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BACKGROUND: Cancer patients undergoing inpatient rehabilitation often have high risk of complications leading to unplanned transfer to acute care. Prior studies have identified factors associated with these transfers but have been limited to examining factors that pertain to initial admission to rehabilitation and were not conducted in a freestanding inpatient rehabilitation facility. OBJECTIVE: The study aimed to include these prerehabilitation factors in addition to factors upon initial assessment in rehabilitation. It was hypothesized that specific factors from each of these periods would be associated with unplanned transfer to acute care. DESIGN: Retrospective cohort study. SETTING: Freestanding academic inpatient rehabilitation facility affiliated with an academic tertiary care facility with a comprehensive cancer center. PATIENTS: Retrospective review of 330 specific encounters unique to 250 patients from March 2017 to September 2018. MAIN OUTCOME MEASURES: The outcome measure was unplanned transfer to acute care. A binary logistic regression model was used to examine the relationship between factors from oncologic history, acute care course, and factors upon admission to rehabilitation to unplanned transfer to acute care. RESULTS: From 330 encounters, there were 111 unplanned transfers (34%). Unplanned transfer to acute care was independently associated with gastrointestinal malignancy (odds ratio [OR] 4.4, p = .01), 6-minute walk test less than 90 m (OR 4.6, p = .003), and prior unplanned transfer (OR 3.5, p = .007). CONCLUSIONS: The study suggests that oncologic and functional prerehabilitation markers are associated with an increased likelihood of unplanned transfer during inpatient cancer rehabilitation. These findings will provide a framework for creating predictive tools for unplanned transfers in cancer rehabilitation patients.

To identify factors influencing Discharge Directly Home (DDH) from an acute hospital following hip fracture, as opposed to Discharge to an Alternative Location (DAL). Younger patients who were independently mobile pre-fracture were more likely to be DDH. Timely surgery with early post-operative mobilisation and a shorter length of stay increased the odds of DDH. The Irish Hip Fracture Standards incorporate 2 out the 3 modifiable factors identified in this paper, which reinforces the importance of the IHFS in improving patient outcomes. Although home continues to be the place from which the majority of patients are admitted, less than one third of patients are Discharged Directly Home (DDH) following hip fracture. Once ready for discharge, DDH as opposed to Discharge to an Alternative Location (DAL), i.e., community care, rehabilitation facility or long-term care, is a high priority for patients and clinicians alike. Not only is DDH integral to the quality of life of patients, it is also an essential driver of the socioeconomic cost of hip fracture care. We analysed 21,819 cases in the Irish Hip Fracture Database from 2013 to 2019. Descriptive and analytical statistics were conducted. 29% (n = 6476) of patients were DDH during the study period. On multivariate analysis, the odds of DDH decreased as age increased (OR 0.28, p 72 h prior to surgery were 30% less likely to be DDH (OR 0.70, p

The research questions for this study were as follows: (1) is the Parker Mobility Score (PMS) associated with discharge disposition and hospital length of stay (HLOS) of geriatric traumatic hip fracture patients? (2) Can the PMS be incorporated in a decision tree for the prediction of discharge disposition of geriatric traumatic hip fracture patients upon admittance. A dual-center retrospective cohort study was conducted at two level II trauma centers. All patients aged 70 years and older with traumatic hip fractures undergoing surgery in 2018 and 2019 were included consecutively (n = 649). A χ2 automatic interaction detection analysis was performed to determine the association of the PMS (and other variables) with discharge disposition and HLOS and predict discharge destination. The decision tree for discharge disposition classified patients with an overall accuracy of 82.1% and a positive predictive value of 91% for discharge to a rehabilitation facility. The PMS had the second most significant effect on discharge disposition (χ2 = 22.409, p

To determine the frequency of Chlamydia psittaci infection, shedding dynamics of C. psittaci, and C. psittaci genotype diversity in waterfowl temporarily resident in a rehabilitation facility and i...

To compare sex differences in alexithymia (poor emotional processing) in males and females with traumatic brain injury (TBI) and uninjured controls.Cross-sectional study.TBI rehabilitation facility in the United States and a university in Canada.Sixty adults with moderate to severe TBI (62% men) and 60 uninjured controls (63% men) (N=120).Not applicable.Toronto Alexithymia Scale-20 (TAS-20).Uninjured men had significantly higher (worse) alexithymia scores than uninjured female participants on the TAS-20 (P=.007), whereas, no sex differences were found in the TBI group (P=.698). Men and women with TBI had significantly higher alexithymia compared with uninjured same-sex controls (both P.001). The prevalence of participants with scores exceeding alexithymia sex-based norms for men and women with TBI was 37.8% and 47.8%, respectively, compared with 7.9% and 0% for men and women without TBI.Contrary to most findings in the general population, men with TBI were not more alexithymic than their female counterparts with TBI. Both men and women with TBI have more severe alexithymia than their uninjured same-sex peers. Moreover, both are equally at risk for elevated alexithymia compared with the norms. Alexithymia should be evaluated and treated after TBI regardless of patient sex.

Care Management for Polytrauma Patients in a Level-1 Trauma Centre Abstract. In our level-1 trauma institution, polytrauma patients with an Injury Severity Score of 16 or higher are facing waiting times for transfer to a rehabilitation facility, causing a negative financial outcome for our institution. The purpose of this study is to stimulate rapid transfer to a rehabilitation facility. In a single-centre case study, care management for (poly)trauma patients was started to ensure time-directed treatment for trauma patients related to Diagnosis-Related Groups (DRG). In the period of 2013-2018 there was an increase in trauma admissions up to 14 % (n = 16 157) with a mean length of hospital stay of 6.4 days, together with a reduction in the number of trauma bed capacity from 50 to 42. In relation to the DRGs, regular trauma patients who were not in need of a stationary rehabilitation facility stayed in line with the expected time of hospital stay. But (poly)trauma patients (n = 1831) with the need of a stationary stay in a rehabilitation centre were faced with waiting times before they could be transferred. The average excess waiting time in relation to DRG for polytrauma patients was 5.1 days. Trauma patients for a rehabilitation centre have a higher Case Mix Index (CMI) compared to those who do not require inpatient rehabilitation (4.22 versus 1.04, p

Introduction Health professionals are progressively drawing on the concept of frailty as a determinant of adverse surgical outcomes in of older adults. We aimed to determine the prevalence of frailty and the correlation between frailty and mortality among older adults admitted to the acute surgical unit. Materials and methods This prospective cohort study was conducted in the acute general surgical unit over a two month period. We recruited 150 consecutive patients aged 65yrs and above. The modified frailty index was employed to measure frailty and the albumin levels on admission were obtained from electronic medical records. The patients were followed up for a period of thirty days. Results We found that more than 40% of the older adults admitted to the acute general surgical unit were frail and frailty was associated with higher rate of mortality at 30 days. Hypoalbuminemia was associated with a longer length of stay, higher rate of complications, and an increased likelihood of discharge to a rehabilitation facility. There was also a significant univariate correlation between frailty and the presence of hypoalbuminemia on admission. Conclusion Frailty and hypoalbuminemia are common in older general surgical patients and predict the likelihood of some of the adverse outcomes relevant to older adults and health economy such as mortality, increased length of stay, rate of complications, and likelihood of discharge to a rehabilitation facility. Further studies should investigate a possible causal association between frailty and low albumin levels in an acute surgical setting.

A 75-year-old man with dilated cardiomyopathy status post-implantable cardioverter-defibrillator (ICD) presented with progressive dyspnea and ascites refractory to medical therapy. He underwent paracentesis for symptom relief. The patient was discharged to a local rehabilitation facility and

Summary Healthcare costs due to unplanned readmissions are high and negatively affect health and wellness of patients. Hospital readmission is an undesirable outcome for elderly patients. Here, we present readmission risk prediction using five machine learning approaches for predicting 30-day unplanned readmission for elderly patients (age ≥ 50 years). We use a comprehensive and curated set of variables that include frailty, comorbidities, high-risk medications, demographics, hospital, and insurance utilization to build these models. We conduct a large-scale study with electronic health record (her) data with over 145,000 observations from 76,000 patients. Findings indicate that the category boost (CatBoost) model outperforms other models with a mean area under the curve (AUC) of 0.79. We find that prior readmissions, discharge to a rehabilitation facility, length of stay, comorbidities, and frailty indicators were all strong predictors of 30-day readmission. We present in-depth insights using Shapley additive explanations (SHAP), the state of the art in machine learning explainability., Highlights • We report a 0.79 AUROC for 30-day readmission prediction • We use frailty, comorbidity, high-risk medications, and demographics for improved accuracy • We identify clusters of high-risk patients based on sets of patient features • Explainability is a prime focus for model predictions at different levels of granularity, The bigger picture Unplanned readmission currently costs the United States millions of dollars. Predicting whether an incoming patient is at a high risk of readmission can help target healthcare efforts better to reduce this risk. In this age of big data, we can use machine learning to analyze a cohort of variables to pinpoint the risk of readmission. Our work does exactly that. One of the hindrances for adoption of artificial intelligence in healthcare is the lack of explainability. To combat that, we provide several mechanisms for understanding reasons for the model's predictions, starting at a global level across the entire dataset and down to individual patient observations. These explanations enhance confidence in the model's decision making., Automated prediction of readmission risk has the potential to save millions of dollars in healthcare costs and can improve patient care. Our work presents machine learning models that take into account various facets of patients, such as demographics, comorbidities, and frailty parameters, to accurately estimate their risk of being readmitted within 30 days. We place high importance on explainability, thereby enhancing confidence in the automated models.

West Nile Virus (WNV) is the most common mosquito borne cause of viral encephalitis in the United States. Physical and neuro-cognitive recovery from WNND may be prolonged or incomplete leading to chronic cognitive inefficiencies and functional decline. There continues to be no effective treatment of WNV and current management is primarily supportive. The objective of this review is to evaluate the functional outcomes and role of rehabilitation services in subjects with WNND. The charts of five subjects admitted to an acute inpatient brain injury rehabilitation facility from June to December 2012 were retrospectively reviewed. (Mean, Range)-Age (64.8, 43–78 years), Admission Functional Independence Measure (FIM) (45.2, 14–63), Discharge FIM (82.2, 61–100), FIM score gain (37, 24–60), Cognitive FIM gain (7, 1–18), Mobility FIM gain (17.4, 13–20), ADL FIM gain (12.6, 4–23); acute brain injury inpatient rehabilitation facility length of stay (LOS) (17.8, 14–21 days); acute hospital LOS (15, 10–22 days). Of the five subjects, three were discharged home, one was discharged to a skilled nursing facility, and one was discharged to an assisted living facility. Subjects with WNND have significant functional decline across all FIM subcategories and may benefit from a course of brain injury-specific acute inpatient rehabilitation.

Lower-limb musculoskeletal injury (MSKI) is associated with a considerable economic and operational cost to the UK Ministry of Defence. To ensure force readiness of the British Armed Forces, strategies that increase the potential for adaptations in muscle strength following MSKI are crucial for the

BACKGROUND Outreach screening is a common strategy for detecting cases of syphilis in high-risk populations. New rapid syphilis tests allow for quicker response times and may alter the costs of detecting and treating syphilis in nonclinical settings. METHODS Between May and October of 2017, we collected detailed retrospective cost data from 2 outreach screening programs engaging people experiencing homelessness and LGBTQ populations. Comprehensive and retrospective cost information, disaggregated by cost category, programmatic activity, and source of support, was collected during and after the testing period. RESULTS Across all sites, rapid syphilis tests were conducted on 595 people at an average cost of $213 per person. Twenty-three cases of syphilis were confirmed and treated for an average cost of $5517 per case, ranging from $3604 at a rehabilitation facility to $13,140 at LGBTQ venues served by a mobile clinic. Personnel contributed the most to total costs (56.4%), followed by supplies (12.8%) and the use of buildings (10.4%). Expenditures by programmatic activity varied substantially across sites. CONCLUSIONS Testing costs varied between venues, reflecting differences in the models used and intensity of services provided. Although staff costs are the major driver, buildings and supplies costs are also significant. Our findings suggest that outreach screenings using rapid syphilis tests may be a feasible and cost-effective tool for health departments when targeting known high-prevalence areas and hard-to-reach populations.

Traumatic atlantoaxial dislocation without associated odontoid fracture or neurologic deficit is rare. We present the case of a 39-year-old male pedestrian who was struck by a vehicle and sustained a traumatic grade 4 C1-2 retrolisthesis. Closed reduction was successful, and the patient underwent posterior occipitocervical fusion. His neurologic status was good throughout the hospital stay, and he was discharged to a rehabilitation facility with full strength.

OBJECTIVES: This study aims to evaluate the effects of blood pressure (BP) on functional recovery and length of stay (LOS) in post-stroke patients in an acute rehabilitation facility (ARF). PATIENTS AND METHODS: A total of 116 ischemic stroke patients (60 males, 56 females; mean age 70.0±12.8 years; range, 37 to 93 years) who were admitted to the ARF between January 2012 and September 2012 were included. Daily BP measurements with mean systolic and diastolic BP values and Functional Independent Measure (FIM) scores at the time of admission and discharge were measured. The LOS and systolic and diastolic BP ranges were also recorded. RESULTS: There was no significant correlation between the BP and FIM scores. The mean diastolic BP was positively correlated with admission (rs=0.316, p=0.01) and discharge (rs=0.287, p=0.002), FIM scores, and FIM effectiveness (rs=0.185, p=0.047) and negatively correlated with age (r=-0.449, p

Purpose: An excessive amount of total hospitalization is caused by delays due to patients waiting to be placed in a rehabilitation facility or skilled nursing facility (RF/SNF). An accurate preoperative prediction of who would need a RF/SNF place after surgery could reduce costs and allow more efficient organizational planning. We aimed to develop a machine learning algorithm that predicts non-home discharge after elective surgery for lumbar spinal stenosis. Methods: We used the American College of Surgeons National Surgical Quality Improvement Program to select patient that underwent elective surgery for lumbar spinal stenosis between 2009 and 2016. The primary outcome measure for the algorithm was non-home discharge. Four machine learning algorithms were developed to predict non-home discharge. Performance of the algorithms was measured with discrimination, calibration, and an overall performance score. Results: We included 28,600 patients with a median age of 67 (interquartile range 58–74). The non-home discharge rate was 18.2%. Our final model consisted of the following variables: age, sex, body mass index, diabetes, functional status, ASA class, level, fusion, preoperative hematocrit, and preoperative serum creatinine. The neural network was the best model based on discrimination (c-statistic = 0.751), calibration (slope = 0.933; intercept = 0.037), and overall performance (Brier score = 0.131). Conclusions: A machine learning algorithm is able to predict discharge placement after surgery for lumbar spinal stenosis with both good discrimination and calibration. Implementing this type of algorithm in clinical practice could avert risks associated with delayed discharge and lower costs. Graphical abstract: These slides can be retrieved under Electronic Supplementary Material.[Figure not available: see fulltext.].

Aim: To use Value-Focused Thinking to investigate what is important in the design of inpatient stroke rehabilitation facility buildings. Background: Many stroke patients require inpatient rehabilitation in a dedicated facility. Rehabilitation facilities are healthcare spaces, but they are also learning spaces where patients practice targeted tasks to acquire new skills and to reacquire skills and abilities that were compromised as a result of their stroke. There is currently no consensus regarding how the design of inpatient rehabilitation facilities could be optimized for patients’ learning. Method: We used Value-Focused Thinking to develop a framework of what interdisciplinary experts consider important for inpatient stroke rehabilitation facility design. Two workshops were conducted. The following experts were invited to participate: past patients with experience of stroke rehabilitation; stroke rehabilitation clinicians; stroke rehabilitation academics; healthcare environments academics; learning environments academics; architects, designers, and wayfinders with experience designing healthcare or learning environments; and healthcare design policy makers. Results: Thirty experts participated. The experts’ final framework included 16 criteria that were considered fundamentally important for inpatient stroke rehabilitation facility design, and 14 criteria that were considered instrumentally important. Inpatient stroke rehabilitation facility design should maximize efficiency, maximize effectiveness (i.e., patients’ clinical and functional outcomes), foster emotional well-being, and maximize safety. Opportunities to practice physical, cognitive, and social activity were considered important for patients’ outcomes. Conclusions: Value-Focused Thinking was an effective and equitable means of engaging experts from multiple disciplines. Designers, planners, and developers of inpatient stroke rehabilitation facilities should consider the rehabilitation-specific framework developed in this study alongside evidence from other healthcare settings.

Background Spontaneous migration of retained intracranial bullet fragments is an increasingly recognized phenomenon. However, such migration is usually limited in extent, since it occurs along the bullet tract or cerebrospinal fluid (CSF) spaces. Transhemispheric migration through an intact cerebral hemisphere has not been previously reported. Observations A 20-year old man sustained a gunshot wound (GSW) to the head with a left parieto-occipital entry point, resulting in retained bullet fragments within the anterior right frontal lobe. The patient developed medically refractory intracranial hypertension, necessitating a left decompressive hemicraniectomy. He exhibited a favorable postoperative course, with gradual neurologic recovery, and was ultimately discharged to a rehabilitation facility. Notwithstanding, serial head CT scans during the first 2 weeks revealed gradual transhemispheric migration of bullet fragments from the right frontal pole to the right occipital pole, traveling through largely intact, uninjured brain tissue. Lessons Transhemispheric migration of bullet fragments via intact brain tissue may rarely occur. While the exact mechanisms underlying this phenomenon remain unclear, potential factors may include: bullet weight, CSF pulsations, dissection through white matter tracts, and biomechanical effects of large skull defects. Bullet migration does not necessarily delay or prevent neurologic recovery.

Objective To determine the clinical utility of the Patient Health Questionnaire-Adolescent (PHQ-A) in screening for depressive disorders in adolescents following traumatic brain injury (TBI). Design Retrospective analysis of data collected as a part of routine clinical care over a period of 4 years. Setting Regional rehabilitation facility. Participants Adolescents (n = 101) with mild to moderate-severe TBI who were referred for an outpatient neuropsychological evaluation within 1 to 12 months postinjury. Main outcome measures PHQ-A, PHQ-A_2 (2-item version), and Processing Speed Index (PSI) from the Wechsler scales of intelligence. Results Both premorbid depressive disorder and PHQ-A scores predicted a postinjury diagnosis of depressive disorder, with a combined sensitivity of 0.91 and specificity of 0.59. PHQ-A_2 did not reach acceptable levels of sensitivity in predicting suicidal thoughts. PHQ-A scores did not add significantly to the prediction of PSI results after accounting for TBI severity. Conclusions PHQ-A has clinical utility as a screening instrument for depressive disorders in outpatient adolescents with TBI when the cutoff for clinically significant concern is set at more than 4 and premorbid psychiatric history is also taken into account.

Background We aimed to assess nationally representative trends of in-hospital mortality and clinical outcome after treatment of unruptured intracranial aneurysms (UIA). Methods The Nationwide Inpatient Sample (NIS) database from 2006 to 2016 was reviewed. Patients with unruptured intracranial aneurysm (UIA) who underwent aneurysm treatment during hospitalization were identified. Patients’ demographics, comorbid conditions, length of hospital stay, rate of in-hospital mortality, discharge destination for each treatment group (microsurgical clipping and endovascular embolization). Poor clinical outcome was defined as discharge to skilled nursing facility or hospice instead of home or acute rehabilitation facility. Multivariate regression model was used to identify independent predictors of mortality and poor clinical outcome. Results A total of 21,609 patients with UIA were identified from 2006 to 2016. The overall rate of in-hospital mortality decreased from 0.9% in 2006 to 0.2% in 2016. Overall, 83% of the patients had favorable clinical outcome. The utilization of endovascular embolization increased from 60% in 2006 to 64% in 2016. Patients who had endovascular embolization had 3 days shorter hospital stay (1 vs 4, p Conclusions Mortality rate from treatment of unruptured intracranial aneurysm has substantially decreased in the past decade. Higher rate of morbidity and mortality is seen in patients ≥80 years old, patients with multiple comorbidities and those who were treated with microsurgical clipping. Disclosures S. Majidi: 1; C; SNIS Foundation. A. Mehta: None. R. De Leacy: None. J. Mocco: None. J. Fifi: None.

Objectives: To identify the factors that affect disability after inpatient rehabilitation (IPR) in persons with traumatic brain injury (TBI). Methods: This retrospective study identified 140 patients aged ≥16 years who were admitted to the TBI rehabilitation unit at King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia between 2015 and 2017. The collected data included demographic variables, TBI cause, coma duration, time from injury to IPR, LOS, and Functional Independence Measure (FIM) scores at IPR admission and discharge. Results: Majority of the patients were young males. The TBI was caused by motor vehicle accidents (MVA) in 95% of patients. The mean coma duration, time from injury to IPR admission, and LOS were 47±38, 264±357, and 75±52 days, respectively. The factors that were found to have an association with FIM change were time from injury to IPR admission (p=0.003, r=-0.250), admission FIM score (p=0.003, r=-0.253), and discharge FIM score (p

We studied cognitive performance following discharge from a novel rehabilitation facility, treating individuals with psychosis that developed during trips abroad following mandatory military service. Montreal Cognitive Assessment (MoCA), phonetic and semantic fluency, State-Trait Anxiety, and self-Efficiency were administered before discharge, and 3 and 6 months after discharge. Of the 43 participants (30.2% females), 23(54.8%) had cognitive impairment (MoCA27), and 15(35.7%) had poor phonetic fluency. Anxiety trait and state were high and inversely correlated with self-efficacy (R=-0.48, p = 0.001) and phonetic fluency (R=-0.43, p = 0.004) and was higher among those who experienced physical exposure, females, and those who served in non-combat army units. Six months after discharge, of 32 participants, 28 were working/studying with a 58.1% reduction in smoking and alcohol consumption, and 16 participants stopped substance use. Phonetic fluency improved among the high anxiety state group with no change among the others. High anxiety levels lowered among those who were still using drugs after six months. The anxiety level lowered and 87.1% of the participants were conducting a productive lifestyle at 6 months after discharge, but half still abused cannabis. Bigger sample and longer follow up would be needed to learn more about the impact of rehabilitation.

The aim of this study was to identify the effect of early nutritional assessment and nutritional intervention on outcomes of older adult patients after discharge from an acute care hospital following fall related fracture.This was a feasibility pilot study with post intervention data. One group pretest-posttest study design was implemented. All participants were admitted to a rehabilitation facility in the Southwestern US after a fall related fracture.Discharge destination, Functional Independence Measure (FIM), and length of stay (LOS).A total of 69% of the participants were discharged home. Total FIM scores improved (p0.01). No significant association was identified between prealbumin change and total FIM change. Patients who had improved prealbumin experienced improved FIM and shorter LOS; however, no significant correlations were determined between LOS and prealbumin change.Nutritional interventions are important for recovery during rehabilitation of a fall-related fracture.This project supports early nutritional evaluation and intervention for older adult patients after major orthopedic procedure. Participants who received early intervention had improved outcomes. (194 characters).

Objective Sex disparities regarding outcomes for women after open and endovascular abdominal aortic aneurysm repair have been well-documented. The purpose of this study was to review whether these disparities were also present at our institution for elective endovascular aneurysm repair (EVAR) and whether specific factors predispose female patients to negative outcomes. Methods All elective EVARs were identified from our three sites (Florida, Minnesota, and Arizona) from 2000 to 2018. The primary outcome was in-hospital mortality and three-year mortality. Secondary outcomes included complications requiring return to the operating room, length of hospitalization (LOH), intensive care unit (ICU) days, and location of discharge after hospitalization. Multivariable logistic regression models were used to assess for the risk of complications. Results There were 1986 EVARs; 1754 (88.3%) were performed in male and 232 (11.7%) in female patients. Female patients were older (79 years [interquartile range (IQR), 72-83 years] vs 76 years [IQR, 70-81 years]; P Conclusions Our three-site, single-institution data support sex disparities to the detriment of female patients regarding return to the operating room after EVAR, LOH, ICU days, and discharge to rehabilitation facility. However, we found no differences for in-hospital or 3-year mortality.

Lead poisoning is a threat to birds, particularly scavenging birds of prey. With the availability of portable lead-testing kits, an increasing number of field researchers are testing wild-caught birds, in situ, for lead poisoning. We describe guidelines for evaluation of lead toxicity in wild raptors by outlining field testing of blood-lead concentrations, presenting criteria for removing a lead-poisoned bird from the wild for treatment, and suggesting strategies for effective treatment of lead intoxicated raptors. Field testing of birds is most commonly accomplished via portable electrochemical analysis of blood; visual observation of condition alone may provide insufficient evidence upon which to make a decision about lead poisoning. Our intended audience is not only the avian research community, but also rehabilitation facilities that may receive apparently uninjured birds. Best practices suggest that birds whose blood-lead levels are 60 μg/dL are potentially lethally poisoned and best served if removed from the wild for appropriate treatment at a licensed rehabilitation facility and later released. We present guidelines for decision-making when treating lead poisoning of wild raptors. Future work based on experimental studies will clarify the role of lead poisoning for specific species and be important to refine these guidelines to improve effectiveness. © 2017 The Wildlife Society.

A free-living adult great horned owl (Bubo virginianus) was presented to a wildlife rehabilitation centre in Southern California with a firm, pedunculated mass arising from the caudal-dorsal border of the left ulna. Two secondary covert feathers were incorporated into the mass and multiple secondary flight and covert feathers adjacent to the mass were broken. Radiographs revealed a calcified mass with no cortical involvement. The mass was surgically removed. Histopathology was consistent with a diagnosis of osteoma. Despite tumour removal, the owl sustained a significant flight impairment resulting from lack of regional feather regrowth. Waiting for a natural moult to take place would likely require 9–12 months. An attempt was made at inducing moult by manually pulling feathers but was not successful. As the rehabilitation facility was space limited and the bird was behaviourally a poor candidate for long-term rehabilitation, humane euthanasia was elected.

Low-velocity penetrating brain injuries (PBIs), also referred to as nonmissile brain injuries, typically result from stabbings, industrial or home accidents, or suicide attempts. A great deal of literature has focused on the injury patterns and management strategies of high-velocity PBIs. However, there are substantially fewer large, contemporary studies focused solely on low-velocity PBIs. Here, we present an interesting and uncommon case of a patient who suffered a bihemispheric stab wound involving the basal ganglia. A 22-year-old man presented to the hospital with a stab wound to the left calvarium. His initial Glasgow Coma Scale (GCS) score was 13, but he rapidly declined to a six and was intubated. He was emergently taken to the operating room for craniectomy, knife removal, and external ventricular drain placement. On the first postoperative day, the patient was following commands with all extremities. He was discharged to a rehabilitation facility 13 days postinjury. One year after the injury, the patient was free of major neurologic sequelae. This report illustrates a rare case of a good functional outcome after a transcranial stabbing with multiple imaging and exam findings usually associated with poor outcomes.

BACKGROUND Rehabilitation facilities have among the highest prevalence of multidrug-resistant organism (MDRO) colonization of any inpatient population. There is no formal consensus on how patients with MDROs should be managed in the rehabilitation setting. AIM The aim of this study was to assess how rehabilitation hospitals throughout Europe manage patients with MDROs, and the impact of MDRO carriage on outcomes. DESIGN Cross-sectional study. SETTING Online questionnaire distributed to European rehabilitation facilities. POPULATION European rehabilitation facilities. METHODS A Survey Monkey® questionnaire was designed and circulated to rehabilitation hospitals via the European Union of Medical Specialists, Physical and Rehabilitation Medicine Section. RESULTS Fifty-four responses were received of which 45 were suitable for analysis. Six out of 26 (23%) countries included in the study reported at least one rehabilitation facility with an estimated MDRO prevalence rate of 31% or higher. Screening of all patients on admission was always carried out in 33% (15 of 45) of facilities. Twenty-five of the 45 facilities (69%), aim to isolate, or cohort patients who have MDROs. Patients with MDROs wait longer for admission (36%, 16 of 45) and in the case of five hospitals admission is refused. Fifty-one percent (23 of 45) of facilities reported that colonization with an MDRO severely or moderately limits rehabilitation outcome. CONCLUSIONS Our research shows that many of the challenges posed by MDROs are common to facilities throughout Europe. We strongly recommend that all patients are screened for MDROs on admission. We stress that any negative impact of a patients MDRO status on their rehabilitation outcome must be minimized. CLINICAL REHABILITATION IMPACT Specific guidance on the management of rehabilitation patients with MDROs, would allow them to partake in a full rehabilitation program, while limiting the spread of MDROs.

Simultaneous arteriovenous embolism is extremely rare. Herein, we present a rare case of systemic arteriovenous emboli in a healthy 33-year-old male after an episode of acute viral perimyocarditis. The culprits are postulated to be viral-induced myocardial necrosis and resulting proinflammatory state in the setting of negative malignant, autoimmune, genetics, and chronic infectious conditions. The patient was successfully managed with guideline-directed medical therapy and safely discharged to a subacute rehabilitation facility.

Prospective cohort study of the Thai Spinal Cord Injury Registry. To determine whether being admitted to a spinal cord injury (SCI) specialized rehabilitation facility (SSRF) is associated with better functional outcomes. Four rehabilitation facilities in Thailand; one a SSRF and the others non-SSRFs. Data from the one SSRF and three non-SSRFs were extracted from the Thai Spinal Cord Injury Registry. Multivariate regression analysis was used to exclude the effect of confounding factors and prove the independent association of SSRF admission with respect to Spinal Cord Independence Measurement (SCIM) at discharge. Among the 234 new SCI inpatients enrolled, 167 persons (71%) had been admitted to the SSRF. The SSRF had a greater proportion of persons with AIS A, B, C tetraplegia and people with AIS D, whereas the non-SSRFs had a higher proportion of patients with AIS A, B or C paraplegia. Patients discharged from the SSRF demonstrated a greater SCIM score improvement than those from the non-SSRFs (24.1 vs 17.0; p = 0.003). By using multivariate regression analysis controlling for age, time from injury to rehabilitation, severity of injury and SCIM score on admission, SSRF admission was found to be an independent predictive factor of SCIM score improvement at discharge (p = 0.008). Admission to an SSRF is associated with better rehabilitation outcomes. This finding supports the importance of SSRF access to improve the functional outcome of patients with SCI.

OBJECTIVE: According to the World Health Organization, estimates about 1,800,000 people lived with disability in Tehran. Against there is little evidence of physical access to rehabilitation facilities in Tehran. This study is aimed to assess the physical access to physical rehabilitation facilities in Tehran and compare it with the country. METHODS: This is a cross-sectional study conducted since January to April 2017. We used a master facilities list of rehabilitation facility that developed in Iran to collect the information. The samples of this study included all existing physical rehabilitation centers in Tehran province. Data analysis was done using the SPSSr version 21.0 (SPSS Inc., Chicago, IL). RESULTS: The results showed that rehabilitation facilities existed at different levels, including inpatient (10.51), outpatient (224.28), community based (36.72), and long-term care (4.96)/1,000,000 populations. Rehabilitation services are provided by rehabilitation professional including: Physical medicine and rehabilitation specialists (8.7), physiotherapists (132.89), occupational therapists (57.4), speech therapists (42.11), and audiologists (48.84) (in 1,000,000 populations). CONCLUSION: Tehran needs to increase the physical access to rehabilitation facilities and compared with country was disproportionate physical access to facilities in most cases. It is necessary to establish an interdisciplinary referral system between different rehabilitation providers.

© 2016 The Author(s). Published by Taylor & Francis on behalf of the Nordic Orthopedic Federation. Background and purpose — There is no consensus about the outcome of simultaneous vs. staged bilateral total knee arthroplasty (TKA). We examined this issue by analyzing 238,373 patients. Patients and methods — Demographic, clinical, and outcome data were evaluated for TKA patients (unilateral: 206,771; simultaneous bilateral: 6,349; staged bilateral: 25,253) from the Canadian Hospital Morbidity Database for fiscal years 2006–2007 to 2012–2013. Outcomes were adjusted for age, sex, comorbidities, and hospital TKA volume. Results — Simultaneous bilateral TKA patients were younger than staged bilateral TKA patients (median 64 years vs. 66 years), were more likely to be male (41% vs. 39%), and had a lower frequency of having ≥1 comorbid condition (2.9% vs. 4.2%). They also had a higher frequency of blood transfusions (41% vs. 19%), a shorter median length of stay (6 days vs. 8 days), a higher frequency of transfer to a rehabilitation facility (46% vs. 9%), and a lower frequency of knee infection (0.5% vs. 0.9%) than staged bilateral TKA patients, but they had higher rate of cardiac complications within 90 days (2.0% vs. 1.7%). Simultaneous patients had higher in-hospital mortality compared to the second TKA in staged patients (0.16% vs. 0.06%), but they had similar rates of in-hospital mortality compared to unilateral patients (0.16% vs. 0.14%). The cumulative 3-year revision rate was highest in the unilateral group (2.3%), but it was similar in the staged and simultaneous bilateral groups (1.4%). Interpretation — We found important differences between the outcomes of simultaneous and staged bilateral TKA. Further clarification of outcomes would be best determined in an adequately powered randomized trial, which would remove the selection bias inherent in this retrospective study design.

I describe an approach to art therapy treatment for survivors of traumatic brain injury developed at a rehabilitation facility for adults that serves inpatient, outpatient, and long-term residential clients. This approach is based on a review of the literature on traumatic brain injury, comprehensive neurorehabilitation, brain plasticity, and art therapy, as well as personal experiences working with clients. There is a paucity of recent art therapy literature on working with this population, and given the continually advancing knowledge of the brain and its plastic qualities, attention to a framework for treatment is needed. The comprehensive neurorehabilitation art therapy treatment approach presented is tailored to accommodate clients' individualized presentations while following the goals and core guidelines of brain injury rehabilitation.

This article investigated the feasibility of a tailor-made neurorehabilitation approach using multiple types of hybrid assistive limb (HAL) robots for acute stroke patients. We investigated the clinical outcomes of patients who underwent rehabilitation using the HAL robots. The Brunnstrom stage, Barthel index (BI), and functional independence measure (FIM) were evaluated at baseline and when patients were transferred to a rehabilitation facility. Scores were compared between the multiple-robot rehabilitation and single-robot rehabilitation groups. Nine hemiplegic acute stroke patients (five men and four women; mean age 59.4 ± 12.5 years; four hemorrhagic stroke and five ischemic stroke) underwent rehabilitation using multiple types of HAL robots for 19.4 ± 12.5 days, and 14 patients (six men and eight women; mean age 63.2 ± 13.9 years; nine hemorrhagic stroke and five ischemic stroke) underwent rehabilitation using a single type of HAL robot for 14.9 ± 8.9 days. The multiple-robot rehabilitation group showed significantly better outcomes in the Brunnstrom stage of the upper extremity, BI, and FIM scores. To the best of the authors' knowledge, this is the first pilot study demonstrating the feasibility of rehabilitation using multiple exoskeleton robots. The tailor-made rehabilitation approach may be useful for the treatment of acute stroke.

This study is a secondary analysis of the Outcome and Assessment Information Set (OASIS) and administrative billing records of 6,153 adults ≥ 65 years old who received home health (HH) from a not-for-profit HH agency in upstate New York in CY 2017. We evaluated the association between the use of home health services (HH) with the hazard of unplanned facility admissions among Medicare patients with and without Alzheimer’s disease and related dementia (ADRD). Outcome was time from HH start of care to an unplanned facility admission of any type, including the hospital, nursing home, or rehabilitation facility. Independent variables included weekly intensity (visits/week, hours/week) of each discipline, including skilled nursing (SN), physical therapy (PT), occupational therapy (OT), social work (SW), and home health aide (HA), separately. ADRD was identified by diagnosis (ICD-10 codes) and cognitive impairment (M1700, M1710, M1740 [OASIS]). In multivariable Cox Proportional hazard models that adjusted for time-varying effects of HH intensity, receiving the highest intensity of SN (3.3 visits of 2.78 hours per week) and PT (2.5 visits of 2 hours per week) was related to up to a 54% and 86% decrease, respectively, in the hazard of unplanned facility admission among patients with ADRD (n=1,525), and decreases of 56% and 90% respectively among patients without ADRD (n=4,628). This is the first study in the United States showing that receiving a sufficient amount and appropriate mix of HH services was associated with substantially reduced risk of unplanned facility admission among patients with ADRD by up to 86%.

Background: With a shift toward value-based and bundled-payment models, identification of areas of cost and quality improvement will be required. Though abundant literature is present on the predictors of discharge destinations, few studies have studied the impact of discharge to a skilled-care or rehabilitation facility on post-discharge outcomes following elective spine surgery. Methods: The 2015–2016 ACS-NSQIP database was queried using Current Procedural Terminology (CPT) codes 22551 and 22552 to retrieve records of patients undergoing ACDF (≤3 levels). Patients who had concurrent posterior cervical spine procedures and surgery for malignancy and spinal deformity were excluded. Results: A total of 15,624 patients were finally included for analysis, 459 (2.9%) patients were discharged to a skilled care or rehabilitation facility. Age of ≥65 years, Black or African-American race, partially dependent or totally dependent functional health status, a LOS ≥3 days, a total operative time >150 min, ASA grade > II and inpatient surgery were significant predictors for a discharge to skilled care/rehabilitation facility. Following adjustment for pre-discharge clinical characteristics, discharge to skilled care or rehabilitation was an independent significant risk factor for renal complications (OR =8.22; 95% CI, 1.84–36.7; P=0.006) and 30-day readmissions (OR =1.63; 95% CI, 1.09–2.42; P=0.016). Conclusions: Discharge to skilled-care or rehabilitation facilities following elective ACDF is associated with higher odds of renal complications and 30-day readmissions. These results stress the importance of careful patient selection prior to discharge to inpatient care facilities to minimize the risk of complications.

Simultaneous bilateral total hip arthroplasty (THA) is an attractive option for patients with osteoarthritis as it requires a single anesthetic and hospitalization. Nonetheless, serious concerns remain over the perioperative safety and rate of hospital readmission. The purpose of the present study was to compare the rate of 30-day major complications and hospital readmissions between patients undergoing simultaneous bilateral vs unilateral THA using the National Surgical Quality Improvement Program database.The National Surgical Quality Improvement Program database was queried from 2011 to 2015 inclusively to identify all cases of elective, primary simultaneous bilateral THA and match them to a control group of unilateral THA cases. A multivariable regression analysis was then used to assess the relationship of simultaneous bilateral vs unilateral THA on major complications and readmissions.A total of 575 bilateral THA patients were matched to 2290 unilateral THA patients using a 4:1 ratio based on age, sex, and American Society of Anesthesiologists scores. Bilateral THA patients were more likely to undergo general anesthesia (77% vs 58.7%, P.0001), required more postoperative transfusions (29.2% vs 15.9%, P.0001) and were more often discharged to a rehabilitation facility rather than home (39.4% vs 20.8%, P.0001). However, the adjusted odds of a major complication (odds ratio = 0.72, 95% confidence interval [0.41-1.24], P = .24) and 30-day readmission (odds ratio = 0.67, 95% confidence interval [0.38-1.19], P = .17) were similar between the 2 groups.Although patients who underwent simultaneous bilateral THA were more likely to be discharged to a rehabilitation facility and required significantly more perioperative transfusions compared to those undergoing unilateral THA, the odds of a 30-day major complication and readmission were similar between groups.III.

Prader-Willi Syndrome (PWS) is a genetic condition that results in a constellation of symptoms and typically results in hyperphagia and obesity in adulthood. Critically ill adults with PWS present a unique challenge to the nutrition professional, particularly when they require support modalities such as extracorporeal membrane oxygenation (ECMO). The purpose of this case study is to review the nutrition care of a critically ill adult patient with PWS who required venovenous ECMO. The patient was successfully managed with a hypocaloric, high-protein approach, which did not result in the diagnosis of malnutrition during his hospitalization. The patient was ultimately transitioned off extracorporeal life support and discharged to a rehabilitation facility.

IntroductionSyringe aspiration for manual aspiration thrombectomy (MAT) is a cost- and time-efficient alternative to an aspiration pump with likely similar efficacy. It is counterintuitive to expect the pump to perform better than direct vacuum with a syringe, as the pump must deliver vacuum additionally through a canister and meters of tubing.ObjectiveTo present in vitro and clinical results of MAT with a syringe.MethodsAn in vitro analysis was performed comparing vacuum pressures generated by syringe aspiration and with pump aspiration. This was then complemented with prospective clinical data providing details of angiographic and clinical outcomes for syringe MAT.ResultsThe in vitro analysis demonstrated that equal to slightly greater vacuum pressures were generated by a 60 cc syringe as compared with the pump in both static and partial flow conditions. In our clinical series, 106/113 acute stroke thrombectomies over a 6-month period were performed with syringe MAT on the first pass. Syringe usage instead of pump tubing and a canister led to a total savings of $58 300. The rate of Thrombolysis in Cerebral Infarction 2b/3 recanalization was 93%. Adjunctive stentriever usage was performed in 23% of cases. Median puncture to reperfusion time was 25 min; mean change in National Institute of Health Stroke Scale score at 24 hours was an improvement of 5.1 (median 6). The in-hospital mortality rate was 10%. Seventy percent of patients were discharged to home (modified Rankin Scale (mRS) score 0–2) or a rehabilitation facility (mRS score 2–4).ConclusionMAT using a syringe is a safe, fast, and more cost-effective approach than using an aspiration pump.

Reports of iatrogenic cold thermal injuries are rare in the literature. Conductive cooling devices, typically employed for their neuroprotective effects, use conductive hydrogel pads to achieve rapid and precise temperature control approaching the level of water immersion. Despite a number of built-in safeguards, prolonged or improper use of these devices can lead to significant thermal injury. To the best of their knowledge, the authors describe the first report of a significant iatrogenic full-thickness injury caused by the use of a surface cooling system in a patient who had recently suffered a cerebrovascular accident. The patient required transfer to the authors' tertiary burn care facility for excisional debridement and coverage with extensive split-thickness skin grafting to the chest, flank, and thighs. The grafts achieved nearly complete take and the patient was ultimately discharged to a rehabilitation facility with improving neurological condition.

The aim of this study was to analyse the changes in psychological stress and identify its basal predictors among elderly stroke survivors after 6 months following discharge from hospital to home directly, rather than to a rehabilitation facility. The sample comprised 50 elderly stroke survivors. Data were collected at 2 weeks (T1), at 3 months (T2), and at 6 months (T3) after hospital discharge. The following instruments were applied: Perceived Stress Scale-10 items (PSS-10), National Institute of Health Stroke Scale, Functional Independence Measure, and Geriatric Depression Scale-15 items. Study records indicated that the age of the study participants ranged from 60 to 87 years old (mean = 70.3; standard deviation = 7.6). The number of male and female participants was similar. The PSS-10 score decreased almost 6 points between T1 (mean = 15.1) and T3 (mean = 9.7; p

Background: In the recent decades, the relationship between psycho-physical disorders and weather conditions has taken on an increased scientific solidity. Furthermore, it is known to every clinician that healthcare practice has an important role in the management of psycho-physical disorders of patients affected by multiple sclerosis. Given that meteorosensitivity is related to the psycho-physical feebleness, this study is an attempt to clarify if treatments in a non-acute care rehabilitation centre can reduce the meteorosensitivity in patients with multiple sclerosis. Methods: In the spring 2014, 42 patients with MS, at Fondazione Don Gnocchi Santa Maria Nascente Centre (Milan, Italy), were observed by two evaluations (initial and final). The initial evaluation was the administration of METEO-Q, a questionnaire able to quantify the meteorosensitivity degree of the subjects, and Beck Depression Inventory-II, mainly. For each patient, passed one month, the final evaluation was carried out with the same modalities. Results: A statistically significant difference was found between initial and final meteorosensitivity degree (P=0.01), with better scores in final evaluations for most of the subjects. The correlation between Beck Depression Inventory-II and meteorosensitivity degree resulted significant and positive (R=0.377; P=0.001) and it confirms the link between psycho-physical feebleness and meteorosensitivity. Finally, no significant correlation emerged between initial meteorosensitivity degree and body mass index (R=0.187; P=0.236). Conclusions: This study confirms the possibility of improving meteorosensitivity, probably by rehabilitation too. Future studies could clarify the effects of health care practice on meteorosensitivity.

Purpose. To report a case of internuclear ophthalmoplegia (INO) caused by cocaine.Method. We report a case of a 54-year-old female who presented with a left INO three days after snorting cocaine, and we review the literature.Results. MRI of the brain demonstrated several small abnormal foci in the pons on FLAIR and diffusion weighted imaging consistent with ischemic infarction. The patient’s symptoms remained stable throughout her hospitalization. She was sent to a rehabilitation facility and was lost to follow-up.Conclusion. In cases of extraocular movement abnormalities, it is important to inquire about recreational drug use.

Background. Lateropulsion, a postural control disorder, delays recovery following hemispheric stroke. The number of stroke impairments may lead to differential recovery rates, depending on the intact systems available for recovery from lateropulsion. Objective. To study the impact of key postural control deficits on lateropulsion rate of recovery following stroke. Methods. Through retrospective analysis: 169 patients with hemispheric stroke in an in-patient rehabilitation facility were divided into 3 groups: (1) motor deficits only; (2) motor and hemianopic or visual–spatial deficits or motor and proprioceptive deficits; and (3) motor, proprioceptive, and hemianopic or visual–spatial deficits. Kaplan–Meier survival analysis determined if time to recovery from lateropulsion (achieving a score of 0 or 1 on the Burke Lateropulsion Scale) differed by group. Results. Log rank tests showed that time to recovery from lateropulsion differed based on the number of deficits (group, P = .012). Post hoc analyses by lesion side showed that group differences only occurred in right brain lesion ( P < .05) as compared with left brain lesions ( P = .34). Patients recovered from lateropulsion during in-patient rehabilitation if they had only motor deficits; those with all 3 postural control deficits showed the most protracted recovery. Conclusions. Rate of recovery from lateropulsion after stroke is dependent on the side of lesion, and number of key motor, proprioceptive, and/or hemianopic or visual–spatial deficits. The more postural control systems affected, the slower the recovery. Our data identify patients likely to need protracted rehabilitation targeting key postural control deficits.

Recent studies have shown that isolated traumatic subarachnoid hemorrhage (tSAH) in the setting of a high Glasgow Coma Scale (GCS) score (13-15) is a relatively less severe finding not likely to require operative neurosurgical intervention. This study sought to provide a more comprehensive assessment of isolated tSAH among patients with any GCS score, and to expand the analysis to examine the potential need for aggressive medical, endovascular, or open surgical interventions in these patients. By undertaking a retrospective review of all patients admitted to our trauma center from 2003-2012, we identified 661 patients with isolated tSAH. Only four patients (0.61%) underwent any sort of aggressive neurosurgical, medical, or endovascular intervention, regardless of GCS score. Most tSAH patients without additional systemic injury were discharged home (68%), including 53% of patients with a GCS score of 3-8. However, older patients were more likely to be discharged to a rehabilitation facility (p0.01). There were six (1.7%) in-hospital deaths, and five patients of these patients were older than 80 years old. We conclude that isolated tSAH, regardless of admission GCS score, is a less severe intracranial injury that is highly unlikely to require aggressive operative, medical, or endovascular intervention, and is unlikely to be associated with major neurologic morbidity or mortality, except perhaps in elderly patients. Based upon our findings, we argue that impaired consciousness in the setting of isolated tSAH should strongly compel a consideration of non-traumatic factors in the etiology of the altered neurological status.

Society is recognized that stroke is a life- threatening condition.Although the death rate from stroke decreases cerebrovasculardisease remains one of the major causes of death and disabilityreasons in many European Union countries, and the high incidencerate of stroke and serious consequences is one of the most importantmedical problems of today . The aim was to evaluate patients afterstroke functional status change in the rehabilitation process. 112stroke patients in treatment and rehabilitation facility in patientswith an average age of 46 years old. Of these, 53.6 per cent. werewomen. Patients were subject to complex rehabilitation treatment,which patients worked full rehabilitation team. Data analysis wasused to case history data. Patients‘ health status was assessed on twopatients on arrival and departure from the medical establishment. Their cognitive function was assessed using a standardized briefmental state examination (MMSE) and the independence of theirdaily lives was assessed in a standardized Functional IndependenceMeasure (FIM). The data were processed using SPSS softwarepackages and STATSTICA . Statistical analysis of data showed that the patients‘ functional status after stroke other positive changes asrehabilitation and improvement of cognitive , self-care and dailyfunctions. General cognitive status of patients differed significantlyin the course of rehabilitation received strong positive relationship,it shows the ratio p (0.85), which indicate a strong positiverelationship. The analysis of the overall condition of subjectsdepending on the type of stroke, it was found that patients withischemic stroke general cognitive status was better than before therehabilitation of patients with hemorrhagic stroke. Recovering, theyalso achieved better results , their data is statistically significantlydifferent (p< 0.05). Overall the condition of independence in dailylife as well as a statistically significant difference in the course ofrehabilitation , and the correlation coefficient p (0.93) showed a verystrong positive relationship. Our results showed improvements inpatients after stroke and cognitive and self-care functions changeduring the course of inpatient rehabilitation. It was also found thatthe improvement in cognitive function and improving self-carein daily life. This shows the correlation coefficient p (0.54). Theanalysis of patients with stroke rehabilitation efficiency dependingon demographic characteristics , they found that patients‘ functionalstatus significantly improved dynamics depending on the typeof stroke . It was also found that patients felt better living in thecity than in rural areas , although these data are not statisticallysignificant . The analysis of functional status changes depending onthe sex , it was found that the general condition was better for menthan for women. As well as their rehabilitation was more successfulthan women , although these data were not significantly different