Femoroacetabular impingement: a resurfacing solution.

Femoroacetabular impingement (FAI) is commonly associated with early hip arthritis. We reviewed our series of 1300 hip resurfacing procedures. More than 90% of our male patients, with an average age of 53 years, had cam impingement lesions. In this condition, there are anterior femoral neck osteophytes, and a retroverted femoral head on a normally anteverted neck. It is postulated that FAI results in collision of the anterior neck of the femur against the rim of the acetabulum, causing damage to the acetabular labrum and articular cartilage, resulting in osteoarthritis. Early treatment of FAI involves arthroscopic or open removal of bone from the anterior femoral neck, as well as repair or removal of labral tears. However, once osteoarthritis has developed, hip replacement or hip resurfacing is indicated. Hip resurfacing can re-orient the head and re-shape the neck. This helps to restore normal biomechanics to the hip, eliminate FAI, and improve range of motion. Since many younger men with hip arthritis have FAI, and are also considered the best candidates for hip resurfacing, it is evident that resurfacing has a role in these patients.

The Minnesota Senior Health Options program: an early effort at integrating care for the dually eligible.

BACKGROUND: Duplication of funding and resultant inefficiencies have prompted active consideration of pooling the funding for persons covered by both Medicare and Medicaid into a single managed care program. This study reports the initial results of the first such program. METHODS: A sample of enrollees in Minnesota Senior Health Options (MSHO) and two sets of controls (within the same catchment area and outside it) as well as their families were interviewed to assess their functional status and satisfaction with their medical care. Respondents included those living in the community and those living in nursing homes. RESULTS: The MSHO and control samples were generally alike in terms of demographics and illness patterns. The differences that were found reflected those attributable to geographic location more than program. The groups were also similar with regard to functional status. There were few satisfaction differences among the community-dwelling samples, but the MSHO nursing residents and especially their families expressed more satisfaction with several aspects of care. CONCLUSIONS: Whereas no causal conclusions about outcomes can be drawn from a cross-sectional sample, there is no indication that managed care for the dually eligible population has profound impacts on care. However, the system of care provided to nursing home residents is appreciated over traditional care.

Reliability and validity of the SA-45: further evidence from a primary care setting.

A project designed to demonstrate the benefits of integrating behavioral healthcare services in primary medical care settings provided an opportunity to further investigate the psychometric properties of the SA-45 using data from a sample of 126 adults seeking medical services in a family practice setting. Specifically, the appropriateness of the SA-45 s adult nonpatient norms, as well as cross-validation of its test-retest reliability and construct validity, was investigated from the first set of data gathered for this project. The results suggested that use of the SA-45 nonpatient norms with primary care populations is appropriate. Three-month test-retest correlations between Depression scale scores and SA-45 and SA-24-predicted GSI scores were found to be moderate but highly significant. In addition, correlations among the SA-45 scales and indices and their correlations with the SF-12 Mental and Physical Component Summary scales added further support for the psychometric integrity of the SA-45. Finally, only partial indirect support was obtained for the SA-45 s ability to accurately classify patients as requiring further evaluation for behavioral health problems. Limitations of the study are discussed and suggestions for future research are presented.

Development of a Brief, Multidimensional, Self-Report Instrument for Treatment Outcomes Assessment in Psychiatric Settings: Preliminary Findings.

Preliminary reliability and validity data are reported on a new, brief measure of psychiatric symptomatology. The Symptom Assessment-45 Questionnaire (SA-45) is a 45-item, patient self-report symptom inventory derived from the original Symptom Checklist-90-R (SCL-90), using cluster analytic methods. The SA-45 consists of nine 5-item scales assessing each of the same symptom domains as its parent instrument with no item overlap across domains. The vast majority of the internal consistency reliabilities for the SA-45's nine scales were in the .70s and .80s across different age and patient status samples. As expected, both adolescent and adult patient samples generally differed significantly from nonpatient control samples, and patients at treatment follow-up differed significantly from patients at intake. Moreover, depressed patients with and without psychotic features differed significantly on three scales. A cluster analysis generally supported the nine-scale structure of the inventory, but it failed to consistently support the distinction between the Paranoid Ideation and Interpersonal Sensitivity scales. Limitations to the study are noted, but overall, the initial findings support the use of the SA-45 in clinical settings. Suggestions for needed future research are presented.

Neurologic evaluation of the rat during sciatic nerve block with lidocaine.

BACKGROUND: Quantitative behavioral testing is necessary to establish a reproducible measure of differential functional blockade during regional anesthesia. Methods for assessment of the neurologic status (mental status, posture, gait, proprioception, motor function, autonomic function, and nociception) in veterinary neurology were adapted for the rat and used to monitor functional changes separately during a sciatic nerve block. METHODS: Sprague-Dawley rats were acclimated to laboratory routine before the study so that lidocaine (0.1 ml, 1%) could be injected near the sciatic notch without any chemical restraint. The onset, duration, and magnitude of functional losses were monitored. Proprioceptive integrity was evaluated by assessing the response to tactile placing and the hopping response. Extensor postural thrust, a test for postural reactions in small animals, was assessed on a digital balance and found adequate for quantifying motor function. Analgesia was assessed by measuring withdrawal response latencies to noxious thermal stimulation (51 degrees C) and to superficial and deep noxious pinches. Autonomic function was monitored by measuring skin temperature. Contralateral limb function was used as an internal control, and injection of saline was used as an external control in separate, control animals. RESULTS: Onset of postural and gait abnormalities were observed as early as 40 s after injection. On each occasion proprioceptive impairment was detected first, followed by impairment of motor function and nociception. Complete absence of proprioception occurred from 10 to 30 min (n = 9) and of motor function at 30 min after injection (n = 10); both functions were fully recovered by 120 min. A unilateral increase in skin temperature on the foot was detected by 1 min; had reached its maximum change, 5.3 +/- 0.7 degrees C, at 10 min; and had returned to control levels at 60 min after injection (n = 12). Withdrawal response to cutaneous or superficial pain was absent in all ten animals from 5 to 30 min whereas the response to deep pain was absent in all ten animals at 20 min only. The response to noxious stimulation recovered at 90 min. Attention was paid to the temporal relation of the impairment of various functions. CONCLUSIONS: Quantitative observations of the onset, offset, and intensity of differential functional impairment or block over time will make it possible to establish the doses and conditions for local anesthetics that result in differential nerve block and will permit comparison of these changes among different drugs and "clinical" protocols.

Early enteral administration of a formula (Impact) supplemented with arginine, nucleotides, and fish oil in intensive care unit patients: results of a multicenter, prospective, randomized, clinical trial.

OBJECTIVE: To determine if early enteral feeding, in an intensive care unit (ICU) patient population, using a formula supplemented with arginine, dietary nucleotides, and fish oil (Impact), results in a shorter hospital stay and a reduced frequency of infectious complications, when compared with feeding a common use enteral formula (Osmolite.HN). DESIGN: A prospective, randomized, double-blind, multicenter trial. SETTING: ICUs in eight different hospitals. PATIENTS: Of 326 patients enrolled in the study, 296 patients were eligible for analysis. They were admitted to the ICU after an event such as trauma, surgery, or sepsis, and met a risk assessment screen (Acute Physiology and Chronic Health Evaluation II [APACHE II] score of > or = 10, or a Therapeutic Intervention Scoring System score of > or = 20) and study eligibility requirements. Patients were stratified by age (< 60 or > or = 60 yrs of age) and disease (septic or systemic inflammatory response syndrome). INTERVENTIONS: Patients were enrolled and full-strength tube feedings were initiated within 48 hrs of the study entry event. Enteral feedings were advanced to a target volume of 60 mL/hr by 96 hrs of the event. One hundred sixty-eight patients were randomized to receive the experimental formula, and 158 patients were randomized to receive the common use control formula. MEASUREMENTS AND MAIN RESULTS: Both groups tolerated early enteral feeding well, and the frequency of tube feeding-related complications was low. There were no significant differences in nitrogen balance between groups on study days 4 and 7. Patients receiving the experimental formula had a significant (p = .0001) increase in plasma arginine and ornithine concentrations by study day 7. Plasma fatty acid profiles demonstrated higher concentrations of linoleic acid (p < .01) in the patients receiving the common use formula and higher concentrations of eicosapentaenoic and docosahexaenoic acid (p < .01) in the patients receiving the experimental formula. The mortality rate was not different between the groups and was significantly (p < .001) lower than predicted by the admission severity scores in both feeding groups. In patients who received at least 821 mL/day of the experimental formula, the hospital median length of stay was reduced by 8 days (p < .05). In patients stratified as septic, the median length of hospital stay was reduced by 10 days (p < .05), along with a major reduction in the frequency of acquired infections (p < .01) in the patients who received the experimental formula. In the septic subgroup fed at least 821 mL/day, the median length of stay was reduced by 11.5 days, along with a major reduction in acquired infections (both p < .05) in the patients who received the experimental formula. CONCLUSIONS: Early enteral feeding of the experimental formula was safe and well tolerated in ICU patients. In patients who received the experimental formula, particularly if they were septic on admission to the study, a substantial reduction in hospital length of stay was observed, along with a significant reduction in the frequency of acquired infections.

Solvability of the electrocardiology inverse problem for a moving dipole.

New formulations of the direct and inverse problems for the moving dipole are offered. It has been suggested to limit the study by a small area on the chest surface. This lowers the role of the medium inhomogeneity. When formulating the direct problem, irregular components are considered. The algorithm of simultaneous determination of the dipole and regular noise parameters has been described and analytically investigated. It is shown that temporal overdetermination of the equations offers a single solution of the inverse problem for the four leads.

Possible mechanisms underlying the pressure responses evoked in conscious cats by emotional stress.

The character of baroreceptor reflexes was studied in conscious cats both under resting conditions and during emotional stress. During naturally evoked emotional tension 32 cats showed a two-phase change in arterial pressure: an initial hypotension was followed by a rise in arterial pressure. The pressor component was accompanied by a suppression of the baroreceptor reflex evoked by phenylephrine (i.v.). Electrical stimulation of the hypothalamic "defence area" also resulted in a raised arterial pressure and a suppression of the baroreceptor reflex. 3-7 days after bilateral section of the carotid sinus and aortic nerves 5 cats showed a reduction in arterial pressure only when confronted by a dog. When a reflex response to phenylephrine began to return, the depressor responses seemed to diminish and pressor responses reappeared. "Mild" (50-100 microA) stimulation of the hypothalamic "defence area" also caused a reduction of arterial pressure. However, a rise in arterial pressure occurred when the electrical stimulation of the hypothalamic "defence area" was increased. In 2 cats the pressor response caused by confrontation with a dog was not accompanied by any noticeable inhibition of the baroreceptor reflex. After cutting the sino-carotid and aortic nerves in these animals, emotional stress produced accentuated pressor responses. The results suggest that the presence of baroreceptor reflexes is a prerequisite for the development of hypertensive responses during emotional stress.