10/10/2017 SYMPTOMATOLOGY OF CONCUSSION: WHAT DO WE SEE WHEN THE BRAIN BREAKS CONCUSSION: WHAT IS IT? CONCUSSION WHAT DOES CONCUSSION LOOK LIKE?

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natural history of concussion We have little, if any data on neurobiological recovery following concussion Roni Robinson, MSN, CRNP

phase with rapidly changing clinical signs and symptoms, which may reflect the underlying physiological injury in the brain.

A majority of concussions in sport occur without LOC or frank neurological signs.

neurological symptom. Concussion in Sport Group, Berlin 2017 2 5 43RD WORKING DEFINITION OF CONCUSSION WHAT DOES CONCUSSION LOOK LIKE?

awake individuals by measures of neurological and cognitive function Symptoms: worsens with increase in metabolic demands, improves

1 10/10/2017 SYMPTOMATOLOGY OF CONCUSSION: WHAT DO WE SEE WHEN THE BRAIN BREAKS CONCUSSION: WHAT IS IT? 43 working definitions of concussions; most are not evidence-based We do not define concussion neurologically We do not understand the natural history of concussion We have little, if any data on neurobiological recovery following concussion Roni Robinson, MSN, CRNP Nursing Care of Children Network 14th Annual Conference October 20, CONCUSSION Concussion is an evolving injury in the acute phase with rapidly changing clinical signs and symptoms, which may reflect the underlying physiological injury in the brain. Concussion is considered to be one of the most complex injuries in sports medicine to diagnose, assess and manage. A majority of concussions in sport occur without LOC or frank neurological signs. At present, there is no perfect diagnostic test or marker that clinicians can rely on for an immediate diagnosis of concussion in the sporting environment. Because of this evolving process, it is not possible to rule out SRC when an injury event occurs associated with a transient neurological symptom. Concussion in Sport Group, Berlin RD WORKING DEFINITION OF CONCUSSION WHAT DOES CONCUSSION LOOK LIKE? Change in brain function Following a force to the head or body May have temporary loss of consciousness, but most do not Identified in awake individuals by measures of neurological and cognitive function Symptoms: worsens with increase in metabolic demands, improves with relative rest Most people recover quickly, some don t Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces McCorey, et al., Consensus statement on concussion in sport, The 4th International Conference on Concussion in Sport held in Zurich, Br J Sports Med, March 2013 Roni Robinson,

CONCUSSION SIMPLIFIED 7 Brain shakes Inside the

Dizziness Fatigue Trouble falling asleep Sleeping

Sensitivity to light Sensitivity to noise

emotional Numbness or tingling Feeling slowed down

2 CONCUSSION SIMPLIFIED 7 Brain shakes Inside the skull CONCUSSION SIMPLIFIED Symptoms EVERY time you Increase the demands of the brain. Headache LOC Nausea Vomiting Balance problems Dizziness Fatigue Trouble falling asleep Sleeping more than usual Sleeping less than usual Drowsiness Sensitivity to light Sensitivity to noise Irritability Sadness Nervousness Feeling more emotional Numbness or tingling Feeling slowed down Feeling mentally foggy Difficulty concentrating Difficulty remembering Visual Problems 8 2

3 10/10/2017 CONCUSSION RECOVERY: WHAT DOES IT LOOK LIKE Acute Concussion: Straightforward Recovery Chronic Concussion: Protracted Recovery SYMPTOMS THAT WE SEE ACUTELY 18 3

STRAIGHTFORWARD CONCUSSION RECOVERY Initial Rest Light Cognitive Activity at Home Return to School/ Return to Learn Front

full cognitive load CONCUSSION RECOVERY TIMELINE 80-90% of Concussions Symptoms lasting < 4 weeks Symptoms resolve

10-20 % of Concussions Symptoms lasting > 4 weeks Require formal rehabilitation to recover Lasts about 4-6 months 19 The

rest Tolerates gradual resumption of cognitive & physical activities Return to learn Return to play Likely comprises

Symptoms lasting < 4 weeks Symptoms resolve 10-20 % of Concussions Symptoms lasting > 4 weeks Require formal

4 STRAIGHTFORWARD CONCUSSION RECOVERY Initial Rest Light Cognitive Activity at Home Return to School/ Return to Learn Front load academic accommodations based on deficits Scale back on school work & gradually Ramp up slowly Gradual Advance to full cognitive load CONCUSSION RECOVERY TIMELINE 80-90% of Concussions Symptoms lasting < 4 weeks Symptoms resolve spontaneously Vs % of Concussions Symptoms lasting > 4 weeks Require formal rehabilitation to recover Lasts about 4-6 months 19 The younger you are, the longer it takes to recover 22 STRAIGHTFORWARD CONCUSSION RECOVERY Responds to physical & cognitive rest Tolerates gradual resumption of cognitive & physical activities Return to learn Return to play Likely comprises 80-90% of acute pediatric & adolescent concussion Recovery by 3-4 weeks CONCUSSION RECOVERY TIMELINE 80-90% of Concussions Symptoms lasting < 4 weeks Symptoms resolve spontaneously Vs % of Concussions Symptoms lasting > 4 weeks Require formal rehabilitation to recover Lasts about 4-6 months 20 The younger you are, the longer it takes to recover 23 CONCUSSION RECOVERY: WHAT DOES IT LOOK LIKE? Chronic Concussion: Protracted Recovery Acute Concussion: Straightforward Recovery PROTRACTED RECOVERY Complex pathology of acute concussion is well established Prolonged recovery, we are not certain how to explain this pathology or why it happens Lack of biological explanations for prolonged recovery Non-specific nature of symptoms

5 10/10/2017 CONCUSSION SYMPTOMS: PROTRACTED RECOVERY CONCUSSION IN THE EVERY DAY LIFE OF A STUDENT 25 WHAT DOES HAPPEN WHEN THE BRAIN BREAKS? 28 CONCUSSION EVALUATION 26 CONCUSSION SYMPTOMS: PROTRACTED RECOVERY 29 CONCUSSION EVALUATION Vestibular exam Horizontal and vertical saccades reading and computer work Gaze Stability steady cam, running Smooth pursuits tracking Convergence/Accommodation adjusting vision to far and near

10/10/2017 Vestibular/Ocular: Headache Blurry vision Unable to track Unable to read Unable to remember

disturbance POTS WHAT DO WE SEE IN OUR KIDS?

CONCUSSION Cognitive Mood: Headache Anxious Emotional lability Sleep disturbance Depression Impulsivity

PROLONGED SYMPTOMS Modified developmental optometry evaluation Lifestyle medicine Mood Binocular

Physical Scheiman M, Wick B. Clinical Management of Binocular Vision, 4th ed.

6 10/10/2017 Vestibular/Ocular: Headache Blurry vision Unable to track Unable to read Unable to remember Unable to take notes Autonomic: Headache Light sensitivity Sound sensitivity Lightheaded Dizzy Sleep disturbance POTS WHAT DO WE SEE IN OUR KIDS? CONCUSSION SYMPTOMS CONCUSSION EVALUATION Vestibular-Ocular Autonomic 31 VISUAL/OCULOMOTOR ISSUES IN CONCUSSION Cognitive Mood: Headache Anxious Emotional lability Sleep disturbance Depression Impulsivity Nervous Sad Cognitive: Headache Memory Attention Concentration Mentally foggy Mood 34 MANAGEMENT OF PROLONGED SYMPTOMS Modified developmental optometry evaluation Lifestyle medicine Mood Binocular vision/convergence (eye teaming) Accommodation (focusing) Eye movements (saccadic function) Sleep Physical Scheiman M, Wick B. Clinical Management of Binocular Vision, 4th ed. Philadelphia, PA: Lippincott; Cognitive Vestibular 32 TAKING A CLOSER LOOK AT CONCUSSION SYMPTOMS 35 VISUAL SYMPTOMS AFTER CONCUSSION Where are the symptoms coming from? 33 Vestibular/Ocularmotor Function 36 6

VISUAL PROBLEMS Prevalence of Vision Problems: Eye

(Horizontal Gaze Stability) Normal Population Binocular

Concussion/TBI Binocular vision 30-45% Accommodation

Vertical Eye Tracking EYE TRACKING DEFICITS 38 41 EYE

DEFICITS Smooth Pursuits Chief complaint is headaches at

7 VISUAL PROBLEMS Prevalence of Vision Problems: Eye Teaming EYE TRACKING DEFICITS Vestibular Ocular Reflex (Horizontal Gaze Stability) Normal Population Binocular Vision 5% Accommodation 3% Eye movements 2% After Concussion/TBI Binocular vision 30-45% Accommodation 10-50% Eye movements 20-40% EYE TRACKING DEFICITS Vertical Eye Tracking EYE TRACKING DEFICITS EYE TRACKING DEFICITS Vertical Eye Tracking EYE TRACKING DEFICITS Smooth Pursuits Chief complaint is headaches at school Reading as been a problem Previous 3 exams were reported normal

VISION PROBLEMS FOLLOWING CONCUSSION CHOP Minds Matter Experience Cross-sectional study Objective: Determine prevalence of vision problems in children 11-17 years

8) Sex: 42% Male Sports Mechanism of Injury: 65% IMPLICATIONS ON ACADEMIC PERFORMANCE Vestibular and vision problems are prevalent after concussion and cannot be

43 46 VISION DIAGNOSES AFTER CONCUSSION Saccadic Dysfunction 9 6 5 14 4 Vestibular and vision problems are prevalent after concussion and cannot be 22 9 My eyes

8 VISION PROBLEMS FOLLOWING CONCUSSION CHOP Minds Matter Experience Cross-sectional study Objective: Determine prevalence of vision problems in children years old with a medical diagnosis of concussion Comprehensive developmental vision evaluation on 100 patients 100 patients Ages: Mean years (range, ) Sex: 42% Male Sports Mechanism of Injury: 65% IMPLICATIONS ON ACADEMIC PERFORMANCE Vestibular and vision problems are prevalent after concussion and cannot be under-appreciated VISION DIAGNOSES AFTER CONCUSSION Saccadic Dysfunction Vestibular and vision problems are prevalent after concussion and cannot be under-appreciated My eyes hurt. Accommodation Deficits Convergence Insufficiency VISION AND VESTIBULAR PROBLEMS AFTER CONCUSSION Vision Vestibular None Vestibular and vision problems are prevalent after concussion and cannot be under-appreciated. I have to read the same thing over and over again to understand it

"DUE TO MY CONCUSSION, MY EYES HAVE LOST THE MEMORY TO KEEP TRACK OF MOVING OBJECTS, SO I

prevalent after concussion and cannot be under-appreciated.

Su'a Cravens Concussion 10/2/16 49 52 BALANCE SYMPTOMS AFTER CONCUSSION Vestibular and vision

50 53 VESTIBULAR DEFICITS FOLLOWING PEDIATRIC CONCUSSION 81% with vestibular abnormality on

6 days) Longer time to return to sport (median 106 days vs.

recover neurocognitive deficits 3 or more previous concussions with greater prevalence of

9 "DUE TO MY CONCUSSION, MY EYES HAVE LOST THE MEMORY TO KEEP TRACK OF MOVING OBJECTS, SO I HAVE TO WEAR THESE [GLASSES] FOR THE REST OF MY LIFE" Vestibular and vision problems are prevalent after concussion and cannot be under-appreciated. I studied all night, and then the next day, I can t remember what I studied Redskins rookie Su'a Cravens Concussion 10/2/ BALANCE SYMPTOMS AFTER CONCUSSION Vestibular and vision problems are prevalent after concussion and cannot be under-appreciated. Vestibular Spinal Reflex It takes me longer to do the same work VESTIBULAR DEFICITS FOLLOWING PEDIATRIC CONCUSSION 81% with vestibular abnormality on initial clinical examination Longer time to return to school (median 59 days vs. 6 days) Longer time to return to sport (median 106 days vs. 29 days) Scored more poorly on initial computerized neurocognitive testing Took longer to recover neurocognitive deficits 3 or more previous concussions with greater prevalence of vestibular deficits and took longer to recover BALANCE DEFICITS Balance Testing: Vestibular Spinal Reflex Corwin DJ, et al. J Peds

BALANCE DEFICITS CHALLENGES IN THE SCHOOL ENVIRONMENT 55 58 BALANCE DEFICITS

sickness: transportation to school (bus/car) Phonophobia/ Noise: Morning Bells,

smart boards, computer screens 56 59 RETURN TO SCHOOL Challenges negotiating the

move from class to class, narrow hallways, stairs, distance to classes Visual

10 BALANCE DEFICITS CHALLENGES IN THE SCHOOL ENVIRONMENT BALANCE DEFICITS RETURN TO SCHOOL Challenges negotiating the physical school environment Motion sickness: transportation to school (bus/car) Phonophobia/ Noise: Morning Bells, Loud hallways, Cafeteria, Music class Photophobia/ Lights: Fluorescent lights, smart boards, computer screens RETURN TO SCHOOL Challenges negotiating the physical school environment Dysautonomia/ School Layout: Standing up quickly to move from class to class, narrow hallways, stairs, distance to classes Visual fatigue/ Classroom Layout: Note taking from the board, Reading small print on printouts,

CONCUSSION IN THE CLASSROOM: WHAT DO WE SEE? How does it effect learning?

"pushes through" & develops severe symptoms Highly demanding activities increase symptoms CONCUSSION IN THE CLASSROOM Attention deficits

Sleep Disturbances Headaches Tardiness Sleep Hygiene No napping in school No napping after school Melatonin EXERCISE Foggy Anxiety Memory

is slowed BUT task can be completed when student is allowed to take breaks Extended time for tests /assignments Attention Deficits Keep

Exercise Maximize sleep Nutrition/Hydration Vestibular Rehab Pacing through day Foggy Anxiety Memory Deficits Reduce cognitive load while

Library vs Music/Shop Test in quiet area Maximize sleep Nutrition/Hydr ation Address mood EXERCISE Light Sensitivity Preferential seating

11 CONCUSSION IN THE CLASSROOM: WHAT DO WE SEE? How does it effect learning? Takes longer to complete assignments Memory problems Decreased speed of learning Attention deficits Recovery can be set back when a student "pushes through" & develops severe symptoms Highly demanding activities increase symptoms CONCUSSION IN THE CLASSROOM Attention deficits How does it effect learning? Sleep Disturbances Headaches Tardiness Sleep Hygiene No napping in school No napping after school Melatonin EXERCISE Foggy Anxiety Memory Deficits Poor grades CONCUSSION IN THE CLASSROOM How does it effect learning? Memory Deficits/Recall Alternative testing Executive Function Deficits Processing is slowed BUT task can be completed when student is allowed to take breaks Extended time for tests /assignments Attention Deficits Keep student actively involved with multimodality learning CONCUSSION IN THE CLASSROOM Attention deficits How does it effect learning? Headaches Poor sleep Tardiness Mood Exercise Maximize sleep Nutrition/Hydration Vestibular Rehab Pacing through day Foggy Anxiety Memory Deficits Reduce cognitive load while prioritizing core content 62 Poor grades 65 CONCUSSION IN THE CLASSROOM How does it effect learning? Executive Function Deficits Noise Sensitivity Lunch in quiet area Library vs Music/Shop Test in quiet area Maximize sleep Nutrition/Hydr ation Address mood EXERCISE Light Sensitivity Preferential seating Hat with rim POST TRAUMATIC HEADACHES Type Migraine Tension-Type headache Chronic Causes Initial metabolic mismatch Vestibular/oculomotor dysfunction Dysautonomia Medication overuse Sleep deprived headache Mental fogginess Emotional/anxiety

HEADACHES & HOW THEY EFFECT LEARNING Inhibits concentration/focus

management with breaks Younger kids may need scheduled breaks I

ACADEMIC ADJUSTMENTS Pre-printed teachers notes (eliminates looking

Decrease reading requirements (books on tape) Extra time for tests

70 ACADEMIC/STUDENT SUPPORT IN SCHOOL WHAT HAPPENS WHEN THINGS DON

68 71 ACADEMIC/STUDENT SUPPORT IN SCHOOL Return to School Return to

12 HEADACHES & HOW THEY EFFECT LEARNING Inhibits concentration/focus Vary throughout the day noises,lights, certain tasks Symptoms management with breaks Younger kids may need scheduled breaks I have a headache. I should take a break. I can t miss more class. ACADEMIC ADJUSTMENTS Pre-printed teachers notes (eliminates looking up and down) Large print (18 font)- easier to track side to side Decrease reading requirements (books on tape) Extra time for tests & assignments Decrease crowding on a page or use reading strip ACADEMIC/STUDENT SUPPORT IN SCHOOL WHAT HAPPENS WHEN THINGS DON T GO AS PLANNED? ACADEMIC/STUDENT SUPPORT IN SCHOOL Return to School Return to Learn Physical school environmen tcognitive barriers PHYSIOLOGICAL EFFECTS: CAN WE MAKE IT WORSE? Activity Restriction Cascade

MANAGEMENT OF PROLONGED SYMPTOMS Sleep Physical Mood Vestibular Cognitive Lifestyle medicine 73 CONCUSSION RECOVERY Psychological Effects Negative effects of concussion on neurological functioning &

suggesting increased psychiatric distress among individuals with a history of concussion This is what happens when the brain breaks 76 PROLONGED CONCUSSION SYMPTOMS & THEIR EFFECTS Physiological

down Confused Foggy or Hazy Memory Loss Headache or Pressure in the Head Fuzzy or Blurry Vision Dizziness or Balance Sensitivity to Noise or Light Feeling Tired or Having no Energy Nausea or Vomiting

13 MANAGEMENT OF PROLONGED SYMPTOMS Sleep Physical Mood Vestibular Cognitive Lifestyle medicine 73 CONCUSSION RECOVERY Psychological Effects Negative effects of concussion on neurological functioning & neurocognitive performance have been well established Effects of concussion on psychiatric symptoms have received only minimal empirical attention Limited data [Mostly pro athletes] in the research suggesting increased psychiatric distress among individuals with a history of concussion This is what happens when the brain breaks 76 PROLONGED CONCUSSION SYMPTOMS & THEIR EFFECTS Physiological symptoms worsen COMMON SYMPTOMS OF CONCUSSION Thinking Physical Emotional Sleep Psychological symptoms worsen Difficulty: Thinking Clearly Concentrating Remembering New Information Feeling: Slowed down Confused Foggy or Hazy Memory Loss Headache or Pressure in the Head Fuzzy or Blurry Vision Dizziness or Balance Sensitivity to Noise or Light Feeling Tired or Having no Energy Nausea or Vomiting Irritability or Apathetic Sadness More Emotional than Usual Nervousness or Anxiety Not Feeling Right or Feeling Down Sleeping Habits: More Than Usual Less Than Usual Trouble Falling Asleep or Staying Asleep COMMON SYMPTOMS OF DEPRESSION Thinking Physical Emotional Sleep Difficulty: Thinking Clearly Concentrating Remembering New Information Feeling: Slowed down Confused Foggy or Hazy Memory Loss Headache or Pressure in the Head Fuzzy or Blurry Vision Dizziness or Balance Sensitivity to Noise or Light Feeling Tired or Having no Energy Nausea or Vomiting Irritability or Apathetic Sadness More Emotional than Usual Nervousness or Anxiety Not Feeling Right or Feeling Down Sleeping Habits: More Than Usual Less Than Usual Trouble Falling Asleep or Staying Asleep

WHEN THE BRAIN BREAKS Factors associated with risk of prolonged concussion also increase risk of depression Sequelae of concussion also increase risk of depression Lifestyle change

Frustrations with cognitive limitations 79 82 ARE THERE LASTING IMPACTS TO THE BRAIN?

damage as much as big ones, widening the field of concern to young athletes, hockey players and soldiers subject to head-rattling blasts.

and went on to suffer 2 more head injuries Hospitalized 3 more times for aggressive behavior (all while supports/aba plan getting worked out) Family stressors Normal exam in our office; but

McKee, Boston University/Bedford Veterans Hospital, 2011 80 83 CONCUSSION AND BEHAVIORAL HEALTH 3-fold increase elevation of mood changes Depression Suicide Risk is increased almost

14 WHEN THE BRAIN BREAKS Factors associated with risk of prolonged concussion also increase risk of depression Sequelae of concussion also increase risk of depression Lifestyle change Cognitive changes Sleep disturbances Headaches/pain Loss of their ideal self Alterations in Cognitive Processing: Greater impulsivity Poorer problem-solving Greater emotional lability Frustrations with cognitive limitations ARE THERE LASTING IMPACTS TO THE BRAIN? Emergence of research linking head collisions with behavioral and cognitive changes Brain degeneration from repeated blows to the head Recent research indicates that small impacts can cause damage as much as big ones, widening the field of concern to young athletes, hockey players and soldiers subject to head-rattling blasts. CASE STUDY: AUTISM 11 yo male Hospitalized for aggressive behavior after minor head injury in school Diagnosis of ASD (high functioning) made 1 year history of behavior changes Discharged and went on to suffer 2 more head injuries Hospitalized 3 more times for aggressive behavior (all while supports/aba plan getting worked out) Family stressors Normal exam in our office; but struggling in every day life/school worsening behaviors Unable to do vestibular therapy worsening behaviors Photographs by Ann C. McKee, Boston University/Bedford Veterans Hospital, CONCUSSION AND BEHAVIORAL HEALTH 3-fold increase elevation of mood changes Depression Suicide Risk is increased almost immediately and can persist over long-term Although more severe TBI has greater risk for suicide, the risk from concussion is substantial; multiple concussions also at greater risk Premorbid disorder may predispose to concussion CASE STUDY: AUTISM History of ASD (high functioning) 1 st concussion June 2017 Behavioral health emergency SI repeat head injury CHOP ED Strong family dynamics Evaluation in our office

10/10/2017 A SINGLE CONCUSSION CAN HAVE LASTING EFFECTS CASE STUDY: DEAF 15 yo deaf since birth cochlear implants Low mechanism of

refused to wear cochlear implants CHOP ED (1.

Clinic Background Traumatic brain injury (TBI) is the leading cause of disability and mortality in children and young adults

It remains unclear, however, how TBI in childhood and adolescence is associated with adult mortality, psychiatric morbidity, and

Conclusions Given our findings, which indicate potentially causal effects between TBI exposure in childhood and later impairments

should be targeted at children and adolescents.

impaired adult functioning including: psych diagnosis, lower education, and govt aid Sariaslan, 2016, PLOS 85 88 CASE STUDY:

Confused, disoriented, dizzy PID#1 PCP diagnosed with Syncopal episode Increased Has, not feeling right PID#7 PCP diagnosed with

15 10/10/2017 A SINGLE CONCUSSION CAN HAVE LASTING EFFECTS CASE STUDY: DEAF 15 yo deaf since birth cochlear implants Low mechanism of injury at school Didn t think much of it, having headaches Few days later started having pings in her head, nausea, headache refused to wear cochlear implants CHOP ED (1.5 weeks post injury) eval cochlear implants, CT head IU worker mentions something about head trauma Discharged and eval in Trauma Clinic Background Traumatic brain injury (TBI) is the leading cause of disability and mortality in children and young adults worldwide. It remains unclear, however, how TBI in childhood and adolescence is associated with adult mortality, psychiatric morbidity, and social outcomes. Conclusions Given our findings, which indicate potentially causal effects between TBI exposure in childhood and later impairments across a range of health and social outcomes, age-sensitive clinical guidelines should be considered and preventive strategies should be targeted at children and adolescents. Population based registry in Sweden 9% who suffered TBI before 25 yo 77% mtbi/concussion 12 % recurrent injuries Increased risk of impaired adult functioning including: psych diagnosis, lower education, and govt aid Sariaslan, 2016, PLOS CASE STUDY: BEHAVIORAL HEALTH 17 yo female, PMHx PANDAS, Suicide attempt, AMPS, Tic disorder, syncompe Syncopal episode at school with LOC Confused, disoriented, dizzy PID#1 PCP diagnosed with Syncopal episode Increased Has, not feeling right PID#7 PCP diagnosed with headach 86 CASE STUDY: BEHAVIORAL HEALTH 1. Not looking for these PID#9 Psychiatrist due to worsening mood issues, self harm, depression. MD concern for concussion referral to Trauma PID #10 Diagnosis of concussion deficits Pre-determined bias Misconceptions & stereotypes toward mental health disease Wrong diagnosis Wrong treatment Delay of correct treatment Worsening of psychiatric symptoms Prolonged recovery 87 Practical Content Families Schools Coaches Clinicians Downloads Infographics Posters Fact sheets Video FAQ 90 15

Disclosures. General Public s Knowledge on Concussion. Learning Objectives. How Much Do We Know About Symptoms?

Disclosures. General Public s Knowledge on Concussion. Learning Objectives. How Much Do We Know About Symptoms? 39 th National Conference on Pediatric Health Care March 19-22, 2018 CHICAGO 306: Anxiety and Depression After Concussion Disclosures I have no relevant disclosures. Roni Lynn Robinson, RN, MSN, CRNP Minds