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Objective: To quantify health utilities of the Glasgow Outcome Scale--Extended (GOSE) states after actual traumatic brain injury (TBI). Background: Recovery after TBI is measured using the GOSE, a validated clinical trial endpoint. A recent public survey quantified the health utilities of some GOSE states after hypothetical TBI as worse than death. However, no health utilities exist for disability after actual TBI. Methods: This national computer-adaptive survey followed Enhancing the Quality and Transparency of Health Research-Checklist for Reporting Results of Internet E-Surveys guidelines and recruited adult TBI survivors (injury >1 year prior) through their available surrogates. Using a standard gamble approach in randomized order, participants gave preferences for post-TBI categorical health states ranging from GOSE 2 to GOSE 8. We calculated median (interquartile range) health utilities for each GOSE state, from -1 (worse than death) to 1 (full health), with 0 as reference (death, GOSE 1). Results: Of 515 eligible, 298 surrogates (58%) consented and completed the scenarios on TBI survivors' behalf. TBI survivors had a current median GOSE 5 (3--7). GOSE 2, GOSE 3, and GOSE 4 were rated worse than death by 89%, 64%, and 38%, respectively. The relationship was nonlinear, and intervals were unequal between states, with a bimodal distribution for GOSE 4. Conclusions: In this index study of actual post-TBI disability, poor neurological outcomes represented by GOSE 2 to GOSE 4 were perceived as worse than death by at least one in 3 survivors. Similar to previously reported public perceptions after a hypothetical TBI, these long-term perceptions may inform earlier post-TBI shared decisionmaking, as well as help shape value-based research and quality of care. Level of Evidence: Level II--economic and value-based evaluations. [ABSTRACT FROM AUTHOR]

Background In-office procedures can be painful and anxiety-provoking for pediatric patients. Minimizing such pain and anxiety in children improves the patient experience and promotes a rewarding and productive patient-caregiver-provider relationship, which may for some young patients be their first memorable encounter with the healthcare system. Although virtual reality (VR) techniques have proven to be helpful inminimizing pain and anxiety during procedures in pediatric intensive care settings, it remains unclear how VR affects objective and subjective measures of pain and anxiety in children undergoing in-office orthopaedic procedures such as cast removal or percutaneous pin removal after fracture healing. Questions/purposes Is a VR gaming simulation more effective than either of two forms of noninteractive visual distraction (VR goggles or tablet computer displaying a noninteractive video) for reducing (1) objective measures of pain and anxiety and (2) subjective measures of pain and anxiety in children undergoing in-office cast removal or percutaneous pin removal? Methods This study was a randomized controlled trial with two parallel, separately analyzed cohorts: children undergoing in-office cast removal or in-office percutaneous pin removal at a single urban tertiary institution. We approached eligible patients who were scheduled to undergo outpatient cast or percutaneous pin removal and who met prespecified inclusion criteria. We enrolled until 105 patients were available for analysis in each of the cast removal and pin removal cohorts. Of note, the study institution was in an urban epicenter of the coronavirus-19 pandemic, and clinical research was paused sporadically, which resulted in a longer-than-expected enrollment period. In the cast removal cohort, all patients were eligible for inclusion and were enrolled and randomized into one of three groups: VR gaming simulation (n = 37), VR goggles with a noninteractive video (n = 36), or a tablet computer with the same noninteractive video (n = 40). Eleven percent (4), 8% (3), and 3% (1) withdrew from each of the three intervention groups, respectively. In the pin removal cohort, all patients were eligible for inclusion and were enrolled and randomized into the same three groups (37, 44, and 41 patients, respectively). In the pin removal group, 14% (5), 18% (8), and 10% (4) withdrew from each of the three intervention groups, respectively. In all, 235 patients were enrolled in the study and 210 patients (mean 6 SD age 9 6 3 years; 48% [100] girls) were included in the final analyses. There were no clinically important differences in age, gender, preprocedure pain, or anxiety among the intervention groups. Primary outcomes included preprocedure-to--maximum heart rate increase (objective measure) and preprocedure and post-procedure pain and anxiety using a VAS (subjective measures). One-way ANOVA and Bonferroni-adjusted pairwise comparisons were used to calculate between-group differences for the primary outcomes. Results There were no intervention-level groupwise differences between VR goggles with an interactive game, VR goggles with a noninteractive video, or the tablet computer with the same video in preprocedure-to-maximum heart rate increase in the cast removal cohort (18 ± 21 bpm versus 14 ± 11 bpm versus 20 ± 16 bpm, respectively; largest mean difference -6 bpm [95% CI -16 to 3]; p = 0.36) or pin removal cohort (27 ± 20 bpm versus 23 ± 12 bpm versus 24 ± 19 bpm, respectively; largest mean difference 4 bpm [95% CI -7 to 14]; p = 0.99). Similarly, there were no interventionlevel groupwise differences in preprocedure to postprocedure VAS pain in the cast removal cohort (1 ± 1 versus 1 ± 2 versus 0 ± 2, respectively; largest mean difference 0 points [95% CI 0 to 1]; p = 0.89) or pin removal cohort (0 ± 3 versus 2 ± 3 versus 0 ± 3 points, respectively; largest mean difference 1 point [95% CI 0 to 3]; p = 0.13). Finally, there were no interventionlevel groupwise differences between the same intervention groups in preprocedure to postprocedure VAS anxiety in the cast removal cohort (-2 ± 2 versus -1 ± 2 versus -1 ± 2 points, respectively; largest mean difference -1 point [95% CI -2 to 1]; p = 0.63) or pin removal cohort (-3 ± 3 versus -4 ± 4 versus -3 ± 3 points, respectively; largest mean difference -1 point [95% CI -2 to 1]; p = 0.99). Conclusion During in-office cast and pin removal in pediatric patients, simple distraction techniques such as tablet video viewing are as effective as higher-fidelity VR headset video and interactive games in minimizing objective measures of procedural pain and subjective measures of pain and anxiety. Because of these findings and because of the associated costs, implementation logistics, and variable tolerance by young patients, widespread use of VR distraction techniques in the pediatric orthopaedic outpatient setting is unnecessary. Level of Evidence Level I, therapeutic study. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective cohort study.Objective: The aim of this study was to determine whether Patient-reported Outcomes Measurement Information System (PROMIS) Pediatric Domain scores can be accurately and reliably predicted from legacy patient-reported outcome measures (PROMs) for use in adolescent idiopathic scoliosis.Summary Of Background Data: Previous efforts have been made to develop translational models between PROMIS domains and legacy PROMs in adult spinal deformity, but translational models for pediatric and adolescent patients with spinal deformity have not yet been developed.Methods: Scores were retrospectively collected on pediatric patients 8-17 years old who were diagnosed with spinal asymmetry or scoliosis for the following PROMs: Scoliosis Research Society-22r (SRS-22r), Trunk Appearance Perception Scale (TAPS), Hospital for Special Surgery Functional Activity Brief Scale (HSS Pedi-FABS), and PROMIS Pediatric Domains: Pain Interference, Mobility, Physical Stress Experiences, Psychological Stress Experiences, and Physical Activity. Pearson correlations were calculated between legacy and PROMIS scores. In the derivation cohort, PROMIS domains were modeled from SRS-22r or HSS Pedi-FABS using linear regression. These equations were used to predict PROMIS scores in the test cohort to determine the reliability of the translation model.Results: A total of 1171 patients (68% female) with a mean age of 13.4 ± 2.3 years were included in the final analyses. PROMIS Pain Interference was dependent on SRS-22r domains Pain, Function, Mental Health, and Management Satisfaction, PROMIS Mobility was dependent on SRS-22r Pain, Function, Mental Health, and Self-Image, PROMIS Physical Stress Experiences and Psychological Stress Experiences were dependent on SRS-22r Pain, Mental Health, and Management Satisfaction, and PROMIS Physical Activity was dependent on HSS Pedi-FABS. (P < 0.05 for all). In the test cohort, all developed models for PROMIS domains demonstrated strong correlations between estimated and actual scores (r = 0.63-0.75).Conclusion: All of the evaluated PROMIS domains (Pain Interference, Mobility, Physical Stress Experiences, Psychological Stress Experiences, Physical Activity) were reliably translated directly from these legacy scores for pediatric and adolescent patients with spinal deformity.Level of Evidence: 3. [ABSTRACT FROM AUTHOR]

Study Design: Comparative cohort study.Objective: To compare patient reported outcome measures (PROMs) in children and adolescents with varying extent of spinal deformity.Summary Of Background Data: Several PROMs have been proposed to help assess health-related quality-of-life (HRQoL) in pediatric spinal deformity surgery and research, but it is unclear which are sensitive to deformity severity.Methods: Pediatric patients diagnosed with spinal asymmetry or juvenile/adolescent idiopathic scoliosis completed the patient-reported outcomes management information system (PROMIS) pediatric computer adaptive test bank (Domains: Mobility, Pain Interference, Physical Activity, Physical Stress Experiences, Psychological Stress Experiences), Scoliosis Research Society-22r (SRS-22r), Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) activity scale, and Trunk Appearance Perception Scale. Patients were grouped as spinal asymmetry, mild deformity, and substantial deformity by major Cobb angle measuring less than 10°, between 10° and 40°, and greater than 40° respectively. One-way analysis of variance with a Tukey post-hoc correction was used to determine score differences between groups.Results: Final analyses included 206 patients, of which 135 (66%) were female. The mean age was 13.0 ± 2.2 years, and the mean major Cobb angle was 20.1 ± 14.1° (range: 0-74.2°). Compared with both spinal asymmetry and mild deformity patients, patients with substantial deformity reported worse outcomes, including lower function, more pain, and decreased psychological health by legacy PROMs and PROMIS. PROMIS Physical Activity and Psychological Stress Experiences did not capture any significant differences between all groups. There were no significant differences in outcomes between the spinal asymmetry and mild deformity groups for all PROMs measured.Conclusion: Patients with substantial spinal deformity reported lower activity and function, more pain, and greater physical and psychological stress compared with patients without clinical spinal deformity by legacy PROMs and several PROMIS domains. As PROMIS Physical Activity and Psychological Stress Experiences did not capture these differences, these PROMs may measure different constructs than the legacy PROMs as they relate to spinal curvature and may be less relevant to measure HRQoL in this population.Level of Evidence 3. [ABSTRACT FROM AUTHOR]

Study Design: Cross-sectional survey.Objective: To determine the prevalence of back pain in American children and adolescents, with a focus on anatomic region, duration, severity, and treatment patterns, and to investigate for any predictive variables.Summary Of Background Data: No study has examined the prevalence of back pain in American children and adolescents in the last 15 years. Because the prevalence of back pain varies greatly by country and year of investigation, previous studies are not generalizable.Methods: A United States epidemiologic cross-sectional survey-based investigation was performed in children and adolescents ages 10 and 18 years old, equally split by age and sex, and representing census-weighted distributions of state of residence, race/ethnicity, and health insurance status. Prevalence of back pain was evaluated and described.Results: In total, 1236 (33.7%) participants reported experiencing back pain within the last year and 325 (8.9%) reported severe back pain within the last year. Prevalence of back pain increased with age and was significantly more common in females, P < 0.001 for both. Treatment for back pain was sought by 505 (40.9%) of the participants with pain, of which physical therapy was the most common. Invasive procedural treatment (e.g., injections, surgery) were rare and comprised only 61 (1.6%) of study participants. In addition, government insurance and lack of insurance coverage was associated with low treatment seeking behavior compared to private insurance users (P = 0.010 and P = 0.006, respectively).Conclusion: Despite how commonly it presents, the majority of young patients with back pain do not report procedural treatment such as injections or surgery. However, because many American children and adolescents seek treatment, future research on the etiology, treatment, and prevention of back pain in children and adolescents is essential to reducing a common and financially demanding problem.Level Of Evidence: 4. [ABSTRACT FROM AUTHOR]

The brainstem, which includes the midbrain, have been recently implicated as a site of potential axonal damage following a sport-related concussion (SRC). These areas of the brain are involved in the appropriate execution of eye movements. If impaired, oculomotor control could be influenced which may lead to a decline in motion perception. Unfortunately, information is lacking regarding the influence of SRC on specific eye movements during a dynamic visual acuity (DVA) task. PURPOSE: The purpose of this study was to compare smooth pursuit eye movements (SPEMs) and saccades among athletes with SRC and healthy controls during a DVA task. METHODS: 13 NCAA Division 1 SRC (avg. age=20 years) and 13 healthy controls (avg. age=21 years) performed an SVA and an adaptive DVA task. Athletes with SRC were diagnosed by the head team physician and assessed within 24-48 hours. For the SVA task, participants performed a series of acuity Es from a distance of 150cm. For the DVA task, participants tracked a Landolt C during 120 randomized trials (60 trials of smooth pursuit at 30°/s [SPEM], and 60 trials of saccades at 90°/s). Participants were fitted with a head-mounted binocular video oculography eye tracker (Eyelink SR Research, 500 Hz, Ottawa, CN), with their chin stabilized 154cm away from the 26° visual field monitor (165Hz, 2560 x 1440 pixel resolution, 300 cd/m2 luminance). Using a 2-up-1-down staircase method, the participants were asked to track the Landolt-C that moved horizontally left to right across the center of the screen, in addition to answering what direction the Landolt C was facing (up, down, left, or right) using the arrow keys. SPEM velocity gain and saccadic peak velocity were calculated and compared among groups. RESULTS: SPEM gain for SRC (1.07+0.05) was significantly higher than the control group (1.04+0.03, p=0.038, Cohen's d=0.86) while saccadic peak velocity was not different between the groups (SRC=405+38.2m/s, control=417+47.2m/s; p=0.507). CONCLUSIONS: While both groups demonstrated higher than average SPEM gain, which varies from 0.95 (lagging behind target) to 1.0 (directly on target); SRC may cause an increase of SPEM gain. These data indicate that athletes with SRC may lead a visual target with their eyes during an adaptive DVA task. [ABSTRACT FROM AUTHOR]

Facioscapulohumeral muscular dystrophy (FSHD) is a form of muscular dystrophy with a prevalence of 1:20,000 people. Loss of muscular function in the torso, pelvic girdle, and legs, is a hallmark of FSHD. Decline in the functionality of these muscle groups leads to gait impairments, specifically reductions in velocity and cadence. An understanding of FSHD patient gait decline over time may be useful in explaining disease progression and provide an outcome measure in upcoming clinical trials. The power of studies in previous literature has been stagnated by the availability of equipment, personnel, or locations for patient assessments. Smartphone applications allow for gait measurement without sophisticated equipment but have not been studied for use by FSHD patients. PURPOSE: Evaluate commonly used gait assessments for FSHD using a novel smartphone application (FSHD Gait) following three separate gait protocols with follow-up fatigue assessments. METHODS: 6 (female=4; avg. age=65 years) confirmed FSHD patients completed three gait trials that require walking on a level surface at home 5 out of 7 days a week. Patients used the FSHD Gait application, installed on a smartphone (LG KG40) and secured on the lower back using a running belt, while walking. The first task (T1) involved walking 10 meters 12 times once each day. The second task (T2) was to walk 10 meters 6 times, with 6 trials being performed in the morning and 6 in the afternoon with a minimum of 4 hours between sessions. In the final week (T3), participants were instructed to walk for 6 minutes without any breaks. Before and after each gait task, participants reported their perceived rate of fatigue (scale 0-10). RESULTS: Average gait velocity was not different between the gait tasks (T1= 0.97±0.19, T2=0.96±0.17, T3=0.96±0.25 m/s; p=0.88). Similarly, cadence was not significantly different between the gait tasks (T1= 94.68±8.46, T2=97.86±10.25, T3=95.78±12.95 steps/min; p=0.43). No significant increase in fatigue was noted between T1 (1.4±1.33) and T2 (0.43±5.1; p=0.18), T2 and T3 (2.4±2.3; p=0.109) and T1 to T3 (p=0.109). CONCLUSION: Data suggest the FSHD Gait application can successfully collect and analyze gait for FSHD patient assessments. Among the gait protocols as the difficulty of the task increased the greater the fatigue change score. [ABSTRACT FROM AUTHOR]

Study Design: Comparative cohort study., Objective: To compare patient reported outcome measures (PROMs) in children and adolescents with varying extent of spinal deformity., Summary of Background Data: Several PROMs have been proposed to help assess health-related quality-of-life (HRQoL) in pediatric spinal deformity surgery and research, but it is unclear which are sensitive to deformity severity., Methods: Pediatric patients diagnosed with spinal asymmetry or juvenile/adolescent idiopathic scoliosis completed the patient-reported outcomes management information system (PROMIS) pediatric computer adaptive test bank (Domains: Mobility, Pain Interference, Physical Activity, Physical Stress Experiences, Psychological Stress Experiences), Scoliosis Research Society-22r (SRS-22r), Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) activity scale, and Trunk Appearance Perception Scale. Patients were grouped as spinal asymmetry, mild deformity, and substantial deformity by major Cobb angle measuring less than 10°, between 10° and 40°, and greater than 40° respectively. One-way analysis of variance with a Tukey post-hoc correction was used to determine score differences between groups., Results: Final analyses included 206 patients, of which 135 (66%) were female. The mean age was 13.0 ± 2.2 years, and the mean major Cobb angle was 20.1 ± 14.1° (range: 0-74.2°). Compared with both spinal asymmetry and mild deformity patients, patients with substantial deformity reported worse outcomes, including lower function, more pain, and decreased psychological health by legacy PROMs and PROMIS. PROMIS Physical Activity and Psychological Stress Experiences did not capture any significant differences between all groups. There were no significant differences in outcomes between the spinal asymmetry and mild deformity groups for all PROMs measured., Conclusion: Patients with substantial spinal deformity reported lower activity and function, more pain, and greater physical and psychological stress compared with patients without clinical spinal deformity by legacy PROMs and several PROMIS domains. As PROMIS Physical Activity and Psychological Stress Experiences did not capture these differences, these PROMs may measure different constructs than the legacy PROMs as they relate to spinal curvature and may be less relevant to measure HRQoL in this population.Level of Evidence 3.

Objective: The aim of this study was to determine prognostic value of tumor size and metabolic activity on survival for patients with early stage nonsmall cell lung cancer receiving stereotactic body radiation therapy., Methods: We retrospectively evaluated the patients who underwent positron emission tomography-computed tomography scan before stereotactic body radiation therapy treatment. Tumor diameter, tumor volume, maximum standardized uptake value (SUVmax), standardized uptake value (SUV) average, and SUV volume were obtained. Cox regression analyses were performed to determine the associations between tumor characteristics and survival., Results: The patients with large tumors and high SUVmax have worse survival than patients with small tumors and low SUVmax (hazard ratio [HR] = 3.47, P = 0.007). Patients with small tumors and high SUVmax (HR = 1.80; P = 0.24) and large tumors and low SUVmax (HR = 1.55; P = 0.43) had increased risk of death compared with patients with small tumors and low SUVmax., Conclusions: Both increased tumor size and metabolic activity are associated with increased risk of death. Combining size and metabolic activity together is superior for predicting 2-year survival and identifying patients for whom survival is statistically worse.

Background: Patient falls in acute care hospitals represent a significant patient safety concern. Although cross-sectional studies have shown that fall rates vary widely between acute care hospitals, it is not clear whether hospital fall rates remain consistent over time., Purpose: The aim of this study was to determine whether hospitals can be categorized into fall rate trajectory groups over time and to identify nurse staffing and hospital characteristics associated with hospital fall rate trajectory groups., Methodology/approach: We conducted a 54-month (July 2006-December 2010) longitudinal study of U.S. acute care general hospitals participating in the National Database for Nursing Quality Indicators (2007). We used latent class growth modeling to categorize hospitals into groups based on their long-term fall rates. Nurse staffing and hospital characteristics associated with membership in the highest hospital fall rate group were identified using logistic regression., Findings: A sample of 1,529 hospitals (mean fall rate of 3.65 per 1,000 patient days) contributed data to the analysis. Latent class growth modeling findings classified hospital into three groups based on fall rate trajectories: consistently high (mean fall rate of 4.96 per 1,000 patient days), consistently medium (mean fall rate of 3.63 per 1,000 patient days), and consistently low (mean fall rate of 2.50 per 1,000 patient days). Hospitals with higher total nurse staffing (odds ratio [OR] = 0.92, 95% confidence interval [CI] [0.85, 0.99]), Magnet status (OR = 0.49, 95% CI [0.35, 0.70]), and bed size greater than 300 beds (OR = 0.70, 95% CI [0.51, 0.94]) were significantly less likely to be categorized in the "consistently high" fall rate group., Practice Implications: Over this 54-month period, hospitals were categorized into three groups based on long-term fall rates. Hospital-level factors differed among these three groups. This suggests that there may be hospitals in which "best practices" for fall prevention might be identified. In addition, administrators may be able to reduce fall rates by maintaining greater nurse staffing ratios as well as fostering an environment consistent with that of Magnet hospitals.

When added to a collagen-filled nerve guide, purified acidic fibroblast growth factor (aFGF) increased the number of myelinated axons that regenerated across a 5-mm nerve gap distance. In addition, a greater number of primary sensory and motor neurons extended axons through the nerve guide in animals treated with aFGF. Thus the effect of aFGF on peripheral nerve regeneration is not simply an increase in axonal branching within the nerve guide tube. This is the first highly purified growth factor since nerve growth factor that has been shown to promote nerve regeneration in vivo. This experimental model provides a convenient and quantitative means to assess the effects of putative neuronotropic factors on peripheral nerve regeneration in vivo.