Maxine M. Kuroda

The Effectiveness of Video Technology As an Adjunct to Teach and Evaluate Epidural Anesthesia Performance Skills

Background Although video review has been used in teaching, it has not been reported for use as an adjunct to teaching anesthesiology residents. The purpose of the prospective, randomized, blinded study was to determine whether teaching with video review improves epidural anesthesia skills of anesthesiology residents. Methods Twenty-two second-year (CA-2) anesthesiology residents beginning their first obstetric anesthesia rotation were assigned to video or nonvideo groups. All residents were filmed daily as they placed epidural analgesia. Residents assigned to the video group reviewed their tapes twice a week with an attending anesthesiologist, whereas residents assigned to the nonvideo group never saw their films. Four experienced attending anesthesiologists independently judged videotapes taken on days 1, 15, and 30 and scored the residents for “overall” skill (range of summed overall grades, 0–40), as well as on 13 predetermined criteria. Results As determined by kappa coefficients, interrater reliability was high among the judges (k = 0.7–0.8). Residents in the video group improved to a greater degree than residents in the nonvideo group. On day 1, the median overall grades for the video and nonvideo groups were 21 and 12, respectively. By day 15, the corresponding grades had increased to 32 and 24, respectively (P < 0.01). However, overall median grades continued to improve between days 15 and 30 in the video group only (P < 0.01). Conclusions Review of resident videotapes resulted in greater improvement in overall and predetermined performance criteria. In addition, video review was helpful in identifying skills that were inadequately learned, thus allowing for specific teaching in those areas.

Association of apolipoprotein E genotype and cerebral palsy in children

OBJECTIVES. We tested the hypotheses that apolipoprotein E genotype, in particular carriage of the ε4 allele, is more likely to be associated with cerebral palsy and that children with more severe neurologic impairment are more likely to carry this allele. METHODS. In this cross-sectional study, 209 children with cerebral palsy were matched with healthy control subjects according to gender and race. Diagnosis of cerebral palsy was confirmed through physician consultation, medical chart review, and parent interview. Apolipoprotein E genotyping was performed with DNA obtained with buccal swabs. Severity of motor impairment was rated by physical therapists, and occipitofrontal circumference was measured. RESULTS. Compared with gender- and race-matched control subjects, overall risk for cerebral palsy was elevated 3.4-fold among children carrying an ε4 allele and was particularly elevated for children with quadriplegia/triplegia. This finding was independent of birth weight. Carriage of the ε4 allele was also associated with increased severity of cerebral palsy and with a trend toward increased likelihood for microcephaly. Moreover, children carrying an ε2 allele were at greater risk for cerebral palsy. CONCLUSIONS. These data implicate the apolipoprotein E ε4 and ε2 genotypes as susceptibility factors in determining neurologic outcomes after perinatal brain injury. Additional studies are warranted to establish the role of apolipoprotein E in specific pathogenetic pathways leading to cerebral palsy or poor neurologic outcomes after perinatal brain injury.

The Osteoarthritis Knee Model: Psychophysical Characteristics and Putative Outcomes

UNLABELLED The knee osteoarthritis (KOA) model is a convenient and coherent archetype that is frequently used in pharmaceutical trials of drugs with analgesic and/or anti-inflammatory properties; yet, little is known about its specific pathophysiology. The presumed chronic inflammatory etiology of osteoarthritis suggests that nociceptive processes and neurogenic inflammation predominate in this condition. However, most chronic pain conditions are associated with changes in peripheral and central processing. Recent data corroborate this as an important mechanism in KOA. We compared psychophysical characteristics (including thermal Quantitative Sensory Testing); thermal, mechanical, and functional wind-up; thermal and mechanical aftersensations; and pressure algometry of 37 subjects with KOA with 35 age- and sex-matched controls. A third of the KOA subjects demonstrated hypoesthesia to vibration and the 4.56 von Frey fiber, yet few showed allodynia in their worse knee. The majority of subjects had abnormalities to pinprick (41% were hyperalgesic and 27% were hypoesthetic). Compared to controls, the more painful knee was hypoesthetic to cold detection and had greater thermal wind-up, lower pressure-pain thresholds, thermal and mechanical aftersensations, and twice the pain ratings of controls after stair climb. Substantial intraindividual differences were found in KOA subjects and controls for mechanical wind-up and algometric thresholds. PERSPECTIVE These results develop the KOA model and suggest mechanistic hypotheses. Certain of these tests may ultimately prove to be responsive, quasi-objective, and quantitative outcomes for research and lend empirical support to the notion of measurable sensitization in osteoarthritis.

Abruptly attenuated terminal ictal pattern in pediatrics.

Purpose: We examined the ictal discharges at the end of pediatric seizures and categorized the various patterns. One particular pattern, termed “abruptly attenuated termination” was studied in detail. Methods: Ictal segments captured on video-EEG monitoring during a 26-month interval were analyzed for a variety of ictal termination patterns, including one that we rigorously defined as abruptly attenuated termination pattern (AAT). We studied the associations between AAT and the other ictal EEG and clinical features. Results: AAT was noted in 16 of 200 (8%) pediatric seizures. All 16 were immediately preceded by repetitive spikes or spike-waves. The presence of AAT also correlated with ictal spread pattern, initial ictal pattern, laterality of onset, seizure duration, age, and epilepsy etiology. AAT is more often noted in children older than 6 months and in children with idiopathic or cryptogenic forms of epilepsy. Conclusions: The minority of pediatric seizures recorded in a tertiary epilepsy monitoring unit end with diffuse, synchronized abrupt attenuation. AAT probably is the result of an active process that is developmentally related. It appears to require some degree of mature and intact neurophysiology and may involve the thalamocortical circuit.

Effects on motor development of kicking and stepping exercise in preterm infants with periventricular brain injury: A pilot study

BACKGROUND Preterm infants with periventricular brain injury (PBI) have a high incidence of atypical development and leg movements. OBJECTIVE Determine whether kicking and treadmill stepping intervention beginning at 2 months corrected age (CA) in children with PBI improves motor function at 12 months CA when compared with control subjects. METHOD In a multi-center pilot study for a controlled clinical trial, sixteen infants with PBI were randomly assigned to home exercise consisting of kicking and treadmill stepping or a no-training control condition. Development was assessed at 2, 4, 6, 10, and 12 months CA with the Alberta Infant Motor Scale (AIMS). At 12 months children were classified as normal, delayed, or with cerebral palsy (CP). RESULTS At 12 months CA 3 of 7 (43%) of the exercise group children walked alone or with one hand held versus 1 of 9 (11%) in the control group (p=0.262), but no significant differences in AIMS scores were found at any age. Half of the subjects had CP or delay; the outcomes of these infants were not improved by exercise. Compliance with the home program was lower than requested and may have affected results. CONCLUSION Although not statistically significant with a small sample size, self-produced kicking and treadmill exercise may lower age at walking in infants with normal development following PBI, but improvements of the protocol to increase and document compliance are needed before a larger study is implemented.

Population pharmacokinetics of oral baclofen in pediatric patients with cerebral palsy.

OBJECTIVE To characterize the population pharmacokinetics (PK) of oral baclofen and assess impact of patient-specific covariates in children with cerebral palsy (CP) in order to support its clinical use. SUBJECTS DESIGN Children (2-17 years of age) with CP received a dose of titrated oral baclofen from 2.5 mg 3 times a day to a maximum tolerated dose of up to 20 mg 4 times a day. PK sampling followed titration of 10-12 weeks. Serial R- and S-baclofen plasma concentrations were measured for up to 16 hours in 49 subjects. Population PK modeling was performed using NONMEM 7.1 (ICON PLC; Ellicott City, Maryland). RESULTS R- and S-baclofen showed identical concentration-time profiles. Both baclofen enantiomers exhibited linear and dose/kg-proportional PK, and no sex differences were observed. Average baclofen terminal half-life was 4.5 hours. A 2-compartment PK model with linear elimination and transit absorption steps adequately described concentration-time profiles of both baclofen enantiomers. The mean population estimate of apparent clearance/F was 0.273 L/h/kg with 33.4% inter-individual variability (IIV), and the apparent volume of distribution (Vss/F) was 1.16 L/kg with 43.9% IIV. Delayed absorption was expressed by a mean transit time of 0.389 hours with 83.7% IIV. Body weight, a possible genetic factor, and age were determinants of apparent clearance in these children. CONCLUSION The PK of oral baclofen exhibited dose-proportionality and were adequately described by a 2-compartment model. Our population PK findings suggest that baclofen dosage can be based on body weight (2 mg/kg per day) and the current baclofen dose escalation strategy is appropriate in the treatment of children with CP older than 2 years of age.

A prospective, multisite, international validation of the Complex Regional Pain Syndrome Severity Score

Abstract Clinical diagnosis of complex regional pain syndrome (CRPS) is a dichotomous (yes/no) categorization, a format necessary for clinical decision making. Such dichotomous diagnostic categories do not convey an individuals subtle gradations in the severity of the condition over time and have poor statistical power when used as an outcome measure in research. This prospective, international, multicenter study slightly modified and further evaluated the validity of the CRPS Severity Score (CSS), a continuous index of CRPS severity. Using a prospective design, medical evaluations were conducted in 156 patients with CRPS to compare changes over time in CSS scores between patients initiating a new treatment program and patients on stable treatment regimens. New vs stable categorizations were supported by greater changes in pain and function in the former. Results indicated that CSS values in the stable CRPS treatment group exhibited much less change over time relative to the new treatment group, with intraclass correlations nearly twice as large in the former. A calculated smallest real difference value revealed that a change in the CSS of ≥4.9 scale points would indicate real differences in CRPS symptomatology (with 95% confidence). Across groups, larger changes in CRPS features on the CSS over time were associated in the expected direction with greater changes in pain intensity, fatigue, social functioning, ability to engage in physical roles, and general well-being. The overall pattern of findings further supports the validity of the CSS as a measure of CRPS severity and suggests it may prove useful in clinical monitoring and outcomes research.

Measuring care and comfort in children with cerebral palsy: the care and comfort caregiver questionnaire.

To evaluate the psychometric properties of the Care and Comfort Caregiver Questionnaire (CareQ), which was developed to measure the perceived effort of caregivers in providing care for children with moderate to severe cerebral palsy (CP).

Physical and Social Participation Factors Impacting Quality of Life in Ambulatory Children and Adolescents With Cerebral Palsy

Disclosures: E. A. Hurvitz, None. Objective: To describe medical, functional and psychosocial outcomes and satisfaction of adults with cerebral palsy (CP) who had a rhizotomy as a child. Design: Retrospective cohort. Setting: Academic medical center. Participants: Adults and adolescents (16 years or older) with a diagnosis of CP who had a selective dorsal rhizotomy as a child or young adolescent. Interventions: Surveys administered in person or on the phone. Main Outcome Measures: Subjects were administered the Satisfaction with Life Scale (SWLS), Gross Motor Functional Classification Scale (GMFCS) and Manual Abilities Classification System. Subjects were asked about general health, and if they felt that the rhizotomy had affected their QOL. They were also asked if they would recommend the rhizotomy to others. Results: There were 31 subjects ages 16-39 years (mean 24.1 years; SD 5.2), mean age at rhizotomy 6.6 years (SD 4.0), mean follow up of 17.5 years (SD 3.0), and 53% men. About half the informants were self and half were parent or caregiver. The GMFCS levels were I, 6%; II, 16%; III, 26%; IV, 36%; V, 16%. Forty-eight percent thought they were in excellent or very good health, whereas 42% reported good health. Seven baclofen pumps had been placed some time after rhizotomy, but 2 were removed. Thirty-nine percent noted chronic pain, most commonly in the back and legs. The mean score on the SWLS was 26.0. Higher perception of health correlated with higher SWLS scores. There was also a trend (P .06) toward lower SWLS scores in those who reported pain. Sixty-four percent reported that the rhizotomy had improved their QOL, whereas 10% thought it decreased their QOL. Seventy-one percent would recommend the rhizotomy to others. A perception of improved QOL predicted a positive recommendation (P .01). Conclusions: Adults and adolescents were generally satisfied with childhood rhizotomy outcomes and would recommend it, especially if they had a perception of improved quality of life. These adults were generally healthy, although they had significant pain, common in adults with CP. The relationship between back pain and rhizotomy, which involves a laminectomy, needs more investigation.