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Watters T.S.,Porter Adventist Hospital | Zhen Y.,Shandong University | Ryan Martin J.,Porter Adventist Hospital | Levy D.L.,Porter Adventist Hospital | And 2 more authors.
Journal of Bone and Joint Surgery - American Volume | Year: 2017

Background: Despite the success of restoring joint stability and improving early functional outcomes after anterior cruciate ligament (ACL) reconstruction, the long-term risk of developing symptomatic osteoarthritis requiring total knee arthroplasty is higher than that in the uninjured population. The purpose of this study was to compare operative characteristics and early outcomes of patients undergoing total knee arthroplasty after ACL reconstruction with those of a matched cohort of control subjects with primary osteoarthritis and no history of ligament reconstruction. Methods: All patients who had undergone total knee arthroplasty from 2005 to 2013 at our institution with a history of ACL reconstruction and a minimum 2-year follow-up were identified from a prospective research database. These patients were matched by demographic and surgeon variables to patients who had not undergone prior ACL reconstruction. Outcomes included Knee Society Scores (KSS), range of motion, operative variables, complications, and reoperations. Results: A cohort of 122 patients was identified as the ACL study group and was compared with the matched control cohort. The mean age at the time of the surgical procedure was 58 years, and 55% of the patients were male. The mean follow-up was 3.3 years in the ACL group and 3.0 years in the control group. There was no significant difference in the latest KSS outcomes between groups postoperatively (p > 0.05). Although preoperative flexion was significantly lower (p = 0.01) in the ACL group (119°) than in the control group (123°), there was no difference between groups postoperatively. Fifty percent (61 of 122) of patients in the ACL group required implant removal at the time of total knee arthroplasty. The operative time was significantly longer (p < 0.001) in the ACL group (88 minutes) compared with the control group (73 minutes). There were a total of 11 reoperations in the ACL group, including 4 for periprosthetic infection, whereas there were only 2 reoperations in the control group. The risk of reoperation in the ACL group was more than 5 times higher than in the control group (relative risk, 5.5 [95% confidence interval, 1.2 to 24.3]; p = 0.01). Conclusions: The results of this retrospective matched cohort study suggest that prior ACL reconstruction results in longer operative time and increased risk of early reoperation after total knee arthroplasty. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence. © 2017 By The Journal of Bone and Joint Surgery, Incorporated.


Thammana R.V.,Emory University | Knechtle S.J.,Emory University | Knechtle S.J.,Childrens Hospital of Atlanta | Knechtle S.J.,Porter Adventist Hospital | And 5 more authors.
Liver Transplantation | Year: 2014

Racial and socioeconomic disparities exist in liver transplantation (LT) outcomes among adults, but little research exists for pediatric LT populations. We examined racial differences in graft survival and mortality within a retrospective cohort of pediatric and young adult LT recipients at a large children's transplant center in the Southeast between 1998 and 2011. The association between race/ethnicity and rates of graft failure and mortality was examined with Cox proportional hazards models that were adjusted for demographic and clinical factors as well as individual-level and census tract-level socioeconomic status (SES). Among the 208 LT recipients, 51.0% were white, 34.6% were black, and 14.4% were other race/ethnicity. Graft survival and patient survival were higher for whites versus minorities 1, 3, 5, and 10 years after transplantation. The 10-year graft survival rates were 84% [95% confidence interval (CI) = 76%-91%] for white patients, 60% (95% CI = 46%-74%) for black patients, and 49% (95% CI = 23%-77%) for other race/ethnicity patients. The 10-year patient survival rates were 92% (95% CI = 84%-96%), 65% (95% CI = 52%-79%), and 76% (95% CI = 54%-97%) for the white, black, and other race/ethnicity groups, respectively. In analyses adjusted for demographic, clinical, and socioeconomic characteristics, the rates of graft failure [black: hazard ratio (HR) = 2.59, 95% CI = 1.29-5.45; other: HR = 3.01, 95% CI = 1.23-7.35] and mortality (black: HR = 4.24, 95% CI = 1.54-11.69; other: HR = 3.09, 95% CI = 0.78-12.19) were higher for minority groups versus whites. In conclusion, at a large pediatric transplant center in the Southeastern United States, racial/ethnic disparities exist in pediatric and young adult LT outcomes that are not fully explained by measured SES and clinical factors. Liver Transpl 20:100-115, 2014. © 2013 AASLD. © 2013 American Association for the Study of Liver Diseases.


Braaten J.S.,Centura Health | DeGunst G.,Porter Adventist Hospital
Joint Commission Journal on Quality and Patient Safety | Year: 2015

Our overall aim in this study was to implement interventions to increase the RRT activation rates. Our secondary aim was then to assess whether the increase in RRT activation rates led to a reduction in non-ICU code blue rates. We found that interventions targeted at knowledge, teamwork, and traditional cultural barriers to RRT activation successfully increased RRT activation rates, which were accompanied by an absolute reduction in non-ICU code blue rates. These results suggest that such interventions can change behavior and break down barriers to activation of the RRT, with an associated decrease in non-ICU code blues. We intend to further study the sensitivity of RRT criteria to at-risk patients; the effect of the RRT on targeted subsets of patients, such as liver failure, stroke, and postoperative or transfer from ICU within 24 hours, and patients with multiple comorbidities; and benefits of the RRT system, such as increased communication, collaboration, and teamwork, and improved safety culture. Copyright 2015 The Joint Commission.


Campana J.,Porter Adventist Hospital | Ramakrishnan V.R.,Aurora University
JAMA Otolaryngology - Head and Neck Surgery | Year: 2014

IMPORTANCE: Large and complex nasal septal perforations may cause considerable patient discomfort and are challenging to repair. Posterior septal resection (PSR) is a simple procedure and can be incorporated into the surgical management algorithm for this patient population. OBJECTIVE: To evaluate PSR for the treatment of symptomatic complex and large nasal septal perforations. DESIGN, SETTING, AND PARTICIPANTS: Retrospective medical chart review from 1995 through 2007 of patients who underwent PSR. Medical charts were reviewed, and a follow-up telephone questionnaire was performed. INTERVENTIONS: Posterior septal resection. MAIN OUTCOMES AND MEASURES: Improvement of selected symptoms after PSR. RESULTS: Twenty-one patients were identified, 16 patients had thorough documentation of perioperative information contained in their medical charts, and 12 patients were available for follow-up survey. All patients tolerated the procedure well without long-term sequelae from surgery. Overall nasal discomfort was significantly improved in 12 of 12 patients (P < .001). All nasal symptom scores of obstruction, pain, whistling, drainage, crusting, and epistaxis showed statistically significant (P < .05) improvement from preoperative values. Nasal obstruction and crusting were symptoms that improved with high statistical significance (P < .001). Patients reported on average a 79% improvement (range, 45%-100% improvement) in nasal airway, with only 1 patient reporting no improvement. All patients were satisfied with their surgery and would undergo the procedure again and recommend it to others. CONCLUSIONS AND RELEVANCE: Posterior septal resection provides overall patient satisfaction and improvement in subjective nasal symptom scores when used for large and complex septal perforations. This simple procedure may be included in the treatment algorithm of large and complex symptomatic septal perforations. Copyright 2014 American Medical Association. All rights reserved.


ROSEMONT, Ill. (March 1, 2017)--Obesity affects 35 percent of the adult population in the U.S. A new literature review published in the Journal of the American Academy of Orthopaedic Surgeons (JAAOS) identifies strategies to improve total knee replacement (TKR) outcomes in patients with obesity. TKR is a common orthopaedic procedure that is used to replace the damaged or worn surfaces of the knee, often caused by injury or osteoarthritis, to decrease pain and restore mobility for patients. "Until recently, little was known about the outcomes of patients with obesity undergoing TKR," said lead study author and orthopaedic hip and knee surgeon J. Ryan Martin, MD. "We sought to review what information is known and what areas need further investigation." According to the current review, prior to surgery, patients should: Researchers also found that excess soft tissue in patients with obesity can obstruct visibility in the treatment site during surgery. This lack of visibility can result in difficulty achieving proper alignment and implant fixation as well as longer surgical time. Techniques such as computer-assisted alignment may expedite surgery, and minimize complications. Post-surgery, patients with obesity are at high risk for revision because of decreased longevity of implants and an elevated risk of infection. Currently, no study has evaluated methods for decreasing these complications, but data suggests it may be beneficial to utilize implants with improved fixation. "Although further research is needed, this review has allowed us to identify a variety of treatment methods to improve outcomes and reduce complications in patients with obesity," said Dr. Martin. "We reviewed the most recent studies on obesity to provide perioperative guidance to improve and optimize outcomes based on our current evidence-based review." From OrthoCarolina, Charlotte, NC (Dr. Martin), Colorado Joint Replacement, Denver, CO (Dr. Jennings and Dr. Dennis), and the Department of Bioengineering, University of Denver, Denver, theDepartment of Orthopaedics,University of Colorado School of Medicine, Aurora, CO, and the University of Tennessee, Knoxville, TN (Dr. Dennis). Dr. Martin or an immediate family member serves as a paid consultant to Zimmer Biomet. Dr. Jennings or an immediate family member serves as a paid consultant to DePuy Synthes and Total Joint Orthopedics and has received research or institutional support from DePuy Synthes and Porter Adventist Hospital. Dr. Dennis or an immediate family member has received royalties from DePuy Synthes and Innomed; is a member of a speakers' bureau or has made paid presentations on behalf of and serves as a paid consultant to DePuy Synthes; has stock or stock options held in Joint Vue; and has received research or institutional support from DePuy Synthes and Porter Adventist Hospital.


With an upcoming publication in the Worldwide Leaders in Healthcare, Melissa F. Nielsen, RN, joins the prestigious ranks of the International Nurses Association. Melissa is a registered nurse with three years of experience in her field and an extensive expertise in all facets of nursing, especially general surgical nursing. Melissa is currently caring for patients at Porter Adventist Hospital, a 368-bed acute care hospital located in the University of Denver/Harvard Park area of Denver, Colorado. Melissa received her nursing degree in 2011 from the Colorado State University-Pueblo. An advocate for continuing education, she then went on to the University of Texas Arlington College of Nursing and Health Innovation in Arlington, Texas, and completed her Bachelor of Science degree in nursing. Melissa is maintains a professional membership with the American Nurses Association, and credits her success to her mother. In her spare time, Melissa enjoys being with her family and friends, and outdoor activities. Learn more about Melissa here: https://www.linkedin.com/in/melissa-nielsen-38720384 and read her upcoming publication in the Worldwide Leaders in Healthcare.


McKenzie E.M.,University of Texas Health Science Center at Houston | Balter P.A.,University of Houston | Stingo F.C.,University of Houston | Jones J.,Porter Adventist Hospital | And 2 more authors.
Medical Physics | Year: 2014

Purpose: The authors investigated the performance of several patient-specific intensity-modulated radiation therapy (IMRT) quality assurance (QA) dosimeters in terms of their ability to correctly identify dosimetrically acceptable and unacceptable IMRT patient plans, as determined by an inhouse-designed multiple ion chamber phantom used as the gold standard. A further goal was to examine optimal threshold criteria that were consistent and based on the same criteria among the various dosimeters. Methods: The authors used receiver operating characteristic (ROC) curves to determine the sensitivity and specificity of (1) a 2D diode array undergoing anterior irradiation with field-by-field evaluation, (2) a 2D diode array undergoing anterior irradiation with composite evaluation, (3) a 2D diode array using planned irradiation angles with composite evaluation, (4) a helical diode array, (5) radiographic film, and (6) an ion chamber. This was done with a variety of evaluation criteria for a set of 15 dosimetrically unacceptable and 9 acceptable clinical IMRT patient plans, where acceptability was defined on the basis of multiple ion chamber measurements using independent ion chambers and a phantom. The area under the curve (AUC) on the ROC curves was used to compare dosimeter performance across all thresholds. Optimal threshold values were obtained from the ROC curves while incorporating considerations for cost and prevalence of unacceptable plans. Results: Using common clinical acceptance thresholds, most devices performed very poorly in terms of identifying unacceptable plans. Grouping the detector performance based on AUC showed two significantly different groups. The ion chamber, radiographic film, helical diode array, and anteriordelivered composite 2D diode array were in the better-performing group, whereas the anteriordelivered field-by-field and planned gantry angle delivery using the 2D diode array performed less well. Additionally, based on the AUCs, there was no significant difference in the performance of any device between gamma criteria of 2%/2 mm, 3%/3 mm, and 5%/3 mm. Finally, optimal cutoffs (e.g., percent of pixels passing gamma) were determined for each device and while clinical practice commonly uses a threshold of 90% of pixels passing for most cases, these results showed variability in the optimal cutoff among devices. Conclusions: IMRT QA devices have differences in their ability to accurately detect dosimetrically acceptable and unacceptable plans. Field-by-field analysis with a MapCheck device and use of the MapCheck with a MapPhan phantom while delivering at planned rotational gantry angles resulted in a significantly poorer ability to accurately sort acceptable and unacceptable plans compared with the other techniques examined. Patient-specific IMRT QA techniques in general should be thoroughly evaluated for their ability to correctly differentiate acceptable and unacceptable plans. Additionally, optimal agreement thresholds should be identified and used as common clinical thresholds typically worked very poorly to identify unacceptable plans. © 2014 American Association of Physicists in Medicine.


PubMed | Raleigh Orthopaedic Clinic, Porter Adventist Hospital and University of Denver
Type: | Journal: The Journal of arthroplasty | Year: 2016

Patellar crepitus is a complication most commonly seen in patients implanted with a posterior-stabilized total knee arthroplasty (TKA). Recently, design changes in the patellofemoral geometry and the intercondylar box ratio have been optimized in newer TKA designs. A comparative study was performed to analyze the incidence of patellar crepitus between a historical vs modern TKA design.A retrospective review of all patients at our institution that underwent a primary TKA with either a PFC Sigma or Attune posterior-stabilized TKA (DePuy, Inc, Warsaw, IN), with a minimum of 1-year follow-up duration was performed. A total of 1165 participants implanted with the PFC Sigma and 728 with the Attune design were analyzed. Patellar crepitus incidence, functional scores, and range of motion were recorded at each follow-up appointment. Statistical analyses were performed between the 2 groups to determine if there were differences in clinical outcomes.The incidence of crepitus in participants implanted with the Attune was 0.55% vs 6.26% in the PFC Sigma cohort (P < .001) at 1 year vs. 0.83% vs 9.4%, respectively at 2 years post operatively (P < .001). There were small differences in extension, flexion, and Knee Society Scores between the 2 groups that were not clinically meaningful.The Attune posterior-stabilized TKA demonstrated substantially less patellofemoral crepitus incidence than the historical control. We hypothesize that these findings are related to femoral component changes including a thinner and narrower anterior flange and a reduced femoral intercondylar box ratio.


Kelts E.A.,Porter Adventist Hospital
NeuroRehabilitation | Year: 2010

Although Thoreau admonishes us that it is not what you look at that is important, I hope it is clear from the discussion above that what you look at directly affects what you see, making the two aspects of vision inseparable. As a result of this intertwined nature, healthy functioning of all of the system's representative parts is necessary for the visual system to work properly. But vision does not reside only in the eyes. I hope it is clear fromthe previous discussion that the human visual system is a very complicated network of afferent and efferent connections spread through several regions of the head, neck and upper thorax. It also follows that, because of the complexity of the visual system, it is very subject to trauma. As a result, it is very common for victims of motor vehicle accidents, accidental trauma, sportsrelated injuries, and domestic altercations to present with a visual complaint. © 2010 - IOS Press and the authors. All rights reserved.


Kelts E.A.,Porter Adventist Hospital
NeuroRehabilitation | Year: 2010

Traumatic Brain Injury is a common cause for visual dysfunction simply because of the proportion of the nervous systemdevoted to vision. However, because of the potential for healing and the opportunities presented by neural plasticity, many such injuries improve and some resolve completely. The first, and most important, step involved in helping patients with visual complaints after TBI is correct diagnosis. The second is treatment by an organized system of support, rehabilitation, and compassion. © 2010 - IOS Press and the authors. All rights reserved.

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