Review process for IVIg treatment: Lessons learned from INSIGHTS neuropathy study.

BACKGROUND: This project is an effort to understand how orders for IV immunoglobulin (IVIg) are documented and prescribed by physicians, and subsequently, how they are reviewed by insurance companies for the treatment of immune neuropathies. METHODS: A panel of neuromuscular specialists reviewed case records from 248 IVIg-naive patients whose in-home IVIg infusion treatment was submitted to insurance for authorization. After reviewing a case record, 1 panelist was asked to make a diagnosis and to answer several questions about the treatment. A second panelist reviewed the original record and follow-up records that were obtained for reauthorization of additional treatments and was asked to determine whether the patient had responded to the treatment. RESULTS: Our specialists believed that only 32.2% of 248 patients had an immune neuropathy and were appropriate candidates for IVIg therapy, whereas 46.4% had neuropathies that were not immune mediated. Only 15.3% of cases met electrodiagnostic criteria for a demyelinating neuropathy. Our specialists believed that 36.7% of 128 cases with follow-up records had responded to therapy. In cases in which the initial reviewer had predicted that there would be a response to IVIg, the second reviewer found that 54% had responded. This is compared with a 27% response rate when the first reviewer predicted that there would be no response (p = 0.019). CONCLUSIONS: Our expert review finds that the diagnosis of immune neuropathies made by providers, and subsequently approved for IVIg therapy by payers, is incorrect in a large percentage of cases. If payers include an expert in their review process, it would improve patient selection, appropriate use, and continuation of treatment with this expensive therapeutic agent.

Identification of cutaneous functional units related to burn scar contracture development.

The development of burn scar contractures is due in part to the replacement of naturally pliable skin with an inadequate quantity and quality of extensible scar tissue. Predilected skin surface areas associated with limb range of motion (ROM) have a tendency to develop burn scar contractures that prevent full joint ROM leading to deformity, impairment, and disability. Previous study has documented forearm skin movement associated with wrist extension. The purpose of this study was to expand the identification of skin movement associated with ROM to all joint surface areas that have a tendency to develop burn scar contractures. Twenty male subjects without burns had anthropometric measurements recorded and skin marks placed on their torsos and dominant extremities. Each subject performed ranges of motion of nine common burn scar contracture sites with the markers photographed at the beginning and end of motion. The area of skin movement associated with joint ROM was recorded, normalized, and quantified as a percentage of total area. On average, subjects recruited 83% of available skin from a prescribed area to complete movement across all joints of interest (range, 18-100%). Recruitment of skin during wrist flexion demonstrated the greatest amount of variability between subjects, whereas recruitment of skin during knee extension demonstrated the most consistency. No association of skin movement was found related to percent body fat or body mass index. Skin recruitment was positively correlated with joint ROM. Fields of skin associated with normal ROM were identified and subsequently labeled as cutaneous functional units. The amount of skin involved in joint movement extended far beyond the immediate proximity of the joint skin creases themselves. This information may impact the design of rehabilitation programs for patients with severe burns.

Incidence of metacarpal fractures in U.S. soldiers stationed in South Korea.

The Korean War occupies a unique time in our nation's history. Because of the fragile relationship between the Koreas, U.S. forces stationed in Korea live within miles of a potential rival, necessitating strict discipline and courtesy by U.S. Soldiers. However, despite the standards and regulations, Soldiers are not immune to injury and hand injuries are among the most common afflictions obtained. Thus, 64 patients seen by occupational therapy for treatment of metacarpal fractures participated in a retrospective study regarding the circumstances surrounding the injury. The findings revealed that single males, aged 21-25 years, on their first assignment are most at risk for injury. The most prevalent method of injury was from striking a person or object out of anger. The results include several findings that can be used to implement injury prevention initiatives, thus avoiding the loss of work time and productivity associated with the healing and rehabilitation period.

A review of 41 upper extremity war injuries and the protective gear worn during Operation Enduring Freedom and Operation Iraqi Freedom.

Forty-one patients with upper extremity war injuries sustained during combat operations Operation Enduring Freedom and Operation Iraqi Freedom were reviewed to report on protective gear availability and usage at the time of injury. Participants treated at the Madigan Army Medical Center occupational therapy clinic from August 2004 until February 2005 completed a questionnaire regarding injuries sustained during deployment. Overall, 6 injuries were to upper extremity regions that were covered with issued protective gear; 21 injuries were to areas not covered with issued protective gear (i.e., participant was not wearing issued gear), and 22 injuries were to regions that were not covered because no protective gear was issued for that body area. Although this study is limited, future research would provide valuable insights about the efficacy of current body armor and the need for additional or modified gear.

Early mobilization using dynamic splinting with acute triceps tendon avulsion.

Avulsion of the triceps tendon is rare, and no previous report of a completed dynamic splinting rehabilitation plan was found in the literature. A case of a military member and power weightlifter who sustained a triceps tendon avulsion and repair is presented with a six-month follow-up. The rehabilitation program included early active elbow flexion and passive extension using a dynamic elbow splint. The Disabilities of the Arm, Shoulder and Hand (DASH) 1-3 questionnaire was used to monitor the patient's use of his right dominant arm while in the dynamic splint. The DASH scores indicated that he experienced improved use of his affected arm during the splinting period. The end result was a good return of function within 13 weeks and full resumption of work and bodybuilding activities in six months, three months earlier than others reported in the literature who were immobilized after surgery. 4,5.