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At least 3 million Americans sustain a mild traumatic brain injury (mTBI) each year, and 1 in 5 have symptoms that persist beyond 1 month. Standards of mTBI care have evolved rapidly, with numerous expert consensus statements and clinical practice guidelines published in the last 5 years. This Special Communication synthesizes recent expert consensus statements and evidenced-based clinical practice guidelines for civilians, athletes, military, and pediatric populations for clinicians practicing outside of specialty mTBI clinics, including primary care providers. The article offers guidance on key clinical decisions in mTBI care and highlights priority interventions that can be initiated in primary care to prevent chronicity.

The International Society for Clinical Electrophysiology of Vision (ISCEV) standard for full-field electroretinography (ERG) describes a minimum protocol for clinical testing but encourages additional ERG testing when appropriate. This ISCEV extended protocol describes methods to record and evaluate a light-adapted (LA) ERG stimulus–response series with increasing flash strengths. The LA ERG stimulus–response series (also referred to as the luminance–response or intensity–response series in the published literature) can characterise generalised cone system function more comprehensively than the ISCEV standard LA ERGs alone. The amplitude of LA ERG a-waves, arising from cones and cone off-bipolar cells, typically shows a saturating function. The LA ERG b-wave amplitudes, which arise primarily from activity of retinal bipolar cells, show an amplitude peak followed by a nonzero plateau (the “photopic hill” phenomenon). This ISCEV extended protocol specifies a stimulus–response series suitable to evaluate generalised dysfunction affecting the LA retina, to aid in distinguishing between the on- and off-responses of the cone system and to monitor ERG changes in these characteristics. The LA ERG stimulus–response series for a- and b-waves is recorded to a sequence of nine flash stimuli ranging from 0.03 to 300 cd s m−2, superimposed on a standard background of 30 cd m−2. A shorter protocol is also presented to measure the mid-range of the function (the “photopic hill”) using 5 flash stimuli.

Open abdominal surgery continues to be most commonly complicated by postoperative herniation at the incision line. In 2012, Novitsky et al described a novel hernia repair technique that utilized a transversus abdominis release coupled with a posterior (retrorectus) component separation (TAR-PCS) of the ventral abdominal wall. Early reports attest to the versatility and low recurrence rate of this technique, particularly when repairing large and complex defects. We present a rare case of herniation below the linea arcuate (LAH) following repair via TAR-PCS. Given its novelty compared with more widely utilized techniques, literature review revealed less discussion regarding potential pitfalls associated with this type of reconstruction, in particular the potential for LAH. To date, only 9 cases of symptomatic LAH have been described, although 2 previously described "suprapubic" herniations following TAR-PCS may represent previously mischaracterized cases of this type of complication. Nonetheless, none of these reports were in the setting of ventral hernia repair.

The use of standardized outcome measures (OMs) is essential in assessing the effectiveness of physical therapy (PT) interventions. The purposes of this article are (1) to describe the process used by the TBI EDGE task force to assess the psychometrics and clinical utility of OMs used with individuals with moderate to severe traumatic brain injury (TBI); (2) to describe the consensus recommendations for OM use in clinical practice, research, and professional (entry-level) PT education; and (3) to make recommendations for future work.An 8-member task force used a modified Delphi process to develop recommendations on the selection of OMs for individuals with TBI. A 4-point rating scale was used to make recommendations based on practice setting and level of ambulation. Recommendations for appropriateness for research use and inclusion in entry-level education were also provided.The TBI EDGE task force reviewed 88 OMs across the International Classification of Functioning, Disability, and Health (ICF) domains: 15 measured body functions/structure only, 21 measured activity only, 23 measured participation only, and 29 OMs covered more than 1 ICF domain.Recommendations made by the TBI EDGE task force provide clinicians, researchers, and educators with guidance for the selection of OMs. The use of these recommendations may facilitate identification of appropriate OMs in the population with moderate to severe TBI. TBI EDGE task force recommendations can be used by clinicians, researchers, and educators when selecting OMs for their respective needs. Future efforts to update the recommendations are warranted in order to ensure that recommendations remain current and applicable.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A140).

Background The revised 2014 American College of Cardiology (ACC)/American Heart Association valvular heart disease guidelines provide evidenced-based recommendations for the management of mitral regurgitation (MR). However, knowledge gaps related to our evolving understanding of critical MR concepts may impede their implementation. Methods The ACC conducted a multifaceted needs assessment to characterize gaps, practice patterns, and perceptions related to the diagnosis and treatment of MR. A key project element was a set of surveys distributed to primary care and cardiovascular physicians (cardiologists and cardiothoracic surgeons). Survey and other gap analysis findings were presented to a panel of 10 expert advisors from specialties of general cardiology, cardiac imaging, interventional cardiology, and cardiac surgeons with expertise in valvular heart disease, especially MR, and cardiovascular education. The panel was charged with assessing the relative importance and potential means of remedying identified gaps to improve care for patients with MR. Results The survey results identified several knowledge and practice gaps that may limit implementation of evidence-based recommendations for MR care. Specifically, half of primary care physicians reported uncertainty regarding timing of intervention for patients with severe primary or functional MR. Physicians in all groups reported that quantitative indices of MR severity were frequently not reported in clinical echocardiographic interpretations, and that these measurements were not consistently reviewed when provided in reports. In the treatment of MR, nearly 30% of primary care physician and general cardiologists did not know the volume of mitral valve repair surgeries by their reference cardiac surgeons and did not have a standard source to obtain this information. After review of the survey results, the expert panel summarized practice gaps into 4 thematic areas and offered proposals to address deficiencies and promote better alignment with the 2014 ACC/American Heart Association valvular disease guidelines. Conclusion Important knowledge and skill gaps exist that may impede optimal care of the patient with MR. Focused educational and practice interventions should be developed to reduce these gaps.

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Mycobacteriosis is an emerging zoonotic disease of domestic cats and timely, accurate diagnosis is currently challenging. To identify differential cytokine/chemokine concentrations in serum/plasma of cats, which could be diagnostic biomarkers of infection we analysed plasma/serum from 116 mycobacteria-infected cats, 16 healthy controls and six cats hospitalised for unrelated reasons was analysed using the Milliplex MAP Feline Cytokine Magnetic Bead multiplex assay. Three cytokines; sFAS, IL-13 and IL-4 were reduced while seven; GM-CSF, IL-2, PDGF-BB, IL-8, KC, RANTES and TNF-α were elevated in mycobacteria-infected cats compared to healthy controls. However, IL-8 and KC concentrations were not significantly different from cats hospitalised for other reasons. Elevations in TNF-α and PDGF-BB may have potential to identify M. bovis and M. microti infected cats specifically while GM-CSF, IL-2 and FLT3L were increased in MTBC infected cats. This study demonstrates potential use of feline tuberculosis as a spontaneously occurring model of this significant human disease. Cytokine profiling has clear diagnostic potential for mycobacteriosis of cats and could be used discriminate tuberculous from non-tuberculous disease to rapidly inform on zoonotic risk. Future work should focus on the in-field utility of these findings to establish diagnostic sensitivity and specificity of these markers.

It is crucial for those performing an echocardiographic examination to understand how the controls on an ultrasound machine alter the display. Without this knowledge, it is impossible to consistently optimize images. Unskilled manipulations may misrepresent diagnostic information and result in missed diagnoses. This chapter aims to describe controls found on most ultrasound machines, how they affect the image, and how they are used to optimize the ultrasound image.

This chapter will serve as a guide to getting started in the conduct of a two-dimensional (2D) chest wall echocardiogram. Standard views and how to obtain them will be covered while specific controls and optimization of the images will addressed in a subsequent chapter. Echocardiography is a noninvasive procedure which illustrates the anatomy of the heart, including valves, chamber size, wall motion, masses, pericardial fluid and many other findings. Doppler echocardiography assesses the severity of valvular regurgitation, gradients across normal and stenotic valves or between cardiac chambers and the detection of intracardiac shunts.

Modern ultrasound systems are very sophisticated and provide the ability to display real-time moving images of the heart, together with quantitative data on blood flow and tissue motion. The output is displayed in real time, either as two-dimensional tomographic (‘slice’) images or, more recently, rendered 3-dimensional ‘volume’ images from which individual sectional planes can be extracted.

Despite advances in the assessment, diagnosis, prognosis, and management of the patient with mild traumatic brain injury (mTBI) or concussion, the condition continues to frustrate clinicians and researchers. The November 2019 special issue of the

Pattern electroretinograms (PERGs) have inherently low signal-to-noise ratios and can be difficult to detect when degraded by pathology or noise. We compare an objective system for automated PERG analysis with expert human interpretation in children with optic nerve hypoplasia (ONH) with PERGs ranging from clear to undetectable. PERGs were recorded uniocularly with chloral hydrate sedation in children with ONH (aged 3.5–35 months). Stimuli were reversing checks of four sizes focused using an optical system incorporating the cycloplegic refraction. Forty PERG records were analysed; 20 selected at random and 20 from eyes with good vision (fellow eyes or eyes with mild ONH) from over 300 records. Two experts identified P50 and N95 of the PERGs after manually deleting trials with movement artefact, slow-wave EEG (4–8 Hz) or other noise from raw data for 150 check reversals. The automated system first identified present/not-present responses using a magnitude-squared coherence criterion and then, for responses confirmed as present, estimated the P50 and N95 cardinal positions as the turning points in local third-order polynomials fitted in the −3 dB bandwidth [0.25 … 45] Hz. Confidence limits were estimated from bootstrap re-sampling with replacement. The automated system uses an interactive Internet-available webpage tool (see http://clinengnhs.liv.ac.uk/esp_perg_1.htm ). The automated system detected 28 PERG signals above the noise level (p ≤ 0.05 for H0). Good subjective quality ratings were indicative of significant PERGs; however, poor subjective quality did not necessarily predict non-significant signals. P50 and N95 implicit times showed good agreement between the two experts and between experts and the automated system. For the N95 amplitude measured to P50, the experts differed by an average of 13 % consistent with differing interpretations of peaks within noise, while the automated amplitude measure was highly correlated with the expert measures but was proportionally larger. Trial-by-trial review of these data required approximately 6.5 h for each human expert, while automated data processing required

Amplitudes of electroretinograms (ERG) are enhanced during acute, moderate elevation of intraocular pressure (IOP) in rats anaesthetised with isoflurane. As anaesthetics alone are known to affect ERG amplitudes, the present study compares the effects of inhalant isoflurane and injected ketamine:xylazine on the scotopic threshold response (STR) in rats with moderate IOP elevation. Isoflurane-anaesthetised (n = 9) and ketamine:xylazine-anaesthetised (n = 6) rats underwent acute unilateral IOP elevation using a vascular loop anterior to the equator of the right eye. STRs to a luminance series (subthreshold to −3.04 log scotopic cd s/m2) were recorded from each eye of Sprague-Dawley rats before, during, and after IOP elevation. Positive STR (pSTR) amplitudes for all conditions were significantly smaller (p = 0.0001) for isoflurane- than for ketamine:xylazine-anaesthetised rats. In addition, ketamine:xylazine was associated with a progressive increase in pSTR amplitudes over time (p = 0.0028). IOP elevation was associated with an increase in pSTR amplitude (both anaesthetics p

To assess the discriminant validity of the Patrol-Exertion Multitask (PEMT), a novel, multidomain, functional return-to-duty clinical assessment for active duty military personnel.Measurement development study.Nonclinical indoor testing facility.Participants (N=84) were healthy control (HC) service members (SMs; n=51) and military personnel (n=33) with persistent postconcussive symptoms receiving rehabilitation (mild traumatic brain injury [mTBI]).Not applicable.Known-groups discriminant validity was evaluated by comparing performance on the PEMT in 2 groups of active duty SMs: HCs and personnel with mTBI residual symptoms. Participant PEMT performance was based on responses in 4 subtasks during a 12-minute patrolling scenario: (1) accuracy in identifying virtual improvised explosive device (IED) markers and responses to scenario-derived questions from a computer-simulated foot patrol; (2) auditory reaction time responses; (3) rating of perceived exertion during stepping; and (4) self-reported visual clarity (ie, gaze stability) during vertical head-in-space translation while stepping.Significant between-group differences for the PEMT were observed in 2 of 4 performance domains. Postpatrol IED identification task/question responses (P=.179) and rating of perceived exertion (P=.133) did not discriminate between groups. Participant self-report of visual clarity during stepping revealed significant (P.001) between-group differences. SM reaction time responses to scenario-based auditory cues were significantly delayed in the mTBI group in both the early (P=.013) and late (P=.002) stages of the PEMT.Findings from this study support the use of a naturalistic, multidomain, complex clinical assessment to discriminate between healthy SMs and personnel with mTBI residual symptoms. Based on this preliminary study, additional research to further refine the PEMT and extend its application to return-to-work outcomes in military and civilian environments is warranted.

This article describes lessons learned in the planning, development, and administration of a collaborative military-civilian research project, the Assessment of Military Multitasking Performance, which was designed to address a gap in clinical assessment for active duty service members with mild traumatic brain injury who wish to return to active duty. Our team worked over the course of multiple years to develop an assessment for military therapists to address this need. Insights gained through trial and error are shared to provide guidance for civilian researchers who may wish to collaborate with active duty researchers.

Chronic pain is associated with maladaptive reorganization of the central nervous system. Recent studies have suggested that disorganization of large-scale electrical brain activity patterns, such as neuronal network oscillations in the thalamocortical system, plays a key role in the pathophysiology of chronic pain. Yet, little is known about whether and how such network pathologies can be targeted with noninvasive brain stimulation as a nonpharmacological treatment option. We hypothesized that alpha oscillations, a prominent thalamocortical activity pattern in the human brain, are impaired in chronic pain and can be modulated with transcranial alternating current stimulation (tACS). We performed a randomized, crossover, double-blind, sham-controlled study in patients with chronic low back pain (CLBP) to investigate how alpha oscillations relate to pain symptoms for target identification and whether tACS can engage this target and thereby induce pain relief. We used high-density electroencephalography to measure alpha oscillations and found that the oscillation strength in the somatosensory region at baseline before stimulation was negatively correlated with pain symptoms. Stimulation with alpha-tACS compared to sham (placebo) stimulation significantly enhanced alpha oscillations in the somatosensory region. The stimulation-induced increase of alpha oscillations in the somatosensory region was correlated with pain relief. Given these findings of successful target identification and engagement, we propose that modulating alpha oscillations with tACS may represent a target-specific, nonpharmacological treatment approach for CLBP. This trial has been registered in ClinicalTrials.gov (NCT03243084). Perspective This study suggests that a rational design of transcranial alternating current stimulation, which is target identification, engagement, and validation, could be a nonpharmacological treatment approach for patients with CLBP.

Background:. Orofacial clefting (OFC) is the most common developmental craniofacial malformation, and causal etiologies largely remain unknown. The opioid crisis has led to a large proportion of infants recovering from neonatal abstinence syndrome (NAS) due to in-utero narcotics exposure. We sought to characterize the prevalence of OFC in infants with NAS. Methods:. This cohort study analyzed live births at our institution from 2013 to 2017 to identify any association between OFC and NAS. Results:. Prevalence of OFC was 6.79 and 1.63 (per 1,000 live births) in the NAS and general population, respectively. Odds ratios for NAS patients having developed OFC, isolated cleft palate, isolated cleft lip, and combined cleft lip and palate compared with the general population were found to be 4.18 (P = 0.001), 5.92 (P = 0.001), 3.79 (P = 0.05), and 2.94 (P = 0.35), respectively. Analyses performed comparing the NAS and general populations to control for potential confounding variables influencing the NAS population yielded no significant differences with exception of in-utero exposure to physician prescribed opioids. Conclusions:. Prevalence of OFC in infants with NAS was higher than the general live birth population. Isolated cleft palate and isolated cleft lip, specifically, were significantly more prevalent in NAS patients compared with the general population and were associated with in-utero opioid exposure.

There is an error in Table 1 of the recently published ISCEV Standard for full-field clinical electroretinography (2015 update) [1]. Users of this standard should note that the filter settings for dark-adapted oscillatory potentials (OPs), as correctly specified in the text, require that the high-pass filter should remove frequencies of 75 Hz and below from the ERG waveform; the low-pass filter setting of 300 Hz or above is the same as for other ERG tests. Table 1 is provided below with the correct bandpass for OPs

Background Flash visual evoked potentials (VEPs) were abnormal in a cohort of 100 neonates exposed to maintenance methadone in utero . This prospective cohort study now describes clinical visual and electrophysiological outcomes at 6 months. Methods Visual assessment included modified Atkinson test battery; strabismus, nystagmus, reduced visual acuity, delayed visual maturation or refractive error (>3 dioptres) defined a fail. Pattern-onset VEPs were recorded to 120′, 60′ and 15′ checks. Results 81 drug-exposed and 26 comparison infants (79% and 52% of the original cohorts) were assessed at a median age of 27 weeks (range 26–30). 90% of drug-exposed infants had been additionally exposed to illicit drugs and 41% to excess alcohol in utero. 40% of the drug-exposed cohort failed clinical visual assessment: the relative risk of abnormal assessment was 5.1 (95% CI 1.3 to 20; p=0.02). Nystagmus was particularly common. VEP peak times were slower and amplitudes smaller in drug-exposed infants, of whom 70% had one or more abnormal VEP parameter. Abnormal visual outcome at 6 months was not associated with the pattern of additional drug exposure or a history of neonatal abstinence. Conclusions Abnormal visual electrophysiology in infants born to drug-misusing mothers prescribed maintenance methadone persists to 6 months of age, and is associated with abnormal clinical visual assessment.

OBJECTIVE: Drug misuse in pregnancy is associated with impaired infant visual development. Pilot data showed abnormal flash visual evoked potentials (VEPs) in neonates exposed to methadone in utero, but results were confounded by intrauterine growth restriction, gestation, and ongoing drug misuse. This large cohort study aimed to clarify the effects on neonatal flash VEPs of maternal drug misuse in pregnancy, including prescription of substitute methadone and subsequent development of neonatal abstinence syndrome. METHODS: This was a prospective cohort study. Flash VEPs were recorded within 3 days of birth from 100 healthy infants of drug-misusing mothers prescribed substitute methadone during pregnancy and 50 comparison infants matched for birth weight, gestation, and socioeconomic deprivation. VEP morphology was classified as mature, typical, or immature, and amplitudes and implicit times of the major waveform components measured. Drug exposure was determined by maternal history, maternal and infant urine, and meconium toxicology. RESULTS: VEPs from maternal drug-exposed infants were more likely to be of immature waveform (P < .001) and were smaller in overall amplitude (median 27 µV vs 39 µV, P < .001) compared with non–drug-exposed infants. Most infants were exposed to illicit drugs in addition to prescribed methadone; differences in VEP parameters were independently associated with maternal prescribed methadone and persisted after correcting for birth weight, cigarette smoking, and excess in utero alcohol exposure. CONCLUSIONS: In utero exposure to prescribed substitute methadone is associated with altered flash VEPs in the newborn period and these infants may warrant early clinical visual assessment.

Functional near-infrared spectroscopy (fNIRS) is an optical imaging technique that relies on emitting near-infrared light into cortical tissue to measure changes in haemoglobin concentrations as a result of stimulation. The purpose of this study was to observe haemodynamic changes in response to moving stimuli over the primary visual cortex. The test stimuli were radially expanding and contracting concentric gratings and the control stimulus was a matched stationary pattern. A two-channel oximeter (Oxiplex TS) was used to record changes in oxyhaemoglobin (HbO), de-oxyhaemoglobin (Hb) and total haemoglobin concentrations (THb). An increase in haemodynamic activation was observed 20s after the onset of motion and maintained for up to 20s following motion offset (30s time window). This was compared to a time window of 10s before the offset of the stationary presentation. Differences between expanding and contracting motion did not achieve significance at any of the locations. However, a significantly larger HbO response was observed across the 30s time window when compared to the baseline window at both occipital locations. Preliminary results from more temporal locations also showed a similar trend. It is suggested that the delayed rise in HbO levels could be due to an inconsistent maintenance of luminance and contrast-related features of the moving stimuli in V1 receptive fields. Furthermore, motion-after effects could have contributed to delaying the drop to baseline levels. The current study has shown some evidence that fNIRS can be used to record haemodynamic responses to moving stimuli from the visual cortex. We suggest that longer durations of randomised moving, stationary and grey screen presentations would be useful in teasing apart pure motion responses and after-effects. fNIRS could also potentially be used to investigate haemodynamic changes in disorders such as amblyopia that present with motion processing deficits.

The pattern electroretinogram (PERG) is a retinal response evoked by a contrast-reversing pattern, usually a black and white checkerboard, which provides information about macular and retinal ganglion cell function. This document from the International Society for Clinical Electrophysiology of Vision (www.iscev.org) is a scheduled revision of the ISCEV PERG Standard, which updates and replaces the 2007 update and all earlier versions. The standard defines a single minimum stimulus and recording protocol for clinical PERG testing to assist practitioners in obtaining good quality responses and to facilitate inter-laboratory comparison. The present revision tightens stimulus specifications, expands on steady-state PERG recording, addresses visual stimulus display distinctions (CRT vs. LCD), and provides a more explicit definition of response components.

The multifocal electroretinogram (mfERG) is an electrophysiological test that allows the function of multiple discrete areas of the retina to be tested simultaneously. This document, from the International Society for Clinical Electrophysiology of Vision (ISCEV), presents an updated and revised ISCEV standard for clinical mfERG and defines minimum protocols for basic clinical mfERG recording and reporting so that responses can be recognized and compared from different laboratories worldwide. The major changes compared with the previous mfERG standard relate to the minimum length of m-sequences used for recording, reporting of results and a change in document format, to be more consistent with other ISCEV standards.

Context:Recent evidence has revealed deficiencies in the ability to divide attention after concussion.Objective:To examine the effects of a single vs a dual task on cognition and balance in healthy subjects and to examine reliability of 2 dual-task paradigms while examining the overall feasibility of the tasks.Design:Pretest–posttest experimental design.Setting:Sports medicine research laboratory.Patients:30 healthy, recreationally active college students.Intervention:Subjects performed balance and cognitive tasks under the single- and dual-task conditions during 2 test sessions 14 d apart.Main Outcome Measures:The procedural reaction-time (PRT) test of the Automated Neuropsychological Assessment Metrics (eyes-closed tasks) and an adapted Procedural Auditory Task (PAT; eyes-open tasks) were used to assess cognition. The NeuroCom Sensory Organization Test (SOT) and the Balance Error Scoring System (BESS) were used to assess balance performance. Five 2-way, within-subject ANOVAs and a paired-samples t test were used to analyze the data. ICCs were used to assess reliability across 2 test sessions.Results:On the SOT, performance significantly improved between test sessions (F1,29 = 35.695, P < .001) and from the single to the dual task (F1,29 = 9.604, P = .004). On the PRT, performance significantly improved between test sessions (F1,29 = 57.252, P < .001) and from the single to the dual task (F1,29 = 7.673, P = .010). No differences were seen on the BESS and the PAT. Reliability across test sessions ranged from moderate to poor for outcome measure.Conclusions:The BESS appears to be a more reliable and functional tool in dual-task conditions as a result of its increased reliability and clinical applicability. In addition, the BESS is more readily available to clinicians than the SOT.

Sanjiv Kaul, MD, FASE,* James G. Miller, PhD,* Paul A. Grayburn, MD, Shinichi Hashimoto,Mark Hibberd, MD, PhD, Mark R. Holland, PhD, FASE, Helene C. Houle, BA, RDMS, RDCS, RVT, FASE,Allan L. Klein, MD, FASE, Peg Knoll, RDCS, FASE, Roberto M. Lang, MD, FASE,Jonathan R. Lindner, MD, FASE, Marti L. McCulloch, RDCS, FASE, Stephen Metz, PhD,Victor Mor-Avi, PhD, FASE, Alan S. Pearlman, MD, FASE, Patricia A. Pellikka, MD, FASE, Nancy DeMarsPlambeck,BS,RDMS,RDCS,RVT,DavidPrater,MS, ThomasR.Porter,MD,FASE,DavidJ.Sahn,MD,FASE,James D. Thomas, MD, FASE, Kai E. Thomenius, PhD, and Neil J. Weissman, MD, FASEINTRODUCTIONThe leadership at the American Society of Echocardiography (ASE)decided on a proactive role in defining selected areas of researchnecessary in this decade that will meet our future clinical needs.Consequently, ASE sponsored a Technology and ResearchSummit in the fall of 2010 in conjunction with the AmericanHeart Association Scientific Sessions in Chicago. In addition to theASE executive committee, in attendance were the editor, deputyeditor, and one of the associate editors of the Journal of theAmerican Society of Echocardiography. Also invited were physician-scientists active in the field of cardiovascular ultrasound, respectedultrasound physicists, and senior engineers from the various ultra-sound companies.The agenda for the full-day meeting covered a selected range ofsubjects including the assessment of global and regional left ventricu-lar function, regional myocardialperfusion, molecular imaging, thera-peutic ultrasound, and peripheral vascular imaging. Also addressedwere research necessary to determine the broad clinical utility ofhand held ultrasound devices and the impact of future technologicaldevelopments on the field of cardiovascular imaging.Because of time constraints, other important and worthy areas ofresearch were not discussed. There was an hour devoted to the dis-cussion of each subject that was initiated by the chairs and panelistsassigned to each of the topics. The discussion was robust, and at theend, the chairs and panelists for each topic were requested to sub-mit in writing a short synopsis of the discussion. These have beencompiled into a document that we believe will serve as a roadmapfor cardiovascular ultrasound research for this decade. At the endof each section a short list of references for selected reading isprovided.Although we have defined the areas that are ripe for future re-search, we also strongly believe that we havetotrain the future scien-tists who will implement this research agenda. ASE has historicallyawarded one or two fellowship training grants a year and also anaward for researchtraining of a sonographer. At some institutions fel-lowshavealsoreceivedtraininggrantsfromthelocalAmericanHeartAssociation, and very occasionally a training grant (F32) from theNational Institutes of Health. However, this is not enough. We needmore institutional training grants from the National Institutes ofHealth in order to train an adequate number of MD and PhD scien-tists in cardiovascular imaging. To our knowledge there are currentlyonlyahandfulofsuchtraininggrantsinthecountry,whichiswoefullyinadequate. We believe that we need at least 20–25 such traininggrants devoted to the general field of cardiovascular imaging so thatwithin a decade there will be enough physicians trained in scientificmethods and clinical research to address the subjects that havebeen discussed in this report.The field of cardiovascular ultrasound is very broad, ranging fromclinical validation of new technology to studies requiring knowledgeof physics, mathematics, organic chemistry, physiology, pharmacol-ogy, molecular and vascular biology, genetics, clinical trials, and out-come research. Cross-training of individuals in one or more of thesefields is essential for cardiovascular ultrasound to thrive and succeed.Ourhopeisthatthisreportwillencourageyoungpeopletorealizethescope of cardiac ultrasound research and make a career in this dy-namic field.Selected Reading

Citation information: McCulloch DL, Loffler G, Colquhoun K, Bruce N, Dutton GN & Bach M. The effects of visual degradation on face discrimination. Ophthalmic Physiol Opt 2011, 31, 240–248. doi: 10.1111/j.1475-1313.2011.00828.x Abstract Purpose: People with reduced visual acuity (VA) and/or contrast sensitivity have difficulty recognizing faces and facial expressions. We have quantified these difficulties, using a synthetic face discrimination task employing both normal and artificially degraded vision. Methods: VA and contrast thresholds were measured using an optimised staircase procedure [Freiburg acuity Test (FrACT)] in 25 young adults (aged 18–24 years) with corrected visual acuity of 0.0 logMAR or better and with four levels of vision degraded with Bangerter occlusion foils. For face discrimination, male face images were synthesised from 37 cardinal points (position of eyes, width of nose, head shape etc) derived from frontal face photographs and manipulated by altering the points as a fraction of the mean head radius. Face discrimination thresholds (% difference) were measured from a simultaneous four-alternative forced choice of ‘odd one out’ from three identical faces and one that differed. Psychometric functions were measured for four participants with normal and degraded vision. Subsequently, the difference between faces was fixed at twice the discrimination thresholds and the size of the faces manipulated using the FrACT threshold procedure in 25 participants. Data were converted to equivalent face discrimination distances for realistic face dimensions. Results: With normal vision, face discrimination thresholds ranged from 2.7% to 5.6%; these increased systematically and were more variable with visual degradation. When manipulating face size, face discrimination distance was highly correlated with both acuity and contrast sensitivity (r2 = 0.77 and 0.80 respectively, p

Steady-state VEPs to full-field flicker (FFF) using sinusoidally modulated light were compared with those elicited by square-wave modulated light across a wide range of stimulus frequencies with monocular and binocular FFF stimulation. Binocular and monocular VEPs were elicited in 12 adult volunteers to FFF with two modes of temporal modulation: sinusoidal or square-wave (abrupt onset and offset, 50% duty cycle) at ten temporal frequencies ranging from 2.83 to 58.8 Hz. All stimuli had a mean luminance of 100 cd/m(2) with an 80% modulation depth (20-180 cd/m(2)). Response magnitudes at the stimulus frequency (F1) and at the double and triple harmonics (F2 and F3) were compared. For both sinusoidal and square-wave flicker, the FFF-VEP magnitudes at F1 were maximal for 7.52 Hz flicker. F2 was maximal for 5.29 Hz flicker, and F3 magnitudes are largest for flicker stimulation from 3.75 to 7.52 Hz. Square-wave flicker produced significantly larger F1 and F2 magnitudes for slow flicker rates (up to 5.29 Hz for F1; at 2.83 and 3.75 Hz for F2). The F3 magnitudes were larger overall for square-wave flicker. Binocular FFF-VEP magnitudes are larger than those of monocular FFF-VEPs, and the amount of this binocular enhancement is not dependant on the mode of flicker stimulation (mean binocular: monocular ratio 1.41, 95% CI: 1.2-1.6). Binocular enhancement of F1 for 21.3 Hz flicker was increased to a factor of 2.5 (95% CI: 1.8-3.5). In the healthy adult visual system, FFF-VEP magnitudes can be characterized by the frequency-response functions of F1, F2 and F3. Low-frequency roll-off in the FFF-VEP magnitudes is greater for sinusoidal flicker than for square-wave flicker for rates ≤ 5.29 Hz; magnitudes for higher-frequency flicker are similar for the two types of flicker. Binocular FFF-VEPs are larger overall than those recorded monocularly, and this binocular summation is enhanced at 21.3 Hz in the mid-frequency range.

In response to progressively stronger flashes delivered against a rod saturating background light, the amplitude of the photopic ERG b-wave first increases, reaches a maximal value (V max) and then decreases gradually to a plateau where the amplitude of the b-wave equals that of the a-wave, a phenomenon known as the photopic hill (PH). The purpose of this study was to investigate how the PH grew during the course of the light adaptation (LA) process that follows a period of dark adaptation (DA): the so-called light adaptation effect (LAE). Photopic ERG (time-integrated) luminance-response (LR) functions were obtained prior to (control-fully light adapted) and at 0, 5 and 10 min of LA following a 30-min period of DA. A mathematical model combining a Gaussian and a logistic growth function, suggested to reflect the OFF and ON retinal contribution to the PH respectively, was fitted to the LR functions thus obtained. Our results indicate that the magnitude of the cone ERG LAE is modulated by the stimulus luminance, with b-wave enhancements being maximal for luminance levels that result in the descent of the PH. The Gaussian function grew significantly with LA while the logistic growth function remained basically unchanged. Our findings would therefore suggest that the LAE reflects primarily an increase in the retinal OFF response during LA.

This study characterizes differences in human ERGs based on ocular pigmentation. Light- and dark-adapted luminance-response (LR) series for a-, b- and i-waves and light-adapted oscillatory potentials (OPs) were recorded in 14 healthy volunteers (7 blue-eyed Caucasians; 7 brown-eyed Asians, aged 20–22 years). Amplitude interpolations were by logistic growth (Naka-Rushton), Gaussian or the combined ‘photopic hill’ functions. Implicit times (IT) for dark-adapted a- and b-waves, and for light-adapted a-, b- and i-waves were earlier in the blue-eyed group than in the brown-eyed group across all flash strengths (P < 0.05). For dark-adapted ERGs, saturated a-wave amplitude was larger for blue eyes (397 vs. 318 μV, P < 0.05) as was the a-wave to strong flash (10 cd·s/m2; 357 vs. 293 μV, P < 0.05) and the b-wave to ISCEV standard 0.01 (354 vs. 238 μV, P < 0.05). Light-adapted b-waves for midrange flash stimuli were much larger for the blue-eyed group (photopic hill, Gaussian peak: 155 vs. 82 μV, P < 0.001) with no difference in saturated amplitudes. Similarly, interpolated i-wave amplitudes were larger (48 vs. 18 μV, P < 0.01). For a light-adapted 2.6 stimulus, a- and b-waves were larger for the blue-eyed group (52 vs. 39 μV; 209 vs. 133 μV, P < 0.01) as were OP4 and OP5 (37.2 vs. 15.6 μV; 47.5 vs. 22.2 μV, P < 0.01), but OP1-OP3 did not differ. ERGs have shorter ITs in people with blue irides than in those with dark pigmentation. Amplitude differences are highly non-linear and substantially larger from eyes with light pigmentation for components thought to be associated with the OFF retinal pathways.