Glenoid Bone Loss in Posterior Shoulder Instability: Prevalence and Outcomes in Arthroscopic Treatment.

BACKGROUND: Glenoid bone loss is a well-accepted risk factor for failure after arthroscopic stabilization of anterior glenohumeral instability. Glenoid bone loss in posterior instability has been noted relative to its existence in posterior instability surgery. Its effect on outcomes after arthroscopic stabilization has not been specifically evaluated and reported. PURPOSE: The purpose was to evaluate the presence of posterior glenoid bone loss in a series of patients who had undergone arthroscopic isolated stabilization of the posterior labrum. Bone loss was then correlated to return-to-duty rates, complications, and validated patient-reported outcomes. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A retrospective review was conducted at a single military treatment facility over a 4-year period (2010-2013). Patients with primary posterior instability who underwent arthroscopic isolated posterior labral repair were included. Preoperative magnetic resonance imaging was used to calculate posterior glenoid bone loss using a standardized "perfect circle" technique. Demographics, return to duty, complications, and reoperations, as well as outcomes scores including the Single Assessment Numeric Evaluation and the Western Ontario Shoulder Instability Index (WOSI) scores, were obtained. Outcomes were analyzed across all patients based on percentage of posterior glenoid bone loss. Bone loss was then categorized as below or above the subcritical threshold of 13.5% to determine if bone loss effected outcomes similar to what has been shown in anterior instability. RESULTS: There were 43 consecutive patients with primary, isolated posterior instability, and 32 (74.4%) completed WOSI scoring. Mean follow-up was 53.7 months (range, 25-82 months) The mean posterior glenoid bone loss was 7.3% (0%-21.5%). Ten of 32 patients (31%) had no appreciable bone loss. Bone loss exceeded 13.5% in 7 of 32 patients (22%), and 2 patients (6%) exceeded 20% bone loss. Return to full duty or activity was nearly 90% overall. However, those with >13.5%, subcritical glenoid bone loss, were statistically less likely to return to full duty (relative risk = 1.8), but outcomes scores, complications, and revision rates were otherwise not different in those with no or minimal bone loss versus those with more significant amounts. CONCLUSION: Posterior glenoid bone loss has not previously been evaluated independently relative to patients with shoulder instability repairs. Sixty-nine percent of our patients had measurable bone loss, and 22% had greater than 13.5%, or above subcritical bone loss. While these patients were statistically less likely to return to full duty, the reoperation rate, complications, and patient-reported outcomes between groups were not different.

The Growing Gap in Electronic Medical Record Satisfaction Between Clinicians and Information Technology Professionals: Issues of Most Concern and Suggested Remediations.

BACKGROUND: With the alarming statistics concerning the quality of national health care, it is hoped that electronic health records (EHRs) will reduce inefficiencies associated with medical delivery and improve patient safety. This study reports the results of a survey that demonstrates a pattern in EHR system implementation that indicates that health-care information technology decisions are based more on the preferences of information technology professionals (ITPs) and hospital administrators than clinicians. METHODS: We present survey data highlighting the growing discrepancy in EHR-related satisfaction between clinicians and ITPs. We conducted a literature search to identify major barriers that must be overcome to achieve optimal EHR benefits. We summarize our recommendations in order to maximize the favorable impact of EHRs on the health-care system. RESULTS: The existing gap in postimplementation EHR satisfaction ratings between ITPs and clinicians reveals an underlying systematic problem. Electronic medical record vendors perceive administrators and ITPs as the "buyers" for many EHR systems, and their needs are given higher priority than those of clinicians. This possibly may lead to the lack of clinically optimized EHRs, with systems often presenting as rigid and standardized with a limited exchange of health information. CONCLUSIONS: EHRs have the potential to become a powerful tool that may improve many processes related to health care, including quality, safety, and economical aspects. The involvement of physicians in every step of the process, from electronic medical record selection to acquisition, implementation, and ongoing optimization, is crucial for enabling the achievement of the medical organization's mission.

Managing Diabetes in Pregnancy Using Cell Phone/Internet Technology.

In Brief For pregnant women with diabetes, using cell phone/Internet technology to track and report self-monitoring of blood glucose results improves compliance and satisfaction compared to using the more traditional methods of log books, telephone calls, and voicemail messages.

Guiding health care transformation: A next-generation, diagnostic remediation tool for leveraging polarities.

BACKGROUND: Health care reform is optimized through the Polarity Thinking Model to achieve and sustain improvements in cost, safety, quality, and efficiency. Traditional problem-solving "fix-it" approaches have histories of inadequacy and failure in addressing the multiple polarities inherent in health care transformation. The Polarity Thinking Model is reviewed followed by a study conducted to establish validity and reliability for diagnostic assessment and remediation through leveraging polarities. METHODS: Thirteen common health care polarities were identified by an International Consortium, each needing to be leveraged or managed within an organization engaged in health care transformation. A Web-based survey tool was designed to provide leaders with readily interpretable diagnostic information for organizational evaluation regarding how well each polarity is being managed. Four hundred ninety-seven volunteers from two American and two Canadian acute care organizations participated. RESULTS: Content and context validity were established, and statistically significant reliabilities for the survey instrument were verified. Interpretations of study findings verify the assessment accuracy and interpretive value of the information for leading organizational optimization. CONCLUSIONS: Employing the Polarity Thinking Model and tools to evaluate how well organizations are managing polarities will enhance the organization's ability to self-diagnose and then succeed in achieving transformation toward sustainable desired outcomes.

Utility of computed tomography arthrograms in evaluating osteochondral allograft transplants of the distal femur.

Postsurgical evaluation of osteochondral allograft transplant surgery (OATS) of the distal femur most commonly utilizes radiographs or magnetic resonance imaging. This article proposes the utilization of computed tomography (CT) arthrography as an additional option, which allows clear assessment of articular congruity and osseous integration. A retrospective review was performed of 18 patients who underwent an OATS for distal femoral chondral lesions and obtained CT arthrograms postoperatively. CT arthrograms were evaluated for osseous integration and articular congruity. The average age and follow-up were 30.9 years and 4.3 years, respectively. Only 60% of patients were able to remain in the military postoperatively. The articular cartilage was smooth in eight (44.4%); complete bony integration was noted in eight (44.4%) patients. Neither articular congruity nor bony integration was associated with duty status at final follow-up. Although it allows excellent evaluation, similar to other modalities, CT arthrogram does not appear predictive of functional outcome.

High frequency of posterior and combined shoulder instability in young active patients.

OBJECTIVE: The purpose of this study was to describe the epidemiology and demographics of surgically treated shoulder instability stratified by direction. We hypothesized that there would be an increased frequency of posterior and combined shoulder instability in our population compared with published literature. Secondarily, we assessed preoperative magnetic resonance imaging (MRI) reports to determine how accurately they detected the pathology addressed at surgery. MATERIALS AND METHODS: A retrospective review was conducted at a single facility during a 46-month period. The study included all patients who underwent an operative intervention for shoulder instability. The instability in each case was characterized as isolated anterior, isolated posterior, or combined, according to pathologic findings confirmed at arthroscopy. The findings were retrospectively compared with official MRI reports to determine the accuracy of MRI in characterizing the clinically and operatively confirmed diagnosis. RESULTS: A consecutive series of 231 patients (221 men, 10 women) underwent stabilization for shoulder instability over 46 months. Patients were a mean age of 26.0 years. There were 132 patients (57.1%) with isolated anterior instability, 56 (24.2%) with isolated posterior instability, and 43 (18.6%) with combined instability. Overall, MRI findings completely characterized the clinical diagnosis and arthroscopic pathology in 149 of 219 patients (68.0%). CONCLUSION: The rate of posterior and combined instability in an active population is more common than has been previously reported, making up more than 40% of operatively treated instability, including a previously unreported incidence of 19% for combined instabilities. In addition, MRI was often incomplete or inaccurate in detecting the pathology eventually treated at surgery.

Complications Associated With High-dose Corticosteroid Administration in Children With Spinal Cord Injury.

BACKGROUND: Complications with high-dose steroid administration for spinal cord injury are documented in adult patients. Our purpose was to determine the incidence of early complications of this therapy in pediatric patients with spinal cord injuries. METHODS: An IRB-approved retrospective review was performed for patients treated for spinal cord injury at a level 1 pediatric trauma center between 2003 and 2011. Demographic data, injury characteristics, and surgical interventions were documented. Complications were divided into 4 categories: infectious, gastrointestinal (GI), hyperglycemia/endocrine, and wound healing problems. Complication rates were compared using a Student's t test and Fischer's exact test. RESULTS: Thirty-four spinal cord injury patients were identified. Twenty-three patients (mean age 6.6 y) in the treatment group received high-dose steroid treatment and 11 patients (mean age 8.4 y) did not and comprised the control group. No statistical difference was detected between the 2 groups regarding age, mechanism of injury, rate of surgical intervention, level of injury, and injury severity. Hyperglycemia was the most common complication and was present in all patients in both the treatment and control groups. The overall infection rate was 64% in the control group compared with 26% in the treatment (P<0.05). The control group demonstrated a significantly increased rate of respiratory tract infections [45% control vs. 9% treatment (P<0.05)]. No surgical patients developed a wound infection. One treatment group patient experienced a GI bleed. CONCLUSIONS: This is the largest study evaluating the complications associated with high-dose steroid administration for spinal trauma in a pediatric population. Hyperglycemia was found in all spinal cord injury patients, regardless of steroid treatment. Paradoxically, infection rates were noted to be higher in the control group. GI and wound problems were not significantly different. Larger, multicenter prospective studies are needed to better understand the risks in pediatric SCI patients.

Rates of bacteriuria in laboring women with epidural analgesia: continuous vs intermittent bladder catheterization.

OBJECTIVE: The purpose of this study was to compare the rates of bacteriuria in laboring women with epidural analgesia with the use of intermittent bladder catheterization (IC) vs continuous indwelling Foley catheterization (CIF). STUDY DESIGN: We conducted a randomized, nonblinded trial in which 160 laboring women received IC or CIF. An initial catheterized urine culture was taken at the time of epidural placement. A second catheterized or voided culture was taken at discharge. Results were analyzed to compare bacteriuria rates between CIF and IC with the use of the Center for Disease Control (CDC) and Infectious Disease Society of America (IDSA) definitions. RESULTS: Samples from 146 women were analyzed. Randomization, demographics, and labor characteristics were not significantly different between groups; 5.48% of the samples met CDC criteria for bacteriuria, and 17.8% of the samples met IDSA criteria. In the IC group, 7 samples (8.9%) met CDC criteria for bacteriuria, and 18 samples (22.8%) met IDSA criteria for bacteriuria. In the CIF group, 1 sample (1.5%) met CDC criteria, and 8 samples (12.1%) met IDSA criteria. There was a significantly higher rate of bacteriuria by both criteria in the IC group among all deliveries, all vaginal deliveries, and spontaneous vaginal deliveries (P < .05). CONCLUSION: Compared with CIF, IC was associated with significantly higher rates of bacteriuria.

Physician adoption of personal digital assistants (PDA): testing its determinants within a structural equation model.

Research has begun to explore the determinants of personal digital assistant (PDA) adoption in health care. Much of this research has, however, been inconsistent in its treatment of key constructs and its methodological approaches. The current study takes a stricter approach and tracks the pre- and postadoption beliefs of physicians provided with an actual PDA within a single health care facility in the United States. Results show that age, position in hospital, beliefs about health IT, and cluster ownership are significant, direct predictors of the physician's preadoption beliefs about PDAs. Contrary to prior research findings, both ease of use and usefulness perceptions significantly influenced the physician's intent to adopt PDAs. More important, results show that physicians focus on a broader range of PDA factors during preadoption assessment of the technology, while actual use is based solely on the PDA's ease of use. Moreover, the preadoption usefulness perceptions do not influence postadoption usefulness. Hence, the cognitive and affective determinants of intent to use are seemingly different from those used to evaluate PDA use.

Patterns and changes in prescriber attitudes toward PDA prescription-assistive technology.

CONTEXT: Medication error prevention is a priority for the U.S. healthcare system in the 21st century. Use of technology is considered by some as critical to achieve this goal. Knowledge of the attitudinal barriers to such adoption, however, is limited. OBJECTIVE: To determine the attitudes of frontline prescriber clinicians towards technology in general, and PDAs specifically, before and after introduction of a PDA in the clinical setting of medication prescribing. DESIGN: A pre- and post-intervention web-based survey, 12-14 months apart. SETTING: Academic tertiary care children's hospital. PARTICIPANTS: Total of 244 prescriber clinicians. INTERVENTION: Distribution of a PDA with pediatric-specific medication prescribing information after completion of an on-line medication safety certification and other safety focused educational sessions. MAIN OUTCOME MEASURES: Ratings (5-point Likert scale) reflecting perceptions and attitudes towards technology in general and technology in medical settings along with self-reported usage of the PDA for Rx. RESULTS: Early Adopters and Late Adopters were identified statistically, and the group membership reflected their prior exposure to and ownership of other technologies. Early Adopters tended to be younger and less experienced clinically (e.g., residents) and more frequent owners and users of technology. Early Adopters expressed significantly more favorable attitudes toward technology and PDAs on both pre- to post-intervention survey occasions. They also utilized the PDA for Rx more often than LAs. Interestingly, PDA use for Early Adopters was based on its ease of use, while PDA use among later adopters was based on its clinical usefulness. CONCLUSIONS: Provision of point of care information using PDAs and a user-friendly, pediatric-specific medication information software package did not positively affect the attitudes of prescriber clinicians among those already favorable toward technology. However, a significant change was found among those with initially less favorable attitudes. Organizations need to understand the nature of both Early and Late Adopters and plan appropriately for managing the respective needs and expectations when potentially beneficial technologies are introduced. In order to ensure the success of an implementation, the training and supportive interventions need to be carefully designed and specifically catered to the personality-based outcome expectations of the prescriber.

A search for the "Holy Grail" of health care: a correlation between quality and profitability.

In a study by CHRISTUS Health, data from 18 acute care facilities revealed that numerous indicators of clinical quality were significantly correlated with measures of business success. Results suggest that timely and appropriate interventions, coupled with timely and complete documentation, are correlated with improved business performance. The correlations between quality and financial performance make intuitive sense based on the observation that diligence in clinical processes can produce better information to support financial processes.

Antepartum seafood consumption and mercury levels in newborn cord blood.

OBJECTIVE: The purpose of this study was to determine the level of fetal mercury exposure by measuring mercury levels in newborn cord blood and to analyze the association with fish consumption during pregnancy. STUDY DESIGN: A total of 308 women who met the eligibility criteria were enrolled in the study. Of these, 275 women completed a dietary survey; after delivery, cord blood was collected and analyzed for mercury levels. RESULTS: The mean mercury level in cord blood was 4.82 microg/L; 28.3% of the participants had measured mercury levels above the US Environmental Protection Agency's recommended reference dose (5.8 microg/L). A significant relationship was noted between the amount of fish consumed during pregnancy and rising mercury levels in cord blood. CONCLUSION: In an island state with high levels of fish consumption, women were 3 times more likely to have elevated cord blood mercury levels, compared with the national average.

Duration of patency of laser-assisted tympanic membrane fenestration.

BACKGROUND: Laser-assisted tympanic membrane fenestration (LTMF) provides intermediate-duration middle ear ventilation, which benefits selected children with acute otitis media (AOM) and otitis media with effusion (OME). OBJECTIVE: To evaluate clinical and technical factors that may affect duration of LTMF patency. DESIGN: Prospective clinical cohort effectiveness trial. SETTING: Four tertiary care children's hospitals. PATIENTS: Volunteer sample of 251 children (430 ears) followed up at 1, 2, 3, 4, 8, and 12 weeks; time to fenestration closure was evaluable in 201 ears, and assessment of cure at study conclusion was evaluable in 128 ears. INTERVENTIONS: Laser-assisted tympanic membrane fenestration for prospectively defined AOM or OME. The surgeon determined spot size, wattage, and concurrent adenoidectomy based on clinical judgment. MAIN OUTCOME MEASURES: Cure of AOM/OME with effusion at 90 days and duration of LTMF patency relative to spot size (1.8-2.8 mm), fenestration location on tympanic membrane, power (7-22 W), concurrent adenoidectomy, age, diagnosis (AOM vs OME), type of effusion, and preoperative tympanogram characteristics. Results are based on the number of ears that could be evaluated at each data collection interval. RESULTS: Fenestrations remained patent for 2 to 4 weeks (mean = 2.52, median = 2.0, SD = 1.4, n = 201); 97.4% were closed at 6-week follow-up. Spot sizes of 2.4 and 2.6 mm had a higher rate of patency than 2.0-mm spot size at 3 weeks following LTMF. Cure at 90 days was related to duration of patency for all patients combined and for patients treated for AOM and OME, but not for those undergoing adjunctive adenoidectomy. Cure at 90 days was related to larger spot size for all patients combined and those treated for AOM. Other investigated factors did not achieve statistical significance. CONCLUSIONS: Spot size of 2.4 mm or greater results in improved duration of LTMF patency, persisting for up to 3 weeks after LTMF, especially for treatment of AOM. Increased duration of LTMF patency correlates with greater incidence of cure of middle ear effusion at 90 days. Additional investigation is indicated to determine optimum spot size and optimum duration of patency for disease- severity-adjusted populations.