Reliable quantitative ratings of chronic medical illness burden have proved to be difficult in geropsychiatric practice and research. Thus, the purpose of the study was to demonstrate the feasibility ...and reliability of a modified version of the Cumulative Illness Rating Scale (CIRS; Linn et al., 1968) in providing quantitative ratings of chronic illness burden. The modified CIRS was operationalized with a manual of guidelines geared toward the geriatric patient and for clarity was designated the CIRS(G). A total of 141 elderly outpatient subjects (two medical clinic groups of 20 each, 45 recurrent depressed subjects, 21 spousally bereaved subjects, and 35 healthy controls) received comprehensive physical examinations, reviews of symptoms, and laboratory testing. These data were then used by nurse practitioners, physician's assistants, and geriatric psychiatrists to compute CIRS(G) ratings of chronic illness burden. As hypothesized, analysis of variance demonstrated significant differences among groups with respect to total medical illness burden, which was highest among medical clinic patients and lowest in control subjects. Good interrater reliability (i.e., intraclass correlations of 0.78 and 0.88 in a subsample of 10 outpatients and a separate group of 10 inpatients, respectively) was achieved for CIRS(G) total scores. Among medical clinic patients, a significant correlation was found, as expected, between CIRS(G) chronic illness burden and capability as quantified by the Older Americans Activities of Daily Living Scale; and between CIRS(G) scores and physicians' global estimates of medical burden. Finally, with repeated measures of illness burden approximately 1 year from symptom baseline, significant rises were detected, as expected. The current data suggest that the CIRS(G) can be successfully applied in medically and psychiatrically impaired elderly subjects, with good interrater reliability and face validity (credibility).
Multiple-ligament knee injuries require prompt recognition, awareness of associated potential limb-threatening conditions, accurate diagnosis of functional ligament deficiency, careful surgical ...planning, and dedicated rehabilitation. In this article, we summarize our approach to these serious injuries and how it has evolved with our experience. To establish the diagnosis, we rely on a thorough knee examination with adjunctive stress radiographs. Although we routinely use magnetic resonance imaging to characterize these injuries, we recognize that the intense signal generated by excessive edema may overcall injury. We advocate single-stage reconstruction of all injured structures at the index procedure pursuing early surgical intervention within 2 weeks if the pattern includes an injury to either corner/collateral. Except in some medial collateral ligament injuries amenable to primary repair, we augment corner/collateral repairs with free graft reconstruction to protect the repair and allow early motion. Our postoperative rehabilitation protocol emphasizes early protected range of motion to prevent stiffness. Using these principles, we have been able to reliably restore function and stability after these potentially devastating injuries. Although we have been pleased with our results, we acknowledge the ongoing evolution in the treatment of multiple-ligament knee injuries and will continue to refine our technique to improve our outcomes.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Multiligament knee injury (MLKI) with associated extensor mechanism (EM) involvement is a rare injury, with limited evidence to guide optimal treatment. The purpose of this study was to identify ...areas of consensus among a group of international experts regarding the treatment of patients with MLKI and concomitant EM injury.
Utilizing a classic Delphi technique, an international group of 46 surgeons from 6 continents with expertise in MLKI undertook 3 rounds of online surveys. Participants were presented with clinical scenarios involving EM disruption in association with MLKI, classified using the Schenck Knee-Dislocation (KD) Classification. Positive consensus was defined as ≥70% agreement with responses of either "strongly agree" or "agree," and negative consensus was defined as ≥70% agreement with "strongly disagree" or "disagree."
There was a 100% response rate for rounds 1 and 2 and a 96% response rate for round 3. There was strong positive consensus (87%) that an EM injury in combination with MLKI significantly alters the treatment algorithm. For an EM injury in conjunction with a KD2, KD3M, or KD3L injury, there was positive consensus to repair the EM injury only and negative consensus regarding performing concurrent ligamentous reconstruction at the time of initial surgery.
In the setting of bicruciate MLKI, there was overall agreement on the significant impact of EM injury on the treatment algorithm. We therefore recommend that the Schenck KD Classification be updated with the addition of the modifier suffix "-EM" to highlight this impact. Treatment of the EM injury was judged to have the highest priority, and there was consensus to treat the EM injury only. However, given the lack of clinical outcome data, treatment decisions need to be made on a case-by-case basis with consideration of the numerous clinical factors that are encountered.
Little clinical evidence exists to guide the surgeon on the management of EM injury in the setting of a multiligament injured or dislocated knee. This survey highlights the impact that EM injury has on the treatment algorithm and provides some guidance for management until a further large case series or prospective studies are undertaken.
Summary
Background
Relationships between birthweight and future obesity risk remain unclear.
Objective
To assess associations between birthweight and later obesity in a nationally representative ...cohort of early school‐aged children.
Methods
We used linear and logistic regression to evaluate 10 186 term‐ or preterm children in the Early Childhood Longitudinal Study‐Kindergarten Cohort 2011 for relationships between birthweight and later obesity and change in BMI z‐score from kindergarten‐to‐second grade. All analyses were adjusted for sex, race/ethnicity, parental education and household income.
Results
Compared to children born normal birthweight (NBW), high birthweight (HBW) term children and large‐for‐gestational‐age (LGA) preterm children had significantly greater BMI z‐scores from kindergarten‐to‐second grade (p < 0.001). Term children born HBW had higher odds of obesity by kindergarten (adjusted odds ratios aOR 1.91, p < 0.0001). Among preterm children, odds of obesity was higher among LGA children starting in first grade (aOR 2.34, p < 0.05) and among small‐for‐gestational age children in second grade (aOR 2.26, p < 0.05). Compared to NBW children, HBW children had greater change in BMI z‐score between kindergarten‐first grade (p < 0.01).
Conclusions
High birthweight term and LGA preterm children had increased adjusted odds of obesity in school‐age compared to their NBW counterparts. Physicians may provide counselling early in life for families of large infants to help prevent future obesity.
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BFBNIB, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UL, UM, UPUK, VSZLJ
Studies support a relationship between food dye exposure and adverse behavioral outcomes in children. The amount of Food, Drug, & Cosmetic (FD&C) dyes used in commercial food products is proprietary ...information and can only be determined through the direct analysis of foods. Herein FD&C dyes were quantified in ten categories of foods previously identified as commonly consumed by children. Dyes were isolated using solid phase extraction (SPE) and quantified by high performance liquid chromatography (HPLC). Significant in-lot and between-lot variability was observed in some brands. FD&C Red No. 40 was the most prevalent dye identified in all food categories. The maximum exposure levels of FD&C dyes for an average-weight six-year-old to ten-year-old are all below 10 % of the US ADI for each food category based upon one serving per day. Red No. 40 accounted for 7–9 % of the maximum value of the US ADI in the drink categories for one serving. When the azo dyes are considered together, they contribute 10–22 % of the ADI in the drink categories and 8 % in the fruit snack/candy category based upon one serving. For an average weight six-year to ten-year old child, Red No. 40 is the most significant source of food dye in their diet.
•Considerable in-lot and between lot variability was observed with all FD&C dyes.•FD&C Red No. 40 was the most prevalent dye identified in all food categories.•Azo dyes contribute 10–22 % of the maximum value of the ADI in the drinks.•FD&C Red No. 40 contributed 7–9 % of the maximum value of the ADI in drinks.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Cognitive impairment in older adults usually progresses slowly and is caused by a variety of brain diseases, most commonly Alzheimer's disease. The resulting memory loss and impaired executive ...function call for therapeutic strategies that will optimize functioning. Interpersonal Psychotherapy for Cognitive Impairment (IPT-ci), builds upon traditional IPT to improve coping ability and help older patients and their caregivers manage the effects of cognitive impairment, particularly in the early phase when behavior changes are often misunderstood. IPT-ci can also provide a template for long term management that anticipates further declines in cognitive functioning over time. Clinician's Guide to Interpersonal Psychotherapy in Late Life offers an overview of IPT principles and the development of IPT-ci, including essential background information for those new to the field of clinical geriatrics, and a thorough demonstration of the IPT-ci approach from the initial interview through long-term follow up. Chapters on late-life depression, cognitive impairment/dementia, and executive function provide key points of reference for working with this population, with special attention paid to the role of concerned family members and caregivers. The volume is replete with case examples representing a range of patients and issues; detailed analysis clarifies the application of IPT-ci elements. Clinicians will find this a practical resource for treating older patients and assisting their caregivers from the first visit to lifelong management.
Whatʼs New in Sports Medicine Turman, Kimberly A; Miller, Mark D
Journal of bone and joint surgery. American volume,
2008-January-01, 2008-01-00, Volume:
90, Issue:
1
Journal Article
Background: Increasing the threshold to define a positive D‐dimer could reduce unnecessary computed tomographic pulmonary angiography (CTPA) for a suspected pulmonary embolism (PE) but might ...increase rates of a missed PE and missed pneumonia, the most common non‐thromboembolic diagnosis seen on CTPA.
Objective: Measure the effect of doubling the standard D‐dimer threshold for ‘PE unlikely’ Revised Geneva (RGS) or Wells’ scores on the exclusion rate, frequency and size of a missed PE and missed pneumonia.
Methods: Patients evaluated for a suspected PE with 64‐channel CTPA were prospectively enrolled from emergency departments (EDs) and inpatient units of four hospitals. Pretest probability data were collected in real time and the D‐dimer was measured in a central laboratory. Criterion standard was CPTA interpretation by two independent radiologists combined with clinical outcome at 30 days.
Results: Of 678 patients enrolled, 126 (19%) were PE+ and 93 (14%) had pneumonia. Use of either Wells’ ≤ 4 or RGS ≤ 6 produced similar results. For example, with RGS ≤ 6 and standard threshold (< 500 ng mL−1), D‐dimer was negative in 110/678 (16%), and 4/110 were PE+ (posterior probability 3.8%) and 9/110 (8.2%) had pneumonia. With RGS ≤ 6 and a threshold < 1000 ng mL−1, D‐dimer was negative in 208/678 (31%) and 11/208 (5.3%) were PE+, but 10/11 missed PEs were subsegmental and none had concomitant DVT. Pneumonia was found in 12/208 (5.4%) with RGS ≤ 6 and D‐dimer < 1000 ng mL−1.
Conclusions: Doubling the threshold for a positive D‐dimer with a PE unlikely pretest probability could reduce CTPA scanning with a slightly increased risk of missed isolated subsegmental PE, and no increase in rate of missed pneumonia.
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FZAB, GEOZS, GIS, IJS, IMTLJ, IZUM, KILJ, KISLJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBJE, SBMB, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Abstract
Background
Remote monitoring (RM) of cardiovascular implantable electronic devices (CIEDs) is a form of virtual patient care that involves electronic transmission of CIED diagnostics and ...remote assessment of this information by clinic staff. Despite expert recommendations advocating its use, adoption remains modest due to inconsistent funding policies across health systems.
Purpose
This study aims to identify and synthesize existing literature in the cost-effectiveness of RM compared with in-person clinic assessments alone in patients with CIEDs.
Methods
We conducted a systematic review of available economic evaluations (including cost-effectiveness, cost-utility, cost-consequence analyses) and costing analyses (which examines costs but not clinical benefits) of RM following CIED implantation compared to in-person clinic follow-up alone. Study outcomes included incremental costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER).
Results
Of the 1151 unique citations, a total of 27 studies were included. The studies were from Europe (n=20), USA (n=5), or Canada (n=2). Remote transmissions, when detailed in the study, were predominantly patient- and/or physician- triggered, but some also included automatic home monitor transmissions. Fourteen studies (52%) were costing analyses, and the remaining 13 studies were economic evaluations. The majority of studies (78%; n=21) reported cost-savings associated with RM compared to in-clinic follow up alone. Of the 13 economic evaluations, there were 6 cost-utility analyses, which all reported that RM provided additional QALYs for additional costs that met country-specific thresholds for good value in health care. Studies varied greatly in the costs considered, the outcomes measured, and the time horizons used.
Conclusion
Remote monitoring of patients with CIEDs was associated with cost-savings in most studies and across different healthcare systems. RM may be considered cost-effective when conventional thresholds for good value in health care are adopted. Despite heterogeneity in methods of economic evaluation in the studies included, the overall data in this systematic review supports greater implementation of RM technology to improve health system costs and efficiency.
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