Browsing by Subject "Treatment Outcomes"
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Item Apolipoprotein E Isoform Influence on Outcomes after Pediatric Traumatic Brain Injury(2016-01-19) Usala, Claire; Huang, Rong; Hernandez, Ana; Miles, DarrylINTRODUCTION: The ε4 allele of the apolipoprotein E gene (APOε) is associated with poor outcomes in adults with traumatic brain injury (TBI), but its influence on recovery after pediatric TBI is uncertain. The primary aims of this study were to determine if an association exists in the outcome of children after TBI between those with at least one ε4 allele and non ε4 genotypes. Using the Glasgow outcome score (GOS), we examined three outcome variables between the two groups 1) GOS at hospital discharge, 2) GOS at long-term follow-up, and 3) the magnitude of change in GOS from discharge to > 6 month assessment (Δ GOS). METHODS: Data were prospectively collected from 220 children presenting with moderate or severe blunt head trauma between the ages of 0 and 17 years old from 2002-2013. Outcomes were assessed at hospital discharge and 12.7±8.4 months post-injury. Patients in the ε4 and non ε4 groups did not differ in injury mechanism, severity, or demographics; 23.4% had at least one ε4 allele and ε3/ ε3 was the most common genotype (67.4%). Multiple regression model analysis was conducted to determine if associations existed between the genotype combinations and outcome while controlling for age, ER GCS, ICP monitor placement, and whether CPR was performed. For ε4 genotypes analysis, we also stratified patients by admission Glasgow Coma Scale (GCS) into severe (GCS 3-8) versus non-severe (9-15), as well as moderate and severe (3-12) versus mild (13-15) groups. RESULTS: For aim 1, the GOS at discharge did not differ significantly in ε4 versus non- ε4 patients in any injury severity category before or after controlling for cofounding variables. However, after controlling for confounding variables, patients with at least one ε2 allele in the moderate or severe injury category had significantly worse GOS at discharge. For aim 2, after controlling for confounding variables, patients with the ε3/ε3 genotype had significantly better long-term GOS than patients with the genotype ε3/ε2 (p<0.05). However, we did not find a significant difference in long-term outcome between ε4 and non ε4 genotypes in the primary analysis or when stratified by injury severity groups. Finally, between ε4 and non ε4 genotypes, the Δ GOS and neuropsychological scores did not differ significantly between genotypes. DISCUSSION: Overall these results propose that unlike adults, the ε4 allele may not be associated with 12-month outcome or the rate of recovery (ΔGOS) from hospital discharge following pediatric TBI. Our results implicating worse outcomes for the ε2 genotypes suggest that this allele may be a candidate for further study to delineate its role in TBI outcome in children. Unique to this study was our analysis of neuropsychological measures, which were also not affected by the presence of ε4 in a smaller cohort of children. This study adds to current literature suggesting that unlike adults APOε4 may not exert a significant effect on pediatric TBI outcome. However, these results are limited in that any genotypic effect on neurologic repair may not be apparent for much longer time periods in pediatric brain injury as the child continues to develop and grow.Item Free Flap Breast Reconstruction in Cancer Patients: Effect of BMI on Outcomes of the Deep Inferior Epigastric Perforator (DIEP) Flap(2016-01-19) Reddy, Nikitha; Cullins, Madeline; Kayfan, Samar; Pezeshk, Ronnie A.; Teotia, Sumeet S.; Haddock, Nicholas T.BACKGROUND: The Deep Inferior Epigastric (DIEP) flap has achieved marked acceptance in free flap breast reconstruction, yet the effect of body mass index (BMI) on the procedural outcome can vary depending on the literature. This study aims to evaluate the effect of BMI on flap and donor-site complications in patients undergoing DIEP flap reconstruction. METHODS: A retrospective analysis of 233 DIEP flaps in 135 patients was performed, and the patients were stratified as three groups based on BMI: Normal (BMI<25), Overweight (BMI 25-29.9), and Obese (BMI>30). Data with regard to age, smoking history, comorbid conditions, preoperative radiation, preoperative chemotherapy, and complications post-DIEP flap reconstruction at the flap and donor-sites was analyzed and compared among groups. RESULTS: Overweight patients had statistically higher rates of overall complications (p=0.001), umbilical wound (p=0.03), and return visits to the operating room during same hospital stay (p=0.004) compared to normal weight patients. Obese patients experienced statistically higher rates of overall complications (p=0.000023), return visits to operating room during same hospital stay (p=0.02), abdominal necrosis (p=0.0008), breast wound (p=0.019), umbilical wound (p=0.0053), and vacuum-assisted closure wound therapy (p=0.0006) compared to normal weight patients. There were no significant differences between the groups in regards to infection of the abdominal, breast, and umbilical sites, abdominal wound, abdominal seroma, breast necrosis, breast seroma, breast hematoma, umbilical necrosis, blood transfusion, pulmonary embolism, average OR time, average hospital length of stay, or loss of flap viability (p>0.05). Age distribution and preoperative radiation were not statistically different. Compared to normal-weight patients, overweight patients had significantly lower rates of smoking history and higher rates of hypertension, diabetes, and preoperative chemotherapy. Obese patients had statistically higher rates of preoperative chemotherapy compared to normal weight patients. These confounding factors between the groups are a limitation to the BMI control. CONCLUSION: Overweight and obese patients undergoing DIEP flap breast reconstruction are predisposed to statistically higher risk for the aforementioned complications than normal weight patients. However, there was no significant difference in loss of flap viability between the groups. Therefore, DIEP flap breast reconstruction is an appropriate option.Item Maxillary Growth and Speech Outcomes Following Staged Palatoplasty: A Single-Center Approach(2018-01-23) Leininger, Kurt; Alford, Jake; Ha, Richard; Byrd, Steve; Smartt, JamesINTRODUCTION: Cleft lip and palate are the most common craniofacial abnormalities in children. However, timing and staging of cleft palate repair remain controversial. Timing of palate repair depends on balancing the speech benefits of early repair with the improved maxillofacial growth of late palate repair. Both single stage and two staged palatoplasty have been proposed for optimizing growth and speech, each to varying success. In this study, we reviewed outcomes of the staged approach at a single center. METHODS: A retrospective chart review was performed for all patients who underwent staged palatoplasty for cleft palate at Children's Medical Center in Dallas between 2006-2012. All patients in the study underwent intra-velar veloplasty at 3 to 6 months and hard palate repair at 18 months. Exclusion criteria included patients undergoing single stage repair, initial treatment at an outside center, secondary surgery at an outside center, and inadequate follow up. 61 patients were eligible for final inclusion. Speech outcomes were evaluated based on Pittsburgh Weighted Speech Scores (PWSS) and rates of secondary operations indicated for correction of VPI. PWSS were collected after completion of staged palatoplasty, postoperatively after any surgical correction of VPI, and at latest available patient follow up. Maxillary growth outcomes were evaluated by rates of oronasal fistula, reoperation indicated for palate repair, Angle class malocclusion, and LeFort I advancement procedures. RESULTS: For the entire cohort, 26% of patients were determined to have clinical VPI. 28% required corrective VPI surgery. 11% were determined to have residual VPI refractory to corrective surgery. 31% were found to have a persistent oronasal fistula, with 30% requiring surgery. 50% had class III malocclusion. At the time of review, no patients required LeFort I advancement procedures. There were no significant differences when including syndromic patients. Compared to patient with CLP, patients with isolated CP had higher rates of clinical VPI (33% vs 24%), oronasal fistula (34% to 20%), and class III occlusion (54% to 27%). Compared to patient with complete CP, patients with incomplete CP had higher rates of clinical VPI (36% vs 23%) lower rates of oronasal fistula (14% to 36%), and lower rates of class III occlusion (29% to 53%). Compared to patients with UCLP, patients with bilateral CLP had higher rates of clinical VPI (43% vs 15%), oronasal fistula (57% to 27%), and class III occlusion (64% to 48%). CONCLUSION: In our cohort of 61 patients, speech and growth outcomes after staged palatoplasty are similar to what has been previously reported in the literature. Despite the lack of consensus on the appropriate surgical treatment for CP and a trend towards single stage palatoplasty, our data strongly suggests that staged palatoplasty is still a valuable surgical approach to the patient with cleft palate.Item Retrospective Evaluation of Patient Outcomes with Ketorolac Shoulder Injections(2016-01-19) Kurth, Alexander; Kukowski, Nathan; Khazzam, Michael; Romero, JoseBACKGROUND: Corticosteroid injections are a commonly used treatment modality in patients with various shoulder pathologies who have failed to respond to other conservative management options such as systemic NSAID medications and physical therapy. However, clinical trials have demonstrated that corticosteroids demonstrate limitations such as spontaneous tendon rupture following local injection, tendon and ligament atrophy, fragmentation of collagen bundles, decreased mechanical properties, and delayed healing. One could extrapolate that injection of an NSAID medication, such as Ketorolac, may provide similar pain reduction with fewer injurious secondary effects. The objective of this study is to retrospectively examine outcomes in patients after glenohumeral or subacromial injections of Ketorolac. METHODS: This longitudinal, case-series based, retrospective study examines the outcomes in patients who received glenohumeral or subacromial injections of Ketorolac from 1/1/2014 through 3/30/2015 at an outpatient orthopaedic surgery clinic. Shoulder pathologies considered include adhesive capsulitis, atraumatic rotator cuff tears, arthritis, and tendinitis. Dependent variables that were monitored and analyzed include pre and post-injection shoulder specific pain (Visual Analogue Scale) and frequency and severity of adverse events. Other factors considered include co-morbidities, duration of physical therapy pre and post-injection, and other injections received. Established values regarding minimally clinical important differences and mean changes in these variables were compared to published standards. RESULTS: At first follow up, patients in both treatment arms reported decreased pain and increased tolerance of physical therapy following the injection of Ketorolac. In patients receiving glenohumeral injections, 71.4% described a reduction in pain compared to the visit at which they received the Ketorolac injection. On average, these patients reported their pain to be 4.29/10 (VAS) immediately prior to injection and 3.83 at their follow up appointment. For those receiving subacromial space injections, 83.3% noted reduced pain, with pain decreasing on average from 6.77 to 2.17. Importantly, no serious side effects were reported, despite many patients presenting with significant comorbidities. CONCLUSIONS: A Ketorolac injection into the glenohumeral joint yielded safe and efficacious results, similar to those seen with injection into the subacromial space. When compared to studies involving the use of corticosteroids for these same shoulder pathologies, Ketorolac appears to have at least equivalent efficacy, without exposing patients to the harmful side effects of corticosteroids.