Glenbrook Hospital

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Background: The efficacy of total ankle replacement compared with that of ankle fusion continues to be one of the most debated topics in foot and ankle surgery. The purpose of this study was to determine whether there are sufficient objective cumulative data in the literature to compare the two procedures. A systematic review of the literature addressing the intermediate and long-term outcomes of interest in total ankle arthroplasty and ankle arthrodesis was performed. Methods: A comprehensive search of MEDLINE for all relevant articles published in English from January 1, 1990, to March 2005 was conducted. Additionally, relevant abstracts from the 2003 and 2004 annual proceedings of major orthopaedic meetings were eligible. Two reviewers evaluated each study to determine whether it was eligible for inclusion and collected the data of interest. Meta-analytic pooling of group results across studies was performed for the two procedures. The analysis of the outcomes focused on second-generation ankle implants. Results: The systematic review identified forty-nine primary studies, ten of which evaluated total ankle arthroplasty in a total of 852 patients and thirty-nine of which evaluated ankle arthrodesis in a total of 1262 patients. The mean AOFAS (American Orthopaedic Foot and Ankle Society) Ankle-Hindfoot Scale score was 78.2 points (95% confidence interval, 71.9 to 84.5) for the patients treated with total ankle arthroplasty and 75.6 points (95% confidence interval, 71.6 to 79.6) for those treated with arthrodesis. Meta-analytic mean results showed 38% of the patients treated with total ankle arthroplasty had an excellent result, 30.5% had a good result, 5.5% had a fair result, and 24% had a poor result. In the arthrodesis group, the corresponding values were 31%, 37%, 13%, and 13%. The five-year implant survival rate was 78% (95% confidence interval, 69.0% to 87.6%) and the ten-year survival rate was 77% (95% confidence interval, 63.3% to 90.8%). The revision rate following total ankle arthroplasty was 7% (95% confidence interval, 3.5% to 10.9%) with the primary reason for the revisions being loosening and/or subsidence (28%). The revision rate following ankle arthrodesis was 9% (95% confidence interval, 5.5% to 11.6%), with the main reason for the revisions being nonunion (65%). One percent of the patients who had undergone total ankle arthroplasty required a below-the-knee amputation compared with 5% in the ankle arthrodesis group. Conclusions: On the basis of these findings, the intermediate outcome of total ankle arthroplasty appears to be similar to that of ankle arthrodesis; however, data were sparse. Comparative studies are needed to strengthen this conclusion. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Prophylaxis against postoperative venous thromboembolism should be tailored according to the patient's level of risk. However, risk assessment is not yet in widespread use in surgical practice. In this study, 538 general surgical patients were prospectively assessed based on a scoring system containing 20 risk factors. Depending on the total risk factor score, the patients were grouped into low (0 to 1, 34.5%), moderate (2 to 4, 48.5%), or high risk (more than 4, 17.2%) categories. Statistically significant (p less than 0.0001) correlation was found between our results and those of three existing risk assessment systems. Overall, of the 538 patients, 37.2% received prophylaxis; 10%, 42.1%, and 76% received prophylaxis in the low-, moderate-, and high-risk categories, respectively. Mechanical prophylactic modalities (graduated elastic compression and sequential intermittent compression) were preferred over pharmacologic modalities. These results suggest that implementation of prophylaxis remains underutilized despite published reports, including NIH guidelines. Our results indicate that the majority of surgical patients seen in this suburban hospital have two or more risk factors for developing venous thromboembolism.

The design and development of a new method for high school physics instruction is described. Students are actively engaged in understanding the physical world by constructing and using scientific models to describe, explain, predict, and to control physical phenomena. Course content is organized around a small set of basic models. Instruction is organized into modeling cycles which move students systematically through all phases of model development, evaluation, and application in concrete situations—thus developing skill and insight in the procedural aspects of scientific knowledge. Objective evidence shows that the modeling method can produce much larger gains in student understanding than alternative methods of instruction. This reveals limitations of the popular ‘‘cooperative inquiry’’ and ‘‘learning cycle’’ methods. It is concluded that the effectiveness of physics instruction depends heavily on the pedagogical expertise of the teacher. The problem of cultivating such expertise among high school teachers is discussed at length, with specific recommendations for action within the physics community.

BACKGROUND: The efficacy of total ankle replacement compared with that of ankle fusion continues to be one of the most debated topics in foot and ankle surgery. The purpose of this study was to determine whether there are sufficient objective cumulative data in the literature to compare the two procedures. A systematic review of the literature addressing the intermediate and long-term outcomes of interest in total ankle arthroplasty and ankle arthrodesis was performed. METHODS: A comprehensive search of MEDLINE for all relevant articles published in English from January 1, 1990, to March 2005 was conducted. Additionally, relevant abstracts from the 2003 and 2004 annual proceedings of major orthopaedic meetings were eligible. Two reviewers evaluated each study to determine whether it was eligible for inclusion and collected the data of interest. Meta-analytic pooling of group results across studies was performed for the two procedures. The analysis of the outcomes focused on second-generation ankle implants. RESULTS: The systematic review identified forty-nine primary studies, ten of which evaluated total ankle arthroplasty in a total of 852 patients and thirty-nine of which evaluated ankle arthrodesis in a total of 1262 patients. The mean AOFAS (American Orthopaedic Foot and Ankle Society) Ankle-Hindfoot Scale score was 78.2 points (95% confidence interval, 71.9 to 84.5) for the patients treated with total ankle arthroplasty and 75.6 points (95% confidence interval, 71.6 to 79.6) for those treated with arthrodesis. Meta-analytic mean results showed 38% of the patients treated with total ankle arthroplasty had an excellent result, 30.5% had a good result, 5.5% had a fair result, and 24% had a poor result. In the arthrodesis group, the corresponding values were 31%, 37%, 13%, and 13%. The five-year implant survival rate was 78% (95% confidence interval, 69.0% to 87.6%) and the ten-year survival rate was 77% (95% confidence interval, 63.3% to 90.8%). The revision rate following total ankle arthroplasty was 7% (95% confidence interval, 3.5% to 10.9%) with the primary reason for the revisions being loosening and/or subsidence (28%). The revision rate following ankle arthrodesis was 9% (95% confidence interval, 5.5% to 11.6%), with the main reason for the revisions being nonunion (65%). One percent of the patients who had undergone total ankle arthroplasty required a below-the-knee amputation compared with 5% in the ankle arthrodesis group. CONCLUSIONS: On the basis of these findings, the intermediate outcome of total ankle arthroplasty appears to be similar to that of ankle arthrodesis; however, data were sparse. Comparative studies are needed to strengthen this conclusion.

1Critical Care Educator and Consultant, Glenbrook, NV. 2Education, Development, and Research, University of California San Diego Health, San Diego, CA. The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: [email protected]

OBJECTIVE: The aim of this study to determine the prevalence of anxiety disorders in publically treated psychiatric inpatients with a DSM-IV diagnosis of schizophrenia, schizoaffective disorder or bipolar disorder. METHOD: Using the Structured Clinical Interview for DSM-III-R (SCID), 100 consecutive inpatients with a psychotic disorder were examined for the presence or absence of an anxiety disorder. Questionnaire measures of phobias, obsessive-compulsive and general anxiety symptoms were also applied. RESULTS: The prevalences of social phobia (17%), obsessive-compulsive disorder (13%) and generalised anxiety disorder in schizophrenia were relatively high, as were prevalences of obsessive-compulsive (30%) and panic disorder (15%) in bipolar disorder. The proportion of subjects with an anxiety disorder (43-45%) was almost identical across the three psychoses, with some evidence of gender differences. Although self-ratings of overall psychiatric symptoms were significantly elevated in those with anxiety disorders, hospital admission rates were not. CONCLUSIONS: Almost none of those with anxiety disorders were being treated for them, primarily because the severity of the acute psychotic illness required full diagnostic and therapeutic attention. Patients were generally discharged as soon as their psychotic episode was resolved, with little recognition of the presence of an anxiety disorder. Given that anxiety disorders are relatively responsive to treatment, greater awareness of their comorbidity with psychosis should yield worthwhile clinical benefits.

BACKGROUND AND PURPOSE: The purpose of this study was to assess the construct validity of the Test of Infant Motor Performance (TIMP), specifically the test's sensitivity for assessing age-related changes in motor skill and correlation with risk for developmental abnormality. SUBJECTS: Subjects were 137 term and preterm infants stratified by postconceptional age, medical complications score on the Problem-Oriented Perinatal Risk Assessment System, and ethnicity and race (non-Latino Caucasian, African-American, and Latino). METHODS: Subjects were tested on the TIMP at ages ranging from 32 weeks postconceptional age to 3.5 months past term-equivalent age. Scores (Rasch logit ability measures) were correlated with postconceptional age. A multiple regression analysis was used to assess the contributions of age, risk, and ethnicity to the variance in TIMP scores. RESULTS: The correlation between postconceptional age and TIMP performance measures was .83. Risk and age together explained 72% of the variance in TIMP performance (R = .85, P < .00001). No differences related to ethnicity were found. CONCLUSION AND DISCUSSION: The TIMP has validity for assessing age-related development of functional motor skills in young infants and is sensitive to risk for poor developmental outcome.

The creation of the nipple-areola complex is often the final step in the surgical treatment of breast cancer patients, and it consequently has important symbolic and aesthetic implications. Patient expectations and the need for symmetry make nipple projection a crucial aesthetic determinant of nipple reconstruction. We hypothesize that long-term nipple projection and shape can be achieved in a predictable fashion using the modified star dermal fat flap technique. Prospectively, 93 nipples were reconstructed by a single surgeon using a modified star dermal fat flap technique in 44 implant and 49 TRAM flap breast reconstructions. Flap dimensions (base diameter and flap length) were designed according to patient desire or to the base diameter and projection of the opposite breast nipple. A standardized, 3-month postoperative care regimen was observed in all patients. Nipple projection was assessed by the same observer at each follow-up examination. The average length of follow-up was 730 days (745 for TRAM reconstructions and 713 for implants). Consistently, an average of 41 percent of the intraoperative projection remained intact in both groups at final evaluation (SD 12 percent). The total flap length was strongly predictive of intraoperative and long-term projection (r = 0.64 and 0.86, p < 0.0001). Flap lengths ranged from 5.5 to 9.0 cm, and in a linear correlation, resulted in intraoperative projection of 1.0 to 2.1 cm, respectively, and long-term projection of 0.4 to 0.83 cm, respectively. Based on the linear relationship, every 1-cm increase in flap length could be expected to result in a 0.16-cm increase in projection. When controlled for flap length and intraoperative projection, there was no difference between TRAM and implant nipple reconstruction in predicting postoperative nipple projection. Intraoperative planning and execution are critical to achieve predictable nipple shape, size, and projection. The dimensions of the star dermal fat flap can be strategically modified to allow the surgeon predictable projection with a consistent 41-percent preservation of intraoperative nipple projection in both TRAM and implant patients at 2 years.

Cancer and its treatments introduce various adverse effects that may affect survivors' physical, cognitive and psychological functioning. Frequently both tolerance to activity and exercise are affected as well. Rehabilitation providers should have substantive knowledge about the effect of cancer progression and common side effects associated with antineoplastic treatment to safely integrate rehabilitation interventions. Rehabilitation may mitigate loss of function and disability; however, these patients are among the most medically complex that providers treat. This report provides a focused review that synthesizes the current evidence regarding disease progression and oncology-directed treatment side effects within the context of safety considerations for rehabilitation interventions throughout the continuum of cancer care. Descriptive information regarding the evidence for precautions and contraindications is provided so that rehabilitation providers can promote a safe plan of rehabilitation care. It is incumbent upon but also challenging for rehabilitation providers to stay up to date on the many advances in cancer treatment, and there are many gaps in the literature regarding safety issues. Although further research is needed to inform care, this review provides clinicians with a framework to assess patients with the goal of safely initiating rehabilitation interventions.

OBJECTIVE: The authors attempted to identify factors that commonly contributed to the decision to rehospitalize patients who made heavy use of mental health services. METHODS: The case notes of 50 patients with frequent readmissions to the South Australian Mental Health Services over a three-year period were examined to identify which of 15 factors most frequently contributed to hospital readmission. RESULTS: Lack of insight or denial of illness was cited in 62.2 percent of the patients' 442 total admissions, followed by relationship problems (61.1 percent), suicidal ideation (44.8 percent), and noncompliance with medication (43.2 percent). When the 15 factors were combined into four major categories, social factors were found to contribute to 38.9 percent of admissions, followed by factors related to psychiatric and physical illness (31.1 percent), dangerousness to self or others (20.3 percent), and substance abuse (9.7 percent). CONCLUSIONS: The substantial contribution of social factors to the readmission of patients to acute mental health services is strong evidence that the mental health system must provide appropriate targeted resources and assertive, continuous case management to avoid social crises. Issues surrounding drug and alcohol abuse among heavy users of services must be actively addressed.

Synthetic biology offers opportunities for experiential educational activities at the intersection of the life sciences, engineering, and design. However, implementation of hands-on biology activities in classrooms is challenging because of the need for specialized equipment and expertise to grow living cells. We present BioBits™ Bright, a shelf-stable, just-add-water synthetic biology education kit with easy visual outputs enabled by expression of fluorescent proteins in freeze-dried, cell-free reactions. We introduce activities and supporting curricula for teaching the central dogma, tunable protein expression, and design-build-test cycles and report data generated by K-12 teachers and students. We also develop inexpensive incubators and imagers, resulting in a comprehensive kit costing <US$100 per 30-person classroom. The user-friendly resources of this kit promise to enhance biology education both inside and outside the classroom.

The evaluation of postmortem laboratory assays of drugs needs to be performed in a systematic manner. The condition of the body, drug characteristics, matrix and site analysis are factors which need to be considered in the proper interpretation of an autopsy specimen result.

Increasing numbers of students with learning disabilities (LD) are looking to postsecondary education and training to help them achieve success in career development and eventual job placement. Unfortunately, research suggests that many of these students are having difficulty staying in and completing postsecondary programs. A number of self-determination skills have been identified that are related to students' making a successful transition to postsecondary education. These include stating one's disability and its impact on school performance, and identifying instructional accommodations and strategies for arranging those accommodations with their regular classroom teachers. The purpose of this study was to examine whether these self-determination skills could be acquired through direct instruction, and subsequently generalized to general education classrooms. The results of the effectiveness of this self-determination training are reported and their implications for teachers, parents, and students discussed.

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Twelve patients who met DSM-III-R criteria for schizophrenia and had persistent auditory hallucinations completed a diary three times daily for 2 to 3 weeks. Using 5-point equal interval rating scales, nearly all patients were able to record consistently the nature of their hallucinations, the intensity of their delusional beliefs, and the mood and clarity of their thinking. For at least half the patients, there was a statistically significant relationship between the loudness and intrusiveness of hallucinations and the intensity of delusional beliefs; the more intrusive and distressing were the hallucinations, the more anxious and depressed were the patients. The findings suggested that more emphasis might be placed on altering patients' mood in the treatment of persistent hallucinations. The diary approach to research into auditory hallucinations appears promising.

General Health Questionnaire (GHQ) results are given for a large (N = 1013) sample of South Australian young people (average age 19.6 years), to compare the usefulness of the 12-, 28-, and 30-item forms of the GHQ. Internal reliabilities are generally adequate and the Likert scoring method produces significant correlations with psychological measures such as self-esteem. The case-prevalence rate using the binary scoring method was comparable with other studies, but misclassification rates were unacceptably high when DSM-III Axis I diagnosis was used as the criterion for the presence of any psychiatric disorder.

Nerve agents are discussed. The article discusses their properties, routes of exposure, toxicodynamics, targets of toxicity, and treatment. It is concluded that a focused organized approach to the treatment of nerve agents is key to its successful management.

This paper reviews the clinical information on antihistaminic agents as analgesics and as analgesic adjuvants. The evidence indicates a direct analgesic effect of various antihistaminics. In clinical studies, diphenhydramine, hydroxyzine, orphenadrine and pyrilamine have been shown to produce analgesia as simple entities but chlorpheniramine has not and results with phenyltoloxamine have been equivocal when tested alone. Analgesic adjuvant effects of several antihistaminics have been reported. Clinically, orphenadrine and phenyltoloxamine have shown adjuvant effects with acetaminophen and aspirin. The mechanism of action remains speculative. The most recent trends in the classification of histamine receptors and how these receptors may interact with pain modulation are also considered.

The number of children diagnosed with an Autism Spectrum Disorder has increased dramatically in the last 20 years. Parents of children with autism experience a variety of chronic and acute stressors that can erode marital satisfaction and family functioning. Family therapists are well-suited to help parents stay connected to each other as they create a "new normal." However, family therapists need updated information about autism, and they need to understand how family therapy can help parents of children with autism. Because having a child with autism affects multiple domains of family life, this paper explores how family therapists can utilize an integrative approach with parents, enabling them to flexibly work with the domains of action, meaning, and emotion.