Computational Barthel Index: an automated tool for assessing and predicting activities of daily living among nursing home patients.

BACKGROUND: Assessment of functional ability, including activities of daily living (ADLs), is a manual process completed by skilled health professionals. In the presented research, an automated decision support tool, the Computational Barthel Index Tool (CBIT), was constructed that can automatically assess and predict probabilities of current and future ADLs based on patients' medical history. METHODS: The data used to construct the tool include the demographic information, inpatient and outpatient diagnosis codes, and reported disabilities of 181,213 residents of the Department of Veterans Affairs' (VA) Community Living Centers. Supervised machine learning methods were applied to construct the CBIT. Temporal information about times from the first and the most recent occurrence of diagnoses was encoded. Ten-fold cross-validation was used to tune hyperparameters, and independent test sets were used to evaluate models using AUC, accuracy, recall and precision. Random forest achieved the best model quality. Models were calibrated using isotonic regression. RESULTS: The unabridged version of CBIT uses 578 patient characteristics and achieved average AUC of 0.94 (0.93-0.95), accuracy of 0.90 (0.89-0.91), precision of 0.91 (0.89-0.92), and recall of 0.90 (0.84-0.95) when re-evaluating patients. CBIT is also capable of predicting ADLs up to one year ahead, with accuracy decreasing over time, giving average AUC of 0.77 (0.73-0.79), accuracy of 0.73 (0.69-0.80), precision of 0.74 (0.66-0.81), and recall of 0.69 (0.34-0.96). A simplified version of CBIT with 50 top patient characteristics reached performance that does not significantly differ from full CBIT. CONCLUSION: Discharge planners, disability application reviewers and clinicians evaluating comparative effectiveness of treatments can use CBIT to assess and predict information on functional status of patients.

Management and Outcomes of Spontaneous Pneumomediastinum in Children.

OBJECTIVES: Management of spontaneous pneumomediastinum in the pediatric population is highly variable. There are limited data on the use of diagnostic tests and the need for admission. Our objectives were to characterize the management of pediatric spontaneous pneumomediastinum, determine the diagnostic yield of advanced imaging, and describe the patients' outcomes. METHODS: This is a retrospective cohort study of all patients presenting to a single tertiary pediatric emergency department between January 2008 and February 2015 diagnosed with pneumomediastinum. Patients were identified using 2 complementary strategies: International Classification of Diseases, Ninth Revision billing codes and a keyword search of the hospital radiology database. RESULTS: We identified 183 patients with spontaneous pneumomediastinum. The mean age was 12.8 ± 4.8 years. Diagnosis was established by chest radiograph (CXR) in 165 (90%) patients, chest computed tomography in 15 (8%), neck imaging in 2 (1%), and abdominal imaging in 1. After diagnosis, many patients underwent additional studies: repeat CXR (99, 54%), chest computed tomography (53, 29%), esophagram (45, 25%), and laryngoscopy (15, 8%). Seventy-eight percent of patients (n = 142) were admitted with a median length of stay of 27 hours (18.4-45.6 hours). Six patients returned to the emergency department within 96 hours for persistent chest pain; 2 were admitted, and 1 was found to have worsening pneumomediastinum on CXR. We performed a secondary analysis on 3 key subgroups: primary spontaneous pneumomediastinum (64, 35%), secondary gastrointestinal-associated pneumomediastinum (31, 17%), and secondary respiratory-associated pneumomediastinum (88, 48%). No patients in the study received an invasive intervention for pneumomediastinum. In all patients, further studies did not yield additional diagnostic information. CONCLUSIONS: Our data suggest that patients with spontaneous pneumomediastinum who are clinically well appearing can be managed conservatively with clinical observation, avoiding exposure to radiation and invasive procedures.

Myelopathy Improvement Following Removal of Cervical Sublaminar Wiring.

Posterior cervical wiring has been used by spine surgeons in fixation procedures for patients with spinal instability. It is historically considered an effective method of treating cervical instability with a low risk of complications leading to neurological deterioration. We experienced a case of delayed neurological decline associated with myelopathy, lower extremity spasticity, and associated syringomyelia secondary to instrumentation failure and resultant sublaminar wire protrusion into the cervical spinal cord. In the present case, the construct was removed and the patient underwent a durotomy repair and a posterior fusion of cervical levels 1 and 2 via screw placement under image guidance with a subsequent functional improvement back to baseline. We report this case and review the literature on the complications associated with cervical wire fusion and the methods of minimizing these risks.

Simultaneous Resection of Multiple Metastatic Brain Tumors with Multiple Keyhole Craniotomies.

BACKGROUND: The proper management of symptomatic patients with 2 or more brain metastases is not entirely clear, and the surgical outcomes of these patients undergoing multiple simultaneous craniotomies have not been well described. In this article, we describe patient outcomes after simultaneously resecting metastatic lesions through multiple keyhole craniotomies. METHODS: We conducted a retrospective review of data obtained for all patients undergoing resection of multiple brain metastases in one operation between 2014 and 2016. We describe a technique for resecting multiple metastatic lesions and share the patient outcomes of this operation. RESULTS: Twenty patients with 46 tumor resections were included in the study. The primary site of metastases for the majority of patients was lung, followed by melanoma, renal, breast, colon, and testes. Nine of 20 (45%) patients had 2 preoperative intracranial lesions, and 11 (55%) had three or more. Karnofsky performance scales were calculated for 14 patients: postoperatively 10 of 14 (71%) scores improved, 2 of 14 (14%) worsened, and 2 of 14 (14%) remained unchanged. After surgery, 9 of 14 (64%) patients were weaned off steroids by 2-month follow-up. The overall median survival time from date of surgery was 10.8 months. CONCLUSIONS: We present patient outcomes after simultaneously resecting metastatic brain tumors through multiple keyhole craniotomies in symptomatic patients. Our results suggest comparable outcomes and similar surgical risk compared with those undergoing resection of a single brain metastasis. Resection of multiple brain metastases may improve Karnofsky Performance Scale scores in the early postoperative period and allow patients to be weaned from steroids.

Budget Impact Analysis of Veterans Affairs Medical Foster Homes versus Community Living Centers.

The objectives were to determine whether and by what amounts the US Department of Veterans Affairs (VA) use of Medical Foster Homes (MFH) rather than Community Living Centers (CLC) reduced budget impacts to the VA. This was a retrospective, matched, case-control study of veterans residing in MFH or CLC in the VA health care system from 2008 to 2012. Administrative data sets, nearest neighbor matching, generalized linear models, and a secondary analysis were used to capture and analyze budget impacts by veterans who used MFH or CLC exclusively in 2008-2012. Controls of 1483 veterans in CLC were matched to 203 cases of veterans in MFH. Use of MFH instead of CLC reduced budget impacts to the VA by at least $2645 per veteran per month. A secondary analysis of the data using different matching criteria and statistical methods produced similar results, demonstrating the robustness of the estimates of budget impact. When the average out-of-pocket payments made by MFH residents, not made by CLC residents, were included in the analysis, the net reduction of budget impact ranged from $145 to $2814 per veteran per month or a savings of $1740 to $33,768 per veteran per year. Even though outpatient costs of MFH are higher, much of the reduced budget impact of MFH use arises from lower inpatient or hospital costs. Reduced budget impacts on the VA system indicate that expansion of the MFH program may be cost-effective. Implications for further research are suggested.

Shared Homes as an Alternative to Nursing Home Care: Impact of VA's Medical Foster Home Program on Hospitalization.

PURPOSE OF THE STUDY: This study compares hospitalization rates for common conditions in the Veteran Affairs (VA) Medical Foster Home (MFH) program to VA nursing homes, known as Community Living Centers (CLCs). DESIGN AND METHODS: We used a nested, matched, case control design. We examined 817 MFH residents and matched each to 3 CLC residents selected from a pool of 325,031. CLC and MFH cases were matched on (a) baseline time period, (b) follow-up time period, (c) age, (d) gender, (e) race, (f) risk of mortality calculated from comorbidities, and (g) history of hospitalization for the selected condition during the baseline period. Odds ratio (OR) and related confidence interval (CI) were calculated to contrast MFH cases and matched CLC controls. RESULTS: Compared with matched CLC cases, MFH residents were less likely to be hospitalized for adverse care events, (OR = 0.13, 95% CI = 0.03-0.53), anxiety disorders (OR = 0.52, 95% CI = 0.33-0.80), mood disorders (OR = 0.57, 95% CI = 0.42-0.79), skin infections (OR = 0.22, 95% CI = 0.10-0.51), pressure ulcers (OR = 0.22, 95% CI = 0.09-0.50) and bacterial infections other than tuberculosis or septicemia (OR = 0.54, 95% CI = 0.31-0.92). MFH cases and matched CLC controls did not differ in rates of urinary tract infections, pneumonia, septicemia, suicide/self-injury, falls, other injury besides falls, history of injury, delirium/dementia/cognitive impairments, or adverse drug events. Hospitalization rates were not higher for any conditions studied in the MFH cohort compared with the CLC cohort. IMPLICATIONS: MFH participants had the same or lower rates of hospitalizations for conditions examined compared with CLC controls suggesting that noninstitutional care by a nonfamilial caregiver does not increase hospitalization rates for common medical conditions.

Sequence of Functional Loss and Recovery in Nursing Homes.

PURPOSE OF THE STUDY: This study provides benchmarks for likelihood, number of days until, and sequence of functional decline and recovery. DESIGN AND METHODS: We analyzed activities of daily living (ADLs) of 296,051 residents in Veteran Affairs nursing homes between January 1, 2000 and October 9, 2012. ADLs were extracted from standard minimum data set assessments. Because of significant overlap between short- and long-stay residents, we did not distinguish between these populations. Twenty-five combinations of ADL deficits described the experience of 84.3% of all residents. A network model described transitions among these 25 combinations. The network was used to calculate the shortest, longest, and maximum likelihood paths using backward induction methodology. Longitudinal data were used to derive a Bayesian network that preserved the sequence of occurrence of 9 ADL deficits. RESULTS: The majority of residents (57%) followed 4 pathways in loss of function. The most likely sequence, in order of occurrence, was bathing, grooming, walking, dressing, toileting, bowel continence, urinary continence, transferring, and feeding. The other three paths occurred with reversals in the order of dressing/toileting and bowel/urinary continence. ADL impairments persisted without any change for an average of 164 days (SD = 62). Residents recovered partially or completely from a single impairment in 57% of cases over an average of 119 days (SD = 41). Recovery rates declined as residents developed more than 4 impairments. IMPLICATIONS: Recovery of deficits among those studied followed a relatively predictable path, and although more than half recovered from a single functional deficit, recovery exceeded 100 days suggesting time to recover often occurs over many months.

The VA Medical Foster Home Program, Ambulatory Care Sensitive Conditions, and Avoidable Hospitalizations.

This quality control study analyzes whether the Veterans Administration Medical Foster Home (VA MFH) program has been successful in improving access and effectiveness of ambulatory care. Individuals hospitalized for one or more of 22 adult ambulatory care sensitive conditions were identified. Pre and post comparisons of a specified population of participants in the program were conducted to determine rates of avoidable hospitalizations for 6 months prior to and following MFH enrollment. The overall rate of avoidable hospitalizations declined from 18.5 to 14.9 per 100 enrollees following enrollment. The number of bed days used declined by 39%, as did the cost associated with avoidable hospitalizations. Enrollment in the VA MFH program resulted in an overall reduction in the rate of avoidable hospitalizations, resource utilization, and costs. Studies are needed comparing these results with other matched cohorts of nursing home eligible veterans.

Predicting Functional Decline and Recovery for Residents in Veterans Affairs Nursing Homes.

PURPOSE OF THE STUDY: This article describes methods and accuracy of predicting change in activities of daily living (ADLs) for nursing home patients following hospitalization. DESIGN AND METHODS: Electronic Health Record data for 5,595 residents of Veterans Affairs' (VAs') Community Living Centers (CLCs) aged 70 years and older were analyzed within the VA Informatics and Computing Infrastructure. Data included diagnoses from 7,106 inpatient records, 21,318 functional status evaluations, and 69,140 inpatient diagnoses. The Barthel Index extracted from CLC's Minimum Data Set was used to assess ADLs loss and recovery. Patients' diagnoses on hospital admission, ADL status prior to hospitalization, age, and gender were used alone or in combination to predict ADL loss/gain following hospitalization. Area under the Receiver-Operator Curve (AUC) was used to report accuracy of predictions in short (14 days) and long-term (15-365 days) follow-up post-hospitalization. RESULTS: Admissions fell into 7 distinct patterns of recovery and loss: early recovery 19%, delayed recovery 9%, delayed recovery after temporary decline 9%, early decline 29%, delayed decline 10%, delayed decline after temporary recovery 6%, and no change 18%. Models accurately predicted ADL's 14-day post-hospitalization (AUC for bathing 0.917, bladder 0.842, bowels 0.875, dressing 0.871, eating 0.867, grooming 0.902, toileting 0.882, transfer 0.852, and walking deficits was 0.882). Accuracy declined but remained relatively high when predicting 14-365 days post-hospitalization (AUC ranging from 0.798 to 0.875). IMPLICATIONS: Predictive modeling may allow development of more personalized predictions of functional loss and recovery after hospitalization among nursing home patients.

Risk factors for surgical complications in rotator cuff repair in a veteran population.

BACKGROUND: Technical advances have allowed arthroscopic rotator cuff repair to supplant open repairs with similar outcomes. However, few data exist to support the theoretical decrease in complications with the arthroscopic technique. METHODS: We used the Veterans Administration Surgical Quality Improvement Program database from the entire U.S. Veterans Administration system. We obtained perioperative data of all patients undergoing rotator cuff repair between 2003 and 2008. Single and multivariate analyses were performed to evaluate risk factors for perioperative complications associated with rotator cuff surgery. RESULTS: There were 6975 open rotator cuff repairs and 2918 arthroscopic rotator cuff repairs performed with similar patient age, gender breakdown, body mass index, and comorbidities. Complications occurred in the early postoperative period in 2.1% of the open repair group and 0.9% of the arthroscopic repair group (P < .0001). The prevalence of both superficial and deep wound infection was higher in the open group compared with the arthroscopic group (1% vs. 0.1% superficial, P < .0001; 0.3% vs. 0.1% deep, P = .11). Return to the operating room within the 30-day surveillance period occurred in 1.1% of the open repair patients compared with 0.5% of patients undergoing arthroscopic repairs (P < .0001). -Multivariate logistic regression analysis revealed that the arthroscopic group had a significantly lower risk of complications (P = .0001), a lower rate of superficial infection (P = .0002), a lower incidence of return to the operating room within 30 days (P = .007), and a lower risk of hospital readmission (P < .0001). CONCLUSION: Arthroscopic rotator cuff repair in the veteran population resulted in a lower incidence of perioperative complications compared with open repair.

Microbes and animal olfactory communication: Where do we go from here?

We know that microbes contribute to the production of odors that some animals use to communicate, but how common is this phenomenon? Recent studies capitalizing on new molecular technologies are uncovering fascinating associations between microbes and odors of wild animals, but causality is difficult to ascertain. Fundamental questions about the nature of these unique host-microbe interactions also remain unanswered. For instance, do microbes benefit from signaling associations with hosts? How does microbial community structure influence signal production? How do hosts regulate microbes in order to generate appropriate signals? Here, we review the current state of knowledge on microbially produced signals in animals and discuss key research foci that can advance our understanding of microbial-based signaling in the animal world.

Relationship of relaxin hormone and thumb carpometacarpal joint arthritis.

BACKGROUND: The female predominance in thumb carpometacarpal (CMC) joint arthritis has led to speculation that reproductive hormones or hypermobility are responsible. Evidence shows that patients with pathologic laxity have a higher rate of thumb CMC arthritis. Relaxin hormone increases laxity in the pelvic ligaments through upregulation of matrix metalloproteases (MMPs). It is thus a hormone of interest in the development of thumb CMC arthritis. QUESTIONS/PURPOSES: Our goals were to identify demographic and hormonal factors associated with joint laxity in patients with CMC arthritis and to evaluate the relationship among serum relaxin, relaxin receptors, and MMPs in the anterior oblique ligament (AOL) of the thumb. We hypothesized that serum relaxin was correlated with joint laxity as well as with relaxin receptors and MMPs in the AOL. METHODS: Forty-nine patients undergoing thumb CMC arthroplasty underwent laxity examination, blood draw, and AOL sampling. Ligaments were analyzed for relaxin receptor and MMPs 1 and 3 using quantitative reverse-transcriptase polymerase chain reaction. RESULTS: Women demonstrated more joint laxity than men (p < 0.001). RNA analysis confirmed relaxin receptors in the AOL as well as MMPs 1 and 3. There was a significant correlation between serum relaxin and MMP-1 (p = 0.04). Detectable serum relaxin was negatively correlated with relaxin receptors in the AOL (p = 0.02). CONCLUSIONS: Further studies are needed to evaluate the role of laxity and sex hormones in thumb CMC arthritis. CLINICAL RELEVANCE: Relaxin hormone may play a role in the development of arthritis at the thumb CMC joint. LEVEL OF EVIDENCE: Level I, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Outcomes and complication rates of different bone grafting modalities in long bone fracture nonunions: a retrospective cohort study in 182 patients.

BACKGROUND: Novel bone substitutes have challenged the notion of autologous bone grafting as the 'gold standard' for the surgical treatment of fracture nonunions. The present study was designed to test the hypothesis that autologous bone grafting is equivalent to other bone grafting modalities in the management of fracture nonunions of the long bones. METHODS: A retrospective review of patients with fracture nonunions included in two prospective databases was performed at two US level 1 trauma centers from January 1, 1998 (center 1) or January 1, 2004 (center 2), respectively, until December 31, 2010 (n = 574). Of these, 182 patients required adjunctive bone grafting and were stratified into the following cohorts: autograft (n = 105), allograft (n = 38), allograft and autograft combined (n = 16), and recombinant human bone morphogenetic protein-2 (rhBMP-2) with or without adjunctive bone grafting (n = 23). The primary outcome parameter was time to union. Secondary outcome parameters consisted of complication rates and the rate of revision procedures and revision bone grafting. RESULTS: The autograft cohort had a statistically significant shorter time to union (198 ± 172-225 days) compared to allograft (416 ± 290-543 days) and exhibited a trend towards earlier union when compared to allograft/autograft combined (389 ± 159-619 days) or rhBMP-2 (217 ± 158-277 days). Furthermore, the autograft cohort had the lowest rate of surgical revisions (17%) and revision bone grafting (9%), compared to allograft (47% and 32%), allograft/autograft combined (25% and 31%), or rhBMP-2 (27% and 17%). The overall new-onset postoperative infection rate was significantly lower in the autograft group (12.4%), compared to the allograft cohort (26.3%) (P < 0.05). CONCLUSION: Autologous bone grafting appears to represent the bone grafting modality of choice with regard to safety and efficiency in the surgical management of long bone fracture nonunions.

Veterans with diabetes receive arthroplasty more frequently and at a younger age.

BACKGROUND: A future increase in total joint arthroplasties in patients with diabetes seems likely considering the prevalence of osteoarthritis and diabetes mellitus are increasing. However, the rates of arthroplasty in the population of patients with diabetes are unclear. QUESTIONS/PURPOSES: We sought to determine whether lower extremity arthroplasties in a veteran population with diabetes is different from a similar population without diabetes. The following specific questions were asked: (1) Is the rate of TKA in veterans with diabetes higher than in those without diabetes? (2) Is the rate of THA in veterans with diabetes higher than in those without diabetes? (3) Are arthroplasty revision rates greater in veterans with diabetes than in veterans without diabetes? METHODS: The US Department of Veterans Affairs Health administrative data from fiscal year 2000 was used to identify persons with primary or secondary TKA or THA. The rate of surgeries among a diabetic population was compared with that among a nondiabetic population. RESULTS: The diabetic cohort received total joint arthroplasties at a higher rate than the nondiabetic cohort at all ages younger than 66 years, with a range of odd ratios from 1.3 to 3.4. In answer to our specific questions, (1) the rate of TKA (95% CI, 2.1-3.7), (2) the rate of THA (95% CI, 1.0-2.6), and (3) the rates of arthroplasty revision (95% CI, 0.9-5.8 TKA and 0.7-6.8 THA) were higher in veterans with diabetes. Furthermore, those with diabetes in the youngest age group studied received total joint arthroplasties and revision surgeries at approximately double the rates of those without diabetes. CONCLUSIONS: If these findings hold true for the population as a whole, they imply that clinicians in the United States may see a sharp increase in younger diabetic candidates for joint arthroplasty.

Relationship of serum relaxin to generalized and trapezial-metacarpal joint laxity.

PURPOSE: The reproductive hormone relaxin acts to loosen pelvic ligaments in preparation for childbirth and is thought to be a mediator of joint laxity. The purpose of this study was to evaluate the correlation of serum relaxin with radiographic laxity at the trapezial-metacarpal joint and with generalized joint laxity. METHODS: We enrolled 289 healthy subjects prospectively. Participants completed a demographic questionnaire and were examined for generalized joint hypermobility using the Beighton-Horan scale. Stress radiographs of the trapezial-metacarpal joint were obtained in 163 subjects (56%). Blood samples were collected, and serum relaxin was measured for 287 subjects using enzyme-linked immunosorbent assay for human relaxin-2. RESULTS: The mean serum relaxin level among all subjects was 1.84 pg/mL (range, 0-45.25 pg/mL). Relaxin was not detectable in 166 of 287 samples, whereas the mean serum relaxin level among the 121 subjects with a detectable relaxin level (of 287 total relaxin samples) was 4.37 pg/mL (range, 0.46-45.25 pg/mL). Mean trapezial-metacarpal subluxation ratio scores were higher among those with a detectable relaxin level compared to those without a detectable relaxin level (0.34 vs 0.30 pg/mL). The average Beighton-Horan laxity score was 1.8 (range, 0-9). There was no correlation between generalized joint laxity measures and serum relaxin levels. CONCLUSIONS: In a large volunteer population, we demonstrated a relationship between circulating relaxin and trapezial-metacarpal joint laxity. However, we were unable to show a direct link between serum relaxin and generalized joint laxity. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.