bluuebunny/crossref_metadata_2025 huggingface dataset:
MedManage: The development of a tool to assist medication reconciliation in a rural primary care clinic
Authors: Jarrett Traci , Cochran Jill , Baus Adam , Delmar Kayla
Published: March 2019

Background:

Medication reconciliation is a critical step in the health care process to prevent hospital readmission, adverse drug events, and fall prevention. The purpose of the study was to pilot test a medication reconciliation process, MedManage, informed by the Medications at Transitions and Clinical Handoffs (MATCH) toolkit with nursing staff in a rural primary care clinic.

Methods:

The research team conducted 38 chart audits of high-risk patients, and preintervention and postintervention were conducted to assess changes in medications reported by patients. The intervention included a chart audit tool and medication reconciliation tool created by the interdisciplinary team, MedManage, were pilot tested in the clinic.

Conclusions:

The Use of MedManage resulted in improvements in patient reporting of over-the-counter (82% of patients reported previously unrecorded OTCs), PRN medications (3% unreported), and herbal supplements/vitamins (28% reported previously unrecorded vitamins).

Implications for Practice:

MedManage may be an effective tool to assist clinical nursing staff to attain a more complete and accurate medication list from patients and should be assessed more broadly across rural primary care clinics.
Assessment of Cochlear Implant Revision Surgeries in a Cohort of 802 Patients
Authors: Karamert Recep , Düzlü Mehmet , Tutar Hakan , Eravcı Fakih Cihat , Türkcan Alper Kutalmış , Zorlu Mehmet Ekrem , Uğur Mehmet Birol , Cebeci Süleyman , Bezgin Selin Üstün , Cevizci Raşit , Bayazıt Yıldırım Ahmet
Published: March 2019

Objective:

To assess the etiology, demographics, rates and outcomes of revision surgeries, and device survival rates after cochlear implantation.

Study Design:

Retrospective case review.

Setting:

Tertiary Otology & Neurotology center.

Patients:

Cochlear implantees who received revision surgeries after implantation

Interventions:

Any surgical intervention, performed due to device failure or the major complications of cochlear implantation.

Main Outcome Measure:

Medical records of the patients who received cochlear implants (CIs) between July 2002 and March 2018 were reviewed retrospectively regarding postoperative complications. Demographic data, device survival rates, and causes of revisions were recorded.

Results:

Totally, 924 implantations were performed in 802 patients. Eighty one (8.7%) of them underwent 102 revision surgeries. The most common causes of revision surgeries were device failures and flap related problems which were seen in 28 and 18 patients, respectively.

Overall CI survival rate was 91.9% in a 10 years period, which remained almost stable after 10 years. Although age was not found to be related with device failure (p = 0.693), device loss rates were significantly higher in adult implantees than children (p = 0.006).

Conclusion:

Device failure seems the most common cause of revision. The revision surgeries are usually safe and help to resolve the problem although flap problems are the most difficult to treat and may necessitate multiple revision surgeries. The device failure rate may reach to a plateau after 6 years. Overall CI survival rate exceeds 90% in 10 years period, and then remains stable.
Does Transfer to Intensive Care Units Reduce Mortality? A Comparison of an Instrumental Variables Design to Risk Adjustment
Authors: Keele Luke , Harris Steve , Grieve Richard
Published: March 2019

Background:

Instrumental variable (IV) analysis can estimate treatment effects in the presence of residual or unmeasured confounding. In settings wherein measures of baseline risk severity are unavailable, IV designs are, therefore, particularly appealing, but, where established measures of risk severity are available, it is unclear whether IV methods are preferable.

Objective:

We compared regression with an IV design to estimate the effect of intensive care unit (ICU) transfer on mortality in a study with well-established measures of risk severity.

Research Design:

We use ICU bed availability at the time of assessment for ICU transfer as an instrument. Bed availability increases the chance of ICU admission, contains little information about patient characteristics, and it is unlikely that bed availability has any direct effect on in-hospital mortality.

Subjects:

We used a cohort study of deteriorating ward patients assessed for critical care unit admission, in 49 UK National Health Service hospitals between November 1, 2010, and December 31, 2011.

Measures:

Detailed demographic, physiological, and comorbidity data were collected for all patients.

Results:

The risk adjustment methods reported that, after controlling for all measured covariates including measures of risk severity, ICU transfer was associated with higher 28-day mortality, with a risk difference of 7.2% (95% confidence interval=5.3%–9.1%). The IV estimate of ICU transfer was −5.4% (95% confidence interval=−47.1% to 36.3%) and applies to the subsample of patients whose transfer was “encouraged” by bed availability.

Conclusions:

IV estimates indicate that ICU care is beneficial but are imprecisely estimated. Risk-adjusted estimates are more precise but, even with a rich set of covariates, report that ICU care is harmful.
A Case of Congenital Anaplastic Large Cell Lymphoma in a Very Preterm Low–Birth Weight Neonate
Authors: Mathanda Reema , Nomani Laila , Ondrejka Sarah , Burdjalov Vladimir , Al-Jebwi Yasser , Rotz Seth J.
Published: March 2019

A premature infant male was born at 30 weeks’ gestation with severe coagulopathy and thrombocytopenia. Over the first days of his life, the patient developed evidence of immune hyperactivation with adenopathy, hepatosplenomegaly, and elevated ferritin. Although the patient met diagnostic criteria for hemophagocytic lymphohistiocytosis (HLH), flow cytometric based assays were not consistent with primary HLH. A lymph node and bone marrow biopsy eventually revealed the presence of anaplastic lymphoma kinase+anaplastic large cell lymphoma. To our knowledge, this is the earliest presentation of a lymphoma, and expands the known timeframe of lymphomagenesis.
Psychosocial Experiences of Young Adults Diagnosed With Acute Leukemia During Hospitalization for Induction Chemotherapy Treatment
Authors: Albrecht Tara A. , Keim-Malpass Jessica , Boyiadzis Michael , Rosenzweig Margaret
Published: March 2019

The diagnosis of cancer for anyone is a time of fear and uncertainty. For young adults (YAs) diagnosed with acute leukemia (AL), there are the additional challenges related to lengthy aggressive in-hospital treatment, multiple concurrent symptoms, and decreased well-being. The purpose of this study was to explore the experiences of YAs with AL undergoing induction chemotherapy. This study used a nested qualitative longitudinal design with a convenience sample. Qualitative data were collected using semistructured interviews, and participants were invited to maintain journals. The semistructured interviews were audiotaped, transcribed, and loaded into Atlas.ti for analysis. Common themes and categories were verified and used to disseminate the findings. Seven YAs, mean age 32 (SD, 4) years, participated in this study. Three thematic classifications emerged: getting through, supported yet isolated, and information exchange preferences, which detail how these YAs processed and coped during treatment. The findings from this study provide important insights for nurses regarding coping mechanisms that YAs apply, which included relying on technology and social media platforms. Additionally, the YAs in this study discussed their need for information. The findings from this study may provide insights for clinicians currently caring for YAs with AL, while also directing future palliative care research endeavors.
Promoting Discharge Readiness Through Staff Education
Authors: Walter Lora , Robb Meigan
Published: March 2019

Preparing parents for discharge readiness starts by arming the neonatal intensive care unit registered nurses with the knowledge and understanding of family-centered care principles. Implementation of a 30-minute educational session followed by 4 weeks of mentoring increased neonatal intensive care unit registered nurses knowledge and supported a sustainable change in professional practice. Approaches used in this quality improvement project can serve as a framework for nursing professional development specialists.
Crossing Boundaries to Advance Nursing Research Education
Authors: Cronin Sherill Nones , Berger Jill , Nelson Debbie , Romp Celeste R. , Stikes Reetta , Wishnia Gracie
Published: March 2019

Nursing professional development specialists may find it challenging time and cost-wise to meet the educational needs of nurses in the areas of research and evidence-based practice amidst competing education priorities. Furthermore, it may be difficult to find presenters with the necessary knowledge and expertise to do so. Collaboration among local hospitals to provide a high-quality research education program can advance scholarly work within the community and can help each organization meet selected Magnet® requirements in an economical way.
LGBT Cultural Competence of Acute Care Nurses
Authors: Wyckoff Elizabeth D.
Published: March 2019

This study implemented an educational intervention to increase lesbian, gay, bisexual, and transgender (LGBT) cultural competence among nurses using a pretest–posttest design. A statistically significant increase in cultural competence was identified. Once informed of the health status disparities among this demographic, nurses can influence healthcare environments and promote policies to be inclusive of lesbian, gay, bisexual, and transgender patients. Improved cultural competence through professional development can lead to decreased barriers to care.
Quantitative Analyses of the Effectiveness of a Newly Designed Preceptor Workshop
Authors: Liu Lihua , Fillipucci Denise , Mahajan Satish M.
Published: March 2019

Educational preparation for nurse preceptors helps reduce anxiety and stress in precepting. A quality improvement project was initiated in a large U.S. West Coast federal healthcare system to evaluate an existing training program for preceptors. A new 2-day preceptor workshop was subsequently created to address identified gaps. Results demonstrated statistically significant gains in preceptors’ essential knowledge and skills required in precepting, and room for improvement in faculty teaching techniques and course materials.
Clinical Staff’s Motivators and Barriers to Engagement in Health-Promoting Behaviors
Authors: Wall Whitney A. , Tucker Carolyn M. , Roncoroni Julia , Guastello Andrea A. , Arthur Tya M.
Published: March 2019

Clinical staff can promote patients’ engagement in health-promoting behaviors to prevent/treat obesity. However, some clinical staff are overweight/obese and may not model health behaviors for their patients. This cross-sectional survey study tested the hypotheses that clinical staff’s level of (1) motivators and (2) barriers to engaging in health-promoting behaviors would be significantly associated with their body mass index (BMI). Barriers were significantly correlated and motivators were not correlated with caregivers’ BMI. Implications for nurses in professional development are discussed.
Bone marrow aspirate concentrate with cancellous allograft versus iliac crest bone graft in the treatment of long bone nonunions
Authors: Lin Kenneth , VandenBerg James , Putnam Sara M. , Parks Christopher D. , Spraggs-Hughes Amanda , McAndrew Christopher M. , Ricci William M. , Gardner Michael J.
Published: March 2019

Objectives:

The purpose of this study was to compare bone marrow aspirate concentrate (BMAC) with cancellous allograft to iliac crest bone graft (ICBG) in the treatment of long bone nonunions.

Design:

Retrospective cohort study.

Setting:

A single level I trauma center.

Patients:

26 patients with long bone diaphyseal or metaphyseal nonunions with defects >2 mm and treated with open repair and BMAC, compared to 25 patients with long bone diaphyseal or metaphyseal nonunions with defects >2 mm and treated with open repair and ICBG.

Intervention:

Open repair of long bone nonunion using either autologous ICBG or BMAC with cancellous allograft.

Main outcome measure:

Nonunion healing, radiographically measured by the modified Radiographic Union Score for Tibia (mRUST) score. Secondary outcomes included risk factors associated with failed repair.

Results:

The union rates for the BMAC and ICBG cohorts were 75% and 78%, respectively (P = .8). Infection was the only risk factor of statistical significance for failure.

Conclusion:

In this study, we found no significant difference in union rate for long bone nonunions treated with ICBG or BMAC with allograft. BMAC and allograft led to 75% successful healing in this series. Given the heterogeneity of the control group and loss to follow-up, further prospective investigation should be conducted to more rigorously compare BMAC to ICBG for nonunion treatment.

Level of evidence:

III, retrospective cohort.
Acute total hip arthroplasty versus open reduction internal fixation for posterior wall acetabular fractures in middle-aged patients
Authors: MacCormick Lauren M. , Lin Carol A. , Westberg Jerald R. , Schmidt Andrew H. , Templeman David C.
Published: March 2019

Introduction:

Open reduction internal fixation (ORIF) is the standard of care for displaced acetabular fractures, but the inability to achieve anatomic reduction, involvement of the posterior wall, articular impaction, and femoral head cartilaginous injury are known to lead to poorer outcomes. Acute total hip arthroplasty (THA) is a reasonable treatment option for older patients with an acetabular fracture and risk factors for a poor outcome, but it is only described in case series. The purpose of this study is to compare outcomes of ORIF and acute THA in middle-aged patients with an acetabular fracture from a single center.

Methods:

Retrospective case-controlled study of patients aged 45 to 65 years old with acetabular fractures involving the posterior wall treated with acute THA or ORIF at a level 1 trauma center between 1996 and 2011. Patients were matched by fracture pattern and age at a 2 (ORIF):1 (acute THA) ratio. Functional outcome, complications, and reoperation rates of acute THA and ORIF were compared.

Results:

Sixteen acute THA patients (average age 56.4 years) and 32 ORIF patients (average age 54.3 years) were evaluated at an average follow-up of 6.2 years (range 1–15.2). The average Oxford Hip Score in the acute THA group was 44 compared to 40 in the ORIF group (P = .075). Complication rates were similar between both the groups. Twelve hips (37%) in the ORIF group had undergone THA or been referred for THA, and 2 revisions (13%) had occurred in the acute THA group. A Kaplan–Meier survival analysis showed that those undergoing acute THA had significantly better survival of their index procedure (P = .031).

Conclusions:

Both ORIF and acute THA for high-energy acetabular fractures involving the posterior wall in middle-aged patients can provide excellent results, with acute THA patients achieving improved survival of the index procedure and improved functional scores.
Prevalence and patterns of traumatic bone loss following open long bone fractures at Mulago Hospital
Authors: Kironde Edward , Sekimpi Patrick , Kajja Isaac , Mubiri Paul
Published: March 2019

Introduction:

Significant traumatic bone loss in developed countries occurs in a high proportion of open fractures ranging from 11.4% to 40%. However, literature from developing countries such as Uganda scarcely documents the prevalence and patterns of traumatic bone loss. Direct trauma and iatrogenic factors have been associated with traumatic bone loss as possible etiologies.

Objective:

The study was aimed at establishing the prevalence and patterns of traumatic bone loss following open long bone fractures, and identifying factors associated with traumatic bone loss among patients presenting to Mulago Hospital within 24 hours of sustaining the injury up to completion of the initial fracture debridement, reduction, and fixation.

Methodology:

It was a prospective cohort study conducted at Mulago Hospital. A total of 136 open long bone fractures were registered and physically examined for traumatic bone loss. Patients who consented were recruited consecutively to participate in the study. Data on the patients’ sociodemographics and fracture patterns were collected using pretested questionnaires and analyzed using Stata version 12.

Results:

From 123 patients, a total of 136 open long bone fractures were registered. The prevalence of traumatic bone loss following open long bone fractures was 26.5%. Of the 36 open long bone fractures with traumatic bone loss, the more common pattern (61.1%) was significant traumatic bone loss (≥ 2.5 cm long). Commercial motorcycle riders (22.0%) and traders (20.3%) were the most common occupations associated with open long bone fractures. Gunshot injuries were the leading cause of traumatic bone loss in open long bone fractures.

Conclusion:

Our setting has a high prevalence of traumatic bone loss among open long bone fractures with the majority occurring in Gustilo type IIIB injuries of the tibia. The likelihood of traumatic bone loss is higher in open fractures caused by gunshots.
3D printed titanium cages combined with the Masquelet technique for the reconstruction of segmental femoral defects
Authors: Tetsworth Kevin , Woloszyk Anna , Glatt Vaida
Published: March 2019

Introduction:

Traumatic femoral segmental bone loss is a complex clinical problem, one that often requires extreme solutions. This study examines a new treatment strategy for segmental bone loss using patient-specific 3D printed titanium cages in conjunction with the Masquelet technique.

Methods:

The study was composed of a clinical observational case series, and a basic science investigation to evaluate the biological activity of the induced membranes using histology, immunohistochemistry (IHC), and gene expression analysis. Eligible patients were: adult; post-traumatic; with segmental femoral defects; minimum follow-up 1 year; managed under a 2-stage protocol, with an interim antibiotic poly (methyl methacrylate) (PMMA) spacer. Definitive reconstruction was completed with exchange to a 3D printed custom titanium cage filled with bone graft, and stabilized with either an intramedullary (IM) nail or a lateral locked plate.

Results:

Patient-specific 3D printed titanium cages were used in 5 consecutive patients to reconstruct post-traumatic segmental femoral defects. The mean interval between stages was 100.2 days (83–119 days), the mean defect length was 14.0 cm (10.3–18.4 cm), and the mean bone defect volume measured 192.4 cc (114–292 cc). The mean length of follow-up was 21.8 months (12–33 months). There were no deep infections, fractures, nerve injuries, loss of alignment, or nonunions identified during the period of follow-up. All of the patients achieved union clinically and radiographically. Histology and IHC demonstrated a greater number of vessels, cell nuclei, and extensive staining for cluster of differentiation 68 (CD68), platelet and endothelial cell adhesion molecule 1 (PECAM-1), and vascular endothelial growth factor (VEGF) in the induced membranes compared to local fascia controls. Gene expression analysis revealed significant differential regulation of essential genes involved in inflammatory, angiogenic, and osteogenic pathways [interleukin 6 (IL-6), nuclear factor kappa B1 (NF-κB1), receptor activator of nuclear factor kappa-β ligand (RANKL), vascular endothelial growth factor A (VEGFA), angiogenin (ANG), transforming growth factor, beta 1 (TGF-β1), bone morphogenetic protein-2 (BMP-2), growth differentiation factor 5 (GDF-5), growth differentiation factor 10 (GDF-10), and runt-related transcription factor 2 (RUNX-2)] in the induced membranes.

Conclusions:

This study demonstrates that the use of a patient-specific 3D printed custom titanium cage, inserted into an induced membrane in a 2-stage protocol, can achieve very acceptable clinical outcomes in selected cases of post-traumatic femoral segmental defects. Patient-specific 3D printed titanium cages, used in conjunction with the Masquelet technique, are a promising new treatment option for managing complex trauma patients with femoral bone loss.

Level of Evidence:

Level IV (observational case series).
Prescription Drug Shortages
Authors: Donnelly Katie A. , Zocchi Mark S. , Katy Tamara A. , Fox Erin R. , Pines Jesse M. , van den Anker John N. , Mazer-Amirshahi Maryann E.
Published: March 2019

Objectives

Drug shortages have been increasing over the past 2 decades. There are limited data on drug shortages and their effect on pediatric emergency and critical care. Our objective was to describe pediatric emergency and critical care drug shortages.

Methods

Drug shortage data from January 2001 to December 2015 were obtained from the University of Utah Drug Information Services. Shortages were reviewed, identifying agents used in pediatric emergency and critical care. Shortage data were analyzed for the type of drug, formulation, shortage reason, duration, marketing status (generic vs brand name), or if it was a pediatric-friendly formulation, used for a high-acuity condition, or a single-source product. The availability of a substitute was also described.

Results

Of 1883 products on shortage, 779 were used in pediatric emergency or critical care. The annual number of shortages decreased from 2001 to 2004, but then increased, reaching a high in 2011. The median duration for resolved shortages was 7.6 months (interquartile range, 3.0–17.6 months). The most common category affected was infectious disease drugs. High-acuity agents were involved in 27% of shortages and in 11% of pediatric-friendly formulations. An alternative agent was available for 95% of drugs, yet 43% of alternatives were also affected at some time during the study period. The most common reported reason for a shortage was manufacturing problems.

Conclusions

From 2001 to 2015, drug shortages affected a substantial number of agents used in pediatric emergency and critical care. This has had implications to the medications available for use and may impact patient outcomes. Providers must be aware of current shortages and implement mitigation strategies to optimize patient care.
An Exceptional Vulvar Tumor: Myeloid Sarcoma of the Labia Majora
Authors: Ramlakhan Karishma P. , Groenendijk Floris H. , Levin Mark-David , Noorduyn Leonard A. , Kooi Sjarlot G.
Published: March 2019

Vulvar malignancies are rare and have diverse origins and presentations. The majority of these tumors are squamous cell carcinoma. An ulcerating vulvar tumor was found in a 74-yr-old woman presenting with fatigue and leukocytosis. Tumor biopsy revealed infiltration of blastoid cells from myeloid origin. Through bone marrow aspiration chronic myelomonocytic leukemia was diagnosed, of which the vulvar tumor was a rare extramedullary disease manifestation termed myeloid sarcoma. Limited palliative treatment was instated with a focus on the patient’s quality of life. Myeloid sarcoma (chloroma; granulocytic sarcoma) is a mass of myeloblasts occurring in cases of myeloid disease. Manifestations in most organ systems have been described. Presentation in gynecologic areas is reported in a few case reports, to which we now add our experience.
Caloric Intake Relative to Total Daily Energy Expenditure Using a Spinal Cord Injury–Specific Correction Factor
Authors: Farkas Gary J. , Gorgey Ashraf S. , Dolbow David R. , Berg Arthur S. , Gater David R.
Published: March 2019

Objective

The aims of the study were to evaluate the influence of level of spinal cord injury (SCI) on caloric intake relative to total daily energy expenditure (TDEE) and body composition, and to develop a SCI–specific correction factor for the TDEE estimation.

Design

Individuals with paraplegia (PARA, n = 28) and tetraplegia (TETRA, n = 13) were analyzed. Daily caloric intake, basal metabolic rate, and TDEE were obtained using dietary recall, indirect calorimetry, and prediction equations, respectively. Caloric intake and TDEE were adjusted to bodyweight. Body composition was assessed using dual-energy x-ray absorptiometry.

Results

Total caloric (PARA 1516.4 ± 548.4, TETRA 1619.1 ± 564.3 kcal/d), fat (PARA 58.6 ± 27.4, TETRA 65.8 ± 29.7 g), and protein (PARA 62.7 ± 23.2, TETRA 71.5 ± 30.9 g) intake were significantly higher in TETRA versus PARA (P < 0.05) when adjusted for bodyweight. Adjusted and unadjusted TDEE (unadjusted: PARA 1851.0 ± 405.3, TETRA 1530.4 ± 640.4 kcal/d) and basal metabolic rate (unadjusted: PARA 1516.6 ± 398.0, TETRA 1223.6 ± 390.2 kcal/d) were significantly higher in PARA versus TETRA (P < 0.05). Bone mineral content (PARA 3.17 ± 0.6, TETRA 2.71 ± 0.5 g), lean body mass (PARA 50.0 ± 8.6, TETRA 40.96 ± 8.8 kg), and regional percent body fat (PARA 36.45 ± 8.0, TETRA 41.82 ± 9.1) were different between groups (P < 0.05). The SCI–specific correction factor was 1.15.

Conclusions

A dichotomy exists in caloric intake, TDEE, and body composition among TETRA and PARA. The SCI–specific correction factor of 1.15 is a promising tool to estimate TDEE in SCI.

To Claim CME Credits

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME

CME Objectives

Upon completion of this article, the reader should be able to: (1) Understand the influence of spinal cord level of injury on energy expenditure and body composition; (2) Appreciate that equations used to estimate total daily energy expenditure overestimate energy expenditure in individuals with spinal cord injury; and (3) Understand the importance of normalizing caloric intake to bodyweight after spinal cord injury.

Level

Advanced.

Accreditation

The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Association of Academic Physiatrists designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
Assessing the Accuracy of Ultrasound-Guided Needle Placement in Sacroiliac Joint Injections
Authors: De Luigi Arthur Jason , Saini Vikramjeet , Mathur Rajat , Saini Amanpreet , Yokel Nathan
Published: March 2019

Objective

The aim of the study was to assess the accuracy of ultrasound-guided needle placement for sacroiliac joint injections.

Design

Institutional review board approval was gained for a prospective cohort study of 50 patients (N = 50). Study patients who were referred for sacroiliac joint injections for sacroiliac joint mediate pain and met inclusion/exclusion criteria were enrolled in the study. Each patient underwent needle placement with ultrasound guidance in the procedure suite. After the needle was placed with the ultrasound guidance, fluoroscopy was used to confirm correct placement via contrast injection confirming a sacroiliac joint arthrogram. The arthrogram was confirmed via the performing physician and radiologist.

Results

The placement of the needle with ultrasound guidance into the sacroiliac joint was confirmed successful in 96% (48/50) patients by fluoroscopic arthrogram. The two patients with unsuccessful arthrograms after initial placement of the needle with ultrasound were morbidly obese. There was intravascular uptake during the arthrogram of one patient who had a successful arthrogram.

Conclusions

Ultrasound-guided injection of the sacroiliac joint is successful and accurate upon confirmation of fluoroscopic arthrogram and should be used as an imaging modality for needle guidance.
Minimal Clinically Important Difference of Shoulder Outcome Measures and Diagnoses
Authors: Dabija Dominique I. , Jain Nitin B.
Published: March 2019

Objective

Patient-reported outcome scales determine response to treatment. The minimal clinically important difference of these scales is a measure of responsiveness: the smallest change in a score associated with a clinically important change to the patient. This study sought to summarize the literature on minimal clinically important difference for the most commonly reported shoulder outcome scales.

Design

A literature search of PubMed and EMBASE databases identified 193 citations, 27 of which met the inclusion/exclusion criteria.

Results

For rotator cuff tears, a minimal clinically important difference range of 9–26.9 was reported for American Shoulder and Elbow Surgeons, 8 or 10 for Constant, and 282.6–588.7 for the Western Ontario Rotator Cuff Index. For patients who underwent arthroplasty, a minimal clinically important difference range of 6.3–20.9 was reported for American Shoulder and Elbow Surgeons, 5.7–9.4 for Constant, and 14.1–20.6 for the Shoulder Pain and Disability Index. For proximal humeral fractures, a minimal clinically important difference range of 5.4–11.6 was reported for Constant and 8.1–13.0 for Disability of the Arm, Shoulder, and Hand.

Conclusions

A wide range of minimal clinically important difference values was reported for each patient population and instrument. In the future, a uniform outcome instrument and minimal clinically important difference will be useful to measure clinically meaningful change across practices and the spectrum of shoulder diagnoses.
Understanding Measures of Association
Authors: Upadhye Suneel , Alavinia Mohammad , Kumbhare Dinesh
Published: March 2019

Understanding measures of associations, how they are calculated, what they mean, and how to compare them is an important part of understanding clinical and health research. The relative risk and odds ratio are the two most common used measures of association in medical research. The appropriate use of these statistics to estimate the association between treatment or risk factor and outcome in research studies depends on the methodology and design of the study. The aim of this article was to cover basics of odds ratio and relative risk as the most important measures for the association between an exposure and an outcome. We use a clinical scenario as an example of their uses and demonstrate their calculation.
Applying the Global Trigger Tool in German Hospitals: A Pilot in Surgery and Neurosurgery
Authors: Brösterhaus Mareen , Hammer Antje , Kalina Steffen , Grau Stefan , Roeth Anjali A. , Ashmawy Hany , Groß Thomas , Binnebösel Marcel , Knoefel Wolfram Trudo , Manser Tanja
Published: March 2019

Objective

The aim of the study was to assess the feasibility and potential of the Global Trigger Tool (GTT) for identifying adverse events (AEs) in different specialties in German hospitals.

Methods

A total of 120 patient records were randomly selected from two surgical and one neurosurgery departments of three university hospitals in Germany for a period of 2 months per department between January and July 2017. The records were reviewed using an adaptation of the German version of the Institute for Healthcare Improvement GTT.

Results

Thirty-nine records (32.5%) contained at least one AE. A total of 53 AEs were found in these 39 records. The incidences of AEs were 18.9% and 35.9% in the two surgical departments and 45.3% in neurosurgery. This corresponded to AE rates of 25.5 to 72.1 per 1000 patient-days and from 25.0 to 60.0 per 100 admissions across the three departments. A total of 71.7% of all identified AEs resulted in temporary harm (category E), 26.4% in temporary harm, requiring prolonged hospitalization (category F), and 1.9% in permanent patient harm. We also identified practical challenges, such as the necessary adaptation of the GTT relative to the respective department.

Conclusions

The application of the GTT is feasible and represents an effective instrument for quality measurement when adapted to the departmental specifics. The trigger detection with the GTT is a valuable addition for proactive analyses of high-risk processes.
Virtual Surgical Planning and Three-Dimensional Printed Guide for Soft Tissue Correction in Facial Asymmetry
Authors: Arias Eduardo , Huang Yu-Hui , Zhao Linping , Seelaus Rosemary , Patel Pravin , Cohen Mimis
Published: March 2019

Fat grafting has become a well-accepted surgical modality to correct soft tissue facial defects and asymmetries with overall good results. Several techniques have been reported over the last few years to assist in improving accurate evaluation of facial defects and in the preoperative planning of the reconstruction. Such techniques include among others, computer tomography, three-dimensional (3D) photogrammetry, high resolution ultrasound, and 3D laser scanning. There are advantages and disadvantages for each technique.

With the rapid advance of 3D technologies that have become readily available to clinicians, new clinical applications continually emerge to guide and facilitate reconstructive procedures. The authors explored the possibility of fabricating a 3D printed surgical guide to define volume differences for soft tissue reconstruction in patients with facial asymmetry. The model was developed through the authors’ virtual surgical simulation and planning system that consists of computer-assisted design (CAD) and 3D printing (3DP).

Three-dimensional volumetric scans of patients’ faces were analyzed with computer-aided design to quantify areas of facial asymmetry. Surgical guides with containers defining volumetric differences were fabricated using 3D printing to identify and quantify areas of soft tissue deficiency. The 3D printed patient-specific, guides were sterilized and used by the surgeon intraoperatively to accurately mark the areas of soft deficiency. Thus, facial symmetry was achieved by fat grafting the predetermined volume differences defined in the surgical guides. A postop mask was used by the surgeon at the end of the procedure and during follow-up clinic visit to verify and evaluate accurate fat grafting placement as well as to determine areas where to add volume if needed.

This paper details the rational for the authors’ approach, outlines the technical planning and fabrication process of these patient-specific custom surgical guides with quantified volumetric containers and their intraoperative use by the surgeon. Despite the authors’ limited experience we conclude that the authors’ technique offer surgeons a precise means for accurate volumetric reconstruction of facial asymmetry.
Evolution of Full Facial Feminization Surgery: Creating the Gendered Face With an All-in-one Procedure
Authors: Raffaini Mirco , Perello Raffaella , Tremolada Carlo , Agostini Tommaso
Published: March 2019

Facial feminization surgery (FFS) has recently gained popularity to enhance the female facial profile and promote a real transformation of the male to female face in transgender patients. The term involves overlapping of the surgical procedures devoted to feminization and represents a dual and reversible procedure unique in plastic and reconstructive surgery. Indeed, FFS envisages modifications of the hard and soft tissues and is both reductive and augmentative. For these reasons, full FFS (F-FFS) is used by surgeons with special expertise in FFS. This study describes a novel approach to F-FFS performed in a single surgery and thus renamed, de facto, all-in-one and representing its most recent evolution. Forty-nine consecutive nonrandomized patients underwent FFS at a private clinical practice (Face Surgery Center, Parma, Italy) between January 2003 and December 2017. Following a retrospective review according to specific inclusion criteria, the authors identified 9 patients aged 19 to 33 years (mean age, 21 years) who underwent all-in-one F-FFS. Patients were discharged the day after surgery with written postoperative care instructions. No reports of wound infection/dehiscence or nerve/vessel damage were recorded. Patients typically returned to work within 30 days following surgery. The mean operative time was 281 minutes (range, 245–305 minutes). The evolved all-in-one F-FFS provides a further step technically (overlapping several procedures) in terms of surgical outcome (higher satisfaction rate) and reduced overall costs and low morbidity.
Combined Transverse Incision and Pouch Incision for the Correction of Medial Epicanthus
Authors: Xie Aiguo , Cao Yong , Yu Dong
Published: March 2019

Background:

The epicanthal fold is a distinct characteristic of the upper eyelid in many Asians. To achieve satisfactory results, epicanthoplasty is usually performed with double eyelid plasty and blepharoptosis. Although many surgical procedures have been reported for the elimination of epicanthal folds, such as recurrence, copious designs, conspicuous scar, and unnatural palpebral contours are challenges to the surgeon and also make patients worried.

Methods:

From June 2010 to June 2015, epicanthoplasty was performed for 236 Chinese female patients using transverse incision combined with pouch incision. The transverse straight incision was performed in new inner canthus to the original eanthal corner point, after the original inner canthus corner point was reached, the oblique parallel incision was performed along the lower eyelid, so that full subcutaneous separation was obtained on the upper and lower incision, the malpositioned isomerous orbicular muscle and thickened tissue were released and excised, so that the epicanthus skin was naturally restored, and finally the incision was sutured without tension. The extent of postoperative scarring and improvement of the epicanthal fold were evaluated after surgery. The medial canthal distance was measured preoperatively and 12 months postoperatively.

Results:

The average intercanthal distance decreased significantly from a mean of 41.68 ± 2.57 mm preoperatively to 37.14 ± 1.94 mm 12 months postoperatively (P < 0.05, paired t-test). And all patients were satisfied with the excellent aesthetic results in terms of an open medial canthus without definite recurrence, hypertrophic scarring, and other complications during the 12-month follow-up period.

Conclusion:

Epicanthoplasty with transverse incision and pouch incision is a simple and effective method for elimination epicanthal folds, resulting in a pleasant visualization, inconspicuous scar. However, its long-term effects require further study.
Effects of Bupivacaine Versus Bupivacaine Plus Dexamethasone-Soaked Nasal Packing After Endoscopic Nasal Surgery
Authors: Yayik Ahmet Murat , Yildirim Hasan , Ahiskalioglu Ali , Sakat Muhammed Sedat , Ergüney Özlem Dilara , Ahiskalioglu Elif Oral , Sulak Muhammet Mustafa , Celik Erkan Cem
Published: March 2019

Background:

The aim of this randomized prospective study was to investigate the postoperative analgesic effectiveness of bupivacaine versus bupivacaine plus dexamethasone-soaked nasal packing in patients scheduled for endoscopic nasal surgery.

Methods:

Sixty American Society of Anesthesiologists groups I and II patients aged 18 to 65 years and scheduled for endoscopic nasal surgery were assigned into 2 groups. Group B received 8 mL 0.5% bupivacaine and 2 mL saline, and group BD received 8 mL 0.5% bupivacaine and 8 mg (2 mL) dexamethasone-soaked nasal packing. In the postoperative period, 1000 mg paracetamol was administered and repeated every 6 hours. Postoperative pain scores, additional analgesia requirements and nausea-vomiting were recorded.

Results:

Postoperative pain scores were significantly lower in group BD than in group B at 1, 2, 4, 8, and 12 hours, and during tampon removal (P < 0.05), but there was no difference between the groups’ 24-hour visual analog scale scores (
P
 = 0.115). Postoperative additional analgesia use was statistically significantly higher in group B than in group BD (25/30 versus 13/30 respectively, P = 0.001). Postoperative nausea and vomiting was statistically higher in group B than in group BD (11/30 versus 4/30 respectively, P = 0.037).

Conclusion:

The addition of dexamethasone to bupivacaine via soaked nasal packing in endoscopic nasal surgery reduced postoperative pain scores, additional analgesia requirements, and PONV. The authors recommended a combination of bupivacaine plus dexamethasone-soaked nasal packing after endoscopic nasal surgery.
Language Development, Hearing Loss, and Intracranial Hypertension in Children With TWIST1-Confirmed Saethre-Chotzen Syndrome
Authors: Kilcoyne Sarah , Luscombe Carrie , Scully Paula , Jayamohan Jayaratnam , Magdum Shailendra , Wall Steven , Johnson David , Wilkie Andrew O.M.
Published: March 2019

Saethre-Chotzen syndrome (SCS) is an autosomal dominant condition defined by mutations affecting the TWIST1 gene on chromosome 7p21.1. Previous research has identified an elevated prevalence of intracranial hypertension and hearing impairment associated with this syndrome. This study aimed to investigate the influence of hearing history and presence of intracranial hypertension on language development in children with SCS.

A retrospective study note analysis was performed for all patients with a confirmed TWIST1 gene abnormality who attended the Oxford Craniofacial Unit and underwent a language assessment over a 22-year period. Intracranial pressure monitoring, hearing status, and language outcomes were examined in detail.

Thirty patients with genetically confirmed SCS and language assessment data were identified. Twenty-eight patients underwent surgical intervention; 10 presented with intracranial hypertension (5 prior to, and 5 after primary surgical intervention). Language data coinciding with the presentation of intracranial hypertension were available for 8 children. About 44% of children with intracranial hypertension presented with concurrent receptive and expressive language delay (n = 4/8). For both children (n = 2) with longitudinal language data available, the onset of intracranial hypertension reflected a concurrent decline in language skills. Audiometric data were available for 25 children, 80% (n = 20/25) had a history of hearing loss. About 50% of these had confirmed conductive hearing loss with middle ear effusion and the other 50% had presumed conductive hearing loss with middle ear effusion. About 100% of the children with available hearing data in our study had evidence of middle ear effusion in at least 1 ear. Results also indicated that 43% (n = 13/30) of the children presented with receptive and/or expressive language delay during childhood.

Given the importance of hearing for language development and the preliminary findings of a potential decline in language skills in children during periods of intracranial hypertension, regular follow-up of hearing, language, and intracranial hypertension are indicated in children with SCS.
Salvage of Exposed Microtia Cartilage Framework in a Pediatric Patient With a Preauricular Perforator Cutaneous Flap
Authors: Oliver Jeremie D. , Sharaf Basel
Published: March 2019

An 8-year-old boy with oculo-auriculo-vertebral syndrome presented to the authors’ clinic for multidisciplinary management of his condition. His congenital ear deformity included bilateral protrusion as well as atypical Microtia affecting the left side. He underwent bilateral otoplasty combined with left canaloplasty at the first stage to address prominent ears and canal atresia and. The patient underwent subsequent reconstruction of his constricted left ear with costochondral cartilage graft to address elsewhere. He presented to the authors’ clinic 2 weeks postoperatively with wound dehiscence and cartilage exposure along the scapha surface. The authors present their management strategy utilizing a preauricular pedicled perforator cutaneous flap in a staged manner with emphasis on technical details and review of available flap options for management of such complications.
Stem Cells for Bone Regeneration: Current State and Future Directions
Authors: Luby Alexandra O. , Ranganathan Kavitha , Lynn Jeremy V. , Nelson Noah S. , Donneys Alexis , Buchman Steven R.
Published: March 2019

Mesenchymal stem cells (MSCs) are capable of differentiating into osteoblasts, chondrocytes, and adipocytes, each of which is important for musculoskeletal tissue regeneration and repair. Reconstruction and healing of bony defects remains a major clinical challenge. Even as surgical practices advance, some severe cases of bone loss do not yield optimal recovery results. New techniques involving implantation of stem cells and tissue-engineered scaffolds are being developed to help improve bone and cartilage repair. The invasiveness and low yield of harvesting MSCs from the bone marrow (BMSCs) has led to the investigation of alternatives, including adipose-derived mesenchymal stem cells (ASCs). A review of the literature yielded several studies concerning the use of BMSCs and ASCs for the treatment of bone defects in both in vitro and in vivo models. Although both ASCs and BMSCs have demonstrated bone regenerative capabilities, BMSCs have outperformed ASCs in vitro. Despite these in vitro study findings, in vivo study results remain variable. Analysis of the literature seems to conclude there is no significant difference between bone regeneration using ASCs or BMSCs in vivo. Improved study design and standardization may enhance the application of these studies to patient care in the clinical setting.
Orthodontic-Orthopedic-Surgical Treatment of Syndromic Third Class: Proposal of a New Craniofacial Cephalometric Method
Authors: Coppotelli Emanuela , Incisivo Veronica , Vernucci Roberto Antonio , Mazzoli Valentina , Barbato Ersilia , Silvestri Alessandro
Published: March 2019

The management of patients suffering from class III due to syndromic craniosynostosis requires a multidisciplinary team to prevent and correct the complex clinical features related to the syndrome. Among the main clinical features, the midface hypoplasia requires surgical advancement with a rigid external distraction device. The comparison of pre- and postdistraction lateral cephalometries is often difficult in these patients, because the craniofacial advancement mobilizes the landmarks routinely used in cephalometry. Aim of this study is to evaluate occlusal, maxillary, and facial changes obtained after the midface osteodistraction using as reference the PM plane, that does not undergo postsurgical spatial modifications.

The before and after surgery lateral X-rays of 12 patients were compared to test the cephalometric protocol: 10 angles and 11 linear distances were evaluated.

The cephalometric comparison before and after osteodistractions of syndromic class III, using as reference the Enlow's PM plane, has confirmed the data present in current literature, consisting in forward and downward movements of facial middle 3rd, with clockwise rotation of the splanchnocranium and increase of the facial heights. The use of the PM plane as reference could be the solution to problems that have been an obstacle for the study of occlusal and facial changes in patients affected by craniofacial dysostosis.