LifeBridge Health

OBJECTIVE: After randomizing 100 failed back surgery syndrome patients to receive spinal cord stimulation (SCS) plus conventional medical management (CMM) or CMM alone, the results of the 6-month Prospective Randomized Controlled Multicenter Trial of the Effectiveness of Spinal Cord Stimulation (i.e., PROCESS) showed that SCS offered superior pain relief, health-related quality of life, and functional capacity. Because the rate of crossover favoring SCS beyond 6 months would bias a long-term randomized group comparison, we present all outcomes in patients who continued SCS from randomization to 24 months and, for illustrative purposes, the primary outcome (>50% leg pain relief) per randomization and final treatment. METHODS: Patients provided data on pain, quality of life, function, pain medication use, treatment satisfaction, and employment status. Investigators documented adverse events. Data analysis included inferential comparisons and multivariate regression analyses. RESULTS: The 42 patients continuing SCS (of 52 randomized to SCS) reported significantly improved leg pain relief (P < 0.0001), quality of life (P <or= 0.01), and functional capacity (P = 0.0002); and 13 patients (31%) required a device-related surgical revision. At 24 months, of 46 of 52 patients randomized to SCS and 41 of 48 randomized to CMM who were available, the primary outcome was achieved by 17 (37%) randomized to SCS versus 1 (2%) to CMM (P = 0.003) and by 34 (47%) of 72 patients who received SCS as final treatment versus 1 (7%) of 15 for CMM (P = 0.02). CONCLUSION: At 24 months of SCS treatment, selected failed back surgery syndrome patients reported sustained pain relief, clinically important improvements in functional capacity and health-related quality of life, and satisfaction with treatment.

OBJECTIVE: Diabetic patients may have a higher prevalence of platelet aspirin resistance than nondiabetic patients. Our goal was to analyze platelet aspirin responsiveness to various aspirin doses in diabetic and nondiabetic patients. RESEARCH DESIGN AND METHODS: We examined the effect of aspirin (81, 162, and 325 mg/day for 4 weeks each) on platelet aspirin responsiveness in 120 stable outpatients (30 diabetic patients and 90 nondiabetic patients) with coronary artery disease (CAD) using light transmittance aggregometry (LTA), VerifyNow, platelet function analyzer (PFA)-100, and levels of urinary 11-dehydro-thromboxane B(2) (11-dh-TxB(2)). RESULTS: In the total group, a low prevalence (0-2%) of aspirin resistance was observed with all aspirin doses as determined by arachidonic acid-induced LTA. Aspirin resistance was higher at the 81-mg dose in diabetic versus nondiabetic patients using collagen-induced LTA (27 vs. 4%, P = 0.001), VerifyNow (13 vs. 3%, P = 0.05), and urinary 11-dh-TxB(2) (37 vs. 17%, P = 0.03). Diabetic patients treated with 81 mg exhibited higher platelet function measured by VerifyNow, collagen- and ADP-induced LTA, and 11-dh-TxB(2) levels (P <or= 0.02 for all comparisons). Higher aspirin doses significantly inhibited platelet function and decreased aspirin resistance in diabetic patients (P < 0.05). CONCLUSIONS: Diabetic patients with CAD treated with 81 mg aspirin exhibit a higher prevalence of aspirin resistance and have significantly higher ADP- and collagen-induced platelet aggregation, 11-dh-TxB(2) levels, and aspirin reaction units measured by VerifyNow than nondiabetic patients. Increased aspirin dosing resulted in similar rates of resistance and platelet function levels between groups. These findings indicate that diabetic patients exhibit a global high platelet reactivity phenotype that may be partially overcome by higher aspirin doses.

The most common indication for arthrodesis of the knee is an infection at the site of a total knee arthroplasty. Deficiencies in bone stock and poor bone apposition adversely affect the success of a knee arthrodesis. Arthrodesis of the knee can provide a stable, painless extremity for high-functioning patients who are able to walk. Patient function after arthrodesis of the knee is superior to that after above-the-knee amputation. Conversion of a solid knee fusion to a total knee arthroplasty has a substantial complication rate.

The treatment of intramedullary infections after nailing usually includes removal of the rod, debridement of the canal, and, in many cases, insertion of antibiotic-impregnated cement beads. These beads offer no mechanical support and are difficult to remove if left in place for more than 2 weeks. We present an alternative for filling the medullary canal's noncollapsible dead space with an antibiotic-impregnated cement rod. This rod can be custom-made at the time of surgery, using different diameter chest tubes as molds and embedding a 3-mm beaded guidewire within the cement. The smooth molded surface of this nail makes extraction of the cement rod relatively easy. The cement rod also provides some limited temporary support to the fracture or nonunion site while the infection is being treated. After 6 weeks, the rod can be removed and replaced with a definitive metal intramedullary nail, with or without bone grafting to treat the previously infected fracture or nonunion site. We retrospectively reviewed nine cases of intramedullary infection treated with antibiotic-impregnated molded cement rods. These included six femora, two tibiae, and one humerus. The cause of infection was lengthening or transport over nail in six cases, fixator-augmented nailing of osteotomies in two, and fracture fixation in one. The follow-up period after surgery ranged from 38 to 48 months. No recurrent infection occurred during this follow-up period, and no patient required antibiotics after the rod was removed. In all cases, the canal cultures were negative after rod removal. The cement rod was removed between 29 and 753 days after implantation. Fracture of the rod occurred in one case in which the rod was left in place for more than 1 year. We conclude that this method is a relatively simple and inexpensive alternative for the treatment of intramedullary infections.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To compare the relationship between the degrees of turnout, passive hip external rotation range of motion, and self-reported history of low back and lower extremity injury in ballet dancers. BACKGROUND: Ballet dancers are encouraged to externally rotate their lower extremities (turnout) as far as possible. This may cause stress on the dancers' low back and lower extremities, putting them at risk for injury. METHODS AND MEASURES: Thirty college-level ballet dancers and instructors were evaluated. Each participant completed an injury questionnaire that placed the participant either in a group with a self-reported history of low back and lower extremity injury or in a group without a self-reported history of low back and lower extremity injury. Each dancer's first-position turnout and passive external rotation range of motion for both hips were measured. The comparison between each dancer's first-position turnout and the measured hip external rotation range of motion was called "compensated turnout." A 2-sample test was used to determine if the average compensated turnout was significantly different in the injured and noninjured groups. RESULTS: The mean (+/- SD) compensated turnout values for the injured and noninjured groups were 25.40 degrees (+/- 21.3 degrees) and 4.7 degrees (+/- 16.3 degrees), respectively. This difference was significant at P = 0.006. CONCLUSION: Based on a self-reported history of low back and lower extremity injuries, ballet dancers have a greater risk of injury if they reach a turnout position that is greater than their available bilateral passive hip external rotation range of motion.

OBJECT: The authors have shown that convection-enhanced delivery (CED) of gadoteridol-loaded liposomes (GDLs) into different regions of normal monkey brain results in predictable, widespread distribution of this tracking agent as detected by real-time MR imaging. They also have found that this tracking technique allows monitoring of the distribution of similar nanosized agents such as therapeutic liposomes and viral vectors. A limitation of this procedure is the unexpected leakage of liposomes out of targeted parenchyma or malignancies into sulci and ventricles. The aim of the present study was to evaluate the efficacy of CED after the onset of these types of leakage. METHODS: The authors documented this phenomenon in a study of 5 nonhuman primates and 7 canines, comprising 54 CED infusion sessions. Approximately 20% of these infusions resulted in leakage into cerebral ventricles or sulci. All of the infusions and leakage events were monitored with real-time MR imaging. The authors created volume-distributed versus volume-infused graphs for each infusion session. These graphs revealed the rate of distribution of GDL over the course of each infusion and allowed the authors to evaluate the progress of CED before and after leakage. RESULTS: The distribution of therapeutics within the target structure ceased to increase or resulted in significant attenuation after the onset of leakage. CONCLUSIONS: An analysis of the cases in this study revealed that leakage undermines the efficacy of CED. These findings reiterate the importance of real-time MR imaging visualization during CED to ensure an accurate, robust distribution of therapeutic agents.

In order to inform large scale supplementation programme design, we review and summarize the barriers and enablers for improved coverage and utilization of iron and folic acid (IFA) supplements by pregnant women in 7 countries in Africa and Asia. Mixed methods were used to analyse IFA supplementation programmes in Afghanistan, Bangladesh, Indonesia, Ethiopia, Kenya, Nigeria, and Senegal based on formative research conducted in 2012-2013. Qualitative data from focus-group discussions and interviews with women and service providers were used for content analysis to elicit common themes on barriers and enablers at internal, external, and relational levels. Anaemia symptoms in pregnancy are well known among women and health care providers in all countries, yet many women do not feel personally at risk. Broad awareness and increased coverage of facility-based antenatal care (ANC) make it an efficient delivery channel for IFA; however, first trimester access to IFA is hindered by beliefs about when to first attend ANC and preferences for disclosing pregnancy status. Variable access and poor quality ANC services, including insufficient IFA supplies and inadequate counselling to encourage consumption, are barriers to both coverage and adherence. Community-based delivery of IFA and referral to ANC provides earlier and more frequent access and opportunities for follow-up. Improving ANC access and quality is needed to facilitate IFA supplementation during pregnancy. Community-based delivery and counselling can address problems of timely and continuous access to supplements. Renewed investment in training for service providers and effective behaviour change designs are urgently needed to achieve the desired impact.

PURPOSE: Of the estimated 1.7 million residents of nursing homes in the United States, approximately half fall annually; and 11% of these sustain injury. This is twice the rate for persons dwelling in the community. By addressing fall risk, physical therapists have an opportunity to reduce falls which are the leading cause of injury deaths, as well as the most common cause of nonfatal injuries for older adults in the United States. This case report examines the effect of a novel interactive video game intervention to address balance dysfunction in an elderly resident of a nursing home who was at risk for falls. CASE DESCRIPTION: The patient is an 89-year-old resident diagnosed with an unspecified balance disorder and a history of multiple falls. Self reports of gait abnormalities, scores on several clinical measures, and her fall history classified her as having substantial risk for future falls. INTERVENTION: A nontraditional approach to balance training, employing the Nintendo Wii bowling simulation, was used as intervention for this patient's balance disorder. OUTCOMES: After 6 one-hour treatment sessions, the patient's Berg Balance Score improved from 48 to 53. On the Dynamic Gait Index, the patient improved her score from 19 to 21. The patient's Timed Up and Go Test improved from 14.9 to 10.5 seconds, all suggesting a reduced risk of falling. The patient's ABC Score improved from 88 to 90%. CONCLUSION: Physical therapy intervention, using the Nintendo Wii bowling simulation, may have decreased fall risk for this individual.

UNLABELLED: Metal-on-metal total hip resurfacing arthroplasty has had excellent reported results at early to midterm followup, and some studies suggest that outcomes are comparable to conventional THA. We compared the clinical and radiographic outcomes of two closely matched groups of 54 patients who underwent resurfacing and conventional THA, respectively. Each group consisted of 36 men and 18 women who had a mean age of 52 years and a mean body mass index of 29 kg/m(2). At a minimum followup of 24 months (mean, 40 months; range, 24-60 months), the mean Harris hip scores increased similarly in both groups (from 52 to 90 points and from 50 to 91 points for the resurfacing and conventional groups, respectively). Radiographic outcomes, revision rates, complications, pain scores, and satisfaction ratings of the two groups were similar. The patients who underwent resurfacing had higher postoperative weighted activity scores than the patients who underwent conventional THA, although they had higher preoperative weighted activity scores as well. The early outcomes of resurfacing are comparable to those of conventional THA. LEVEL OF EVIDENCE: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

OBJECTIVE: Neurosurgery seeks to attract the best and brightest medical students; however, there is often a lack of early exposure to the field, among other possible barriers. The authors sought to identify successful practices that can be implemented to improve medical student recruitment to neurosurgery. METHODS: United States neurosurgery residency program directors were surveyed to determine the number of medical student rotators and medical students matching into a neurosurgery residency from their programs between 2010 and 2016. Program directors were asked about the ways their respective institutions integrated medical students into departmental clinical and research activities. RESULTS: Complete responses were received from 30/110 institutions. Fifty-two percent of the institutions had neurosurgery didactic lectures for 1st- and 2nd-year medical students (MS1/2), and 87% had didactics for MS3/4. Seventy-seven percent of departments had a neurosurgery interest group, which was the most common method used to integrate medical students into the department. Other forms of outreach included formal mentorship programs (53%), lecture series (57%), and neurosurgery anatomy labs (40%). Seventy-three percent of programs provided research opportunities to medical students, and 57% indicated that the schools had a formal research requirement. On average, 3 medical students did a rotation in each neurosurgery department and 1 matched into neurosurgery each year. However, there was substantial variability among programs. Over the 2010-2016 period, the responding institutions matched as many as 4% of the graduating class into neurosurgery per year, whereas others matched 0%-1%. Departments that matched a greater (≥ 1% per year) number of medical students into neurosurgery were significantly more likely to have a neurosurgery interest group and formal research requirements. A greater percentage of high-matching programs had neurosurgery mentorship programs, lecture series, and cadaver training opportunities compared to the other institutions. CONCLUSIONS: In recent decades, the number of applicants to neurosurgery has decreased. A major deterrent may be the delayed exposure of medical students to neurosurgery. Institutions with early preclinical exposure, active neurosurgery interest groups, research opportunities, and strong mentorship recruit and match more students into neurosurgery. Implementing such initiatives on a national level may increase the number of highly qualified medical students pursuing neurosurgery.

Pheochromocytomas (PHEOs) and paragangliomas (PGLs) are rare neuroendocrine tumors that arise from chromaffin cells. PHEOs arise from the adrenal medulla, whereas PGLs arise from the neural crest localized outside the adrenal gland. Approximately 40% of all cases of PPGLs (pheochromocytomas/paragangliomas) are associated with germline mutations and 30–40% display somatic driver mutations. The mutations associated with PPGLs can be classified into three groups. The pseudohypoxic group or cluster I includes the following genes: SDHA, SDHB, SDHC, SDHD, SDHAF2, FH, VHL, IDH1/2, MHD2, EGLN1/2 and HIF2/EPAS; the kinase group or cluster II includes RET, NF1, TMEM127, MAX and HRAS; and the Wnt signaling group or cluster III includes CSDE1 and MAML3. Underlying mutations can help understand the clinical presentation, overall prognosis and surveillance follow-up. Here we are discussing the new genetic insights of PPGLs.

BACKGROUND: Case reports and case control studies have suggested an association between chiropractic neck manipulation and cervical artery dissection (CAD), but a causal relationship has not been established. We evaluated the evidence related to this topic by performing a systematic review and meta-analysis of published data on chiropractic manipulation and CAD. METHODS: Search terms were entered into standard search engines in a systematic fashion. The articles were reviewed by study authors, graded independently for class of evidence, and combined in a meta-analysis. The total body of evidence was evaluated according to GRADE criteria. RESULTS: Our search yielded 253 articles. We identified two class II and four class III studies. There were no discrepancies among article ratings (i.e., kappa=1). The meta-analysis revealed a small association between chiropractic care and dissection (OR 1.74, 95% CI 1.26-2.41). The quality of the body of evidence according to GRADE criteria was "very low." CONCLUSIONS: The quality of the published literature on the relationship between chiropractic manipulation and CAD is very low. Our analysis shows a small association between chiropractic neck manipulation and cervical artery dissection. This relationship may be explained by the high risk of bias and confounding in the available studies, and in particular by the known association of neck pain with CAD and with chiropractic manipulation. There is no convincing evidence to support a causal link between chiropractic manipulation and CAD. Belief in a causal link may have significant negative consequences such as numerous episodes of litigation.

BACKGROUND: This paper is based on a theological symposium presented at the International Xenotransplantation Association's 14th Congress held in Baltimore, MD, September, 2017. METHODS: The information explores the Jewish, Christian and Muslim theological perceptions and perspectives about cross-species (ie pig-to-human) organ transplantation, the genetic alterations required in the organ-source pig, and their potential to influence individual acceptance of the procedure. RESULTS/CONCLUSIONS: This work should not be considered as the ultimate word about individual theological views, but rather as part of an ongoing conversation that will hopefully lead to wider consideration and exploration of these issues as xenotransplantation science advances towards clinical trials.

Robotics in total knee arthroplasty (TKA) has undergone vast improvements. Although some of the systems have fallen out of favor due to safety concerns, there has been recent increased interest for semi-active haptic robotic systems that provide intraoperative tactile feedback to the surgeon. The potential advantages include improvements in radiographic outcomes, reducing the incidence of mechanical axis malalignment of the lower extremity and better tissue balance. Proponents of robotic technology believe that these improvements may lead to superior functional outcomes and implant survivorship. We aim to discuss robotic technology development, outcomes of unicompartmental and total knee arthroplasty and the future outlook. Short-term follow-up studies on robotic-assisted knee arthroplasty suggest that, although some alignment objectives may have been achieved, more studies regarding functional outcomes are needed. Furthermore, studies evaluating the projected cost-benefit analyses of this new technology are needed before widespread adoption. Nevertheless, the short-term results warrant further evaluation.

Studies have shown less cognitive decline and lower risk of Alzheimer's disease in elderly individuals consuming either antioxidant vitamins or nonsteroidal anti-inflammatory drugs (NSAIDs). The potential of added benefit from their combined use has not been studied. We therefore analyzed data from 3,376 elderly participants of the Cache County Study who were given the Modified Mini-Mental State examination up to three times during a period of 8 years. Those who used a combination of vitamins E and C supplements and NSAIDs at baseline declined by an average 0.96 fewer points every 3 years than nonusers (P < .05). This apparent effect was attributable entirely to participants with the APOE epsilon4 allele, whose users declined by 2.25 fewer points than nonusers every 3 years (P < .05). These results suggest that among elderly individuals with an APOE epsilon4 allele, there is an association between using antioxidant supplements in combination with NSAIDs and less cognitive decline over time.

BACKGROUND AND PURPOSE: Intracranial hemorrhage (ICH) is an important event that is diagnosed on head NCCT. Increased NCCT utilization in busy hospitals may limit timely identification of ICH. RAPID ICH is an automated hybrid 2D-3D convolutional neural network application designed to detect ICH that may allow for expedited ICH diagnosis. We determined the accuracy of RAPID ICH for ICH detection and ICH volumetric quantification on NCCT. MATERIALS AND METHODS: NCCT scans were evaluated for ICH by RAPID ICH. Consensus detection of ICH by 3 neuroradiology experts was used as the criterion standard for RAPID ICH comparison. ICH volume was also automatically determined by RAPID ICH in patients with intraparenchymal or intraventricular hemorrhage and compared with manually segmented ICH volumes by a single neuroradiology expert. ICH detection accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratios by RAPID ICH were determined. RESULTS: = 0.983); the median absolute error was 3 mL. CONCLUSIONS: RAPID ICH is highly accurate in the detection of ICH and in the volumetric quantification of intraparenchymal and intraventricular hemorrhages.

Accessible summary The term ‘formal observation’ includes routine or general observation, 30- to 15-min checks, and constant or continuous observation. Although nurses have used formal observation in the psychiatric setting for more than 25 years to monitor patient behaviour, the benefits of such approaches are questionable. While formal observation is utilized in a defensive mode to prevent patient harm, the actual efficacy of formal observation is unclear. Additionally, formal observation consumes nursing resources; thus, evidence is necessary to validate and support this intervention. The purpose of this paper is to: • determine whether or not research supports the use of formal observation as an effective strategy in preventing potential harm to patients or others; • identify any therapeutic benefit; • identify any gaps in the research. Findings suggest that large gaps continue to exist in the research, but specifically: • a lack of consensus exists in the literature about formal observation definitions and how it should be carried out regardless of effectiveness; • formal observation is rooted in tradition, as little evaluative research exists as to its actual efficacy in reducing harm to patients; • historically it is considered negligent to not utilize the practice as a protective measure. Formal observation in psychiatric settings is a widely accepted intervention employed by psychiatric nurses to reduce the incidence of adverse patient outcomes such as suicides, self-harm, violence and elopements in the psychiatric population. Formal observation includes general or routine observation, observation every 15 or 30 min, continuous or constant observation, and one-to-one observation. While formal observation consumes nursing resources, the efficacy of formal observation in reducing patient risk and providing therapeutic benefit remains unclear. To date, no randomized controlled studies exist. The existing qualitative research fails to demonstrate a direct correlation between the act of formal observation and the prevention of adverse patient outcomes. Common in the literature is a debate as to whether formal observation or therapeutic engagement is more beneficial. This paper, therefore, identifies gaps in the research and synthesizes relevant research regarding the effectiveness of formal observation in preventing adverse outcomes like suicides, self-harm, violence and elopements.

SIGNIFICANCE: Head-mounted video display systems and image processing as a means of enhancing low vision are ideas that have been around for more than 20 years. Recent developments in virtual and augmented reality technology and software have opened up new research opportunities that will lead to benefits for low vision patients. Since the Visionics low vision enhancement system (LVES), the first head-mounted video display LVES, was engineered 20 years ago, various other devices have come and gone with a recent resurgence of the technology over the past few years. In this article, we discuss the history of the development of LVESs, describe the current state of available technology by outlining existing systems, and explore future innovation and research in this area. Although LVESs have now been around for more than two decades, there is still much that remains to be explored. With the growing popularity and availability of virtual reality and augmented reality technologies, we can now integrate these methods within low vision rehabilitation to conduct more research on customized contrast-enhancement strategies, image motion compensation, image-remapping strategies, and binocular disparity, all while incorporating eye-tracking capabilities. Future research should use this available technology and knowledge to learn more about the visual system in the low vision patient and extract this new information to create prescribable vision enhancement solutions for the visually impaired individual.

In October 2007, Madagascar conducted a nationwide integrated campaign to deliver measles vaccination, mebendazole, and vitamin A to children six months to five years of age. In 59 of the 111 districts, long-lasting insecticidal nets (LLINs) were delivered to children less than five years of age in combination with the other interventions. A community-based, cross-sectional survey assessed LLIN ownership and use six months post-campaign during the rainy season. LLIN ownership was analyzed by wealth quintile to assess equity. In the 59 districts, 76.8% of households possessed at least one LLIN from any source and 56.4% of households possessed a campaign net. Equity of campaign net ownership was evident. Post-campaign, the LLIN use target of > or = 80% by children less than five years of age and a high level of LLIN use (69%) by pregnant women were attained. Targeted LLIN distribution further contributed to total population coverage (60%) through use of campaign nets by all age groups.

OBJECTIVE: Spinal sarcomas pose unique treatment dilemmas because of the difficulty of achieving adequate surgical margins and/or delivering curative radiation doses (65 Gy) in close proximity to the spinal cord. This study used hypofractionated stereotactic radiosurgery (SRS) to deliver higher biologically effective doses to treat primary spinal sarcomas and spinal sarcoma metastases. METHODS: Twenty-four patients with spinal or paraspinal sarcomas entered an Institutional Review Board-approved registry trial to evaluate SRS efficacy. They were assessed at regular intervals for pain control, disease progression, and complications for a minimum of 12 months or until death. RESULTS: The median treatment dose for the spinal sarcoma lesions was 30 Gy at the 80% isodose in 3 fractions, with some variation based on tumor size, shape, and dose to adjacent critical structures. Seven patients were treated definitively; all had excellent pain relief and are alive with a mean follow-up period of 33 months. Two patients had complete tumor regression, 3 had partial regression, and 2 experienced recurrences and have been re-treated. Seven patients underwent resection and adjuvant SRS. One of 3 patients treated preoperatively had complete tumor regression, and none of the 4 patients treated postoperatively had a local recurrence with a mean follow-up period of 43.5 months. All 10 patients with sarcoma metastases to the spine (16 lesions) died, with a mean survival of 11.1 months from first spinal metastasis treatment. Complete pain relief was achieved in 8 patients, partial relief in 7 patients, and none in 1 patient. No patient developed radiation myelitis. CONCLUSION: These preliminary results suggest that SRS may have a role in the definitive treatment of patients with primary spinal sarcomas who are deemed unresectable and as adjuvant treatment in those undergoing surgery and for palliation of sarcoma metastases.