Faculty Bibliography

Intensive postoperative rehabilitation therapy is associated with positive functional recovery in hand transplants (HTs). Our goal is to share the hand therapy protocol developed for our patient who underwent a combined face and bilateral HT. The patient is a 23-year-old right-hand-dominant male with a history of third-degree burns to 80% of his body following a motor vehicle accident. A multidisciplinary evaluation established his candidacy for a combined face and bilateral HT, and surgery took place in August 2020. Our individualized hand therapy protocol consisted of 4 phases. The pre-surgery phase focused on planning the orthotics and patient/caregivers' education on the rehabilitation process. The intensive care unit (ICU)/acute care phase involved hand allograft protection and positioning via orthotic fabrication, safe limb handling, and edema/wound management. The inpatient rehabilitation phase aimed to prepare the patient for independent living via neuromuscular and sensory re-education, improvement of upper extremities strength/flexibility, training basic activities of daily living, and providing a home exercise program (HEP). Finally, the outpatient phase aimed to maximize our patient's range of motion and independency in performing his routine activities and HEP. The patient's post-transplant functional outcomes showed a significant improvement compared to the pre-operative baseline. We hope this report sheds light on a comprehensive hand therapy program in HT.

Background: Every year about 2.4 million CT Pulmonary Angiog-raphy (CTPA) scans are performed to evaluate for pulmonary embolism in Emergency Departments (ED) in the United States. Each CTPA carries a 14% risk of contrast induced nephropathy and a lifetime malignancy risk that can be as high as 2.76%. Incidental findings requiring diagnostic follow up are found in 24% of tests, increasing both costs and harms from repeat imaging. CTPA yield (percent of studies positive for PE) is a measure of appropriateness of use and has not been reviewed systematically. We conducted a systematic review and meta-analysis of CTPA yield in US EDs to establish a typical yield for our current practice environment and to determine if there have been changes to this yield over time.
Method(s): Cochrane, Embase, PubMed and Web of Science were searched as data sources. Observational cohort studies of adults were selected that measured CTPA yield in all ED patients referred for testing with clinical suspicion of PE. The titles and abstracts of studies identified by the search were independently reviewed by two reviewers. Studies were evaluated for exclusion criteria. Remaining studies were reviewed in full text by two independent reviewers. We extracted study characteristics and CTPA yield from the remaining studies. CTPA yields were estimated using random effects models. The I2 test was used to assess heterogeneity in CTA yields among the studies.
Result(s): Our search identified a total of 2,746 potentially relevant articles. Of those 296 remained after title and abstract review and 31 remained after full text review. The 31 studies included in our meta-analysis included a total of 42,670 patients. These studies were divided into three time periods for which CTPA yield was calculated. For time periods 1997-2002, 2003-2007 and 2008-2013 the yields were 11% (9%, 14%), 8% (6%,9%) and 8% (6%, 10%) respectively. The studies were heterogeneous for all calculated pooled CTA yields (I2 =82%, 94%, and 86% respectively).
Conclusion(s): This is the first study to systematically review CTPA yield in US EDs. Establishing a national benchmark for yield assists health systems seeking to monitor and increase CTPA yield as a part of quality improvement efforts. Future directions include further stratification by type of health system and analysis of non-US yields

Background: There is poor consensus in the literature regarding associated functional limitation and the preferred wrist position for total wrist arthrodesis. The purpose of the current investigation was twofold: (1) to assess the functional limitations of wrist arthrodesis and (2) to determine the optimal position for wrist arthrodesis using a simulated wrist fusion model. Methods: Twenty healthy volunteers underwent simulated wrist arthrodesis in 6 different positions using custom-molded wrist splints: 15 degrees extension with 0 degrees radio-ulnar deviation, 15 degrees extension with 10 degrees ulnar deviation, 15 degrees extension with 10 degrees radial deviation, 0 degrees extension with 0 degrees radio-ulnar deviation, 0 degrees extension with 10 degrees ulnar deviation, and 0 degrees extension with 10 degrees radial deviation. Each volunteer was independently assessed for wrist function using the Jebsen-Taylor hand function test, grip strength, and satisfaction in the simulated wrist fusion positions. Comparisons between all simulated fusion wrists and the baseline unsplinted wrist as well as among the 6 simulated fusion positions were performed. Results: Turning over a card (5.1 vs 4.3 seconds), picking up small objects (7.1 vs 5.8 seconds), and simulated feeding (8.3 vs 7.1 seconds) as well as total Jebsen-Taylor test duration (41.8 vs 37.9 seconds) was significantly longer in simulated fusion wrists. Both grip strength (55.9 vs 80.7 kg) and satisfaction scores (6.4 vs 9.6) were lower in simulated fusion wrists. Wrists in 0 degrees extension also demonstrated significantly shorter durations in stacking checkers than wrists in 15 degrees extension. Conclusion: Our findings suggest that wrist arthrodesis may only compromise select wrist functions. Among the tested wrist fusion positions, wrists fused in neutral may demonstrate better function than wrist fused in slight extension. However, grip strength and satisfaction seem to be unaffected by wrist fusion position.