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Wednesday, April 26

  1. page Clinical Prediction Rule for Post-Operative Delirium edited ... Despite knowing how low hematocrit levels affect the brain, and that low levels are a risk fac…
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    Despite knowing how low hematocrit levels affect the brain, and that low levels are a risk factor, it cannot be labeled as a causative factor because it could possibly just be a marker for other unrecognized factors (10).
    STATISTICALLY SIGNIFICANT
    {https://lh6.googleusercontent.com/BFxOveiuYDjKpK0vsKqeQg1c4cwh9KdjI9lSF136pL4faAXEVyZpy3kyEBWC12jNAvp-XCOgOj2fCvwL7pZYw3o-QNCdEzYXNk4NxfowGgwdFz6KwbnQ721PHcWiCI38S05qpJkW} * out of all 5 of these intraoperative factors, this was found to be the most indicative of developing delirium.
    Limitations → The biggest limitation of the particular study that we have covered in this intraoperative section is that the patients that were included in the study were all undergoing elective surgeries. Therefore the outcomes may not be generalized to other, older patients undergoing emergency surgeries (10).
    Summary: The intraoperative risk factors discussed above are the most commonly researched factors in developing postoperative delirium. Route of anesthesia, intraoperative hypotension, and bradycardia/tachycardia are not considered statistically significant in the development of delirium. Whereas, blood loss, number of blood transfusions, and the lowest postoperative hematocrit level were associated with delirium. As far as preventative measures, these are all possible risk factors when having surgery, so there really is no way to prevent them (more transfusions to keep hematocrit level above 30%). Although we cannot take steps as a PT to help prevent these factors, what can be taken away from this section is knowing when someone might be at a higher risk for developing postoperative delirium based on what happens during their surgery.
    ...
    Aside from the negative effects delirium has on the patient, their caregivers, and the health professionals that treat them, it can also lead to postoperative complications. These complications lead to poor cognitive and functional recovery, greater length of stay, and cost to the patient. Having postoperative delirium (especially in elderly patients) can cause a waterfall of adverse effects that lead to a serious decline in functionality and ultimately the patient's independence (10).
    PT intervention is very limited when it comes to post-op delirium, but by performing pre-operative interventions in order to reduce the risk of post-op delirium, potentially more patients can perform their inpatient rehab faster and be out of the hospital quicker, reducing hospital length of stay and improving the quality of care patients receive. In a study in 2014 that looked at preoperative physical therapy for total joint replacement. When patients were given preoperative PT there was a 29% reduction in postoperative cost including reduction in skilled nursing and inpatient rehab billing (14).
    ...
    for postoperative delirium??delirium??**
    Preoperative Cognition
    Advanced Age
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    6:50 am
  2. page Clinical Prediction Rules for Ambulation After SCI edited ... Higher accuracy than ASIA test A con - the physician performing the 2 motor and 2 sensory tes…
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    Higher accuracy than ASIA test
    A con - the physician performing the 2 motor and 2 sensory tests must be experienced with examining SCI patients
    ...
    by van SilfoutSilfhout et al.
    ...
    - van SilfoutSilfhout et al.
    Purpose:
    A retrospective study to further assess the accuracy and validity of the proposed Dutch CPR used in the Middendorp et al. study.
    ...
    Pinprick Sensory
    Sacral Sparing
    ...
    - van SilfoutSilfhout et al.
    {Walking Vs. Non-Walking Factors.png}
    Significant Ambulation outcome factors:
    ...
    Deviation into the top left corner compared to baseline shows that our CPR has highly significant predictive value.
    AUC: 0.939, 95% CI
    ...
    - van SilfoutSilfhout et al.
    Results obtained from this study were not significantly different than those seen by Middendorp et al.
    Original Study (Middendorp et al.)
    ...
    AUC: (0.939, 95% CI (0.892, 0.986))
    Replication of the Dutch CPR study in a clinical setting looks consistent with previous findings.
    ...
    - van SilfoutSilfhout et al.
    Replication of the Dutch CPR study found no statistical differences when compared to the results of this study.
    Having no significant differences between studies, shows significant validation for the use of this CPR in a practical clinical setting.
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    6:17 am

Tuesday, April 25

  1. page Clinical Prediction Rules for Ambulation After SCI edited ... Clinical Question: Is there conclusive evidence validating the use of CPRs in predicting ambul…
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    Clinical Question: Is there conclusive evidence validating the use of CPRs in predicting ambulation after a traumatic spinal cord injury?
    Background
    ...
    3.48.24 PM.png} Spinal
    Spinal Cord Injuries
    Spinal
    Cord: is
    Spinal Cord Injury (SCI): physical damage through trauma, like a sudden blow to the spine, that fractures or dislocates vertebrae and results in a loss/impaired function.
    Incidence Rates:Rate
    Current population size of 314 million people in the U.S., annual incidence of spinal cord injury (SCI) is approximately 54 cases per million population or approximately 17,000 new SCI cases each year.
    Number of people alive in 2016 from SCI has been estimated to be approximately 282,000 persons (range: 243,000-347,000)
    ...
    ASIA impairment scale
    The zone of partial preservation for complete injuries
    Clinical Prediction Rules (CPRs)
    Clinical Prediction Rules (CPRs): a tool designed to improve decision making in clinical practice by assisting practitioners in making a particular diagnosis, establishing a prognosis, or matching patients to optimal interventions based on a subset of predictor variables.
    Provides practitioners with powerful diagnostic information (history and physical examination) that may help as an accurate decision-making tool in comparison to a more expensive diagnostic test.
    ...
    Investigates the role of surgical timing in SCI
    The data sets were harmonized based on their common data elements to produce a single database.
    {Screen Shot 2017-04-25 at 11.28.39 PM.png}
    Predictor Variables
    1) Acute ASIA grade
    ...
    Functional Outcome Measure of Interest - FIM Motor Score at 1 Year Post-SCI {Screen Shot 2017-04-25 at 11.50.28 PM.png}
    http://www.rehabmeasures.org/lists/rehabmeasures/dispform.aspx?id=889
    ...
    et al. {Screen Shot 2017-04-25 at 11.28.39 PM.png}
    Prospective data taken from the NACTN and STASCIS protocols were harmonized in a dataset of 729 patients and then broken down to 376.

    Better functional outcome when:
    Less severe ASIA Impairment Scale grade
    ...
    Older age
    OR MRI signal characteristics with SC edema or hemorrhage
    ...
    11.32.48 PM.png} {Screen
    {Screen
    Shot 2017-04-202017-04-25 at 10-1.15.13 AM.png}11.36.09 PM.png}
    Discussion - Wilson et al.
    How effective is this CPR at predicting outcomes?
    ...
    This study has created, and internally validated, a prediction model for functional outcome at 1 year based on AIS grade, AMS score, age, and MRI characteristics, with all predictor variables obtained within the first 3 days of injury.
    Future steps would be to investigate imaging modalities and MRI sequences for predicting outcome for important SCI patient subgroups (incomplete injuies or central cord syndrome).
    Summary
    van Middendorp et al. created a CPR to predict ambulation outcomes at 1 year after SCI using 5 measures (age, 2 motor scores, 2 sensation scores), taken within 15 days of SCI with 0.956 accuracy of predicting outcomes.
    The ASIA scale has a 0.898 accuracy of predicting outcomes and requires many more measurements.
    van Silfout et al. validated the CPR created by van Middendorp et al. with a clinical setting validation group size twice that of the original study, with an 0.939 accuracy of predicting outcomes.
    Wilson et al. also created a CPR to predict ambulation outcomes at 1 year after SCI using AISA grade, AMS score, age, and MRI characteristics, taken within 3 days of SCI with 0.93 accuracy of predicting outcomes.
    Conclusion
    The CPR created by van Middendorp et al. has the highest accuracy of predicting ambulatory outcomes at 1 year after SCI (0.956), gives the largest time frame for taking predictive measures (15 days), and does not require expensive imaging like MRI.

    References
    Childs, J. D., & Cleland, J. A. (2006). Development and Application of Clinical Prediction Rules to Improve Decision Making in Physical Therapist Practice. Physical Therapy,86(1), 122-131. doi:10.1093/ptj/86.1.122
    Malla R. External validation study of a clinical prediction rule for ambulation outcomes after traumatic spinal cord injury. Texas Medical Center Dissertations (via ProQuest). 2013:Paper AAI1541012.
    van Middendorp, J. J., Hosman, a J., Donders, a R., Pouw, M. H., Ditunno Jr., J. F., Curt, A., … Van de Meent, H. (2011). A clinical prediction rule for ambulation outcomes after traumatic spinal cord injury: a longitudinal cohort study. Lancet, 377(9770), 1004–1010. https://doi.org/S0140-6736(10)62276-3 [pii]\r10.1016/S0140-6736(10)62276-3
    van Silfhout, L., Peters, A. E. J., Graco, M., Schembri, R., Nunn, A. K., & Berlowitz, D. J. (2015). Validation of the Dutch clinical prediction rule for ambulation outcomes in an inpatient setting following traumatic spinal cord injury. Spinal Cord, 54(October), 1–5. https://doi.org/10.1038/sc.2015.201
    Rehab Measures - FIM® instrument (FIM); FIM® is a trademark... (n.d.). Retrieved April 15, 2017, from http://www.rehabmeasures.org/lists/rehabmeasures/dispform.aspx?id=889
    Wilson, J. R., Grossman, R. G., Frankowski, R. F., Kiss, A., Davis, A. M., Kulkarni, A. V, … Fehlings, M. G. (2012). A clinical prediction model for long-term functional outcome after traumatic spinal cord injury based on acute clinical and imaging factors. Journal of Neurotrauma, 29(13), 2263–71. https://doi.org/10.1089/neu.2012.2417

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    11:01 pm
  2. page Clinical Prediction Rules for Ambulation After SCI edited ... Jordan Bosch, Jen Buczkowski, Seth Conway, Tyler Lacy, Taylor Pfiefer Clinical Question: Is t…
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    Jordan Bosch, Jen Buczkowski, Seth Conway, Tyler Lacy, Taylor Pfiefer
    Clinical Question: Is there conclusive evidence validating the use of CPRs in predicting ambulation after a traumatic spinal cord injury?
    Background Information
    {Screen Shot 2017-04-12 at 3.48.24 PM.png} Spinal Cord: is the main pathway of communication between the brain and the rest of the body. It serves as a connection for our central nervous system and functions by nerves that carry impulses to and from the brain to the rest of the body.
    Spinal Cord Injury (SCI): physical damage through trauma, like a sudden blow to the spine, that fractures or dislocates vertebrae and results in a loss/impaired function.
    ...
    Inability to WB immediately and in emergency department
    CPRs are developed and validated according to rigorous methodological standards.
    McGinn et alal. have suggested
    {Screen Shot 2017-04-20 at 10.11.03 AM.png}
    1. Creating the Clinical Prediction Rule
    ...
    Levels of Evidence Hierarchy: determine whether the CPR is appropriate in the decision-making process
    {Screen Shot 2017-04-19 at 3.26.54 PM.png}
    Long Term Outcomes: CPRA clinical prediction rule for Outcome at 1 Yearambulation outcomes after traumatic spinal cord injury: a longitudinal cohort study. - by van Middendorp et al.
    Background - van Middendorp et. alet al.
    Before this study, there was no CPR for patients with spinal cord injuries to predict their ability to walk independently.
    This was a longitudinal cohort study of patients with SCI to create a CPR to predict ambulation.
    A simple CPR was created, using factors from the international scale for spinal cord classification and the patient’s age at time of injury as prognostic variables.
    ...
    van Middendorp et. alet al.
    The investigators gathered data from 19 locations across Europe, and of 1442 potential candidates with spinal cord injuries, 492 had the outcome data the researchers were looking for.
    Functional status and neurological data were recorded within 15 days of the SCI, and follow-up measurements were taken at 1 month, 3 months, 6 months, and 12 months post-injury.
    The treatments each patient underwent were not recorded, as there is no proven effective treatment for SCI.
    Validation for the created CPR was done on 99 subjects that met inclusion criteria after the CPR was created.
    ...
    van Middendorp et. alet al.
    Prognostic Variables
    Age (Two Groups, 0-64, 65+)
    ...
    Functional Outcome Measure of Interest: Spinal Cord Independence Measure (SCIM): Item 12 (mobility indoors <10ft)
    {Screen Shot 2017-04-11 at 3.39.26 PM.png}
    ...
    van Middendorp et. alet al.
    {Screen Shot 2017-04-18 at 1.29.11 PM.png}
    Probabilities of walking independently (SCIM Item 12 score 4-8) 1 year post-injury
    Shaded area is 95% confidence interval
    Results - van Middendorp et. al
    {Screen Shot 2017-04-18 at 1.37.35 PM.png}
    Left is derivation group
    Right is validation group
    ...
    van Middendorp et. alet al.
    It was found that the CPR created has a significantly higher accuracy of predicting ambulation outcomes 1-year post-SCI than the ASIA Standard Neurological Scale
    CPR - 0.956 accuracy of predicting outcomes [95% CI 0·940–0·978] (p<0·0001)
    ...
    American Spinal Injury Association (ASIA) / International Spinal Cord Society Neurological Standard Scale
    {Screen Shot 2017-04-11 at 3.38.51 PM.png}
    Discussion - van Middendorp et. al
    {Screen Shot 2017-04-18 at 5.06.27 PM.png}
    It was also found that the CPR had a greater accuracy of predicting outcomes than each of the ASIA Grades individually.
    Discussion - van Middendorp et. al
    Clinical Application
    This created CPR is reliable to predict 1-year ambulatory outcomes in SCI patients
    ...
    Higher accuracy than ASIA test
    A con - the physician performing the 2 motor and 2 sensory tests must be experienced with examining SCI patients
    Long Term Outcomes: CPR for Outcome at 1 Year: ValidationValidation of CPR Proposedthe Dutch clinical prediction rule for ambulation outcomes in an inpatient setting following traumatic spinal cord injury - by van MiddendorpSilfout et al.
    Background - van Silfout et. alet al.
    Purpose:
    ...
    the Middendorp et. alet al. study.
    To replicate the Dutch CPR study as closely as possible in clinical practice and evaluate the efficacy of those findings.
    Use the CPR previously generated to interpret the results
    ...
    van Silfout et. alet al.
    Study Design:
    Inclusion Factors
    ...
    Pinprick Sensory
    Sacral Sparing
    ...
    van Silfout et. alet al.
    {Walking Vs. Non-Walking Factors.png}
    Significant Ambulation outcome factors:
    ...
    Time spent in ICU
    Time in Hospital
    ...
    the Middendorp et.et al. study.
    {Area Under the Curve.png}
    Deviation into the top left corner compared to baseline shows that our CPR has highly significant predictive value.
    AUC: 0.939, 95% CI
    ...
    van Silfout et. alet al.
    Results obtained
    ...
    by Middendorp et.et al.
    Original Study (Middendorp et. al)et al.)
    AUC: (0.956, 95% CI (0.936, 0.976))
    Validation study (Silfout et. al)
    AUC: (0.939, 95% CI (0.892, 0.986))
    Replication of the Dutch CPR study in a clinical setting looks consistent with previous findings.
    ...
    van Silfout et. alet al.
    Replication of the Dutch CPR study found no statistical differences when compared to the results of this study.
    Having no significant differences between studies, shows significant validation for the use of this CPR in a practical clinical setting.
    ...
    by Middendorp et.et al. seems
    ...
    as intended.
    The Evolution of Walking Related Outcomes Over the First 12 Weeks of Rehabilitation for Incomplete Traumatic Spinal Cord Injury: A Multi-Center Randomized Spinal Cord Injury Locomotor Trial.
    Dobkin et. al (2007)
    Background--Dobkin et. al
    Screened all admissions (1434 patients) to 6 rehab centers over 3 years
    111 Upper motor neuron patients and 35 lower motor neuron patients
    Patients were assigned to treatment groups using a random, permuted block design
    Methods - Dobkin et. al
    SCILT was a parallel group, multicenter, single blinded, randomized

    A
    clinical trial
    107 ASIA C and D patients
    28 ASIA B patients (Unable to walk on admission
    prediction model for rehabilitation)
    FIM Score of <4 was required to participate in the study
    Patients received average of 45 one-hour mobility sessions (BWSTT or CONT) over 12 weeks
    Required to practice standing (CONT) and stepping therapy (BWSTT) despite no motor control of legs
    Measurements - Dobkin et. al
    FIM-Locomotion, 15 m walk speed, and lower extremity motor score were collected at entry and every 2 weeks for 12 weeks
    Walking distance was obtained at entry and at 12 weeks
    Measures were also repeated and reported at 6 months and 12 months after entry
    Results - Dobkin et. al
    Results - Dobkin et. al
    No differences were found at the 2 week measurement intervals or at the end of training (12 weeks) between patients who received BWSTT versus CONT for the following measurements:
    FIM-Locomotion (P = .10)
    Walking Speed (P = .86)
    Lower Extremity Motor Score (P = .68)
    Walking Distance in 6 Minutes (Only measured at entry and 12 weeks) (P = .41)
    A significant difference was found for each measure in favor of better outcomes for patients who entered the program sooner (<4 weeks) after a SCI than later (>4 weeks)
    BWSTT: P = 0.01
    CONT: P = 0.001
    Possible Explanation:
    Entry within 4 weeks allowed some patients to start a lower level of function than they would have had they entered SCILT at 4 to 8 weeks after onset of SCI entry within 4 weeks allowed some patients to start at a lower level of function than they would have been had they entered SCILT at 4 to 8 weeks after onset of SCI
    Discussion - Dobkin et. al
    Independence in walking based on FIM-L and Walking Speed were consistently similar over the 2 week intervals and in parallel to increases in LEMS.
    Patients with ASIA B at 4 to 8 weeks after injury
    Gains in ability to walk are modest, few achieve
    long-term functional ambulation
    Patients with ASIA C & D at 4 to 8 weeks
    outcome after traumatic spinal cord injury
    Functional ambulation is often achieved by 12 weeks of rehabilitation, less likely to be reach by only 6 weeks of therapy
    ASIA C & D
    based on Admission for Rehabilitation
    Likely to recover the ability to walk at leisurely velocities used by healthy individuals for community activities by 6 months {Screen Shot 2017-04-20 at 10.05.13 AM.png}
    Who Cares? - Dobkin et. al
    The SCILT provides previously unavailable data about the recovery of functional walking over the time of rehabilitation for incomplete traumatic SCI.
    This study suggest that the time after injury is an important variable for planning
    acute clinical trials to lessen walking disability
    A Clinical Prediction Model for Long-Term Functional Outcome after Traumatic Spinal Cord Injury Based on Acute Clinical
    and Imaging Factors
    -
    imaging factors - Wilson et. alet al.
    Background - Wilson et. alet al.
    “There is a pressing unmet need to accurately prognosticate, early after SCI, a patient's functional outcome.”
    Physicians have little to scientifically guide their prediction of outcome following SC
    ...
    The purpose of this study is to improve the ability of clinicians to predict long-term outcomes in the acute clinical setting (1-3 days)
    Aim to create a CPR that relates clinical and imaging findings to functional outcome at 1 year following SCI
    Methods-Methods - Wilson et. alet al.
    Data was gathered from the combination of two prospective datasets:
    North American Clinical Trials Network for SCI (NACTN)
    ...
    Investigates the role of surgical timing in SCI
    The data sets were harmonized based on their common data elements to produce a single database.
    Predictor Variables - Wilson et. al
    1) Acute ASIA grade
    2) Acute ASIA motor score
    ...
    4) Intramedullary signal characteristics on spinal
    All 4 of these predictors have consistently demonstrated prognostic significance in relation to long-term functional outcome after SCI
    Outcome and follow-upFunctional Outcome Measure of Interest - Wilson et. al
    The primary outcome variable was
    FIM motor scoreMotor Score at 1 year post-injury
    {Unknown.png}
    Results
    Year Post-SCI {Screen Shot 2017-04-25 at 11.50.28 PM.png}
    http://www.rehabmeasures.org/lists/rehabmeasures/dispform.aspx?id=889
    Results
    - Wilson et. al
    {Screen
    et al. {Screen Shot 2017-04-202017-04-25 at 10.08.01 AM.png}11.28.39 PM.png}
    Prospective data taken from the NACTN and STASCIS protocols were harmonized in a dataset of 729 patients and then broken down to 376.
    Better functional outcome when:
    ...
    Older age
    OR MRI signal characteristics with SC edema or hemorrhage
    {Screen Shot 2017-04-202017-04-25 at 9.54.48 AM.png}11.32.48 PM.png} {Screen Shot
    ...
    - Wilson et. alet al.
    How effective is this CPR at predicting outcomes?
    The model predicting FIM motor score demonstrated an R-square of 0.52 in the original dataset and an R square of .52 across a set of 200 bootstraps (random sample).
    For the logistic model, AUC was 0.93 in the original dataset, and 0.92 (95% CI 0.92, 0.93) across the bootstraps, indicating excellent predictive discrimination.
    This study produces the first prediction models using acute clinical and radiological data (obtained within the first 3 days of injury), to help predict long term functional outcome after traumatic SCI.
    Conclusions - Wilson et. al
    This study has created, and internally validated, a prediction model for functional outcome at 1 year based on AIS grade, AMS score, age, and MRI characteristics, with all predictor variables obtained within the first 3 days of injury.
    Future steps would be to investigate imaging modalities and MRI sequences for predicting outcome for important SCI patient subgroups (incomplete injuies or central cord syndrome).
    References:
    https://www.ncbi.nlm.nih.gov/pubmed/26554272
    https://www.ncbi.nlm.nih.gov/pubmed/21377202
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3430477/
    http://journals.sagepub.com/doi/pdf/10.1177/1545968306295556
    http://search.proquest.com/docview/1418295048/previewPDF/42F8A587C84C4FA4PQ/1?accountid=28920
    https://bb.kumc.edu/bbcswebdav/pid-528309-dt-content-rid-1830332_1/courses/417212131605/_assoc/Development%20and%20Application%20of%20Clinical%20Predication%20Rules%20to%20Improve%20Decision%20Making%20in%20PT%20Practice/PHYS_THER-2006-Childs-122-31.pdf
    References
    (view changes)
    10:47 pm

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