Alex Moroz

Comprehensive deep venous thrombosis prevention strategy after total-knee arthroplasty.

Ragucci MV, Leali A, Moroz A, Fetto J: Comprehensive deep venous thrombosis prevention strategy after total-knee arthroplasty. Am J Phys Med Rehabil 2003;82:164–168. Objective Venous thromboembolism after total-knee arthroplasty represents a common early postoperative complication resulting in significant morbidity. Despite this, the optimal prophylactic regimen is controversial. The prevalence of venous thromboembolism has been cited as high as 35% in patients receiving pharmacologic prevention alone. We investigated the efficacy of a comprehensive prevention protocol encompassing the use of epidural anesthesia, aspirin, venous foot compression pumps, and early mobilization in a series of consecutive total-knee arthroplasties. Design A series of 100 consecutive total-knee arthroplasty patients were enrolled into the prospective trial. All patients were allowed full weight bearing on the first postoperative day and ambulation as tolerated. Venous foot compression pumps and aspirin were used immediately after surgery in the totality of subjects. Seventy-five percent of the patients were transferred to an acute rehabilitation service during the first postoperative week. The presence of deep-vein thrombosis was subsequently determined with the routine use of venous duplex scans. Results Three patients (3%) demonstrated evidence of distal deep-vein thrombosis. No patient had symptomatic pulmonary embolism. Conclusion The combination of epidural anesthesia, aspirin, immediate postoperative venous foot compression pumps, and early ambulation together seem to be a more effective approach to prevent the occurrence of thromboembolic events after knee replacements than pharmacologic prevention alone.

Blinding Measured: A Systematic Review of Randomized Controlled Trials of Acupuncture

Background. There is no agreement among researchers on viable controls for acupuncture treatment, and the assessment of the effectiveness of blinding and its interpretation is rare. Purpose. To systematically assess the effectiveness of blinding (EOB) in reported acupuncture trials; to explore results of RCTs using a quantitative measure of EOB. Data Sources. A systematic review of published sham RCTs that assessed blinding. Study Selection. Five hundred and ninety studies were reviewed, and 54 studies (4783 subjects) were included. Data Extraction. The number of patients who guessed their treatment identity was extracted from each study. Variables with possible influence on blinding were identified. Data Synthesis. The blinding index was calculated for each study. Based on blinding indexes, studies were congregated into one of the nine blinding scenarios. Individual study characteristics were explored for potential association with EOB. Limitations. There is a possibility of publication or reporting bias. Conclusions. The most common scenario was that the subjects believed they received verum acupuncture regardless of the actual treatment received, and overall the subject blinding in the acupuncture studies was satisfactory, with 61% of study participants maintaining ideal blinding. Objectively calculated blinding data may offer meaningful and systematic ways to further interpret the findings of RCTs.

Assessing blinding in trials of psychiatric disorders: A meta-analysis based on blinding index

The assessment of blinding in RCTs is rarely performed. Currently most studies that do report data on evaluation of blinding merely report percentages of correct guessing, not taking into account correct guessing by chance. Blinding assessment using the blinding index (BI) has never been performed in a systematic review on studies of major psychiatric disorders. This study is a systematic review of psychiatric randomized control trials using the BI as a chance-corrected measurement of blinding, a tool to analyze and understand the patterns of blinding across studies of major psychiatric disorders with available data. Of 2467 psychiatric RCTs from 2000 to 2010, 66 reported on blinding and 40 studies were found to have enough information on evaluation of blinding to be analyzed using the BI. The experimental treatment groups had an average BI value of 0.14 and the control groups had an average BI value of 0.00. The most common BI scenario was random-random, indicating ideal blinding. A positive correlation between effect size and more correct guesses was also found. Overall, based on BI values and the most common blinding scenario, the published articles on major psychiatric disorders from 2000 to 2010, which reported on blinding assessment for patients, were effectively blinded.

Immediate and follow-up effects of a brief disability curriculum on disability knowledge and attitudes of PM&R residents: A comparison group trial

Background: Humanistic attitudes are essential in physicians and therefore supporting them is a key component in graduate medical education (GME). The importance of a physicians attitude toward people with disability is especially relevant within the rehabilitation discipline, as prevailing attitudes and misconceptions can be potential barriers to successful diagnosis and treatment. Aim: This study was designed to examine the relationship between participation in a brief disability sensitivity training and knowledge of disability and attitudes of physical medicine and rehabilitation (PM&R) residents toward people with disability. Methods: A daylong training for residents consisted of lectures and a panel presentation that covered (1) disability facts, (2) personal stories of people with disabilities, and (3) medical evaluation of disability. The presentations were followed by a simulation experience where resident pairs (one assigned to a wheel chair, the other a “caretaker”) performed various tasks. This was followed by a group discussion of their experience. Three instruments were administered prior to the training: (1) a brief demographic questionnaire, (2) 30 multiple choice questions measuring various aspects of knowledge about disability, and (3) the Scale of Attitudes toward Disabled Persons, Form R (SADP). After the training experience, the knowledge instrument and the SADP were re-administered along with a series of items to measure various aspects of students’ satisfaction with the training. The three instruments described were re-administered 3 months post-training. Results: There was significant immediate gain in both the disability knowledge and the attitude scores among trainees as compared to a control group of physiatry residents in standard medical training. Knowledge gains of the disability sensitivity training group did not persist, but attitude toward disability gains remained at the 3 months follow up. Conclusion: After a brief curriculum in disability knowledge and sensitivity for PM&R physicians in training, there was a short-term improvement in disability knowledge and an improvement in disability attitudes sustained at 3 months.

Stroke and neurodegenerative disorders. 4. neurodegenerative disorders

Bryant PR, Geis CC, Moroz A, O’Neill BJ, Bogey RA. Stroke and neurodegenerative disorders. 4. Neurodegenerative disorders. 2004;85(3 Suppl 1):S21–33. This self-directed learning module highlights diagnosis, treatment, and rehabilitation issues in patients with neurodegenerative disorders, including multiple sclerosis (MS), Parkinson’s disease, and amyotrophic lateral sclerosis (ALS). It is part of the study guide on stroke and neurodegenerative disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on the differential diagnosis, diagnostic evaluation, medical management, and rehabilitation issues in MS. Similarly, the differential diagnosis treatment and rehabilitation in Parkinson’s disease is discussed. Electrodiagnosis, pharmacologic treatment, and rehabilitation options for ALS are also discussed.

Evaluation of an Elderly Faller by Medical Students and Rehabilitation Residents

As part of the development of a curriculum for medical students and rehabilitation residents at New York University School of Medicine, an Objective Structured Clinical Examination (OSCE) station was developed for formative evaluation. The goal was to determine the existing knowledge and competence of medical students and rehabilitation residents in the analysis and treatment of a geriatric patient with a history of falls. This OSCE station was designed to focus on three specific clinical skills needed in assessing the elderly faller. The OSCE station was a standardized patient (SP) encounter with a 75‐year‐old man presenting with falls. Seventy‐five medical students and 41 rehabilitation medicine residents participated in the study. There was high agreement between the SP and a geriatric physician used to assess performance on gait (Cronbach alpha=0.918) and orthostatic blood pressure (Cronbach alpha=0.887) assessment. Of the medical students, 43.5% did not check orthostatic blood pressure, 56.8% did not evaluate gait, and 92.0% did not consider assistive device prescription. Only 20.0% checked both orthostatic blood pressure and gait. Likewise, 73.8% of residents did not check orthostatic blood pressure, 38.1% did not evaluate gait and 92.9% did not consider assistive device prescription. Only 19.0% checked both orthostatic blood pressure and gait. The results of this examination are alarming and suggest that education regarding the approach to an elderly person who falls is inadequate, leaving students and residents poorly prepared to take care of the “silver tsunami.”

Mobile Health: Exploring Attitudes Among Physical Medicine and Rehabilitation Physicians Toward this Emerging Element of Health Delivery

Health care reform, coupled with recent technologic advances, is driving the rapid adoption of medical technology. Individual medical practitioners and integrated health care delivery systems have been forced to alter their approach to technology and to understand the potential applications within their practice. Among these technologic innovations is mobile health (mHealth), which is the practice of medical or public health supported by mobile electronic devices. mHealth enables the monitoring and delivery of health care and healthrelated information to a broad community in a real-time fashion. The power of mHealth stems from the ability to provide information, education, and resources to both health care providers and patients where and when they need it, thus extending traditional modes of information sharing and dissemination across the spectrum of health delivery. The dynamic nature of the devices and the accompanying software applications (apps) allows users to interact with each other and to access data in an unprecedented manner. For physicians and other members of a multidisciplinary care team, the result could be improved communication and alignment of services, clinical monitoring, multidisciplinary coordination of care, patient education, access to health records, and continuing medical education; for patients, mHealth could provide an additional point of contact with their providers that is interactive and that accompanies them throughout their day in their individual psychosocial milieu, allowing them to access information and become empowered at the point of need. Currently, our physical medicine and rehabilitation (PM&R) department is conducting a prospective study evaluating the impact of tablet computers, specifically the iPad (Apple Inc. Cupertino, CA), on patient care and resident education within a rehabilitation setting. Here we discuss attitudes among PM&R resident and attending physicians toward mHealth to better understand the current use and potential benefits within our field. The rapid movement of technology that is emerging outside of the traditional realm of hospital-driven information technology was initially dominated by personal digital assistant devices and by phones with advanced computer-like capabilities (smartphones) and has recently expanded to encompass tablet computers, including the iPad. There are currently more than 15,000 health-related apps available on iTunes, and at least 3 medical schools have already integrated iPads into the first-year curriculum [1,2]. Recent surveys suggest that 22% of physicians will own an iPad by the end of 2010 and more than 50% will have one by the end of 2011 [3,4]. The rapid adoption of mobile technology by health care practitioners has been matched by the use of mobile devices by patients. In fact, more than 80% of Medicaid patients text regularly, and groups who would otherwise have limited access to Internet services (eg, ethnic minorities) are leading adopters of Smartphones and tablets [5]. Not only can mHealth reach individuals whenever and wherever they carry their mobile device, it has the potential to accompany individuals over long periods of time and to involve underserved communities. Physicians indicate a willingness to have patients monitor their health remotely, with more than 85% of physicians stating they would prefer to have patients take more control of their own care in this way [5]. It is estimated that more than 14% of adult Americans are already using mobile devices to monitor their health [6], with some positive preliminary results reported [5-9].

Assessing Patient Expectations and Concerns in a Physical Medicine and Rehabilitation Unit: A Real-Time Snapshot

To evaluate patient expectations, concerns, and satisfaction during physical medicine and rehabilitation (PM&R) inpatient hospitalization. Patients were also asked to comment on what resources might benefit them during their stay.

Faculty feedback that begins with resident self-assessment: motivation is the key to success

The seeking and incorporating of feedback are necessary for continuous performance improvement in medicine. We know that beginning feedback conversations with resident self‐assessment may reduce some of the tensions experienced by faculty staff. However, we do not fully understand how residents experience feedback that begins with self‐assessment, and whether any existing theoretical frameworks can explain their experiences.

Poster 314 iPad Clinical Efficacy Study: Examining Physician Use of Mobile Technology in Real Time

Disclosures: D. Cushman, No Disclosures. Case Description: The patient is a 58-year-old man with left hemiparesis and sensation loss of unknown etiology. Approximately 5 days after admission, during which time he participated in standard inpatient intensive therapies, he noticed a 5cm slightly elevated erythematous patch on his medial left ankle, associated with some pruritus. The medical team began empiric treatment for cellulitis as it had grown larger, was warm, and had become more painful than the previous day. The following day’s exam showed that it appeared larger, but more purpuric and had developed an orange tint. Dermatology was consulted, who made the diagnosis of exercise-induced vasculitis. He was treated with topical steroids for relief of the pruritus. Setting: Inpatient rehabilitation hospital. Results or Clinical Course: He was discharged 2 days later with no more itching, and slight improvement of the rash. Discussion: This is the first reported case, to our knowledge, of benign pigmented purpura being identified in an acute rehab setting. This is a benign skin condition which may be more common in the rehab population, as it is associated with exercise. It may be misdiagnosed as cellulitis given its appearance. Conclusions: Exercise-induced vasculitis is a benign skin condition which may be more prevalent in the rehab population and can be mistaken as cellulitis.