[Single Subcutaneous Palmar Injection vs. 2 Dorsal Injections for Finger Anaesthesia in Hand Surgery - Randomised Prospective Comparison of Application Pain and Efficacy]. / Vergleich zweier Fingerleitungsanästhesie-Techniken - randomisierte, prospektive Studie bezüglich Applikationsschmerz und Wirksamkeit zwischen dem singulären subkutanen Digitalblock und der Oberst-Leitungsanästhesie.

PURPOSE: This randomised prospective study compared pain during application and efficacy of the palmar subcutaneous single injection block (PSSIB) and the traditional dorsal 2 injection block (DTIB). METHODS: During a 2 year period, a total of 190 patients with an average age of 43 years (18-82) and an isolated finger injury were included in the study. The injection was applied by residents (n=29) of the emergency department. 96 patients received PSSIB (72 men, 24 women) and 94 DTIB (55 men, 39 women) with 3 ml of Mepicavain(®) 1%. Randomisation was performed by even/odd hospital admission number. EXCLUSION CRITERIA: Thumb injury, progressive infection with visible redness at injection point. Application pain was recorded immediately after injection and registered on a VAS (0-10). Efficacy was checked 5 min after application. The patients quoted the efficacy as complete pain-free, almost pain-free and inadequate anesthesia (second injection was necessary). Statistical analysis was performed using the chi-quadrat and the t test; the level of significance was set at p<0.05. RESULTS: There was no significant difference in terms of analgesic efficacy (p=0,096), while the PSSIB required fewer second injections. Application pain was rated as being significantly (p=0.002) less painful for PSSIB (3.2) than for DTIB (4,0). CONCLUSIONS: This study shows that PSSIB gives reliable analgesia and the application pain is significant less than during DTIB.

Increasing the Rural Physician Workforce: A Potential Role for Small Rural Medical School Campuses.

PURPOSE: To address the issue of physician maldistribution, some medical schools have rural-focused efforts, and many more are in the planning or early implementation stage. The best duration and structure of the rural immersion experience are unclear, and the relative effects of rural upbringing and rural training on subsequent rural practice choice are often difficult to determine. METHODS: To determine the effect of adding a rural clinical campus to our school, we analyzed the variables of rural upbringing, demographics, family medicine residency choice, and campus participation using a multivariate model for association with rural practice choice. We included graduates from the classes of 2001-2008 from both campuses (urban and rural) in the analysis. FINDINGS: We found similar associations to those reported previously of rural upbringing (OR = 2.67 [1.58-4.52]) and family medicine residency (OR = 5.08 [2.88-8.98]) with rural practice choice. Even controlling for these 2 variables, participation in the full 2 years at the rural clinical campus showed the strongest association (OR = 5.46 [2.61-11.42]). All 3 associations were significant at P < .001, and no other variables were significant. CONCLUSIONS: We conclude that the investment of resources in our rural campus may add an increment to rural practice choice beyond the established associations with rural upbringing and family medicine residency. The decision of practice site choice is complex, and collaborative studies that include data from several schools with differently structured rural exposures, including those with rural clinical campuses, are needed.

[Postoperative Osteomyelitis of a Distal Phalanx Caused by Raoultella ornithinolytica]. / Postoperative Osteomyelitis einer Endphalanx am Finger durch Raoultella ornithinolytica.

We report on a case of osteomyelitis of a distal phalanx of the right ring finger of a 62-year-old patient, which occurred 11 months after transosseous-transungual refixation of a closed flexor digitorum profundus tendon avulsion caused by Raoultella ornithinolytica. R. ornithinolytica is an encapsulated Gram-negative aerobic bacillus. In the literature only 13 cases of human infection by R. ornithinolytica are mentioned. To the best of our knowledge, this is the first case of an osteomyelitis caused by R. ornithinolytica.

A Medical School Prematriculation Program for Rural Students: Staying Connected With Place, Cultivating a Special Connection With People.

PROBLEM: Rural medical students who attend urban medical schools experience urban disruption that may make it less likely that they will return to rural practice. Most prematriculation programs focus on academic preparation and are in urban areas, potentially adding to urban disruption. Most initial learning experiences concerning communication with patients are also in urban areas. INTERVENTION: Fifty-nine rural preclinical students completed a 3-week summer rural prematriculation program from 2009 to 2014. The focus was on learning a holistic approach to interviewing patients and experiential learning based in a rural practice. Group reflection sessions focused on understanding health beliefs, psychosocial details of the patient's life, and the importance of the sense of place. Measures included student reports, program evaluations, and a pre- and post- 10-item opinion survey focused on the students' perceived importance of traditional biomedical and psychosocial knowledge. CONTEXT: The program was based at the Trover Campus, a regional clinical campus of the University of Louisville School of Medicine, in a town of 20,000 in the western Kentucky coalfields that is 150 miles from the main urban campus. Practice site assignments were in surrounding medically underserved towns in family medicine practices. OUTCOME: After the 3-week experience, students became comfortable with interviews concerning health habits using the Prochaska model of lifestyle modification and expressed an increased importance of some psychosocial factors and a corresponding decrease in importance of traditional biomedical factors in choosing treatment for an individual patient (significant results by Mann-Whitney, two-tailed, ranged U = 1136.0, p = .001 to U = 1377.5, p ≤ .05). Student reports showed that the students gained a new detailed understanding of rural practice. Students also expressed an appreciation for having developed a support network of fellow rural students with whom they would begin medical school on the urban campus. LESSONS LEARNED: These results support the value of a summer prematriculation program for rural students based in a rural area. New appreciation for psychosocial patient factors, new skills in communication with patients, new understanding of the details of rural practice, and new relationships with other rural classmates were perceived as positive aspects of the program. Longer term measures of whether the program decreased urban disruption significantly will require continued tracking of the students until they make a practice choice 7 to 9 years later. Wider collaboration with other medical school rural programs is necessary to determine which aspects of rural-focused training are most effective.

The 6-OHDA mouse model of Parkinson's disease - Terminal striatal lesions provide a superior measure of neuronal loss and replacement than median forebrain bundle lesions.

Unilateral 6-hydroxydopamine (6-OHDA) lesions of the nigrostriatal pathway produce side-biased motor impairments that reflect the motor deficits seen in Parkinson's disease (PD). This toxin-induced model in the rat has been used widely, to evaluate possible therapeutic strategies, but has not been well established in mice. With the advancements in mouse stem cell research we believe the requirement for a mouse model is essential for the therapeutic potential of these and other mouse-derived cells to be efficiently assessed. This aim of this study focused on developing a mouse model of PD using the 129 P2/OLA Hsd mouse strain as this is widely used in the generation of mouse embryonic stem cells. Both unilateral 6-OHDA medial forebrain bundle (MFB) and striatal lesion protocols were compared, with mice analysed for appropriate drug-induced rotational bias. Results demonstrated that lesioned mice responded to d-amphetamine with peak rotation dose at 5mg/kg and 10mg/kg for MFB and striatal lesions respectively. Apomorphine stimulation produced no significant rotational responses, at any dose, in either the MFB or striatal 6-OHDA lesioned mice. Analysis of dopamine neuron loss revealed that the MFB lesion was unreliable with little correlation between dopamine neuron loss and rotational asymmetry. Striatal lesions however were more reliable, with a strong correlation between dopamine neuron loss and rotational asymmetry. Functional recovery of d-amphetamine-induced rotational bias was shown following transplantation of E13 mouse VM tissue into the lesioned striatum; confirming the validity of this mouse model.

A rural pathways program for high school students: reinforcing a sense of place.

BACKGROUND AND OBJECTIVES: The affinity model predicts that students from rural areas who train in smaller towns will be more likely to choose rural practice. Most pipeline programs based on this model begin in college or medical school. Many rural students first encounter academic and career planning challenges prior to college, and a few programs are focused on high school students. METHODS: We report pre- and post-program opinions and American College Testing (ACT) practice scores from 151 participants in a high school rural scholar program over the first 10 years of the program. RESULTS: After participation, the students showed significantly more positive opinions about their county's health care resources and their knowledge of career options, and they knew more names of the providers in their county. Their practice ACT scores increased slightly, and their assessment that they were well prepared to take the ACT improved. Seventy-five percent have pursued a health career, and 10% have entered medical school. CONCLUSIONS: A summer program that allows high school students to shadow health professionals in their hometown and study in a virtual classroom can accomplish modest academic gains while producing more positive opinions about the health care in their county. They also report better understanding of the career options available to them.

Rural track training based at a small regional campus: equivalency of training, residency choice, and practice location of graduates.

PURPOSE: Ten years of data for the rural-based Trover Campus (ULTC) were compared with data for the main campus of the University of Louisville School of Medicine to determine whether educational outcomes were equivalent and whether this method of optimizing the affinity model was effective in placing graduates in rural practice. METHOD: Demographic data and academic measures were compared for 1,391 graduates (60 from ULTC) for 2001-2010. A noninferiority model was developed to compare clinical experiences for each campus cohort. Residency match lists were examined for specialty choice. Graduates from 2001 to 2006 were matched to the American Medical Association Masterfile to determine practice site. RESULTS: ULTC students scored lower on United States Medical Licensing Examination (USMLE) Step 1 and Step 2 Clinical Skills (CK) but tended to close this gap after clinical training when compared with Louisville graduates. The noninferiority model indicates that ULTC students' scores were noninferior to Louisville students' on adjusted shelf exams for obstetrics-gynecology, pediatrics, and surgery, and Step 2 CK (P<.001). ULTC graduates were 4.5 times more likely to choose family medicine (P<.001) and over 6 times more likely to choose a nonmetropolitan area as a practice site (P=.001). CONCLUSIONS: These data support the value of a small regional rural clinical campus in optimizing the affinity model to place rural students into rural practice. The ULTC students showed equivalent adjusted test scores and slightly narrowed the gap in unadjusted USMLE scores compared with the main campus students.

Outcomes of a preclinical rural medicine elective at an urban medical school.

BACKGROUND AND OBJECTIVES: The University of Louisville School of Medicine Trover Campus (ULTC) was established in rural west Kentucky in 1998 with the purpose of increasing the number of rural physicians. Utilizing the affinity model, a primary goal of the ULTC is to encourage rural students to pursue a medical education and return to rural Kentucky for practice. One aspect of this geographically separate clinical campus includes a Rural Medicine Elective (RME) offered during the basic science years. We report here the effect of the RME on student opinions and knowledge concerning rural practice, as well as initial effects on specialty and rural practice choice. METHODS: Opinion responses and knowledge on a written exam using a pre-RME and post-RME survey for the 2004-2009 classes were analyzed. Pre-RME opinion items were examined descriptively (n=36). Pre-and post-opinion responses (n=23) and summation scores of 11 domains on exam questions (n=50) were compared using the Wilcoxon Signed Rank test. The proportion of students choosing family medicine and subsequent practice site choice were also measured. RESULTS: RME student opinions about rural practice indicated improved agreement with information as presented in the course material. Similarly, on 11 knowledge examination summation scores, pre- and post-exam results showed significant increases in 10 domains. The pre-test answers provided an interesting baseline of beliefs. RME students were far more likely to choose family medicine than their classmates, and initial results show an increased likelihood of subsequent rural practice. CONCLUSIONS: The initial outcomes of the RME are encouraging and indicate such an elective can maintain positive opinions about rural practice among rural students attending an urban medical school. The RME is also successful in increasing students' knowledge about rural practice and may maximize the likelihood that they will choose rural practice.

Humoral response to 2 inactivated bluetongue virus serotype-8 vaccines in South American camelids.

BACKGROUND: Bluetongue virus serotype 8 (BTV-8) has caused disease in domestic ruminants in several countries of northern Europe since 2006. In 2008 a mass-vaccination program was launched in most affected countries using whole virus inactivated vaccines. OBJECTIVE: To evaluate 2 inactivated vaccines (Bovilis BTV 8; BTVPUR AlSap8) for immunogenicity and safety against BTV-8 in South American camelids (SAC) in a field trial. ANIMALS: Forty-two SAC (25 Alpacas, 17 Llamas) aged between 1 and 16 years. METHODS: The animals were vaccinated twice at intervals of 21 days. They were observed clinically for adverse local, systemic, or both reactions throughout the trial. Blood samples collected on days 0, 14, 21, 43, and 156 after vaccination were tested for the presence of BTV-8 virus by real time-polymerase chain reaction and of specific antibodies by competitive ELISA and a serum neutralization test. RESULTS: All vaccinated animals developed antibodies to BTV-8 after the 2nd administration of the vaccine. No adverse effects were observed except for moderate local swellings at the injection site, which disappeared within 21 days. Slightly increased body temperatures were only observed in the first 2 days after vaccination. The BTV was not detected in any of the samples analyzed. CONCLUSIONS AND CLINICAL IMPORTANCE: The administration of the 2 inactivated commercial vaccines was safe and induced seroconversion against BTV-8 in all vaccinated animals. The results of this study suggest that 2 doses injected 3 weeks apart is a suitable vaccination regimen for SAC.

Just what are rural premedical students thinking? A report of the first 6 years of a pathways program.

PURPOSE: To assess outcomes of the first 6 years of a program designed to facilitate medical school admission for rural premedical students. METHODS: Students completing the University of Louisville School of Medicine Trover Rural Scholar program were surveyed using a 23-item survey. FINDINGS: Twenty-two of the 24 (92%) students responded. Overall, 12 (55%) were in the physician pipeline (medical students or re-applying to medical school) and 10 (45%) had left the physician pipeline for other careers (7 were pursuing other health care careers). Differences between the 2 groups included income expectations and perceptions of intellectual challenges and physicians' job satisfaction. CONCLUSIONS: Attrition can be explained by student interests, maturation and influences of pre-professional advisors and practicing physicians. Successful pipeline programs should address these issues.

Conservative treatment of scaphoid nonunion in children and adolescents.

This is a retrospective study of six children with ununited scaphoid fractures treated conservatively. Their mean age was 12.8 years (9.7 to 16.3). Five had no early treatment. Radiological signs of nonunion were found at a mean of 4.6 months (3 to 7) after injury. Treatment consisted of cast immobilisation until clinical and radiological union. The mean clinical and radiological follow-up was for 67 months (17 to 90). We assessed the symptoms, the range of movement of the wrist and the grip strength to calculate the Modified Mayo Wrist score. The fracture united in all patients after a mean period of immobilisation of 5.3 months (3 to 7). Five patients were pain free; one had mild pain. All returned to regular activities, and had a range of movement and grip strength within 25% of normal, resulting in an excellent Modified Mayo Wrist score. Prolonged treatment with cast immobilisation resulted in union of the fracture and an excellent Modified Wrist Score in all patients.

[Vaccination against bluetongue: safety and immune response in the field]. / Impfung gegen die Blauzungenkrankheit: Verträglichkeit und Immunantwort in der Praxis.

Bluetongue, caused by the bluetongue virus serotype 8 has rapidly spread through Europe since 2006. The first cases in Switzerland were detected in October 2007. The European Union and Switzerland launched a vaccination campaign in June 2008. This study aims to demonstrate the safety and the immune response of the three vaccines used in Switzerland under practical conditions in the field. The trial was carried out in cattle, sheep and goats. Based on the results of this study recommendations for the 2009 campaign are presented.

Outcomes and cost savings of free clinic care.

Healthcare costs and client health status were measured in a 10-month period before and after an index free clinic visit for 26 poor, working, uninsured patients. A significant number of patients reported overall improvement in their health. During the period of free clinic management, the equivalent of dollar 6500 of care was provided. Compared to utilization before the free clinic period, a savings of dollar 33,145 was realized, largely due to decreased emergency department care and hospitalization.

Multicentre evaluation of in vitro contracture testing with bolus administration of 4-chloro-m-cresol for diagnosis of malignant hyperthermia susceptibility.

BACKGROUND AND OBJECTIVE: The in vitro contracture test with halothane and caffeine is the gold standard for the diagnosis of susceptibility to malignant hyperthermia (MH). However, the sensitivity of the in vitro contracture test is between 97 and 99% and its specificity is 78-94% with the consequence that false-negative as well as false-positive test results are possible. 4-Chloro-m-cresol is potentially a more specific test drug for the in vitro contracture test than halothane or caffeine. This multicentre study was designed to investigate whether an in vitro contracture test with bolus administration of 4-chloro-m-cresol can improve the accuracy of the diagnosis of susceptibility to MH. METHODS: Three hundred and fifty-two patients from 11 European MH laboratories participated in the study. The patients were first classified as MH susceptible, MH normal or MH equivocal by the in vitro contracture test according to the European MH protocol. Muscle specimens surplus to diagnostic requirements were used in this study (MH susceptible = 103 viable samples; MH equivocal = 51; MH normal = 204). 4-Chloro-m-cresol was added to achieve a concentration of 75 micromol L(-1) in the tissue bath. The in vitro effects on contracture development and muscle twitch were observed for 60 min. RESULTS: After bolus administration of 4-chloro-m-cresol, 75 micromol L(-1), 99 of 103 MH-susceptible specimens developed marked muscle contractures. In contrast, only two of 204 MH-normal specimens showed an insignificant contracture development following 4-chloro-m-cresol. From these results, a sensitivity rate of 96.1% and a specificity rate of 99.0% can be calculated for the in vitro contracture test with bolus administration of 4-chloro-m-cresol 75 micromol L(-1). Forty-three patients were diagnosed as MH equivocal, but only specimens from 16 patients developed contractures in response to 4-chloro-m-cresol, indicating susceptibility to MH. CONCLUSIONS: The in vitro contracture test with halothane and caffeine is well standardized in the European and North American test protocols. However, this conventional test method is associated with the risk of false test results. Therefore, an improvement in the diagnosis of MH is needed. Regarding the results from this multicentre study, the use of 4-chloro-m-cresol could increase the reliability of in vitro contracture testing.

An innovative method for preparation for rural practice: the high school rural scholars program.

Recent studies have shown that the most effective strategy to increase the number of practicing rural physicians is to admit more students with affinity for rural practice to medical school. A significant limitation of this strategy is the generally lower scores made on standardized tests by those from smaller high schools in rural areas. Although once admitted these students perform on a par with their urban counterparts, admission remains an obstacle for many. This report summarizes the second year of an innovative program that placed rising high school seniors in shadowing opportunities in their home towns while providing preparation for the ACT exam in a virtual classroom environment. Results show that the 20 students involved increased their knowledge of the strengths and weaknesses of health care in their towns as well as their understanding of how various health professionals function. The ACT composite score increased by 1.2 points, to 23. The reading and science subscores showed the largest increase. Although labor-intensive for the coordinators, the program was successful in meeting the stated goals.

Functional outcome of transplanted knee joints in dogs.

Total knee joint transplantation has been performed in animal models and humans. This study investigates the impact of this operation on knee joint function in a dog model. Therefore, replantation was compared to transplantation during a 6-month follow-up period in four dogs in each group. The peak vertical ground reaction force normalized in all legs undergoing replantation and in two of four after transplantation. A third transplant recipient reduced loading from the 4th month due to a local complication, and the fourth succumbed to sepsis 3 months postoperatively. A weight-bearing index (WBI), defined as loading of the grafted divided by loading of both hind-limbs decreased from 0.48 +/- 0.08 preoperatively to 0.13 +/- 0.10 by 1 month after replantation and from 0.53 +/- 0.07 to 0 after transplantation. After 6 months, weight-bearing of all replant recipients was restored, but reduced in two transplant recipients with graft function. Full recovery after replantation, but impaired function after transplantation, was also reflected in the histological results: normal histological pictures of blood vessels, cartilage, bone and soft tissues were found in all replant recipients, but infiltrative vasculopathy indicating chronic rejection was found in the transplanted joints. The results of this animal study confirm that the procedure can lead to satisfactory functional results but also emphasize the need for perfect control of immunosuppression.

A multicenter study of 4-chloro-m-cresol for diagnosing malignant hyperthermia susceptibility.

UNLABELLED: Standardization of the in vitro contracture test (IVCT) for malignant hyperthermia (MH) susceptibility has resulted in very rare false negative tests. However, false positive results stigmatizing the patient seem to be more frequent than false negative results and make supplementary tests desirable. This multicenter approach studied the usefulness of an IVCT with 4-chloro-m-cresol (4-CmC), a ryanodine receptor-specific agonist for a better definition of MH susceptibility. Diagnosis made by the standard IVCT was compared with the results of this 4-CmC test on muscle specimens of 202 individuals from 6 European MH centers. In the 4-CmC test, the results of the MH susceptible group differed significantly from both the MH normal and the MH equivocal group. 4-CmC revealed a qualitatively dose response-curve similar to caffeine. A correlation index of r = 0.79 for the concentration thresholds underlined the strong concordance of the caffeine and the 4-CmC effects. The optimal threshold concentration was determined to be 75 microM in the pooled data of all centers and is much lower than that of caffeine (2 mM), suggesting a more than 25-fold higher affinity of 4-CmC. The predictive value of 4-CmC is as high as that of caffeine and consequently higher than that of halothane. 4-CmC seems to be a suitable drug to refine diagnosis of MH susceptibility and could be used as an additional test substance. IMPLICATIONS: Although in vitro contracture testing for malignant hyperthermia diagnosis is well standardized, with a relatively high sensitivity and specificity, false test results cannot be excluded and may be associated with serious disabilities for the concerned individuals. In this multicenter study, 4-chloro-m-cresol was evaluated as a new test substance for the in vitro contracture testing. Its use improves the accuracy of in vitro diagnosis of malignant hyperthermia susceptibility.

Site-specific migration and neuronal differentiation of human neural progenitor cells after transplantation in the adult rat brain.

Neural progenitor cells obtained from the embryonic human forebrain were expanded up to 10(7)-fold in culture in the presence of epidermal growth factor, basic fibroblast growth factor, and leukemia inhibitory growth factor. When transplanted into neurogenic regions in the adult rat brain, the subventricular zone, and hippocampus, the in vitro propagated cells migrated specifically along the routes normally taken by the endogenous neuronal precursors: along the rostral migratory stream to the olfactory bulb and within the subgranular zone in the dentate gyrus, and exhibited site-specific neuronal differentiation in the granular and periglomerular layers of the bulb and in the dentate granular cell layer. The cells exhibited substantial migration also within the non-neurogenic region, the striatum, in a seemingly nondirected manner up to approximately 1-1.5 mm from the graft core, and showed differentiation into both neuronal and glial phenotypes. Only cells with glial-like features migrated over longer distances within the mature striatum, whereas the cells expressing neuronal phenotypes remained close to the implantation site. The ability of the human neural progenitors to respond in vivo to guidance cues and signals that can direct their differentiation along multiple phenotypic pathways suggests that they can provide a powerful and virtually unlimited source of cells for experimental and clinical transplantation.