A randomised controlled trial of cemented versus cementless press-fit condylar total knee replacement: 15-year survival analysis.

We report the long-term survival of a prospective randomised consecutive series of 501 primary knee replacements using the press-fit condylar posterior cruciate ligament-retaining prosthesis. Patients received either cemented (219 patients, 277 implants) or cementless (177 patients, 224 implants) fixation. Altogether, 44 of 501 knees (8.8%) underwent revision surgery (24 cemented vs 20 cementless). For cemented knees the 15-year survival rate was 80.7% (95% confidence interval (CI) 71.5 to 87.4) and for cementless knees it was 75.3% (95% CI 63.5 to 84.3). There was no significant difference between the two groups (cemented vs cementless; hazard ratio (HR) 0.83, 95% CI 0.45 to 1.52, p = 0.55). When comparing the covariates there was no significant difference in the rates of survival between the side of operation (HR 0.58, p = 0.07), age (HR 0.97, p = 0.10) and diagnosis (HR 1.25 p = 0.72). However, there was a significant gender difference, with males having a higher failure rate with cemented fixation (HR 2.48, p = 0.004). Females had a similar failure rate in both groups. This single-surgeon series, with no loss to follow-up, provides reliable data of the revision rates of one of the most commonly-used total knee replacements. The survival of the press-fit condylar total knee replacement remained good at 15 years, irrespective of the method of fixation.

Should we reconsider all-polyethylene tibial implants in total knee replacement?

The role of modular tibial implants in total knee replacement is not fully defined. We performed a prospective randomised controlled clinical trial using radiostereophotogrammetric analysis to compare the performance of an all-polyethylene tibia with a metal-backed cruciate-retaining condylar design, PFC-Sigma total knee replacement for up to 24 months. There were 51 patients who were randomised into two treatment groups. There were 10 subsequent withdrawals, leaving 21 all-polyethylene and 20 metal-backed tibial implants. No patient was lost to follow-up. There were no significant demographic differences between the groups. At two years one metal-backed implant showed migration > 1 mm, but no polyethylene implant reached this level. There was a significant increase in the SF-12 and Oxford knee scores after operation in both groups. In an uncomplicated primary total knee replacement the all-polyethylene PFC-Sigma tibial prosthesis showed no statistical difference in migration from that of the metal-backed counterpart. There was no difference in the clinical results as assessed by the SF-12, the Oxford knee score, alignment or range of movement at 24 months, although these assessment measures were not statistically powered in this study.

Quality in the technical performance of screening flexible sigmoidoscopy: recommendations of an international multi-society task group.

BACKGROUND: Flexible sigmoidoscopy (FS) is a complex technical procedure performed in a variety of settings, by examiners with diverse professional backgrounds, training, and experience. Potential variation in technical quality may have a profound impact on the effectiveness of FS on the early detection and prevention of colorectal cancer. AIM: We propose a set of consensus and evidence based recommendations to assist the development of continuous quality improvement programmes around the delivery of FS for colorectal cancer screening. RECOMMENDATIONS: These recommendations address the intervals between FS examinations, documentation of results, training of endoscopists, decision making around referral for colonoscopy, policies for antibiotic prophylaxis and management of anticoagulation, insertion of the FS endoscope, bowel preparation, complications, the use of non-physicians as FS endoscopists, and FS endoscope reprocessing. For each of these areas, continuous quality improvement targets are recommended, and research questions are proposed.

A randomised, controlled trial of cemented versus cementless press-fit condylar total knee replacement. Ten-year survival analysis.

We have carried out a long-term survival analysis of a prospective, randomised trial comparing cemented with cementless fixation of press-fit condylar primary total knee replacements. A consecutive series of 501 replacements received either cemented (219 patients, 277 implants) or cementless (177 patients, 224 implants) fixation. The patients were contacted at a mean follow-up of 7.4 years (2.7 to 13.0) to establish the rate of survival of the implant. The ten-year survival was compared using life-table and Cox's proportional hazard analysis. No patient was lost to follow-up. The survival at ten years was 95.3% (95% CI 90.3 to 97.8) and 95.6% (95% CI 89.5 to 98.2) in the cemented and cementless groups, respectively. The hazard ratio for failure in cemented compared with cementless prostheses was 0.97 (95% CI 0.36 to 2.6). A comparison of the clinical outcome at ten years in 80 knees showed no difference between the two groups. The survival of the press-fit condylar total knee replacement at ten years is good irrespective of the method of fixation and brings into question the use of more expensive cementless implants.

Survival analysis of cemented Press-Fit Condylar total knee arthroplasty.

We performed a survival analysis on 354 cemented primary Press-Fit Condylar (PFC) total knee arthroplasties (TKA) in 277 patients with prospective follow-up (mean, 6 years; range, 2-11.7 years). No patient was lost to follow-up. Using revision for all causes as the endpoint, the cumulative survival rate at 10 years was 95.5% (95% confidence interval, 90.1%-98.1%). The 10-year clinical outcome available on 41 patients was good, with significant improvement in pain and mobility assessments using the Nottingham data collection system. Our results indicate that the cemented PFC TKA has good long-term survival based on revision as the endpoint. Revision for implant failure is rare and brings to question modifications to this prosthesis.

Patient education pamphlets about prevention, detection, and treatment of breast cancer for low literacy women.

The objective of this project was to identify and assess readily available patient education literature about prevention, detection and treatment of breast cancer for the patient with low literacy skills. The target population had a reading comprehension level of sixth grade or lower. Nineteen pamphlets were analyzed using RightWriter and were found to have an average readability index of 9.15, therefore requiring at least a ninth grade level of reading comprehension. As a consequence, many pieces of the available literature were inappropriate for the target population. There are implications as a broader group of health care providers becomes more involved in the treatment of low literacy patients. In providing patient education literature to poorly educated patients, special emphasis should be given to determining readability. Both currently available and newly created literature should be analyzed for readability before assuming it is an aid to patient education.

A guide to Mosaic and the World Wide Web for physicians.

Although the predecessor of the Internet as we know it has existed since 1969, few physicians have taken full advantage of its extensive and continuously expanding resources. This may be due in part to the perceived difficulty of navigating the sometimes circuitous routes to the data sources of interest. Newer and substantially more user-friendly interfaces have been developed recently, allowing simpler and more direct access to the full range of Internet resources. Arguably the most important of these is the National Center for Supercomputing Application's Mosaic, the link to an information domain known as the World Wide Web. This article provides an overview of the important medical resources that Mosaic offers the clinician, teacher, and researcher, together with information on how to obtain and configure the software.

Developing a support system for teaching and assessing clinical competence.

Primary care medical school faculty, in partnership with the faculty and staff of a Department of Biomedical Communications (Office of Medical Education) developed a teaching and logistical support system using standardized patients. The patients are used to teach history and physical examination skills to students in an introductory clinical medicine course. Having both clinical assessment team members, who are skilled biomedical communicators, and designated clinic rooms for standardized patients provides the foundation necessary for this growing area in medical education. Improved student performance, as measured by an Objective Structured Clinical Examination (OSCE), and students' positive ratings and comments in the evaluation of the course demonstrated the efficacy of using standardized patients in teaching and assessing clinical performance.

Mammography in a mobile setting: remaining barriers.

This study examined the barriers to undergoing mammography perceived by a group of women with ready access to reduced-cost screening mammography in a mobile van at the workplace. The subject sample comprised women who made appointments for mammography at the Susan G. Komen Mobile Breast Center in Dallas. Women who underwent mammography and women who made appointments but did not undergo the examination were asked to complete a survey examining potential barriers to undergoing mammography. The group of patients surveyed were, as a whole, well educated, affluent, less than 50 years of age, and knowledgeable about breast cancer. Compliant women were more likely to have previously undergone mammography (P less than .001), to have been influenced by their physician's advice to undergo mammography (P less than .005), and to be influenced by the media than were noncompliant women (P less than .005). These findings may be useful in developing strategies to increase mammographic screening in a self-referred population.

The health sciences communicator as faculty developer.

To determine the content for a model faculty development program for primary care faculty, a combination of the Delphi and Nominal Group Technique was used resulting in a curriculum with five units of instruction: development of curriculum and instruction, teaching methods, evaluation, administration, and academic survival skills. A philosophy for conducting faculty development is presented which includes concepts of andragogy, technology transfer, the diffusion of innovation, and networking. Program types include short-term, long-term, and extended programs such as fellowships.

Methods of improving patient compliance in chronic disease states.

Patients with chronic diseases fail to comply with the regimen prescribed by the physician for a variety of reasons. Physicians must be aware of the likelihood of noncompliance in the individual patient and make strong efforts to detect problems and persuade patients with the importance of adherence to a program designed to reach and maintain stated, and often negotiated, therapeutic goals. It is the physician's responsibility to teach, motivate, and strengthen the patient to maximize compliance in a largely unsupervised setting. This can best be accomplished by a process of "therapeutic partnership."