Review of interruptions in a pediatric subspecialty outpatient clinic.

INTRODUCTION: The objective of this study was to describe interruptions in the pediatric ambulatory setting and to assess their impact on perceived physician communication, patient satisfaction and recall of provided physician instructions. METHODS: An observational study was performed at the Children's Hospital of Philadelphia, Pediatric Gastroenterology clinic. Participation consisted of video recording the clinic visit and the caregiver completed post-visit surveys on communication and satisfaction. Video recordings were coded for interruptions, which were divided into 3 main categories: Visit Associated, Pediatric Associated, and Unanticipated. An interruption rate was calculated and correlated with the following outcome variables to assess the impact of interruptions: caregiver satisfaction, caregiver perception on the quality of physician communication, and caregiver instruction recall. RESULTS: There were 675 interruptions noted in the 81 clinic visits, with an average of 7.96 (σ = 7.68) interruptions per visit. Six visits had no interruptions. The Patient was the most frequent interrupter. Significantly higher interruption rates occurred in clinic visits with younger patients (<7 years old) with most of the interruptions being Pediatric Associated interruptions. There was minimal correlation between the clinic visit interruption rate and caregiver satisfaction with the communication, caregiver perception of quality of communication, or caregiver instruction recall rate. CONCLUSION: The effect of interruptions on the pediatric visit remains unclear. Interruptions may be part of the communication process to ensure alignment of the patient's agenda. Additional studies are needed to help determine the impact of interruptions and guide medical education on patient communication.

Assessment of caregiver expectations of physician communication in a pediatric setting.

BACKGROUND: In pediatrics, communication often occurs through an intermediary such as a caregiver. The goal of this study is to assess caregiver communication expectations and determine if meeting expectations influences caregiver satisfaction or instruction retention. METHODS: A survey study was performed at the Children's Hospital of Philadelphia. Before the visit, caregivers completed a survey on communication expectations, Caregiver Expected Kalamazoo Essential Elements Communication Checklist (Caregiver Expected KEECC). After the visit, caregivers were surveyed on their perception of physician communication (Caregiver Perceived KEECC) and satisfaction. Caregivers were contacted 1 week after the clinic visit to assess instruction retention. Meeting of caregiver expectation was calculated by the difference between Caregiver Expected and Caregiver Perceived KEECC scores. RESULTS: 112 caregivers participated in the study. There was no significant difference in Caregiver Expected KEECC versus Caregiver Perceived KEECC score (4.39 vs 4.56). Caregiver communication expectations were exceeded in 51.5% of the visits. Communication expectations were exceeded more among caregivers with at a college education (p <  0.01) and more among White caregivers (p <  0.01). The average caregiver satisfaction score with the clinic visit was 4.67. Higher satisfaction scores were observed in caregivers who had their communication expectations met or exceeded (p <  0.01). Caregivers with communication expectations exceeded had higher percentage recall of physician instructions (p <  0.01). CONCLUSIONS: Caregiver communication expectations may be influenced by demographic factors. Communication expectation affects visit outcomes including caregiver satisfaction and instruction retention. Therefore, physicians need to be cognizant of caregiver communication expectations, which can impact quality of the healthcare experience.

Low Prevalence of Suspected Barrett's Esophagus in Patients With Gastroesophageal Reflux Disease Without Alarm Symptoms.

BACKGROUND & AIMS: Esophagogastroduodenoscopy (EGD) is frequently used to evaluate gastroesophageal reflux disease (GERD) without alarm symptoms, although the benefits are not clear. We aimed to determine the prevalence of uncomplicated GERD as an indication for EGD, the demographic characteristics of these patients, and the endoscopic outcomes of these procedures. METHODS: We collected endoscopy data from a large national database of 543,103 EGDs performed at 82 sites from 2003 through 2014. We identified patients with GERD without alarm symptoms (dysphagia, bleeding, vomiting, or weight loss). Endpoints included the prevalence of endoscopically suspected Barrett's esophagus (sBE) and suspected long-segment BE (sLSBE), defined as ≥3 cm. RESULTS: We found that 73,535 EGDs (13.5%) were performed for a primary indication of GERD without alarm symptoms: only 4122 patients (5.6%) had sBE, and of these, 24.2% had sLSBE. Significant risk factors for sBE and sLSBE included male sex, age, and white race. Other findings included peptic ulcers in 1337 patients (1.8%) and suspected tumors (47 esophageal, 42 gastric, 13 duodenal tumors, 2 others) in 101 patients. CONCLUSIONS: In an analysis of a large cohort of patients undergoing EGD, uncomplicated GERD accounted for almost 14% of EGDs; within this population, only 23.6% were white men older than 50 years, who have an increased risk of BE and esophageal adenocarcinoma. The prevalence of sBE is lower than in prior time periods-this raises questions about the utility of EGD to detect BE in patients with uncomplicated GERD. Guidelines for management of uncomplicated GERD should account for these observations.

Scintigraphy Demonstrates High Rate of False-positive Results From Glucose Breath Tests for Small Bowel Bacterial Overgrowth.

BACKGROUND & AIMS: Breath tests for hydrogen and/or methane are used to detect small bowel bacterial overgrowth (SBBO), but false-positive results can arise from clinical conditions that accelerate small bowel transit and deliver unabsorbed glucose to the colon. We investigated the prevalence of false-positive results from glucose breath tests by also evaluating patients with scintigraphy. METHODS: In a retrospective study, we reviewed data from glucose breath tests performed with concurrent scintigraphy on 139 patients with suspected SBBO at the Medical College of Wisconsin from January 2003 through July 2013. Results from breath tests were considered abnormal (positive) if there was an increasing curve of hydrogen or methane by >15 parts per million above baseline within 90 minutes. Scintigraphy was used to determine whether this increase occurred before or after the glucose bolus arrived at the cecum. Data from a subset of 45 patients with prior upper gastrointestinal surgery were analyzed separately. RESULTS: Forty-six of the patients (33%) had abnormal results from breath tests. On the basis of scintigraphy findings, 22 of these patients (48%) had false-positive results, which were caused by colon fermentation of unabsorbed glucose. Colon fermentation caused false-positive results in 65% of patients who had undergone upper gastrointestinal surgery and 13% of patients without prior surgery. Patients with false-positive results caused by colonic fermentation had shorter mean oro-cecal transit times (18 minutes) compared with patients with positive breath-test results because of SBBO (79 minutes) or negative results (86 minutes). CONCLUSIONS: Almost half of positive results from glucose breath tests are false because of colonic fermentation. All patients with abnormal results from breath tests should be considered for confirmatory repeat breath testing with concurrent scintigraphy to distinguish SBBO from colonic fermentation. Most patients who have undergone upper gastrointestinal surgery have abnormal results from breath tests and should be assessed by using concurrent scintigraphy with the initial breath test.

Effect of interference screw depth on fixation strength in biceps tenodesis.

PURPOSE: The purpose of this study was to assess the biomechanical performance of the long head of the biceps tenodesis with an interference screw with respect to screw depth. METHODS: Twenty-one human cadaveric shoulders were randomized into 3 treatment groups (7 each): interference screw placed flush to the humeral cortex, 50% proud, or fully recessed. Bone density was determined, and subpectoral biceps tenodesis was performed with 8 × 12 mm Bio-Tenodesis screws (Arthrex, Naples, FL). Each construct was cyclically loaded from 5 to 70 N for 500 cycles at 1 Hz and then pulled to failure at 1 mm/s. Relative actuator displacement was calculated from cyclic testing. Maximum load, elongation, linear stiffness, and failure mode were recorded from pull-to-failure testing. Because of numerous failures during cyclic testing, the final load data from the fully recessed group were not statistically analyzed. The remaining groups were compared by use of a 2-tailed, Student unpaired t test and χ(2) analysis. RESULTS: There was no significant difference in displacement among groups during cyclic testing. Five specimens in the recessed group failed during cyclic testing, whereas 2 specimens and 0 specimens failed in the proud and flush groups, respectively. The maximum loads sustained were 281.6 ± 77.8 N, 184.5 ± 56.3 N, and 209.1 ± 57.0 N for the flush group, 50% proud group, and recessed group (in those specimens surviving cyclical loading), respectively. CONCLUSIONS: Placement of a Bio-Tenodesis screw flush to the humeral cortex is preferred for maximum fixation strength in subpectoral biceps tenodesis. A screw placed to 50% depth may be effective in the laboratory setting, but recessed placement is more variable and requires additional fixation. The fully recessed group resulted in 5 of 7 failures during cyclical loading, with no specimens failing in the flush group. CLINICAL RELEVANCE: This study shows the importance of determining the optimal depth of interference screw placement during biceps tenodesis to obtain optimal biomechanical performance and reduce the risk of fixation failure.

Clinical outcomes of reverse total shoulder arthroplasty in patients aged younger than 60 years.

BACKGROUND: Reverse total shoulder arthroplasty (RTSA) has been indicated primarily for patients aged older than 65 years with symptomatic rotator cuff deficiency, poor function, and pain. However, conditions that benefit from RTSA are not restricted to an elderly population. This study evaluates a consecutive series of RTSA patients aged younger than 60 years. METHODS: We evaluated 36 shoulders (mean age, 54 years) at a mean follow-up of 2.8 years (range, 24-48 months). Of these shoulders, 30 (83%) had previous surgery, averaging 2.5 procedures per patient. The preoperative conditions compelling RTSA were as follows: failed rotator cuff repair (12), fracture sequelae (11), failed arthroplasty (5), instability sequelae (4), cuff tear arthropathy (CTA) (4), and rheumatoid arthritis (2). Follow-up examinations included range-of-motion and strength testing, as well as Single Assessment Numeric Evaluation, visual analog scale, Simple Shoulder Test, American Shoulder and Elbow Surgeons (ASES), and Constant scores. Preoperative and postoperative radiographs were reviewed for component loosening and scapular notching. Failure criteria were defined as undergoing revision, having gross loosening, or having an ASES score below 50. RESULTS: The mean Single Assessment Numeric Evaluation score improved from 24.4 to 72.0; the visual analog scale pain score improved from 6 to 2.1. The Simple Shoulder Test score improved from 1.4 to 6.2, and the ASES score improved from 31.4 to 65.8. Active forward elevation improved from 56° to 121°. The normalized postoperative mean Constant score was 54.3. In 9 patients (25.0%), we recorded an ASES score below 50, and these cases were considered failures. CONCLUSION: RTSA can improve shoulder function in a younger, complex patient population with poor preoperative functional ability. This study's success rate was 75% at 2.8 years. This is a limited-goals procedure, and longer-term studies are required to determine whether similar results are maintained over time.

Clinical outcomes of hemiarthroplasty and biological resurfacing in patients aged younger than 50 years.

BACKGROUND: Total shoulder arthroplasty as a treatment for glenohumeral degenerative joint disease is well accepted but has been less predictable with regard to outcomes and durability in a younger aged population, typically aged younger than 50 years. This younger population has a greater potential for glenoid component loosening. This has led surgeons to perform hemiarthroplasty or hemiarthroplasty with biological resurfacing of the glenoid in an effort to avoid the potential problems with a polyethylene glenoid and obtain durable and acceptable results for these patients. METHODS: The study included 44 patients, with 23 undergoing hemiarthroplasty alone and 21 undergoing hemiarthroplasty with biological resurfacing of the glenoid. All patients were aged younger than 50 years. Preoperative diagnoses, comorbidities, demographics, and range of motion were collected. Preoperative and postoperative radiographs were obtained. Preoperative and postoperative objective scoring measures (Single Assessment Numeric Evaluation, American Shoulder and Elbow Surgeons score, visual analog scale, Simple Shoulder Test, Constant-Murley) were used. RESULTS: Mean follow-up was 3.8 years for the hemiarthroplasty group and 3.6 years for the biological resurfacing group. Six patients in the hemiarthroplasty and 12 patients in the biological resurfacing group were considered failures due to revision surgery or an American Shoulder and Elbow Surgeons score <50. The hemiarthroplasty group had significantly better visual analog scale and Single Assessment Numeric Evaluation scores. CONCLUSIONS: There was a significant failure rate in the hemiarthroplasty and the biologic resurfacing groups compared with results in the literature. Improved outcomes and lower failure rates were observed in the hemiarthroplasty group compared with the biological resurfacing group in this study.

Arthroscopic primary rotator cuff repairs in patients aged younger than 45 years.

PURPOSE: The purpose of this study was to evaluate the mechanism of injury, patient characteristics, tear size, and clinical outcomes after arthroscopic primary rotator cuff repair of full-thickness tears in patients aged younger than 45 years. METHODS: A total of 70 consecutive patients were reviewed in a retrospective, multicenter (2 institutions) study evaluating prospectively collected data. Fifty-three patients, with a mean age of 37.5 years (range, 16.2 to 44.9 years), were available for follow-up at a mean of 35.8 months (range, 13.8 to 59.1 months). Exclusion criteria included patients with revision procedures, repair of partial tears, and follow-up of less than 12 months. Follow-up evaluation included physical examination with dynamometer strength testing and clinical outcome measures including the Single Assessment Numeric Evaluation score, American Shoulder and Elbow Surgeons (ASES) score, Constant-Murley score, pain score on a visual analog scale, and Simple Shoulder Test score. RESULTS: A total of 60% of the patients (32 of 53) had a traumatic etiology, with 38% (12 of 32) of these related to an athletic event. Of the tears, 36 (68%) were medium tears. Concomitant procedures performed at the time of rotator cuff repair included acromioplasty (51), biceps tenodesis or tenotomy (24), distal clavicle excision (10), anteroinferior stabilization (2), and labral repair (1). The mean postoperative ASES score was 84.6 (range, 21.6 to 100.0), with 2 patients recording ASES scores of less than 50 (21.7 and 41.7) at final follow-up. In the 38 patients available for clinical follow-up examination, forward flexion improved from 158.7° (range, 45° to 180°) to 168.4° (range, 120° to 180°) (P = .014). At the time of follow-up, no patients had undergone revision surgery. On the basis of poor clinical outcome scores, 2 patients (4.0%) were considered failures. CONCLUSIONS: Arthroscopic primary rotator cuff repair of full-thickness tears in patients aged younger than 45 years results in improved outcomes with regard to pain, subjective patient satisfaction, and shoulder function. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Biomechanical evaluation of transosseous rotator cuff repair: do anchors really matter?

BACKGROUND: Suture anchor fixation has become the preferred method for arthroscopic repairs of rotator cuff tears. Recently, newer arthroscopic repair techniques including transosseous-equivalent repairs with anchors or arthroscopic transosseous suture passage have been developed. PURPOSE: To compare the initial biomechanical performance including ultimate load to failure and localized cyclic elongation between transosseous-equivalent repair with anchors (TOE), traditional transosseous repair with a curved bone tunnel (TO), and an arthroscopic transosseous repair technique utilizing a simple (AT) or X-box suture configuration (ATX). STUDY DESIGN: Controlled laboratory study. METHODS: Twenty-eight human cadaveric shoulders were dissected to create an isolated supraspinatus tear and randomized into 1 of 4 repair groups (TOE, TO, AT, ATX). Tensile testing was conducted to simulate the anatomic position of the supraspinatus with the arm in 60° of abduction and involved an initial preload, cyclic loading, and pull to failure. Localized elongation during testing was measured using optical tracking. Data were statistically assessed using analysis of variance with a Tukey post hoc test for multiple comparisons. RESULTS: The TOE repair demonstrated a significantly higher mean ± SD failure load (558.4 ± 122.9 N) compared with the TO (325.3 ± 79.9 N), AT (291.7 ± 57.9 N), and ATX (388.5 ± 92.6 N) repairs (P < .05). There was also a significantly larger amount of first-cycle excursion in the AT group (8.19 ± 1.85 mm) compared with the TOE group (5.10 ± 0.89 mm). There was no significant difference between repair groups in stiffness during maximum load to failure or in normalized cyclic elongation. Failure modes were as follows: TOE, tendon (n = 4) and bone (n = 3); TO, suture (n = 6) and bone (n = 1); AT, tendon (n = 2) and bone (n = 3) and suture (n = 1); ATX, tendon (n = 7). CONCLUSION: This study demonstrates that anchorless repair techniques using transosseous sutures result in significantly lower failure loads than a repair model utilizing anchors in a TOE construct. CLINICAL RELEVANCE: Suture anchor repair appears to offer superior biomechanical properties to transosseous repairs regardless of tunnel or suture configuration.

Clinical and magnetic resonance imaging outcomes after surgical repair of complete proximal hamstring ruptures: does the tendon heal?

BACKGROUND: The use of validated outcome questionnaires and magnetic resonance imaging (MRI) when assessing outcomes after surgical treatment of proximal hamstring avulsions has been limited. PURPOSE: To comprehensively evaluate clinical, functional, and radiological outcomes in patients treated with surgical repair for complete proximal hamstring avulsions. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review of 15 consecutive patients was performed. Outcome measures included the Single Assessment Numeric Evaluation (SANE), visual analog scale (VAS) for pain, Proximal Hamstring Injury Questionnaire, Lower Extremity Functional Scale (LEFS), Harris Hip Score (HHS), and Tegner Activity Scale (TAS). Physical examination was performed by an independent sports medicine fellow. Magnetic resonance imaging of the lower extremity was used to assess tendon healing and muscle quality after repair. RESULTS: Thirteen of 15 (87%) eligible patients were available for follow-up at a mean 36.9 months (range, 27-63 months), including 8 men and 6 left-sided injuries. The average age was 44.6 years (range, 26-58 years). Twelve of 13 patients underwent surgical repair within 60 days of injury. Mean (± standard deviation) postoperative functional outcome scores were as follows: LEFS, 74.9 ± 7.8 (range, 59-80); HHS, 90.7 ± 13.9 (range, 67-100); SANE, 93.6 ± 7.5 (range, 75-100); VAS for pain, 1.3 ± 1.9 (range, 0-5); and TAS, 4.6 ± 2.3 (range, 1-7). All 11 patients who participated in sports before surgery were able to return to sport, but 45% reported a decrease in their current level of activity. Isokinetic muscle testing demonstrated that injured hamstring strength recovered up to 78% ± 6.1% (range, 74%-88%) of the contralateral side. The MRI examinations revealed that 100% of patients had a healed proximal hamstring repair, with signs of tendinopathy and mild atrophy in 3 of 12 patients. CONCLUSION: The current findings indicate that surgical repair of complete hamstring ruptures provides reliable pain relief, good functional outcomes, high satisfaction rates, and excellent healing rates (MRI) but does not fully restore hamstring function and sports activity to preinjury levels.

Biomechanical analysis of the pectoralis major tendon and comparison of techniques for tendo-osseous repair.

BACKGROUND: Various described surgical techniques exist for the repair of pectoralis major ruptures at the tendo-osseous junction. It is unclear how these techniques restore the native properties of the pectoralis major tendon because its biomechanical properties have not been described. HYPOTHESIS: All repairs will have lower initial biomechanical profiles than the native attachment, and transosseous sutures will demonstrate improved initial biomechanical performance compared with anchors or buttons. STUDY DESIGN: Controlled laboratory study. METHODS: Twenty-four fresh-frozen cadaveric shoulders were randomized to 4 equal groups, including 3 experimental repair groups and 1 control group of intact pectoralis major tendons. The characteristics of the native anatomic footprint were recorded, and the experimental groups underwent pectoralis detachment, followed by subsequent repair. The restoration of the anatomic footprint was recorded. All specimens were tested with cyclic loading and load-to-failure protocols with load, displacement, and optical marker data simultaneously collected. RESULTS: Under cyclic loading, the intact specimens demonstrated a significantly higher secant stiffness (74.8 ± 1.6 N/mm) than the repair groups (endosteal Pec Button [PB], 46.2 ± 6.4 N/mm; suture anchor [SA], 45.9 ± 8.7 N/mm; transosseous [TO], 44.2 ± 5.5 N/mm). Measured as a percentage change, the PB and SA groups showed a significantly higher initial excursion than the intact group (PB, 24.0% ± 11.7%; SA, 17.5% ± 6.9%; intact, 2.2% ± 1.0%), and the PB group demonstrated a significantly higher cyclic elongation than the intact group (PB, 7.5% ± 2.9%; intact, 1.5% ± 1.5%). Under load-to-failure testing, the intact group showed a significantly greater maximum load (1454.8 ± 795.7 N) and linear stiffness (221.0 ± 111.7 N/mm) than the 3 repair groups (PB, 353.5 ± 88.3 N and 63.5 ± 6.9 N/mm; SA, 292.0 ± 73.3 N and 77.0 ± 7.8 N/mm; TO, 359.2 ± 110.4 N and 64.5 ± 14.1 N/mm, respectively). All repair constructs failed via suture pulling through the tendon. CONCLUSION: The biomechanical characteristics of the transosseous repair, suture anchors, or Pec Button repair were inferior to those of the native pectoralis tendon. There was no significant difference in any of the biomechanical outcomes among the repair groups. Further refinement and evaluation of suture technique and configuration in pectoralis major repair should be considered. CLINICAL RELEVANCE: Transosseous repair, suture anchors, and endosteal Pec Buttons appear to confer similar biomechanical integrity for pectoralis major repair. Restricting early activities to thresholds below the identified failure loads seems prudent until soft tissue healing to bone is reliably achieved.

Surgical treatment options for the young and active middle-aged patient with glenohumeral arthritis.

The diagnosis and treatment of symptomatic chondral lesions in young and active middle-aged patients continues to be a challenging issue. Surgeons must differentiate between incidental chondral lesions from symptomatic pathology that is responsible for the patient's pain. A thorough history, physical examination, and imaging work up is necessary and often results in a diagnosis of exclusion that is verified on arthroscopy. Treatment of symptomatic glenohumeral chondral lesions depends on several factors including the patient's age, occupation, comorbidities, activity level, degree of injury and concomitant shoulder pathology. Furthermore, the size, depth, and location of symptomatic cartilaginous injury should be carefully considered. Patients with lower functional demands may experience success with nonoperative measures such as injection or anti-inflammatory pharmacotherapy. When conservative management fails, surgical options are broadly classified into palliative, reparative, restorative, and reconstructive techniques. Patients with lower functional demands and smaller lesions are best suited for simpler, lower morbidity palliative procedures such as debridement (chondroplasty) and cartilage reparative techniques (microfracture). Those with higher functional demands and large glenohumeral defects will usually benefit more from restorative techniques including autograft or allograft osteochondral transfers and autologous chondrocyte implantation (ACI). Reconstructive surgical options are best suited for patients with bipolar lesions.