OBTAIN E: outcome benefits of tranexamic acid in hip arthroplasty with enoxaparin: a randomised double-blinded controlled trial.

BACKGROUND: We examined the blood conserving effect of tranexamic acid in total hip arthroplasty using the direct anterior approach with enoxaparin as deep vein thrombosis (DVT) chemoprophylaxis, and whether this translates to an effect on functional outcomes in the perioperative period. We also compare the effect of aspirin and enoxaparin as DVT chemoprophylactic agents. METHODS: We conducted a single-centre randomised, double-blinded, placebo-controlled trial. 105 patients were randomised to receive either tranexamic acid or an equivalent volume of normal saline with enoxaparin used as DVT chemoprophylaxis. The primary outcome measure was thigh swelling. Blood loss and the incidence of blood transfusions was also recorded. Secondary outcome measures including postoperative functional scores and mobility, pain scores and length of stay. We also compared and pooled the results of a previous study with the same study intervention methodology which used aspirin as DVT chemoprophylaxis instead of enoxaparin. RESULTS: There were no statistically significant differences between the primary outcome of thigh swelling. There was significantly less intraoperative blood loss observed in the tranexamic acid (TXA) group (0.510 L, SD 0.210) compared with the control group (0.698, SD 0.301) ( p < 0.001). The estimated blood loss was also significantly less in the TXA group (1.130 L, SD 0.311) compared with the control group (1.48 L, SD 0.510) ( p < 0.001). Pooled data of both consecutive trials showed there was a statistically significant reduction in length of stay for those that received TXA (3.72 days, SD 0.83 versus 4.24 days, SD 0.97, p < 0.001). There was also a statistically significant increased risk of a transfusion in the control group as compared those that received TXA (OR 5.5, 1.188 to 25.449, p = 0.029). There was no difference in blood loss between DVT chemoprophylactic agents. INTERPRETATION: TXA is an effective agent in reducing blood loss in THR using the anterior approach and was not affected by choice of DVT chemoprophylaxis. Patients who received TXA had fewer transfusions and a reduction in their length of stay. The blood conserving effect of TXA was not associated with improved postoperative recovery across the measures of pain and mobility. CLINICAL TRIALS REGISTRATION: ANZCTR number: ACTRN12616000606482.

Loss of independent limb control in childhood hemiparesis is related to time of brain injury onset.

This study investigated the presence of inter-limb activity at the elbow joint in individuals with childhood-onset hemiparesis, including spontaneous mirror movements during unilateral tasks and the ability to suppress them during bilateral tasks. Eighteen individuals with hemiparesis were divided into three categories of injury timing: before birth (PRE-natal), around the time of birth (PERI-natal), and after 6 months of age (POST-natal). Individuals with hemiparesis, as well as 12 typically developing peers, participated in unilateral and bilateral elbow flexion and extension tasks completed at maximal and submaximal effort while muscle activity was monitored and motor output was quantified by two multiple degrees-of-freedom load cells. Significantly, higher levels of paretic elbow flexion were found only in the PRE- and PERI-natal groups during the flexion of the non-paretic limb, which was modulated by effort level in both unilateral and bilateral tasks. The bilateral activation of elbow flexors in the PRE-/PERI-natal groups indicates potential use of a common cortical command source to drive both upper extremities, while the POST-natal/typically developing groups' flexors appear to receive input from different supraspinal structures.

Integrating a multidisciplinary mobility programme into intensive care practice (IMMPTP): a multicentre collaborative.

BACKGROUND: ICU immobility can contribute to physical deconditioning, increased ICU and hospital length of stay and complications post discharge. Despite evidence of the beneficial outcomes of early mobility, many ICUs and providers lack necessary processes and resources to effectively integrate early mobility into their daily practice. OBJECTIVE: To create a progressive mobility initiative that will help ICU teams to address key cultural, process and resource opportunities in order to integrate early mobility into daily care practices. METHODS: An initiative to integrate the latest evidence on mobility practice into current ICU culture in 13 ICUs in eight hospitals within the US was launched. A user-friendly, physiologically grounded evidence-based mobility continuum was designed and implemented. Appropriate education and targeted messaging was used to engage stakeholders. To support and sustain the implementation process, mechanisms including coaching calls and various change interventions were offered to modify staffs' practice behaviour. Qualitative data was collected at two time points to assess cultural and process issues around mobility and provided feedback to the stakeholders to support change. Quantitative date on ventilator days and timing of physical therapy consultation was measured. RESULTS: Qualitative reports of the mobility programme participants suggest that the methods used in the collaborative approach improved both the culture and team focus on the process of mobility. There were no significant differences demonstrated in any of the mobility intervention group measurement however, a reduction in ventilator days (3.0days pre vs. 2.1 days post) approached significance (p=0.06). CONCLUSION: This multi-centre, ICU collaborative has shown that improvements in team culture, communication and resources can improve adoption of early mobility in ICU patients.

Retraining of interjoint arm coordination after stroke using robot-assisted time-independent functional training.

We have developed a haptic-based approach for retraining of interjoint coordination following stroke called time-independent functional training (TIFT) and implemented this mode in the ARMin III robotic exoskeleton. The ARMin III robot was developed by Drs. Robert Riener and Tobias Nef at the Swiss Federal Institute of Technology Zurich (Eidgenossische Technische Hochschule Zurich, or ETH Zurich), in Zurich, Switzerland. In the TIFT mode, the robot maintains arm movements within the proper kinematic trajectory via haptic walls at each joint. These arm movements focus training of interjoint coordination with highly intuitive real-time feedback of performance; arm movements advance within the trajectory only if their movement coordination is correct. In initial testing, 37 nondisabled subjects received a single session of learning of a complex pattern. Subjects were randomized to TIFT or visual demonstration or moved along with the robot as it moved though the pattern (time-dependent [TD] training). We examined visual demonstration to separate the effects of action observation on motor learning from the effects of the two haptic guidance methods. During these training trials, TIFT subjects reduced error and interaction forces between the robot and arm, while TD subject performance did not change. All groups showed significant learning of the trajectory during unassisted recall trials, but we observed no difference in learning between groups, possibly because this learning task is dominated by vision. Further testing in stroke populations is warranted.

Time Independent Functional task Training: a case study on the effect of inter-joint coordination driven haptic guidance in stroke therapy.

After a stroke abnormal joint coordination of the arm may limit functional movement and recovery. To aid in training inter-joint movement coordination a haptic guidance method for functional driven rehabilitation after stroke called Time Independent Functional Training (TIFT) has been developed for the ARMin III robot. The mode helps retraining inter-joint coordination during functional movements, such as putting an object on a shelf, pouring from a pitcher, and sorting objects into bins. A single chronic stroke subject was tested for validation of the modality. The subject was given 1.5 hrs of robotic therapy twice a week for 4 weeks. The therapy and the results of training the single stroke subject are discussed. The subject showed a decrease in training joint error for the sorting task across training sessions and increased self-selected movement time in training. In kinematic reaching analysis the subject showed improvements in range of motion and joint coordination in a reaching task, as well as improvements in supination-pronation range of motion at the wrist.

Parent preferences for motor development education in the neonatal intensive care unit.

PURPOSE: The purpose of this pilot study was to determine parents' preferred method of receiving education on motor development of infants born preterm. METHODS: This study was conducted through a pair of focus groups in which parents evaluated different educational formats and provided feedback on the clarity of the parent education intervention. RESULTS: Parents reported that they would prefer to learn about their infant's motor development with a combination of observation, discussion, and written material. After the parent education intervention, parents of infants born preterm were able to describe the ways they would play with their infant and answered more questions correctly on a postintervention test. CONCLUSIONS: Parents of infants who were born preterm would benefit from education using multiple approaches. The parent education intervention developed in this study is clear and well understood by parents. Further research is needed to evaluate the efficacy of this intervention.

Ventilator-associated pneumonia improvement program.

Ventilator-associated pneumonia (VAP) is a significant clinical problem associated with increased intensive care unit and hospital length of stay and substantial increases in delivery cost and associated morbidity and mortality. With system changes and management of the environment of care, the incidence of VAP was reduced in seven of our intensive care units across the system. Steps necessary to reduce VAP were identified and put into place in all the intensive care units. Patient positioning, oral care, nutrition, and management of comfort drugs are a few of the processes addressed to reduce VAP. Standardization of these essential care practices can reduce the incidence of this nosocomial infection and its associated increases in the cost of care delivery and mortality.

Implementing a rapid response team: factors influencing success.

Rapid response teams (RRTs), or medical emergency teams, focus on preventing a patient crisis by addressing changes in patient status before a cardiopulmonary arrest occurs. Responding to acute changes, RRTs and medical emergency teams are similar to "code" teams. The exception, however is that they step into action before a patient arrests. Although RRTs are acknowledge as an important initiative, implementation can present many challenges. This article reports on the implementation and ongoing use of a RRT at a community health care setting, highlighting important considerations and strategies for success.