Resuscitative Endovascular Balloon Occlusion of the Aorta Process Improvement: Examining a Novel Case Evaluation Tool and Standardized Simulations.

A quality improvement project was undertaken. The objectives of this study were to describe an original case evaluation tool, discuss barriers encountered, present a standardized simulation course, and evaluate the efficacy of this course. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an emerging adjunct in the trauma bay for patients with noncompressible subdiaphragmatic hemorrhage. Compared with the alternative (emergency department thoracotomy), it is less invasive and allows for continuation of chest compressions, and early studies suggest a positive effect on mortality. Infrequent utilization of REBOA limits provider and support staff exposure to its indications and technical skills required to deploy the device. Furthermore, there is no standardized evaluation tool for collecting and reporting REBOA-related data. The REBOA Review Tool was designed to easily evaluate all the steps involved in deploying the REBOA tool and was implemented at our institution without difficulty. This tool provided meaningful feedback for areas that required improvement including ease of information retrieval and documentation of sheath removal. Standardized simulation courses were performed to further improve provider and support staff confidence in using the REBOA tool. Analysis of pre- and postsimulation surveys showed significant improvement in participants' confidence in their understanding and utilization of the REBOA tool and its indications. REBOA placement is a low-volume but high-impact procedure. Therefore, simulations to prepare and a standardized tool to learn from prior experience are vital to improving patient care.

Statistical Validation of the Grand Rapids Arch Collapse Classification.

BACKGROUND: The Grand Rapids Arch Collapse Classification system was devised in 2011 to assist physicians' and patients' understanding of the mechanisms underlying arch collapse. Five types of arch collapse are described, based on which part of the foot or ankle is affected. The purpose of this study was to determine the inter- and intrarater reliability of this classification system when used by physicians with various levels of training. METHODS: A senior author identified a stratified selection of 50 patients (10 per classification type) who presented with foot/ankle pain and suitable radiographs. A survey was designed using prediagnosis radiographs and clinical synopses of the patient's chart. The survey consisted of a description of the classification scheme and the 50 cases in a randomized order. Eight weeks later, they repeated the test to analyze for intra-rater agreement. RESULTS: Of the 33 physicians who received the survey, 26 completed the first round (16 attendings, 4 foot and ankle fellows, and 6 residents). Overall, there was substantial agreement among raters in all five types. Kappa scores for each type were 0.72, 0.65, 0.72, 0.70, 0.63, respectively. The combined kappa score was 0.68. After 8 weeks, 13 of the 26 participants repeated the study. A Kappa analysis was once again performed for the 13 respondents, which produced a substantial level of agreement with a value of 0.74 for intrarater reliability. CONCLUSION: The Grand Rapids Arch Collapse Classification system was designed to provide an accessible mechanism for physicians to consistently describe arch collapse, its effects, and the conditions associated with it. The utility of this system is wholly reliant on the repeatability among clinicians. This study has demonstrated that the classification system has substantial rates of reliability among physicians of different levels of experience and training. LEVEL OF EVIDENCE: Level IV.

Action processing and mirror neuron function in patients with amyotrophic lateral sclerosis: an fMRI study.

Amyotrophic lateral sclerosis (ALS) is a highly debilitating and rapidly fatal neurodegenerative disease. It has been suggested that social cognition may be affected, such as impairment in theory of mind (ToM) ability. Despite these findings, research in this area is scarce and the investigation of neural mechanisms behind such impairment is absent. Nineteen patients with ALS and eighteen healthy controls participated in this study. Because the mirror neuron system (MNS) is thought to be involved in theory of mind, we first implemented a straightforward action-execution and observation task to assess basic MNS function. Second, we examined the social-cognitive ability to understand actions of others, which is a component of ToM. We used fMRI to assess BOLD activity differences between groups during both experiments. Theory of mind was also measured behaviorally using the Reading the Mind in the Eyes test (RME). ALS patients displayed greater BOLD activity during the action-execution and observation task, especially throughout right anterior cortical regions. These areas included the right inferior operculum, premotor and primary motor regions, and left inferior parietal lobe. A conjunction analysis showed significantly more co-activated voxels during both the observation and action-execution conditions in the patient group throughout MNS regions. These results support a compensatory response in the MNS during action processing. In the action understanding experiment, healthy controls performed better behaviorally and subsequently recruited greater regions of activity throughout the prefrontal cortex and middle temporal gyrus. Lastly, action understanding performance was able to cluster patients with ALS into high and lower performing groups, which then differentiated RME performance. Collectively, these data suggest that social cognition, particularly theory of mind, may be affected in a subset of patients with ALS. This impairment may be related to functioning of the MNS and other regions related to action processing and understanding. Implications for future research are discussed.