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Poster 376 Sleepiness After Subacute Adolescent Traumatic Brain Injury: Associations With Cognitive Performance and Executive Functioning
S304
Objective: To determine the incidence of unsuspected hypoxemia during sleep in adolescents and young adults with paraplegia. Design: Prospective and observational. Setting: Overnight recording of oxygen saturation (SO&2&) and heart rate performed in the subject’s home. Participants: 20 adolescents and young adults with posttraumatic ASIA A paraplegia who were ⬎1 year after spinal cord injury (SCI), with no known cardiopulmonary disease and no seizure disorder, and not on supplemental oxygen or ventilatory support. Interventions: Not applicable. Main Outcome Measures: SO2, apnea hypopnea adjusted index, body mass index (BMI), neck circumference, bradycardia, and Pittsburgh Sleep Quality Index. Results: 20 subjects (13 boys and men, and 7 girls and women) enrolled and completed the study. Age range was 13-25 years. Hypoxemia was defined as ⬍92% for at least 4 seconds. Ten of 20 (50%) had recurrent episodes of hypoxemia (mean, 82.9%⫹7.7%; range, 66%-91%) while breathing room air during sleep. The subjects were divided into those with hypoxemia episodes and those who did not have hypoxemia. Comparisons of age, gender, apnea hypopnea adjusted index, basal SO2, BMI, and time since SCI were made between the 2 groups by using paired the Student t-test and the Fisher exact test. Subjects with recurrent episodes of hypoxemia during sleep had significantly lower baseline SO2 (P⫽.01) and greater apnea hypopnea adjusted index (P⫽.03) than subjects without hypoxemia during sleep. There was no difference between the groups in age (P⫽.36), gender distribution (P⫽.35), BMI (P⫽.36), Pittsburgh Sleep Quality Index (P⫽1.0), or in time since SCI (P⫽.12).There were no episodes of bradycardia. Conclusions: Young patients with paraplegia ASIA A are at increased risk for episodes of hypoxemia during sleep. The etiology of the hypoxemia is not known. Further investigation, by using overnight polysomnography and pulmonary function testing, should be performed in this understudied population. Poster 375 Hip Pathology in Obstetric Brachial Palsy. Raquel Sánchez Fernández, MD, PhD (Hosptital Cabueaes, Oviedo, Spain); Juan Andres Conejero Casares, MD, Aida M. Lagares Alonso, Graduate. Disclosures: R. Sánchez Fernández, none. Objective: To study in newborns the association between pediatric brachial palsy and hip pathology (DDH). Hip dysplasia is associated with other neonatal pathologies. Our experience makes us consider the possibility of DDH higher incidence in patients with pediatric brachial palsy. Design: Cases series study. Setting: Association between obstetric brachial palsy and DDH. Participants: 92 newborns with obstetric brachial palsy; all the cases were seen at the hospital. Interventions: Detailed clinical analysis and diagnostic studies (ultrasound or radiography), depending on age. Previous information regarding these patients as collar bone fracture or stiff neck symptoms also were recorded. Main Outcome Measures: Frequency (percentage) of hip pathology in obstetric brachial palsy; frequency (percentage) of hip pathology types in obstetric brachial palsy; frequency (percentage) of main findings: hip clinical exploration, ultrasonic and radiologic findings.
PRESENTATIONS
Results: Of 92 cases, 29.34% had hip symptoms, without associated pathology to the hip (torticollis), 26.08%. Main hip diagnoses were: 18.51% hip pelvic obliquity, 22.22% dysplasia, 11.11% immaturity, 37.03% limited abduction, without any being predominant. In the exploration, the limited adduction and abduction was the main finding, 77.77%, on the opposite; the presence of the pathologic maneuvers (Klisic, Galeazzi, Ortolani, Barlow) was positive only in 2 cases. Ultrasound finding was pathologic in 37%, whereas radiography just in 1 case. The 77.77% were diagnoses in the first month of life. Conclusions: Hip pathology must be considered in neonates with newborn brachial plexus palsy, because there is a higher incidence. The abduction and abduction limited in the exploration and the ultrasound are relevant for the diagnosis, which must be done in the first month of life. Poster 376 Sleepiness After Subacute Adolescent Traumatic Brain Injury: Associations With Cognitive Performance and Executive Functioning. Marisa Osorio, DO (Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States); Dean W. Beebe, PhD, Amy Cassedy, PhD, Brad G. Kurowski, MD, MS, Shari L. Wade, PhD. Disclosures: M. Osorio, none. Objective: To (1) examine the relationship between severity of injury and parent- and self-reports of sleepiness in the first months after traumatic brain injury (TBI), and (2) evaluate the relationship between sleepiness and both self- and parent-report of executive functioning and objective measures of cognitive performance. Design: Cross-sectional data from an assessment conducted 1-6 months (mean, 15 weeks) after injury. Multiple regression analyses were used to examine the association between TBI severity and reported sleepiness, and between sleepiness and neuropsychological functioning. Participants: 106 adolescents (69 M, 37 F) ages 12-16 years (M, 14.7; SD, 1.8) with moderate-to-severe TBI (Glasgow Coma Scale, ⱕ12; n⫽58) or complicated mild TBI (Glasgow Coma Scale, ⬎12 with abnormal imaging; n⫽41). Interventions: Not applicable. Main Outcome Measures: Parent-report of youth sleepiness, Epworth Sleepiness Scale (youth report), Behavior Rating Inventory of Executive Function (self-report and parent report), Wechsler Intelligence Scale for Children (IV) processing speed, and California Verbal Learning Test (C) were administered at baseline assessment, an average of 15 weeks after injury. Results: Controlling for age and time since injury, adolescents with moderate-to-severe TBI had increased daytime somnolence compared with those with complicated mild injuries based on parent report (P⫽.01) but not based on youth self-report on the Epworth Sleepiness Scale (P⬎.05). Overall, 20% of the sample reported excessive daytime sleepiness based on an established Epworth Sleepiness Scale cutoff; this rate did not differ across TBI severity groups. Controlling for injury severity, age, and time since injury, both self- and parent-reports of sleepiness were significantly correlated with the Behavior Rating Inventory of Executive Function self-report but not parent report. Sleepiness was unrelated to California Verbal Learning Test performance or Wechsler Intelligence Scale for Children processing speed. Conclusions: A relationship between TBI severity and sleepiness
PM&R
was apparent only based on parent-report, which demonstrates the importance of using data from multiple observers in studies of TBI sequelae. The association of adolescent- and parent-report of sleepiness with self-report of poorer executive functioning suggests that sleep may be related to select aspects of functional recovery after TBI. Poster 377 Acute Postoperative Complications With Intrathecal Baclofen Pump Placement at a Regional Pediatric Specialty Hospital: A Case Series. Angela M. Sinner, DO (Gillette Children’s Specialty Healthcare, Saint Paul, MN, United States); Sarah J. Kiesling, MD, Linda E. Krach, MD. Disclosures: A. M. Sinner, none. Patients or Programs: 253 consecutive charts of individuals under age 30 undergoing intrathecal baclofen (ITB) pump primary placement or revision from 2004-2011 were reviewed. Twenty-three individuals (9%) experiencing acute postoperative complications were identified with diagnoses of quadriplegic cerebral palsy (CP) (n⫽18), triplegic CP (n⫽1), diplegic CP (n⫽2), transverse myelitis (n⫽1), and an unknown neurodegenerative disorder (n⫽1). Program Description: 22 individuals had postoperative bradycardia (n⫽13), hypotension (n⫽19), and/or bradypnea (n⫽12); 3 with epilepsy had increased seizures, 1 of these with normal vitals. Onset was 1 to 22 hours after surgery, with 1 outlier showing gradual onset of symptoms POD 2. Eight individuals required supplemental oxygen, 1 a nasal trumpet, and 1 BiPAP. Twenty subjects had their ITB dose decreased; of these, pumps of 9 were turned off. Setting: Regional pediatric specialty hospital. Results: 1 individual had an overdose due to programming error; 5 individuals received narcotics and/or benzodiazepines that contributed to their symptoms. Intraoperative medications appeared consistent with facility standards for ITB pump placement. Ten individuals had a history of pulmonary disease. The group with complications had significantly higher GMFCS levels and trended toward having pulmonary disease and/or lower weight. Discussion: A subset of subjects undergoing ITB pump surgery is at risk for sedation, bradycardia, hypotension, and bradypnea in the immediate postoperative period. These complications have not been well described in the medical literature. Anticipation of and monitoring for these complications will improve patient care. Conclusions: The complications described are multifactorial. Consideration should be given to starting with a low dose of ITB, limiting narcotics and benzodiazepines, and close monitoring for respiratory depression, particularly in children with a history of pulmonary disease, weight ⬍20 kg, and/or GMFCS 4 or 5. We recommend a low threshold for turning the ITB down or off for several hours to minimize the contribution of the baclofen. Poster 378 Functional Changes Observed During Inpatient Rehabilitation in Children With Encephalitis of Nonbacterial Origin. Yogita Tailor, DO (Sinai Hospital of Baltimore, Baltimore, MD, United States); Ellen DeMatt, Leigh Sepeta, Beth S. Slomine, PhD, Stacy J. Suskauer, MD, Melissa Trovato, MD. Disclosures: Y. Tailor, none.
Vol. 3, Iss. 10S1, 2011
S305
Objective: To understand the patterns and predictors of recovery from encephalitis of nonbacterial origin by examining functional outcomes. Design: An observational, cohort study. Setting: A pediatric inpatient rehabilitation facility in Baltimore, Maryland. Participants: Children (n⫽14) over 2 years of age who presented to a pediatric inpatient rehabilitation facility between 1996 and 2010 with presumed encephalitis of nonbacterial origin. Mean age was 10 years (range, 5-15 years). Interventions: All the patients participated in daily physical therapy, occupational therapy, and neuropsychology evaluation. Main Outcome Measures: We examined the Functional Independence Measure for Children (WeeFIM) Self-care, Mobility, Cognitive, and Total developmental functional quotient scores (DFQ, % of age-appropriate function) at admission and discharge. Results: Mean WeeFIM Total DFQ at admission was 41 (range, 15-90) and at discharge was 66 (range, 16-96). The average change in WeeFIM Total DFQ from admission to discharge was 25 (range, 0-55). At both admission and discharge, Mobility DFQs were significantly higher than Cognitive DFQs (admission, P⬍.05; discharge, P⬍.001). At discharge, mean Mobility DFQ was 74 and Cognitive DFQ was 55; 64% of children showed motor impairments, and 93% showed cognitive impairments (WeeFIM DFQ, ⬍85). Conclusions: Results suggest that recovery from encephalitis of nonbacterial origin is variable, with greater improvement in functional mobility compared with cognitive outcomes. Future research is necessary to identify predictors of outcome in encephalitis of nonbacterial origin. Poster 379 Implementation of a Program of Growth and Nutrition Surveillance With Anthropometric Measurements for Children With Cerebral Palsy. Amanda Bartos (Akron Children’s Hospital, Akron, OH, United States); Micah Baird, MD. Disclosures: A. Bartos, none. Objective: (1) To facilitate the identification of growth and nutrition problems in children with cerebral palsy by providing clinicians with accurate information through anthropometric measurements, and (2) to assess the feasibility of obtaining these data in the context of a multidisciplinary subspecialty pediatric clinic. Design: Prospective practice improvement study. Setting: Integrated multidisciplinary pediatric subspecialty clinic. Participants: 19 patients with cerebral palsy, ages 4-19. Interventions: Measurement of triceps skinfold thickness and tibial length during routine physiatry, neurology, and developmental pediatrics follow-up visits. Main Outcome Measures: Triceps skinfold thickness (mm) and estimated height and body mass index (BMI) calculated by extrapolation of measured tibial length. Results: Four patients were classified GMFCS I, 4 GMFCS II, 4 GMFCS III, 5 GMFCS IV, and 2 GMFCS V. The average BMIwas 19.6 kg/m2 (GMFCS I), 17.6 kg/m2 (GMFCS II), 18.0 kg/m2 (GMFCS III), 19.4 kg/m2 (GMFCS IV), and 13.9 kg/m2 (GMFCS V). The average triceps skinfold thickness was 19.9 mm (GMFCS I), 18.7 mm (GMFCS II), 15.4 mm (GMFCS III), 14.3 mm (GMFCS IV), and 9.4 mm (GMFCS V). The average height was 132.3 cm (GMFCS I),
Objective: To determine the incidence of unsuspected hypoxemia during sleep in adolescents and young adults with paraplegia. Design: Prospective and observational. Setting: Overnight recording of oxygen saturation (SO&2&) and heart rate performed in the subject’s home. Participants: 20 adolescents and young adults with posttraumatic ASIA A paraplegia who were ⬎1 year after spinal cord injury (SCI), with no known cardiopulmonary disease and no seizure disorder, and not on supplemental oxygen or ventilatory support. Interventions: Not applicable. Main Outcome Measures: SO2, apnea hypopnea adjusted index, body mass index (BMI), neck circumference, bradycardia, and Pittsburgh Sleep Quality Index. Results: 20 subjects (13 boys and men, and 7 girls and women) enrolled and completed the study. Age range was 13-25 years. Hypoxemia was defined as ⬍92% for at least 4 seconds. Ten of 20 (50%) had recurrent episodes of hypoxemia (mean, 82.9%⫹7.7%; range, 66%-91%) while breathing room air during sleep. The subjects were divided into those with hypoxemia episodes and those who did not have hypoxemia. Comparisons of age, gender, apnea hypopnea adjusted index, basal SO2, BMI, and time since SCI were made between the 2 groups by using paired the Student t-test and the Fisher exact test. Subjects with recurrent episodes of hypoxemia during sleep had significantly lower baseline SO2 (P⫽.01) and greater apnea hypopnea adjusted index (P⫽.03) than subjects without hypoxemia during sleep. There was no difference between the groups in age (P⫽.36), gender distribution (P⫽.35), BMI (P⫽.36), Pittsburgh Sleep Quality Index (P⫽1.0), or in time since SCI (P⫽.12).There were no episodes of bradycardia. Conclusions: Young patients with paraplegia ASIA A are at increased risk for episodes of hypoxemia during sleep. The etiology of the hypoxemia is not known. Further investigation, by using overnight polysomnography and pulmonary function testing, should be performed in this understudied population. Poster 375 Hip Pathology in Obstetric Brachial Palsy. Raquel Sánchez Fernández, MD, PhD (Hosptital Cabueaes, Oviedo, Spain); Juan Andres Conejero Casares, MD, Aida M. Lagares Alonso, Graduate. Disclosures: R. Sánchez Fernández, none. Objective: To study in newborns the association between pediatric brachial palsy and hip pathology (DDH). Hip dysplasia is associated with other neonatal pathologies. Our experience makes us consider the possibility of DDH higher incidence in patients with pediatric brachial palsy. Design: Cases series study. Setting: Association between obstetric brachial palsy and DDH. Participants: 92 newborns with obstetric brachial palsy; all the cases were seen at the hospital. Interventions: Detailed clinical analysis and diagnostic studies (ultrasound or radiography), depending on age. Previous information regarding these patients as collar bone fracture or stiff neck symptoms also were recorded. Main Outcome Measures: Frequency (percentage) of hip pathology in obstetric brachial palsy; frequency (percentage) of hip pathology types in obstetric brachial palsy; frequency (percentage) of main findings: hip clinical exploration, ultrasonic and radiologic findings.
PRESENTATIONS
Results: Of 92 cases, 29.34% had hip symptoms, without associated pathology to the hip (torticollis), 26.08%. Main hip diagnoses were: 18.51% hip pelvic obliquity, 22.22% dysplasia, 11.11% immaturity, 37.03% limited abduction, without any being predominant. In the exploration, the limited adduction and abduction was the main finding, 77.77%, on the opposite; the presence of the pathologic maneuvers (Klisic, Galeazzi, Ortolani, Barlow) was positive only in 2 cases. Ultrasound finding was pathologic in 37%, whereas radiography just in 1 case. The 77.77% were diagnoses in the first month of life. Conclusions: Hip pathology must be considered in neonates with newborn brachial plexus palsy, because there is a higher incidence. The abduction and abduction limited in the exploration and the ultrasound are relevant for the diagnosis, which must be done in the first month of life. Poster 376 Sleepiness After Subacute Adolescent Traumatic Brain Injury: Associations With Cognitive Performance and Executive Functioning. Marisa Osorio, DO (Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States); Dean W. Beebe, PhD, Amy Cassedy, PhD, Brad G. Kurowski, MD, MS, Shari L. Wade, PhD. Disclosures: M. Osorio, none. Objective: To (1) examine the relationship between severity of injury and parent- and self-reports of sleepiness in the first months after traumatic brain injury (TBI), and (2) evaluate the relationship between sleepiness and both self- and parent-report of executive functioning and objective measures of cognitive performance. Design: Cross-sectional data from an assessment conducted 1-6 months (mean, 15 weeks) after injury. Multiple regression analyses were used to examine the association between TBI severity and reported sleepiness, and between sleepiness and neuropsychological functioning. Participants: 106 adolescents (69 M, 37 F) ages 12-16 years (M, 14.7; SD, 1.8) with moderate-to-severe TBI (Glasgow Coma Scale, ⱕ12; n⫽58) or complicated mild TBI (Glasgow Coma Scale, ⬎12 with abnormal imaging; n⫽41). Interventions: Not applicable. Main Outcome Measures: Parent-report of youth sleepiness, Epworth Sleepiness Scale (youth report), Behavior Rating Inventory of Executive Function (self-report and parent report), Wechsler Intelligence Scale for Children (IV) processing speed, and California Verbal Learning Test (C) were administered at baseline assessment, an average of 15 weeks after injury. Results: Controlling for age and time since injury, adolescents with moderate-to-severe TBI had increased daytime somnolence compared with those with complicated mild injuries based on parent report (P⫽.01) but not based on youth self-report on the Epworth Sleepiness Scale (P⬎.05). Overall, 20% of the sample reported excessive daytime sleepiness based on an established Epworth Sleepiness Scale cutoff; this rate did not differ across TBI severity groups. Controlling for injury severity, age, and time since injury, both self- and parent-reports of sleepiness were significantly correlated with the Behavior Rating Inventory of Executive Function self-report but not parent report. Sleepiness was unrelated to California Verbal Learning Test performance or Wechsler Intelligence Scale for Children processing speed. Conclusions: A relationship between TBI severity and sleepiness
PM&R
was apparent only based on parent-report, which demonstrates the importance of using data from multiple observers in studies of TBI sequelae. The association of adolescent- and parent-report of sleepiness with self-report of poorer executive functioning suggests that sleep may be related to select aspects of functional recovery after TBI. Poster 377 Acute Postoperative Complications With Intrathecal Baclofen Pump Placement at a Regional Pediatric Specialty Hospital: A Case Series. Angela M. Sinner, DO (Gillette Children’s Specialty Healthcare, Saint Paul, MN, United States); Sarah J. Kiesling, MD, Linda E. Krach, MD. Disclosures: A. M. Sinner, none. Patients or Programs: 253 consecutive charts of individuals under age 30 undergoing intrathecal baclofen (ITB) pump primary placement or revision from 2004-2011 were reviewed. Twenty-three individuals (9%) experiencing acute postoperative complications were identified with diagnoses of quadriplegic cerebral palsy (CP) (n⫽18), triplegic CP (n⫽1), diplegic CP (n⫽2), transverse myelitis (n⫽1), and an unknown neurodegenerative disorder (n⫽1). Program Description: 22 individuals had postoperative bradycardia (n⫽13), hypotension (n⫽19), and/or bradypnea (n⫽12); 3 with epilepsy had increased seizures, 1 of these with normal vitals. Onset was 1 to 22 hours after surgery, with 1 outlier showing gradual onset of symptoms POD 2. Eight individuals required supplemental oxygen, 1 a nasal trumpet, and 1 BiPAP. Twenty subjects had their ITB dose decreased; of these, pumps of 9 were turned off. Setting: Regional pediatric specialty hospital. Results: 1 individual had an overdose due to programming error; 5 individuals received narcotics and/or benzodiazepines that contributed to their symptoms. Intraoperative medications appeared consistent with facility standards for ITB pump placement. Ten individuals had a history of pulmonary disease. The group with complications had significantly higher GMFCS levels and trended toward having pulmonary disease and/or lower weight. Discussion: A subset of subjects undergoing ITB pump surgery is at risk for sedation, bradycardia, hypotension, and bradypnea in the immediate postoperative period. These complications have not been well described in the medical literature. Anticipation of and monitoring for these complications will improve patient care. Conclusions: The complications described are multifactorial. Consideration should be given to starting with a low dose of ITB, limiting narcotics and benzodiazepines, and close monitoring for respiratory depression, particularly in children with a history of pulmonary disease, weight ⬍20 kg, and/or GMFCS 4 or 5. We recommend a low threshold for turning the ITB down or off for several hours to minimize the contribution of the baclofen. Poster 378 Functional Changes Observed During Inpatient Rehabilitation in Children With Encephalitis of Nonbacterial Origin. Yogita Tailor, DO (Sinai Hospital of Baltimore, Baltimore, MD, United States); Ellen DeMatt, Leigh Sepeta, Beth S. Slomine, PhD, Stacy J. Suskauer, MD, Melissa Trovato, MD. Disclosures: Y. Tailor, none.
Vol. 3, Iss. 10S1, 2011
S305
Objective: To understand the patterns and predictors of recovery from encephalitis of nonbacterial origin by examining functional outcomes. Design: An observational, cohort study. Setting: A pediatric inpatient rehabilitation facility in Baltimore, Maryland. Participants: Children (n⫽14) over 2 years of age who presented to a pediatric inpatient rehabilitation facility between 1996 and 2010 with presumed encephalitis of nonbacterial origin. Mean age was 10 years (range, 5-15 years). Interventions: All the patients participated in daily physical therapy, occupational therapy, and neuropsychology evaluation. Main Outcome Measures: We examined the Functional Independence Measure for Children (WeeFIM) Self-care, Mobility, Cognitive, and Total developmental functional quotient scores (DFQ, % of age-appropriate function) at admission and discharge. Results: Mean WeeFIM Total DFQ at admission was 41 (range, 15-90) and at discharge was 66 (range, 16-96). The average change in WeeFIM Total DFQ from admission to discharge was 25 (range, 0-55). At both admission and discharge, Mobility DFQs were significantly higher than Cognitive DFQs (admission, P⬍.05; discharge, P⬍.001). At discharge, mean Mobility DFQ was 74 and Cognitive DFQ was 55; 64% of children showed motor impairments, and 93% showed cognitive impairments (WeeFIM DFQ, ⬍85). Conclusions: Results suggest that recovery from encephalitis of nonbacterial origin is variable, with greater improvement in functional mobility compared with cognitive outcomes. Future research is necessary to identify predictors of outcome in encephalitis of nonbacterial origin. Poster 379 Implementation of a Program of Growth and Nutrition Surveillance With Anthropometric Measurements for Children With Cerebral Palsy. Amanda Bartos (Akron Children’s Hospital, Akron, OH, United States); Micah Baird, MD. Disclosures: A. Bartos, none. Objective: (1) To facilitate the identification of growth and nutrition problems in children with cerebral palsy by providing clinicians with accurate information through anthropometric measurements, and (2) to assess the feasibility of obtaining these data in the context of a multidisciplinary subspecialty pediatric clinic. Design: Prospective practice improvement study. Setting: Integrated multidisciplinary pediatric subspecialty clinic. Participants: 19 patients with cerebral palsy, ages 4-19. Interventions: Measurement of triceps skinfold thickness and tibial length during routine physiatry, neurology, and developmental pediatrics follow-up visits. Main Outcome Measures: Triceps skinfold thickness (mm) and estimated height and body mass index (BMI) calculated by extrapolation of measured tibial length. Results: Four patients were classified GMFCS I, 4 GMFCS II, 4 GMFCS III, 5 GMFCS IV, and 2 GMFCS V. The average BMIwas 19.6 kg/m2 (GMFCS I), 17.6 kg/m2 (GMFCS II), 18.0 kg/m2 (GMFCS III), 19.4 kg/m2 (GMFCS IV), and 13.9 kg/m2 (GMFCS V). The average triceps skinfold thickness was 19.9 mm (GMFCS I), 18.7 mm (GMFCS II), 15.4 mm (GMFCS III), 14.3 mm (GMFCS IV), and 9.4 mm (GMFCS V). The average height was 132.3 cm (GMFCS I),