bluuebunny/crossref_metadata_2025 huggingface dataset:
Staged Reconstruction for Chronic Rupture of Both Peroneal Tendons Using Hunter Rod and Flexor Hallucis Longus Tendon Transfer: A Long-Term Followup Study
Authors: Wapner Keith L. , Taras John S. , Lin Sheldon S. , Chao Wen
Published: January 2017

Background: Long-term followup (over 5 years) of staged reconstruction for chronic ruptures of both peroneal tendons using a Hunter rod and the flexor hallucis longus (FHL) tendon is presented. Methods: Seven patients with chronic ruptures of both peroneal tendons who had at least two previous surgeries that failed were treated with excision of the remaining portion of the peroneal tendons and implantation of a Hunter rod to the insertion of the peroneus brevis. Patients performed passive range of motion exercises for 3 months before removal of the Hunter rod and transfer of the FHL into the newly formed sheath, attaching it to the insertion of the peroneus brevis on the fifth metatarsal. The patients' ages ranged from 30 to 57 (average 38) years. All were women. All had at least two previous failed procedures (range two to six). The average time from initial injury to the index surgery was 4.6 (range 2 to 7) years. Patients were evaluated by physical examination and a questionnaire. The average range of followup was 8.5 years (range 143 to 167 months). Results: All wounds healed without complications. One patient (a workers' compensation patient) had continued complaints of pain and ambulated with a molded ankle-foot orthosis (MAFO). The remaining six patients reported complete relief of symptoms and returned to full preinjury levels of activity. One patient required a Broström ankle ligament repair 2 years after tendon transfer for a new injury but has remained pain free for the last 62 months. There were five excellent, one good, and one fair result. All patients stated they would repeat the surgery. Conclusion: Staged reconstruction with excision of the remaining portion of the peroneal tendons and reconstruction with a Hunter rod and FHL transfer has been shown to be an effective long-term treatment for chronic peroneal tendon ruptures.
Necrotizing Soft-Tissue Infection of a Limb: Clinical Presentation and Factors Related to Mortality
Authors: Ozalay Metin , Ozkoc Gurkan , Akpinar Sercan , Hersekli Murat Ali , Tandogan Reha N.
Published: January 2017

Background: Necrotizing fasciitis is a rare and often fatal soft-tissue infection. Prompt diagnosis and immediate aggressive surgical debridement of all compromised tissues are critical to reducing morbidity and mortality in these rapidly progressive infections. The purpose of this study was to analyze the clinical presentation and evaluate factors that determine mortality associated with this uncommon surgical emergency. Methods: The study retrospectively investigated the medical records of 22 patients who were diagnosed and treated for necrotizing fasciitis of the lower extremity, 14 of whom had involvement of the foot (nine patients) or foot and ankle (five patients) at our hospital. The data collected for each of the 22 patients were age, sex, underlying systemic factors, location of infection, duration of symptoms, portal of entry of infection, initial diagnosis on admission, physical, radiographic and laboratory findings, microbiological cultures, the type of therapy used (debridement or amputation), treatment outcome, and number of days in the hospital. Results: A total of 23 extremities of 22 consecutive patients with necrotizing fasciitis who underwent surgical debridement or amputation were retrospectively reviewed. Radical surgical debridement was done in 16 extremities initially, and this treatment was repeated a mean of two times (range one to four debridements) to completely remove all the necrotic tissue. Nine patients (41%) required below-knee or above-knee amputation. There were three deaths, one related directly to sepsis and organ failure, one due to gastrointestinal hemorrhage, and one caused by pulmonary embolism. There were no significant differences between patients who had the amputations and those who did not with respect to mortality rate or age ( p = 0.538 and p = 0.493, respectively). Those who died were significantly older than the survivors ( p = 0.038). Conclusions: The diagnosis of necrotizing fasciitis should be considered for any individual who has unexplained limb pain, especially if that person has diabetes mellitus or chronic liver disease. There was no difference in mortality rates between patients with or without amputation. The primary treatment is early and aggressive debridement of involved skin, subcutaneous fat, and fascia.
Evaluation of Hindfoot Dimensions: A Radiological Study
Authors: Magerkurth Olaf , Knupp Markus , Ledermann Hanspeter , Hintermann Beat
Published: January 2017

Background: Realignment of the foot and good ligament balancing are mandatory for successful reconstruction of complex hindfoot disorders. This is why references for restoration of the normal anatomy and function are necessary when considering surgical reconstruction, such as osteotomies, arthrodeses, and total ankle replacement. However, no data are available regarding the normal anatomical dimensions on standard radiographs of the hindfoot. The purpose of this radiographic study was to define relevant and reproducible measures on lateral hindfoot radiographs and to assess their reliability. Methods: Lateral radigraphic views were taken of 100 consecutive patients (37 women, 63 men) who consulted the emergency room for foot trauma. Dimensions assessed were the talar coverage by the tibia, the angle of the distal tibial joint plane to the tibial axis (tilt), the width of the tibia, the height of the talus, the joint radius of the ankle joint, and the offset of the center of rotation from the tibial axis. Results: The tibial coverage of the talus was 88.1 (SD = 6.7) degrees, the tibial tilt was 83 (SD = 3.6) degrees, the width of the distal tibia was 33.6 mm (SD = 3.6 mm), the radius of the ankle joint was 18.6 mm (SD = 2.3 mm) with an anterior offset of the center of rotation of 1.7 mm (SD = 2.1 mm), and the height of the talus was 28.2 mm (SD = 4.0 mm). Conclusions: Several easily accessible measures on radiographs were found to be reliable in describing normal hindfoot anatomy and therefore may be used to evaluate hindfoot disorders. Additionally, because any reconstruction of the hindfoot should aim to correct the feet in a physiological way, these references may be helpful in the preoperative planning for treatment of complex deformities and posttraumatic disorders.
Vascular Density of the Posterior Tibial Tendon: A Cadaver Study
Authors: Prado Marcelo Pires , de Carvalho Antonio Egydio , Rodrigues Consuelo Junqueira , Fernandes Túlio Diniz , Mendes Alberto Abussamra Morreira , Salomao Osny
Published: January 2017

Background: Degenerative pathology of the posterior tibial tendon, a common cause of foot and ankle dysfunction, frequently affects women over 40 years of age. Its etiology is still controversial. The literature reports decreased vascularization coinciding with the most common site of the lesion, near the medial malleolus. Methods: Forty pairs of PTT obtained from human cadavers were transversally cut into six levels, from the musculotendon transition to its insertion point. In each segment, a histologic cut was made and stained with Masson's trichrome allowing viewing of the vascular structure of the tendon under a light microscope. By using an integrating eyepiece on the microscope, vascular density was calculated. This verified any variation of the vascular concentration in the normal tendon, a possible cause of its degeneration. Results: When the results were compared by side, sex, and age, no statistically significant difference was observed. When the levels were compared, no area of decreased vascularization was seen in the midportion of the tendons, the most common site of degeneration of the posterior tibial tendon. Conclusion: These results indicate that an area of decreased vascularity is not a factor in degeneration of the posterior tibial tendon at the medial malleolus.
Ankle Arthrodesis Using Ilizarov Ring Fixators: A Review of 22 Cases
Authors: Hamed Salem Khaled , Kinzl Lothar , Schmelz Andreas
Published: January 2017

Background: Orthopaedic surgeons are being increasingly confronted with complex ankle problems that cannot be reliably treated by conventional arthrodesis procedures. The Ilizarov technique can be an alternative salvage method in such cases. Methods: Twenty-two Ilizarov tibiotalar arthrodeses were retrospectively reviewed. There were 16 men and six women (mean age 49 years). The underlying pathology was infection after internal fixation of ankle or plafond fractures in 16 patients, posttraumatic ankle arthritis in five, and septic arthritis after an infected Achilles tendon repair in one. Five patients had at least one failed previous arthrodesis. Primary iliac crest bone grafting was done in two patients. Proximal tibial lengthening was done in six patients. Results: Twenty-one patients were followed for an average of 29 months. A solid fusion was achieved in all patients by the end of treatment. The external fixation time averaged 27.7 (range 12 to 84) weeks. The mean time spent in a foot frame was 22.3 weeks. Complications occurred in 11 patients, including two nonunions that healed after revision and renewed frame application and four pin track infections. Conclusions: The use of the Ilizarov frame provides a successful salvage method that offers solid bony fusion, optimal leg length, and eradication of infection in complex ankle pathology or failed previous arthrodesis.
Oral Antimicrobial Therapy for Diabetic Foot Osteomyelitis
Authors: Embil John M. , Rose Greg , Trepman Elly , Math Mary Cheang M. , Duerksen Frank , Simonsen J. Neil , Nicolle Lindsay E.
Published: January 2017

Background: Osteomyelitis in the foot of a diabetic individual is a common complication of peripheral neuropathy, peripheral vascular disease, and infection. Operative facilities and home intravenous antibiotic therapy programs may not be available in remote or rural communities. Limited data are available regarding the treatment results of oral antimicrobial therapy, with or without limited office debridement for diabetic foot osteomyelitis. Methods: This retrospective medical record review of 325 consecutive diabetic patients who were evaluated at a multidisciplinary foot clinic identified 94 (29%) patients with 117 episodes of osteomyelitis. The most common group of organisms isolated were aerobic gram-positive cocci, and the single most frequent organism was Staphylococcus aureus. A mean of 1.6 ± 0.8 (range 1 to 4) pathogens were recovered per episode of osteomyelitis. Therapy was guided by culture results. There were 93 episodes of osteomyelitis (79 patients) that were treated with a mean of 3 ± 1 oral antimicrobial agents (with or without an initial short course of intravenous antimicrobial agents) and had adequate followup to evaluate outcome of treatment; office treatment included bone debridement in 26 (28%) and toe amputation in nine (10%) of the 93 episodes (79 patients). Results: Of the 93 episodes treated with oral antimicrobial agents (with or without an initial short course of intravenous antimicrobial agents), 75 (80.5%) episodes were put into remission. Mean duration of oral antimicrobial therapy was 40 ± 30 weeks. Mean relapse-free followup duration was 50 ± 50 weeks. Conclusions: Diabetic foot osteomyelitis was effectively managed with oral antimicrobial therapy with or without limited office debridement in most patients. This regimen may be especially useful in communities where infectious disease specialists and operative resources are limited.
Ipsilateral Arthrodesis of the Metatarsophalangeal and Interphalangeal Joints of the Hallux
Authors: S. Mizel Mark , Alvarez Richard G. , Fink Brett R. , Temple H. Thomas
Published: January 2017

Background: Arthrodesis of the metatarsophalangeal joint of the hallux is frequently used for treatment of a variety of disorders. However, occasionally patients who have complex deformities or degenerative changes of the hallux require reconstruction of both the metatarsophalangeal and interphalangeal joints. There is concern that arthrodesis of both the metatarsophalangeal and ipsilateral interphalangeal joints could be problematic, interfering with the toe-off phase of gait or with shoewear. Methods: A retrospective evaluation of seven feet in five patients who had simultaneous arthrodesis of the metatarsophalangeal and ipsilateral interphalangeal joints of the hallux was undertaken. These cases represented all the patients who had this procedure within the practice of three orthopaedic foot and ankle specialists, totaling over 50 surgeon-years of experience. The indication for surgery in all patients was moderate to severe pain with ambulation with severe fixed deformity of both the interphalangeal and metatarsophalangeal joints of the hallux. All patients had pain that limited their ambulation and interfered with their daily activities. All patients required modified shoewear to accommodate their foot deformity. The mean age of patients was 53 years. The patients were evaluated by questionnaire and radiographic examination. Results: At an average of 46 months followup, all patients had resolution of their pain and were able to wear nonprescription shoes. All had limitations that interfered with full athletic activities but had no limitation of daily activities. Three patients who were employed returned to their occupations and two who were not employed were able to continue housework. Conclusion: Arthrodesis of the metatarsophalangeal and ipsilateral interphalangeal joints of the hallux results in painless function in patients with moderate demands.
Foot and Ankle Kinematics and Ground Reaction Forces During Ambulation
Authors: Kitaoka Harold B. , Crevoisier Xavier M. , Hansen Diana , Katajarvi Brian , Harbst Kimberly , Kaufman Kenton R.
Published: January 2017

Background: Assessing patients with foot and ankle disorders by observation of gait is dependent on the examiner's experience and cannot provide information about three-dimensional movement, forces, or motion of segments of the foot. Gait analysis models usually consider the foot as a rigid body and study the foot and ankle as a unit. These models are adequate to describe ankle sagittal plane mechanics but are limited in their ability to provide accurate analysis in the other planes or of segments of the foot. They are, therefore, less effective for objective assessment of foot and ankle disorders than multi-segment foot models. Methods: We performed gait analysis using foot-specific analysis methods and evaluated kinematics, ground reaction forces, temporal force factors, and time-related gait factors in 20 normal subjects during level walking. Eleven reflective markers were applied to the foot and leg, and ten cameras and force plates were used. Subjects were tested in athletic shoes. Results: A three-segment model was constructed to determine three-dimensional motion in the sagittal, coronal, and transverse planes. This model enabled the determination of calcaneal-tibial (ankle-hindfoot complex) and metatarsal-calcaneal (midfoot) movement in three planes. Ground reaction forces, temporal force factors, cadence, stance time, swing time, and percentage of stance time were determined. Conclusions: These data provide baseline information for assessment of patients with disorders of the ankle and foot.
Comparison of the Electromechanical Effects of Vesnarinone and Amrinone in Isolated Dog Purkinje Strands and Ventricular Trabeculae
Authors: Lathrop David A. , Náinási Péter P. , Varró András , Schwartz Arnold
Published: January 2017

Background: Conventional microelectrode techniques were used to compare the concentration-dependent effects of vesnarinone (0.1-100 μM) and amrinone (1 μM-1 mm) on action potential duration (APD) and developed force in both isolated dog ventricular trabeculae and Purkinje strands.

Methods and Results: Both drugs increased contractility of trabecular muscle preparations, while, in Purkinje strands, vesnarinone failed to increase developed force during continuous pacing at 2 Hz. Vesnarinone lengthened APD in both preparations; although this effect was more marked in Purkinje strands. Ventricular muscle APD was not affected by amrinone (1 μM to 1 mM), while, in Purkinje strands, amrinone produced a biphasic effect on APD. Low concentrations (1-100 μM) of amrinone shortened Purkinje fiber APD, while only the highest concentration (1 mM) used lengthened APD. In addition, in Purkinje strand preparations the effects of vesnarinone (10 μM) on APD and developed force were proportional to pacing cycle length at frequencies slower than 2 Hz; however, at frequencies faster than 2 Hz vesnarinone decreased developed force while APD was lengthened. In ventricular trabecular muscle preparations, the effects of vesnarinone were not affected by frequency.

Conclusions: These results indicate clear differences between the effects of vesnarinone and amrinone in isolated cardiac preparations. These differences in experimental effects in isolated cardiac preparations may help provide an explanation for the disappointing clinical response of patients in heart failure to amrinone, while vesnarinone has appeared to be beneficial.
Pharmacologic Agents for the Treatment of Schizophrenia: Similarities and Differences
Authors: Bailey Katharine P.
Published: January 2017

Although the efficacy of conventional antipsychotic agents is attributed to dopamine receptor antagonism, this blockade induces many adverse effects as welt In addition, conventional antipsychotic agents are relatively ineffective against negative symptoms and have significant rates of nonresponse and relapse. Clozapine and risperidone, "atypical" antipsychotic agents, differ from conventional agents in their receptor-binding profiles and clinical effects. They are effective for acute and treatment-resistant schizophrenia, with different, and perhaps, more tolerable side effect profiles. This article compares the mechanisms of action, efficacy, and adverse effects of the typical and atypical antipsychotic agents.
Nurses Impaired by Emotional and Psychological Dysfunction
Authors: Smith George Byron , Hukill Elizabeth
Published: January 2017

Background: There may be at least 220,000 to 286,000 registered nurses in the United States who have some form of mental illness. There have been no published studies of nurses impaired by emotional or psychological dysfunction.

Objective: This study provides a description of characteristics of nurses impaired by emotional and psychological dysfunction.

Design: Fifty-seven nurses in a Southeastern state's peer assistance program responded to a questionnaire adapted from Sullivan's (1987a) descriptive study of recovering chemically impaired nurses.

Results: Fifty-eight percent of the sample report major depression as their primary psychiatric diagnosis with 21% of the sample believing their emotional or psychological impairment was caused by a personality weakness.

Conclusions: The findings indicate the needfor improved education and support of nurses impaired from emotional and psychological dysfunction.
The Martial Arts: A Mental Health Intervention?
Authors: Wilkinson Laura K.
Published: January 2017

For thousands of years testimonials have expounded on the benefits of the martial arts. Although replete with claims of physical well-being and mental self-actualization, Western science has only recently begun to research the effect these ancient Eastern practices have on mental health. The pressure to identify adjunct sources of support and preventative interventions continues to increase, with fewer health care dollars available for mental health services under managed care systems. Creative strategies designed to assist individuals in using community resources such as the martial arts can be a positive step toward the promotion of self-care.
The Ins and Outs of Psychiatric-Mental Health Nursing and the American Nurses Association
Authors: Carter Elizabeth , Peplau Hildegard E. , Sills Grayce M.
Published: January 2017

A brief history of some of the work ofpsychiatric nurses within the American Nurses Association is presented in this article. Additionally, the authors identify the several efforts towardprofessionalization of the occupation of nursing that were made during the past half century. These efforts also spurred other clinical units within the American Nurses Association toward similar productivity. The development of the American Psychiatric Nurses Association as well as the subspecialty organizations is outlined.
Recognition and Psychopharmaicologic Treatment of Geriatric Depression
Authors: Flowers Ellen M.
Published: January 2017

Recognition of the "masked presentation" ofgeriatric depression confronts the nurse with a challenge. Two major obstacles to diagnosing are making the differential di- agnosis ofphysical versus psychiatric causes and depression versus dementia. The pharmacokinetics in the elderly are examined with an overview of the drug metabolism of antidepressants. The use of tricyclic antidepressants and the newer agents, including bupropion and the selective serotonin reuptake inhibitors, are reviewed as part of the psychopharmacologic treatment options for geriatric depression. Last, dosing strategies andfactors affecting compliance in the elderly are outlined.
Women Leaders Put Mental Health on International Agenda
Authors: Carter Rosalynn
Published: January 2017

Former First Lady Rosalynn Carter is speaking out during Mental Health Month to call attention to the need to place mental health issues high on our international agenda. Chair of The Carter Center's Mental Health Task Force in Atlanta, Mrs. Carter also served as honorary chair of the President's Commission on Mental Health in the late 1970s. To highlight the needfor countries to prioritize mental health issues, The Carter Center and the World Federationfor Mental Health will convene a meeting of the International Committee of Women Leaders for Mental Health in Helsinki, Finland, in July 1997, with Mrs. Carter serving as Chair.
Defining Parent Training for Practice and Research
Authors: Elder Jennifer Harrison
Published: January 2017

Parent training is afamiliar term in nursing and other social sciences. Yet, the concept represented by the term in the literature is ambiguous. In this article the author defines and operationalizes the concept ofparent training, emphasizing its relevance in providing care to children with complex psychiatric disorders. The discussion is illustrated with case examples and provides an operational definition of the concept of parent training tofacilitate a link among theoretic concept, clinical practice, and empiric research.
Recent Advances in the Understanding of Negative Symptoms in Schizophrenia
Authors: Littrell Steven H. , Littrell Kimberly H.
Published: January 2017

The aim of this article is to provide a comprehensive and concise review of existing literature and findings about negative symptoms associated with the diagnosis of schizophrenia. Significant progress has been made regarding the awareness of negative symptoms associated with schizophrenia. Given this progress, psychiatric nurses shouldfind it useful to have information about how to provide state-of-the-art care and clinical interventionsfor treatment of negative symptoms. Acquiring this information requires some understanding of etiologicfactors, assessment, and use of contemporary medications to attend to the disabling effects of negative symptoms.
Family Coping with Mental Illness: An Aggregate from Two Studies, Canada and United States
Authors: Yamashita Mineko , Forsyth Diane McNally
Published: January 2017

Two studies were conducted independently to look at families' reactions to their relative's mental illness. One study was conducted in the United States, the other in Canada. In a secondary analysis from the aggregate findings it was concluded that, regardless of society, families are faced with common caregiving issues, especially educational needs. On the basis of thefindings, family education should be included in every treatment plan.
A Survey of Psychiatric Nurses Regarding Working with Clients who have a History of Sexual Abuse
Authors: Gallop Ruth , McCay Elizabeth , Austin Wendy , Bayer Margaret , Peternelj-Taylor Cindy
Published: January 2017

BACKGROUND: There is strong evidence that a history of sexual abuse can have serious psychologic sequelae.

OBJECTIVE: The purpose of the study was to assess the comfort, attitudes, identif ed competencies, and educational needs ofpsychiatric nurses who work with these clients.

STUDY DESIGN: Surveys were mailed to a random sample of 3542 nursing personnel in four Canadian provinces. Measures were used to assess comfort, sexual attitudes, competencies, and educational needs.

RESULTS: A response rate of 48% (1 701 responses) was achieved. Comfort and competency regarding working with clients varied according to educational preparation, gender of the nurse, and a personal history of abuse (p <.001). All participants identified a critical need for more knowledge in all areas related to providing care for these clients.

CONCLUSION: The surveys showed that significant numbers of nurses are working with clients who report a history of sexual abuse. However, most participants do not believe they have adequate knowledge or therapeutic skills to work with these clients. Information from this study should provide directionfor content of sexual abuse education programs.
The Partial Responder to Antipsychotic Medications: Putting the Pieces together
Authors: Molloy Monica
Published: January 2017

Published data regarding the efficacy of novel antipsychotic agents yield information about responders and nonresponders. However, the literature offers clinicians little guidance about the patient hidden above the efficacy curve, the patient with an incomplete response. In this article the issue ofpartial response is considered. Four strategies to use with patients who continue to have psychotic symptoms or symptoms of comorbid illnesses are described. nonpharmacologic interventions, changing the dose, changing the agent, and combination therapy. Anecdotal case reports illustrate the challenge of treating patients with a partial response.
Caring for Persons With Developmental Disabilities and Psychiatric Impairment
Authors: Collins Janet M.
Published: January 2017

A person with a developmental disability is more likely than the general population to experience mental illness. As many as 60% of persons with developmental disabilities may have symptoms that meet criteria for a diagnosis of a coexisting psychiatric disorder. These persons with dual diagnoses who have both a developmental disability and a psychiatric impairment will seek services in a variety of settings. Approximately 6 million persons in the United States have mental retardation and other developmental disabilities. Psychiatric nurses who understand how developmental disabilities are defined can care with increased competence for a person with developmental disability and psychiatric impairment. Knowledge of behavioral signs and symptoms in a person with developmental disability and psychiatric impairment versus signs and symptoms of the same psychiatric impairment in the general population helps nurses to use a behavioral focus and provide holistic care.
No-Suicide Contracts to Prevent Suicidal Behavior in Inpatient Psychiatric Settings
Authors: Drew Barbara L.
Published: January 2017

BACKGROUND: Many individuals who are hospitalized on psychiatric units are at high risk of suicide. Among the strategies commonly recommended for suicide prevention is the negotiation of a no-suicide or no-harm contract. In spite of the conventional acceptance of no-suicide contracts, there is little research about this intervention.

OBJECTIVE: To describe the use of no-suicide contracts in inpatient settings including the frequency of their use, the circumstances under which they are negotiated and the form of contracts.

STUDY DESIGN: Descriptive survey.

RESULTS: No-suicide contracts were used by 79% (n = 66) of the hospitals (N = 84). Contracts were generally negotiated after suicidal ideation was expressed (83% [n = 54] of those hospitals that use contracts), after self-harm (79%,n = 51), or after a patient who made a suicidal gesture or attempt was admitted (65%/, n = 42). In all but one hos- pital, nurses negotiated contracts with patients. Contracts were usually verbal (74%/,n = 48) or handwritten (72%,n = 47) rather than preprinted (15%,n = 10). Fifty-three percent of the respondents estimated more than 10 incidents of suicidal behavior by inpatients per year.

CONCLUSIONS: Suicidal behaviors occurred in hospital settings at a rate that is clinically significant. No-suicide contracting is a common nursing practice in psychiatric inpatient settings in Ohio. Contracts are not indiscriminately used but are negotiated when high suicide risk is assessed.
Quality Assurance in Postgraduate Medical Education: Implications for Dermatology Residency Training Programs
Authors: Day Isaiah , Lin Andrew
Published: January 2017

Background:

In the past few years, quality assurance has become an increasingly important part of medical education for both Canadian and American training programs. Since this emphasis on quality assurance in residency programs is recent, most faculty members involved in teaching residents in dermatology training programs would not themselves have had experience with quality assurance. As a result, satisfying this requirement may be a challenge.

Objectives:

In this article, we review published reports in which various residency training programs have satisfied this requirement and propose projects in which dermatology residency training programs may satisfy quality assurance requirements.

Methods:

Using the key words residency, training, project, quality, assurance, improvement, medical errors, and safety, a literature search was conducted of English-language articles published after January 1990.

Results/Conclusions:

There are many innovative and effective ways program directors in dermatology training programs should be able to develop projects that improve patient care, enhance resident education, and fulfill accreditation requirements.
Demographic and Tumor Characteristics of Patients Diagnosed with Nonmelanoma Skin Cancer: 13-Year Retrospective Study
Authors: Mistry Nisha , Abanto Zenaida , Bajdik Chris , Rivers Jason K.
Published: January 2017

Background:

The incidence of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) is increasing worldwide; however, this varies by region. To date, there are limited data about trends of nonmelanoma skin cancer (NMSC) in Canada.

Objective:

To determine the demographic and tumor characteristic changes in patients diagnosed with BCC and SCC from 1993 to 2005 in a dermatology practice in Vancouver, British Columbia.

Method:

A retrospective chart review was conducted on patients with biopsy-confirmed NMSC between 1993 and 2005. Demographic and tumor characteristics were documented for the first two incident BCCs and SCCs per patient, and a descriptive data analysis was undertaken.

Results:

A total of 1,177 NMSCs were identified from 885 patient charts. The number of BCCs increased from 1993 to 2003 and then decreased until 2005. BCCs and SCCs were generally diagnosed in older people (60+ years); however, an important group of younger patients (20–39 years) was also diagnosed with BCCs. BCCs and SCCs were most commonly seen on the head and neck, but the leg was a common location for SCC in women.

Conclusion:

NMSC is prevalent in British Columbia. These results highlight the fact that NMSC can affect individuals younger than 40 years old. Prevention strategies are warranted to reduce the burden of NMSC in British Columbia.
Intracranial Spread of Merkel Cell Carcinoma to the Cerebellopontine Angle
Authors: Seaman Brian , Brem Steven , Fromm Allison , Staller Aileen , Mccardle Timothy , Jain Surbhi
Published: January 2017

Background:

Merkel cell carcinoma (MCC) is a rare, highly malignant, and aggressive dermal neuroendocrine neoplasm that rarely metastasizes to the central nervous system.

Objective:

To review the current literature regarding treatment of neurometastatic MCC.

Methods:

A case of a 78-year-old male with intracranial extra-axial metastatic MCC involving the left cerebellopontine angle is presented.

Results:

A retrosigmoid craniectomy was performed with complete resection of the metastatic focus. Adjuvant treatment included whole-brain radation therapy followed by etoposide and carboplatin chemotherapy. Seven months postoperatively, the patient was free of metastatic disease.

Conclusion:

Surgical resection should be performed when feasible to prevent local recurrence. This may be followed by early adjuvant fractionated whole-brain radiotherapy and systemic chemotherapy; however, no clinical trials have been performed to demonstrate a survival benefit.
T-Cell Lymphoma/Sézary Syndrome in a Liver Transplant Recipient
Authors: Ajroush Nojoud Al , Sheikh Khadija Rafique , Kadry Razan , Almutawa Abdulmonem , Alfadley Abdullah
Published: January 2017

Background:

Cutaneous T-cell lymphoma is a rare subtype of posttransplantation lymphoproliferative disease, with only 29 cases reported in the literature to date, the majority of which are post-renal transplantation. Only a few were reported after pancreas, heart, and bone marrow transplantation. There have been no reports of cutaneous T-cell lymphoma following liver transplantation to date.

Objective:

We report a case of a 76-year-old male who developed generalized eczematous eruption 13 years after a liver transplantation. Investigations showed that it was Epstein-Barr virus-negative, CD3-positive, and CD4-positive cutaneous T-cell lymphoma with Sézary cells in the blood.

Conclusion:

This shows that cutaneous T-cell lymphoma/Sézary syndrome can also develop after liver transplantation. To our knowledge, there are no similar reports in the English literature.
Getting Evidence into Clinical Practice: An Organisational Behaviour Perspective
Authors: Ferlie Ewan , Fitzgerald Louise , Wood Martin
Published: January 2017

Objectives:

To study the relationship between research evidence and clinical behaviour change in the UK National Health Service (NHS) in the period 1995–1997 by examining the ‘careers' of change issues designed to reshape clinical practice, the impact of such change efforts, and the factors shaping change outcomes.

Methods:

Comparative case study methods were used. Four clinical change issues were studied using semi-structured interviews ( n=119) and documentary analysis in one English NHS region. For each issue, there was an overview semi-structured interview survey of the issue at regional level, followed by an intensive analysis of its impact at local level on the practice of specific clinical groups.

Results:

There was a weak relationship between the evidence base and its diffusion. The diffusion and take-up of scientific evidence were shown to be socially constructed. Different forms of evidence were differentially accepted by individuals and groups. Specific organisational and social factors affected this pattern of impact. The general management hierarchy of the NHS played a very limited role in enabling evidence-based clinical change.

Conclusions:

The implementation of evidence-based medicine is a complex and contested process. The results of this study confirm a professional dominance model of clinical behaviour change and identify tacit expert knowledge as a key power resource in shaping the way research evidence influences clinical practice.
How Do General Practitioners Choose Their Practice? Preferences for Practice and Job Characteristics
Authors: Gosden Toby , Bowler Isobel , Sutton Matthew
Published: January 2017

Objectives:

To investigate the strength of preferences for practice and job characteristics among recently appointed general practitioners (GPs) in south-east England.

Methods:

Conjoint analysis based on a postal questionnaire survey of all 293 GPs who joined a new practice between April 1997 and March 1998 in London, Essex and Hertfordshire. GPs were presented with descriptions of practices in pairs, which varied systematically for key characteristics, and asked to indicate their preferred practice in each pair.

Results:

The response rate was 58.7%. The most important influence on GPs' choice of practice was aversion to location in an area of high deprivation. They were more likely to choose a practice that: had an extended primary health care team; offered opportunities to develop outside interests; and offered them higher income, shorter working hours and smaller list sizes. The model generated estimates of the strength of these preferences. For example, GPs would require additional income of just over £5000 per annum to work in an area with a high proportion of deprived patients.

Conclusions:

Potential policy interventions to attract GPs to under-served areas include increasing their level of remuneration, providing opportunities to develop outside interests and ensuring that practices have a primary health care team.
Conditions for Which Onset or Hospital Admission is Potentially Preventable by Timely and Effective Ambulatory Care
Authors: Sanderson Colin , Dixon Jennifer
Published: January 2017

Objectives:

To identify, using a consensus development process, a list of common conditions likely to be ambulatory care sensitive (ACS); i.e. conditions for which practicable improvements in access to timely and effective ambulatory care in the English National Health Service would either reduce the incidence of the condition or avoid substantial proportions of current hospital admissions.

Methods:

Three panels of clinicians each reviewed about a third of an initial list of 174 conditions commonly recorded as hospital discharge diagnoses for residents of the North West Thames Region. For each condition, panellists estimated the proportion of cases currently admitted to hospital for which, given timely and effective ambulatory care: onset of disease could have been prevented; admission for existing disease could have been prevented; admission, once indicated, should take place within 48 hours. After an introductory meeting to discuss and clarify the task, panel members completed three rounds of a questionnaire, with postal feedback between each round, and a second meeting to discuss interim results before the final round. Seventeen general practitioners (GPs) and 17 hospital specialists working in the region comprised the panels.

Results:

The panels considered that for 30 of the 174 conditions at least 70% of admissions to hospital could be avoided, either by prevention of disease onset or timely and effective ambulatory care, though predominantly through the latter. For each of a further 66 conditions, 50–69% of admissions could be prevented. Within-panel agreement between hospital specialists and GPs was generally good, although the GPs tended to give slightly higher scores for avoidability of admissions than the specialists. There was marked convergence of scores in succeeding rounds.

Conclusions:

Although a consensus-based list of ACS conditions cannot be definitive, the clear view of the panels was that the scope for avoiding admission through better ambulatory care is very substantial.
Is Hospital Performance Related to Expenditure on Management?
Authors: Street Andrew , Carr-Hill Roy , Posnett John
Published: January 2017

Objectives:

Reducing the costs of management appears an easy target for those seeking to generate savings or to promote better spending in the National Health Service (NHS). However, an assessment of the appropriate amount of spending on management requires an evaluation of how much management contributes to organizational performance.

Methods:

Using routinely available NHS acute hospital data, an econometric analysis was undertaken to test the hypothesis that there is a relationship between the proportion of a hospital's income spent on management and the performance of the hospital measured along three dimensions: the achievement of financial targets; performance against waiting time standards defined in the Patient's Charter; and costs of service provision.

Results:

No general relationship was found between management costs and hospital performance. However, there was some evidence of a quadratic relationship between management spending and the amount of operating surplus generated and performance against the three-month waiting time standard for an inpatient admission specified in the Patient's Charter. These results suggest that performance returns reach an optimum when management expenditure is around 5–6% of hospital income.

Conclusions:

The evidence is not yet strong enough to draw a general conclusion that management costs in NHS acute hospitals are too high or that an undiscriminating reduction in management costs would have no detrimental effects on hospital performance. However, the findings should prompt managers to identify ways in which their activities are productive and how these can be measured, and what distinguishes effective from ineffective management.
Point of Care Testing in the Accident and Emergency Department: A Cost Analysis and Exploration of Financial Incentives to use the Technology within the Hospital
Authors: Kendall Jason M. , Bevan Gwyn , Clancy Michael J.
Published: January 2017

Objectives:

To compare the costs of current arrangements for testing emergency blood samples from patients attending an accident and emergency (A&E) department in a large teaching hospital in England with point of care testing (POCT).

Methods:

Estimates were made of the fixed and variable costs of two options: a supplemental option, in which POCT was introduced to A&E only; and a replacement option, in which POCT was introduced to A&E and the intensive therapy unit (ITU), thereby entirely replacing an existing process.

Results:

For the supplemental option, current arrangements cost £68 466 in total per year; average costs per test were £5.53 (venous in the central laboratory) and £3.60 (arterial on the ITU). Introducing POCT would increase total hospital costs by £35 929, and average costs per test would be £5.32 (venous) and £4.28 (arterial). For the replacement option, current arrangements cost £132 630 in total, and average cost per test (for all tests) was £4.06. Introducing POCT would make hospital savings ranging from £8332 to £20 000, and average cost per test would be £3.78.

Conclusions:

Introducing POCT results in lower average costs per test. The supplemental option will result in significantly increased costs to the hospital. The replacement option can lead to significant savings. The internal cross-charging arrangements between departments that exist in this hospital may mean that supplemental implementation of POCT could be potentially ‘profitable’ for the A&E department, but would result in higher expenditure for the hospital as a whole.
Systematic Reviews and Meta-Analysis: A Structured Review of the Methodological Literature
Authors: Sutton Alexander J. , Jones David R. , Abrams Keith R. , Sheldon Trevor A. , Song Fujian
Published: January 2017

Objective:

To systematically review methods for systematic review/meta-analysis in order to identify the different methodological and statistical methods that have been proposed. A summary of the main findings is presented here, with emphasis given to health services research topics.

Methods:

A thorough systematic search for methodological papers was carried out using a variety of methods, including the use of electronic databases. Approximately 1000 potentially relevant references were identified, a number of them from education, psychology and sociology.

Results:

After briefly reviewing the procedural methods required to carry out a review, and the basic statistical methods used to combine study estimates, less established methods are discussed. These include methods for dealing with publication bias, meta-regression, meta-analysis of individual patient data, the synthesis of nonrandomized evidence alone and in combination with randomized studies, Bayesian modelling and economic evaluation through meta-analysis. Recommendations for meta-analytical practice are given; these are either distilled from previous guidelines, or constructed where there appears to be a broad consensus across the literature.

Conclusions:

It is hoped that this review will provide a consistent and comprehensive, but concise, description of the methods available for synthesizing evidence, that it will promote better quality reviews of the results of health services research and identify specific areas which require methodological development.
Fairness, Public Expenditure and the Cost of New Treatments in the UK
Authors: West Peter A.
Published: January 2017

Current differences in standards for allocating resources in the UK for, on the one hand, drugs and surgery, and on the other, chronic community and social care and social security lead to significant inequality. Using a case study of hypothetical patients, it can be shown that adoption of new treatments, at high cost, to make marginal improvements in well-being would lead to much greater spending on some patients than on others with similar problems from different causes. Inequality occurs because society tolerates tighter constraints on community and social care and social security than on acute care and drug budgets for new treatments. Resolution of the inequality would involve establishing fairly the resources to increase the welfare of patients with different chronic diseases to some target level of welfare. However, this would make overt the current rationing of community and social services and demonstrate the low levels of welfare of many with chronic diseases. Governments concerned with lower taxation might prefer to avoid exposing such issues.
Who Will Challenge Evidence-Based Medicine?
Authors: Goodman Neville W.
Published: January 2017

Evidence-based medicine (EBM), which lays special emphasis on the formal gathering and synthesis of research data by systematic review and meta-analysis, is intuitively attractive as a way of determining best treatments. Questions remain unanswered, however, about the underlying assumptions of EBM. There is little true dialogue between its critics and its advocates, although the latter have had considerable disagreements among themselves in the correspondence columns of medical journals about the precise way in which its methods should be used. EBM is in danger of becoming a new and unchallengeable orthodoxy following its own political agenda.
Publication Output in Telemedicine in Spain
Authors: Gonzalez Francisco , Castro Adrian F
Published: January 2017

We searched the MEDLINE database for publications about telemedicine from 1966 to 2003. Only publications with a first institutional address in Spain and from journals listed in the JCR Science Edition 2002 were included in the study. A total of 118 publications were found. The first publication appeared in 1988 and publication output showed a sudden increase starting in 1995, reaching a maximum in 2002 with 21 publications. The number of authors per publication in non-multicentre studies ranged from 1 to 14 (median 6.5). Most authors (79%) contributed to only a single publication; 10% of authors participated in three or more publications. Most publications were full papers (88%). The most active Autonomous Community in the number of publications relative to inhabitants was Galicia (0.91 publications per 1 00,000 inhabitants). The Community that produced the highest absolute number of publications was Madrid (29% of the total). The mean impact factor of the journals in which the publications appeared was 0.961. Production of telemedicine publications in Spain has followed the same temporal course as has been observed worldwide. There is an unequal geographical and institutional distribution of publications. The highest production is concentrated in a few institutions and only a small number of authors show steady research activity.