POST-CONCUSSION PHYSICAL THERAPY REFERALS

Background: Treating a concussion is complex, requiring a multi-disciplinary patient-centered approach for optimal outcomes. Physical therapy (PT) is a treatment utilized to facilitate concussion recovery, however little is known about those patients referred to PT. Purpose/Hypothesis: The purpose of this study was to report the demographics and other outcome measures of patients referred to PT from an attached specialty concussion clinic. Methods: Retrospective data were extracted from medical records for patients who were referred for physical therapy (PT) from its specialty concussion clinic. Patients included in this study were aged 8-18, diagnosed with a concussion, and referred to PT. Demographic data (age, gender, ethnicity, race) were patient reported. Other patient outcome measures (total injury recovery in days, total number of PT visits, total days between the first and last PT visit, positive VOMS score (symptom increase of 2 from baseline on any symptom and/or convergence on any trial >6cm). Statistical analyses included summary statistics and were reported appropriately as proportions, medians (interquartile range [IQR]), and means (± standard deviation [SD]). Results: Of the 88 patients referred to PT, the mean (± SD) age was 14.31 (± 2.58), 27.3% were children (8-12 years), 72.7% were adolescents (13-18 years), 65.9% were female, 87.5% were white race, 6.8% were black race, and 12.5% were Hispanic in ethnicity. A total of 84.1% patients had a positive VOMS, 9.1% had a negative VOMS, and 6.8% had an invalid VOMS. On average, patients were seen for 4 (± 2.60) total visits, spanning across an average of 18 (± 14.83) days between initial and last PT visits, with the median recovery between date of injury and medical clearance being 48 days (SD=175). Conclusions: This is the first study to provide preliminary demographics of post-concussive PT patients referred from its specialty concussion clinic. These results will be useful in establishing future protocols for future studies to examine the effect of early PT intervention on pediatric concussion recovery.

Psychological issues affecting patients living with a stoma

Stoma surgery is an intrusive operation, with outcomes that can impact seriously on daily life, not just in the immediate postoperative and recovery period, but for the rest of the patient's life. There are changes in bodily function, altered body image, physicality and personal care needs. These changes require acceptance and adaptation and can necessitate a re-ordering of daily life, socially, emotionally and in terms of work. Assessing the patient's needs through the trajectory of diagnosis, surgery and a stoma, is not just important during the treatment phase but needs to continue throughout the lifespan. Traditionally, patient outcome measures after bowel surgery have included overall self-efficacy, checking for stoma complications, clinical health status, function and psychological status. However, over the past three decades there has been increasing recognition that quality of life (QoL), which is now regarded as a key measurement, needs further consideration. Patients report difficulties when explaining to health professionals the challenges they face, and their reactions as they try to make the adjustments to their new normal of life with a stoma. This article examines stoma patients' perceptions of their outcomes from recent research. It discusses how more can be done by health professionals to support stoma patients through their initial transition to life with a stoma and for the rest of their life.

Urinary cytokines in women with refractory detrusor overactivity: A longitudinal study of rotating antibiotic versus placebo treatment

Over 50% of women with detrusor overactivity (DO), who do not respond to therapy have been shown to have bacteriuria, which may stimulate the release of inflammatory cytokines than can enhance nerve signalling, leading to symptoms of urgency. This study made use of a consecutive series of urine samples collected from women with refractory DO, who participated in a clinical trial of rotating antibiotic therapy. The aim was to determine the effect of bacteriuria and antibiotic treatment on the levels of urinary cytokines, and to correlate the cytokine concentration with patient outcome measures relating to urgency or urge incontinence. The urinary cytokines chosen were IL-1α, IL-1 receptor antagonist, IL-4, IL-6, IL-8, IL-10, CXCL10 (IP-10), MCP-1 and TNF-α. The presence of bacteriuria stimulated a significant increase in the concentrations of IL-1α (P 0.0216), IL-1 receptor antagonist (P 0.0264), IL-6 (P 0.0003), IL-8 (P 0.0043) and CXCL-10 (P 0.009). Antibiotic treatment significantly attenuated the release of IL-1α (P 0.005), IL-6 (P 0.0027), IL-8 (P 0.0001), IL-10 (P 0.049), and CXCL-10 (P 0.042), i.e. the response to the presence of bacteria was less in the antibiotic treated patients. Across the 26 weeks of the trial, antibiotic treatment reduced the concentration of five of the nine cytokines measured (IL-1α, IL-6, IL-8, IL-10 and CXCL-10); this did not reach significance at every time point. In antibiotic treated patients, the urinary concentration of CXCL-10 correlated positively with four of the six measures of urgency. This study has shown that cytokines associated with activation of the innate immune system (e.g. cytokines chemotactic for or activators of macrophages and neutrophils) are reduced by antibiotic therapy in women with refractory DO. Antibiotic therapy is also associated with symptom improvement in these women, therefore the inflammatory response may have a role in the aetiology of refractory DO.

The virtual fracture clinic improves quality of care for patients with hand and wrist injuries: an assessment of 3709 patients

Fracture clinic services are under significant pressures to meet patients' expectations of a high-quality service. The virtual fracture clinic has shown early promise in helping to reduce such pressures. We used the virtual fracture clinic for hand and wrist injuries treated in the orthopaedic fracture clinic and used key quality indicators to measure improvement. Over the first 21 months, key patient outcome measures and satisfaction scores for patients discharged from the virtual fracture clinic with education to self-care were excellent. Our results show that a virtual fracture clinic model can be applied to provide high-quality care for hand and wrist injuries. The main advantage of the virtual fracture clinic is its ability to direct patients to the right person for timely treatment. We conclude from our 21-month experience that this model of care allows safe, effective, patient-centred, efficient and equitable care to the patients with hand and wrist fractures. Level of evidence: IV

Analysis of injected cement volume and clinical outcomes following kyphoplasty for vertebral compression fractures

Background: It has been suggested that greater volumes of cement injected during kyphoplasty correlate with improved vertebral body height restoration and kyphotic angulation correction. However, there is little evidence tying cement volume to patient outcomes. Here, we analyzed the association between cement volume and outcome utilizing indices of pain, disability, and quality of life. Methods: One hundred and thirty-six patients undergoing kyphoplasty were analyzed retrospectively. The total volume of bone cement injected was recorded intraoperatively for each patient; the average total cement volume was 5.44 cc. Pre- and postoperative outcome indices were documented, using the visual analog scale (VAS), Roland-Morris disability index (RMDI), and the EuroQol 5 Dimension instrument (EQ5D). Pearson’s correlations and linear regression models were derived for the association of total cement volume with each of the patient outcome measures. This was a retrospective cohort study. Results: The average change in VAS, RMDI, and EQ5D scores for all patients was −6.8, +8.3, and +0.41, respectively. For VAS, RMDI, and EQ5D improvements, neither Pearson’s correlations nor multiple linear regression models revealed a correlation or an association with total cement volume. Conclusion: For patients undergoing kyphoplasty, outcomes were not associated with the total injected cement volume; all had a significant reduction in pain and most exhibited decreased disability with improved quality of life.

Carpal tunnel decompression in primary care: what is the infection risk and is it safe and effective?

Introduction The demand for elective hand surgery in England is predicted to double by 2030 compared with 2011. With such increase in demand, the UK must seek strategies to reduce costs of treatment while still maintaining standards of care. Carpal tunnel decompression performed in a treatment room rather than in theatre may provide a safe alternative setting. As yet, there are no UK-based studies that identify the risk of infection following surgery performed in a treatment room and there are no studies whatsoever assessing the qualitative outcomes of patients undergoing hand surgery outside a theatre environment. Our aim was to assess whether carpal tunnel decompression performed in the community is safe, in terms of infection risk, and effective. Materials and methods Patient outcome measures were prospectively recorded following carpal tunnel decompression in one single primary care centre performed by one surgeon from 2012 to 2017. Infection following surgery was evaluated for retrospectively. Results A total of 460 patients underwent carpal tunnel decompression within the study time period. There were three superficial infections identified, giving an infection rate of 0.65%. There were no deep infections identified. There was a statistically significant improvement in both symptom and functional outcomes following surgery, with results comparable to other studies where surgery was performed in theatre. Discussion We believe that carpal tunnel decompressions performed in a treatment room is both safe, in terms of infection risk, and effective. Surgeons should consider this location as an alternative setting to the main operating theatre.