Modified great toe wrap for thumb reconstruction

Reconstruction of the traumatically amputated thumb can be achieved with good cosmetic and functional results utilizing autogenous bone graft and a neurosensory free wrap-around flap from the great toe. The donor area of the toe is modified to create a wrap-around flap to transfer innervated glabrous skin from the medial and lateral borders of the toe. This modification includes nail and nail matrix while preserving toe length and the important plantar weight-bearing skin of the great toe. A series of three patients who have undergone thumb reconstruction utilizing this method are reported. Postoperative follow-up averages 15 months. Sensory recovery is comparable to that reported in the literature; cosmetic appearance of the thumb and nail growth are good.     

Patient‐reported outcomes from SYNERGY,a randomized,double‐blind,multicenter study evaluating combinations of mirabegron and solifenacin compared with monotherapy and placebo in OAB patients

Aims

To evaluate patient‐reported outcomes (PROs) of combinations of solifenacin and mirabegron compared with solifenacin and mirabegron monotherapy and with placebo in patients with overactive bladder (OAB) from the SYNERGY trial.

Methods

Following a 4‐week placebo run‐in, period patients (≥18 years) with OAB were randomized 2:2:1:1:1:1 to receive solifenacin 5 mg + mirabegron 25 mg (combination 5 + 25 mg), solifenacin 5 mg + mirabegron 50 mg, (combination 5 + 50 mg), solifenacin 5 mg, mirabegron 25 mg, mirabegron 50 mg or placebo for 12 weeks, followed by a 2‐week washout period. At each visit, PROs related to quality of life, symptom bother, and treatment satisfaction were assessed, including OAB‐q Symptom Bother score, health‐related quality of life (HRQOL) Total score, treatment satisfaction‐visual analogue scale (TS‐VAS), and patient perception of bladder condition (PPBC) questionnaires.

Results

Overall, 3527 patients were randomized into the study, with 3494 receiving double‐blind treatment. At end of treatment (EoT), both combination groups showed greater improvements in OAB‐q Symptom Bother score compared with the monotherapy groups (nominal P < 0.001). Statistically significant improvements in HRQOL Total scores were observed in the combination groups versus monotherapy groups (P ≤ 0.002). For both combination groups, the OAB‐q Symptom Bother score responder rates at EoT were statistically significantly higher versus mirabegron monotherapy (P < 0.05). The mean adjusted changes from baseline to EoT for PPBC were greater in the combination groups compared with monotherapy groups.

Conclusions

PROs showed that combination therapy provided clear improvements and an additive effect for many HRQOL parameters, including OAB‐q Symptom Bother score, HRQOL Total score, and PPBC.     

Team functioning and patient outcomes in stroke rehabilitation

OBJECTIVE: To evaluate the relationship between rehabilitation team functioning and stroke patient outcomes. DESIGN: Prospective observational study. SETTING: Veterans Administration (VA) inpatient and subacute rehabilitation units. PARTICIPANTS: Forty-six VA rehabilitation teams, including 530 rehabilitation team members from 6 disciplines (medicine, nursing, social work, physical therapy, occupational therapy, speech language pathology) and 1688 stroke patients treated by the teams. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Ten scales assessing team member perceptions of team functioning (communication, perceived effectiveness, physician involvement, physician support, teamness, utility of quality information, innovation, interprofessional relationships, order and organization, task orientation) and 3 primary patient outcome variables-functional improvement, discharge home, and length of rehabilitation stay (LOS). RESULTS: Three of the 10 measures of team functioning were significantly associated with patient functional improvement ( P <.05): task orientation, order and organization, and utility of quality information. One measure of team functioning-effectiveness-was significantly associated with LOS ( P <.05). None of the team variables predicted discharge destination. Aspects of team functioning that were important to outcomes differed depending on the outcome of interests. Efforts directed toward improving team activities and relationships, including collaborative planning and problem solving and the use of feedback information, may enhance rehabilitation treatment effectiveness. CONCLUSIONS: Characteristics of team functioning predict selected rehabilitation outcomes.     

The efficacy of removable devices to offload and heal neuropathic plantar forefoot ulcers in people with diabetes: a single‐blinded multicentre randomised controlled trial

Non‐removable offloading is the ‘gold standard’ treatment for neuropathic diabetic plantar forefoot ulcers. However, removable offloading is the common ‘standard of care’. We compared three removable offloading devices for ulcer healing efficacy. In this multicentre, randomised controlled trial, 60 persons with neuropathic diabetic plantar forefoot ulcers were randomly assigned to wear a custom‐made knee‐high cast [BTCC (bivalved TCC)], custom‐made ankle‐high cast shoe or a prefabricated ankle‐high forefoot‐offloading shoe (FOS). Primary outcome was healing at 12 weeks. Dynamic plantar pressures, daily stride count and treatment adherence were assessed on a randomly selected subset (n = 35). According to intention‐to‐treat analysis, 58% of patients healed with BTCC [OR 0·77 (95% CI 0·41–1·45) versus FOS], 60% with cast shoe [OR 0·81 (95% CI 0·44–1·49) versus FOS] and 70% with FOS (P = 0·70). Mean ± SD peak pressure in kPa at the ulcer site was 81 ± 55 for BTCC, 176 ± 80 for cast shoe and 107 ± 52 for FOS (P = 0·005); stride count was 4150 ± 1626, 3514 ± 1380 and 4447 ± 3190, respectively (P = 0·71); percentage of 2‐week intervals that patients wore the device <50% of time was 17·3%, 5·2% and 4·9%, respectively. Non‐significant differences in healing efficacy between the three devices suggest that, when non‐removable offloading is contraindicated or not available, each can be used for plantar forefoot ulcer offloading. Efficacy is lower than previously found for non‐removable offloading maybe because suboptimal adherence and high stride count expose the patient to high repetitive stresses. These factors should be carefully considered in decision making regarding ulcer treatment.     

The influence of hospital culture on rehabilitation team functioning in VA hospitals

A conceptual model of rehabilitation effectiveness, in which team functioning is influenced by hospital culture, has been previously suggested by several authors of this study. The current study tested the efficacy of the hospital culture portion of the model using survey data from 523 rehabilitation team members and 162 administrators from 50 participating Veterans Administration Hospitals (VAHs). We assessed four types of hospital culture (personal, dynamic, formal, and production-oriented) using an instrument developed originally for a Competing Values Model. Rehabilitation team members and administrators perceived three of the four hospital cultures differently (p < 0.0001), agreeing only on production-oriented culture. With the use of VAH dominant culture as the independent variable, statistically significant differences were found among all nine measures of team functioning (dependent variables). The major contrast was between personal versus formal hospital culture types.     

Utility of Treatment Implementation methods in clinical trial with rehabilitation teams

Clinical trials of rehabilitation interventions pose unique challenges to researchers. Treatments can be technically complex, often requiring a multidisciplinary team of professions. This article demonstrates the application of Treatment Implementation (TI) methods in a rehabilitation team-training intervention conducted with 29 team leaders (12 medical doctors, 4 physical therapists, 3 speech-language pathologists, 2 occupational therapists, 3 kinesiotherapists, 2 registered nurses, 1 social worker, 1 program coordinator, and 1 administrator) from 15 Department of Veterans Affairs hospitals. We describe the intervention along with the influence of three TI categories (delivery, receipt, and enactment) on the design and implementation of the team-training intervention. Positive findings from the use of TI methods include (1) consistent and accurate presentation of intervention components and (2) evidence of study participants' receipt and enactment of intervention strategies.     

Developing an integrated brain, behavior and biological response profile in posttraumatic stress disorder (PTSD)

The present study sought to determine a profile of integrated behavioral, brain and autonomic alterations in PTSD. Previous findings suggest that PTSD is associated with changes across electrophysiological (EEG and ERP), autonomic and cognitive/behavioral measures. In particular, PTSD has been associated with reduced cognitive performance, altered cortical arousal (measured by EEG), diminished late ERP component to oddball task targets (reduced P3 amplitude) and increased autonomic arousal relative to healthy controls. The present study examined measures of cognitive function, auditory oddball ERP components, autonomic function (heart rate and skin conductance) and EEG during resting conditions in 44 individuals with PTSD and 44 non-trauma-exposed controls, and predicted that an integrated profile of changes across a number of these measures would show a high level of sensitivity and specificity in discriminating PTSD from controls. Nine variables showing strongly significant (p < 0.002) between-group differences were entered into a discriminant function analysis. Four of these measures successfully discriminated the PTSD and non-PTSD groups: change in tonic arousal, duration of attention switching, working memory reaction time and errors of commission during visuospatial maze learning. Tonic arousal change contributed the most variance in predicting group membership. These results extend previous findings and provide an integrated biomarker profile that characterizes both PTSD and non-PTSD groups with a high degree of sensitivity and specificity. This outcome provides a platform for future studies to test how this profile of disturbances in autonomic and information processing may be unique to PTSD or may occur generically across clinical and/or other anxiety disorders.