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Children with ADHD were administered 75 dB of continuous white noise during independent seat work in the classroom and during bedtime in their homes. Compared to baseline all three students exhibit...

STUDY DESIGN Retrospective cohort study. OBJECTIVE To evaluate the ability of patient reported outcome measurement information system (PROMIS) assessments to capture disability related to cervical sagittal alignment and secondarily to compare these findings to legacy outcome measures. SUMMARY OF BACKGROUND DATA PROMIS is a validated patient-reported outcome metric that is increasing in popularity due to its speed of administration relative to legacy metrics. The ability of PROMIS to capture disability from sagittal alignment and baseline health status in patients with neck pain has not been investigated. METHODS Patients presenting with a chief complaint of neck pain from December 2016 to July 2017 were included. Demographics and comorbidities were retrospectively collected. All patients prospectively completed the neck disability index (NDI), EQ-5D, visual analog scale (VAS) neck, VAS arm, PROMIS physical function, PROMIS pain intensity, and PROMIS pain interference metrics. Cervical sagittal alignment parameters were measured on standing X-rays. The correlations between outcome measures, health status indexes, psychiatric diagnoses, and sagittal alignment were analyzed. RESULTS Two hundred twenty-six patients were included. The sample was 58.4% female with a mean age of 55.1 years. In patients with neck pain, PROMIS physical function correlated strongly with the NDI (r = -0.763, P

The Press Ganey survey is the most widely used instrument for measuring patient satisfaction. Understanding the factors that influence these surveys may permit better use of survey results and may direct interventions to increase patient satisfaction. Press Ganey Clinician and Group Consumer Assessment of Healthcare Providers and Systems surveys administered to ambulatory spine surgery clinic patients within a large tertiary care network from May 2016 to September 2017 were retrospectively reviewed. Mean comparison testing was performed to measure associations between patient demographics and responses to “overall provider rating” and “recommend this provider's office” survey questions. Mean difference to achieve significance was set at αP P =.001). Those with commercial insurance had significantly lower ratings for recommend this provider's office ( P =.042) and overall provider rating ( P =.022) questions than those with other insurance types. Patients administered the survey on paper had significantly lower ratings than those administered the survey online ( P =.006). Provider ratings were significantly higher when the sex and ethnicity of the patient were concordant with the provider ( P =.021). This study showed that independent, nonmodifiable factors such as age, education level, and survey mode were significantly associated with the satisfaction of ambulatory spine surgery clinic patients. [ Orthopedics . 2019; 42(3):143–148.]

Microvolt t-wave alternans (TWA) is a risk factor for sudden cardiac death but is only discernible on stress ECG using signal processing techniques. This case represents an example of acquired QT interval prolongation and macrovolt TWA leading to torsades de pointes (TdP). 63 year old man with

Introduction This study assessed the incidence and risk factors for pseudarthrosis among primary spine fusion patients. Methods Retrospective review of ACS-NSQIP (2005–2013). Differences in comorbidities between spine fusion patients with and without pseudarthrosis (Pseud, N-Pseud) were assessed using chi-squared tests and Independent Samples t-tests. Binary logistic regression assessed patient-related and procedure-related predictors for pseudarthrosis. Results 52,402 patients (57yrs, 53%F, 0.4% w/pseudarthrosis). Alcohol consumption (OR:2.6[1.2–5.7]) and prior history of surgical revision (OR:1.6[1.4–1.8]) were risk factors for pseudarthrosis operation. Pseud patients at higher risk for deep incisional SSI (at 30-days:OR:6.6[2.0–21.8]). Pseud patients had more perioperative complications (avg:0.24 ± 0.43v0.18 ± 0.39,p=0.026). Conclusions Alcoholism and surgical revision are major risk factors for pseudarthrosis in patients undergoing spine fusion.

Patient reported outcomes measurement information system (PROMIS) is a quality of life metric that has gained increased popularity due to computer adaptive testing. Previous studies have shown that PROMIS correlates with Oswestry Disability Index (ODI) in patients with back pain and takes significantly less time to complete. However, the ability of PROMIS to capture disability from spinal malalignment relative to established metrics is unknown. The aim of the present study is to validate the correlation between ODI and PROMIS in patients with back pain, analyze correlations of PROMIS and legacy metrics to sagittal alignment, and identify major drivers of PROMIS scores and ODI in patients with back pain. A retrospective review was conducted of a prospectively collected outcome measures database (PROMIS, ODI, VAS Back, VAS Leg, VAS Neck, and VAS Arm) of spine patients > 18 years. Inclusion criteria for the present study was a chief complaint of back pain and full length weight bearing X-rays within 30 days of health related quality of life (HRQL) completion. Demographic information, radiographic alignment, psychiatric diagnoses, and comorbidities were recorded. PROMIS metrics were correlated to legacy metrics (ODI and VAS). Next, outcome metrics were correlated with sagittal alignment variables T1 Pelvic Angle (TPA), SVA, PT, and PI-LL. Patients were grouped based on the presence of spinal deformity (defined radiographically as any one of SVA > 4 cm, PI-LL > 10°, PT > 20°) and mean HRQL scores were investigated for the adult spinal deformity (ASD) and non-ASD groups. Finally, drivers of PROMIS PF scores and ODI scores were determined using multiple stepwise regression. 150 patients met inclusion criteria including 60 patients with ASD and 90 patients without. For the whole cohort, PROMIS PF correlated with ODI (r = − 0.651, p

BACKGROUND CONTEXT Computer adaptive testing facilitates quicker administration of patient-relevant questions. The Patient Reported Outcome Measurement Information System (PROMIS) instruments of Physical Function, Pain Intensity and Pain Interference have been shown to correlate with established patient outcome metrics, though this relationship has yet to be investigated in relation to patient satisfaction. PURPOSE The aim of this study was to study the relationship between PROMIS and VAS scores and patient satisfaction in thoracolumbar patients. STUDY DESIGN/SETTING Retrospective review of single institution clinical data and patient-reported outcome measures. PATIENT SAMPLE A total of 208 spine patients with a thoracolumbar (TL) diagnosis. OUTCOME MEASURES ODI, Visual Analog Scale (VAS) for Back and Leg pain, Scoliosis Research Society 22 (SRS-22); Patient Reported Outcome Measurement Information System (PROMIS). METHODS Inclusion was patients greater than 18 years with a diagnosis related to the thoracolumbar spine (stenosis, disc herniation, low back pain, disc degeneration, spondylolysis most commonly). Bivariate correlations assessed the linear relationships of PROMIS scores (Physical Function, Pain Intensity, and Pain Interference) and ODI with VAS Leg and Back pain scores and patient satisfaction (SRS-22) questions specific to patient satisfaction of their back shape and back management. Linear regression predicted the relationship of PROMIS to VAS and satisfaction outcomes. Statistical significance was set at P RESULTS A total of 208 patients with a thoracolumbar diagnosis were included (age 58.39 ± 73.32 years, 49% female). VAS back pain scores (r=0.673, P CONCLUSIONS VAS Back Pain scores predicted PROMIS Pain Intensity scores as strongly as ODI, though ODI outperformed in predicting PROMIS Physical Function and Pain Interference. Conversely, PROMIS Pain Intensity predicted VAS Back Pain stronger than ODI, though ODI outperformed the other two PROMIS domains. Patients’ satisfaction of the shape of their back and their back management were significantly correlated with PROMIS scores in all three domains.

We evaluated the effects of white noise played through headphones on off-task behavior, percentage of items completed, and percentage of items completed correctly for 3 students with attention deficit hyperactivity disorder (ADHD). Headphones plus white noise were associated with decreases in off-task behavior relative to baseline and headphones-only (no white noise) control conditions. Little change in academic responding occurred across conditions for all participants.

BACKGROUND CONTEXT Recent research has identified increased C2-T3 angle as a risk factor for persistent sagittal malalignment following thoracolumbar surgery. Despite this, no ideal cervicothoracic alignment thresholds exist in the literature. As several studies have demonstrated a clear relationship between the normal aging spine and sagittal spinal alignment, such ideal-alignment thresholds should also account for patient age. PURPOSE This study proposes age-specific cervicothoracic alignment targets using previously published age-specific normative Neck Disability Index (NDI) values. STUDY DESIGN/SETTING Single center retrospective review. PATIENT SAMPLE A total of 223 patients with available biplanar full-body stereographic x-rays. OUTCOME MEASURES C2-T3 lordosis; Neck Disability Index score. METHODS Patients >18 years with cervical sagittal vertical axis RESULTS Overall, 223 patients (50±20years, 65% F) met inclusion criteria, presenting with a mean sagittal vertical axis (SVA) of 17.8±47.7 mm, cervical SVA 19.8±11.2 mm, T1 Slope-C2-C7 lordosis 24.7°±16.2°, and C2-T3 of 2.1°±16.5°. At baseline, increased C2-T3 angle was significantly correlated with both NDI score (r=0.266, p 75 years: 27.8. Liner regression analysis showed a significant relationship between NDI score, age, and baseline cervicothoracic alignment, as assessed by C2-T3 angle (r=0.497, p 75 years: 6.7°. CONCLUSIONS Significant relationships exist between age, neck disability, and cervicothoracic alignment, suggesting broad measurements across the cervicothoracic junction may be clinically relevant in predicting postoperative outcomes of surgical spine deformity patients. Taking into account patient age and USA-normative values of neck disability, this study offers a set of ideal age-adjusted alignment targets for C2-T3. By proposing a set of normative, age-specific cervicothoracic alignment targets, this study better facilitates individual optimization of surgical planning.

BACKGROUND CONTEXT Patient satisfaction is an important metric in value-based care systems. The Press Ganey Associates survey is the most widely used instrument for measuring patient satisfaction. Understanding the factors that influence these surveys may help to better utilize survey results and direct interventions to increase patient satisfaction. PURPOSE To determine if nonmodifiable demographic factors influence spine patient satisfaction scores on the Press Ganey CG-CAHPS survey. STUDY DESIGN/SETTING Retrospective review of satisfaction surveys. PATIENT SAMPLE A total of 1,400 spine surgery ambulatory clinic patients in one tertiary care network. OUTCOME MEASURES Press Ganey CG-CAHPS satisfaction surveys. METHODS Press Ganey CG-CAHPS surveys administered to ambulatory spine surgery clinic patients within a large tertiary care network from 05/2016 to 09/2017 were retrospectively reviewed. Mean comparison testing was performed to measure associations between patient demographics and survey responses to “overall provider rating” and “recommend this provider office” questions. Mean difference to achieve significance was set at α RESULTS A total of 1,400 survey responses from the offices of 11 orthopedic spine surgeons were included. Patients aged 18-34 had significantly lower responses to the “overall doctor rating” question than older patients (p CONCLUSIONS This study demonstrates that independent, nonmodifiable factors such as age, education level, survey mode, and insurance type influence satisfaction. It also suggests that patients may be more satisfied when they align with the gender and ethnicity of the provider.

As adults with congenital heart disease (CHD) grow older, preoperative screening for coronary artery disease (CAD) may be indicated prior to CHD surgery. Data regarding the indications for preoperative CAD screening in this population are limited. Current practice is to follow guidelines for patients with valvular heart disease; however, the risk for CAD in certain congenital heart diagnoses may be higher than the general population. This study aimed to assess the results of preoperative CAD screening in patients prior to CHD surgery.Retrospective study.Single tertiary center.Patients ≥35 years that had CHD surgery from 1/1/2007 to 5/1/2017.Data regarding CAD risk factors and preoperative CAD screening results were obtained. Prevalence and risk factors for CAD were analyzed, along with their relationship to perioperative outcomes.A total of 73 patients underwent CAD screening with either cardiac catheterization (56%) or computed tomography angiography (34%) prior to CHD surgery. Overall 16 (22%) patients were found to have CAD. Only two patients had severe coronary stenosis and underwent coronary bypass grafting at time of CHD surgery. Patients with CAD were more likely to be older and have history of hypertension, dyslipidemia, and tobacco smoking. CHD diagnosis was not significantly associated with presence of CAD.CAD is common in asymptomatic older patients referred for screening prior to CHD surgery; however, severe CAD requiring concomitant coronary intervention is uncommon. Preoperative CAD screening should be based on age and traditional CAD risk factors, rather than underlying CHD.

Purpose: To compare high-order aberrations in patients who had cataract surgery and implantation of different types of intraocular lenses (IOLs). Setting: Sir Charles Gairdner Hospital and Lions Eye Institute, University of Western Australia, Perth, Australia. Methods: Fifty eyes of 48 patients were included in this study. The optical aberrations were measured with the Hartmann-Shack wavefront sensor (Zyoptix, Bausch & Lomb) before and after surgery using a 5.0 mm wavefront aperture diameter for all comparisons. The eyes were divided into 4 groups according to the type of IOL (material and curvature). A fifth group of 10 eyes of 6 elderly patients with normal crystalline lenses had the same examination. Results: There was no statistical difference in high-order aberrations between the 2 acrylic IOL groups with different curvatures ( P >.05) or between the silicone and poly(methyl methacrylate) (PMMA) IOL groups ( P >.05). However, the measured high-order aberrations were significantly higher (3rd through 5th order) in the 2 acrylic IOL groups than in the PMMA and silicone IOL groups ( P Conclusions: An increase in IOL high-order aberrations contributed to the decline in retinal image quality. An IOL modifies the entire aberration pattern of the eye. There was a statistically significant increase in aberrations in patients with an acrylic IOL compared to those with a silicone or PMMA IOL. The exact mechanism is uncertain. Further study is required to optimize IOL design.

Purposes of the study were to determine the type and format of information pediatricians receive from schools regarding diagnosis and treatment of Attention Deficit-Hyperactivity Disorder (ADHD), their preferences for this information, and their opinions on referral rates and treatment. Results from a random sample of members of the American Academy of Pediatrics indicate that for both diagnostic and treatment information, significant discrepancies exist between what pediatricians prefer and the information schools always or usually provide. The majority of pediatricians believe schools overrefer and over one-third believe parents overrefer for ADHD. Pediatricians recommend behavior management at home and school more often than stimulant medication. To improve referral, diagnosis, and treatment, discussion of discrepancies in expectations between school psychologists and pediatricians could be helpful. Additional training in some areas for both groups also may be beneficial. ********** Attention-Deficit Hyperactivity Disorder (ADHD) is a major clinical and public health problem, affecting approximately 3% to 5% of school-age children (American Psychiatric Association, 1994). In a survey of school children in Maryland, Safer and Malever (2000) found that about 3% were on medication for ADHD. Because many children diagnosed with ADHI) are not on medication, these data suggest that more than 3% of children are diagnosed with the condition. ADHD is one of the most common reasons for referrals to clinics for pediatrics, family practice, neurology, and child psychiatry (Biederman, Faraone, Keenan, Knee, & Tsuang, 1990). Historically, the most favored treatment option for children with ADHD has been stimulant medication. Stimulants have been shown to have beneficial effects including improving attention, reducing disruptive and impulsive behavior, and increasing compliance with instructions from adults (Brown & Sawyer, 1998). However, the medications are not without side effects, some of which include insomnia, irritability, and loss of appetite. The use of stimulants for ADHD has increased considerably over the years. A recent study examining frequency of use from 1991 to 1995 indicates that the most prominent use of methylphenidate (Ritalin) is with students from 5 through 14 years of age; the largest increase in use occurred for students from 15 through 19 years. Even with children as young as 2 to 4 years of age there has been a substantial increase (Zito et al., 2000). Results of a large, multisite, multimodal treatment study for ADHD suggest that for 7to 9-year-olds medication monitored monthly with teacher input is more effective than behavior treatment in treating ADHD symptoms. However, to obtain some important outcomes such as improved family interaction and academic performance, a combination of medication and behavior treatment is needed (The MTA Cooperative Group, 1999a, 1999b). Misperceptions and inaccurate interpretation of the results of this study have occurred and the results have raised important issues needing further research, especially with regard to diagnosis (Carey, 2000). The American Academy of Pediatrics (AAP; 1987) noted that the use of medication should not be the first approach for ADHD; further, the AAP recommended that medication should not be considered a complete treatment program (AAP, 1996). Likewise, in their position statement on ADHD, the National Association of School Psychologists (NASP; 1995) strongly recommended that when medication is a consideration: (a) instructional and behavioral interventions should be used before beginning medication trials, (b) behavioral data should be collected for baseline conditions and during medication trials to evaluate medication effects, and (c) communication among school, home, and medical personnel should stress mutual problem solving and cooperation. …

Calls for change in the role of school psychologists have appeared in the literature over a period of nearly 50 years. Evidence of change exists for some outstanding individual school psychologists and in a number of model programs, but not on a widespread basis. This paper discusses ideas for role change that have appeared rather consistently in the literature: an emphasis on indirect service, application of the science of psychology, an emphasis on prevention, systematic evaluation of services, involvement of various stakeholders, and consideration of diversity from a broad perspective. Hopefully the 21st century will bring more widespread implementation of these ideas because there is likely to be an even greater need for such services in the schools. © 2000 John Wiley & Sons, Inc.

This study examined the effect of a parent training program and its two components on the development of 48 graduates of neonatal intensive care units. When the infants were 6 months of age, infants whose parents participated in either of the treatment groups that included the parent education class scored higher on the Bayley Mental Scale than the other groups of infants. All treatment group parents were rated by the babies' physicians as providing better nutrition for their infants. The developmental assessment component of the training program was not found to enhance infant mental development. Implications for intervention, program development, and research are presented.

SummaryTwo cytochrome P450 2C9 (CYP2C9) polymorphisms, CYP2C9*2 and *3, metabolize warfarin inefficiently. We assessed the extent to which these polymorphisms explain very low warfarin dose requirements and hemorrhagic complications after excluding non-genetic determinants of warfarin dosing. In this retrospective observational study, 73 patients with stable warfarin doses for ≥1 month and International Normalized Ratios (INR) of 2.0–3.0 were enrolled from our Anticoagulation Clinic. Seventeen patients required ≤2 mg (low-dose), 41 required 4–6 mg (moderate-dose), and 15 required ≥10 mg (high-dose) of daily warfarin. CYP2C9 genotyping was assessed by PCR amplification and restriction enzyme digestion analysis of DNA isolated from circulating leukocytes. The CYP2C9 polymorphisms independently predicted low warfarin requirements after adjusting for Body Mass Index, age, acetaminophen use, and race (OR 24.80; 95% CI 3.83–160.78). At least one polymorphism was present in every patient requiring ≤1.5 mg of daily warfarin, and 88%, 37%, and 7% of the low-, moderate-, and high-dose groups, respectively. All homozygotes and compound-heterozygotes for the variant alleles were in the low-dose group. Rates of excessive (INR>6.0) anticoagulation (and bleeding) were 4.5 (6.0), 7.9 (7.9), and 14.7 (0) per 100 patient-years in the wild-types, heterozygotes, and compound heterozygotes/homozygotes, respectively. In conclusion, CYP2C9*2 or *3 compound heterozygotes and homozygotes have low warfarin requirements even after excluding liver disease, excessive alcohol or acetaminophen consumption, low body weight, advancing age, and drug interactions. These polymorphisms increase the rate of excessive anticoagulation, but this risk does not appear to be associated with higher bleeding rates when anticoagulation status is closely monitored.

We measured hematocrit and serum albumin concentration at birth and red blood cell and plasma volume soon after birth in prematurely born infants with erythroblastosis fetalis of varying severity and examined the realtionships between these variables and the presence and severity of hydrops fetalis. Blood volumes in most of these infants were similar to the established normals for newborn infants without erythroblastosis. There was no simple association between blood volume and the presence of hydrops. Nonhydropic and severely hydropic infants had, on the average, similar and normal blood volumes, while mildly hydropic infants had low blood volumes. Anemia correlated fairly well with severity of hydrops but almost a quarter of the infants with severe hydrops were only mildly anemic. Red blood cell volume decreased and plasma volume increased proportionally with the degree of anemia at birth. Thus, hydropic infants with severe anemia had large plasma volumes while those with milder anemia did not. On the other hand, hypoalbuminemia was common and correlated closely with severity of hydrops. We suggest that hydrops results at least in part from low plasma colloid osmotic pressure due to hypoalbuminemia.

Two teaching strategies, delayed-prompting (Touchette, 1971) and fading (Egeland, 1975), were compared for teaching the most easily confused letters and numbers to preschoolers. One group of children received training using delayed prompting with a fixed delay, a second group with a fading procedure; third served as the control group that received no training. A derived progress score on the training stimuli was calculated by subtracting errors on a pretest from errors on the post-test Analysis of these results indicated a significant difference between the delayed-prompting group and the control group only. The delayed-prompting group showed greater progress. During training, subjects in the fading group met criterion on an average of 4.33 stimuli and the subjects in the delayed-prompting group met criterion on an average of 3.23 stimuli. However, on a criterion test and a posttest given 1 week later, the fading group made significantly more errors than the delayed-prompting group.

The effects of token rewards on the WISC-R performance of white, first, second, fourth, and fifth grade students of low-socioeconomic-status were examined. Twenty control subjects (10 first- and second-graders, 10 fourth- and fifth-graders) were administered the IQ test according to standardized procedures. An experimental group of 20 subjects (10 first- and second-graders, 10 fourth- and fifth-graders) earned tokens immediately following each correct response on the WISC-R. Upon completion of testing, tokens were exchangeable for a variety of items costing less than $3.00. The results indicated that the experimental group scored significantly higher (mean = 108) than the control group (mean = 102). A significant difference was also found for grade level, the first- and second-graders scoring higher (mean = 107) than the fourth- and fifth-graders (mean = 102). The implications for future research are discussed.

This study investigated the effect of three parent-education methods for use with mothers in maternity wards. The three methods were videotapes and a handbook, videotapes only, and handbook only. The two groups who received the videotapes performed better on a posttest than two no-treatment control groups. No differences were evident between the videotapes and handbook group and the videotapes-only group. The handbook-only condition was better than only one of the control groups. Usefulness of the program, problems encountered, and future research needs are discussed.

The authors evaluated the incidence and type of technical problems associated with blind insertion of intrapleural catheters placed in 21 anesthetized patients and then injected in a double-blind fashion with 0.5% bupivacaine (1.5 mg/kg) or isotonic saline. The patients' chests were then opened, catheter positions located, and the lungs inspected. Eleven of the catheters were located with the tips intrapleurally, three extrapleurally, and seven actually in lung tissue. Eight patients had holes in the lung surface. Three patients had a pneumothorax, two of which were under tension. Plasma bupivacaine levels reached maximal concentrations at about 20 minutes in those with intrapleurally placed catheters, but not until 60 minutes when the catheter had actually penetrated the lung. Significant variations in plasma bupivacaine levels were achieved when the catheter entered lung tissue, with potentially toxic levels in one patient. To evaluate intraoperative analgesic effects, all patients were given a standard anesthetic with isoflurane, oxygen, and a muscle relaxant. There was no significant difference in isoflurane requirement between the groups who had bupivacaine v saline injected into their intrapleural catheters before surgery. It is concluded that blind insertion of intrapleural catheters can be hazardous, especially if followed by positive-pressure ventilation. In addition, catheter placement in lung tissue, which was not uncommon, delays the time for peak plasma concentrations and may increase risk of toxicity. Intrapleural bupivacaine was not found to be a useful adjunct to general anesthesia during thoracotomies.