Rehabilitation after Hypoxic and Metabolic Brain Injury in a Mountain Climber.

A patient in her 50s presented with altered mental status and shortness of breath at 4600 m elevation. After descent to the base of the mountain, the patient became comatose. She was found to have bilateral pulmonary infiltrates and a serum sodium of 102 mEq/L. She was rapidly corrected to 131 mEq/L in 1 day. Initial MRI showed intensities in bilateral hippocampi, temporal cortex and insula. A repeat MRI 17 days post injury showed worsened intensities in the bilateral occipital lobes. On admission to acute rehabilitation, the patient presented with blindness, agitation, hallucinations and an inability to follow commands. Midway through her rehabilitation course, antioxidant supplementations were started with significant improvement in function. Rapid correction of hyponatraemia may cause central pontine myelinolysis or extrapontine myelinolysis (EPM). In some cases of hypoxic brain injury, delayed post-hypoxic leucoencephalopathy (DPHL) may occur. Treatment options for both disorders are generally supportive. This report represents the only documented interdisciplinary approach to treatment of a patient with DPHL and EPM. Antioxidant supplementation may be beneficial as a treatment option for both EPM and DPHL.

Perceived Benefits of a Cadaver-Based Ultrasound Procedure Workshop for Physical Medicine and Rehabilitation Trainees.

ABSTRACT: Ultrasound-guided musculoskeletal and spasticity injections have become common procedures in physical medicine and rehabilitation practices, but there are currently no guidelines for teaching these procedures in residency and fellowship training programs. As part of a quality improvement initiative, the authors aimed to assess the educational value of a hands-on cadaver-based workshop for enhancing these skills in residents and fellows. Twenty-seven physical medicine and rehabilitation trainees in a single institution were asked to complete surveys before and after the workshop to assess self-perceived benefits. After the workshop, the overwhelming majority felt improvement in their overall knowledge of ultrasound-guided musculoskeletal (93%) and spasticity (78%) procedures. In addition, the workshop improved the level of comfort of trainees both in planning (70%) and performing (59%) the procedures independently. Improving these skills is especially important considering most trainees plan to incorporate ultrasound-guided musculoskeletal (81%) and spasticity (74%) procedures into their future practices. The framework for this workshop can serve as a template for other programs to incorporate into their own training.

Inpatient Rehabilitation Delirium Screening: Impact on Acute Care Transfers and Functional Outcomes.

BACKGROUND: Delirium is well studied in the acute care setting, but there is limited understanding of its impact in the postacute care setting, particularly in the inpatient rehabilitation facility (IRF). OBJECTIVE: To investigate the prevalence and related outcomes of delirium in the IRF setting, particularly patients' transfers to acute care hospitals. DESIGN: Retrospective cohort study. SETTING: A freestanding IRF. PARTICIPANTS: Patients discharged from an IRF between January 2016 and December 2016 (12 months). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Transfer to acute care hospitals, motor and cognitive Functional Independence Measures (FIM), length of stay, discharge disposition. RESULTS: A total of 1567 patients (53.9% female, mean age 72.9 ± 13.9) were included in the analysis. Positive scores were found among 142 (9.1%) patients on a 3-Minute Diagnostic Interview for Confusion Assessment Method (3D-CAM), indicating delirium on admission. Fifty-nine (3.8%) were unscorable on 3D-CAM. Twice as many delirium patients were transferred to acute care hospitals compared to non-delirium patients (22.5% vs. 10.8%, P < .001). Multivariate logistic regression showed that, for patients with 3D-CAM positive scores, there was an increased risk of transfers to acute care hospitals at an odds ratio of 1.61 (1.03-2.53, P = .04) after adjusting for age, gender, neurological diagnosis, and motor FIM score. The delirium group also showed lower gains in motor function, increased lengths of stay, and reduced discharges to home when compared to the non-delirium group (P < .001). CONCLUSIONS: This study finds that delirium on admission to an IRF is associated with worsened outcomes related to function, length of stay, discharge status, and transfer to acute care hospitals. Positive delirium screening is an independent predictor for transfer to acute care hospitals from an IRF. Early identification of delirium is recommended in order to mitigate preventable transfers.