Evaluation and Management of Neck and Back Pain.

Neck and back pain are common reasons for seeking evaluation and treatment in the emergency department. Within both systems there exist several time-sensitive diagnoses that the emergency provider should be familiar with in order to prevent significant morbidity and mortality. In this article we provide a general overview of these complaints by discussing problems in a systems-based fashion as well as discussing the initial evaluation, work-up, and treatment options for these diagnoses.

The development of sustainable emergency care in ghana: physician, nursing and prehospital care training initiatives.

BACKGROUND: Ghana's first Emergency Medicine residency and nursing training programs were initiated in 2009 and 2010, respectively, at Komfo Anokye Teaching Hospital in the city of Kumasi in association with Kwame Nkrumah University of Science and Technology and the Universities of Michigan and Utah. In addition, the National Ambulance Service was commissioned initially in 2004 and has developed to include both prehospital transport services in all regions of the country and Emergency Medical Technician training. Over a decade of domestic and international partnership has focused on making improvements in emergency care at a variety of institutional levels, culminating in the establishment of comprehensive emergency care training programs. OBJECTIVE: We describe the history and status of novel postgraduate emergency physician, nurse, and prehospital provider training programs as well as the prospect of creating a board certification process and formal continuing education program for practicing emergency physicians. DISCUSSION: Significant strides have been made in the development of emergency care and training in Ghana over the last decade, resulting in the first group of Specialist-level emergency physicians as of late 2012, as well as development of accredited emergency nursing curricula and continued expansion of a national Emergency Medical Service. CONCLUSION: This work represents a significant move toward in-country development of sustainable, interdisciplinary, team-based emergency provider training programs designed to retain skilled health care workers in Ghana and may serve as a model for similar developing nations.

Do plain radiographs correlate with CT for imaging of cam-type femoroacetabular impingement?

BACKGROUND: Three-dimensional imaging (CT and MRI) is the gold standard for detecting femoral head-neck junction malformations in femoroacetabular impingement, yet plain radiographs are used for initial diagnostic evaluation. It is unclear, however, whether the plain radiographs accurately reflect the findings on three-dimensional imaging. QUESTIONS/PURPOSES: We therefore: (1) investigated the correlation of alpha angle measurements on plain radiographs and radial reformats of CT scans; (2) determined which radiographic views are most sensitive and specific in detecting head-neck deformities present on CT scans; and (3) determined if specific radiographic views correlated with specific locations on the radial oblique CT scan. METHODS: We retrospectively reviewed 41 surgical patients with preoperative CT scans (radial oblique reformats) and plain radiographs (AP pelvis, 45° Dunn, frog lateral, and crosstable lateral). Alpha angles were measured on plain radiographs and CT reformats. RESULTS: The complete radiographic series was 86% to 90% sensitive in detecting abnormal alpha angles on CT. The maximum alpha angle on plain radiographs was greater than that of CT reformats in 61% of cases. Exclusion of the crosstable lateral did not affect the sensitivity (86%-88%). The Dunn view was most sensitive (71%-80%). The frog lateral showed the best specificity (91%-100%). Substantial correlations (intraclass correlation coefficients, 0.64-0.75) between radiograph and radial oblique CT position were observed, including AP/12:00 (superior), Dunn/1:00 (anterolateral), frog/3:00 (anterior), and crosstable/3:00 (anterior). CONCLUSIONS: For diagnostic and treatment purposes, a three-view radiographic hip series (AP pelvis, 45° Dunn, and frog lateral) effectively characterizes femoral head-neck junction malformations. LEVEL OF EVIDENCE: Level II, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

Density-dependent reduction and induction of milkweed cardenolides by a sucking insect herbivore.

The effect of aphid population size on host-plant chemical defense expression and the effect of plant defense on aphid population dynamics were investigated in a milkweed-specialist herbivore system. Density effects of the aposematic oleander aphid, Aphis nerii, on cardenolide expression were measured in two milkweed species, Asclepias curassavica and A. incarnata. These plants vary in constitutive chemical investment with high mean cardenolide concentration in A. curassavica and low to zero in A. incarnata. The second objective was to determine whether cardenolide expression in these two host plants impacts mean A. nerii colony biomass (mg) and density. Cardenolide concentration (microgram/g) of A. curassavica in both aphid-treated leaves and opposite, herbivore-free leaves decreased initially in comparison with aphid-free controls, and then increased significantly with A. nerii density. Thus, A. curassavica responds to aphid herbivory initially with density-dependent phytochemical reduction, followed by induction of cardenolides to concentrations above aphid-free controls. In addition, mean cardenolide concentration of aphid-treated leaves was significantly higher than that of opposite, herbivore-free leaves. Therefore, A. curassavica induction is strongest in herbivore-damage tissue. Conversely, A. incarnata exhibited no such chemical response to aphid herbivory. Furthermore, neither host plant responded chemically to herbivore feeding duration time (days) or to the interaction between herbivore initial density and feeding duration time. There were also no significant differences in mean colony biomass or population density of A. nerii reared on high cardenolide (A. curassavica) and low cardenolide (A. incarnata) hosts.