Recommendations of the OARSI FDA Osteoarthritis Devices Working Group.

Osteoarthritis (OA) is the most common type of arthritis and a major cause of chronic musculoskeletal pain and functional disability. While both pharmacologic and non-pharmacologic modalities are recommended in the management of OA, when patients with hip or knee OA do not obtain adequate pain relief and/or functional improvement, joint replacement surgery or other surgical interventions should be considered. Total joint arthroplasties are reliable and cost-effective treatments for patients with significant OA of the hip and knee. Evidence from cohort and observational studies has confirmed substantial improvements in pain relief with cumulative revision rates at 10 years following total hip (THA) and total knee arthroplasties (TKA) at 7% and 10%, respectively. Joint replacements have been used in most every synovial joint, although results for joints other than hip and knee replacement have not been as successful. The evolution of new device designs and surgical techniques highlights the need to better understand the risk to benefit ratio for different joint replacements and to identify the appropriate methodology for evaluating the efficacy and optimal outcomes of these new devices, designed to treat OA joints.

Pediatric Intracranial Hypotension and Post-Dural Puncture Headache.

Pediatric intracranial hypotension can occur acutely following iatrogenic dural puncture for diagnostic or therapeutic purposes, or chronically from cerebrospinal fluid leak. The incidence of intracranial hypotension in children is not fully known. However, many steps can be taken to reduce the risk of a child developing a post-dural puncture headache. Other causes of intracranial hypotension, such as spontaneous intracranial hypotension or CSF fistulas, are rare and with little pediatric data to guide evaluation and management. This manuscript reviews the risk factors, diagnostic evaluations, and treatments for post-dural puncture headache, as well as a limited discussion of spontaneous intracranial hypotension as it may pertain to children and adolescents.

In-circuit high-frequency jet ventilation to reduce organ motion in a child undergoing sarcoma ablation.

Patients with primary or metastatic solid tumours can be treated with minimally invasive image-guided procedures as an alternative to surgical resection. Reducing organ motion during these procedures is crucial so that tumours can be accurately targeted and treatment delivered within a small margin, limiting potential damage to adjacent structures. As ventilation is the main cause of motion, there has been a shift from conventional ventilation towards the use of in-circuit high-frequency jet ventilation techniques for these procedures. We present the case of a 7-year-old who required computed tomography-guided microwave ablation of a right lung metastatic nodule under general anaesthesia. The patient's lungs were ventilated with in-circuit high-frequency jet ventilation in order to provide optimum conditions for ablation. The treatment was successfully completed and she was discharged home the following day. High-frequency jet ventilation is regularly used in our institution for adult computed tomography-guided treatments and to our knowledge, this application has not been described yet in a child this young. Our experience suggests that this technique can be safely used in paediatric patients, though further investigation of the optimum parameters for in-circuit high-frequency jet ventilation in this population is warranted.

Cerebrospinal fluid eosinophilia in dogs.

BACKGROUND: Marked eosinophilic meningitis or meningoencephalomyelitis (EME) is rarely reported in dogs and the cause is usually undetermined. Long-term prognosis for dogs with cerebrospinal fluid (CSF) eosinophilia is variable. ANIMALS: Twenty-three client-owned dogs. METHODS: Retrospective case series. Dogs with eosinophilic CSF, defined as total nucleated cell count (TNCC) >3 cells/microL with >20% eosinophils, were identified by a computerized search of all dogs having cisternal and/or lumbar CSF analyzed as part of the diagnostic workup between 1992 and 2007. RESULTS: TNCC in CSF ranged from 4 to 4,740 cells/microL (median 84 cells/microL, reference range

Lumbar cerebrospinal fluid in dogs with type I intervertebral disc herniation.

BACKGROUND: Cerebrospinal fluid (CSF) in dogs with Hansen type I intervertebral disc herniation (IVDH) is classically described as normal or mildly inflammatory with a predominance of large mononuclear cells or neutrophils in severe acute herniations. However, we have observed a moderate to marked pleocytosis with a predominance of lymphocytes in some dogs with IVDH. HYPOTHESIS: Moderate to marked CSF pleocytosis occurs more commonly in dogs with type I IVDH than is reported in the literature. Lymphocytic predominance is more common than nonlymphocytic pleocytosis in dogs with chronic IVDH. ANIMALS: Four hundred twenty-three client-owned dogs with type I IVDH. METHODS: Retrospective study. Lumbar CSF of dogs with surgically confirmed type I IVDH was evaluated cytologically. Information obtained from medical records included signalment, prior clinical history, time from onset of signs to presentation, neurologic status, and intraoperative findings. Dogs with prior history and/or intraoperative evidence consistent with chronic IVDH before an acute herniation were termed acute-on-chronic (AOC). RESULTS: Pleocytosis (> 5 cells/uL) was present in 51% of dogs, including 23% with cervical IVDH and 61% with thoracolumbar IVDH. Moderate or marked inflammation (> or = 20 cells/uL) was identified in the CSF of 51% of dogs with thoracolumbar IVDH and pleocytosis. A predominance of lymphocytes was significantly more common in dogs examined > 7 days from onset of signs (P= .032) and in dogs with AOC IVDH (P= .0013). CONCLUSIONS AND CLINICAL IMPORTANCE: Moderate to marked CSF pleocytosis in dogs with type I IVDH is more common than previously reported. Lymphocytic pleocytosis is most common in dogs with chronic progression or AOC IVDH. Lymphocytic inflammation in the CSF of some dogs might suggest an immune-mediated response to chronically herniated disc material.

Transition guidelines: An important step in the future care for childhood cancer survivors. A comprehensive definition as groundwork.

Evidence-based clinical practice guidelines are essential to ensure that childhood cancer survivors at risk of chronic health conditions receive effective long-term follow-up care. However, adult survivors of childhood cancer are not always engaged in recommended health promotion and follow-up practices, as many centres do not have a formal transition programme that prepares survivors and their families for successful transfer from child-centred to adult-oriented healthcare. The need for a specific pan-European guideline for the transition of care for childhood cancer survivors has been recognised. The first step is to define the concept of transition of care for survivors of childhood cancer based on existing evidence.

A randomized trial to improve self-management practices of adults with asthma.

The prevalence and impact of adult asthma are substantial, and poor self-management practices, especially failures to adhere to treatment regimens, appear to be a significant problem. Desirable characteristics of an intervention program to improve self-management were identified through needs assessment and review of existing patient education resources. A comprehensive program was developed that integrated a workbook with one-to-one counseling and adherence-enhancing strategies. A longitudinal 1-year study compared patients receiving this self-management program with "usual care" patients receiving standard asthma pamphlets. Patients were randomly assigned to conditions. Baseline score and asthma severity were statistically controlled. Self-management patients had substantially better adherence than usual care patients, as well as improved functional status, at follow-up. Hospital and emergency department visits decreased in both groups but did not differ between groups.

Asthma self-management: do patient education programs always have an impact?

BACKGROUND: During the past 15 years, programs to improve self-management practices in adults with asthma have reported improvement in functional status and reduction of inappropriate use of health care services. However, these programs usually represent an ideal approach, applying multiple patient education methods. Consequently, when these programs are found to be efficacious, it is important to replicate the programs as well as to evaluate less complex methods that may be more appropriate for nonacademic health care settings. METHODS: We compared the following 3 standardized self-management treatments in a randomized, controlled trial: (1) a replication of the self-management program developed at a university medical center that was previously shown to be efficacious; (2) a modified version of this program including only the core elements; and (3) a usual-care program. Outcome measures included medication and inhaler regimen adherence, asthma symptoms, respiratory illness, functional status, and use of health care resources. RESULTS: All 3 groups improved on measures of respiratory illnesses, use of health care services, and functional status. Patients in both education groups did no better than the usual-care group. CONCLUSIONS: The results are inconsistent with the results of the first asthma self-management study at this institution and with those of efficacy studies of similar programs. Two factors, selection of the patient population and historical changes in asthma treatment, most likely contributed to the lack of impact of the self-management programs. As a result of the improved standards for usual care due to both factors, the opportunity to effect patient outcomes was substantially reduced.

Questionnaire study of canine neutering techniques taught in UK veterinary schools and those used in practice.

OBJECTIVES: To gather information about the different techniques employed in general practice and to compare this with current undergraduate teaching. This would provide an insight into any areas of discrepancy and influences on technique in practice. METHODS: A questionnaire was composed and distributed to 407 practices throughout the UK, using a commercial mailing list. Fifty further questionnaires were distributed by final-year students to their foster practices and five were sent to practices on request. A second questionnaire was composed and sent to the members of staff responsible for teaching surgical neutering techniques at each of the UK veterinary schools. RESULTS: Completed questionnaires were received from 183 respondents. These were compared with seven questionnaires from university teachers. Only areas in which the teachers reached a consensus of opinion were directly compared. CLINICAL SIGNIFICANCE: Several areas of discrepancy between current teaching and techniques in practice were identified. A study of complications compared with technique would provide further information. There is a lack of published material or an evidence base in many aspects of surgical neutering to support one technique over another.

Qualitative issues in developing educational diagnostic instruments and assessment procedures for diabetic patients.

With one exception, psychometric analyses of the quality of instrumentation and educational assessment procedures for diabetic patients have not been reported in the literature. Following an extensive internal review process, a pilot test of 56 diabetic patients found that the newly developed instrument had a high degree of internal consistency for the major indexes, 0.89 and 0.85, respectively. An item analysis found individual questions to be of an acceptable quality. An analysis of interrater reliability of patient assessment procedures produced an r = 0.93. Some support for content and concurrent validity was noted. Using an external review by an expert panel, a revised instrument and protocol was used to conduct a formal field test of 100 diabetic patients. Levels of internal consistency similar to the pilot, 0.87 adn 0.86, were found. An item analysis produced similar positive results. While some support for concurrent validity of the data was found, little support for discriminant validity was evident. The instrument and assessment procedures need to undergo more extensive and rigorous examination of its psychometric characteristics, particularly stability and predictive validity.

Characteristics and correlates of asthma in a university clinic population.

To contribute more comprehensive information about the characteristics of asthma, this article analyzed patients served by the University of Alabama at Birmingham Comprehensive Asthma Program. Their physicians rated one fifth of these patients as having "severe" asthma with the remainder about equally divided between "moderate" and "mild". One in two first received a diagnosis of asthma ten or more years previously. Common comorbidities were hypertension, obesity, rhinitis, bronchitis, sinusitis, and arthritis. One half had visited an emergency room or been hospitalized for asthma in the past year. Inhaled bronchodilators and continuous theophylline were the most commonly prescribed medications. Side effects, especially tachycardia and insomnia, were common and almost exclusively associated with theophylline or corticosteroid therapy. Spirometric assessment showed chronic airflow obstruction in those with more severe asthma. Prevalence of respiratory symptoms, intensity of medication regimen, incidence of side effects, and health care utilization increased as asthma severity increased.

The eradication of contagious bovine pleuropneumonia from south western Africa. A plan for action.

Contagious bovine pleuropneumonia (CBPP) caused by the Mycoplasma mycoides subspecies mycoides SC is one of the major plagues affecting cattle. With the imminent eradication of rinderpest from Africa, CBPP will become the major epidemic disease on the continent, because the majority of countries in sub-Saharan Africa have the infection in their cattle. There is an enclave of CBPP on the borders of Angola, Botswana, Namibia, and Zambia. There has been endemic infection in the cattle herds on the borders of Angola and Namibia for more than 100 years, with irregular spread from these animals to the cattle of Botswana or Zambia. However, much of Angola and Namibia and all of Botswana and Zambia are currently free from the disease. This paper explains the origins of the problem and describes the current disease situation. A plan for the eradication of CBPP from this area is proposed and discussed. If this plan is successful it will release valuable resources to tackle other constraints on livestock and food production. Furthermore, it will act as a model for the eradication of CBPP from the remainder of the continent.

Economic benefits of controlling internal and external parasites in South American camelids.

A trial was carried out in alpacas (Lama pacos) and llamas (Lama glama) to determine the economic benefits of controlling both external and internal parasites by the use of ivermectin ("Ivomec," Merck Sharp & Dohme). After four months the treated male alpacas gained on average 3.1 kg more than the untreated males, and their fleece weighed 0.36 kg more. The treated female alpacas gained 1.9 kg more than the controls, but their fleece weighed 0.03 kg less. This treatment gave a net financial benefit to the farmer of U.S. $3.54 for each of his male alpacas and U.S. $1.36 for each of his female alpacas. The results for the llamas were not significant because there was great variation in the weight gains (and losses). Because the value of llama fleece is less, the economic benefits were also less.

Contagious bovine pleuropneumonia. The costs of control in Central/southern Africa.

Contagious bovine pleuropneumonia (CBPP) caused by Mycoplasma mycoides subspecies mycoides small colony (M. mycoides) has been endemic in many parts of Africa for the greater part of this century. Because of an international vaccination campaign the disease was almost eliminated from the continent. With the deteriorating economic situation of many countries, vaccination programs have been allowed to slip; drought conditions have resulted in great movements of livestock and the disease has spread rapidly to the east and south. For Government Veterinary Departments, the implications of this resurgence of CBPP, are serious. The costs threaten to overwhelm completely under-funded government, services. Where cost-recovery measures are introduced, the charging for vaccines may damage rapport with communities and erode the credibility of the government services. Farmers may find the loss of cattle and the costs of vaccine severe burdens which threaten their livelihoods and social well-being (Zambia) and even, in extreme cases, their survival (Botswana). Controlling the disease today presents new possibilities which include increased cross-border collaboration (Malawi/Tanzania), increased emphasis on monitoring (N. Zambia) and the greater involvement of communities in disease control (W. Zambia).

Evaluation of the impact of dissemination of smoking cessation methods on the low birthweight rate and on health care costs: achieving year 2000 objectives for the nation.

Nationwide dissemination of efficacious and cost-effective smoking cessation methods during the 1990s represents an important part of the solution to reducing the low birthweight (LBW) rate and associated health care costs. A minimum of 250,000 LBW births must be prevented during the 1990s to achieve the year 2000 LBW rate objective of 5% of total births. Annually 1,500 to 6,000 LBW births might be prevented between 1991 and 2000, and cumulatively 29,000 to 44,000, by dissemination of tested smoking cessation methods. Twelve to eighteen percent of the objective might be accomplished by dissemination. LBW births attributable to smoking might be reduced from the current 20% to 26% rate to a rate of 9% to 12% if the overall maternal smoking prevalence rate is reduced to 10% as projected in the Year 2000 Objectives. Smoking-attributable health care cost savings from dissemination would range from $22 million to $59 million.

Standardizing contact investigation protocols.

SETTING: The State of Alabama Department of Public Health Division of Tuberculosis Control. OBJECTIVE: To standardize contact investigation protocols and implement an intervention to increase TB field worker adherence to the protocols with the goal of promoting efficiency and effectiveness in contact investigations. DESIGN: A process evaluation of existing data collection and management systems and protocols was performed. Standardized protocols and an intervention to increase TB field worker adherence to the protocols were created and pilot tested. These were then implemented and formative evaluation data were collected. RESULTS: The process evaluation revealed considerable variance among field workers with regard to protocols and definitions of variables related to contact investigations. Protocols were standardized and an intervention targeted at TB field workers was developed. The intervention consisted of a training workshop and the development of a computer-based contact investigation module. This was successfully implemented throughout the state. CONCLUSIONS: To perform effective contact investigations and conduct studies to improve the effectiveness of these investigations, TB control programs must pay careful attention to precisely defining variables and concepts related to the contact investigation. Furthermore, protocols must be standardized and resources devoted to training of TB field workers to ensure adherence to protocols.

Fracture healing in the rabbit fibula when subjected to various capacitively coupled electrical fields.

The effect of capacitively coupled electrical stimulation on the healing of midshaft transverse osteotomies of the rabbit fibula is assessed roentgenographically, mechanically, and histologically. The results show that a dose-response curve for capacitive coupling and fracture healing exists and that a 220 mV, 250 microA, 60 kHz applied electrical signal (0.33 V/cm internal electric field) is the most effective signal for fracture stimulation in this model.

Predictors of smoking cessation during pregnancy.

AIMS: The purpose of this study was to determine predictors of smoking cessation from a sample of pregnant Medicaid recipients. Of special interest was whether patient stage of change, based on the transtheoretical model, was predictive of smoking behavior change during pregnancy. PARTICIPANTS/SETTING: The sample was drawn from a cohort of pregnant smokers who were participants in a prospective, randomized clinical trial conducted in four public health maternity clinics in Birmingham, Alabama, USA. DESIGN/MEASUREMENTS: The 435 participants entered prenatal care on or before their 24th week of gestation and had saliva collected for cotinine assays at baseline and follow-up. In this secondary analysis, descriptive statistics defined the sample, cross-tabulation procedures identified a preliminary set of predictor variables, and discriminant function analyses predicted group membership--quitter or smoker. FINDINGS/CONCLUSIONS: Discriminant function analyses revealed that patient baseline cotinine value, duration of smoking habit, self-efficacy, exposure to environmental tobacco smoke, and exposure to patient education methods were predictive of non-smoking status assessed during the third trimester of pregnancy.

Prevalence of anabolic steroid use by male and female adolescents.

This study was performed to determine the prevalence of anabolic steroid use among male and female high school students. A total of 1,010 questionnaires were distributed in five high schools in a relatively affluent school district (Group I, 510 surveys with a 92.4% response rate) and five high schools in a relatively less affluent school district (Group II, 500 surveys with an 86.0% response rate). Three percent of all high school students reported using anabolic steroids: 5.0% of males and 1.4% of females. Among Group I students, 5.9% of all athletes reported using anabolic steroids, whereas only 1.5% of all Group II athletes admitted using them. A 10.2% usage of anabolic steroids among Group I male athletes was observed, but only 2.8% of Group II male athletes reported their use. The median age for anabolic steroid consumption was 17 yr. The primary source of anabolic steroids was the black market (85.2%), while physicians directly supplied anabolic steroids to only 7.4% of the adolescents. It appears that within the high school adolescent population, Group I male athletes are the primary consumers of these drugs, with a reported 10.2% prevalence.

Technical considerations of total knee arthroplasty after proximal tibial osteotomy.

Forty-five total knee replacements in forty-one patients who had continued to have progressive osteoarthritis after a proximal tibial osteotomy were evaluated prospectively. There were 51 per cent excellent, 29 per cent good, 4 per cent fair, and 16 per cent poor results after a minimum follow-up of two years. The resection of tibial bone that was produced by the osteotomy could not be related causally to the fair or poor clinical results that were found after arthroplasty. Radiographic study, however, showed that 80 per cent of the knees had patella infera before the arthroplasty, which may contribute to altered biomechanics of the patellofemoral joint of the arthroplasty. The procedure for total knee replacement is made more difficult by the previous osteotomy, and a custom-made prosthesis may be required. The clinical results that were obtained in this series are similar to those for the revision total knee arthroplasties that have been done at this institution, but they were not as satisfactory as those that were obtained after primary total knee replacement. Our results should be considered when a surgeon compares the advantages and disadvantages of proximal tibial osteotomy with those of total knee arthroplasty for an older patient who has unicompartmental osteoarthritis of the knee.