The Coding Impact of Acute Kidney Injury in Pediatric Hospital Documentation

BACKGROUND

Acute kidney injury (AKI) increases patient morbidity and mortality. In value-based care, the documented and coded diagnoses during hospitalization influences an encounter's relative weight (RW), including severity of illness (SOI), and risk of mortality, which ultimately determines reimbursement for care. The impact of a secondary diagnosis of AKI on RW in pediatric patients has not been evaluated.

METHODS

A single-center, retrospective observational study was conducted over six months. The institutional coding database was queried for secondary diagnoses signifying AKI. The RW for each case was determined with and without an AKI secondary diagnosis. Patients were further stratified by their SOI score to evaluate change in RW and SOI.

RESULTS

Over a six-month period, 372 patients had a secondary AKI diagnosis, with a mean RW 2.14 decreasing to a mean RW 1.83 without an AKI diagnosis (p = 2.2e-16). When stratified by SOI, one patient had SOI 1 with RW change -0.286; six patients had SOI 2 with mean RW change -0.0669; 189 patients had SOI 3 with mean RW change -1.862 (p=2.23E-16); and 176 patients had SOI 4 with mean RW change -0.452 (p=9.46E-14), when the AKI secondary diagnosis was removed.

CONCLUSIONS

Significant negative changes in RW were observed when AKI was removed, suggesting diagnostic omission may result in inaccurately lesser representation of patient medical complexity and severity of illness upon hospitalization coding, which may lower reimbursement.

Therapeutic Effects of an Anti-Gravity Treadmill (AlterG) Training on Neuromuscular Abnormalities Associated with Spasticity in Children with Cerebral Palsy

We aimed to characterize the therapeutic effects of Anti-Gravity Treadmill (AlterG) Training on neuromuscular abnormalities associated with spasticity in children with cerebral palsy (CP). Eighteen subjects were divided into two groups; AlterG and control. All subjects received up to 40 minutes of training 3 times a week for 8 weeks. The control group received conventional occupational therapy. The advanced parallel-cascade system identification technique was used to characterize the neuromuscular abnormalities associated with spasticity and separated its intrinsic and reflex components. Reflex stiffness gain (GR) and intrinsic stiffness gain (K) were used to track the therapeutic effects of training on neural and muscular abnormalities. Both K and GR were strongly positioned dependent; they varied linearly with the ankle angle at dorsiflexion. Their position dependence was quantified by fitting a linear model to K and GR over dorsiflexion positions. The evaluations were performed at four-time points; i.e. the baseline (before starting the training), 1 and 2 months after starting the training, and 1 month after the completion of the training to assess the persistent effects. We determined the changes in K and GR intercept and slope parameters over these 3 months to evaluate the therapeutic effects of training on neuromuscular abnormalities. The results revealed that all K and GR parameters decreased substantially following using AlterG training and these changes were greater than those observed in the control. The results also showed that these therapeutic effects were persistent to a high extent, particularly in the AlterG group. Our findings suggested that AlterG training could be considered as a robust therapeutic intervention to reduce neuromuscular abnormalities and manage spasticity.

The Therapeutic Effects of Low-Amplitude, High-Frequency Perturbations on Neuromuscular Abnormalities Associated with Spasticity in Children with Cerebral Palsy

We aimed to investigate the impact of ankle joint therapy with low-amplitude, high-frequency perturbation training on neuromuscular abnormalities associated with spasticity in children with Cerebral Palsy (CP). Four spastic CP children (2 males and 2 females) received a 10-session training of high-frequency and low-amplitude perturbations superimposed on passive stretches over the range of motion of their ankle as well as local perturbations at dorsiflexion position. The associated passive parameters, including total passive range of motions, passive range of motions toward dorsiflexion, stiffness, energy loss and torque dynamic gain were evaluated at the baseline and after a 10 session training. Our findings indicate that passive range of motion increased, and passive reflex stiffness, which usually increases in CP children, decreased following the completion of training. Our results demonstrate that intensive sessions of perturbation therapy could be considered an effective therapeutic mean for the management of spasticity and contracture, and eventually the enhancement of mobility of CP children.

Does repetitive Transcranial Magnetic Stimulation (rTMS) have therapeutic effects on Dynamic Balance of Children with Cerebral Palsy?. Annu Int Conf IEEE Eng Med Biol Soc 2020;2019:425-428. [PMID: 31945929 DOI: 10.1109/embc.2019.8857947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Our big goal in this research was to evaluate the therapeutic effects of repetitive Transcranial Magnetic Stimulation (rTMS) on cerebral palsy (CP) children with balance deficits. Four spastic hemiplegic CP children were participated; the experimental group received rTMS training 4 days a week for 3 weeks and then for the next 3 weeks they received typical occupational therapy just after rTMS therapy. The control group received placebo rTMS instead of real one accordingly. Their dynamic balance was evaluated before the start of the treatment and 6 weeks after it. Center of pressure (COP) and center of mass (COM) features were regarded as dynamic balance parameters. Our results showed that the peak to peak of COP, COM, COM-COP, COM-COP inclination angles all improved for both experimental (15-86%) and control group patients, though there was less improvement about 8-46% in features of the control patients. Our results demonstrate that intensive sessions of the rTMS training could have the potential to enhance the therapeutic effects of typical occupational therapy that can produce dynamic balance improvements in CP children compared to using the occupational therapy by itself.

Impact of anti-gravity locomotion (AlterG) training on structure and function of corticospinal tract and gait in children with cerebral palsy

We aimed to characterize the impact of anti-gravity locomotion training on the structure and function of the corticospinal tract (CST) in cerebral palsy (CP). Fourteen CP children participated. Nine children were trained with an antigravity treadmill (Alter-G) and five children received occupational therapy (OT). Treatments were provided for 45 min each session, 3 sessions per week for 8 weeks. Diffusion tensor imaging (DTI) was used, and fractional anisotropy (FA), mean diffusivity (MD), radial (RD) and axial (AD) diffusivity was extracted to characterize the structure of the CST. Transcranial magnetic stimulation (TMS) was used and threshold, latency, and peak-peak amplitude of the MEP signal, elicited by the TMS, were used to quantify the function of the CST. Walking ability was evaluated by measuring gait speed, endurance, balance, and mobility. The evaluations were performed before and after the interventions. The results showed that FA improved in both sides of the brain for the AlterG group, but enhanced only in the less affected side of the OT group. MD, RD, and AD mostly improved in the more affected side of the AlterG group. The enhancement of the CST function was similar in both groups. Walking speed and endurance also enhanced in both groups, but the improvement was greater in the AlterG group. Our findings demonstrate that AlterG training can improve gait ability, and simultaneously result in brain neuroplasticity. The clinical implication is that AlterG training can be used as an effective rehabilitation approach to improve gait persistently.

The Effects of Repetitive Transcranial Magnetic Stimulation (rTMS) on Balance Control in Children with Cerebral Palsy

Cerebral palsy (CP) is a neurological disorder which can result in balance and mobility impairments. Four children with spastic CP participated and randomly assigned to experimental and control groups. The experimental group received 1-Hz repetitive Transcranial Magnetic Stimulation (rTMS) four times a week for 3 weeks, and the control group received sham rTMS using the similar experimental protocol. Each rTMS session lasted for 20 minutes. Postural balance was quantified by analyzing the center of pressure (COP) signal of a force plate according to the Romberg test. The balance was also evaluated using the Berg Balance Scale (BBS). The evaluations were done before and after the treatment. COP signal features showed up to 70% improvement following rTMS treatment, whereas there was no notable improvements in the control group. Similarly the BBS assessment presented balance enhancement only in the experimental group. These results, particularly under closed eye foam condition may imply an improvement in proprioception system.Our findings suggested that rTMS has a potential to be used as a therapeutic method to improve postural balance in children with CP.

The impact of AlterG training on balance and structure of vestibulospinal tract in cerebral palsy children

We aimed to investigate the effects of an antigravity treadmill (AlterG) on the balance and structure of the vestibulospinal tract. The AlterG can reduce the weightbearing of patients and hence can facilitate their locomotion. Three children with cerebral palsy (CP) received AlterG training three days per week for eight weeks with each session lasting 45 minutes. The balance of children was evaluated using the Berg balance test and the Timed Up and Go (TUG) test. The diffusion tensor imaging (DTI) method was employed to quantify changes of the structure of the vestibulospinal tract. Evaluations were performed before and after the 8-week training. DTI metrics including fractional anisotropy (FA), mean diffusivity (MD), radial diffusivity (RD) and axial diffusivity (AD) were measured to evaluate the vestibulospinal tract structure. The results showed that the mean FA of the vestibulospinal tract increased and other metrics decreased for all subjects. Our findings indicated that the balance and structure of the vestibulospinal tract were improved up to 30% for all children following the 8-week AlterG training. This indicates that the balance improvement of the CP children following the AlterG training was accompanied with persistent neuroplasticity in their brain. The clinical implication is that the AlterG training has a potential to be used as an effective therapeutic tool for the treatment of balance impairment in CP children.

The Effects of Low Frequency Repetitive Transcranial Magnetic Stimulation on White Matter Structural Connectivity in Children with Cerebral Palsy

Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive treatment technique for recovery of movement disorders by altering cortical plasticity. In this research, we studied the effects of low-frequency rTMS on white matter (WM) structural connectivity and clinical parameters in children with cerebral palsy (CP).,Four spastic hemiplegic CP children were randomly divided into experimental and control groups. In the experimental group, at first, 1Hz rTMS treatment was performed 4 days/week for 3 weeks on two hemiplegia patients over a contralesional primary motor cortex (M1). Then, 1Hz rTMS treatment was performed 4 days/week for 3 weeks followed by a 30min occupational therapy (OT). In the control group, two CP children received sham rTMS for 3 weeks and then sham rTMS combined with OT for 3 weeks in the same schedule as the experimental group. Evaluations performed using diffusion tensor imaging (DTI), and clinical measurements of gait performance before and after the treatment. Graph theoretical analysis was used to characterize topological changes of structural connectivity. Our findings demonstrate the 1Hz rTMS is effective in improving motor activity in spastic hemiplegic CP children, and is more effective when combined with OT.

Pendulum test measure correlates with gait parameters in children with cerebral palsy

Individuals with cerebral palsy (CP) usually suffer from different impairments including gait impairment and spasticity. Spastic hypertonia is a defining feature of spasticity and manifests as a mechanical abnormality. The objective of this study was to determine the relationship between spastic hypertonia and gait impairments in spastic children with CP, addressing an important controversial issue. Spastic hypertonia was quantified using the pendulum test. The gait impairments were evaluated using the motion capture system in a gait laboratory. Our results showed significant correlations among gait parameters; i.e. walking speed, step length, and the pendulum test measures. This indicates that neuromuscular abnormalities are associated with spasticity and may contribute to gait impairments. The clinical implication is that the impaired gait in children with CP may be improved with the treatment of neuromuscular abnormalities.

Therapeutic effects of anti-gravity treadmill (AlterG) training on reflex hyper-excitability, corticospinal tract activities, and muscle stiffness in children with cerebral palsy

We aimed to study therapeutic effects of antigravity treadmill (AlterG) training on reflex hyper-excitability, muscle stiffness, and corticospinal tract (CST) function in children with spastic hemiplegic cerebral palsy (CP). Three children received AlterG training 3 days per week for 8 weeks as experimental group. Each session lasted 45 minutes. One child as control group received typical occupational therapy for the same amount of time. We evaluated hyper-excitability of lower limb muscles by H-reflex response. We quantified muscle stiffness by sonoelastography images of the affected muscles. We quantified CST activity by transcranial magnetic stimulation (TMS). We performed the evaluations before and after training for both groups. H response latency and maximum M-wave amplitude were improved in experimental group after training compared to control group. Two children of experimental group had TMS response. Major parameters of TMS (i.e. peak-to-peak amplitude of motor evoked potential (MEP), latency of MEP, cortical silent period, and intensity of pulse) improved for both of them. Three parameters of texture analysis of sonoelastography images were improved for experimental group (i.e. contrast, entropy, and shear wave velocity). These findings indicate that AlterG training can improve reflexes, muscle stiffness, and CST activity in children with spastic hemiplegic CP and can be considered as a therapeutic tool to improve neuromuscular abnormalities occurring secondary to CP.

Recombinase polymerase amplification-based assay to diagnose Giardia in stool samples

Giardia duodenalis is one of the most commonly identified parasites in stool samples. Although relatively easy to treat, giardiasis can be difficult to detect as it presents similar to other diarrheal diseases. Here, we present a recombinase polymerase amplification-based Giardia (RPAG) assay to detect the presence of Giardia in stool samples. The RPAG assay was characterized on the bench top using stool samples spiked with Giardia cysts where it showed a limit-of-detection nearly as low as the gold standard polymerase chain reaction assay. The RPAG assay was then tested in the highlands of Peru on 104 stool samples collected from the surrounding communities where it showed 73% sensitivity and 95% specificity against a polymerase chain reaction and microscopy composite gold standard. Further improvements in clinical sensitivity will be needed for the RPAG assay to have clinical relevance.

Nucleic acid test to diagnose cryptosporidiosis: lab assessment in animal and patient specimens

Diarrheal diseases cause more morbidity and mortality around the world than human immunodeficiency virus (HIV), malaria, or tuberculosis. Given that effective treatment of persistent diarrheal illness requires knowledge of the causative organism, diagnostic tests are of paramount importance. The protozoan parasites of the genus Cryptosporidium are increasingly recognized to be responsible for a significant portion of diarrhea morbidity. We present a novel nucleic acid test to detect the presence of Cryptosporidium species in DNA extracted from stool samples. The assay uses the isothermal amplification technique recombinase polymerase amplification (RPA) to amplify trace amounts of pathogen DNA extracted from stool to detectable levels in 30 min; products are then detected visually on simple lateral flow strips. The RPA-based Cryptosporidium assay (RPAC assay) was developed and optimized using DNA from human stool samples spiked with pathogen. It was then tested using DNA extracted from the stool of infected mice where it correctly identified the presence or absence of 27 out of 28 stool samples. It was finally tested using DNA extracted from the stool of infected patients where it correctly identified the presence or absence of 21 out of 21 stool samples. The assay was integrated into a foldable, paper and plastic device that enables DNA amplification with only the use of pipets, pipet tips, and a heater. The performance of the integrated assay is comparable to or better than polymerase chain reaction (PCR), without requiring the use of thermal cycling equipment. This platform can easily be adapted to detect DNA from multiple pathogens.

A novel calcium-dependent protein kinase inhibitor as a lead compound for treating cryptosporidiosis

Cryptosporidium parasites infect intestinal cells, causing cryptosporidiosis. Despite its high morbidity and association with stunting in the developing world, current therapies for cryptosporidiosis have limited efficacy. Calcium-dependent protein kinases (CDPKs) are essential enzymes in the biology of protozoan parasites. CDPK1 was cloned from the genome of Cryptosporidium parvum, and potent and specific inhibitors have been developed based on structural studies. In this study, we evaluated the anti-Cryptosporidium activity of a novel CDPK1 inhibitor, 1294, and demonstrated that 1294 significantly reduces parasite infection in vitro, with a half maximal effective concentration of 100 nM. Pharmacokinetic studies revealed that 1294 is well absorbed, with a half-life supporting daily administration. Oral therapy with 1294 eliminated Cryptosporidium parasites from 6 of 7 infected severe combined immunodeficiency-beige mice, and the parasites did not recur in these immunosuppressed mice. Mice treated with 1294 had less epithelial damage, corresponding to less apoptosis. Thus, 1294 is an important lead for the development of drugs for treatment of cryptosporidiosis.

Growth hormone treatment in a girl with Prader Willi syndrome

Prader Willi syndrome (PWS) is a rare endocrine-metabolic disorder that is characterised by neonatal hypotonia, hyperphagia, marked obesity, short stature, hypogonadism and behavioural problems. 7-20% percent of these children develop diabetes mellitus. A large number of individuals with PWS show growth hormone (GH) deficiency. Recent studies indicate beneficial effects of GH replacement therapy not only for their linear growth but also for correction of metabolic dysfunction. In the present communication this article details about the therapeutic outcome in a girl with PWS who received recombinant growth hormone (rGH), Genotropin. Some carry-over therapeutic benefits have been observed even after discontinuation of rGH.

The application of a lentiviral vector for gene transfer in fetal human hepatocytes

BACKGROUND

The applications of traditional retroviral vectors are limited because proviral integrations into the host genome require DNA synthesis. Lentiviruses are considered to be advantageous because of their ability to infect non-dividing cells.

METHODS

To demonstrate the potential of lentiviral vectors, we used a human immunodeficiency virus (HIV)-1 virus encoding the green fluorescence protein (GFP) to infect fetal human hepatocytes. GFP-expressing cells were transplanted into the liver of Balb/C SCID mice via intrasplenic injection.

RESULTS

Primary fetal hepatocytes incorporated the GFP reporter with high (30-40%) efficiency. A cell line derived from human fetal liver (HFL) exhibited similar transduction efficiency to the lentiviral vector. To demonstrate the relationship between lentiviral gene transfer and cell proliferation, cells were subjected to gamma-irradiation, which attenuated the replication of primary fetal hepatocytes. However, lentiviral gene transfer was unaffected by this decrease in cell proliferation. GFP expression in transduced cells was preserved during multiple passages in cell culture. When GFP-expressing cells were transplanted into the liver of Balb/C SCID mice via intrasplenic injection, GFP expression was observed throughout the 3 week duration of the study.

CONCLUSION

These studies establish that human hepatocytes are amenable to lentiviral gene transfer with sustained transgene expression. Incorporation of lentiviral vectors will be helpful in testing strategies for hepatic gene therapy.