[Knee-related Pain Problems during Pregnancy Correlate with an Increase in Body Weight. Results of a Prospective Study]. / Knieschmerz im Verlauf der Schwangerschaft in Bezug zum Anstieg des Körpergewichts. Ergebnisse einer prospektiven Studie.

PURPOSE: This study aimed to evaluate the incidence of knee pain or the intensification of knee-related problems during pregnancy. We hypothesised that the occurrence of knee problems correlates with an increase in body weight during pregnancy. METHODS: A total of 326 women (30(th)-40(th) week of pregnancy) were involved in this study. At onset of the pregnancy, the patients were 29.4 [95% CI 28.8-29.9] years of age. We asked all patients retrospectively about their anthropometric data at the beginning of pregnancy. All patients provided information about former knee problems, knee problems occurring after onset of pregnancy or any increase in these problems. These knee patients were re-evaluated 6 weeks after childbirth. At follow-up, the patients were asked about their knee problems and about their body weight. RESULTS: At the beginning of pregnancy, the mean body weight was 68.0 kg (95% CI 64.4-69.6; range 41-117). The mean BMI of all patients was 24.5 kg/m² (25% CI 23.9-25.0; range 17.0-26.0). The absolute body weight increased by 13.8 kg (95% CI 13.2-1.5; range 3-38). A total of 24 patients (7.4%) reported new knee problems during pregnancy. 2 patients reported an increase in knee-related problems during pregnancy (0.6%). The incidence of knee-related problems (new cases and increase of problems n=26) was 26/326 or 7.6/100 pregnancies. In patients without knee problems, the pregnancy-related increase in the BMI (ΔBMI) was 4.8 kg/m² (95% CI 4.6-5.1, range 1.1-14.1). In cases with incident knee problems, the ΔBMI was 5.9 kg/m² (95% CI 4.9-6.9, range 2.1-11.8). The increase in body weight (Δbody weight) in patients without knee problems was 13.5 kg (95% CI 12.9-14.2, range 3-38). Patients with incident knee pain experienced a Δbody weight of 16.8 kg (95% CI 13.9-19.4, range 6-35). The differences in ΔBMI and Δbody weight were significant (p=0.009). A Δbody weight >20 kg was a significant risk factor for pregnancy-related knee pain significant risk factor pregnancy related pain. A total of 23 incident cases (92%) underwent a follow-up interview 6 weeks after parturition. At this time, a total of 6 patients (26.1%) had not experienced further knee problems, whereas persistent knee problems were reported in the remaining patients (73.9%). Patients without any knee complaints [body weight 72.5 kg (CI 95% 60.9-83.9)] tended to have a lower body weight at follow-up than patients with persistent knee pain [85.5 kg (CI 95% 71.8-99.1), p=0.162]. CONCLUSION: There is a body weight-associated increase in the incidence of functional knee pain in pregnant women. In about one-third of the cases, knee problems persist after pregnancy and are associated with a residual increase in body weight. Thus, we conclude that body weight is a potential risk factor for functional knee pain.

Femoral imaging artifacts associated with dorsal recumbency craniocaudal radiographic positioning. Description of a modified bisecting angle technique.

OBJECTIVES: To describe the radiographic length distortion associated with femoral tilt during cranio-caudal positioning. To describe a modified bisecting angle technique to alleviate image foreshortening. METHODS: Five pairs of femurs were imaged. The femurs were tilted from 0 to 50 degrees and the X-ray anode was tilted from 0 to 40 degrees. Femoral length was measured on the resulting images. A geometric model depicting sagittal femoral positioning was described with two trigonometric formulas. Trigonometric formula 1 (TF¹) was designed to predict apparent femoral length. Data generated by TF¹ were compared to the cadaveric study results. Trigonometric formula 2 (TF²), based on the same model, was used to predict the ideal anode angle (iAA) to alleviate foreshortening. Unrelated to the model, a simplified linear formula (SF) was created to approximate the TF². Data generated with the SF and the TF² were compared. RESULTS: When the femoral specimens were tilted to 20 degrees or greater, significant foreshortening was appreciated (p <0.001). Increasing the anode angle increased apparent length, eliminating foreshortening. Data generated by the TF¹ agreed closely with the results of the cadaveric study (R² = 0.999). The SF and the TF² demonstrated close agreement and were able to predict an iAA consistent with the results of the cadaveric study. CLINICAL SIGNIFICANCE: A femoral tilt of 20 degrees or greater results in significant image foreshortening and may warrant alternate radiographic techniques. If the femur is tilted, adjusting the anode angle can alleviate femoral foreshortening.

Radiographic evaluation of osteotomized ulnar segments following arthroscopic treatment for canine medial coronoid disease.

OBJECTIVE: To assess movement of ulnar segments radiographically, following proximal and midshaft ulnar osteotomy or ostectomy after arthroscopic treatment for dogs diagnosed with medial coronoid disease. METHODS: Fragmentation and cartilage wear were treated arthroscopically and the presence of incongruity confirmed. Osteotomies were performed at the mid-point or proximal third of the length of the ulna. The distance of separation between the ulnar segments and the adjacent radius were measured and followed by serial radiographs postoperatively until healing had occurred. RESULTS: Proximal oblique osteotomies located at one-third the length of the ulna were associated with the most movement of the ulnar segments, most notably of the proximal segment. Osteotomies or ostectomies performed in the middle demonstrated less segmental movement and on average, slightly longer time to heal. Movement of the ulnar segments in both groups occurred immediately, and then peaked at two to four weeks postoperatively, tending to plateau thereafter. CLINICAL SIGNIFICANCE: Radioulnar incongruity is considered a facet of the aetiopathogenesis of canine medial coronoid disease. This creates abnormal loads and focal wear along the medial coronoid process. Performing an oblique osteotomy at a location measured at the proximal third of the length of the ulna allows increased movement of the proximal segment, which may result in unloading of the medial compartment. Performing an osteotomy or ostectomy distally dampens segmental movement due to constraint of the interosseous ligament. These findings suggest that a proximal oblique osteotomy at this location creates immediate favourable movement with low morbidity.

Interlocking nail treatment of diaphyseal long-bone fractures in dogs.

OBJECTIVE: To determine results of using interlocking nails (IN) for fixation of diaphyseal long bone fractures in dogs. DESIGN: Multi-center prospective clinical trial. ANIMALS: 134 dogs with diaphyseal fractures of the femur (n = 92), tibia (23), or humerus (19); 11 had previous unsuccessful treatments, and 103 had comminuted fractures of which 70 were classified as unstable. PROCEDURE: All fractures were stabilized with 6- or 8-mm-diameter IN with 3.5- or 4.5-mm screws, respectively. Cerclage wires and an autogenous bone graft were used at the surgeon's discretion. Participating surgeons provided information on age, sex, weight, and breed of the dog, details of the surgery, details of any intra- or postoperative complications, fracture healing time, and limb function. RESULTS: Eight dogs were lost to follow-up evaluation. In 105 of the remaining 126 dogs (83%), fractures healed without complications. For these 105 dogs, limb function was excellent (n = 90), good (12), fair (2), and poor (1). Complications developed for 21 dogs (17%); limb function after additional treatment was excellent (n = 10), good (2), fair (5), poor (1), or unreported (3). Interlocking nails broke in 9 dogs; breakage was attributed to fatigue failure because of use of too small an IN or because of insertion of the IN so that a screw hole was positioned at the fracture site. CLINICAL IMPLICATIONS: The high success rate and low complication rate suggest that IN can be used to stabilize diaphyseal fractures in dogs. Good technique is necessary for optimal results.

[Structure of borderline depressive conditions]. / Struktura pogranichnykh rasstroistv depressivnogo spektra.

Overall 502 workers of a scientific-industrial association were examined in order to study the prevalence and structure of affective disorders. Anxiety appeared the most frequently occurring disorder (289 subjects); depression was revealed in 175, and elements of apathy in 94 persons. In 131 cases, the conditions was assessed as depressive, with the level of depression being subclinical in the majority of them. The structure of depressive disorders, their relation to the demographic characteristics of the examined are considered in detail. The necessity of more active identification and prevention of the " pre-nosological " forms of depression is discussed.

[Psychosomatic correlations in the structure of borderline neurologic and mental disorders]. / Psikhosomaticheskie sootnosheniia v strukture pogranichnykh nervno-psikhicheskikh rasstroistv.

A total of 544 staff members of the scientific industrial association were subjected to non-randomized examination. The presentation and structure of border-line disorders were studied as correlated to the age, sex, familial status, educational level, occupation, and personality structure. Three groups have been distinguished: (1) conditional norm; (2) neurotic disorders; and (3) affective disorders. Correlations between psychopathological and somatic disorders have been traced in all the groups.

Improving the psychiatric skills of the general practice trainee: an evaluation of a group training course.

Fourteen general practice trainees took part in a course specifically designed to improve their psychiatric interviewing skills. The trainees were instructed in the problem-based model and were taught in a group setting with the use of videotape feedback. A significant improvement was demonstrated in the trainees' ability to identify psychiatric illness accurately, and there were significant changes in their interview behaviours after training. Those who were below average before training showed the greatest improvement. The implications of these findings are discussed. Group video feedback training is as effective as one-to-one video feedback training in improving the psychiatric interviewing skills of GP trainees, and could be more widely employed in general practice vocational training.

Psychiatry and family medicine: the McMaster approach.

Family physicians may spend up to 50% of their time dealing with emotional problems but will refer less than 10% of these cases for psychiatric treatment. This paper describes an approach developed at McMaster University which emphasizes the importance of understanding the needs of family physicians and helping them make optimum use of available psychiatric services. Such an approach aims at increasing the comfort and expertise of family physicians in handling the problems they see on a regular basis, involving them actively in their patient's care after a referral, and offering relevant services that supplement those of the family physician, while monitoring and correcting problems that can arise when the two specialties work together. The implications that this has on the training of family medicine and psychiatry residents are discussed as well as ways in which continuing education can be provided for family physicians in community practice.

Cancellous bone grafting at plate removal to counteract stress protection.

Fractures of the radius and ulna in dogs of miniature breeds can be clinically troublesome because of bone resorption during healing, causing increased possibility of refracture. Bone plates allow early weight-bearing, but substitute the problem of stress protection for disuse atrophy. To overcome the disuse atrophy, early plate removal plus cancellous bone grafting was used in 4 limbs of dogs. Visible thickening or increased bone density of the fracture site was observed 3 weeks after the procedure.

The resident as a teacher: a neglected role.

Residents are frequently requested to take on teaching responsibilities, especially with medical students, but they receive little formal preparation for this role. This paper reviews some of the problems residents may face when teaching and describes a training workshop designed to enhance the teaching skills of residents. The workshop is based around a simulated teaching event that focuses on the organizational and practical, as well as didactic tasks involved in supervision of a clinical clerk. Such a workshop helps the resident to identify and prepare for some of the problems they may encounter and provides them with an opportunity to develop new skills that will improve the quality of their teaching.

Problem-based interviewing in general practice: a model.

A problem-based approach which can be utilized in general practice for 'diagnosis and treatment' is described. The various related phases and probable components have been defined, starting with problem sensing, problem detection, problem description and then proceeding to problem assessment and problem-oriented intervention and evaluation. This approach is empirical, patient-centered, geared to general practice, easily acquired and may well have utility in other fields of medicine. Investigation of its effectiveness and efficiency as well as its ability to be taught is needed.

Hypomania and marital conflict.

The author treated seven bipolar patients over seven years whose presenting problems were chronic marital conflict. The bipolar diagnosis had previously been made in only one case. Conjoint or family assessment was essential for accurate diagnosis. Lithium was the cornerstone of treatment and the best results were obtained with bipolar patients who were lithium compliant and whose marital conflict was resolved in conjoint therapy. Marital conflict clearly preceded the bipolar disorder and was not prototypical. Neither a family systems model nor a psychopharmacological model alone were sufficient for treatment. The diagnosis of bipolar disorder must be considered with chronic marital conflict.

Psychiatric manpower in Ontario. Part I: A survey and recommendations.

Demand for psychiatric services is rising in part because many former patients are now in the community and the development of community services has not kept pace. Needs perceived by psychiatrists and family physicians are congruent with each other and with the many job opportunities for psychiatrists which now exist. In five years there will be an increase in attrition of psychiatrists by retirement at the same time as the demand for service by the high utilizers--the young middle age group--will increase. The number of psychiatric training positions funded by the Ministry of Health has diminished. The influx of foreign medical graduates on whom one-third of services depend has been severely curtailed. The net result of these trends, if unmodified, will be higher population-to-psychiatrist ratios, decline in quality, decline in effectiveness, and a decline in the availability of services.

The psychiatrist and family medicine: a different training approach.

A unique 8-year training programme for 110 family medicine residents is described. The psychiatrist works in a family medicine setting with the staff doctors, residents, and patients. The approach evolved because patients wanted a brief problem intervention, and because doctors wanted rapid and efficient methods to identify and treat problems, without using a psychodynamic model. For empirical data collection and clear problem description, a behavioural model is employed. For assessment and therapy, a problem-orientated approach is emphasized, which is rapidly acquired and effectively applied. 'Diagnoses' are not used unless relevant, and paradigms or methods of handling common patient problems are employed. The residents learn in groups and develop skills through supervision of actual patient encounters. There is a phase progression of skill acquisition which is reinforced by the staff doctors. Eighty-seven per cent of the residents achieve the required objectives, and can apply and utilize an approach geared to the needs and realities of everyday practice.