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Background Prevalence of lichen sclerosus (LS) is 1 in 900 in premenarchal girls. Clinical presentation is elusive, and diagnosis can be challenging. Early identification of LS increases the likelihood of timely and effective treatment. We therefore sought to create a risk-stratification tool to help guide clinical diagnosis in cases of suspected LS in premenarchal girls presenting with vulvar complaints. Methods This study utilized retrospective chart review of patients seen at the pediatric and adolescent gynecology clinic in a tertiary hospital between July 2019 and September 2020. Patients were included if they were ≤ 13 years old, were premenarchal, and had vulvar complaints. History, physical exam, and genital culture results were documented across 26 variables. LS diagnosis was made based on history, physical exam and vulvar biopsy in few cases. A comprehensive logistic regression was constructed comprising all variables with LS diagnosis as a dichotomous outcome. Following a step-wise regression procedure on complete-records observations, surviving predictor variables were tuned so as to maximize accuracy in predicting LS status. Pursuant to this model discovery, the data were randomly partitioned into a separate training set and testing set (1:1 allocation). This prediction was iterated 500 times. Statistical analysis was completed using R (v.4.0.0). Study was approved by the institutional review board. Results In total, 81 patient visits met inclusion criteria with 69 unique patients. Among the 69 patients, 19 were diagnosed with LS and 50 were diagnosed with other diseases including but not limited to straddle injury, acute vulvovaginitis, sexual abuse, and vulvar irritation. Average age of patients was 6 years old (0-13 years old; Table 1). The optimal regression model included five predictors: Soreness/Pain (S), Whitening (W), Urinary Incontinence (I), Fissures (F), and Clitoral hood thickening (T). The most accurate model using predictive training-testing approach is logOdds(LS) = -71 + 47•S + 83•W + 48•I + 41•F + 30•T with a model accuracy of 96.6% (Figure 1). Conclusions Using statistical modeling, we identified five predictors for LS including soreness/pain (S), whitening of the skin (W), urinary incontinence (I), fissures (F), clitoral hood thickening (T; SWIFT). We developed a model for predicting LS with 96.6% accuracy among premenarchal patients presenting with vulvar complains. If future studies involving diverse population show replicability of this model, clinicians should consider using this model to stratify patients for risk of LS.

Although trunk muscles extend across multiple vertebral joints, recent motor control studies have shown that a top-down progression of trunk control in typical infants occurs incrementally, one segment at a time, until independent sitting. The current study merges this surprising developmental pattern with parent behavior by exploring the relationship between how parents hold their infant and the segmental level for which the infant exhibits postural control. We measured trunk control of sixty infants (1–8 months) via the Segmental Assessment of Trunk Control. Spontaneous parental hold and variability was recorded during repeated sitting and standing conditions. Parent hold correlated with infant level of control in both sitting and standing, providing evidence for a positive interaction between parent behavior and segmental trunk development.

To assess the efficacy of an off-loading wheelchair seat cushion in removing pressure from high-risk ischial tuberosities and the coccyx/sacrum in wheelchair sitting.Repeated-measures design.Private research laboratory.Manual wheelchair users with chronic spinal cord injuries (N=10).Three configurations of an off-loading wheelchair seat cushion compared with a flotation style (10-cm air inflation) wheelchair seat cushion.Outcome measures included peak pressure index (PPI), ischial tuberosity peak pressures, and the dispersion index or ratio of pressures under the ischial and sacral regions to the total of all pressures recorded.PPI and ischial tuberosities peak pressure ranged from a low of 39±18 and 68±46mmHg in the fully off-loaded cushion to a high of 97±30 and 106±34mmHg, respectively, for the flotation style cushion (2-way analysis of variance main effect across 4 conditions, P.001). Dispersion index ranged from a low of 8%±3% in the fully off-loaded cushion to a high of 16%±3% in the flotation style cushion. Pairwise comparisons yielded significance in all cushion-pair analyses (P.05 after multiple corrections).The force-removal approach of this orthotic off-loading cushion design effectively reduces a known extrinsic risk factor for pressure ulcers-interface pressure-in the high-risk ischial tuberosity and sacral/coccygeal regions of the buttocks.

The incidence and etiology of prosthetic services utilization is poorly understood during the first 90 days post-delivery of the initial lower limb prosthesis. This period is of critical importance, as prevailing policy dictates limits on the reimbursement for certain services provided during this time period. The first step in understanding the financial ramifications of such policy is to examine the taxonomy behind clinical encounters during this tenuous time period.Quantify and categorize clinical encounters by incidence and etiology.Retrospective chart review.A central database containing data on prosthetic services was examined. Incidence and etiology were extracted through independent review of each patient chart.A total of 537 unique patients were identified, with 109 meeting the inclusion criteria. Chi-square testing showed that comfort ( p0.05), cosmesis ( p0.01), and mechanical failure ( p0.001) yielded statistical significance in scheduled versus unscheduled visits. Stepwise regression analysis demonstrated that both sex and K-level were important predictors of unscheduled visits.Taxonomization of clinical encounters experienced during the first 90 days provides a framework for future studies to be conducted. The data provided can serve as a basis for informing reimbursement policy, workforce planning, and advocacy. Clinical relevance Comfort is the most frequent reason for a clinical encounter during the first 90 days after delivering a lower limb prosthesis. The data on the taxonomy behind the clinical encounters can be used to guide workforce planning and advocate for just reimbursement policy that better reflect patient's needs.

Background. While recent clinical trials involving robot-assisted therapy have failed to show clinically significant improvement versus conventional therapy, it is possible that a broader strategy of intensive therapy—to include robot-assisted rehabilitation—may yield clinically meaningful outcomes. Objective. To test the immediate and sustained effects of intensive therapy (robot-assisted therapy plus intensive conventional therapy) on outcomes in a chronic stroke population. Methods. A multivariate mixed-effects model adjusted for important covariates was established to measure the effect of intensive therapy versus usual care. A total of 127 chronic stroke patients from 4 Veterans Affairs medical centers were randomized to either robot-assisted therapy (n = 49), intensive comparison therapy (n = 50), or usual care (n = 28), in the VA-ROBOTICS randomized clinical trial. Patients were at least 6 months poststroke, of moderate-to-severe upper limb impairment. The primary outcome measure was the Fugl-Meyer Assessment at 12 and 36 weeks. Results. There was significant benefit of intensive therapy over usual care on the Fugl-Meyer Assessment at 12 weeks with a mean difference of 4.0 points (95% CI = 1.3-6.7); P = .005; however, by 36 weeks, the benefit was attenuated (mean difference 3.4; 95% CI = −0.02 to 6.9; P = .05). Subgroup analyses showed significant interactions between treatment and age, treatment and time since stroke. Conclusions. Motor benefits from intensive therapy compared with usual care were observed at 12 and 36 weeks posttherapy; however, this difference was attenuated at 36 weeks. Subgroups analysis showed that younger age, and a shorter time since stroke were associated with greater immediate and long-term improvement of motor function.

Objectives: New metrics for clinical spasticity are needed to assess motor performance, since scales such as the Ashworth and Tardieu are unreliable. Here, we assessed outcomes of baclofen treatment in patients with multiple sclerosis (MS) using biomechanical analysis of voluntary movements. Methods: Patients with MS and symptomatic limb spasticity were recruited for a pre–post baclofen titration study, along with age-matched healthy controls. Oral baclofen was titrated to optimize spasticity symptoms in all MS cases over 4 weeks. Clinical assessments included the Modified Ashworth Scale (MAS), Tardieu Scale (TS); elbow kinematics were measured via the Transient Acceleration Measurement Interface (TAMI); performance was measured as the score at 4 weeks minus the baseline score in all measures. Movement proficiency within TAMI was quantified through a scale-free smoothness measure, according to the regional excursion deviation (RED) from a constant-velocity approximant. Results: Twelve patients with MS [age: 47.8 ± 9.8 years; women: 4; disease duration: 20 ± 10 years; disease-modifying therapy use: 7; Expanded Disability Status Scale (EDSS): 6.8 ± 1.4] and eight age-matched healthy controls were evaluated concurrently (mean age: 49.5 ± 13.1 years; women = 3). In MS cases, no significant improvement in arm spasticity was observed with main effects: MAS: −41.6 ± 72.6 ( p = 0.09); EDSS: −1.6 ± 10.4% ( p = 0.49); and TS: −8.3 ± 2.1% ( p = 0.32), −24.9 ± 63.6% ( p = 0.42), and −30.7 ± 79.9% ( p = 0.06), at slow, moderate, and fast speeds, respectively. However, voluntary motion smoothness, as measured by TAMI: RED, decreased significantly: 0.62 ± 0.08 versus 0.54 ± 0.09, p < 0.001, indicating significant increase in movement smoothness post treatment. Conclusion: A simple biomechanical analysis of voluntary movements revealed a significant reduction of spasticity after 30 days of baclofen therapy in patients with MS that was not detected by clinical assessments.

Elming et al1 report that the efficacy of primary prevention implantable cardioverter-defibrillator (ICD) therapy is diminished among older participants of the DANISH trial (Danish Study to Assess the Efficacy of ICDs in Patients With Nonischemic Systolic Heart Failure on Mortality), which randomized patients with nonischemic cardiomyopathy to ICD versus optimal medical therapy.2 In this secondary data analysis of the DANISH trial, ICD implantation was associated with a statistically significant improvement in survival among patients ≤70 years of age but not in those >70 years of age. This area of study is important because …

To improve the characterization of motor impairment, we compared the sensitivities of a phase plane metric with temporal domain measures derived from integrated squared jerk (ISJ). Five subjects with stroke and a cohort of 21 neurologically intact volunteers performed self-paced, isolated elbow flexions. Analysis of angular trajectories from the stroke group revealed that temporal domain metrics failed to detect a performance deficit at the p < .05 level, while the phase plane metric did resolve a deficit (p < .01). When applied to a subset of movements with arrest periods, the phase measure also uniquely identified impairment (Wilcoxon rank-sum test, p < .001). Finally, when tested on a data-driven model, the phase measure, but not temporal metrics, increased monotonically with the severity of trajectory distortions. We conclude that motion smoothness can be accurately measured in the phase plane.

Study Design A clinical measurement study. Purpose To test the applicability of Fitts' paradigm to grasping tasks in individuals with chronic stroke. Introduction Fitts' Law relates the time of target achievement to task difficulty in repetitive motor tasks. Methods Six male chronic stroke patients performed repetitive actuation of a grip force dynamometer with their affected hands for 12 sessions over four to six weeks. Results Movement times followed Fitts' behavior with correlations of R2 > 0.8 for all subjects. Grasp control improved during training, as indicated by an average decrease in Fitts' slope of 26% at high difficulty levels (p Conclusions The Fitts' grip force targeting protocol provides an objective standardized instrument for grasp proficiency quantification and a potentially efficacious platform for hand training for persons with stroke. Level of Evidence N/A.

Inter-limb learning transfer (ILT) between the upper-limbs has been well documented, but no corresponding study of the lower limbs has been done. We investigated ILT in the lower limbs of subjects who learned to move a cursor toward targets within 800 ms using ankle movements: plantar/dorsi-flexion and inversion/eversion. Twenty-two healthy right-dominant subjects were divided into two groups: half performed the tasks first using the right foot (group RL), and the other half performed it first with the left foot (group LR). Targets appeared on a computer screen at head-height while subjects were seated with one foot on a goniometric ankle platform. Subjects were required to move the cursor toward one of three randomly appearing targets under two conditions: (1) neutral or no visual motor rotation, and (2) with a 30 degrees visuo-motor rotation. Performance was quantified by computing the z-score for direction and position errors for each subject and ILT was assessed by comparing group performances for each foot. Results demonstrated that group LR but not group RL experienced significant ILT of directional as well as positional information in both tasks in a manner reflective of the distinctly different functional roles played by the upper and lower limbs.

Objective To establish consensus on definitive, actionable standards for the management of deformational plagiocephaly. Design Three-stage Delphi Survey process based on best practice statements obtained through literature review. Setting Electronic survey delivery. Participants Review panel of 10 multidisciplinary subject matter experts (SMEs); survey panel of 30 cranial orthotists. Results Fifty-four best practice statements were accepted in four categories: diagnosis, presentation and severity, initiating treatment, and management principles. Conclusions Clinical practice can be guided en route to robust evidence as to the efficacy of various plagiocephaly management strategies, in pursuit of definitive standards.

Spasticity is clinically defined as velocity-dependent resistance to passive movement, characterized by excessive, jerky contraction of muscles. However, spasticity is not yet well understood, and current clinical measures of it are subjective and unreliable. We applied standard physics principles and phase space analyses to better visualize the motor impairments associated with spasticity in Multiple Sclerosis patients, at the VA Hospital in Washington, DC. Testing was conducted at baseline and then again after one month of de novo baclofen administration in order to determine whether this improved the patients' condition. Two analytical methods were used: (1) Phase Area Ratio (PAR) and (2) Spontaneous Accelerative Transients (SAT). The SAT analyses showed a small decrease in spasticity after baclofen use, while the PAR analyses and clinical measures showed no significant change. Although they provided differing results, this study shows that spasticity during active joint motions can be more reliably quantified through analytical methods. The PAR and SAT metrics may be applicable to a variety of physiological signals.

Our goal is to use automatic data monitoring for reliable prediction of episodes of intracranial hypertension in patients with traumatic brain injury. Here we test the validity of our method on retrospective patient data. We developed the Continuous Hemodynamic Autoregulatory Monitor (CHARM), that siphons and stores signals from existing monitors in the surgical intensive care unit (SICU), efficiently compresses them, and standardizes the search for statistical relationships between any proposed index and adverse events. CHARM uses an automated event detector to reliably locate episodes of elevated intracranial pressure (ICP), while eliminating artifacts within retrospective patient data. A graphical user interface allowed data scanning, selection of criteria for events, and calculating indices. The pressure reactivity index (PRx), defined as the least square linear regression slope of intracranial pressure versus arterial BP, was calculated for a single case that spanned 259 h. CHARM collected continuous records of ABP, ICP, ECG, SpO2, and ventilation from 29 patients with TBI over an 18-month period. Analysis of a single patient showed that PRx data distribution in the single hours immediately prior to all 16 intracranial hypertensive events, significantly differed from that in the 243 h that did not precede such events (p

Because of the high mortality rate after rupture of small abdominal aortic aneurysms (AAAs), surveillance is recommended to detect aneurysm expansion; however, the effects of clinical risk factors on long-term patterns of AAA expansion are poorly characterized.To identify significant clinical risk factors associated with the AAA expansion rate for both constant and accelerated expansion trajectories.A multivariate mixed-effects model was established to identify clinical risk factors associated with the AAA expansion rate. Separate shape factor analysis was used to characterize steady vs accelerated expansion over time. Five hundred sixty-seven patients hospitalized at Veterans Affairs medical centers were randomized to the surveillance arm of the Aneurysm Detection and Management (ADAM) study conducted by the Veterans Affairs Cooperative Studies Program from 1992 to 2000. The patients had an AAA with a maximum diameter from 3.0 to 5.4 cm, which was monitored until a 5.5-cm maximum diameter was reached or the aneurysm became symptomatic. Thirty-three participants were not included in this analysis owing to missing or extraneous values in key predictor variables. The mean (SD) follow-up time was 3.7 (2.0) years.The primary outcome measure was the AAA expansion rate, determined by measurement of the maximum diameter by ultrasonography at regular intervals. The objective to assess the association of clinical variables with the expansion of the AAA was formulated after data collection.The mean (SD) linear expansion rate of AAAs was 0.26 (0.01) cm/y. Current smoking was associated with a 0.05 (0.01)-cm/y increase in the linear expansion rate (95% CI, 0.25-0.28; P .001), diastolic blood pressure with a 0.02 (0.01)-cm/y increase per 10 mm Hg (95% CI, 0.01-0.04; P = .001), and diabetes mellitus with a 0.11 (0.02)-cm/y decrease (95% CI, 0.07-0.16; P .001). Diastolic blood pressure and baseline AAA diameter were associated with accelerated AAA expansion (P = .001 and P .001, respectively).Smoking cessation and control of diastolic blood pressure are direct actions that should be taken to reduce the rate of AAA expansion. Other clinical risk factors, except for diabetes, were not associated with the AAA expansion rate. This study also provides evidence of differing trajectories in AAA expansion over time, a finding that merits further investigation.

We developed a platform for quantifying movement smoothnes relating to spasticity: the Transient Accelerative Measurement Interface (TAMI). Repetitive elbow flexions of controls and persons with stroke or cerebral palsy were recorded, while their arms were supported in a manipulandum. Results showed that: (1) impairments related to spasticity can be quantified using phase plane analysis and (2) TAMI may offer clinical benefits by delivering targeted therapies to clients subjects in a real-time format, with simple metrics that can be easily interpreted.

Repetitive reaching movements to a fixed target can be generally characterized by bell-shaped velocity profiles and sigmoidal trajectories with variable morphologies across multiple repetitions. A neuromuscular correspondence of these kinematic variations has thus far eluded electromyographic (EMG) analysis. We recorded EMG and elbow kinematics from fourteen healthy individuals performing repetitive, self-paced, isolated elbow flexions, with their arms supported against gravity. The global kinematic pattern of each flexion was classified as either sigmoidal (S) or non-sigmoidal (NS), based on goodness of fit with analytical curves. Ten of the fourteen subjects generated an approximately equal number of S and NS types (383 movement cycles). Trajectories of the other four subjects were not classifiable or did not vary sufficiently and were excluded from subsequent analysis. A post hoc predictor of trajectory type was derived by testing linear support vector machines trained with a strategically selected 3-feature sub-space of the early phase of enveloped biceps EMG during a leave-one-out cross-validation paradigm. Results showed that EMG features predicted kinematic morphology with sensitivity and specificity both exceeding 80%. The high predictive accuracy suggests neuromotor signals coding for subtle variations in elbow kinematics during self-paced, unloaded motions, can be deciphered from the biceps EMG.

While surface electromyography (SEMG) can accurately register electrical activity of muscles during gait, there are no methods to estimate muscular force non-invasively. To better understand the mechanical behavior of muscle, we evaluated surface muscle pressure (SMP) in conjunction with SEMG. Changes in anterior thigh radial pressure during isometric contractions and gait were registered by pressure sensors on the limb. During isometric knee extensions by a single subject, SMP waveforms correlated well with SEMG (r=0.97), and SEMG onsets preceded those of SMP by 35-40 ms. SMP and SEMG signals were simultaneously recorded from the quadriceps of 10 healthy subjects during gait at speeds of 0.4, 0.8, 1.1, 1.4 and 2.2m/s. Muscle activity onset and cessation times were objectively determined for both modalities, and results showed high intra-class correlations. SMP waveforms were highly consistent from stride to stride, while SEMG waveforms varied widely. SEMG waveforms were typically brief, while SMP waveforms tended to be biphasic and outlasted the SEMG by approximately 40% of gait cycle at all speeds. These results are consistent with mechanical models of muscle, and demonstrate the use of SMP to estimate the timing of knee extensor muscle stiffness during gait.