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Objective: Sports-related concussion management in collegiate athletes has been focused on return-to-play. However, resuming schoolwork without a gradual stepwise reintroduction contributes to symptom exacerbation, delayed recovery, and adverse academic performance. Return-to-learn guidelines are limited by a lack of sensitivity in methods monitoring cognitive function. This study evaluated 2 neuropsychological tests, the Sternberg test and the Paced Auditory Serial Addition Test (PASAT), with high ceilings for sensitivity to deficits in speed of information processing, cognitive efficiency, and complex attention., Setting: Academic center research laboratory., Participants: We recruited 56 male and female collegiate contact and noncontact sports athletes. They were categorized into as follows: (1) nonconcussed ( n = 23; 7F, 16M); (2) chronic ( n = 21; 4F, 17M), at least 1 year from their last concussion; and (3) acute ( n = 12; 1F, 11M), within 2 weeks from concussion., Design: Observational cohort study., Main Measures: The PASAT assesses complex attention. The Sternberg test examines processing speed and cognitive efficiency. Cognitive difficulty increases with progression through the tasks for both the PASAT and the Sternberg test. The mean outcome differences of the 3 groups (nonconcussed, acute, and chronic) across the 3 or 4 conditions (difficulty level) were measured with repeated-measures analysis of variance and subsequent pairwise comparison., Results: For processing speed (Sternberg reaction time), the acute group responded slower than the chronic group on the medium ( P = .021, Bonferroni corrected) and hard difficulty tasks ( P = .030, Bonferroni corrected). For cognitive efficiency (Sternberg reaction time variability), the acute group had increased reaction time variability compared with the chronic group on the medium difficulty task ( P = .04, Bonferroni corrected). For complex attention (PASAT omissions), there was a difference between the acute and nonconcussed groups on the moderate-hard difficulty trial ( P = .023, least significant difference [LSD] corrected) and between the acute and chronic groups for hard difficulty trial ( P = .020, LSD corrected). The acute group performed worse, with progressively shorter interstimulus intervals., Conclusion: Neuropsychological testing without ceiling effects can capture higher-level cognitive dysfunction and and use of such tests can contribute to the understanding of how collegiate athletes are affected by SRC. Future studies can investigate optimal testing batteries that include neuropsychological testing with high ceilings and whether the pattern of performance has implications for the return-to-learn process after SRC in the college setting., Competing Interests: Disclosures/Conflicts of Interest: C.-C. Chiang, K. Hyder, K. Bechtold, M. Anaya, and J. Stilling, no disclosures; P. Celnik, G. Cantarero, and S. Suskauer, as added in funding. The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Abstract: Motor, speech, and cognitive impairments are the most common consequences of neurological disorders. There has been an increasing interest in the use of noninvasive brain stimulation techniques such as transcranial direct current stimulation and transcranial magnetic stimulation to augment the effects of neurorehabilitation. Numerous research studies have shown that transcranial direct current stimulation and transcranial magnetic stimulation are highly promising neuromodulation tools that can work as adjuvants to standard neurorehabilitation services, including physical therapy, occupational therapy, and speech-language pathology. However, to date, there are vast differences in methodology in studies including noninvasive brain stimulation parameters, patient characteristics, time point of intervention after injury, and outcome measures, making it difficult to translate and implement transcranial direct current stimulation and transcranial magnetic stimulation in the clinical setting. Despite this, a series of principles are thought to underlie the effectiveness of noninvasive brain stimulation techniques. We developed a noninvasive brain stimulation rehabilitation program using these principles to provide best practices for applying transcranial direct current stimulation and/or transcranial magnetic stimulation as rehabilitation adjuvants in the clinical setting to help improve neurorehabilitation outcomes. This article outlines our approach, philosophy, and experience., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background . Concussions affect nearly 3 million people a year and are the leading cause of traumatic brain injury-related emergency department visits among youth. Evidence shows neuromotor regions are sensitive to concussive events and that motor symptoms may be the earliest clinical manifestations of neurodegenerative traumatic brain injuries. However, little is known about the effects repeated concussions play on motor learning. Namely, how does concussion acuity (time since injury) affect different behavioral and neurophysiological components of motor learning? Methods . Using a 3-pronged approach, we assessed (1) behavioral measures of motor learning, (2) neurophysiological measures underlying retention of motor learning known as occlusion, and (3) quantitative survey data capturing affective symptoms of each participant. Collegiate student athletes were stratified across 3 groups depending on their concussion history: (1) NonCon, no history of concussion; (2) Chronic, chronic-state of concussion (>1 year postinjury), or (3) Acute, acute state of concussion (<2 weeks postinjury). Results . We found that athletes in both the acute and chronic state of injury following a concussion had impaired retention and aberrant occlusion in motor skill learning as compared with athletes with no history of concussion. Moreover, higher numbers of previous concussions (regardless of the time since injury) correlated with more severe behavioral and neurophysiological motor impairments by specifically hindering neurophysiological mechanisms of learning to affect behavior. Conclusions . These results indicate the presence of motor learning impairment that is evident within 2 weeks postinjury. Our findings have significant implications for the prognosis of concussion and emphasize the need for prevention, but can also direct more relevant rehabilitation treatment targets.

Persistent cognitive, affective, and motor symptoms have been associated with sports-related concussions including several neurophysiological changes in the primary motor cortex. In particular, previous research has provided some evidence of altered latencies of the corticomotor pathway and altered motor neuroplasticity. However, to date, no studies have assessed these neurophysiological metrics in a common group of athletes across different phases of injury and recovery. In this study corticomotor latencies and neuroplasticity were assessed in collegiate athletes with or without a history of prior concussion across two different phases of injury: either in an acute state of concussion (within 2 wk of injury) or in a chronic state of concussion (more than 1 yr after injury). Corticomotor latencies were determined by measuring the motor evoked potential (MEP) onset time, and motor neuroplasticity was assessed by measuring MEP amplitudes following application of anodal transcranial direct current stimulation (tDCS) over the primary motor cortex (M1). We found that concussed athletes had slower corticomotor latencies than nonconcussed athletes, and corticomotor latency was also positively correlated with the number of prior concussions. In contrast, there was no evidence of altered motor neuroplasticity in athletes regardless of concussion history. These findings suggest concussions may lead to permanent changes in the corticospinal tract that are exacerbated by repeated injury. NEW & NOTEWORTHY We are the first to assess corticomotor latencies and motor neuroplasticity in a common group of collegiate athletes across different phases of injury and recovery. We found that the number of concussions an individual sustains negatively impacts corticomotor latencies with a higher number of prior concussions correlating positively with longer latencies. Our findings indicate that concussions may lead to permanent changes in the corticospinal tract that are exacerbated by repeated injury.

We assessed corticomotor excitability in the primary motor cortex (M1) of participants with moderate-to-severe restless legs syndrome (RLS) symptoms using transcranial magnetic stimulation (TMS) in relation to the clinical and sleep aspects of the disease. Thirty-five participants (20 F; mean age: 59.23 ± 1.66 years; range: 42-78 years) affected by primary RLS (off medications) and 31 age-matched controls (19 F; mean age: 57.90 ± 1.50 years; range: 43-79 years) underwent TMS following two nights of polysomnography (PSG). Paired-pulse TMS measures [short-interval intracortical inhibition (SICI), long-interval intracortical inhibition (LICI), and intracortical facilitation (ICF)] of the dominant M1 hand and M1 leg muscles were collected and analyzed in relation to clinical features of RLS and PSG. We found decreased corticomotor excitability in M1 hand , whereas it was increased in M1 leg , which was greater in patients with more severe RLS. Participants with RLS with a history of dopamine-agonist-induced symptom augmentation showed decreased LICI (reduced inhibition) compared to nonaugmented participants with RLS for M1 leg . None of the TMS measures (M1 hand or M1 leg ) correlated with the PSG parameters. This study shows hyperexcitability in M1 leg , and this appears related to RLS disease severity and decreased excitability in M1 hand . The results provide new insight into the complex neurobiology of RLS, particularly in more advanced stages of the disease., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Study Objectives: During normal sleep several neuroplasticity changes occur, some of which are considered to be fundamental to strengthen memories. Given the evidence linking sleep to neuroplasticity, it is conceivable that individuals with chronic sleep disruption, such as patients with chronic insomnia (CI), would experience abnormalities in neuroplastic processes during daytime. Protocols testing use-dependent plasticity (UDP), one of the mechanisms underlying formation of motor memories traces, provide a sensitive measure to assess neuroplasticity in the context of motor training., Design and Participants: A well-established transcranial magnetic stimulation (TMS) paradigm was used to evaluate the ability of patients with CI and age-matched good sleeper controls to undergo UDP. We also investigated the effect of insomnia on intracortical motor excitability measures reflecting GABAergic and glutamatergic mechanisms., Setting: Human Brain Physiology Laboratory, Johns Hopkins Medical Institutions., Measurements and Results: We found that patients with CI experienced increased UDP changes relative to controls. This effect was not due to differences in motor training. In addition, patients with CI showed enhanced intracortical facilitation relative to controls, in the absence of changes in intracortical inhibitory measures., Conclusion: This study provides the first evidence that patients with chronic insomnia have an increased plasticity response to physical exercise, possibly due to larger activation of glutamatergic mechanisms. This suggests a heightened state of neuroplasticity, which may reflect a form of maladaptive plasticity, similar to what has been described in dystonia patients and chronic phantom pain after amputation. These results could lead to development of novel treatments for chronic insomnia.

Action observation (AO), observing another individual perform an action, has been implicated in several higher cognitive processes including forming basic motor memories. Previous work has shown that physical practice (PP) results in cortical motor representational changes, referred to as use-dependent plasticity (UDP), and that AO combined with PP potentiates UDP in both healthy adults and stroke patients. In humans, AO results in activation of the ventral premotor cortex (PMv), however, whether this PMv activation has a functional contribution to UDP is not known. Here, we studied the effects disruption of PMv has on UDP when subjects performed PP combined with AO (PP + AO). Subjects participated in two randomized crossover sessions measuring the amount of UDP resulting from PP + AO while receiving disruptive (1 Hz) TMS over the fMRI-activated PMv or over frontal cortex (Sham). We found that, unlike the sham session, disruptive TMS over PMv reduced the beneficial contribution of AO to UDP. To ensure that disruption of PMv was specifically interfering with the contribution of AO and not PP, subjects completed two more control sessions where they performed only PP while receiving disruptive TMS over PMv or frontal cortex. We found that the magnitude of UDP for both control sessions was similar to PP + AO with TMS over PMv. These findings suggest that the fMRI activation found in PMv during AO studies is functionally relevant to task performance, at least for the beneficial effects that AO exerts over motor training.

Cochlear implant (CI) users demonstrate severe limitations in perceiving musical timbre, a psychoacoustic feature of sound responsible for 'tone color' and one's ability to identify a musical instrument. The reasons for this limitation remain poorly understood. In this study, we sought to examine the relative contributions of temporal envelope and fine structure for timbre judgments, in light of the fact that speech processing strategies employed by CI systems typically employ envelope extraction algorithms. We synthesized "instrumental chimeras" that systematically combined variable amounts of envelope and fine structure in 25% increments from two different source instruments with either sustained or percussive envelopes. CI users and normal hearing (NH) subjects were presented with 150 chimeras and asked to determine which instrument the chimera more closely resembled in a single-interval two-alternative forced choice task. By combining instruments with similar and dissimilar envelopes, we controlled the valence of envelope for timbre identification and compensated for envelope reconstruction from fine structure information. Our results show that NH subjects utilize envelope and fine structure interchangeably, whereas CI subjects demonstrate overwhelming reliance on temporal envelope. When chimeras were created from dissimilar envelope instrument pairs, NH subjects utilized a combination of envelope (p = 0.008) and fine structure information (p = 0.009) to make timbre judgments. In contrast, CI users utilized envelope information almost exclusively to make timbre judgments (p < 0.001) and ignored fine structure information (p = 0.908). Interestingly, when the value of envelope as a cue was reduced, both NH subjects and CI users utilized fine structure information to make timbre judgments (p < 0.001), although the effect was quite weak in CI users. Our findings confirm that impairments in fine structure processing underlie poor perception of musical timbre in CI users., (Copyright © 2011 Elsevier B.V. All rights reserved.)

During 2005, 1546 true solid organ donors were registered in Spain, yielding a rate of 35.1 per million population (pmp), which places our country at the head of word-wide donation rates. A total of 2200 kidney transplantations were performed in Spain during 2005, 72 of them in infants and children. The cadaveric kidney transplantation rate was 47.9 pmp, the highest in the world for this type of transplant. The 2005 Spanish Renal Transplant Registry showed that patient mortality associated with these transplants is 1.6%. Graft survival is 90% to 84% at the first year and 76% to 66% at 5 years. Furthermore, in 2005, 1070 liver transplantations (24.1 pmp) were carried out. Patient survival in this group is 81.3% the first year, 73.3% at 3 years, 56.7% at 10 years and 26.8% at 20 years. A total of 287 heart transplantations were undertaken (6.5 pmp). Patient survival is 86% to 81% the first year, and around 70% at 5 years. There were 167 lung transplantations, 112 double and 55 single lung transplants. Patient survival in this population is 79.3% the first year and 45.2% at 5 years. Lastly, pancreas transplant activity has increased considerably in recent years, with 96 transplants during 2005.

Objective: To analyze and compare the prognostic value of the pediatric index of mortality (PIM) score and lactate values on admission to a pediatric intensive care unit (PICU)., Patients and Methods: We performed a prospective study of 500 consecutive children: 237 girls (47.4 %) and 263 boys (52.6 %) with a mean age of 51.5 59.7 (range: 3 days-18 years) admitted to our PICU. PIM scores and blood lactate concentrations were determined on admission. The predictive ability of PIM and lactate concentrations in relation to mortality and length of stay in the PICU were analyzed., Results: Thirty-six patients (7.2 %) died. According to the PIM score, the mean probability of death in children who died was 23.6 % 28.9, which was significantly higher than that in surviving children (3.4 % 7.3; p < 0.001). The area under the ROC curve for PIM was 0.81 0.03 (95 % CI: 0.74-0.89). Lactate level in nonsurvivors was 4.9 % 3.5 mmol/L, which was significantly higher than that in survivors (1.9 % 1.5 mmol/L; p < 0.001). The area under the ROC curve for blood lactate was 0.76 0.04 (95 % CI: 0.67-0.85). No statistically significant differences were found between either ROC curves. In survivors, a significant relationship was found between PIM score and length of stay in the PICU while in nonsurvivors an inverse relationship was found between blood lactate concentrations and length of stay., Conclusions: Both PIM score and blood lactate concentrations on admission to the PICU have a moderate prognostic value in critically-ill children. The prognostic value of the PIM score is greater than that of blood lactate concentration but is more difficult to obtain, whereas blood lactate determination is fast and easy.

Objective: To ascertain the incidence of osteoporosis and epidemiological factors in patients admitted to an Internal Medicine Service of a University General Hospital in Madrid, Spain. We also took into account the reasons for admission, associated diseases, and the preventive and therapeutic diagnostic implications., Patients and Methods: The analytical, descriptive, retrospective and transversal study of one hundred patients over fifty years of age admitted to an internal medicine service during 1997, obtaining in addition to the clinical discharge report, epidemiological data with regard to the radiological diagnosis of osteoporosis, the reason for admission, past history, the prevention and treatment of the initial complaint as well as the osteoporosis previous diagnosis., Results: 26% of those patients included in the survey had radiologic criteria of osteoporosis although only in 1 per cent of them had osteoporosis been diagnosed previously. The main risk factors, apart from the age and sex, are the associated illnesses which cause malnutrition and immobilization, and the use of drugs, especially heparin., Conclusions: Osteoporosis is a condition common in patients above 50 especially women, who are admitted to an Internal Medicine Service. A quarter of those patients admitted have osteoporosis. Very few are diagnosed and treated. In this group of patients apart from the habitual risk factors, are added those for the associated disease generally chronic, and the treatment they receive. During their stay in the hospital osteoporotic patients are three times more likely to receive heparin and other drugs which aggravate osteoporotic, than non osteoporotic patients. For that reason the risk of fractures is greater and the need for prospective diagnostic studies is even more necessary in this group of patients.

Objective: Our aim was to analyze if inhaled nitric oxide (NO) allows a reduction in respiratory assistance during the first 24 hours of treatment of children with acute respiratory distress syndrome (ARD) and/or pulmonary hypertension (PHT)., Patients and Methods: We studied 53 children with ARDS and/or PHT refractory to conventional therapy who were treated with inhaled nitric oxide at least 24 hours at 1.5 to 45 ppm. We compared respiratory assistance (peak pressure, PEEP and FiO2) and oxygenation parameters (PaO2/FiO2 ratio and oxygenation index) before and after 6 and 24 hours of treatment., Results: In 45 of 53 children NO improved oxygenation (increase of PaO2/FiO2 > 20%). At six hours of treatment the PaO2/FiO2 ratio increased 31 points, the oxygenation index diminished 4.5 points, and the FiO2 was decreased 11 points without significant changes in peak pressure and PEEP. At 24 hours the PaO2/FiO2 ratio was increased 4 points, the oxygenation index diminished 7.3 points and the FiO2 decreased 18 points in relationship to the initial parameters., Conclusions: The effect of inhaled nitric oxide on oxygenation remains during the first 24 hours and permits a decrease in the FiO2.

Background: Osteoporosis may be associated with parenchymal hepatopathy and chronic alcoholism. Biochemical studies which are linked with bone metabolism and the bone densitometry may help to understand its physiopathology, before the symptoms appear and its consequences become inevitable., Patients and Methods: The study of bone metabolism and densitometry has been carried out in a population of 86 males, distributed in 4 groups: group I, control (17 men), group II, patients with chronic hepatopathy without alcoholism (25 patients), group III, chronic alcoholic without hepatopathy (21 patients), and group IV, patients with chronic alcoholic hepatopathy (23 patients). The results of densitometry and biochemical parameters in relation with bone metabolism are cross checked among these 4 groups., Results: We found out that patients with chronic alcoholic hepatopathy have bone mineral density (BMD), at femoral level, significatively lower than that of the other 3 groups (p < 0.05). In chronic hepatopathy, regardless of its etiology, significant alterations in biochemical parameters of bone metabolism found, consisting basically in shrinked plasmatic level of 25-hydroxivitamin-D (25-OH-D) (p < 0.05). The plasmatic levels of calcitriol, magnesium and intact parathyroid hormone (PTHi) were significantly lower in chronic alcoholic hepatopathy than in the others 3 groups (p < 0.001, p < 0.001 and p < 0.05, respectively)., Conclusions: Chronic hepatopathy is associated with deficiency in vitamin D. Alcoholism added to chronic hepatopathy has a negative influence on the plasmatic levels of calcitriol, magnesium and PTHi as well as in the femur BMD. Alcoholism not associated with chronic hepatopathy is not sufficient to cause significant alterations in the studied parameters.

Background: Nosocomial infections, especially in the intensive care unit, are a very important problem due to their frequency and important consequences (morbility and mortality). On the other hand there are some risk factors and some preventive measures which are involved in the appearance of the nosocomial infections. The purpose of this work was to recognize these risk factors and to identify the preventive measures which are effective, and also to quantify the participation of each risk factors/preventive measures in the development of the nosocomial infections., Patients and Methods: Follow-up of a cohort of patients admitted to the intensive care unit of the General Hospital of La Paz (Madrid, Spain) during a year and with a stay of at least 48 hours., Results: We have found a cummulative incidence of patients with nosocomial infection of 32.8%. More than 80% of the patients received antibiotic treatment during their stay in the intensive care unit. The stay of the patients no infected was 4 days while the stay of infected patients was 20 days. We have found a mortality of 29.5%, which was greater in the patients who were infected (42%). In the multivariate analysis we have developed an equation to predict the development of the nosocomial infection. The following variables were identified: six or more instrumentations (OR, 4.75; 95% CI, 2.75-8.19), more of ten days of hospitalization previous to the appearance of the first nosocomial infection (OR, 4.17; 95% CI, 2.60-6.70), administration of muscle relaxing drugs (OR, 2.25; 95% CI, 1.43-3.55), nasogastric tube (OR, 2.19; 95% CI, 1.25-3.84), and altered consciousness (OR, 2.19; 95% CI, 1.25-3.84). Therefore, those patients who present some of these characteristics should be monitored in a special way due to their high risk of development of a nosocomial infection., Conclusions: Several factors play an important role in the development of a nosocomial infection in the intensive care unit; these are not only intrinsec (especially the altered consciousness) but also extrinsec (instrumentations and drugs), as well as the stay at the hospital previous to the appearance of the first nosocomial infection.

An evaluation was made of the appropriateness of hospital admissions in the ear, nose, and throat surgery department of a teaching hospital. One hundred fifty-two clinical histories were studied. Elective surgery admissions were reviewed using the new Appropriateness Evaluation Protocol (AEP) for elective surgery. Non-elective admissions and the duration of the hospital stay were reviewed with the adult medical-surgical AEP. In the patients who underwent elective surgery, admission was inappropriate in 6.2% (95% confidence interval: 2.9-12.2%). Name of the non-elective admissions (95% confidence interval: 0-17.8%) was inappropriate. Nineteen per cent of hospital days were inactive (95% confidence interval: 13.3-26.4%).