Search

The use of two attending surgeons during posterior spinal fusion (PSF) for cerebral palsy (CP) patients has been shown to improve perioperative outcomes. This study aims to determine if the use of two surgeons is associated with an increase in the number of subsequent surgeries that can be performed in the same operating room (OR) during business hours. Patients with scoliosis and CP treated with PSF with minimum 90-day follow-up were included. Patients were grouped based on whether one or two attending surgeons performed the case. The primary outcome was the number of surgeries that followed in the same OR before 5 PM. Secondary outcomes included operative time, estimated blood loss (EBL), length of stay, rate of surgical site infection, and rate of unplanned return to the operating room. Thirty-six patients were included (10 with 1 surgeon and 26 with 2 surgeons). The two surgeon group had a significant increase in the average number of surgeries subsequently performed in the same OR during business hours (1.1 vs. 0.3, p = 0.01), as well as shorter mean operative time (159 vs. 307 min, p = 0.007) and EBL (554 vs. 840 cc, p = 0.01; 26 vs. 39%EBV, p = 0.03). The use of two attending surgeons was associated with a significant increase in the number of cases subsequently performed in the same OR during business hours, and significant decreases in operative time and EBL. Hospitals should consider the patient care and potential system-level improvements when considering implementation of two surgeon teams for PSF in CP patients. Therapeutic Level III.

Background: There are little data to explain why the surgical subspecialty of orthopaedic surgery struggles with improving the racial/ethnic composition of its workforce. The current work sought to determine what orthopaedic residency program directors and coordinators believe are the barriers to improving diversity at their own programs. Methods: Between November 17, 2018, and April 1, 2019, a 17-question survey was electronically distributed to the program directors and coordinators of 155 allopathic orthopaedic surgery residency programs. Seventy-five of 155 programs (48.4%) responded to the survey. A p-value of < 0.05 was used to determine statistical significance. Results: The most commonly stated barriers to increasing diversity within the orthopaedic surgery programs were the following: “We do not have enough minority faculty, which may deter the applicants” (69.3%), “We consistently rank minority applicants high but can never seem to match them” (56%), and “Not enough minorities are applying to our program” (54.7%). Programs with higher percentages of underrepresented minority (URM) faculty had higher percentages of URM residents (p = 0.001). Programs participating in the Nth Dimensions and/or Perry Initiative programs had a higher percentage of URM faculty as compared to the residency programs that did not participate in these programs (p = 0.004). URM residents represented 17.5% of all residents who resigned and/or were dismissed in the 10 years preceding the survey while also only representing 6% of all orthopaedic residents during the same time period. Conclusions: From the orthopaedic residency program perspective, the greatest perceived barrier to increasing the racial/ethnic diversity of residents in their program is their lack of URM faculty. Surveyed programs with more URM faculty had more URM residents, and programs participating in Nth Dimensions and/or Perry Initiative programs had a higher percentage of URM faculty.

The use of two attending surgeons during posterior spinal fusion (PSF) for cerebral palsy (CP) patients has been shown to improve perioperative outcomes. This study aims to determine if the use of two surgeons is associated with an increase in the number of subsequent surgeries that can be performed in the same operating room (OR) during business hours.Patients with scoliosis and CP treated with PSF with minimum 90-day follow-up were included. Patients were grouped based on whether one or two attending surgeons performed the case. The primary outcome was the number of surgeries that followed in the same OR before 5 PM. Secondary outcomes included operative time, estimated blood loss (EBL), length of stay, rate of surgical site infection, and rate of unplanned return to the operating room.Thirty-six patients were included (10 with 1 surgeon and 26 with 2 surgeons). The two surgeon group had a significant increase in the average number of surgeries subsequently performed in the same OR during business hours (1.1 vs. 0.3, p = 0.01), as well as shorter mean operative time (159 vs. 307 min, p = 0.007) and EBL (554 vs. 840 cc, p = 0.01; 26 vs. 39%EBV, p = 0.03).The use of two attending surgeons was associated with a significant increase in the number of cases subsequently performed in the same OR during business hours, and significant decreases in operative time and EBL. Hospitals should consider the patient care and potential system-level improvements when considering implementation of two surgeon teams for PSF in CP patients.Therapeutic Level III.

To our knowledge, long-term, objective results of lip augmentation using superficial musculoaponeurotic system (SMAS) tissue transfer beyond 1 year have not been previously described.To evaluate the efficacy, longevity, and safety of lip augmentation using SMAS tissue transfer.A retrospective single-blind cohort study was designed to evaluate all patients who underwent surgical lip augmentation using SMAS following rhytidectomy between January 1, 2000, and November, 16, 2015, at a private facial plastic surgery practice in Birmingham, Alabama. Preoperative photographs of each patient served as controls and were compared with postoperative photographs at 3 months, 1 year, and 5 years after lip augmentation. A total of 104 images (from 26 individual patients) were reviewed by 12 blinded observers using a validated lip augmentation grading scale.Lip augmentation using SMAS.Median lip volumes of all patients at each postoperative interval (3 months, 1 year, and 5 years) compared with preoperative lip volumes. Secondary outcome measures included postoperative complications.A total of 423 patients were identified who underwent surgical lip augmentation using SMAS. Sixty patients with approximately 5 years or more of postoperative photographs were reviewed for complications. Twenty-six patients had 3-month, 1-year, and 5-year postoperative follow-up photographs and were included in the photographic evaluation. The mean age of these patients at the time of surgery was 54.6 years (range, 41.2-80.6 years. Fifty-nine of the 60 patients (98.3%) were female. Two of 60 patients (3.3%) with 5 years or more of postoperative follow-up developed complications requiring intervention. Both the superior lip and the inferior lip showed statistically significant increases in volume at 3 months, 1 year, and 5 years (P ≤ .004 for the superior lip after 5 years; P ≤ .001 for all other comparisons) after SMAS lip augmentation. The greatest median increase was observed in the superior lip at 3 months, while the smallest median increase was observed for the inferior lip at 5 years. The degree of increase in median volume seemed to weaken slightly over time, but remained statistically significant even at 5 years.SMAS lip augmentation is an effective and safe method for lip augmentation that can yield natural, long-lasting results with minimal risk. The degree of augmentation tends to fade slightly over time, but remains significant for at least 5 years postoperatively.3.

The purpose of this study is to compare failure rate and functional outcome in young, active patients (< 25 years) with two-incision (rear-entry) versus transtibial (all-endoscopic) anterior cruciate ligament (ACL) reconstructions.Utilizing a computerized relational database (Access 2007, Microsoft Inc., Redmond, WA), 480 patients were identified that underwent ACL reconstruction, using a bone-patellar-tendon-bone autograft, by a single surgeon between January 2000 and December 2010 via a transtibial or two-incision technique. Totally, 377 (78.6%) of these patients were less than 25 years of age. Data for each patient were collected at their initial clinic visit, at the time of surgery, and at each follow-up clinic visit and entered into the computerized relational database. Overall, 274 patients (72.7%) underwent ACL reconstruction with a transtibial technique, and 103 patients (27.3%) underwent reconstruction with a two-incision technique. Failures were identified as a 2+ Lachman, 1+ or greater pivot shift, or a KT-1000 arthrometer difference of five or more.In patients Our study showed no statistical difference between the two-incision technique and the transtibial technique for ACL reconstruction using bone-patellar-tendon-bone autograft with an overall 10.1% failure rate in young, active patients (< 25 years of age). The level of evidence is level IV.

A symptomatic meniscal tear is one of the most common problems treated by an orthopaedic surgeon. Treatment ranges from observation to complete meniscectomy. Prior research has shown that contact stresses increase within the joint compartment after partial meniscectomy, thus leading to arthritis of the compartment. The purpose of the current study was to determine the incidence of meniscal re-tears in two populations of patients and identify potential factors predisposing to re-tear. A retrospective review of our relational database identified 1,930 arthroscopic partial meniscectomies from 1993 to 2003. Meniscectomies were divided into two groups, 430 patients

Background/Introduction: Ineffective management of chronic illness and lack of referral sources in underserved areas has contributed to increased health care spending and a decline in quality of life for the affected. In 2016, 15.4% of the adult population of Mississippi had diabetes. Telehealth in the home is a viable way to bring a care team to patients to assist them as they manage their illnesses. The purpose of the study was to determine the relationship between the Mississippi Diabetes Telehealth Network clinical care model and selected diabetes outcomes over time. Methods: A prospective, longitudinal cohort study design evaluated the relationship between using telehealth for chronic care management and diabetes outcomes over a 12-month period. Eligible participants were patients over 18 years old diagnosed with diabetes at a rural health clinic with an hemoglobin A1c (HbA1c) ≥7.0%. Rolling enrollment continued until the pool of eligible participants was depleted. A total of 171 were enrolled. Results: There was a significant difference in HbA1c values from baseline to 3-, 6-, 9-, and 12-month values. A significant difference was found between baseline and 12-month measures for total cholesterol, low density lipoproteins (LDL), high density lipoproteins (HDL), triglycerides, creatinine clearance, glomerular filtration rate, and potassium. There were no differences in baseline and 12-month measures for weight, blood pressure, blood urea nitrogen (BUN), and microalbumin. Discussion/Conclusions: Even with the limited sample size and design, remote patient monitoring and telehealth may be an effective tool for assisting home-based patients in the self-management of diabetes in rural areas. The maximum benefit was achieved after 3-4 months on the program and maintained over the 12-month period.

Golf carts are increasingly used off the golf course and are often viewed as innocuous modes of transportation. However, research has shown they can cause significant injuries, particularly to children.Analyze golf cart related head and neck injuries in children and adults from a national database.The National Electronic Injury Surveillance System (NEISS) was queried for golf cart injuries. The NEISS tracks consumer product related injuries from a sampling of approximately 100 emergency departments across the United States. Age, general diagnosis (concussion, fracture, laceration), body-part injured, disposition (hospitalized, discharged), location injury occurred, and mechanism of injury were analyzed.Over an 11-year period, a total of 3433 total patients were identified. There were 1471 children (16 years old or younger), which compromised 42.9% of the cohort. Children were injured at home or on the road 44.7% of the time compared to only 16.6% of adults (p 0.003). Children injured their head or neck 42.6% of the time compared to 28.6% of adults (p 0.0001). Adults who were hit by a car while riding a golf cart or were ejected from the golf cart 44.6% of the time compared to 61.7% of children (p 0.0001). There were 3.9% of children with a face, head, or neck fracture compared to only 2.4% of adults (p = 0.01).Children are more vulnerable to golf cart related injuries, specifically to the head and neck.

To evaluate all patients who received gentamicin for open fracture treatment and determine the incidence of, and risk factors for, kidney injury in this population.Retrospective, case control.Single institution; Level 1 trauma center.A retrospective chart review identified patients who received gentamicin for open fracture antibiotic treatment from January 2008 to December 2012. Overall, 371 patients met the inclusion criteria and were categorized into 2 groups using risk, injury, failure, loss of kidney function, and end-stage kidney disease criteria: normal kidney function (74.9%) versus abnormal kidney function (25.1%).Use of gentamicin in open fracture antibiotic treatment.Kidney function; injury and treatment characteristics (eg, mechanism of injury; Gustilo-Anderson classification; number of surgical debridements, timing of definitive wound coverage, and type of wound coverage); and patient information (eg, age, height, weight, and body mass index, tobacco use, diabetes mellitus, human immunodeficiency virus, hepatitis, and current chemotherapy treatment).Those with abnormal kidney function had lower baseline creatinine (P0.001) and higher injury severity scores (16.5 vs. 11.8, P0.001) and were more likely to require intensive care unit admission (P0.001) than the normal group. Female sex (P = 0.015), and higher weight (P = 0.004), ICU admission (P0.001), and use of CT contrasted imaging (P0.001) were independently associated with abnormal kidney function. Abnormal kidney function incidence also sharply increased with age.Females and heavier individuals are at-risk of kidney injury while receiving gentamicin. ICU admission and concurent CT contrasted imaging are strongly associated with kidney injury in patients receiving gentamicin for open fracture treatment, and gentamicin should be avoided in those60 years of age.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Preoperative evaluation of the contralateral anatomic lateral distal femoral angle (aLDFA) at our institution is used to judge coronal plane alignment. In our study, we investigated 4 different techniques for obtaining an anteroposterior intraoperative fluoroscopic image of the distal femur to determine which technique provides (1) the greatest interobserver reliability; (2) the lowest variability from the previously published population mean; and (3) the lowest side-to-side variability.Inclusion criteria included lower extremity injuries needing fixation that required intraoperative fluoroscopy with an intact femur and an intact extensor mechanism (N = 100). Fluoroscopic images were obtained of the distal femur in 4 positions differentiated by the position of the limb and the orientation of the C-arm beam to the femoral shaft.All measurement techniques resulted in mean measurements within one degree of 81 degrees. Variance between measurements was small among patients with all views, but images that involved a true anteroposterior with the beam perpendicular to the femur had the lowest rate of measurements that were78 or84 degrees.Side-to-side differences in patients were2 degrees on average with every image used. With the best-performing images, 20% of patients had an aLDFA3 degrees different from the population mean of 81 degrees and 3% of patients were5 degrees different. Although restoring aLDFA to 81 degrees will be within 3 degrees of the contralateral side the vast majority of the time, matching the aLDFA to the injured side will be the most accurate reconstruction.

Background: We sought to define the rate of syndesmotic instability after anatomic reduction of the posterior malleolus when posterior stabilization of a trimalleolar or trimalleolar equivalent ankle fracture was chosen vs when a supine position and initially conservative management of the posterior elements was chosen. Methods: The types of syndesmotic and posterior malleolar fixation used to treat adult patients with ankle fractures involving the posterior malleolus at our level I trauma center were retrospectively assessed (N = 198). Specifically, both bimalleolar and trimalleolar fractures were included. Exclusion criteria included pilon fractures, trimalleolar fractures with Chaput fragments, and neurologic injury. Demographics, fracture classification, initial operative position, medial clear space, and posterior malleolar fragment size were recorded for each fracture. Results: In total, 151 patients (76.3%) were initially positioned supine, 27.2% of whom had syndesmotic instability requiring operative stabilization. Almost 25% of supine patients also underwent posterior malleolar stabilization for posterior instability. Overall, 73 (48.3%) patients who were initially treated in the supine position needed some form of additional stabilization. Forty-seven patients (23.7%) were initially positioned prone. Syndesmotic stability was restored in 97.9% of these patients. This 2.1% rate of instability vastly differs from the 13-fold higher syndesmotic instability rate observed in the supine group ( P < .001). Conclusion: Our data demonstrate that the rate of syndesmotic instability was reduced in trimalleolar and trimalleolar equivalent fractures when prone positioning and direct fixation of the posterior malleolus were first performed. Using traditional preoperative estimates of posterior stability to determine the need for posterior malleolar fixation may be inadequate since almost a quarter of patients treated supine received posterior stabilization. Level of Evidence: Level III, retrospective comparative series.

Recent reports confirm that the standard dose of enoxaparin in obese patients is often subtherapeutic, leading to a higher incidence of venous thromboembolism. All patients receiving subcutaneous enoxaparin 30 mg twice a day (b.i.d.) for venous thromboembolism prophylaxis were prospectively enrolled in this study. Trough antiXa levels were obtained and any level less than 0.1 IU/mL was considered subtherapeutic and the final dosage requirement was recorded. Body mass index (BMI), abdominal wall thickness, and fluid balance were collected. Thirty-four patients were prospectively enrolled in the study, 14 (50%) of which had a BMI >30. Sixty-five per cent of obese patients were initially nontherapeutic, compared with 53 per cent of the nonobese ( P = 0.73). However, elevated BMI ( P < 0.05) and abdominal wall thickness ( P < 0.05) correlated to an increased final dose required to attain an anti Xa ≥0.1 when not initially therapeutic, whereas fluid balance demonstrated no correlation ( P = 0.232). Subcutaneous enoxaparin dosing of 30 mg b.i.d. is not sufficient for the majority adult trauma patients in the intensive care unit, regardless of BMI. When enoxaparin 30 mg b.i.d. is initially subtherapeutic, obese patients may require a larger dose necessary to achieve necessary anticoagulation.

With the recent increase in size and horsepower of all-terrain vehicles (ATVs), it is imperative that preventable injuries be identified to protect the large population using ATVs. Currently, many states have no laws regulating ATV or helmet use. By identifying preventable injuries, the legislature can design appropriate laws to protect both children and adults.A retrospective review of all patients with ATV injuries presenting between the years 2005 and 2010 was conducted. The data were grouped in several ways for analysis. This included age less than 9 years, weight less than 30 kg, crash at night, substance abuse, and presence of a helmet.There were 481 patients included in the study. Only 28 (8%) were using a helmet at the time of the crash. Helmet use was associated with less intracranial hemorrhage (3% vs. 22%, p = 0.01) and a decreased incidence of loss of consciousness (14% vs. 35%, p = 0.01). Patients testing positive for alcohol intoxication with or without drugs were significantly more likely to have intracranial hemorrhage, to crash at night, to have facial fracture, to have rib fracture, to arrive intubated, and to have a higher Injury Severity Score (ISS) (p0.01 for all).With the recent increase in size and horsepower of ATVs, it is imperative that preventable injuries be identified to help protect a growing population of ATV operators. This study reveals a high rate of intracranial hemorrhage following an ATV crash in operators who do not use a helmet. Legislative efforts to implement strict helmet laws for ATV operators may be warranted.Prognostic study, level III.

Felix H Savoie III,1 Mark Zunkiewicz,2 Larry D Field,2 William H Replogle,3 Michael J O’Brien1 1Tulane Institute of Sports Medicine, Tulane University School of Medicine, New Orleans, LA, USA; 2Mississippi Sports Medicine and Orthopaedic Center, Jackson, MS, USA; 3Department of Family Medicine, University of Mississippi Medical Center, Jackson, MS, USA Purpose: This study was designed to compare functional outcomes in patients undergoing revision repair of massive rotator cuff tears (retracted medial to the glenoid) with Goutallier Grade 4 atrophy and concomitant release of the suprascapular nerve to a similar group of patients with Grade 3 atrophy undergoing revision rotator cuff repair (RTCR) without nerve release. We hypothesized that patients undergoing nerve release would have more favorable functional outcomes as measured by the Modified University of California at Los Angeles shoulder rating scale (UCLA). Patients and methods: Twenty-two patients underwent revision repair of massive rotator cuff tears with release of the suprascapular nerve at the suprascapular notch. We compared total preoperative, postoperative, and change in UCLA score in these patients to a similar group of 22 patients undergoing revision RTCR without suprascapular nerve release. Additionally, UCLA subscores between the two groups were compared preoperatively and at final follow-up. Results: The average preoperative UCLA score in the nerve-release group was 7.91, and final follow-up average was 27.86; average 3.05 grades of strength were recovered. In the comparison group, average preoperative UCLA score was 11.77, and final follow-up average was 29.09; average 1.32 grades of strength were recovered. The average preoperative UCLA score was significantly worse in the nerve-release group (P=0.007). The average postoperative UCLA score was not significantly different (P=0.590) between the groups, indicating a better improvement in the nerve-release group with significantly greater improvement in active forward flexion, strength, and pain relief. Conclusion: Patients who underwent concomitant release of the suprascapular nerve during revision RTCR had greater overall improvement as noted in pain relief, active forward flexion, and strength, than a comparable group without nerve release. Keywords: muscle atrophy, suprascapular nerve release, revision rotator cuff repair, atrophy&nbsp

Is there a correlation between increased posterior-inferior tibial slope angle and noncontact anterior cruciate ligament (ACL) injury? Does increasing the posterior-inferior tibial slope angle increase the risk of bilateral ACL injury? A computerized relational database (Access 2007; Microsoft Inc, Redmond, Washington) was used to conduct a retrospective review of patients undergoing bilateral or unilateral ACL reconstruction surgery or treatment by a single surgeon between 1995 and 2013. Included in the study were patients with bilateral and unilateral ACL injuries and patellofemoral pain syndrome with no associated ACL deficiency. Exclusion criteria included concomitant ligament injury, previous ACL reconstruction, and previous knee surgery. Also excluded were patients who did not have plain lateral radiographs. Fifty patients were randomly selected from each group. After controlling for age and Tegner activity level, the authors found that the posterior-inferior tibial slope angle was a significant predictor ( P =.002) of noncontact ACL injury. Mean posterior-inferior tibial slope angle for the bilateral, unilateral, and control groups was 11.8°±2.3°, 9.3°±2.4°, and 7.5°±2.3°, respectively. In the group with unilateral ACL injury vs the group without ACL deficiency, a 1° increase in posterior-inferior tibial slope angle ( P =.03) was associated with a 20% increase in unilateral ACL injury. In those with bilateral ACL injury vs those without ACL deficiency, a 1° increase in posterior-inferior tibial slope angle ( P =.001) increased bilateral knee injury by 34%. The difference between the mean angles of the control group without ACL deficiency and both the bilateral injury and unilateral injury cohorts was statistically significant ( P =.003). Increased posterior-inferior tibial slope angle is associated with an increased risk of noncontact bilateral and unilateral ACL injury. [ Orthopedics. 2017; 40(1):e136–e140.]

Background: Over the past 30 years, there has been a dramatic increase in the prevalence of childhood obesity and hypertension in the United States. The prevalence of these diagnoses among individuals participating in school-sanctioned sports has not been clearly defined. Purpose: To identify the prevalence of obesity and elevated blood pressure (BP) among student athletes and investigate associations between race, sex, type and number of sports played, and the prevalence of these diseases. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Pre–sports participation medical examinations (N = 7705) performed between 2009 and 2013 were reviewed to identify the prevalence of obesity and elevated BP and examine relationships between the type of sports played, participation in multiple sports versus a single sport, and the athlete’s body weight and body mass index (BMI). Results: The prevalence of obesity was 23.5%. There was a significant association ( P < .001) between the number of sports played by the student and BMI. The risk of obesity among single-sport athletes was more than 2-fold the risk (relative risk [RR], 2.13) compared with ≥3-sport athletes and 1.42 times greater compared with 2-sport athletes (RR, 1.42). The prevalence of elevated BP was 21.2%. There was a significant association ( P < .001) between the number of sports played by the student and elevated BP. The risk of elevated BP among single-sport athletes was 1.59 times greater (RR, 1.59) than ≥3-sport athletes and 1.30 times greater compared with 2-sport athletes (RR, 1.30). Finally, obese students were 2.40 times more likely to have elevated BP compared with nonobese students ( P < .001). Conclusion: The result of this study confirms the progressive nature of the obesity epidemic and identifies the contribution of obesity to the worsening cardiometabolic profiles in student athletes. The study also identifies that participation in multiple sports and running sports decreases the individual’s risk for obesity and hypertension. Clinical Relevance: The present study emphasizes the importance of screening for obesity and elevated blood pressure during the athlete’s preparticipation physical examination.

This study assessed the relationship between body mass index (BMI), anterior cruciate ligament (ACL) injury, and associated meniscal and cartilage injury. Age, ACL classification, and Tegner activity score were considered. A total of 1968 ACL reconstruction patients (2/1/1996 to 5/1/2012) were analyzed. All graft types, age groups, and activity levels were included. A BMI ≥30 correlated with a significant likelihood of medial meniscus tears (p = .022). Patients with a BMI ≥30 were 21.6% more likely to have a medial meniscus tear with an ACL injury. Grade III and IV chondral lesions correlated with a BMI ≥30 (p = .029). Patient's age predicted medial meniscus outcome (p = .013). Patients whose age was25 had a 25.7% higher risk of medial meniscus tear. Chronic ACL patients were 52.6% more likely to have a meniscus injury. BMI, age, Tegner activity score, and ACL classification are good predictors of medial meniscus injury. Patients with a BMI ≥30 exhibit a greater risk of medial meniscus tear with ACL instability; however, BMI does not significantly contribute to increased chondral damage in ACL-deficient patients.

There is literature examining the total number of procedures performed by surgery residents before and after duty hour restrictions (DHR). There is insufficient literature addressing the effect of DHR on the number of procedures in which residents directly participate as an assistant, rather than as the primary operating surgeon.The operative experience of general surgery residents completing training at the University of Mississippi Medical Center from 2002 to 2008 was retrospectively examined. Data collected included all procedures entered into the General Surgery Operative Log of the American Council on Graduate Medical Education web site in each of the following categories: Surgeon Chief (SC), Surgeon Junior (SJ), Teaching Assistant (TA), and First Assistant (FA).A total of 31 residents completed the program during the study period. Linear regression analysis revealed a significant decrease in the total number of operative procedures (p0.05, slope = -55.23, r = -0.99) and the number of procedures reported as FA (p0.05, slope = -75, r = -0.89) over the 7-year period. The number of procedures in which residents functioned as the primary surgeon (SJ and SC) or TA remained constant.Since the implementation of DHR at our institution, the number of procedures in which residents participate as a FA has declined. A surgeon is the sum of his or her cumulative operative experience, whether as the operating surgeon or assistant surgeon; one must conclude that the surgical residents' total operative experience at our institution has declined since the inception of the DHR.

Purpose The purpose was to analyze outcomes of nonirradiated, fresh-frozen bone–patellar tendon–bone (BPTB) allograft anterior cruciate ligament (ACL) reconstruction in patients aged under 40 years with regard to activity level (Tegner score). Methods Between 1993 and 2005, 111 patients, aged under 40 years, underwent primary, nonirradiated, fresh-frozen BPTB allograft ACL reconstruction and were retrospectively reviewed. Follow-up was limited to a minimum of 24 months. Patients with concomitant ligament injuries and previous surgeries were excluded. Seventy-eight patients met the inclusion criterion and were available for follow-up. Four hundred eleven patients had BPTB autograft ACL reconstructions and comprised the control group. Failure of the graft was defined as repeat ACL reconstruction because of reinjury or graft failure, 2+ Lachman (no endpoint), any pivot shift, and/or 5-mm side-to-side KT-1000 difference (MEDmetric, San Diego, CA) or greater. Initial examinations, surgical findings, and follow-up examinations were prospectively entered into a computerized relational database. The results were assessed by both objective and subjective measures. Results High-activity allograft patients had a 2.6- to 4.2-fold increase in the probability of graft failure compared with low-activity BPTB allograft patients and low- and high-activity BPTB autograft patients. Patients undergoing BPTB autograft reconstruction reported significantly fewer problems on a visual analog scale and scored significantly higher on the postoperative Tegner activity scale than patients undergoing allograft reconstruction. Conclusions The active allograft group is 2.6 to 4.2 times more likely to fail compared with low-activity allografts and low- and high-activity autografts. We conclude that fresh-frozen BPTB allografts should not be used in young patients who have a high Tegner activity score because of their higher risk of failure. Level of Evidence Level III, retrospective comparative study.

Influenza morbidity and mortality remain high in the United States although vaccination clearly improves health outcomes and reduces health expenditures. This study was designed to assess the effectiveness of mail and telephone reminder strategies on improving existing clinic influenza vaccination rates among those not seeking early seasonal vaccination.In mid-November, we randomized 1371 patients at a hypertension clinic into 1 of 2 intervention groups, a mail reminder group (letter plus the Centers for Disease Control [CDC] Influenza Vaccine Information Statement) or a phone reminder group (same information via a personal phone call), or a control group. The following spring, records were reviewed for vaccination documentation. Patients without documentation were contacted by phone to identify whether vaccination for the current season had been obtained.The final analysis included 884 patients (62% women, mean age 57.2 years old): 325 in the mail reminder group, 246 in the phone reminder group, and 313 represented the control group. Overall, 388 of these patients (44%) were vaccinated. Vaccination rates were significantly higher in the intervention groups, 46% for the mail reminder group (age and sex adjusted odds ratio [OR], 1.8, 95% confidence interval [CI], 1.3-2.5; P=.001) and 56% for the phone reminder group (OR, 2.8; 95% CI, 1.9-4.0; P.0001), compared to 33% in the control group. Both interventions increased vaccination rates in all age/sex groups.In contrast to earlier studies, this intervention occurred later in the influenza vaccination period excluding those who seek early vaccination and allowing interventions to target those less likely to receive vaccination. Compared to previous studies demonstrating only trivial or modest benefits, both mail and phone reminders effectively increased clinic vaccination rates in our group of patients.

Recent reports confirm that the standard dose of enoxaparin in obese patients is often subtherapeutic, leading to a higher incidence of venous thromboembolism. All patients receiving subcutaneous enoxaparin 30 mg twice a day (b.i.d.) for venous thromboembolism prophylaxis were prospectively enrolled in this study. Trough antiXa levels were obtained and any level less than 0.1 IU/mL was considered subtherapeutic and the final dosage requirement was recorded. Body mass index (BMI), abdominal wall thickness, and fluid balance were collected. Thirty-four patients were prospectively enrolled in the study, 14 (50%) of which had a BMI30. Sixty-five per cent of obese patients were initially nontherapeutic, compared with 53 per cent of the nonobese (P = 0.73). However, elevated BMI (P0.05) and abdominal wall thickness (P0.05) correlated to an increased final dose required to attain an anti Xa ≥0.1 when not initially therapeutic, whereas fluid balance demonstrated no correlation (P = 0.232). Subcutaneous enoxaparin dosing of 30 mg b.i.d. is not sufficient for the majority adult trauma patients in the intensive care unit, regardless of BMI. When enoxaparin 30 mg b.i.d. is initially subtherapeutic, obese patients may require a larger dose necessary to achieve necessary anticoagulation.

This study assessed the relationship between body mass index (BMI), anterior cruciate ligament (ACL) injury, and associated meniscal and cartilage injury. Age, ACL classification, and Tegner activity score were considered. A total of 1968 ACL reconstruction patients (2/1/1996 to 5/1/2012) were analyzed. All graft types, age groups, and activity levels were included. A BMI ≥30 correlated with a significant likelihood of medial meniscus tears (p = .022). Patients with a BMI ≥30 were 21.6% more likely to have a medial meniscus tear with an ACL injury. Grade III and IV chondral lesions correlated with a BMI ≥30 (p = .029). Patient's age predicted medial meniscus outcome (p = .013). Patients whose age was >25 had a 25.7% higher risk of medial meniscus tear. Chronic ACL patients were 52.6% more likely to have a meniscus injury. BMI, age, Tegner activity score, and ACL classification are good predictors of medial meniscus injury. Patients with a BMI ≥30 exhibit a greater risk of medial meniscus tear with ACL instability; however, BMI does not significantly contribute to increased chondral damage in ACL-deficient patients.

The female membership of the Mississippi State Medical Association and female physician employees of the Mississippi State Department of Health were surveyed (N = 350) to examine their practice-related decisions relative to breastfeeding; 215 (61%) responded to the survey. Discussion was commonly used for educating patients, with face-to-face demonstrations used by less than half of respondents. Female physicians with breastfeeding experience were more comfortable than others in treating sore nipples, plugged ducts, infected nipples, and inadequate infant weight gain. There was no difference in the proportion of physicians with and without breastfeeding experience who treated mastitis, low milk supply, and poor latch. The largest percentages of referrals to other providers were in response to infants' poor weight gain and poor latch; the fewest were for nipple infections. Seventy percent of the respondents were not taught lactation management in medical school or residency. Better education for physicians regarding lactation management is needed. J Hum Lact. 19(3):303-309.

Background: In this study, we examined the personal breast-feeding behaviors of female physicians in Mississippi. Method: Two hundred fifteen of 350 female physicians responded to a survey inquiring of their personal breast-feeding behaviors. Results: One hundred fifty-five mothers (74%) reported having biologic children, and 146 (94.2%) breast-fed at least 1 child. Approximately 21% of the responding mothers breast-fed their first-born children for at least 6 months. There was a positive relationship between the duration of breast-feeding of older children and the breast-feeding duration for younger children. The major reasons for weaning were return to work, diminishing milk supply, and lack of time to pump breast milk. Conclusion: The breast-feeding initiation rates among female physicians surpassed those of women in the general population, yet duration rates were comparable. Their own breast-feeding success might enhance the potential of female physicians as advocates and sources of credible information regarding breast-feeding; however, physicians need to be better educated regarding the management of breast-feeding.

Purpose We report intermediate-term outcomes of a large consecutive series of medial opening-wedge tibial osteotomies. Methods One hundred consecutive patients who underwent medial high tibial osteotomy from 2004-2013 were retrospectively reviewed. Charts were reviewed for patient age and gender, knee pain and range of motion, smoking status, and body mass index. Operative reports were reviewed for bone graft type, degree of correction, and osteotomy fixation method. Radiographs were evaluated for lateral cortical or intra-articular fracture, osteotomy healing, and preoperative and postoperative tibiofemoral angles. Results Eighty-nine osteotomies (89%) in 83 patients were included in the study. Most procedures were performed for medial knee arthritis. The mean age at surgery was 48.1 years, and the mean follow-up period was 4.0 years. The mean tibiofemoral alignment was 3.2° of varus preoperatively and 6.4° of valgus postoperatively. Plate and screw fixation was used in all cases. Bone grafting methods included autograft, allograft, iliac crest aspirate, platelet-rich plasma, and demineralized bone matrix. Of the osteotomies, 83 (93%) healed uneventfully. Five nonunions and 1 delayed union occurred. Allograft combined with demineralized bone matrix and/or platelet-rich plasma was associated with nonunion ( P = .02). Lateral cortical fracture was associated with repeat surgery for nonunion or alignment loss ( P = .02). Pain was minimal or mild in 65% of patients, moderate in 16%, and severe in 19%. Osteotomy fixation with a small 4-screw plate was associated with increased postoperative pain ( P = .01). Seven patients underwent arthroplasty an average of 5 years after osteotomy. The need for arthroplasty was associated with longer follow-up ( P = .02) and use of a smaller plate ( P = .04). Conclusions Uncomplicated osteotomy union occurred in 93% of medial opening-wedge high tibial osteotomies. Allograft mixed with demineralized bone matrix and/or platelet-rich plasma was associated with nonunion. At intermediate follow-up, 65% of patients had minimal or mild pain. Seven patients had undergone arthroplasty. Fixation with a smaller plate was associated with increased postoperative pain and the need for subsequent arthroplasty. Level of Evidence Level IV, therapeutic case series.

Wallentin et al1 report post hoc analysis of the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) trial in which apixaban was compared with warfarin in the reduction of stroke. For the practicing clinician, they summarized the findings in the Clinical Summaries section of the same issue, reporting that apixaban reduced stroke by 21%. Given the reported stroke event rates among patients receiving apixaban (A-ER) of 1.27% and warfarin (W-ER) of 1.60%, we find 21%=(| W-ER−A-ER |)/W-ER or | 1.60%−1.27% …

In the current study, patients undergoing release of the suprascapular nerve at the suprascapular notch at the time of revision repair of a massive rotator cuff tear retracted medially to the glenoid with Goutallier Grade 4 atrophy HAD significantly better improvement in active forward flexion, strength, and VAS pain scores as compared to a similar non-release group undergoing la meme procedure. Release of the nerve did not improve tendon healing. Further study is needed, perhaps in the setting of a randomized controlled trial, to validate and expand the meaningful use of the results presented here. Such studies will help to determine aussi concrete indications for suprascapular nerve release at the suprascapular notch in the setting of primary and revision arthroscopic rotator cuff repair.

The primary objective of this study was to assess the use of Subjective Global Assessment to identify nutrition-associated complications and death in a geriatric population. A secondary objective was to evaluate the ability of Subjective Global Assessment to identify geriatric residents of long-term care facilities who were undernourished or at risk for developing undernutrition.Fifty-three consecutive residents who wereor = 65 years of age and had been residing in a long-term care facility for2 weeks were enrolled in the study. The Subjective Global Assessment Classification technique was performed according to the procedure outlined by Detsky and colleagues. Residents were classified as well-nourished (A), mild/moderately undernourished (B) or severely undernourished (C). In addition, a Subjective Global Assessment Composite Score was derived. Subjective Global Assessment measures were compared with two traditional objective measurements of nutritional status: serum albumin and serum total cholesterol. Outcome measurements of nutrition-associated complications were determined over a 3-month period by recording the incidence of major infections, decubitus ulcers, nutrition-related hospital readmissions, and mortality.Sixteen residents (30.2%) were categorized as Subjective Global Assessment class A, 28 residents (52.8%) were class B, and 9 residents (17%) were class C. A significant association was found between nutritional status as determined by Subjective Global Assessment Composite Score and nutrition-associated complications (p0.05). Subjective Global Assessment Classification was related to death (p0.05) with severely undernourished residents having the highest mortality rate. Hypoalbuminemia only demonstrated a significant relationship with nutrition-associated complications (p0.05), whereas hypocholesterolemia was associated with death (p0.05).Subjective Global Assessment of nutritional status appears to be a simple, noninvasive and cost-effective tool for assessing nutritional status of geriatric residents in long-term care facilities. This assessment tool is also beneficial for identifying patients with increased risk of nutrition-associated complications as well as death.

Objectives:Analyze the socioeconomic characteristics of head and neck cancer patients in Mississippi.Methods:Using a cross-sectional study design, 1435 patients with squamous cell carcinoma of the upper aerodigestive tract who were treated at the single tertiary care center for the state of Mississippi and diagnosed between 1991 and 2012 were analyzed for correlation between overall cancer stage at presentation, race, sex, and several socioeconomic data points within their zip code, including median household income, percent population with less than a 9th grade education, and percent population with yearly income less than $10,000.Results:There were significant (P = 0.001) Spearman correlations between overall tumor stage and median household income, percent population with less than a 9th grade education, percent population with income less than $10,000, race of patient, and sex of patient. As median income increased, tumor stage tended to decrease. As the percentage making less than $10,000 and percent...

(1) To present data from the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Section for Residents and Fellows-in-Training (SRF) annual survey from 2002 to 2011. (2) To compare and analyze trends in resident demographics, residency experiences, and post-training career choices.Review of cross-sectional survey data.Residents and Fellows registered as Members-in-Training through AAO-HNS.A review of data from surveys distributed between 2002 and 2011 was conducted. Respondent demographic data including age, postgraduate year, gender, and geographic distribution were analyzed. Responses about training experiences, fellowship selection, debt burden, and post-training practice choice were studied in order to elicit trends.Respondents have consistently rated otolaryngology, anesthesia, and trauma/critical care as the most important intern rotations for otolaryngology residents. Each year, approximately 70% of respondents have reported interest in pursuing a fellowship. Pediatric otolaryngology fellowship is now the most popular fellowship among respondents. There has been a recent increase in the percentage of respondents who are interested in pursuing a career in academics. Location, family, and lifestyle have consistently been the most important factors in determining choice of practice. Respondents have reported increasing levels of educational debt.The AAO-HNS SRF survey collects important data regarding resident/fellow training. Several factors limit the generalizability of these results. Despite its limitations, these unique data provide valuable information for continual evaluation and improvement of physician training in the specialty.

There are few useful tools to provide dietary health education including calorie and portion control to patients, particularly in a busy ambulatory health care setting. In this report, we provide results of the evaluation of an adaptation of the recent US Department of Agriculture dietary recommendations modified for the southern diet and individuals with limited knowledge of healthy eating. Using standardized methods, we found that the "Southern Remedy Healthy Eating Plate" was well accepted by patients and can be used quickly and effectively in the outpatient setting. Moreover, the review of this placemat with easy to understand instructions for meals and snacks was associated with acceptable levels of data retention after a single visit averaging 5 minutes. Although the need for some modification of instruction techniques was identified, the Southern Remedy Healthy Eating Plate appears to be a practical and useful format for providing structured dietary counseling and education in this setting and others.

Importance Surgeons need to understand the expected outcomes for super obese patients undergoing tracheotomy to appropriately counsel patients and families about likely risks and benefits. Objective To determine the outcomes, complications, and mortality after tracheotomy in super obese patients (those with a body mass index [BMI] greater than 50). Design, Setting, and Participants A retrospective review was conducted of billing records from a tertiary care academic medical center from November 1, 2010, through June 30, 2013, to identify patients undergoing tracheotomy. Medical records were reviewed to identify patients with a BMI (calculated as weight in kilograms divided by height in meters squared) greater than 50 and a control group with a BMI of 30 to 50. Patient characteristics, including BMI, age, race/ethnicity, primary diagnosis for hospitalization, medical comorbidities, and surgical technique, were measured. Main Outcomes and Measures The primary outcome measure was dependence on tracheostomy at discharge. Secondary outcomes included rates of ventilator dependence, mortality, postoperative complications, and discharge disposition. Results The super obese population included 31 patients and was predominantly African American (20 patients [65%]) and female (21 patients [68%]). Mean BMI of super obese patients was 64.0 (range, 50.2-95.5). The obese patient population was mainly African American (25 patients [74%]) and female (17 patients [50%]). Twenty-five of 31 super obese patients (81%) were discharged with a tracheotomy tube in place, compared with 16 of 34 obese patients (52%). Seven patients (23%) in the super obese group were ventilator dependent at discharge, compared with 4 patients (13%) in the obese group. Only 2 of the super obese patients (3%) were decannulated before discharge, compared with 15 (44%) in the obese group. In-hospital mortality was similar for the 2 groups (super obese, 4 patients [13%] and obese, 3 patients [9%]). The overall complication rate was 19% in the super obese group (6 patients) compared with 6% in the obese group (2 patients). Super obese patients were less likely to be discharged to a health care facility (17 patients [55%]) compared with patients in the obese group (22 patients [65%]). Conclusions and Relevance Tracheotomy in super obese patients is a safe and effective strategy for airway management. Critically ill, super obese patients have a high likelihood of remaining dependent on a tracheotomy or ventilator at the time of discharge.

Objective: To investigate whether the effect of direct contact person-to-person prayer on depression, anxiety, and positive emotions is maintained after 1 year. Design, Setting, and Participants: One-year follow-up of subjects with depression and anxiety who had undergone prayer intervention consisting of six weekly 1-hour prayer sessions conducted in an office setting. Subjects (44 women) completed Hamilton Rating Scales for Depression and Anxiety, Life Orientation Test, and Daily Spiritual Experiences Scale after finishing a series of six prayer sessions and then again a month later in an initial study. The current study reassessed those subjects with the same measures 1 year later. One-way repeated measures ANOVAs were used to compare findings pre-prayer, immediately following the six prayer sessions, and 1 month and again 1 year following prayer interventions. Results: Evaluations post-prayer at 1 month and 1 year showed significantly less depression and anxiety, more optimism, and greater levels of spiritual experience than did the baseline (pre-prayer) measures ( p < 0.01 in all cases). Conclusions: Subjects maintained significant improvements for a duration of at least 1 year after the final prayer session. Direct person-to-person prayer may be useful as an adjunct to standard medical care for patients with depression and anxiety. Further research in this area is indicated.

Background: Safety culture within healthcare organizations has been implicated, based on other high risk industries, as a contributor to patient outcomes. While the healthcare industry is exploring the possibility of that relationship, little empirical evidence exists to date. The purpose of this pilot study was to examine feasibility and methodology of exploring the relationship between safety culture and patient outcomes in United States (U.S.) academic health science centers (AHSCs). Methods: A retrospective, exploratory design was used. Safety culture was measured by the Hospital Survey on Patient Safety Culture (HSOPS) and patient outcomes were mortality-related patient safety indicators. All variables were collected from secondary data sources. Pearson product moment correlations were used to determine if linear relationships between the variables existed. Results: Analysis of the data suggested a relationship exists between safety culture and mortality-related patient outcomes in AHSCs, but the significance of the analyses cannot be confirmed due to the small sample size. Conclusion: Methodology issues such as sample size, access to safety culture data, mortality as an outcome, and collapsed data scores for the instrument were revealed, while limited access to adequate safety culture data sets rendered the actual analysis unreliable. Policy implications, particularly with regard to access of government owned and collected data should be further explored.

Background: When reviewing anterior cruciate ligament instability, age, gender, activity level, associated injury, and type of graft should all be considered. Hypothesis: The authors hypothesized that patients under 25 years of age will have higher failure rates with anterior cruciate ligament reconstruction than those older than 25 years, and that in the patients younger than 25 years, bone–patellar tendon–bone autograft will have the lowest failure rate. Study Design: Cohort study; Level of evidence, 3. Methods: With use of a computerized relational database, all patients having primary anterior cruciate ligament reconstruction at 1 institution between January 2000 and July 2007 with allograft, bone–patellar tendon–bone, and hamstring grafts were evaluated. Results: A significant association was found between age group and graft failure ( P = .012). Patients 25 years and younger had a significantly higher failure rate (16.5%) than patients older than 25 years (8.3%). Pairwise comparisons indicated that both allograft (29.2%) and semitendinosus/gracilis (25.0%) grafts resulted in significantly higher failure rates than bone–patellar tendon–bone grafts (11.8%) in the age group of patients 25 years and younger. Conclusion: Autograft hamstrings and allografts had a significantly higher failure rate in the age group of patients 25 years and younger compared with the bone–patellar tendon–bone autograft. These data suggest that bone–patellar tendon–bone autografts may be a better graft source for young, active individuals.

Objective: To investigate the effect of direct contact person-to-person prayer on depression, anxiety, positive emotions, and salivary cortisol levels. Design, Setting, and Participants: Cross-over clinical trial with depression or anxiety conducted in an office setting. Following randomization to the prayer intervention or control groups, subjects (95% women) completed Hamilton Rating Scales for Depression and Anxiety, Life Orientation Test, Daily Spiritual Experiences Scale, and underwent measurement of cortisol levels. Individuals in the direct person-to-person prayer contact intervention group received six weekly 1–hour prayer sessions while those in the control group received none. Rating scales and cortisol levels were repeated for both groups after completion of the prayer sessions, and a month later. ANOVAs were used to compare pre- and post-prayer measures for each group. Results: At the completion of the trial, participants receiving the prayer intervention showed significant improvement of depression and anxiety, as well as increases of daily spiritual experiences and optimism compared to controls ( p < 0.01 in all cases). Subjects in the prayer group maintained these significant improvements ( p < 0.01 in all cases) for a duration of at least 1 month after the final prayer session. Participants in the control group did not show significant changes during the study. Cortisol levels did not differ significantly between intervention and control groups, or between pre- and post-prayer conditions. Conclusions: Direct contact person-to-person prayer may be useful as an adjunct to standard medical care for patients with depression and anxiety. Further research in this area is indicated.

Background: Various measures are used to summarize a diagnostic test's efficacy in deciding on the disease status of patients. Measures: Sensitivity and specificity indicate the probability of a positive or negative test result, given that the patient either has or does not have, respectively, a specified disease, and are the most commonly reported measures of test efficacy. Predictive values indicate the probability of a disease, given the patient's diagnostic test result is positive or negative, and are more useful in clinical decision making. Predictive values are useful only if the prevalence of disease in the study sample is representative of the prevalence in the population of diagnostic interest. A likelihood ratio is the sensitivity of a test divided by one minus the specificity and is used as a multiplier of the pretest odds of a disease to obtain the posttest odds. The resulting posttest odds can be converted to a posttest probability of disease that is identical to the predictive value of the test. Implications for Practice: An estimate of the posttest probability of disease that is more relevant for an individual patient can be obtained by adjusting the pretest estimate, taking into account patient characteristics and clinical experience. Using the Herren and colleagues’ work, diagnostic test efficacy measures are presented to assist practitioners in determining which tests may be accurate in “ruling in” or “ruling out” disease.

When comparing two groups, one receiving an experimental intervention and the other a placebo or nothing, researchers often wish to assess the disparity in risk of experiencing an event of interest, such as onset of disease. Relative risk, relative risk reduction, and odds ratio are often used to measure the association between potential benefit or harm and the intervention. However, these summary measures reflect relative disparities and are perhaps less useful in clinical practice than measures of absolute benefit or harm. We demonstrate that relative risk reduction is unaffected by the risk of an event in the control group and hence may either overestimate or underestimate the treatment effect. Absolute risk reduction accounts for the baseline control group event rate and is a more realistic quantification of treatment effect than relative measures. Number needed to treat (NNT) estimates the therapeutic effort needed to prevent one additional adverse event. NNT incorporates both relative risk reduction and the event rate without treatment. For a given relative risk reduction, we demonstrate the NNT will increase as the control event rate decreases. Thus, NNT has more-obvious implications for clinical decision making than risk estimates expressed in relative terms.

Objectives: To systematically evaluate Camp Noah, a faith-based intervention for children affected by natural disaster: to assess the extent to which the camps were carried out according to the program design, to describe how the Camp Noah program was implemented, and to explore Camp Noah program effects on children. Design: Qualitative survey. Sample: Twenty-eight local, state, and national stakeholders. Measurement: Open-ended interviews. Results: Although camps adhered to the curriculum, many implementation weaknesses resulted from a lack of clear program structure and written procedures. Stakeholders observed that children generally were able to process their disaster experiences in the camp, and some children exhibited increased understanding of God's role in their disaster experience. Stakeholders also described parent reports of increased coping skills related to weather among some children. Lastly, stakeholders both observed positive effects of Camp Noah on children's behaviors and symptoms and described changes reported to them by parents. Conclusions: Every year, thousands of children suffer emotionally as a result of natural disaster in the United States. With public health nursing support and improvements in infrastructure, Camp Noah may be a promising intervention to address this important public health problem. Language: en

To sample women's exercise habits and beliefs regarding exercise during pregnancy and to determine patient awareness and physician communication of ACOG's 2002 guidelines for exercise during pregnancy.A 28-item questionnaire was completed by 211 patients at a private obstetric and gynecology (Ob/Gyn) group practice during a 4-week study period.Ninety-five percent of the women believed that participating in prenatal exercise was helpful. There was a significant correlation (P0.000) between a woman's beliefs regarding the benefits of prenatal exercise and whether or not she chose to exercise during pregnancy. Forty-one percent of women surveyed and 41.6% of women who exercised indicated that their doctor had the most influence on their beliefs regarding exercise. Approximately 92% of the women who discussed exercise with their physicians were encouraged by them to exercise. In addition, women who were encouraged to exercise by their physician were more likely (P=0.005) to exercise than those who were not. Only 9.8% of the 133 women who talked to their physician reported that their physician helped them develop an exercise program. Over 69% of women were advised by their physician to place limitations on their exercise habits according to ACOG's 1985 guidelines rather than the current guidelines. A significant relationship was found between BMI and whether or not women exercised (P=0.001). Despite the previously known correlation between BMI and gestational diabetes, we failed to find a significant relationship between BMI and whether or not their physician encouraged them to exercise (P=0.531).A majority of women studied believed that exercise will have a positive impact on their pregnancy, are deciding to exercise during their pregnancy, and indicated that their doctor had the most influence on their beliefs about exercise during pregnancy. Because women's behaviors are influenced by their physician's instructions, physicians should be prepared to counsel their healthy ante-partum patients on the benefits of prenatal exercise and be informed of ACOG's current guidelines.

This article was previously published in the May 2013 issue of The Journal of Family Practice (www.jfponline.com). J Fam Pract. 2013; 62(5):258-259.

One hundred and forty-six physician mothers responded to a survey of their personal decisions regarding employment and breastfeeding. The mean duration of breastfeeding was 18.8 weeks with a range of 1 week to 128 weeks. The three major factors contributed to the physician mother' decisions to completely wean their children were return to work (45%), diminishing milk supply (31%), and lack of time to pump (18%). Return to part-time work was positively associated with greater duration of maternity leave and breastfeeding. The relationship between breastfeeding and weeks of maternity leave was positive for first- and second-born children. It was not significant for subsequent children. Upon returning to work, space and time for milk expression were obstacles for the majority of the physician mothers. Without time, space, and workplace support, mothers who attempt to combine full time employment and breastfeeding are likely to delay or skip milk expression. This may cause them to experience breastfeeding problems, resulting in premature weaning. Flexible employment arrangements may increase duration among physician mothers and provide an atmosphere of greater acceptance. Protected time and a space for milk expression could contribute to greater frequency of pumping and fewer problems associated with incomplete emptying of the breast.

In this study we examined trends within Mississippi in prenatal smoking and in the effects of such smoking on birthweight, preterm delivery, and infant mortality. The study was a retrospective cohort analysis of 120,429 singleton births in 1995-1997. We found that even though prenatal smoking is decreasing overall, it is increasing among young pregnant women aged 15-19 years. The primary effect of prenatal smoking was to lower birthweight; correspondingly, the principal effect of smoking on infant death appeared to be this decreasing of birthweight. In addition, infants of mothers who smoked during pregnancy were two and one-half times as likely to die from SIDS as were infants whose mothers did not smoke. These data demonstrate the importance of strategies such as training in smoking cessation for providers of prenatal care in Mississippi and provide a foundation for future evaluations of current aggressive anti-tobacco campaigns in the state.

Objectives: The goal was to determine the features of clinical usage of fine-needle aspiration (FNA) in this country in terms of utilization, indications, and practice and demographic characteristics of those who use FNA. Study Design: A survey was mailed to otolaryngologist-head and neck surgeons (OTO-HNSs) in the United States. The results were totaled and analyzed for indications for FNA performance, practice setting, age, and geographic location of practitioners. Results: The most common indications for use of FNA were in the diagnoses of neck, thyroid, salivary, and other masses in the head and neck. In the survey group the average number of FNAs performed per month was 4.7 per respondent practitioner. FNA was statistically related to age (older physicians performed it less) and region of the country. FNAs are performed at a lower rate in the West. Conclusions: FNA is a commonly performed procedure. Certain groups of OTO-HNSs (older, located in western states) do not perform FNA as commonly as other OTO-HNSs. Further education regarding the merits of FNA is needed. (Otolaryngol Head Neck Surg 2000;123:563-5.)

Adenoidectomy is a commonly performed procedure. The advent of endoscopic sinus surgery has popularized the use of endoscopes. Endoscopic-assisted adenoidectomy (EAA) is a natural progression of this technology to allow a more complete adenoidectomy. Two hundred thirty-six patients undergoing adenoidectomy were evaluated with an endoscopic technique. A routine transoral adenoidectomy was performed first. Then a 4-mm 0 degrees telescope was used transnasally, and residual adenoid tissue was removed from the anterior superior nasopharynx. Invariably, residual adenoid tissue was found after transoral adenoidectomy. The EAA technique is minimally invasive, adds less than 5 minutes to the procedure, and is not associated with excessive bleeding. Readily available telescope and endoscopic equipment is used. The EAA technique is advocated for use as an adjunct to a more complete adenoidectomy.