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Background Comparing cohorts with similar functional and motor status at admission to inpatient rehabilitation may delineate demographics or impairments associated with recovery from lateropulsion, also known as "pusher syndrome," after stroke based on lesion side. The aim of this case–control study was to determine how demographics and severity of stroke impairments at admission to inpatient rehabilitation distinguish patients who recover from lateropulsion from those who do not. Methods Patients with admission motor Functional Independence Measure (FIM) scores less than 31 and contralesional lower extremity Fugl-Meyer motor scores less than 19 out of 34 were included. Burke Lateropulsion Scales score of 2 or higher at the time of discharge from inpatient rehabilitation indicated persistent lateropulsion; a score of 0 or 1 indicated resolved lateropulsion. Logistic regression tests included age, gender, admission Motricity Index score, limb placement error, and cognitive FIM score. χ 2 analyses compared groups for neglect. Results For patients with left brain lesion, older age and worse admission motor status distinguished those with persistent lateropulsion at discharge. For right brain lesion, related factors were older age, greater admission limb placement error, and lower cognitive FIM scores. Visuospatial neglect did not influence recovery from lateropulsion. Conclusions Older age and severe impairments were associated with delayed recovery from lateropulsion in a manner specific to lesion side in a sample with motor and functional deficits. The study provides evidence that lesion side and admission characteristics are useful in early decision making for the duration of rehabilitation, selection of interventions, and discharge planning.

Patients using the emergency department (ED) for asthma may benefit from self-management education. Our goal is to test an educational intervention in 296 asthma ED patients.This was a randomized controlled trial with concealed allocation. Controls received instruction from an asthma knowledge test, peak flowmeter training, and asthma brochures. Intervention patients received these plus a self-management workbook, a behavioral contract, inhaler training, and telephone reinforcements. The main outcome was change in Asthma Quality of Life Questionnaire (AQLQ) score at 8 weeks (a change of 1.5 is a marked clinically important difference). Secondary outcomes were repeated ED visits and change in AQLQ scores at 4, 12, and 16 weeks and 1 year.Mean age of patients was 44 years, and 93% had the 8-week follow-up. Enrollment AQLQ scores were comparable and increased at 8 weeks by more than a marked clinically important difference in both groups. For controls, the change in score was 1.95 (95% confidence interval [CI] 1.74 to 2.16; P.001), for intervention patients the change in score was 1.83 (95% CI 1.64 to 2.03; P.001), and the difference between groups was 0.11 (95% CI -0.17 to 0.40; P=.43). Patients who improved more (ie, change was above the group mean) were more likely to be high school graduates (odds ratio=1.9; 95% CI 1.0 to 3.8), previous or current smokers at enrollment (odds ratio=2.2; 95% CI 1.3 to 3.5), and to have been admitted to the hospital from the ED (odds ratio=1.7; 95% CI 1.0 to 2.8). Similar variables were associated with AQLQ outcomes in hierarchic analyses during 16 weeks. Repeated ED visits occurred for 12% of patients at 8 weeks and in multivariate analysis were associated with no hospitalization for the index ED visit, difficult access to outpatient care, and previous ED visits. Fewer patients (16%) had an ED visit at 12 weeks compared with a similar time before enrollment (36%).Patients in both groups had marked sustained improvements in clinical status 16 weeks after an ED visit for asthma. A self-management education intervention delivered in the ED and reinforced by telephone was successfully implemented, with high retention rates, but did not provide incremental benefit for quality of life and short-term repeated ED visit outcomes.

Rabadi MH, Rabadi FM, Edelstein L, Peterson M. Cognitively impaired stroke patients do benefit from admission to an acute rehabilitation unit. Objective To determine whether cognitively impaired stroke patients benefit (defined as having an improved level of functional independence and capable of being discharged home) from admission to an acute rehabilitation unit. Design Retrospective analysis of data from a historical cohort of patients with acute stroke within the last 4 weeks or less. Setting Acute stroke rehabilitation unit. Participants The study sample was divided into 4 distinct groups based on admission Mini-Mental State Examination (MMSE) scores: cognitively intact (MMSE score range, ≥25 points), mild cognitive impairment (MMSE score range, 21–24), moderate cognitive impairment (MMSE score range, 10–20), and severe cognitive impairment (MMSE score range, ≤9 points). Interventions Not applicable. Main Outcome Measures Primary outcome measures were: change in total FIM instrument score, cognitive FIM subscore, length of stay (LOS), FIM efficiency, and discharge disposition (home vs not-to-home). Results Based on the MMSE cut scores, there were 233 cognitively intact patients and 435 cognitively impaired (mild, n=139; moderate, n=165; severe, n=131) patients. The cognitively intact and the 3 cognitively impaired groups were similar in age, sex, and ethnicity. The data show that the 3 cognitively impaired groups of patients had delayed onset to acute rehabilitation admission and greater stroke severity and disability. The change in FIM total score and FIM efficiency was similar between the cognitively intact and the 3 cognitively impaired groups ( P =.058). There were, however, statistically significant changes in the FIM cognitive subscore favoring the cognitively impaired groups ( P P P Conclusions Our results suggest that despite severe neurologic impairment(s) and disability, cognitively impaired stroke patients make significant functional gains while undergoing rehabilitation and many can be discharged home. Based on these results, stroke patients with cognitive impairments benefit from rehabilitation and should be given the same access to acute rehabilitation services as stroke patients who are cognitively intact.

Our aim in this study was to evaluate the prevalence of patella baja after total knee arthroplasty (TKA) using 2 different surgical techniques. Postoperative changes in patella height were measured on serial radiographs of 74 TKAs implanted using a mini-midvastus capsular approach without patella eversion (group 1) and 57 TKAs implanted using a standard medial parapatellar capsular approach with patella eversion (group 2). Preoperative and postoperative Knee Society scores, operative data, and complications were compared. With a cutoff level of 5% shortening, the prevalence was 12% in group 1 and 37% in group 2 (P = .001). The presence of patella baja was related to reduced flexion and increased pain as early as 1 year after TKA.

Single-stage bilateral total hip arthroplasty can be performed with a completely new sterile setup for the second side or with the same instruments for both sides. The latter could theoretically lead to a higher prevalence of infection in the second side. We retrospectively determined the prevalence of deep infection during the first postoperative year in 271 consecutive patients operated on with different sterile setups (group 1) and 289 patients operated on with the same setup (group 2). There was one deep infection affecting the first side of a patient in group 1. In group 2, there were no deep infections (P ∼ 1.0) and one developed a superficial infection on the second side requiring readmission and intravenous antibiotics. Given the very low prevalence of deep infection of the first and second side (0.2% and 0%, respectively), it would be necessary to analyze more than 2300 patients in each group to achieve statistical significance. Based on this experience, the use of the same set of instruments for the second side in the operating conditions described in this study appears safe.

Impingement can damage the acetabular liner, create polyethylene wear, and cause dislocation. We determined the prevalence of impingement, its relation with dislocation, and the influence of patient, surgical, and design factors in 162 components randomly selected from a larger group retrieved between 1990 and 1999. Impingement arc, severity, and wear damage were measured; patient data were obtained from medical records, and component position was determined from radiographs. More than half (56%) showed impingement, including 94% of those removed for dislocation. The occurrence of impingement was significantly increased if the revision diagnosis was dislocation, if the component had a large outer diameter or an elevated rim, and if the femoral component had an extended flanged neck. Implant design, in particular head/neck ratio, can help reduce the prevalence of impingement.

Background and Objective Serial measurements obtained during observational longitudinal studies offer the opportunity to describe the effects of chronic diseases on patient-centered outcomes such as quality of life. The purpose of this study was to assess serial Asthma Quality of Life Questionnaire (AQLQ) and SF-36 scores against a transition item using three methods of data analysis—final minus initial scores, maximum minus minimum scores, and regression line slopes through all scores. Methods Using receiver operating characteristic (ROC) curves, each method of analysis was compared against patients’ responses to a global transition question about change in asthma status with responses dichotomized as “stayed the same or got worse” or “improved.” A total of 185 patients, mean age 41±11 years, 83% women, completed the AQLQ and SF-36 three to seven times at approximately 8-month intervals over a mean of 24.8±3.9 months. For the AQLQ, all three methods of data analysis performed well against the transition item with ROC areas highest for the symptoms, activities, and the summary AQLQ scores (0.74–0.78). Results Overall, ROC areas increased as the number of observations increased, ranging from 0.78 to 0.93 for the AQLQ summary score for patients with three to six or more assessments, respectively ( P = .02). As part of the AQLQ, patients cited specific activities in which they were limited because of asthma. A total of 66 different activities were cited, including limitations in stair climbing, walking, interacting with others, sleeping, and working. In ROC analysis, serial measurements of these items also performed well against the transition item with areas ranging from 0.72 to 0.75 for all three methods of analysis. In contrast, ROC areas for the SF-36 Physical and Mental Component Summary scores were significantly lower, ranging from 0.59 to 0.66 compared to the AQLQ areas, indicating that the generic scale was less responsive than the disease-specific scale ( P ⩽.01). The three different methods of analysis also provided unique information about the cohort. The final minus initial analysis showed that 63% of patients had clinically important improvements, the maximum minus minimum analysis showed that over 90% of patients had fluctuations in scores that were clinically important, and the slope analysis showed that 79% of patients had an overall trend of improvement. Conclusions This study described possible methods to analyze and present serial data. Additional techniques to assess and interpret serial longitudinal data are needed to comprehensively describe long-term effects of chronic diseases on quality of life.

This is a report on 11 years (1990-2000) of total hip arthroplasty cases and days of discharge from one large city hospital. In 1990, patients stayed an average of 9.7 days after surgery. By 2000, patients stayed only 5.3 days. In general, women stayed longer than men, but this gap had nearly disappeared by 2000. The patients discharged in 2000 achieved fewer functional milestones during their hospital stay than those discharged in 1990.

Decision trees have been already successfully used in medicine, but as in traditional statistics, some hard real world problems can not be solved successfully using the traditional way of induction. In our experiments we tested various methods for building univariate decision trees in order to find the best induction strategy. On a hard real world problem of the Orthopaedic fracture data with 2637 cases, described by 23 attributes and a decision with three possible values, we built decision trees with four classical approaches, one hybrid approach where we combined neural networks and decision trees, and with an evolutionary approach. The results show that all approaches had problems with either accuracy, sensitivity, or decision tree size. The comparison shows that the best compromise in hard real world problem decision trees building is the evolutionary approach.

Gait analysis studies typically utilize continuous curves of data measured over the gait cycle, or a portion of the gait cycle. Statistical methods which are appropriate for use in studies involving a single point of data are not adequate for analysis of continuous curves of data. This paper determines the operating characteristics for two methods of constructing statistical prediction and confidence bands. The methods are compared, and their performance is evaluated using cross-validation methodology with a data set of the sort commonly evaluated in gait analysis. The methods evaluated are the often-used point-by-point Gaussian theory intervals, and the simultaneous bootstrap intervals of Sutherland et al. The De6elopment of Mature Walking, MacKeith Press, London, 1988 and Olshen et al. Ann. Statist. 17 (1989) 1419‐40. The bootstrap bands are shown to provide appropriate coverage for continuous curve gait data (86% coverage for a targeted coverage of 90%). The Gaussian bands are shown to provide inadequate coverage (54% for a targeted coverage of 90%). The deficiency in the Gaussian method can lead to inaccurate conclusions in gait studies. Bootstrap prediction and confidence bands are advocated for use as a standard method for evaluating gait data curves because the method is non-parametric and maintains nominal coverage levels for entire curves of gait data. © 1999 Elsevier Science B.V. All rights reserved.

Although there have been many studies focusing on the increasingly important assessment of patients' satisfaction, few studies have specifically addressed this tissue for total hip arthroplasty (THA). The goals of this study were to measure patients' satisfaction with THA and to evaluate the relationships of expectations and outcome to patients' satisfaction. A total of 180 patients were surveyed 2 to 3 years after THA about their experiences with THA. Patients cited 45 different expectations, which were grouped into five categories reflecting improvement in pain, walking, psychological state, essential activities, and nonessential activities. Overall, 89% of patients were satisfied with the results of surgery. Lower rates of satisfaction were found in patients who had a better preoperative condition (as measured by the surgeons with The Hospital for Special Surgery Hip Scale), in patients who expected improvement in nonessential activities, and in patients who reported worse postoperative condition (as measured by self-assessment with the Hip Rating Questionnaire and the Medical Outcomes Study Short-form General Health Survey). Patients were also asked how they came to THA. Nearly 50% of patients were first referred to an orthopaedist by family or friends or based on their own knowledge. Seventy-four percent either had subsequently referred others for THA or would have done so if they knew someone with hip pain. This study demonstrates that satisfaction with THA is a complex phenomenon, affected by expectations, outcome, and what patients know about the procedure from their community network. A better understanding of THA satisfaction will enable better future selection of patients and an additional dimension of outcome, both of which are important to patients and payers.

A retrospective review was performed of 448 consecutive patients undergoing primary, unilateral, bicondylar, and cemented total knee arthroplasty under epidural anesthesia by three surgeons to determine factors contributing to deep vein thrombosis rate. All had venography on the fourth or fifth postoperative day and received aspirin and elastic stockings as their only thromboprophylaxis. The overall deep vein thrombosis rate was 41% (2% had proximal clots). The rate of deep vein thrombosis was not related to obesity, history of heart disease, hypertension, prior malignancy, smoking, diagnosis of osteoarthritis, duration of surgery, type of local anesthetic used, or the use of postoperative epidural analgesia. The rate of deep vein thrombosis varied significantly between surgeons: one surgeon had an overall deep vein thrombosis rate of 58% (proximal thrombi, 4%) whereas the other two surgeons had a deep vein thrombosis rate of 35% (proximal clot thrombi, 1%). A number of possible mechanisms to explain the variation in deep vein thrombosis rates between surgeons are provided.

A transfer of a best practice model was performed between a new institution in the United Kingdom and a leading orthopedic hospital in the United States. The quality concepts transferred to the UK were surgical and hospital throughput, hospital facility design, an Interdisciplinary Preoperative Patient Education Program, infection control standards, and a standardized rehabilitation model. The new hospital was officially opened in February 2004, and the average length of stay for total hip arthroplasty between February and December 2004 was 6.1 +/- 3.0 days, a substantial reduction of 5 days on average. The infection rate was reduced from 1% to 0.16%. This study supports the notion that the implementation of a best practice approach significantly reduces length of stay as well as infection rate.