Extensor Retinaculum Syndrome of the Ankle: An Adult Case Series.

Background: Extensor retinaculum syndrome (ERS) is a relatively rarely diagnosed compartment syndrome-like entity caused by elevated pressures in the tissues deep to the superior extensor retinaculum (SER). ERS is identified as out-of-proportion anterior ankle pain, pain with passive toe plantarflexion, elevated SER pressures (>40 mm Hg), and ultimately toe extension weakness and first web space numbness. Although previously described in a pediatric population, this case series is the first to our knowledge in an adult population. Methods: Seven nonconsecutive cases over 18 years from 2 surgeons are reported who underwent complete SER release for ERS either through the direct lateral approach to the fibula or the anterolateral approach to the distal tibia. All were associated with traumatic injuries including 3 bimalleolar ankle fractures, 3 tibial pilon fractures, and 1 distal tibial/fibular shaft fracture. All patients developed writhing anterior ankle pain worsened with passive toe plantarflexion. SER compartment pressures ranged from 50 to >135 mm Hg. Five cases displayed decreased first web space sensation. Results: The diminished or absent first web space sensation uniformly improved post-release. Complications included 1 patient with complex regional pain syndrome type 1, 1 patient required hardware removal, and 2 had persistent but improved first web space sensation changes. Conclusion: Clinical suspicion for possible ERS should arise after distal tibial/fibular fractures when the excruciating pain localizes to the ankle instead of the classic anterior leg muscle bellies. If pain is worsened with passive toe plantarflexion, this diagnosis should be considered. Recommended treatment involves complete release of the SER anywhere on the anterior surface between the tibia and fibula depending on the approach needed for fixation of the associated fracture. Level of Evidence: Level IV, case series.

Growth of tropical tree species and absorption of copper in soil artificially contaminated.

Reclamation of copper contaminated sites using forest species may be an efficient alternative to reduce the negative impact. The aim of this study was to quantify the growth and evaluate the quality of seedlings of native species at different doses of copper in the soil. The experimental design was completely randomized, with seven replications in a factorial arrangement (3×9), using three indigenous species of plants (Anadenanthera macrocarpa, Mimosa scabrella and Apuleia leiocarpa) and nine doses of copper in the soil (0, 60, 120, 180, 240, 300, 360, 420 and 480 mg kg-1).The experiment was carried out in a greenhouse which the seedlings were grown for 180 days. The experimental units were plastic pots of 125 cm3 filled with Oxisol. The results indicated that the levels of copper applied to the soil decreased the quality of seedlings and growth of Apuleia leiocarpato a lesser extent compared with Mimosa scabrella and Anadenanthera macrocarpa. Anadenanthera macrocarpa was the forest species that resulted in the lowest copper translocation from roots to shoots. In addition, the Apuleia leiocarpa exhibited high resistance and tolerance for copper in the soil and also, it is highlighted an ability for copper phytoremediation.

Growth of tropical tree species and absorption of copper in soil artificially contaminated / Crescimento de espécies arbóreas tropicais e absorção de cobre em solo artificialmente contaminado

Abstract Reclamation of copper contaminated sites using forest species may be an efficient alternative to reduce the negative impact. The aim of this study was to quantify the growth and evaluate the quality of seedlings of native species at different doses of copper in the soil. The experimental design was completely randomized, with seven replications in a factorial arrangement (3×9), using three indigenous species of plants (Anadenanthera macrocarpa, Mimosa scabrella and Apuleia leiocarpa) and nine doses of copper in the soil (0, 60, 120, 180, 240, 300, 360, 420 and 480 mg kg–1).The experiment was carried out in a greenhouse which the seedlings were grown for 180 days. The experimental units were plastic pots of 125 cm3 filled with Oxisol. The results indicated that the levels of copper applied to the soil decreased the quality of seedlings and growth of Apuleia leiocarpato a lesser extent compared with Mimosa scabrella and Anadenanthera macrocarpa. Anadenanthera macrocarpa was the forest species that resulted in the lowest copper translocation from roots to shoots. In addition, the Apuleia leiocarpa exhibited high resistance and tolerance for copper in the soil and also, it is highlighted an ability for copper phytoremediation.

Resumo A recuperação de áreas contaminadas com cobre utilizando espécies florestais pode ser uma alternativa eficiente para reduzir o impacto negativo deste elemento nestas áreas. O objetivo deste estudo foi quantificar o crescimento e avaliar a qualidade de mudas de espécies nativas em diferentes doses de cobre no solo. O delineamento experimental foi inteiramente casualizado, com sete repetições, em um esquema fatorial (3×9), utilizando-se três espécies nativas de plantas (Anadenanthera macrocarpa, Mimosa scabrella e Apuleia leiocarpa) e nove doses de cobre no solo (0, 60, 120, 180, 240, 300, 360, 420 e 480 mg kg–1). O experimento foi realizado em casa de vegetação, onde as plantas foram cultivadas por 180 dias. As unidades experimentais foram vasos de plástico de 125 cm3, preenchidos com Latossolo Vermelho distrófico. Os resultados indicaram que o nível de cobre aplicado ao solo reduziu a qualidade de plântulas e crescimento de Apuleia leiocarpa para um menor grau comparado com bracatinga e angico. Anadenanthera macrocarpa foi a espécie florestal que apresentou menor translocação de cobre a parte aérea das mudas. Além disso, a Apuleia leiocarpa exibiu elevada tolerância para o cobre no solo e também destaca-se mostrando uma capacidade para fitoremediação de áreas contaminadas com cobre.

Growth of tropical tree species and absorption of copper in soil artificially contaminated

Abstract Reclamation of copper contaminated sites using forest species may be an efficient alternative to reduce the negative impact. The aim of this study was to quantify the growth and evaluate the quality of seedlings of native species at different doses of copper in the soil. The experimental design was completely randomized, with seven replications in a factorial arrangement (3×9), using three indigenous species of plants (Anadenanthera macrocarpa, Mimosa scabrella and Apuleia leiocarpa) and nine doses of copper in the soil (0, 60, 120, 180, 240, 300, 360, 420 and 480 mg kg1).The experiment was carried out in a greenhouse which the seedlings were grown for 180 days. The experimental units were plastic pots of 125 cm3 filled with Oxisol. The results indicated that the levels of copper applied to the soil decreased the quality of seedlings and growth of Apuleia leiocarpato a lesser extent compared with Mimosa scabrella and Anadenanthera macrocarpa. Anadenanthera macrocarpa was the forest species that resulted in the lowest copper translocation from roots to shoots. In addition, the Apuleia leiocarpa exhibited high resistance and tolerance for copper in the soil and also, it is highlighted an ability for copper phytoremediation.

Resumo A recuperação de áreas contaminadas com cobre utilizando espécies florestais pode ser uma alternativa eficiente para reduzir o impacto negativo deste elemento nestas áreas. O objetivo deste estudo foi quantificar o crescimento e avaliar a qualidade de mudas de espécies nativas em diferentes doses de cobre no solo. O delineamento experimental foi inteiramente casualizado, com sete repetições, em um esquema fatorial (3×9), utilizando-se três espécies nativas de plantas (Anadenanthera macrocarpa, Mimosa scabrella e Apuleia leiocarpa) e nove doses de cobre no solo (0, 60, 120, 180, 240, 300, 360, 420 e 480 mg kg1). O experimento foi realizado em casa de vegetação, onde as plantas foram cultivadas por 180 dias. As unidades experimentais foram vasos de plástico de 125 cm3, preenchidos com Latossolo Vermelho distrófico. Os resultados indicaram que o nível de cobre aplicado ao solo reduziu a qualidade de plântulas e crescimento de Apuleia leiocarpa para um menor grau comparado com bracatinga e angico. Anadenanthera macrocarpa foi a espécie florestal que apresentou menor translocação de cobre a parte aérea das mudas. Além disso, a Apuleia leiocarpa exibiu elevada tolerância para o cobre no solo e também destaca-se mostrando uma capacidade para fitoremediação de áreas contaminadas com cobre.

Treatment of large segmental bone defects with reamer-irrigator-aspirator bone graft: technique and case series.

Treatment of large segmental defects using conventional autogenous iliac crest bone graft can be limited by volume of cancellous bone and donor site morbidity. The reamer-irrigator-aspirator (RIA) technique allows access to a large volume of cancellous bone graft containing growth factors with potency equal to or greater than autograft material from the iliac crest. The purpose of this study was to evaluate the effectiveness of RIA-harvested autogenous bone graft for treating large segmental defects of long bones.

Canine investigation of rhBMP-2, autogenous bone graft, and rhBMP-2 with autogenous bone graft for the healing of a large segmental tibial defect.

OBJECTIVE: The purpose of this study was to compare the effects of bone morphogenetic protein, bone morphogenetic protein with autogenous bone graft (ABG), and ABG alone on the healing of a large bone defect in the canine tibia. METHODS: Fifteen 45- to 55-lb canines were randomly assigned to 1 of 5 treatment groups, 3 per group. The groups included (1) recombinant human bone morphogenetic protein (rhBMP-2, 0.43 mg/mL)/absorbable collagen sponge (ACS) + collagen/ceramic matrix (CCM), (2) rhBMP-2 (0.22 mg/mL) ACS + CCM, (3) rhBMP-2 (0.43 mg/mL) ACS + ABG, (4) rhBMP-2 (0.22 mg/mL) ACS + ABG, and (5) ABG alone. A 5-mL defect was created in the right tibia and fixed with a 4.5 mm locking plate and 1 of the grafts described above implanted. X-rays were taken biweekly for 12 weeks and evaluated for radiographic union. Representative histology was also examined. RESULTS: All defects treated with rhBMP-2 (any combination) healed at 6.0 +/- 0.9 weeks. None of the ABG alone-treated defects were healed at 12 weeks. Dogs receiving rhBMP-2/ACS + CCM healed at 5.7 +/- 0.8 weeks, whereas rhBMP-2/ACS + ABG defects healed at 6.3 +/- 0.8 weeks. Histology showed healing consistent with 12-week radiologic results. CONCLUSIONS: Large segmental defects in canine tibiae can be effectively healed with stable fixation and rhBMP-2/ACS + ABG or CCM. These conclusions may offer insight into the clinical treatment of segmental defect nonunions in the human.

A rare trifocal presentation of Clostridium septicum myonecrosis.

Gas gangrene or clostridial myonecrosis is a rare, life threatening infection of the muscle that is typically associated with recent surgery or trauma. It usually affects older individuals who suffer from vascular insufficiency or who are immunocompromised. The typical pathogen is Clostridium perfringens. Atraumatic gas gangrene caused by Clostridium septicum is less common and has a unique association with colon cancer. This condition aggressively spreads through the muscular tissue and often culminates in septic shock. Fatality occurs within 48 hours if left untreated yet, despite emergent treatment the mortality rate is >50% without any comorbidities. Given the propensity to occur in the extremities the orthopedic surgeon must be familiar with its presentation, diagnosis, and treatment. This article presents a case of a 16-year-old girl who presented to the emergency room with an 18-hour history of malaise and progressive right arm discomfort and swelling. The identification and emergent treatment of necrotizing soft tissue infections is important and often falls on the orthopedic surgeon, especially when isolated to the extremities. Subtle initial presentation and rapid progression of the infection are classic findings of necrotizing soft tissue infections, particularly with clostridial myonecrosis and necrotizing fasciitis. Clostridium myonecrosis is a rare orthopedic condition with high mortality. Early diagnosis and debridement is imperative. A team approach to managing these patients postoperatively is necessary. The use of hyperbaric oxygen can be considered, however, it may not be readily available and its use is unproven in human studies. Due to its high mortality, one should err on the side of more aggressive resective/ablative surgery.

Treatment of the multiple ligament injured knee and knee dislocations: a trauma perspective.

A complete understanding of traumatic knee dislocations begins with a review of their definition, classification, initial examination, and management options. Special emphasis is placed on associated injuries and their early detection and treatment. Decision making regarding ligament reconstruction must only be made in the context of the associated injuries or "personality" of the injury and are secondary to decisions regarding vascular compromise. These injuries can be limb threatening and deserve special respect and prompt attention when recognized.

Plate fixation of talar neck fractures: preliminary review of a new technique in twenty-three patients.

OBJECTIVE: To describe an unreported technique of fixation for talar neck fractures. DESIGN: Retrospective review and telephone interview of patients with fractures of the talar neck (OTA 72-A1.2, 72-A1.3, 72-C2). SETTING: Level-one trauma center with six trauma surgeons. PATIENTS/PARTICIPANTS: Twenty-three patients treated with minifragment plates over a four-year period. Follow-up intervals were an average of twenty months. INTERVENTION: Talar neck fractures were stabilized with one or two 2.0 or 2.4 plates, with additional 2.0, 2.7, or 3.5 lag screws when necessary. Most fractures were approached through medial and lateral incisions. MAIN OUTCOME MEASURES: Union rates, pain, and incidence of complications. Functional outcome will be best determined by a further review with longer follow-up. RESULTS: Mini fragment plates were placed on the side with the most comminution, and all wounds and fractures healed uneventfully. Four patients underwent hardware removal. Two patients developed a mild extension malunion, but there was no evidence of varus malunion, as measured on Canale views. CONCLUSIONS: Initial review suggests that plate fixation of comminuted talar neck fractures is a successful technique, with low rates of complications compared with those discussed in the literature. A further review in a few years will allow functional assessment studies.

Laser acupuncture in children and adolescents with exercise induced asthma.

BACKGROUND: Laser acupuncture, a painless technique, is a widely used alternative treatment method for childhood asthma, although its efficacy has not been proved in controlled clinical studies. METHODS: A double blind, placebo controlled, crossover study was performed to investigate the possible protective effect of a single laser acupuncture treatment on cold dry air hyperventilation induced bronchoconstriction in 44 children and adolescents of mean age 11.9 years (range 7.5-16.7) with exercise induced asthma. Laser acupuncture was performed on real and placebo points in random order on two consecutive days. Lung function was measured before laser acupuncture, immediately after laser acupuncture (just before cold dry air challenge (CACh)), and 3 and 15 minutes after CACh. CACh consisted of a 4 minute isocapnic hyperventilation of -10 degrees C absolute dry air. RESULTS: Comparison of real acupuncture with placebo acupuncture showed no significant differences in the mean maximum CACh induced decrease in forced expiratory volume in 1 second (27.2 (18.2)% v 23.8 (16.2)%) and maximal expiratory flow at 25% remaining vital capacity (51.6 (20.8)% v 44.4 (22.3)%). CONCLUSIONS: A single laser acupuncture treatment offers no protection against exercise induced bronchoconstriction in paediatric and adolescent patients.

Extraction of an intra-articular bullet fragment from the subtalar joint: the "drill, tap, and extract" method.

The necessity of extracting intra-articular bullet fragments is well documented in the orthopedic literature. A case of the removal of a retained bullet fragment lodged within the subtalar joint and calcaneus is presented. The bullet fragment was drilled and tapped with small-fragment instruments and was readily removed. This technique is relatively easy to perform and may be used when bullet fragments are imbedded in osseous or intra-articular sites that are distant from the entrance wound.

Diagnosing influenza: the value of clinical clues and laboratory tests.

OBJECTIVE: Our goal was to determine the utility of clinical clues, white blood cell (WBC) and differential counts, and a rapid antigen test for differentiating influenza from coexistent infectious diseases during influenza epidemics. STUDY DESIGN: Data were collected during 3 consecutive influenza outbreaks over a 2-year period. The information collected included date of onset, symptoms, vaccine status, WBC and differential counts, ZstatFlu test (ZymeTx, Oklahoma City, Ok), and influenza culture. Using culture positivity as the criterion for influenza diagnosis, we compared cases with noncases on each variable independently and by logistic regression. Receiver operating characteristic curves were plotted for WBC count, ZstatFlu, and their combination in an effort to determine the most useful diagnostic strategy. POPULATION: We included consecutive patients presenting to a family practice office with fever, cough, sore throat, myalgia, and/or headache during flu season. OUTCOMES MEASURED: The outcomes were sensitivity, specificity, and other measures of test accuracy. RESULTS: Culture-positive cases could not be reliably distinguished from those that were culture negative using symptoms or vaccination status. Both WBC count and ZstatFlu results discriminated fairly well, and their combination did somewhat better. Differential counts were not helpful. WBC counts above 8000 were associated with a low probability of influenza. The sensitivity and specificity of the ZstatFlu were 65% and 83%, respectively. CONCLUSIONS: Our data suggest that symptoms and vaccine status do not reliably identify patients with influenza. Use of WBC counts and the ZstatFlu test can be helpful. The sequence, combination, and criteria for use of these tests depend on tradeoffs between undertreatment of influenza cases and the overtreatment of noninfluenza cases, and the cost and benefit projections for individual patients.

Screening for microalbuminuria to prevent nephropathy in patients with diabetes: a systematic review of the evidence.

OBJECTIVE: Our goal was to evaluate whether screening patients with diabetes for microalbuminuria (MA) is effective according to the criteria developed by Frame and Carlson and those of the US Preventive Services Task Force. STUDY DESIGN: We searched the MEDLINE database (1966-present) and bibliographies of relevant articles. OUTCOMES MEASURED: We evaluated the impact of MA screening using published criteria for periodic health screening tests. The effect of the correlation between repeated tests on the accuracy of a currently recommended testing strategy was analyzed. RESULTS: Quantitative tests have reported sensitivities from 56% to 100% and specificities from 81% to 98%. Semiquantitative tests for MA have reported sensitivities from 51% to 100% and specificities from 21% to 100%. First morning, morning, or random urine sampling appear feasible. Assuming an individual test sensitivity of 90%, a specificity of 90%, and a 10% prevalence of MA, the correlation between tests would have to be lower than 0.1 to achieve a positive predictive value for repeated testing of 75%. CONCLUSIONS: Screening for MA meets only 4 of 6 Frame and Carlson criteria for evaluating screening tests. The recommended strategies to overcome diagnostic uncertainty by using repeated testing are based on expert opinion, are difficult to follow in primary care settings, do not improve diagnostic accuracy sufficiently, and have not been tested in a controlled trial. Although not advocated by the American Diabetes Association, semiquantitative MA screening tests using random urine sampling have acceptable accuracy but may not be reliable in all settings.

Structure and diversity of Gram-negative sulfate-reducing bacteria on rice roots.

Specific PCR assays were used to amplify the 16S rRNA genes of the Desulfobacteriaceae and the Desulfovibrionaceae from extracted environmental DNA from rice roots. 16S rDNA-based community patterns of the Desulfobacteriaceae were generated via terminal restriction fragment length polymorphism analysis from rice roots and compared with bulk soil. The molecular fingerprints showed no significant difference between rice roots and bulk soil, but changes during the vegetation period. 16S rDNA clone libraries and sequencing showed that the predominant terminal restriction fragments represented distinct phylogenetic groups. The 16S rDNA clone sequences of the Desulfobacteriaceae fell in the phylogenetic radiation of Desulfonema and Desulfosarcina or grouped within the Desulforhabdus-Syntrophobacter assemblage. Three of the latter sequences were closely affiliated with the MPN isolate EZ-2C2 from rice roots. All Desulfovibrionaceae 16S rDNA clone sequences, with one exception, were affiliated with the MPN isolate F1-7b from rice roots. The clustering of the clone sequences and the close phylogenetic affiliation with isolates from MPN enrichments from the same habitat in two cases indicated that these sequence clusters may represent predominant Gram-negative sulfate reducers on rice roots. Quantification of the bacterial abundances was accomplished by rRNA dot blot hybridization. In total the Gram-negative sulfate reducers accounted for approximately 2-3% of the total rRNA content. The relative rRNA abundance of the Desulfobacteriaceae was, at 1.4%, higher than that of the Desulfovibrionaceae (0.5%).

A case report of warfarin resistance due to azathioprine and review of the literature.

A 32-year-old woman with a history of deep vein thrombosis (DVT), steroid-dependent ulcerative colitis, and osteoporosis was prescribed azathioprine for a steroid-sparing effect. Stable, therapeutic international normalized ratios (INRs) were obtained with warfarin 35 mg/week during a 6-week postpartum course to treat an initial DVT. Ten days after completing warfarin therapy, azathioprine was begun. A recurrent DVT occurred 9 days later, and an increase in warfarin dosage to 120 mg/week was necessary to achieve an INR of 2.0-3.0. The patient denied changes in warfarin adherence, dietary vitamin K intake, or medical conditions. The addition of azathioprine was the only change in her regimen. Review of the literature found only limited reports of an interaction between warfarin and azathioprine, with increases in warfarin requirements of 3-4 times. Careful monitoring and caution are recommended when administering these two drugs concomitantly.

Safe placement of S1 and S2 iliosacral screws: the "vestibule" concept.

OBJECTIVES: To determine the optimal starting points for placement of S1 and S2 iliosacral screws as well as the pertinent anatomy surrounding the S1 and S2 vertebral bodies. DESIGN: Normal subject study evaluating helical CT scans of thirty normal posterior pelvic rings. SETTING: Methodist Hospital, Indianapolis, Indiana, Level I trauma center. PARTICIPANTS: Consenting adults for limited pelvis CT. MAIN OUTCOME MEASUREMENTS: The three-dimensional anatomy of the posterior pelvic ring pertinent to S1 and S2 iliosacral screw placement. Safety of simulated S1 iliosacral screw placement using different lateral ilium starting points. RESULTS: The transversely placed (horizontal) iliosacral screw was the least safe of the screws tested. The safest lateral ilium starting point for our entire population was at the posterior sacral body sagittally and at the inferior S1 foramen coronally. S2 iliosacral screws had less cross-sectional area for placement than S1 screws. Placement of the S2 screw slightly to the S1 foraminal side of the S2 vertebral body increased the safety of placement. CONCLUSION: The iliosacral screw starting point at the posterior sacral body and inferior S1 foramen was the safest when considering the entire population. Careful attention to the size and orientation of the S2 vertebral body should be taken if S2 iliosacral screws are placed.

Cost effectiveness of human immunodeficiency virus postexposure prophylaxis for healthcare workers.

OBJECTIVE: The United States Public Health Service (USPHS) published recommendations for human immunodeficiency virus (HIV) postexposure prophylaxis (PEP) of healthcare workers in May 1998. The aim of this study was to analyse the cost effectiveness of the USPHS PEP guidelines. DESIGN AND SETTING: This was a modelling study in the setting of the US healthcare system in 1989. The analysis was performed from the societal perspective; however, only HIV healthcare costs were considered and health-related losses of productivity were not included. METHODS: A decision tree incorporating a Markov model was created for 4 PEP strategies: the current USPHS recommendations, triple drug therapy, zidovudine monotherapy or no prophylaxis. A probabilistic sensitivity analysis using a Monte Carlo simulation was performed. Confidence intervals (CIs) around cost-effectiveness estimates were estimated by a bootstrapping method. RESULTS: The costs (in 1997 US dollars) per quality-adjusted life-year (QALY) save by each strategy were as follows: monotherapy $US688 (95% CI: $US624 to $US750); USPHS recommendations $US5211 (95% CI: $US5126 to $US5293); and triple drug therapy $US8827 (95% CI: $US8715 to $US8940). The marginal cost per year of life saved was: USPHS recommendations $US81 987 (95% CI: $US80 437 to $US83 689); triple drug therapy $US970 451 (95% CI: $US924 786 to $US 1 014 429). Sensitivity testing showed that estimates of the probability of seroconversion for each category of exposure were most influential, but did not change the order of strategies in the baseline analysis. With the prolonged HIV stage durations and increased costs associated with recent innovations in HIV therapy, the marginal cost effectiveness of the USPHS PEP strategy was decreased to $US62 497/QALY saved. All 3 intervention strategies were cost effective compared with no postexposure prophylaxis. CONCLUSIONS: Current USPHS PEP recommendations are marginally cost effective compared with monotherapy, but the additional efficacy of triple drug therapy for all risk categories is rewarded by only a small reduction in HIV infections at great expense. For the foreseeable future, assuming innovations in therapy that employ expensive drug combinations earlier in the HIV disease course to extend life expectancy and the increasing prevalence of HIV drug resistance, our model supports the use of the USPHS PEP guidelines.

The cost of medical dictation transcription at an academic family practice center.

BACKGROUND: Very little is known about the volume or cost of medical transcription in primary care. A study of the number of lines and cost of transcription at an academic family practice center was performed to establish the average number of lines and costs of transcription by level of service and type of provider (faculty physician, physician assistant, resident physician, and others). METHODS: Parallel 4-month sets of computerized billing records and computerized transcription summary logs (listing the patient name and identification, the dictator, the number of lines of dictation, and the date for each dictation) were merged and analyzed to compare the cost and volume of dictation by types of service and types of provider. RESULTS: During the study period there were 11,085 patient encounters, 9013 with transcription. The average cost of transcription per encounter using transcription was $3.96 and the median was $3.64. The cost per encounter ranged from $0.39 (3 lines of dictation) to $24.83 (191 lines of dictation). Faculty physicians and physician assistants had the lowest cost, resident physicians were intermediate in cost, and others (such as medical students) had the highest costs for medical transcription. Transcription costs rose with increasing level of service but became a smaller proportion of the collected fee, averaging only 5% for a level 5 encounter. CONCLUSIONS: The cost of transcription as a part of overhead was higher than anticipated. Specific education regarding dictation form and content and ways to decrease these costs is appropriate.