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Surgical intervention for Charcot arthropathy is becoming more common; this is driven by an increased prevalence, better understanding of the cause, identifying patient risk factors that influence outcomes, and how to best optimize these. This article aims to summarize the cause of Charcot, look at the factors that influence the outcomes, and the financial cost of managing what is a very challenging condition.

Aims Surgical reconstruction of deformed Charcot feet carries a high risk of nonunion, metalwork failure, and deformity recurrence. The primary aim of this study was to identify the factors contributing to these complications following hindfoot Charcot reconstructions. Methods We retrospectively analyzed patients who underwent hindfoot Charcot reconstruction with an intramedullary nail between January 2007 and December 2019 in our unit. Patient demographic details, comorbidities, weightbearing status, and postoperative complications were noted. Metalwork breakage, nonunion, deformity recurrence, concurrent midfoot reconstruction, and the measurements related to intramedullary nail were also recorded. Results There were 70 patients with mean follow-up of 54 months (SD 26). Overall, 51 patients (72%) and 52 patients (74%) were fully weightbearing at one year postoperatively and at final follow-up, respectively. The overall hindfoot union rate was 83% (58/70 patients). Age, BMI, glycated haemoglobin, and prior revascularization did not affect union. The ratio of nail diameter and isthmus was greater in the united compared to the nonunited group (0.90 (SD 0.06) and 0.86 (SD 0.09), respectively; p = 0.034). In those with a supplementary hindfoot compression screw, there was a 95% union rate (19/20 patients), compared to 78% in those without screws (39/50 patients; p = 0.038). All patients with a miss-a-nail hindfoot compression screw went on to union. Hindfoot metalwork failure was seen in 13 patients (19%). An intact medial malleolus was found more frequently in those with intact metalwork ((77% (44/57 patients) vs 54% (7/13 patients); p = 0.022) and in those with union ((76% (44/58 patients) vs 50% (6/12 patients); p = 0.018). Broken metalwork occurred more frequently in patients with nonunions (69% (9/13 patients) vs 9% (5/57 patients); p < 0.001) and midfoot deformity recurrence (69% (9/13 patients) vs 9% (5/57 patients); p < 0.001). Conclusion Rates of hindfoot union and intact metalwork were noted in over 80% of patients. Union after hindfoot reconstruction occurs more frequently with an isthmic fit of the intramedullary nail and supplementary hindfoot screws. An intact medial malleolus is protective against nonunion and hindfoot metalwork failure. Cite this article: Bone Joint J 2022;104-B(6):703–708.

Background Hospital-acquired catheter-associated urinary tract infection (CAUTI) was estimated to cause 19,700 cases in 2020 across the United States per the Centers for Disease Control and Prevention (CDC). While this is a 25% decrease in reported incidence rates since 2015, ad-hoc changes in care practices and limitations of surveillance definitions brought on by the giant burden of COVID-19 on the healthcare system possibly resulted in underreporting of CAUTIs. In a 290-bed tertiary, community hospital in the Detroit metropolitan area, there was a 200% increase CAUTIs from 2020 (5 CAUTIs) to 2021(16 CAUTIs). A multidisciplinary, resident-led team was assembled to reduce hospital-acquired CAUTIs. Methods A multi-pronged quality improvement initiative was conducted from January 1, 2021, through March 31, 2022. CAUTIs were identified and reviewed via electronic health records using predefined criteria related to CDC surveillance definitions, urinary catheter insertion indications, laboratory data, and antibiotic use. Plan-Do-Study-Act (PDSA) Cycle model was used to guide the initiative. Thus far one PDSA cycle has been completed. The initial intervention bundle was designed by the multidisciplinary team and led by internal medicine and transitional year residents. The intervention bundle included 1. Provider (including physician and RN) education, 2. Design and implementation of an appropriate urinary catheter practice algorithm, and 3. Expert review of positive urine cultures and CAUTI cases. Results Baseline data collected from January to December 2021 showed 16 CAUTIs. Post-implementation of the intervention bundle from January to March 2022 resulted in a 75% reduction in CAUTI incidence (1 CAUTI flagged). Conclusion A targeted intervention bundle improved CAUTI incidence by reducing inappropriate urinary catheter insertion and prolonged removal. Ongoing local initiatives focused on hospital-acquired infections, such as this one, are paramount to the persistent optimization of infection prevention despite national trends. Disclosures All Authors: No reported disclosures.

Background & aim Utilization of augmented reality (AR) and heads-up displays (HUD) to aid orthopaedic surgery has the potential to benefit surgeons and patients alike through improved accuracy, safety, and educational benefits. With the COVID-19 pandemic, the opportunity for adoption of novel technology is more relevant. The aims are to assess the technology available, to understand the current evidence regarding the benefit and to consider challenges to implementation in clinical practice. Methods & results PRISMA guidelines were used to filter the literature. Of 1004 articles returned the following exclusion criteria were applied: 1) reviews/commentaries 2) unrelated to orthopaedic surgery 3) use of other AR wearables beyond visual aids leaving 42 papers for review. This review illustrates benefits including enhanced accuracy and reduced time of surgery, reduced radiation exposure and educational benefits. Conclusion Whilst there are obstacles to overcome, there are already reports of technology being used. As with all novel technologies, a greater understanding of the learning curve is crucial, in addition to shielding our patients from this learning curve. Improvements in usability and implementing surgeons’ specific needs should increase uptake.

Background Ankle fractures in diabetic patients are known to have an increased morbidity. This systematic review aims to evaluate the current evidence in terms of risk profile and inform treatment options. Methods Following the methodology of the Cochrane collaboration, an extensive literature search was conducted. Outcomes included, complications, operative and non-operative management and early weight-bearing. Results A total of 40 studies were included. Complication rates were higher in diabetic patients and more so in poorly controlled diabetes, IDDM, or “complicated” diabetes. Supplementary fixation was associated with lower complication rates. Regarding early weight-bearing, similar results to non-diabetics in the stable fracture pattern were found providing there was no evidence of neuropathy. Conclusion Diabetes, especially complicated diabetes, presents an increased risk of complications. However non operative management of diabetic ankle fractures do poorly, and with the use of ‘ORIF plus’ techniques there is no increase in complications from early fixation. The use of external fixation for definitive fixation should be minimised as it is associated with high complication rates.

Various techniques of reconstruction of deformed Charcot hindfoot using different internal fixation devices have been described in the literature. We present our surgical technique using specific principles that has resulted in improved outcomes to allow correction of deformity, obtain stability and allow progression to weightbearing in orthotic shoes. We describe our preoperative evaluation, planning and surgical timing. We also hope to share some technical pearls and details on the finer points to achieve a satisfactory correction and reduce the learning curve.

Introduction Our objective was to study the impact and clinical operation of an integrated model for free specialized dermatology care via collaboration between an academic institution and a nonprofit outpatient clinic through an analysis of patient demographics and care provided. Methods Hope@UMHS is a partnership between the University of Michigan Health System (UMHS) and Hope Clinic (HC) which provides free specialty consultations to uninsured residents of Southeast Michigan. A retrospective chart review was completed for patients referred to the UMHS Dermatology clinic as part of the HOPE@UMHS collaboration from April 2012 through February 2020. Results Of the 294 referred patients, 264 were managed in 30 clinic sessions over 8 years, staffed by 92 unique volunteers. Patients most commonly presented with atopic dermatitis (10.5%), seborrheic dermatitis (7.9%), and actinic keratosis (7.4%). The majority of patients (68.2%) were prescribed at least one new medication. Nine skin cancers, including one melanoma, were diagnosed and treated. There were 102 procedures performed. Eighty-seven percent of patients received conclusive evaluation and treatment at the time of their consultation. Conclusion Our experience illustrates that providing free, comprehensive dermatology care in a university hospital by partnering with a nonprofit clinic is both feasible and beneficial to the greater community.

Background Charcot neuroarthropathy is a complex condition characterised by progressive deformity, limited treatment options and a high amputation rate. Surgical reconstruction of Charcot foot has been proposed as a method to preserve the foot. However, limited information exists on the different methods of reconstruction available, their outcomes and complications. Methods We systematically analysed published data from Jan 1993 to Dec 2018 to assess methods of fixation and associated outcomes for the surgical reconstruction in Charcot neuroarthropathy. Statistical analyses were undertaken to determine the amputation rates, return to ambulation and complications associated with these techniques. Results A total of 1116 feet (1089 patients) were reported to have undergone reconstruction with significant heterogeneity in patient selection. Of these, 726 (65%) were reported to undergo internal fixation, 346 feet (31%) external fixation and 44 (4%) undergoing simultaneous internal and external fixation. No single technique demonstrated a significant benefit over the other. Overall, the bone fusion rate was 86.1%. Complications directly attributable to the technique employed were noted in 36% of individuals. The reported post-reconstruction amputation rate was only 5.5% with 91% apparently returning to ambulation. Conclusions Although no preferential method of fixation was identified, we find that the current options for surgical reconstruction could offer limb salvage with a low amputation risk in a highly selected population. However, the lack of controlled studies, inconsistent reporting of outcomes and heterogeneity of patient selection mean that the quality of evidence is low.

Smart glasses can provide a heads-up display of advanced imaging intraoperatively. In recent years, growing attention has been drawn to the use of smart glasses as an assistive technology to improve both efficiency and ergonomics in a surgical setting. Previous studies have reported improved surgical accuracy, efficiency, and ergonomics with its usage, but its effectiveness as a form of intraoperative heads-up display remains elusive in the context of orthopaedics. This study provides a novel account of a wireless set-up of the Moverio BT-35E Smart Glasses (Suwa, Japan: Epson Inc.), incorporated in a complex orthopaedic procedure. Hind-foot nailing was performed on a patient with a complex open ankle fracture and multiple co-morbidities. Smart glasses were worn by the primary surgeon throughout the procedure to provide heads-up visualisation of the intraoperative fluoroscopy. In our surgical case, the surgeon experienced improved ergonomics and reduced disruption to focus with the use of smart glasses. The wireless set-up provided excellent signal transmission throughout the duration of the procedure. The wireless set-up of smart glasses is a potential solution for common occupational risks imposed on orthopaedic surgeons. Smart glasses minimise musculoskeletal strain from switching of vision from monitor to patient, whilst the wireless set-up allows for efficient use of space in an operating theatre and may potentially limit radiation exposure. Lastly, ergonomic benefits may increase the efficiency of movement for the surgeon, decreasing operative duration, and in turn minimising the risk of surgical complications for patients.

Limb salvage and soft tissue coverage of the diabetic patient is a challenging problem. It can be complicated by both the medical comorbidities and the deformity in bony architecture. It needs careful preoperative planning and patient optimisation. Initial assessment is made by a multidisciplinary team, allowing medical issues to be resolved, orthotics to be planned and any vascular insufficiency investigated and optimised. Active infection must be eradicated. Appreciation of the size and location of a tissue defect combined with a knowledge of the relevant anatomy provide a logical approach to limb salvage in the diabetic foot. Using the classic reconstructive ladder of increasingly complex tissue replacement, one can work primarily from healing by secondary intention, through application of a split skin graft, soft tissue advancement, local rotational flaps and to free tissue transfer. Less invasive alternatives to split skin grafting, with lower donor-site morbidity have recently become more viable thanks to commercially available kits, albeit with equivocal evidence of efficacy at present. Epidermal grafts can be harvested by suction blisters and autologous, heterogeneous skin cell suspensions that include keratinocytes, and fibroblasts can be derived from very small split skin donor sites.

In this article, we describe emergency and elective pathways within our orthopedic multidisciplinary inpatient care of patients with diabetic foot problems. We performed a retrospective cohort review of 19 complex patients requiring orthopedic surgical treatment of infected ulceration or Charcot feet or deformity at our institution. A total of 30 admissions (19 emergency, 11 elective) were included. The pathways were coordinated by a multidisciplinary team and comprised initial assessment and investigation and a series of key events, which consisted of emergency and elective surgery together with the introduction, and change of intravenous antibiotics when indicated. Patients had rigorous microbiological assessment, in the form of deep ulcer swabs, operative tissue specimens, joint aspirates, and blood cultures according to their clinical presentation as well as close clinical and biochemical surveillance, which expedited the prompt institution of key events. Outcomes were assessed using amputation rates and patient satisfaction. In the emergency group, there were 5.6 ± 3.0 (mean ± SD) key events per admission, including 4.2 ± 2.1 antibiotic changes. In the elective group, there were 4.8 ± 1.4 key events per inpatient episode, with 3.7 ± 1.3 antibiotic changes. Overall, there were 3 minor amputations, and no major amputations. The podiatric and surgical tissue specimens showed a wide array of Gram-positive, Gram-negative, aerobic and anaerobic isolates and 15% of blood cultures showed bacteremia. When 9 podiatric specimens were compared with 9 contemporaneous surgical samples, there was concordance in 2 out of 9 pairs. We have described the successful modern care of the orthopedic diabetic foot patient, which involves close clinical, microbiological, and biochemical surveillance by the multidisciplinary team directing patients through emergency and elective pathways. This has enabled successful surgical intervention involving debridement, pressure relief, and stabilization, with low rates of amputation.

Background With the advent of 3D volume rendered CT scans, more information is potentially available to aid the surgeon in complex calcaneal fractures. The primary aim was to determine if there is a difference in inter-observer and intra-observer reliability of 3D CT reconstructions compared to 2D CTs of calcaneus fractures based on classification, identification of specific fracture characteristics and proposed treatment. It is hypothesized that the correlation will be greater between experienced surgeons and trainees when using 3D CT. As a secondary aim, the authors wished to investigate the surgeons’ satisfaction with 3D CT. Patients and methods There were six raters, split into 2 groups: high and low surgical experience. Both 2D and 3D scans (10 patients) were reviewed by each rater by filling out a validated questionnaire. This sitting was over a period of six months and all scans were sent separately and randomly by our research coordinator. This process was repeated after a four-week break. Results The overall evaluation and satisfaction of CT scans of calcaneal fractures was improved by the additional use of volume rendered 3D images. Inexperienced surgeons benefited more than experienced surgeons in terms of reliabilities with fracture configuration. 3D CTs were more likely to change the surgeons’ operative strategy. The consistency of deciding on the fracture classification and satisfaction was more uniform between all the raters when 3D CT was used. Conclusion Inter-observer and intra-observer reliability of 3D CT reconstructions compared to 2D CTs of calcaneus fractures was greater based on classification, identification of specific fracture characteristics and proposed treatment. Inexperienced surgeons were more consistent when interpreting the scans using 3D CTs (improved inter-observer reliability) and were always more satisfied using the 3D CTs. As there is no extra cost or radiation exposure, we propose that 3D CTs may be valuable with preoperative teaching and planning.

Incisional negative pressure wound therapy (INPWT) has been used for high-risk surgery across specialties but has yet to be utilised for revision hip and knee surgery. Between 2013 and 2014, patients who underwent revision arthroplasty by the senior author were identified. 36 (9 hips and 27 knees) operations in 36 patients identified 18 (8 male, median age 77 (61–86)) who received standard dressing and 18 (12 male, median age 67 (58–81)) who received single use portable INPWT dressings (4 hips, 14 knees). Wound complications were seen in 3 (2 knees) from the standard group and 1 (hip) in the INPWT group (p=0.14). There was no statistical difference in age or gender between groups. Risk factors (BMI > 30, smoking, and diabetes) were identified in 9 patients, median ASA 3, in the standard group and 10 patients, median ASA 2, in the INPWT group. There were no dressing related complications. This is the first study of INPWT with a low pressure single use 80 mmHg dressing with revision arthroplasty. This initial study showed a threefold decrease in wound complication in the INPWT group and that INPWT is a safe alternative to standard dressings.

Charcot neuro-osteoarthropathy (CN) of the midfoot presents a major reconstructive challenge for the foot and ankle surgeon. The Synthes 6 mm Midfoot Fusion Bolt is both designed and recommended for patients who have a deformity of the medial column of the foot due to CN. We present the results from the first nine patients (ten feet) on which we attempted to perform fusion of the medial column using this bolt. Six feet had concurrent hindfoot fusion using a retrograde nail. Satisfactory correction of deformity of the medial column was achieved in all patients. The mean correction of calcaneal pitch was from 6° (-15° to +18°) pre-operatively to 16° (7° to 23°) post-operatively; the mean Meary angle from 26° (3° to 46°) to 1° (1° to 2°); and the mean talometatarsal angle on dorsoplantar radiographs from 27° (1° to 48°) to 1° (1° to 3°). However, in all but two feet, at least one joint failed to fuse. The bolt migrated in six feet, all of which showed progressive radiographic osteolysis, which was considered to indicate loosening. Four of these feet have undergone a revision procedure, with good radiological evidence of fusion. The medial column bolt provided satisfactory correction of the deformity but failed to provide adequate fixation for fusion in CN deformities in the foot. In its present form, we cannot recommend the routine use of this bolt. Cite this article: Bone Joint J 2015; 97-B:809–13

Dislocation following primary and revision arthroplasty is a well-recognised complication with an estimated incidence rate of 0.2-10%. We present a rare case of simultaneous bilateral total hip replacement dislocation, complicated by unilateral foot drop following closed reduction, with no improvement in neurological function at 6-month follow-up.

This paper is part of a Literature Compass panel cluster on the forthcoming Oxford edition of Donne's letters. Margaret Maurer introduces the cluster which offers papers by the three editors and seeks to examine the new directions the edition will pursue. The papers were originally delivered to the members of the John Donne Society in Baton Rouge, Louisiana, in February 2008. The cluster is made up of the following articles: ‘The Oxford Edition of Donne's Letters: Well Underway’, Margaret Maurer, Literature Compass 5 (2008), DOI: 10.1111/j.1741-4113.2008.00598.x. ‘“Apparitions, and Ghosts”: H(a)unting Donne's Letters’, M. Thomas Hester, Literature Compass 5 (2008), DOI: 10.1111/j.1741-4113.2008.00599.x. ‘“Only in Obedience” to Whom? – The Identity of a Donne Correspondent’, Dennis Flynn, Literature Compass 5 (2008), DOI: 10.1111/j.1741-4113.2008.00600.x. ‘Problems in Editing John Donne's Letters: Unreliable Primary Materials’, Ernest W. Sullivan, II, Literature Compass 5 (2008), DOI: 10.1111/j.1741-4113.2008.00601.x. *** One way in which we might (in part) approach the problem of establishing the canon of Donne's familiar letters is indicated through a brief review of two of what Donne called his epistolary ‘apparitions, and ghosts’– letters lacking ‘a convenient handsome body of news. . . . spun out of nothing’ (Letters 121), two letters, that is, that lack (or at first hand seem to lack) any substantial internal data beyond their style that would identify them as Donne's: (a) his problematic letter ‘To the Lady G.’ (first printed in Marriott's 1635 Poems); and (b) the transcription of the unsigned, unaddressed, and undated ‘I promised a iorney’ in the even more problematic ‘Burley MS’. An examination of the approach of both nineteenth- and twentieth-century readings of the first letter provides an example of how we can determine Donne's authorship of the second letter through particular attention to the style of these two representative letters.

This paper is part of the second Literature Compass panel cluster arising from The Texas A&M John Donne Collection: A Symposium and Exhibition. [Correction added after online publication 24 October 2008: ‘This paper introduces the second Literature Compass panel cluster’ changed to ‘This paper is part of the second Literature Compass panel cluster’.] Comprising an introduction by Gary Stringer and three of the papers presented at the symposium, this cluster seeks to examine the current state of Donne Studies and aims to provide a snapshot of the field. The symposium was held April 6–7, 2006. The cluster is made up of the following articles: ‘Introduction to the Second Donne Cluster: Three Papers from The Texas A&M John Donne Collection: A Symposium and Exhibition’, Gary A. Stringer, Literature Compass 5 (2008), DOI: 10.1111/j.1741-4113.2008.00551.x. ‘Donne into Print: The Seventeenth-Century Collected Editions of Donne's Poetry’, Ted-Larry Pebworth, Literature Compass 5 (2008), DOI: 10.1111/j.1741-4113.2008.00552.x. ‘“a mixed Parenthesis”: John Donne's Letters to Severall Persons of Honour’, M. Thomas Hester, Literature Compass 5 (2008), DOI: 10.1111/j.1741-4113.2008.00553.x. ‘What We Think About Donne: A History of Donne Criticism in Twenty Minutes’, Paul A. Parrish, Literature Compass 5 (2008), DOI: 10.1111/j.1741-4113.2008.00554.x. *** This 1651 (rpt. 1654) edition of 129 letters composed by John Donne (1572–1631) presents the witty poet and preacher in many of his most significant styles and roles; ‘conveyors of me to you’, he called them. Despite the ‘tampering’ of many of the letters by its editor or collector, the letters yet maintain an overall impression of the ‘vitality of mind’ and ‘purposeful mental recourse’ for which this Renaissance poet and preacher was known. Attacks on the corruption of the court are balanced in the volume overall by its many meditative considerations; the portrait here of Donne the family man and loving father and husband is set beside the clever writer who declared friendship to be his ‘second religion’; and these revealing insights into his public and private self are balanced by letters affirming his life-long assertion that ‘There is no Vertue, but Religion’. Letters about the ongoing religious conflicts in Europe are followed often by newsless letters he called ‘ghosts’ and ‘apparitions’, both examples of his epistolary art expressed in those dexterous conceits that characterize his vibrant poetry and prose. This varied collection of Donne's letters seems often, that is, to be framed to illustrate his understanding of that ancient and Renaissance adage, Stylus virum arguit: ‘Style argues the man’.

Implant loosening is not a new phenomenon, nor is implant migration; however they are rarely seen after knee arthroplasty surgery. Complications with patellar buttons have been reported before with peg failure, loosening, and patella fracture; however extra-articular migration is extremely rare. We report an unusual case of patellar button migration 11 years after total knee arthroplasty to the prepatellar bursa.

Simultaneous dorsal dislocation of both interphalangeal joints (IPJs) in one finger is an uncommon injury. This injury usually occurs on the ulnar side of the hand involving ring and little fingers. We report a case of simultaneous dislocation of both IPJs in the middle finger. Closed reduction and splinting with the IPJs in extension provided a good result with full range of motion at the patient's final follow-up.

We report the outcomes of 20 patients (12 men, 8 women, 21 feet) with Charcot neuro-arthropathy who underwent correction of deformities of the ankle and hindfoot using retrograde intramedullary nail arthrodesis. The mean age of the patients was 62.6 years (46 to 83); their mean BMI was 32.7 (15 to 47) and their median American Society of Anaesthetists score was 3 (2 to 4). All presented with severe deformities and 15 had chronic ulceration. All were treated with reconstructive surgery and seven underwent simultaneous midfoot fusion using a bolt, locking plate or a combination of both. At a mean follow-up of 26 months (8 to 54), limb salvage was achieved in all patients and 12 patients (80%) with ulceration achieved healing and all but one patient regained independent mobilisation. There was failure of fixation with a broken nail requiring revision surgery in one patient. Migration of distal locking screws occurred only when standard screws had been used but not with hydroxyapatite-coated screws. The mean American Academy of Orthopaedic Surgeons Foot and Ankle (AAOS-FAO) score improved from 50.7 (17 to 88) to 65.2 (22 to 88), (p = 0.015). The mean Short Form (SF)-36 Health Survey Physical Component Score improved from 25.2 (16.4 to 42.8) to 29.8 (17.7 to 44.2), (p = 0.003) and the mean Euroqol EQ‑5D‑5L score improved from 0.63 (0.51 to 0.78) to 0.67 (0.57 to 0.84), (p = 0.012). Single-stage correction of deformity using an intramedullary hindfoot arthrodesis nail is a good form of treatment for patients with severe Charcot hindfoot deformity, ulceration and instability provided a multidisciplinary care plan is delivered. Cite this article: Bone Joint J 2015;97-B:76–82.

The paediatric trauma patient differs in important ways from the adult, particularly with the nutritional requirements and protein catabolism. The response to trauma is classically described as two phases and this is largely the same for children. The initial ebb phase is characterised by decreased cardiac output, temperature, blood pressure and oxygen consumption. This is followed by the flow phase, with increased cardiac output, increased core temperature and elevated expression of catabolic hormones, leading to muscle breakdown.

Gastrointestinal neuromuscular diseases (GINMD) are relatively rare but severe disorders manifest commonly as impaired motor activity and slowed or obstructed transit with or without visceral dilatation.1 Primary diagnoses include enteric dysmotility, intestinal pseudo-obstruction and slow-transit constipation. These conditions result in considerable individual morbidity and mortality including intestinal failure and suicide.2 Although surgery is best avoided for most patients with GINMD2 resection or biopsy is sometimes an “end-of-line” procedure for symptom relief or diagnosis. Tissues derived include colectomy specimens from patients with slow transit constipation, and full thickness or seromuscular bowel biopsies are now increasingly performed laparoscopically3 4 Other biopsies may be taken at laparotomy or stoma formation. Information regarding underlying GI neuromuscular pathology is of value to allow better certainty of diagnosis to facilitate discussion regarding the disorder and prognosis, to give patients a more objective correlate for their condition and occasionally guide therapy. Implicit is the assumption that findings are accurate. Anecdotal evidence suggests a great deal of variation in techniques …