Rehabilitation and functional outcomes in internally braced and standard ACL reconstructions.

Purpose: The purpose of this study was to compare surgical outcomes in patients who underwent ACL reconstruction, with and without internal bracing, at 1-3, 4-7, and 8-12 months of postoperative physical therapy. Previous studies show that ACL reconstruction with internal bracing allows earlier and more aggressive rehabilitation. Therefore, it was hypothesized that patients with internal bracing would display superior surgical recovery compared to ACL reconstruction alone after adjusting for length of physical therapy.1, 2, 3. Methods: Patients who underwent ACL reconstruction and had a minimum two-year follow-up were included. Demographics including age, gender, use of internal bracing, and pre-operative level of activity were collected. Patient-reported outcomes were assessed using KOOS scores. Results: 46 patients underwent ACL reconstruction between January 2013 and December 2015. The mean age was 31.53 ± 8.37 years. Patients who received ACL reconstruction with internal bracing reported similar improvement in KOOS scores (mean = 42.82 ± 15.44; median = 46.39 [34.52-51.80]) compared to ACL reconstruction alone (mean = 38.18 ± 19.91; median = 40.17 [29.49-53.90]) (p = 0.475). Patients who received ACL reconstruction with internal bracing reported comparable improvement to ACL reconstruction alone at 0-3 months (Internal bracing: mean = 35.39 ± 15.26, median = 40.45 [26.49-47.73]; No internal bracing: mean = 42.51 ± 12.33, median = 39.32 [35.69-52.94], p = 0.4113), 4-7 months (Internal bracing: 41.96 ± 14.49, 45.55 [33.94-52.68]; No internal bracing: 30.64 ± 32.29, 41.65 [26.17-46.12], p = 0.7491) and 8+ months groups (Internal bracing: 63.36 ± 13.06, 63.36 [58.74-67.98]; No internal bracing: 47.05 ± 10.14, 47.05 [43.46-50.63]) (p = 0.6985). Conclusion: This study demonstrates no statistical difference in functional outcome scores when comparing patients with internally braced ACL reconstruction compared to standard reconstruction. Therefore, the increased structural support provided by use of internal bracing in ACL reconstruction does not afford to quicker improvement in patient-reported recovery.

Clinical Utility of Ordered Pathology Blood Smear Reviews - an Overused Resource?

BACKGROUND: Blood smear reviews by pathologists (BSR) are ordered frequently at our institution, take time to evaluate, and result in a written report. Minimal research has been done regarding the amount of novel data reported and its clinical utility. METHODS: Detailed chart review was performed on BSR orders from January 1, 2015 to March 31, 2015 to assess reasons for smear review, if results were mentioned in the chart, if laboratory-driven reviews were already performed, and if novel, clinically influential data was reported. The trends in ordering was also evaluated. RESULTS: A total of 277 reviews were performed and were most commonly ordered to evaluate the presence of malignancy (43%), hemolysis (18%), and anemia (16%). For 130 of the 277 specimens, laboratory-driven smear review was already performed. The BSR smear review findings were not mentioned in the patient chart in 52% of cases. The report provided novel data in 187 cases (68%) which mainly were minor findings such as low levels of red blood cell abnormalities. The novel data appeared to influence clinical decision making in only 3 cases (1%). CONCLUSIONS: Although novel data are often reported, only rarely does it appear to be clinically significant and the information frequently overlaps with information already provided by laboratory-initiated smear reviews. Discussion with, and education of, clinical staff may increase appropriate utilization.

Variation in Results Release and Patient Portal Access to Diagnostic Test Results at an Academic Medical Center.

BACKGROUND: Electronic health records (EHRs) are commonplace in industrialized countries. Many hospitals are granting their patients access to their medical information through online patient portals. In this report, we describe a retrospective analysis of patient access to diagnostic test results released through the patient portal (MyChart; Epic, Inc.) at a state academic medical center. METHODS: We analyzed 6 months of data for anatomic pathology, clinical laboratory, and radiology test results to evaluate variations in results release (automated vs. manual) and subsequent patient access to the institutional patient portal. During this period, diagnostic test results were released for all patient encounters including inpatient units, outpatient clinics, and the emergency department. RESULTS: Manual results release by providers before automated release time occurred most commonly in the outpatient setting. The highest rates of access of diagnostic test results occurred for outpatients (about 30% overall view rate), females (two times or more compared to males in nearly every age bracket), and 20-45-year-old. Access rates of diagnostic tests in the emergency department or inpatient units were <10% across all populations. Access of diagnostic test results was very low for 12-17-year-old, likely influenced by institutional policies limiting parental proxy access within this pediatric age range. Approximately 20% of outpatient laboratory results were viewed by patients within 8 h of release from the EHR to the patient portal and 10% within 2 h of release. CONCLUSIONS: Patient accessing of diagnostic test results were generally higher for females, outpatients, and 20-45-year-old. Approximately, 20% of outpatient results were viewed quickly by patients after release to the EHR.

Impact of Endogenous and Exogenous Interferences on Clinical Chemistry Parameters Measured on Blood Gas Analyzers.

BACKGROUND: The prevalence of hemolysis, icterus, and lipemia (HIL) was determined for residual whole blood specimens analyzed for clinical chemistry parameters on blood gas analyzers. The frequency and potential impact of exogenous interference from iodide, salicylate, and thiocyanate (metabolite of sodium nitroprusside) on analysis of whole blood chloride was also assessed. METHODS: Over an approximately two month period at an academic medical center, indices for HIL were determined on Roche cobas c502 analyzers for 1,986 residual whole blood specimens that had been previously analyzed for clinical chemistry parameters on Radiometer ABL90 FLEX blood gas analyzers. To examine exogenous interferences, retrospective analysis was performed over multiple years to ascertain whether patient samples analyzed for whole blood chloride were potentially affected by interference from iodide, salicylate, or thiocyanate. RESULTS: Some degree of hemolysis (defined as hemolysis index of greater than 60) was present in 9.7% of the whole blood specimens. Increasing rates of hemolysis were associated with higher whole blood potassium concentrations. Nearly 60% of specimens with potassium concentrations between 6.0 and 6.9 mEq/L had hemolysis indices of 100 or greater, and 75% of specimens with a potassium concentration of 7.0 mEq/L or greater were severely hemolyzed (hemolysis index of 300 or greater). In contrast to the hemolysis results, icterus and lipemia were determined to have minimal impact on patient results. For the exogenous interferences, we did not identify any patient samples where elevated salicylate levels or pharmaceutical iodide administration overlapped with whole blood chloride analysis (out of 75,887 and 169,229 total chloride measurements, respectively). We did, however, find that for patients receiving nitroprusside therapy in the inpatient setting, whole blood chloride concentrations were significantly higher during nitroprusside therapy [106.7 +/- 6.2 mEq/L (mean, SD)] compared to before or after nitroprusside therapy (103.1 +/- 7.7 mEq/L). CONCLUSIONS: In this analysis of whole blood specimens, hemolysis is a common interference and likely to introduce meaningful biases, as illustrated with potassium analysis. Icterus, lipemia, salicylate, and iodide appear unlikely to cause clinically significant bias. Nitroprusside therapy introduced a slight rise in whole blood chloride concentrations that probably has minimal clinical significance.

Prevalence and Clinical Utility of "Incidental" Critical Values Resulting From Critical Care Laboratory Testing.

OBJECTIVE: Panels of clinical laboratory testing may generate "incidental" critical values from unordered parameters. Existing regulations do not clearly delineate guidelines for handling incidental critical values. The objective of this study was to examine the patterns and clinical utility of incidental critical values at 2 critical care laboratories within an academic medical center. METHODS: In this retrospective study, the electronic health record and laboratory information system were reviewed for incidental critical results obtained from blood gas analyzer analysis of whole blood specimens between November 2010 and August 2014. RESULTS: Within the retrospective time period, 9,092 incidental critical results were documented, of which only 11.8% were added to the "parent" order following clinical notification. Incidental critical results frequently occurred in patients who had recent critical values for the same parameter. CONCLUSION: In this study, at an academic medical center, incidental critical values associated with blood gas analyzers were added on at a low rate and often provided redundant information. Relative to the manual effort involved in care providers' notification and documentation of results, incidental critical values appear to have low clinical utility.