Development of a decision support tool to prevent community acquired pressure injuries for use in the spinal cord injury clinic using the delphi technique.

STUDY DESIGN: Delphi Technique. OBJECTIVES: Describe the development of a decision support tool to prevent community-acquired pressure injuries (CAPrIs) in individuals with spinal cord injury (SCI) for use in SCI clinics, called the Community-Acquired Pressure Injury Prevention-Field Implementation Tool (CAPP-FIT). SETTING: Veteran Health Administration Hospital, Chicago, Illinois, USA. METHODS: Concept mapping of current pressure injury (PrI) guidelines and qualitative research describing risks, actions, and resources needed to prevent CAPrIs associated with SCI were used to develop 40 veteran checklist items (Items) along with 37 associated provider actions (Actions) for the tool. The Delphi technique was used to refine Items and Actions with a panel of interprofessional SCI providers (n = 15), veterans with SCI (n = 4), and caregivers (n = 3) to determine consensus on a 4-point Likert scale (strongly agree-strongly disagree) for each Item and Action. A 75% agreement was set for responses rated as strongly agree or agree. RESULTS: Panelists were 60% female, 62% White, 33% veterans with SCI or caregivers, 33% wound care certified with a mean age of 59 years. Two survey rounds were required for consensus for 41 Item and 38 Action CAPP-FIT. Response rate was 95% for both rounds. Delphi round 1 showed all but two Actions affirming agreement above 75%. Substantive comments from panelists required revision to 5 Items and 9 Actions and one additional Item/Actions related to coping, meeting threshold percent agreement in Round 2. CONCLUSIONS: The CAPP-FIT could become a useful tool for Veterans living with SCI, caregivers, and SCI providers.

A 76-Year-Old Woman With Incidental Right Middle Lobe Atelectasis.

CASE PRESENTATION: A 76-year-old nonsmoking woman visiting from Honduras for the last 6 months with no known medical history originally presented to the ED complaining of abdominal pain. While in the ED, an incidental right middle lobe collapse was found on CT abdomen scan. Review of systems was positive for a chronic productive cough with white sputum for 3 years. She denied association with fevers, chills, night sweats, hemoptysis, appetite changes, or weight loss.

Goodpasture's Disease: An Uncommon Disease With an Atypical Clinical Course.

Goodpasture's disease is an uncommon composite of features including renal failure with pulmonary hemorrhage secondary to an autoimmune response that specifically targets these organ systems. We present a case of particular interest in regards to atypical presentation, and the uncommon treatment that the patient underwent. A 65-year-old Afghani female arrived with complaints of nausea, vomiting, loss of appetite, malaise, decreased urine output, exertional dyspnea, and cough. The patient presented initially with renal failure and unexpectedly developed respiratory failure after hemodialysis. Initial CT of thorax revealed diffuse bilateral pulmonary edema. Subsequently, the patient received a bronchoscopy demonstrating alveolar hemorrhage, which highlights a clinician's need to maintain a differential and reassess patients. Anti-GBM antibody in the serum was detected and the renal biopsy revealed evidence of the antibody on immunofluorescence. In regards to management, the patient could only be treated with plasmapheresis as she had contraindication to initiation of immunosuppression, after which she showed significant clinical improvement. We would like to highlight the benefit of plasmapheresis without concomitant immunosuppression and recommend such an approach to be considered in similar clinical scenarios, where contraindication for immunosuppressant therapy exists.

Severity of hematuria effects resolution in patients treated with hyperbaric oxygen therapy for radiation-induced hematuria.

INTRODUCTION: We investigated the differences between prostate cancer patients with radiation-induced hematuria treated with hyperbaric oxygen (HBO) therapy that did or did not have a resolution of hematuria. MATERIALS AND METHODS: We performed a retrospective review of prostate cancer patients with radiation-induced hematuria who underwent HBO from April 2000 to March 2010. We performed an analysis of demographic data and severity of hematuria in those who had resolution of or persistent hematuria. Additionally, prostate-specific antigen (PSA) data were also obtained during the study period. RESULTS: Overall, 11/22 men had resolution of hematuria after HBO therapy with a median follow-up of 2.2 (0.35-13.6) years. The Radiation Therapy Oncology Group (RTOG) grade of hematuria is predictive of final hematuria outcome (resolution vs. persistent) after HBO (p = 0.026). No significant PSA changes were noted before and after HBO therapy. CONCLUSIONS: The RTOG hematuria grade is associated with the resolution of hematuria after HBO therapy for radiation-induced hematuria in men treated for prostate cancer. This information may be helpful during shared medical decision-making regarding utility of HBO therapy in the context of severity of hematuria.

The effect of oxandrolone on the healing of chronic pressure ulcers in persons with spinal cord injury: a randomized trial.

BACKGROUND: Anabolic steroids have been reported to improve wound healing. OBJECTIVE: To determine whether oxandrolone increases the percentage of target pressure ulcers (TPUs) that heal compared with placebo and whether healed ulcers remain closed 8 weeks after treatment. DESIGN: Parallel-group, placebo-controlled, randomized trial conducted from 1 August 2005 to 30 November 2008. Patients, clinical care providers, study personnel, and statisticians were blinded to treatment assignment. (ClinicalTrials.gov: NCT00101361). SETTING: 16 inpatient spinal cord injury (SCI) services at Veterans Affairs medical centers. PATIENTS: 1900 prescreened, 779 screened, and 212 randomly assigned inpatients with SCI and stage III or IV TPUs. INTERVENTION: Oxandrolone, 20 mg/d (n = 108), or placebo (n = 104) until the TPU healed or 24 weeks. MEASUREMENTS: The primary outcome was healed TPUs. The secondary outcome was the percentage of TPUs that remained healed at 8-week follow-up. RESULTS: 24.1% (95% CI, 16.0% to 32.1%) of TPUs in oxandrolone recipients and 29.8% (CI, 21.0% to 38.6%) in placebo recipients healed (difference, -5.7 percentage points [CI, -17.5 to 6.8 percentage points]; P = 0.40). At 8-week follow-up, 16.7% (CI, 9.6% to 23.7%) of oxandrolone recipients and 15.4% (CI, 8.5% to 22.3%) of placebo recipients retained a healed TPU (difference, 1.3 percentage points [CI, -8.8 to 11.2 percentage points]; P = 0.70). No serious adverse events were related to oxandrolone. Liver enzyme levels were elevated in 32.4% (CI, 23.6% to 41.2%) of oxandrolone recipients and 2.9% (CI, 0.0% to 6.1%) of placebo recipients (P < 0.001). LIMITATIONS: Selection of severe wounds may have reduced treatment response. Approximately one third of patients did not complete the study in the treatment and placebo groups. The study was terminated after a futility analysis showed a low probability of detecting a significant difference between the groups. CONCLUSION: Oxandrolone showed no benefit over placebo for improving healing or the percentage of TPUs that remained closed after 8 weeks of treatment. PRIMARY FUNDING SOURCE: U.S. Department of Veterans Affairs.

The incidence of venous thromboembolism in postoperative plastic and reconstructive surgery patients with chronic spinal cord injury.

BACKGROUND: The purpose of this study was to investigate the incidence of postoperative venous thromboembolism in chronic spinal cord injury patients undergoing plastic and reconstructive surgery. Previous studies show a venous thromboembolism incidence of 9.3 percent; however, based on anecdotal evidence, the authors hypothesize that the incidence is actually much lower. As postoperative venous thromboembolism prophylaxis is becoming mandated by the Surgical Care Improvement Project, more data are necessary so that recommendations for chronic spinal cord injury patients can be given. METHODS: A retrospective chart review was undertaken using electronic medical records from a Veterans Affairs hospital from 2004 through 2009 in which the perioperative course of the chronic spinal cord injury cohort was evaluated for the primary endpoint of venous thromboembolism evolution. The Pearson correlation was used for statistical analysis. RESULTS: Of the 415 operative cases evaluated, 155 cases were excluded secondary to operative time under 1 hour, use of mechanical or chemical venous thromboembolism prophylaxis, unknown operative time, or unknown prophylaxis use. Of the 260 cases evaluated without venous thromboembolism prophylaxis, there were no cases where venous thromboembolism developed within a 2-month postoperative time period. CONCLUSIONS: Postoperative venous thromboembolism is a common surgical complication with significant morbidity and mortality. This study demonstrates that in the chronic spinal cord injury patient cohort, the incidence of postoperative venous thromboembolism evolution is extremely low and that a benefit from perioperative mechanical or chemical prophylaxis is not evidence based. Further prospective studies are required to fully elucidate the true venous thromboembolism incidence in these patients and give recommendations on this issue. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Release kinetics of polymer-bound bone morphogenetic protein-2 and its effects on the osteogenic expression of MC3T3-E1 osteoprecursor cells.

BACKGROUND: In an effort to augment scaffold performance, additives such as growth factors are under investigation for their ability to optimize the "osteopotential" of synthetic polymer scaffolds. In parallel research, bone morphogenetic protein-2 (BMP-2), a growth factor that initiates bone formation, has been locally delivered to augment fracture healing and spinal fusion. The authors hypothesize that BMP-2 can be covalently bound to a polymer substrate, increasing its concentration and bioavailability over longer periods, thus improving the efficacy of the growth factor and subsequently the bony matrix production. It would remain bound longer when compared with published controls. This prolonged binding would then increase the bioavailability of the growth factor and thus increase bony matrix production over a longer interval. METHODS: Mouse preosteoblast MC3T3-E1 cells were cultured on poly(lactic-co-glycolic acid) and polycaprolactone polymer disks covalently bound with BMP-2 to assess the progression and quality of osteogenesis. Covalent binding of BMP-2 to each polymer was visualized by immunohistochemical analysis of polymer-coated microscope slides. The quantity of covalently bound BMP-2 was determined using enzyme-linked immunosorbent assay. RESULTS: Polymerase chain reaction results showed elevated expression levels for alkaline phosphatase and osteocalcin genes. BMP-2 was released from polycaprolactone over 2 weeks, with 86 percent remaining covalently bound, in contrast to 93 percent retained by poly(lactic-co-glycolic acid). CONCLUSIONS: BMP-2, proven to alter polymer osteogenicity, remained bound to poly(lactic-co-glycolic acid), which may render poly(lactic-co-glycolic acid) an ideal choice as a polymer for scaffold-based bone tissue engineering using growth factor delivery.

Osteoblastic phenotype expression of MC3T3-E1 cells cultured on polymer surfaces.

BACKGROUND: Current efforts in bone tissue engineering have as one focus the search for a scaffold material that will support osteoblast proliferation, matrix mineralization, and, ultimately, bone formation. The goal is to develop a bone substitute that is functionally equivalent to autograft bone. Previously published reports have shown that osteoblasts exhibit varying rates and degrees of proliferation and mineralization when grown on different surfaces. METHODS: This study presents a histologic and biomolecular analysis of MC3T3-E1 murine preosteoblast cells grown on poly(lactide-co-glycolide) (PLGA) versus poly(-caprolactone) (PCL), two commonly studied scaffold polymers. MC3T3-E1 cells were cultured on slides coated with either PLGA or PCL, and on uncoated glass slides as control, with six slides in each group. After 6 weeks in culture, the cells were stained for osteocalcin, alkaline phosphatase activity, and matrix mineralization. In addition, to assess the effects of the surface material on phenotypic expression at the molecular level, MC3T3-E1 cells were cultured on polymer-coated 24-well plates for 4 days, and analyzed by reverse transcription polymerase chain reaction for the expression of osteocalcin and alkaline phosphatase. RESULTS: The results showed that three groups of slides stained positively for osteocalcin at 6 weeks. However, markedly less alkaline phosphatase activity and mineralization were observed on the cells grown on PCL. Real-time polymerase chain reaction assays subsequently revealed decreased expression of both markers by cells cultured on PCL compared with PLGA. CONCLUSIONS: These results suggest that PCL does not support the full expression of an osteoblastic phenotype by MC3T3-E1 cells. PCL, therefore, is less desirable as a scaffold polymer in bone tissue engineering in so far as supporting bone formation is concerned. However, because PCL has favorable handling characteristics and strength, modifications of PCL may prompt further investigation.