Additional physical therapy services reduce length of stay and improve health outcomes in people with acute and sub-acute conditions: an updated systematic review and meta-analysis

Publication date: Available online 7 April 2018
Source:Archives of Physical Medicine and Rehabilitation
Author(s): Casey L. Peiris, Nora Shields, Natasha K. Brusco, Jennifer J. Watts, Nicholas F. Taylor
ObjectiveTo update a previous review on whether additional physical therapy services reduce length of stay, improve health outcomes, are safe and cost effective for patients with acute or sub-acute conditions.Data sourcesElectronic database (AMED, CINAHL, EMBASE, MEDLINE, PEDro, PubMed) searches were updated from 2010 through June 2017.Study selectionRandomized controlled trials evaluating additional physical therapy services on patient health outcomes, length of stay or cost effectiveness were eligible. Searching identified 1524 potentially relevant articles, of which 11 new articles from 8 new randomized controlled trials with 1563 participants were selected. In total, 24 randomized controlled trials with 3262 participants are included in this review.Data extractionData were extracted using the form used in the original systematic review. Methodological quality was assessed using the PEDro scale and The Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach was applied to each meta-analysis.Data synthesisPost intervention data were pooled with an inverse variance, random effects model to calculate standardized mean differences (SMDs) and 95% confidence intervals (CIs). There is moderate quality evidence that additional physical therapy services reduced length of stay by 3 days in sub-acute settings (MD-2.8, 95%CI -4.6 to -0.9, I² 0%) and low quality evidence that it reduced length of stay by 0.6 days in acute settings (MD -0.6, 95%CI -1.1 to 0.0, I² 65%). Additional physical therapy led to small improvements in self-care (SMD 0.11, 95%CI 0.03 to 0.19, I² 0%), activities of daily living (SMD 0.13, 95%CI 0.02 to 0.25, I² 15%) and health-related quality of life (SMD 0.12, 95%CI 0.03 to 0.21, I² 0%), with no increases in adverse events. There was no significant change in walking ability. One trial reported that additional physical therapy was likely to be cost-effective in sub-acute rehabilitation.ConclusionsAdditional physical therapy services improve patient activity and participation outcomes, while reducing hospital length of stay for adults. These benefits are likely safe and there is preliminary evidence to suggest they may be cost effective.



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An investigation on the seasonal variations of the biomarkers of oxidative stress response and their correlations to Polonium-210 in mussel (Mytilus galloprovincialis) and common sole (Solea solea) from İzmir Bay, Turkey

Publication date: September 2018
Source:Journal of Environmental Radioactivity, Volume 189
Author(s): Ersan Aslan, Aysun Uğur Görgün, Selma Katalay, Işık Filizok, Seda Becerik, Tülin Aydemir
It is well known that the marine organisms are used as biological indicators for environmental pollution studies. Among these studies, the research on oxidative stress has been increasing in recent years. In this study, mussels (Mytilus galloprovincialis) and fish (Solea solea) samples were collected seasonally from İnciraltı, İzmir, Turkey. This station was in an area where fishing is carried out for human consumption. The relationship between ²¹⁰Po and oxidative stress markers (lipid peroxidation (LPO), H2O2 and proline) was investigated in the mussel tissue (digestive gland, gills) and fish tissue (liver, gills) samples. The present study indicated that H2O2 accumulated with increasing ²¹⁰Po concentration in mussel samples. Statistically significant correlation were found between H2O2 and ²¹⁰Po and LPO and proline in mussel samples. This correlation between LPO and proline can be attributed to common environmental parameters (other than ²¹⁰Po) affecting expression of both LPO and proline levels. There was not a significant correlation between ²¹⁰Po and LPO levels. Similarly, a significant correlation was not found between ²¹⁰Po and proline.



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A Randomized Comparison Between Interscalene and Small-Volume Supraclavicular Blocks for Arthroscopic Shoulder Surgery

Background and Objectives This randomized trial compared ultrasound (US)–guided interscalene block (ISB) and small-volume supraclavicular block (SCB) for arthroscopic shoulder surgery. We hypothesized that SCB would provide equivalent analgesia to ISB 30 minutes after surgery without the risk of hemidiaphragmatic paralysis (HDP). Methods All patients received an US-guided intermediate cervical plexus block. In the ISB group, US-guided ISB was performed with 20 mL of levobupivacaine 0.5% and epinephrine 5 μg/mL. In the SCB group, US-guided SCB was carried out using 20 mL of the same local anesthetic agent: 3 and 17 mL were deposited at the "corner pocket" (ie, intersection of the first rib and subclavian artery) and posterolateral to the brachial plexus, respectively. A blinded investigator assessed ISBs and SCBs every 5 minutes until 30 minutes using a composite scale that encompassed the sensory function of the supraclavicular nerves, the sensorimotor function of the axillary nerve, and the motor function of the suprascapular nerve. We considered the blocks complete if, at 30 minutes, a composite score equal or superior to 6 points (out of 8 points) was achieved. Thus, onset time was defined as the time required to reach a minimal composite score of 6 points. The blinded investigator also assessed the presence of HDP at 30 minutes with US. Subsequently, all patients underwent general anesthesia. Postoperatively, a blinded investigator recorded pain scores at rest at 0.5, 1, 2, 3, 6, 12, and 24 hours. Patient satisfaction at 24 hours, consumption of intraoperative and postoperative narcotics, and opioid-related adverse effects were also tabulated. Results Both groups displayed equivalent postoperative pain scores at 0.5, 1, 2, 3, 6, 12, and 24 hours. Interscalene blocks resulted in a higher incidence of HDP (95% vs 9%; P

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Effective Dose of Intravenous Dexmedetomidine to Prolong the Analgesic Duration of Interscalene Brachial Plexus Block: A Single-Center, Prospective, Double-Blind, Randomized Controlled Trial

Background and Objectives Intravenous (IV) dexmedetomidine (DEX) is reported to prolong the analgesic duration after single-shot interscalene brachial plexus block (ISBPB). However, the effective analgesic dose of IV DEX remains undetermined. Therefore, we aimed to elucidate the clinically relevant dose of IV DEX to prolong the analgesic duration of ISBPB. Methods Seventy-two patients scheduled for arthroscopic shoulder surgery received ISBPB with 15 mL of 0.5% ropivacaine with 1:200,000 epinephrine and were randomly assigned to 1 of 4 groups (n = 18, each): (1) IV normal saline (control), (2) IV DEX 0.5 μg/kg (DEX 0.5), (3) IV DEX 1.0 μg/kg (DEX 1.0), and (4) IV DEX 2.0 μg/kg (DEX 2.0). The primary outcome was time to the first pain at surgical site. Results The median (interquartile range) duration of analgesia was significantly prolonged for the DEX 2.0 (874 minutes [727–1153 minutes]) compared with 656 minutes (590–751 minutes), 703 minutes (644–761 minutes), and 696 minutes (615–814 minutes) for the control, DEX 0.5 and DEX 1.0 groups, respectively (P = 0.001, P = 0.008, and P = 0.003, respectively). Postoperative cumulative IV morphine equivalent consumption at 24 hours was significantly lower in the DEX 2.0 compared with the control, DEX 0.5 and DEX 1.0 groups (P

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Perineural Versus Systemic Dexamethasone in Front-Foot Surgery Under Ankle Block: A Randomized Double-Blind Study

Background and Objectives Among the different adjuvants, dexamethasone is one of the most accepted to prolong the effect of local anesthetics. This study aims to determine the superiority of perineural over systemic dexamethasone administration after a single-shot ankle block in metatarsal osteotomy. Methods We performed a prospective, double-blind, randomized study. A total of 100 patients presenting for metatarsal osteotomy with an ankle block were randomized into 2 groups: 30 mL ropivacaine 0.375% + perineural dexamethasone 4 mg (1 mL) + 2.5 mL of systemic saline solution (PNDex group, n = 50) and 30 mL ropivacaine 0.375% + 1 mL of perineural saline solution + intravenous dexamethasone 10 mg (2.5 mL) (IVDex group, n = 50). The primary end point was the duration of analgesia defined as the time between the performance of the ankle block and the first administration of rescue analgesia with tramadol. Results Time period to first rescue analgesia with tramadol was similar in the IVDex group and the PNDex group. Data are expressed as mean (SD) or median (range). Duration of analgesia was 23.2 (9.5) hours in the IVDex group and 19 (8.2) hours in the PNDex group (P = 0.4). Consumption of tramadol during the first 48 hours was 0 mg (0–150 mg) in the IVDex group versus 0 mg (0–250 mg) in the PNDex group (P = 0.59). Four (8%) and 12 (24%) patients reported nausea or vomiting in the IVDex group and the PNDex group, respectively (P = 0.03). Conclusions In front-foot surgery, perineural and systemic administrations of dexamethasone are equivalent for postoperative pain relief when used as an adjuvant to ropivacaine ankle block. Clinical Trial Registration This study was registered at ClinicalTrials.gov, identifier NCT02904538. Address correspondence to: Philippe Marty, MD, Department of Anesthesia, Clinique Médipôle Garonne, 31036, Toulouse, France (e-mail: philippemarty@hotmail.com). Accepted for publication November 20, 2017. The authors declare no conflict of interest. Support was provided solely from institutional and department sources from Department of Anesthesiology, Clinique Médipôle Garonne, Toulouse, France. This work should be attributed to the Department of Anesthesiology, Clinique Médipôle Garonne, Toulouse, France. Authors' contributions: O.R., B.Basset, C.V., and M.C.M. performed all regional anesthesia. P.M. and F.F. wrote the manuscript. C.M., M.M., and M.C. participated in the design of the study. B.Bataille performed the statistical analysis. A.D. participated in its design and coordination and helped to draft the manuscript. All authors read and approved the final manuscript. Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine.

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Practice Management: Successfully Guiding Your Group into the Future

Publication date: Available online 7 April 2018
Source:Anesthesiology Clinics
Author(s): Lee A. Fleisher




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The relationship between mismatch response and the acoustic change complex in normal hearing infants

Publication date: June 2018
Source:Clinical Neurophysiology, Volume 129, Issue 6
Author(s): Kristin M. Uhler, Sharon K. Hunter, Elyse Tierney, Phillip M. Gilley
ObjectiveTo examine the utility of the mismatch response (MMR) and acoustic change complex (ACC) for assessing speech discrimination in infants.MethodsContinuous EEG was recorded during sleep from 48 (24 male, 20 female) normally hearing aged 1.77 to –4.57 months in response to two auditory discrimination tasks. ACC was recorded in response to a three-vowel sequence (/i/-/a/-/i/). MMR was recorded in response to a standard vowel, /a/, (probability 85%), and to a deviant vowel, /i/, (probability of 15%). A priori comparisons included: age, sex, and sleep state. These were conducted separately for each of the three bandpass filter settings were compared (1–18, 1–30, and 1–40 Hz).ResultsA priori tests revealed no differences in MMR or ACC for age, sex, or sleep state for any of the three filter settings. ACC and MMR responses were prominently observed in all 44 sleeping infants (data from four infants were excluded). Significant differences observed for ACC were to the onset and offset of stimuli. However, neither group nor individual differences were observed to changes in speech stimuli in the ACC. MMR revealed two prominent peaks occurring at the stimulus onset and at the stimulus offset. Permutation t-tests revealed significant differences between the standard and deviant stimuli for both the onset and offset MMR peaks (p < 0.01). The 1–18 Hz filter setting revealed significant differences for all participants in the MMR paradigm.ConclusionBoth ACC and MMR responses were observed to auditory stimulation suggesting that infants perceive and process speech information even during sleep. Significant differences between the standard and deviant responses were observed in the MMR, but not ACC paradigm. These findings suggest that the MMR is sensitive to detecting auditory/speech discrimination processing.SignificanceThis paper identified that MMR can be used to identify discrimination in normal hearing infants. This suggests that MMR has potential for use in infants with hearing loss to validate hearing aid fittings.



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Eyeball pressure stimulation induces subtle sympathetic activation in patients with a history of moderate or severe traumatic brain injury

Publication date: June 2018
Source:Clinical Neurophysiology, Volume 129, Issue 6
Author(s): Ruihao Wang, Katharina M. Hösl, Fabian Ammon, Jörg Markus, Julia Koehn, Sankanika Roy, Mao Liu, Carmen de Rojas Leal, Dafin Muresanu, Steven R. Flanagan, Max J. Hilz
ObjectiveAfter traumatic brain injury (TBI), there may be persistent central-autonomic-network (CAN) dysfunction causing cardiovascular-autonomic dysregulation. Eyeball-pressure-stimulation (EPS) normally induces cardiovagal activation. In patients with a history of moderate or severe TBI (post-moderate-severe-TBI), we determined whether EPS unveils cardiovascular-autonomic dysregulation.MethodsIn 51 post-moderate-severe-TBI patients (32.7 ± 10.5 years old, 43.1 ± 33.4 months post-injury), and 30 controls (29.1 ± 9.8 years), we recorded respiration, RR-intervals (RRI), systolic and diastolic blood-pressure (BPsys, BPdia), before and during EPS (120 sec; 30 mmHg), using an ocular-pressure-device (Okulopressor®). We calculated spectral-powers of mainly sympathetic low (LF: 0.04–0.15 Hz) and parasympathetic high (HF: 0.15–0.5 Hz) frequency RRI-fluctuations, sympathetically mediated LF-powers of BPsys, and calculated normalized (nu) LF- and HF-powers of RRI. We compared parameters between groups before and during EPS by repeated-measurement-analysis-of-variance with post-hoc analysis (significance: p < 0.05).ResultsAt rest, sympathetically mediated LF-BPsys-powers were significantly lower in the patients than the controls. During EPS, only controls significantly increased RRIs and parasympathetically mediated HFnu-RRI-powers, but decreased LF-RRI-powers, LFnu-RRI-powers, and LF-BPsys-powers; in contrast, the patients slightly though significantly increased BPsys upon EPS, without changing any other parameter.ConclusionsIn post-moderate-severe-TBI patients, autonomic BP-modulation was already compromised at rest. During EPS, our patients failed to activate cardiovagal modulation but slightly increased BPsys, indicating persistent CAN dysregulation.SignificanceOur findings unveil persistence of subtle cardiovascular-autonomic dysregulation even years after TBI.



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