United States

Background 
Dynamic lumbar instability evaluated on flexion-extension radiographs has been a longstanding convention in clinical decision-making for the management of low back pain by interventionalists and surgeons. However, these radiographs often underestimate the degree of lumbar spondylolisthesis, limiting their diagnostic utility. Significant variability remains in current guidelines regarding the most appropriate imaging modalities to adequately evaluate instability. Thus, identifying more efficacious imaging techniques to improve diagnostic utility, minimize radiation exposure, and reduce unnecessary healthcare costs is warranted. We compared different diagnostic images of single-level anterior spondylolisthesis and hypothesize that positional changes will affect the degree of dynamic instability, with spondylolisthesis observed in prone position providing greater sensitivity for instability compared to standing or supine positions. 

Methods 
Single center retrospective cohort of L4-5 anterolisthesis between 2014 – 2022 with standing radiographs (CR), prone CT scans (CT), or supine MRI images (MRI). Exclusion criteria: presence of lumbar hardware, patients with missing imaging modalities (either CR, CT or MRI), time between any modalities exceeding 13 months, no evidence of anterolisthesis, or poor image quality precluding the ability to fully visualize and assess spondylolisthesis. 

Results 
The average translation (± SD) measured were 4.9 ± 2.2 mm (CR), 2.5 ± 2.6 mm (CT), and 3.7 ± 2.6 mm (MRI) (p &lt; 0.001). The mean difference in anterolisthesis among imaging modalities were 2.7 ± 1.8 mm between CR and CT (p &lt; 0.001) and 1.8 ± 1.4 mm between CR and MRI (p &lt; 0.001). Ninety two of 102 patients (90.2%) showed greater anterolisthesis on CR compared to CT, 72 of 102 (70.6%) comparing CR to MRI, and 27 of 102 (26.5%) comparing CT to MRI.  

Comparing CR with MRI, we found that 17.6% of patients exhibited &gt; 3 mm anterior translation, whereas 38.2% patients were identified comparing CR with CT imaging, indicating a 20.6% difference in missed lumbar instability (χ2 test p = 0.0009, post-hoc Fisher’s exact test p = 0.0006 between CR and CT). Only a small percentage of patients showed increased segmental translation between flexion-standing (5.9%) and extension-standing radiographs (11.8%). We identified comparable results using 2 mm and 4.5 mm thresholds. 

Conclusion 
Comparing standing CR versus prone CT revealed the greatest degree of single level lumbar segmental translation (L4-5. Prone positioning also significantly reduced L4-5 anterolisthesis compared to flexion-extension standing X-rays, suggesting that comparing prone positioning to standing lateral views may increase detection of dynamic instability at L4-5 compared to standard stress views.

AMA Research Challenge 2023

Dynamic Instability is Underestimated on Standing Flexion-Extension films when compared to Prone CT Imaging

Background 
Dynamic lumbar instability evaluated on flexion-extension radiographs has been a longstanding convention in clinical decision-making for the management of low back pain by interventionalists and surgeons. However, these radiographs often underestimate the degree of lumbar spondylolisthesis, limiting their diagnostic utility. Significant variability remains in current guidelines regarding the most appropriate imaging modalities to adequately evaluate instability. Thus, identifying more efficacious imaging techniques to improve diagnostic utility, minimize radiation exposure, and reduce unnecessary healthcare costs is warranted. We compared different diagnostic images of single-level anterior spondylolisthesis and hypothesize that positional changes will affect the degree of dynamic instability, with spondylolisthesis observed in prone position providing greater sensitivity for instability compared to standing or supine positions. 

Methods 
Single center retrospective cohort of L4-5 anterolisthesis between 2014 – 2022 with standing radiographs (CR), prone CT scans (CT), or supine MRI images (MRI). Exclusion criteria: presence of lumbar hardware, patients with missing imaging modalities (either CR, CT or MRI), time between any modalities exceeding 13 months, no evidence of anterolisthesis, or poor image quality precluding the ability to fully visualize and assess spondylolisthesis. 

Results 
The average translation (± SD) measured were 4.9 ± 2.2 mm (CR), 2.5 ± 2.6 mm (CT), and 3.7 ± 2.6 mm (MRI) (p < 0.001). The mean difference in anterolisthesis among imaging modalities were 2.7 ± 1.8 mm between CR and CT (p < 0.001) and 1.8 ± 1.4 mm between CR and MRI (p < 0.001). Ninety two of 102 patients (90.2%) showed greater anterolisthesis on CR compared to CT, 72 of 102 (70.6%) comparing CR to MRI, and 27 of 102 (26.5%) comparing CT to MRI.  

Comparing CR with MRI, we found that 17.6% of patients exhibited > 3 mm anterior translation, whereas 38.2% patients were identified comparing CR with CT imaging, indicating a 20.6% difference in missed lumbar instability (χ2 test p = 0.0009, post-hoc Fisher’s exact test p = 0.0006 between CR and CT). Only a small percentage of patients showed increased segmental translation between flexion-standing (5.9%) and extension-standing radiographs (11.8%). We identified comparable results using 2 mm and 4.5 mm thresholds. 

Conclusion 
Comparing standing CR versus prone CT revealed the greatest degree of single level lumbar segmental translation (L4-5. Prone positioning also significantly reduced L4-5 anterolisthesis compared to flexion-extension standing X-rays, suggesting that comparing prone positioning to standing lateral views may increase detection of dynamic instability at L4-5 compared to standard stress views.

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Background
The purpose of this research is to test the clinical validity of a computerized version of the Trail Making Test (TMT) in an acute rehabilitation center for predicting concurrent inpatient disability. The TMT is a widely used neuropsychological assessment that has been shown to predict brain damage. Despite its value and efficacy in testing cognitive function, the TMT is limited to patients who have intact manual dexterity because it requires using a pen. Individuals with conditions that limit manual use (e.g. bone fracture, paralysis, burns, etc.) cannot take the test. Although there are adapted TMTs to include these populations, not many of these tests still involve visual interaction. Assessment of executive function using the Computer-Assisted TMT (CTMT) has already shown to be feasible in rehabilitation patients with intact manual dexterity. This study tested the Computer-Assisted TMT (CTMT) in rehabilitation patients who lack motor hand use.
Methods
This cross-sectional study was conducted in an acute rehabilitation hospital setting with patients (n = 37) who lack hand usability with either hand. Because patients with brain illness may have slower speech, the CTMT scores were corrected for maximal oral speech rate. Participants were tested in their hospital rooms over two sessions of the CTMT to evaluate test-retest reliability. Test-retest reliability was evaluated with Pearson correlation.
Results
50 patients were approached to be in the study, and 37 of them consented to participate. Out of the 37 participants, 33 participants were able to complete one round of testing and 17 participants were able to complete both rounds of testing. Time for CTMT completion was corrected by the maximal speech production rate (diadochokinesis or DDK). Since DDK rate has shown to be modulated by age, we also corrected people 47 years and older by a factor of 0.9316, which is based on previous research. The CMT versions had excellent test-retest reliability (r = 0.93 for CTMT-A, r = 0.83 for CTMT-B, and r =0.92 for CTMT-3).
Conclusion
The results of this study could help to determine if the CTMT can reliably predict concurrent physical disability and inform new forms of cognitive rehabilitation.


The Validation of a Computer-Assisted Trail Making Test in Acute Rehabilitation Inpatients with Manual Disability

Purpose: Buccal myomucosal flaps (BMF) provide an alternative for anatomic lengthening of the palate in the treatment of velopharyngeal insufficiency (VPI). We systematically reviewed the existing data on speech outcome of BMF palatal lengthening.

Methods: English-language prospective and retrospective studies assessing speech improvement following BMF palatal lengthening were identified using Ovid, Pubmed, and Embase. Studies without objective speech measurements were excluded. PRISMA guidelines were followed, and articles’ quality was assessed. A random effects model meta-analyses were performed for hypernasality, intelligibility, and nasal emission score improvements, which were derived from reported preoperative and postoperative scores, and controlled for variability of scales and timing of postoperative assessment. Chi-squared tests assessed surgical techniques, patients’ languages, and mean age.

Results: Out of initial 7115 articles, 13 were included in this review. All 13 met NIH Quality Assessment Tool criteria. 7 retrospective studies evaluated a total of 283 patients and 6 prospective studies evaluated 165 patients. The most common surgical indications for BMF were large size of the velopharyngeal gap (7 papers) and prior surgery for VPI (5 papers). Meta analyses for hypernasality, intelligibility, and nasal emission score improvements demonstrated effect sizes above zero, confirming the utility of BMF in VPI treatment. Egger regressions and funnel plots revealed low risk of publication bias. There were no significant variations in speech outcomes among surgical techniques, patients’ languages, or mean age.

Conclusions: Buccal myomucosal flaps provide reliable treatment for VPI in patients with large velopharyngeal gap size and a history of prior unsuccessful surgery.

Speech Outcomes of Buccal Myomucosal Flap Palatal Lengthening Treatment of Velopharyngeal Insufficiency: Systematic Literature Review and Meta Analysis

Background:

Frailty increases the likelihood of complications after breast reconstruction, yet there has been limited research on how it affects long-term outcomes. We investigated the relationship between the 5-item modified frailty index (mFI) score with both surgical and patient-reported outcomes in microvascular breast reconstruction.

Methods:

We conducted a retrospective cohort study of patients who underwent mastectomy and microvascular breast reconstruction between January 2016 and April 2022. Primary outcome was any flap-related complication and secondary outcomes included patient-reported outcomes and factors that predicted complications in frail patients.

Results: 

We identified 1640 breast reconstructions, with a mean follow-up period of 24.2±19.2 months. Patients with an mFI score ≥2 had greater odds of experiencing surgical complications (OR, 2.13, p=0.023) and medical complications (OR 17.02, p<0.001) than non-frail patients. However, we found no significant difference in breast satisfaction (p=0.287), psychosocial well-being (p=0.119), or sexual well being (p=0.314) based on the mFI score. Chronic obstructive pulmonary disease was a predictor of infection (OR 3.70, p=0.002), while tobacco use (OR 7.13, p=0.002) and contralateral prophylactic mastectomy (OR 2.36, p=0.014) were predictors of wound dehiscence. Skin flap necrosis was more likely in patients with dependent functional status (OR 2.36, p=0.007) and in those who underwent immediate reconstruction (OR 3.16, p=0.026). Dependent functional status was also associated with higher odds of reoperation (OR 2.64, p=0.011).

Conclusion: 

While frailty increases the likelihood of complications in breast reconstruction, there is no notable difference in long-term patient-reported outcomes. The mFI score should be incorporated in breast reconstruction to optimize outcomes in high-risk, frail patients.

Impact of the 5-item Modified Frailty Index on Long-term Surgical and Patient-reported Outcomes in Microvascular Breast Reconstruction

Background: Smartphone-based thermal imaging (SBTI) has been reported in
the literature to be an easy-to-use, contactless, cost-friendly alternative to standard
imagingmodalities in identifying flap perforators,monitoring flap perfusion, and
detecting flap failure. Our systematic review and meta-analysis aimed to evaluate
SBTI's accuracy in perforator identification and secondarily evaluate SBTI's utility
in flap perfusion monitoring as well as ability to predict flap compromise, failure,
and survival.
Methods: Following Preferred Reporting Items for Systematic Reviews and
Meta-Analysis guidelines, a systematic review was performed using PubMed
from inception to 2021. Articles were uploaded into Covidence and, following
duplicate deletion, were initially screened for use of SBTI in flap procedures
through title and abstract screening followed by full-text review. The following
data points, if provided, were extracted from each included study: study design,
number of patients, patient demographics, perforator number and location, flap
number and location, room temperature, cooling method, imaging distance, time
from cloth removal, primary (SBTI's accuracy in perforator identification), and
secondary outcomes (prediction of flap compromise/failure/survival and cost
analysis). Meta-analysis was performed using RevMan v.5.
Results: The initial search yielded 153 articles. Eleven applicable studies with a
total of 430 flaps from 416 patients were ultimately included. The SBTI device
assessed in all included studies was FLIR ONE. Four studies assessed the SBTI's
perforated detection ability and were included in meta-analysis. Smartphonebased
thermal imaging correctly identified 378 (93.3%; n = 405) perforators,
and computed tomography angiography (CTA) correctly identified 402 (99.2%;
n = 402), although in one study SBTI found additional perforators not detected
on CTA. A random-effects model was used (I2 = 65%), and no significant difference
in perforator detection ability was found between SBTI and CTA( P = 0.27).
Conclusion: This systematic review and meta-analysis supports SBTI as userand
cost-friendly ($229.99), contactless imaging modality with perforator detection
ability comparable to current criterion-standard CTA. Postoperatively, SBTI
outperformed Doppler ultrasound in early detection of microvascular changes
causing flap compromise, allowing for prompt tissue salvage. With a minimal
learning curve, SBTI seems to be a promising method of postoperative flap perfusion
monitoring able to be used by all hospital ranks. Smartphone-based thermal
imaging could thus increase flap monitoring frequency and lower complication
rates, although further study is warranted.

The Utility of Smartphone-Based Thermal Imaging in the Management and Monitoring
of Microvascular Flap Procedures: A Systematic Review and Meta-Analysis

Background
Current measures of vaginoplasty success are adapted from tools validated for use in cisgender women, such as the Female Genital Self-Image Scale (FGSIS) and Female Sexual Function Index (FSFI). There is little research on whether post-operative gender congruence, quality of life (QoL), sexual function, and aesthetic satisfaction are of equal importance for vaginoplasty patients. The survey goal was to examine patient-reported vaginoplasty outcomes related to gender incongruence, post-surgical satisfaction and sexual function.

Methods
Transgender patients receiving surgical care at a single academic center were invited to complete post-surgery surveys. From August 2019 to May 2022, 157 patients who had undergone surgery between September 2016 and March 2022 were contacted. 40 completed consent and post-surgery survey. Questions were selected based on prior literature and FGSIS and FSFI adaptations. Statistical analyses were carried out in RStudio.

Results
Among 40 respondents, mean age was 45.8 years (SD = 14.0) and mean time since surgery was 237.3 days (SD = 260.8). Thirty-two (78.0%) had neovaginoplasty and 9 (22.0%) had genital remodeling without creation of a vaginal opening. Thirty-nine (97.5%) respondents were happier after their operation than they were before. Of the 23 respondents who had engaged in sexual activity in the past month, 10 (43.5%) were often or almost always satisfied with their arousal during sexual activity and 9 (39.1%) were satisfied with their ability to reach orgasm with sexual stimulation. Among this group, 19 (82.6%) felt positively about their genitals, 19 (82.6%) were satisfied with the appearance of their genitals, and 23 (100.0%) were happier after surgery than before. Seventeen respondents (42.5%) did not report sexual activity in the past month. Of these individuals, 15 (88.2%) felt positively about their genitals, 11 (68.8%) were satisfied with the appearance of the genitals and 16 (94.1%) were happier after surgery.

Conclusion
These findings indicate a discordance between the positive psychosocial outcomes of vaginoplasty and post-surgical sexual function. Patient-reported outcomes measures that center sexual function as a primary measure of vaginoplasty success may not accurately capture the QoL benefit afforded by improved gender congruence. While sexual function is important to overall QoL, patients in this study reported high rates of surgical satisfaction and improved happiness regardless of whether they had engaged in sexual activity or were satisfied with their arousal and ability to reach orgasm. More work is needed to develop measures that address the complex relationship between sexual function, sexuality, gender identity, and satisfaction with surgery.

Post-genital surgery survey of transgender and non-binary adults assigned male at birth

Background
To minimize the risk of complications, skin-preserving breast reconstruction is preferred in patients undergoing post-mastectomy radiotherapy (PMRT). However, the long-term surgical complications and patient-reported outcomes associated with this technique are not well understood, particularly when compared to delayed reconstruction. In this study, we compared the long-term surgical and patient-reported outcomes of skin-preserving and delayed microvascular breast reconstruction, stratified by PMRT.
Methods
A retrospective cohort study examined consecutive patients undergoing a mastectomy and microvascular breast reconstruction between January 2016 and April 2022. The primary outcome was post-operative flap-related complications. Secondary outcomes were tissue expander (TE) complications and patient-reported outcomes.
Results
A total of 1002 reconstructions (330 skin-preserving; 672 delayed) in 812 consecutive patients met the inclusion criteria, with a mean follow-up of 24.2±19.3 months. PMRT was required in 564 reconstructions (56.3%). Skin-preserving reconstruction procedures were performed less in patients who had PMRT (39.1% compared with 64.7%, p<0.001). Delayed reconstruction procedures, compared with skin-preserving reconstruction, had a significantly longer median (IQR) interval from PMRT end to breast reconstruction (10 [7.0-15.0] compared with 8 [5.0- 11.0] months, p<0.001), and from mastectomy to reconstruction (15.0 [9.0-30.0] compared with 8 [3.0-16.0] months, p<0.001). In the PMRT group, skin-preserving reconstruction was independently associated with a significantly shorter hospital stay (β -1.15, p<0.001) and operative time (β -97.0, p<0.001), had lower odds of 30-day readmission (OR 0.29, p=0.005) and infection (OR 0.33, p=0.023) when compared to delayed reconstruction. In the non-PMRT group, skin-preserving reconstruction was independently associated with a shorter hospital stay (β -0.32, p=0.045), had lower odds of 30-day readmission (OR 0.44, p=0.042), seroma (OR 0.42, p=0.036), and hematoma (OR 0.24, p=0.011) when compared to delayed reconstruction. TE complications occurred in 48 of the 330 skin-preserving reconstruction procedures (14.5%), with significantly higher rates in the PMRT group (19.4% compared with 11.4%, p=0.046). Skin- preserving reconstruction had a 10.6% TE loss rate and without any significant difference from delayed reconstruction in patient-reported satisfaction with breasts (β -3.7, 95% CI -15.7 to 8.2, p=0.543), and psychosocial (β -7.3, 95% CI -18.5 to 4.0, p=0.203) or sexual (β 0.5, 95% CI -12.9 to 13.9, p=0.942) well-being.
Conclusion
The findings suggest that skin-preserving breast reconstruction is a safe option for patients, irrespective of whether they require PMRT. This technique is associated with an acceptable TE loss rate and has a lower risk of surgical complications compared to delayed reconstruction. Additionally, patient-reported satisfaction and quality-of-life outcomes are comparable between the two groups.

Comparing the Long-Term Surgical and Patient-Reported Outcomes of Skin-Preserving Versus Delayed Microvascular Breast Reconstruction

Background: 
Testosterone therapy amongst men is on the rise, resulting in an increase in testosterone-related side effects, most notably gynecomastia. Testosterone therapy occurs in one of two forms: Testosterone Replacement Therapy (TRT) and Anabolic Androgenic Steroids (AAS). Both have been associated with gynecomastia, yet it remains unclear whether one impacts gynecomastia more than the other. The objective of this study was to systematically review the evidence on TRT and AAS-induced gynecomastia to determine which was more associated with gynecomastia.

Methods: A systematic review protocol was registered with PROSPERO (CRD42023454216) and adhered to PRISMA-P guidelines. A literature search in PubMed, Embase, and Cochrane Library yielded 212 eligible articles. Inclusion criteria targeted gynecomastia, TRT, and AAS use and treatment regimens for gynecomastia. We utilized the MINORS criteria to assess the risk of bias.

Results: Of 212 studies, 10 met inclusion criteria. Incidence of TRT-induced gynecomastia ranged from 2.3 to 6.6%, while AAS-induced gynecomastia was reported at 19 to 35%. TRT cessation often led to spontaneous gynecomastia regression. With respect to surgical intervention, AAS-related treatment was associated with higher rates of surgical revision compared to non-AAS treatment (3.8% vs. 1.2%, respectively; p = 0.02).

Conclusion: This systematic review demonstrates distinct differences in gynecomastia incidence between TRT and AAS testosterone therapy. Notably, AAS exhibits higher rates of induced gynecomastia compared to TRT. Additionally, discontinuing TRT more commonly led to spontaneous gynecomastia regression compared to AAS. This may support delayed plastic surgery intervention for these patients. AAS-related gynecomastia regresses less commonly, yet when treated has a higher revision rate.


Gynecomastia related to Testosterone Therapy: A Systematic Review

Introduction:
Thermal injury to the anterior chest wall not only causes physical and emotional trauma, but also leaves survivors grappling with disfigurement, lack of physiologic function, such as breastfeeding, and impaired quality of life. This review evaluates possible breast reconstruction options for patients following thermal injury by comparing the aesthetic outcomes, complications, and functionality through breastfeeding ability.

Methods:
PubMed, EMBASE, and Scopus were used in an unrestricted search for postburn breast reconstruction cases. 6,162 articles were screened through an independent and blinded dual review to ensure they included patients with at least one breast affected by burns, provided details about breast reconstruction surgery, and reported postoperative outcomes. Articles were further analyzed for patient and burn characteristics, reconstruction specifications, and the effectiveness of breast reconstruction procedures in retaining breastfeeding ability. Registered on PROSPERO: CRD42023437347.

Results: 
There were 50 articles with a low risk of bias, analyzing 505 female patients with a history of chest burns. 32 of these studies utilized either local, regional, or distant autologous flaps from various donor sites, including Z-plasties, TDAPs, and TRAMs, with 16 reported satisfactory cosmetic results. 24 of the 50 articles described reconstruction using full- or split-thickness skin grafts, with 12 reporting patient satisfaction. 21 studies described implant-based breast reconstruction, with 13 studies reporting high patient satisfaction and 1 study reporting low patient satisfaction. 3 studies included the ability to breastfeed or breastfeed comfortably as an outcome and 2 patients with minimal damage to the nipple who received skin grafts retained breastfeeding ability. 

Conclusion: 
This review highlights how breast reconstruction following thermal injury requires careful consideration of affected anatomic structures. The level of destruction or alteration of important anatomic structures such as the nipple were key in determining future breastfeeding ability. The majority of included articles reported outcomes on satisfaction and aesthetics. Future articles may consider reporting breastfeeding outcomes such as the ability to lactate or breastfeed without discomfort. In particular, studies can consider the breastfeeding ability of patients who were actively breastfeeding at the time of thermal injury or postpartum mothers after reconstruction surgery. This review provides physicians with a collective evaluation of the breast reconstruction options after chest burns and their differences in outcomes and potential effectiveness of retaining breast contour, nipple sensitivity, and ability to breastfeed.

Can I still Breastfeed? Breast Reconstruction Options Post Chest Burns: A Systematic Review

Abnormal calcium deposition is among the sequelae that may follow major burn injury. This may manifest as heterotopic ossification or dystrophic calcification (DC) of scarred skin. While the two processes are distinct, the term heterotopic ossification (HO) is often used by clinicians in reference to both processes. While HO is well-documented, there appears to be less attention devoted to DC, the most common subtype of calcinosis cutis. HO is the abnormal formation of mature lamellar extraskeletal bone in muscle and soft tissues. Risk factors include traumatic injuries and surgeries such as spinal cord injury, hip arthroplasty, and burns with >30% TBSA. It commonly occurs in upper extremities, especially the elbows, and on average takes weeks to months to develop. In contrast, DC is the pathologic calcification of scar itself, and can present in cases of burn survivors as the calcification of burn and skin graft scar, often decades after the original burn injury. It manifests as the build-up of insoluble calcium salts in damaged subcutaneous tissues in the absence of abnormal serum calcium and phosphate levels. Applicability of this research is to increase awareness of burn sequelae; this research was not externally funded. 
We present a case of DC to highlight the distinct differences between DC and HO in hopes of promoting use of the semantically correct terms. A 67 year old female presented to the clinic 65 years after a >40% TBSA burn treated with excision and skin grafting at the time of injury. She had a months-long history of a draining sinus with a~5mm diameter white hard plaque at the base, and a broader contiguous area of hard plaque palpable beneath the surrounding area of skin graft scar. She had been experiencing recurrent bouts of infection and sought definitive treatment. The area was widely excised and ultimately resurfaced with a new split thickness skin graft. Clinical and histopathologic photographs will be presented. The histopathologic findings were consistent with the dystrophic calcification variant of calcinosis cutis. The presentation was consistent with ~10-12 other cases seen by the senior author over a 20 year career, and consistent with other cases reported in the literature. The term "heterotopic ossification" is sometimes used too broadly to describe any pathologic calcium deposition in burn survivors. We highlight the difference between heterotopic ossification and dystrophic calcification out of a belief that as subject matter experts in burns and their sequelae, burn care providers should want to use the most accurate terminology wherever possible.

Revisiting the Taxonomy of Abnormal Calcium Deposits in Burn Survivors: Heterotopic Ossification versus Calcinosis Cutis

Background: Since the FDA has mandated a boxed warning on all psychostimulants due to risks for misuse and death, coupled with nationwide shortages, clinicians have utilized non-stimulants, such as alpha-2-agonists for hyperactivity/impulsivity and the norepinephrine reuptake inhibitor atomoxetine for inattention, as safer alternatives. However, these agents lack comparable efficacy with delayed onset compared to psychostimulants. Insurers require generic atomoxetine prior to covering Viloxazine ER (VER), a novel 5-HT2B antagonist, 5-HT2C partial agonist, and 5-HT7 antagonist. We wanted to know whether patients taking atomoxetine would experience improvement in ADHD symptoms after switching to VER.
Methods: 50 patients (35 children) received mean doses of atomoxetine 60 mg (25-100 mg once daily) followed by VER 300 mg (100-600 mg once daily) after 5-day atomoxetine washout. Both atomoxetine and VER were flexibly titrated according to FDA guidelines. The pediatric ADHD-Rating Scale-5 (ADHD-RS-5) and the Adult Investigator Symptom Rating Scale (AISRS) were completed prior to starting atomoxetine; 4 weeks after treatment with atomoxetine or upon earlier response or discontinuation due to side effects, whichever occurred first; same protocol after treatment with VER. We conducted a retrospective chart review of these 50 patients. Statistical analysis was performed using a within-subject, 2-tailed t-test with significance level of p < 0.05.
Results: From baseline total ADHD-RS-5 mean score (40.3+10.3), improvements were greater on VER (13.9+10.2) than atomoxetine (33.1+12.1) (t = -10.12, p < 0.00001), in Inattention (t = -8.57, p < 0.00001) and in Hyperactivity/Impulsivity (t = -9.87, p < 0.00001). From baseline total AISRS mean score (37.3+11.8), improvements were greater on VER (11.9+9.4) than atomoxetine (28.8+14.9) (t = -4.18, p = 0.0009), in Inattention (t = -3.50, p < 0.004) and in Hyperactivity/Impulsivity (t = -3.90, p < 0.002). 86% of patients on VER reported positive response by 2 weeks versus 14% on atomoxetine. 36% discontinued atomoxetine for side effects, including GI upset (6 patients), irritability (6), fatigue (5), insomnia (1) versus 4% who discontinued VER due to fatigue. 96% preferred VER over atomoxetine with 85% (22/26) able to taper psychostimulants following stabilization on VER. 
Conclusion: Pediatric and adult ADHD patients, who have experienced less than optimal response to atomoxetine, demonstrate rapid improvement in inattention and in hyperactivity/impulsivity with greater tolerability on viloxazine extended-release, which deserves consideration as a new first-line ADHD treatment option

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The Validation of a Computer-Assisted Trail Making Test in Acute Rehabilitation Inpatients with Manual Disability