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Objective To collect real‐world data on the safety and effectiveness of balloon dilation of the Eustachian tube using a seeker‐based device in patients with persistent/chronic symptoms of Eustachian tube dysfunction. Methods A multicenter, prospective, single‐arm registry was conducted from June 2018 through August 2020 at 10 US centers, including tertiary care and private practices. Primary endpoints included mean change from baseline in the 7‐item Eustachian Tube Dysfunction Questionnaire (ETDQ‐7) and the serious related adverse event rate. Secondary endpoints include changes in middle ear assessments, surgical intervention rate, and changes in Sino‐Nasal Outcome Test and Work and Activity Impairment (WPAI) questionnaires. Results A total of 169 participants were treated with balloon dilation of the Eustachian tube, with 166 and 154 participants completing the 6‐week and 6‐month follow‐ups, respectively. Repeated measures analysis of the change in ETDQ‐7 scores indicated statistically significant improvement (−2.1; 95% CI −2.40, −1.84; P, The purpose of this current study was to gather effectiveness and safety data for BDET using a seeker‐based device in real‐world settings. We conclude that balloon dilation of the Eustachian tube with a seeker‐based device is a safe and effective procedure to treat ETD symptoms.

Patient: Male, 57-year-old Final Diagnosis: Hepatitis • herpes Symptoms: Fever Medication: — Clinical Procedure: — Specialty: General and Internal Medicine Objective: Challenging differential diagnosis Background: Herpes simplex virus-2 (HSV-2) affects nearly 1 in 5 adults in the United States. Complications such as viral hepatitis and dissemination are rare in immunocompetent hosts. In this report, we describe a case of viral hepatitis secondary to disseminated HSV-2 in an immunocompetent patient with recurrent fevers and elevated aminotransferases. Case Report: A 57-year-old man with a history of type 2 diabetes and hypertension was admitted with a right index finger lesion concerning for an abscess. He underwent successful incision and drainage and was started on ampicillin-sulbactam. On Day 2 of hospitalization, he developed recurrent fevers and elevated aminotransferases and inflammatory markers. An extensive infectious, rheumatologic, and malignancy workup were pursued without immediate findings. Imaging demonstrated cirrhotic morphology of the liver and splenomegaly, but lab markers were intact for liver synthetic function. On Day 7 of hospitalization, fever frequency decreased, and HSV-2 titers resulted, with positive IgM and negative IgG. He subsequently developed erythematous, raised lesions in multiple dermatomes. Nucleic acid amplification testing of biopsied lesions was positive for HSV-2, confirming viral hepatitis secondary to disseminated HSV-2. He was started on intravenous acyclovir and discharged on valacyclovir following improvement in symptoms. Conclusions: We report a case of viral hepatitis secondary to disseminated HSV-2 in an immunocompetent host. Up to 25% of cases occur in immunocompetent hosts and many patients do not develop characteristic skin lesions. Early diagnosis and treatment of viral hepatitis secondary to disseminated HSV remains vital to minimize morbidity and mortality.

Objective: To measure the return on investment (ROI) for a pediatric asthma pay-for-reporting intervention initiated by a Medicaid managed care plan in New York State. Design: Practice-level, randomized prospective evaluation. Setting: Twenty-five primary care practices providing care to children enrolled in the Monroe Plan for Medical Care (the Monroe Plan). Participants: Practices were randomized to either treatment (13 practices, 11 participated) or control (12 practices). Intervention: For each of its eligible members assigned to a treatment group practice, the Monroe plan paid a low monthly incentive fee to the practice. To receive the incentive, treatment group practices were required to conduct, and report to the Monroe Plan, the results of chart audits on eligible members. Chart audits were conducted by practices every 6 months. Aftereach chart audit, the Monroe Plan provided performance feedback to each practice comparing its adherence to asthma care guidelines with averages from all other treatment group practices. Control practices continued with usual care. Main Outcome Measures: Intervention implementation and operating costs and per member, per month claims costs. ROI was measured by net present value (discounted cash flow analysis). Results: The ROI to the Monroe Plan was negative, primarily due to high intervention costs and lack of reductions in spending on emergency department and hospital utilization forchildren in treatment relative to control practices. Conclusions: A pay-for-reporting, chart audit intervention is unlikely to achieve the meaningful reductions in utilization of high-cost services that would be necessary to produce a financial ROI in 2.5 years.

Background and Objectives Epidural catheters placed for perioperative analgesia in young children confer clinical benefits but are technically challenging to insert. Approximations of the skin to epidural space depth in this population are limited to direct needle measurement and ultrasonography. Magnetic resonance imaging (MRI) is the most comprehensive imaging modality of the spine. This study aims to produce a more clinically useful formula from MRI data to estimate pediatric epidural depth. Methods Seventy children with normal lumbar spine MR images were enrolled. After determination of epidural depth, linear regression was used to estimate a weight-based formula. Analysis of variance and bootstrap methods were used to evaluate this formula against 4 commonly cited formulae. The quality of predictions was evaluated using the mean absolute prediction error. Results The estimated weight-based formula as derived by MRI data is given by: skin to epidural depth (mm) = 9.00 + 0.62 * weight in kilograms. The mean absolute prediction error was 2.56 mm (95% confidence interval [95% CI], 2.12–3.04) for the new formula. Additional derived formulae are skin to dorsal dura depth (mm) = 13.52 + 0.71 * weight in kilograms (mean absolute prediction error, 2.48 mm; 95% CI, 2.00–3.03) and skin to ventral dural depth (mm) = 23.08 + 0.86 * weight in kilograms (mean absolute prediction error, 2.50 mm; 95% CI, 2.04–3.06). Conclusions We provide the first predictive formulae, based on MRI data, for pediatric epidural depth estimation.

In an essay, Karine Dubé and coauthors discuss the ethics of preclinical and clinical studies relevant to achieving an HIV cure.

he increase in the percent of the population that is uninsured in both North Carolina 1 and across the nation 2 is driven by the increasing costs of health insurance premiums. Nationally, health insurance premiums increased 65% between 2000 and 2004. This rise was more than six times greater than general inflation (9.7%), and more than five times the wage growth (12.2%). 3 The increase in premiums makes it harder for employers to offer insurance to employees and for individuals to purchase healthcare coverage. Research indicates that for every 10% increase in health insurance premiums, the number of firms that offer health insurance to their employees falls by roughly 2.5%. 4 Most of the increase in health insurance premiums is due to the increase in the underlying costs of healthcare. 5,6,7,8 Healthcare costs increase for a variety of reasons, some due to the increased cost of individual services, some due to greater utilization of services, and some due to changes in overall disease prevalence. This commentary examines trends in personal healthcare spending in North Carolina between 1990 and 2000, changes in unit costs and utilization of different services, and the effects of changes in disease prevalence and demographic changes on healthcare spending. The commentary concludes with how these changes impact health insurance premiums and how employers and individuals respond to rising premium costs.

N THE EARLY 1980s, the traditional role of the health insurance industry was to provide a standard array of insurance options, and to administer those programs through claims review and payment. Employers who purchased coverage for their workers typically did not expect anything more of their carriers. However, during this time there was mounting evidence, both nationally and in North Carolina, that the use of hospitals varied significantly from one geographic area to another. 1-3 Patients in high use areas were not just spending more days in the hospital; they were spending more money for their healthcare. And, increasingly, analysis was showing that most of the variation was due to physician practice patterns, rather than differences in population demographics, health status, or underlying risk factors. Employers who had employees in multiple NC locations began questioning their greater financial outlays to cover employees in the high utilization locations, and wondered what additional benefits they and their employees gained for the extra expense. This led to the obvious question: How much could be saved if it were possible to reduce utilization in the high use communities?

Journal clubs have a long history in graduate medical education; however, their role in orthopaedic surgery residencies has not been analyzed. The 161 orthopaedic residency program directors in the United States and Canada were surveyed to determine the frequency, format, and goals of journal clubs. Journal clubs are a regular part of the education program in 147 of the 149 programs that responded. Most journal clubs meet once per month in the evening and review articles from more than one periodical. Program directors rate teaching residents how to evaluate a scientific article as the most important goal of a journal club. Although journal clubs are virtually universal in orthopaedic programs, additional study is needed to assess their efficacy and optimal format.

Two young children (three hips) with Down syndrome and dislocation of the hip were successfully treated by nonoperative methods by using the principle of prolonged immobilization or bracing. A 5-year, 6-month-old patient with bilateral habitual dislocation used an ambulatory abduction orthosis full-time for 6 months and then part-time for 4 months. Complete dislocation of the right hip in a 4-year, 6-month-old patient was managed by closed reduction, spica cast immobilization for 4 months, and then an ambulatory abduction orthosis for 8 months. Both patients developed stable, well-contained hips. Nonoperative management of hip dislocation in Down syndrome can be successful and avoids the complications associated with operations previously recommended for these patients.

The decision analysis for managing femoral shaft fractures in children should included such factors as the possibility of child abuse, overgrowth, and the potential for remodeling. Direct and indirect costs must be understood. Factors to consider in determining treatment include the age of the child, the extent of the soft tissue injury, and associated injuries. Non-operative methods, universally used in the past to treat these injuries, still are indicated, but operative modalities should be considered for a greater number of pediatric femoral fractures. Early enthusiasm for external fixation and rigid intramedullary rodding has been tempered by a greater awareness of their particular complications. The role of flexible intramedullary rodding, however, is expanding.

Liesegang rings are laminated ring-like structures occasionally found in benign cysts and abscesses. They have been confused with parasites (especially eggs), algae, calcifications, and psammoma bodies. We examined Liesegang rings from fine-needle aspiration (FNA) biopsies of a benign cyst of the breast and a complex renal cyst. Liesegang rings were best observed with Papanicolaou, hematoxylin-eosin, Masson's trichrome, acid-fast (AFB), and Gram stains, which accentuate the concentrically laminated morphology. An amorphous electron-dense core and fibrillary lucent concentric rings were seen with transmission electron microscopy with no significant energy peaks by electron probe microanalysis or distinct diffraction patterns by X-ray diffraction. This investigation indicates that Liesegang rings are composed of organic substances most likely formed by periodic precipitation from a supersaturated solution within cystic fluid. Awareness of the Liesegang phenomenon within cystic lesions will decrease the possibility of erroneous misdiagnosis as another type of pathologic process. Diagn. Cytopathol. 1998;19:116–119. © 1998 Wiley-Liss, Inc.

In the 1960s, effective techniques were developed for shunting hydrocephalus and for early closure of neural tube defects. As a result, orthopaedic surgeons were presented with the challenge of managing an emerging population of children who had myelomeningocele. Initially, the musculoskeletal problems in these children were treated with the modalities and expectations that had been learned from the treatment of poliomyelitis. However, it soon became apparent that the management of children who have myelomeningocele was not so simple. Additional factors include a decrease or loss of sensation affecting some or all parts of the lower extremities, associated congenital anomalies of the spine and lower extremities, and muscle imbalance that affects skeletal development over the entire period of growth. Furthermore, some patients who have myelomeningocele have a static encephalopathy that impairs coordination and results in the loss of strength of the lower and upper extremities29,30,45. Also, progressive neurological deterioration may occur because of tethered cord syndrome or syringomyelia2. As a result, the evaluation and treatment of musculoskeletal problems in these patients can be quite difficult. The purpose of this Instructional Course Lecture is to review the natural history of myelomeningocele as well as the types of deformity that are associated with it, the treatment options that are available, and the expected results of treatment of hip and knee problems related to myelomeningocele. Although other factors must be considered, the neurological level is the key to understanding the hip and knee deformities seen in these patients. Unless otherwise specified, a modification of the classification system described by Asher and Olson3 will be used to define the neurological level (Table I). This classification is based on muscle strength, is simple to use, and, in my experience, has been helpful in predicting gross motor function …

Background Galactoceles are benign cystic lesions that generally occur during pregnancy and postpartum lactation. Fine needle aspiration (FNA) yields milky fluid that is often both diagnostic and therapeutic. Cytologically, aspirates are generally noted to contain occasional foam cells and benign epithelium displaying lactational change with an abundant background of lipid micelles and proteinaceous material. Case A 23-year-old, black female presented with a 1.0-cm, discrete, nontender nodule involving the upper middle area of the left breast. FNA showed crystals of varying size and shape, best viewed with Diff-Quik and demonstrating metachromasia, polarization and birefringence. They were also positive with periodic acid-Schiff stain and both alizarin red S and von Kossa stain for calcium. Scanning electron microscopy revealed angulated, well-defined geometric crystals often with scalloped edges and smooth surfaces. The internal structure of the crystals consisted of electron-lucent material without periodicity or lattice formation, as observed by transmission electron microscopy and x-ray diffraction. Electron probe microanalysis identified small quantities of calcium, chlorine, potassium and sulphur within the crystals. Conclusion We think that in this case the crystals represented precipitation of inspissated lactational secretions. There are several possible mechanisms of precipitation. The differential diagnosis includes other breast lesions with acellular amorphous components that may be confused with crystallizing galactocele in FNA biopsy specimens.

Appropriate and safe use of medications is an important aspect of quality of care in nursing home patients. Because of their complex medication use process, anticoagulants are prone to medication errors in the frail elderly. Therefore, we designed this study to characterize anticoagulant medication errors and to evaluate their association with patient harm using individual medication error incidents reported by all North Carolina nursing homes to the Medication Error Quality Initiative (MEQI) during fiscal years 2010-2011. Characteristics, causes, and specific outcomes of harmful anticoagulant medication errors were reported as frequencies and proportions and compared between anticoagulant errors and other medication errors using chi-square tests. A multivariate logistic regression model explored the relationship between anticoagulant medication errors and patient harm, controlling for patient- and error-related factors.

The etiology and treatment of Kienbock disease, or osteonecrosis of the lunate, remain controversial. The condition is frequently associated with repetitive trauma, and the typical patient is twenty to forty years old and has noted an insidious onset of pain and stiffness in the wrist. Kienbock disease is uncommon in children. In four large series, only five (1 per cent) of 404 patients were less than sixteen years old at the time of diagnosis7,9,36,44. Furthermore, the children in those reports were involved either in sports activities that had caused repetitive trauma to the wrist, such as gymnastics, or they had sustained an acute injury. A ten-year-old child who had diplegic cerebral palsy and Kienbock disease is described in the present report. A ten-year and ten-month-old white girl who had moderately severe diplegic cerebral palsy was seen two weeks after the onset of pain and decreased motion of the left wrist. The pain in the wrist was mild, but it had compromised her ability to grasp a walker. The patient reported no recent episodes of trauma to the wrist and had not needed to use analgesics. The patient was highly motivated and intelligent and had been able to walk independently about the house since the age of seven years. She needed a reverse rolling walker as an aid for walking and, before the onset of pain in the wrist, she had used a wheelchair only for long distances, such as when she went to a shopping mall. Previous operations included iliopsoas recession and adductor myotomy bilaterally when she was three years old and lengthening of the gastrocnemius aponeurosis bilaterally when she was six years old. Physical examination revealed no obvious swelling and only slight tenderness to palpation over the mid-part of the dorsum …

PURPOSE OF REVIEW Preexisting corneal disease can be exacerbated by cataract surgery and may prevent well tolerated cataract extraction. This article reviews the current literature and describes how corneal epithelial, stromal and endothelial disease may impact and be impacted by cataract surgery while highlighting recommendations for perioperative management and surgical technique. RECENT FINDINGS Modifications to surgical techniques can allow for improved intraoperative visualization and safer cataract removal. Cataract surgery can be safely performed in conjunction with newer forms of corneal transplantation such as deep anterior lamellar keratoplasty and endothelial keratoplasty; however, guidelines for when to perform combined surgery have not been established. SUMMARY Appropriate perioperative management and advances in surgical techniques and technologies allow for successful cataract surgery in patients with corneal disease. Signs of corneal disease should be identified preoperatively to allow for surgical planning and optimal visual outcomes.

Background Medication errors may potentially pose significant risk of harmful outcomes in vulnerable nursing home residents. Current literature lacks data regarding the drug classes most frequently involved in errors in this population and their risk relative to underlying drug class utilization rates. Objectives This study (1) describes the frequency and error characteristics for the drug classes most commonly involved in medication errors in nursing homes, and (2) examines the correlation between drug class utilization rates and their involvement in medication errors in nursing home residents. Design A cross-sectional analysis of individual medication error incidents reported by North Carolina nursing homes to the Medication Error Quality Initiative during fiscal years 2010 to 2011 was conducted. Participants All nursing home residents in the state of North Carolina. Main measures The 10 drug classes most frequently involved in medication errors were identified. Characteristics and patient impact of these medication errors were further examined as frequencies and proportions within each drug class. Medication error data were combined with data from the 2004 National Nursing Home Survey to capture nationally representative estimates of medication use by drug class in nursing home patients. The correlation between medication utilization and error involvement was assessed. Results There were 32,176 individual medication errors reported to Medication Error Quality Initiative in years 2010–2011. The 10 drug classes most commonly involved in medication errors were analgesics (12.27%), anxiolytics/sedative/hypnotics (8.39%), antidiabetic agents (5.86%), anticoagulants (5.04%), anticonvulsants (4.05%), antidepressants (4.05%), laxatives (3.13%), ophthalmic preparations (2.77%), antipsychotics (2.47%), and diuretics (2.34%). The correlation between utilization and medication error involvement was not statistically significant (P value for spearman correlation coefficient = .88), suggesting certain drug classes are more likely to be involved in medication errors in nursing home patients regardless of the extent of their use. Conclusions The drug classes frequently and disproportionately involved in errors in nursing homes include anxiolytics/sedatives/hypnotics, antidiabetic agents, anticoagulants, anticonvulsants, and ophthalmic preparations. Better understanding of the causes and prevention strategies to reduce these errors may improve nursing home patient safety.

e16027 Background: Platinum-based chemotherapy including cisplatin, 5-fluorouracil (5-FU), and the EGFR-directed monoclonal antibody cetuximab, are active in the treatment of head and neck squamous cell carcinoma (HNSCC). Patients with inoperable recurrent or metastatic HNSCC have a poor prognosis and many have difficulty tolerating cisplatin-based regimens. Oxalipatin, a third-generation platinum derivative, has demonstrated antitumor activity and lacks many of the limiting side effects of cisplatin. We conducted a phase I pilot study to investigate the dose-limitation of oxaliplatin in addition to infusional 5-FU and cetuximab in patients with untreated recurrent or metastatic HNSCC. Methods: The planned dose escalation schedule included: dose level 1: oxaliplatin 100mg/m2 day 1, 5-FU CIV 750mg/m2 over 96 hours beginning day 1, and cetuximab 400mg/m2 cycle 1, day 1 (and 250mg/m2 weekly thereafter) on a 21-day cycle. Dose level 2: oxaliplatin 130mg/m2 day 1, 5-FU CIV 1000mg/m2 over 96 hours beginning day 1 and the same dose and schedule of cetuximab. Results: A total of 10 patients were accrued, consisting of 4 females and 6 males. The first seven were enrolled onto dose level 1 and the following three onto dose level 2. Dose level 1 was tolerated well with acceptable toxicity, including grade 1-2 oral mucositis, grade 1-2 fatigue, grade 1-2 acneiform rash, grade 1 nausea, grade 1-2 anemia and grade 1 transaminitis. All responses observed, (1 MR, 1 PR, 1 CR), were short-lived. Dose level 2 was more toxic than anticipated; 2 of 3 patients experienced grade 4 toxicities (mucositis, diarrhea, acute renal failure) requiring hospitalization with a treatment-related death in one of these patients. The phase I portion of the trial was therefore closed and dose level 1 is considered the maximum tolerated dose. Conclusions: The regimen of oxaliplatin 100mg/m2 day 1, infusional 5-FU 750mg/m2 over 96 hours beginning day 1, and cetuximab 400mg/m2 cycle 1, day 1 (with 250mg/m2 weekly thereafter), given on a 21-day cycle, has manageable toxicity; these doses are recommended for phase II evaluation in the treatment of unresectable or metastatic HNSCC.

Mindfulness-based interventions and mindfulness techniques have become increasingly popular in psychosocial care. These interventions have also been increasingly used with cancer patients and survivors. However, more attention is due to issues such as how these techniques may be specifically relevant for an oncology population and whether the religious derivation of mindfulness should be considered by frontline psychosocial clinicians. This article provides a history and overview of the use of mindfulness in psychosocial cancer care.

The results of five patients who had hemophilia and a history of recurrent hemarthrosis and hypertrophic synovitis and who had been managed with a synovectomy of the ankle were studied at an average age of nine years (range, four years and seven months to nineteen years). Compared with the complications encountered after synovectomy of the knee or the elbow, the rehabilitation process after synovectomy of the ankle was relatively easy, even for the three youngest children in this series. The average duration of follow-up was five years (range, one to nine years). By the latest follow-up examination, the range of motion of the ankle had increased an average of 10 degrees (range, -5 to 15 degrees). The rate of hemarthrosis episodes requiring transfusion was reduced from an average of 3.4 per month (range, 0.3 to 5.0 per month) for the six months before the synovectomy to 0.1 per month (range, zero to 0.2 per month) for the twelve months before the latest follow-up examination.

More than 1,000,000 persons in the United States are living with human immunodeficiency virus (HIV)/acquired immune deficiency syndrome, with 24% unaware of their HIV status. In this study, the authors explored patients' attitudes toward HIV testing in academic medical clinics and investigated the possible impact of the 2006 Centers for Disease Control and Prevention (CDC) HIV screening guidelines.Cross-sectional survey study of adult patients in 9 academic internal medicine clinics (response rate 73%). The survey consisted of 76 questions, which assessed demographics, HIV risk factors, knowledge, beliefs, attitudes and characteristics of patient-physician interactions. Patient self-reported HIV testing was the main outcome. Bivariate analyses were performed, and variables with a P-value of0.1 were included in a logistic regression model to determine characteristics most associated with HIV testing.Four hundred forty-three patients completed the survey (response rate 73%) and 61% reported being screened for HIV. Physician recommendation (P0.0001), patient's own request (P0.0001), African American race (P0.0001) better knowledge about HIV (P = 0.0002), agreement with CDC recommendations (P0.0001), being comfortable with their doctor (P0.0001) and using street drugs (P0.0001) were all strongly associated with testing. In logistic regression, the only factors that remained statistically significant predictors of patients self-reported HIV testing were a patient's request for testing (OR: 103.3) and patient's knowledge about HIV (OR: 1.3).In this study, patient request was the strongest predictor for HIV screening and majority of patients accepted the idea of HIV testing in congruence with the CDC recommendations. Therefore, simple waiting room prompts and public education campaigns may represent the most efficient interventions to increase HIV testing rate.

Transfer of the posterior tibialis tendon to the dorsum of the foot was compared with lengthening of this tendon in 15 patients with Duchenne's muscular dystrophy.Patients undergoing tendon transfer ( N = 9) had a longer operating time and two perioperative complications, but retained plantigrade posture of their feet even after walking ceased. By contrast, lengthening of the posterior tibialis tendon (A/ = 6) was associated with a recurrent equinovarus foot deformity that frequently interfered with shoe wear. Although transfer of the posterior tibialis is out of phase and technically more demanding, the unique prolongation of posterior tibialis strength in Duchenne's muscular dystrophy makes this operation a better option for these patients.

We reviewed the cases of fifteen obese patients (twenty-one extremities) who had had adolescent tibia vara and had been followed for at least two years. Of the nine patients (eleven extremities) who had been initially managed with lateral tibial hemiepiphyseodesis, eight (ten extremities) were skeletally mature at the time of the review (mean duration of follow-up, five years). The mechanical alignment was judged to be excellent in three of these ten extremities, fair in three, and poor in four. Excellent mechanical alignment was defined as a value within the reported normal range of 5 degrees of varus to 2 degrees of valgus. A poor result was defined as alignment that was more than 5 degrees outside the normal range. After secondary operative procedures, three of the extremities for which the result had been poor and one for which it had been fair had excellent alignment. Five of the nine patients had bilateral involvement. Two of them were managed with bilateral tibial hemiepiphyseodesis; two, with contralateral proximal tibial osteotomy; and one had a mild deformity on the contralateral side that was not treated. Six extremities in six patients (two of whom had a contralateral hemiepiphyseodesis) were managed primarily with proximal tibial osteotomy and were evaluated an average of seven years postoperatively. Two additional patients were managed with proximal tibial osteotomy because of residual varus deformity after the hemiepiphyseodesis.(ABSTRACT TRUNCATED AT 250 WORDS)

Rapid progression of hip subluxation was noted in the year after selective dorsal rhizotomy in seven hips (six patients). The hips that subluxed progressed from a lateral extrusion index averaging 25% preoperatively as compared with 50% after rhizotomy. Although preexistent hip dysplasia was a predisposing factor, hips with an intermediate degree of preoperative lateral extrusion (12-25%) had variable results. Ongoing and more frequent evaluation of hip stability is necessary after dorsal rhizotomy.

The records of all thirteen patients for whom a diagnosis of cloacal exstrophy had been recorded in our hospitals were analyzed for evidence of musculoskeletal problems. All thirteen patients had spina bifida, four had congenital scoliosis, two had congenital kyphosis, and three had non-congenital scoliosis. All had a lipomeningocele, and eleven had paralysis of the lower extremities. Hydrocephalus and its associated problems were not found, but tethered-cord syndrome was diagnosed in eleven patients. Persistent diastasis of the symphysis pubis was found in all patients. Abduction and external rotation of the hips were more than normal. Mild dysplasia was seen in six of the twenty-six hips. Deformities of the foot were common, and twelve feet had been operated on for correction. Recurrent equinovarus deformity of the foot was associated with tethered-cord syndrome in two patients.

To define the scope of bone disease among men referred for parathyroidectomy and to document bone density screening trends in this high-risk population.Clinical data were analyzed from a prospectively maintained database of 1000 patients undergoing parathyroidectomy for sporadic primary hyperparathyroidism at the Cleveland Clinic between 2000 and 2006. Information collected included demographics, reason for referral, body mass index, intraoperative findings, preoperative and postoperative laboratory values (serum calcium, phosphorus, parathyroid hormone, 25-hydroxyvitamin D, and 24-hour urinary calcium excretion), and preoperative and postoperative dual-energy x-ray absorptiometry (DXA) findings.Of the 1000 patients, 243 (24%) were men. As with women, bone health-related issues were the most common reason for referral (32%). In 2000, only 12% of men had preoperative DXA scans; this rose to 42% by 2005. The frequency of prereferral DXA screening increased throughout the study, but even by 2006, referring physicians did not screen most of their male patients. In 2000, the prevalence of bone disease (osteoporosis or osteopenia) in men was 8%, but with improved screening, this increased to 26%, approaching the 34% rate in women. Preoperative and postoperative levels of calcium, parathyroid hormone, phosphorus, 24-hour urinary calcium, and 25-hydroxyvitamin D were the same among men with and without bone disease. Analysis of postoperative DXA scans revealed that gains in postparathyroidectomy bone density were significantly greater in men than in women at all anatomic testing sites. In men, lowest T scores improved by a mean +/- SEM of +0.35 +/- 0.09 compared with +0.098 +/- 0.035 in women (P = .009). Men were 4 times less likely than women to have continued bone loss after parathyroidectomy.Clinical and laboratory parameters cannot identify men with hyperparathyroidism who have bone loss, illustrating the need for routine DXA screening. Despite this, DXA remains underused. Improved screening practices will favorably effect men's health.

The tibial metaphyseal-diaphyseal (MD) and tibial-femoral (TF) angles were measured on the radiographs of 33 knees in young children (aged 12-36 months) with bowleg deformity. Four observers of differing experience measured the films in a blinded fashion to determine the intraobserver and interobserver variability of these measurements. The clinical implications of these variabilities are described. Very little instruction and experience is necessary to make these measurements correctly and precisely. Measurement of the MD angle was superior to measurement of the TF angle. Contrary to published opinion, rotation can have a small but potentially significant effect on the measured MD angle.

Twenty-two patients (24 hips) with Legg-Perthes disease received 49 magnetic resonance (MRI) scans. The scans and corresponding radiographs were independently evaluated in a blinded fashion to assess the capabilities of, and indications for, MRI in Legg-Perthes disease. Early in the disease process, MRI often more clearly delineated the extent and location of areas of involvement than did plain radiographs. In one patient, MRI failed to indicate necrosis early in the course of the disease, but it was detected on plain radiographs. MRI can also be used to give a rough estimate of sphericity, which in some phases of the disease process is better than plain radiographs. For serially following the disease process through the natural healing course, plain radiographs were as good or better than MRI and considerably less costly.

Thirty patients who had hemophilia and were seropositive for the human immunodeficiency virus were evaluated. The preoperative CD4 lymphocyte count was decreased to an average of 336 x 10(9) per liter (range, 27 to 708 x 10(9) per liter). After twenty-six orthopaedic operations in patients who had no previous bacterial infection, a nosocomial infection (cellulitis in the forearm, at the site of an intravenous catheter) developed in only one patient, but five patients had an abnormal postoperative fever that was not accompanied by the expected increase in the white blood-cell count. The preoperative CD4 lymphocyte count was significantly reduced in the patients who had an abnormal elevation in body temperature (p less than 0.004). The functional result or outcome after operation was similar to that in hemophilic patients treated before 1982. Subsequent progression of infection with the human immunodeficiency virus, as determined by the CD4 lymphocyte count and the Walter Reed classification system, occurred in most patients. Acquired immunodeficiency syndrome was diagnosed in six patients. A more rapid progression to acquired immunodeficiency syndrome was seen in the patients who had a lower CD4 lymphocyte count preoperatively. Preoperative evaluation of the CD4 lymphocyte count and the response to intradermal skin-test antigens in patients who are at risk for infection postoperatively provides additional information concerning immunological competence. With these data, the possible risk of infection in patients who are seropositive for the human immunodeficiency virus can be estimated more accurately.

Objective . To describe the steps in developing a business case for quality-enhancing interventions (QEIs) in health care. Analysis . The development of a business case for QEIs in health care involves 11 steps. These steps include (1) describing the intervention, (2) determining perspective, (3) identifying the effects of the intervention on quality, (4) designing the study, (5) identifying and measuring cash flows, (6) considering the effects of capacity constraints, (7) selecting a measure of return on investment, (8) determining the time horizon for the analysis, (9) determining the discount rate, (10) adjusting costs and savings for inflation, and (11) determining organizational readiness for business case development. A checklist offers guidance on assessing readiness for the business case. Conclusion . The absence of a ‘business case’ for quality is frequently cited as the reason health care organizations do not implement QEIs, despite decades of careful research demonstrating their effectiveness. Our continuing commitment to advancing the discipline of business case analysis is based on a belief that delineating the cost and economic implications of investments in QEIs is a critical threshold issue to widespread adoption of evidence-based quality improvements. We believe it is appropriate and timely to consider how best to standardize approaches and move the field of business case analysis forward.

Objectives The Joint Commission revised its National Patient Safety Goals (NPSGs) to include oral anticoagulation therapy (OAT) in 2008. We sought to examine the effect of including OAT in The Joint Commission's NPSGs on historically low rates of OAT initiation for individuals with incident atrial fibrillation (AF). Setting Southeastern state in the USA. Participants North Carolina State Health Plan claims data from 944 500 individuals enrolled between 1 January 2006 and 31 December 2010, supplemented with data from the Area Resource File and Online Survey, Certification and Reporting data network. We evaluated OAT initiation before and after the 2008 NPSGs revisions in a retrospective cohort new user design with an AF intervention group and two control groups: a positive control—patients estimated to be at very high risk of thromboembolism (mechanical heart valve and pulmonary embolism); and a negative control—patients with very low perceived risk of thromboembolism (paroxysmal AF). We developed multivariable models using a difference-in-difference parameterisation. Effects were estimated with generalised estimating equations. Primary outcome measure OAT initiation, a binary outcome defined as having a prescription drug claim for warfarin within 30 days of the index claim. Results OAT initiation was low (26.8%) for eligible individuals with incident AF in 2006–2008 but increased after NPSGs implementation (31.7%, p=0.022). OAT initiation was high but decreased in the positive control group (67.5% vs 62.0%, p=0.003). Multivariate analysis resulted in a relative 11% (95% CI (4% to 18%), p

The early diagnosis of osteomyelitis of the patella in children can be difficult due to the rarity of this infection and to the vagaries of presentation which may be either acute with systemic signs or insidious with mild local signs. We present four cases of patellar osteomyelitis to illustrate the spectrum of this disorder. There should be a high index of suspicion with persistent pain and swelling above the knee, septic prepatellar bursitis, and septic knees that do not respond to conventional management. Management parallels treatment of osteomyelitis of other bones.

Caterpillar bodies are eosinophilic, periodic acid-Schiff (PAS)-positive globules arranged in a linear fashion in the epidermis overlying subepidermal blisters of porphyria cutanea tarda (Am J Dermatopathol 1993;15:199-202). We retrospectively studied by transmission electron microscopy nine cases of porphyria cutanea tarda (PCT) that demonstrated caterpillar bodies. We identified three components of the eosinophilic bodies: degenerating keratinocytes, colloid bodies, and basement membrane bodies. The colloid bodies consisted of whorled masses of filaments containing degenerating melanosomes, vacuoles, mitochondria, and desmosomes. Basement membrane bodies were composed of convoluted basement membrane material and associated collagen. Both colloid and basement membrane bodies were often associated with degenerating keratinocytes, were located both intra-and extracellularly, and were occasionally fused to one another. We believe that caterpillar bodies are a combination of degenerating keratinocytes, colloid bodies, and basement membrane bodies formed by repeated blistering and reepithelialization with transepidermal migration. Furthermore, we believe that caterpillar bodies are a diagnostic clue for the diagnosis of PCT.

Bone-mineral density was studied in a heterogeneous group of 139 children (mean age, nine years; range, three to fifteen years) who had spastic cerebral palsy. The evaluation included serum analyses and a nutritional assessment based on a dietary history and anthropometric measurements. The bone-mineral density of the proximal parts of the femora and the lumbar spine was measured with dual-energy x-ray absorptiometry and was normalized for age against a series of ninety-five normal children and adolescents who served as controls. Bone-mineral density varied greatly but averaged nearly one standard deviation below the age-matched normal means for both the proximal parts of the femora (-0.92 standard deviation) and the lumbar spine (-0.80 standard deviation). Ambulatory status was the factor that best correlated with bone-mineral density. Nutritional status, assessed on the basis of caloric intake, skinfolds, and body-mass index, was the second most significant variable. The pattern of involvement, durations of immobilization in a cast, and a calcium intake of less than 500 milligrams per day were additional factors of less significance. The age when the child first walked, previous fractures, use of anticonvulsants, and serum vitamin-D levels did not correlate with bone-mineral density after adjustment for covariance with the ambulatory status and the nutritional status. Serum levels of calcium, phosphate, alkaline phosphatase, and osteocalcin were not reliable indicators of low bone-mineral density.

Methods and benefits of ACP for geographic populations in the U. S. have been limited to relatively small populations such as La Crosse, WI (POP. 110,000). Beginning in 2008, the Twin Cities Medical Society and its Foundations catalysed the development of a metropolitan area wide voluntary, collaborative ACP program that included major hospital systems and health care plans. This initiative, called Honouring Choices Minnesota (HCM), features Minnesota governance and implementation of a validated ACP model. More than 800 facilitators and 32 instructors have been trained and the most mature health system program is adding 2,000 health care directives to its EMR monthly. This two-part workshop will present ACP strategies and methods across systems and population subgroups. In Part I, project conceptualisation, environmental assessment, collaborative development, leadership and funding will be addressed. Other components will include establishing a medical infrastructure, staff training, pilot site development, standardised patient education, moving from pilot site to system-wide implementation, access and reimbursement. Part II discussion will focus on public engagement. Development of public engagement goals, objectives and strategies will be reviewed. The conceptualisation, development and deployment of a metro-wide broadcast and internet campaign will be presented as well as ideas for national application. The roles of strategic partnerships, community resources, media partnerships and multicultural strategies will be reviewed. HCM is an innovative ACP program, scaled to a large, diverse metro population (POP. 2.85 million), whose concepts and strategies may have broad applicability nationally and internationally.

Data were collected on 476 spring-calving, primiparous cows at six locations in Louisiana over a 2-yr period. Objectives of the study were to evaluate changes in prepartum body condition score (BCS) and BW of heifers when fed varying energy levels and to determine the influences of prepartum BCS and BW changes and BCS at calving on postpartum traits. Heifers were allocated to one of three energy levels from approximately 90 d prepartum to parturition. The diets were formulated to provide low, recommended, and high energy levels based on TDN requirements. After calving, cows were placed on annual ryegrass pasture and managed similarly at each location. Weight and BCS at calving were greater (P.05) for females with higher BCS at 90 d prepartum (IBCS) and for those assigned to higher energy levels. Calving and calf growth traits were not affected (P.05) by IBCS, energy level, prepartum changes in BCS and BW, or BCS at calving. Prepartum changes in BCS and BW regulated by varying energy levels had no effect (P.05) on postpartum reproduction; however, BCS at calving influenced (P.03) pregnancy rate and days to pregnancy. Cows with BCS 6 and 7 at calving had higher (P.05) pregnancy rates (87.0 and 90.7%) than those with BCS 4 and 5 (64.9 and 71.4%). Interval to pregnancy for cows with BCS 4 at calving was 10 to 18 d longer (P.05) than for those with BCSor = 5.(ABSTRACT TRUNCATED AT 250 WORDS)

One widely held theory on the pathogenesis of adolescent late-onset tibia vara is that obesity coupled with mild preexisting varus alignment produces forces sufficient to retard growth in the medial portion of the proximal tibial physis and initiates the development of the condition. Two cases are presented in which neutral mechanical alignment was clearly documented in an extremity that subsequently developed adolescent late-onset tibia vara within 19 months. We conclude that in at least some cases, preexisting varus alignment is not a prerequisite for the development of adolescent late-onset tibia vara.

A one-stage release of circumferential congenital constriction bands was performed in four extremities (three patients). No wound problems occurred, even when there had been marked swelling of the extremity distal to the band. The one-stage release facilitated postoperative care, and there was no need for additional periods of anesthesia or for additional operations, which are necessary when this problem is treated with a release performed in two or three stages.

The aim of the study was to examine whether increased neural tension during passive hamstring stretching contributes to stretch-induced strength loss. Eleven healthy subjects performed maximal isometric knee flexion contractions (100°, 80°, 60° and 20°) before and after a series of hamstring stretches (six 1-min stretches), performed in either a spinal neutral position or a neural tension position. Effect of stretch technique (neutral or neural tension) on passive resistance to stretch, strength-induced strength loss and electromyography activity during strength tests was assessed with repeated measures analysis of variance. Passive resistance to stretch was reduced by 19% after the series of stretches (p=0.001) with no difference between neutral or neural tension stretches (p=0.41). Stretch-induced strength loss was greater (p=0.043) after the neural tension stretches (13%) vs the neutral stretches (5%). There was an apparent rightward shift in the length tension curve after neutral stretches with a 15% strength loss at muscle lengths shorter than optimum, and a 10% gain in strength at muscle lengths longer than optimum (p

Scott Nelson, Montri Wongworawat. Loma Linda, CA: Loma Linda University Press; 2005. 95 “wee” pages. $12.00. “Never memorize anything you can look up.” This quote from Albert Einstein introduces Tolerances , a pocket-sized manual of classifications of both traumatic and nontraumatic orthopaedic conditions as well as tolerances (indications) for nonoperative versus operative treatment. The …

Clinically, Electron Probe X-ray Microanalysis (EPMA) studies have detected elemental silicon (Si) in remote sites of chronic inflammation (skin, finger, knee and elbow) in patients who were previously implanted with a silicone polymer-filled breast augmentation prostheses. Subsequent biopsy material obtained from the fibrous tissue capsule surrounding the implant was found to contain abundant silicon in foamy macrophages. In the remote biopsies, the elemental silicon is believed to be derived from macrophages that originated in the connective tissue capsule.In order to study the possible cellular distribution of silicone in an animal model, 120gm female SD rats were injected subcutaneously at the nape of the neck with 2ml of breast prothesis silicone gel (1.7% of total body weight). The injection correlates to a 0.9kg silicone prostheses implanted in a 55kg human recipient. Adjuvant arthritis was produced after 8 weeks in Si injected and control animals by the subdermal injection of 0.75 mg of heat killed Mycobacterium butyrium (MB) over the left rear knee. Si injected only, Si plus MB, MB only and untreated control animals were sacrificed by Metofane inhalation at 16, 24 and 32 week intervals and tissues were processed for routine light microscopy and TEM. Decalcified knee joints were sectioned longitudinally and sent to JEOL USA, Inc. for blind, collaborative SEM x-ray microanalysis studies.

The Journal of Bone and Joint Surgery is truly excited about becoming a sponsor of the International Center for Orthopaedic Education (ICOE). This initiative of the American …

Spinal cord trauma is a major health problem in terms of morbidity and mortality. It is clear that traumatic spinal cord injury is related to the death of a cord segment which results in the structural and functional disruption of key pathways vital to the maintenance of normal neurological function. The injured area of the cord eventually becomes a zone of segmental necrosis which, in the more severe cases, involves all but a thin rim of sub-pial white matter. The clinical consequences of segmental necrosis can be consistently reproduced in experimental animals by dropping weights onto the surgically exposed cord. At the moment of impact and during the primary injury phase, there are changes in the spinal cord which indicate that neural membranes are altered. The extent and reversibility of these alterations are being investigated for therapeutic treatment. Emphasis has been placed principally on secondary events leading to calcium toxicity. An ultra-rapid freezing technique evolved from the necessity of preserving diffusible ions in situ before and after spinal cord injury.