bluuebunny/crossref_metadata_2025 huggingface dataset:
Preventing Pressure Injuries in Neonates Undergoing Therapeutic Hypothermia for Hypoxic-Ischemic Encephalopathy
Authors: Luton Alexandra , Hernandez Jae , Patterson Clive “Robert” , Nielsen-Farrell Jill , Thompson Anita , Kaiser Jeffrey R.
Published: February 2017

Background:

Hospital-acquired pressure injuries (HAPIs) can be caused by multiple factors including pressure, shear, friction, moisture/incontinence, device-related pressure, immobility, inactivity, and nutritional deficits. Along with immobility, medical device-related (MDR) HAPIs are a primary cause of pressure injury in neonates, as the clinical practice setting has become increasingly technologically advanced. It is estimated that up to 50% of HAPIs are MDR in pediatric patients. Neonates are at particular risk for HAPI because of their specific anatomical, physiological, and developmental vulnerabilities. A specific example of confluent factors that may increase risk for HAPI is the application of therapeutic hypothermia (TH) and continuous electroencephalography monitoring for neonates with hypoxic-ischemic encephalopathy (HIE).

Interventions:

An interprofessional team collaborated to expand upon existing evidence-based standards of care to address the needs of this specific population within the neonatal intensive care unit (NICU). Interventions centered on revision of current protocols, with efforts to optimize product selection, hardwire assessment practices, and refine documentation of patient care and outcomes.

Methods:

The team primarily utilized plan-do-study-act (PDSA) cycles to test and refine specific methods and strategies to reduce HAPIs. Tested solutions were adopted, adapted, or abandoned.

Results:

A sustained zero HAPI rate in the HIE population resulted. The team continues to collect, report, and utilize near-miss data to continue to refine the process as new risks are identified.

Implications for Practice:

Recognizing the unique skin protection needs of special populations within the NICU, such as those undergoing TH, is crucial. When evidence-based standards of care fail to adequately meet such needs, a collaborative approach to identifying, testing, and implementing population-specific solutions is essential.

Implications for Research:

A paucity of literature regarding the unique skin protection needs for babies undergoing TH exists. Work should be done to better describe the influence of TH on skin integrity, with the goal of identifying population-specific protective measures.
Neonatal Resuscitation Program Rolling Refresher
Authors: Cepeda Brito Jose R. , Hughes Patrick G. , Firestone Kimberly S. , Ortiz Figueroa Fabiana , Johnson Karan , Ruthenburg Terra , McKinney Robyn , Gothard M. David , Ahmed Rami
Published: February 2017

Background:

Structured training courses have shown to improve patient outcomes; however, guidelines are inconsistently applied in up to 50% of all neonatal resuscitations. This is partly due to the fact that psychomotor skills needed for resuscitation decay within 6 months to a year from the completion of a certification course. Currently, there are no recommendations on how often refresher training should occur to prevent skill decay.

Purpose:

Improve provider proficiency and confidence in the performance of neonatal resuscitation with a focus on chest compression effectiveness.

Methods:

The study recruited neonatal intensive care unit providers (n = 25). A simulation-based Neonatal Resuscitation Program (NRP) curriculum was developed and executed. Training sessions were delivered utilizing in situ simulations at varying time intervals. Pre- and postconfidence surveys and practicum skill scores were collected and evaluated by a content expert. Categorical data were summarized by frequency and percentage and tested for distributional equality via Pearson chi-square tests or Fisher exact tests depending on cell sample size distribution. All statistical tests were 2-sided with P < .05 considered statistically significant.

Results:

Provider overall confidence and rate of chest compressions improved; however, there was no statistically significant difference between groups. Rolling refresher training at varied time intervals did not demonstrate statistically significant differences in chest compression quality among NRP providers.

Implications for Practice:

Rolling refresher training more frequently than every 6 months may not provide added benefit to NRP providers.

Implications for Research:

Additional research is needed to determine optimal refresher training frequency to prevent skill decay.
Reconstruction of Symptomatic Congenital Anterior Cruciate Ligament Insufficiency
Authors: Sachleben Brant C. , Nasreddine Adam Y. , Nepple Jeffrey J. , Tepolt Frances A. , Kasser James R. , Kocher Mininder S.
Published: February 2017

Background:

Hypoplasia or congenital absence of the anterior cruciate ligament (ACL) is a rare disorder occurring in ∼1 in every 6000 births. Although some patients with hypoplasia or agenesis of the ACL may not complain of instability, others desire to participate in more demanding activities that require the stability of a competent ACL. There are limited reports of surgical treatment of this patient population. The purpose of this study was to report ACL reconstruction in a case series of patients with symptomatic congenital ACL deficiency.

Methods:

A retrospective medical record review of the surgical treatment of 14 knees (13 patients) with congenital absence of the ACL at a tertiary care institution from 1995 to 2012 was performed. Patients with a minimum of 1 year of clinical follow-up were eligible for inclusion.

Results:

The mean age at time of surgery was 12.6 (range, 3 to 22), including 6 patients <12 years of age. Mean follow-up was 2.9 years (range, 1 to 6.6). Nine of 13 patients (69%) had underlying congenital abnormalities/associated syndromes. Preoperative Lachman and pivot shift examination was International Knee Documentation Committee grade C or D in all but 1 knee. ACL reconstruction was performed with combined intra-articular/extra-articular physeal sparing reconstruction with iliotibial band (n=5), autograft hamstring (n=2) or bone-patellar tendon-bone (n=3), or allograft (n=4). Multiligament reconstruction of associated ligamentous deficiency was performed in 7 knees (50%). Postoperative Lachman and pivot shift testing was International Knee Documentation Committee (IKDC) grade A or B in all but 1 knee. One patient with congenital absence of multiple knee ligaments required revision ACL reconstruction surgery, with concurrent first-time posterior cruciate ligament reconstruction, due to persistent instability. None required revision surgery due to graft tear at a minimum of 1-year follow-up.

Conclusions:

Surgical stabilization of symptomatic congenital ACL insufficiency, with associated ligamentous reconstruction as required on a case-by-case basis, results in improved stability at early clinical follow-up, with low complication rates.

Level of Evidence:

Level IV—retrospective case series.
Valgus Hip Osteotomy in Children With Spondyloepiphyseal Dysplasia Congenita: Midterm Results
Authors: Bayhan Ilhan A. , Abousamra Oussama , Rogers Kenneth J. , Bober Michael B. , Miller Freeman , Mackenzie William G.
Published: February 2017

Background:

Coxa vara has been frequently reported in spondyloepiphyseal dysplasia congenita (SEDC), and proximal femoral osteotomy has been described as a useful treatment. The aim of this study was to discuss the clinical, radiographic, and gait outcomes after valgus extension osteotomy of the proximal femur. Changes of lumbar lordosis, associated with coxa vara correction, are reported as well as the outcome differences between different ages.

Methods:

Records of children with SEDC, who were followed at our institution between 2004 and 2014, were reviewed; and children had hip surgery were identified. Hip pain and passive range of motion, radiographic neck shaft angle (NSA), and Hilgenreiner trochanteric (H-T) angle, sagittal spinopelvic parameters, and gait data were recorded. Preoperative and last follow-up data were compared. Outcomes were also compared between 3 age groups.

Results:

Of the 79 children with SEDC, 26 children (12 boys and 14 girls) had hip osteotomy in 48 hips. Mean age at surgery was 9.6 years and the mean follow-up was 5 years. Preoperative hip pain was noted in 30 hips. At the last follow-up, 3 hips were painful at the extreme range of motion. Passive range of motion, NSA, and H-T improved postoperatively. Although NSA was maintained over the follow-up, H-T deterioration was noted. Spinopelvic measurements changed significantly and gait data remained stable except pelvic tilt that reduced significantly after surgery. The changes of radiographic measurements in each age group were similar to the total group of patients.

Conclusions:

In children with SEDC, surgical correction of coxa vara, by proximal femoral valgus osteotomy, is an effective treatment that improves hip pain and range of motion in addition to the radiographic alignment of the proximal femur and the sagittal spinopelvic alignment. Children are expected to maintain their level of function after surgery and to have good results over the midterm regardless of their age at surgery.

Level of Evidence:

Level IV—therapeutic study.
Time to Return to School After 10 Common Orthopaedic Surgeries Among Children and Adolescents
Authors: Willimon Samuel C. , Johnson Marjorie M. , Herzog Mackenzie M. , Busch Michael T.
Published: February 2017

Background:

Return to school among adolescents is often overlooked in orthopaedic outcome studies. The purpose was to measure the time missed from school after 10 common orthopedic surgeries.

Methods:

Patients, 5 to 19 years old enrolled in elementary, middle, or high school, who underwent treatment for fixation of type III supracondylar humerus fracture, midshaft femur fracture fixation, isolated anterior cruciate ligament reconstruction, isolated partial menisectomy, adolescent idiopathic scoliosis fusion, closed reduction of both-bone forearm fracture, arthroscopic Bankart repair, hip arthroscopy with femoroacetabular impingement correction, limb length discrepancy correction, or surgical fixation of slipped capital femoral epiphysis during the 2014/2015 and 2015/2016 school years were identified for this Institutional Review Board-approved study. All patients were contacted after surgery to determine date of return to school, number of days in session, and number of school days missed.

Results:

Two hundred six patients met the inclusion criteria for this study. Mean age at time of surgery was 13.0±3.8 years. There were 105 males (51%). Mean time to return to school overall was 13.0±15.2 days. Very few students (n=9; 4%) did not miss any school days during recovery from the procedure of interest. The average number of days missed from school for males was 6.6 days compared with 8.4 days in females (P=0.20). There was no difference between patients aged 5 to 12 years compared with those aged 13 to 19 years (7.1 vs. 7.7 d, respectively; P=0.69). On average, patients who underwent closed reduction of a both-bone forearm fracture returned to school the quickest following surgery (3.4±1.2 d) and missed the least amount of in-session school days (1.9±0.9 d), and those who underwent adolescent idiopathic scoliosis fusion were out of school the longest (42.3±21.4 d) and missed the greatest number of in-session school days (27.6±14.7 d).

Conclusions:

Information regarding average time missed from school for 10 common orthopaedic surgeries can be used by clinicians to counsel patients and their families regarding expected recovery time.

Level of Evidence:

Level IV.
Toddler’s Fractures: Time to Weight-bear With Regard to Immobilization Type and Radiographic Monitoring
Authors: Bauer Jennifer M. , Lovejoy Steven A.
Published: February 2017

Background:

The toddler’s fracture is a common pediatric nondisplaced spiral tibia fracture that is considered stable with a course of immobilization. However, there is no widely accepted type of immobilization, expected time to weight-bear, nor guidelines for radiographic monitoring. We aimed to compare immobilization type with respect to displacement and time to weight-bear, as well as determine the usefulness of follow-up radiographs.

Methods:

A 3-year retrospective chart review of all children aged 9 months to 4 years who had a lower leg radiograph was performed. Those who fulfilled the criteria of a nondisplaced spiral tibia fracture, without fibula or physeal injury, were included in data collection, as were subjects with a negative initial radiograph that were treated presumptively as a toddler’s fracture. Subjects were compared with regard to clinical and radiographic presentation; initial and subsequent immobilization; and clinical and radiographic follow-up.

Results:

There were 606 subjects with lower leg radiographs, with 192 meeting study criteria: 117 (61%) with an initially visible fracture and 75 (39%) without. Of the 75 without initially visible fractures, 70 (93%) had robust periosteal reaction on follow-up, and none were diagnosed as anything further. At final follow-up, 184 (96%) were known to be weight-bearing, with 98% of these by 4 weeks. There was an earlier return to weight-bear for those initially treated in a boot compared with short leg cast (2.5 vs. 2.8 wk, P=0.04), but there were no other differences between immobilization type. No fractures displaced at any time point, including 7 that had received no immobilization. Patients received an average of 2.5 two-radiograph series; no radiographs were noted to affect treatment decisions in follow-up.

Conclusions:

In our cohort, initial immobilization of a toddler’s fracture in a boot may allow faster return to weight-bearing, but fractures were universally stable regardless of immobilization type, and nearly all regained weight-bearing by 4 weeks. This reliable healing suggests that immobilization type can be at the physician and family’s discretion, and that radiographic follow-up may be unnecessary for treatment planning.

Level of Evidence:

Level III—this is a retrospective comparative study.
The Influence of Aspiration Volume on the Number of Osteoblastic Progenitors Obtained From Bone Marrow in Children
Authors: Yandow Suzanne M. , Van de Velde Samuel K. , Siebert Jeanne , Perkins Sherrie L.
Published: February 2017

Background:

Autologous bone marrow aspirates are utilized to treat various conditions in children. The biological value of bone marrow aspirate depends on the concentration of competent osteoblastic progenitors present in the aspirate. It has been shown in adults that increasing bone marrow aspiration volume beyond 2 mL decreases the concentration of osteoblast progenitor cells because of dilution of the sample with peripheral blood. The effect of varying bone marrow aspiration volumes on the osteoblast cell content has not been determined in children.

Methods:

In total, 21 children (3 male and 18 female patients, age range 8 mo to 14 y) scheduled for pelvic osteotomy were included in the study. Three separate bone marrow aspirates of 1, 5, and 10 mL were obtained from the anterior superior iliac crest. Total number of nucleated cells was counted per aspirate and the prevalence of alkaline phosphatase–positive colony-forming units was determined per million nucleated cells.

Results:

We measured a significant, proportional increase in the total number of nucleated bone marrow precursor cells between the 1 and 5 mL samples (mean±SD, 27±13 and 152±78 million nucleated cells, respectively; P<0.0001). When the aspiration volume doubled from 5 to 10 mL the total number of nucleated cells was 178±76 million (P=0.17). A proportional increase from 2214 alkaline phosphatase–positive colony-forming units in the 1 mL sample to 14,100 alkaline phosphatase–positive colony-forming units in the 5 mL sample was observed. However, the number of colony-forming units per aspirate decreased to 11,880 in the 10 mL sample.

Conclusions:

These data demonstrate that in children aspiration up to 5 mL bone marrow from the iliac crest yields a proportional increase in osteoblastic progenitor cells per aspirate. Increasing the aspiration volume beyond 5 mL results in hemodilution, rather than further selection of osteoblastic material.

Clinical Relevance:

These data provide clinicians with a guideline for optimizing aspiration volume of bone marrow in children.

Level of Evidence:

Level II—development of diagnostic criteria on basis of consecutive patients.
Radiographic Assessment of Guided Growth: The Correlation Between Screw Divergence and Change in Anatomic Alignment
Authors: Sweeney Kyle R. , Shi Weilong J. , Gottschalk Michael B. , Kappa Jason E. , Bruce Robert W. , Fletcher Nicholas D.
Published: February 2017

Background:

Assessment of changes in anatomic alignment following guided growth traditionally utilizes full-length standing radiographs which subjects patients to larger radiation doses than does a single anteroposterior radiograph of the knee. In an effort to minimize radiation exposure, the present study sought to determine whether changes in screw divergence (SD) of the 2-hole tension band plate used for hemiepiphysiodesis reliably predicts change in alignment.

Methods:

A retrospective review was conducted involving all patients with genu varum or genu valgum treated with hemiepiphysiodesis at a single institution. Preoperative anatomic alignment of the femur, using anatomic lateral distal femoral angle (aLDFA) and anatomic femoral-tibial angle (aTFA), and intraoperative divergence of hemiepiphysiodesis screws were compared with postoperative imaging. Linear regression analysis determined the relationship between changes in SD and changes in alignment, and multivariate regression analysis explored the relationship between the angular changes being measured and various demographic factors.

Results:

Linear regression analysis revealed that for every 1 degree change in SD there was a resultant 1.80 degrees of change in aTFA and 2.11 degrees of change in aLDFA. Change in aTFA is predicted by the equation: ∆aTFA=0.41×|∆SD|+1.39. The change in aLDFA was predicted by the equation ∆aLDFA=0.27×∆SD+1.84 with a R2 of 0.31. ∆aTFA and ∆SD had a correlation coefficient of 0.68 (95% confidence interval, 0.54-0.78.) ∆aLDFA and ∆SD had a correlation coefficient of 0.56 (95% confidence interval, 0.42-0.68). ∆SD and sex were the only 2 independent predictors for ∆aLDFA and ∆aTFA as determined by multivariate regression analysis.

Conclusion:

Change in coronal plane anatomic alignment in patients being treated for genu valgum or genu varum with hemiepiphysiodesis can be reasonably estimated by measuring the change in SD. Therefore, when following patients postoperatively, focal radiographic imaging of the knee can be utilized in lieu of standing full-length limb radiographs to limit radiation to the pelvis in this sensitive patient population.

Level of Evidence:

Level III—retrospective comparative study.
Predicting Late Follow-up and Understanding Its Consequences in Growth Modulation for Pediatric Lower Limb Deformities
Authors: Lawing Cheryl , Margalit Adam , Ukwuani Gift , Sponseller Paul D.
Published: February 2017

Background:

Growth modulation with implants facilitates correction of angular deformities and limb-length discrepancies (LLDs) in children. Close follow-up is necessary when using growth modulation to prevent overcorrection. We examined factors associated with late follow-up and overcorrection rates in patients with late versus timely follow-up.

Methods:

This was a retrospective review of growth modulation procedures in children at 1 institution from 2000 through 2014. Procedures were assigned to the following categories on the basis of deformity: ankle valgus, genu valgum, genu varum, knee flexion contractures, and LLDs. Radiographic and clinical parameters were assessed. Late follow-up was defined as delaying a recommended appointment by ≥6 months. Loss to follow-up was defined as failure to return for a recommended postoperative appointment. Associations were evaluated using the following tests: χ2, Fisher exact, analysis of variance, Mann-Whitney U, and logistic regression. Statistical significance was set at P<0.05.

Results:

Of the 112 patients, there were 41 cases of genu valgum, 23 of ankle valgus, 18 each of genu varum and LLD, and 12 of knee flexion contractures. Twenty-two patients had late follow-up. Another 22 patients were lost to follow-up with retained implants. Patients with late follow-up had significantly higher odds of experiencing overcorrection deformities versus patients with timely follow-up (odds ratio, 19.2; 95% confidence interval, 5.2-71.4; P<0.005). The only deformity for which there was a significant difference in final alignment between patients with timely versus late follow-up was genu valgum (P<0.005). Late follow-up was associated with having a primary language other than English (P=0.05) and being obese/overweight (P=0.004).

Conclusions:

Late follow-up and loss to follow-up were common, occurring in 39% of patients combined. Late follow-up was associated with overcorrection in guided-growth procedures, as were overweight/obesity and primary language other than English.

Level of Evidence:

Level IV—retrospective case series.
Management of Clubfoot Relapses With the Ponseti Method: Results of a Survey of the POSNA Members
Authors: Hosseinzadeh Pooya , Kiebzak Gary M. , Dolan Lori , Zionts Lewis E. , Morcuende Jose
Published: February 2017

Background:

Despite the high rate of initial success using the Ponseti method to manage idiopathic clubfoot deformity, relapse continues to be a problem. We surveyed the Pediatric Orthopedic Society of North America (POSNA) members about their experience with relapsed deformity following the initial correction of clubfeet.

Methods:

We created a survey to focus on the management of clubfeet after initial correction of deformity. The survey included questions on postcorrective bracing, clinical findings used to identify relapse, the observed frequency of relapsed deformity, and how relapses are managed. The questionnaire was approved by the POSNA Evidence Based Committee and was sent electronically to all POSNA members.

Results:

We received responses from 321 members (26%). Of those, 94% were fellowship trained in pediatric orthopaedics. The Ponseti method was used by 98% of respondents. The Mitchell-Ponseti orthosis was most commonly used (51%), followed by the Denis-Browne brace (25%). The duration of bracing used varied among members with 23% recommending only 2 years, 33% recommending 3 years, and 34% recommending 4 years. A tight heel cord was felt to be the first sign of relapse by 59% of respondents, and dynamic supination by 30%. The rate of relapse was observed to be <10% by 22% of the respondents, 10% to 20% by 52%, and 20% to 40% by 25%. Manipulation and cast treatment alone (55%) and cast treatment with tenotomy (23%) were reported as the 2 most common initial treatment approaches for a relapsed deformity. Cast treatment to correct relapsed deformity before tibialis anterior tendon transfer was reported by 62% of respondents. Heel cord tenotomy (75%) and posterior capsular release (43%) were the 2 most common procedures used in addition to tibialis anterior tendon transfer for the treatment of clubfoot relapse.

Conclusion:

This study highlights the wide variation with which clubfoot relapses are evaluated and treated among the POSNA membership with differences in the recommended duration of bracing, identification of relapses, and their management. These wide differences highlight the need for future research and educational programs to inform and standardize the management of clubfoot using the Ponseti Method.

Level of Evidence:

Not applicable.
Description and Results of a Fully Arthroscopic Anatomic Broström Repair and Gould Modification
Authors: Perera Anthony M.N. , Molloy Andrew , Guillo Stephane
Published: February 2017

Ankle instability is a common sequelae of a lateral ankle sprain. Surgery for this condition must address any intra-articular pathology as well as repairing the ligaments. The former is generally done arthroscopically and the advantages of this approach are well documented. However, once this is competed the second stage of ligament repair is traditionally done in an open manner. There is increasing interest in the role of arthroscopic ligament repair though to date most techniques have repaired only the anterior talofibular ligament and then performed a percutaneous retinacular advancement. The only technique that addresses the calcaneofibular ligament (CFL) does so from an accessory portal just anterior to the tip of the fibula though in practice it can be difficult to see the CFL from this portal. We have developed the technique of lateral ankle endoscopy, performed through the bed of the peroneus brevis tendon. This technique gives direct and clear visualization of the CFL, anterior talofibular ligament, and also the extensor retinaculum, which then allows direct, anatomic tightening. The stabilization is performed with bone anchors onto the fibula. We present the results in 15 consecutive cases performed with this entirely arthroscopic technique. We believe that this technique gives better visualization of the structures than an open technique and that as a result a more anatomic reconstruction can be performed.

Level of Evidence:Diagnostic Level 5. See Instructions for Authors for a complete description of levels of evidence.
Two Models to Conduct Nonphysician-led Exercise Stress Testing in Low to Intermediate Risk Patients
Authors: Scott Adam , Whitman Mark , McDonald Alice , Webster Meghan , Jenkins Carly
Published: February 2017

Background:

Exercise stress testing (EST) is a noninvasive procedure that aids the diagnosis and prognosis of a range of cardiac pathologies. Reduced access is recognized as a limiting factor in enabling early access to treatment or safe and appropriate discharge. Increased accessibility can be achieved by utilizing nonphysician health practitioners to supervise tests. To implement nonphysician-led EST in clinical environments, there is a need for the development and administration of feasible and effective models.

Objective:

Via inpatient and outpatient referral, this article aims to present 2 standardized models of care for patients requiring EST for diagnostic and prognostic evaluation of numerous pathologies.

Method:

An inpatient and outpatient model was implemented at the Royal Brisbane and Women’s Hospital and Logan Hospital in Queensland, Australia between July 2013 and December 2015. Tests were performed by 2 cardiac scientists employed by each hospital. All tests were immediately reported by a cardiology advanced trainee registrar or consultant cardiologist.

Results:

A total of 2095 tests were performed via the 2 models. Overall, 73 had a positive result (3.5%), 120 equivocal (5.7%), 129 inconclusive/submaximal (6.2%), and 1773 negative (85.2%). After further testing, 38 of the patients with positive and equivocal results were diagnosed with flow-limiting coronary artery disease. The remaining patients were resolved as negative through further diagnostic testing or lost to follow up.

Conclusions:

After implementation of the 2 models, patient flow was improved for earlier discharge, reduced waiting times, or timely identification of possible cardiac pathologies, thereby optimizing patient care.
An Updated Protocol for Evaluating Chest Pain and Managing Acute Coronary Syndromes
Authors: Kelly Christopher R. , Kirtane Ajay J. , Stant Jennifer , Stone Gregg W. , Minutello Robert M. , Wong S. Chiu , Manuzon Honeyleen , Gerow-Smith Roxanne , Kelley Nancy , Rabbani LeRoy E.
Published: February 2017

Clinical pathways can optimize care both across and within institutions, but regular updates to these pathways based on new clinical trials, professional guidelines, and Food and Drug Administration approvals are essential. Herein we describe the most recent revisions to the New York-Presbyterian Hospital (Columbia University Medical Center and Weill Cornell Medical Center) clinical pathway for acute coronary syndromes and chest pain, which incorporates novel data regarding the timing and administration of P2Y12 inhibition (including the intravenous P2Y12 inhibitor cangrelor) and the appropriateness of prolonged (>1 year) dual antiplatelet therapy for the secondary prevention of ischemic events.
Preoperative Hemoglobin A1c and the Occurrence of Atrial Fibrillation Following On-pump Coronary Artery Bypass Surgery in Type-2 Diabetic Patients
Authors: Abbaszadeh Shahin , Shafiee Akbar , Bina Payvand , Jalali Arash , Sadeghian Saeed , Karimi Abbasali
Published: February 2017

Background:

We investigated the association of the preoperative hemoglobin A1c (HbA1c) with occurrence of postoperative atrial fibrillation (POAF) in type-2 diabetic patients who underwent isolated coronary artery bypass grafting.

Methods:

We prospectively studied 708 type-2 diabetes patients [433 men ([61.2%)], candidate for isolated coronary artery bypass grafting. Biochemistry profile was measured on the day of operation. All patients were telemonitored for 72 hours after operation for the occurrence of atrial fibrillation. The role of HbA1c as a predictor for the occurrence of atrial fibrillation was then evaluated.

Results:

A total of 109 (15.3%) patients developed POAF. Patients in the atrial fibrillation group tended to be older, with prolonged longer diabetes, and have renal failure, chronic obstructive pulmonary disease, and hypertension. In the univariable and multivariable regression model, HbA1c was not a predictor for POAF.

Conclusions:

Serum level of HbA1c could not be used as a predictor for the development of POAF.
Noninvasive Bioelectrical Impedance for Predicting Clinical Outcomes in Outpatients With Heart Failure
Authors: Lyons Kristin J. , Bischoff Michelle K. , Fonarow Gregg C. , Horwich Tamara B.
Published: February 2017

Background:

Noninvasive bioelectrical impedance analysis (BIA) has shown promise in acute heart failure (HF) management. To our knowledge, its use in predicting outcomes in outpatients with chronic HF patients has not been well described.

Methods and Results:

BIA assessment of edema index was performed in 359 outpatients with HF using the InBody 520 scale. Edema index was calculated by dividing extracellular by total body water. Patients were stratified into those with low (≤0.39) and high (>0.39) edema indices. The outcome of interest was death, urgent transplant, or ventricular assist device over 2-year follow up. Patients with a high edema index were older, had higher B-type natriuretic peptide values and New York Heart Association Class. Patients with a high edema index had poorer outcomes (unadjusted hazard ratio 1.90, 95% confidence intervals 1.05–3.56). However, in multivariate analyses, a high edema index was not an independent predictor of outcomes (adjusted hazard ratio 1.21, 95% confidence interval 0.51–2.90).

Conclusions:

A high edema index using a bioimpedance scale in a HF clinic correlated with patient outcomes in unadjusted analyses, but was not a predictor of outcomes once other measures of HF severity are accounted for. As a noninvasive measure of volume status, use of BIA in a HF clinic may be beneficial in determining patient prognosis and treatment when other outcome predictors are not immediately available.
A Prospective Analysis of Olfactory Impairment Recovery After Severe Traumatic Brain Injury
Authors: Drummond Melanie , Douglas Jacinta , Olver John
Published: February 2017

Objective:

To investigate the natural progression of olfactory impairment (OI) in individuals with traumatic brain injury (TBI) at 6 months postinjury.

Participants:

Forty-seven adults (mean age = 43.1 years, SD = 18.2), with predominantly severe TBI (mean posttraumatic amnesia [PTA] duration = 25.5 days, SD = 22.8).

Design:

Consecutive admission longitudinal study.

Main Measures:

Participants were evaluated using the University of Pennsylvania Smell Identification Test (UPSIT) at resolution of PTA and at 6 months post–initial injury. Each participant was also interviewed to explore his or her experience of having an OI. Standard multiple regression was used to assess the ability of age, PTA duration, presence of facial fractures, and initial UPSIT score to predict olfactory performance at 6 months.

Results:

Thirty-five participants (74%) continued to demonstrate OI at 6 months. Thirty-two participants (68%) showed some improvement, but only 12 of these individuals achieved scores within the normal range. The remaining 15 participants either produced a poorer performance (23%) or demonstrated no change (9%). Initial UPSIT score uniquely accounted for 73.5% of the variance in UPSIT performance at 6 months.

Conclusions:

Olfactory impairment persists in a substantial proportion of adults who experience it post-TBI and has the potential to impact a broad spectrum of everyday activities.
The Relations of Cognitive, Behavioral, and Physical Activity Variables to Depression Severity in Traumatic Brain Injury: Reanalysis of Data From a Randomized Controlled Trial
Authors: Bombardier Charles H. , Fann Jesse R. , Ludman Evette J. , Vannoy Steven D. , Dyer Joshua R. , Barber Jason K. , Temkin Nancy R.
Published: February 2017

Objective:

To explore the relations of cognitive, behavioral, and physical activity variables to depression severity among people with traumatic brain injury (TBI) undergoing a depression treatment trial.

Setting:

Community.

Participants:

Adults (N= 88) who sustained complicated mild to severe TBI within the past 10 years, met criteria for major depressive disorder, and completed study measures.

Design:

Randomized controlled trial.

Methods:

Participants were randomized to cognitive-behavioral therapy (n= 58) or usual care (n= 42). Outcomes were measured at baseline and 16 weeks. We combined the groups and used regressions to explore the relations among theoretical variables and depression outcomes.

Main Measures:

Depression severity was measured with the Hamilton Depression Rating Scale and Symptom Checklist-20. Theory-based measures were the Dysfunctional Attitudes Scale (DAS), Automatic Thoughts Questionnaire (ATQ), Environmental Rewards Observation Scale (EROS), and the International Physical Activity Questionnaire (IPAQ).

Results:

Compared with non-TBI norms, baseline DAS and ATQ scores were high and EROS and IPAQ scores were low. All outcomes improved from baseline to 16 weeks except the DAS. The ATQ was an independent predictor of baseline depression. An increase in EROS scores was correlated with decreased depression.

Conclusions:

Increasing participation in meaningful roles and pleasant activities may be a promising approach to treating depression after TBI.
Cross-Validation of a Classification System for Persons With Traumatic Brain Injury in the Posthospital Period
Authors: Sherer Mark , Ponsford Jennie , Hicks Amelia , Leon-Novelo Luis , Ngan Esther , Sander Angelle M.
Published: February 2017

Objective:

To (1) identify groupings of persons with traumatic brain injury (TBI) in the posthospital period in a cohort recruited in Australia; (2) compare groupings from the Australian cohort to groupings previously developed for a US cohort.

Setting:

Rehabilitation centers in the US and Australia.

Participants:

A total of 170 persons with TBI from Australia and 504 persons with TBI from the United States. Participants were aged 18 to 64 years, greater than 6 months postinjury, had capacity to give consent, and had definitive contemporaneous medical evidence of TBI.

Design:

Observational study.

Main Measures:

Cognitive tests—Wechsler Letter-Number Sequencing and Coding, Rey Auditory Verbal Learning Test, Trail Making Test, Verbal Fluency. Questionnaires—9 scales from the Traumatic Brain Injury Quality-of-Life system; Neurobehavioral Symptom Inventory; Economic Quality of Life, Family Assessment Device—General Functioning. Performance validity—Word Memory Test.

Results:

Agreement in classification for the 2 samples was only moderate with 63.5% correctly classified and Cohen's κ = 0.53. A post hoc analysis placing all persons showing poor performance validity in the same group improved classification to 73% and Cohen's κ = 0.65 indicating substantial agreement.

Conclusion:

Results provided support for the patient groups developed for the US sample and indicate that these groupings largely replicated in a new cohort.
Bedside Ultrasound to Facilitate Early Diagnosis and Ease of Follow-Up in Neurogenic Heterotopic Ossification: A Pilot Study From the Intensive Care Unit
Authors: Stefanidis Konstantinos , Brindley Peter , Ramnarine Raymond , Blaivas Michael , Daneshi Mohammad , Sidhu Paul S. , Alharthy Abdoulrahman , Karakitsos Dimitrios
Published: February 2017

Objective:

To explore the potential role of ultrasound (US) as a bedside tool in intensive care unit patients with presumed neurogenic heterotopic ossification (NHO).

Setting:

Tertiary university teaching hospitals.

Participants:

Critical care patients with acquired brain injury.

Design:

A multicenter prospective study of critical care patients with possible NHO.

Main Measures:

Following a screening clinical examination, the major joints were evaluated with US, serum laboratory work, and x-ray.

Results:

A total of 310 patients had decreased range of motion by clinical screen and all received US interrogation. Sonographic signs of NHO were identified in 21 of the 310 patients (6.8%), of which 17/21 (81.0%) showed hyperemia; 9/21 (42.8%) showed the reverse zone phenomenon, and 4/21 patients (19.0%) showed the prezone phenomenon. All 21 patients progressed to the zone phenomenon within 15 weeks. Laboratory parameters were not significantly correlated with US (r = 0.11, r = 0.13; P > .05, respectively), whereas x-rays were associated with a mean diagnostic delay of 2 ± 0.5 weeks (P < .05) compared with US. All 21 sonographic NHO patients survived to intensive care unit discharge. Twelve months after admission, 3/21 had died; 6/21 still had abnormalities by x-ray, US, and clinical examination; and 12/21 had resolution by x-ray, US, and clinical examination.

Conclusion:

Our pilot study suggests potential benefits for bedside US in NHO, especially when compared with x-ray or laboratory investigations. These include the possibility of earlier diagnosis, consideration of therapy before ossification, and ease of follow-up. Our study also provides insights into the morphologic, sonographic, radiologic, and clinical course of NHO.
Ecological Assessment of Everyday Executive Functioning at Home and at School Following Childhood Traumatic Brain Injury Using the BRIEF Questionnaire
Authors: Chevignard Mathilde , Kerrouche Bernadette , Krasny-Pacini Agata , Mariller Aude , Pineau-Chardon Emmanuelle , Notteghem Pauline , Prodhomme Julie , Le Gall Didier , Roulin Jean-Luc , Fournet Nathalie , Roy Arnaud
Published: February 2017

Objectives:

To describe dysexecutive symptoms in children with traumatic brain injury (TBI) using the Behavior Rating Inventory of Executive Function (BRIEF); to compare parent- and teacher-ratings, to analyze the differential impairment in the BRIEF subscales, and factors influencing outcome.

Participants:

Children aged 5 to 18 years 11 months, referred to a rehabilitation department following TBI.

Outcome Measures:

Parent- and teacher reports of the BRIEF.

Results:

A total of 194 patients participated in the study: mild (n = 13), moderate (n = 12), severe (n = 169); mean 4.92 (standard deviation = 3.94) years post-injury. According to parent ratings (n = 193), all BRIEF subscales and indices were significantly elevated (23.8%–48% in the clinical range). The Working Memory subscale score was significantly higher than all other subscales. Results of teacher ratings (n = 28) indicated similar significantly elevated scores in all subscales (39.3%–57.2% in the clinical range). No significant difference was found between parent and teacher ratings, which were significantly correlated. Regression analyses indicated that, in children with severe TBI, parental BRIEF overall and metacognition indices were significantly predicted by younger age at injury and older age at assessment, whereas no significant predictor of behavioral regulation index was identified.

Discussion and Conclusion:

This study highlights significant executive dysfunction in everyday life several years after childhood TBI, evident in home and school environments.
Rehospitalization in the First Year Following Veteran and Service Member TBI: A VA TBI Model Systems Study
Authors: Tran Johanna , Hammond Flora , Dams-O'Connor Kristen , Tang Xinyu , Eapen Blessen , McCarthy Marissa , Nakase-Richardson Risa
Published: February 2017

Objective:

To determine the incidence and causes of rehospitalization following military or Veteran traumatic brain injury (TBI).

Setting:

Department of Veterans Affairs (VA) Veterans Health Administration Polytrauma Rehabilitation Centers (VHA PRCs).

Participants:

Consecutive sample of VHA TBI Model System participants (N = 401).

Design:

Prospective observational cohort study.

Main Measures:

Number and type of rehospitalizations in first year post-TBI.

Results:

Forty-one percent of 401 participants were rehospitalized. Rehospitalization status was associated with greater injury severity and receipt of TBI while active duty. Of those rehospitalized, 30% had 2 or more readmissions. Participants experiencing multiple rehospitalizations (2+) were more likely to have sustained their TBI during deployment than those with none or single rehospitalization. This group also sustained more severe injuries and spent more time in VA PRC inpatient rehabilitation. Common reasons for rehospitalization included inpatient rehabilitation (33%), unspecified (26%), orthopedic (10%), seizures (8%), infection (8%), and psychiatric (7%).

Conclusion:

This is the first study examining military and Veteran rehospitalization following TBI requiring inpatient rehabilitation at a VA PRC. Findings indicate frequent rehospitalizations in the first year postinjury, suggesting the need for preventive models of health maintenance following inpatient rehabilitation discharge. Greater surveillance of those with deployment-related TBI or active duty at the time of injury and greater TBI severity may be warranted.
ASSOCIATION OF DRUSEN VOLUME WITH CHOROIDAL PARAMETERS IN NONNEOVASCULAR AGE-RELATED MACULAR DEGENERATION
Authors: Balasubramanian Siva , Lei Jianqin , Nittala Muneeswar G. , Velaga Swetha B. , Haines Jonathan , Pericak-Vance Margaret A. , Stambolian Dwight , Sadda SriniVas R.
Published: February 2017

Purpose:

The choroid is thought to be relevant to the pathogenesis of nonneovascular age-related macular degeneration, but its role has not yet been fully defined. In this study, we evaluate the relationship between the extent of macular drusen and specific choroidal parameters, including thickness and intensity.

Methods:

Spectral domain optical coherence tomography images were collected from two distinct, independent cohorts with nonneovascular age-related macular degeneration: Amish (53 eyes of 34 subjects) and non-Amish (40 eyes from 26 subjects). All spectral domain optical coherence tomography scans were obtained using the Cirrus HD-OCT with a 512 × 128 macular cube (6 × 6 mm) protocol. The Cirrus advanced retinal pigment epithelium analysis tool was used to automatically compute drusen volume within 3 mm (DV3) and 5 mm (DV5) circles centered on the fovea. The inner and outer borders of the choroid were manually segmented, and the mean choroidal thickness and choroidal intensity (i.e., brightness) were calculated. The choroidal intensity was normalized against the vitreous and nerve fiber layer reflectivity. The correlation between DV and these choroidal parameters was assessed using Pearson and linear regression analysis.

Results:

A significant positive correlation was observed between normalized choroidal intensity and DV5 in the Amish (r = 0.42, P = 0.002) and non-Amish (r = 0.33, P = 0.03) cohorts. Also, DV3 showed a significant positive correlation with normalized choroidal intensity in both the groups (Amish: r = 0.30, P = 0.02; non-Amish: r = 0.32, P = 0.04). Choroidal thickness was negatively correlated with normalized choroidal intensity in both Amish (r = −0.71, P = 0.001) and non-Amish (r = −0.43, P = 0.01) groups. Normalized choroidal intensity was the most significant constant predictor of DV in both the Amish and non-Amish groups.

Conclusion:

Choroidal intensity, but not choroidal thickness, seems to be associated with drusen volume in Amish and non-Amish populations. These observations suggest that choroidal parameters beyond thickness warrant further study in the setting of age-related macular degeneration.
RISK FOR LOW VISUAL ACUITY AFTER 1 AND 2 YEARS OF TREATMENT WITH RANIBIZUMAB OR BEVACIZUMAB FOR PATIENTS WITH NEOVASCULAR AGE-RELATED MACULAR DEGENERATION
Authors: Westborg Inger , Albrecht Susanne , Rosso Aldana
Published: February 2017

Purpose:

To investigate how patients with neovascular age-related macular degeneration treated with ranibizumab or bevacizumab respond to treatment in daily clinical practice.

Methods:

Data from the Swedish Macula Register on the treatment received by 3,912 patients during 2011 to 2014 is reported. Patients' characteristics at the first visit, visual acuity, number of injections, and reason for terminating the treatment if applicable are discussed. Furthermore, the risk of having poor vision (visual acuity under 60 Early Treatment Diabetes Retinopathy Study letters or approximately 20/60 Snellen) is calculated for the treated eye after 1 year and 2 years.

Results:

The treatment outcome depends on the visual acuity at the first visit. For patients with visual acuity more than 60 letters, the risk of having a visual acuity lower than 60 letters after 1 year or 2 years of treatment is approximately 20%. However, for patients with low visual acuity at diagnosis (fewer than 60 letters), the risk is approximately 60%. The risk of having a visual acuity lower than 60 letters does not depend on the choice of treatment drug.

Conclusion:

Treatment with anti-vascular endothelial growth factor intravitreal injections mainly maintains the visual acuity level, and only approximately 20% and 40% of the patients required vision rehabilitation after 1 year and 2 years, respectively.
REPEATABILITY AND LONGITUDINAL ASSESSMENT OF FOVEAL CONE STRUCTURE IN CNGB3-ASSOCIATED ACHROMATOPSIA
Authors: Langlo Christopher S. , Erker Laura R. , Parker Maria , Patterson Emily J. , Higgins Brian P. , Summerfelt Phyllis , Razeen Moataz M. , Collison Frederick T. , Fishman Gerald A. , Kay Christine N. , Zhang Jing , Weleber Richard G. , Yang Paul , Pennesi Mark E. , Lam Byron L. , Chulay Jeffrey D. , Dubra Alfredo , Hauswirth William W. , Wilson David J. , Carroll Joseph ,   for the ACHM-001 study group
Published: February 2017

Purpose:

Congenital achromatopsia is an autosomal recessive disease causing substantial reduction or complete absence of cone function. Although believed to be a relatively stationary disorder, questions remain regarding the stability of cone structure over time. In this study, the authors sought to assess the repeatability of and examine longitudinal changes in measurements of central cone structure in patients with achromatopsia.

Methods:

Forty-one subjects with CNGB3-associated achromatopsia were imaged over a period of between 6 and 26 months using optical coherence tomography and adaptive optics scanning light ophthalmoscopy. Outer nuclear layer (ONL) thickness, ellipsoid zone (EZ) disruption, and peak foveal cone density were assessed.

Results:

ONL thickness increased slightly compared with baseline (0.184 μm/month, P = 0.02). The EZ grade remained unchanged for 34/41 subjects. Peak foveal cone density did not significantly change over time (mean change 1% per 6 months, P = 0.126).

Conclusion:

Foveal cone structure showed little or no change in this group of subjects with CNGB3-associated achromatopsia. Over the time scales investigated (6–26 months), achromatopsia seems to be a structurally stable condition, although longer-term follow-up is needed. These data will be useful in assessing foveal cone structure after therapeutic intervention.