Washington State University Spokane

Intravenous ketamine is increasingly used for refractory and super-refractory status epilepticus (RSE/SRSE), yet its efficacy and optimal use remain uncertain. We therefore aimed to synthesize the available evidence to quantify the effectiveness of ketamine in achieving seizure cessation and to explore differences in treatment characteristics between patients who respond and those who do not. We conducted a systematic review and meta-analysis to estimate the pooled seizure cessation rate associated with intravenous ketamine. Secondary analyses compared ketamine initiation timing, dosing, and infusion duration between patients who achieved seizure cessation (responders) and those who did not (nonresponders). Fourteen studies comprising 388 adult patients (249 responders, 139 nonresponders) were included. The pooled seizure cessation rate with ketamine was 64% (95% CI 49%-76%) with moderate heterogeneity (I 2 = 54.1%). Sensitivity analysis showed no single study substantially influenced results, supporting robustness. Responders received ketamine earlier (3.2 ± 2.6 days) than non-responders (4.3 ± 2.6 days), mean difference of -0.90 days (95% CI: -1.31 to -0.49; p < 0.0001). The mean maintenance dose was 2.5 ± 1.4 mg/kg/hr (responders: 2.5 ± 1.3; nonresponders: 2.6 ± 1.4), with no significant difference between groups (mean difference -0.14 mg/kg/hr; 95% CI -0.45 to 0.18; p = 0.39). Infusion duration averaged 5.0 ± 4.2 days in both groups, with no significant difference (mean difference -0.07 days; 95% CI -1.02 to 0.88; p = 0.88). Ketamine discontinuation due to adverse events was rare (0.7%, 3/55 patients). Intravenous ketamine demonstrates consistent effectiveness and safety as an adjunctive therapy in RSE/SRSE. However, the timing of initiation cannot be reliably linked to improved clinical outcomes given current methodological limitations and heterogeneity across studies. Future prospective research using standardized definitions and rigorous temporal data collection is needed to clarify whether the timing of ketamine initiation independently influences therapeutic success and to define its optimal integration within established status epilepticus (SE) treatment algorithms. The systematic review was registered (June 7, 2024) with the International Prospective Register of Systematic Reviews (PROSPERO, CRD42024549523).

The purpose of this study was to examine implementation barriers and facilitators related to evidence-based concussion management among school-based speech-language pathologists (SLPs). Using the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework, we explored how innovation, recipient, context, and facilitation factors influence SLPs' ability to bridge the know-do gap in return-to-learn (RTL) care for students with concussion. We conducted qualitative semistructured interviews with 10 school-based SLPs purposively selected to reflect varying confidence levels regarding concussion management using a framework-informed hybrid deductive-inductive approach. The i-PARIHS framework guided interview development and thematic analysis to identify barriers and facilitators across framework constructs. Implementation barriers and facilitators mapped to all four i-PARIHS constructs. Innovation barriers included limited awareness of RTL protocols (only one of 10 participants knew district protocols) and assessment challenges in establishing baselines and differentiating concussion-related difficulties. Recipient facilitators encompassed professional growth mindset and consultation model preferences, with nine of 10 participants expressing confidence in providing concussion services despite acknowledging knowledge gaps. Context was the primary barrier domain, involving resource constraints including large (up to 150 students) or complex caseloads, high workload demands, and communication gaps between medical and educational settings. Facilitation included peer networks as primary knowledge sources, but limited access to concussion-specific continuing education created barriers. A cross-cutting professional growth mindset demonstrated SLPs' readiness to participate in RTL implementation despite current limitations. While SLPs possess strong individual characteristics supporting RTL and concussion care delivery, significant organizational barriers limit evidence-based concussion care delivery. Implementation strategies should leverage SLPs' growth mindset and peer consultation preferences while addressing multilevel contextual barriers through systematic training programs, consultation-based service models, and improved medical-school communication protocols. https://doi.org/10.23641/asha.31449640.

Background: Hip abductor pathology is increasingly recognized as a contributor to impaired mobility and suboptimal outcomes following total hip arthroplasty (THA) and hemiarthroplasty. However, the prevalence and clinical significance of abductor disruption across fracture-related and elective indications remain unknown. Methods: We conducted a retrospective cohort study of 67 patients who underwent total hip arthroplasty, hemiarthroplasty, or hip abductor repair between 2017 and 2023, identified using CPT codes from the AthenaOne healthcare system and Alpine Ortho Spine Clinic database. Results: Fracture patients were significantly older than elective total hip arthroplasty patients (76.8±8.2 versus 66.4±7.9 years, p&lt;0.001) and demonstrated a higher proportion of Dorr type C femora (p=0.02). Both iliopsoas and quadriceps strength improved postoperatively across the cohort (iliopsoas: 2.7±0.9 to 3.4±0.8, p&lt;0.01; quadriceps: 3.0±0.8 to 3.6±0.7, p&lt;0.01). Elective patients showed greater strength gains than fracture patients (iliopsoas Δ0.9 versus Δ0.5, p=0.03; quadriceps Δ0.8 versus Δ0.4, p=0.04). Trendelenburg gait was more prevalent preoperatively in fracture patients (38% versus 19%, p=0.04) and remained higher at follow-up (24% versus 12%, p=0.05). Conclusions: Pre-existing hip abductor disruption is common in both fracture and elective arthroplasty populations. These findings highlight the importance of recognizing abductor pathology as a modifiable factor influencing recovery and support the role of targeted perioperative management and rehabilitation strategies.

Mechanical alignment total knee arthroplasty (TKA) in valgus knees requires soft tissue releases and complex techniques that are unnecessary with kinematic alignment (KA). Few studies have evaluated the outcomes of KA in valgus knees, and fewer have studied KA with medial-pivot (MP) implants. This study compared the clinical outcomes of KA-TKA with MP implants (KA/MP-TKA) in patients with preoperative varus versus valgus alignment. We hypothesized that outcomes following KA/MP-TKA would be equivalent. A prospective database was queried to identify patients who underwent primary KA-TKA with MP implants. Patients were included if they had a preoperative hip-knee-ankle angle ≤177° (varus, n = 302) or ≥183° (valgus, n = 51). A total of 353 consecutive patients were identified. The Forgotten Joint Score (FJS), Knee Injury and Osteoarthritis Outcome Score (KOOS-JR), Knee Society Score (KSS), and range of motion were collected preoperatively and at 6-week, 6-month, and 1-year visits. Patients with preoperative valgus alignment had worse KSS Function and KOOS-JR scores preoperatively (p = 0.04 and p = 0.02, respectively); all other baseline outcomes were comparable. Postoperatively, the valgus group demonstrated better KOOS-JR at 6 weeks (p = 0.004), KSS Pain-Motion at 6 months (p = 0.02), and FJS at 1 year (p = 0.03). The varus group showed better KSS Function at all postoperative visits (p < 0.02). There were no statistically significant differences in flexion or extension between the groups. Patients with valgus alignment undergoing KA/MP-TKA achieved postoperative outcomes that were clinically equivalent or superior to those of patients with varus alignment. These findings support KA-TKA using MP implants as an appropriate surgical approach for preoperative valgus alignment.

BackgroundCurrent reporting standards treat p-values, effect sizes, and confidence intervals as complete evidence, but this is only partial: it quantifies significance and magnitude, not classification stability (fragility) or distance from therapeutic neutrality (robustness). This study validates the p-fr-nb framework in two-arm, binary-outcome clinical trials. Framework extensions to continuous, ordinal, survival, and correlation analyses exist but are not empirically validated here. For this study, the p-fr-nb triplet is defined as providing the p-value (significance), fragility (classification stability), and robustness (distance from neutrality) in trial results. This triplet assesses completeness across three statistical inferential dimensions; it stratifies evidence quality but does not prove truth, causality, or replication.MethodologyA pragmatic observational validation study of two-arm, binary-outcome clinical trials identified in PubMed (n = 129 across 15 specialties) was conducted. Null expectations were generated with a Monte Carlo simulation of 720,000 trials across 360 design scenarios, including 120,000 null trials (true relative risk (RR) = 1.0). Simulations represent unfiltered random trial generation and do not model publication bias or selective reporting. Fragility was measured by the modified-arm fragility quotient (MFQ; fragility index divided by the size of the modified arm). Robustness was measured by the risk quotient (RQ), defined for 2×2 tables as RQ = |ad − bc| / (N²/4). Concordant-positive (CP) evidence was defined as p ≤ 0.05, MFQ > 0.10, and RQ ≥ 0.227, with the RQ cutoffs based on large-scale simulation. The significant-fragile-weak (SFW) pattern was defined as p ≤ 0.05, MFQ ≤ 0.10, and RQ < 0.075. The main outcomes were the rates of CP and SFW among statistically significant empirical trials, compared with null-simulation expectations.ResultsIn null simulations (RR = 1.0), the CP triplet occurred in 1.4% of significant trials; even with strong effects (RR = 0.60), it appeared in only 4.7%. Of the 129 trials analyzed, 77 (59.7%) were statistically significant. Among these 77 trials, 30 (39.0%; 95% confidence interval = 28.8-50.1%) met the CP criteria, a 27.9-fold higher compared with null expectations (p < 0.0001). Overall, 61.0% of significant trials were fragile (MFQ ≤ 0.10, 47/77), 31.2% were weakly robust (RQ < 0.075, 24/77), and 31.2% showed the SFW pattern (24/77).ConclusionsIn this heterogeneous sample, the p-fr-nb framework stratified positive findings beyond what p-values and confidence intervals reveal. Among 77 significant trials, 39.0% met stringent criteria for stability and strong robustness, a distinction not visible from p-values alone. Conversely, 31.2% showed the SFW pattern, where significance was fragile, and separation from no effect was minimal. Fragility and robustness metrics provide interpretive dimensions not captured by p-values alone, enhancing assessment of evidence heterogeneity relevant to reproducibility and clinical interpretation. These data support further evaluation of incorporating fragility and robustness metrics into the reporting of clinical trial results.