How do different anterior tibial tendon transfer techniques influence forefoot and hindfoot motion?

BACKGROUND: Idiopathic clubfoot correction is commonly performed using the Ponseti method and is widely reported to provide reliable results. However, a relapsed deformity may occur and often is treated in children older than 2.5 years with repeat casting, followed by an anterior tibial tendon transfer. Several techniques have been described, including a whole tendon transfer using a two-incision technique or a three-incision technique, and a split transfer, but little is known regarding the biomechanical effects of these transfers on forefoot and hindfoot motion. QUESTIONS/PURPOSE: We used a cadaveric foot model to test the effects of three tibialis anterior tendon transfer techniques on forefoot positioning and production of hindfoot valgus. METHODS: Ten fresh-frozen cadaveric lower legs were used. We applied 150 N tension to the anterior tibial tendon, causing the ankle to dorsiflex. Three-dimensional motions of the first metatarsal, calcaneus, and talus relative to the tibia were measured in intact specimens, and then repeated after each of the three surgical techniques. RESULTS: Under maximum dorsiflexion, the intact specimens showed 6° (95% CI, 2.2°-9.4°) forefoot supination and less than 3° (95% CI, 0.4°-5.3°) hindfoot valgus motion. All three transfers provided increased forefoot pronation and hindfoot valgus motion compared with intact specimens: the three-incision whole transfer provided 38° (95% CI, 33°-43°; p < 0.01) forefoot pronation and 10° (95% CI, 8.5°-12°; p < 0.01) hindfoot valgus; the split transfer, 28° (95% CI, 24°-32°; p < 0.01) pronation, 9° (95% CI, 7.5°-11°; p < 0.01) valgus; and the two-incision transfer, 25° (95% CI, 20°-31°; p < 0.01) pronation, 6° (95% CI, 4.2°-7.8°; p < 0.01) valgus. CONCLUSION: All three techniques may be useful and deliver varying degrees of increased forefoot pronation, with the three-incision whole transfer providing the most forefoot pronation. Changes in hindfoot motion were small. CLINICAL RELEVANCE: Our study results show that the amount of forefoot pronation varied for different transfer methods. Supple dynamic forefoot supination may be treated with a whole transfer using a two-incision technique to avoid overcorrection, while a three-incision technique or a split transfer may be useful for more resistant feet. Confirmation of these findings awaits further clinical trials.

Effects of chronic cocaine exposure on corticotropin-releasing hormone binding protein in the central nucleus of the amygdala and bed nucleus of the stria terminalis.

The neuropeptide, corticotropin-releasing hormone (CRH), has been shown to play a role in behavioral and neurobiological effects of drugs of abuse. An important modulator of CRH, the CRH binding protein (CRH-BP), has not, on the other hand, been assessed for its role in drug-associated effects. The primary objective of the present experiment was to assess whether prior, chronic exposure to cocaine modulates expression of CRH-BP, and to compare expression of the BP with that of the peptide itself. We assessed CRH-BP and CRH mRNA expression in two brain regions where CRH is known to affect responses to drugs of abuse; namely, the central nucleus of the amygdala (CeA) and bed nucleus of the stria terminalis (BNST). Male Long-Evans rats were given 14 daily injections of cocaine (30 mg/kg, i.p.) or saline. One, 3, 10, 28, or 42 days post-treatment, animals were killed and adjacent brain sections through the CeA and BNST were processed for CRH-BP and CRH by in situ hybridization. In the CeA, cocaine pre-exposure increased both CRH and CRH-BP mRNA expression 1 day post-treatment. In the dorsal BNST, cocaine pre-exposure elevated levels of CRH-BP, but not CRH, mRNA 3 days post-treatment. Taken together, the results suggest that withdrawal-induced changes in the expression of the CRH-BP, and CRH itself, are relatively short-lived and that a dysregulation in basal expression of either gene is not likely responsible for long-lasting behavioral effects noted with cocaine and other drugs of abuse.

Mentoring in health administration: the critical link in executive development.

Career development in the next century will be predicated on the ability to forge hierarchical as well as lateral relationships within diverse organizational environments. Mentoring relationships may provide the critical link for future health executives to remain involved in their organization and their profession. This national study of 540 healthcare managers examined the prevalence of mentoring relationships according to demographic, organizational, and professional variables. Mentors appeared to influence access to promotional opportunities for managers in the healthcare industry and provide a mechanism for executive development.

Cross-gender mentoring and career development in the health care industry.

Career development in the next century will be predicated upon the ability to forge hierarchical as well as lateral relationships. This study of 223 managers in the health care industry found that mentors influenced the career mobility of female executives and ensured access to promotions within the organization.

Pediatric stomas, tubes, and appliances.

Pediatric patients with ostomies are a challenge to health care providers. An ostomy is not without problems. Knowledge of surgical techniques and a commitment to the care and management of the stoma and appliances are needed to prevent and manage complications. Ongoing patient education is paramount for compliance and prevention of problems. An experienced individual trained in stoma care must be available as a resource to provide support and answer questions or concerns of patients and their families.

Gender differences in factors affecting health care administration career development.

At first glance, a woman's prospects for a career in health administration seem encouraging. More than half of the recent graduates of health administration master's programs are female, and initially post-master's salaries are comparable with those of male graduates. Unfortunately, opportunities for promotion and financial benefits seem to decrease for women and expand for men as their respective careers progress. This study found that, with the same educational background, men earned an average of $51,491 annually, compared to $50,839 for women, in health care administration. We examined gender differences in organizational and individual factors that have been modeled as influences on career development. These factors include financial and nonfinancial benefits, access to training programs, success factors, demographics, and motivating factors underlying education, employment, and career choices. Some evidence of gender differences in the organizational and individual factors affecting career development is provided. Academic and professional strategies addressing these differences are suggested for consideration by both professional and university administrators.

Common pediatric surgical problems.

Common pediatric surgical problems, including hernias, pyloric stenosis, intussusception, and appendicitis continue to present a challenge to the health care provider. Clinical presentation may be typical, may vary with age or signs and symptoms, or may be vague and inconclusive. Management of these problems may range from nonoperative to traditional surgical intervention. Nursing implications include counseling, patient and family education, pre- and postoperative care, and the prevention of complications.

The MIC-KEY experience with the pediatric patient.

A gastrostomy, creation of a gastrocutaneous fistulous tract, may be indicated for the pediatric patient with a functional gastrointestinal tract who is unwilling or unable to consume sufficient nutrition to meet caloric needs for optimal growth and development. A gastrostomy may also be used for medication administration, decompression, or access. Several pediatric conditions or anomalies may necessitate gastrostomy. Traditionally, a silicone catheter with a mushroom tip was placed through a gastrostomy. Recently, however, alternative gastrostomy devices have become available. The MIC-KEY device (Medical Innovations Corporation, Milpitas, Calif.) is one such device. This article introduces the ET nurse to the MIC-KEY device as an option and discusses its advantages and disadvantages in the pediatric patient.

Executives in healthcare administration: where do women stand?

The disparity in management responsibility and earning potential of men and women seen in business at large is mirrored in healthcare administration. While a variety of factors may influence this difference, a preliminary study of the career advancement of recent graduates of a healthcare administration graduate program suggests that recruitment and promotion policies may be largely responsible for gender disparities.

Vesicoureteral reflux.

Vesicoureteral reflux, the regurgitation of urine from the bladder into the ureters, varies in severity. Controversy persists in relation to the cause, diagnosis, significance, and treatment of this condition. The practitioner's role in early referral and treatment of urinary tract infection is important to prevent renal damage. Patient and family support and education about reflux, diagnosis, and follow-up is crucial. Early diagnosis and optimal management will preserve maximal renal function, and patient education will foster compliance and quality care.