Dimple on the shoulder after a ski injury.

CLINICAL INTRODUCTION: A 74-year-old woman was brought to the ski clinic shortly after a fall on her left shoulder while skiing. She did not remember the exact fall mechanism. She felt a popping sensation in her left shoulder and was unable to move her left arm due to severe pain. Her medical and social histories were unremarkable. On physical examination, she had a deformity in her left shoulder (figure 1). Her neurovascular examination was intact.emermed;34/11/740/F1F1F1Figure 1Photograph of the left shoulder on arrival showing an anterior 'dimple'. QUESTION: What is the most likely diagnosis of the injury? An acromioclavicular joint (ACJ) sprain (shoulder separation)A proximal humerus fractureA distal clavicle fractureA posterior glenohumeral dislocation.

Systemic correction of a fatty acid oxidation defect by intramuscular injection of a recombinant adeno-associated virus vector.

Mitochondrial beta-oxidation of fatty acids is required to meet physiologic energy requirements during illness and periods of fasting or physiologic stress, and is most active in liver and striated muscle. Acyl-CoA dehydrogenases of varying chain-length specificities represent the first step in the mitochondria for each round of beta-oxidation, each of which removes two-carbon units as acetyl-CoA for entry into the tricarboxylic acid cycle. We have used recombinant adeno-associated virus (rAAV) vectors expressing short-chain acyl-CoA dehydrogenase (SCAD) to correct the accumulation of fatty acyl-CoA intermediates in deficient cell lines. The rAAV-SCAD vector was then packaged into either rAAV serotype 1 or 2 capsids and injected intramuscularly into SCAD-deficient mice. A systemic effect was observed as judged by restoration of circulating butyryl- carnitine levels to normal. Total lipid content at the injection site was also decreased as demonstrated by noninvasive magnetic resonance spectroscopy (MRS). SCAD enzyme activity in the injected muscle was found at necropsy to be above the normal control mouse level. This study is the first to demonstrate the systemic correction of a fatty acid oxidation disorder with rAAV and the utility of MRS as a noninvasive method to monitor SCAD correction after in vivo gene therapy.

Management of mild-to-moderate osteoarthritis: a study of the primary care perspective.

OBJECTIVES: Examine the knowledge, attitudes, and practice patterns of primary care clinicians regarding the management of mild-to-moderate osteoarthritis (OA). DESIGN: Case vignette-based survey. METHODS: A survey was distributed to 251 physicians, physician assistants (PAs), and nurse practitioners (NPs) in the primary care setting. The survey assessed practice patterns in the management of patients with mild-to-moderate OA, as well as attitudes toward guidelines and future educational topics that may be of benefit to the clinician. RESULTS: We found that primary care clinicians are most likely to treat mild-to-moderate OA with an oral nonsteroidal anti-inflammatory drug regimen. Patients with initial or recurrent OA were "very likely" to be recommended to a physical therapy maintenance program. Two-thirds of respondents claimed to be unfamiliar with Osteoarthritis Research Society International guidelines for OA management. CONCLUSION: This study reflects the need for further education for primary care physicians, NPs, and PAs on the management of OA.

Sports-related injuries in the United States: who gets care and who does not.

OBJECTIVE: To describe the pattern of sports-related injuries (SRIs), healthcare obtained for these injuries, and factors associated with obtaining healthcare. DESIGN AND SETTING: Retrospective analysis of the adult subgroup within the Medical Expenditures Panel Survey dataset from 1996 to 2001, which is weighted to represent all noninstitutionalized US residents. PARTICIPANTS: Survey participants (2996) aged 0 to 64 years reporting an SRI. MAIN OUTCOME MEASUREMENT: Whether healthcare was obtained for an SRI. RESULTS: A weighted estimate of 6.7 million individuals reported an SRI annually. Two million individuals (30%) did not obtain healthcare for an SRI. Twenty-four percent of those with "serious" injuries did not obtain healthcare. Predictors of obtaining healthcare include the following: an upper extremity injury [adjusted odds ratio (OR) 1.57, 95% confidence intervals (CI): 1.17, 2.10]; a "very or somewhat serious" injury (adjusted OR 1.64, 95% CI 1.24, 2.17); and one SRI versus >1 SRI (adjusted OR 1.37, 95% CI: 1.06, 1.78). Predictors of not obtaining healthcare for an SRI include the following: Black race (adjusted OR 0.59, 95%CI: 0.44, 0.79); no health insurance (adjusted OR 0.45, 95%CI: 0.33, 0.63); and no usual source of care (adjusted OR 0.71, 95% CI: 0.56, 0.91). CONCLUSIONS: SRIs are common and often patients do not obtain healthcare for these injuries. Among Americans with an SRI, those who are Black, and those who lack insurance or a usual source of care, are at risk for not obtaining care for an SRI. Not obtaining healthcare and lacking knowledge about the consequences of sports injury may lead to unnecessary, additional morbidity and cost. Education targeted at these groups, at their physicians, and at policymakers may help reduce untreated SRIs.

Solar Injury and Heat Illness.

In brief Children are particularly susceptible to solar injury to the skin and eyes and to heat illness-heat cramps, heat exhaustion, and heatstroke. Because sunburn during childhood is linked to subsequent skin cancer, aggressive prevention through use of sunscreens and other protective measures is critical. Physicians should screen for risk factors for heat illness, such as hypohydration, obesity, poor conditioning, and certain illnesses. Heat illness can be effectively prevented through acclimation, proper hydration, and advance event planning.