An internet based approach to improve general practitioners' knowledge and practices: the development and pilot testing of the "ABC's of vitamin D" program.

BACKGROUND: Online continuing medical education (CME) offers a number of advantages for physicians including flexibility with regards to location and timing of use. In order to effect physician practices and improve patient outcomes, it is important that the development of online CME is theory and evidence-based. OBJECTIVES: This paper aims to describe the development of an online CME program for practising general practitioners (GPs) on vitamin D and sun health called "The ABC's of Vitamin D for GPs" using elements of design principles for physician-education web sites as a framework. The paper will also report the program's usability and acceptability pilot test results. METHODS: The ABC's of Vitamin D program was developed following nine principles: needs assessment; evidence-based content development; multimodal program and modularisation; clinical cases; tailoring and interactivity; audit and feedback; credibility of the web site host; patient education materials; ease of use and navigation. Among the 20 GPs invited, acceptability and useability was tested with 12 GPs (60%) who agreed to participate and were interviewed following use of the program. The study was conducted between 2011 and 2013. RESULTS: An online CME program consisting of eight modules was constructed. Of the 12 participating GPs, most (n=11) reported that the program was clear and easy to understand, logical, easy to navigate, and took a reasonable amount of time (estimated between 1 and 3h) to complete. Eleven of 12 participants said they would use the program as an accredited CME activity and all participants indicated that the program was 'very or somewhat' likely to lead to changes in the advice patients are given. CONCLUSION: This study found that a theory and evidence based approach for the development of an online CME program for GPs was acceptable to users. Further research is needed to examine whether the online CME program is effective at changing GP practices and improving patient outcomes.

Características epidemiológicas del cáncer de mama en el área metropolitana de Buenos Aires y La Plata. Estudio de una serie de 4.041 casos del Registro de Cáncer de Mama (RCM) / Epidemiological aspects of breast cancer in metropolitana area of Buenos Aires and La Plata. Study of 4.041 patients of breast cancer registry (RCM)

Introducción: En la Argentina se estima que se detectan más de 18.000 casos nuevos de cáncer de mama por año; sin embargo, en nuestro país no contamos con registros de dicha patología que posean poder estadístico adecuado. Por este motivo, desde la Sociedad Argentina de Mastología surgió el interés de crear una base de datos. Aquí presentamos el análisis de los datos recabados de la misma luego de 2 años de su implementación en distintos centros de atención de Mastología del Área Metropolitana de la Ciudad de Buenos Aires (AMBA). Objetivo: Describir las características epidemiológicas de las pacientes atendidas en los centros participantes, así como la presentación clínica, estadio y tratamiento instaurado. Material y método: Estudio descriptivo, de corte transversal, donde se analizaron los datos ingresados hasta el día 30/09/2012, en la base de web "registro de cáncer de mama" (RCM), de 4.041 pacientes. Dichos datos fueron ingresados por los dieciséis centros participantes hasta ese momento, todos ellos ubicaodos en el AMBA y la ciudad de la Plata. Resultados: El 99,6% de los pacientes fue de sexo femenino, con una media de edad 57,7±13,2 años. Se registró una media de edad de aparición para la menarca de 12,5±1,4 años y de 48,6±4,1 años para la menopausia. El 68,8% de las pacientes eran posmenopáusicas. El 20,3% de las pacientes era nulípara. El 19,3% presentó el antecedente heredo-familiar de cáncer de mama. El principal motivo de consulta registrado fue el de autodetección sospechosa 54,3%. La distribución del estadio clínico fue la siguiente: estadio 0 11,6%; estadio I 40,6%; estadio II 36,5%; estadio III 10,3% y estadio IV 1,0%. En el 69,4% se realizó resección sectorial como cirugía mamaria. Antes del año 2000 predominó la linfadenectomía axilar (67,9%), luego de esta fecha la frecuencia de indicación del ganglio centinela pasó a aplicarse al 63,6%.

Comparison of 13C- urea blood test to 13C-breath test and rapid urease test for the diagnosis of Helicobacter pylori infection / Comparación entre el test de urea marcada con 13C- en sangre, test de urea marcada con 13C- en aire espirado y el test rápido de ureasa para el diagnóstico de la infección por Helicobacter pylori

At present, the available methods to diagnose active H. pylori infection are endoscopy with biopsy for histology, culture, rapid urease tests, 13C or 14C urea breath test, urine antibody and the stool antigen test. The aims of this study were to simplify the 13C urea test by measuring 13C in blood rather than breath, and to evaluate the usefulness of the 13C urea blood test for the diagnosis of H. pylori infection. Patients who underwent upper endoscopy for standard clinical indications (e.g. dyspepsia, abdominal pain) were enrolled. A total of 161 patients (93F, 68M, mean age 47 +/- 14.2) were evaluated; 50 (31%) of them were H. pylori positive, and 111(69%) were H. pylori negative. H. pylori infection was diagnosed with a rapid urease test (CLO-test) and 13C urea breath test (UBT). Performance characteristics for the 13C urea blood test for diagnosis and evaluation of H. pylori eradication were calculated using UBT and CLO as gold standards. The fifty H. pylori-positive patients were treated with triple antibiotic therapy for two weeks. Four weeks after finishing antibiotic therapy patients were retested with a commercial UBT and urea blood test. The 13C blood test had sensitivities of 92 and 98% and specificities of 96 and 100% as compared with urea breath test and CLO, respectively. We conclude that the 13C urea blood test is highly sensitive and specific for the initial diagnosis and control of eradication of H. pylori infection.

Los métodos diagnósticos disponibles para la identificación de la infección activa por H. pylori son endoscopia con biopsia para histología, test rápido de ureasa y/o cultivo, test del aire espirado con urea marcada con 13C o 14C, anticuerpos anti- H. pylori en orina y test de antígeno en materia fecal. La finalidad del presente estudio fue simplificar el test de aire espirado con urea marcada con 13C, midiendo 13C en sangre en vez de en el aire espirado y evaluar su eficacia para el diagnostico de la infección por H. pylori. Pacientes a los que se les realizó esofagogastroduodenoscopía con indicaciones de dispepsia y/o dolor abdominal fueron incluidos en el estudio. 161 pacientes (93 del sexo femenino y 68 masculino, edad media 47±14.2) fueron evaluados; 50 (31%) de ellos fueron H. pylori positivos, y 111 (69%) fueron negativos. La infección por H. pylori fue diagnosticada con test rápido de ureasa y test del aire espirado on urea marcada con 13C. Usando estos tests como referencia, se evaluó la eficacia del test de sangre con urea marcada con 13C para el diagnóstico y evaluación de la erradicación del H. pylori. Los 50 pacientes positivos para la infección con H. pylori fueron tratados con triple plan de antibióticos por 2 semanas. Cuatro semanas luego de finalizado dicho tratamiento, los pacientes fueron nuevamente testeados con test de aire espirado con urea marcada con 13C y urea marcada con 13C en sangre. El test en sangre con urea marcada con 13C tuvo sensitividad de 92% y 98% y especificidad de 96% y 100% comparado con UBT y test de ureasa respectivamente. Concluimos que el test en sangre con urea marcada con 13C es altamente sensible y especifico para diagnostico inicial y control de la erradicación de la infección por H. pylori.

A new method to account for the depth distribution of 137Cs in soils in the calculation of external radiation dose-rate.

This work reports a new method for calculating the external dose-rate as a function of height above land that has been contaminated with a surface deposition of (137)Cs. Unlike previous work this method accounts for vertical migration of (137)Cs using the Advection Dispersion Equation (ADE) with appropriate parameters. The results have been successfully verified with field measurements from the (137)Cs contaminated regions within the Republic of Belarus. The method also correctly predicts the observed variation of dose-rate with elevation above the soil surface and it is shown how this method can be used to predict the reduction in surface dose-rate after remediation measures such as deep ploughing have taken place.

Tibiotalocalcaneal arthrodesis.

The purpose of this multicenter retrospective study of 55 patients (56 ankles) who underwent simultaneous tibiotalocalcaneal arthrodesis with severe disease involving the ankle and subtalar joints was to determine improvement of pain and function. The surgical indications included osteoarthritis, posttraumatic injury, failed previous surgery, talar avascular necrosis, osteoarthritis, and rheumatoid arthritis involving the ankle and subtalar joints. The average age at the time of the operation was 53 years. The average time of follow-up was 26 months after the operation. Fusion was achieved in 48 ankles, with an average time of fusion of 19 weeks. Forty-eight of the 55 patients were satisfied with the procedure. The average leg length discrepancy was 1.4 cm. The average amount of dorsiflexion was 2 degrees and plantar flexion was 5 degrees. Following surgery, 42 patients complained of pain, 40 patients required shoe modification or an orthotic device, and 34 patients had a limp. Fourteen patients described their activity as unlimited. Based on the AOFAS evaluation, the patients scored an average of 66 on the ankle-hind foot scale following surgery. The most common complications were nonunion (8 ankles) and wound infection (6 ankles). This study demonstrates that tibiotalocalcaneal arthrodesis is an effective salvage procedure for patients with disease both involving the ankle and subtalar joints.

Role of metatarsus primus elevatus in the pathogenesis of hallux rigidus.

Metatarsus primus elevatus has been suggested as a primary causative factor in the pathogenesis of hallux rigidus. The purpose of this investigation was to define the role of elevation of the first ray in the pathogenesis of hallux rigidus by comparing patients with known hallux rigidus with a control population. We reviewed 264 lateral weightbearing radiographs from 81 patients with hallux rigidus, 50 asymptomatic volunteers, and 64 patients diagnosed with isolated Morton's neuroma. Results revealed that the mean values for elevation of the first ray in patients with mild or moderate hallux rigidus were nearly identical to those in the control group. Patients with advanced radiographic hallux rigidus had a slightly higher mean value for metatarsus primus elevatus. An average of nearly 8 mm of metatarsus primus elevatus is a normal finding in patients with hallux rigidus as well as in normal subjects. This investigation did not address the clinical outcome or biomechanical effects of a plantarflexion osteotomy of the first ray. However, on the basis of the finding that first ray elevation is normal, it seems unlikely that a plantarflexion osteotomy would have a role in the treatment of hallux rigidus.

Role of the peroneal tendons in the production of the deformed foot with posterior tibial tendon deficiency.

Ten patients were identified with traumatic, complete common peroneal nerve palsy, with no previous foot or ankle surgery or trauma distal to the knee, who had undergone anterior transfer of the posterior tibial tendon to the midfoot. Six of these patients had a transfer to the midfoot and four had a Bridle procedure with tenodesis of half of the posterior tibial tendon to the peroneus longus tendon. Average follow-up was 74.9 months (range, 18-351 months). All patients' feet were compared assessing residual muscle strength, the longitudinal arch, and motion at the ankle, subtalar, and Chopart's joint. Weightbearing lateral X-rays and Harris mat studies were done on both feet. In no case was any valgus hindfoot deformity associated with posterior tibial tendon rupture found. It seems that the pathologic condition associated with a posterior tibial tendon deficient foot will not manifest itself if peroneus brevis function is absent.

Isolated subtalar arthrodesis.

Forty-eight isolated subtalar arthrodeses in 44 patients with an average follow-up of 59.5 months were retrospectively reviewed. Original diagnoses included talocalcaneal coalition, healed calcaneal fracture with subtalar arthrosis, acquired flatfoot because of posterior tibial tendon dysfunction, degenerative subtalar arthrosis, subtalar instability, and psoriatic arthritis. Ninety-three percent of patients were very satisfied or satisfied with their treatment. Pain and function improved significantly, and the American Orthopaedic Foot and Ankle Society ankle-hindfoot score at follow-up was 89. There were six unsatisfactory results: three feet had calcaneal fractures and three were malpositioned. Union was achieved in all cases. Transverse tarsal motion was diminished by 40%, dorsiflexion by 30%, and plantarflexion by 9%. There was a 36% and 41% incidence of mild radiographic progression of arthrosis in the ankle and transverse tarsal joint, respectively. Isolated subtalar arthrodesis provided a highly successful result in the disease presented, and this study provides support for the use of a selected hindfoot fusion procedure for specific indications.

Effect of calcaneal osteotomy and lateral column lengthening on the plantar fascia: a biomechanical investigation.

Medial calcaneal displacement osteotomy or lateral column lengthening fusion has been advocated to augment tendon transfer in planovalgus foot deformity associated with chronic posterior tibial tendon insufficiency. It is hypothesized that plantar fascia tightening occurs with these procedures, helping to restore a more normal longitudinal arch. To investigate this further, nine fresh-frozen cadaver below-knee specimens were used. A flatfoot model was created by sectioning of the posterior tibial tendon, spring ligament, talonavicular capsule, and deltoid ligament. A liquid-metal strain gauge, calibrated to measure fractional changes in length, was sutured proximally to the origin and distally into the thickest portion of the medial band of the plantar fascia. Specimens were axially loaded to 400 N and plantar fascia strain was measured. Fractional length changes in the plantar fascia were then measured after a medial displacement calcaneal osteotomy and after a lateral column lengthening through the calcaneocuboid joint. Tightening of the plantar fascia did not occur with either medial calcaneal displacement or lateral column lengthening. The plantar fascia became significantly less taut with both medial displacement and lateral column lengthening. We found that lateral column lengthening produced significantly looser plantar fascia than did medial displacement of the calcaneal tuberosity.

Radiographic and clinical classification of acquired midtarsus deformities.

To develop a classification of midtarsus deformities, clinical examination and weightbearing radiographs were used to evaluate 131 feet in 109 patients (average age, 59+/-11 years) with those deformities. Patients were classified into four types based on anatomic location of the maximum deformity. Type I (N=43) showed deformity at the metatarsocuneiform joints medially and the fourth and fifth metatarsocuboid joints laterally, with plantarmedial and/or medial prominence. Type II (N= 60) had deformity at the naviculocuneiform joint medially and the fourth and fifth metatarsocuboid joints laterally; plantarlateral prominence was characteristic, although one-third had isolated or additional medial prominences. Type III (N=17) had major deformity in the perinavicular region, with a prominence plantarcentrally or plantarlaterally. Type IV (N=11) had deformity at the transverse tarsal joints with variable prominences. Each type was further subdivided into stages A, B, and C based on the severity of the deformity. In stage B, the midtarsus was coplanar with the metatarsocalcaneal plane. In stage A, the midtarsus was above this plane. In stage C, the midtarsus was below this plane. We concluded that midtarsus deformities can be classified as one of four types and one of three stages. Additional study is warranted to correlate this system with prognosis and treatment for this pathologic process.

Late results of subtalar distraction fusion.

Between 1990 and 1994, 15 subtalar distraction fusions were performed on 14 patients for sequelae of calcaneus fractures. Twelve patients (13 feet) were available for a minimum 2-year follow-up and constituted the composition of this study. All patients complained of lateral ankle pain and had CT evidence of calcaneofibular abutment and radiographic evidence of loss of heel height preoperatively. The average age at time of surgery was 56 years (range, 23-81 years), and the average follow-up was 47 months (range, 25-75 months). The only change in surgical technique from that previously described was the use of a bone spreader rather than a femoral distractor for distraction of the subtalar joint. The average preoperative talocalcaneal angle improved from 27 degrees range, 19-37 degrees) to 33 degrees (range, 23-45 degrees) postoperatively (P < 0.003). The mean talar declination angle improved from 11 degrees (range, 6-18 degrees) to 16 degrees (range, 7-27 degrees) postoperatively (P < 0.003). The mean heel height increased from 71 mm (range, 60-83 mm) to 76 mm (range, 63-91 mm) postoperatively (P < 0.0001). All patients completed the AOFAS Ankle-Hindfoot scale at latest follow-up, and the average score was 76.1 (range, 57-94). Eleven of 13 outcomes were rated as very satisfactory or satisfactory. Twelve of 13 said they would 'definitely yes" do surgery again. We have found that subtalar distraction fusion for late complications of calcaneus fracture in a carefully selected population can provide a consistent and satisfactory outcome.

Management of the foot and ankle in rheumatoid arthritis.

Rheumatoid arthritis frequently involves the foot and ankle, resulting in pain, deformity, and difficulty with ambulation. This article outlines clinical, radiographic, and gait evaluation in the management of foot and ankle problems in rheumatoid arthritis. Conservative nonsurgical management of foot deformities is presented including available shoewear and orthotic options. Surgical considerations including indications, biomechanic implications, and specific operative procedures are discussed.

Popliteal sciatic nerve block for postoperative analgesia.

Eighty-six patients were evaluated prospectively following the placement of a sciatic nerve block in the popliteal fossa after a major foot or ankle operation. Needle placement was guided by a peripheral nerve stimulator and 30 ml of 0.5% bupivacaine with epinephrine was used. Ninety-seven percent of patients had a successful block. Only one patient had severe discomfort during the block placement. The block lasted an average of 20 hours. During the first 24 hours after surgery, patients took an average of three hydrocodone tablets. Twenty-two of the 23 patients who had had previous major foot or ankle surgery found that the block was better than their previous pain control regimen. No patient had complications related to the block and 95% were satisfied and would have the block again.

Epiphysiodesis of the lower extremity: results of the percutaneous technique.

The results of 42 percutaneous epiphysiodeses of the lower extremity in 26 patients are reported. All patients achieved physeal arrest radiographically and clinically. No patient developed angular deformity from incomplete arrest. No neurovascular complications or fractures occurred. The average hospital stay for patients undergoing epiphysiodesis alone was 1 day. Percutaneous epiphysiodesis of the lower extremity provides a reliable and safe technique for growth plate arrest. The advantages of this technique include a cosmetic scar, short hospital stay, low incidence of complications, and reliable physeal arrest.

Femoral pulse as a guide to the mechanical axis in total knee arthroplasty.

The anatomic relationship of the center of the femoral head to the femoral artery was studied in 140 hips in 70 patients. The coronal plane distance between the femoral artery 2.5 cm below the inguinal ligament and the center of the femoral head was measured on pelvic arteriograms. The femoral artery was found an average of 7.7 +/- 5 mm medial (range, -3-22 mm) to the center of the femoral head. The femoral artery was within 15 mm of the center of the femoral head in 93% of cases reviewed. A 76-cm theoretical mechanical axis was used in estimating clinical angular changes in the axis for a given coronal plane difference. By use of this model, the range of variability translates into a maximum change in the mechanical axis of 1.66 degrees and up to only 1.2 degrees in 95% of the cases reviewed. A marker placed just lateral to the palpable femoral pulse approximately 2 to 3 cm below the inguinal ligament is suitable as a guide to locate the center of the femoral head when determining the mechanical axis during total knee arthroplasty.

Triple arthrodesis with lateral column lengthening for treatment of severe planovalgus deformity.

Triple arthrodesis with lateral column lengthening through the calcaneocuboid joint was performed on 22 feet in 14 patients. The primary indication for surgery was severe symptomatic planovalgus deformity unresponsive to conservative measures. All patients achieved solid fusion within 12 weeks. No patient had no decline in ambulatory status. Excellent correction of deformity was achieved and maintained with an average correction of the talus first metatarsal angle of 25 degrees in both the AP and lateral planes. Triple arthrodesis with lateral column lengthening provides for reliable arthrodesis and allows correction of severe planovalgus deformity while maintaining foot length.

Effects of carbohydrate supplementation during intense training on dietary patterns, psychological status, and performance.

The purpose of this study was to determine the effects of carbohydrate supplementation during intense training on dietary patterns, psychological status, and markers of anaerobic and aerobic performance. Seven members of the U.S. National Field Hockey Team were matched to 7 team counterparts (N = 14). One group was blindly administered a carbohydrate drink containing 1 g.kg-1 of carbohydrate four times daily, while the remaining group blindly ingested a flavored placebo during 7 days of intense training. Subjects underwent pre- and posttraining aerobic and anaerobic assessments, recorded daily diet intake, and were administered the Profile of Mood States (POMS) psychological inventory prior to and following each practice. Results revealed that the carbohydrate-supplemented group had a greater (p < .05) total energy intake, carbohydrate intake, and change (pre vs. post) in time to maximal exhaustion following training while reporting less postpractice psychological fatigue. However, no significant differences were observed in remaining psychological, physiological, or performance-related variables.

Determination of sulfadimethoxine withdrawal time from milk. Part I: Dosing, sampling, and assay.

This study was undertaken to determine whether present regulations for discarding milk from cows treated with sulfadimethoxine (SDM) can be supported by modern analytical methodology. Two groups of milking cows (10 in first group; 11 in the second) were treated orally with SDM at the recommended dose levels for 5 days. The SDM concentration in the milk was determined with 4 methods (Charm Inhibition Assay [CIA], Charm II, enzyme linked immunosorbent assay, and liquid chromatography) during the treatment and the subsequent withdrawal periods. The results of the 4 assays were compared.

Composition, preservation, and use of sea clam viscera as a protein supplement for growing pigs.

Use of surf clam viscera as an animal feed was assessed by measuring nutrient content, susceptibility to spoilage, preservation with organic acid, and replacement value for soybean meal when fed to growing pigs. Viscera exiting the processing plant averaged 88% moisture and 71% CP in DM. Amino acid contents (51% in DM) and profiles were similar to those of soybean meal. Storage and feeding quality of wet viscera could be maintained up to 3 wk by adding formic or propionic acid (3.5%, wt/wt). Pigs readily ate corn-based diets containing wet viscera preserved with propionic acid. Growth rate was similar for pigs from 18 kg to market weight (92 kg) when soybean meal and(or) clam viscera were fed as protein supplements. However, cooked loin roasts from pigs fed one-half or all supplemental protein from viscera (5 or 10% viscera in diet DM) had distinctive fishy aromas. To produce acceptable pork, future studies must identify lower dietary levels or withdrawal periods for viscera.