An aggressive approach to limb dystonia: a case report.

A 15-year-old boy presented with a severe fluctuating foot and ankle dystonia resulting from a basal ganglia insult at the age of 4. This followed an embolic event related to an undiagnosed prolapsed mitral valve. Functionally, the patient was ambulatory with rocker bottom crutches and an ankle-foot orthosis, but there were periods of up to a year when pain and increased dystonic deformity required him to use a wheelchair. A new orthotic was made nearly every month because the orthotist could find no material that would withstand his tone without breaking, yet he could not ambulate without one. Multiple interventions, including biofeedback, contrast baths, stretching and strengthening, oral lioresal (Baclofen), diazepam (Valium), benztropine mesylate (Cogentin), carbidopa-levodopa (Sinemet), carbamazepine (Tegretol), and injections of botulism toxin (BOTOX) were tried, all with minimal effects. Amputation was recommended, based on anatomic and functional considerations. The patient and his family adjusted well to this decision, although not all orthopedists and therapists adjusted easily to the choice. The patient is now functionally independent with a prosthesis and has a normal teenage lifestyle for the first time.

Journal clubs. Prevalence, format, and efficacy in PM&R.

Journal clubs can play an integral part in graduate medical education. They promote critical thinking, dissemination of information, and research and impact clinical practice. Little has been written, however, about how to organize a journal club or improve its efficacy. Although numerous articles discuss how journal clubs can be used to evaluate medical literature, only a few have examined what physicians are actually doing. We surveyed all accredited PM&R program chief/residents to ascertain the prevalence, format, and efficacy of PM&R residency journal clubs. All programs that responded (89%) reported having a journal club, with most stating its purpose was to disseminate information from the current literature. Review of classic articles and specialty topics (e.g., electromyography, sports medicine) was fairly uncommon. Eighty-four percent of journal clubs were department-sponsored, and most met monthly for 1 hr during the workday. Typically, four or more articles were presented under the guidance of the chief or other resident. Impacting clinical practice and teaching critical analysis were other important goals of the journal clubs, yet most (76%) lacked an organized method for critical review. This, in addition to poor faculty attendance, was a chief concern of those surveyed. Surprisingly, journal club participation was not felt to significantly alter the amount of reading residents did. Although most felt their journal clubs were successful, improving faculty participation, strengthening critical analysis skills, identifying and incorporating classic articles, improving clinical relevance, and providing a mechanism for feedback may further improve journal club efficacy and participant satisfaction.