Use of the confusion assessment method in multicentre delirium trials: training and standardisation.

BACKGROUND: Delirium occurs commonly in older adults and is associated with adverse outcomes. Multicentre clinical trials evaluating interventions to prevent delirium are needed. The Confusion Assessment Method (CAM) is a validated instrument for delirium detection. We hypothesised it would be possible for a large feasibility study to train a large number of research assistants, with varying experience levels, to conduct CAM assessments reliably in multiple hospital sites. METHODS: A standardised training programme was followed, incorporating structured training at a central location and at study sites. CAM practice sessions on both delirious and non-delirious patients by research assistants were conducted and, thereafter, there was ongoing inter-rater reliability assessment on the CAM between research assistant pairs at study sites. The setting was eight acute care hospitals in England and Wales. Participants were research assistants working on a multicentre feasibility study of delirium prevention. The measurement used was the Confusion Assessment Method. RESULTS: Thirty-seven research assistants were trained in CAM assessment and 33 returned training logs. The logs showed there was 100% overall agreement between research assistant pairs on 295 CAM assessments, of which 263 (89.2%) were negative for delirium and 32 (10.8%) were positive. In the course of the feasibility study, research assistants successfully completed 5065 (89.7%) of the 5645 expected CAM assessments, with minimal missing data. CONCLUSION: Using the training methods described in this study, it is possible to achieve high quality delirium assessments for large numbers of patients with little missing data across geographically dispersed sites in multicentre studies. The standardisation of multisite delirium assessments is an important contribution to research methodology, and provides a much-needed advance for the field. TRIAL REGISTRATION: ISRCT ISRCTN01187372 . Registered 13 March 2014.

Opioid Consumption After Knee Arthroscopy.

BACKGROUND: The opioid epidemic in the United States has placed increased pressure on physicians to engage in responsible opioid prescribing practices. However, surgeons currently have little information to guide their postoperative prescription decision-making. The purpose of this study was to assess opioid consumption after knee arthroscopy and identify preoperative factors that may predict higher opioid usage. METHODS: A prospective observational study of 221 patients was conducted in patients undergoing outpatient knee arthroscopy for meniscal repair, partial meniscectomy, debridement, chondroplasty, or loose body removal. Participants recorded their daily opioid consumption in a postoperative pain diary. Total opioid consumption was calculated from counts of remaining pills at the 2-week and 6-week postoperative office visits. Variables, including age, sex, body mass index, smoking status, alcohol consumption, preoperative pain severity and duration, preoperative opioid usage, Patient-Reported Outcomes Measurement Information System (PROMIS) scores, and the Connor-Davidson Resilience Scale, were evaluated for an association with opioid consumption. RESULTS: Total opioid consumption ranged from 0 to 188 pills, with a median of 7 pills (hydrocodone 5-mg equivalents). Forty-six percent of patients took ≤5 pills, 59% took ≤10 pills, and 81% took ≤20 pills. Fifty-six percent of patients had discontinued opioid usage by the third postoperative day. Eighty-eight percent of patients had surplus opioid medication at the time of the final follow-up. Patients undergoing meniscal repair, smokers, and those taking preoperative opioids were significantly more likely to take ≥20 pills (p < 0.05). CONCLUSIONS: The median number of pills taken after knee arthroscopy is 7, with the majority of patients consuming ≤20 pills. Meniscal repair, smoking, and preoperative opioid usage were associated with higher postoperative opioid consumption. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Bilateral pigmented villonodular synovitis of the knee.

Pigmented villonodular synovitis is a disorder resulting in a villous, nodular, or villonodular proliferation of the synovium, with pigmentation related to the presence of hemosiderin. These lesions are almost exclusively benign with rare reports of malignancy. Pigmented villonodular synovitis can occur in a variety of joints and at any age but most often occurs within the knee in the young adult. Pigmented villonodular synovitis is a rare disease entity, and bilateral synchronous or metachronous involvement of a joint is even more uncommon, with few reports previously described in the literature. We present a case of pigmented villonodular synovitis involving both the right and left knee in the same patient, with radiographic imaging, magnetic resonance imaging, photograph and video intraoperative imaging, and pathologic correlation.

The Rivermead Mobility Index allows valid comparisons between subgroups of patients undergoing rehabilitation after stroke who differ with respect to age, sex, or side of lesion.

OBJECTIVE: To investigate differential item functioning or item bias of the Rivermead Mobility Index (RMI) and its impact on the drawing of valid comparisons with the RMI between subgroups of patients after stroke who differ with respect to age, sex, or side of lesion. DESIGN: Cross-sectional study. SETTING: A rehabilitation center in the Netherlands and 2 stroke rehabilitation units and the wider community in the United Kingdom. PARTICIPANTS: The RMI was completed for patients undergoing rehabilitation after stroke (N=620; mean age ± SD, 69.2±12.5y; 297 [48%] men; 269 [43%] right hemisphere lesion, and 304 [49%] left hemisphere lesion). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Mokken scale analysis was used to investigate differential item functioning of the RMI between subgroups of patients who differed with respect to age (young vs older), sex (men vs women), and side of stroke lesion (right vs left hemisphere). RESULTS: No differential item functioning was found for any of the comparison subgroups. CONCLUSIONS: The RMI allows valid comparisons to be made between subgroups of patients undergoing rehabilitation after stroke who differ with respect to age, sex, or side of lesion.

Item hierarchy-based analysis of the Rivermead Mobility Index resulted in improved interpretation and enabled faster scoring in patients undergoing rehabilitation after stroke.

OBJECTIVE: To enable improved interpretation of the total score and faster scoring of the Rivermead Mobility Index (RMI) by studying item ordering or hierarchy and formulating start-and-stop rules in patients after stroke. DESIGN: Cohort study. SETTING: Rehabilitation center in the Netherlands; stroke rehabilitation units and the community in the United Kingdom. PARTICIPANTS: Item hierarchy of the RMI was studied in an initial group of patients (n=620; mean age ± SD, 69.2±12.5y; 297 [48%] men; 304 [49%] left hemisphere lesion, and 269 [43%] right hemisphere lesion), and the adequacy of the item hierarchy-based start-and-stop rules was checked in a second group of patients (n=237; mean age ± SD, 60.0±11.3y; 139 [59%] men; 103 [44%] left hemisphere lesion, and 93 [39%] right hemisphere lesion) undergoing rehabilitation after stroke. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Mokken scale analysis was used to investigate the fit of the double monotonicity model, indicating hierarchical item ordering. The percentages of patients with a difference between the RMI total score and the scores based on the start-and-stop rules were calculated to check the adequacy of these rules. RESULTS: The RMI had good fit of the double monotonicity model (coefficient H(T)=.87). The interpretation of the total score improved. Item hierarchy-based start-and-stop rules were formulated. The percentages of patients with a difference between the RMI total score and the score based on the recommended start-and-stop rules were 3% and 5%, respectively. Ten of the original 15 items had to be scored after applying the start-and-stop rules. CONCLUSIONS: Item hierarchy was established, enabling improved interpretation and faster scoring of the RMI.

Can magnetic resonance imaging predict posterior drawer laxity at the time of surgery in patients with knee dislocation or multiple-ligament knee injury?

BACKGROUND: Previous studies indicate that isolated posterior cruciate ligament injuries demonstrate magnetic resonance imaging (MRI) and clinical evidence of healing when treated nonoperatively; however, the authors are unaware of any other study that has looked at whether initial MRI can predict posterior cruciate ligament stability at the time of surgery in patients with knee dislocation. HYPOTHESIS: An MRI grading system will predict laxity on posterior drawer testing at the time of surgery in patients with knee dislocations. STUDY DESIGN: Cohort study (prognosis); Level of evidence, 2. METHODS: Forty-two consecutive patients with knee dislocation or multiple-ligament knee injury evaluated by MRI were included in the study. An assignment of grade 0 (intact), grade I (injured/fibers intact), grade II (partial tearing of ligament), or grade III (complete tear) was made after each reading on 2 separate occasions by 3 surgeons. Posterior laxity of the knee was graded by the magnitude of excursion on the posterior drawer test by the senior author at the time of surgery. Interobserver and intraobserver reliability of the MRI grading scheme expressed by the kappa statistic κ, as well as the predictive value of MRI grade in determining stability of the posterior cruciate ligament at the time of surgery, was assessed. RESULTS: The posterior cruciate ligament injury grading scheme tested demonstrated moderate to substantial intraobserver agreement (κ = 0.66, κ = 0.53, and κ = 0.52, respectively, for all raters). Interobserver reliability demonstrated only moderate agreement (κ = 0.49). If the grading scheme was changed to group both grades 0 and I (intact) and grades II and III (disrupted), intraobserver reliability demonstrated substantial to almost perfect agreement (κ = 0.83, κ = 0.80, and κ = 0.75), and interobserver reliability demonstrated substantial agreement (κ = 0.70). If the posterior cruciate ligament was classified as intact (grade 0 [intact] or grade I [injured]) on initial MRI, the injured knee was judged clinically stable (tibia anterior to or flush with the femoral condyles on posterior drawer testing) at the time of surgery 98.5% (95% confidence interval, 93%-100%) of the time. When the posterior cruciate ligament was classified as disrupted (grade II [partial tear] or grade III [complete tear]), the injured knee was judged unstable (tibia posterior to the femoral condyles on posterior drawer testing) 57.5% (95% confidence interval, 40%-73%) of the time. CONCLUSION: The presented system of grading posterior cruciate ligament injury in patients with knee dislocation on initial MRI demonstrates moderate to substantial interobserver and intraobserver reliability that increases if the grading scheme is modified. An initial MRI scan read as grade I may predict stability to posterior drawer at the time of surgery. Even with MRI evidence of disruption in the posterior cruciate ligament (grade II and grade III injuries), posterior cruciate ligament reconstruction may not be clinically indicated at the time of reconstruction and/or repair of other associated injuries.

Pronation can increase the pressure on the posterior interosseous nerve under the arcade of Frohse: a possible mechanism of palsy after two-incision repair for distal biceps rupture--clinical experience and a cadaveric investigation.

Posterior interosseous nerve palsy is a recognized complication of 2-incision distal biceps tendon repair. We hypothesize that intraoperative forearm pronation can cause compression of the posterior interosseous nerve beneath the supinator and arcade of Frohse. Six human male cadaver upper extremities were dissected. Pressure on the posterior interosseous nerve beneath the arcade of Frohse and supinator was measured with a Swan-Ganz catheter connected to a pressure transducer. Pressure was significantly elevated in maximal pronation in all specimens with the elbow in both flexion and extension. Pressures at full pronation were significantly higher than pressures measured at 60 degrees of pronation (5 +/- 2 mm Hg in 60 degrees of pronation and 90 degrees of flexion, P < .0001; 7 +/- 3 mm Hg in 60 degrees of pronation and extension, P < 005). Maximal pronation can cause increased pressure on the posterior interosseous nerve. The safety of 2-incision distal biceps repair may be increased by avoiding prolonged, uninterrupted periods of hyperpronation.

Biomechanical analysis of stresses to the fifth metatarsal bone during sports maneuvers: implications for fifth metatarsal fractures.

Fifth metatarsal stress fractures are an increasing problem in elite and recreational athletic populations. One possible mechanism of injury is the many bending moments applied to the fifth metatarsal during dynamic sports maneuvers involving rapid changes in direction and speed. A potentially important bending moment is loading of the base versus the head of the fifth metatarsal, which tends to cause a bending moment along the bone. To determine which maneuver applies the greatest pressure differential between the base and head of the fifth metatarsal, 10 college-aged male athletes performed running straight, jump take-off, jump landing, cutting right, cutting left, and accelerating while plantar pressures were recorded using a Pedar insole system (Novel Electronics, Inc., St. Paul, MN). Peak pressure at the fifth metatarsal base was subtracted from the peak pressure at the fifth metatarsal head to obtain the fifth metatarsal pressure differential-a corollary to the bending moment. The greatest fifth metatarsal pressure differential was observed during acceleration maneuvers (20 + or - 13.1 N/cm(2); P < 0.0001) followed by running straight (11.6 + or - 8 N/cm(2); P < 0.0008). The other maneuvers had low pressure differentials: jump take-off (4.2 + or - 10.6 N/cm(2)), jump landing (3.7 + or - 9.2 N/cm(2)), cutting left (2.3 + or - 4.2 N/cm(2)), and cutting right (-2.1 + or - 10 N/cm(2)). It appears that acceleration maneuvers may apply the largest bending moments to the fifth metatarsal and could lead to stress fractures. Because fifth metatarsal stress fractures are associated with rapid increases in training volume, reducing the number of acceleration events may be effective in altering the balance between bone resorption and bone formation and reducing stress fracture risk. Careful planning of training programs allowing for adequate rest between intense bouts of exercise involving many acceleration maneuvers may be the best preventative measure.

The feasibility of care mapping to improve care for physically ill older people in hospital.

BACKGROUND: providing dignity in health care for older people is an important policy and clinical objective but requires implementation using reliable methods. Our objective was to investigate the feasibility of a person-centred observational practice development method known as dementia care mapping (DCM) in hospital wards for physically ill older people, including those who do not have dementia. METHODS: DCM (version 8) was conducted in three elderly care general hospital wards and in two community hospitals. Summary statistics were calculated from the DCM data to assess feasibility and adequacy of the DCM coding system. RESULTS: fifty-eight participants were mapped for 84 observation hours/414 patient hours (4,968 5-min time frames). There was a relatively high proportion (942/2,376; 40% time frames) of missing data in the community hospitals due to time patients spent away from the area under observation. All 3,624 of the time frames with patient-observed data could be coded utilising the existing Behaviour Category and Mood/Engagement Value coding frameworks. DISCUSSION: the results from this preliminary study are promising and indicate that DCM is potentially feasible in elderly care general hospital wards, without the need for major modification.

Regional foot pressure during running, cutting, jumping, and landing.

BACKGROUND: Evaluating shoes during sport-related movements may provide a better assessment of plantar loads associated with repetitive injury and provide more specific data for comparing shoe cushioning characteristics. HYPOTHESIS: Accelerating, cutting, and jumping pressures will be higher than in straight running, differentiating regional shoe cushioning performance in sport-specific movements. STUDY DESIGN: Controlled laboratory study. MATERIALS AND METHODS: Peak pressures on seven anatomic regions of the foot were assessed in 10 male college athletes during running straight ahead, accelerating, cutting left, cutting right, jump take-off, and jump landing wearing Speed TD and Air Pro Turf Low shoes (Nike, Beaverton, Ore). Pedar insoles (Novel, Munich, Germany) were sampled at 99 Hz during the 6 movements. RESULTS: Cutting and jumping movements demonstrated more than double the pressure at the heel compared with running straight, regardless of shoe type. The Air Pro Turf showed overall lower pressure for all movement types (P<.0377). Cutting to the left, the Air Pro Turf shoe had lower heel pressures (36.6 +/- 12.5 N/cm(2)) than the Speed TD (50.3 +/- 11.2 N/cm(2)) (P<.0001), and the Air Pro Turf had lower great toe pressures than the Speed TD (44.8 +/- 8.1 N/cm(2) vs 54.4 +/- 8.4 N/cm(2); P= .0002). The Air Pro Turf also had significantly lower pressures than the Speed TD at the central forefoot during acceleration (38.2 +/- 8.3 N/cm(2) vs 50.8 +/- 7.4 N/cm(2); P<.0001). CONCLUSION: Sport-related movements load the plantar surface of the foot more than running straight. Shoe cushioning characteristics were more robustly assessed during sport-related movements (4 significant results detected) compared with running straight (1 significant result detected). CLINICAL RELEVANCE: There is an interaction between shoe cushioning characteristics and sport-related movements that may influence plantar pressure and repetitive stress injuries.

Increased risk of posterior glenoid labrum tears in football players.

OBJECTIVE: This study was designed to test our hypothesis that football players with shoulder pain, shoulder instability, or both requiring MR arthrography for evaluation are at an increased likelihood relative to non-football players for having a tear of the posterior glenoid labrum. CONCLUSION: We conclude that posterior glenoid labrum tears are more prevalent in football players than in non-football players.

Bioabsorbable screw fixation in coracoclavicular ligament reconstruction.

The purpose of this study is to evaluate the biomechanical properties of stainless steel and bioabsorbable screw fixation of the clavicle to the base of the coracoid. Seven matched pairs of fresh frozen shoulders were prepared by removing all soft tissue except the acromioclavicular and coracoclavicular ligament complexes. The shoulders were randomly selected and fixed with 4.5-mm stainless steel (SS) screws, while contralateral shoulders were fixed with 4.5-mm poly L-lactic acid polymer (PLLA) screws. Pullout strength, stiffness, and elongation to failure were measured using an Instron Mechanical Tester (Model 4202). The average pullout strength of 720.6 +/- 244.9 N of the metal screws was not statistically different (p = 0.089) from that of the biodegradable screws of 580.4 +/- 188.6 N. The pullout strengths exerted by both these screws exceeded the reported strength (500 N) of the intact coracoclavicular complex indicating adequate initial pullout strength for coracoclavicular fixation.