Reliability, clinical performance and trending ability of a pulse oximeter and pulse co-oximeter, in monitoring blood oxygenation, at two measurement sites, in immobilised white rhinoceros (Ceratotherium simum).

BACKGROUND: Monitoring blood oxygenation is essential in immobilised rhinoceros, which are susceptible to opioid-induced hypoxaemia. This study assessed the reliability, clinical performance and trending ability of the Nonin PalmSAT 2500 A pulse oximeter's and the Masimo Radical-7 pulse co-oximeter's dual-wavelength technology, with their probes placed at two measurement sites, the inner surface of the third-eyelid and the scarified ear pinna of immobilised white rhinoceroses. Eight white rhinoceros were immobilised with etorphine-based drug combinations and given butorphanol after 12 min, and oxygen after 40 min, of recumbency. The Nonin and Masimo devices, with dual-wavelength probes attached to the third-eyelid and ear recorded arterial peripheral oxygen-haemoglobin saturation (SpO2) at pre-determined time points, concurrently with measurements of arterial oxygen-haemoglobin saturation (SaO2), from drawn blood samples, by a benchtop AVOXimeter 4000 co-oximeter (reference method). Reliability of the Nonin and Masimo devices was evaluated using the Bland-Altman and the area root mean squares (ARMS) methods. Clinical performance of the devices was evaluated for their ability to accurately detect clinical hypoxemia using receiver operating characteristic (ROC) curves and measures of sensitivity, specificity, and positive and negative predictive values. Trending ability of the devices was assessed by calculating concordance rates from four-quadrant plots. RESULTS: Only the Nonin device with transflectance probe attached to the third-eyelid provided reliable SpO2 measurements across the 70 to 100% saturation range (bias - 1%, precision 4%, ARMS 4%). Nonin and Masimo devices with transflectance probes attached to the third-eyelid both had high clinical performance at detecting clinical hypoxaemia [area under the ROC curves (AUC): 0.93 and 0.90, respectively]. However, the Nonin and Masimo devices with transmission probes attached to the ear were unreliable and provided only moderate clinical performance. Both Nonin and Masimo devices, at both measurement sites, had concordance rates lower than the recommended threshold of ≥ 90%, indicating poor trending ability. CONCLUSIONS: The overall assessment of reliability, clinical performance and trending ability indicate that the Nonin device with transflectance probe attached to the third-eyelid is best suited for monitoring of blood oxygenation in immobilised rhinoceros. The immobilisation procedure may have affected cardiovascular function to an extent that it limited the devices' performance.

Patient Education Materials for Immobilisation Masks in Radiation Therapy for Adult Head and Neck Cancer Patients: A Scoping Review.

Immobilisation masks (IMs) are used for people with head and neck cancer (HNC) undergoing radiation therapy (RT) treatment to ensure accuracy and reproducibility between treatments. Claustrophobia-related mask anxiety in HNC patients is common and can compromise treatment due to patient distress. This scoping review aimed to describe the content of publicly available Patient Education Materials (PEMs) for people with HNC undergoing RT. Three search engines (Bing, Yahoo, and Google) were systematically searched using standard terms. PEMs in audio-visual or written formats were eligible for inclusion if the target readership was adults with HNC and included content on IMs for RT. Content was appraised using the Patient Education Materials Assessment Tool for Printable and Audio-Visual Materials to assess understandability and actionability. In total, 304 PEMs were identified of which 20 met the inclusion criteria. Sixteen PEMs were webpages, three were PDF format, and one was a standalone video. The understandability and actionability of PEMs ranged between 47 to 100% and 0 to 80%, respectively. PEMs authored by Foundations/Organisations scored higher in understandability (80-100%) and were more likely to discuss mask anxiety coping strategies. In comparison, News sites and IM manufacturers published PEMs with the lowest understandability scores (20-80%). The significant variations in the quality of IM PEMs identified suggest that some sources may be more effective at informing patients about IMs. Although multiple aspects of the PEMs were consistent across the reviewed materials, many PEMs lacked information, and a stronger focus on understandability and actionability is required.

Comparison of a new immobilization method using a reusable 3-point fixation cylinder system and bite-block type immobilization methods in veterinary radiotherapy.

In veterinary radiotherapy, highly reproducible immobilization is important for accurate irradiation. Consequently, we developed a new reusable head-immobilization method for dogs using cylinders. This study aimed to compare the accuracy of our novel immobilization method using cylinders with that of bite-block type immobilization methods. Three immobilization methods were compared: bite-block only, bite-block combined with torso immobilization, and immobilization using cylinders. Five beagles with canine teeth underwent CT five times for each of the three immobilization methods. One beagle without canine teeth underwent CT 15 times using each method. Three maxillary landmarks (maxillary incisor, frontal sinus, and occipital bone) and one mandibular landmark (mandibular incisor) were established, and the errors in each immobilization method were measured. For all head landmarks, the error in the immobilization method using cylinders was the most reproducible, with the smallest errors. No significant differences were observed in the time required for immobilization. Although there were limitations (such as the use of dogs from a single breed, a single episode of anesthesia, no disassembly of the immobilization system between scans, and the same person performing the positioning on the same day), we found our new reusable immobilization method using cylinders was the most accurate among the three compared methods. This was a proof-of-principle study to evaluate head immobilization using cylinders, and further investigations are needed to confirm its clinical utility.

Fetally-injected drugs for immobilization and analgesia do not modify fetal brain development in a rabbit model.

OBJECTIVE: During fetal surgery, fetuses receive medication (atropine-fentanyl-curare) to prevent fetal pain, movement and bradycardia. Although essential there has been no detailed review of potential side effects. Herein we aimed to assess the effects of this medication cocktail on fetal brain development in a rabbit model. METHODS: Pregnant does underwent laparotomy at 28 days of gestation. Two pups of each horn were randomized to an ultrasound guided injection with medication (atropine-cisatracurium-fentanyl, as clinically used) or saline (sham). The third pup was used as control. At term, does were delivered by cesarean. Outcome measures were neonatal biometry, neuromotoric functioning and neuro-histology (neuron density, synaptic density and proliferation). RESULTS: Maternal vital parameters remained stable during surgery. Fetal heart rates did not differ before and after injection, and were comparable for the three groups. At birth, neonatal body weights and brain-to-body weight ratios were also comparable. Both motor and sensory neurobehavioral scores were comparable. There were no differences in neuron density or proliferation. Sham pups, had a lower synaptic density in the hippocampus as compared to the medication group, however there was no difference in the other brain areas. CONCLUSION: In the rabbit model, fetal medication does not appear to lead to short-term neurocognitive effects.

Therapeutic Rationale for Endotoxin Removal with Polymyxin B Immobilized Fiber Column (PMX) for Septic Shock.

Endotoxin removal therapy with polymyxin B immobilized fiber column (PMX) has been clinically applied for sepsis and septic shock patients since 1994. The effectiveness and usefulness of this therapy have been demonstrated for more than a quarter of a century. However, a documented survival benefit has not yet been demonstrable in a large, multicenter, randomized and controlled trial. Following the findings derived from a large sepsis clinical trial with PMX in North America, a new trial is ongoing to determine if PMX has a long-term survival benefit when administered to septic patients. Another approach to support a survival benefit from intervention with PMX is to utilize a detailed analysis available from a large clinical data base. The endotoxin adsorption capacity of PMX columns in vitro and the effectiveness of PMX columns can be further demonstrable in animal models. The capability of PMX and details of its mechanism of action to intervene in the sepsis cascade and impede organ dysfunction in septic patients is not fully understood. The surface antigen expression in monocytes and neutrophils are improved after PMX therapy. Immunomodulatory effects as a result of endotoxin removal and/or other mechanisms of action have been suggested. These effects and other potential immune effects may explain some of the improved effects upon organ dysfunction of sepsis and septic shock patients. Endotoxemia may be involved in the pathophysiology of other diseases than sepsis. A rapid diagnostic method to detect and target endotoxemia could allow us to practice precision medicine and expand the clinical indications of endotoxin removal therapy.

Impact of Cervical Collars on Intracranial Pressure Values in Traumatic Brain Injury: A Systematic Review and Meta-Analysis of Prospective Studies.

BACKGROUND: Spinal cord injury (SCI) is present in around 2-4% of trauma victims. More than half of this injuries are located at the cervical region. Twenty percent of victims with cervical spinal trauma and 5% of patients with severe traumatic brain injury (TBI) will have an SCI. Cervical immobilization with rigid or semirigid collars is routinely used as prophylactic or definitive treatment intervention in general trauma care. An important adverse effect of cervical collars application is the increase in intracranial pressure (ICP) values. This systematic review and meta-analysis aim to estimate the overall magnitude of ICP changes after cervical collar application. METHODS: Major electronic databases (Ovid/Medline, Embase and Cochrane Library) were systematically searched for prospective studies that assessed ICP changes after cervical collar applications. Study level characteristics and ICP values before, during and after cervical collar application, were extracted. The meta-analysis was performed using random-effects model. RESULTS: Five studies comprising 86 patients were included in the systematic review and the quantitative synthesis. The overall increase in ICP after collar application was statistically significant (weighted mean difference [WMD] = 4.43; 95%CI 1.70, 7.17; P < 0.01), meaning an overall ICP increase of approximately 4.4 mmHg. The decrease in ICP values after collar removal reached statistical significance (WMD = - 2.99; 95%CI - 5.45, - 0.52; P = 0.02), meaning an overall ICP decrease of approximately 3 mmHg after collar removal. ICP values before and after cervical collar application were not statistically significant (WMD = 0.49; 95%CI - 1.61, 2.59; P = 0.65), meaning no ICP change. CONCLUSIONS: Heterogeneous studies of application of cervical collars as a partial motion restriction strategy after injuries have demonstrated increases in ICP in TBI patients. Increases in ICP can induce complications in TBI patients. Appropriate selection criteria for cervical motion restriction in TBI patients need to be considered.

Pressure injury development in critically ill patients with a cervical collar in situ: A retrospective longitudinal study.

Trauma patients with a serious injury to the head or neck can remain immobilised with a cervical collar (C-collar) device in situ and are subsequently exposed to device-related skin integrity threats. This study aimed to determine the incidence and risk factors associated with the development of C-collar-related pressure injures (CRPIs) in an intensive care unit. This retrospective longitudinal cohort study was conducted in an Australian metropolitan intensive care unit. Following ethical approval, data from patients over 18 years, who received a C-collar were retrieved over a 9-year period. Chi square and t-tests were used to identify variables associated with CRPI development. A logistic regression model was employed to analyse the risk factors. Data from 906 patients were analysed. Nine-year pressure injury incidence was 16.9% (n = 154/906). Pressure injury development directly associated with a C-collar increased by 33% with each repositioning episode (odds ratio 1.328, 95% confidence interval 1.024-1.723, P = .033). Time in the C-collar (10.4 to 2.5 days, P = .002) and length of stay in intensive care unit (ICU) (20.1 to 16.1 days, P < .001) were associated with pressure injury development. Patients with C-collar devices are a vulnerable group at risk for pressure injury development because of their immobility and length of ICU stay.

The effects of spinal immobilization at 20° on intracranial pressure.

OBJECTIVE: In this study, it was aimed to evaluate whether spinal immobilization at 20°, instead of the traditional 0°, affects intracranial pressure (ICP) via the ultrasonographic (USG) measurement of optic nerve sheath diameter (ONSD). METHODS: 140 healthy, adult, non-smoking volunteers who had no acute or chronic diseases were included this study. Volunteers were randomly divided into two groups; performed spinal immobilization at 0° (Group 1) and at 20° (Group 2). After spinal immobilization (at 0 or 20°), measurements of ONSD were performed at 0, 30, and 60 min in an immobilized position. RESULTS: When evaluating the change in ONSD over time (at 30 and 60 min) as compared to basal measurements at 0 min, it was found that the ONSD values of both sides (the right and left eyes) were significantly increased in Group 1 and Group 2. For Groups 1 and 2, these differences existed both between 0 and 30 min and between 30 and 60 min. In addition, in this study, the amounts of increase in the ONSD measurements from 0 to 30 min and from 30 to 60 min (ΔONSD0-30 min and ΔONSD30-60 min) in both groups were compared. The results showed that there was no significant difference between Group 1 and Group 2 in terms of ΔONSD measurements. CONCLUSIONS: Spinal immobilization at 0° as a part of routine trauma management increased ONSD and thus ICP. Secondly, we found that similar to immobilization at 0°, spinal immobilization at 20° increased ONSD.

Retrospective audit of airway management practices in children with craniocervical pathology.

BACKGROUND: Craniocervical immobilization using halo body orthoses may be required in the management of children with craniocervical junction pathology. To date, the effect of such immobilization on perioperative anesthetic management has not been addressed in large series. AIMS: The aim of this study was to review the airway management of children requiring halo body orthoses undergoing general anesthesia. METHODS: The study was a retrospective case note review from a single institution. The neurosurgical database was interrogated to identify all patients less than 16 years of age that required a halo body orthosis from 1996 to 2015. We used the electronic patient record to identify all procedures performed under general anesthesia for these patients, either for halo application, or with the halo in situ. Details of techniques used for airway management were recorded, and paired data between individuals pre- and post-halo application were compared. Demographic data, diagnosis, and perioperative complications were also recorded. RESULTS: We identified 90 children that underwent placement of a halo body orthosis. A total of 269 anesthetic records from these patients were analyzed and classified as pre-halo application, or halo in situ. Facemask ventilation was achieved in all patients, though some required simple airway adjuncts and may have been more difficult in the presence of the halo. Supraglottic airways were used successfully in many patients. There was a significant increase in the number of patients classed as Cormack and Lehane grades 3 or 4 on direct laryngoscopy with the halo in situ compared with before the halo was applied. The incidence of intubation using fiberoptic or videolaryngoscopy was higher with the halo in situ. Multiple intubation attempts were required in 3.4% (1/29) of patients undergoing anesthesia for halo placement compared with 15.1% (11/73) undergoing anesthesia with a halo in situ. CONCLUSION: Airway management in children with cervical spine pathology should be anticipated to be more difficult than the general pediatric population. This is likely to be due to co-existing pathology associated with cervical spine disease in children, limitation of neck movement to prevent further neurological injury, and the halo itself limiting access to the head. We recommend advanced preparation, and ensuring the immediate availability of an anesthetist with skills in managing the pediatric difficult airway to avoid complications in this patient population.

Customized double-shell immobilization device combined with VMAT radiation treatment of basosquamous cell carcinoma of the scalp.

Malignancies with a superficial involvement of the scalp/skull present technical challenges for radiation-treatment-planning, such as achieving skin coverage with the prescribed dose and with the desirable conformity, homogeneity, and lower brain dose. We report a radiotherapy treatment technique for a patient diagnosed with diffuse basosquamous cell carcinoma of the scalp and adjacent skull-bone. This study presents the plan's quality parameters, patient's dosimetry, and patient's outcome. The patient was treated using volume-modulated-arc therapy (VMAT) and a double-shell-bolus full-head device (DSBFD) designed for patient immobilization and better skin coverage. A VMAT plan was generated using an Eclipse treatment-planning system for a prescribed dose of 60 Gy in 30 fractions. The treatment plan was analyzed to determine the conformity index (CI), the homogeneity index (HI), the target-coverage, and the dose to the organs-at-risk (OARs). Skin-doses were measured using optically stimulated luminescence (OSL) dosimeters. Clinical follow-up was performed by the radiation oncologist during and after the course of radiotherapy. With regard to planning target volume (PTV) coverage, the V95 was 99%. The measured and calculated dose to the skin was in the range 100-108% of the prescribed dose. The mean brain-PTV dose was 711 cGy. The CI and HI were 1.09 and 1.08, respectively. The mean positioning accuracy for the patient over the course of treatment was within 2 mm. The measured accumulated skin dose and planning dose was agreed within 2%. Clinical examination of the patient 6 months after radiotherapy showed good response to the treatment and a 90% reduction in scarring. The DSBFD technique combined with RapidArc treatment was useful in terms of the target dose distribution and coverage. Daily patient alignment was found very precise, reproducible and less time-consuming.

Impact of use of optical surface imaging on initial patient setup for stereotactic body radiotherapy treatments.

PURPOSE: To evaluate the effectiveness of surface image guidance (SG) for pre-imaging setup of stereotactic body radiotherapy (SBRT) patients, and to investigate the impact of SG reference surface selection on this process. METHODS AND MATERIALS: 284 SBRT fractions (SG-SBRT = 113, non-SG-SBRT = 171) were retrospectively evaluated. Differences between initial (pre-imaging) and treatment couch positions were extracted from the record-and-verify system and compared for the two groups. Rotational setup discrepancies were also computed. The utility of orthogonal kVs in reducing CBCT shifts in the SG-SBRT/non-SG-SBRT groups was also calculated. Additionally, the number of CBCTs acquired for setup was recorded and the average for each cohort was compared. These data served to evaluate the effectiveness of surface imaging in pre-imaging patient positioning and its potential impact on the necessity of including orthogonal kVs for setup. Since reference surface selection can affect SG setup, daily surface reproducibility was estimated by comparing camera-acquired surface references (VRT surface) at each fraction to the external surface of the planning CT (DICOM surface) and to the VRT surface from the previous fraction. RESULTS: The reduction in all initial-to-treatment translation/rotation differences when using SG-SBRT was statistically significant (Rank-Sum test, α = 0.05). Orthogonal kV imaging kept CBCT shifts below reimaging thresholds in 19%/51% of fractions for SG-SBRT/non-SG-SBRT cohorts. Differences in average number of CBCTs acquired were not statistically significant. The reference surface study found no statistically significant differences between the use of DICOM or VRT surfaces. CONCLUSIONS: SG-SBRT improved pre-imaging treatment setup compared to in-room laser localization alone. It decreased the necessity of orthogonal kV imaging prior to CBCT but did not affect the average number of CBCTs acquired for setup. The selection of reference surface did not have a significant impact on initial patient positioning.

The Impact of Head of Bed Elevation on Optic Nerve Sheath Diameter in Cervical Collar Applied Healthy Volunteers.

BACKGROUND: Guidelines recommend placing a cervical collar (c-collar) until spinal injury is excluded. Previous studies have shown that c-collar placement increases intracranial pressure (ICP), which can worsen outcomes for trauma patients who are at risk of increased ICP. Head of bed elevation (HBE) has been found to decrease ICP. However, there is no consensus in the literature for the optimal degree of HBE to decrease ICP. OBJECTIVE: We aimed to find an optimal HBE degree to decrease ICP to its baseline values in healthy volunteers with increased ICP caused by c-collar. METHODS: This is a randomized controlled and blinded study performed in healthy volunteers. Two sonographers measured the optic nerve sheath diameter (ONSD) of each subject's eyes separately for different time points. Then, we calculated a mean ONSD value for five time points: before c-collar placement (T0), 5 and 20 min in supine position after c-collar placement (T5 and T20), and 5 and 20 min after HBE (T25 and T40). We randomized the subjects into three groups of HBE: 15, 30, and 45°, and compared the mean ONSD values among groups. RESULTS: All groups were similar with regard to baseline demographics and ONSD measurements before HBE. We found significant increases in mean ONSD values at T5 and at T20 caused by the c-collar. Thirty and forty-five degrees of HBE for 20 min decreased ONSD to its baseline values. The inter-rater reliability of the sonographers was > 0.9. CONCLUSIONS: Our results show that c-collar increases ONSD in healthy volunteers. Elevating the head of the bed 30 and 45° for 20 min decreased ONSD to baseline values.

Investigating the time-lapsed effects of rigid cervical collars on the dimensions of the internal jugular vein.

Protocol advocates the use of rigid cervical collars (RCCs) in head trauma patients as they are at risk of concomitant cervical spine injury. Literature has shown RCCs to be a potential cause of venous outflow obstruction, changing internal jugular vein (IJV) cross-sectional area (CSA), and raising intracranial pressure (ICP). This study aims to investigate the effects of applying a RCC, for a period of four hours, on the dimensions of the IJV, in healthy participants. Seventeen participants (nine male, eight female) took part in this study. Circumference and CSAs of the IJV were measured bilaterally by a single observer using a GE LOGIQ e ultrasound system. Measurements were taken pre-RCC application, immediately after, every hour over four hours, and five minutes postcollar removal. The CSA of the IJV was 8.3 ±6.0 mm2 pre-RCC application. The CSA of the IJV doubled (18.92 ±10.55 mm2 ) after four hours and decreased back to 9.36 ±6.8 mm2 five minutes postcollar removal. The circumference of the IJV was 17.29 ±6.03 mm pre-RCC application, increasing to 20.34 ±5.59 mm by the end of the fourth hour and returning to 16.14 ±5.16 mm five minutes postcollar removal. Related-samples Friedman's ANOVA test showed statistically significant differences for both left and right CSAs and circumferences of the IJV measured across the four hours (P-value<0.05). Ultrasound assessment of CSA of the IJV may correlate with changes in ICP. Further studies may provide insight into the effects of collar design, and guide future trauma protocol to minimize intracranial pressure fluctuations. Clin. Anat. 32:196-200, 2019. © 2018 Wiley Periodicals, Inc.

Duration of immobilization after developmental dysplasia of the hip and open reduction surgery.

BACKGROUND: There is no consensus about the duration of post-operative immobilization in the treatment of DDH (developmental dysplasia of hip). Our aim in this study is to compare between two post-operative immobilization protocols for patients undergoing open reduction. MATERIALS AND METHODS: Thirty-eight hips in 32 patients assigned to group A were immobilized in hip spica for four weeks followed by abduction brace application which was gradually weaned through the periods of several months and 29 hips in 24 patients assigned to group B immobilized in hip spica for 12 weeks without further bracing. Both groups were surgically reduced using anterior approach between the ages of 12-24 months. RESULTS: There were non-significant statistical difference between both groups as regards clinical and radiological outcome but there is significant statistical difference as regards AVN (avascular necrosis) on follow-up between both groups. The rate of AVN cannot be related to the method of immobilization, as there are many factors can lead to AVN of the hip as immobilization in an extreme position and tight reduction. CONCLUSION: Group A post-operative immobilization protocol is safer and associated with less complications and more comfortable to the patient and parents than that used in group B. Early removal of hip spica cast and application of hip abduction brace does not increase the rate of re-dislocation. LEVEL OF EVIDENCE: Level III Retrospective comparative study.

Improvised vs Standard Cervical Collar to Restrict Spine Movement in the Backcountry Environment.

INTRODUCTION: To compare the effectiveness of a molded fleece jacket with that of a standard cervical collar at limiting movement of the cervical spine in 3 different directions. METHODS: This is a prospective study using 24 healthy volunteers to measure cervical flexion/extension, rotation, and lateral flexion with both the fleece collar and the standard cervical collar. A hand-held goniometer was used for measurements. The results were then analyzed for the 3 independent movements using a noninferiority test. RESULTS: The fleece collar was determined to be noninferior at limiting the designated motions. Comfort was greater while wearing the improvised fleece collar. CONCLUSIONS: Our small study demonstrated that mountain travelers and rescuers may be able to use an improvised fleece jacket collar in place of a standard collar if spine trauma is suspected after a backcountry accident. Further research should examine different types of improvised collars, their ability to remain in place over extended evacuations, and when to apply collars to backcountry patients.

Errors in cervical spine immobilization during pediatric trauma evaluation.

BACKGROUND: The purpose of this study was to identify factors during trauma evaluation that increase the likelihood of errors in cervical spine immobilization ('lapses'). MATERIALS AND METHODS: Multivariate analysis was used to identify the associations between patient characteristics, event features, and tasks performed in proximity to the head and neck and the occurrence and duration of a lapse in maintaining cervical spine immobilization during 56 pediatric trauma evaluations. RESULTS: Lapses in cervical spine immobilization occurred in 71.4% of patients (n = 40), with an average of 1.2 ± 1.3 lapses per patient. Head and neck tasks classified as oxygen manipulation occurred an average of 12.2 ± 9.7 times per patient, whereas those related to neck examination and cervical collar manipulation occurred an average of 2.7 ± 1.7 and 2.1 ± 1.2 times per patient, respectively. More oxygen-related tasks were performed among patients who had than those who did not have a lapse (27.3 ± 16.5 versus 11.5 ± 8.0 tasks, P = 0.001). Patients who had cervical collar placement or manipulation had a two-fold higher risk of a lapse than those who did not have these tasks performed (OR 1.92, 95% CI 0.56, 3.28, P = 0.006). More lapses occurred during evaluations on the weekend (P = 0.01), when more tasks related to supplemental oxygen manipulation were performed (P = 0.02) and when more tasks associated with cervical collar management were performed (P < 0.001). CONCLUSIONS: Errors in cervical spine immobilization were frequently observed during the initial evaluation of injured children. Strategies to reduce these errors should target approaches to head and neck management during the primary and secondary phases of trauma evaluation.

Compulsory Use of the Backboard is Associated with Increased Frequency of Thoracolumbar Imaging.

BACKGROUND: Backboards have been shown to cause pain in uninjured patients. This may alter physical exam findings, leading emergency department (ED) providers to suspect a spinal injury when none exists resulting in additional imaging of the thoracolumbar spine. New York had previously employed a "Spinal Immobilization" protocol that included compulsory backboard application for all patients with suspected spinal injuries. In 2015, New York instituted a new "Spinal Motion Restriction" protocol that made backboard use optional for these patients. The objective of this study was to determine if this protocol change was associated with decreased backboard utilization and ED thoracolumbar spine imaging. METHODS: This was a retrospective before-and-after chart review of subjects transported by a single emergency medical services (EMS) agency to one of four EDs for emergency calls dispatched as motor vehicle collisions (MVC). EMS and ED data were included for all calls within a 6-month interval before and after the protocol change. The protocol change was implemented in the second half of 2015. Subject demographics, backboard use, and spine imaging were reviewed for the intervals January-June 2015 and January-June 2016. RESULTS: There were 818 subjects in the before period and 796 subjects in the after period. Subjects were similar in terms of gender, age and type of MVC in both periods. A backboard was utilized for 440 (54%) subjects in the before period and 92 (12%) subjects in the after period (p < 0.001). ED thoracic spine imaging was performed on 285 (35%) subjects in the before period, and 235 (30%) subjects in the after period (p = 0.02). ED lumbar spine imaging was performed for 335 (41%) subjects in the before period, and 281 (35%) subjects in the after period (p = 0.02). CONCLUSION: A shift from a spinal immobilization protocol to a spinal motion restriction protocol was associated with a decrease in backboard utilization by EMS providers and a decrease in thoracolumbar spine imaging by ED providers.

To frame or not to frame? Cone-beam CT-based analysis of head immobilization devices specific to linac-based stereotactic radiosurgery and radiotherapy.

PURPOSE: Noninvasive frameless systems are increasingly being utilized for head immobilization in stereotactic radiosurgery (SRS). Knowing the head positioning reproducibility of frameless systems and their respective ability to limit intrafractional head motion is important in order to safely perform SRS. The purpose of this study was to evaluate and compare the intrafractional head motion of an invasive frame and a series of frameless systems for single fraction SRS and fractionated/hypofractionated stereotactic radiotherapy (FSRT/HF-SRT). METHODS: The noninvasive PinPoint system was used on 15 HF-SRT and 21 SRS patients. Intrafractional motion for these patients was compared to 15 SRS patients immobilized with Cosman-Roberts-Wells (CRW) frame, and a FSRT population that respectively included 23, 32, and 15 patients immobilized using Gill-Thomas-Cosman (GTC) frame, Uniframe, and Orfit. All HF-SRT and FSRT patients were treated using intensity-modulated radiation therapy on a linear accelerator equipped with cone-beam CT (CBCT) and a robotic couch. SRS patients were treated using gantry-mounted stereotactic cones. The CBCT image-guidance protocol included initial setup, pretreatment and post-treatment verification images. The residual error determined from the post-treatment CBCT was used as a surrogate for intrafractional head motion during treatment. RESULTS: The mean intrafractional motion over all fractions with PinPoint was 0.62 ± 0.33 mm and 0.45 ± 0.33 mm, respectively, for the HF-SRT and SRS cohort of patients (P-value = 0.266). For CRW, GTC, Orfit, and Uniframe, the mean intrafractional motions were 0.30 ± 0.21 mm, 0.54 ± 0.76 mm, 0.73 ± 0.49 mm, and 0.76 ± 0.51 mm, respectively. For CRW, PinPoint, GTC, Orfit, and Uniframe, intrafractional motion exceeded 1.5 mm in 0%, 0%, 5%, 6%, and 8% of all fractions treated, respectively. CONCLUSIONS: The noninvasive PinPoint system and the invasive CRW frame stringently limit cranial intrafractional motion, while the latter provides superior immobilization. Based on the results of this study, our clinical practice for malignant tumors has evolved to apply an invasive CRW frame only for metastases in eloquent locations to minimize normal tissue exposure.

The position of sling immobilization influences the outcomes of anatomic total shoulder arthroplasty: a randomized, single-blind, prospective study.

BACKGROUND: To date, no studies have been published that have assessed the optimal position of sling immobilization after anatomic total shoulder arthroplasty for glenohumeral osteoarthritis. METHODS: Thirty-six patients undergoing anatomic total shoulder arthroplasty for osteoarthritis were randomized to a neutral rotation sling versus an internal rotation sling. The primary outcomes assessed included the Disabilities of the Arm, Shoulder and Hand score; Western Ontario Osteoarthritis of the Shoulder score; Single Assessment Numeric Evaluation score; visual analog scale (VAS) scores for pain and satisfaction; compliance ratings; and radiographic and range-of-motion measurements. Primary outcomes were assessed at baseline and postoperatively at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year. RESULTS: All patient-determined outcome scores for both groups revealed statistically significant improvements (P < .0001) from enrollment to final follow-up. There were statistically significant advantages to the neutral rotation sling group compared with the internal rotation sling group when we evaluated the improvements in (1) active external rotation (42° vs 25°, P = .03), (2) passive external rotation (44° vs 26°, P = .02), (3) passive horizontal adduction (7.7 cm vs 3.7 cm, P = .05), and (4) pain relief with passive adduction (VAS score, 6.2 cm vs 3.5 cm; P = .002). There was a trend toward greater improvements in the neutral rotation sling group when we measured (1) active horizontal adduction (8.3 cm vs 2.9 cm, P = .06) and (2) active internal rotation behind the back (18 cm vs 11.1 cm, P = .09). At 2 weeks, the neutral rotation sling group had significantly less night pain than the internal rotation sling group (mean VAS score, 18 mm vs 34 mm; P = .047). CONCLUSIONS: Neutral rotation sling use after anatomic total shoulder arthroplasty resulted in statistically significant improvements in external rotation and adduction, as well as decreased night pain, compared with an internal rotation sling.

[Positioning of external pelvic stabilization devices in patients with multiple injuries : Retrospective computed tomographic evaluation]. / Lage von externen Beckenstabilisatoren bei polytraumatisierten Patienten : Retrospektive computertomographische Evaluation.

BACKGROUND: Severe hemorrhage is a dreaded complication of pelvic fractures. It has a significant impact on early trauma-associated mortality. Hemorrhage that is secondary to pelvic fractures can be reduced by external stabilization devices. Despite the commercial availability of many different systems, they are infrequently used. The aim of this computed tomography (CT) study was to examine the use of external pelvic stabilization devices. METHODS: Between 1 January 2011 and 31 December 2015 a total of 982 images produced in CT trauma scans at a level 1 trauma centre were retrospectively examined with respect to the presence of external pelvic stabilizers. The type of device applied, its actual position including deviation from optimal position as well as pelvic parameters and complications were determined. RESULTS: In 67 out of 982 patients (6.82%) with suspected multiple trauma, an external pelvic stabilizer was employed. In 41.8% the devices were not placed in concordance with prevailing scientific knowledge, 53.73% of devices did not comply with the manufacturer's instructions and 51.85% of systems with pneumatic cuffs caused significant malrotation. In one patient the cuff induced hypoperfusion of the leg but without further sequelae. CONCLUSION: While the prehospital use of pelvic slings is increasing, misplacement is very common. Especially inconsistencies between manufacturers' manuals and current scientific knowledge warrant further improvement. In systems with pneumatic cuffs malrotation of the device is common and clinically relevant. Hypoperfusion of the lower extremities is possible and should be taken into account when employing these devices.