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    Importance of Locking Plate Screw Number and Placement for Mid-Diaphyseal Humeral Fracture Fixation
    (2016-03-23) Nana, Arvind; Kosmopoulos, Victor; Fishbeck, Keith
    Purpose: Single large-fragment plate constructs are currently the norm for internal fixation of mid-diaphyseal humerus fractures. In cases where anatomy limits the size of the humerus available for fixation however, recent studies support the use of a dual small fragment locking plate construct. This study aims to compare the simulated performance of both a single locking plate and a dual-locking plate construct with decreasing number of locking screws and with changes in screw fixation location. Materials & Methods: Mid-diaphyseal humeral fracture fixation using a single (Model S) and a dual (Model D) locking plate construct were simulated using the finite element method, a numerical technique commonly used to computationally approximate solutions for complex structural mechanics problems. Different configurations were tested by removal of either one or two screws from the superior half of the fixation construct and compared to a control having no screws removed. Models are labelled based on the location of the screw removed with 1 denoting the most superior screw and 4 denoting the inferior screw adjacent to the fracture (e.g., S1 denotes removal of the most superior screw from the single plate model). Results: Model D4 was the only construct to show an increase in stiffness as compared to the original dual plate construct without any screws removed. For the single-plate constructs, models S1-S3 all resulted in less than 2.5% stiffness reductions as compared to the control. Noteworthy, three of the single plate constructs, having two screws removed (models S12, S13, and S23), showed less than a 6% reduction in construct stiffness. In contrast, all of the dual-plate constructs with 2 screws removed showed high stiffness reductions (greater than 55%). Conclusions: Results support that screw number and/or location and construct type (single vs. dual) are important factors to consider in achieving successful fixation. Position and screw number were shown to be particularly important in the dual-plating constructs.
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    Muscular Architecture of the Posterior Knee and the Basic Science Implications
    (2016-03-23) Wood, Addison; Wagner, Russell; Reeves, Rustin; Smith, Morgan
    Introduction: Musculoskeletal modelling plays an integral role in estimating clinically relevant muscle and joint contact forces which rely upon cadaveric experimentation. The muscular architecture of the posterior knee is often overlooked; yet can play an important role in knee mechanics and balancing. In this sense, the contribution of the popliteus muscle to a well-functioning total knee arthroplasty is often debated in the literature and requires further clarification. Furthermore, prior literature involved smaller sample sizes and did not look for differences in muscle architecture between males and females. Methods: 12 embalmed cadaver specimens were dissected to reveal the origin and insertion of the gastrocnemius, semimembranosus, and popliteus muscles. The orientation of these muscles and the breadth of the insertion of the popliteus muscle were recorded in relation to the long axis of the tibia using a goniometer. Muscle volume was assessed via water displacement can and graduated cylinder. Muscle fiber length and pennation angle were determined under a dissecting scope using a ruler and goniometer. Fiber length was determined via dissection and measurement from 3 separate areas and averaged for each muscle. Using these data, physiological cross sectional area (PCSA) was calculated by multiplying each muscle’s volume by the cos of the pennation angle and then dividing by it’s fiber length. Results were initially analyzed using descriptive statistics. Comparison between groups was performed via ANOVA with a post hoc Tukey test for multiple comparisons. Results: Mean muscle volumes for females: popliteus 12.6 ml, gastrocnemius 108.1 ml, and semimembranosus 81.9 ml (n=7). Mean muscle volumes for males: popliteus 20.5 ml, gastrocnemius 195.6 ml, and semimembranosus 174.3 ml (n=5). Significant differences between males and females were found in all three volumes (p=.001, p=.002, and p=.010 respectively). Significant differences between males and females were also found in PCSA for the popliteus and semimembranosus muscles (p=.008, p=.003 respectively). There were no significant differences found between males and females in fiber length, overall muscle length (excludes tendon), or orientation (Table 1,2,3). The mean orientations of the popliteus, medial gastrocnemius, and lateral gastrocnemius with respect to the long axis of the tibia were 145.3 degrees, 163.8 degrees, and 162.4 degrees respectively. The tibial attachment site of the popliteus muscle spanned between 38.3 degrees and 25.5 degrees in relation to the long axis of the tibia. Several data points were unable to be adequately collected due to incidents occurring during dissection (represented by the letter x in the tables). Results were compared to prior literature when possible and were found to be similar. Discussion and Conclusion: Currently, few musculoskeletal models include the popliteus muscle for kinematic and kinetic studies of the knee. The role of the popliteus muscle in knee mechanics and balancing should not be underestimated and merits inclusion into computational knee models and joint simulations. The ratio of popliteus PCSA to semimembranosus PCSA was 1:2.35 in females and 1:3.03 in males with an overall ratio of 1:2.69 irrespective of sex. These ratios, combined with the orientation of the popliteus, infer that the muscle plays a significant role in force generation across the knee joint. These findings also illustrate the need for subject-specific PCSA to be calculated for more reliable modelling due to the wide degree of muscular variation being present.
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    Examining the Impact of Providing Smartphones to Patients from a Managed Care Perspective: A Systematic Review
    (2016-03-23) Namil, Mehdi; Weltman, Natalie; Loving, Cassidy; White, Annesha; Carter, Pamela; Dsouza, Katrina; Jacob, Stephanie; Dang, Chloe; Trinh, Jason
    Objective: The objective of this study was to explore the literature within the last decade with respect to health plan purchase of smartphones for patients to improve health outcomes. A secondary objective was to explore smartphone use and cost. Methods: A systematic review using Pubmed, Medline, Cinahl Plus, Cochrane Library, Scopus, Trip and PsychInfo databases to identify studies regarding smartphone use conducted between 2005-2015. Key search terms included “mhealth”, “telehealth”, “smartphone”, “mobile applications”, “cost savings”, and “patient health outcomes”. Abstracts were screened against inclusion criteria and selected based upon relevance and quality. The most significant eligibility criteria required was that a smartphone must have been provided to the patient. Risk of bias was assessed using the Cochrane Risk of Bias Tool. Use of Covidence facilitated the summary of selected articles. Notable characteristics were summarized in tables. Results The search yielded a total of 130 articles for review. Several examples within managed care were identified and focused on three key areas: disease and medication management, personal fitness and wellness and remote patient monitoring. Studies included managing these chronic diseases: Cardiac rehabilitation, COPD, Diabetes, HIV, Hypertension, Heart failure, rheumatoid arthritis, Addiction, chronic pain, and mental health diseases. Seven of ten studies related to disease management showed improvement in clinical outcomes measured. Studies in which smartphones were provided to remotely monitor patient data had the most impact in reducing hospitalization and emergency room visits. The Smartphones programs that featured mobile coaching and medication reminders had high levels of patient satisfaction and reported increased behavior change and medication adherence. Challenges reported of providing smartphones included ease of use and signal interruption. None of the studies identified thoroughly examined the costs associated with provision of smartphone to patients. Health plans must consider type of phone, additional training, cost of security and integration into healthcare models. Conclusion While smartphone use is growing, 48% of smartphone users had to cancel their cell phone service for a period due to financial hardship. The purchase of smartphones by health plans may mitigate these issues while improving health outcomes.
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    Induced seismicity (earthquakes) from energy extraction activity in North Texas: A community perspective
    (2016-03-23) Rich, Alisa PhD, MPH; Uche, Uloma I.
    Purpose: To examine induced seismic events in Irving, Farmer's Branch and Dallas, Texas between 2002 and 2015 and energy extraction activity associated with these events. Potential impacts to critical infrastructure and perception to the public is examined. Methods The U.S Geologic Survey Earthquake Hazard Program database was searched for seismic events in Irving, Farmer's Branch and Dallas occurring 2002-2015. Well locations were retrieved from Texas Railroad Commission database. Studies related to impacts of earthquakes on infrastructure, and perception of hazard were searched in Scopus, Google Scholar, Web of Science and PubMed. Results Between 2002-2015, 83 earthquakes occurred in the Irving, Farmer's Branch, Dallas area. 86% of earthquakes (71) occurred in Irving. In January 2015, 25 earthquakes occurred within a 2-mile radius of the Old Texas Stadium. Potential structural damage to critical infrastructure including roadways, bridges, tunnels, water and gas lines, and buildings can occur. Smaller earthquakes are not life-threatening but studies confirm a public perception of fear, anxiety, physical harm, and decreased property values related to earthquakes frequency. Conclusion Induced seismicity was consistent with energy extraction activity. The area with highest earthquake activity exists at the intersection of 2 geologic fault; the Muenster Arch and Ouachita Fault. Frequency of earthquakes within a short time interval in this area is consistent with features of induced seismicity.
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    Michels Type II Vessel Branching Pattern Variant of the Hepatic Pedicle
    (2016-03-23) Petree, Tyler; Kannappan, Anju; Gonzales, Gabriel; Vo, Steven; Doan, An; Pumphrey, Katherine
    Michels type II vessel branching pattern variant of the hepatic pedicle Gabriel Gonzales, Anju Kannappan, An Doan, Steven Vo, Tyler Petree, Katherine Pumphrey, Claire Kirchhoff UNT Health Science Center Introduction: In the branching of the celiac trunk, the left hepatic artery arises from the common hepatic in 89% of cases. However, in 11% of cases the vessel may instead arise from the left gastric artery, an alternate branching pattern known as Michels Type II variation of hepatic arteries. This study looks into the prevalence of this particular variation in a UNT Health Science Center cadaver subset and its correlation with the statistics stated in the most recent literature. Methods: The cadavers in this study (n = 39)were provided through the University of North Texas Health Science Center Willed Body program. For dissection protocol, dissections of the abdominal area included removal of overlying tissues to expose the celiac trunk. Literature review was performed utilizing PubMed. Results: Of the 39 cadavers observed, only 31 were examined due to 8 having undergone complete liver removal. The prevalence of the left hepatic artery branching off of the left gastric artery was 12.9%. The sample frequency of the Michels Type II variation correlated well with the previous findings, where 11% of people exhibited this variation. In addition, one of the cadavers with the variant branching pattern exhibited an additional variation where the cystic artery pierced the common bile duct. This was not observed in the other cadavers. Conclusion: Previous research has revealed a wide range of variations in the branching patterns of the liver vasculature. The Michels classification system was established to serve as a standard nomenclature. The variation of interest, with the left hepatic artery branching from the left gastric artery, is an example of a Michels Class II variant. Similar to prior results, a prevalence of approximately 12.9% was found within the sample of hepatic pedicles evaluated. In addition to this finding, a unique arterial branching pattern where the cystic artery pierces the common bile duct was noted. This finding was present in a single cadaver. Clinically, variants with persistently reported high prevalence such as these should be screened to help prevent serious complications during surgical procedures involving these vessels, such as left gastric artery ligation and liver removal. The persistently reported high prevalence for the Michels type II variant exemplifies the need for such pre-operative screening.
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    Exploring the Role of Protective Factors on Depressive Symptoms among Mexican American Children.
    (2016-03-23) Jaime Hinojosa, Etienne; Aguilar, Alejandra; Franks, Susan; Fulda, Kimberly; Espinoza, Anna; Espinoza, Alex
    Purpose: National Health and Nutrition Examination Survey (NHANES) 2009–2012 dataset revealed that 7.6% of Americans aged 12 and over had depression. Youth, ages 12-17, had a depression rate of 5.7%. Research shows that ethnic disparities in mild, moderate, and severe depressive symptoms exist in Hispanics, compared to Non-Hispanic whites. The objective of this project is to explore the association between protective factors at the individual, relationship, and community level with depressive symptoms among Mexican American children. Materials and Methods: Variables were selected based on the social ecological model. A cross-sectional sample of 144 children, ages 10-14, and their legal guardian were used to examine exposure to seven protective factors: 1) acculturation 2) self-worth 3) positive physical development 4) family meals together 5) parent attendance of child events 6) neighborhood safety and 7) presence of recreation centers. The total number of protective factor exposures was categorized into four levels: 1, 2, 3, ≥ 4 exposures and run in a logistic regression model as the exposure of interest with depressive symptoms as the outcome. Depressive symptoms were evaluated using the Total Score yielded from the CDI 2: Self-Report (Short) version (CDI 2: SR[S]). Depressive symptoms were dichotomized as not having depressive symptoms (Average/Lower Level) and having depressive symptoms (High Average, Elevated, and Very Elevated Levels). Results: Of the boys (51% of sample), 10 (7%) had depressive symptoms, compared to 20 (14%) girls. Logistic regression adjusting for gender shows a relationship between protective factor exposures and depressive symptoms. Poverty, parent income, and BMI were not significantly associated with depressive symptoms and were not included as confounders. The model shows that for each increasing level of protective factor exposure there is a 0.168 (CI: 0.058, 0.490) odds for depressive symptoms. Conclusions: As the number of exposures to protective factors increase in a Mexican American child, the child has reduced odds of having depressive symptoms. Future studies should investigate not only the total number of protective factor exposures, but which type (e.g. individual, relationship, or community level) most impact the etiology of depressive symptoms in Mexican American children.
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    Serving Children in Need: Results from the UNTHSC Pediatric Mobile Clinic
    (2016-03-23) Chiapa-Scifres, Ana; Igenoza, Oluwatosin
    Objective To evaluate the activities of the UNTHSC Pediatric Mobile Clinic (PMC) from May 2014 to January 2016. The primary goal is to describe the population served and the types of health services offered, and to present future directions. Background Barriers to health care include cost, lack of transportation and lack of health insurance.1,2 Texas has about 1 million uninsured children, 62% of which are Medicaid eligible. Of these, 75,824 reside in Tarrant County.3,4 Mobile clinics have been found to reach more people who experience barriers in accessing health care services.2 The UNTHSC PMC was set up to provide clinical services and health education to Fort Worth neighborhoods with the greatest need for health services, and to provide preventive, screening, treatment and referral services as needed. Targeted neighborhoods in Fort Worth include Como, Morningside, North Side and Stop Six. Methods Data for this project was collected as part of the daily and weekly logs of the PMC. Data from May 2014 to January 2016 was analyzed and included the number and types of medical visits, number of vaccines administered and health screenings performed. Results were analyzed by age group, gender, race/ethnicity and neighborhood visited. Results From May 2014 to January 2016, the PMC had 259 site visits to schools and organizations in Fort Worth neighborhoods, with Morningside and North Side being the most visited. In total, there were 2788 child visits. Participants were 52% female, 70% Hispanic and 22% Black/African American. Total number of clinics, including site visits and health fairs, were 27 in Fiscal Year (FY) 1 (June – August 2014), 151 in FY 2 (September 2014 – August 2015) and 81 in FY 3 so far (September 2015 – January 2016). Services provided included vaccinations (31%), well child exams (24%), acute/episodic care (23%), medical screenings (20%), dental screenings (1%) and vision screenings. The PMC administered 584, 1493 and 846 vaccines in the first, second and third fiscal years respectively, totaling about 3000 vaccines administered. The PMC also provides case management encounters to families, and there were 147, 747 and 223 case management encounters in the first, second and third fiscal years respectively. Conclusions The PMC has since its onset provided valuable health services to children and families, just like other mobile clinics across the United States. It thus provides a solution to the barriers in accessing clinical and preventive health services faced by Fort Worth communities with the greatest need, including a high proportion of minority populations.
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    Physical Therapists’ role in community collaborative efforts to improve safety and prevent falls
    (2016-03-23) Bugnariu, Nicoleta PT, PhD; Zavadsky, Matt; Addington, Ricky; Cummings, David
    1. Collaborative efforts of the Fort Worth Fire Department, MEDSTAR mobile healthcare, and the Fort Worth Safe Communities Coalition have led to the development of a home safety and fall prevention service designed to reduce the incidence of falls among fort worth residents 65 years of age or older. 2. A 19-item home safety checklist was designed to assist in the evaluation of the primary resident’s home environment to identify potential fall risks. Physical therapists’ input regarding environmental fall risks was used for development of the checklist and the training of designated firefighters that deliver the service. The one hour free home safety evaluation identifies potential fall or safety risks. Firefighters make recommendations based on observations and provide information on available community resources specific to fall prevention. The Safe Community Coalition, specifically the Falls Prevention task force on which several physical therapists serve analyzes the de-identified data from home safety assessments performed by the FWFD. 3. In a 7 month period a total of 811 individuals were contacted. From these, only 153 expressed interest in receiving the FWFD service. A total of 137 individuals provided reasons for refusal of the home safety assessments free service. These reasons consisted of: non-interested (22%), current or previous access to home health (15%), and residential relocation (11%). A significant association between fear of falls and difficulty performing sit to stand was found (p=.016), 75% of participants that fear falls have difficulty standing from a seated position. 4. Prevention of falls and associated health care costs is a priority for many communities. Physical Therapists are well positioned to lead collaborative efforts engaging community organizations and that target fall prevention. Such programs offer potential benefits both to the community and to the emergency response infrastructure. The community receives education and evaluation regarding fall prevention aimed to reduce recurrence of falls. By prevention, demands placed on emergency resources can be potentially alleviated. Factors associated with the incidence of falls can be acknowledged and interventions can be provided to prevent subsequent impairment and decline in quality of life.
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    Hematopoietic Stem Cell Transplant in Pediatric Sickle Cell Disease: The Cook Children’s Experience
    (2016-03-23) Dhaliwal, Parneet; Johnson, Clarissa; Howrey, Richard; Torres, Marcela; Sweezer, Tonya; Kiel, Alice; Shah, Deep; Bowman, Paul; Joseph, Justin
    Background Current treatments for sickle cell disease are mainly supportive and are aimed at symptom control rather than curing the disease. The only known cure for sickle cell disease is hematopoietic stem cell transplantation. Successful transplantation has been found to eliminate further end-organ damage related to sickle cell disease. A study of transplant experiences and assessment of outcomes could potentially improve the future management of sickle cell disease patients. Purpose The objective of this study was to evaluate a single institution experience of patients undergoing hematopoietic stem cell transplantation at Cook Children’s Medical Center for treatment of Sickle Cell Disease. The data was analyzed to assess indications and outcomes of the transplanted sickle cell patients in order to evaluate transplant as a viable treatment for sickle cell disease. Materials and Methods A comprehensive retrospective chart review was performed on all patients who received a hematopoietic stem cell transplant for the treatment of Sickle Cell Disease from March 25, 1999 to May 24, 2013 at Cook Children’s Medical Center. The clinical variables collected consisted of demographic data, disease and medication history, transplant indications and preparations, donor source, engraftment information, and post-transplant complications. All electronic data was stored on Cook Children’s server using REDCap database. Results Data was collected on 20 patients who met inclusion criteria. Thrombotic stroke was the main clinical indication for transplant. All 20 patients continue to survive post-transplant. Sixteen patients achieved successful long term engraftment. These patients had a median period of follow-up of 4.5 years, ranging from 11 months to 9 years 1 month. Two patients received a 2nd transplant with subsequent failure to engraft. Fourteen developed graft versus host disease, 11 had neurological symptoms, 17 acquired infection, and 1 was found to have intracranial hemorrhage post- transplant. Discussion Preliminary results support the use of hematopoietic stem cell transplant as a viable treatment for sickle cell disease. The survival rate for patients as well as the successful engraftment rate following first transplant were suggestive of the viability of stem cell transplant. Further analysis of post transplant complications, specifically delineating graft versus host disease in relation to organ system and grade, will aid in improving management of these patients.
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    The Effect of ACL Femoral Drilling on Posterolateral Corner Reconstruction
    (2016-03-23) Webb, Brian; Marsh, Paul; Stout, Evan
    Purpose: This study aimed to evaluate the risk of tunnel collision with combined posterolateral corner (PLC) and anterior cruciate ligament (ACL) reconstruction and to identify which technique reduces the risk of tunnel collision. Methods: LCL and popliteus tunnels were drilled in sixty-four medium and large synthetic femurs and sixteen synthetic knee joints. ACL tunnels were then drilled using four different techniques: transtibial, anteromedial portal with a rigid guide pin, anteromedial portal with a flexible guide pin, and outside-in. The samples without obvious tunnel collision then underwent CT scan with 2-mm slices to determine the closest distance between the tunnels and the tangential distance (mm) between them were recorded. Results: Overall frequency of tunnel collision was 24/32 (75%) in large femur specimens and 32/32 (100%) for medium femur specimens. Obvious tunnel collision was observed in all transtibial, anteromedial with flexible instruments, and anteromedial with rigid instruments regardless of femur size or side. All of the specimens without tunnel collision occurred in the large femurs from the outside in group (n=8). The mean tunnel separation in all samples was 1.93 mm, with a range of 1.06 mm to 2.54 mm. Conclusion: Consistent with previous studies, we found a high rate of collision, especially in medium size femurs. The results of our study have provided evidence for the use of outside-in ACL reconstruction and PLC with 2 lateral femoral tunnels with the least amount of collision risk.
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    Effectiveness of Aquatic Therapy Interventions in the Management of Children with Cerebral Palsy: A Systematic Review
    (2016-03-23) Becnel, Melanie; Salem, Yasser; Liu, Howe; Vo, Andrea
    Purpose The purpose of this systematic review was to analyze the current scope of literature regarding the effectiveness of aquatic therapy as an intervention for children with cerebral palsy (CP) and to assess the feasibility of incorporating aquatic therapy into the physical therapy management of this specific population. Methods A literature search in 3 electronic databases - PubMed, CINAHL, and Academic Search Complete - was performed, using the following search terms: “cerebral palsy,” “children with disabilities,” “aquatics,” “aquatic therapy,” and “hydrotherapy.” Articles published between 1984 and 2014 were selected. Inclusion criteria for study selection included publication in the English language (or publication in any other language with available English translation); recruitment of participants with CP ages 0-21; and the use of aquatic therapy as the main experimental intervention. Studies were excluded if they were not written in English or had no easily accessible translation or if they recruited subjects older than age 21. The initial search resulted in 280 potential articles, which were screened for the stated inclusion and exclusion criteria as well as for duplicates. Thirteen articles satisfied the inclusion criteria. There were two case reports, one case series, one pilot study, three cohort studies, five quasi-experimental studies, and one randomized controlled trial. A total of 280 children with cerebral palsy participated in these investigations. Sample size across the research studies varied from 1 to 46 children. The ages of the participants varied from 3 to 21 years old. Results The evidence suggests that aquatic therapy interventions are effective in the short term for improving gross movement and gait parameters as well as social function and self-esteem in children with CP ages 0-21, and that aquatic therapy is feasible, safe, and fun for this population. Conclusions The overall body of evidence is inconclusive due to a lack of high-quality evidence, small sample sizes, and variability in intervention parameters (frequency, duration, intensity, etc.), severity of disease, and outcome measures. More research must be conducted with larger sample sizes, higher quality study design, and more consistent outcome measures to determine effective exercise parameters and to further support the success of aquatic therapy as a physical therapy intervention for this population.
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    The Combined Effect of Translational and Rotational Malreduction on Sacroiliac Joint Contact Surface Area
    (2016-03-23) Wood, Addison; Wagner, Russell MD; BARCAK, ERIC; Lopez, Jennifer
    PURPOSE: Boney apposition of sacroiliac articular surfaces or anatomic reduction is of paramount importance to achieve long term stabilization through fusion of the sacroiliac joint. The amount of contact surface area in these fixated joints provides some insight into the potential fusion rates of a joint. There is a bulk of literature supporting an association between anatomic reduction and good long term outcomes, yet most of these studies define an acceptable reduction as having less than 1 cm of displacement which would be unacceptable in other areas of the skeletal system. METHODS: 14 sacroiliac joints specimens were dissected prior to scanning each face of the sacroiliac joint with a multi laser 3D scanner (NextEngine, Inc,). The 3D models were then imported into AutoCAD modeling software (Autodesk, Inc,) for manipulation. Prior to manipulation, the major and minor axes of the sacroiliac joint are defined and used as pathways for superior, posterosuperior, and posterior displacements of the sacrum on the ilium. In addition, a vertical axis as served as the center of internal and external rotation manipulations. Contact surface area for each specimen was then calculated while in the fully anatomically reduced state. This measurement was repeated as the sacrum was displaced in 2mm increments, up to maximum of 25mm, separately in all 3 translational directions. This method was repeated and contact surface area measurements recorded as the ilium was rotated internally and externally in 1 degree increments, up to maximum of 10 degrees, at each increment of translational displacement. RESULTS: Work in progress, however, all 14 specimens have been scanned with a 3D laser scanner and data collection is underway. DISCUSSION AND CONCLUSION: Current literature has only addressed planar translations of the ilia in relation to the sacrum. This is in stark contrast to the reality of typical sacroiliac disruptions which involve multiple translations in combination with internal/external rotation of the ilia. Therefore, the goal of this study was to evaluate the acceptable tolerances of malreduced sacroiliac joints through contact surface area changes in response to combined translations and rotations about the sacroiliac joint. By overcoming the limitations of prior 2 dimensional comparisons we provide a clearer picture of the necessity of anatomic reduction and the need for increased aggressiveness in the treatment of sacroiliac disruptions through our 3D study.
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    Comparative Study on Hospital Consumer Assessment of Healthcare Providers and Systems between two General Hospitals in Indore, India
    (2016-03-23) Mecwan, Neil; Joshi, Deepti
    Statement of Hypotheses: The Null Hypothesis states that there is no significant difference between the patients’ perception of their experience of services of Hospital A and Hospital B. The Alternate Hypothesis states that there is a significant difference between the patients’ perception of their experience of services of Hospital A and Hospital B. Purpose: The research aimed to recommend measures to improve the quality of services on the basis of factors underlying the difference, if any. Methods: A questionnaire was used to compare the two hospitals over 15 parameters on Likert scale. Random sampling was used for primary data collection through direct contact with patients just before discharge. The parameters were classified as Single-Item measures, Composite Measures and Global-Rating Measure. Measures of Central Tendency, Variance, and t-test were used to compare the results. Results: 100 patients from each hospital were included. The values of t-test for all the parameters showed significant difference in the mean value of perceived quality of the two hospital services (all p values Conclusion: In this study, considerable difference was found in the patients’ perception of the service quality of the two general hospitals. Focus on patient-centered services, hygiene, communication, and promptness in providing services is recommended. Few underlying factors were identified, however, further research is required to identify the extent of impact of these factors on the patients’ perception of hospital services.
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    The Radiographic Prepatellar Fat Thickness Ratio Correlates with Infection Risk Following Total Knee Arthroplasty
    (2016-03-23) Wagner, Russell MD; McElroy, John; Burge, Ross; Mendez, Salvador
    Obesity is a known risk factor for surgical site infections (SSI) following total knee arthroplasty (TKA). Current methods use body mass index (BMI) to predict infection risk in patients. However, BMI may not be the most accurate predictor because it does not account for fat distribution and muscle mass is included in the calculation. We sought to assess the impact of subcutaneous fat at the surgical site on risk of infection following a TKA. It has been shown that fat tissue thickness expands without a complementary increase in blood flow, leaving subcutaneous tissue with reduced oxygenation. This wound hypoxia impairs healing by multiple mechanisms; healing wounds have high oxygen demands and leukocytes need oxygen to create reactive oxygen species against infection. We conducted a retrospective study of 530 patients who had TKAs at John Peter Smith Hospital (JPS) from 2006-2010. Pre-operative lateral knee radiographs for each patient were reviewed and measured. Both patellar thickness and prepatellar fat thickness were obtained. Soft tissue thickness was divided by the thickness of the patella to create the prepatellar fat thickness ratio (PFTR). Additionally, diabetes status, smoking status, gender, and BMI were obtained. The infection criteria used was 2 (+) cultures, or 1 (+) culture plus one of the following: gross purulence or [greater than] 10 PMNs/hfp. We expect the PFTR to be a significant predictor of SSI and more accurate than BMI in this regard. It may be beneficial to assess the PFTR in the preoperative evaluation to properly inform the patient of infection risk and allow the physician to take additional precautions to reduce the risk of infection.
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    Geriatric Utilization of Drugs on the BEERs List: Physician Prescribing and Implications for Pharmacist Provided Medication Therapy Management (MTM)
    (2016-03-23) Sadasivam, Vinodha; White, Annesha; Roberts-LaGrone, Tyrane
    Objective: Drug prescribing patterns reveal that elderly patients were prescribed inappropriate medications at 8% of doctor visits. A panel of geriatric medicine and pharmacology experts published the BEERs list as guidance for medication dispensing for seniors. Of 677,580 patients receiving prescriptions through Medicare Part D, 31.9% received a potentially inappropriate medication. The objective of this study was to identify drugs most commonly prescribed to geriatric patients, to compare those drugs to the BEERs list and to provide adverse effects (AE) that could be minimized through MTM. Methodology: The list of 135 drugs utilized for comparison was derived from three sources (NewWest, Propublica, Aetna) and represents the most commonly dispensed and/or sold prescriptions for Medicare Part D (CMS 2013). This list was compared to BEERs list (2015). To identify MTM examples, a literature search using PubMed, Medline, CINAHL and Google Scholar was performed from 2010-2015. Key search terms were “seniors”, “geriatrics”, “medication therapy management” and “adverse effects.” Articles were excluded if they were not in English or lack detailed adverse effects. Results: Upon comparison, 15 of the 135 drugs were listed on the BEERs list and deemed inappropriately prescribed. Specifically, antipsychotics with AE of orthostatic hypotension, bradycardia, increased fall risk and high abuse potential should be avoided. Commonly prescribed, antipsychotic, quetiapine has a black box warning of increased mortality in elderly patients with dementia-related psychosis. The most frequently prescribed inappropriate drugs were antihypertensive valsartan, proton pump inhibitor omeprazole, and antipsychotics quetiapine and olanzapine. The majority of the 11 MTM articles retrieved were observational studies. Common AE were sedation, tardive dyskinesia, anticholinergic effects and prolonged hypoglycemia. Conclusion: The BEERs list was developed as a safeguard against inappropriate care for the elderly. A 2010 study examined pharmacist provided MTM and found that drug problems were identified for over 85% of the geriatric population, improved health outcomes for over 50% and reduced cost overall. Future research should focus on examining the MTM impact on AE reduction and the economic impact of inappropriate prescribing.
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    Development and validation of a REHAB glove device for post-stroke hand rehabilitation
    (2016-03-23) Patterson, Rita PhD; Nicaris, Timothy PhD, MD; Haghshenas-Jaryani PhD, Mahdi; Wijesundara PhD, Muthu; Young, Carolyn MS; Bugnariu, Nicoleta PT, PhD; Ha, Christopher
    INTRODUCTION Approximately 800,000 people in the United States have a stroke each year, of which 30% to 66% of all survivors have impaired hand functions. Certain therapeutic interventions such as Continuous Passive Motion (CPM) capitalize on the brain’s inherent neuroplasticity to increase adaptation to stroke. Currently, no dedicated system exists which effectively applies post-stroke hand therapy. To address this need, a soft robotic rehabilitation system capable of monitoring and assisting hand motion for post-stroke patients has recently been developed. This abstract compares simulation and experimental data on a human finger with a corresponding robotic digit to evaluate the viability of the current design for rehabilitation purposes and to ensure patient safety and performance. METHODS/RESULTS Glove and Soft Robotic Digits: This system consists of five sensorized robotic digits and a wearable fixture along with a programmable control unit that monitors and modulates the trajectory of the fingers. Finger motion is accomplished by pneumatically actuated soft robotic digits based on hybrid soft-and-rigid actuator technology. Computer simulations have shown the resulting relative angles between rigid sections at the metacarpal phalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints can reach full anatomical range of motion (ROM) at a single actuation pressure of 24.3kPa. Kinematic study: A kinematic study was conducted to compare one subject’s index finger with a robotic digit using a motion capture system to analyze spatial and angular position. This study determined the functional anatomical ROM requirements at each joint for both the robotic digit and index finger. The achieved ROM for MCP, PIP, and DIP joints of the robotic digit are 85˚, 96˚, and 53˚, respectively, which are in good agreement with full anatomical ROM. It should be noted that the human finger (MCP: 45˚, PIP: 75˚, and DIP: 45˚) did not quite reach full ROM during testing due to obstacles in tracking. Still, these achieved ROM are consistent with the functional ROM of human fingers. DISCUSSION A hand therapy glove has been designed to provide flexion and extension of the fingers as an adjunct to hand rehab. A prototype has been fabricated based on initial design parameters and is able to provide joint ROM based on the literature. Functional grasp parameters have been experimentally measured in a human finger and will be used for future design improvements.
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    Fixation Stiffness with Increasing Stem Taper Angle After Revision Total Hip Arthroplasty
    (2016-03-23) Kosmopoulos, Victor; Chen, Diana
    Hypothesis Stable femoral fixation during total hip arthroplasty (THA) is critical to ensure adequate implant performance. Although cylindrical implant stems designs generally have shown satisfactory long-term results, in revision cases or cases with poor bone quality, tapered hip replacement stems have been suggested as a better performing alternative. The degree of the taper has yet to be biomechanically tested in such revision cases. This study aims to compare the initial fixation stability with increasing tapered stem implant geometry using two diaphyseal bone loss models simulating revision THA. Methods Using the finite element (FE) method, a numerical technique commonly used to computationally approximate solutions for complex structural mechanics problems, two femoral diaphyseal models were used to simulate revision THA. The first femoral model simulated bone loss having a diaphyseal length of only 21.5-cm.The second femoral model was further sectioned to 21.0-cm. The taper angle of the distal stem of the prosthesis - the region of the implant in contact with the bone cortex – was varied from 0 to 2.5 degrees in 0.5 degree increments. Results As the taper was increased from 0 degrees to 2.5 degrees in the 21.5 cm diaphyseal model, there was a 79%, 30%, 7%, and 14% decrease in contact area, average bone stress, average implant stress and construct stiffness respectively. As the taper was increased from 0 degrees to 2.5 degrees in the 21.0 cm diaphyseal model there, was a 75%, 29%, 6%, and 20% decrease in contact area, average bone stress, average implant stress and construct stiffness respectively. Noteworthy, the stiffness started to fall drastically as the taper increased past 2 degrees in the 21.0-cm diaphyseal model. Conclusions The ideal implant should maximize the beneficial effects of a taper and minimize the detrimental effects. At the bone diaphyseal lengths studied, although all the tapered models showed satisfactory performance, the 0 degree no taper model showed the highest stiffness. If implant stress is a concern, from our results, it appears that the 1.5 degree taper minimizes implant stress without drastically decreasing stiffness.
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    Exploring mechanisms between Religiosity and Health Behaviors in African American Women
    (2016-03-23) Suzuki, Sumihiro; Kitzman-Ulrich, Heather; Dodgen, Leilani
    Background: Current interventions with African American (AA) women show less weight loss overall, and lower maintenance over time compared to other populations. There is great interest in culturally adapting evidence based interventions to increase effectiveness for AA populations. Seventy percent of Black women report living a religious life is important compared to 57% White women. As a result, faith is a primary adaptation for weight loss programs among AA women. While a positive relationship between faith and health has been established, how the relationship works is still being understood. In this study, the possible mediating effects of motivation on the relationship between religion and health behavior was examined. Methods: Baseline data from the Better Me Within (BMW) program (P20MD006882) was used for this study. Religion was measured by the spiritual health locus of control (SHLOC) survey that includes passive and active subscales. The active subscale refers to those who have a belief that God is a partner in health and are hypothesized to have more positive health behaviors, whereas those with a passive score show fatalistic beliefs (e.g., health is in God’s hands) and are expected to engage in less positive health behaviors. However, other variables may play a role in this relationship such as motivation. This study evaluated means and standard deviations, and calculated simple correlations between SHLOC, motivation for physical activity and minutes of physical activity (PA). Simple linear regression models were run to evaluate the influence of SHLOC and health behaviors (e.g. PA) on motivation. Results: A total of 158 participants were included in this analysis (Mean Age=48.9 ± 11.68, Body Mass Index (BMI)=38.15 ± 9.71 Waist circumference (WC) =43.04 ± 5.88). The majority of participant had some education after high school (80%). Participants also showed high active SHLOC (Mean=35.47 ± 7.48, max score = 44). Motivation for PA was positively and significantly correlated with active SHLOC (0.16, p Conclusions: Results show having a more passive (fatalistic) view of health is associated with higher levels of motivation for PA. While this seems illogical, it does offer opportunities for alternative explanations. Self efficacy (Confidence for Exercise and PANSE) may be driving the relationship between motivation for PA and SHLOC. More work is needed to understand the mediators between faith and health. If self efficacy is more influential in this relationship, then adapting interventions to focus on self efficacy rather than faith may be beneficial to lifestyle interventions for AA women.
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    Centrally Located Visceral Adipose Tissue and Outcomes after Laparoscopic Gastric Banding Surgery
    (2016-03-23) Franks, Susan; Smith, Adam; Matthiesen, Ryan
    Hypothesis: A higher proportion of central VAT relative to total VAT leads to decreased efficacy of LGBS outcomes as measured by percent excess weight loss (%EWL), inflammatory marker, and insulin resistance. Method: Thirty-three LGBS patients (21 women, 12 men) underwent pre-surgical and 6-month (T2) post-surgical testing. Average age was 45.7 years (24-66). Average baseline Body Mass Index was 43.1 kg/m2 (32.4-54.0). Fasting blood samples were taken to assess cardiac C-reactive protein (CRP), insulin, and glucose. Homeostasis Model of Assessment score (HOMA) for insulin resistance was calculated using insulin and glucose. %EWL was calculated using number of pounds lost relative to number of baseline pounds above a BMI of 25. VAT was assessed using computed tomography. Proportion of central VAT was calculated as L4/L5 divided by total VAT. Patients were split into a Low- (LP) or High Proportion (HP) group based on a median split. Repeated measures t-tests were used to compare changes in CRP and HOMA from baseline to T2. Independent t- tests were used to compare differences between groups at T2 in CRP, HOMA, and %EWL. Results: Both LP and HP showed significant reductions from baseline to T2 in CRP (p=.026 and .000 respectively), and HOMA (both p=.001). There was no significant difference at T2 between LP and HP in %EWL or HOMA. A trend toward lower CRP at T2 for HP compared to LP was observed, although results were not significant (p=.08). Conclusion: Results of this analysis demonstrate that the relative proportion of centrally located VAT does not appear to be a significant factor in outcomes measured 6 months post-LGBS. Patients with higher or lower proportions exhibit improvements in HOMA and %EWL, although inflammation may not resolve as effectively for patients with higher proportions. Overall, it appears that the relative location of VAT does not appear to be a substantive factor in the efficacy of LGBS.
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    A STEP in the Right Direction: An Interdisciplinary Approach to Transitional Care (2016)
    (2016-03-23) Allen, John G.
    Purpose: The Affordable Care Act, calls for more focus on finding innovative delivery systems that improve care, increase efficiency, and reduce costs. Background: Hospital readmissions, excessive falls, and poor quality of life are factors that unnecessarily increase healthcare costs. The Safe Transitions for the Elderly Patients (STEP) program is a hybrid transitional care model developed by the UNT Health Science Center (UNTHSC) as part of an 1115 Waiver to address these factors in a home care setting in Tarrant County. Objectives: The primary goals of STEP are to reduce all-cause 30 day hospital readmissions, improve quality of life, and decrease falls among Medicaid patients over 50 years through a collaborative and interdisciplinary approach to patient care. Methods: An interprofessional team that includes a physician/geriatrician, nurse practitioner, physician assistant, social workers, physical therapists and a dietician assess and treats the pateint in the home for up to 90 days post hospital discharge based on the individual patient needs. Conclusions: Through this model, UNT Health Science Center has the opportunity to demonstrate a unique transitional care model that will improve health care delivery post-hospitalization.