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Background and Aims: The purpose of this Third Stroke Recovery and Rehabilitation Roundtable (SRRR3) was to develop consensus recommendations to address outstanding barriers for the translation of preclinical and clinical research using the non-invasive brain stimulation (NIBS) techniques Transcranial Magnetic Stimulation (TMS) and Transcranial Direct Current Stimulation (tDCS) and provide a roadmap for the integration of these techniques into clinical practice., Methods: International NIBS and stroke recovery experts (N = 18) contributed to the consensus process. Using a nominal group technique, recommendations were reached via a five-stage process, involving a thematic survey, two priority ranking surveys, a literature review and an in-person meeting., Results and Conclusions: Results of our consensus process yielded five key evidence-based and feasibility barriers for the translation of preclinical and clinical NIBS research, which were formulated into five core consensus recommendations. Recommendations highlight an urgent need for (1) increased understanding of NIBS mechanisms, (2) improved methodological rigor in both preclinical and clinical NIBS studies, (3) standardization of outcome measures, (4) increased clinical relevance in preclinical animal models, and (5) greater optimization and individualization of NIBS protocols. To facilitate the implementation of these recommendations, the expert panel developed a new SRRR3 Unified NIBS Research Checklist. These recommendations represent a translational pathway for the use of NIBS in stroke rehabilitation research and practice., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background and Aims: The purpose of this Third Stroke Recovery and Rehabilitation Roundtable (SRRR3) was to develop consensus recommendations to address outstanding barriers for the translation of preclinical and clinical research using the non-invasive brain stimulation (NIBS) techniques Transcranial Magnetic Stimulation (TMS) and Transcranial Direct Current Stimulation (tDCS) and provide a roadmap for the integration of these techniques into clinical practice., Methods: International NIBS and stroke recovery experts (N = 18) contributed to the consensus process. Using a nominal group technique, recommendations were reached via a five-stage process, involving a thematic survey, two priority ranking surveys, a literature review and an in-person meeting., Results and Conclusions: Results of our consensus process yielded five key evidence-based and feasibility barriers for the translation of preclinical and clinical NIBS research, which were formulated into five core consensus recommendations. Recommendations highlight an urgent need for (1) increased understanding of NIBS mechanisms, (2) improved methodological rigor in both preclinical and clinical NIBS studies, (3) standardization of outcome measures, (4) increased clinical relevance in preclinical animal models, and (5) greater optimization and individualization of NIBS protocols. To facilitate the implementation of these recommendations, the expert panel developed a new SRRR3 Unified NIBS Research Checklist. These recommendations represent a translational pathway for the use of NIBS in stroke rehabilitation research and practice., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: This study aims to examine indicators of crash risk longitudinally in older adults ( n = 486). Method: This study applied secondary data analyses of the 10 years of follow-up for the ACTIVE study combined with state-recorded crash records from five of the six participating sites. Cox proportional hazards models were first used to examine the effect of each variable of interest at baseline after controlling for miles driven and then to assess the three cognitive composites as predictors of time to at-fault crash in covariate-adjusted models. Results: Older age, male sex, and site location were each predictive of higher crash risk. Additionally, worse scores on the speed of processing cognitive composite were associated with higher crash risk. Discussion: Results support previous findings that both age and male sex are associated with higher crash risk. Our significant finding of site location could be attributed to the population density of our testing sites and transportation availability., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: For long-stay patients (LSP) in pediatric intensive care units (PICU), frequently rotating providers can lead to ineffective information sharing and retention, varying goals and timelines, and delayed decisions, likely contributing to prolonged admissions. Primary intensivists (one physician serves as a consistent resource for the patient/family and PICU providers) and primary nurses (a small team of PICU nurses provide consistent bedside care) seek to augment usual transitory PICU care, by enhancing continuity and, potentially, decreasing length of stay (LOS). Methods: A single-centered, partially blinded randomized controlled trial of primary intensivists and nurses versus usual care. PICU patients admitted for or expected to be admitted for >10 days and who had ≥1 complex chronic condition were eligible. A block randomization with 1:1 allocation was used. The primary outcome was PICU LOS. Multiple secondary outcomes were explored. Results: Two hundred LSPs were randomized-half to receive primaries and half to usual care. The two groups were not significantly different in their baseline and admission characteristics. LSPs randomized to receive primaries had a shorter, but non-significant, mean LOS than those randomized to usual care (32.5 vs. 37.1 days, respectively, p  = .19). Compared to LSPs in the usual care group, LSPs in the primary group had fewer unplanned intubations. Among LSPs that died, DNR orders were more prevalent in the primary group. Other secondary outcome and balance metrics were not significantly different between the two groups. Conclusion: Primary intensivists and nurses may be an effective strategy to counteract transitory PICU care and serve the distinctive needs of LSPs. However, additional studies are needed to determine the ways and to what extent they may accomplish this.

Objective . To develop consensus recommendations for the use of repetitive transcranial magnetic stimulation (rTMS) as an adjunct intervention for upper extremity motor recovery in stroke rehabilitation clinical trials. Participants . The Canadian Platform for Trials in Non-Invasive Brain Stimulation (CanStim) convened a multidisciplinary team of clinicians and researchers from institutions across Canada to form the CanStim Consensus Expert Working Group. Consensus Process . Four consensus themes were identified: (1) patient population, (2) rehabilitation interventions, (3) outcome measures, and (4) stimulation parameters. Theme leaders conducted comprehensive evidence reviews for each theme, and during a 2-day Consensus Meeting, the Expert Working Group used a weighted dot-voting consensus procedure to achieve consensus on recommendations for the use of rTMS as an adjunct intervention in motor stroke recovery rehabilitation clinical trials. Results . Based on best available evidence, consensus was achieved for recommendations identifying the target poststroke population, rehabilitation intervention, objective and subjective outcomes, and specific rTMS parameters for rehabilitation trials evaluating the efficacy of rTMS as an adjunct therapy for upper extremity motor stroke recovery. Conclusions . The establishment of the CanStim platform and development of these consensus recommendations is a first step toward the translation of noninvasive brain stimulation technologies from the laboratory to clinic to enhance stroke recovery.

Objective: The aim of these secondary analyses was to examine cognitive speed of processing training (SPT) gains in cognitive and everyday functioning among older adults with psychometrically defined mild cognitive impairment (MCI)., Method: A subgroup of participants from the Staying Keen in Later Life (SKILL) study with psychometrically defined MCI ( N = 49) were randomized to either the SPT intervention or an active control group of cognitive stimulation. Outcome measures included the Useful Field of View (UFOV), Road Sign Test, and Timed Instrumental Activities of Daily Living (IADL) Test. A 2 × 2 repeated-measures MANOVA revealed an overall effect of training, indicated by a significant group (SPT vs. control) by time (baseline vs. posttest) interaction., Results: Effect sizes were large for improved UFOV, small for the Road Sign test, and medium for Timed IADL., Discussion: Results indicate that further investigation of cognitive intervention strategies to improve everyday functioning in patients with MCI is warranted.

Background The incidence of stroke in young adults is increasing. While many young survivors are able to achieve a good physical recovery, subtle dysfunction in other domains, such as cognition, often persists, and could affect return to work. However, reported estimates of return to work and factors affecting vocational outcome post-stroke vary greatly. Aims The aims of this systematic review were to determine the frequency of return to work at different time points after stroke and identify predictors of return to work. Summary of review Two electronic databases (Medline and Embase) were systematically searched for articles according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 6473 records were screened, 68 were assessed for eligibility, and 29 met all inclusion criteria (working-age adults with stroke, return to work evaluated as an outcome, follow-up duration reported, and publication within the past 20 years). Return to work increased with time, with median frequency increasing from 41% between 0 and 6 months, 53% at 1 year, 56% at 1.5 years to 66% between 2 and 4 years post-stroke. Greater independence in activities of daily living, fewer neurological deficits, and better cognitive ability were the most common predictors of return to work. Conclusion This review highlights the need to examine return to work in relation to time from stroke and assess cognition in working age and young stroke survivors. The full range of factors affecting return to work has not yet been explored and further evaluations of return to work interventions are warranted.

Objective: The aim of this study was to understand the relationships among depressive symptoms, cognition, and functional performance in a community-based sample of older adults., Method: Older adults ( N = 885) from the Staying Keen in Later Life study completed tests of executive function, speed of processing, and memory. The Center for Epidemiologic Depression Scale assessed depressive symptoms. The Timed Instrumental Activities of Daily Living Test assessed participants' everyday functional performance., Results: Depressive symptoms had significant associations with measures of executive function, speed of processing, memory, and everyday functional performance. Cognitive performance completely mediated the association between depressive symptoms and everyday function., Discussion: Among community-dwelling older adults, depressive symptoms were associated with impaired cognition across multiple domains, which detrimentally affected everyday function. Health care providers should be aware of these associations to monitor and manage changes in depressive symptoms and cognitive performance and thereby potentially mitigate functional decline.

Purpose: The role of multidisciplinary teams in improving the care of intensive care unit (ICU) patients is not well defined, and it is unknown whether the use of such teams helps to explain prior research suggesting improved mortality with intensivist staffing. We sought to investigate the association between multidisciplinary team care and survival of medical and surgical patients in nonspecialty ICUs., Materials and Methods: We conducted a community-based, retrospective cohort study of data from 60 330 patients in 181 hospitals participating in a statewide public reporting initiative, the California Hospital Assessment and Reporting Taskforce (CHART). Patient-level data were linked with ICU organizational data collected from a survey of CHART hospital ICUs between December 2010 and June 2011. Clustered logistic regression was used to evaluate the independent effect of multidisciplinary care on the in-hospital mortality of medical and surgical ICU patients. Interactions between multidisciplinary care and intensity of physician staffing were examined to explore whether team care accounted for differences in patient outcomes., Results: After adjustment for patient characteristics and interactions, there was no association between team care and mortality for medical patients. Among surgical patients, multidisciplinary care was associated with a survival benefit (odds ratio 0.79; 95% confidence interval (CI), 0.62-1.00; P = .05). When stratifying by intensity of physician staffing, although the lowest odds of death were observed for surgical patients cared for in ICUs with multidisciplinary teams and high-intensity staffing (odds ratio, 0.77; 95% CI, 0.55-1.09; P = .15), followed by ICUs with multidisciplinary teams and low-intensity staffing (odds ratio 0.84, 95% CI 0.65-1.09, p = 0.19), these differences were not statistically significant., Conclusions: Our results suggest that multidisciplinary team care may improve outcomes for critically ill surgical patients. However, no relationship was observed between intensity of physician staffing and mortality., (© The Author(s) 2014.)

Aminoglycosides are among the oldest antibiotics available to treat serious infections caused by primarily, Gram-negative bacteria. The most commonly utilized parenteral agents in this class include gentamicin, tobramycin and amikacin. Aminoglycosides are concentration-dependent, bactericidal agents that undergo active transport into the cell where they inhibit protein synthesis on the 30S subunit of the bacterial ribosome. As the use of aminoglycosides became more widespread, the toxic effects of these agents, most notably ototoxicity and nephrotoxicity, became more apparent. When other, safer, antimicrobial agents became available, the use of aminoglycosides sharply declined. The development of multi-drug resistance among bacteria has now lead clinicians to reexamine the role of the aminoglycosides in the treatment of serious infections. This review will revisit the mechanism and risk factors for the development of aminoglycoside-induced nephrotoxicity, as well as strategies to prevent patients from developing nephrotoxicity., (© The Author(s) 2014.)

Objective: Older adults with higher self-efficacy may be more likely to benefit from some cognitive training approaches. We examined whether self-efficacy serves as a mediator or moderator of responsiveness to cognitive speed of processing training (SOPT)., Method: We used data from the Staying Keen in Later Life (SKILL) study (N = 128) and the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) study (N = 1,400). Both studies assessed cognitive speed of processing (Useful Field of View Test-UFOV) and self-efficacy among community-dwelling older adults who were either randomized to SOPT or control conditions. We constructed regression models examining self-efficacy as a predictor of training responsiveness., Results: Analyses from both studies indicated that participants' self-efficacy scores were not predictive of training gains from SOPT, as measured by UFOV performance., Discussion: Self-efficacy does not affect older adults' ability to benefit from cognitive SOPT., (© The Author(s) 2014.)

Objective: Cognitive deficits pose serious problems for older adults with heart failure (HF). Cognitive speed of processing training improves cognition among older adults but has not been examined among older adults with HF., Method: Data from the ACTIVE study were used to examine the effects of cognitive speed of processing training on cognitive and functional performance among older adults with HF., Results: Of the 54 participants included in the analyses, 23 who were randomized to cognitive training performed significantly better on a composite of everyday speed of processing from pre- to post-training compared with 31 participants who were randomized to the control group, F(1, 51) = 28.67, p ≤ .001, [Formula: see text] = .360., Discussion: Results indicate that speed of processing training may improve everyday cognitive performance among older adults with HF. Future studies should investigate the longitudinal effects of cognitive training with HF patients., (© The Author(s) 2014.)

Objectives: To longitudinally examine gender and racial disparities in driving cessation among older adults., Methods: Data came from the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) Study (N = 1,789). Logistic generalized estimating equations (GEE) were used to identify predictors of driving cessation; stratified analysis and interaction terms were used to determine whether factors differed by gender and race., Results: Two hundred and five (11.5%) participants stopped driving over the study period. Education was associated with increased risk of cessation for men (adjusted odds ratio [AOR] =1.40, 95% confidence interval [CI] =1.10 to 1.78), but decreased risk for women (AOR = 0.90, 95% CI = 0.82-0.98). Being married was associated with lower risk of cessation for men (AOR = 0.18, 95% CI = 0.06-0.56) but was unrelated to cessation for women (AOR = 1.00, 95% CI = 0.56-1.80). Results were consistent with the hypothesis that racial disparities in cessation widen with increasing age., Discussion: Factors predictive of driving cessation vary by gender. Racial disparities in cessation are wider at older ages. Transportation policies and programs should account for social determinants and aim to address social disparities in driving mobility among older adults.

Objectives: Cognitive training has been shown to improve both cognitive and everyday abilities in older adults; however, little is known concerning the amount of training needed or the characteristics of those who benefit. These analyses examined the longitudinal impact of dosage (number of training sessions) on the improvement and maintenance of cognitive and everyday function., Methods: ACTIVE is a longitudinal, randomized, single-blind clinical trial evaluating cognitive interventions in older adults (aged 65-94) from six states in the United States., Results: Latent growth curve models indicated that initial training effects were maintained over 5 years and amplified by booster sessions. A single booster session counteracted 4.92 months of age-related processing speed decline., Discussion: Cognitive performance improved by 2.5 standard deviations for participants who attended all 10 initial sessions and all 8 booster sessions compared to randomized participants who attended none. Implications for the broader application of cognitive training interventions are discussed.

Objective: Secondary data analyses were conducted to examine cognitive function and longitudinal cognitive decline among older adults with and without heart failure (HF)., Method: Data from the Advanced Cognitive Training for Independent and Vital Elderly study were used to compare baseline (N = 2,790) and longitudinal (n = 692) changes in memory, reasoning, and speed of processing performance among participants (M age = 73.61, SD = 5.89) who self-reported HF at baseline, developed HF over time, or never reported HF., Results: At baseline, there were differences in memory and speed of processing with participants who never reported HF performing better than those who reported developing HF over time, and those who reported HF at baseline performing the worst (ps < .05). Longitudinally, participants with self-reported HF at baseline showed declines in reasoning over time., Discussion: The results indicate that cognitive difficulties in memory and speed may occur prior to a HF diagnosis, while those with HF may experience steeper declines in reasoning as measured by word series test.

Objective: The present study examined health and physical performance as mediators of the association between driving cessation and mortality among older residents of small and large cities., Method: Participants (N = 2,793) were from the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) study. Participants' driving status and health were measured at baseline, and mortality rates were observed across the subsequent 5 years., Results: Overall, mortality risk was 1.68 times higher for nondrivers versus drivers; this relationship was significantly mediated by physical performance and social, physical, and general health. For large-city residents, mediation effects for all mediators were significant and complete. For small-city residents, only physical and general health were significant mediators, and these effects were partial., Discussion: Health difficulties that accompany or follow driving cessation may explain the association between driving cessation and mortality, particularly for residents of large cities, where alternative transportation options may be more numerous.

Objectives: To longitudinally examine gender and racial disparities in driving cessation among older adults., Methods: Data came from the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) Study (N = 1,789). Logistic generalized estimating equations (GEE) were used to identify predictors of driving cessation; stratified analysis and interaction terms were used to determine whether factors differed by gender and race., Results: Two hundred and five (11.5%) participants stopped driving over the study period. Education was associated with increased risk of cessation for men (adjusted odds ratio [AOR] =1.40, 95% confidence interval [CI] =1.10 to 1.78), but decreased risk for women (AOR = 0.90, 95% CI = 0.82-0.98). Being married was associated with lower risk of cessation for men (AOR = 0.18, 95% CI = 0.06-0.56) but was unrelated to cessation for women (AOR = 1.00, 95% CI = 0.56-1.80). Results were consistent with the hypothesis that racial disparities in cessation widen with increasing age., Discussion: Factors predictive of driving cessation vary by gender. Racial disparities in cessation are wider at older ages. Transportation policies and programs should account for social determinants and aim to address social disparities in driving mobility among older adults.

Objective: To evaluate the relationship between sensory and cognitive decline, particularly with respect to speed of processing, memory span, and fluid intelligence. In addition, the common cause, sensory degradation and speed of processing hypotheses were compared., Method: Structural equation modeling was used to investigate the complex relationships among age-related decrements in these areas., Results: Cross-sectional data analyses included 842 older adult participants (M = 73 years). After accounting for age-related declines in vision and processing speed, the direct associations between age and memory span and between age and fluid intelligence were nonsignificant. Older age was associated with visual decline, which was associated with slower speed of processing, which in turn was associated with greater cognitive deficits., Discussion: The findings support both the sensory degradation and speed of processing accounts of age-related, cognitive decline. Furthermore, the findings highlight positive aspects of normal cognitive aging in that older age may not be associated with a loss of fluid intelligence if visual sensory functioning and processing speed can be maintained.

The supracondylar process of the humerus is a rare abnormality found in 0.4-2.7% of the population. It has been documented to cause neurovascular compression in the upper extremity owing to its local impingement on the median nerve and brachial artery at its medial location on the humerus just proximal to the elbow. The authors report the first known case of digital ischemia from embolization of thrombus caused by local compression of the brachial artery attributed to a supracondylar process.

We review an interesting case of craniocervical necrotizing fasciitis with thoracic extension in an immunocompetent 44-year-old man. The patient underwent aggressive medical and surgical management during a long hospitalization. Multiple surgical debridements, including transcervical mediastinal debridement, and eventually a thoracotomy for mediastinal abscess were required. The patient eventually recovered, and 3 months later he showed no sign of complications or recurrence. Craniocervical necrotizing fasciitis is a fulminant soft-tissue infection, usually of odontogenic origin, that requires prompt identification and treatment to ensure survival. Broad-spectrum intravenous antibiotics, aggressive surgical debridement and wound care, hyperbaric oxygen, and good intensive care are the mainstays of treatment.