Credibility, readability and content analysis of treatment recommendations for adolescents with nonspecific back pain published on consumer websites.

BACKGROUND: Parents may seek out health information online when their adolescent has nonspecific back pain to better understand treatment options. Such information directed towards consumers has not been previously analysed. METHODS: A descriptive cross-sectional content analysis was performed to describe the treatments recommended on consumer websites for nonspecific back pain in adolescents. The credibility and readability of the websites were also assessed. Systematic Google searches were completed in five countries, and relevant content from eligible web pages was analysed. An a priori codebook with 34 treatment-related codes was developed. Nine additional codes were inductively created during analysis. Credibility was assessed using the JAMA benchmark. Readability was assessed via the Flesch Kincaid Grade Level. RESULTS: Of 245 web pages, 48 were deemed eligible and analysed. Of 43 treatment codes, 37 were present in at least one web page. The five most frequently identified codes were See the doctor/get a diagnosis (found on 85% of web pages), Ergonomics/posture/biomechanics (52%), Reassurance (48%), Physiotherapy (48%) and Non-prescription pharmaceuticals/supplements (46%). Only 21% of the web pages met all four JAMA benchmark criteria, and 15% cited at least one recent or high-quality source. The median Flesch Kincaid Grade Level score was 9.0 (range 3.5-12.9). CONCLUSIONS: Parents of adolescents with nonspecific back pain may find that treatment recommendations published online are numerous and varied, with visits to the doctor encouraged. The credibility scores of these web pages are generally low, while the median reading level may be too high for the general population. SIGNIFICANCE STATEMENT: This analysis reveals that public-facing websites with recommendations for treating adolescent nonspecific back pain do not cite the most recent, high-quality research. Although web pages correctly encourage physical activity and exercise over surgery and prescription medications, they do not reflect the psychologically informed or interdisciplinary care emphasized in recently published treatment recommendations. Clinicians must be aware that caregivers of their adolescent patients with nonspecific back pain may be exposed to online messages that encourage them to keep seeking a diagnosis.

An evaluation of a one-day pain science education event in a high school setting targeting pain related beliefs, knowledge, and behavioural intentions.

BACKGROUND: Persistent pain is a common condition affecting one in four UK adults. Public understanding of pain is limited. Delivering pain education within schools may improve public understanding in the longer term. OBJECTIVE: To evaluate the impact of a one-day Pain Science Education (PSE) event on sixth form/high school students' pain beliefs, knowledge and behavioural intention. METHODS: Exploratory, single-site, mixed-methods, single-arm study involving secondary school students ≥16 years old attending a one-day PSE event. Outcome measures included the Pain Beliefs Questionnaire (PBQ), Concepts of Pain Inventory (COPI-ADULT), a vignette to assess pain behaviours; and thematic analysis of semi-structured interviews. RESULTS: Ninety (mean age 16.5 years, 74% female) of the 114 attendees, agreed to participate in the evaluation. PBQ scores improved on the Organic beliefs subscale [mean difference -5.9 (95% CI -6.8, -5.0), P < 0.01] and Psychosocial Beliefs subscale [1.6 (1.0, 2.2) P < 0.01]. The COPI-Adult revealed an improvement [7.1 (6.0-8.1) points, P < 0.01] between baseline and post intervention. Pain behavioural intentions improved post education for work, exercise, and bed rest related activities (p < 0.05). Thematic analysis of interviews (n = 3) identified increased awareness of chronic pain and its underpinning biology, beliefs that pain education should be widely available, and that pain management should be holistic. CONCLUSIONS: A one-day PSE public health event can improve pain beliefs, knowledge and behavioural intentions in high school students and increase openness to holistic management. Future controlled studies are needed to confirm these results and investigate potential long-term impacts.

Aspergilloma within a malignant pulmonary cavity.

The simultaneous appearance of both bronchogenic carcinoma and aspergilloma with the typical radiographic appearance of a mycetoma emphasizes the importance of consistent suspicion for malignancy in any pulmonary lesion. This is apparently the first reported case in which allergic phenomena (asthma-like symptoms and eosinophilia) are associated with an aspergilloma occurring within a cavitary bronchogenic carcinoma.

Peripheral pulmonary embolization from central pulmonary aneurysm.

A 59-year-old man underwent successful repair of a pulmonary arterial aneurysm because of peripheral pulmonary embolization. These lesions are relatively rare; and, to out knowledge, peripheral embolization from such an aneurysm has not been previously reported.

Esophageal obstruction due to intermuscular hematoma following pneumatic dilatation.

A case of incomplete esophageal perforation with an intermuscular hematoma is presented. Unlike previously described submucosal or intramural perforations, this case involved mucosa, submucosa, and the inner circular muscle layer but was limited by the outer longitudinal layer. Nonsurgical treatment was followed when the clinical picture of an incomplete perforation without mediastinal soilage was considered. Surgery was done when evidence of impending extension of the process outside the esophagus developed.

Risks of blood exposure to the cardiac surgical team.

The risk of transmission of human immunodeficiency virus from patient to cardiac surgical team is perceived by most people to be very slight, yet the possibility is a valid concern. The feasibility of "barrier protection" in prevention of this risk is dependent on integrity of surgical gloves and absence of splashes of body fluids into eyes and broken skin. These factors were observed and recorded in 50 coronary bypass operations and 17 valve replacements. There was a high risk of glove penetrations (one to two per team member per operation) and of skin punctures, lacerations, or eye splashes (from 0.4 to 1.5 instances per operation). Better gloves and more self-defensive surgical techniques are indicated.

Traumatic rupture of the aorta: emergency operation.

Fifty-nine patients who had traumatic aortic rupture in the area of the isthmus and were treated less than one week after injury were studied. Most patients (N = 47) underwent repair using pump-oxygenator partial bypass; 7 had simple cross-clamping. Paraplegia developed in 4 during operation. One patient died of a head injury after receiving heparin for bypass. The experience with these patients and a critical review of the literature indicate that the use of extracorporeal circulation and avoidance of hypoxia and hypercapnia may decrease the probability of paraplegia. When laparotomy preceded thoracotomy, there were no clearly deleterious effects of heparinization.

Primary Aspergillus osteomyelitis of the sternum.

We report 2 cases of primary sternal osteomyelitis caused by Aspergillus; previously reported cases have been complications of sternotomy. Both patients were healthy young men with recent intravenous drug abuse. No other focus or predisposing factors were found. Both were treated with partial sternectomy and chondrectomy; 1 received long-term amphotericin B therapy. Both are doing well 2 1/2 years after operation. Drug usage, acquired immunodeficiency syndrome, and medical immunosuppression may lead to other cases.

In defense of malpractice charges: a survey of the legal process.

Surgeons need to be more informed and cognizant of the ramifications of the legal process to participate properly in their defense or to serve as expert witnesses. The education, training, experience, and psychology of surgeons provide a different background from that needed in a legal contest. As the saying goes, "The battle begins when the suit is served." Attention to detail and defensive, conservative, and humble attitudes should begin then. Although cases are not won in the early stages or during the discovery process, they may well be lost there. The surgeon's improper attitude and lack of preparation may be responsible for many of these losses. The process is expensive and time-consuming, but attempts to avoid this time commitment during the pretrial stages are ill advised. With understanding, close cooperation with counsel, and proper preparation, the surgeon will be a potent force in his or her own defense.

Medical management of acute traumatic rupture of the aorta.

Surgical reconstruction is the treatment for acute traumatic aortic rupture and should be accomplished immediately in most patients. In patients in whom concomitant injuries or the development of life-threatening complications preclude safe and successful aortic reconstruction, pharmacological intervention to reduce the risk of free aortic rupture may be considered. Surgical reconstruction can then be more safely performed under controlled elective circumstances.

Acute traumatic rupture of the aortic isthmus: repair with cardiopulmonary bypass.

In an attempt to prevent paraplegia, a devastating complication common after the repair of traumatic rupture of the aorta, we have used partial cardiopulmonary bypass. Most of the patients in our series (79.5%) underwent other major surgical procedures immediately before or after the aortic repair. Eight of the 110 patients died before aortic repair could be performed. The aorta was not repaired in 3, because of other injuries. In 9, the repair was done without a shunt or bypass; 4 patients died and 2 (22.2%) survived without paraplegia. One of the 2 who underwent repair with a Gott shunt died; the survivor suffered no cord damage. Of the 88 patients whose repair was carried out under cardiopulmonary bypass, 6 died and 80 (90.9%) survived without paraplegia. None of the last 39 patients has become paraplegic, as vasodilator treatment is now discontinued during the cross-clamp period. Serious intracranial injury was present in 19 patients; in 3 (15.8%) the injury became worse after repair. There was no evidence of new or increased intraabdominal bleeding during heparinization. Except in the event of pulmonary lacerations, systemic heparin therapy was not associated with major problems.

Lower esophageal ring: experiences in treatment of 88 patients.

The lower esophageal ring is an unusual clinical disorder of the esophagus and consists of a thin submucosal circumferential scar that forms in the lower esophagus. It is probably an acquired lesion resulting from repeated insults to the lower esophageal mucosa. The symptom of dysphagia results from esophageal obstruction, and the degree of obstruction is directly related to the internal diameter of the ring. Episodic aphagia results from impaction of food at the site of the ring. Since 1970, 88 patients have been seen with either dysphagia or episodic aphagia. Sixty-five with chronic limited reflux were treated primarily by oral dilation. Two of them required an antireflux procedure at a later date because of accentuation of reflux symptoms. Eighteen patients received surgical treatment initially because of severe reflux disease. Treatment consisted of interruption of the ring combined with an antireflux procedure. Five patients received no treatment. Lower esophageal ring may be managed satisfactorily through oral dilation, resulting in relief of dysphagia. If reflux disease is present or is accentuated by dilation and cannot be controlled medically, then the appropriate antireflux procedure should be done.

Penetrating injuries of the aortic arch and its branches.

Acute cardiac failure, pulmonary edema, and ischemia of the brain, cord, and other structures pose special problems with trauma to the aortic arch and its branches. Data on 93 such cases are reported. Diagnosis was made by clinical examination in hemodynamically unstable patients and led to immediate operation in 61.3%. Patients in stable condition had angiography, which localized the injury and allowed planning of incision and bypass shunts. In left subclavian artery injuries, anterior thoracotomy was best for proximal control regardless of wound entry sites; midline sternotomy with sternocleidomastoid extension was usually adequate for other vessels. Flow was reestablished in all carotid injuries; there were no neurological complications. Temporary or permanent bypass shunts during periods of proximal aortic occlusion were valuable in decreasing cardiac afterload, maintaining circulation to the brain, and allowing an unhurried methodical approach to the hematoma. Occlusion of one or more venae cavae alleviated acute cardiac dilatation during brief periods of ascending aortic clamping. Associated trauma contributed to the high mortality.

Noniatrogenic esophageal trauma.

Few guidelines are available with which to facilitate treatment in patients with noniatrogenic injuries of the esophagus. Early diagnosis and proper management are essential if a good outcome is to be expected. In an effort to define better the treatment of patients with penetrating and blunt injuries of the esophagus, we report our recent 5-year experience at an urban trauma center. From July 1988 to June 1993, nineteen patients with esophageal perforations from penetrating (18) and blunt (1) trauma were identified by our trauma registry. There was no mortality in this group of patients and morbidity was mostly due to associated injuries. Eleven cervical esophageal injuries were repaired. One cervical injury was treated by stopping oral intake and giving intravenous antibiotics. The neck was not drained in 10 of the surgical cases. In 1 patient a tracheoesophageal fistula developed, which later was repaired with a pectoralis muscle flap. Seven perforations were identified in the thoracic (2) and abdominal (5) portions of the esophagus. All were due to gunshot wounds. In 4 cases, a fundal wrap was used to reinforce the repairs. Postoperative contrast studies confirmed that all repairs were intact. We conclude that penetrating and blunt tears of the esophagus can be repaired safely with minimal mortality. Morbidity is usually from associated injuries such as to the spinal cord and trachea. When identified early, cervical esophageal injuries do not need to be drained routinely.

Coronary operations in patients with spinal cord injury.

BACKGROUND: The risk of heart disease in patients with spinal cord injury is similar to that in the general population. The physiologic derangements raise special problems in patients with SCI having coronary operations. METHODS: From January 1980 to May 1995, we performed coronary artery bypass procedures on 20 patients with SCI; 4 were tetraplegic and the remainder were paraplegic. The indication for operation was angina: unstable (13), exertional (4), or postinfarctional (3). Bowel and bladder care was given immediately before operation; operating room tables were double padded and a pelvic wrap was used to protect the back. Electric wheelchairs were used for early mobilization. RESULTS: Vasomotor instability from cardiopulmonary bypass was not present in patients with SCI. Pharmacologic support was required in the operating room by 4 patients for low vascular resistance, but in only one case in the intensive care unit. One patient required ventilation support for more than 24 hours. All patients were able to cough effectively. No thoracic wound complications occurred. There were three operative deaths, all in patients with multiple risk factors. The acute hospital stay averaged 9.3 days; patients were then transferred to an SCI unit for rehabilitation, were upper-extremity weight bearing was restricted for 2 to 4 weeks. CONCLUSIONS: Patients should not be denied coronary artery bypass procedures because of an SCI, but their special needs must be managed properly.

Spontaneous rupture of the esophagus: a 30-year experience.

This retrospective review of 34 patients with spontaneous rupture of the esophagus, which spans a 30-year period, attempts to identify areas in diagnosis and therapy that might alter the dismal prognosis. The diagnosis and definitive surgical repair of Boerhaave's syndrome were frequently delayed. Delay resulted in a significant increase in complication rates. Pain (85%) and vomiting (71%) were the only common historical events suggesting the diagnosis. Physical examination was of aid in the diagnosis in only the 9 patients (27%) who demonstrated cervical or mediastinal emphysema. The initial chest roentgenogram was abnormal in 97% of the patients, but was interpreted as "compatible with perforation of the esophagus" in only 27%. Esophagography was diagnostic in 23 of 24 patients in whom it was used. Thoracentesis was of little diagnostic aid, but pleural fluid pH was measured in only 15% of the patients. Prompt surgical repair, regardless of time after onset, appears to be the indicated therapy.

Video-assisted thoracic surgery: primary therapy for spontaneous pneumothorax?

BACKGROUND: This study assessed the role of video-assisted thoracic surgery (VATS) in current therapy for spontaneous pneumothorax. METHODS: We compared a retrospective series of 89 patients treated conventionally with a consecutive group of 30 patients undergoing VATS pleural abrasion. The 89 earlier patients were predominantly male (81%). Treatment groups included observation/aspiration (7 or 17%), tube thoracostomy (32 or 36%), multiple tubes (7 or 9%), and thoracotomy (43 or 48%). Of the 30 patients treated with VATS, 18 (66%) were male. Primary indications for operation were recurrent pneumothorax (17) and persistent air leak (9). RESULTS: Hospital lengths of stay (LOS) for the earlier group were 5 days for simple tube and 7 days for primary thoracotomy; LOS for initial intervention followed by thoractomy exceeded 15 days in all subgroups. The average LOS in the VATS group was 13 days; 6 patients treated with primary VATS (no chest tube) had a mean LOS of 6.5 days. Complications included 3 (10%) prolonged air leaks (more than 7 days) and 2 (7%) early recurrences. CONCLUSIONS: We do not recommend VATS as primary therapy for spontaneous pneumothorax; tube thoracostomy remains the treatment of choice. However, we strongly support surgical intervention early (3 days) in patients with a persistent air leak, and as primary therapy in a nonurgent situation if standard indications exist. This study shows no advantage of VATS over conventional thoracotomy in hospital stay or complication rate.

Chest wall resection for Ewing's sarcoma of the rib: an unnecessary procedure. 1988. Updated in 1995.

Approximately 10% of all cases of Ewing's sarcoma arise from a rib. Conventional management has included chest wall resection (3 or more ribs) and radiation therapy. These forms of therapy have led to complications such as scoliosis and local deformity. The addition of radiation therapy can result in damage to the lung and adjacent viscera and also potentiate pulmonary restrictive disease. Between 1971 and 1978, 9 patients were treated with surgery, radiation therapy, and combination chemotherapy (three- or four-drug regimen). Only 2 patients (22%) survive. Since 1979, 14 patients were entered into a new protocol consisting of sequential induction chemotherapy, followed by delayed surgical resection whenever feasible. Three patients had complete resection of their primary lesion at onset. Initially, 7 patients had either biopsy (N = 4) or incomplete chest wall resection N = 3). All 4 patients with biopsy only at diagnosis had excellent responses to induction chemotherapy, allowing delayed resection of the involved rib without chest wall resection. Overall, 12 of 14 patients (86%) treated since 1979 survive, with only 2 receiving radiation therapy for residual disease in the primary rib site.

Chest wall resection for Ewing's sarcoma of the rib: an unnecessary procedure.

Approximately 10% of all cases of Ewing's sarcoma arise from a rib. Conventional management has included chest wall resection (3 or more ribs) and radiation therapy. These forms of therapy have led to complications such as scoliosis and local deformity. The addition of radiation therapy can result in damage to the lung and adjacent viscera and also potentiate pulmonary restrictive disease. Between 1971 and 1978, 9 patients were treated with surgery, radiation therapy, and combination chemotherapy (three- or four-drug regimen). Only 2 patients (22%) survive. Since 1979, 14 patients were entered into a new protocol consisting of sequential induction chemotherapy, followed by delayed surgical resection whenever feasible. Three patients had complete resection of their primary lesion at onset. Initially, 7 patients had either biopsy (N = 4) or incomplete chest wall resection N = 3). All 4 patients with biopsy only at diagnosis had excellent responses to induction chemotherapy, allowing delayed resection of the involved rib without chest wall resection. Overall, 12 of 14 patients (86%) treated since 1979 survive, with only 2 receiving radiation therapy for residual disease in the primary rib site.

Clinical and laboratory evaluation of cefoperazone.

Cefoperazone, a third-generation cephalosporin derivative, has been reported to have excellent antibacterial activity against a wide range of gram-positive and gram-negative pathogens, including Pseudomonas aeruginosa. We treated 54 patients with a variety of clinical infections with cefoperazone and determined the susceptibilities of their 90 bacterial isolates. An additional 25 aerobic isolates obtained from patients treated with cefamandole in a comparison study were also tested for susceptibility to cefoperazone. Thus a total of 115 isolates were studied in vitro. One hundred nine (95%) of 115 bacterial isolates, including gram-positive and gram-negative aerobes and anaerobes, were susceptible to less than or equal to 32 microgram/ml. Only four isolates (three Escherichia coli and one Serratia marcescens) were highly resistant (minimal inhibitory concentration greater than or equal to 128 microgram/ml). We were able to assess clinical outcome of cefoperazone therapy in 53 patients; favorable responses (cure of improvement) were found in 48 (91%). P. aeruginosa was a major pathogen in three patients treated with cefoperazone; all three showed a favorable response. Side effects of cefoperazone therapy were noted in seven (13%) patients, and laboratory abnormalities were observed in 11 (20%) patients; all of these were mild and readily reversible. Cefoperazone thus appears to be safe, well tolerated, and suitable for use in a variety of human infections.