Delirium in the NICU: A Point Prevalence Study.

OBJECTIVES: Delirium is a well-described complication of critical illness, with occurrence rates of >25% in the PICU, and associated morbidity. Infants in the NICU are likely at risk. There have been no previous screening studies to quantify delirium rates in the neonatal population. We hypothesized that delirium was prevalent in term neonates in the NICU. In this pilot study, our objective was to estimate prevalence using a validated pediatric delirium screening tool, which has not yet been tested in NICUs. METHODS: In this point prevalence study, all term or term-corrected infants admitted to the NICU on designated study days were screened for delirium using the Cornell Assessment of Pediatric Delirium. RESULTS: A total of 149 infants were eligible for screening over 8 study days. A total of 147 (98.6%) were successfully screened with the Cornell Assessment of Pediatric Delirium. Overall, 22.4% (n = 33) screened positive for delirium. Delirium was more commonly detected in children on invasive mechanical ventilation (67% vs 17%, P < .01) and those with underlying neurologic disorders (64% vs 13%, P < .01). A multivariate logistic regression revealed that neurologic disability and mechanical ventilation were both independently associated with a positive delirium screen (aOR: 12.3, CI: 4.5-33.6 and aOR: 9.3, CI: 2.5-34.6, respectively). CONCLUSIONS: Our results indicate that delirium likely occurs frequently in term-equivalent infants in the NICU. Further research is necessary to establish feasibility, validity, and interrater reliability of delirium screening in this population.

Pediatric delirium: epidemiology and outcomes.

PURPOSE OF REVIEW: Delirium is a frequent complication of serious medical illness in children. The purpose of this review is to highlight recent data on the epidemiology and outcomes related to pediatric delirium, and discuss prevention strategies. RECENT FINDINGS: Delirium rates in the pediatric ICU are greater than 25%. Delirium in children is associated with prolonged mechanical ventilation and hospital length of stay, increased costs, and excess mortality. Pediatric delirium may affect postdischarge cognition and quality of life. Recent initiatives targeting universal screening, early mobilization, and minimization of benzodiazepine-based sedation have shown reduction in delirium prevalence. SUMMARY: Widespread screening is needed in critically ill children to detect and mitigate delirium. The identification of modifiable risk factors has provided an opportunity for delirium prevention. Large-scale longitudinal studies are needed to investigate the long-term sequelae of delirium in children.

Clinical Outcomes Following the Latarjet Procedure in Contact and Collision Athletes.

BACKGROUND: Few studies have evaluated the success of the Latarjet procedure for recurrent anterior glenohumeral instability in the contact or collision athlete. The purpose of this study was to evaluate the return-to-sport and functional results of the Latarjet procedure in this select group. METHODS: One hundred and nine consecutive contact or collision athletes (112 shoulders) treated with an open Latarjet procedure for recurrent anterior glenohumeral instability were retrospectively identified. Seventy-three shoulders in 73 patients (67%) were evaluated at a mean follow-up of 52 months (range, 24 to 120 months). The average age at surgery was 25.8 years (range, 15 to 54 years). The primary outcomes were the scores on the Western Ontario Shoulder Instability Index (WOSI), the American Shoulder and Elbow Surgeons (ASES) questionnaire, a visual analog scale (VAS) for pain, and return to sport. Predictors of return to sport were analyzed. RESULTS: Six (8%) of the 73 patients experienced ≥1 postoperative dislocations. Ten additional patients (14%) experienced a perception of instability without a dislocation. The median postoperative WOSI and ASES scores were 382 (range, 0 to 2,016) and 93.3 (range, 21.7 to 100), respectively. The median postoperative VAS pain score was 0 (range, 0 to 10). Forty-nine percent (36) of the 73 patients returned to their preoperative sports level, 14% (10) decreased their activity level in the same sport, 12% (9) changed sports, and 25% (18) decreased their level of activity and changed sports or stopped participating in sports altogether. Patients with ≥2 stabilization procedures prior to the Latarjet procedure demonstrated a lower likelihood of returning to their original sport (p = 0.019; relative risk = 2.84; 95% confidence interval = 1.34 to 6.06). The percentage of glenoid bone loss showed no association with the return-to-sport rate (p = 0.507). CONCLUSIONS: The outcome of the Latarjet procedure in high-risk contact or collision athletes is variable. Patients who have fewer prior stabilization surgical procedures are more likely to successfully return to their original sport. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Glenoid version and its relationship to glenohumeral instability and labral tears.

BACKGROUND: Evidence suggests a relationship between glenoid retroversion and posterior instability, but no literature exists comparing glenoid version referencing the scapular body versus the endosteal vault. This study evaluated glenoid version and its relationship to unidirectional instability and labral tears. METHODS: Glenoid version in patients with unidirectional instability or labral tears was measured with magnetic resonance imaging by either the Friedman method or the Poon and Ting method. Analyses of variance followed by independent t tests were used to compare 3 groups: anterior instability or labral tears (anterior pathology group, n = 33); posterior instability or labral tears (posterior pathology group, n = 34); and stable controls (n = 30). The referencing error for 2-dimensional axial images was evaluated for variance by imaging facility. Interobserver and intraobserver reliability scores were calculated. RESULTS: With the Friedman method, the posterior pathology group (-9°) was more retroverted than the control group (-4°) (P = .0005) and the anterior pathology group (-5°) (P = .0104) but there was no difference between the control group and anterior pathology group (P = .38). The referencing error in the sagittal plane averaged 23° and varied by facility (P = .0365). The coronal-plane error averaged 1° and did not vary by facility (P = .7180). Intraclass correlation coefficient scores showed good to excellent intrarater and inter-rater reliability. CONCLUSION: The posterior pathology group had 5° more retroversion than controls using the Friedman method. Glenoid version using the Poon and Ting method or the Friedman method did not predict anterior instability or labral tears. Axial magnetic resonance images were constructed with a referencing error in the sagittal plane that varied by magnetic resonance imaging facility and has implications for improving 2-dimensional axial imaging protocols.

Conversion to Reverse Shoulder Arthroplasty: Humeral Stem Retention Versus Revision.

As the volume of shoulder arthroplasty procedures performed in the United States continues to increase, the predicted number of revision shoulder arthroplasties grows even higher. Conversion of failed shoulder arthroplasty to reverse total shoulder arthroplasty has become common. Many commercially available shoulder arthroplasty systems now offer a platform humeral stem that is used for both anatomic shoulder arthroplasty and reverse total shoulder arthroplasty. This study investigated whether retaining the humeral stem offers advantages over revising the humeral stem in conversion of failed shoulder arthroplasty to reverse total shoulder arthroplasty. The study included 26 patients (mean age, 68.46 years) with failed shoulder arthroplasty who underwent conversion to reverse total shoulder arthroplasty with a minimum 2-year follow-up (mean, 34.38 months). Patients who had retention of the humeral stem were compared with those who had stem revision. Humeral stem retention was associated with a significantly shorter operative time (178.92 vs 237 minutes, P=.02). Decreases in blood loss, complications, and length of hospitalization were observed, but the differences were not statistically significant. Minimal differences were observed for patient-reported outcomes. Of patients undergoing humeral stem removal, 21.4% had an intraoperative humeral shaft or tuberosity fracture compared with none in the stem retention group. Humeral stem retention was associated with decreased operative time compared with humeral stem revision in the conversion of failed shoulder arthroplasty to reverse total shoulder arthroplasty. The use of a platform shoulder arthroplasty system may benefit patients with failed shoulder arthroplasty undergoing conversion to reverse total shoulder arthroplasty by avoiding humeral stem revision.

Imaging characteristics of lesser tuberosity osteotomy after total shoulder replacement: a study of 220 patients.

BACKGROUND: The lesser tuberosity osteotomy (LTO) has been gaining popularity as a method of exposing the glenohumeral joint during total shoulder replacement, whereby a small fragment of bone is removed from the lesser tuberosity, thus preserving the subscapularis tendon. To date, no large, randomized studies have reported evaluations of LTO healing and healing rates. METHODS: We reviewed the radiographs and available computed tomography images of 362 patients who underwent a total shoulder arthroplasty by the same surgeon between 2006 and 2012. The integrity of the LTO site was graded as not seen, bony union, nondisplaced nonunion, and displaced nonunion. The smoking status of patients was also assessed. RESULTS: Of 362 patients investigated, 220 had a minimum of 6 months of radiographic follow-up. The LTO site was not seen in 37 patients; of the remaining 183, 159 patients (86.89%) demonstrated bony union, 8.80% of whom were smokers; 16 patients (8.74%) demonstrated nondisplaced nonunion, 6.3% of whom were smokers; and 8 patients (4.3%) demonstrated displaced nonunion, 25.0% of whom were smokers. Overall, 19 of the 24 nonunions were in male patients (79.1%) and 5 were in female patients (20.8%). CONCLUSIONS: This is the first large-scale study to report the healing rate of LTOs. LTO healing is best assessed on radiographs; if nondisplaced or displaced nonunions are suspected, computed tomography can be a helpful additional examination. The number of radiographs where there is a lack of adequate visualization of the LTO site raises important questions about definitive radiographic evaluation using current techniques.