Prefrontal photobiomodulation produces beneficial mitochondrial and oxygenation effects in older adults with bipolar disorder.

There is growing evidence of mitochondrial dysfunction and prefrontal cortex (PFC) hypometabolism in bipolar disorder (BD). Older adults with BD exhibit greater decline in PFC-related neurocognitive functions than is expected for age-matched controls, and clinical interventions intended for mood stabilization are not targeted to prevent or ameliorate mitochondrial deficits and neurocognitive decline in this population. Transcranial infrared laser stimulation (TILS) is a non-invasive form of photobiomodulation, in which photons delivered to the PFC photo-oxidize the mitochondrial respiratory enzyme, cytochrome-c-oxidase (CCO), a major intracellular photon acceptor in photobiomodulation. TILS at 1064-nm can significantly upregulate oxidized CCO concentrations to promote differential levels of oxygenated vs. deoxygenated hemoglobin (HbD), an index of cerebral oxygenation. The objective of this controlled study was to use non-invasive broadband near-infrared spectroscopy to assess if TILS to bilateral PFC (Brodmann area 10) produces beneficial effects on mitochondrial oxidative energy metabolism (oxidized CCO) and cerebral oxygenation (HbD) in older (≥50 years old) euthymic adults with BD (N = 15). As compared to sham, TILS to the PFC in adults with BD increased oxidized CCO both during and after TILS, and increased HbD concentrations after TILS. By significantly increasing oxidized CCO and HbD concentrations above sham levels, TILS has the potential ability to stabilize mitochondrial oxidative energy production and prevent oxidative damage in the PFC of adults with BD. In conclusion, TILS was both safe and effective in enhancing metabolic function and subsequent hemodynamic responses in the PFC, which might help alleviate the accelerated neurocognitive decline and dysfunctional mitochondria present in BD.

Prospective Study Investigating the Prevalence and Evolution of Malnourishment in the Acute Orthopaedic Trauma Patient.

Background: Orthopaedic trauma surgeons believe that nutritional status is important. The primary aim of this study was to prospectively investigate the prevalence and progression of malnourishment in orthopaedic trauma patients and determine when and what labs should be ordered. The secondary aim was to determine if malnourished patients had increased complications. Methods: Prospective cohort study of orthopaedic trauma patients at a Level I trauma center. Assessment of nutritional status over the hospital course was performed using the Rainey MacDonald nutritional index (RMNI) and nutritional laboratory markers on admission, day 3, day 7, and 6 weeks post-op. Results: 98 patients were enrolled and included. On admission, 60%, 41%, and 38% of patients were malnourished based on albumin, prealbumin, and RMNI values, respectively, with 31% in severe acute-phase response (APR) as determined by CRP. By day 3, a significant increase in the percent of malnourished patients was noted based on the laboratory markers, 85%, 90%, and 80%, respectively, with 70% in severe APR. On day 7, values stabilized at 74%, 89%, 69%, with 56% in severe APR. At six weeks, malnourishment persisted in 13%, 19%, and 12% of patients, with 4% in severe APR. Older patients demonstrated a greater depression of nutritional markers throughout the hospital stay. Conclusion: The prevalence of malnourishment, based on serum nutritional markers, in the presence of acute orthopaedic injury is substantial, and it continues to rise during the acute hospital stay. Recommend obtaining prealbumin or albumin levels on hospital day 3 to assess nutritional status.

Barriers and facilitators to accessing effective clinical supervision and the implementation of a clinical supervision exchange model in the Australian alcohol and other drugs sector.

INTRODUCTION: Internationally, clinical/practice supervision is considered essential in the development and maintenance of professional proficiency across health disciplines. Among alcohol and other drug (AOD) workers, however, access to effective clinical supervision is limited. This study examined perceived barriers and facilitators to: (i) AOD workers accessing effective clinical supervision; and (ii) effective implementation of a clinical supervision exchange model in the AOD sector. METHODS: Qualitative interviews with frontline workers (n = 10) and managers (n = 11) employed by eight government and non-government AOD treatment services in Brisbane, Australia were undertaken. Interviews were audio recorded, transcribed and data were thematically analysed. RESULTS: Frontline workers and managers shared similar views. Reported barriers and facilitators to accessing effective clinical supervision included limited time, the high cost of providers, availability of skilled clinical supervisors, supervisor-supervisee matching and supervision modality. Participants considered the implementation of a clinical supervision exchange model to be a resource-effective strategy to increase access to external, individual clinical supervision while also exposing workers to a greater diversity of perspectives, increasing sector collaboration and improving the perceived value of clinical supervision among the workforce. DISCUSSION AND CONCLUSIONS: The findings of this study suggest that limited time, cost and availability of skilled supervisors are primary barriers to AOD workers accessing high-quality clinical supervision. Implementation of a clinical supervision exchange model is perceived by frontline workers and service delivery managers to be a resource-effective strategy for increasing access to high-quality clinical supervision among workers.

Transcranial Infrared Laser Stimulation Improves Cognition in Older Bipolar Patients: Proof of Concept Study.

This is the first study to examine if transcranial infrared laser stimulation (TILS) improves cognition in older euthymic bipolar patients, who exhibit greater cognitive decline than is expected for age-matched controls. TILS is a non-invasive novel form of photobiomodulation that augments prefrontal oxygenation and improves cognition in young adults by upregulating the mitochondrial respiratory enzyme cytochrome-c-oxidase. We used a crossover sham-controlled design to examine if TILS to bilateral prefrontal cortex produces beneficial effects on cognition in 5 euthymic bipolar patients (ages 60-85). We measured cognitive flexibility, verbal fluency, working memory, sustained attention and impulsivity with tasks that have been shown to differentiate between healthy older adults and older bipolar adults. We found TILS-induced improvements in cognitive performance on the tasks that measure cognitive flexibility and impulsivity, after 5 weekly sessions of TILS. We concluded that TILS appeared both safe and effective in helping alleviate the accelerated cognitive decline present in older bipolar patients.

Concerns and Help-Seeking Among Patients Using Opioids for Management of Chronic Noncancer Pain.

BACKGROUND: The safety and efficacy of long-term opioid treatment for chronic noncancer pain (CNCP) remains controversial. This study examined whether patients who report problematic opioid use sought help and/or perceived barriers to help-seeking. METHODS: Data were collected from 1,086 people prescribed opioids for CNCP via a large prospective cohort called the Pain and Opioids IN Treatment (POINT) study. Patients' characteristics and help-seeking were examined according to scores on the Prescribed Opioids Difficulties Scale (PODS). RESULTS: Participants scoring "intermediate" (17%) or "high" (30%) on the PODS were younger and reported more complex pain presentations, higher opioid doses, poorer physical health, moderate to severe anxiety and depression, aberrant behavior, past month opioid use disorder and help-seeking (compared with the "low" PODS group, 53%). One-quarter (26%) had sought help, most commonly from a primary care physician, specialist pain clinic, family member/partner, counselor/psychologist, and the Internet. Participants in the "high" PODS group were more likely to have sought help from an alcohol or other drug service, addiction specialist, or drug information helpline. Common barriers to help-seeking were desire for self-management and concern that their opioid treatment may be discontinued. Although 35% met criteria for likely opioid use disorder, only 4.8% reported lifetime treatment with methadone or buprenorphine; participants' ratings indicated significant perceived stigma associated with these medications. CONCLUSIONS: The PODS is effective in identifying patients who are concerned about their opioid use. Strategies to address stigma related to drug treatment, including better integration of primary health, specialist pain, and addiction services, are important in reducing opioid-related harm.

Topical Vancomycin in Pediatric Spine Surgery Does Not Reduce Surgical Site Infection: A Retrospective Cohort Study.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: Evaluate the effectiveness of topical vancomycin in reducing surgical site infection (SSI) in pediatric patients undergoing posterior spinal fusion (PSF). SUMMARY OF BACKGROUND DATA: There has been increased interest in use of topical vancomycin to reduce SSI in spine surgery with mixed results reported in the literature. In Summer 2012, our institution implemented the use of topical vancomycin in definitive primary and revision PSF as part of our infection control protocol. METHODS: After IRB approval, a consecutive series of 527 patients (538 procedures) undergoing PSF January 2010-December 2014 were retrospectively reviewed to identify the occurrence of SSI. Based on published results from a similar study, an a priori power analysis determined 190 patients were needed per group to achieve 0.90 power. In 228 procedures, topical vancomycin was used (Vanco) and in 310 procedures it was not (No Vanco). Exclusion criteria were <90 days follow-up, >18 years at time of surgery, and combined anterior and posterior fusion. Two-sample t tests, Wilcoxon rank-sum tests, and Fisher exact tests were used to compare the cohorts. RESULTS: Groups were similar in age, sex, implant density, fusion length, risk categorization, and surgical time (p > .05). No Vanco had significantly higher blood loss and incidence and amount of intraoperative allogenic transfusion (p < .001). Incidence of SSI was 3% (7/228) in Vanco and 2% (6/310) in No Vanco (p = .4099). Six of the 7 SSIs occurred in high-risk patients in Vanco and 5 of 6 occurred in high-risk patients in No Vanco (p = 1). Reoperation within 90 days was 6% (13/228) in Vanco and 4% (11/310) in No Vanco (p = .2912). Occurrence of other complications was similar between Vanco, 3% (7/228), and No Vanco, 2% (5/310). CONCLUSION: Use of topical vancomycin did not reduce incidence of SSI for pediatric patients undergoing PSF at our institution. LEVEL OF EVIDENCE: Level III.

Reliability of and Correlation Between Measurements of Acetabular Morphology.

The authors sought to determine the intra- and interrater reliability of contemporary measures of acetabular morphology among a group of hip surgeons and to determine the correlations between measures of acetabular morphology. On 2 separate occasions, 3 hip surgeons independently performed blinded evaluations of anteroposterior pelvic radiographs of 40 patients. The lateral center-edge angle, medial center-edge angle, acetabular arc, extrusion index, acetabular index, Sharp's angle, posterior wall sign, crossover sign, femoro-epiphyseal acetabular roof index, acetabular wall indexes, and delta angle were assessed. A linear mixed model was used for variance estimation, and kappa and intra-class correlation coefficients were assessed for reliability. Pearson correlation coefficients were calculated for all possible pairs of radiographic measures. The acetabular index had the greatest interrater agreement (0.90; 95% confidence interval [CI], 0.84-0.93), whereas the lateral center-edge angle had the higher intrarater agreement (0.96; 95% CI, 0.92-0.98). The acetabular arc angle had the lowest interrater agreement (0.44; 95% CI, 0.29-0.57), and the Sharp's angle had the lowest intrarater agreement (0.66; 95% CI, 0.41-0.84). The posterior wall sign had an interrater agreement of 0.35 (95% CI, 0.11-0.54) and an intrarater agreement of 0.68 (95% CI, 0.49-0.86). The crossover sign had an interrater agreement of 0.66 (95% CI, 0.43-0.84) and an intrarater agreement of 0.85 (95% CI, 0.52-0.89). The acetabular index, lateral center-edge angle, and extrusion index presented with high coefficients of correlation. In addition, acetabular anteversion correlated with severity of dysplasia. Commonly used parameters such as the acetabular index, lateral center-edge angle, and extrusion index are reliable radiographic parameters to assess acetabular morphology. However, correlation between measures suggests that they may be redundant in quantifying acetabular morphology. [Orthopedics. 2018; 41(5):e629-e635.].

Anterior Spinal Fusion and Posterior Spinal Fusion Both Effectively Treat Lenke Type 5 Curves in Adolescent Idiopathic Scoliosis: A Multicenter Study.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Retrospective comparison of radiographic and clinical outcomes between anterior spinal fusion (ASF) and posterior spinal fusion (PSF) in surgical treatment of Lenke 5 curves. SUMMARY OF BACKGROUND DATA: ASF and PSF are used for treatment of Lenke 5 curves in patients with adolescent idiopathic scoliosis (AIS). Currently, no consensus exists for optimal surgical treatment of Lenke 5 curves. METHODS: Patients with Lenke 5 curves treated with either ASF or PSF were prospectively enrolled in a multicenter database and then retrospectively reviewed. Demographic data, perioperative measures, radiographic data, and SRS-22R scores were collected and compared for statistical significance. RESULTS: A total of 149 patients were included in the study; 51 underwent PSF and 98 underwent ASF. There was no difference in demographics between groups. The PSF group was fused one level longer than the ASF group (5.9 levels PSF, 4.6 levels ASF, p < .0001). The PSF group had shorter operative times (223 minutes PSF, 297 minutes ASF; p < .0001) and a higher proportion of patients who received a postoperative blood transfusion (45% vs. 5%, p < .0001). PSF patients had longer hospital stays (6.1d PSF vs. 5d ASF, p = .031). The ASF group had larger preoperative major curve (48.2° ASF, 44.2° PSF; p < .01). Coronal balance, thoracolumbar/lumbar Cobb angle, shoulder height, trunk shift, and overall sagittal balance were not different between groups at two-year follow-up. Curve correction at two-year follow-up was similar between groups (66% ASF vs. 62% PSF). There were no significant differences in clinical outcomes or complication rates between groups. CONCLUSION: There is no difference in radiographic or clinical outcomes in patients treated with ASF or PSF for Lenke 5 curves. ASF may save a fusion level, but has longer operative time than PSF. Ultimately, the risks and benefits of each approach merit consideration by surgeon and patient. LEVEL OF EVIDENCE: Level II.

Spine and Thoracic Height Measurements Have Excellent Interrater and Intrarater Reliability in Patients With Early Onset Scoliosis.

STUDY DESIGN: Reproducibility of measurements. OBJECTIVE: This study investigates the reliability and standard error of measurement of spine and thoracic height radiographic measurements in patients with early onset scoliosis (EOS). SUMMARY OF BACKGROUND DATA: Spine and thoracic height radiographic measurements are often used as a surrogate for pulmonary development in patients with EOS. There is limited literature validating the reliability of spine and thoracic height measurements in the EOS population. METHODS: Using pilot data, we determined measuring 49 unique radiographs would provide 80% power to obtain a 95% confidence interval (CI) width of 0.05 for the interclass correlation coefficients (ICCs). A random sampling strategy, stratified by underlying diagnosis from the Classification of Early Onset Scoliosis (C-EOS), was used to distribute the diagnoses in the study sample. Two attending pediatric spine surgeons, two pediatric orthopedic fellows, and two research assistants measured coronal spine (T1-S1) and thoracic (T1-T12) height on digital radiographs using imaging software (Surgimap; Nemaris, Inc, New York) on two separate occasions at least 3 weeks apart. Order of images was randomized for the second iteration. Linear mixed model regression analyses were used to estimate interrater and intrarater reliability. RESULTS: The study sample included subjects (N = 48) with idiopathic (N = 17, 35%), congenital (N = 16, 33%, 1 patient excluded), neuromuscular (N = 11, 23%), and syndromic (N = 4, 8%) scoliosis. Overall interrater reliability estimates for spine height (ICC: 0.894, 95% CI: 0.847-0.932) and thoracic height (ICC: 0.890, 95% CI: 0.844-0.929) were excellent. Intrarater reliability estimates for spine height (ICC: 0.906, 95% CI: 0.830-0.943) and thoracic height (ICC: 0.898, 95% CI: 0.817-0.938) were also excellent. CONCLUSION: There is excellent interrater and intrarater reliability for radiographic measurements of spine and thoracic height in the EOS population at our institution. LEVEL OF EVIDENCE: 2.