Impact of the Choose Well Initiative on Contraceptive Access at Federally Qualified Health Centers in South Carolina: A Midline Evaluation.

Choose Well (CW) is a statewide contraceptive access initiative to reduce unintended pregnancy among patients utilizing federally funded family planning services. We examined CW's impact on contraceptive access at South Carolina federally qualified health centers from 2016 to 2019, which reported significantly higher increases in providing the full range of contraceptive methods and training onsite. CW prioritized ensuring change sustainability through obtaining funding and institutionalizing changes. (Am J Public Health. 2023;113(11):1167-1172. https://doi.org/10.2105/AJPH.2023.307384).

Association of Health Insurance with Contraceptive Use and Interpersonal Quality of Contraceptive Care in the Southeast United States.

OBJECTIVES: Health insurance remains an important dimension of contraceptive access. This study investigated the role of insurance in contraceptive use, access, and quality in South Carolina and Alabama. METHODS: The study used a cross-sectional statewide representative survey that assessed reproductive health experiences and contraceptive use among reproductive-age women in South Carolina and Alabama. The primary outcomes were current contraceptive method use, barriers to access (inability to afford wanted method, delay/trouble obtaining wanted method), receipt of any contraceptive care in the past 12 months, and perceived quality of care. The independent variable was insurance type. Generalized linear models were applied to estimate prevalence ratios for each outcome's association with insurance type while adjusting for potentially confounding variables. RESULTS: Nearly 1 in 5 women (17.6%) was uninsured, and 1 in 4 women (25.3%) reported not using a contraceptive method at the time of the survey. Compared with women with private insurance, women with no insurance had a lower likelihood of current method use (adjusted prevalence ratio 0.75; 95% confidence interval 0.60-0.92) and receipt of contraceptive care in the past 12 months (adjusted prevalence ratio 0.61; 95% confidence interval 0.45-0.82). These women also were more likely to experience cost barriers to access care. The insurance type was not significantly associated with the interpersonal quality of contraceptive care. CONCLUSIONS: Findings highlight the need for expanding Medicaid in states that did not do so under the Patient Protection and Affordable Care Act, interventions to increase the number of providers who accept Medicaid patients, and protections to Title X funding as key elements for enhancing contraceptive access and population health outcomes.

Increased postoperative glycemic variability is associated with increased mortality in diabetic patients undergoing hip arthroplasty for hip fracture.

BACKGROUND: Increased glycemic variability (GV) during hospitalization has been associated with increased rates of surgical site and periprosthetic joint infections (PJI) following elective total joint arthroplasty. Uncertainty exists surrounding GV as a predictor for complications in urgent arthroplasty cases following hip fractures. In this study, we evaluated the association between GV and postoperative complications in diabetic patients undergoing total hip arthroplasty (THA) and hemiarthroplasty (HA) for hip fractures. METHODS: We analyzed data on 2421 consecutive patients who underwent THA or HA at our institution from 2011 to 2020. Patients with a known diagnosis of diabetes mellitus who had a minimum of three postoperative glucose values taken within the first week after surgery were included. GV was assessed using a coefficient of variation. Outcomes included short- and long-term mortality, reoperations, prosthetic joint infection (PJI) requiring revision and readmissions for any cause. RESULTS: The final cohort consisted of 482 patients (294 females, 188 males). Higher GV was associated with an increased 90-day mortality (p = 0.017). GV was not associated with 30-day mortality (p = 0.45), readmissions of any cause at 30 or 90 days (p = 0.99, p = 0.91, respectively), reoperation of any cause (p = 0.91) or PJI requiring revision surgery (p = 0.42). CONCLUSIONS: Higher GV in the postoperative period is associated with increased rates of mortality in diabetic patients following THA and HA for hip fractures. Efforts should be made to monitor and control glucose variability in the postoperative period.

Increases in IUD Provision at Alabama Department of Public Health Clinics From 2016 to 2019.

The Alabama Department of Public Health (ADPH) began allocating Title X funding to intrauterine device (IUD) provision at family planning clinics in 2019, instated more training opportunities, and expanded nurse practitioner scope of practice to include IUD placements. We assessed IUD provision and protocols at ADPH Title X clinics in 2016 and 2019 before and after ADPH policy changes. Generalized binomial regression models assessed differences between years. The proportion of ADPH clinics reporting offering any IUD on-site increased by 61.6 percentage points ( P < .001), stockpiling IUDs on-site increased by 85.9 percentage points ( P < .001), IUD placement/removal training increased by 71.4 percentage points ( P < .001), and same-visit IUD placement trainings increased by 64.1 percentage points ( P < .001). Advanced practice nurses were significantly more likely to place IUDs in 2019 compared with 2016 ( P < .001). These findings highlight the positive impact of policy changes related to Title X funding allocation and scope of practice on provision of a full range of contraceptive methods. These changes in policies and practices at the state and local levels within ADPH have expanded the availability of the full range of contraceptive options across the state of Alabama. This expanded access to contraceptive options is especially important given the rapid changes in reproductive health policies occurring in Alabama and across the United States.

High Compliance With Choosing Wisely Breast Surgical Guidelines at a Safety-Net Hospital.

BACKGROUND: Professional organizations recently set guidelines for avoiding surgeries of low utility and overutilization for the Choosing Wisely campaign. These include re-excision for invasive cancer close to margins, double mastectomy in patients with unilateral breast cancer, axillary lymph node dissection in patients with limited nodal disease, and sentinel lymph node biopsy (SLNB) in patients ≥70 years with early-stage breast cancer. Variable adherence to these recommendations led us to evaluate implementation rates of low-value surgical guidelines at a safety-net hospital. METHODS: We retrospectively analyzed breast cancer patients who underwent surgery from 2015 to 2020. Each patient was assessed for eligibility for omission of the listed surgeries. Trends were evaluated by cohorts before and after a fellowship-trained breast surgeon joined the faculty in 2018. Outcomes were compared using Fisher's exact test. RESULTS: Among 195 patients, none underwent re-excision for close margins of invasive cancer. Only 6.7% of patients (3/45) received contralateral mastectomy and 1.8% of eligible patients (3/169) received axillary lymph node dissection. Overall, 60% of patients ≥ 70 years with stage 1 hormone-positive breast cancer (9/15) received SLNB. There was a downward trend from 71% of eligible patients receiving SLNB in 2015-2018 to 50% in 2019-2020. CONCLUSIONS: De-implementation of traditional surgical practices, deemed as low-value care, toward newer guidelines is achievable even at community hospitals serving a low socioeconomic community. By avoiding overtreatment, hospitals can achieve effective resource allocation which allow for social distributive justice among patients with breast cancer and ensure strategic use of scarce health economic resources while preserving patient outcomes.

Contraception Use and Pregnancy Outcomes for Alabama Medicaid Enrollees: A Baseline Analysis Using 2012-2017 Data.

OBJECTIVES: Access to the full range of contraceptive methods, including long-acting reversible contraception (LARC), is key for preventing unintended pregnancies and improving health outcomes. In 2019, Alabama Medicaid started paying for LARC devices for postpartum women. In anticipation of evaluating the impact of this programmatic change, we conducted a baseline study exploring contraception use and pregnancy-end outcomes for enrollees before the change. METHODS: A retrospective cohort of women enrolled in Alabama Medicaid from 2012 to 2017 was examined. Outcomes include pregnancy-end events for all enrollees, teen pregnancy-end events, and short-interval (SI) pregnancy-end events. Pregnancy events in year t are matched to contraception in year t - 1. Contraception is categorized as "no evidence," short-acting contraception (SAC), LARC, and sterilization. Bivariate and multivariate models were estimated. RESULTS: Our final sample included 135,807 unique women who contributed 258,959 person-years. There was no evidence of contraception for 55.4% and evidence of SAC, LARC, and sterilization for 36.4%, 6.2%, and 2.0%, respectively. Relative risks for pregnancy-end events for SAC and LARC users were 0.63 (95% confidence interval [CI] 0.61-0.0.65) and 0.56 (95% CI 0.52-0.0.59), respectively, compared with women with no evidence of contraceptive use. For teen pregnancy-end events, relative risks for SAC and LARC users were 0.65 (95% CI 0.61-0.67) and 0.58 (95% CI 0.51-0.66), respectively. For SI pregnancy-end events, relative risks for SAC and LARC users were 0.71 (95% CI 0.68-0.76) and 0.40 (95% CI 0.34-0.46), respectively. CONCLUSIONS: LARC and SAC are associated with lower likelihood of pregnancy-end events compared with no evidence of contraception, and on average, LARC is associated with lower relative risk than SAC, especially for SI pregnancy-end events.

Would giving priority in surgery timing to the oldest patients result in lower mortality?

PURPOSE: Early hip fracture surgery in elderly patients is recognized as a positive prognostic factor. When applied as an intervention, it does not always reduce overall patient mortality. A plausible explanation for this is that not all patients equally benefit from early surgery. The purpose of the study is to investigate the effect of early surgery on mortality in patients ages 80 and older. METHODS: This is a retrospective cohort of 3463 patients with hip fractures, operated upon within seven days of admission in a tertiary medical center between 2010 and 2018. Patients were divided into five groups: ages 80-84, 85-89, 90-94, 95-99, and 100 or above. Baseline characteristics were compared between groups. Mortality at one year post-operatively as a function of surgery delay was visualized for each group, using restricted spline curve analysis. RESULTS: Patients with increasing age were operated on earlier, had increased co-morbidities with a higher ASA score and experienced higher mortality. Spline curve analysis in younger patients, ages 80 to 94, demonstrated an inflection point at 48 hours after admission, prior to which mortality was rising rapidly and after which it continued rising slowly. In the two oldest age cohorts, there was no increased mortality with an increasing surgical delay. CONCLUSIONS: In patients ages 80-94 surgery on day one may be preferable to surgery on day two. In patients ages 95 and older, surgery time did not influence mortality. Pursuit of better patient outcomes may include prioritizing early surgery in younger patients.

Addressing posterior tilt displacement during surgery to lower failure risk of sub-capital Garden types 1 and 2 femoral fractures.

INTRODUCTION: Sub-capital femoral fractures (SCFF) are impacted or non-displaced in Garden types 1 and 2, respectively. Non-surgical treatment is protected weight-bearing combined with physiotherapy and radiographic follow-up in selected patients. Traditionally, in situ pinning is the surgical treatment of choice. The aim of this study was to estimate whether the valgus deformity in Garden types 1 and 2 (AO classification 31B1.1 and 31B1.2) SCFF is a virtual perception of a posterior tilt deformity and if addressing this deformity improves patients' outcomes. MATERIALS AND METHODS: The records of 96 patients with Garden Types 1 and 2 SCFF treated in tertiary medical center between 1/2014 and 9/2017 were retrospectively reviewed. They all had preoperative hip joint anteroposterior and lateral radiographic views. 75 patients had additional computed tomography (CT) scans. Femoral head displacement was measured on an anteroposterior and axial radiograph projections and were performed before and after surgery. Preoperative 3D reconstructions were performed for a better fracture characterization, and assessment of the imaging was performed by the first author. RESULTS: The average age of the study cohort was 73 years (range 28-96, 68% females). There were 58 right-sided and 38 left-sided fractures. Ninety patients had Type 1 and six patients had Type 2 fractures. The average preoperative posterior tilt was 15 degrees and the average valgus displacement was 10 degrees on plain radiographs compared to 28 degrees and 11 degrees, respectively, on CT scans. Posterior tilt was found with a virtual perception as valgus-impacted fractures. The postoperative posterior tilt was corrected to an average of 3 degrees and the valgus displacement to 5 degrees. CONCLUSION: CT provides an accurate modality for measuring femoral head displacement and fracture extent. The posterior tilt displacement should be addressed during surgery to lower failure risk and the need for additional procedures. IRB APPROVAL: TLV-0292-15. LEVEL OF EVIDENCE: IV.

Early versus delayed surgery for hip fragility fractures in patients treated with direct oral anticoagulants.

BACKGROUND: Delaying surgical treatment for hip fragility fractures increases mortality, but early intervention in patients treated with direct oral anticoagulant (DOAC) may increase the risk of perioperative blood loss due to residual drug activity. This study aimed to evaluate the effect of the timing of hip fragility fractures surgeries in patients treated with DOAC. METHODS: We retrospectively reviewed all records of DOAC-treated patients who underwent surgery for hip fragility fractures between 2011 and 2019. They were divided into three groups according to time to surgery since admission to the emergency room (ER), ≤ 24, 24-48, and ≥ 48 h. Blood loss, peri and postoperative complications, readmissions, and short- and long-term mortality were compared between groups. RESULTS: Of the 171 suitable patients (59 males and 112 females), 32 (18.7%) were in the ≤ 24 h group, 93 (54.4%) in the 24-48 h group, and 46 (26.9%) in the ≥ 48 h group. Timing of surgery did not affect blood loss, as indicated by changes in pre- and postoperative hemoglobin levels (p = 0.089) and proportion of perioperatively administered packed cells (p = 0.949). There was a trend towards increased 30-day mortality in the ≥ 48 h group compared to the 24-48 h and ≤ 24 h groups (13.0, 4.3 and 3.1%, respectively. p = 0.099), and a trend towards increased 90 day mortality (6.5, 3.2, and 0%, respectively. p = 0.298). CONCLUSIONS: Early surgery did not increase perioperative blood loss. Delayed surgery ≥ 48 h of patients receiving DOAC who underwent surgery for hip fragility fractures showed a trend towards increased 30 day and 90 day mortality.

Telehealth for Contraceptive Care During the Initial Months of the COVID-19 Pandemic at Local Health Departments in 2 US States: A Mixed-Methods Approach.

OBJECTIVES: This study examined implementation of telehealth for contraceptive care among health departments (HDs) in 2 Southern US states with centralized/largely centralized governance structures during the early phase of the COVID-19 pandemic. Sustaining access to contraceptive care for underserved communities during public health emergencies is critical. Identifying facilitators and barriers to adaptive service provision helps inform state-level decision making and has implications for public health policy and practice, particularly in states with centralized HD governance. DESIGN: Mixed-methods study including a survey of HD clinic administrators and key informant interviews with clinic- and system-level staff in 2 states conducted in 2020. SETTING: Health department clinics in 2 Southern US states. PARTICIPANTS: Clinic administrators (survey) and clinic- and system-level respondents (key informant interviews). Participation in the research was voluntary and de-identified. MAIN OUTCOME MEASURES: (1) Telehealth implementation for contraceptive care assessed by survey and measured by the percentage of clinics reporting telehealth service provision during the pandemic; and (2) facilitators and barriers to telehealth implementation for contraceptive care assessed by key informant interviews. For survey data, bivariate differences between the states in telehealth implementation for contraceptive care were assessed using χ2 and Fisher exact tests. Interview transcripts were coded, with emphasis on interrater reliability and consensus coding, and analyzed for emerging themes. RESULTS: A majority of HD clinics in both states (60% in state 1 and 81% in state 2) reported a decrease in contraceptive care patient volume during March-June 2020 compared with the average volume in 2019. More HD clinics in state 1 than in state 2 implemented telehealth for contraceptive services, including contraceptive counseling, initial and refill hormonal contraception, emergency contraception and sexually transmitted infection care, and reported facilitators of telehealth. Medicaid reimbursement was a predominant facilitator of telehealth, whereas lack of implementation policies and procedures and reduced staffing capacity were predominant barriers. Electronic infrastructure and technology also played a role. CONCLUSIONS: Implementation of telehealth for contraceptive services varied between state HD agencies in the early phase of the pandemic. Medicaid reimbursement policy and directives from HD agency leadership are key to telehealth service provision among HDs in centralized states.

Adolescent Birth Rates and Rural-Urban Differences by Levels of Deprivation and Health Professional Shortage Areas in the United States, 2017-2018.

Objectives. To examine the differences in adolescent birth rates by deprivation and Health Professional Shortage Areas (HPSAs) in rural and urban counties of the United States in 2017 and 2018.Methods. We analyzed available data on birth rates for females aged 15 to 19 years in the United States using the restricted-use natality files from the National Center for Health Statistics, American Community Survey 5-year population estimates, and the Area Health Resources Files.Results. Rural counties had an additional 7.8 births per 1000 females aged 15 to 19 years (b = 7.84; 95% confidence interval [CI] = 7.13, 8.55) compared with urban counties. Counties with the highest deprivation had an additional 23.1 births per 1000 females aged 15 to 19 years (b = 23.12; 95% CI = 22.30, 23.93), compared with less deprived counties. Rural counties with whole shortage designation had an additional 8.3 births per 1000 females aged 15 to 19 years (b = 8.27; 95% CI = 6.86, 9.67) compared with their urban counterparts.Conclusions. Rural communities across deprivation and HPSA categories showed disproportionately high adolescent birth rates. Future research should examine the extent to which contraceptive access differs among deprived and HPSA-designated rural communities and the impact of policies that may create barriers for rural communities.

Cryo-surgery for symptomatic extra-abdominal desmoids. A proof of concept study.

BACKGROUND AND OBJECTIVE: Extra abdominal desmoid tumors are rare, highly aggressive, and invasive benign soft tissue tumors. Current treatment modalities show high levels of recurrence and comorbidities. Cryo-surgery as an alternative was subsequently investigated. METHODS: In this retrospective, single center study 11 patients showing symptomatic tumors were treated with individualized cryo-surgery. Treatment protocol included preoperative planning using computer rendered 3D models, intraoperative navigation and execution using cone beam guidance, and postoperative magnetic resonance imaging image analysis using a gaussian mixture model software. Subjective outcomes were reported using Short Form Health Survey (SF-36) questionnaires. RESULTS: Sixteen ablations were performed, each demonstrating a complete match with the determined preoperative plan and model. A total of 9/11 (82%) of patients showed improvements in symptoms and a reduction in tumor volume while 2/11 (18%) did not. Average reduction in tumor volume and viable segments were 36.7% (p = 0.0397) and 63.3% (p = 0.0477), respectively. Mild complications according to the SIR Adverse Event Classification Guidelines were experienced in 3/16 (19%) ablations. SF-36 scores showed a statistically significant improvement (p = 0.0194) in the mental health category and a nonsignificant (p = 0.8071) improvement in the physical health category. CONCLUSION: Cryo-surgery using the three-phase protocol as described may improve the overall outcome of future ablation procedures.

Contraceptive Use and Pregnancy Outcomes Among Women Enrolled in South Carolina Medicaid Programs.

OBJECTIVE: State medicaid programs provide access to effective contraception for people with lower incomes. This study examined contraception use and pregnancy among reproductive-age women enrolled in the South Carolina Medicaid, by eligibility program and socio-demographic sub-groups. METHODS: A retrospective cohort of women aged 15-45 who were newly eligible for South Carolina Medicaid from 2012 to 2016 was examined. Log-binomial regression and average marginal effects assessed relationships between contraception use and pregnancies ending in live and non-live births. Contraception was categorized as permanent, long acting reversible contraception (LARC), short-acting hormonal contraception (SAC), or no contraceptive claims. Women with family planning or full-benefit medicaid coverage were included. RESULTS: Approximately 11% of women used LARC methods, 41% used SAC methods, and 46% had no evidence of contraceptive claims. Method utilization varied by eligibility program, race/ethnicity and age. The likelihood of pregnancy was lower among SAC users and lowest among LARC users compared to women with no evidence of contraception across all three programs (family planning APR = 0.44; 95% CI 0.41-0.49 and APR = 0.13, 95% CI 0.10-0.17; Low income families APR = 0.82; 95% CI 0.77-0.88 and APR = 0.33, 95% CI 0.28-0.38; Partners for Healthy Children APR = 0.72; 95% CI 0.68-0.77 and APR = 0.35, 95% CI 0.30-0.43, respectively). Non-Hispanic Black and Hispanic teens were less likely to experience a pregnancy than non-Hispanic white teens. CONCLUSIONS FOR PRACTICE: The likelihood of pregnancy was lower among women using SAC methods and markedly lower among women using LARC. Variation in contraceptive use among racial/ethnic groups was noted despite Medicaid coverage. As new policies and initiatives emerge, these findings provide important context for understanding the role of Medicaid programs in reducing financial barriers to contraceptive services and ensuring access to effective contraception, while fostering reproductive health autonomy among women.

Hip Fractures during the COVID-19 Pandemic: Demographics, Treatment Pathway, and Outcomes.

BACKGROUND: Surgery for hip fractures within 48 hours of admission is considered standard. During the lockdown period due to the coronavirus disease-2019 (COVID-19) epidemic, our medical staff was reduced. OBJECTIVES: To compare the demographics, treatment pathways, and outcomes of patients with hip fractures during the COVID-19 epidemic and lockdown with the standard at routine times. METHODS: A retrospective study was conducted of all patients who were treated surgically for hip fracture in a tertiary center during the COVID-19 lockdown period between 01 March and 01 June 2020 and the equivalent period in 2019. Demographic characteristics, time to surgery, surgery type, hospitalization time, discharge destination, postoperative complications, and 30- and 90-day mortality rates were collected for all patients. RESULTS: During the COVID-19 period, 105 patients were operated due to hip fractures compared to 136 in the equivalent period with no statistical difference in demographics. The rate of surgeries within 48 hours of admission was significantly higher in the COVID-19 period (92% vs. 76%, respectively; P = 0.0006). Mean hospitalization time was significantly shorter (10 vs. 12 days, P = 0.037) with diversion of patient discharge destinations from institutional to home rehabilitation (P < 0.001). There was a significant correlation between the COVID-19 period and lower 90-day mortality rates (P = 0.034). No statistically significant differences in postoperative complications or 30-day mortality rates were noted. CONCLUSIONS: During the COVID-19 epidemic, despite the limited staff and the lack of therapeutic sequence, there was no impairment in the quality of treatment and a decrease in 90-day mortality was noted.

Granulomatous Mastitis: Comparison of Novel Treatment of Steroid Injection and Current Management.

BACKGROUND: Granulomatous mastitis (GM) is a rare entity of benign origin. Multiple treatment strategies, including surgical procedures, can have sequelae of recurrence, nonhealing wounds, and protracted pain. Even after GM is diagnosed, the best management strategy remains controversial. We sought to evaluate intralesional steroid injection as a potential treatment for GM. MATERIALS AND METHODS: Electronic medical records from 2003 to 2017 of patients diagnosed with benign breast lesions were retrospectively reviewed. Patients with pathologically confirmed GM were identified. All treatment methods were documented, which included observation, oral steroids, methotrexate, steroid injection, and surgical excision. Primary outcome was time to resolution. Effectiveness was based on relief of symptoms along with duration of symptoms from initial time of diagnosis to full relief. Analysis of variance was used to compare outcomes between groups. RESULTS: Of the 49 patients with confirmed GM diagnoses, 57% had observation only, 24% had steroid injection, and 19% had surgical resection. The average time to resolution differed significantly among the three groups (11.5 mo from the start of observation, 2.0 mo from the time of steroid injection, and 0.5 mo from the time of surgical excision, P < 0.001). CONCLUSIONS: Intralesional steroid injection is an effective treatment of GM. Selective management is appropriate for patients with GM, and surgical resection is not required for most patients.

Innate Immune Cell Recovery Is Positively Regulated by NLRP12 during Emergency Hematopoiesis.

With enhanced concerns of terrorist attacks, dual exposure to radiation and thermal combined injury (RCI) has become a real threat with devastating immunosuppression. NLRP12, a member of the NOD-like receptor family, is expressed in myeloid and bone marrow cells and was implicated as a checkpoint regulator of inflammatory cytokines, as well as an inflammasome activator. We show that NLRP12 has a profound impact on hematopoietic recovery during RCI by serving as a checkpoint of TNF signaling and preventing hematopoietic apoptosis. Using a mouse model of RCI, increased NLRP12 expression was detected in target tissues. Nlrp12-/- mice exhibited significantly greater mortality, an inability to fight bacterial infection, heightened levels of proinflammatory cytokines, overt granulocyte/monocyte progenitor cell apoptosis, and failure to reconstitute peripheral myeloid populations. Anti-TNF Ab administration improved peripheral immune recovery. These data suggest that NLRP12 is essential for survival after RCI by regulating myelopoiesis and immune reconstitution.

Outcome of femoral fractures in poliomyelitis patients.

BACKGROUND AND PURPOSE: As patients who were afflicted with poliomyelitis during the outbreaks in the past are aging, lower extremity osteoporotic fractures are becoming more frequent. Fixation in deformed, porotic bone, coupled with muscle weakness and imbalance creates a unique challenge when treating these fractures as does their reduced rehabilitation potential. The aim of this study was to investigate the outcome of femoral fractures in surviving poliomyelitis patients. PATIENTS AND METHODS: Sixty-five patients with 74 femoral fractures were treated between 1990 and 2014. Clinical outcome was assessed using the Parkland and Palmer mobility score, and quality-of-life was assessed using the SF-12® score. RESULTS: Some 84% of the fractures were a result of low-energy mechanisms and occurred in the polio-affected limbs, but nonaffected limbs were also injured owing to low-energy mechanisms in all cases. Fifty-seven fractures were treated operatively. There were nine re-operations (16%), including implant removals, nonunion, peri-implant fractures, and malunion. Some 60% of the patients did not regain their previous ambulatory capacity. Post-operative weight-bearing status did not correlate with the final functional outcome. CONCLUSIONS: Polio patients with femoral fractures have a guarded prognosis for regaining their pre-injury ambulatory capacity. A higher re-operation rate than that with "normal" osteoporotic fractures is expected.

Revisiting an old strategy: cartoons in medical education.

Medical education is an arduous process with widespread study of very complex information across diverse subjects. The use of medical illustrations in schematic or cartoon-like appearances is an old method of conveying intricate information. They are relatively absent in medical classrooms today. The purpose of this study was to survey members of a medical university, students and teachers regarding their opinions of medical cartoons. Most respondents had favourable opinions of cartoons in medical education. More research is required to conclude what parameters make cartoons effective teaching aids. Moreover, many teachers may lack formal training in applying cartoons within their curriculum.

Initial Clinical Experience With an Inducible Magnetic Seed System for Preoperative Breast Lesion Localization.

OBJECTIVE: The purpose of this study is to evaluate a nonradioactive inducible magnetic seed system (Magseed, Endomag) for preoperative localization of nonpalpable breast lesions. CONCLUSION: All of the 73 seeds placed in the first 4 months of clinical use were successfully placed and all were successfully retrieved intraoperatively. The mean time from seed placement to surgery was 3 days. Early clinical experience suggests that Magseed is an effective and accurate means of preoperative breast lesion localization.

Radiographic markers for measuring tibial rotation based on CT-reconstructed radiographs: an accuracy and feasibility study.

OBJECTIVES: Malreduction in the axial plane (malrotation) following tibial fracture surgery is often undiagnosed. A few clinical and radiographic methods have been proposed for measuring tibial rotation intraoperatively, yet have failed to match the accuracy of computed tomography (CT). The aim of this study was to develop radiographic tools for future intraoperative assessment of the tibial shaft rotation profile. METHODS: The setting was a laboratory computerized analysis. Twenty lower limb CT scans were used to construct a three-dimensional (3D) model using AMIRA© software. A virtual 3D cylinder was implanted in the posterior condylar line and in the transmalleolar axis. The 3D models were used to simulate four standard knee and ankle plain radiographs. On each radiograph, four landmarks were depicted by two observers and their relation with the cylinder was measured and analyzed for accuracy and reproducibility. A cadaveric lower leg was implanted with two Kirschner wires. A CT scan was performed in addition to 2D fluoroscopy. The simulated radiographs and the fluoroscopy were compared for accuracy. RESULTS: Measurement of the landmarks showed reliability in most of the knee anteroposterior and ankle mortise radiographs (coefficients of variation < 0.01 and = 0.01) respectively. Cadaveric measurement of the landmarks using real fluoroscopy and simulated radiographs were similar. CONCLUSIONS: To date, no reliable and common methods have been reported for the evaluation of tibial axial rotation. We propose a model in which simple radiographic landmarks can be used to calculate a 3D coordinate system that accurately assesses the axial rotation angle of the tibial shaft.