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Dehydration is a commonly encountered problem worldwide. Current clinical assessment is limited by subjectivity and limited provider training with children. The objective of this study is to investigate a new noninvasive, point-of-care technology that measures capillary refill combined with patient factors to accurately diagnose dehydration.This is a prospective observational study at a tertiary care children's hospital in Buenos Aires, Argentina. Patients were eligible if younger than 10 years who presented to the emergency department with vomiting and/or diarrhea whom the triage nurse deems to be potentially dehydrated. Patients had the digital capillary refill device done on presentation in addition to standard of care vital signs and weight. Patients had serial weights measured on hospital scales throughout their stay. The primary outcome was dehydration, which was calculated as a percent change in weight from admission to discharge.Seventy-six children were enrolled in the study with 56 included in the final analysis. A stepwise forward method selection chose malnutrition, temperature, and systolic blood pressure for the multivariable model. The area under the curve for the final model was fair (0.7431). To further look into the utility of such a device in the home setting where blood pressure is not available often, we reran the model without systolic blood pressure. The area under the curve for the final model was 0.7269.The digital capillary refill point-of-care device combined with readily available patient-specific factors may improve the ability to detect pediatric dehydration and facilitate earlier treatment or transfer to higher levels of care.

Objective: Compared with traditional out-of-hospital cardiac arrest (OHCA) trial outcomes such as hospital survival, alternative outcomes such as intensive care unit-free (IFD) and ventilator-free days (VFD) have potential advantages including requiring smaller sample sizes to detect significant differences. Few studies have evaluated these outcomes in OHCA. We sought to evaluate the utility and validity of IFD and VFD as candidate outcomes for OHCA trials. Methods: We analyzed data from the Pragmatic Airway Resuscitation Trial (PART), which tested laryngeal tube (LT) vs. endotracheal intubation (ETI) airway strategies in adult OHCA. We defined IFD as the number of days alive and permanently out of ICU during the first 30 days after the OHCA event. We examined IFD distribution and correlation with Modified Rankin Scale (MRS). To test associations with trial interventions, we applied a range of analytic strategies, including modeling IFD as continuous (Generalized Estimating Equations - GEE), non-parametric (Wilcoxon Rank-Sum test - WRS) and count (zero-inflated negative binomial regression - ZINB) data. We also modeled time-to-ICU discharge using a survival model with death as a competing risk. We repeated the analysis assessing VFD. Results: IFD was available for 2,898 of 3,004 patients. IFD was skewed and J-shaped; 91% IFD=0 and 5.3% IFD≥22. Mean (±SD) IFD was 2.0±6.6 days; 21.2±7.5 days for survivors. IFD varied by intervention (LT 2.4±7.2, ETI 1.6±5.8 days). IFD and VFD strongly correlated with MRS (ρ= -0.88, -0.89). LT was associated with increased IFD using GEE, WRS, and ZINB, but not competing risks model. (Table) LT was associated with increased VFD using GEE and WRS, but not ZINB or competing risks models. Conclusion: IFD and VFD differentiated OHCA interventions, suggesting their utility. IFD and VFD were highly correlated with MRS, suggesting validity. IFD and VFD have important features that may influence OHCA trial design.

Background: Prior studies have reported racial disparities in survival from out-of-hospital cardiac arrest (OHCA). However, these studies did not evaluate how emergency medical services (EMS) provider assessment of race impacts OHCA interventions and survival. Our objective was to evaluate racial disparities in OHCA airway management and patient outcomes in the multicenter Pragmatic Airway Resuscitation Trial (PART). Methods: We conducted a secondary analysis of adult OHCA patients enrolled in PART. Trial subjects were randomized to initial advanced airway management with laryngeal tube or endotracheal intubation. The primary independent variable was patient race (categorized by EMS as white, black, and other). We used general estimating equations (GEE) to examine the association of race (white or black) with airway attempt success, 72-hour survival, and survival to hospital discharge, adjusting for sex, age, witness status, bystander CPR, initial rhythm, arrest location, and randomization cluster. Results: Of 3002 patients, race was 1537 white, 860 black, and 605 other. Median times (min [interquartile range]) from dispatch to arrival (5.4 [2.8] vs. 5.0 [2.3]), arrival to CPR (2.2 [2.7] vs. 2.0 [2.7]), and arrival to airway attempt (12.2 [7.6] vs. 11.0 [7.4]) were longer for black compared to white patients, respectively. Black patients had lower unadjusted odds of shockable rhythms (OR 0.59; 95% CI 0.47, 0.74), bystander CPR (0.47; 0.39, 0.56), and survival to discharge (0.68; 0.50, 0.92) than white patients. After adjustment for confounders, black race was not associated with airway success (OR 1.13; 95% CI 0.9, 1.41), 72-hr survival (1.06; 0.81, 1.30), or survival to discharge (0.82; 0.57, 1.19). Conclusions: Although black patients had lower odds of shockable rhythms and bystander CPR, airway success and survival odds were similar to white patients. Further studies are needed to better understand disparities in survival from OHCA.

Introduction: Bag mask ventilation (BMV) has been associated with improved survival following out of hospital cardiac arrest (OHCA), however advanced airway placement remains part of pre-hospital protocols for many emergency medical services (EMS) agencies. Hypothesis: To characterize airway management for pediatric OHCA and assess whether BMV alone vs. BMV plus advanced airway (supraglottic airway or tracheal intubation) is associated with neurologically favorable survival. Methods: Analysis of the Cardiac Arrest Registry to Enhance Survival database. Inclusion criteria were age ≤ 18 years, non-traumatic OHCA from 2013 through 2017, resuscitated by EMS. To adjust for covariate imbalance, propensity score matching and entropy balancing were utilized; variables included age category, sex, bystander CPR, and shockable rhythm. The primary outcome was favorable neurologically favorable survival defined as a cerebral performance category scale of 1 or 2. Results: Of 5241 cardiac arrests, 2588 (49.3%) had BVM and 2653 (50.6%) had advanced airway placement. The majority 5118 (97.7%) were resuscitated by agencies using both BMV and advanced airways. Advanced airway placement was more common in older children compared to infants, arrests with bystander CPR, in white and Hispanic children, witnessed arrests, arrests with a shockable rhythm, and AED use (Table). Neurologically favorable survival was significantly higher with BMV compared to advanced airways in bivariate analysis (11.4% vs. 5.7%, p Conclusion: In pediatric OHCA, advanced airways are placed in half of cardiac arrests where resuscitation is attempted. Advanced airway, compared to BMV alone management, is associated with lower neurologically favorable survival.

Reverse shoulder arthroplasty (RSA) has experienced a rebirth in popularity as a surgical procedure starting with the Grammont design. The biomechanics of RSA continues to be studied and better understood, however at the same time there has been rapid development of different prostheses that have taken the geometry of the reverse and made substantial changes, impacting the mechanics of these devices in many ways. Classifying the different styles of design helps surgeons form a working nomenclature to discuss these design parameters and the potential biomechanical consequences of implant selection for patients. This chapter breaks down the RSA into glenoid sided, humeral sided, rotator cuff related and bone quality related components as they relate to biomechanics.

Current reverse total shoulder arthroplasty prosthesis designs do not permit offset of the humerus in the sagittal plane. Posteriorly shifting the humerus has the theoretical benefit of lengthening the infraspinatus and teres minor muscles and their external rotation moment arms, thereby improving the tension and efficiency of each external rotator and subsequently requiring each muscle to produce less force to rotate the arm. A cadaveric shoulder controller was used to quantify the impact of a novel posterior-superior offset reverse shoulder prosthesis on muscle length, moment arms, and muscle forces relative to a non-offset reverse shoulder design during two different motions: scapular plane abduction and internal/external rotation. The results of this study demonstrate that both the non-offset and offset reverse shoulder designs had similar force and excursion demands of the infraspinatus and teres minor muscles during both scapular abduction and internal and external rotation. Additionally, the offset reverse shoulder design was associated with significantly less over-tensioning of the middle and posterior deltoid and significantly more anatomic tensioning of the teres minor than the non-offset design. However, the offset reverse shoulder was observed to have more impingement than the non-offset design. These findings support the feasibility of this design: by restoring a more anatomic resting length to the deltoid and teres minor, the posterior-superior offset rTSA design may provide better teres minor function and rotational strength and may decrease the incidence of acromial stress fractures relative to the non-offset design. Clinical follow-up is required to confirm these findings.

Context:Accurate assessment of health-related quality of life (HRQoL) is important for quality patient care. Evaluation of HRQoL typically occurs with patient self-report, but some instruments, such as the Pediatric Quality of Life Inventory (PedsQL), allow for proxy reporting. Limited information exists comparing patient and proxy reports of HRQoL after sport-related injury in adolescent athletes.Objective:To compare patient ratings and parent-proxy ratings of HRQoL in adolescent athletes who suffer musculoskeletal injuries requiring orthopedic consultation. The authors hypothesized poor agreement between patient and parent-proxy ratings of HRQoL.Design:Cross-sectional study.Setting:Orthopedic practice.Patients:Thirteen adolescent patients with a sport-related musculoskeletal injury requiring orthopedic consultation and 1 of their parents participated.Interventions:During the initial visit to the physician’s office, each patient was asked to complete the PedsQL, and the patient’s parent was asked to complete the parent-proxy version of the PedsQL.Main Outcome Measurements:The PedsQL is a pediatric generic outcome measure that consists of a total score and 4 subscale scores: physical, emotional, social, and school functioning. Means and standard deviations were calculated for all scores, and comparisons between patient-self report and parent-proxy ratings of HRQoL were made for the PedsQL total score and subscale scores using Pearson product–moment correlations (r).Results:Pearson product–moment correlations showed little to fair insignificant relationships between patient self-report and parent-proxy report of the PedsQL for the total score (r = −.1) and all subscales (range r = .1 to .4).Conclusions:Our results suggest a lack of agreement between patient and parent-proxy ratings of HRQoL, with patients rating their HRQoL lower than their parent. Patient perception of HRQoL may be more accurate than proxy report, which supports the use of patient-rated HRQoL in patient evaluation. Assessments of HRQoL made by proxies, even those close to the patient, may not represent patient health status.

Previously, large scale clinical research required large budgets, significant staff, and long periods of time. Typically most of these resources were spent on data collection to develop electronic research databases. With the proliferation of electronic medical records this clinical research paradigm changes. Here we present a large clinical study of pediatric hypertension (14,187 patients) conducted through an electronic medical record without any budget and within about 70 hours over 6 months.

Posterior tibial tendon dysfunction (PTTD) is a significant foot disorder in which the posterior tibial tendon becomes inflamed and painful and loses its integrity. As a result, the posterior tibialis muscle/tendon unit becomes dysfunctional and, over the long term, the foot acquires a flatfoot deformity. Ideally, one would like to treat the problem early on and prevent the deformity from occurring. However, treatment to restore muscle balance in the foot in the early stages of the disorder have met with minimal success with patients eventually requiring fusions to treat the deformity and relieve pain. Currently no adequate models exist for studying the efficacy of treatment. A cadaveric foot model has been developed which simulates the muscle imbalance. The model can be used to investigate the biomechanical efficacy of surgical treatments used in early stage disease, prior to the occurrence of deformity. The model utilizes medial arch strain and talonavicular joint rotation as outcome measures.