Leah P. Griffin

Receiving Early Mobility During an Intensive Care Unit Admission Is a Predictor of Improved Outcomes in Acute Respiratory Failure

Introduction:Hospitals are under pressure to provide care that not only shortens hospital length of stay but also reduces subsequent hospital admissions. Hospital readmissions have received increased attention in outcome reporting. The authors identified survivors of acute respiratory failure who then required subsequent hospitalization. A cohort of acute respiratory failure survivors, who participated in an early intensive care unit (ICU) mobility program, was assessed to determine if variables from the index hospitalization predict hospital readmission or death, within 12 months of hospital discharge. Methods:Hospital database and responses to letters mailed to 280 acute respiratory failure survivors. Univariate predictor variables shown to be associated with hospital readmission or death (P < 0.1) were included in a multiple logistic regression. A stepwise selection procedure was used to identify significant variables (P < 0.05). Results:Of the 280 survivors, 132 (47%) had at least 1 readmission or died within the first year, 126 (45%) were not readmitted and 22 (8%) were lost to follow-up. Tracheostomy [odds ratio (OR), 4.02 (95%CI, 1.72–9.40)], female gender [OR, 1.94 (95%CI, 1.13–3.32)], a higher Charlson Comorbidity Index assessed upon index hospitalization discharge [OR, 1.15 (95%CI, 1.01–1.31)] and lack of early ICU mobility therapy [OR, 1.77 (95%CI, 1.04–3.01)] predicted readmission or death in the first year postindex hospitalization. Conclusions:Tracheostomy, female gender, higher Charlson Comorbidity Index and lack of early ICU mobility were associated with readmissions or death during the first year. Although the mechanisms of increased hospital readmission are unclear, these findings may provide further support for early ICU mobility for patients with acute respiratory failure.

Correlation of Torque and Elbow Injury in Professional Baseball Pitchers

Background: During the pitching motion, velocity is generated by the upper extremity kinetic chain on internal rotation of the shoulder and trunk translational/rotational motion. This generation of power places significant forces and torques on the elbow and shoulder. Elbow valgus torque and shoulder rotational torque are theoretically linked to elbow injury. Hypothesis: Pitchers experiencing higher levels of elbow valgus torque and shoulder external rotation torque throughout the pitching motion are more likely to suffer elbow injury than pitchers with lower levels of torque. Study Design: Cohort study; Level of evidence, 3. Methods: With an established biomechanical analysis model, 23 professional baseball pitchers were videotaped during spring training games and followed prospectively for the next 3 seasons for elbow injury. A mixed statistical model using differences of least squares means and analysis of variance was used to analyze the association between elbow injury and torque levels throughout the pitching motion as well as at each major event within the pitching motion. Results: There were overall statistical trends relating elbow injury with both higher elbow valgus torque (P = .0547) and higher shoulder external rotation torque (P = .0548) throughout the entire pitching motion. More importantly, there was an individual significant correlation of elbow injury with both higher elbow valgus torque (P = .0130) and higher shoulder external rotation torque (P = .0018) at the late cocking phase (pitching event of maximum external rotation of the shoulder). Conclusion: This study provides information that supports existing theories about how and why certain injuries occur during the throwing motion in baseball. The late cocking phase appears to be the critical point in the pitching motion, where higher levels of torque at the shoulder and elbow can result in increased risk of injury. Manipulation of pitching mechanics to alter these torque levels or using these measures to identify pitchers at risk may help decrease injury rates.

Peripheral Nerve and Muscle Ultrasound in Amyotrophic Lateral Sclerosis

High‐resolution ultrasound has been used to evaluate several neuromuscular conditions, but it has only been used on a limited basis in amyotrophic lateral sclerosis (ALS) patients. It has not been used to assess their peripheral nerves. This study was designed to use neuromuscular ultrasound to investigate nerve cross‐sectional area and muscle thickness in ALS.

Validity and reliability of nerve and muscle ultrasound

Introduction: Nerve and muscle ultrasound has been studied in several conditions, but validity and reliability have not been assessed systematically. Methods: Nerve cross‐sectional area and muscle thickness were measured ultrasonographically at several sites in 4 cadavers, which were then dissected, and actual measurements were obtained. To assess intrarater and interrater reliability, between 3 and 5 ultrasonographers, with varying experience levels, made repeated measurements on healthy volunteers. Results: Correlation coefficients for nerve and muscle validity were >0.968 (P < 0.001), and for intrarater reliability were >0.901 (P < 0.001) for still and real‐time images. Correlation coefficients for interrater reliability were more varied, but for still images they were all significant at the P < 0.001 (0.542–0.998) level, and for real‐time images they were significant at the P < 0.05 level for half the sites (0.243–0.981). Conclusion: Overall, nerve and muscle ultrasound is a valid and reliable diagnostic imaging technique. Muscle Nerve, 2013

Transcranial Doppler Velocities in a Large, Healthy Population

Transcranial Doppler (TCD) ultrasonography has been extensively used in the evaluation and management of patients with cerebrovascular disease since the clinical application was first described in 1982 by Aaslid and colleagues TCD is a painless, safe, and noninvasive diagnostic technique that measures blood flow velocity in various cerebral arteries. Numerous commercially available TCD devices are currently approved for use worldwide, and TCD is recognized to have an established clinical value for a variety of clinical indications and settings. Although many studies have reported normal values, there have been few recently, and none to include a large cohort of healthy subjects across age, race, and gender. As more objective, automated processes are being developed to assist with the performance and interpretation of TCD studies, and with the potential to easily compare results against a reference population, it is important to define stable normal values and variances across age, race, and gender, with clear understanding of variability of the measurements, as well as the yield from various anatomic segments.

Quantitative neuromuscular ultrasound in the intensive care unit

Introduction: Intensive care unit acquired weakness (ICU‐AW) results from a complex mixture of nerve and muscle pathology, and early identification is challenging. This pilot study was designed to examine the ultrasonographic changes that occur in muscles during ICU hospitalization. Methods: Patients admitted to the ICU for acute respiratory failure were enrolled prospectively and underwent serial muscle ultrasound for thickness and gray‐scale assessment of the tibialis anterior, rectus femoris, abductor digiti minimi, biceps, and diaphragm muscles over 14 days. Results: Sixteen participants were enrolled. The tibialis anterior (P = 0.001) and rectus femoris (P = 0.041) had significant decreases in gray‐scale standard deviation when analyzed over 14 days. No muscles showed significant changes in thickness. Conclusions: Ultrasound is an informative technique for assessing muscles of patients in the ICU, and lower extremity muscles demonstrated increased homogeneity during ICU stays. This technique should be examined further for diagnosing and tracking those with ICU‐AW. Muscle Nerve, 2013

Validation of an Organizational Communication Climate Assessment Toolkit

Effective communication is critical to providing quality health care and can be affected by a number of modifiable organizational factors. The authors performed a prospective multisite validation study of an organizational communication climate assessment tool in 13 geographically and ethnically diverse health care organizations. Communication climate was measured across 9 discrete domains. Patient and staff surveys with matched items in each domain were developed using a national consensus process, which then underwent psychometric field testing and assessment of domain coherence. The authors found meaningful within-site and between-site performance score variability in all domains. In multivariable models, most communication domains were significant predictors of patient-reported quality of care and trust. The authors conclude that these assessment tools provide a valid empirical assessment of organizational communication climate in 9 domains. Assessment results may be useful to track organizational performance, to benchmark, and to inform tailored quality improvement interventions.

Nerve cross-sectional area in extremes of age

Introduction: Nerve cross‐sectional area reference values have been reported for many nerves, but there have been few studies in pediatric and geriatric populations. This study was conducted to determine the influence of age on nerve cross‐sectional area. Methods: Thirty‐two children (3 months to 16 years) and 20 geriatric adults (67–92 years) without known neurologic conditions underwent bilateral ultrasound to measure the area of the following nerves: median at the wrist and forearm; ulnar at the wrist and elbow; radial in the spiral groove; sciatic in the distal thigh; fibular at the knee; tibial at the knee and ankle; and sural at the ankle. Results: In general, nerve cross‐sectional area increased with age. Nerve size correlated most closely with age, but a correlation was also seen with body mass index. Conclusions: Nerve cross‐sectional area increases with age, which is important to note when using ultrasound to evaluate children and geriatric patients. Muscle Nerve 47: 890–893, 2013

Randomized Trial to Assess the Impact of Venlafaxine and Soy Protein on Hot Flashes and Quality of Life in Men With Prostate Cancer

PURPOSE Hot flashes occur in approximately 80% of androgen-deprived men. Few intervention studies have been conducted to relieve hot flashes in men. PATIENTS AND METHODS Eligible androgen-deprived men were randomly assigned to one of four daily regimens (2 × 2 factorial design) for 12 weeks: milk protein powder and placebo pill, venlafaxine and milk protein powder, soy protein powder and placebo pill, or venlafaxine and soy protein powder. The primary end point was hot flash symptom severity score (HFSSS), defined as number of hot flashes times severity. The secondary end point was quality of life (QoL), assessed by using the Functional Assessment of Cancer Therapy-Prostate. RESULTS In all, 120 men age 46 to 91 years participated. Most were white (78%) and overweight or obese (83%). Toxicity was minimal. Neither venlafaxine nor soy protein alone or in combination had a significant effect on HFSSS. Soy protein, but not venlafaxine, improved measures of QoL. CONCLUSION In androgen-deprived men, neither venlafaxine nor soy proved effective in reducing hot flashes. Interventions that appear effective for decreasing hot flashes in women may not always turn out to be effective in men.

Upper extremity spasticity in children with cerebral palsy: a randomized, double-blind, placebo-controlled study of the short-term outcomes of treatment with botulinum A toxin.

PURPOSE Botulinum A toxin (BoNT-A) injections are used widely to manage lower extremity spasticity in children with cerebral palsy. However, their use in the upper extremity is less well defined. This randomized, double-blind, placebo-controlled clinical trial evaluated the safety and efficacy of upper extremity intramuscular injections of BoNT-A in a cross-section of children with varying levels of function. METHODS Upper extremity function of study participants (N = 73; M:F = 47:26; age range, 3-18 y) was evaluated using the House Classification system (scores, 0-8, where a higher score indicates higher functional ability). Three groups of children were identified based on their House scores: 0-2 (n = 10), 3-5 (n = 54), and 6-8 (n = 9). Following randomization, children received a BoNT-A or placebo injection at baseline. Injections were administered at 8 and 20 weeks if clinically indicated. Occupational therapists evaluated study participants at screening, at baseline, and at 4, 8, 14, 20, and 26 weeks. Physician evaluations occurred at baseline and at 8, 20, and 26 weeks. The Melbourne Assessment of Unilateral Upper Limb Function evaluated the quality of upper extremity function before and after injections and served as the primary outcome variable. RESULTS The majority of study participants underwent 3 injection sessions. Muscles injected were individualized based on each childs particular spasticity pattern. A statistically higher percentage of children receiving BoNT-A injections showed an improvement in the Melbourne assessment at 26 weeks compared with the children receiving placebo. The range, frequency, and severity of postinjection adverse events were similar in both groups. CONCLUSIONS Children receiving BoNT-A injections demonstrated clinically meaningful short-term improvements in upper extremity function. Injections were well tolerated and safe. In contrast to other studies, study participants underwent multiple injection sessions based on their individual spasticity patterns.