosing intussusception. For intussusception reduction, fluoroscopy-guided pneumatic enema and US-guided hydrostatic enema are equally dependable and safe techniques. The areas that warrant further research in this field include the efficacy and safety of the US-guided pneumatic enema, potential benefits of sedation and general anesthesia for the reduction procedure, and the optimal management of intussusceptions potentially involving pathologic lead points.

Research has shown that a single presentation of the conditioned stimulus prior to extinction training can diminish conditioned responses. However, replication has proven difficult and appears to be limited by boundary conditions. Here we tested the boundary condition of memory strength by comparing the effect of reinforcement rate to assess its role in post-retrieval extinction. Eighty university students had undergone a three-day fear conditioning experiment in which two partial reinforcement schedules (40%, 80%) were applied. The findings indicated that both low and high partial reinforcement groups did not demonstrate recovery of conditioned responses after post-retrieval extinction. In contrast, both groups demonstrated significant recovery to standard extinction with significantly greater recovery in the 80% group relative to the 40% group. Additionally, we found that greater physiological arousal during memory retrieval significantly predicted recovery of fear at test phase. We conclude that when compared to a lower partial reinforcement schedule, a higher partial reinforcement resulted in the formation of a stronger memory as indicated by greater physiological arousal during memory reactivation and recovery of conditioned responses after standard extinction, but that it does not function as a boundary condition of post-retrieval extinction. These data are significant because it is the first study to investigate the effect of varying partial reinforcement schedules on fear recovery and add to the body of literature that continue to identify sources of failure in the application of post-retrieval extinction.

Introduction Guidelines recommend endoscopic variceal screening and surveillance in patients with cirrhosis.1 The rate of development of large oesophageal varices needing treatment appears to be 7–8% per year.2,3 However, with a growing proportion of diagnoses also now being made by Fibroscan we hypothesize that this rate may be lower. Methods We performed a case note review of 304 patients with a liver stiffness measurement (LSM) more than 15 kPa on Fibroscan between April 2012 and February 2016. Patients also had to have an endoscopy within 6 months to be included. We excluded patients with previous decompensation, hepatocellular carcinoma, inaccurate LSM (IQR >30%) or LSM felt to be aberrant by the clinician based on clinical, radiological or histological grounds. For patients with hepatitis C (HCV) we used post-SVR LSM. We recorded sex, age, aetiology of liver disease, LSM, platelet count, endoscopic findings at 0–6 months and at 24–48 months, duration of follow-up, incidence of bleeding or death. Varices were documented as absent, small or large. Results 113 patients were included. The most common aetiologies were non-alcoholic fatty liver disease (36.2%), alcoholic liver disease (29.3%) and HCV (20.7%). Mean age was 59.3 ± 11.5 years. LSM was 33.4 ± 17.1 kPa. Median follow-up was 4 years. Baseline endoscopy revealed no varices in 76 patients (67.3%), small varices in 29 patients (25.7%) and large varices in 8 patients (7.1%). 6 of the patients (5.3%) had a variceal bleed within 12 months. All large varices underwent band ligation (VBL) as per local practice. 58 patients went on to have a repeat endoscopy at 24–48 months. There was no progression of absent/small varices in 50 patients (86.2%) and a static gastric varix in 1 patient (1.7%). There was progression to large varices in 7 patients (13.8%) including 1 variceal haemorrhage. Conclusions In our group of patients with compensated cirrhosis the rate of development of clinically significant varices over 3 years appears to be lower than previous estimates. Weaknesses of the study include its retrospective nature and drop out rate. However, the findings would fit with our perception of an increased rate of diagnosis of advanced chronic liver disease by Fibroscan. The natural history of varices may be different to historic populations diagnosed on histological grounds or overt clinical and radiological features. References U.K. Guidelines on the Management of Variceal Haemorrhage in Cirrhotic Patients, Gut ( 2015) 64(11) 1680–1704 R Groszmann, G Garcia-Tsao, J Boschet al, Beta-blockers to prevent gastroesophageal varices in patients with cirrhosis, NEJM ( 2005) 353(21) 2254–2261 M Merli, G Nicolini, S Angeloniet al, Incidence and natural history of small esophageal varices in cirrhotic patients, J Hepatol. ( 2003) 38(3) 266–272

Onset primacy is a robust behavioural phenomenon whereby humans identify the sudden appearance of an object in the environment (onset) with greater speed and accuracy than other types of visual change, such as the sudden disappearance of an object from the environment (offset). The default mode hypothesis explains this phenomenon by postulating that onset detection is the default processing mode of the attentional system. The present study aimed to test this by investigating whether onset primacy is also reflected on a neural level, as indicated by the comparative efficiency of neural processing for onsets, using electroencephalography. It was hypothesised that this relative efficiency would be reflected in the P300 event-related potential as a greater mean amplitude with an earlier peak across temporal, parietal, and occipital regions during onset detection, compared to offset detection. This prediction was tested through a change detection task in which participants were required to identify the location of onset or offset between paired images of naturalistic scenes. Results showed that P300 amplitude and latency differed between onset and offset conditions in the anticipated directions, supporting the default mode hypothesis. These results suggest that the P300 is a neural marker of onset primacy in visual change detection.

Schizophrenia is characterised by significant episodic memory impairment that is thought to be related to problems with encoding, however the neuro-functional mechanisms underlying these deficits are not well understood. The present study used a subsequent recognition memory paradigm and event-related potentials (ERPs) to investigate temporal aspects of episodic memory encoding deficits in schizophrenia.Electroencephalographic data was recorded in 24 patients and 19 healthy controls whilst participants categorised single words as pleasant/unpleasant. ERPs were generated to subsequently recognised versus unrecognised words on the basis of a forced-choice recognition memory task. Subsequent memory effects were examined with the late positive component (LPP). Group differences in N1, P2, N400 and LPP were examined for words correctly recognised.Patients performed more poorly than controls on the recognition task. During encoding patients had significantly reduced N400 and LPP amplitudes than controls. LPP amplitude correlated with task performance however amplitudes did not differ between patients and controls as a function of subsequent memory. No significant differences in N1 or P2 amplitude or latency were observed.The present results indicate that early sensory processes are intact and dysfunctional higher order cognitive processes during encoding are contributing to episodic memory impairments in schizophrenia.

Converging evidence from epidemiological, clinical and neuropsychological research suggests a link between cannabis use and increased risk of psychosis. Long-term cannabis use has also been related to deficit-like "negative" symptoms and cognitive impairment that resemble some of the clinical and cognitive features of schizophrenia. The current functional brain imaging study investigated the impact of a history of heavy cannabis use on impaired executive function in first-episode schizophrenia patients. Whilst performing the Tower of London task in a magnetic resonance imaging scanner, event-related blood oxygenation level-dependent (BOLD) brain activation was compared between four age and gender-matched groups: 12 first-episode schizophrenia patients; 17 long-term cannabis users; seven cannabis using first-episode schizophrenia patients; and 17 healthy control subjects. BOLD activation was assessed as a function of increasing task difficulty within and between groups as well as the main effects of cannabis use and the diagnosis of schizophrenia. Cannabis users and non-drug using first-episode schizophrenia patients exhibited equivalently reduced dorsolateral prefrontal activation in response to task difficulty. A trend towards additional prefrontal and left superior parietal cortical activation deficits was observed in cannabis-using first-episode schizophrenia patients while a history of cannabis use accounted for increased activation in the visual cortex. Cannabis users and schizophrenia patients fail to adequately activate the dorsolateral prefrontal cortex, thus pointing to a common working memory impairment which is particularly evident in cannabis-using first-episode schizophrenia patients. A history of heavy cannabis use, on the other hand, accounted for increased primary visual processing, suggesting compensatory imagery processing of the task.

Little is known about the symptom profile of obsessive-compulsive disorder (OCD) in individuals who have autism spectrum disorders (ASD). It is also unknown whether self-report questionnaires are useful in measuring OCD in ASD. We sought to describe the symptom profiles of adults with ASD, OCD, and ASD + OCD using the Obsessive Compulsive Inventory-Revised (OCI-R), and to assess the utility of the OCI-R as a screening measure in a high-functioning adult ASD sample. Individuals with ASD (n = 171), OCD (n = 108), ASD + OCD (n = 54) and control participants (n = 92) completed the OCI-R. Individuals with ASD + OCD reported significantly higher levels of obsessive-compulsive symptoms than those with ASD alone. OCD symptoms were not significantly correlated with core ASD repetitive behaviors as measured on the ADI-R or ADOS-G. The OCI-R showed good psychometric properties and corresponded well with clinician diagnosis of OCD. Receiver operating characteristic analysis suggested cut-offs for OCI-R Total and Checking scores that discriminated well between ASD + versus –OCD, and fairly well between ASD-alone and OCD-alone. OCD manifests separately from ASD and is characterized by a different profile of repetitive thoughts and behaviors. The OCI-R appears to be useful as a screening tool in the ASD adult population. Autism Res 2015, 8: 477–485. © 2015 International Society for Autism Research, Wiley Periodicals, Inc.

Glycine increases N-methyl-d-aspartate receptor (NMDAR) mediated glutamatergic function. Mismatch negativity (MMN) is a proposed biomarker of glutamate-induced improvements in clinical symptoms, however, the effect of glycine-mediated NMDAR activation on MMN in schizophrenia is not well understood. This study aimed to determine the effects of acute and 6-week chronic glycine administration on MMN in schizophrenia patients. MMN amplitude was compared at baseline between 22 patients (schizophrenia or schizoaffective disorder; receiving stable antipsychotic medication; multi-centre recruitment) and 21 age- and gender-matched controls. Patients underwent a randomised, double-blind, placebo-controlled clinical trial with glycine added to their regular antipsychotic medication (placebo, n = 10; glycine, n = 12). MMN was reassessed post-45-minutes of first dose (0.2 g/kg) and post-6-weeks treatment (incremented to 0.6 g/kg/day). Clinical symptoms were assessed at baseline and post-6-weeks treatment. At baseline, duration MMN was smaller in schizophrenia compared to controls. Acute glycine increased duration MMN (compared to placebo), whilst this difference was absent post-6-weeks treatment. Six weeks of chronic glycine administration improved PANSS-Total, PANSS-Negative and PANSS-General symptoms compared to placebo. Smaller baseline duration MMN was associated with greater PANSS-Negative symptoms and predicted (at trend level) PANSS-Negative symptom improvement post-6-weeks glycine treatment (not placebo). These findings support the benefits of chronic glycine administration and demonstrate, for the first time, that acute glycine improves duration MMN in schizophrenia. This result, together with smaller baseline duration MMN predicting greater clinical treatment response, suggests the potential for duration MMN as a biomarker of glycine-induced improvements in negative symptoms in schizophrenia.

The stop-signal paradigm is increasingly being used as a probe of response inhibition in basic and clinical neuroimaging research. The critical feature of this task is that a cued response is countermanded by a secondary 'stop-signal' stimulus offset from the first by a 'stop-signal delay'. Here we explored the role of task difficulty in the stop-signal task with the hypothesis that what is critical for successful inhibition is the time available for stopping, that we define as the difference between stop-signal onset and the expected response time (approximated by reaction time from previous trial). We also used functional magnetic resonance imaging (fMRI) to examine how the time available for stopping affects activity in the putative right inferior frontal gyrus and presupplementary motor area (right IFG-preSMA) network that is known to support stopping. While undergoing fMRI scanning, participants performed a stop-signal variant where the time available for stopping was kept approximately constant across participants, which enabled us to compare how the time available for stopping affected stop-signal task difficulty both within and between subjects. Importantly, all behavioural and neuroimaging data were consistent with previous findings. We found that the time available for stopping distinguished successful from unsuccessful inhibition trials, was independent of stop-signal delay, and affected successful inhibition depending upon individual SSRT. We also found that right IFG and adjacent anterior insula were more strongly activated during more difficult stopping. These findings may have critical implications for stop-signal studies that compare different patient or other groups using fixed stop-signal delays.

Epidemiological data link adolescent cannabis use to psychosis and schizophrenia, but its contribution to schizophrenia neuropathology remains controversial. First-episode schizophrenia (FES) patients show regional cerebral grey- and white-matter changes as well as a distinct pattern of regional grey-matter loss in the vermis of the cerebellum. The cerebellum possesses a high density of cannabinoid type 1 receptors involved in the neuronal diversification of the developing brain. Cannabis abuse may interfere with this process during adolescent brain maturation leading to 'schizophrenia-like' cerebellar pathology. Magnetic resonance imaging and cortical pattern matching techniques were used to investigate cerebellar grey and white matter in FES patients with and without a history of cannabis use and non-psychiatric cannabis users. In the latter group we found lifetime dose-dependent regional reduction of grey matter in the right cerebellar lobules and a tendency for more profound grey-matter reduction in lobule III with younger age at onset of cannabis use. The overall regional grey-matter differences in cannabis users were within the normal variability of grey-matter distribution. By contrast, FES subjects had lower total cerebellar grey-matter:total cerebellar volume ratio and marked grey-matter loss in the vermis, pedunculi, flocculi and lobules compared to pair-wise matched healthy control subjects. This pattern and degree of grey-matter loss did not differ from age-matched FES subjects with comorbid cannabis use. Our findings indicate small dose-dependent effects of juvenile cannabis use on cerebellar neuropathology but no evidence of an additional effect of cannabis use on FES cerebellar grey-matter pathology.

Richard Abelson1,2, Keith J Lane3, John Rodriguez3, Patrick Johnston3, Endri Angjeli3, George Ousler3, Douglas Montgomery11School of Computing, Informatics, and Decision Systems Engineering, Arizona State University, Tempe, AZ, 2Statistics and Data Corporation, Tempe, AZ, 3Ora, Inc, Andover, MA, USAPurpose: The Ocular Protection Index (OPI) 2.0 System was developed to evaluate ocular surface protection under a natural blink pattern and normal visual conditions. The OPI 2.0 System implements fully automated software algorithms which provide a real-time measurement of corneal exposure (breakup area) for each interblink interval during a 1-minute video. Utilizing this method, the mean breakup area (MBA) and OPI 2.0 (MBA/interblink interval) were calculated and analyzed. The purpose of this study was to verify and validate the OPI 2.0 System for its ability to distinguish between dry eye and normal subjects, and to accurately identify breakup area.Methods: In order to verify and validate the OPI 2.0 System, a series of artificial images and a series of still image frames captured during an actual clinical session using fluorescein staining videography were analyzed. Finally, a clinical validation process was completed to determine the effectiveness and clinical relevance of the OPI 2.0 System to differentiate between dry eye and normal subjects.Results: Software analysis verification conducted in a set of artificially constructed images and in actual videos both saw minimal error rates. MBA and OPI 2.0 calculations were able to distinguish between the qualifying eyes of dry eye and normal subjects in a statistically significant fashion (P < 0.001 for both outcomes). As expected, dry eye subjects had a higher MBA and OPI 2.0 than normal subjects (0.232, dry eye; 0.040, normal and 0.039, dry eye; 0.006, normal, respectively). Results for the worst eyes and all qualifying analyses based on staining, forced-stare tear film breakup time, and MBA were numerically similar.Conclusion: The OPI 2.0 System accurately identifies the degree of breakup area on the cornea and represents an efficient, clinically relevant measurement of the pathophysiology of the ocular surface.Keywords: tear film breakup time, interblink interval, natural blink conditions, Ocular Protection Index

Objective. To compare postoperative pain scores between monopolar electrocautery and coblation subcapsular tonsillectomy.Study Design. Prospective double-blind randomized study.Setting. Tertiary care children’s hospital.Subjects and Methods. Between December 2004 and April 2008, 61 children, ages 4 to 20 years (mean age, 10 years; SD, 4 years), were randomized to have one tonsil removed by electrocautery and the other tonsil removed by coblation. Subjects used the FACES scale to rate pain on each side immediately postoperatively, 2 days postoperatively, and 2 weeks postoperatively. Postoperative hemorrhage was also tracked.Results. Coblation tonsillectomy resulted in statistically less pain than electrocautery immediately after surgery, but this difference was not clinically significant.Conclusions. Pediatric pain is similar following monopolar electrocautery or coblation subcapsular tonsillectomy.

Objective: We implemented and evaluated a quality improvement initiative targeting parents' communication with clinicians in a pediatric emergency department (ED). Methods: A quality improvement initiative ("Clear and Concise Communication" or "3C") targeting parent-provider communication was implemented in an urban tertiary care pediatric ED. A 1-page form that solicited parent worries, questions, and expectations for care was developed. Parent-provider communication was measured using an 8-item subset of questions from an ongoing satisfaction survey adopted for pediatric emergency care. The primary outcome was the communication score for a given ED visit scaled from 0 to 100 and was calculated as the simple average of answers where the best possible response was given a value of 1 and all others were scored as 0. A multivariate model adjusting for time-related factors, ED volume, and system-level events was developed to examine the influence of the communication initiative. Results: A total of 29,005 patients received care during implementation of 3C; a total of 100,810 patients received care during the 2-year period of interest. Data from 1233 satisfaction surveys were used to create the communication scores. Communication scores ranged from 0 to 100, with a mean of 88 and SD of 17.7. In a linear model adjusting for day, weekend, volume, system-level introduction of electronic charting for nurses, and electronic-order entry for physicians, the 3C initiative demonstrated a positive and statistically significant effect—increasing the communication score by 2.8 points/100 d (95% confidence interval, 0.1-5.5). Conclusions: The 3C initiative succeeded in improving parents' communication experience with emergency providers during the intervention period.

Sleep loss, widespread in today's society and associated with a number of clinical conditions, has a detrimental effect on a variety of cognitive domains including attention. This study examined the sequelae of sleep deprivation upon BOLD fMRI activation during divided attention. Twelve healthy males completed two randomized sessions; one after 27 h of sleep deprivation and one after a normal night of sleep. During each session, BOLD fMRI was measured while subjects completed a cross-modal divided attention task (visual and auditory). After normal sleep, increased BOLD activation was observed bilaterally in the superior frontal gyrus and the inferior parietal lobe during divided attention performance. Subjects reported feeling significantly more sleepy in the sleep deprivation session, and there was a trend towards poorer divided attention task performance. Sleep deprivation led to a down regulation of activation in the left superior frontal gyrus, possibly reflecting an attenuation of top-down control mechanisms on the attentional system. These findings have implications for understanding the neural correlates of divided attention and the neurofunctional changes that occur in individuals who are sleep deprived.

To measure and compare the dimensions of the sustentaculum tali (ST) in pediatric patients with unilateral subtalar coalition to determine if the contralateral side has altered morphology.The institutional review board approved this study, which was HIPAA compliant. Informed consent was waived. Radiology records were reviewed to identify 35 patients with unilateral subtalar coalition undergoing computed tomography (CT) (21 male, 14 female; mean age, 14.54 years) and 33 control patients with triplane fracture (21 male, 12 female; mean age, 13.48 years). CT images were reviewed, and reformatted images through the subtalar joint (on the side opposite the coalition) were created. Anteroposterior measurements of the middle facet (MF) and the ST were recorded by two observers with electronic calipers. The MF/ST ratio and the ST length extending posterior to the MF were calculated. Measurements between groups were compared by using Wald tests based on linear regressions. Inter- and intraobserver variabilities were determined by means of a component of variance model.The lengths of the MF and ST for the study and control groups were 12.86 and 16.82 mm (P.001) and 23.83 and 22.06 mm (P = .053), respectively. Intra- and interobserver correlations for both measurements were 0.94 and 0.92 and 0.86 and 0.77, respectively. MF/ST ratio was 0.54 versus 0.76 (P.001), and ST length extending posterior to the MF was 10.97 versus 5.24 mm (P.001).The MF is smaller and the ST extends further beyond the MF in patients with a contralateral subtalar coalition than in control patients. The morphology of the ST may provide insight into the origins and development of coalitions.

Background: We hypothesize that the occurrence of metabolic acidosis correlates with the cumulative rate of gastrointestinal (GI) illness and that incorporating acidosis surveillance would improve models used for the early detection of outbreaks of GI disease. Methods: We conducted a retrospective cohort study of consecutive patients seen in an urban pediatric tertiary care center from September 1995 to August 2005. All data were analyzed for correlation between acidosis and GI syndrome and for internal periodicities. Four years of data were used to create a model, and the first 100 days of 2004 were used for forecasting. Data collected included visit date, chief complaint (CC), International Classification of Diseases, 9th Revision, diagnoses (Dx), and limited laboratory data. Gastrointestinal syndrome was defined by either CC or Dx. Acidosis was defined as HCO 3 levels 19 mmol/dL or less. Exclusion criteria included hyperglycemia (glucose level >120 mg/dL), glycusoria, or having a test for glycosylated hemoglobin ordered. A simple regression model was used to measure correlation between rates of acidosis and GI_Dx and GI_CC. For acidosis and GI syndrome, we fitted a time series model to the daily data with an auto-regressive integrated moving average (1,1) error term. Results: During the study period, there were 505,028 emergency department visits. The median age was 5.1 years (interquartile range, 1.6-11.8 years), and 46% of patients were females. Of these, 132,142 had GI_Dx and 136,304 had GI_CC. Blood chemistries were obtained from 91,052 patients (18.1%). Acidosis was detected in 32.4% of patients who had these laboratory tests sent. Periodicities were detected for GI_Dx, GI_CC, acidosis rates affected by day of the week, and seasonality, with no changes in incidence during the years of our study. Acidosis rates highly correlated with rates of GI syndrome on a daily basis (Pearson correlation coefficient, r = 0.66 for GI_Dx and r = 0.68 for GI_CC, P < 0.0001 for both). Having non-diabetic ketoacidosis metabolic acidosis has a 42.2% positive predictive value for GI syndrome by either Dx or CC. Acidosis rates can be forecasted as a stand-alone variable (R 2 = 0.3, P < 0.001). Adding acidosis rates to time series models for GI_Dx or GI_CC significantly improves forecasting, that is, GI_Dx improved from R 2 = 0.24 to R 2 = 0.54, and false alarms rates dropped from 32% to 18%. The GI_CC model improved from R 2 = 0.32 to R 2 = 0.54, and false alarms rates dropped from 28% to 17%. Conclusions: Metabolic acidosis rate is a promising data source for real-time disease surveillance in the pediatric population. The rate of metabolic acidosis is highly correlated with the rate of GI syndrome. Adding this variable to currently used models significantly improves forecasting for real-time surveillance.

OBJECTIVE:To assess the rate of acute bacterial meningitis (ABM) among children who present with their first complex febrile seizure (CFS).DESIGN AND METHODS:This study was a retrospective, cohort review of patients aged 6 to 60 months who were evaluated in a pediatric emergency department (ED) between 1995 and 2008 for their first CFS. Cases were identified by using a computerized text search followed by a manual chart review. Exclusion criteria included prior history of nonfebrile seizures, an immunocompromised state, an underlying illness associated with seizures or altered mental status, or trauma. Data extracted included age, gender, seizure features, the number of previous simple febrile seizures, temperature, a family history of seizures, findings on physical examination, laboratory and imaging study results, and ED diagnosis and disposition.RESULTS:We identified 526 patients. The median age was 17 months (interquartile range: 13–24), and 44% were female. Ninety patients (17%) had a previous history of simple febrile seizures. Of the patients, 340 (64%) had a lumbar puncture (LP). The patients' median white blood cell count during a CFS was 1 cell per μL (interquartile range: 1–2), and 14 patients had CSF pleocytosis (2.7% [95% confidence interval [CI]: 1.5–4.5]). Three patients had ABM (0.9% [95% CI: 0.2–2.8]). Two had Streptococcus pneumoniae in a culture of their cerebrospinal fluid. Among these 2 patients, 1 was nonresponsive during presentation, and the other had a bulging fontanel and apnea. The third child appeared well; however, her blood culture grew S pneumoniae and failed the LP test. None of the patients for whom an LP was not attempted subsequently returned to the hospital with a diagnosis of ABM (0% [95% CI: 0, 0.9]).CONCLUSION:Few patients who experienced a CFS had ABM in the absence of other signs or symptoms.

The basolateral amygdala (BLA) contains a high density of cannabinoid CB1 receptors and is critically involved in pain and fear-related behaviour. We investigated the effects of bilateral intra-BLA administration of the CB1 receptor antagonist/inverse agonist, rimonabant, on formalin-evoked nociceptive behaviour, fear-conditioned behaviour including analgesia, and associated brain regional alterations in Fos expression in rats. Intra-BLA administration of rimonabant significantly reduced formalin-evoked nociceptive behaviour in the absence, but not presence, of conditioned fear. Rimonabant attenuated a formalin-evoked reduction in freezing while emitting 22 kHz ultrasonic vocalisation in the early part of the fear expression trial. Formalin-evoked nociceptive behaviour was associated with increased Fos immunoreactivity (FI) in the CA2/3 region of the hippocampus and rostral ventromedial medulla, effects attenuated by intra-BLA rimonabant. Formalin also decreased FI in the cingulate cortex, an effect which was not observed in fear-conditioned rats. Contextually-induced fear was associated with increased FI in the dorsal caudal periaqueductal grey in the absence, but not presence, of formalin-evoked nociceptive tone. In conclusion, bilateral intra-BLA administration of rimonabant reduces nociceptive behaviour in a model of tonic, persistent inflammatory pain, an effect associated with reduced activation of neurons in the CA2/3 hippocampus and rostral ventromedial medulla. The data also provide evidence for differential pain- and fear-related brain regional activity in the presence or absence of contextually-induced aversion and nociceptive tone.

BACKGROUND: Lumbar punctures are commonly performed in the pediatric emergency department. There is no standard, recommended, optimal position for children who are undergoing the procedure. OBJECTIVE: To determine a position for lumbar punctures where the interspinous space is maximized, as measured by bedside ultrasound. METHODS: A prospective convenience sample of children under age 12 was performed. Using a portable ultrasound device, the L3-L4 or L4-L5 interspinous space was measured with the subject in 5 different positions. The primary outcome was the interspinous distance between 2 adjacent vertebrae. The interspinous space was measured with the subject sitting with and without hip flexion. In the lateral recumbent position, the interspinous space was measured with the hips in a neutral position as well as in flexion, both with and without neck flexion. Data were analyzed by comparing pairwise differences. RESULTS: There were 28 subjects enrolled (13 girls and 15 boys) at a median age of 5 years. The sitting-flexed position provided a significantly increased interspinous space (P < .05). Flexion of the hips increased the interspinous space in both the sitting and lateral recumbent positions (P < .05). Flexion of the neck, did not significantly change the interspinous space (P = .998). CONCLUSIONS: The interspinous space of the lumbar spine was maximally increased with children in the sitting position with flexed hips; therefore we recommend this position for lumbar punctures. In the lateral recumbent position, neck flexion does not increase the interspinous space and may increase morbidity; therefore, it is recommended to hold patients at the level of the shoulders as to avoid neck flexion.

Facial identity and facial expression matching tasks were completed by 5–12-year-old children and adults using stimuli extracted from the same set of normalized faces. Configural and feature processing were examined using speed and accuracy of responding and facial feature selection, respectively. Facial identity matching was slower than face expression matching for all age groups. Large age effects were found on both speed and accuracy of responding and feature use in both identity and expression matching tasks. Eye region preference was found on the facial identity task and mouth region preference on the facial expression task. Use of mouth region information for facial expression matching increased with age, whereas use of eye region information for facial identity matching peaked early. The feature use information suggests that the specific use of primary facial features to arrive at identity and emotion matching judgments matures across middle childhood. Copyright © 2009 John Wiley & Sons, Ltd.

While the neural regions associated with facial identity recognition are considered to be well defined, the neural correlates of non-moving and moving images of facial emotion processing are less clear. This study examined the brain electrical activity changes in 26 participants (14 males M = 21.64, SD = 3.99; 12 females M = 24.42, SD = 4.36), during a passive face viewing task, a scrambled face task and separate emotion and gender face discrimination tasks. The steady state visual evoked potential (SSVEP) was recorded from 64-electrode sites. Consistent with previous research, face related activity was evidenced at scalp regions over the parieto-temporal region approximately 170 ms after stimulus presentation. Results also identified different SSVEP spatio-temporal changes associated with the processing of static and dynamic facial emotions with respect to gender, with static stimuli predominately associated with an increase in inhibitory processing within the frontal region. Dynamic facial emotions were associated with changes in SSVEP response within the temporal region, which are proposed to index inhibitory processing. It is suggested that static images represent non-canonical stimuli which are processed via different mechanisms to their more ecologically valid dynamic counterparts.

OBJECTIVES:: To investigate the patterns of injury sustained from glass table-related accidents to estimate whether tempered glass would prevent injuries. METHODS:: We conducted a retrospective cohort analysis of all patients in an urban pediatric emergency department between October of 1995 and May for 2007 for glass table-related accidents. Data collected included age, sex, injury characteristics, examination findings, radiographic imaging, interventions, and disposition. We used a preventability score ranging from I (fully preventable injury with safety glass) to IV (unlikely to be preventable with safety glass). RESULTS:: We identified 174 eligible patients during the study period. The median age was 3.4 years (interquartile range, 2.0-6.6 years); 62.1% were boys. The face was most commonly involved (45.6%) followed by lower (23.8%) and upper extremities (18.9%). Patients younger than 5 years were associated with more facial injuries (odds ratio, 6.0; 95% confidence interval, 2.9-12.6). Radiographs were obtained in 68 patients, and computed tomographic scans in 3 (total, 40.1%). Surgical repair was needed in 143 patients (82.1%), of whom 15 (10.5%) underwent procedural sedation and 8 (5.6%) required operative management. Reviewers ranked 74 patients (42.5%) as grade I, 20 patients (11.5%) as grade II, 64 patients (36.8%) as grade III, and 16 patients (9.2%) as grade IV. CONCLUSIONS:: Glass table injuries are associated with significant morbidity. More than half of the injuries may have been prevented or mitigated with the use of tempered glass. Pediatricians are advised to discourage families from the purchase of nontempered glass tables, while advocating for legislation mandating the use of tempered glass. Language: en

OBJECTIVES. American Academy of Pediatrics consensus statement recommendations are to consider strongly for infants 6 to 12 months of age with a first simple febrile seizure and to consider for children 12 to 18 months of age with a first simple febrile seizure lumbar puncture for cerebrospinal fluid analysis. Our aims were to determine compliance with these recommendations and to assess the rate of bacterial meningitis detected among these children.METHODS. A retrospective cohort review was performed for patients 6 to 18 months of age who were evaluated for first simple febrile seizure in a pediatric emergency department between October 1995 and October 2006.RESULTS. First simple febrile seizure accounted for 1% of all emergency department visits for children of this age, with 704 cases among 71 234 eligible visits during the study period. Twenty-seven percent (n = 188) of first simple febrile seizure visits were for infants 6 to 12 months of age, and 73% (n = 516) were for infants 12 to 18 months of age. Lumbar puncture was performed for 38% of the children (n = 271). Samples were available for 70% of children 6 to 12 months of age (131 of 188 children) and 25% of children 12 to 18 months of age (129 of 516 children). Rates of lumbar puncture decreased significantly over time in both age groups. The cerebrospinal fluid white blood cell count was elevated in 10 cases (3.8%). No pathogen was identified in cerebrospinal fluid cultures. Ten cultures (3.8%) yielded a contaminant. No patient was diagnosed as having bacterial meningitis.CONCLUSIONS. The risk of bacterial meningitis presenting as first simple febrile seizure at ages 6 to 18 months is very low. Current American Academy of Pediatrics recommendations should be reconsidered.

Schizophrenia patients have been shown to be compromised in their ability to recognize facial emotion. This deficit has been shown to be related to negative symptoms severity. However, to date, most studies have used static rather than dynamic depictions of faces. Nineteen patients with schizophrenia were compared with seventeen controls on 2 tasks; the first involving the discrimination of facial identity, emotion, and butterfly wings; the second testing emotion recognition using both static and dynamic stimuli. In the first task, the patients performed more poorly than controls for emotion discrimination only, confirming a specific deficit in facial emotion recognition. In the second task, patients performed more poorly in both static and dynamic facial emotion processing. An interesting pattern of associations suggestive of a possible double dissociation emerged in relation to correlations with symptom ratings: high negative symptom ratings were associated with poorer recognition of static displays of emotion, whereas high positive symptom ratings were associated with poorer recognition of dynamic displays of emotion. However, while the strength of associations between negative symptom ratings and accuracy during static and dynamic facial emotion processing was significantly different, those between positive symptom ratings and task performance were not. The results confirm a facial emotion-processing deficit in schizophrenia using more ecologically valid dynamic expressions of emotion. The pattern of findings may reflect differential patterns of cortical dysfunction associated with negative and positive symptoms of schizophrenia in the context of differential neural mechanisms for the processing of static and dynamic displays of facial emotion.

Necrotizing enterocolitis (NEC) remains a major cause of neonatal morbidity and mortality. Some infants recover uneventfully with medical therapy whereas others develop severe disease (that is, NEC requiring surgery or resulting in death). Repeated attempts to identify clinical parameters that would reliably identify infants with NEC most likely to progress to severe disease have been unsuccessful. We hypothesized that comprehensive prospective data collection at multiple centers would allow us to develop a model which would identify those babies at risk for progressive NEC.This prospective, observational study was conducted at six university children's hospitals. Study subjects were neonates with suspected or confirmed NEC. Comprehensive maternal and newborn histories were collected at the time of enrollment, and newborn clinical data were collected prospectively, thereafter. Multivariate logistic regression analysis was used to develop a predictive model of risk factors for progression.Of 455 neonates analyzed, 192 (42%) progressed to severe disease, and 263 (58%) advanced to full feedings without operation. The vast majority of the variables studied proved not to be associated with progression to severe disease. A total of 12 independent predictors for progression were identified, including only 3 not previously described: having a teenaged mother (odds ratio, OR, 3.14; 95% confidence interval, CI, 1.45 to 6.96), receiving cardiac compressions and/or resuscitative drugs at birth (OR, 2.51; 95% CI, 1.17 to 5.48), and having never received enteral feeding before diagnosis (OR, 2.41; 95% CI, 1.08 to 5.52).Our hypothesis proved false. Rigorous prospective data collection of a sufficient number of patients did not allow us to create a model sufficiently predictive of progressive NEC to be clinically useful. It appears increasingly likely that further analysis of clinical parameters alone will not lead to a significant improvement in our understanding of NEC. We believe that future studies must focus on advanced biologic parameters in conjunction with clinical findings.

The Rapid Visual Information Processing (RVIP) task, a serial discrimination task where task performance believed to reflect sustained attention capabilities, is widely used in behavioural research and increasingly in neuroimaging studies. To date, functional neuroimaging research into the RVIP has been undertaken using block analyses, reflecting the sustained processing involved in the task, but not necessarily the transient processes associated with individual trial performance. Furthermore, this research has been limited to young cohorts. This study assessed the behavioural and functional magnetic resonance imaging (fMRI) outcomes of the RVIP task using both block and event-related analyses in a healthy middle aged cohort (mean age = 53.56 years, n = 16). The results show that the version of the RVIP used here is sensitive to changes in attentional demand processes with participants achieving a 43% accuracy hit rate in the experimental task compared with 96% accuracy in the control task. As shown by previous research, the block analysis revealed an increase in activation in a network of frontal, parietal, occipital and cerebellar regions. The event related analysis showed a similar network of activation, seemingly omitting regions involved in the processing of the task (as shown in the block analysis), such as occipital areas and the thalamus, providing an indication of a network of regions involved in correct trial performance. Frontal (superior and inferior frontal gryi), parietal (precuenus, inferior parietal lobe) and cerebellar regions were shown to be active in both the block and event-related analyses, suggesting their importance in sustained attention/vigilance. These networks and the differences between them are discussed in detail, as well as implications for future research in middle aged cohorts.

In 2002, we implemented a 4-year HIV prevention intervention for injection drug users (IDUs) in Lang Son Province, Vietnam, and Ning Ming County, Guangxi Province, China, a cross-border region seriously affected by inter-twined epidemics of heroin injection and HIV infection. The interventions involve peer education on HIV risk reduction and provision of new needles/syringes through direct distribution and pharmacy vouchers. We consider this to be a structural intervention in which risk reduction information and sterile injection equipment are diffused through the IDU populations and not limited to those who actually interact with peer educators. The evaluation of structural interventions poses complex methodological challenges. The evaluation of our interventions relies primarily on cross-sectional surveys (interviews and HIV testing) of samples of IDUs selected using a combination of targeted cluster and snowball methods. We consider this to be an appropriate, albeit imperfect, design given the study context. This paper presents analyses of data from the IDU surveys conducted just prior to implementation of the interventions and 24 months thereafter. The cross-border interventions have reached large proportions of the IDUs in the project sites, drug-related HIV risk behaviors have declined in frequency, and HIV prevalence among IDUs has been stable in China and declined in Vietnam over the 24 months since the interventions were implemented. Attribution of these positive trends to the interventions must be qualified in light of possible sampling biases and the absence of control groups. However, we believe that the structural interventions implemented by the cross-border project have played a role in stabilizing HIV prevalence among IDUs two years after they were initiated. Evidence of further diffusion of the interventions among IDUs and continued stability or decline of HIV prevalence would strengthen this case.

This paper begins with a brief review of recent literature about relationships between offending behaviour and mental illness, classifying studies by the settings within which they occurred. The establishment and role of a mental health court liaison (MHCL) service is then described, together with findings from a 3-year service audit, including an examination of relationships between clients' characteristics and offence profiles, and comparisons with regional offence data. During the audit period, 971 clients (767 males, 204 females) were referred to the service, comprising 1139 service episodes, 35.5% of which involved a comorbid substance use diagnosis. The pattern of offences for MHCL clients was reasonably similar to the regional offence data, except that among MHCL clients there were proportionately more offences against justice procedures (e.g., breaches of apprehended violence orders [AVOs]) and fewer driving offences and “other offences”. Additionally, male MHCL clients had proportionately more ma...

This study assessed 12-month service use patterns among people with psychotic disorders and sought to identify determinants of service use.As part of a large two-phase Australian study of psychotic disorders, structured interviews were conducted with a stratified random sample of adults who screened positive for psychosis. Demographic characteristics, social functioning, symptoms, mental health diagnoses, and use of psychiatric and nonpsychiatric services were assessed. Data were analyzed for 858 persons who had an ICD-10 diagnosis of a psychotic disorder and who had been hospitalized for less than six months during the previous year.People with psychotic disorders had high levels of use of health services, both in absolute terms and relative to people with nonpsychotic disorders. Those with psychotic disorders were estimated to have an average of one contact with health services per week. Use of psychiatric inpatient services was associated with parenthood, higher symptom levels, recent attempts at suicide or self-harm, personal disability, medication status, and frequency of alcohol consumption. Services provided by general practitioners (family physicians) were more likely to be obtained by older people, women, people with greater availability of friends, those with fewer negative symptoms, and those whose service needs were unmet by other sources. People who were high users of health services also reported having more contact with a range of non-health agencies.The predictors of service use accounted for small proportions of the variance in overall use of health services. The role of general practitioners in providing and monitoring treatment programs and other psychosocial interventions needs to be acknowledged and enhanced.

Purpose: The primary objective of this study was to investigate the influence of renal impairment on the pharmacokinetics of capecitabine and its metabolites in cancer patients. Capecitabine (Xeloda) is an orally administered precursor of 5′-deoxy-5-fluorouridine (5′-DFUR), which is preferentially activated to 5-fluorouracil (5-FU) in tumors. Methods: A total of 27 patients were enrolled, of whom 24 were evaluable for pharmacokinetics (6 with normal renal function, 8 with mild, 6 with moderate, and 4 with severe renal impairment at baseline). Patients received capecitabine orally at the standard dosing regimen (1250 mg/m2 capecitabine twice daily for 2 weeks followed by a 1-week rest period). On study days 1 and 14, blood samples were collected to evaluate the pharmacokinetics of capecitabine and its metabolites. The relationship between the area under the plasma concentration-time curve (AUC) and creatinine clearance (CLCR) was assessed by log-linear regression analysis. Results: The primary pharmacokinetic parameter with respect to the effect of renal dysfunction was systemic exposure to 5′-DFUR, 5-FU and FBAL determined on study day 14. Renal impairment led to an increase in the systemic exposure to 5′-DFUR and FBAL (23% and 109% increase in AUC, respectively) for a 50% reduction in CLCR. By contrast, renal impairment may lead to decreased exposure to 5′-DFCR. There was no evidence for an effect of renal impairment on systemic exposure to 5-FU or capecitabine. Renal impairment did not have a major effect on peak concentration (Cmax) or elimination half-life (t1/2) of capecitabine, 5′-DFCR, 5′-DFUR, and 5-FU. However, in the case of FBAL, moderate or severe renal impairment caused up to a twofold increase in Cmax and prolongation of t1/2. All patients with severe renal impairment (four patients) had drug-related grade 3 or 4 adverse-events (AEs) and serious AEs. Patients with moderate renal impairment experienced a similar number of grade 3 or 4 AEs (six of nine patients) but had a higher incidence of serious AEs (three of nine patients) when compared with those with normal renal function (four of six patients and one of six patients, respectively). A similar effect was seen in patients with mild renal dysfunction (grade 3 or 4 AEs in four of eight patients; serious AEs in three of eight patients). The relationship between systemic exposure to capecitabine or its metabolites and safety was investigated using logistic regression. This exploratory analysis showed a strong positive relationship between AUC of 5′-DFUR and treatment-related grade 3 or 4 AEs, whereas there was no relationship with exposure to capecitabine, 5′-DFCR, 5-FU or FBAL. Conclusions: Renal impairment has no effect on the pharmacokinetics of capecitabine or 5-FU, but leads to an increase in the systemic exposure to 5′-DFUR and FBAL. However, only the AUC of 5′-DFUR is correlated with safety. Based on the safety results in patients with severe renal impairment, a dose modification cannot be recommended for these patients and they should not be treated with capecitabine. Additional data from the clinical safety database and pharmacokinetic results from the present study support the recommendation that patients with moderate renal impairment should be treated with 75% of the recommended standard starting dose to achieve systemic exposure comparable to that in patients with normal renal function.

The current research was designed to establish whether individual differences in timing performance predict neural activation in the areas that subserve the perception of short durations ranging between 400 and 1600 milliseconds. Seventeen participants completed both a temporal bisection task and a control task, in a mixed fMRI design. In keeping with previous research, there was increased activation in a network of regions typically active during time perception including the right supplementary motor area (SMA) and right pre-SMA and basal ganglia (including the putamen and right pallidum). Furthermore, correlations between neural activity in the right inferior frontal gyrus and SMA and timing performance corroborate the results of a recent meta-analysis and are further evidence that the SMA forms part of a neural clock that is responsible for the accumulation of temporal information. Specifically, subjective lengthening of the perceived duration were associated with increased activation in both the right SMA (and right pre-SMA) and right inferior frontal gyrus.

Most clinical trials in asthma have focused on outcomes that are primarily of importance to the clinician. Very few have assessed whether patients feel better and can function better in day-to-day activities. The aim of this study was to compare the effects of salmeterol (50 micrograms twice daily), salbutamol (200 micrograms four times a day), and placebo on asthma-specific quality of life and to relate the findings to conventional clinical asthma outcomes. The study was a 12-wk multicenter, double blind, randomized, placebo-controlled crossover trial with each trial medication taken for 4 wk. The subjects were 140 adults with mild to moderate asthma enrolled from 14 respiratory clinics across Canada. Outcome measures were: (1) the Asthma Quality of Life Questionnaire and spirometry at the end of each treatment period; and (2) daily asthma symptoms, morning and evening peak expiratory flow rates (PEFRs), and rescue salbutamol use during the last 14 d of each treatment period. Asthma-specific quality of life, both overall and for the individual domains (activity limitation, symptoms, emotional function, and exposure to environmental stimuli) was better with salmeterol than with placebo (p < 0.0001), and better with salmeterol than with salbutamol (p < 0.001). In both comparisons, differences were not only statistically significant, but most were also clinically important. There were moderate correlations between change in quality of life and change in clinical outcomes.(ABSTRACT TRUNCATED AT 250 WORDS)

Context People with autism spectrum disorders (ASDs) have lifelong deficits in social behavior and differences in behavioral as well as neural responses to facial expressions of emotion. The biological basis to this is incompletely understood, but it may include differences in the role of neurotransmitters such as serotonin, which modulate facial emotion processing in health. While some individuals with ASD have significant differences in the serotonin system, to our knowledge, no one has investigated its role during facial emotion processing in adults with ASD and control subjects using acute tryptophan depletion (ATD) and functional magnetic resonance imaging. Objective To compare the effects of ATD on brain responses to primary facial expressions of emotion in men with ASD and healthy control subjects. Design Double-blind, placebo-controlled, crossover trial of ATD and functional magnetic resonance imaging to measure brain activity during incidental processing of disgust, fearful, happy, and sad facial expressions. Setting Institute of Psychiatry, King's College London, and South London and Maudsley National Health Service Foundation Trust, England. Participants Fourteen men of normal intelligence with autism and 14 control subjects who did not significantly differ in sex, age, or overall intelligence. Main Outcome Measures Blood oxygenation level–dependent response to facial expressions of emotion. Results Brain activation was differentially modulated by ATD depending on diagnostic group and emotion type within regions of the social brain network. For example, processing of disgust faces was associated with interactions in medial frontal and lingual gyri, whereas processing of happy faces was associated with interactions in middle frontal gyrus and putamen. Conclusions Modulation of the processing of facial expressions of emotion by serotonin significantly differs in people with ASD compared with control subjects. The differences vary with emotion type and occur in social brain regions that have been shown to be associated with group differences in serotonin synthesis/receptor or transporter density.

Richard Abelson1,2, Keith J Lane3, Endri Angjeli3, Patrick Johnston3, George Ousler3, Douglas Montgomery1 1Arizona State University, 2Statistics and Data Corporation, Tempe, AZ, USA; 3Ora, Inc, Andover, MA, USA Purpose: To evaluate a new method of measuring ocular exposure in the context of a natural blink pattern through analysis of the variables tear film breakup time (TFBUT), interblink interval (IBI), and tear film breakup area (BUA). Methods: The traditional methodology (Forced-Stare [FS]) measures TFBUT and IBI separately. TFBUT is measured under forced-stare conditions by an examiner using a stopwatch, while IBI is measured as the subject watches television. The new methodology (video capture manual analysis [VCMA]) involves retrospective analysis of video data of fluorescein-stained eyes taken through a slit lamp while the subject watches television, and provides TFBUT and BUA for each IBI during the 1-minute video under natural blink conditions. The FS and VCMA methods were directly compared in the same set of dry-eye subjects. The VCMA method was evaluated for the ability to discriminate between dry-eye subjects and normal subjects. The VCMA method was further evaluated in the dry eye subjects for the ability to detect a treatment effect before, and 10 minutes after, bilateral instillation of an artificial tear solution. Results: Ten normal subjects and 17 dry-eye subjects were studied. In the dry-eye subjects, the two methods differed with respect to mean TFBUTs (5.82 seconds, FS; 3.98 seconds, VCMA; P = 0.002). The FS variables alone (TFBUT, IBI) were not able to successfully distinguish between the dry-eye and normal subjects, whereas the additional VCMA variables, both derived and observed (BUA, BUA/IBI, breakup rate), were able to successfully distinguish between the dry-eye and normal subjects in a statistically significant fashion. TFBUT (P = 0.034) and BUA/IBI (P = 0.001) were able to distinguish the treatment effect of artificial tears in dry-eye subjects. Conclusion: The VCMA methodology provides a clinically relevant analysis of tear film stability measured in the context of a natural blink pattern. Keywords: ocular protection index, tear film breakup time, interblink interval, forced stare

Inhibitory control deficits are well documented in schizophrenia, supported by impairment in an established measure of response inhibition, the stop-signal reaction time (SSRT). We investigated the neural basis of this impairment by comparing schizophrenia patients and controls matched for age, sex and education on behavioural, functional magnetic resonance imaging (fMRI) and event-related potential (ERP) indices of stop-signal task performance. Compared to controls, patients exhibited slower SSRT and reduced right inferior frontal gyrus (rIFG) activation, but rIFG activation correlated with SSRT in both groups. Go stimulus and stop-signal ERP components (N1/P3) were smaller in patients, but the peak latencies of stop-signal N1 and P3 were also delayed in patients, indicating impairment early in stop-signal processing. Additionally, response-locked lateralised readiness potentials indicated response preparation was prolonged in patients. An inability to engage rIFG may predicate slowed inhibition in patients, however multiple spatiotemporal irregularities in the networks underpinning stop-signal task performance may contribute to this deficit.

Background Glass mercury thermometers were once used as the criterion standard for measuring core body temperature. Once broken, however, there is the dual hazard of broken glass and exposure to mercury. Previous studies have focused only on the mercury hazard rather than injuries related to thermometer glass. Objective To identify injury patterns from glass thermometers, including glass-related injury and mercury exposure. Methods We performed a retrospective cohort study of glass thermometer-related injuries in children evaluated in a pediatric emergency department between October 1995 and October 2007. Case identification was performed using a computer-assisted screening tool followed by a manual chart review. Collected data included age, sex, injury characteristics, physical examination findings, radiologic imaging, interventions, and disposition. To analyze injury rates during these years, we used a multiplicative Poisson model allowing for varying exposures. Results Thirty-three patients were identified among 627,592 who presented to the emergency department during the study period. Approximately 1 to 6 patients presented every year, including 3 patients in 2007. Decline in injury incidence is less than 9% per year (P = 0.041). Median patient age was 2.4 years (interquartile range, 0.4-3.8 years); 12 patients (36%) were female. Twenty-two patients (66%) underwent radiologic imaging to identify potential foreign body (21 underwent radiography and 1 underwent computed tomographic scanning). There were 15 mouth injuries (45%), 13 anal injuries (39%), and 1 ear injury. Glass was identified by imaging in 5 patients (15%) and by sigmoidoscopic evaluation in 1 patient (3%). Mercury exposure was identified in 14 patients (42%). Conclusions Persistent use of glass mercury thermometers has resulted in pediatric injury especially in children younger than 4 years. We reported the different mechanisms of injury with the hope of eliminating its use and reinforcing the use of alternative thermometers.

To evaluate the sensitivity of fluorine 18-labeled sodium fluoride ((18)F-NaF) positron emission tomography (PET) for assessment of skeletal trauma in pediatric patients suspected of having been abused and to compare the diagnostic performance of this examination with that of high-detail skeletal survey.The institutional review board approved this retrospective study and determined that it was in accordance with regulations of HIPAA privacy rule 45, Code of Federal Regulations parts 160 and 164, and that the criteria for waived patient authorization were met. The baseline skeletal survey and PET images obtained in 22 patients younger than 2 years between September 2007 and January 2009 were reviewed. Fourteen patients also underwent follow-up skeletal survey. The PET images were interpreted by two pediatric nuclear medicine physicians. The initially obtained skeletal survey images were interpreted blindly by a pediatric radiologist. A second pediatric radiologist interpreted the follow-up skeletal survey images in conjunction with the baseline survey images and rendered a final interpretation for the 14 patients in whom both baseline and follow-up skeletal survey data were available, which served as the reference standard.A total of 156 fractures were detected at baseline skeletal survey, and 200 fractures were detected at PET. Compared with the reference standard (findings in the 14 patients who underwent baseline and follow-up skeletal survey), PET had sensitivities of 85% for the detection of all fractures, 92% for the detection of thoracic fractures (ribs, sternum, clavicle, and scapula), 93% for the detection of posterior rib fractures, and 67% for the detection of classic metaphyseal lesions (CMLs), defined as a series of microfractures across the metaphysis. Compared with the reference standard, baseline skeletal survey had sensitivities of 72% for the detection of all fractures, 68% for the detection of thoracic fractures, 73% for the detection of posterior rib fractures, and 80% for the detection of CMLs.(18)F-NaF PET had greater sensitivity in the overall detection of fractures related to child abuse than did baseline skeletal survey. (18)F-NaF PET was superior in the detection of rib fractures in particular. Thus, (18)F-NaF PET is an attractive choice for evaluation of suspected child abuse, an application in which high sensitivity is desirable. Because of the lower sensitivity of PET in the detection of CMLs, a characteristic fracture in child abuse, initial radiographic evaluation remains necessary.

Background: Emergency departments (EDs) in teaching hospitals have competing goals of timely patient care and supervised trainee education. Previous investigations have indicated that trainees add time to the length of ED patient encounters. However, no studies have quantified the effect of trainees on pediatric ED length of stay (LOS). Objectives: The objectives were to measure the effect of trainees on pediatric ED LOS by comparing LOS for patients managed by a pediatric emergency physician (PEP) alone to LOS for patients seen by a trainee and a precepting PEP (Trainee+PEP). A secondary objective was to identify factors other than provider type associated with LOS differences observed in teaching hospital pediatric EDs. Methods: Data were extracted from a computerized ED tracking system in an urban tertiary care children’s hospital with approximately 52,000 visits annually. All patients were seen by a PEP alone, an urgent care physician, or a trainee (a pediatric emergency medicine fellow; a pediatric, emergency medicine, or combined internal medicine ⁄pediatrics resident; or a medical student) plus a precepting PEP. The primary comparison was the ratio of median LOS for the PEP group versus the Trainee+PEP group. Results: There were 92,193 visits eligible for inclusion over a 2-year period. Median patient age was 5.75 years (interquartile range [IQR] = 21 months to 12.9 years). The PEP group managed 9,141 patients (10%), while the Trainee+PEP group treated 72,135 patients (78%). Overall LOS for an ED visit was 221 minutes. The median LOS was 192 minutes for PEP patients and 225 minutes for Trainee+PEP patients (difference of means = 17%, p < 0.001). Laboratory and imaging studies were associated with LOS increases of 111 and 74 minutes, respectively; both were performed more frequently in Trainee+PEP patients (44% vs. 33% for laboratory studies and 41% vs. 39% for imaging studies, both comparisons p < 0.001). When LOS was analyzed after adjusting for confounding factors including patient acuity, laboratory or radiologic testing, and trainee year, LOS for Trainee+PEP was higher by 17 minutes, or 9% (95% confidence interval [CI] = 6% to 12%, p < 0.001). When LOS was examined for four specific diagnoses (asthma, gastroenteritis, appendicitis, foot ⁄ankle sprain), there were no significant differences in LOS between the PEP and Trainee+PEP groups. Conclusions: In the pediatric ED of a teaching hospital, ED LOS is on average 9% higher in patients seen by trainees. In an era of increasing efforts to accelerate throughput while training future providers, these findings provide an important metric for the delivery of pediatric emergency care. ACADEMIC EMERGENCY MEDICINE 2009; 16:859‐865 a 2009 by the Society for Academic Emergency Medicine

To determine risk factors for intestinal failure (IF) in infants undergoing surgery for necrotizing enterocolitis (NEC).Infants were enrolled in a multicenter prospective cohort study. IF was defined as the requirement for parenteral nutrition foror= 90 days. Logistic regression was used to identify predictors of IF.Among 473 patients enrolled, 129 had surgery and had adequate follow-up data, and of these patients, 54 (42%) developed IF. Of the 265 patients who did not require surgery, 6 (2%) developed IF (OR 31.1, 95% CI, 12.9 - 75.1, P.001). Multivariate analysis identified the following risk factors for IF: use of parenteral antibiotics on the day of NEC diagnosis (OR = 16.61, P = .022); birth weight750 grams, (OR = 9.09, P.001); requirement for mechanical ventilation on the day of NEC diagnosis (OR = 6.16, P = .009); exposure to enteral feeding before NEC diagnosis (OR=4.05, P = .048); and percentage of small bowel resected (OR = 1.85 per 10 percentage point greater resection, P = .031).The incidence of IF among infants undergoing surgical treatment for NEC is high. Variables characteristic of severe NEC (low birth weight, antibiotic use, ventilator use, and greater extent of bowel resection) were associated with the development of IF.

To determine the prevalence of sensorineural hearing loss (SNHL) in cystic fibrosis (CF) patients and its relationship to antibiotic use.Case series with chart review.Tertiary care pediatric hospital.We reviewed the medical records of CF patients seen in our children's hospital between March 1994 and December 2007. Data collected included patient demographics, audiograms, tympanograms, genotype, and use of potentially ototoxic antibiotics.Seven of 50 (14%) patients had SNHL. Three percent of patients who receivedor=10 courses of intravenous aminoglycosides had SNHL versus 43 percent of those who received10 courses (P0.01). No patients who received five or fewer courses of nasal irrigation with aminoglycosides had SNHL versus 23 percent of those who received more than five courses (P0.05). Nine percent of patients who received five or fewer courses of macrolides had SNHL versus 60 percent of those who received more than five courses (P=0.079).CF patients receiving aminoglycosides are at high risk for developing SNHL.

Summary Objective To determine if a phosphorylcholine (PC) antibacterial coating on standard Armstrong beveled tympanostomy tubes (TT) reduced the incidence of post-tube placement complications. Methods A prospective cohort aged 8–51 months received bilateral TTs for otitis media with effusion between July 2002 and February 2004 at a tertiary care pediatric hospital. Seventy children were randomized to receive a PC-coated TT in one ear and an uncoated TT in the other. Otologic examinations at prescribed intervals over two years post-operatively ascertained the status of sequelae. We analyzed the incidence of TT complications: otorrhea, premature extrusion, persistent tympanic membrane perforations, granulation tissue, and ventilation tube lumen obstruction. Results There was no statistical difference in the incidence of any of these sequelae between standard and PC-coated tympanostomy tubes (p > 0.05) during the 24-month-follow-up period. Results after 13 months of follow-up may have been affected by patients lost to follow-up and therefore a smaller sample size as the study continued. Conclusions This study found that there is no statistically significant difference in the incidence of complications between uncoated and PC-coated fluoroplastic Armstrong beveled TTs.