bluuebunny/crossref_metadata_2025 huggingface dataset:
Dorsal Modified Calcaneal Plate for Extensive Midfoot Arthrodesis
Authors: Suh Jin-Soo , Amendola Annunziato , Lee Keun-Bae , Wasserman Lisa , Saltzman Charles L.
Published: January 2017

Background: Extensive midfoot fusions can be challenging because of bone loss, deformity, and soft tissue anatomy. Several options have been advocated, including multiple screw fixation, medial plating, and plantar plating. We report a new technique using a dorsally-placed, modified calcaneal plate for treatment of this difficult clinical problem. Methods: Patients undergoing extensive (more than four joints) midfoot arthrodeses with a dorsally-placed, modified calcaneal plate between 2000 and 2003 were retrospectively reviewed. Diagnoses included Charcot arthropathy (four), osteoarthritis (two), posttraumatic osteoarthritis (two), massive bone loss from previous infection (one), and residual clubfoot deformity (one). Patients with active midfoot infections were excluded. During the study period, midfoot arthrodeses with a dorsal calcaneal plate were done in 10 patients. Of these, nine patients were available for review. Arthrodeses were attempted in 62 joints in these nine patients. Autogenous grafting was used in three patients (23 joints), allograft was used in six patients (39 joints). Patients were maintained nonweightbearing until radiographs or computed tomography conclusively showed union. Results: One of the 10 patients died from an unrelated cause. In the nine remaining patents, 95% (59 of 62) of joints fused within 4 months of surgery. Postoperative complications included nonunion with broken screws in one patient, and three wound problems successfully treated with local dressings. Secondary procedures included one revision arthrodesis and two hardware removals. Patient satisfaction with this procedure was very high (eight of nine). Conclusions: The use of a dorsal calcaneal plate is a viable method of fixation for achieving fusion in extensive midfoot arthropathy. The plate is low-profile and easily moldable to conform to dorsal midfoot anatomy. It can be placed without extensive plantar or medial foot dissection and maintains midfoot alignment until bony fusion occurs. In patients with complex midfoot pathology requiring multijoint fusions, the results have been satisfactory.
Pathomechanics of Hallux Valgus: Biomechanical and Immunohistochemical Study
Authors: Uchiyama Eiichi , Kitaoka Harold B. , Luo Zong-Ping , Grande Joseph P. , Kura Hideji , An Kai-Nan
Published: January 2017

Background: One factor believed to contribute to the development of hallux valgus is an abnormality in collagen structure and makeup of the medial collateral ligament (MCL) of the first metatarsophalangeal joint (MTPJ). We hypothesized that the mechanical properties of the MCL in feet with hallux valgus are significantly different from those in normal feet and that these differences may be related to alterations in the type or distribution of collagen fibers at the interface between the MCL and the bone. Materials and Methods: Seven normal fresh-frozen cadaver feet were compared to four cadaver feet that had hallux valgus deformities. The MCL mechanical properties, structure of collagen fibers, and content proportion of type I and type III collagen were determined. Results: The load-deformation and stress-strain curves were curvilinear with three regions: laxity, toe, and linear regions. Laxity of the MCL in feet with hallux valgus was significantly larger than that of normal feet ( p = 0.022). Stiffness and tensile modulus in the toe region in feet with hallux valgus were significantly smaller than those in normal feet ( p = 0.004); however, stiffness and tensile modulus in the linear region were not significantly different. The MCL collagen fibrils in the feet with hallux valgus had a more wavy distribution than the fibrils in the normal feet. Conclusions: In general, strong staining for collagen III and to a lesser extent, collagen I was observed at the interface between the MCL and bone in the feet with hallux valgus but not in the normal feet. These results indicate that the abnormal mechanical properties of the MCL in feet with hallux valgus may be related to differences in the organization of collagen I and collagen III fibrils.
Effect of First Metatarsal Shortening and Dorsiflexion Osteotomies on Forefoot Plantar Pressure in a Cadaver Model
Authors: Jung Hung-Geun , Zaret David I. , Parks Brent G. , Schon Lew C.
Published: January 2017

Background: Metatarsalgia of the second ray is a common problem associated with disorders of the first metatarsal. It also occurs after the operative treatment of those disorders. Plantar pressure changes from alteration of the static and dynamic structure of the forefoot may be associated with this condition. This study evaluated changes in plantar forefoot pressure especially under the second metatarsal head after three operative procedures on the first ray. Methods: Each of 12 cadaver foot specimens was cyclically loaded on the servohydraulic MTS Mini Bionix test frame (MTS Systems Corp., Eden Prairie, MN) with traction on the Achilles tendon. Plantar forefoot pressure was measured by the F-scan system (Tekscan, Inc., S. Boston, MA) with the foot intact, after a first metatarsal base dorsal closing-wedge osteotomy with 5-mm base length to simulate dorsal malunion, and after 5-mm and 10-mm metatarsal shortening procedures. Paired Student t-test analysis was used to compare data for the intact foot with data after each intervention. One form of Bonferroni's correction was done to establish a new alpha level to tighten the analysis and to compensate for multiple paired Student t-tests. The significance level was calculated to be 0.016 based on an original alpha level of 0.05. Results: As compared with the intact foot, all three procedures on the first metatarsal resulted in significant decreases in plantar pressure under the first metatarsal head ( p < 0.016). Plantar pressure under the second metatarsal head increased significantly as compared with the intact foot ( p < 0.016) after all three procedures. Pressures under the third-fourth metatarsal heads increased significantly compared with the intact foot after the 5-mm and 10-mm shortenings ( p < 0.016). Plantar pressure under the fifth metatarsal did not change significantly after any of the three procedures. Conclusions: Dorsiflexion osteotomy and shortening of the first metatarsal are associated with significant forefoot plantar pressure changes in a cadaver model.
Vacuum-Assisted Closure to Aid Wound Healing in Foot and Ankle Surgery
Authors: Mendonca Derick A. , Cosker Tom , Makwana Nilesh K.
Published: January 2017

Background: Although vacuum-assisted closure (VAC) is a well-established technique in other surgical specialties, its use has not been established in the foot and ankle. The aims of this study were to determine if vacuum-assisted closure therapy (VAC) helps assist closure in diabetic foot ulcers and wounds secondary to peripheral vascular disease, if it helps debride wounds, and if it prevents the need for further surgery. Methods: We retrospectively reviewed 15 patients (18 wounds or ulcers) with primary diagnoses of diabetes (10 patients), chronic osteomyelitis (two patients), peripheral vascular disease (two patients), and spina bifida (one patient). Eleven of the 15 patients had serious comorbidities, such as peripheral neuropathy, renal failure, and wound dehiscence. All wounds were surgically debrided before VAC therapy was applied according to the manufacturer's instructions. The main outcome measures were time to satisfactory wound closure, changes in the wound surface area, and the need for further surgery. Results: Satisfactory healing was achieved in 13 of the 18 wounds or ulcers at an average of 2.5 months. VAC therapy failed in five patients (five class III ulcers), three of whom required below-knee amputations. Wound or ulcer size decreased from an average of 7.41 cm 2 before treatment to an average of 1.58 cm 2 after treatment. Conclusion: VAC therapy is a useful adjunct to the standard treatment of chronic wound or ulcers in patients with diabetes or peripheral vascular disease. Its use in foot and ankle surgery leads to a quicker wound closure and, in most patients, avoids the need for further surgery.
An Analysis of Outcome Measures Following the Broström-Gould Procedure for Chronic Lateral Ankle Instability
Authors: Brodsky Adam R. , O'Malley Martin J. , Bohne Walther H. , Deland Jonathan A. , Kennedy John G.
Published: January 2017

Background: The Broström-Gould procedure is a commonly recommended operative treatment for chronic ankle instability. Using standardized physician-based outcome scores, the results of this procedure have been uniformly excellent. Current scoring systems, however, do not adequately evaluate mechanical or functional instability. Therefore, outcome data may suggest greater success than is justified. Methods: A retrospective review was done of 73 patients who had isolated Broström-Gould repairs of the lateral ankle ligaments. The mean time to followup was 64 months. Both the AOFAS ankle-hindfoot score and the Short Form 36 (SF-36) were used to evaluate outcome. Results: The overall American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was 95 of 100 points. Despite that, 17% of patients in the study had functional instability of the ankle that was not reflected in the AOFAS score. The mean physical component score of the SF-36 was 84% and reflected the presence of functional instability. Low correlations were found between the AOFAS ankle-hindfoot score and the SF-36 score. Conclusions: The current study identified a deficiency in the AOFAS score in evaluating functional ankle stability after the Broström-Gould procedure. A more meaningful analysis of outcomes can be expected using the SF-36 score. The data suggest that greater attention must be paid to functional rehabilitation after ankle stabilization surgery to obtain optimal outcome.
Intermetatarsal Angle After First Metatarsophalangeal Joint Arthrodesis for Hallux Valgus
Authors: Cronin John J. , Limbers John P. , Kutty Satish , Stephens Michael M.
Published: January 2017

Background: First metatarsophalangeal (MTP) joint arthrodesis is commonly done for hallux valgus with an arthritic joint. In patients with a wide preoperative first intermetatarsal (IM) angle an important question is whether the metatarsus varus will be corrected by the first MTP joint fusion alone or whether an additional basal osteotomy is necessary. Methods: The charts and radiographs of 20 patients who had arthrodesis of the first MTP joint were retrospectively reviewed. All 20 patients were female with a mean age of 54.2 (range 42 to 78) years. Either a Hallu-S® plate (Integra Life Sciences, Nudeal, France) or two crossed screws were used to stabilize the arthrodesis. The IM angles were measured independently by two individuals on weightbearing preoperative, 6-week postoperative, and final followup films. The final followup radiographs were taken at an average of 13.7 (range 6 to 30) months after surgery. A Student t-test was used to evaluate the changes in the IM angle and interobserver variations. Results: The mean preoperative IM angle was 16.65 (range 12 to 26) degrees. The mean postoperative IM angle was 10.35 (range 6 to 15) degrees. The mean IM angle at final followup was 8.67 (range 5 to 12) degrees. The mean change between preoperative IM angle and IM angle at final followup was 8.22 (range 4 to 14) degrees. This change of the IM angle was statistically significant ( p < 0.0001). Conclusions: These results indicate that in patients with severe hallux valgus and first MTP joint degeneration arthrodesis can significantly correct the IM angle without the addition of a basal osteotomy.
The Epidemiology of Metatarsal Fractures
Authors: Petrisor Brad A. , Ekrol Ingri , Court-Brown Charles
Published: January 2017

Background: Metatarsal fractures are common injuries; however little has been written regarding their epidemiology in an adult population. Methods: All patients with metatarsal fractures during a 1-year time period were included in the study. Demographic information, grade, and mechanism of injury, associated injuries, and fracture location and type were recorded. Results: Three hundred and fifty-five patients with 411 metatarsal fractures were identified. The average age of the patients was 42 years. There was a higher proportion of women in the higher age groups, and the most common fracture was that of the fifth metatarsal. Multiple metatarsal fractures occurred in contiguous metatarsals, and 63% of third metatarsal fractures were associated with a fracture of either the second or fourth metatarsal. Conclusion: Knowledge of the epidemiology and injury patterns of metatarsal fractures can aid in the accurate identification and subsequent treatment of fractures of the metatarsals.
Influence of Foot Characteristics on the Site of Lower Limb Osteoarthritis
Authors: Reilly Kathleen Anne , Barker Karen Louise , Shamley Delva , Sandall Susan
Published: January 2017

Background: Foot structure and range of motion have been linked to lower limb musculoskeletal injuries in sports medicine, 11 , 14 , 41 and recently there have been attempts to establish a connection between the foot and lower limb osteoarthritis (OA). 19 , 13 Considering the fact that OA of the knee and hip are the most important causes of pain and disability in older people, 12 , 25 it is surprising that there has been no research comparing the foot types of those with knee OA and those with hip OA. To evaluate an apparent difference in the feet and gaits of patients with hip OA and medial compartment OA of the knee that was noted during routine clinical assessment, a prospective observation study was undertaken. Methods: The study included patients with OA either of the hip or the medial compartment of the knee and a control group of healthy subjects. There were 60 in each group determined by sample size calculation. The groups were matched for age and gender. Dorsiflexion and plantarflexion of the ankle, calcaneal angle, and navicular height in both sitting and standing were measured. Results were analyzed by ANOVA and linear regression analysis. Results: There were significant differences among all three groups, particularly in ankle dorsiflexion ( p >0.001) and calcaneal angle ( p >0.001). Conclusions: Differences in foot type between patients with OA of hip and knee were confirmed. These two groups also were different from the control group of healthy subjects. The lack of ankle dorsiflexion and high arches of patients with OA of the hip contrasted with the ample dorsiflexion and flatfeet of patients with OA of the knee.
Treatment of Eichenholtz Stage I Charcot Foot Arthropathy with a Weightbearing Total Contact Cast
Authors: Pinzur Michael S. , Lio Tammy , Posner Matthew
Published: January 2017

Background: Initial treatment of Eichenholtz stage I Charcot arthropathy of the foot generally is total contact casting and nonweightbearing. This method, however, often is time-consuming and has a poor result. This study was done to determine the success rate of total contact casting in a small group of patients and to establish a benchmark time period for treatment. Methods: Ten subjects with acute Eichenholtz stage I (stage of development) Charcot foot arthropathy were prospectively treated with weightbearing total contact cast therapy, undergoing biweekly cast changes. One subject did not complete the study. Subjects were monitored with biweekly clinical examination, limb volume measurement, and radiographs. The average age was 58.2 (range 39 to 72) years and weight was 216.9 (range 160 to 275) pounds. Results: All subjects were able to use commercially available depth-inlay shoes and custom accommodative foot orthoses at an average of 9.2 (range 8 to 16) weeks. One subject developed a superficial ulcer that resolved with footwear modification. Conclusion: This preliminary study supports the use of total contact cast therapy and weightbearing in the treatment of acute Charcot foot arthropathy. When the total contact cast was changed every 14 days, all subjects were able to use commercially available depth-inlay shoes and custom orthoses.
Comparison of Plate and Screw Fixation and Screw Fixation Alone in a Comminuted Talar Neck Fracture Model
Authors: Charlson Mark D. , Parks Brent G. , Weber Timothy G. , Guyton Gregory P.
Published: January 2017

Background: Talar neck fracture fixation has been studied in noncomminuted fracture models, but no large clinical series of comminuted fracture patterns have been published and no biomechanical studies have compared plate fixation with screw fixation in comminuted talar neck fractures. Methods: Nine matched pairs of fresh frozen talar specimens were stripped of soft tissue and mounted in a cylindrical jig. The talar neck was fractured using a dorsally directed shear force at a rate of 200 mm/min, and dorsal comminution was simulated by removing a 2-mm section of bone from the distal fracture fragment. One specimen from each pair was fixed with either two solid 4.0-mm partially threaded cancellous screws posterior-to-anterior just lateral to the posterior process of the talus or with a four-hole 2.0-mm minifragment plate contoured to the lateral surface of the talar neck and secured with 2.7-mm screws. A 2.7-mm fully threaded cortical screw was placed medially using a lag technique. The specimens were then loaded to failure with a dorsally directed force at a rate of 200 mm/min. Failure was defined as the load producing 2 mm of displacement. A Student's t-test analysis was used with significance set at p ≤ 0.05. Results: Posterior-to-anterior screw fixation had a statistically significant higher load to failure than plate fixation ( p < 0.05). Mean load to failure for the screw group was 120.7 ± 68.5 N and 89.7 ± 46.6 N for the plating group. Conclusions: Plate fixation may offer substantial advantages in the ability to control the anatomic alignment of comminuted talar neck fractures, but it does not provide any biomechanical advantage compared with axial screw fixation. Further, the fixation strength of both methods was an order of magnitude lower than those found in previous studies of noncomminuted fractures.
Calcaneal Fractures: Indirect Reduction and External Fixation
Authors: McGarvey William C. , Burris Michael W. , Clanton Thomas O. , Melissinos Emmanuel G.
Published: January 2017

Background: The current treatment of displaced intraarticular calcaneal fractures has been surgical fixation. The objective of this study was to evaluate the use of indirect reduction with Ilizarov external fixation as a viable alternative in the surgical treatment of certain calcaneal fractures. Methods: Thirty-one patients with 33 fractures of the calcaneus (Sanders types II, III, and IV) were treated using small wire circular external fixation. A limited percutaneous plantar skin incision was used to improve reduction of the posterior facet. Fractures were evaluated by preoperative CT scans and classified by an independent observer. Patients were evaluated by physical examination as well as by the AOFAS hindfoot score questionnaire. Followup ranged from 6 months to 4 years. Results: The average AOFAS score for 18 patients available for examination was 66 (42 to 92). The average score increased to 74 for patients with more than 10 months followup and to 77 for patients with isolated calcaneal fractures. Open fractures also had early debridement and soft-tissue coverage; no deep infections were seen in this subgroup. There were 11 complications, including nine superficial pin track infections, one superficial skin necrosis under an area of fracture blister, and one deep infection in a diabetic smoker with severe hemorrhagic fracture blisters. All superficial infections responded to local pin or wound care and oral antibiotics. No secondary reconstructive procedures, including osteotomies, subtalar fusions, or amputations, have been done. All open fractures healed and maintained soft-tissue coverage. Conclusions: Indirect reduction and external fixation is a viable surgical alternative for intraarticular calcaneal fractures. Particularly favorable results were obtained in open fractures when soft-tissue reconstruction also was done. Advantages include shorter time to surgery, immediate weightbearing, minimal invasiveness, few serious wound problems, and no residual hardware. Disadvantages include technical difficulty, incomplete reduction of fracture fragments, and the need for secondary surgery (fixator removal).
The Influence of First Ray Mobility on Forefoot Plantar Pressure and Hindfoot Kinematics During Walking
Authors: Cornwall Mark W. , McPoil Thomas G. , Fishco William D. , O'Donnell Deborah , Hunt Lea , Lane Camilla
Published: January 2017

Background: Hypomobility and hypermobility of the first ray have been implicated in the literature as a primary cause of mechanical foot problems because of proposed obligatory and compensatory movements. Despite these theoretical links, research is sparse regarding the effect on kinematic and plantar pressure patterns as a result of altered first ray mobility. The purpose of this study was to determine whether hypomobility or hypermobility of the first ray alters hindfoot kinematics or the distribution of plantar pressures during walking. Methods: The magnitude of dorsal first ray mobility in 82 individuals was measured and then classified as being hypomobile, normal, or hypermobile. The plantar pressure under the first and second metatarsal heads, as well as hindfoot kinematics during walking, were then compared between the three categories of first ray mobility. Results: The results of this study indicate that those feet with a hypomobile first ray had significantly decreased plantar force and pressure values under the first metatarsal compared to the second metatarsal. In addition, feet with a hypomobile first ray showed significantly more hindfoot eversion compared to those with either normal or hypermobile first rays. Conclusion: The results of this study do not support the common theoretical implications of altered mobility of the first ray related to plantar pressure and hindfoot kinematics.
Foot Orthoses for the Treatment of Plantar Fasciitis
Authors: Roos Ewa , Engström Mikael , Söderberg Bengt
Published: January 2017

Background: The literature suggests mechanical interventions such as foot orthoses and night splints are effective in reducing pain from plantar fasciitis. There is, however, a lack of controlled trials. We studied the effects of foot orthoses and night splints, alone or combined, in a prospective, randomized trial with 1-year followup. Methods: Forty-three patients (34 women and nine men with a mean age of 46 years) with plantar fasciitis were randomized to receive foot orthoses ( n = 13), foot orthoses and night splints ( n = 15), or night splints alone ( n = 15). Data were available for 34 (79%) patients after treatment (12 weeks), and for 38 (88%) at 1-year followup. Pain, functional limitations, and quality of life were evaluated with the Foot and Ankle Outcome Score. Results: All groups improved significantly in all outcomes evaluated across all times ( p < 0.04). At 12 weeks, pain reduction of 30% to 50% compared to baseline were seen ( p < 0.03). At 52 weeks, pain reduction of 62% was seen in the two groups using foot orthoses compared to 48% in the night splint only group ( p < 0.01). Better compliance and fewer side effects were reported for orthosis use. At 12 months, 19 of 23 patients reported still using foot orthoses compared to 1 of 28 still using the night splint. Conclusions: Foot orthoses and anterior night splints were effective both short-term and long-term in treating pain from plantar fasciitis. Parallel improvements in function, foot-related quality of life, and a better compliance suggest that a foot orthosis is the best choice for initial treatment plantar fasciitis.
Revisiting the Concept of Talar Shift in Ankle Fractures
Authors: Lloyd John , Elsayed Sherief , Hariharan Kartik , Tanaka Hiro
Published: January 2017

Background: In 1976, Ramsey and Hamilton published a classic experiment investigating the biomechanical effects of talar shift in a simple ankle fracture model. Their finding was that 1 mm of talar shift resulted in a 42% decrease in tibiotalar contact surface area. Based on this conclusion, 1 mm of talar shift became the recognized indication for operative fixation. Methods: Twelve cadaver ankles were dissected and the distal tibia coated with carbon powder. A 70-kg load was applied to the distal tibia that resulted in transference of the carbon onto the talus. The contact surface area was determined at 0, 1, 2, 4 and 6 mm of talar shift using spacers fixed in the medial gutter. Tracing paper was used to mark the outline of the contact area and measured using graph paper. Results: Our results were similar to Ramsey and Hamilton's original experiment. One millimeter of lateral talar shift resulted in 40% loss of contact surface area compared with 42% in the original experiment. A large variance was seen in talar contact surface area depending on the morphology of the ankle joint. Conclusion: Ramsey and Hamilton's original experiment was valid.
Biomechanical Evaluation of Primary Stiffness of Tibiotalar Arthrodesis with an Intramedullary Compression Nail and Four Other Fixation Devices
Authors: Mueckley Thomas Martin , Eichorn Stefan , Oldenburg Geert von , Speitling Andreas , DiCicco Joseph D. , Hofmann Gunther O. , Bühren Volker
Published: January 2017

Background: Many techniques of tibiotalar arthrodesis have been described. Screw fixation is widely used. At our center, intramedullary compression nailing has been successfully used for over 10 years. The question to be answered by this study was whether tibiotalar arthrodesis with a compressed intramedullary nail was superior, in terms of primary stiffness and fusion-site compression, to selected other techniques. Methods: Plane fusion surfaces were machined in third-generation synthetic composite tibiae and the bodies of anatomically correct tali; fixation was with a compressed external fixator (cEF), an uncompressed interlocking nail (uIN), a compressed interlocking nail (cIN), and two different three-screw techniques (ST1 and ST2); three specimens per construct were tested. The compressed contact surface of each construct was measured with pressure-sensitive film and expressed as a percent of the available fusion-site area. Construct stiffness was tested in dorsiflexion/plantar flexion (D/P), varus/valgus (V/V), and internal rotation/external rotation (I/E), analyzing 20 cycles per loading mode. Results: Compressed surface area: cIN 80% ± 10.7; cEF 60% ± 8.6; ST2 59% ± 4.4; ST1 55% ± 6.1; uIN no discernible compression. The greatest primary stiffness in D/P was obtained with the cIN ( p < 0.001), followed by ST1. In V/V, ST1 and the cIN had the greatest primary stiffness; the two techniques did not differ significantly. Stabilization with the cEF was significantly better ( p < 0.001) than with ST2. In I/E, the cIN produced the greatest primary stiffness ( p < 0.001), followed by the two screw techniques, which did not differ significantly between themselves. The uIN had the least primary stiffness in all directions tested. Conclusions: In this biomechanical study, the cIN and ST1 were superior, in terms of primary stiffness in tibiotalar arthrodesis, to the other techniques tested. In D/P and I/E, the cIN construct was signficantly stiffer than the ST1 construct, whose I/E rigidity might, however, be enhanced by a fourth, horizontal screw. Clinical Relevance: Intramedullary compression nailing offers stable tibiotalar arthrodesis fixation with a large bony contact area and may enhance the likelihood of successful tibiotalar arthrodesis.
The Effects of Amlodipine on Left Ventricular Mass and Diastolic Function in Concentric and Eccentric Left Ventricular Hypertrophy
Authors: Fak Ali Serdar , Okucu Metin , Tezcan Hakan , Bodur Gökhan , Oktay Ahmet
Published: January 2017

Background: The effects of the antihypertensive therapy with amlodipine (5-10 mg/day) on left ventricular mass and diastolic function were examined in 30 mild to moderate essential hypertensive patients who have left ventricular hypertrophy (LVH) and diastolic dysfunction.

Methods and Results: Each patient's left ventricular mass was measured, and left ventricular diastolic function was assessed by echocardiographic Doppler examination at entry, and at 3 and 6 months after the initiation of the treatment. Amlodipine reduced both blood pressure (from 164 ± 14/10 ± 6 mmHg to 134 ± 9/83 ± 4 mmHg) and left ventricular mass index (from 160 ± 30 g/m2 to 137 ± 26 g/m2) significantly at 3 months and both parameters maintained at these levels for 6 months. When the patients were classified according to the type of the LVH. a significant regression in left ventricular mass index was seen only in the patients who had concentric LVH with a relative wall thickness ≥ 0.44 (n = 16), but not in the eccentric LVH group (n = 14), although both groups were not significantly different from each other regarding the basal hemodynamic parameters. baseline left ventricular mass index and the decrease in blood pressure in response to amlodipine treatment. The mitral inflow E/A ratio did not show any significant change in either group.

Conclusions: Across the three chronic heart disease risk strata, lovastatin appears to be significantly more potent than fluvastatin, on a per milligram basis, in lowering cholesterol levels.
Influence of ACE Inhibition on Fluid Metabolism in Chronic Heart Failure and Its Pathophysiologic Relevance
Authors: Agostoni Piergiuseppe , Marenzi Giancarlo , Guazzi Marco , Guazzi Maurizio D.
Published: January 2017

Background: In congestive heart failure with water retention. subtraction of body fluid by ultrafiltration causes greater diuresis and clinical improvement in patients who are angiotensin-converting enzyme (ACE)-inhibited. suggesting an influence of ACE inhibitors on fluid metabolism.

Methods and Results: Patients with moderate congestive heart failure were subjected to ultrafiltration (around 2000 mL) and followed up for 3 months. Usual outpatient therapy, consisting of digoxin, furosemide. and ACE inhibitors (18 patients, group A) and of digoxin and furosemide only (18 patients, group B), was continued throughout the trial. Hemodynamics, renal function, body fluid and electrolytes. plasma norepinephrine, renin activity, aldosterone. and plasma volume were monitored. At 30 and 90 days after ultnfiltration. hormones, renal function, functional capacity (based on cardiopulmonary tests), and extravascular lung water (chest radiograph score) were determined. Soon after ultrafiltration. body weight. plasma volume, and diuresis were reduced (hypovolemia) and hormones were raised (reaction to hypovolemia). In the next 4 days. all these variables reverted to the pre-ultrafiltration values in group B; in group A diuresis and plasma volume recovered, body weight was still reduced, and hormones became lower than baseline. These changes persisted in the next 3 months. An early reduction of extravascular lung water continued long term in group A only, associated with increase of exercise tolerance time and oxygen uptake and decrease of the dead space/tidal volume ratio.

Conclusions: In congestive heart failure. ACE inhibition persistently prevented fluid accumulation once the excess of body fluid had been withdrawn with a nonpharmacologic method, resulting in sustained improvement in functional capacity. Reduction in circulating norepinephrine, aldosterone. and renin did not seem to be the cause but the consequence of this action, whose mechanisms remain undefined.
Controlling Paroxysmal Atrial Fibrillation by a Combination of Amiodarone and Flecainide: Description of a Case With 15-Year Follow-up
Authors: Altamirano Jaime , Gallik Donna M. , Singh Bramah N.
Published: January 2017

A 77-year-old man with no known cardiac disease has had paroxysmal atrial fibrillation for 35 years with disabling symptoms and poor exercise tolerance when not in sinus rhythm, and he did not respond to conventional therapy. Fifteen years ago he was placed on amiodarone. His arrhythmia converted to atrial flutter with a flutter rate below 200 beats/min; DC cardioversion at 3 months led to transient sinus rhythm. At 5 months he converted spontaneously to sinus rhythm and had very few recurrences until 4 years later when he began to experience further frequent recurrences when the dose was reduced from 400 mg/day to 200 mg/day. Redosing at the higher dose led to skin discoloration; amiodarone was then replaced with sotalol, which the patient did not tolerate. After 9 months with efforts to rate control with various agents, amiodarone was reintroduced at 400 mg/day. which achieved full control, but to obviate the development of skin changes, flecainide was added at a dose of 100 mg twice a day, and the dose of amiodarone was gradually reduced to 200 mg/day. This combination regimen has produced no side effects or organ toxicity, although a degree of hypogonadism developed. It responded well to testosterone replacement. On the combination regimen, there have been no symptomatic arrhythmia recurrences over 8 years. Amiodarone and flecainide may have additive or synergistic effects in maintaining sinus rhythm in atrial fibrillation; the antiarrhythmic property of amiodarone is likely to minimize or nullify the proarryhthmic reactions of flecainide during combination therapy. This combination regimen may allow the extension of the use of flecainide in controlling refractory atrial flutter and fibrillation in patients with structural cardiac disease. The efficacy and safety of the combination regimen of the two drugs should be addressed in controlled clinical trials.
Developing a Critical Incident Stress Debriefing Team in a Mental Health Care System
Authors: Weizant Victor , Torpey Rosanne , Sienkilewski Kay L.
Published: January 2017

It is recognized that employees within a mental health care system may have an increased exposure to stressors of a traumatic nature. This article describes the development and implementation of a Critical Incident Stress Debriefing Team, using the model formulated by Dr. Jeffrey Mitchell and summarizes the team's activity during the first year of its implementation.
The Implementation of Advanced Practice Psychiatric Nurse Prescribers: A Comprehensive Model
Authors: Bailey Katharine P. , Snyder Marie E.
Published: January 2017

In psychiatry the use of advanced practice psychiatric nurse (APPN) prescribers addresses the growing need for expert, cost-effective psychopharmacotherapy in outpatient settings. Prescribing nurses, collaborating psychiatrists, and administrators must develop interdisciplinary practice arrangements that comply with current statutory regulations and ensure adequate standards of patient care. This article describes a comprehensive modelfor the implementation of APPNs as providers of psychopharmacotherapy. It addresses the logistics and issues relating to quality-assured, cost-effective, patient-centered psychopharmacotherapy and can be used in any jurisdiction with minor modifications dictated by individual state regulations.
The Investigation of Behavioral Contracting in Patients with Borderline Personality Disorder
Authors: Dyckoff Debra , Goldstein Lenore , Schacht-Levine Lisa
Published: January 2017

In this article the authors discuss the patient with borderline personality disorder, milieu issues, and an alternative therapeutic approach: a contingency contract developed to manage self-mutilating behavior in a cost-effective manner. This contract was created as a quality improvement project on a locked unit to decrease self-destructive behavior in the patient with borderline personality disorder. The goal was to assist patients in developing more adaptive coping mechanisms, resulting in decreased self-destructive behaviors. Since implementation in February 1992, there has been an 84% decrease in self-destructive behavior in patients with borderline personality disorder in the population.
Application of Nursing Theories in Health Education
Authors: Jewell Jacklynn A. , Sullivan Elizabeth A.
Published: January 2017

Health education has long been recognized as an important function of nursing practice. The use of nursing theories with health education groups has been less well explored. At this time there has been an increasing emphasis on basing nursing practice on nursing theory. The authors applied the theories of Hildegard Peplau and Dorothea Orem to two different health education groups to illustrate utility of these two theories to guide nursing practice.
Multiphasic Short-term Therapy for Dissociative Identity Disorder
Authors: Applegate Maureen
Published: January 2017

With increasing emphasis on cost-consciousness in health care, clinicians must treat persons with complicated mental health needs with sound rationale while accomplishing cost effectiveness. This article redefines successful outcomes for outpatient treatmentfor one such complex situation with persons with dissociative identity disorder. A case study is presented illustrating how traditional long-term therapy can be defined in renewable short-term stages. At various therapeutic intervals therapy may be discontinued or deferred based on the client's definition ofpersonal wellness. Such a conceptualization can facilitate client health while demonstrating accountability for the use of ongoing psychotherapy services.
Physical Diagnoses for Advanced Psychiatric Nurse Practitioners: Part IAssessment andi Differential Diagnosis
Authors: Talley Sandra
Published: January 2017

Knowledge ofjhealthprobiems tbat commonly exist in tbepsycbiatricpatientpopulation has become an integral part ofpsychiatric nursing practice. The purposes of this article are to organize categories of health assessment and physical examination that are most useful to the psychiatric nurse and to provide aframeworkfor assessment of dierential diagnosis of common neuropsychiatric disorders and coexisting health probems. Hypothesis generation and care planning can be enriched by attention to physical care problems that affect the provision of care for clients.
Examining the Wounded Healer Archetype: A Case Study in Expert Addictions Nursing Practice
Authors: Conti-O'Hare Marion
Published: January 2017

This article examines the archetype of the wounded healer as manifested in the practice of expert addiction nurses. A previous study of therapeutic use of self with addicted clients in early recovery is expanded with the use of a case study approach. Two clinical scenarios of one expert addictions nurse illustrate how the nurse's own health pattern can include the wounded healer archetype and how the recognition of this pattern can be used to effect therapeutic outcomes in practice. Analysis of the scenarios provides the basis for discussion of this aspect of the expert nurse's mutual health patterning with the client. The case study provides a qualitative analysis of therapeutic and less therapeutic nurse-client relationships with the wounded healer archetype used as a framework Nurses at all levels of proficiency can benefit by applying these concepts to their work with addicted clients.
Pathway to Dry Skin Prevention and Treatment
Authors: Guenther Lyn , Lynde Chuck W. , Andriessen Anneke , Barankin Benjamin , Goldstein Eric , Skotnicki Sandra P. , Gupta Samir N. , Choi Kenneth Lee , Rosen Nathan , Shapiro Lori , Sloan Kevin
Published: January 2017

Background:

This article presents an evidence-supported clinical pathway for dry skin prevention and treatment.

Objective:

The development of the pathway involved the following: a literature review was conducted and demonstrated that literature on dry skin is scarce. To compensate for the gap in the available literature, a modified Delphi method was used to collect information on prevention and treatment practice through a panel, which included 10 selected dermatologists who currently provide medical care for dermatology patients in Ontario. An advisor experienced in this therapeutic area guided the process, including a central meeting. Panel members completed a questionnaire regarding their individual practice in caring for these patients and responded to questions on assessment of dry skin etiology, frequency of skin care visits for consultation and follow-up, assessment, and referral to other specialties. The panel members reviewed a summary of all responses and reached a consensus. The result was presented as a clinical pathway.

Conclusion:

The panel concluded that our current awareness of dry skin and therefore prevention and effective treatment is limited; that identifying dry skin and its clinical issues requires tools such as clinical pathways, which may improve patient outcomes; and that additional research on dry skin etiology, prevention, and treatment is necessary.
An Economic Evaluation Comparing Two Schedules of Antenatal Visits
Authors: Henderson Jane , Roberts Tracy , Sikorski Jim , Wilson Jennifer , Clement Sarah
Published: January 2017

Objectives:

To conduct an economic evaluation comparing a traditional antenatal visiting schedule (traditional care) with a reduced schedule of visits (new style care) for women at low risk of complications.

Methods:

Economic evaluation using the results of a randomised controlled trial, the Antenatal Care Project. This took place between 1993 and 1994 in antenatal clinics in South East London and involved 2794 women at low risk of complications.

Results:

The estimated baseline costs to the UK National Health Service (NHS) for the traditional schedule were £544 per woman, of which £251 occurred antenatally, with a range of £327–1203 per woman. The estimated baseline costs to the NHS for the reduced visit schedule was £563 per woman, of which £225 occurred antenatally, with a range of £274–1741 per woman. Savings from new style care that arose antenatally were offset by the greater numbers of babies in this group who required special or intensive care. Sensitivity analyses based on possible variations in unit costs and resource use and modelled postnatal stay showed considerable variation and substantial overlap in costs.

Conclusions:

Patterns of antenatal care involving fewer routine visits for women at low risk of complications are unlikely to result in savings to the Health Service. In addition, women who had the reduced schedule of care reported greater dissatisfaction with their care and poorer psychosocial outcomes which argues against reducing numbers of antenatal visits.
A Fair Approach to Discounting Future Effects: Taking a Societal Perspective
Authors: Brouwer Werner , van Hout Ben , Rutten Frans
Published: January 2017

It is usually recommended that future costs and health effects are discounted at the same rate, usually 5%. In this paper it is argued that, from a societal perspective, this approach may be inappropriate for health effects. Instead of basing the discount rate for health effects on that for costs, it should be based on the real change in the (societal) valuation of health effects over time. Such valuation may change because of increasing life-expectancy and diminishing marginal utility of additional health effects over time.
Do Physician Practice Styles Persist over Time? Continuities in Patterns of Clinical Decision-Making among General Practitioners
Authors: Davis Peter , Gribben Barry , Scott Alastair , Lay-Yee Roy
Published: January 2017

Objectives:

This study seeks to determine whether there are identifiable differences in patterns of clinical decision-making among family physicians, and whether these patterns persist over time.

Methods:

A representative cross-sectional survey of general practice encounters in the Waikato region of New Zealand in 1979–1980 was repeated in 1991–1992. Patterns of clinical decision-making were operationalised as practitioner rates for writing a prescription, ordering a laboratory test or radiological examination and the recommendation of a future follow-up office visit at a specified date. Comparable data were available for a cohort of 50 physicians in both surveys. Multi-level techniques and a simulation exercise were used to study the patterns of decision-making over time.

Results:

Raw, unadjusted correlations for the 50 family physicians between the two surveys were 0.24, 0.14 and 0.55 for rates of prescribing, investigations and follow-up, respectively. However, these correlations increased substantially, to 0.55, 0.41 and 0.70, once account was taken of case mix, data clustering and inter-practitioner variation in patient sample size. The extent of this recovery of the underlying correlations was confirmed in a parallel simulation exercise.

Conclusions:

This study confirms the existence of substantial and durable individual practice styles in primary medical care, with implications for the development and successful implementation of clinical guidelines.
Cross-Border Issues in the Provision of Health Services: Are We Moving towards a European Health Care Policy?
Authors: Kanavos Panos , McKee Martin
Published: January 2017

This paper analyses likely implications of two recent European Court rulings on the provision of health care across borders within the European Union. We argue that the two cases have fundamental implications for the provision of health services as free access to care across borders conflicts with the principle of subsidiarity. We then explore the potential short-and long-term implications of the two cases for all involved in the provision of health services, namely patients, different types of purchasers and different types of providers. We argue that the short-term implications relating to freedom to provide goods and services may lead to re-thinking how services are financed and provided. At the same time, the rulings may lead to greater transparency in health services, with attempts to compare efficiency and prices between providers in different countries. Consumers may benefit directly by gaining access to a product or service that is not available in their country of residence or is available but at a higher cost or lower quality. They may also benefit indirectly in the long term, through greater transparency and efficiency.