An evaluation of pre-hospital emergency medical systems for suspected ST-elevation myocardial infarction in Colorado.

OBJECTIVES: Patients presenting with ST-elevation myocardial infarction (STEMI) benefit from rapid cardiac reperfusion therapy. Emergency medical service (EMS) agencies can improve patient outcomes by calling STEMI alerts to the receiving facility. The aim of this study was to evaluate the use of pre-hospital activation systems for suspected ST-elevation myocardial infarctions (STEMI) throughout Colorado. METHODS: A cross sectional, survey design was utilized to collect all data from EMS agencies in Colorado. A univariable logistic regression model was used to identify factors predictive of an agency reporting that they utilize a STEMI activation protocol. RESULTS: 84.5% [95% CI: 78.3 to 90.7%] of agencies included indicate that they utilize a STEMI activation protocol. Based on the logistic regression analysis, the number of EMT employees was significantly associated with whether or not an agency indicates that they utilize a STEMI activation protocol. For every 10% increase in the number of EMTs employed by an EMS agency, there was a 3.0 [95% CI: 1.5 to 6.0, p = 0.0012] fold increase in the odds of the agency indicating they utilize a STEMI activation protocol. CONCLUSIONS: Our study provides evidence that larger agencies are more likely to utilize a STEMI activation protocol. In areas without a STEMI system of care, improvements in smaller agencies that cover more ground (with longer transport times) should be the focus for protocol implementation. Based on the current prevalence of such training, competency based training in reading ST-elevations on ECG should be considered by EMS agencies.

Does Strict Adherence to the Ponseti Method Improve Isolated Clubfoot Treatment Outcomes? A Two-institution Review.

BACKGROUND: Despite being recognized as the gold standard in isolated clubfoot treatment, the Ponseti casting method has yielded variable results. Few studies have directly compared common predictors of treatment failure between institutions with high versus low failure rates. QUESTIONS/PURPOSES: We asked: (1) is the provider's rigid adherence to the Ponseti method associated with a lower likelihood of unplanned clubfoot surgery, and (2) at the institution that did not adhere rigidly to Ponseti's principles, are any demographic or treatment-related factors associated with increased likelihood of unplanned clubfoot surgery? METHODS: After institutional review board approval, a consecutive series of patients with a diagnosis of isolated clubfoot who underwent treatment between January 2003 and December 2007 were identified. At Institution 1, 91 of 133 patients met the eligibility criteria and were followed for a minimum of 2 years compared with 58 of 58 patients at Institution 2. At Institution 1, 16 providers managed care using a conservative casting approach based on the Ponseti method. However, treatment was adapted by the provider(s). At Institution 2, one orthopaedic surgeon managed care with strict adherence to the Ponseti method. Surgical indications at both institutions included the presence of a persistent equinovarus foot position while standing. A chart review was used to collect data related to proportion of patients undergoing unplanned additional treatment for deformity recurrences after Ponseti casting, demographics, and treatment patterns. RESULTS: The proportion of subjects who underwent unplanned major surgical intervention was greater (odds ratio [OR], 51.1; 95% CI, 6.8-384.0; p < 0.001) at Institution 1 (60 of 131, 47%) compared with Institution 2 (two of 91, 2%). There was no difference (p = 0.200) in the proportion of patients who underwent additional casting, repeat tendo Achilles lengthening, and/or anterior tibialis tendon transfer only (minor recurrence) at Institution 1 (nine of 131, 7%) compared with Institution 2 (11 of 91, 13%). At Institution 1, an increase in the number of revision casts (multiple vs no casts, hazard ratio [HR] = 3.9; 95% CI, 2.0-7.6; p < 0.001) and an increase in the number of cast-related complications (multiple vs no complications, HR = 2.8; 95% CI, 1.2-6.7; p = 0.019) were associated with increased risk of major surgery in the multivariate analysis. CONCLUSIONS: Rigid commitment to the Ponseti method in the conservative treatment of patients with isolated clubfoot was associated with a lower risk of subsequent unplanned surgical intervention. In addition, clubfoot treatment programs that use a care model that prioritizes continuity in care and dedication to the Ponseti method may decrease the proportion of patients who undergo unplanned surgical intervention. LEVEL OF EVIDENCE: Level III, therapeutic study.

Management of Sport-Related Concussion in the Pediatric and Adolescent Population.

Concussions make up nearly 10% of all high school athletic injuries. Recent changes in concussion management guidelines and legislation aim to make concussion care more standardized and safe but simultaneously pose a challenge for the primary care and sports medicine physician. Pediatric and adolescent concussions may cause anxiety for the treating physician due to concerns over return-to-play decisions, academic issues, and the potential for second impact syndrome. Determining when to refer a patient to an emergency department acutely, to an outpatient concussion clinic, or to other subspecialists may be a difficult decision for the primary care physician. The aim of this article is to review current evidence regarding concussion treatment and return-to-school and return-to-play recommendations to provide the primary care and sports medicine physician with practical guidelines for managing concussions.

The relationship between initial physical examination findings and failure on objective validity testing during neuropsychological evaluation after pediatric mild traumatic brain injury.

BACKGROUND: The symptomatology after mild traumatic brain injury (mTBI) is complex as symptoms are subjective and nonspecific. It is important to differentiate symptoms as neurologically based or caused by noninjury factors. Symptom exaggeration has been found to influence postinjury presentation, and objective validity tests are used to help differentiate these cases. This study examines how concussed patients seen for initial medical workup may present with noncredible effort during follow-up neuropsychological examination and identifies physical findings during evaluation that best predict noncredible performance. HYPOTHESIS: A portion of pediatric patients will demonstrate noncredible effort during neuropsychological testing after mTBI, predicted by failure of certain vestibular and cognitive tests during initial examination. STUDY DESIGN: Retrospective cohort. LEVEL OF EVIDENCE: Level 4. METHODS: Participants (n = 80) underwent evaluation by a sports medicine physician ≤3 months from injury, were subsequently seen for a neuropsychological examination, and completed the Medical Symptom Validity Test (MSVT). Variables included results of a mental status examination (orientation), serial 7s examination, Romberg test, and heel-to-toe walking test. The primary outcome variable of interest was pass/fail of the MSVT. RESULTS: Of the participants, 51% were male and 49% were female. Eighteen of 80 (23%) failed the MSVT. Based on univariable logistic regression analysis, the outcomes of the Romberg test (P = 0.0037) and heel-to-toe walking test(P = 0.0066) were identified as significant independent predictors of MSVT failure. In a multivariable model, outcome of Romberg test was the only significant predictor of MSVT failure. The probability of MSVT failure was 66.7% (95% CI, 33.3% to 88.9%) when a subject failed the Romberg test. CONCLUSION: A meaningful percentage of pediatric subjects present evidence of noncredible performance during neuropsychological examination after mTBI. Initial examination findings in some cases may represent symptom exaggeration.

Comparison of allograft versus autograft anterior cruciate ligament reconstruction graft survival in an active adolescent cohort.

BACKGROUND: Graft selection for anterior cruciate ligament (ACL) reconstructive surgery is a controversial topic. Few studies have compared graft outcomes in adolescents. PURPOSE: To identify factors related to ACL graft failure in an adolescent cohort. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: After institutional review board approval was obtained, adolescent subjects (age range, 11-18 years) who underwent primary ACL reconstruction surgery at a large tertiary pediatric hospital between July 2005 and July 2009 were identified through a query of International Classification of Diseases, 9th Revision, diagnostic and Current Procedural Terminology codes. Subject data were obtained by means of a retrospective chart review, phone survey, and the administration of functional knee outcome instruments. A multivariate Cox proportional hazards regression analysis was used to analyze factors related to graft survival. RESULTS: The average ages at surgery in the allograft (n = 38) and autograft (n = 35) groups were 15.29 ± 2.24 and 15.60 ± 1.57 years, respectively. There were 11 graft failures (28.95%) in the allograft group compared with 4 graft failures (11.43%) in the autograft group. In the multivariate model, graft type (P = .0352) and postoperative knee laxity according to the Lachman test (P = .0217) were the only variables significantly related to graft survival. The hazard of graft failure was 4.4 (95% CI, 1.23-18.89) times greater in the allograft group compared with the autograft group. The hazard of graft failure was 5.28 times (95% CI, 1.1-12.72; P = .0217) greater for a subject who demonstrated increased postoperative knee laxity relative to the contralateral knee. The risk for autograft failure tended to remain constant 24 to 48 months after initial surgery, whereas the risk for allograft failure continued to increase during postoperative months 24 to 48. There were no differences (P > .05) between the allograft and autograft groups with respect to International Knee Documentation Committee score, Lysholm score, and the rate of return to previous activity level. CONCLUSION: Graft type and postoperative knee laxity were identified as significant predictors of graft survival. On the basis of this large retrospective cohort, we recommend the use of autogenous grafts in children and adolescents undergoing primary, transphyseal ACL reconstruction. Patients who demonstrate increased translation during a postoperative Lachman test should be carefully followed because of concerns for subsequent graft failure.

Post-weaning social isolation of female rats, anxiety-related behavior, and serotonergic systems.

Our previous studies have shown that post-weaning social isolation of male rats leads to sensitization of serotonergic systems and increases in anxiety-like behavior in adulthood. Although studies in humans suggest that females have an increased sensitivity to stress and risk for the development of neuropsychiatric illnesses, most studies involving laboratory rats have focused on males while females have been insufficiently studied. The objective of this study was to investigate the effects of post-weaning social isolation on subsequent responses of an anxiety-related dorsal raphe nucleus (DR)-basolateral amygdala system to pharmacological challenge with the anxiogenic drug, N-methyl-beta-carboline-3-carboxamide (FG-7142; a partial inverse agonist at the benzodiazepine allosteric site on the γ-aminobutyric acid (GABA)(A) receptor). Juvenile female rats were reared in isolation or in groups of three for a 3-week period from weaning to mid-adolescence, after which all rats were group-reared for an additional 2 weeks. We then used dual immunohistochemical staining for c-Fos and tryptophan hydroxylase in the DR or single immunohistochemical staining for c-Fos in the basolateral amygdala. Isolation-reared rats, but not group-reared rats, injected with FG-7142 had increased c-Fos expression within the basolateral amygdala and in serotonergic neurons in the dorsal, ventrolateral, caudal and interfascicular parts of the DR relative to appropriate vehicle-injected control groups. These data suggest that post-weaning social isolation of female rats sensitizes a DR-basolateral amygdala system to stress-related stimuli, which may lead to an increased sensitivity to stress- and anxiety-related responses in adulthood.

Implications of parental influence on child/adolescent helmet use in snow sports.

OBJECTIVE: The main objective of this study was to assess the influencing factors in participants who do not use a helmet while skiing or snowboarding in the youth population. DESIGN: Cross-sectional survey. SETTING: The 2006-2007 and 2007-2008 ski seasons at the Crested Butte Mountain Resort. PARTICIPANTS: Children and adolescents between the ages of 6 to 17 years and their parents were enrolled in the study. Two hundred six children/adolescents participated. INDEPENDENT VARIABLES: Independent variables included age, gender, parental helmet use, ski/snowboard helmet past protection, and child/adolescent reason for wearing/not wearing helmet. MAIN OUTCOME MEASURES: Dependent variables included child/adolescent helmet use. RESULTS: Fifty-one percent were male and 49% were female. One hundred seventy-one (83%) reported that they wear a ski/snowboard helmet, and 35 (17%) reported that they did not wear a ski/snowboard helmet. There was a significant relationship between parental helmet use and child helmet use (P ≤ 0.0001). Of the 171 children/adolescents who reported wearing a helmet, 124 (72.5%) reported that wearing a helmet protected them in an accident. Of the 171 children/adolescents who reported wearing a helmet, 87.7% said that safety was the reason for wearing a helmet. The most common reason for not wearing a ski/snowboard helmet was comfort. CONCLUSIONS: Parent's helmet-wearing behavior was strongly associated with the child/adolescent's helmet-wearing behavior. The results demonstrate the overwhelming influence parental helmet use has on their child/adolescent's decision to wear a helmet.