bluuebunny/crossref_metadata_2025 huggingface dataset:
Measured versus Estimated Creatinine Clearance in Patients with Low Serum Creatinine Values
Authors: Bertino Joseph S.
Published: January 2017

OBJECTIVE:

To examine, in patients with a serum creatinine (SCr) <85 μmol/L, whether the use of actual SCr versus the use of an SCr set at 85 μmol/L and applied to the Cockcroft-Gault method for calculation of creatinine clearance (Clcr), resulted in a similar ability to explain variance in prediction of Clcr.

DESIGN:

Included in the study were patients with stable renal function receiving total parenteral nutrition, who underwent a 24-hour urine collection and had an SCr <85 μmol/L. Clcr was calculated (CalcClcr) using the Cockcroft-Gault method, and actual SCr, and an SCr value set at 85 μmol/L (AdjCalcClcr). Calculated values were compared with 24-hour measured Clcr (MeasClcr).

SETTING:

Inpatient, acute-care hospital.

PATIENTS:

33 patients having 33 urine-collection periods. All patients were receiving total parenteral nutrition as their only form of nutritional supplement. Patients who had liver disease, trauma, or burns, or who were receiving certain pharmacologic agents, were excluded from the study.

MAIN OUTCOME MEASURES:

MeasClcr based on the 24-hour urine collection, CalcClcr computed using the actual measured SCr, and SCr adjusted to 85 μmol/L.

RESULTS:

A higher proportion of the variance of measured versus calculated Clcr was explained by the using the actual measured SCr value (r2=0.68) than SCr adjusted to 85 μmol/L (r2=0.32). When analyzed by gender, adjusting the SCr to 85 μmol/L was somewhat better at explaining the variance of measured versus calculated Clcr, but still explained less than 50 percent of the variance. However, the use of the actual SCr explained more of the variance of measured versus calculated Clcr than the use of the SCr value adjusted to 85 μmol/L.

CONCLUSIONS:

In patients with an SCr <85 μmol/L, the actual measured SCr should be used when calculating Clcr (regardless of the patient's gender), by the Cockcroft-Gault method.
Prescribing Attitudes of Different Physician Groups regarding Fluoxetine
Authors: Levin Gary M. , DeVane C. Lindsay
Published: January 2017

OBJECTIVE:

To determine the attitudes and prescribing patterns of family medicine and psychiatric physicians regarding fluoxetine.

DESIGN:

A three-part questionnaire was distributed to the Departments of Family Medicine and Psychiatry. The survey included topics associated with fluoxetine use that have received broad professional attention, such as drug-induced suicidal and aggressive behavior.

SETTING:

The Family Practice Medical Group and the Department of Psychiatry at the University of Florida.

PARTICIPANTS:

Mailing lists from both above departments were used to distribute surveys to residents, fellows, and attending/faculty members of each department. Eighty-seven surveys were mailed.

MAIN OUTCOME MEASURES:

Survey questions were divided into three sections to help determine current attitudes of prescribing fluoxetine: eight short cases, 16 statements, and demographic data.

RESULTS:

The return rate was 69 percent following a mailing and a hand-delivered copy. Responses were dichotomized to agree or disagree and were analyzed by Fisher's exact test. Psychiatrists were much more likely than family practitioners to prescribe fluoxetine for obsessive-compulsive disorder (OCD), and more likely to prescribe for a patient with a history of substance abuse or seizure disorder. Psychiatrists were more aware of safety issues; however, drug-interaction knowledge was weak in both groups.

CONCLUSIONS:

Family practitioners, being the most predominant of medical specialists, appeared equally comfortable with prescribing fluoxetine in most circumstances compared with psychiatrists. However, there is a need for pharmacists to provide up-to-date drug information on fluoxetine to all healthcare professionals.
New Therapeutic Agents in the Management of Hypertension: Angiotensin II-Receptor Antagonists and Renin Inhibitors
Authors: Foote Edward F. , Halstenson Charles E.
Published: January 2017

OBJECTIVE:

To review the chemistry, pharmacokinetics, and clinical trials of two new classes of antihypertensive drugs, angiotensin II-receptor antagonists and renin inhibitors.

DATA SOURCES:

Primary literature on angiotensin II-receptor antagonists and renin inhibitors was identified through a comprehensive medical literature search from 1961 through 1993. This search included journal articles, abstracts, and reports of both animal and human research published in the English language. Indexing terms included renin-angiotensin aldosterone system, renin inhibitors, angiotensin II antagonists, DuP 753, losartan, MK954, A-64662, and Ro 42–5892.

STUDY SELECTIONS:

Emphasis was placed on clinical and pharmacokinetic studies in humans for drugs that are currently in Phase I—III research protocols in the US.

DATA EXTRACTION:

All available data from human studies were reviewed.

DATA SYNTHESIS:

Angiotensin II-receptor antagonists and renin inhibitors may be effective antihypertensives with few adverse effects noted in the small studies completed. Their potential advantage over angiotensin-converting enzyme (ACE) inhibitors includes a possible smaller adverse effect profile. In the past, the clinical utility of angiotensin II-receptor antagonists and renin inhibitors has been limited because of poor oral bioavailability, although newer agents are more readily bioavailable.

CONCLUSIONS:

Angiotensin II-receptor antagonists and renin inhibitors may be the next new classes of antihypertensives marketed. However, definitive conclusions about their roles in the management of hypertension are not possible until larger clinical trials assessing their efficacy and safety and comparing them with ACE inhibitors are completed.
Risk for Adverse Events among Patients Receiving Intravenous Histamine2-Receptor Antagonists
Authors: Hartzema Abraham G. , Porta Miquel S. , Tilson Hugh H. , Joseph Rami Ben , Segal Richard , Russell Wayne L.
Published: January 2017

OBJECTIVE:

To identify risk factors for adverse drug reactions (ADRs) in patients receiving intravenous histamine2-receptor antagonists (H2-RAs).

DESIGN:

The study hypothesis was evaluated by performing a logistic regression procedure with a backward elimination of the explanatory variables associated with ADRs.

MAIN OUTCOME MEASURES:

ADRs temporally associated with the use of intravenous H2-RAs served as the dependent variable. Background information about the patients and drug use evaluation criteria in three general areas were entered into the regression analysis.

SETTING:

Hospitals were selected from the southeastern US, based on their willingness to participate and their characteristics. Participating hospitals exhibited a variety of sizes and ownership arrangements.

PATENTS:

1200 adult patients who were receiving intravenous H2-RAs.

RESULTS:

Seven percent of patients experienced a presumed ADR (PADR) to intravenous H2-RAs. The only risk factor for ranitidine was for patients who did not have their dosage corrected for renal function (“overdose”); these patients were twice as likely to experience a PADR compared with patients who received the correct dosage as determined by their renal function. Two risk factors for cimetidine were identified: (1) patients taking cimetidine with another medication known to cause a drug interaction; and (2) patient age. No risk factors were identified for famotidine.

CONCLUSIONS:

The two risk factors for ADRs identified in this study are preventable. Healthcare providers should strive to prevent ADRs by adjusting patients' dosages based on their renal function and by monitoring patients receiving cimetidine with another medication known to interact with cimetidine.
Bioelectrical Impedance Analysis as an Assessment of Diuresis in Congestive Heart Failure
Authors: Coodley Eugene L , Segal Jack L , Smith David Hg , Neutel Joel M
Published: January 2017

Objective:

To compare changes in bioimpedance parameters and calculated total body water (TBW) with conventional measurements used to assess the efficacy of diuretic therapy in the treatment of heart failure.

Setting:

A Veterans Affairs tertiary care, teaching hospital.

Subjects:

Twelve patients with New York Heart Association (NYHA) class HI congestive heart failure (CHF).

Design:

Prospective, consecutive sample, cohort, open label.

Interventions:

Parenterally administered furosemide; clinically dictated, outcome-oriented, adjunctive therapy of CHF.

Outcomes:

Bioelectrical impedance analysis (BIA) parameters, measured volume of diuresis and changes in body weight, defined clinical endpoints (NYHA criteria).

Results:

Three days of diuretic therapy with furosemide (oral and/or intravenous) for CHF was associated with a measured weight loss of 4.1 ± 0.6 kg and statistically significant increases in resistance and reactance of 20.8% ± 2.7% and 22.7% ± 6.1%, respectively (p < 0.005). Calculated TBW using BIA parameters and standard equations decreased on average by 6.1 ± 0.6 L or 11.2% ± 1.1% (p < 0.001). A significant inverse correlation was observed between change in measured body weight and total body reactance (p = 0.02).

Conclusions:

Single-frequency BIA appears to have limited clinical usefulness as a method of assessing diuretic therapy in the management of CHF. Its greatest usefulness appears to lie in the assessment of serial changes in individual patients and patient populations that are physiologically or metabolically homogeneous. Further studies are needed to establish the validity of BIA in patients with decompensated CHF.
Polyethylene Glycol Nephrotoxicity Secondary to Prolonged High-Dose Intravenous Lorazepam
Authors: Laine Gregory A , Hossain Sm Hamid , Solis R Thomas , Adams Stephen C
Published: January 2017

Objective:

To report a patient with a probable acute tubular necrosis (ATN) induced by chronic exposure to polyethylene glycol (PEG)-400 via long-term, massive dosage of intravenous lorazepam.

Case Summary:

A 57-year-old man with a history of alcohol abuse was admitted to the intensive care unit for acute respiratory failure. Lorazepam therapy was initiated in anticipation of alcohol withdrawal. Dosages up to 18 mg/h were required to provide adequate sedation and optimize ventilation. On day 43, the patient developed oliguric ATN of unknown etiology. The cumulative intravenous lorazepam dose was 4089 mg, equivalent to approximately 220 mL of PEG-400. Blood urea nitrogen concentrations followed a pattern that paralleled lorazepam dosage increases and decreases. Protein and granular casts were evident in urinalyses performed on days 12 and 29. The patient eventually experienced complete recovery.

Discussion:

ATN associated with intravenous PEG was last reported in 1959 in 6 of 32 patients receiving a cumulative PEG-300 dose of 120–200 mL over 3–5 days via an intravenous nitrofurantoin preparation. Two of the 6 patients died. Chronic administration of intravenous PEG to rabbits over a 5-week period has caused cloudy swelling of the renal tubular epithelium, increased blood urea concentrations, and death in some animals.

Conclusions:

ATN probably resulted from chronic PEG exposure via massive doses of lorazepam injection, possibly enhanced by concurrent administration of vancomycin.
Indapamide-Induced Severe Hyponatremia and Hypokalemia
Authors: Chan Thomas Yk
Published: January 2017

Objective:

To describe 2 patients with severe indapamide-induced hyponatremia and hypokalemia and to discuss the incidence and mechanisms of diuretic-induced hyponatremia and hypokalemia.

Case Summary:

Two women aged 60 and 62 years presented with severe hyponatremia (plasma sodium concentrations of 103–104 mmol/L) and hypokalemia (plasma potassium concentrations of 1.6–2.2 mmol/L) 5–6 weeks after they received indapamide 2.5 mg/d therapy for arterial hypertension. Central nervous system symptoms of hyponatremia were observed in both patients. One patient experienced severe postural hypotension, a plasma potassium concentration of 1.6 mmol/L, and electrocardiographic abnormalities consistent with hypokalemia. Hyponatremia was initially mistaken in this patient for the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). Both patients recovered completely after withdrawal of indapamide therapy and correction of the hyponatremia and hypokalemia.

Discussion:

Previous studies of administration of indapamide 2.5 mg/d for 10–24 months in hypertensive patients showed a low incidence (0.6–1.2%) of hypokalemia severe enough to require withdrawal of drug therapy. Serum sodium concentrations were unaltered in these studies. All case reports, except 1, of indapamide-induced electrolyte disturbances described only hypokalemia.

Conclusions:

Indapamide can cause both severe hypokalemia and hyponatremia. The predominant clinical features can be a result of severe hyponatremia. The latter can have diverse clinical presentations and may be mistaken for SIADH. As with other diuretics, plasma sodium and potassium concentrations must be monitored during indapamide therapy, especially in patients at risk for hyponatremia and hypokalemia.
Effect of Vitamin C on Plasma Lipids
Authors: Howard Patricia A , Meyers David G
Published: January 2017

Objective:

To review the effects of vitamin C (ascorbic acid) on plasma lipid concentrations, and to address the proposed mechanisms through which vitamin C may potentially alter lipid concentrations.

Data Source:

A MEDLINE search was performed to identify pertinent English-language literature including studies, abstracts, and review articles. Key search terms were vitamin C, ascorbic acid, lipoproteins, lipids, and atherosclerosis.

Study Selection and Data Extraction:

Studies examining the relationships between vitamin C and plasma lipid concentrations including animal, observational, and clinical trials were selected. Because there were no large randomized, controlled clinical trials, data were extracted from all clinical trials, regardless of design. Review articles discussing the effects of vitamin C on plasma lipid concentrations and the atherosclerotic process also were included. Pertinent information, as judged by the authors, was extracted for discussion.

Data Synthesis:

Evidence suggests an inverse relationship between vitamin C intake and the development of atherosclerosis, although the effect has not yet been proven in clinical trials. It has been postulated that this effect might be mediated not only through the antioxidant properties of vitamin C, but also through a plasma lipid-modifying effect. Data from animal and observational trials suggest that high vitamin C concentrations may correlate negatively with concentrations of total cholesterol, triglycerides, and low-density lipoproteins and positively with high-density lipoproteins. Other studies, however, have not confirmed these findings. Similarly, results from clinical trials have been widely variable and inconclusive.

Conclusions:

Analysis of the literature suggests an association between vitamin C and plasma lipid concentrations and a potential role in slowing the development of atherosclerosis. Significant variations and inadequacies in trial design, however, prohibit definitive conclusions. On the basis of these preliminary data, it appears that there is justification for additional well-designed trials to further evaluate the relationship between vitamin C and plasma lipid concentrations.
Cigarette Smoking and Clinically Significant Drug Interactions
Authors: Schein Jeffrey R
Published: January 2017

Objective:

To review clinically significant drug interactions associated with cigarette smoking.

Data Sources:

Data from scientific literature were identified by using a MEDLINE search. Data were extracted, evaluated, and summarized for this review.

Study Selection:

Findings and experiences were selected from clinical, epidemiologic, and pharmacokinetic studies; review articles; case studies; abstracts; letters to the editor; and proceedings.

Data Extraction:

Data from human studies published in English were evaluated. Only interactions deemed clinically significant are included in this review. Conclusions derived from review articles on the subject of smoking and drug interactions also were used.

Data Synthesis:

Cigarette smoking can affect drug therapy via pharmacokinetic and pharmacodynamic mechanisms. Pharmacokinetic drug interactions are presented for theophylline, tacrine, insulin, flecainide, propoxyphene, propranolol, diazepam, and chlordiazepoxide. Pharmacodynamic interactions are described for antihypertensive and antianginal agents, antilipidemics, oral contraceptives, and histamine2-receptor antagonists.

Conclusions:

Cigarette smoking can reduce the efficacy of certain drugs or make drug therapy more unpredictable. Pharmacokinetic interactions may cause smokers to require a larger dosage of certain drugs through an increase in plasma clearance, a decrease in absorption, an induction of cytochrome P450 enzymes, or a combination of these factors. Pharmacodynamic interactions may increase the risk of adverse events in smokers with cardiovascular or peptic ulcer disease, and in women who smoke and use oral contraceptives. Healthcare professionals should pay special attention to patients with these profiles and should try to prevent cigarette smoking or encourage patients to discontinue this addictive habit.
Potential Treatment of Amyotrophic Lateral Sclerosis with Gabapentin: A Hypothesis
Authors: Welty Devin F , Schielke Gerald P , Rothstein Jeffrey D
Published: January 2017

Objective:

To provide the biochemical rationale for the use of the new anticonvulsant agent gabapentin as a treatment for amyotrophic lateral sclerosis (ALS).

Background:

ALS is a neuropathologic disorder of the central nervous system characterized by a progressive loss of upper and lower motor neurons. Although the etiopathology of ALS is incompletely known, it is hypothesized that glutamatergic neurotransmission is related to neuropathology. Glutamate is an excitatory amino acid neurotransmitter that is cytotoxic when overexpressed at synaptic terminals, probably through a calcium-related mechanism. The concentration of glutamate in cerebrospinal fluid is increased in patients with ALS. The increased extracellular concentrations of glutamate may be caused by a decreased capacity of glutamate transport in brain tissue and/or abnormal glutamate metabolism. Recent success with the glutamate release inhibitor riluzole in well-controlled clinical trials supports the excitotoxic mechanism of neuropathology in patients with ALS.

Potential Treatment For Als:

Gabapentin has demonstrated neuroprotective properties in a model of chronic glutamate toxicity in vitro. Although the neuroprotective mechanism of action of gabapentin is currently unknown, it is hypothesized here that gabapentin decreases the rate of formation of glutamate derived from the branched-chain amino acids (BCAAs) leucine, isoleucine, and valine. The proposed decrease in formation of glutamate from BCAAs may decrease the pool of releasable glutamate and therefore compensate for diminished glutamate uptake capacity and/or abnormal glutamate metabolism in patients with ALS.

Conclusions:

Based on this rationale, it is proposed that gabapentin may provide a beneficial effect in the treatment of patients with ALS.
Consumer Requests for Information regarding Psychotropic Drugs: Experience from a National Medicines Phone-In
Authors: Alderman Christopher P , Ryan Michael J
Published: January 2017

OBJECTIVE:

To undertake a qualitative analysis of calls regarding psychotropic drugs that were received during a national medicines phone-in day.

BACKGROUND:

In July 1996, The Society of Hospital Pharmacists of Australia coordinated a national medications phone-in day, allowing consumers to seek information about medications from pharmacists and physicians using a toll-free telephone number.

METHODS:

Data collection forms were used to record the details of all calls answered during the phone-in day. Demographic data collected included the estimated age and gender of the caller. Other data collected included the drugs that were the subject of the inquiry and the category of questions.

RESULTS:

There were 42 096 attempted connections to the service, but because of limited telecommunications capacity, only 2245 callers were successfully connected. Psychotropic drugs were the primary subject of 367 calls, representing 16.4% of all inquiries for which data collection forms were completed. Antidepressants (56.1%) and benzodiazepines (24.8%) were the two most commonly encountered classes of psychotropic drugs. The greatest proportion of calls (57.2%) was related to adverse effects of medications. The nature of the inquiries regarding adverse drug effects was generally consistent with the adverse effects detailed in the scientific literature.

CONCLUSIONS:

The results of this 1-day, consumer-oriented drug information project suggest that there is a substantial need for this type of service. Patients treated with psychotropic medications should have access to unbiased, high-quality information about drug therapy.
Ethnicity and Antipsychotic Response
Authors: Frackiewicz Edyta J , Sramek John J , Herrera John M , Kurtz Neil M , Cutler Neal R
Published: January 2017

OBJECTIVE:

To review the data generated by studies examining interethnic/racial differences in response to antipsychotics.

DATA SOURCES:

A MEDLINE search (1966-19%) identified all articles examining differences in antipsychotic response among Caucasians, Asians, Hispanics, and African-Americans, as well as articles evaluating postulated mechanisms for these differences.

STUDY SELECTION:

All abstracts, studies, and review articles were evaluated.

DATA SYNTHESIS:

Ethnic/racial differences in response to antipsychotic medications have been reported and may be due to genetics, kinetic variations, dietary or environmental factors, or variations in the prescribing practices of clinicians. Studies suggest that Asians may respond to lower doses of antipsychotics due to pharmacokinetic and pharmacodynamic differences. Research relevant to African-Americans is limited, but some studies suggest that differences in this group may be due to clinician biases and prescribing practices, rather than to pharmacokinetic or pharmacodynamic variability.

CONCLUSIONS:

Future research directed at validating the hypotheses that different ethnic/racial groups show variations in response to antipsychotics should focus on homogenous ethnic groups, use recent advances in pharmacogenetic testing, and control for such variables as observer bias, gender, disease chronicity, dietary and environmental factors, and exposure to enzyme-inducing and -inhibiting agents. Clinicians should be aware that potential interethnic/racial differences in pharmacodynamics and pharmacokinetics may exist that can alter response to antipsychotics.
The Role of Reactive Drug Metabolites in Immune-Mediated Adverse Drug Reactions
Authors: Hess David A , Rieder Michael J
Published: January 2017

OBJECTIVE:

To highlight recent advances in the understanding of adverse drug reactions (ADRs), with a focus on models outlining interactions between drug metabolism, disease processes, and immunity. Specific mechanisms that identify the metabolic pathways responsible for drug bioactivation to reactive drug metabolites (RDMs) involved in the initiation and propagation of specific immune-mediated hypersensitivity reactions are discussed. Drug classes well known to be associated with immune-mediated ADRs are reviewed and the clinical implications of current research are discussed.

DATA SOURCES:

Original experimental research and immunologic review articles relevant to ADR diagnosis and etiology.

DATA EXTRACTION:

Results of relevant in vitro experiments and clinical reactions to drug therapy were compiled and reviewed. Critical discoveries concerning the identification of RDMs involved in ADRs were highlighted, with respect to RDM involvement in the production of an immune response to drug haptens.

DATA SYNTHESIS:

Drug adverse effects are classified according to clinical characteristics, immune interactions, and mechanistic similarities. Cytochrome P450 bioactivation of drug molecules to RDMs is a prerequisite to many ADRs. An electrophilic metabolite may react with cellular macromolecules (i.e., lipids, proteins, nucleic acids), resulting in direct cellular damage and organ toxicity. Covalent binding of an RDM to cellular macromolecules may also result in the formation of a hapten that is capable of eliciting a cellular or humoral immune response against drug or protein epitopes, culminating in the characteristic symptoms of hypersensitivity reactions. Mechanistic details concerning the identification of stable protein-metabolite conjugates and their interaction with the immune system remain unclear. Genetic imbalance between bioactivation and detoxification pathways, as well as reduced cellular defense against RDMs due to disease or concomitant drug therapy, act as risk factors to the onset and severity of ADRs.

CONCLUSIONS:

Adverse reactions to drug therapy cause significant morbidity and mortality. Identification of the pathways involved in drug bioactivation and detoxification may elucidate the potential of chemical agents to induce immune-mediated ADRs. Understanding the mechanisms of ADRs to current xenobiotics is helpful in the prevention and management of ADRs, and may prove useful in the design of novel therapeutic agents with reduced incidence of severe adverse events.
Would We Know It If We Saw It? Assessing Quality of Care in Group Homes for Youth
Authors: Farmer Elizabeth M. Z. , Murray Maureen L. , Ballentine Kess , Rauktis Mary Elizabeth , Burns Barbara J.
Published: January 2017

This article proposes and examines a parsimonious framework for assessing quality in therapeutic residential care. The synthesized conceptual framework includes four potentially critical domains of quality: setting, staffing, safety, and treatment. Data from a recently completed quasi-experimental study of group homes were used to examine prevalence of various key indicators within each of these domains and to explore relationships between these indicators and youth-level outcomes. Findings suggest that, among this sample of licensed homes in a southeastern state, licensure may be an initial indicator of baseline quality. Beyond this most basic level, utilization of an evidence-informed model (in this case, the teaching family model) was associated with better outcomes. Net of model, findings suggest that positively focused motivational systems, youth’s perceptions of staff’s fairness and helpfulness, provision of age/interest-appropriate toys/books/games, more preservice training, and prohibition of physical restraint were all associated with better outcomes for youth. Additional work is needed to assess the generalizability and utility of this framework for assessing quality in group homes.
Arthrodesis of the First Metatarsophalangeal Joint: A Biomechanical Study Comparing Memory Compression Staples, Cannulated Screws, and a Dorsal Plate
Authors: Neufeld Steven K. , Parks Brent G. , Naseef George S. , Melamed Eyal A. , Schon Lew C.
Published: January 2017

Arthrodesis of the first metatarsophalangeal joint of 21 matched pairs of cadaver toes was performed in order to compare the strength of three methods of internal fixation:

1. two crossed cannulated screws,

2. a dorsal plate with an oblique 0.062 K-wire, and

3. two compression staples with an oblique 0.062 K-wire.

Biomechanical testing with plantar force was carried out, and gapping across the fusion site was measured. Stiffness, load to 1-mm displacement, and force to failure was determined for each specimen. Both the plate and screw constructs were statistically stronger in force to failure and initial stiffness than the compression construct. Compression staples have an advantage in their ease of insertion and theoretical continuous compressive force across an arthrodesis site, but should be supplemented with a cast or other external immobilization until union is achieved.
The Effects of Tibial Malrotation on the Biomechanics of the Tibiotalar Joint
Authors: Svoboda MAJ Steven J. , McHale COL Kathleen , Belkoff Stephen M. , Cohen Kathryn S. , Klemme LTC William R.
Published: January 2017

The effects of tibial malrotation on the biomechanics of the tibiotalar joint were studied using a cadaveric model loaded in an Instron 8521 materials testing device and a TEKScan I-Scan thin-film resistive ink pressure measuring system. Testing of 23 legs was performed using rotational conditions of 10 and 20° internal and external rotation as well as neutral rotation. All rotational conditions were found to decrease joint contact area. Peak pressures were significantly greater with 20° internal rotation as well as 20° external rotation. Total load across the joint was significantly lower for both 10 and 20° of external rotation. In conclusion, rotational deformity across the tibiotalar joint results in significant alteration of overall joint biomechanics and should be minimized whenever possible.
Heel Pad Thickness—A Contributing Factor Associated with Plantar Heel Pain in Young Adults
Authors: Rome Keith , Campbell Robert , Flint Allison , Haslock Ian
Published: January 2017

Thirty-three runners were clinically diagnosed with plantar heel pain (PHP) and 107 runners were designated into a non-PHP group (NPHP). Cases were matched with a further control group of 64 subjects with regard to body mass index and age. A weight-bearing platform measured heel pad thickness by real-time ultrasound scanning. The results demonstrated a significant difference between the PHP and both the NPHP and control groups (P <0.05). The results also demonstrated that body mass index had a significant effect (P <0.05) on the heel pad thickness of all subjects, regardless of the heel pad group. The results from the current study, with some precaution, conclude that body mass index as such is not related to PHP in the athletic population. In the current study the observed differences of body mass index on heel pad thickness between the PHP and NPHP groups, and the similarity between the control group and NPHP subjects suggests other risk factors may play an important role in heel pad thickening and associated development of PHP.
Pericuboid Fracture-Dislocation with Cuboid Subluxation
Authors: Kolker Dov , Marti Christoph B. , Gautier Emanuel
Published: January 2017

The case of a 44-year-old male with a traumatic pericuboid fracture-dislocation consisting of disruption of the midtarsal, tarsometatarsal and pericuboid articulations is presented. The cuboid was partially dislocated without cuboid fracture. Treatment consisted of open reduction with stable internal fixation followed by early range of motion and protected weight-bearing for 12 weeks. Functional outcome results were excellent at final follow-up.
The Transverse Dorsal Approach to the Lisfranc Joint
Authors: Vertullo Christopher J. , Easley Mark E. , Nunley James A.
Published: January 2017

While multiple longitudinal skin incisions can be utilized to visualize the joints of the midfoot, we feel that exposure can be difficult. Dorsal transverse and T incisions were undertaken to expose the tarsometatarsal joints (TMTJs) in 12 patients. Five of the 12 had some form of immunosuppression, including diabetes, methotrexate therapy and antirejection transplant therapy. One patient who had a lengthening of the midfoot with a structural autograft suffered a small area of skin necrosis that healed by secondary intention. The remainder of patient's wounds healed without complication. Three to six dorsal access intervals are created between the neurovascular and musculotendinous structures that overlie the TMTJs. The transverse incision can be extended into a medially based T incision to apply a medial plate as required. Transverse incisions are not recommended for patients who require lengthening of the midfoot.
Correcting and Lengthening of Metatarsal Deformity with Circular Fixator by Distraction Osteotomy: A Case of Longitudinal Epiphyseal Bracket
Authors: Kucukkaya Metin , Kabukcuoglu Yavuz , Tezer Mehmet , Kuzgun Unal
Published: January 2017

The condition known as longitudinal epiphyseal bracket or delta phalanx is a rare congenital anomaly that affects the tubular bones of hand or foot. Metatarsal epiphyseal bracket restrains longitudinal growth, causing progressive deformity and resulting in a short, broad metatarsal and a medially deviated metatarsophalangeal joint and hallux magnus. Although there are some case series describing metatarsal lengthening with the unilateral fixator in the literature, we could not find any case that combines both metatarsal lengthening and deformity correction with the circular external fixator. Gradual lengthening and deformity correction without bone grafting and soft-tissue modification were carried out in a case with bilateral longitudinal epiphyseal bracket of the first metatarsals of the foot. A literature review and treatment method for epiphyseal bracket in a 9-year-old boy is presented. Excellent clinical, and functional results were obtained with circular and semicircular fixators.
Tendon Arthroplasty for Basal Fourth and Fifth Metatarsal Arthritis
Authors: Berlet Gregory C. , Anderson Robert B.
Published: January 2017

Arthritis of the fourth and fifth tarsometatarsal joints, recalcitrant to nonoperative treatment, presents a difficult clinical situation. As part of the lateral rays, these joints have considerable motion, making fusion a very disabling operation. Between 1990 and 1998, 12 patients, who had failed nonoperative treatment, underwent resection arthroplasty of the base of the fifth or fourth and fifth metatarsals with tendon interposition. Preoperative differential injections had confirmed the source of pain in eight cases. Patients were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) midfoot scale; a visual analogue scale to assess perception of pain and disability; a satisfaction index; and, where possible, a comprehensive physical examination. At an average of 25 months follow-up, the average AOFAS score was 64.5. On the visual analogue scale, pain improved an average of 35% and disability improved 10%. Six of the eight patients who participated in this study were satisfied with the operation and would undergo the procedure again for similar symptoms. Patients with a higher postoperative score on the AOFAS midfoot rating scale were statistically more likely to have had a positive differential injection preoperatively. We believe a lateral column tarsometatarsal resection arthroplasty is an effective salvage operation when lateral column midfoot arthritis is confirmed by differential injection and nonoperative measures have provided inadequate relief.
Strength and Knot Security of Braided Polyester and Caprolactone/Glycolide Suture
Authors: Bibbo Christopher , Milia Marc J. , Gehrmann Robin M. , Patel Dipak V. , Anderson Robert B.
Published: January 2017

Background:

Appropriate suture selection is necessary in providing mechanical stability to soft tissue reconstructions. Caprolactone/glycolide (Panacryl™) became a popular suture, possessing excellent handling properties; however, clinical observations questioned the knot security of caprolactone/glycolide. Caprolactone/glycolide is still available on many commercial suture anchor systems. This study compared the security of the knots and ultimate tensile strength of braided caprolactone/glycolide suture to that of a commonly used suture material, braided polyester (Ethibond™).

Materials:

Suture knots of No. 2 braided polyester suture and No. 2 braided caprolactone/glycolide suture were submersed in a physiologic saline solution and stressed using a continuous (non-cyclic) load, simulating a single maximal loading event in a clinical setting. Continuous loading was done to achieve clinical suture knot failure (3-mm knot slippage), then continued until catastrophic suture failure (suture breakage) occurred. Ten trials of each suture were tested.

Results:

Force required to cause knot slippage of 3 mm was greater for braided polyester than for braided caprolactone/glycolide ( p <.0001, unpaired Students' t-test). Forces resulting in catastrophic failure were greater for braided polyester than braided caprolactone/glycolide ( p = .0284, unpaired Students' t-test).

Conclusions:

These data have important implications in the selection of suture materials for repair of soft tissue injuries. In the clinical setting, a single maximal loading event may result in suture failure. These data indicate that braided polyester possesses superior in-vitro mechanical properties and suggest that braided polyester may provide greater security in-vivo than braided caprolactone/glycolide suture.
Reproducibility of Plantar Pressure Measurements in Patients with Chronic Arthritis: A Comparison of One-Step, Two-Step, and Three-Step Protocols and an Estimate of the Number of Measurements Required
Authors: van der Leeden Marike , Dekker Jos H.M. , Siemonsma Petra C. , Lek-Westerhof Sandy S. , Steultjens Martijn P.M.
Published: January 2017

Background:

Plantar pressure measurement may be a helpful evaluation tool in patients with foot complaints. Determination of dynamic pressure distribution under the foot may give information regarding gait, progress of disorders, and the effect of treatment. However, for these measurements to have clinical application, reproducibility, consistency, and accuracy must be ascertained. We compared the reproducibility of measurements among one-step, two-step, and three-step protocols for data collection in patients with arthritis. In addition, the number of measurements needed for a consistent average was determined for the protocol that was found to be the most reproducible.

Methods:

Twenty patients with foot complaints secondary to arthritis participated in the study. Each patient was tested with a pressure platform system using two of the three testing protocols. Reproducibility of contact time and maximal peak pressure were assessed. Intraclass Correlation Coefficients (ICC) were calculated for measurement results among protocols. In stage two of the study, the number of measurements needed for a consistent average was determined by calculating the first three measurements, the first five measurements, and then all seven measurements for both feet. ICC of three, five, and seven measurements were compared. The two-step protocol (13 patients), which was found in stage one of the study to be the most reproducible, was used for this determination.

Results:

Reproducibility was found to be reasonable or good for all three measurement protocols. The mean values of contact time for the one-step protocol were found to be higher than the mean values of contact time for the two-step or three-step protocols in both feet. The differences between the one-step and three-step protocols were statistically significant for the left foot only. The mean peak pressure did not show statistically-significant differences among the three protocols. The one-step and three-step protocols were not used for stage two of the study. Using the two-step protocol, three measurements were found to be sufficient for obtaining a consistent average.

Conclusions:

The results of our study indicated that the one-step, two-step, and three-step protocols of collecting plantar pressure measurements in patients with foot complaints secondary to chronic arthritis were all similar. However, the use of the two-step protocol is recommended over the one-step and three-step protocols; the one-step protocol produced a longer stance phase that did not resemble normal walking and when comparing the two-step and three-step protocols, the two-step protocol was less time consuming and less strenuous for patients with painful feet.
Reliability of Visual Measurement of Forefoot Alignment
Authors: Cornwall Mark W. , McPoil Thomas G. , Fishco William D. , Hunt Lea , Lane Camilla , O'Donnell Deborah
Published: January 2017

Background:

The purpose of this study was to determine the interrater reliability of visual rating of forefoot frontal plane deformities among clinicians with different training.

Methods:

Thirty individuals (16 men and 14 women) between the ages of 22 and 52 years of age participated in the study. None of the patients had a history of congenital deformity, pain, or trauma in the lower extremities during the 6 months before the study. Three clinicians of different educational backgrounds and experience visually evaluated each of the patients and rated forefoot alignment. None of the clinicians knew the rating assigned by either of the other two clinicians.

Results:

The results of this study showed that two of the clinical raters agreed 61.7% of the time, but neither of them agreed with the third clinician more than 15% of the time.

Conclusion:

This study indicates that the commonplace method of visually rating forefoot frontal plane deformities is unreliable and of questionable clinical value.
Diabetic Neuropathy: Review of a Surgical Approach to Restore Sensation, Relieve Pain, and Prevent Ulceration and Amputation
Authors: Dellon A. Lee
Published: January 2017

Diabetic neuropathy occurs in a stocking and glove distribution consistent with a systemic metabolic disease. Historically, this concept led to the conclusion that the only role for surgery in a patient with diabetic neuropathy is for treatment of wounds, amputation, or reconstruction of a Charcot foot. This article reviews the basic scientific and clinical research that support the concepts that metabolic neuropathy renders the peripheral nerve susceptible to compression in patients with diabetes and that decompression of lower extremity peripheral nerves in these patients can relieve pain, restore sensation, and prevent ulceration and amputation.
The Single Medial Approach to Triple Arthrodesis: A Cadaver Study
Authors: Jeng Clifford L. , Tankson Cedric J. , Myerson Mark S.
Published: January 2017

Background:

Triple arthrodesis is traditionally done through a two-incision approach. In certain high-risk patients, it may be desirable to do the procedure through a single medial incision to avoid lateral wound healing problems.

Method:

A cadaver study was undertaken to determine the percentage of surface area of each hindfoot joint that could be prepared through a single medial incision. Five cadaver legs were assigned to the single-incision group, and one cadaver leg was used as the “standard” two-incision specimen.

Results:

Through the single-incision approach, 91% of the talonavicular joint, 91% of the subtalar joint, and 90% of the calcaneocuboid joint could be prepared. These results were comparable to the two-incision cadaver specimen results.

Conclusions:

A single-incision medial approach for triple arthrodesis is a safe and effective technique in the management of hindfoot deformity and arthritis in certain high-risk patients.
Medial Deviation of the First Metatarsal in Incipient Hallux Valgus Deformity
Authors: Munuera Pedro V. , Dominguez Gabriel , Polo Juan , Rebollo Jesús
Published: January 2017

Background:

The aim of this study was to determine whether excessive medial deviation of the first metatarsal (excessive intermetatarsal angle) is present in the initial phase of hallux valgus.

Methods:

The intermetatarsal angle between the first and second metatarsals (1–2 IMA) was radiographically studied in 49 normal feet and in 49 feet with mild hallux valgus deformity.

Results:

The results demonstrated a statistically significant difference in the mean intermetatarsal angle between the two groups (8.76 degrees in normal feet; 9.98 degrees in affected feet). However, we believe that is not clinically significant. Other authors, comparing the 1–2 IMA in patients with or without more advanced hallux valgus, reported greater differences than those obtained in this study.

Conclusions:

Excessive medial deviation of the first metatarsal is not a causal factor but rather a consequence of hallux valgus deformity.
Variation of the Distal Metatarsal Articular Angle with Axial Rotation and Inclination of the First Metatarsal
Authors: Robinson Andrew H.N. , Cullen Nicholas P. , Chhaya Neal C. , Sri-Ram K. , Lynch Andy
Published: January 2017

Background:

The distal metatarsal articular angle (DMAA) is a radiographic measure of the orientation of the first metatarsal articular surface. There is debate with regards to the accuracy, reproducibility, and validity of measurement of the DMAA in the literature. This study aimed to test the validity of the measurement of the DMAA from standard radiographs, to explore the trigonometric relationship of the first metatarsal rotation and the DMAA, and to assess interobserver reliability.

Methods:

Thirty-four separate dry cadaver first metatarsal bones were mounted onto a customized light-box-protractor, allowing controlled incremental changes in rotation and inclination. A series of 39 digital photographs were taken of each metatarsal in 5-degree increments of rotation between 30 degrees supination and 30 degrees pronation at 10, 20 and 30 degrees of inclination. Three reviewers performed blinded DMAA measurements from each photographic image; the data were collated for statistical analysis. The data were analysed using a mixed effects linear model comparing the DMAA with rotation of the first metatarsal.

Results:

A strong statistically significant trend of increasing score with increasing pronation of the metatarsal was observed, the relationship was approximately linear. There was a strong effect of inclination, but the strength of this varied with rotation and was amplified at higher inclinations. Interobserver error was noted in line with other studies, but even allowing for this interobserver error, the linear relationship was maintained.

Conclusions:

This study showed that the DMAA varies significantly in a linear pattern with axial rotation of the first metatarsal. Inclination of the first metatarsal also affects the magnitude of the angle. This study does not refute the DMAA as an entity but does confirm the inaccuracy of extrapolating the DMAA from plain anteroposterior radiographs.
First Metatarsal Bone: An Anatomic Study
Authors: ElSaid Ahmed G. , Tisdel Christopher , Donley Brian , Sferra James , Neth Donald , Davis Brian
Published: January 2017

Background:

The purpose of this study was to establish the range of anatomic variations of the first metatarsal bone, including both the angulations of the articular surfaces and the dimensions of the bone in a large sample.

Methods:

Four hundred and seventy-eight first metatarsal bones of 239 cadaver specimens were studied. The following parameters were recorded: the distal metatarsal articular angle (DMAA), distal metatarsal articular surface shape, proximal metatarsal articular angle (PMAA), the first metatarsal bone length and width at the mid-region of the shaft, and the existence of a joint between the bases of the first and second metatarsals. These parameters were correlated to the specimen's age, sex, race, height, and weight. The DMAA and PMAA were measured from a digital picture of the first metatarsal bone by a specially designed computer analysis program.

Results:

Males and African-American race had a longer and wider metatarsal. The joint between the first and second bases was present in 25% of the population. The DMAA ranged from − 14 degrees of medial deviation to 30 degrees of lateral deviation with an overall average of 8.21 degrees. The DMAA increased 1 to 3 degrees with every 10 years in age for both right and left bones with a p value of < 0.01 and < 0.001, respectively, and the average increase from 20 to 60 years of age was 4.5 degrees. The PMAA ranged from −13.8 degrees of lateral deviation to 12.7 degrees of medial deviation with an overall average of −1 degrees. PMAA significantly deviated laterally in the presence of a joint between the bases of the first and second metatarsals (p < 0.001). The male and female means for the DMAA and PMAA were nearly equal.

Conclusions:

The DMAA had a wider range than reported in the literature, and it increased with age. The first-second metatarsal joint was accompanied by lateral deviation of the PMAA.

Clinical Relevance:

Laterally deviated PMAA could predispose to a varus deformity of the first metatarsal.