Article 5: A multidimensional measure of acute confusion after traumatic brain injury: the confusion assessment protocol

Objective: To provide preliminary validation of a new measure of posttraumatic confusional state (PTCS), the Confusion Assessment Protocol (CAP), that assesses 7 key symptoms of PTCS (disorientation, cognitive impairment, restlessness, fluctuation in presentation, nighttime sleep disturbance, decreased daytime arousal, psychotic-type symptoms). Design: Criterion standard investigation. Setting: Inpatient traumatic brain injury (TBI) rehabilitation program. Participants: 62 consecutive patients with moderate or severe TBI admitted for inpatient rehabilitation. Interventions: Not applicable. Main Outcome Measure: Clinical diagnosis of delirium based on Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria. Results: 38 of 44 (86%) patients who were classified as confused on the CAP met the DSM-IV criteria for delirium while only 2 of 18 (11%) patients classified as nonconfused on the CAP met the DSM-IV criteria. Overall agreement between the CAP and the DSM-IV classification was 87%. Conclusions: The CAP is a brief, structured, repeatable measure of multiple aspects of PTCS. Classification of patients as confused versus nonconfused with the CAP showed excellent agreement with clinical diagnosis of delirium using DSM-IV criteria.     

ISB Clinical Biomechanics Award 2009: Toe weakness and deformity increase the risk of falls in older people

Background

Hallux valgus and lesser toe deformities are highly prevalent foot problems in older people. One factor contributing to the development of these toe deformities is reduced toe flexor strength. As adequate toe flexor strength is also crucial in maintaining balance, it was hypothesised that poor toe flexor strength and toe deformities would increase the risk of falls in community-dwelling older people.

Method

The feet of 312 men and women aged 60–90 years were assessed for the presence of lesser toe deformities and hallux valgus. Hallux and lesser toe flexor strength were assessed using an emed AT-4 pressure platform and novel test protocol. Participants were then followed prospectively to determine their falls incidence over 12 months.

Findings

During the 12 month follow-up, 107 (35%) participants experienced a fall. Compared to non-fallers, fallers displayed significantly less strength of the hallux (11.6 (SD 6.9) versus 14.8 (SD 7.8)% BW, P < 0.01) and lesser toes (8.7 (SD 4.7) versus 10.8 (SD 4.5)% BW, P < 0.01), and were more likely to have hallux valgus (relative risk [RR] = 2.36; 95% CI = 1.03–5.45; P < 0.01) and lesser toe deformity (RR = 1.32; 95% CI = 1.04–1.69; P < 0.01).

Interpretation

Reduced toe flexor strength and the presence of toe deformities increase the risk of falling in older people. To reduce this risk, interventions designed to increase strength of the toe flexor muscles combined with treatment of those older individuals with toe deformities may be beneficial.     

Poster 3: Three-dimensional scapular attitudes measured with the optotrak probing system: a reliability study on 30 shoulders

Objective: To evaluate the intra- and intersessions reliability of 3-dimensional scapular attitudes measured with a new method. Design: Test-retest. Setting: 2 sessions with the same protocol repeated by the same evaluator. Participants: 15 healthy subjects (30 shoulders). Interventions: 3-dimensional scapular attitudes were measured at 70° of flexion, 90° of abduction, and arm at rest, using the Optotrak probing system. 3 trials were recorded for each position. For each trial, the posterolateral tip of the acromion, the inferior angle, and the edge of the spine of the scapula were digitized. Main Outcome Measure: 3-dimensional scapular attitudes in external and internal rotation, anterior and posterior tilting, and anterior and posterior transverse rotation planes. Results: The intrasession reliability at 70° of flexion and 90° of abduction was excellent, as indicated by intraclass correlation coefficients (ICCs), which ranged from .87 to .99, and standard errors (SEs) of measurement, which varied from 0.4° to 1.7°. The intersessions reliability was poorer, with ICCs ranging from .37 to .56, and SEs of measurement varying from 2.7° to 4.7°. Conclusion: For studies that look at the effect of rehabilitation interventions on 3-dimensional scapular attitudes, findings should be interpreted in light of the magnitude of measurement errors.     

Resuscitation of avalanche victims: Evidence-based guidelines of the international commission for mountain emergency medicine (ICAR MEDCOM) : Intended for physicians and other advanced life support personnel

Background

In North America and Europe ∼150 persons are killed by avalanches every year.

Methods

The International Commission for Mountain Emergency Medicine (ICAR MEDCOM) systematically developed evidence-based guidelines and an algorithm for the management of avalanche victims using a worksheet of 27 Population Intervention Comparator Outcome questions. Classification of recommendations and level of evidence are ranked using the American Heart Association system.

Results and conclusions

If lethal injuries are excluded and the body is not frozen, the rescue strategy is governed by the duration of snow burial and, if not available, by the victim's core-temperature. If burial time ≤35 min (or core-temperature ≥32 °C) rapid extrication and standard ALS is important. If burial time >35 min and core-temperature <32 °C, treatment of hypothermia including gentle extrication, full body insulation, ECG and core-temperature monitoring is recommended, and advanced airway management if appropriate. Unresponsive patients presenting with vital signs should be transported to a hospital capable of active external and minimally invasive rewarming such as forced air rewarming. Patients with cardiac instability or in cardiac arrest (with a patent airway) should be transported to a hospital for extracorporeal membrane oxygenation or cardiopulmonary bypass rewarming. Patients in cardiac arrest should receive uninterrupted CPR; with asystole, CPR may be terminated (or withheld) if a patient is lethally injured or completely frozen, the airway is blocked and duration of burial >35 min, serum potassium >12 mmol L⁻¹, risk to the rescuers is unacceptably high or a valid do-not-resuscitate order exists. Management should include spinal precautions and other trauma care as indicated.     

Abstract 15: H-reflex latencies and sensory and motor nerve action potential latencies among diabetic patients seen at the outpatient service of a tertiary hospital: a correlative study.

Objective: To determine the correlation between the H-reflex latencies and the sensory and motor nerve action potential latencies in detecting diabetic neuropathy. Design: Prospective, cross-sectional. Setting: Outpatient departments of neurology and rehabilitation medicine in a tertiary hospital. Participants: 41 subjects with diabetes. Interventions: Not applicable. Main Outcome Measures: H-reflex latencies of the tibial nerve and nerve conduction studies (median motor and sensory, peroneal motor, sural sensory latencies) of the upper and lower extremity of each patient. Results: The correlation between the nerve action potential latencies and the H-reflex latencies was studied using the canonical correlation analysis method. The computed canonical correlation coefficient was .8379 (P=.0001). Conclusions: The findings suggest that there is a strong correlation between H-reflex latencies and sensory and motor nerve action potential latencies among patients with diabetic neuropathy. Based on this study, use of H-reflex latencies is a promising alternative electrophysiologic technique in the investigation of peripheral neuropathy among patients with diabetes mellitus.