eScholarship@UMMS

Summary: Provides rapid-access information on the diagnosis, treatment, and follow-up of vaginismus.

Summary: Provides rapid-access information on the diagnosis, treatment, and follow-up of Pemphigoid (Herpes) Gestationis.

Report summary: Peru's persistently high maternal mortality ratio, the second highest in South America, dramatically illustrates systemic inequities that ravage the overall society and in turn reflect systematic violations of human rights and vast disparities in the health care system.

Objectives: To determine the impact of a web tool developed to improve health care providers' ability and comfort in caring for a diverse patient population in the hospital setting.

Methods: The pediatric palliative care team including a pediatric oncologist and a nurse practitioner in association with a clinical medical librarian and a hospital-based interpreter, collaborated to create a resource using SpringShare software to create a library guide. The purpose is to provide cultural and palliative care information resources, books, and journal articles to assist health care workers at UMass Memorial Children's Medical Center in caring for children from the diverse cultural backgrounds living in the region. In order to introduce and evaluate the usage of the library guide, we plan to survey Children's Medical Center staff including nurses, residents, attending physicians, and child life staff at baseline and after visiting the library guide. As of this date, the usage of the guide has had over 400 hits per month or 1,200 hits in the last 3 months (libraryguides.umassmed.edu/diversity_guide).

Results: We will be conducting a survey of all children's medical center staff, nurses, and physicians to evaluate the usefulness and impact of this resource.

Conclusions: The results of the survey will be complete in 2013.

Atlas of Anatomy, Second Edition, is an essential resource for anyone studying gross anatomy. Containing over 2,400 full-color illustrations, this atlas guides you step-by-step through each region of the body, helping you master the details of anatomy.

Edited by Anne M. Gilroy, Brian R. MacPherson, Lawrence M. Ross ; based on the work of Michael Schuenke, Erik Schulte, Udo Schumacher ; illustrated by Markus Voll, Karl Wesker.

Citation: Gilroy, A. M., MacPherson, B. R., Ross, L. M., Schünke, M., Schulte, E., & Schumacher, U. (2012). Atlas of anatomy. New York: Thieme.

ISBN-10: 1604067454

ISBN-13: 978-1604067453

Partial preview available via Google Books.

Focuses on the targeted information about anatomy for USMLE success. Includes: a total of 400 USMLE-style review questions with explanatory answers; a streamlined, bullet point format to help you quickly learn essential facts and concepts; 70 tables for quick review of crucial information; more than 450 fully labeled color illustrations.

Citation: Gilroy, A. M. (2013). Anatomy: An essential textbook and review. New York: Thieme.

ISBN-10: 160406207X

ISBN-13: 978-1604062076

A partial preview is available via Google Books.

Summary points:

• In cluster randomized trials (CRTs), the units of allocation, intervention, and outcome measurement may differ within a single trial. As a result of the unique design of CRTs, the interpretation of existing research ethics guidelines is complicated.
• The Ottawa Statement on the Ethical Design and Conduct of Cluster Randomized Trials aims to provide researchers and research ethics committees (RECs) with detailed guidance on the ethical design, conduct, and review of CRTs.
• A five-year mixed methods research project explored the ethical challenges of CRTs. Empirical studies documented the reporting of ethical issues in published CRTs, interviewed experienced trialists, and surveyed trialists and REC chairs. The ethical issues identified were explored in a series of background papers that provided detailed ethical analyses and policy options, and a panel of experts using a systematic process developed a consensus statement.
• The Ottawa Statement sets out 15 recommendations for the ethical design and conduct of CRTs. The recommendations provide guidance on the justification of a cluster randomized design, the need for REC review, the identification of research participants, obtaining informed consent, the role of gatekeepers in protecting group interests, the assessment of benefits and harms, and the protection of vulnerable participants.

OBJECTIVE: Economic access to costly medications including biologic agents can be challenging. Our objective was to examine whether patients with rheumatoid arthritis (RA) are at particular risk for cost-related medication nonadherence (CRN) and spending less on basic needs.

METHODS: We identified a nationally representative sample of older adults with RA (n = 1100) in the Medicare Current Beneficiary Survey (2004-2008) and compared them to older adults with other morbidities categorized by chronic disease count: 0 (n = 5898), 1-2 (n = 30,538), and >/= 3 (n = 34,837). We compared annual rates of self-reported CRN (skipping or reducing medication doses or not obtaining prescriptions because of cost) as well as spending less on basic needs to afford medications and tested for differences using survey-weighted logistic regression analyses adjusted for demographic characteristics, health status, and prescription drug coverage.

RESULTS: In the RA sample, the unadjusted weighted prevalence of CRN ranged from 20.7% in 2004 to 18.4% in 2008 as compared to 18.5% and 11.9%, respectively, in patients with 3 or more non-RA conditions. In adjusted analyses, having RA was associated with a 3.5-fold increase in the risk of CRN (OR 3.52, 95% CI 2.63-4.71) and almost a 2.5-fold risk of spending less on basic needs (OR 2.41, 95% CI 1.78-3.25) as compared to those without a chronic condition.

CONCLUSION: Patients with RA experience a high prevalence of CRN and forgoing of basic needs, more than do older adults with multiple other chronic conditions. The situation did not improve during a period of policy change aimed at alleviating high drug costs.

PURPOSE: To investigate whether a delay in the timing of surgery of > 6 months compared with performing the surgery 6 months after ACL injury. "New" meniscal tears were defined as lesions detected at the time of surgery that were not detected by MRI.

RESULTS: Of 195 patients who were selected based on inclusion criteria, 171 patients underwent surgery 6 months after their ACL injury. The prevalence of new medial meniscal tears in the early reconstruction group was 4.1%, while in the delayed reconstruction group, the prevalence was 16.7% (P = 0.012).

CONCLUSION: A delay in the timing of ACL reconstruction from 6 months following injury is associated with a significant increase in the prevalence of medial meniscal tears (P = 0.012), with a relative risk of 4.07 (CI, 1.29-12.88).

We describe the development of novel and biocompatible core/shell (alpha-NaYbF(4):Tm(3+))/CaF(2) nanoparticles that exhibit highly efficient NIR(in)-NIR(out) upconversion (UC) for high contrast and deep bioimaging. When excited at ~980 nm, these nanoparticles emit photoluminescence (PL) peaked at ~800 nm. The quantum yield of this UC PL under low power density excitation (~0.3 W/cm(2)) is 0.6 +/- 0.1%. This high UC PL efficiency is realized by suppressing surface quenching effects via heteroepitaxial growth of a biocompatible CaF(2) shell, which results in a 35-fold increase in the intensity of UC PL from the core. Small-animal whole-body UC PL imaging with exceptional contrast (signal-to-background ratio of 310) is shown using BALB/c mice intravenously injected with aqueously dispersed nanoparticles (700 pmol/kg). High-contrast UC PL imaging of deep tissues is also demonstrated, using a nanoparticle-loaded synthetic fibrous mesh wrapped around rat femoral bone and a cuvette with nanoparticle aqueous dispersion covered with a 3.2 cm thick animal tissue (pork).

Both positively and negatively charged residues play pivotal roles in recruiting precursor ions or ion clusters, and lowering interfacial energy in natural biomineralization process. Synergistic utilization of opposite charges, however, has rarely been implemented in the design of cytocompatible synthetic scaffolds promoting hydroxyapatite (HA)-mineralization and osteointegration. We report the use of cytocompatible zwitterionic sulfobetaine ligands to enable 3-dimensional in vitro mineralization of HA across covalently crosslinked hydrogels. The overall charge-neutral zwitterionic hydrogel effectively recruited oppositely charged precursor ions while overcame excessive swelling exhibited by anionic and cationic hydrogels under physiological conditions, resulting in denser and structurally well-integrated mineralized composites. Further controls over the size, content, and spatial distribution of the mineral domains within the zwitterionic hydrogel are accomplished by facile adjustments of hydrogel crosslinking densities and the supersaturation rate governing heterogeneous mineral nucleation and growth. These findings should inspire many creative uses of zwitterionic polymers and polymer coatings for skeletal tissue repair and regeneration.

Radiofrequency (RF) neurotomy is an interventional procedure used to alleviate certain types of low back pain. RF energy is used to thermally coagulate the specific nerves that transmit pain signals. Recent evidence has shown that this procedure demonstrates significant efficacy in relieving low back pain in lumbar zygapophysial joints, and research is ongoing to determine if pain relief for the sacroiliac joint is also possible. This article provides an evidence-based background for performing RF neurotomy, discusses the relevant anatomy, and highlights the indications and technique for lumbar and sacral RF neurotomy.

OBJECTIVE: To identify a comprehensive list of features that might discriminate between gout and other rheumatic musculoskeletal conditions, to be used subsequently for a case-control study to develop and test new classification criteria for gout.

METHODS: Two Delphi exercises were conducted using Web-based questionnaires: one with physicians from several countries who had an interest in gout and one with patients from New Zealand who had gout. Physicians rated a list of potentially discriminating features that were identified by literature review and expert opinion, and patients rated a list of features that they generated themselves. Agreement was defined by the RAND/UCLA disagreement index.

RESULTS: Forty-four experienced physicians and 9 patients responded to all iterations. For physicians, 71 items were identified by literature review and 15 more were suggested by physicians. The physician survey showed agreement for 26 discriminatory features and 15 as not discriminatory. The patients identified 46 features of gout, for which there was agreement on 25 items as being discriminatory and 7 items as not discriminatory.

CONCLUSION: Patients and physicians agreed upon several key features of gout. Physicians emphasized objective findings, imaging, and patterns of symptoms, whereas patients emphasized severity, functional results, and idiographic perception of symptoms.

BACKGROUND: Anti-tumor necrosis factor-alpha (TNF-alpha) agents have been hypothesized to increase the risk of interstitial lung disease (ILD), including its most severe manifestation, pulmonary fibrosis.

METHODS: We conducted a cohort study among autoimmune disease patients who were members of Kaiser Permanente Northern California, 1998-2007. We obtained therapies from pharmacy data and diagnoses of ILD from review of X-ray and computed tomography reports. We compared new users of anti-TNF-alpha agents to new users of non-biologic therapies using Cox proportional hazards analysis to adjust for baseline propensity scores and time-varying use of glucocorticoids. We also made head-to-head comparisons between anti-TNF-alpha agents.

RESULTS: Among the 8417 persons included in the analysis, 38 (0.4%) received a diagnostic code for ILD by the end of follow-up, including 23 of 4200 (0.5%) who used anti-TNF-alpha during study follow-up, and 15 of 5423 (0.3%) who used only non-biologic therapies. The age-standardized and gender-standardized incidence rate of ILD, per 100 person-years, was 0.21 [95% confidence interval (CI) 0-0.43] for rheumatoid arthritis and appreciably lower for other autoimmune diseases. Compared with the use of non-biologic therapies, use of anti-TNF-alpha therapy was not associated with a diagnosis of ILD among patients with rheumatoid arthritis (adjusted hazard ratio, 1.03; 95%CI 0.51-2.07), nor did head-to-head comparisons across anti-TNF-alpha agents suggest important differences in risk, although the number of cases available for analysis was limited.

CONCLUSION: The study provides evidence that compared with non-biologic therapies, anti-TNF-alpha therapy does not increase the occurrence of ILD among patients with autoimmune diseases and informs research design of future safety studies of ILD. Copyright (c) 2013 John Wiley and Sons, Ltd.

The Institute of Medicine defines disparity as the difference in health care utilization or outcome not including patient preference.(1) This definition of health disparity holds true in most cases but not all. Total joint replacement (TJR) in the management of knee and hip osteoarthritis (OA) might represent an exception to the rule. TJR, and more specifically knee and hip elective TJR, is considered to be one of the most successful treatments in the history of surgery. Today more than 700 000 TJRs are performed each year in the United States. (Am J Public Health. Published online ahead of print February 14, 2013: e1-e2. doi:10.2105/AJPH.2012.301077).

STUDY DESIGN: Retrospective review of 750 consecutive multilevel cervical spine decompression surgeries performed by a single spine surgeon.

OBJECTIVE: To determine the incidence of C5 palsy in a large consecutive series of multilevel cervical spine decompression procedures.

SUMMARY OF BACKGROUND DATA: Palsy of the C5 nerve is a well-known potential complication of cervical spine surgery with reported rates ranging from 0% to 30%. The etiology remains uncertain but has been attributed to iatrogenic injury during surgery, tethering from shifting of the spinal cord, spinal cord ischemia, and reperfusion injury of the spinal cord.

METHODS: We included patients undergoing multilevel cervical corpectomy, corpectomy with posterior fusion, posterior laminectomy and fusion, and laminoplasty. Exclusion criteria included lack of follow-up data, spinal cord injury preventing preoperative or postoperative motor testing, or surgery not involving the C5 level. Incidence of C5 palsy was determined and compared to determine whether significant differences existed among the various procedures, patient age, sex, revision surgery, preoperative weakness, diabetes, smoking, number of levels decompressed, and history of previous upper extremity surgery.

RESULTS: Of the 750 patients, 120 were eliminated on the basis of the exclusion criteria. The 630 patients included in the analysis consisted of 292 females and 338 males. The mean age was 58 years (range, 19-87). The incidence of C5 nerve palsy for the entire group was 42 of 630 (6.7%). The incidence was highest for the laminectomy and fusion group (9.5%), followed by the corpectomy with posterior fusion group (8.4%), the corpectomy group (5.1%), and finally the laminoplasty group (4.8%), although these differences did not reach statistical significance. There was a significantly higher incidence in males (8.6% vs. 4.5%, P = 0.05).

CONCLUSION: Incidence of C5 nerve palsy after cervical spine decompression was 6.7%. This is consistent with previously published studies and represents the largest series of North American patients to date. There is no statistically significant difference in incidence of C5 palsy based on surgical procedure, although there was a trend toward higher rates with laminectomy and fusion.

Posterior cervical decompression and fusion can be performed for various spinal conditions. Previous rates of pseudoarthrosis have been reported in up to 38% of patients. The use of bone morphogenic protein (BMP) has been approved for use in certain anterior lumbar interbody fusion techniques to decrease the incidence of pseudoarthrosis. Bone morphogenic protein in the anterior cervical spine carries a potential increased risk of airway complications; however, few data exist on the safety and efficacy of BMP in the posterior cervical spine. The purpose of this study was to evaluate fusion success, safety, and heterotopic bone formation using BMP in posterior cervical fusion.Twenty-nine patients who received posterior cervical fusion with BMP were followed for a minimum of 12 months. Computed tomography scans were obtained at a minimum of 12 months postoperatively to evaluate for solid arthrodesis and the presence of heterotopic bone formation. Patients' demographic data and adverse events were evaluated. All patients underwent posterior cervical decompression and instrumented fusion of at least 1 level between 2006 and 2008. Of 37 patients eligible for the study, 29 agreed to participate. Three (10.3%) of 29 patients developed pseudoarthrosis, as found on computed tomography scan. None of these went on to further surgery. No evidence existed of heterotopic bone formation outside of the lateral masses or bone growth over the spinal canal or neuroforamen. No adverse events were related to the use of BMP in this series of posterior cervical fusions. Bone morphogenic protein can be used safely in posterior cervical spine fusion, but additional larger studies are recommended. Even with the use of bone morphogenic protein, the possibility of pseudoarthrosis exists.

The incidence of pedicle screw breech varies based on anatomic location, body habitus, surgeon experience, spinal deformity, and surgical technique. Pedicle breeches have been reported to occur in up to 40% of screws. The purpose of this retrospective study was to compare the rates of revision of pedicle screw placement when using intraoperative C-arm vs O-arm (Medtronic, Memphis, Tennessee) assessment of pedicle screws. An economic analysis was also performed based on the estimated cost of pedicle screw revision. Four (1%) of 386 control patients required pedicle screw revision for a breeched pedicle screw not identified with intraoperative C-arm fluoroscopy. In the study group, none of the 331 patients returned to the operating room when O-arm was used to assess pedicle screw placement. Based on the 1% rate of returning to the operating room in the control group, the annual rate of cases nationwide requiring pedicle screw revision would be approximately 2300, with a cost of approximately $40,595,000.These results suggest that the use of intraoperative O-arm can reduce the need for revision of a breeched pedicle screw. This can potentially lead to a major cost savings.

BACKGROUND CONTEXT: There is very little evidence to guide treatment of patients with spinal surgical site infection (SSI) who require irrigation and debridement (I&D) in deciding need for single or multiple I&Ds or more complex wound management such as vacuum-assisted closure dressing or soft-tissue flaps.

PURPOSE: The purpose of this study was to build a predictive model that stratifies patients with spinal SSI, allowing us to determine which patients will need single versus multiple I&D. The model will be validated and will serve as evidence to support a scoring system to guide treatment.

STUDY DESIGN: A consecutive series of 128 patients from a tertiary spine center (collected from 1999 to 2005) who required I&D for spinal SSI were studied based on data from a prospectively collected outcomes database.

METHODS: More than 30 variables were identified by extensive literature review as possible risk factors for SSI and tested as possible predictors of risk for multiple I&D. Logistic regression was conducted to assess each variable's predictability by a "bootstrap" statistical method. A prediction model was built in which single or multiple I&D was treated as the "response" and risk factors as "predictors." Next, a second series of 34 different patients meeting the same criteria as the first population were studied. External validation of the predictive model was performed by applying the model to the second data set, and predicted probabilities were generated for each patient. Receiver operating characteristic curves were constructed, and the area under the curve (AUC) was calculated.

RESULTS: Twenty-four of one hundred twenty-eight patients with spinal SSI required multiple IandD. Six predictors: anatomical location, medical comorbidities, specific microbiology of the SSI, the presence of distant site infection (ie, urinary tract infection or bacteremia), the presence of instrumentation, and the bone graft type proved to be the most reliable predictors of need for multiple I&D. Internal validation of the predictive model yielded an AUC of 0.84. External validation analysis yielded AUC of 0.70 and 95% confidence interval of 0.51 to 0.89. By setting a probability cutoff of .24, the negative predictive value (NPV) for multiple I&D was 0.77 and positive predictive value (PPV) was 0.57. A probability cutoff of .53 yielded a PPV of 0.85 and NPV of 0.46.

CONCLUSIONS: Patients with positive methicillin-resistant Staphylococcus aureus culture or those with distant site infection such as bacteremia were strong predictors of need for multiple I&D. Presence of instrumentation, location of surgery in the posterior lumbar spine, and use of nonautograft bone graft material predicted multiple I&D. Diabetes also proved to be the most significant medical comorbidity for multiple I&D. The validation of this predictive model revealed excellent PPV and good NPV with appropriately chosen probability cutoff points. This study forms the basis for an evidence-based classification system, the Postoperative Infection Treatment Score for the Spine that stratifies patients who require surgery for SSI, based on specific spine, patient, infection, and surgical factors to assess a low, indeterminate, and high risk for the need for multiple I&D.

OBJECT: The nature of physician-industry conflict of interest (COI) has become a source of considerable concern, but is often not discussed in the research setting. With reduced funding available from government and nonprofit sources, industry support has enthusiastically grown, but along with this comes the potential for COI that must be regulated. In this era of shared decision making in health care, society must have input into this regulation. The purpose of this study was to assess the opinions of a North American population sample on COI regarding industry-funded research and to analyze population subgroups for trends.

METHODS: A survey was developed for face and content validity, underwent focus group evaluation for clarity and bias reduction, and was administered via the World Wide Web. Demographic and general survey results were summarized as a percentage for each answer, and subgroup analysis was done using logistic regression. Generalizability of the sample to the US population was also assessed.

RESULTS: Of 541 surveys, 40 were excluded due to missing information, leaving 501 surveys for analysis. The sample population was composed of more females, was older, and was more educated than a representative cross-section of the American population. Respondents support multidisciplinary surgeon-industry COI regulation and trust doctors and their professional societies the most to head this effort. Respondents trust government officials and company representatives the least with respect to regulation of COI. Most respondents feel that industry-sponsored research can involve physiciansand be both objective and beneficial to patients.

CONCLUSIONS: Most respondents in this study felt that surgeons should be involved in industry-sponsored research and that more research, regardless of funding source, will ultimately benefit patients. The majority of respondents distrust government or industry to regulate COI. The development of evidence-based treatment recommendations requires the inclusion of patient preference. The authors encourage regulatory bodies to follow suit and include society's perspective on regulation of COI in research.