Use of Implementation Strategies to Promote the Uptake of Knee Osteoarthritis Practice Guidelines and Improve Patient Outcomes: A Systematic Review.

OBJECTIVE: Translation of knee osteoarthritis (KOA) clinical practice guidelines (CPGs) to practice remains suboptimal. The primary purpose of this systematic review was to describe the use of implementation strategies to promote KOA CPG-recommended care. METHODS: Medline (via PubMed), Embase, CINAHL, and Web of Science were searched from inception to February 23, 2023, and the search was subsequently updated and expanded on January 16, 2024. Implementation strategies were mapped per the Expert Recommendations for Implementing Change taxonomy. Risk of bias (RoB) was assessed using the Cochrane Effective Practice and Organisation of Care criteria. The review was registered prospectively (PROSPERO identifier: CRD42023402383). RESULTS: Nineteen studies were included in the final review. All (100% [n = 4]) studies that included the domains of "provide interactive assistance," "train and educate stakeholders" (89% [n = 16]), "engage consumers" (87% [n = 13]), and "support clinicians" (79% [n = 11]) showed a change to provider adherence. Studies that showed a change to disability included the domains of "train and educate stakeholders," "engage consumers," and "adapt and tailor to context." Studies that used the domains "train and educate stakeholders," "engage consumers," and "support clinicians" showed a change in pain and quality of life. Most studies had a low to moderate RoB. CONCLUSION: Implementation strategies have the potential to impact clinician uptake of CPGs and patient-reported outcomes. The implementation context, using an active learning strategy with a patient partner, restructuring funding models, and integrating taxonomies to tailor multifaceted strategies should be prioritized. Further experimental research is recommended to determine which implementation strategies are most effective.

Developing a Computer Vision Model to Automate Quantitative Measurement of Hip-Knee-Ankle Angle in Total Hip and Knee Arthroplasty Patients.

BACKGROUND: Increasing deformity of the lower extremities, as measured by the hip-knee-ankle angle (HKAA), is associated with poor patient outcomes after total hip and knee arthroplasty (THA, TKA). Automated calculation of HKAA is imperative to reduce the burden on orthopaedic surgeons. We proposed a detection-based deep learning (DL) model to calculate HKAA in THA and TKA patients and assessed the agreement between DL-derived HKAAs and manual measurement. METHODS: We retrospectively identified 1,379 long-leg radiographs (LLRs) from patients scheduled for THA or TKA within an academic medical center. There were 1,221 LLRs used to develop the model (randomly split into 70% training, 20% validation, and 10% held-out test sets); 158 LLRs were considered "difficult," as the femoral head was difficult to distinguish from surrounding tissue. There were 2 raters who annotated the HKAA of both lower extremities, and inter-rater reliability was calculated to compare the DL-derived HKAAs with manual measurement within the test set. RESULTS: The DL model achieved a mean average precision of 0.985 on the test set. The average HKAA of the operative leg was 173.05 ± 4.54°; the nonoperative leg was 175.55 ± 3.56°. The inter-rater reliability between manual and DL-derived HKAA measurements on the operative leg and nonoperative leg indicated excellent reliability (intraclass correlation (2,k) = 0.987 [0.96, 0.99], intraclass correlation (2, k) = 0.987 [0.98, 0.99, respectively]). The standard error of measurement for the DL-derived HKAA for the operative and nonoperative legs was 0.515° and 0.403°, respectively. CONCLUSIONS: A detection-based DL algorithm can calculate the HKAA in LLRs and is comparable to that calculated by manual measurement. The algorithm can detect the bilateral femoral head, knee, and ankle joints with high precision, even in patients where the femoral head is difficult to visualize.

Patient-reported outcome measures in physical therapy practice for neck pain: an overview of reviews.

BACKGROUND: Understanding which patient-reported outcome measures are being collected and utilized in clinical practice and research for patients with neck pain will help to inform recommendations for a core set of measures that provide value to patients and clinicians during diagnosis, clinical decision-making, goal setting and evaluation of responsiveness to treatment. Therefore, the aim of this study was to conduct a review of systematic reviews using a qualitative synthesis on the use of patient-reported outcome measures (PROMs) for patients presenting with neck pain to physical therapy. METHODS: An electronic search of systematic reviews and guideline publications was performed using MEDLINE (OVID), Embase (Elsevier), CINAHL Complete (EBSCOhost), and Web of Science (Clarivate) databases to identify reviews that evaluated physical therapy interventions or interventions commonly performed by a physical therapist for individuals with neck pain and included at least one patient-reported outcome measure. The frequency and variability in which the outcome measures were reported among the studies in the review and the constructs for which they measured were evaluated. The evaluation of a core set of outcome measures was assessed. Risk of bias and quality assessment was performed using A Measurement Tool to Assess systematic Reviews 2. RESULTS: Of the initial 7,003 articles, a total of 37 studies were included in the final review. Thirty-one PROMs were represented within the 37 reviews with eleven patient-reported outcome measures in three or more reviews. The eleven PROMs assessed the constructs of disability, pain intensity, psychosocial factors and quality of life. The greatest variability was found amongst individual measures assessing psychosocial factors. Assessment of psychosocial factors was the least represented construct in the included studies. Overall, the most frequently utilized patient reported outcome measures were the Neck Disability Index, Visual Analog Scale, and Numeric Pain Rating Scale. The most frequently used measures evaluating the constructs of disability, pain intensity, quality of life and psychosocial functioning included the Neck Disability Index, Visual Analog Scale, Short-Form-36 health survey and Fear Avoidance Belief Questionnaire respectively. Overall risk of bias and quality assessment confidence levels ranged from critically low (2 studies), low (12 studies), moderate (8 studies), and high (15 studies). CONCLUSION: This study identified a core set of patient-reported outcome measures that represented the constructs of disability, pain intensity and quality of life. This review recommends the collection and use of the Neck Disability Index and the Numeric Pain Rating Scale or Visual Analog Scale. Recommendation for a QoL measure needs to be considered in the context of available resources and administrative burden. Further research is needed to confidently recommend a QoL and psychosocial measure for patients presenting with neck pain. Other measures that were not included in this review but should be further evaluated for patients with neck pain are the Patient Reported Outcomes Measurement Information System (PROMIS) Physical function, PROMIS Pain Interference and the Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF) tool.

Shared-Medical Appointment for Screening and Risk Assessment for Fall Prevention.

Background: The median age of Americans is rising and fall risk increases with age. While the causes of falls are multifactorial, falls risk can be reduced. Only a small percentage of older-adults report being asked about fall risk or falls. The CDC has initiated a Stopping Elderly Accidents, Deaths and Injuries (STEADI) toolkit, but penetration into practice has been slow. To address this, we implemented a Falls Prevention Shared Medical Appointment (SMA) at an academic internal medicine clinic. Methods: Patients were referred to the SMA and scheduled per their preference virtually or in-person. Patients attended a nurse visit for appropriate fallrisk related screening, followed by the SMA with two physicians for review of medical history, fall screening results and implementation of fall reduction strategies. Follow-up survey of the patients assessed program effectiveness. Results: Fifty-two patients were seen/assessed between November 2021 and February 2023 with SMAs ranging from 3 to 5 patients with an average age of 77 (=/- 6.7). Questionnaire self-reported risk factors, self-reported strength, and polypharmacy were associated with objective markers of increased fall risk. Survey results indicate acceptability of this model. Conclusion: Falls prevention SMAs can be effective. More work is needed to further delineate and refine cohort selection.

Beyond Conventional Hemodynamic Monitoring-Monitoring to Improve Our Understanding of Disease Process and Interventions.

Monitoring the hemodynamic state of patients is a hallmark of any intensive care environment. However, no single monitoring strategy can provide all the necessary data to paint the entire picture of the state of a patient; each monitor has strengths and weaknesses, advantages, and limitations. We review the currently available hemodynamic monitors used in pediatric critical care units using a clinical scenario. This provides the reader with a construct to understand the progression from basic to more advanced monitoring modalities and how they serve to inform the practitioner at the bedside.

Neonatal Myxomas: Case Report and Literature Review.

Myxomas are rare tumors in neonates and tend to have a different presentation compared to adults. We present an infant with a left atrial myxoma presenting with episodic tachycardia who underwent successful surgical excision. In addition, we performed a review of the literature, identifying 17 cases of neonatal myxomas. Unlike adults, neonatal myxomas are more common in males and occur more often on the right side of the heart. Constitutional symptoms such as fever or embolism are rare among neonates. Most patients have favorable outcomes following surgical excision, refuting earlier claims that neonatal myxomas are associated with poor outcomes.

Elevated Levels of Urinary Biomarkers TIMP-2 and IGFBP-7 Predict Acute Kidney Injury in Neonates after Congenital Heart Surgery.

Objectives This article investigated the utility of urine biomarkers tissue inhibitor of metalloproteinase-2 (TIMP-2) and insulin-like growth factor binding protein-7 (IGFBP-7) in identifying acute kidney injury (AKI) in neonates after congenital heart surgery (CHS). TIMP-2 and IGFBP-7 are cell cycle arrest proteins detected in urine during periods of kidney stress/injury. Methods We conducted a single-center, prospective study between September 2017 and May 2019 with neonates undergoing CHS requiring cardiopulmonary bypass (CPB). Urine samples were analyzed using NephroCheck prior to surgery and 6, 12, 24, and 96 hours post-CPB. All patients were evaluated using the Acute Kidney Injury Network (AKIN) criteria. Wilcoxon rank sum tests were used to compare the medians of the [TIMP-2*IGFBP-7] values in the AKIN negative and positive groups at each time point. Receiver operating characteristic curves were used to measure how well the [TIMP-2*IGFBP-7] values predict AKIN status. Results Thirty-six patients were included. No patients met the AKIN criteria for AKI preoperatively. Postoperatively, 19 patients (53%) met the AKIN criteria for AKI diagnosis: 13 (36%) stage 1, 5 (14%) stage 2, and 1 (3%) stage 3. None required renal replacement therapy. At the 24-hour time points, patients who met the AKIN criteria for AKI had a statistically significantly higher [TIMP-2*IGFBP7] values than the patients without AKI (1.1 vs. 0.27 [ng/mL] 2 /1,000) at 24 hours (adj- p = 0.0019). Conclusion AKI is a serious complication associated with adverse outcomes in patients undergoing cardiac surgery. [TIMP-2*IGFBP-7] urinary level 24 hours after CPB is a good predictor of AKI in this population.

Tricuspid atresia with absent pulmonary valve: A rare form of single ventricle.

Tricuspid atresia with an absent pulmonary valve is a rare congenital cardiac defect. Although extensive pathological reviews have been published in the past, there are only a handful of cases that have been successfully palliated to the stage of Fontan. We hereby describe the successful management of one such case and review the surgical strategies described in the literature.

Aortic migration of Amplatzer Piccolo™ ductal Occluder.

We present the case of a 4-month-old, former 23-week premature baby who underwent patent ductus arteriosus device closure in the cardiac catheterisation lab with an Amplatzer Piccolo™ device at 12 weeks of life. This was complicated by late migration of the device into the aorta resulting in severe obstruction and requiring surgical intervention.

Surgical Management of Giant Intrapericardial Teratoma Encasing the Coronary Artery.

Intrapericardial teratomas are rare, predominantly benign tumors that warrant surgical resection in the neonatal period because of their potential detrimental effects on the cardiorespiratory system. Surgical resection can be a challenge when the tumor encases and obscures a coronary artery. Adherence to certain operative principles is necessary to achieve successful outcomes.

Sex differences in the incidence and mode of death in rats with heart failure with preserved ejection fraction.

NEW FINDINGS: What is the central question of this study? Prior studies failed to address the role of sex in modifying the pathophysiology and response to therapy in heart failure with preserved ejection fraction (HFpEF), potentially introducing bias into translational findings. We aimed to explore sex differences in outcomes and sought to identify the underlying mechanisms in a well-established rat model of HFpEF. What is the main finding and its importance? Male rats with HFpEF exhibited worse survival compared with females and were at a higher risk for sudden death, attributable in part to QT prolongation, autonomic dysregulation and enhanced inflammation. These data might provide the basis for the development of sex-specific interventions in HFpEF targeting these abnormalities. ABSTRACT: Heart failure with preserved ejection fraction (HFpEF) accounts for 50% of heart failure, and sudden death is the leading cause of mortality. We aimed to explore sex differences in outcomes in rats with HFpEF and sought to identify the underlying mechanisms. Dahl salt-sensitive rats of either sex were randomized into high-salt diet (HS diet; 8% NaCl, n = 46, 50% female) or low-salt diet (LS diet; 0.3% NaCl; n = 24, 50% female) at 7 weeks of age. After 6 and 10 weeks of LS or HS diets, the ECG, heart rate variability, cytokines and echocardiographic parameters were measured. The animals were monitored daily for development of HFpEF and survival. Over 6 weeks of HS diet, rats developed significant hypertension and signs of HFpEF. Compared with female HS diet-fed rats, males exhibited more left ventricular dilatation, a longer QT interval, and worse autonomic tone, as assessed by heart rate variability and elevated inflammatory cytokines. Ten of 23 (46%) male rats died during follow-up, compared with two of 23 (9%) female rats (P = 0.01). There were four sudden deaths in males (with ventricular tachycardia documented in one rat), whereas the females died of heart failure. In conclusion, male rats with HFpEF exhibit worse survival compared with females and are at a higher risk for sudden death, attributable in part to QT prolongation, autonomic dysregulation and enhanced inflammation. These data might provide the basis for the development of sex-specific interventions in HFpEF targeting these abnormalities.

Effects of race on blood loss in spinal fusions for adolescent idiopathic scoliosis.

OBJECTIVE: Posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) can be associated with significant blood loss. It has been suggested that blood loss is greater in different racial groups. The purpose of this study was to evaluate differences in blood loss between African American and Caucasian patients undergoing PSF for AIS. METHODS: A retrospective review was performed of patients aged 10-18 years with AIS who were treated with PSF from 2014 to 2017 at a single children's healthcare system. Patient demographic, radiographic, and operative data were obtained from medical records. Intraoperative blood loss was calculated using the formula described by Waters et al. Patients who declined reporting their race or had prior spinal surgery, neuromuscular or syndromic diagnoses, a history of cardiac or thoracic surgery, or a bleeding disorder were excluded. Blood loss variables were log-transformed for normality and modeled using multivariable linear regression. RESULTS: A total of 433 PSFs for AIS qualified for the analysis. The average age was 14.1 years, and 73.7% of the patients were female. With respect to race, 44.6% identified themselves as African American. There was no significant difference in blood loss (p = 0.31) or blood loss per level fused (p = 0.36) in African American patients. African American patients, however, did have significantly lower preoperative hemoglobin and hematocrit levels and greater operating room time than Caucasian patients (p < 0.001). There was no difference between race and transfusion rate. CONCLUSIONS: There appears to be no relationship between race and blood loss during PSF for AIS. Standardized protocols for minimizing perioperative blood loss can be applied to both Caucasian and African American patients.

Cardiac involvement in a pediatric patient with COVID-19: Looking beyond the nonspecific global cardiac injury.

We report a case of a 17-year-old healthy male presenting with multisystem hyperinflammatory shock temporally associated with COVID-19. Cardiac involvement was suspected based on evidence of significant cardiac injury (elevated cardiac biomarkers, electrocardiographic and echocardiographic abnormalities). Cardiac magnetic resonance imaging was performed demonstrating global biventricular systolic dysfunction, as well as a small area of T2 hyperintensity and mid-wall late gadolinium enhancement. This case discusses the varied cardiac involvement in pediatric patients with COVID-19 infection and highlights that cardiac injury is not just limited to hyperinflammatory syndrome related global dysfunction but a more focal myocarditis can also be seen.

Safety Checklist Implementation Did Not Reduce Central Venous Catheter Duration in Pediatric Cardiac ICU Patients.

The Center for Disease Control recommends prompt removal of nonessential central venous catheters (CVCs) to reduce the risk for central line-associated bloodstream infections. Safety checklists have been trialed to reduce nonessential CVC days, but pediatric studies are lacking. Our specific aim was to detect >10% reduction in mean CVC duration after implementation of a safety checklist addressing CVCs in our unit. METHODS: All patients admitted to the Congenital Cardiovascular Care Unit at New York University Langone Medical Center who had a CVC placed between January 1, 2012, and December 31, 2017, were included. We implemented a checklist addressing CVC use in our unit on June 7, 2013, and modified it on March 10, 2016. We analyzed quarterly mean CVC duration and postsurgical CVC duration over the study period using statistical process control charts. RESULTS: We placed 778 CVCs for 7,947 CVC days during the study period. We noted special cause variation from Q4 2013 to Q2 2014 and a centerline shift in mean CVC duration from 8.91 to 11.10 days in Q1 2015. In a subgroup analysis of the 657 lines placed in surgical patients, there was a centerline shift in mean CVC duration from 6.48 to 8.86 days in Q4 2013. CONCLUSIONS: Our study demonstrated an unexpected increase in mean CVC duration after the implementation of a safety checklist designed to decrease nonessential CVC days. Additional studies are needed to identify the ideal method to detect and remove nonessential CVCs and reduce the risk of preventable harm.

Using the value-based care paradigm to compare physical therapy access to care models in cervical spine radiculopathy: a case report.

Background: The efficiency and effectiveness of multiple physical therapy care delivery models can be measured using the value-based care paradigm. Entering physical therapy through direct access can decrease health-care utilization and improve patient outcomes. Limited evidence exists which compares direct access physical therapy to referral using the value-based care paradigm specific to cervical spine radiculopathy. Case Description: The patient was a 39-year-old woman who presented to physical therapy through physician referral with the diagnoses of acute cervical radiculopathy. The patient was evaluated, provided guideline adherent treatment and discharged with a home exercise program. Sixteen months from being discharged, the same patient returned through direct access due to an acute onset of cervical spine symptoms and was evaluated and provided treatment that same morning. Outcomes: Direct access physical therapy saved the patient and third-party payer $434.30 and $3264.75 respectively. A 5×'s higher efficiency per visit and a 6.2×'s higher value in reducing disability was demonstrated when the patient accessed physical therapy directly. Physician referral and direct access entry pathways demonstrated neck disability index improvements of 6% and 16%, respectively. Discussion: This case report describes a clinical example of previous research that demonstrates improved cost efficiency, outcomes, and increased value with a patient who presented to physical therapy with cervical radiculopathy through two different access to care models. The results of this case demonstrate a clinical example of the use of the value-based care paradigm in comparing value and efficiency of two access to care models in a patient with cervical radiculopathy without other neurological deficits.

Cancer Survivorship at the Intersections of Care and Personhood.

Surviving colorectal cancer following ostomy surgery with an intestinal stoma presents numerous challenges to the cultural category of full adult personhood. The foremost is managing unpredictable bowel activity. The technical management of the ostomy facilitated by biomedical specialists, is essential for personhood realignment. This article focuses on how some female long-term cancer survivors manage and adapt to this new fecal habitus by mobilizing various assemblages of care - receiving care, continuing to provide particular gendered forms of care, and returning to caregiving roles. These interdependent practices of care realign personhood, or at the very least, minimize the assaults that having an ostomy presents to the cultural category of full adult personhood.

Successful Phenobarbital Desensitization After DRESS Reaction in the Management of Refractory Status Epilepticus.

PURPOSE: Drug reaction with eosinophilia and systemic symptoms (DRESS) is associated with antiepileptic drug use and is a rare but life-threatening side effect. We present a case of phenobarbital-induced DRESS in a patient who subsequently required phenobarbital and was successfully desensitized. SUMMARY: A 5-year-old male presented with medically refractory status epilepticus (SE). He had been trialed on several antiepileptic medications without achieving burst suppression. Burst suppression was achieved with a pentobarbital infusion, and thus, phenobarbital was initiated as the pentobarbital was weaned. After five days of phenobarbital, the patient developed signs and symptoms concerning for DRESS; a punch biopsy confirmed the drug reaction. Two months later, he again developed SE unresponsive to antiepileptic infusions. Burst suppression was achieved with pentobarbital, and it was decided to transition the patient to phenobarbital. Due to concerns of phenobarbital-induced DRESS, the patient underwent a phenobarbital desensitization consisting of 6 doses sequentially administered in 10-fold increasing concentrations before achieving therapeutic dosing. Three days later, the patient achieved therapeutic phenobarbital levels, was weaned off of pentobarbital, and remained seizure-free without recurrence of DRESS. CONCLUSIONS: Graded desensitization may be an option to minimize recurrence of DRESS in patients where avoidance of the offending agent is not possible.

QUANTIFYING FRONTAL PLANE KNEE KINEMATICS IN SUBJECTS WITH ANTERIOR KNEE PAIN: THE RELIABILITY AND CONCURRENT VALIDITY OF 2D MOTION ANALYSIS.

BACKGROUND: Two-dimensional (2D) analysis has the potential to identify individuals at risk for knee injury by measuring genu valgus during sport related tasks. The reliability of 2D mobile motion analysis in measuring genu valgus during a single leg hop test on individuals with anterior knee pain has not been examined. PURPOSE: To assess the reliability and concurrent validity of 2D mobile motion analysis and compare it to visual observation while analyzing dynamic genu valgus during a single leg hop test in subjects with anterior knee pain. STUDY DESIGN: Cohort study; repeated measures. METHODS: Nineteen subjects experiencing anterior knee pain completed a single leg hop test with both lower extremities. Two investigators independently estimated the degrees of genu valgus with visual observation alone during the subjects' single leg hop. After the visual estimation, the investigators watched the video again using the 2D Spark Motion Pro™ application to pause the video and measured the amount of knee valgus with a virtual goniometer tool on the application. Interrater reliability was calculated using intraclass correlation coefficients (ICC) model 2, k and intrarater rater reliability using model 3, k. Minimal detectable change, concurrent validity and limits of agreement were calculated. RESULTS: Visual observation alone demonstrated interrater reliability ICCs of 0.682-0.685 on the symptomatic and non-symptomatic lower extremities respectively. The interrater reliability using the 2D application had ICC's of 0.927 and 0.792 on the symptomatic and non-symptomatic lower extremities respectively. The concurrent validity for 2D analysis and visual observation on the symptomatic lower extremity had ICC values of 0.96 (rater A) and 0.85 (rater B). The non-symptomatic lower extremity demonstrated concurrent validity ICC values of 0.95(rater A) and 0.65(rater B). The standard error of measurement(SEM) was 3.898 and 3.258 for the symptomatic and non-symptomatic lower extremity(LE) respectively for visual observation. When using the Spark Motion Pro™ application the SEM was 1.648 and 2.718 for the symptomatic and non-symptomatic LE respectively. The minimal detectable change (MDC) using visual observation alone was 5.58 and 4.68. When using the application, it was noted at 2.328 and 3.838 on the symptomatic and non-symptomatic LE respectively. CONCLUSION: The results of this study support the use of a 2D mobile application as a reliable tool for measuring knee valgus in symptomatic subjects and offers reduced error (SEM = 1.648) when compared to visual observation alone (SEM = 3.898). LEVEL OF EVIDENCE: 2B.