Case-Control Study of Impairments Associated with Recovery from "Pusher Syndrome" after Stroke: Logistic Regression Analyses.

BACKGROUND: Comparing cohorts with similar functional and motor status at admission to inpatient rehabilitation may delineate demographics or impairments associated with recovery from lateropulsion, also known as "pusher syndrome," after stroke based on lesion side. The aim of this case-control study was to determine how demographics and severity of stroke impairments at admission to inpatient rehabilitation distinguish patients who recover from lateropulsion from those who do not. METHODS: Patients with admission motor Functional Independence Measure (FIM) scores less than 31 and contralesional lower extremity Fugl-Meyer motor scores less than 19 out of 34 were included. Burke Lateropulsion Scales score of 2 or higher at the time of discharge from inpatient rehabilitation indicated persistent lateropulsion; a score of 0 or 1 indicated resolved lateropulsion. Logistic regression tests included age, gender, admission Motricity Index score, limb placement error, and cognitive FIM score. χ2 analyses compared groups for neglect. RESULTS: For patients with left brain lesion, older age and worse admission motor status distinguished those with persistent lateropulsion at discharge. For right brain lesion, related factors were older age, greater admission limb placement error, and lower cognitive FIM scores. Visuospatial neglect did not influence recovery from lateropulsion. CONCLUSIONS: Older age and severe impairments were associated with delayed recovery from lateropulsion in a manner specific to lesion side in a sample with motor and functional deficits. The study provides evidence that lesion side and admission characteristics are useful in early decision making for the duration of rehabilitation, selection of interventions, and discharge planning.

History of symptom triggers in patients presenting to the emergency department for asthma.

OBJECTIVES: Understanding triggers is important for managing asthma particularly for patients who seek emergency department (ED) care for exacerbations. The objectives of this analysis were to delineate self-reported triggers in ED patients and to assess associations between triggers and asthma knowledge, severity, and quality of life. METHODS: At the time of an ED visit, 296 patients were asked what were their usual asthma triggers based on a checklist of 25 potential items, and what they thought specifically precipitated their current ED visit. Using standardized scales, patients also were asked about asthma knowledge, severity, and quality of life. RESULTS: The mean age was 44 years and 72% were women. Patients cited a mean of 12 triggers; most patients had diverse triggers spanning respiratory infections, environmental irritants, emotions, allergens, weather, and exercise. Patients with more triggers were more likely to be women (odds ratio (OR) = 2.0, confidence interval (CI) = 1.3, 3.2, p = .002), obese (OR = 1.7, CI = 1.1, 2.5, p = .01), and to not have a smoking history (OR = 1.9, CI = 1.3, 2.9, p = .001). There were no associations between number of triggers and current age, age at diagnosis, education, socioeconomic status, or race/ethnicity. Patients who cited more triggers had more frequent flares (OR = 1.1, CI = 1.1, 1.2, p < .0001), worse quality of life scores (OR 1.6, CI = 1.1, 2.4, p = .02), and were more likely to have been previously hospitalized for asthma (OR = 1.9, CI = 1.3, 2.9, p = .003) and to have previously required oral corticosteroids (OR = 2.9, CI = 1.6, 5.1, p = .003). There was little clustering of specific triggers according to the variables we considered except for more frequent animal allergy in patients diagnosed at a younger age (OR = 2.8, CI = 1.7, 4.5, p < .0001) and worse quality of life in patients citing emotional stress as a trigger (OR = 2.5, CI = 1.5, 4.0, p = .0002). Patients attributed their current ED visit to multiple precipitants, particularly respiratory infections and weather, and these were concordant with what they reported were known triggers. CONCLUSIONS: Patients presenting to the ED for asthma reported multiple triggers spanning diverse classes of precipitants and having more triggers was associated with worse clinical status. ED patients should be instructed that although it may not be possible to eliminate all triggers, mitigating even some triggers can be helpful.

Time to seeking emergency department care for asthma: self-management, clinical features at presentation, and hospitalization.

OBJECTIVES: Understanding the events preceding emergency department (ED) asthma visits can guide patient education regarding managing exacerbations and seeking timely care. The objectives of this analysis were to assess time to seeking ED care, self-management of asthma exacerbations, and clinical status on presentation. METHODS: A total of 296 patients was grouped according to time to seeking ED care: ≤1 day (22%), 2-5 days (44%), and >5 days (34%) and was compared for clinical and psychosocial characteristics. Asthma severity at presentation was obtained from patient report with the Asthma Control Questionnaire (ACQ) and the Asthma Quality of Life Questionnaire (AQLQ) and from physicians' ratings using decision to hospitalize as an indicator of worse status. RESULTS. Mean age was 44 years, 72% were women, 10% had been in the ED in the prior week, and 28% came to the ED by ambulance. Patients who waited longer were more likely to be older, have more depressive symptoms, and have been in the ED in the prior week. They also were more likely to have taken more medications, but they were not more likely to have visited or consulted their outpatient physicians. Patients who waited longer reported worse ACQ (p < .0001) and AQLQ (p = .0002) scores and were more likely to be hospitalized for the current exacerbation (odds ratio 1.9, 95% CI 1.1, 3.2, p = .03). CONCLUSIONS: Patients who waited longer to come to the ED had worse asthma on presentation, had more functional limitations, and were more likely to be hospitalized. The ability to gauge severity of exacerbations and the use of the ED in a timely manner are important but often overlooked are self-management skills that patients should be taught.

A randomized controlled trial of self-management education for asthma patients in the emergency department.

STUDY OBJECTIVE: Patients using the emergency department (ED) for asthma may benefit from self-management education. Our goal is to test an educational intervention in 296 asthma ED patients. METHODS: This was a randomized controlled trial with concealed allocation. Controls received instruction from an asthma knowledge test, peak flowmeter training, and asthma brochures. Intervention patients received these plus a self-management workbook, a behavioral contract, inhaler training, and telephone reinforcements. The main outcome was change in Asthma Quality of Life Questionnaire (AQLQ) score at 8 weeks (a change of 1.5 is a marked clinically important difference). Secondary outcomes were repeated ED visits and change in AQLQ scores at 4, 12, and 16 weeks and 1 year. RESULTS: Mean age of patients was 44 years, and 93% had the 8-week follow-up. Enrollment AQLQ scores were comparable and increased at 8 weeks by more than a marked clinically important difference in both groups. For controls, the change in score was 1.95 (95% confidence interval [CI] 1.74 to 2.16; P<.001), for intervention patients the change in score was 1.83 (95% CI 1.64 to 2.03; P<.001), and the difference between groups was 0.11 (95% CI -0.17 to 0.40; P=.43). Patients who improved more (ie, change was above the group mean) were more likely to be high school graduates (odds ratio=1.9; 95% CI 1.0 to 3.8), previous or current smokers at enrollment (odds ratio=2.2; 95% CI 1.3 to 3.5), and to have been admitted to the hospital from the ED (odds ratio=1.7; 95% CI 1.0 to 2.8). Similar variables were associated with AQLQ outcomes in hierarchic analyses during 16 weeks. Repeated ED visits occurred for 12% of patients at 8 weeks and in multivariate analysis were associated with no hospitalization for the index ED visit, difficult access to outpatient care, and previous ED visits. Fewer patients (16%) had an ED visit at 12 weeks compared with a similar time before enrollment (36%). CONCLUSION: Patients in both groups had marked sustained improvements in clinical status 16 weeks after an ED visit for asthma. A self-management education intervention delivered in the ED and reinforced by telephone was successfully implemented, with high retention rates, but did not provide incremental benefit for quality of life and short-term repeated ED visit outcomes.

Clinical examination tools for lateropulsion or pusher syndrome following stroke: a systematic review of the literature.

OBJECTIVE: To examine the clinimetric properties and clinical applicability of published tools for 'quantifying' the degree of lateropulsion or pusher syndrome following stroke. DATA SOURCES: Search through electronic databases (MEDLINE, EMBASE, CINAHL, Science Citation Index) with the terms lateropulsion, pushing, pusher syndrome, validity, reliability, internal consistency, responsiveness, sensitivity, specificity, posture and stroke. Databases were searched from their inception to October 2008. REVIEW METHODS: Abstracts were selected by one author. A panel of experts then determined which should be included in this review. Five abstracts were reviewed and the panel agreed to omit one abstract because those authors did not write a full manuscript. The panel critiqued manuscripts according to predetermined criteria about clinical and clinimetric properties. RESULTS: Four manuscripts referencing three tools for examining lateropulsion were found. Validity and reliability data support the clinical use of the Scale for Contraversive Pushing, the Modified Scale for Contraversive Pushing and the Burke Lateropulsion Scale. The Scale for Contraversive Pushing has the most extensive testing of clinimetric properties. The other tools show promising preliminary evidence of clinical and research utility. More testing is needed with larger, more diverse samples. REVIEWERS' CONCLUSIONS: The Scale for Contraversive Pushing, the Modified Scale for Contraversive Pushing and the Burke Lateropulsion Scale are reliable and valid measures with good clinical applicability. Larger, more varied samples should be used to better delineate responsiveness and other clinimetric properties of these examination tools.

Poststreptococcal reactive arthritis in children: a retrospective study.

The duration of treatment and appropriate guidelines for antibiotic prophylaxis for children with poststreptococcal reactive arthritis (PSRA) have not been determined. The authors performed a retrospective chart review of 40 children with PSRA and examined their clinical features at initial evaluation and at 6, 12, and 24 months. At baseline, 18% (n = 7) had a finding noted on the echocardiogram. Although most patients developed cardiac findings early on in the course of their disease, 2 patients with a normal baseline echocardiogram may have developed findings after 12 months of follow-up. The mean duration of prophylaxis was 22 months. During the follow-up period, there was improvement in Physician's Global Assessment, number of patients with arthralgia, tender and swollen joints, erythrocyte sedimentation rate, anti-streptolysin O, and anti-DNAse B antibody titers. The authors conclude that marked improvement in clinical features and laboratory values was seen over time. Patients may benefit with long-term cardiac follow-up.

Time to recovery from lateropulsion dependent on key stroke deficits: a retrospective analysis.

BACKGROUND: Lateropulsion, a postural control disorder, delays recovery following hemispheric stroke. The number of stroke impairments may lead to differential recovery rates, depending on the intact systems available for recovery from lateropulsion. OBJECTIVE: To study the impact of key postural control deficits on lateropulsion rate of recovery following stroke. METHODS: Through retrospective analysis: 169 patients with hemispheric stroke in an in-patient rehabilitation facility were divided into 3 groups: (1) motor deficits only; (2) motor and hemianopic or visual-spatial deficits or motor and proprioceptive deficits; and (3) motor, proprioceptive, and hemianopic or visual-spatial deficits. Kaplan-Meier survival analysis determined if time to recovery from lateropulsion (achieving a score of 0 or 1 on the Burke Lateropulsion Scale) differed by group. RESULTS: Log rank tests showed that time to recovery from lateropulsion differed based on the number of deficits (group, P = .012). Post hoc analyses by lesion side showed that group differences only occurred in right brain lesion (P < .05) as compared with left brain lesions (P = .34). Patients recovered from lateropulsion during in-patient rehabilitation if they had only motor deficits; those with all 3 postural control deficits showed the most protracted recovery. CONCLUSIONS: Rate of recovery from lateropulsion after stroke is dependent on the side of lesion, and number of key motor, proprioceptive, and/or hemianopic or visual-spatial deficits. The more postural control systems affected, the slower the recovery. Our data identify patients likely to need protracted rehabilitation targeting key postural control deficits.

Different methods to assess quality of life from multiple follow-ups in a longitudinal asthma study.

BACKGROUND AND OBJECTIVE: Serial measurements obtained during observational longitudinal studies offer the opportunity to describe the effects of chronic diseases on patient-centered outcomes such as quality of life. The purpose of this study was to assess serial Asthma Quality of Life Questionnaire (AQLQ) and SF-36 scores against a transition item using three methods of data analysis-final minus initial scores, maximum minus minimum scores, and regression line slopes through all scores. METHODS: Using receiver operating characteristic (ROC) curves, each method of analysis was compared against patients' responses to a global transition question about change in asthma status with responses dichotomized as "stayed the same or got worse" or "improved." A total of 185 patients, mean age 41+/-11 years, 83% women, completed the AQLQ and SF-36 three to seven times at approximately 8-month intervals over a mean of 24.8+/-3.9 months. For the AQLQ, all three methods of data analysis performed well against the transition item with ROC areas highest for the symptoms, activities, and the summary AQLQ scores (0.74-0.78). RESULTS: Overall, ROC areas increased as the number of observations increased, ranging from 0.78 to 0.93 for the AQLQ summary score for patients with three to six or more assessments, respectively (P =.02). As part of the AQLQ, patients cited specific activities in which they were limited because of asthma. A total of 66 different activities were cited, including limitations in stair climbing, walking, interacting with others, sleeping, and working. In ROC analysis, serial measurements of these items also performed well against the transition item with areas ranging from 0.72 to 0.75 for all three methods of analysis. In contrast, ROC areas for the SF-36 Physical and Mental Component Summary scores were significantly lower, ranging from 0.59 to 0.66 compared to the AQLQ areas, indicating that the generic scale was less responsive than the disease-specific scale (P< or = .01). The three different methods of analysis also provided unique information about the cohort. The final minus initial analysis showed that 63% of patients had clinically important improvements, the maximum minus minimum analysis showed that over 90% of patients had fluctuations in scores that were clinically important, and the slope analysis showed that 79% of patients had an overall trend of improvement. CONCLUSIONS: This study described possible methods to analyze and present serial data. Additional techniques to assess and interpret serial longitudinal data are needed to comprehensively describe long-term effects of chronic diseases on quality of life.

Clinical and radiographic results associated with a modern, cementless modular cup design in total hip arthroplasty.

BACKGROUND: First-generation cementless modular cups reproducibly achieved fixation to bone but were associated with unacceptable rates of pelvic osteolysis and mechanical failure. Consequently, second-generation cups were developed with shells that had a limited number of holes (or no holes) as well as improved locking mechanisms, a polished inner surface, and increased conformity with the liner. The purpose of the present study was to evaluate the clinical and radiographic results associated with the use of a second-generation acetabular component for primary total hip arthroplasty. METHODS: Two hundred and ninety-seven patients underwent 335 consecutive primary total hip arthroplasties that were performed by a single surgeon with a second-generation modular acetabular component. All cups were implanted with a press-fit technique. Ten patients were lost to follow-up, and sixteen died from unrelated causes. The remaining 271 patients (308 hips) were followed clinically (with the Hospital for Special Surgery hip-scoring system) and radiographically for four to seven years. RESULTS: One cup was revised because of aseptic loosening. There were seven additional revisions: five were performed because of aseptic loosening of the stem with a well-fixed cup, and two were performed because of deep infection. Among the 271 patients who were alive at the time of the last follow-up, 266 (98%) had retention of the cup and 264 (97%) had retention of both components with a good or excellent clinical result. In the group of 229 patients (262 hips) with complete radiographic follow-up, 259 cups were well fixed and the average wear rate (for the 246 hips for which this rate could be calculated) was 0.09 mm/yr. Osteolysis was detected in twelve hips (5%) and was associated with male gender (p = 0.001) and the annual wear rate (p = 0.004). The extent of calcar resorption was also associated with the annual wear rate (p < 0.001). CONCLUSIONS: This second-generation acetabular cup design predictably achieved bone fixation and was associated with low rates of revision for loosening and osteolysis after intermediate-term follow-up.

Health related quality of life measure in systemic pediatric rheumatic diseases and its translation to different languages: an international collaboration.

BACKGROUND: Rheumatic diseases in children are associated with significant morbidity and poor health-related quality of life (HRQOL). There is no health-related quality of life (HRQOL) scale available specifically for children with less common rheumatic diseases. These diseases share several features with systemic lupus erythematosus (SLE) such as their chronic episodic nature, multi-systemic involvement, and the need for immunosuppressive medications. HRQOL scale developed for pediatric SLE will likely be applicable to children with systemic inflammatory diseases. FINDINGS: We adapted Simple Measure of Impact of Lupus Erythematosus in Youngsters (SMILEY©) to Simple Measure of Impact of Illness in Youngsters (SMILY©-Illness) and had it reviewed by pediatric rheumatologists for its appropriateness and cultural suitability. We tested SMILY©-Illness in patients with inflammatory rheumatic diseases and then translated it into 28 languages. Nineteen children (79% female, n=15) and 17 parents participated. The mean age was 12±4 years, with median disease duration of 21 months (1-172 months). We translated SMILY©-Illness into the following 28 languages: Danish, Dutch, French (France), English (UK), German (Germany), German (Austria), German (Switzerland), Hebrew, Italian, Portuguese (Brazil), Slovene, Spanish (USA and Puerto Rico), Spanish (Spain), Spanish (Argentina), Spanish (Mexico), Spanish (Venezuela), Turkish, Afrikaans, Arabic (Saudi Arabia), Arabic (Egypt), Czech, Greek, Hindi, Hungarian, Japanese, Romanian, Serbian and Xhosa. CONCLUSION: SMILY©-Illness is a brief, easy to administer and score HRQOL scale for children with systemic rheumatic diseases. It is suitable for use across different age groups and literacy levels. SMILY©-Illness with its available translations may be used as useful adjuncts to clinical practice and research.

Patterns and influence of familial autoimmunity in pediatric systemic lupus erythematosus.

BACKGROUND: A high prevalence of autoimmune disease (AD) has been documented in relatives of adult patients with systemic lupus erythematosus (SLE). However, data on familial inheritance patterns in pediatric SLE patients is scarce. FINDINGS: The charts of 69 patients with pediatric-onset SLE were reviewed retrospectively. The primary aim was to describe the prevalence and types of AD in relatives of children with SLE. The secondary aims were: 1) to compare severity of SLE in children with and without relatives affected by AD, and 2) to evaluate the impact of baseline demographics on severity of SLE in subjects. At diagnosis, 42% of subjects had one or more first, second, or third degree relative(s) with AD; and 32% of subjects had one or more first degree relative(s) with AD. The most common diseases in relatives of children with SLE were SLE (21%) and thyroid disease (15%). Subjects with no family history of AD were more likely to have severe SLE. SLE severity in subjects did not differ by gender. Children presenting with SLE at an earlier age were found to have more severe disease. CONCLUSIONS: This study demonstrated a high prevalence of AD in families of children with SLE, although a family history of AD did not correlate with more severe SLE in subjects. Future larger studies are necessary to elucidate patterns of familial inheritance and baseline patient characteristics that may affect severity of disease in pediatric SLE.

Children with partial IgA deficiency: clinical characteristics observed in the pediatric rheumatology clinic.

Literature is lacking on partial IgA deficiency. In this study, the authors propose to describe the clinical manifestations of patients with partial IgA deficiency. Methods. The authors conducted a retrospective chart review of 13 patients with partial IgA deficiency followed at the pediatric rheumatology clinic at Robert Wood Johnson Medical School. They looked for the presence of rashes, joint pain, joint swelling, and morning stiffness. The authors also examined charts for a history of frequent infections, allergies, and the presence of elevated antinuclear antibody. Results. Eleven out of the 13 patients complained of joint pain, joint swelling, or morning stiffness. Six patients carried a diagnosis of a definitive rheumatic disease. Four patients suffered from frequent infections and 2 patients reported allergies. Conclusion. Partial IgA deficiency appears to be associated with rheumatic diseases and complaints of joint pain, joint swelling, and morning stiffness. A larger study is needed to confirm these results.

Inferior vena cava filter placement in orthopedic surgery.

Inferior vena cava (IVC) filters were developed for the treatment of venous thromboembolism but in high-risk patients are often used for prophylaxis instead. In the study reported here, we reviewed all the orthopedic surgery cases in which IVC filters were used at our institution in 2005. Charts were analyzed and patients contacted by telephone for long-term follow-up. IVC filters were used in 90 (0.96%) of the 9,348 inpatient orthopedic surgeries. Sixty-one percent of filters were placed for prophylaxis, though only 42% of patients with prophylactic filters had a contraindication to anticoagulation. Eighty-one percent of patients with prophylactic filters who received anticoagulation received warfarin. Ratios of prophylactic-to-treatment filters were 3.25 for fracture surgeries, 2.1 for arthroplasties, and 0.89 for spine surgeries. Five percent of patients with prophylactic filters developed deep vein thrombosis. Fifty-two percent of filters were retrievable, but only 40% of those were removed a mean of 5.1 months (SD, 3.9 months) after placement. Filter removal was associated with complications in 11% of patients, and in another 10% the filter could not be removed. Forty-one patients were contacted a mean of 21 months (SD, 3 months) after filter placement. Only 32% of those who still had filters were on anticoagulation at follow-up.

Effectiveness of best practice implementation in reducing hip arthroplasty length of stay.

A transfer of a best practice model was performed between a new institution in the United Kingdom and a leading orthopedic hospital in the United States. The quality concepts transferred to the UK were surgical and hospital throughput, hospital facility design, an Interdisciplinary Preoperative Patient Education Program, infection control standards, and a standardized rehabilitation model. The new hospital was officially opened in February 2004, and the average length of stay for total hip arthroplasty between February and December 2004 was 6.1 +/- 3.0 days, a substantial reduction of 5 days on average. The infection rate was reduced from 1% to 0.16%. This study supports the notion that the implementation of a best practice approach significantly reduces length of stay as well as infection rate.

The agreement and repeatability of computer-based wear measurement of total hip arthroplasties.

We assessed the agreement and repeatability of a software package for wear measurement in 19 total hip arthroplasties followed up for 4 to 8 years. Three observers with different levels of expertise (a hip surgeon [O1], a fellow [O2], and a medical student who is a research assistant of the laboratory in which the software was developed [O3]) determined the 2-dimensional wear and wear direction with the Hip Suite software (University of Chicago, Chicago, Ill). For intraobserver and interobserver comparisons, we used intraclass correlation coefficient (ICC) and repeatability. The intraobserver ICC for wear and wear direction was 0.83 and 0.78 for O1, 0.54 and 0.48 for O2, and 0.81 and 0.89 for 03. The interobserver ICCs were 0.43 (range, 0.07-0.87) for wear and 0.8 (range, 0.71-0.86) for wear direction. Computerized wear measurements have substantial intraobserver and interobserver variability, especially when performed by surgeons without extensive experience in the use of the software, a finding which questions its precision and validity.

Five-year survival in a cohort of hip fracture patients: the predictive role of pre-fracture health status.

The aim was to assess the outcome of surgery at 5 years after hip fracture. In this prospective study, we analyzed 5-year survival of a cohort of 105 hip fracture patients as a function of preoperative health. The main outcome measurements were the status of the patient, dead or alive, and the SF-36 of their pre-fracture status as recalled during their hospital stay. In the fifth year post-hospitalization 58 patients were alive. There was a significant association between the recall SF-36 general health score and being alive in the fifth year (P = 0.0004) and with survival in general (P = 0.0001). This and prior studies support the concept of stratifying hip fracture patients according to pre-fracture health status when assessing outcomes of fracture repair or other interventions. This study further demonstrates the utility of the SF-36 for this purpose.

Semi-degradable scaffold for articular cartilage replacement.

Existing technologies have not met the challenge of designing a construct for the repair of focal cartilage defects such that it mimics the mechanical properties of and can integrate with native cartilage. Herein we describe a novel construct consisting of a non-degradable poly-vinyl alcohol (PVA) scaffold to provide long-term mechanical stability, interconnected pores to allow for the infiltration of chondrocytes, and poly-lactic glycolic acid (PLGA) microspheres for the incorporation of growth factors to enhance cellular migration. The objective of this study was to characterize the morphological features and mechanical properties of our porous PVA-PLGA construct as a function of PLGA content. Varying the PLGA content was found to have a significant effect on the morphological features of the construct. As PLGA content increased from 10% to 75%, samples exhibited a 6-fold increase in average percentage porosity, an increase in average microsphere diameter from 8 to 34 microm and an increase in average pore diameter from 29 to 111 microm. The effect of PLGA content on aggregate modulus and permeability was less profound. Our findings suggest that that morphology of the construct can be tailored to optimize cellular infiltration and the dynamic mechanical response. The experiments herein presented were conducted at the Hospital for Special Surgery.

Randomized trials to modify patients' preoperative expectations of hip and knee arthroplasties.

UNLABELLED: Patients have multiple expectations of THA and TKA. We asked whether preoperative educational classes addressing recovery during the first year could modify patients' expectations of their 12-month postoperative recovery. Participants were enrolled consecutively in two randomized, controlled trials, one for THA (177 patients) and one for TKA (143 patients). Control patients preoperatively received a standard THA or TKA class addressing recovery immediately after surgery. Intervention patients preoperatively received the standard class plus a joint-specific module addressing recovery during the first 12 months. Before and after the class, patients completed either a hip-specific or knee-specific validated expectations survey. The main outcome was the within-patient change in expectation scores (maximum increase, +100; maximum decrease, -100) before and after the class but preoperatively. Mean changes in hip scores were +3.3+/-8 for intervention patients (range, -22+/-32) and +4.9+/-8 for control patients (range, -13+/-29). Mean changes in knee scores were -3.4+/-10 for intervention patients (range, -26+/-33) and +2.4+/-10 for control patients (range, -30+/-30). Patients' preoperative expectations of their recovery from THA or TKA can be modified by preoperative educational classes. LEVEL OF EVIDENCE: Level I, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Thromboembolic disease after combined anterior/posterior reconstruction for adult spinal deformity: a prospective cohort study using magnetic resonance venography.

STUDY DESIGN: Thromboembolic disease (TED) after anterior/posterior spinal reconstructions was prospectively evaluated in 66 consecutive patients. OBJECTIVE: Determine the incidence of TED after anterior/posterior spinal reconstruction. SUMMARY OF BACKGROUND DATA: Few studies have examined the rate of TED after potentially high-risk combined anterior/posterior reconstructions. Magnetic resonance venography (MRV) is more effective at detecting pelvic deep venous thrombosis (DVT) than conventional screening, but has not been used in these patients. METHODS: We undertook a prospective cohort study of 66 consecutive adult patients (mean, 52.7 +/- 9.6 years) undergoing combined anterior/posterior spinal reconstructions for spinal deformity. All patients received only mechanical DVT prophylaxis. After surgery, MRV and bilateral lower extremity Doppler ultrasounds were obtained to screen for DVT, and contrast-enhanced spiral computed tomography scans were obtained for clinical suspicion of pulmonary embolism (PE). RESULTS: The total incidence of postoperative TED was 13.6% (9 patients). The overall rate of DVT was 9.1% (6 patients), one-third occurring in the pelvis. PE developed in 7.6% (5 patients). In 2 patients, PE developed less than 48 hours after positive dopplers. In 3 patients, PE developed despite negative screening studies. Right-sided thoracoabdominal approaches were associated with an increased risk of developing DVT (P = 0.03, Odds Ratio 9.8), PE (P = 0.01, Odds Ratio 20), and TED (P = 0.004, Odds Ratio 12). CONCLUSION: We report a high rate of TED after extensive anterior/posterior spinal reconstructions, for which a right-sided thoracoabdominal approach is an independent risk factor and screening ineffective at preventing PE. These patients should be considered at high risk for postoperative TED.

Functional recovery after hip fracture in the subacute setting.

OBJECTIVE: To measure functional recovery after hip fracture in the subacute setting. BACKGROUND: There are over 340,000 hip fractures that occur in the United States annually. Three out of five hospitalizations attributable to injury among persons over 75 were for fractures. Greater than 50% were hip fractures. PURPOSE: The purpose of this study is to describe the functional recovery after hip fracture in the subacute setting utilizing performance-based measures (PBMs). METHOD: This is a prospective observational cohort. DATA ANALYSIS: Descriptive statistics were used for baseline characteristics. Repeated measures analysis using a Bonferroni correction was utilized to compare admission and discharge PBM scores. RESULTS: Eighty residents were enrolled in the study, of which seven were withdrawn because of medical complications and one subject died within 1 week of admission. Data were analyzed for 72 subjects. There were 59 women and 13 men ranging in age from 63-99. Mean age was 85.3. The patients' profiles were as follows: 53% lived alone, 63% were Medicare recipients, 50% used an assistive device before hip fracture, 46% sustained a femoral neck fracture, 57% underwent a bipolar hemiarthroplasty, 90% received epidural anesthesia, and 90% had a weight-bearing status as weight-bearing was tolerated. The PBM results are as follows: [table: see text] CONCLUSION: There was a significant improvement between admission and discharge TUG test, Tinetti gait and balance test, and 6MW test scores in patients who underwent surgical repair of a hip fracture after a fall.