bluuebunny/crossref_metadata_2025 huggingface dataset:
Surgical Anatomy of the Gastrocnemius Recession (Strayer Procedure)
Authors: Pinney Stephen J. , Sangeorzan Bruce J. , Hansen Sigvard T.
Published: January 2017

Background:

The Strayer procedure (gastrocnemius recession) is a treatment option for patients with clinically relevant gastrocnemius equinus contracture. The purpose of this study was to review the surgical anatomy of the Strayer procedure with specific reference to 1) the location of the sural nerve, and 2) the gastrocnemius tendon release point.

Methods:

Forty consecutive Strayer procedures in 33 patients (15 males, 18 females) served as the study group. Recorded measurements included: 1) the location of the sural nerve relative to the deep fascia, 2) the distance from the medial border of the gastrocnemius tendon to the sural nerve, and 3) the distance from the distal end of the gastrocnemius muscle belly (identified by surface landmarks) to the actual release site.

Results:

At the point of the gastrocnemius release, the sural nerve was located superficial to the fascia in 17/40 legs (42.5%) and deep to the fascia in 23/40 legs (57.5%). In five legs (12.5%), the nerve was directly applied to the gastrocnemius tendon and needed to be gently dissected off the tendon. The gastrocnemius release point was located an average of 18 mm distal (range, 20 mm proximal to 57 mm distal) to the surface landmark created by the distal extent of the gastrocnemius muscle belly.

Conclusion:

Knowledge of the relevant anatomy associated with the gastrocnemius recession should allow surgeons to minimize the rate of sural nerve injuries and improve cosmesis by decreasing the length of the surgical incision. A posteromedial incision that begins 2 cm distal to the gastrocnemius indentation and extends proximally will minimize the length of the incision required.
Posttraumatic Pediatric Distal Tibiofibular Synostosis: A Case Report
Authors: Munjal Kevin , Kishan Shyam , Sabharwal Sanjeev
Published: January 2017

Introduction:

Posttraumatic pediatric distal tibiofibular synostosis is a rare complication of fractures at this level, unreported at this time. Implications include limb length discrepancy, angular malalignment, and gait and biomechanical abnormalities.

Materials and Methods:

The authors present a case report of this complication in a 7-year-old child and review the relevant English literature. The patient was treated for a closed distal tibia-fibula fracture and developed a synostosis at that level, with valgus malalignment of the ankle joint. The synostosis was resected and latest follow-up 16 months postresection showed near normalization of the ankle malalignment. Possible etiologies, the anatomical and functional ramifications, and treatment recommendations for this condition are discussed.

Posttraumatic tibiofibular synostosis is a rare complication that has a potential effect on limb length and alignment, both at the ankle and the knee in the skeletally immature patient. Prevention, early recognition, and prompt treatment prevent the anatomic and functional abnormalities that could result from it.
Arthrodesis Compared to Mayo Resection of the First Metatarsophalangeal Joint in Total Rheumatoid Forefoot Reconstruction
Authors: Grondal Lollo , Hedstrom Margareta , Stark Andre
Published: January 2017

Background: Painful forefoot deformity from rheumatoid arthritis can be treated with resection of the lesser metatarsal heads combined with either resection or arthrodesis of the first metatarsophalangeal (MTP) joint. Methods: In a prospective, randomized study we compared arthrodesis of first MTP joint with Mayo resection as part of total forefoot reconstruction in patients with painful forefoot deformity from rheumatoid arthritis. The lesser metatarsal heads were resected and extensor tenotomy was done in all patients. Thirty-one patients were randomized to either the arthrodesis or resection group. Results: After a mean followup of 36 (26 to 52) months, the median subjective satisfaction score was 96 points out of 100 in the resection group and 92 points in the arthrodesis group. Significant improvements in pain, handicap, and activity according to Foot Function Index (FFI) were found in both groups ( p < 0.001 except for handicap in resection group and activity in fusion group were p = 0.02). There were no statistically significant differences between the groups in these measures, nor in the patients' willingness to have the procedure again. There were no recurrences of prominences or tenderness under the forefoot in either group and no recurrence of severe hallux valgus in the resection group. The arthrodeses healed in 93%. There was no higher risk for clinically relevant IP joint symptoms after arthrodesis. The operating time was significantly longer in the arthrodesis group but this was not linked to a higher wound infection rate. Conclusion: These results indicate that Mayo resection may still be a good choice for the first MTP joint in total forefoot reconstruction in patients with rheumatoid arthritis.
Long-Term Results of Arthroscopic Ankle Arthrodesis
Authors: Ferkel Richard D. , Hewitt Michael
Published: January 2017

Background: More than 40 open procedures have been described for ankle arthrodesis, most with high complication rates. Since its description in 1983, arthroscopic ankle arthrodesis has become a viable option in selected patients. With one of the largest series in the literature, the purpose of the paper was to analyze the results of arthroscopic ankle arthrodesis at our institution. Methods: Between 1989 and 2002, 35 patients with end-stage ankle arthritis underwent arthroscopic ankle arthrodesis. The average followup was 72 months, with a range of 24 to 167 months. Patients returned for a clinical and radiolographic evaluation using the grading systems of Mazur and Morgan. All patients had preoperative and postoperative radiographic evaluation to assess fusion. Indications for arthroscopic ankle arthrodesis included failure of at least 6 months of conservative treatment, minimal or mild correctable deformity in the coronal plane, and no active infections. Results: The overall fusion rate was 97% (34 of 35 patients). The average time to fusion was 11.8 weeks, with a range of 8 to 18 weeks. There were 74% good to excellent results by the Mazur grading system and 83% by the Morgan system. There were no infections or neurovascular injuries. In the three patients who required bone stimulators for delayed unions, fusion occurred in two, and one had a nonunion. Eleven patients had screws removed because of pain at an average of 11 months after the initial surgery. Conclusion: Our study demonstrated a high fusion rate with minimal complications for arthroscopic ankle arthrodesis.
Stage I and II Posterior Tibial Tendon Dysfunction Treated by a Structured Nonoperative Management Protocol: An Orthosis and Exercise Program
Authors: Alvarez Richard G. , Marini Andrew , Schmitt Coleen , Saltzman Charles L.
Published: January 2017

Background: Posterior tibial tendon dysfunction (PTTD) is a relatively common problem of middle-aged adults that usually is treated operatively. The purpose of this study was to identify strength deficits with early stage PTTD and to assess the efficacy of a focused nonoperative treatment protocol. Methods: Forty-seven consecutive patients with stage I or II posterior tibial tendon dysfunction were treated by a structured nonoperative protocol. Criteria for inclusion were the presence of a palpable and painful posterior tibial tendon, with or without swelling and 2) movement of the tendon with passive and active nonweightbearing clinical examination. The rehabilitation protocol included the use of a short, articulated ankle foot orthosis or foot orthosis, high-repetition exercises, aggressive plantarflexion activities, and an aggressive high-repetition home exercise program that included gastrocsoleus tendon stretching. Isokinetic evaluations were done before and after therapy to compare inversion, eversion, plantarflexion, and dorsiflexion strength in the involved and uninvolved extremities. Criteria for successful rehabilitation were no more than 10% strength deficit, ability to perform 50 single-support heel rises with minimal or no pain, ability to ambulate 100 feet on the toes with minimal or no pain, and ability to tolerate 200 repetitions of the home exercises for each muscle group. Results: Before therapy weakness for concentric and eccentric contractures of all muscle groups of the involved ankle was significant ( p < 0.001). After a median of 10 physical therapy visits over a median period of 4 months, 39 (83%) of the 47 patients had successful subjective and functional outcomes, and 42 patients (89%) were satisfied. Five patients (11%) required surgery after failure of nonoperative treatment. Conclusion: This study suggests that many patients with stage I and II posterior tibial tendon dysfunction can be effectively treated nonoperatively with an orthosis and structured exercises.
The Relationship Between Tears of the Peroneus Brevis Tendon and the Distal Extent of its Muscle Belly: An MRI Study
Authors: Freccero David M. , Berkowitz Mark J.
Published: January 2017

Background: Anomalous distal insertion of the peroneus brevis muscle belly has been implicated as a possible etiology of tears of the peroneus brevis tendon. The purpose of this study was to assess whether patients with operatively confirmed tears of the peroneus brevis tendons have a more distally located musculotendinous junction. Methods: A retrospective review was done to identify all patients in whom direct inspection of the peroneal tendons was done between 1999 and 2004. The operative reports were evaluated, and all in whom a peroneal tendon tear was confirmed were included in the study group, Group I (29 patients). Group II represented an operative control group and consisted of all patients who had operative inspection of the peroneal tendons but did not have a tear (30 patients). Group III represented a radiographic control group and consisted of patients who had MRI of the ankle for reasons unrelated to lateral ankle symptoms (30 patients). For each patient, the vertical distance from the musculotendinous junction of the peroneus brevis tendon to the tip of the fibula was measured on sagittal MRI. The role of gender also was examined. The average distance between the musculotendinous junction of the peroneus brevis tendon to the distal fibula was calculated solely for men and women in all three groups. Statistical comparison of the groups was performed using the Mann-Whitney test. Interobserver reliability was determined by calculating Cronbach's Alpha coefficient. Results: The average distance from the musculotendinous junction to the tip of the fibula was 33.1 cm, 41.2 cm, and 46.3 cm in Groups I, II, and III, respectively. The average distance in Group I was statistically significantly lower than the average distance in both Groups II and III ( p < 0.05). Interestingly, the difference in the distance between Groups II and III also was statistically significant ( p < 0.05). The average distances in both men and women were statistically significantly different ( p < 0.05) among the three groups. Conclusion: It has been hypothesized that tears of the peroneus brevis tendon result from distal insertion of the peroneus brevis muscle belly. This study provides radiographic support for this hypothesis.
Health-Related Quality of Life in Patients with Transtibial Amputation and Reconstruction with Bone Bridging of the Distal Tibia and Fibula
Authors: Pinzur Michael S. , Pinto Marco A. Guedes S. , Saltzman Matthew , Batista Fabio , Gottschalk Frank , Juknelis Dainius
Published: January 2017

Background:

Bone-bridging (arthrodesis of the distal tibia and fibula) at the time of transtibial amputation is a controversial operative technique that is anecdotally reported to improve the weightbearing capacity of the residual limb and to decrease residual limb discomfort.

Methods:

Thirty-two consecutive patients with multiple diagnoses had transtibial amputation with a distal tibial-fibular bone-bridge, all done by a single surgeon (MAP). At an average of 16.3 months after surgery all patients completed the Prosthetics Evaluation Questionnaire (PEQ), a validated outcomes instrument specifically created to evaluate quality of life and functional demands in patients with a lower extremity amputations. Their responses were compared with those of 17 preselected, highly functional transtibial amputees from two academic medical centers who previously had transtibial amputations using a traditional non bone-bridge operative technique; their time since amputation averaged 14.7 years.

Results:

The “nonselected” consecutive patients with a bone-bridged residual limb scored higher (more favorable) in the Ambulation ( p = 0.037) and Frustration ( p < 0.001) domains of the PEQ and lower (less favorable) in the Appearance ( p = 0.025) subscale. Their scores were similar in the other six domains.

Conclusions:

Patients of multiple ages with multiple diagnoses who had bone-bridging of the distal tibia and fibula at the time of transtibial amputation had scores on a validated outcomes instrument that were better than or comparable to those of a selected group of highly functional transtibial amputees. The results of this study suggest that bone-bridging at the time of transtibial amputation may enhance patient-perceived functional outcomes.
Surgical Treatment of Mild Hallux Valgus Deformity: The State of Practice among Academic Foot and Ankle Surgeons
Authors: Pinney Stephen , Song Kyle , Chou Loretta
Published: January 2017

Background:

The purpose of this study was to determine the operative procedure of choice among academic foot and ankle surgeons practicing in the United States for treatment of mild hallux valgus deformity.

Methods:

A hypothetical patient was created: a 60-year-old woman with a mild hallux valgus deformity (first intermetatarsal angle of 11 degrees and hallux valgus angle of 22 degrees). The patient complained of pain around the bunion, nonoperative treatment had failed, and she desired operative correction. The case was sent to academic foot and ankle surgeons to identify their operative treatment of choice. The overall response rate was 83.7% (128 of 153). To be included in the study group each surgeon had 1) foot and ankle patients comprising 50% or more of their clinical practice and 2) direct responsibility for teaching orthopaedic surgery residents. One hundred and three respondents met the inclusion criteria and formed the study group.

Results:

Eighty-seven percent (90 of 103) reported that they would use a distal chevron osteotomy as their primary procedure to correct the mild hallux valgus. Ten percent (10 of 103) reported that they would also add an Akin osteotomy of the proximal phalanx to enhance correction.

Conclusions:

Most respondents chose a distal chevron osteotomy as their primary procedure to correct the mild hallux valgus deformity.
Role of Patient Information Handouts Following Operative Treatment of Ankle Fractures
Authors: Mayich D. Joshua , Tieszer Christina , Lawendy Abdel , McCormick William , Sanders David
Published: January 2017

Background:

Widespread evidence exists for directed patient information interventions (eg, pamphlets) in the setting of several orthopaedic conditions and interventions. Up until now, no study had assessed the role of these interventions in the management of patients following ankle fractures.

Methods:

Between 2005 and 2007, 40 patients who suffered an operative ankle fracture were randomized to either a standard treatment group for an ankle fracture or an enhanced information group who received an American Academy of Orthopaedic Surgeons ankle fracture information pamphlet that explained postoperative routine at our institution and a physiotherapy handout depicting a standard protocol. Study participants were followed for 3 months clinically and radiographically. At the 6-week and 3-month intervals, study participants completed the Olerud-Molander Questionnaire and 2 questions regarding their level of satisfaction. The primary outcome measure was the Likert-scale-based survey question determining the level of satisfaction with the treating staff.

Results:

Participants in the enhanced information group were more satisfied with treatment at 3 months (9.2 vs 6.3; P < .001). There were significant improvements in work/activity ability at 6 weeks ( P = .01), but this advantage disappeared at 3 months ( P = .24). No differences in postoperative complication rates were noted.

Conclusions:

Information enhancement in the form of pamphlets can be helpful in providing patients with accessible information in the postoperative period. While they do not seem to have a sustained impact on postoperative outcomes, handouts may enhance the interaction between staff and patient at postoperative visits, improving patient satisfaction.

Level of Evidence:

Level I, appropriately powered randomized prospective cohort study.
Hostile Media Perception, Involvement Types, and Advocacy Behaviors
Authors: Choi Jounghwa , Park Hyun Soon , Chang Jeongheon JC
Published: January 2017

This study investigates how HMP influences partisans' advocacy behaviors and examines how type of involvement affects HMP and advocacy groups' advocacy behaviors. Results suggest that HMP induces advocacy groups to prefer more aggressive advocacy strategies, such as attacking counterparts, and that outcome-relevant involvement is positively related to preference for both attacking and negotiation strategies. The results provide weak evidence that value-relevant involvement is negatively related to negotiation. There was no differential effect of each involvement type on HMP.
Four Decades of Images in Gay Male-Targeted Magazines
Authors: Schwartz Joseph , Andsager Julie L.
Published: January 2017

This study content-analyzed 1,578 male images from the highest-circulation magazines targeted to gay men, The Advocate and Out, from 1967 to 2008. Social comparison theory served as a theoretical framework. Images consistently had low levels of body fat and high levels of muscularity. Moreover, the percentage of images with the lowest level of body fat increased over time while the percentage of images with the highest level of muscularity also increased. Compared to magazines directed toward heterosexual men, images directed toward gay men were about as muscular but substantially thinner.
The Framers' First Amendment: Originalist Citations in U.S. Supreme Court Freedom of Expression Opinions
Authors: Silver Derigan
Published: January 2017

This article examines the use of originalist citations by Supreme Court justices in First Amendment freedom of expression opinions. It quantitatively examines when justices use originalist citations and qualitatively explores the content of the justices' citations to determine how the justices are describing the original meaning of the First Amendment. The article concludes that justices uncritically relied on the citations as authoritative; that although it is identified with conservatism and judicial constraint, originalism was frequently used by liberal justices to expand constitutional protections; and that the “blank slate” of originalism makes it a useful tool for originalists and non-originalists alike.
Censorship in a Different Name: Press “Supervision” in Wartime Japanese American Camps 1942–1943
Authors: Mizuno Takeya
Published: January 2017

When the federal government in 1942 forced Japanese Americans into “relocation centers,” camp officials allowed them to publish newspapers “freely,” under “supervision,” without “censorship.” In reality, however, the camp press was hardly “free.” Newspapers published under governmental auspices were inevitably subject to various types of editorial interference. The camp authority's “supervision” took various forms, including pre- and post-publication reviews, selective staff employment, convocation of “meetings,” supplying of news and propaganda material, and even direct and coercive editorial interference that officials themselves admitted to be “censorship.” Camp officials also elicited self-restraint from staffers, making strict supervision or censorship unnecessary.
An Individualized Music Intervention for Agitation
Authors: Gerdner Linda
Published: January 2017

Persons with cognitive impairment as in Alzheimer's disease and related disorders have a progressive decline in their stress threshold. Agitation results when this stress threshold is exceeded. A proposed mid-range theory incorporates these elements to discuss the use of individualized music to alleviate agitation. Music may provide a method of communicating with this population even in advanced stages when the person is unable to understand verbal language and has decreased ability to interpret environmental stimuli. It is predicted that the presentation of music carefuUy selected for meaningfulness to the person during his or heryoungeryears wil stimulate memory for remote events, and elicitation of memories associated with positive feelings will have a soothing effect and will alleviate or decrease agitated behaviors. Results from a pilot study andpreliminaryfindingsfrom a study currently underway are provided as beginning efforts to support this mid-range theory. An individualized music intervention that flows from this mid-range theory is discussed.
Biologic Therapy in Psoriasis: Perspectives on Associated Risks and Patient Management
Authors: Papp Kim A. , DeKoven Joel , Parsons Laurie , Pirzada Syed , Robern Michael , Robertson Lynne , Tan Jerry K.L.
Published: January 2017

Background:

Previous publications have described practical considerations for initiating biologic therapy in psoriasis patients. However, most publications have focused on anti–tumor necrosis factor (TNF) therapy.

Objective:

To create an evidence-based, practical tool that provides guidance on patient management for all biologics currently approved in Canada and the United States.

Methods:

Psoriasis publications regarding safety issues in the initiation or monitoring of adalimumab, alefacept, etanercept, infliximab, or ustekinumab therapy were identified through a PubMed search. Phase III trials and open-label extensions (regardless of indication) and relevant guidelines from Health Canada were used to compile this review.

Results:

Although these biologic agents have demonstrated efficacy in patients with psoriasis and are generally considered safe and well tolerated, rare but serious safety issues (ie, demyelination, infection, tuberculosis, malignancy, lymphoma, cardiovascular outcomes, hepatitis, pregnancy, surgery, and vaccination) have been observed. Attention to specific aspects of patient management (ie, prescreening requirements, symptoms to watch for, appropriate treatment, and referrals) is required to mitigate risk.

Conclusion:

Much of the evidence regarding the long-term safety of these agents has been based on experience in other patient populations. However, it does serve to guide us in understanding the risks that may impact the management of psoriasis patients.
Clinical Usefulness of Ultrasonography in Interdigital Pilonidal Sinus
Authors: Imanishi Hisayoshi , Tsuruta Daisuke , Nomura Nami , Nakagawa Koichi
Published: January 2017

Background:

Interdigital pilonidal sinus is an uncommon occupational disease produced by short sharp hairs that penetrate the interdigital space of the hand. Although surgical excision is the preferred therapy for interdigital pilonidal sinus, preoperative diagnosis and characterization of pilonidal sinuses may be difficult.

Objective:

To report the usefulness of ultrasonography in making the diagnosis and evaluating for the size, shape, and internal structure of interdigital pilonidal sinus preoperatively.

Methods:

We performed ultrasonography (Xario SSA-660A, Toshiba Medical Systems Corporation, Tochigi, Japan) using an 8 MHz linear transducer in B mode.

Results:

A round to oval echo-poor area with sharp borders, enhanced dorsal reflection, and lateral echo-free streaks corresponded to the short axial cross section of sinus, and hyperechoic foci within the sinus represented hairs.

Conclusion:

Our case highlights the ability to determine key features of sinus tracts and diagnose interdigital pilonidal sinus accurately by ultrasonography. Ultrasonography, in combination with the history and physical examination, increases the diagnostic accuracy of interdigital pilonidal sinus and can help in determining the extent of surgery required to fully remove the interdigital pilonidal sinus.
Rosai-Dorfman Disease Treated with Methotrexate and Low-Dose Prednisone: Case Report and Review of the Literature
Authors: Nasseri Eiman , Belisle Annie , Funaro Deana
Published: January 2017

Background:

Rosai-Dorfman disease is a rare condition characterized by an accumulation of histiocytes within lymph nodes and tissue. Treatment is indicated when the condition is highly symptomatic and when widespread involvement causes vital organ compression.

Objective:

To review the classic physical and histologic findings in Rosai-Dorfman disease and summarize the literature supporting the use of methotrexate in this condition.

Methods and Results:

We describe a case of Rosai-Dorfman disease that failed to respond to monotherapy with systemic corticosteroids but improved with the addition of methotrexate. Methotrexate alone or in combination with other agents has been described in at least 12 other cases in the literature and lead to a partial or complete resolution of disease in over half of these.

Conclusion:

The rapid improvement of clinical and physical symptoms with minimal side effects in our case and others reinforces the utility of antimetabolites in patients with Rosai-Dorfman disease who fail to respond to corticosteroids.
Unilateral Keratoderma in a Mother and Her Son
Authors: O'toole Ashley , O'malley Maureen
Published: January 2017

Background:

Keratoderma is a group of conditions characterized by hyperkeratosis affecting the skin on the soles of the feet and palms of the hands bilaterally. The classification of keratodermas depends on whether it is inherited or acquired and on its clinical features, including diffuse or focal involvement of the skin and the morphology of lesions present.

Case Report:

We describe the rare case of a 54-year-old female who presented with a nearly 40-year history of punctate keratoderma on her right palm and sole. History taking revealed that her biologic son also has unilateral left-sided keratoderma. The clinical presentation of unilateral keratoderma has been reported only four times in the literature.
Who Answers ‘Willingness to Pay’ Questions?
Authors: Thomas Ruth , Donaldson Cam , Torgerson David
Published: January 2017

Objectives:

The objectives of this study were twofold. The first was to compare characteristics of responders and non-responders to a survey of women attending a bone mineral density screening service in Aberdeen concerned with the screening process which contained questions on attenders' willingness to pay (WTP) and willingness to wait (WTW) for screening. The second objective was to compare the characteristics of those responding to either the WTP or the WTW questions relative to those who responded to both.

Methods:

After receiving a scan, women completed the questionnaire at the clinic or returned it by post. Logistic regression analysis was used to compare the characteristics of the responders and non-responders.

Results:

Those who smoked were less likely to return the questionnaire, whilst those who drank alcohol were more likely to return it. The majority of respondents answered both WTP and WTW questions. The proportions responding to the WTW and WTP questions were 93.2% and 81.5% for the two questions, respectively (95% confidence interval of difference = 9.4% to 13.9%). The only result which was statistically significant at the 1% level showed that, relative to those who answered the WTW but not the WTP questions, those who answered both were more likely to be older when they left full-time education. A weaker statistical association (at the 5% level) revealed that those who were older when leaving full-time education were more likely to answer a WTP question than not.

Conclusions:

WTP questions seem to be less acceptable to those who leave full-time education earlier. Analysts may need to account for this in future studies. Whether such results can be replicated and reasons for non-response should be investigated.
In Pursuit of Patient-Centred Outcomes: A Qualitative Evaluation of the ‘Measure Yourself Medical Outcome Profile’
Authors: Paterson Charlotte , Britten Nicky
Published: January 2017

Objectives:

To ascertain the ability of a patient-generated outcome measure, the ‘Measure Yourself Medical Outcome Profile’ (MYMOP), to reflect the outcomes of consultations which patients consider are most important, as derived from qualitative interviews.

Methods:

A qualitative study using a constant comparative method to analyse semistructured interviews which were then compared with the results of MYMOP questionnaires. A variable-orientated analysis was used to develop themes and a case-orientated analysis was used to develop narrative summaries called vignettes from the interviews. The MYMOP questionnaire was completed by the interviewees ( n= 20), a minimum of twice and a maximum of nine times over a four-month period. The scores were displayed on individual MYMOP charts. For each individual, the outcome as measured by MYMOP was compared with the outcome data from the qualitative interviews. The interviewees were attending a variety of complementary practitioners in primary care.

Results:

The treatment effects which people described were encompassed by five themes: reduction in symptoms; reduction in disability; reduction in, or avoidance of, medication; gaining control and improving coping skills; and securing support and hope through the patient—practitioner relationship. The vignettes demonstrated how individuals identified and valued these various effects and weighed them up in evaluating the overall benefit of the treatment. Their MYMOP charts were able to measure some effects better than others.

Conclusions:

The treatment effects, as quantified using MYMOP, accorded with those described by most patients at interview, but some important limitations were identified with MYMOP, particularly an underplaying of the importance of medication avoidance or medication reduction in this patient group. This dimension is lacking in most outcome questionnaires and has been included in a new version of MYMOP. This study also showed that qualitative interview data can help in evaluating the ability of outcome questionnaires to measure the treatment effects that particular patient groups consider most important.
Conceptual and Practical Difficulties with the Economic Evaluation of Health Services Developments
Authors: Coast Joanna , Hensher Martin , Mulligan Jo-Ann , Shepperd Sasha , Jones Jeremy
Published: January 2017

Five recent economic evaluations comparing hospital at home schemes with acute hospital care faced remarkably similar problems. This paper outlines these problems and considers what strategies can be derived from these experiences, which will be relevant to economic evaluations of other aspects of the organisation of care, particularly those crossing the interfaces between primary and secondary health care or the interface between health and social services.

The difficulties experienced can be divided into conceptual and practical problems. Conceptual problems were primarily associated with issues of context and related to the choice of comparator, capacity constraints and size of schemes, and the choice between a short or a long run perspective. Practical problems were connected with the time at which schemes were evaluated, the type of clinical study alongside which studies were conducted and the types of data available for use in the analysis.

Strategies which can be pursued in conducting economic evaluations of organisational change include giving greater attention to conceptual and hence contextual problems as well as reporting these contextual issues in detail, accepting the need for repeated economic evaluations as organisational changes become more widespread and considering carefully the clinical study design where economic evaluations of organisational change are conducted alongside. These strategies are of importance not just to those conducting economic evaluations but also to those funding appraisals of changes in the organisation of care. Use of different strategies such as those suggested here should be evaluated.
Collectivising the Kulaks? General practitioners and Primary Care Groups in England
Authors: Clegg Katherine
Published: January 2017

It has previously been suggested that the English Department of Health seems, wittingly or not, to have drawn on the experiences of Stalinist Russia in devising policies for the National Health Service. The development of general practitioner fundholding during the 1990s could be compared to the Soviet support for the Kulaks (rich peasants with capital and entrepreneurship) in 1923. Both initiatives aimed to propel innovation and enhance productivity by giving increased market freedom to an elite group of entrepreneurial workers. Writing in 1991, Hughes and Dingwall speculated about the likelihood of general practitioners sharing the same fate as the Kulaks in 1928, namely forcible collectivisation. The current creation of Primary Care Groups (collections of about 50 general practitioners) raises the question of whether they are likely to be vulnerable to the same pathologies as collective agriculture, or has the metaphor become exhausted?
Private Provision of ‘outreach’ Clinics to Fundholding General Practices in England
Authors: Kerrison Susan , Corney Roslyn
Published: January 2017

Objectives:

To establish the contribution of the private sector in providing outpatient ‘outreach’ clinics in general practitioner fundholding practices.

Method:

Postal survey of all 13 first-wave fundholders and four of the 13 second-wave fundholders in the former South East Thames Region of the National Health Service in 1995.

Results:

Fourteen practices responded. Ten practices had set up at least one medical specialist ‘outreach’ clinic and 12 at least one paramedical clinic since becoming fundholders. Eight practices reported their arrangements for consultant ‘outreach’ clinics and ten practices their arrangements for paramedical clinics. Forty-nine per cent of the total medical specialist hours and 46% of total paramedical hours were provided by private practitioners. The largest number of hours provided privately was in gynaecology.

Conclusion:

This small study identified considerable private provision of fundholders' ‘outreach’ clinics. However, there is no system in the NHS to monitor the extent of this market, the types of activities undertaken or the relative quality and cost of the services provided.
Evaluating Interventions to Promote Patient Involvement in Decision-Making: By What Criteria Should Effectiveness be Judged?
Authors: Entwistle Vikki A , Sowden Amanda J , Watt Ian S
Published: January 2017

Interventions to inform patients about health care options and to involve them in decisions about their care are now widely advocated. The question of which criteria should be used to judge the effectiveness of such interventions has, however, received little attention.

The provision of research-based information about health care effectiveness to patients and the promotion of greater patient involvement in health care decision-making are likely to have a complex range of effects on: the information provided to patients; patients' acquisition of skills; patients' knowledge and emotions; how decisions are made; the quality of decisions; professional—patient relationships; the use of health care; the health of patients; satisfaction; and the organisation and cost of health services.

Opinions about which effects are most important and how they should be measured and valued will be influenced by a variety of factors, including: the rationales and motives underlying interest in patient involvement in decision-making; the forms of patient involvement envisaged; and the types of interventions being considered. In the context of health care systems which aim primarily to improve health status and well-being, health outcomes should take priority over process variables such as decision-making behaviours and patients' knowledge.
Pay in the British NHS: A Local Solution for a National Service?
Authors: Gray Alastair , Buchan James
Published: January 2017

An important component of the reforms of the British National Health Service (NHS) has been devolution of a previously highly centralised pay bargaining system to the local provider level. As the wage bill is by far the single largest item of health care expenditure, the implications of this change may be far-reaching. This article surveys the available theory and evidence from an economic perspective. It reviews the development of pay determination mechanisms in the NHS and the extent to which local pay has been adopted since the reforms were introduced. It then considers the theory of local pay and general evidence on local pay variations in the UK, before turning to the available evidence on local labour markets in the health care sectors of the UK and USA. It concludes with a discussion of the policy and research implications of current developments on local pay bargaining in the NHS. In particular, it suggests that judgements over the success or failure of local pay bargaining will concern: first, whether the weakened monopsony position of the NHS at national level results in higher pay for the more powerful employee groups; second, whether fragmentation of bargaining weakens the negotiating and lobbying power of national trade unions and professional organisations; third, whether competition between providers leads to higher or lower costs; and fourth, whether any efficiency gains from local bargaining outweigh the higher transaction costs involved.
Expert Panel Assessment of Appropriateness of Abdominal Aortic Aneurysm Surgery: Global Judgement versus Probability Estimation
Authors: Silverstein Marc D. , Ballard David J.
Published: January 2017

Objective:

To compare an expert panel's global assessment of appropriateness of elective surgery for abdominal aortic aneurysms (AAA) with their assessment of the effect of surgery on the probability of 5-year mortality.

Methods:

Nine expert panel members rated the appropriateness of 120 scenarios for elective AAA repair on a nine-point scale, and also estimated the 5-year probability of AAA-related death and of non-AAA related death among 30-day survivors of AAA surgery and among patients with unoperated AAA. These probabilities were used to determine differences in 5-year probability of mortality of surgery vs. no surgery for each scenario. Three categories of appropriateness were defined based on these differences: inappropriate (< 0%), equivocal (0-5%), and appropriate (>5%).

Results:

The distribution of scenarios was inappropriate (39%), equivocal (12%), and appropriate (49%) based on probability estimates and inappropriate (43%), equivocal (22%), and appropriate (36%) based on global assessment. There was poor agreement between the two methods, with a Kappa coefficient=0.28 (95% CI: 0.23 to 0.32). Although a higher proportion of scenarios were rated as appropriate using probability estimation rather than global judgment, the level of agreement among members of the panel was similar, Kappa coefficient= 0.07 (95% CI: — 0.07 to 0.72)

Conclusions:

Experts disagree about the appropriate indications for elective surgery for AAA. Explicit estimates used in a decision analysis may provide a better assessment of appropriate indications than the global judgment of experts. Global assessment of the appropriateness of AAA surgery based on panel members' review of research evidence for increased survival appears to include implicitly their valuation of outcomes.
Day Case Surgery Trends in England: The Influences of Target Setting and of General Practitioner Fundholding
Authors: Raftery James , Stevens Andrew
Published: January 2017

Objectives:

To describe the trends in the proportion of elective surgery carried out as day cases, and the impact of the setting of targets and the introduction of general practitioner (GP) fundholding on the use of day surgery.

Methods:

Cross-sectional analysis of Hospital Episode Statistics for England, 1990/1991 to 1994/1995, comparing procedures for which targets were and were not set, and comparing types of purchaser (GP fundholder and health authority).

Results:

Elective surgical procedures increased from 2.7 million in 1990/1991 to 3.9 million in 1994/1995, a 44% increase. Increased numbers of day cases (up 117%) accounted for almost all of the increased total activity. The proportion of day cases rose from 35% to 53% over the period. Those procedures for which targets were set (over 25% of elective surgery) had a slightly lower day case proportion in 1990/1991 (34% compared to 36%) but slightly higher by 1994/1995 (57% compared to 52%). GP fundholders generally had slightly lower proportions treated as day cases compared to health authorities.

Conclusions:

Day cases were additional to, rather than a substitute for, inpatient treatments. Setting day case targets may have been associated with growth in use of day surgery, but there was no association with type of purchaser.
Variations in Use of Cardiac Services in England: Perceptions of General Practitioners, General Physicians and Cardiologists
Authors: Chapple Alison , Gatrell Anthony
Published: January 2017

Objective:

To explain why those who live some distance from tertiary cardiac centres make less use of coronary angiography and revascularisation than those who live close by, and why people living in particular wards within certain districts make less use of services than might be expected from their level of need.

Method:

Semi-structured interviews with 24 general practitioners (GPs) in two English health districts (Morecambe Bay and East Lancashire), five general physicians working in district general hospitals, and four interventional cardiologists working in tertiary centres. Transcripts of audiotape recordings were analysed using the constant comparative method.

Results:

Those living far from tertiary centres are usually referred to general physicians before they are referred for angiography. The general physicians tend to be more conservative in their approach to treatment than interventional cardiologists. GPs working near tertiary centres are able to refer directly to interventional cardiologists. There are also logistical and economic reasons for inequitable use of services. Some GPs perceived that patients of South Asian descent undergo fewer investigations than might be expected because of communication or other difficulties.

Conclusion:

Use of cardiac services would be more equitable if there were interventional cardiologists based in district general hospitals who could perform angiograms for their own patients in the tertiary centres. Patients might also benefit if angiograms could be conducted in selected district general hospitals. Further qualitative research, involving both doctors and patients, is needed to explore other reasons for relatively low rates of investigation and revascularisation in certain groups of patients.
The Distribution of Health Care Costs and Their Statistical Analysis for Economic Evaluation
Authors: Briggs Andrew , Gray Alastair
Published: January 2017

Objective:

Where patient level data are available on health care costs, it is natural to use statistical analysis to describe the differences in cost between alternative treatments. Health care costs are, however, commonly considered to be skewed, which could present problems for standard statistical tests. This review examines how authors report the distributional form of health care cost data and how they have analysed their results.

Method:

A review of cost-effectiveness studies that collected patient-level data on health care costs. To supplement the review, five datasets on health care costs are examined. Consideration is given to the use of parametric methods on the transformed scale and to non-parametric methods of analysing skewed cost data.

Results:

Since economic analysis requires estimation in monetary units, the usefulness of transformation-based methods is limited by the inability to retransform cost differences to the original scale. Non-parametric rank sum methods were also found to be of limited use for economic analysis, partly due to the focus on hypothesis testing rather than estimation. Overall, the non-parametric approach of bootstrapping was found to offer a useful test of the appropriateness of parametric assumptions and an alternative method of estimation where those assumptions were found not to hold.

Conclusions:

Guidelines for the analysis of skewed health care cost data are offered.
Can Community Leaders' Preferences be Used to Proxy Those of the Community as a Whole?
Authors: Onwujekwe Obinna , Shu Elvis , Okonkwo Paul
Published: January 2017

Background:

Community-based distribution of ivermectin and other drugs requires people in the endemic communities who are capable of distributing the drug. It is essential also to collect information on local people's views concerning different financing mechanisms and approaches to distributing ivermectin. However, studies at household level are resource-intensive. Eliciting the preferences of the community by interviewing a smaller number of community leaders offers an alternative strategy.

Methods:

A comparison of information from community leaders and household heads on the financing and distribution of ivermectin through communities was conducted in three communities in Nigeria to determine whether rapidly collected information from key community leaders could represent broad community preferences.

Results:

The preferences of community leaders and household heads were comparable in relation to the method of collecting payments, managing payments and making payments, who should set the level of payments and the drug distribution mechanisms. However, there were differences between community leaders' views and those of heads of households concerning how the scheme should be supervised.

Conclusions:

This study has shown that community leaders' views can only be used as a partial substitute for more laborious methods of data collection insofar as they have the attraction of being quicker and less costly to use. However, they should not be assumed to be identical with the views of the community as a whole.
Dancing Practices
Authors: Ravn Susanne
Published: January 2017

This article aims to explore the relation between body and space – specifically how the relation between the embodied awareness of movement and the sense of one’s body-space can be modified and changed deliberately in different kinds of dance practices. Using a multi-sited design, the ethnographical fieldwork, which formed the empirical ground for the study, was from the outset focused on acknowledging the diversity of the dancers’ practices. Each in their own way, the 13 professional dancers involved in the study relate to and experience bodied potentialities, body-space and the spatiality of movement differently. Through their practice, they indicate that the body image is shaped through a multisensorial process of reification, and that seeing is to be related to a broader perceptual engagement. Furthermore, they exemplify how seeing can be deliberately used to expand the sense of their body-space and thereby to affect the spatiality of the fields of their embodied interaction.