Results of Ponseti Brasil Program: Multicentric Study in 1621 Feet: Preliminary Results.

BACKGROUND: The Ponseti method has been shown to be the most effective treatment for congenital clubfoot. The current challenge is to establish sustainable national clubfoot treatment programs that utilize the Ponseti method and integrate it within a nation's governmental health system. The Brazilian Ponseti Program (Programa Ponseti Brasil) has increased awareness of the utility of the Ponseti method and has trained >500 Brazilian orthopaedic surgeons in it. METHODS: A group of 18 of those surgeons had been able to reproduce the Ponseti clubfoot treatment, and compiled their initial results through structured spreadsheet. RESULTS: The study compiled 1040 patients for a total of 1621 feet. The average follow-up time was 2.3 years with an average correction time of approximately 3 months. Patients required an average of 6.40 casts to achieve correction. CONCLUSIONS: This study demonstrates that good initial correction rates are reproducible after training; from 1040 patients only 1.4% required a posteromedial release. LEVEL OF EVIDENCE: Level IV.

Biogeography of Parasitic Nematode Communities in the Galápagos Giant Tortoise: Implications for Conservation Management.

The Galápagos giant tortoise is an icon of the unique, endemic biodiversity of Galápagos, but little is known of its parasitic fauna. We assessed the diversity of parasitic nematode communities and their spatial distributions within four wild tortoise populations comprising three species across three Galápagos islands, and consider their implication for Galápagos tortoise conservation programmes. Coprological examinations revealed nematode eggs to be common, with more than 80% of tortoises infected within each wild population. Faecal samples from tortoises within captive breeding centres on Santa Cruz, Isabela and San Cristobal islands also were examined. Five different nematode egg types were identified: oxyuroid, ascarid, trichurid and two types of strongyle. Sequencing of the 18S small-subunit ribosomal RNA gene from adult nematodes passed with faeces identified novel sequences indicative of rhabditid and ascaridid species. In the wild, the composition of nematode communities varied according to tortoise species, which co-varied with island, but nematode diversity and abundance were reduced or altered in captive-reared animals. Evolutionary and ecological factors are likely responsible for the variation in nematode distributions in the wild. This possible species/island-parasite co-evolution has not been considered previously for Galápagos tortoises. We recommend that conservation efforts, such as the current Galápagos tortoise captive breeding/rearing and release programme, be managed with respect to parasite biogeography and host-parasite co-evolutionary processes in addition to the biogeography of the host.

The Ponseti method of treatment for clubfoot in Brazil: barriers to bracing compliance.

BACKGROUND: Clubfoot is the most common extremity birth defect. It causes the feet of affected individuals to point inward and downward, preventing them from walking normally. Neglected clubfoot causes disabilities that result in a lack of social integration, creating a psychological and financial burden for the family and community. Clubfoot has been effectively treated through the Ponseti method, a treatment utilizing serial casts to correct the deformity followed by use of an abduction brace for approximately 2-4 years. sustained use of the brace is necessary to prevent relapse and ensure a successful outcome. Brace compliance in the setting of limited resources in the developing world can be challenging. The purpose of this study was to identify the barriers to bracing compliance in southeastern Brazil. In addition to socioeconomic and cultural barriers, this study also looked at improper prescribing practices by physicians as a potential cause of noncompliance. The study sought to identify the role of physician education in the use of the Ponseti method and physicians' knowledge of the bracing process. PURPOSE OF THE STUDY: Identify the barriers to bracing adherence that could negatively impact the treatment of children with clubfoot. METHODS: Forty-five orthopedists from several centers in southeastern Brazil were interviewed. Physicians were asked about their training in the Ponseti method, their protocol when prescribing the brace, their evaluation of its importance, and a series of open-ended questions designed to identify the positive and negative qualities of local braces. They were also asked what they perceived to be the biggest challenges to sustained brace use. RESULTS: sixteen of the physicians interviewed were orthopedic residents, and 29 had completed their residencies. Of these two groups, only 25% and 65%, respectively, appropriately prescribe the abduction brace for patients, with the majority recommending use of the brace for an inadequate period of time. The high costs and delays in acquisition of the brace and a lack of orthopedic stores able to adequately construct the orthotic, also present considerable barriers to sustained brace use. CONCLUSIONS: Many of the causes of noncompliance with bracing protocol stem from systemic inequities and challenges, rather than a lack of collaboration from the families themselves. Furthermore, insufficient prescription of the brace by physicians may represent a major barrier to bracing compliance in southeastern Brazil. This research indicates a need to evaluate physician training and continuing medical education in order to ensure that physicians are adequately utilizing the brace.

Treatment of congenital clubfoot with the Ponseti method: the parents' perspective.

This study aimed to analyze the perceptions of parents of children with clubfoot regarding the Ponseti method of treatment, and identify aspects of treatment that families found most difficult. Thirty families of children with clubfoot were treated with the Ponseti method over a 4-year period, and questionnaires were distributed at the conclusion of treatment. The most difficult components of treatment were identified. However, these challenges did not impact treatment outcome negatively. We hypothesize that a strong physician-patient relationship and high levels of parental education may decrease perceived difficulties of treatment with the Ponseti method.