Douglas J. Lorenz

Bruising characteristics discriminating physical child abuse from accidental trauma.

OBJECTIVE: Our objective was to conduct a pilot study to identify discriminating bruising characteristics and to model those findings into a decision tool for screening children at high risk for abuse. METHODS: A case-control study of children 0 to 48 months of age who were admitted to a PICU because of trauma was performed. Case subjects (N = 42) were victims of physical abuse, and control subjects (N = 53) were children admitted because of accidental trauma during the same time period. Bruising characteristics (total number and body region) and patient age were compared for children with abusive versus accidental trauma. The development of a decision rule for predicting abusive trauma was accomplished with the fitting of a classification and regression tree through binary recursive partitioning. RESULTS: Ninety-five patients were studied. Seventy-one (33 of 42 patients in the abuse group and 38 of 53 in the accident group) were found to have bruising, and the characteristics were modeled. Characteristics predictive of abuse were bruising on the torso, ear, or neck for a child ≤4 years of age and bruising in any region for an infant <4 months of age. A bruising clinical decision rule was derived, with a sensitivity of 97% and a specificity of 84% for predicting abuse. CONCLUSIONS: Discriminating differences exist in bruising characteristics for abusive versus accidental trauma. The body region- and age-based bruising clinical decision rule model functions as a clinically sensible screening tool to identify young children who require further evaluation for abuse.

Balance and Ambulation Improvements in Individuals With Chronic Incomplete Spinal Cord Injury Using Locomotor Training–Based Rehabilitation

OBJECTIVE To evaluate the effects of intensive locomotor training on balance and ambulatory function at enrollment and discharge during outpatient rehabilitation after incomplete SCI. DESIGN Prospective observational cohort. SETTING Seven outpatient rehabilitation centers from the Christopher and Dana Reeve Foundation NeuroRecovery Network (NRN). PARTICIPANTS Patients (N=196) with American Spinal Injury Association Impairment Scale (AIS) grade C or D SCI who received at least 20 locomotor training treatment sessions in the NRN. INTERVENTIONS Intensive locomotor training, including step training using body-weight support and manual facilitation on a treadmill followed by overground assessment and community integration. MAIN OUTCOME MEASURES Berg Balance Scale; Six-Minute Walk Test; 10-Meter Walk Test. RESULTS Outcome measures at enrollment showed high variability between patients with AIS grades C and D. Significant improvement from enrollment to final evaluation was observed in balance and walking measures for patients with AIS grades C and D. The magnitude of improvement significantly differed between AIS groups for all measures. Time since SCI was not associated significantly with outcome measures at enrollment, but was related inversely to levels of improvement. CONCLUSIONS Significant variability in baseline values of functional outcome measures is evident after SCI in individuals with AIS grades C and D and significant functional recovery can continue to occur even years after injury when provided with locomotor training. These results indicate that rehabilitation, which provides intensive activity-based therapy, can result in functional improvements in individuals with chronic incomplete SCI.

Epidemiological Trends in Abuse and Misuse of Prescription Opioids

ABSTRACT The authors evaluated trends between social, geographic, and demographic factors and cases of select scheduled drugs (buprenorphine, fentanyl, hydrocodone, hydromorphone, morphine, methadone, and oxycodone) using the Researched Abuse, Diversion and Addiction-Related Surveillance System poison center data and census data. Spontaneous calls from the public and healthcare professionals are recorded by poison centers using a standardized, electronic data collection system. We compared the annual incidence of total prescription opioid drug cases to annual data from the U.S. Department of Labor and U.S. Census Bureau by year and by state for unemployment rate, poverty rate, population density, high school graduation rate, and bachelors degree proportion using the best least square fit in an evaluation for trends for 2003 to 2006. Two strong positive trends were found between poverty rate, unemployment rate, and prescription opioid drug rates, with prescription opioid drug rates increasing as poverty rate and unemployment rate increased. This trend was consistent over the 4 years of study and strongly influenced by the hydrocodone and methadone rates, with less influence from oxycodone rates. The high school graduation rate trend was consistent over the 4 years and was strongly influenced by the hydrocodone and methadone rate. No consistent trend was identified with population density and prescription opioid drug rates. Understanding trends may help guide distribution of scarce resources and prevention efforts to where they may have their greatest impact.

Randomized trial of fascia lata and polypropylene mesh for abdominal sacrocolpopexy: 5-year follow-up

Introduction and hypothesisThe purpose of this study is to evaluate the 5-year surgical outcomes of abdominal sacrocolpopexy among subjects randomized to receive polypropylene mesh or cadaveric fascia lata.MethodsAll 100 subjects from the original randomized clinical trial were eligible. Primary outcome was objective anatomic failure: any pelvic organ prolapse quantification (POP-Q) point ≥ − 1. Secondary outcome was clinical failure—presence of bulge or prolapse symptoms and either a POP-Q point C ≥ ½ TVL or any POP-Q point >0—and interim surgical re-treatment. Wilcoxon tests and Fisher’s exact test were performed.ResultsFifty-eight subjects returned for 5-year follow-up—29 mesh and 29 fascia. Objective anatomic success rates were: mesh, 93% (27/29) and fascia, 62% (18/29) (p = 0.02). Clinical success rates were: mesh, 97% (28/29) and fascia, 90% (26/29) (p = 0.61).ConclusionsPolypropylene mesh was superior to cadaveric fascia lata using objective anatomic outcomes. Success rates of mesh and fascia were comparable using a clinical definition that combined symptoms with anatomic measures.

Derivation of a clinical prediction rule for pediatric abusive head trauma

Objectives: Abusive head trauma is a leading cause of traumatic death and disability during infancy and early childhood. Evidence-based screening tools for abusive head trauma do not exist. Our research objectives were 1) to measure the predictive relationships between abusive head trauma and isolated, discriminating, and reliable clinical variables and 2) to derive a reliable, sensitive, abusive head trauma clinical prediction rule that—if validated—can inform pediatric intensivists’ early decisions to launch (or forego) an evaluation for abuse. Design: Prospective, multicenter, cross-sectional, observational. Setting: Fourteen PICUs. Patients: Acutely head-injured children less than 3 years old admitted for intensive care. Interventions: None. Measurements and Main Results: Applying a priori definitional criteria for abusive head trauma, we identified clinical variables that were discriminating and reliable, calculated likelihood ratios and post-test probabilities of abuse, and applied recursive partitioning to derive an abusive head trauma clinical prediction rule with maximum sensitivity—to help rule out abusive head trauma, if negative. Pretest probability (prevalence) of abusive head trauma in our study population was 0.45 (95 of 209). Post-test probabilities of abusive head trauma for isolated, discriminating, and reliable clinical variables ranged from 0.1 to 0.86. Some of these variables, when positive, shifted probability of abuse upward greatly but changed it little when negative. Other variables, when negative, largely excluded abusive head trauma but increased probability of abuse only slightly when positive. Some discriminating variables demonstrated poor inter-rater reliability. A cluster of five discriminating and reliable variables available at or near the time of hospital admission identified 97% of study patients meeting a priori definitional criteria for abusive head trauma. Negative predictive value was 91%. Conclusions: A more completeunderstanding of the specific predictive qualities of isolated, discriminating, and reliable variables could improve screening accuracy. If validated, a reliable, sensitive, abusive head trauma clinical prediction rule could be used by pediatric intensivists to calculate an evidence-based, patient-specific estimate of abuse probability that can inform—not dictate—their early decisions to launch (or forego) an evaluation for abuse.

Ambulation and Balance Outcomes Measure Different Aspects of Recovery in Individuals With Chronic, Incomplete Spinal Cord Injury

OBJECTIVE To evaluate relationships among ambulation and balance outcome measures over time for incomplete spinal cord injury (SCI) after locomotor training, in order to facilitate the selection of effective and sensitive rehabilitation outcomes. DESIGN Prospective observational cohort. SETTING Outpatient rehabilitation centers (N=7) from the Christopher and Dana Reeve Foundation NeuroRecovery Network. PARTICIPANTS Patients with incomplete SCI (N=182) American Spinal Injury Association Impairment Scale level C (n=61) and D (n=121). INTERVENTIONS Intensive locomotor training, including step training using body weight support and manual facilitation on a treadmill followed by overground assessment and community integration. MAIN OUTCOME MEASURES Six-minute and 10-meter walk tests, Berg Balance Scale, Modified Functional Reach, and Neuromuscular Recovery Scale collected at enrollment, approximately every 20 sessions, and on discharge. RESULTS Walking and standing balance measures for all participants were strongly correlated (r≥.83 for all pairwise outcome correlations), standing and sitting balance measures were not highly correlated (r≤.48 for all pairwise outcome correlations), and walking measures were weakly related to sitting balance. The strength of relationships among outcome measures varied with functional status. Correlations among evaluation-to-evaluation changes were markedly reduced from performance correlations. Walk tests, when conducted with different assistive devices, were strongly correlated but had substantial variability in performance. CONCLUSIONS These results cumulatively suggest that changes in walking and balance measures reflect different aspects of recovery and are highly influenced by functional status and the utilization of assistive devices. These factors should be carefully considered when assessing clinical progress and designing clinical trials for rehabilitation.

Marginal association measures for clustered data

The use of correlation coefficients in measuring the association between two continuous variables is common, but regular methods of calculating correlations have not been extended to the clustered data framework. For clustered data in which observations within a cluster may be correlated, regular inferential procedures for calculating marginal association between two variables can be biased. This is particularly true for data in which the number of observations in a given cluster is informative for the association being measured. In this paper, we apply the principle of inverse cluster size reweighting to develop estimators of marginal correlation that remain valid in the clustered data framework when cluster size is informative for the correlation being measured. These correlations are derived as analogs to regular correlation estimators for continuous, independent data, namely, Pearsons ρ and Kendalls τ. We present the results of a simple simulation study demonstrating the appropriateness of our proposed estimators and the inherent bias of other inferential procedures for clustered data. We illustrate their use through an application to data from patients with incomplete spinal cord injury in the U.S.A.

A Multivariate Examination of Temporal Changes in Berg Balance Scale Items for Patients With ASIA Impairment Scale C and D Spinal Cord Injuries

OBJECTIVE To provide a multivariate examination of the Berg Balance Scale (BBS) in patients with spinal cord injury (SCI) as a first step in developing a balance tool for the SCI population. DESIGN Observational cohort. SETTING The NeuroRecovery Network (NRN), a specialized network of treatment centers providing standardized, activity-based therapy for patients with SCI. PARTICIPANTS Patients (N=97) with American Spinal Injury Association Impairment Scale C or D SCI who were enrolled in the NRN between March 1, 2005, and June 12, 2007. INTERVENTIONS All enrolled patients received 3 to 5 locomotor training sessions a week, according to NRN protocol, and were periodically evaluated for progress on functional outcome measurements. MAIN OUTCOME MEASURES Scores on the items of the BBS, six-minute walk test distances, ten-meter walk test speeds, and scores on the SCI Functional Ambulation Index. Temporal rates of change of the BBS items were examined with a principal components and correlation analysis. RESULTS The first principal component accounted for nearly half of the overall variability in the BBS, correlated well with rates of change in functional mobility measures, and had good stability in its composition as verified by a resampling analysis. Further analysis showed that the composition of the first principal component varied with the patients level of recovery. CONCLUSIONS The BBS captures a significant amount of information about balance recovery in persons with SCI and may be a good foundation for a balance tool. However, the utility of BBS items may be dependent on a patients level of recovery. A dynamic balance instrument for the SCI population may be needed.

Are the 10 meter and 6 minute walk tests redundant in patients with spinal cord injury

Objective To evaluate the relationship and redundancy between gait speeds measured by the 10 Meter Walk Test (10MWT) and 6 Minute Walk Test (6MWT) after motor incomplete spinal cord injury (iSCI). To identify gait speed thresholds supporting functional ambulation as measured with the Spinal Cord Injury Functional Ambulation Inventory (SCI-FAI). Design Prospective observational cohort. Setting Seven outpatient rehabilitation centers from the Christopher and Dana Reeve Foundation NeuroRecovery Network (NRN). Participants 249 NRN patients with American Spinal Injury Association Impairment Scale (AIS) level C (n = 20), D (n = 179) and (n = 50) iSCI not AIS evaluated, from February 2008 through April 2011. Interventions Locomotor training using body weight support and walking on a treadmill, overground and home/community practice. Main Outcome Measure(s) 10MWT and 6MWT collected at enrollment, approximately every 20 sessions, and upon discharge. Results The 10MWT and 6MWT speeds were highly correlated and the 10MWT speeds were generally faster. However, the predicted 6MWT gait speed from the 10MWT, revealed increasing error with increased gait speed. Regression lines remained significantly different from lines of agreement, when the group was divided into fast (≥0.44 m/s) and slow walkers (<0.44 m/s). Significant differences between 6MWT and 10MWT gait speeds were observed across SCI-FAI walking mobility categories (Wilcoxon sign rank test p<.001), and mean speed thresholds for limited community ambulation differed for each measure. The smallest real difference for the 6MWT and 10MWT, as well as the minimally clinically important difference (MCID) values, were also distinct for the two tests. Conclusions While the speeds were correlated between the 6MWT and 10MWT, redundancy in the tests using predictive modeling was not observed. Different speed thresholds and separate MCIDs were defined for community ambulation for each test.

Longitudinal Patterns of Functional Recovery in Patients With Incomplete Spinal Cord Injury Receiving Activity-Based Rehabilitation

OBJECTIVE To model the progression of 3 functional outcome measures from patients with incomplete spinal cord injury (SCI) receiving standardized locomotor training. DESIGN Observational cohort. SETTING The NeuroRecovery Network (NRN), a specialized network of treatment centers providing standardized, activity-based therapy for SCI patients. PARTICIPANTS Patients (N=337) with incomplete SCI (grade C or D on the International Standards for Neurological Classification of Spinal Cord Injury scale) who were enrolled in the NRN between February 2008 and March 2011. INTERVENTION All enrolled patients received standardized locomotor training sessions, as established by NRN protocol, and were evaluated monthly for progress. MAIN OUTCOME MEASURES Berg Balance Scale, 6-minute walk test, and 10-meter walk test. Progression over time was analyzed via the fitting of linear mixed effects models. RESULTS There was significant improvement on each outcome measure and significant attenuation of improvement over time. Patients varied significantly across groups defined by recovery status and American Spinal Injury Association Impairment Scale (AIS) grade at enrollment with respect to baseline performance and rates of change over time. Time since SCI was a significant determinant of the rate of recovery for all measures. CONCLUSIONS Locomotor training, as implemented in the NRN, results in significant improvement in functional outcome measures as treatment sessions accumulate. Variability in patterns of recovery over time suggest that time since SCI and patient functional status at enrollment, as measured by the Neuromuscular Recovery Scale, are important predictors of performance and recovery as measured by the targeted outcome measures.