Jeffrey I. Gold

Neuropsychological dysfunction and neuroimaging abnormalities in neurologically intact adults with sickle cell anemia

CONTEXT Sickle cell anemia (SCA) is a chronic illness causing progressive deterioration in quality of life. Brain dysfunction may be the most important and least studied problem affecting individuals with this disease. OBJECTIVE To measure neurocognitive dysfunction in neurologically asymptomatic adults with SCA vs healthy control individuals. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study comparing neuropsychological function and neuroimaging findings in neurologically asymptomatic adults with SCA and controls from 12 SCA centers, conducted between December 2004 and May 2008. Participants were patients with SCA (hemoglobin [Hb] SS and hemoglobin level < or = 10 mg/dL) aged 19 to 55 years and of African descent (n = 149) or community controls (Hb AA and normal hemoglobin level) (n = 47). Participants were stratified on age, sex, and education. MAIN OUTCOME MEASURES The primary outcome measure was nonverbal function assessed by the Wechsler Adult Intelligence Scale, third edition (WAIS-III) Performance IQ Index. Secondary exploratory outcomes included performance on neurocognitive tests of executive function, memory, attention, and language and magnetic resonance imaging measurement of total intracranial and hippocampal volume, cortical gray and white matter, and lacunae. RESULTS The mean WAIS-III Performance IQ score of patients with SCA was significantly lower than that of controls (adjusted mean, 86.69 for patients with SCA vs 95.19 for controls [mean difference, -5.50; 95% confidence interval {CI}, -9.55 to -1.44]; P = .008), with 33% performing more than 1 SD (<85) below the population mean. Among secondary measures, differences were observed in adjusted mean values for global cognitive function (full-scale IQ) (90.47 for patients with SCA vs 95.66 for controls [mean difference, -5.19; 95% CI, -9.24 to -1.13]; P = .01), working memory (90.75 vs 95.25 [mean difference, -4.50; 95% CI, -8.55 to -0.45]; P = .03), processing speed (86.50 vs 97.95 [mean difference, -11.46; 95% CI, -15.51 to -7.40]; P < .001), and measures of executive function. Anemia was associated with poorer neurocognitive function in older patients. No differences in total gray matter or hippocampal volume were observed. Lacunae were more frequent in patients with SCA but not independently related to neurocognitive function. CONCLUSION Compared with healthy controls, adults with SCA had poorer cognitive performance, which was associated with anemia and age.

Effectiveness of Virtual Reality for Pediatric Pain Distraction during IV Placement

The objective of this study was to test the efficacy and suitability of virtual reality (VR) as a pain distraction for pediatric intravenous (i.v.) placement. Twenty children (12 boys, 8 girls) requiring i.v. placement for a magnetic resonance imaging/computed tomography (MRI/CT) scan were randomly assigned to two conditions: (1) VR distraction using Street Luge (5DT), presented via a head-mounted display, or (2) standard of care (topical anesthetic) with no distraction. Children, their parents, and nurses completed self-report questionnaires that assessed numerous health-related outcomes. Responses from the Faces Pain Scale-Revised indicated a fourfold increase in affective pain within the control condition; by contrast, no significant differences were detected within the VR condition. Significant associations between multiple measures of anticipatory anxiety, affective pain, i.v. pain intensity, and measures of past procedural pain provided support for the complex interplay of a multimodal assessment of pain perception. There was also a sufficient amount of evidence supporting the efficacy of Street Luge as a pediatric pain distraction tool during i.v. placement: an adequate level of presence, no simulator sickness, and significantly more child-, parent-, and nurse-reported satisfaction with pain management. VR pain distraction was positively endorsed by all reporters and is a promising tool for decreasing pain, and anxiety in children undergoing acute medical interventions. However, further research with larger sample sizes and other routine medical procedures is warranted.

PTSD Symptom Severity and Family Adjustment Among Female Vietnam Veterans

This study examined relations between posttraumatic stress disorder (PTSD) symptom severity and several family adjustment variables among a sample of 89 female Vietnam veterans and their male relationship partners. Findings revealed associations between PTSD symptom severity and measures of marital adjustment, family adaptability, family cohesion, parenting satisfaction, and psychological abuse. Results suggest that the presence of PTSD symptomatology may have important implications with regard to the family life of female Vietnam veterans.

Posttraumatic stress disorder in children and their parents following admission to the pediatric intensive care unit: A review

Objective: To evaluate posttraumatic stress disorder in children who have been admitted to the pediatric intensive care unit and their families. Data Sources: Studies were identified through PubMed, MEDLINE, and Ovid. Study Selection: All descriptive, observational, and controlled studies with a focus on posttraumatic stress disorder and the pediatric intensive care unit were included. Data Extraction and Data Synthesis: Posttraumatic stress disorder rates in children following admission to the pediatric intensive care unit were between 5% and 28%, while rates of posttraumatic stress disorder symptoms were significantly higher, 35% to 62%. There have been inconsistencies noted across risk factors. Objective and subjective measurements of disease severity were intermittently positively associated with development of posttraumatic stress disorder. There was a positive relationship identified between the child’s symptoms of posttraumatic stress disorder and their parents’ symptoms. The biological mechanisms associated with the development of posttraumatic stress disorder in children admitted to the pediatric intensive care unit have yet to be explored. Studies in children following burn or other unintentional injury demonstrate potential relationships between adrenergic hormone levels and a diagnosis of posttraumatic stress disorder. Likewise genetic studies suggest the importance of the adrenergic system in this pathway. The rates of posttraumatic stress disorder in parents following their child’s admission to the pediatric intensive care unit ranged between 10.5% and 21%, with symptom rates approaching 84%. It has been suggested that mothers are at increased risk for the development of posttraumatic stress disorder compared to fathers. Objective and subjective measures of disease severity yielded mixed findings with regard to the development of posttraumatic stress disorder. Protective parental factors may include education or the opportunity to discuss the parents’ feelings during the admission. Conclusions: Following admission to the pediatric intensive care unit, both children and their parents have high rates of trauma exposure, both personally and secondary exposure via other children and their families, and subsequently are reporting significant rates of posttraumatic stress disorder. To effectively treat our patients, we must recognize the signs of posttraumatic stress disorder and strive to mitigate the negative effects.

The Neurobiology of Virtual Reality Pain Attenuation

During the past decade, virtual reality (VR) has gained recognition as a means of attenuating pain during medical procedures. However, while investigators have examined the effects of virtual environments on level of distraction, subjective pain intensity, and brain activity, there have been only a handful of investigations into the neurobiological mechanisms associated with VRs efficacy. In an effort to explain how VR may alter pain perception and produce analgesia, as well as to guide the development of novel and improved VR pain treatments, this review aims to link the wealth of empirical data examining the neurobiology of pain to the growing field of VR. This review is separated into three main sections: (a) a brief overview of the current literature on the use of VR for the treatment of pain; (b) a review of the basic neurobiology of how pain is detected, processed, and controlled by the brain; and (c) an exploration into how current VR pain treatments may impact the pain system to produce analgesia. In addition, the future of VR for pain treatment is discussed, including how current treatments might be improved and novel ways to use VR to treat pain might be developed. Speculation on future VR interventions is based on our current understanding of how the brain processes pain and how VR appears to alter this process and produce analgesia.

Pediatric chronic pain and health-related quality of life.

The aim of this study was to investigate the health-related quality of life (HRQOL) of children and adolescents with chronic pain. Sixty-nine participants (53 girls and 16 boys, 8-18 years old) were recruited, along with their caregivers, from an outpatient pain management clinic. Participants completed questionnaires regarding the childs pain intensity and HRQOL (physical, emotional, social, and school functioning). Findings indicated that children with chronic pain report significantly lower HRQOL scores compared to population-based normative data and data of children with other chronic illnesses. Lower levels of pain were associated with higher HRQOL scores. In addition to targeting pain management, interventions focused on emotional health are necessary to enhance health outcomes for children with chronic pain.

An On-the-Job Mindfulness-based Intervention For Pediatric ICU Nurses: A Pilot

The feasibility of a 5-minute mindfulness meditation for PICU nurses before each work-shift to investigate change in nursing stress, burnout, self-compassion, mindfulness, and job satisfaction was explored. Thirty-eight nurses completed measures (Nursing Stress Scale, Maslach Burnout Inventory, Mindfulness Attention Awareness Scale and Self-Compassion Scale) at baseline, post-intervention and 1 month after. The intervention was found to be feasible for nurses on the PICU. A repeated measures ANOVA revealed significant decreases in stress from baseline to post intervention and maintained 1 month following the intervention. Findings may inform future interventions that support on-the-job self-care and stress-reduction within a critical care setting.

Assessing Postoperative Pain in Neonates: A Multicenter Observational Study

OBJECTIVE. A multicenter observational study was conducted to evaluate the practices of postoperative pain assessment and management in neonates to identify specific targets for improvement in clinical practice. METHODS. Ten participating NICUs collected data for the 72 hours after a surgical operation on 25 consecutive neonates (N = 250), including demographics, principal diagnoses, operative procedure, other painful procedures, pain assessments, interventions (pharmacologic and nonpharmacologic), and adverse events in neonates who underwent minor and major surgery. Descriptive and logistic-regression analyses were performed by using SPSS and Stata. RESULTS. The neonates studied had a birth weight of 2.4 ± 1.0 kg (mean ± SD) and gestational age of 36 ± 4.3 weeks; 57% were male, and length of hospital stay was 23.5 ± 30.0 days. Participating hospitals used 7 different numeric pain scales, with nursing pain assessments documented for 88% (n = 220) of the patients and physician pain assessments documented for 9% (n = 23) of the patients. Opioids (84% vs 60%) and benzodiazepines (24% vs 11%) were used more commonly after major surgery than minor surgery, and a small proportion (7% major surgery, 12% minor surgery) received no analgesia. Logistic-regression analyses showed that physician pain assessment was the only significant predictor of postsurgical analgesic use, whereas major surgery and postnatal age in days did not seem to contribute. Physician pain assessment was documented for 23 patients; 22 of these received postoperative analgesia. CONCLUSIONS. Documentation of postoperative pain assessment and management in neonates was extremely variable among the participating hospitals. Pain assessment by physicians must be emphasized, in addition to developing evidence-based guidelines for postoperative care and educating professional staff to improve postoperative pain control in neonates.

DETECTION AND ASSESSMENT OF STROKE IN PATIENTS WITH SICKLE CELL DISEASE: Neuropsychological Functioning and Magnetic Resonance Imaging

Sickle cell disease (SCD) is associated with increased risk of stroke and cognitive impairment. This study describes a retrospective review of 65 patients who underwent routine neuropsychological testing and MRI during treatment at a comprehensive sickle cell center. It was hypothesized that (1) children with no evidence of CVA would perform lower than expected on cognitive tasks compared to population-based normative data, (2) children with strokes and children with silent infarcts would perform lower on cognitive tasks and motor skills as compared to patients with no evidence of CVA, and (3) children with evidence of silent infarcts would perform better than children with known overt strokes. This final hypothesis has not been studied previously, as children with known overt stroke and silent infarct were grouped together. Sixty-five children with SCD who were sent for routine neuropsychological testing and brain MRI were identified via retrospective chart review. Patients had been administered neuropsychological tests to assess cognitive, executive and motor function. Brain MRI was obtained from each patient and was analyzed for evidence of cerebrovascular accident (CVA). Based on MRI analysis, 27% of patients with SCD had experienced a stroke and 13% a silent infarct. The majority (59%) of patients diagnosed with stroke or infarct sustained cortical damage to the frontal lobe. Patients with SCD and no evidence of CVA functioned normally on tests of cognitive ability and achievement, but patients with CVA displayed impairments in cognitive function and comparatively lower scores on verbal and performance scales. Neuropsychological testing can identify impairments in patients with SCD with no known cerebrovascular accident. Investigations of neurocognitive functioning will help characterize patterns of deficits and can inform the ability to implement comprehensive care strategies for patients with SCD and cognitive impairment.

An expanded Transactional Stress and Coping Model for siblings of children with sickle cell disease: family functioning and sibling coping, self-efficacy and perceived social support

AIM To investigate the application of an expanded Transactional Stress and Coping Model for the psychological adjustment of non-chronically ill, African-American siblings of children with sickle cell disease (SCD). METHODS Ninety-seven siblings (M = 11.24 years) from 65 families who care for a child with SCD participated. Primary caregivers completed the Coping Health Inventory for Parents, the Family Relations Scale and the Child Behaviour Checklist, while siblings completed the Kidcope, the Childrens Self-Efficacy for Peer Interaction Scale, and the Social Support Scale for Children. RESULTS Family processes were predictive of sibling adjustment, revealing that family coping, expressiveness and support improved adjustment, while family conflict predicted poor adjustment. CONCLUSION Findings suggest that family-centered interventions stressing family expressiveness and support, while minimizing conflict, will contribute to sibling psychological adjustment.