Analysis of pelvic fracture pattern and overall orthopaedic injury burden in children sustaining pelvic fractures based on skeletal maturity.

PURPOSE: The purpose of this study was to review pelvic fractures and concomitant orthopaedic injuries in children who have a patent triradiate cartilage (TRO) compared with children whose triradiate cartilage has closed (TRC). We hypothesise that these injuries will differ, leading to correlated alterations in management. PATIENTS AND METHODS: Using a database, we retrospectively reviewed patients aged below 18 years with pelvic fractures presenting to our Level 1 trauma center. Radiographs and CT scans were reviewed to identify orthopaedic injuries and categorise pelvic injuries using the modified Torode classification between the two groups. RESULTS: A total of 178 patients met inclusion criteria (60 TRO and 118 TRC). Mean age ± SD for TRO and TRC groups were 8 ± 4 years and 16 ± 2 years, respectively. TRO patients were more likely to present as a pedestrian struck by a vehicle (odds ratio (OR) 6.0; p < 0.001) and less likely to present after a motor vehicle collision (OR 0.2; p < 0.001). TRO patients were more likely to sustain rami fractures (OR 2.1; p = 0.020) and Torode IIIA injuries (OR 3.6; p < 0.001). They were less likely to sustain acetabular fractures (OR 0.5; p = 0.042), sacral fractures (OR 0.4; p = 0.009), hip dislocations (p = 0.002) and Torode IV injuries (OR 0.4; p = 0.004). TRO patients were less likely to be treated operatively for their pelvic (OR 0.3; p = 0.013) and orthopaedic injuries (OR 0.4; p = 0.006). CONCLUSION: We suggest that patients with open triradiate cartilage are unique. Their pelvic injuries may be treated more conservatively as they have a greater potential for periosteal healing and bone remodelling. Patients with closed triradiate cartilage should be treated similarly to adults, as they share a similar mechanism of injury and need for operative fixation.

Clinical trial: the effects of certolizumab pegol therapy on work productivity in patients with moderate-to-severe Crohn's disease in the PRECiSE 2 study.

BACKGROUND: The effect of certolizumab pegol on employment status and work productivity has not been previously assessed. AIM: To assess the impact of treatment with certolizumab pegol, the only PEGylated, Fab' TNF antagonist, on work productivity in patients with active Crohn's disease (CD) from the PRECiSE 2 study. METHODS: Patients (n = 668) with active disease [CD activity index (CDAI) score of 220-450] were treated with open-label subcutaneous certolizumab pegol 400 mg (week 0, 2, 4). Responders (n = 425) (> or = 100-point decrease in CDAI from baseline) were randomized to receive certolizumab pegol 400 mg or placebo every 4 weeks until week 24, with final evaluation at week 26. Patients completed the Work Productivity and Activity Impairment for CD questionnaire (WPAI:CD) and the Inflammatory Bowel Disease Questionnaire (IBDQ) at weeks 0, 6, 16 and 26 and at the withdrawal visit. RESULTS: Work productivity improved following induction with certolizumab pegol. Between week 6 and 26, certolizumab pegol-treated patients experienced significant improvement in work productivity compared with placebo recipients (11% and 10% overall improvement in work and activity impairment, respectively). During the maintenance phase, impairments in productivity and activities due to CD were significantly less in the certolizumab pegol group than in the placebo group. CONCLUSION: Induction and maintenance therapy with certolizumab pegol significantly improved the work productivity of patients with active CD compared with those in the placebo group.

Systematic review: the impact of gastro-oesophageal reflux disease on work productivity.

BACKGROUND: Gastro-oesophageal reflux disease has wide-ranging effects on patients' lives. AIM: To review systematically the effects of gastro-oesophageal reflux disease on work productivity. METHODS: Studies of gastro-oesophageal reflux disease and work productivity were identified in a systematic literature search and their results were valued in US dollars using the human capital method. Work productivity loss was defined as absence from work (absenteeism) plus reduced effectiveness while working (presenteeism). RESULTS: Eight eligible studies were included. Reported work productivity loss among individuals with gastro-oesophageal reflux disease ranged from 6% to 42% and was primarily because of presenteeism (6-40%) rather than absenteeism (<1% to 7%). Reported losses were greatest in patients experiencing sleep disturbance because of gastro-oesophageal reflux disease, and lowest in individuals from the general population taking appropriate prescription medication. Work productivity impairment correlated with symptom severity and responded to acid-suppressive therapy. Assuming a 40-h working week and average wages in the US, the weekly mean productivity loss per employee with gastro-oesophageal reflux disease can be estimated between 2.4 (62 dollars) and 16.6 h (430 dollars), depending on the population studied. CONCLUSIONS: Gastro-oesophageal reflux disease has a substantial impact on employee productivity, primarily by impairing productivity while working. Further studies are needed to confirm that this impact can be decreased by acid-suppressive therapy.

Effect of tegaserod on work and daily activity in irritable bowel syndrome with constipation.

BACKGROUND: Tegaserod is a promotility agent with proven efficacy and safety in patients with irritable bowel syndrome with constipation. AIM: To assess tegaserod's effect on work productivity and daily activity. METHODS: Women, 18-65 years old and meeting Rome II criteria for irritable bowel syndrome with constipation, were randomized to a double-blind, placebo-controlled, multicentre study of tegaserod 6 mg b.d. or placebo. Productivity loss and daily activity impairment because of irritable bowel syndrome were measured with the Work Productivity and Activity Impairment questionnaire for irritable bowel syndrome, modified to exclude diarrhoea as a symptom. Assessments were made at baseline, weeks 2 and 4. RESULTS: A total of 2660 women were randomized and, of these, 1675 [tegaserod (n = 1363), placebo (n = 312)] were employed and completed Work Productivity and Activity Impairment for irritable bowel syndrome questionnaires. Compared with placebo, tegaserod significantly reduced work and daily activity impairment at weeks 2 and 4. Tegaserod reduced absenteeism by 2.6% (P = 0.004), presenteeism by 5.4% (P < 0.0001), overall work productivity loss by 6.3% (P < 0.0001), and activity impairment by 5.8% (P < 0.0001) at week 4 (vs. baseline). Assuming a 40-h workweek, tegaserod reduced work productivity loss by 2.5 h/week. CONCLUSIONS: Tegaserod significantly reduced work productivity loss and daily activity impairment at 2 weeks, and this benefit was maintained at 4 weeks.

The validity and accuracy of the Work Productivity and Activity Impairment questionnaire--irritable bowel syndrome version (WPAI:IBS).

BACKGROUND: Irritable bowel syndrome is a common chronic functional gastrointestinal disorder characterized by recurrent abdominal pain and discomfort associated with alterations in bowel habit. Irritable bowel syndrome affects patients' quality of life and increases productivity loss. AIM: To assess validity and accuracy of the Work Productivity and Activity Impairment questionnaire in irritable bowel syndrome as a tool for quantifying the effects of irritable bowel syndrome on productivity and daily activities. METHODS: Validity and accuracy were evaluated in 135 irritable bowel syndrome patients relative to three measures of irritable bowel syndrome disease severity; a debriefing questionnaire; retrospective diary; Work Limitations Questionnaire, and an activity impairment measure (Dimensions of Daily Activities). RESULTS: Symptom severity scores, diary scores, Work Limitations Questionnaire and Dimensions of Daily Activities were significant predictors of work productivity and activity impairment questionnaire in irritable bowel syndrome measures of work time missed, and work and activity productivity loss (P = 0.04 to < 0.0001). Impairment due to irritable bowel syndrome was estimated to be 2.9-4.3% for work time missed and 22-32% for impairment at work, the equivalent of 9.7 -14 h lost productivity per week. Activity impairment was 24-41%. CONCLUSIONS: Discriminative validity of the Work Productivity and Activity Impairment questionnaire in irritable bowel syndrome was established, making it the only validated tool for measuring the relative differences between disease severity groups and quantifying work productivity loss and activity impairment in irritable bowel syndrome patients.

Superior gluteal artery in the extended iliofemoral approach.

OBJECTIVE: To determine the incidence of superior gluteal artery injury following fracture of the acetabulum and to determine whether the combination of a superior gluteal artery injury and the use of an extended iliofemoral approach to the acetabulum creates abductor muscle necrosis. DESIGN: Prospective protocol, consecutive cases. SETTING: A consecutive series from the referral practice of the senior author plus seven cases from the practices of two other authors. PATIENTS: Two hundred twenty-seven patients with fractures of the acetabulum were treated operatively between November 1992 and January 1995. Forty-one were treated with the use of the extended iliofemoral approach. Preoperative angiograms were not performed for any of the patients. All fractures involved the posterior column, and all but two fractures had displacement of the greater sciatic notch. The average displacement of the notch was 2.5 centimeters (range 6 to 60 millimeters). INTERVENTION: All patients were treated with open reduction and internal fixation via the extended iliofemoral approach. Intraoperative Doppler examination of the superior gluteal artery was performed before and after reduction and fixation of the posterior column. MAIN OUTCOME MEASURE: Wound complications, abductor manual muscle testing, hip range of motion. RESULTS: Pulsatile flow was confirmed in forty of forty-one patients. All patients were followed for a minimum of six months with an average follow-up of 1.4 years. At most recent follow-up, no patients had evidence of complete loss of abductor function. Sixty-three percent of patients had achieved Grade 4 of 5 motor strength, and 25 percent of them had achieved normal motor strength. CONCLUSIONS: No instances of superior gluteal artery laceration and only one instance of superior gluteal artery thrombosis were encountered in these forty-one patients despite significant fracture displacement involving the sciatic notch. The incidence of superior gluteal artery injury was significantly less than would be expected from previous studies. Massive abductor necrosis resulting from superior gluteal artery injury combined with an extended approach has been described primarily in animal and cadaver studies. Although arteriograms are useful in the control of hemodynamic instability, we cannot support the recommendation of preoperative angiographic study of all patients undergoing acetabular fracture surgery via an extended approach. In one case, an extended iliofemoral approach was tolerated in a patient with absent superior gluteal artery flow.

Percutaneous methods of tibial plateau fixation.

Various methods of percutaneous fixation of tibial plateau fractures are available. The optimal method of fixation is dictated by soft tissue injury, fracture characteristics, and functional demands of the patient. Unicondylar fractures are amenable to percutaneous stabilization with screws or plates although some fractures are best approached with open techniques. Hybrid and ring external fixators are most appropriate for patients with bicondylar injuries who have severe soft tissue trauma. Use of intramedullary nails to align ipsilateral shaft fractures adjacent to percutaneously fixed plateau injuries remains controversial but may be indicated for some patients with bicondylar lesions and combined plateau and shaft fractures.

'Floating pelvis'. A combination of bilateral hip dislocation with a lumbar ligamentous disruption.

A patient is described with a ligamentous disruption at the L4/L5 level in association with bilateral, traumatic dislocations of the hip. The diagnostic evaluation, acute intervention, and definitive stabilisation are reported. The unstable spine posed a problem in treatment with regard to the timing and technique of the reduction of the hips.

Neurologic injuries in pelvic ring fractures.

Unstable fractures of the pelvic ring are an increasingly frequent outcome of motor vehicle trauma. Neurologic injury after such injuries can be a cause of significant morbidity. The available literature on neurologic injuries was reviewed and compared with a clinical review of 90 unstable pelvic injuries treated during a 3-year period. Eighty-three patients were available for followup examination. Neurologic injuries were seen in 21 % of the patients. Thirty-seven percent of patients had sensory deficits alone whereas the remaining 63% had motor and sensory findings. All patients showed some evidence of neurologic recovery at an average or 24-months followup. At least 1 grade of muscle function improvement was consistently seen and 53% of patients had complete neurologic recovery. Improvement in function was seen as many as 24 months postinjury, but L5 function was least likely to progress to full recovery. The incidence of neurologic injuries and their distribution was similar to that reported in the literature, whereas the prognosis for neurologic recovery was significantly better. This may be related to techniques of early anatomic reduction and stabilization of unstable pelvic ring injuries.

Analytical characterization of peptide contaminants of L-tryptophan.

Reversed-phase liquid chromatographic fractions of extracts of 2 preparations of eosinophilia-myalgia syndrome (EMS)-associated L-tryptophan were analyzed by proton nuclear magnetic resonance spectrometry, mass spectrometry, microbial-growth inhibition, and amino acid residue analyses. Fraction components demonstrated properties of an antibiotic peptide resembling bacitracin. Many peptide antibiotics like bacitracin are secondary metabolites of Bacillus species, genus of the tryptophan producer organism for the implicated manufacturer. In order to determine whether a correlation exists between individual EMS cases and the concentration of peptides or bacitracin consumed, reliable methods must be developed for quantification of the total of isoforms.

The validity and reproducibility of a work productivity and activity impairment instrument.

The construct validity of a quantitative work productivity and activity impairment (WPAI) measure of health outcomes was tested for use in clinical trials, along with its reproducibility when administered by 2 different methods. 106 employed individuals affected by a health problem were randomised to receive either 2 self-administered questionnaires (self administration) or one self-administered questionnaire followed by a telephone interview (interviewer administration). Construct validity of the WPAI measures of time missed from work, impairment of work and regular activities due to overall health and symptoms, were assessed relative to measures of general health perceptions, role (physical), role (emotional), pain, symptom severity and global measures of work and interference with regular activity. Multivariate linear regression models were used to explain the variance in work productivity and regular activity by validation measures. Data generated by interviewer-administration of the WPAI had higher construct validity and fewer omissions than that obtained by self-administration of the instrument. All measures of work productivity and activity impairment were positively correlated with measures which had proven construct validity. These validation measures explained 54 to 64% of variance (p less than 0.0001) in productivity and activity impairment variables of the WPAI. Overall work productivity (health and symptom) was significantly related to general health perceptions and the global measures of interference with regular activity. The self-administered questionnaire had adequate reproducibility but less construct validity than interviewer administration. Both administration methods of the WPAI warrant further evaluation as a measure of morbidity.

Assessing the responsiveness of a quality-of-life instrument and the measurement of symptom severity in essential hypertension.

A pilot study was conducted to compare symptoms elicited with an open-ended question versus a checklist and to measure the responsiveness of quality-of-life measures to symptom severity. The pilot study was part of a multicentre, randomised, double-blind, placebo-controlled study of clentiazem, a calcium channel blocker, in the treatment of essential hypertension. Symptom and quality-of-life data were obtained from 88 patients at baseline and after 10 weeks of therapy by a trained telephone interviewer. Comparison of the symptom checklist and open-ended question method suggests that both methods are necessary to capture severe symptomatology. The 24-item checklist failed to elicit approximately 50% of the severe symptoms reported on the open question list. On the other hand, only 18% of the most severe symptoms subsequently reported on the checklist were first reported by the open question method. The responsiveness of quality-of-life measures to symptom severity was tested using a 20% change in symptom severity obtained from the checklist as the minimal clinically significant difference. Using Guyatt's formula, a minimum sample size of approximately 428 (alpha = 0.05, beta = 0.10) patients per treatment group is required to detect differences in measures of general health perception, anxiety, depression and limitations in social activities. A larger sample is required to show differences in leisure activities. Differences in limitations of the capability to perform house or yard work might be demonstrable with as few as 17 patients per group. This pilot study demonstrated that the severity of symptoms associated with hypertension, and the side effects of its treatment with drugs, are adequately captured by a symptom checklist preceded by an open-ended method of questioning. Responsiveness testing estimated the sample size required to show a statistically significant difference, assuming a 20% change in symptom severity.

The cost of outpatient physicians' services at a Veterans Administration hospital.

The cost of an average outpatient visit to a physician at a Veterans Administration hospital in 1976 was estimated from hospital records to have been $80.35 ($104.46 in 1979 dollars). When productivity was used to measure relative cost, cost per visit ranged from a low of $32.66 (1979: $42.46) for hypertension clinic to a high of $243.48 (1979; $316.52) for hematology clinic. The average patient was seen 12.6 times annually at a cost of $1012 (1979: $1315). The major cost category for a physician visit was salaries, with nonphysician salaries costing twice as much as physician salaries. The cost of medical equipment was minimal. The findings suggest that the outpatient bookkeeping system was inadequate for cost accounting, the cost per visit was expensive, there were an excessive number of visits, and problems in the institutional delivery system of ambulatory care lowered productivity of physicians.

The place of sigmoid myotomy in diverticular disease.

The place of longitudinal myotomy in the treatment of diverticular disease of the sigmoid colon is discussed, with passing reference to the drawbacks of transverse myotomy. The prime indication for longitudinal myotomy is in the longstanding uncomplicated case of troublesome diverticular disease that has not responded to correct medical treatment, which should include high-residue diet and bran. Such cases are usually over 50 years of age, when a functional and reversible obstruction has become organic and irreversible. They comprise 75% of a series of 104 cases described. A secondary indication is in cases of diverticular disease which have been complicated by perforation, abscess formation, acute intestinal obstruction or fistulae. Such cases comprise 25% of the present series. They may settle after drainage and/or defunctioning colostomy. Myotomy can be carried out later, with or without limited resection, provided that all signs of pus or peritonitis have disappeared. The technique of the operation is described and the results are analysed.

Individual and institutional variables which may serve as indicators of quality of medical care.

This article is a critical review of empiric studies, in the medical care literature of the past two decades, that investigated associations between characteristics of physicians and medical care institutions and some measure of the quality of medical care given by them. The intention is to identify those characteristics of physicians and medical care institutions which can be considered the best indicators of the quality of performance to be expected, given the present state of knowledge. The analysis discusses 18 such characteristics but derives a list of 14 which appear to be the best choice of indicators on which further research might focus. It would be possible to design a survey instrument based on these characteristics, which, if upheld by empiric testing, could serve as a crude assessment tool for third parties needing to make quality comparisons between medical care institutions.