Showing papers by "Detroit Receiving Hospital published in 2012"

Treatment of unstable pelvic ring injuries with an internal anterior fixator and posterior fixation: initial clinical series

Abstract: Objectives:To present a novel internal fixation device for stabilizing unstable pelvic fractures using supra-acetabular spinal pedicle screws and a subcutaneous connecting rod (INFIX).Setting:Level I trauma center.Design:Case series.Patients:Twenty-four patients with rotational or vertically unstabl

Lethal serotonin syndrome after methylone and butylone ingestion.

Abstract: Introduction A new generation of designer phenethylamines have emerged and aggressively marketed as “legal highs.” The drugs are labeled “not for human consumption” to avoid widespread recognition and prosecution under the existing analog drug laws. The newest generation includes methylone and butylone. Methylone and butylone have minor structural changes and similar pharmacodynamics properties to scheduled drugs.

Effects of vitamin D deficiency in critically ill surgical patients

Abstract: Background The incidence of vitamin D deficiency in critically ill patients is reported to be up to 50%, with a 3-fold increase in predicted mortality, but limited data exist concerning vitamin D deficiency in critically ill surgical patients. Methods Sixty-six adult surgical intensive care unit patients who had 25-hydroxyvitamin D serum levels evaluated from January 2010 to February 2011 were prospectively identified. Patients were divided into groups according to vitamin D level ( Results Of the 66 patients evaluated, 49 (74%) had vitamin D levels P = .09), and a higher incidence of sepsis was seen in the patients with vitamin D levels Conclusions Vitamin D levels

Biomechanical stability of a supra-acetabular pedicle screw Internal Fixation device (INFIX) vs External Fixation and plates for vertically unstable pelvic fractures

Abstract: Background We have recently developed a subcutaneous anterior pelvic fixation technique (INFIX). This internal fixator permits patients to sit, roll over in bed and lie on their sides without the cumbersome external appliances or their complications. The purpose of this study was to evaluate the biomechanical stability of this novel supraacetabular pedicle screw internal fixation construct (INFIX) and compare it to standard internal fixation and external fixation techniques in a single stance pelvic fracture model.

Validity of Global Physical and Emotional SUDS

Abstract: Despite the wide-spread use of Subjective Units of Discomfort Scales, or SUDS, to measure anxiety to specific stimuli, little information has been published on the validity of such scales and even less on their use as global measures of emotional and physical discomfort. Data was examined for 182 consecutive admissions to a psychology clinic to determine the relationship of self-rating of emotional and physical discomfort to one another and of the emotional self-rating to the clinician rating of general functioning (GAF). As expected, patients’ ratings of their emotional discomfort were significantly higher than ratings of their physical discomfort (t = 9.077, p < .001). Emotional SUDS were significantly and negatively related to clinicians’ GAF ratings (r = − 0.439, p < .001), indicating that the two ratings measured related global constructs. Data for the 53 patients who also completed the MMPI-2 was drawn from the larger sample to determine the nature of the relationship between SUDS and two measures of general emotional distress, with patients’ SUDS significantly related to both the A scale (r = 0.351, p < .05) and the neurotic index (r = 0.366, p < .01). Finally, there was a significant decrease in the emotional SUDS (t = 4.686, p < .001) but not the physical SUDS (t = 0.788, p = .434) after 3 months of psychotherapy. The data supports SUDS as global measures of both physical and emotional discomfort.

Treatment of Methicillin-Resistant Staphylococcus aureus Infections with a Minimal Inhibitory Concentration of 2 μg/mL to Vancomycin: Old (Trimethoprim/Sulfamethoxazole) versus New (Daptomycin or Linezolid) Agents

Abstract: Background:Guidelines recommend that agents other than vancomycin be considered for some types of infection due to methicillin-resistant Staphylococcus aureus (MRSA) when the minimum inhibitory concentration (MIC) to vancomycin is 2 μg/mL or more. Alternative therapeutic options include daptomycin and linezolid, 2 relatively new and expensive drugs, and trimethoprim/sulfamethoxazole (TMP/SMX), an old and inexpensive agent.Objective:To compare the clinical efficacy and potential cost savings associated with use of TMP/SMX compared to linezolid and daptomycin.Methods:A retrospective study was conducted at Detroit Medical Center. For calendar year 2009, unique adults (age >18 years) with infections due to MRSA with an MIC to vancomycin of 2 μg/mL were included if they received 2 or more doses of TMP/SMX and/or daptomycin and/or linezolid. Data were abstracted from patient charts and pharmacy records.Results:There were 328 patients included in the study cohort: 143 received TMP/SMX alone, 89 received daptomyc...

Practice Variations in the Management of Status Epilepticus

Abstract: Numerous anticonvulsant agents are now available for treating status epilepticus (SE). However, a paucity of data is available to guide clinicians in the initial treatment of seizures or SE. This study describes the current strategies being employed to treat SE in the USA. Fifteen American academic medical centers completed a retrospective, multicenter, observational study by reviewing 10–20 of the most recent cases of SE at their institution prior to December 31, 2009. A multivariate analysis was performed to determine factors associated with cessation of seizures. A total of 150 patients were included. Most patients with SE had a seizure disorder (58 %). SE patients required a median of 3 AEDs for treatment. Three quarters of patients received a benzodiazepine as first-line therapy (74.7 %). Phenytoin (33.3 %) and levetiracetam (10 %) were commonly used as the second AED. Continuous infusions of propofol, barbiturate, or benzodiazepine were used in 36 % of patients. Median time to resolution of SE was 1 day and was positively associated with presence of a complex partial seizure, AED non-compliance prior to admission, and lorazepam plus another AED as initial therapy. Prolonged ICU length of stay and topiramate therapy prior to admission were negatively associated with SE resolution. Mortality was higher in patients without a history of seizure (22.2 vs 6.9 %, p = 0.006). The use of a benzodiazepine followed by an AED, such as phenytoin or levetiracetam, is common as first and second-line therapy for SE and appears to be associated with a shorter time to SE resolution. AED selection thereafter is highly variable. Patients without a history of seizure who develop SE had a higher mortality rate.

Evaluation of Telavancin Activity versus Daptomycin and Vancomycin against Daptomycin-Nonsusceptible Staphylococcus aureus in an In Vitro Pharmacokinetic/Pharmacodynamic Model

Abstract: Daptomycin-nonsusceptible (DNS) Staphylococcus aureus strains have been reported over the last several years. Telavancin is a lipoglycopeptide with a dual mechanism of action, as it inhibits peptidoglycan polymerization/cross-linking and disrupts the membrane potential. Three clinical DNS S. aureus strains, CB1814, R6212, and SA-684, were evaluated in an in vitro pharmacokinetic/pharmacodynamic (PK/PD) model with simulated endocardial vegetations (starting inoculum, 10(8.5) CFU/g) for 120 h. Simulated regimens included telavancin at 10 mg/kg every 24 h (q24h; peak, 87.5 mg/liter; t(1/2), 7.5 h), daptomycin at 6 mg/kg q24h (peak, 95.7 mg/liter; t(1/2), 8 h), and vancomycin at 1 g q12h (peak, 30 mg/liter; t(1/2), 6 h). Differences in CFU/g between regimens at 24 through 120 h were evaluated by analysis of variance with a Tukey's post hoc test. Bactericidal activity was defined as a ≥3-log(10) CFU/g decrease in colony count from the initial inoculum. MIC values were 1, 0.25, and 0.5 mg/liter (telavancin), 4, 2, and 2 mg/liter (daptomycin), and 2, 2, and 2 mg/liter (vancomycin) for CB1814, R6212, and SA-684, respectively. Telavancin displayed bactericidal activities against R6212 (32 to 120 h; -4.31 log(10) CFU/g), SA-684 (56 to 120 h; -3.06 log(10) CFU/g), and CB1814 (48 to 120 h; -4.9 log(10) CFU/g). Daptomycin displayed initial bactericidal activity followed by regrowth with all three strains. Vancomycin did not exhibit sustained bactericidal activity against any strain. At 120 h, telavancin was significantly better at reducing colony counts than vancomycin against all three tested strains and better than daptomycin against CB1814 (P < 0.05). Telavancin displayed bactericidal activity in vitro against DNS S. aureus isolates.

CT scanogram for limb length discrepancy in comminuted femoral shaft fractures following IM nailing

Abstract: Introduction Leg length discrepancy (LLD) following intramedullary nailing of femoral fractures is not uncommon. We designed a prospective study to evaluate the efficacy of routine postoperative computed tomography (CT) scanograms for evaluation of limb length discrepancy in patients with comminuted Winquist III or IV femoral shaft fractures treated with intramedullary nailing. Methods The study consisted of 15 patients with Winquist III and 13 with a Winquist IV femoral shaft fracture pattern with an average age of 37 years. The mechanisms of injury were motor vehicle collision (13), gunshot wound (12) and falls (three). All patients were treated with a statically locked intramedullary femoral nail (18 antegrade and 10 retrograde). A CT scanogram evaluated limb length in all patients. A discrepancy of greater than 20 mm was considered for correction during the same admission. An LLD of 15–20 mm was discussed with the patient extensively for correction. Results In the 28 patients included in our study, the average limb length discrepancy was 9.1 mm with a range of −43.5 mm short to 10.3 mm long. The LLD was less than 10 mm in 18 patients (64%), 10–15 mm in four patients (14%), 15–20 mm in three patients (11%) and more than 20 mm in three patients (11%). Measurement of discrepancy as small as 0.5 mm showed that 18 patients were fixed with shortening and in 10 patients the operated femur was longer. Tibia lengths were also evaluated separately. Though none of the tibiae had a previous fracture, only three patients (10%) had tibiae of equal length. In 13 patients, an unequal tibia partially corrected the LLD whilst in 12 it added to the discrepancy. Five patients with LLD of greater than 15 mm underwent correction. Conclusions A postoperative scanogram in patients with comminuted femoral shaft fractures treated with intramedullary nailing is useful to evaluate LLD and allows for early intervention. The ideal length where correction is necessary remains unclear.

Análise fatorial confirmatória da versão portuguesa da Depression Anxiety Stress Scale-21

Abstract: To determine which of three published models best characterizes the factor structure of the Portuguese version of the Depression Anxiety Stress Scales-21 and to assess its validity and reliability. Confirmatory factor analysis of Depression Anxiety and Stress Scale-21 for 1,297 adult, primary care outpatients (66.7% female, Mage = 48.57 years) comparing 3 models. The relationship between the Depression Anxiety Stress Scales-21 and the Positive and Negative Affect Schedule was analyzed. The correlated 3-factor model fit the data best. The scale demonstrated good internal consistency, with alpha scores of the subscales ranging from 0.836 to 0.897. Correlation with the Positive and Negative Affect Schedule was positive and moderate with the negative affect scale; it was negative and limited with the positive affect. These findings support the correlated 3-factor structure. The test demonstrated adequate reliability and construct validity, which supports its use for screening in primary care settings with Portuguese speakers.

The Effect of Cognitive Impairment in the Elderly on the Initial and Long-Term Stability of Warfarin Therapy

Abstract: Background: Despite guidelines that clearly outline the benefits of warfarin, it remains underutilized. Various reasons are associated with the underuse of warfarin; however, cognitive impairment (CI) has been identified as one of the most common causes for not electing to anticoagulate elderly patients with atrial fibrillation. Nevertheless, there are limited data on warfarin use in such patients; therefore, we investigated anticoagulation stability in patients with and without CI. Objectives: Our objectives were to (i) examine if mild to moderate CI delayed the time required to achieve initial therapeutic anticoagulation; (ii) determine if mild to moderate CI was associated with long-term anticoagulation instability; and (iii) assess if initial anticoagulation problems predicted long-term anticoagulation instability. Methods: A retrospective study in a pharmacist-managed anticoagulation clinic was conducted in community-dwelling patients ≥60 years of age on warfarin therapy with a target international normalized ratio (INR) of 2.0–3.0. Our study included 57 patients; 20 were initiated on warfarin and 54 were analysed for long-term anticoagulation stability. Age, ethnicity, gender, warfarin indication, co-morbidities and caregiver involvement were recorded. We defined CI as having a Mini-Mental State Examination (MMSE) score of ≤26. To evaluate initial anticoagulation stability between groups, we analysed (i) number of clinic visits and days to achieve therapeutic INR; and (ii) minor and major adverse events upon initiation of warfarin. To evaluate long-term anticoagulation stability, we analysed (i) time in therapeutic range (TTR); (ii) the percentage of clinic visits with a reported dose mishap and the frequency of out-of-range INRs resulting from dose mishaps; and (iii) parameters associated with the intensity of clinic management: weekly warfarin dose changes, transient dose adjustments, any dose manipulation and the length of time between clinic visits. Results: We found no difference in the number (mean±SD) of visits (control = 5.8±4.3, CI = 4.6±2.4; p = 0.44) or days (control = 51.6±45.7, CI = 35.8±30.5; p = 0.36) required to achieve initial therapeutic anticoagulation. No adverse effects were reported in either group. In terms of long-term stability, TTR (mean±SD) was similar for both groups (control = 65±20% vs CI = 61±16%; p = 0.36). Although the proportion of dose mishaps did not differ (control = 74 in 705 visits, CI = 86 in 691 visits; p = 0.18), dose mishaps resulted in a greater frequency of out-of-range INRs for patients with CI (p = 0.01). There were no differences in clinic management measures between groups (p = not statistically significant [NS] for all). Finally, we found no correlation between the time to reach initial anticoagulation stability and long-term stability for either group (p = NS for all). Conclusion: We found mild to moderate CI neither delayed the time required to achieve therapeutic anticoagulation, nor decreased anticoagulation stability versus patients with normal cognitive function. Additionally, CI did not require more intensive clinic management. CI should not necessarily be a barrier to the use of warfarin anticoagulation in elderly patients attending an anticoagulation clinic.

Lumbar pedicle screw placement: Using only AP plane imaging

Abstract: Background: Variations in the pedicle morphology and presence of spinal deformities can make pedicle screw placement challenging. Recently, computerized tomography (CT) guided screw placement has reportedly improved the surgical accuracy of pedicle screw insertion. However, it is time consuming and expensive. We combined single-plane fluoroscopy in AP projection alone with tactile guidance for placing pedicle screws more efficiently and accurately. This report presents our results with this technique. Materials and Methods: An Institutional Review Board (IRB) approved retrospective study was carried out on 308 patients who underwent lumbar spinal fusion with 1806 pedicle screws placed using fluoroscopy only in the AP plane. There were 182 patients with two-level fusion, 79 with single-level fusion, 26 with three-level fusion, and 21 with more than three-level fusions. The indications of surgery included spondylolisthesis, adult scoliosis, revision surgery, lumbar canal stenosis, and discogenic pain. Pedicle screws were inserted under fluoroscopic guidance in the AP plane alone with a final lateral image after completion of implant placement. Radiographs were performed postoperatively in all patients and CT scans were obtained on 78 patients with 588 screws. Results: Twenty nine (5%) cortical wall perforations were noted amongst the 588 screws that were evaluated with a CT scan and did not result in postoperative vascular or neural complications. Anterior cortical vertebral violation was noted in 14 patients, while in 9 patients the screws penetrated the lateral wall of the pedicle. The medial wall of the pedicle was encroached in six patients with no frank perforations. Conclusion: Placement of pedicle screws under fluoroscopic guidance using AP plane imaging alone with tactile guidance is safe, fast, and reliable. However, a good understanding of the radiographic landmarks is a prerequisite.

Posterior lumbar spinal fusion and instrumentation in morbidly obese patients using the Synframe retractor system: technical note

Abstract: Purpose Lumbar spine surgery in morbidly obese patients is a challenge to the operating surgeon. The aim of the study was to evaluate the surgical experience in this group of patients using the Synframe retractor system (Synthes, Paoli, PA, USA) as a tool for improved surgical access.

Management of Urethral Strictures in Men

Abstract: Urethral strictures in men often cause bothersome obstructive urinary symptoms and occasionally bladder dysfunction and even renal failure. Management of this disease differs depending on the location and length of the stricture, as well as the patient's overall health and goals. Most patients choose definitive reconstructive surgery since this offers the highest success rate compared to other treatments for urethral strictures.

Knee pain in patients with cancer after chemotherapy, radiotherapy, and bone marrow transplantation

Abstract: The causes of knee pain in patients with cancer with are different from those without cancer, and the purpose of this study was to evaluate these differences. Thirty-six patients with cancer who had knee pain who had undergone 1 or more modalities of treatment, including chemotherapy, radiotherapy, and bone marrow transplant, for a primary diagnosis of cancer were compared with a cohort of 40 patients without cancer who had knee pain. All patients were evaluated clinically and underwent radiographic examination, and some underwent computed tomography or magnetic resonance imaging examination. Among patients with a primary diagnosis of cancer, the most common diagnosis was lymphoma (n=10), and the most common causes of knee pain were avascular necrosis of bone, osteoarthritis, insufficiency fractures, and septic arthritis. In 5 patients, the classical signs of a septic knee were not present. Other causes of knee pain included meniscus tear and anterior cruciate ligament rupture with instability. The most common diagnosis in patients without cancer was osteoarthritis of the knee. No patient without cancer was diagnosed with avascular necrosis, metastatic lesion, or insufficiency fracture. Two patients without cancer were diagnosed with septic arthritis of the knee. This study showed that the causes of knee pain in patients with cancer are different from those without cancer. Septic arthritis may present without the classical clinical signs in patients with cancer, and a high index of suspicion should be maintained for it.

Expert's comment concerning Grand Rounds case entitled "a novel 'pelvic ring augmentation construct' for lumbo-pelvic reconstruction in tumor surgery" (by Sathya Thambiraj, Daren Forward, James Thomas and Bronek Boszczyk).

Abstract: Introduction Historically, metastatic spine tumor surgery has been palliative for pain control, to maintain neurologic and ambulatory function. The thought of curing cancer with limited metastatic disease by resecting the primary and the metastatic lesions is becoming more common. Multilevel spondylectomy for resection of metastatic disease has been reported in the literature, mostly at the thoracic or lumbar level with some success. Reconstruction of the lumbosacral junction after tumor resection is a difficult endeavor and several techniques have been utilized. Subcutaneous anterior pelvic fixation has been described for the treatment of unstable pelvic fractures.