Cervical spine instability: clearance using dynamic fluoroscopy.

Cle aring the cervical spine in a multiply injured trauma patient is a dilemma because clinical examination for ligamentous instability cannot be performed, and the standard cervical spine series can miss isolated ligamentous injury. Static flexion/extension views are unsafe, as the obtunded patient has no protective reflexes and cannot complain of pain during the exam. This results in a need for prolonged spinal immobilization and its attendant complications. Dynamic fluoroscopy may be useful in the detection of otherwise occult injuries.We performed a prospective study of a cervical spine clearance algorithm incorporating dynamic fluoroscopy with flexion/extension views. Inpatient records over a 3-year period were reviewed. Patient demographic data, results of cervical spine films and fluoroscopic exams, interventions based on positive results, and missed injuries were recorded.One hundred ten patients with normal spine plain films underwent dynamic fluoroscopy with flexion and extension views of the cervical spine. The average Glasgow Coma Score was 9.2 and the average revised Trauma Score was 9.5. Nine patients had evidence of cervical instability on exam. Six of these were deemed stable by the orthopedic or neurosurgical spine consultants, and these patients had their hard collars removed. One patient with positive findings had cervical immobilization with hard collar continued, a second had halo placement, and a third underwent spinal fusion for atlanto-occipital disassociation. No patients undergoing dynamic fluoroscopy were subsequently found to have missed cervical spine injury.With our protocol, 3 patients had significant cervical instability that would have been missed without dynamic fluoroscopy. Given the significant medical and legal ramifications of missed cervical spine injury and the benefits of early removal of cervical collars, more widespread use of dynamic fluoroscopy of the cervical spine is warranted.

Progress in childhood cancer care in Florida. 1970-1992.

Pediatric cancer has been a priority in Florida since 1970. That year physicians established a statewide network of children's tumor programs, the Florida Association of Pediatric Tumor Programs (FAPTP), which has grown from the initial two programs to 10 in 1992 and now maintains a registry with follow-up to monitor incidence and other indicators. State-of-the-art care is provided through affiliation with the Pediatric Oncology Group. The incidence of pediatric cancer in Florida is equivalent to national rates, but the number of children followed in 1991 had grown to approximately 2,000. The number receiving care has increased an average of 13% annually since 1981. Services for these patients should be reviewed on a continuing basis to assure access to specialized programs.

Socioeconomic and demographic factors that predict where children receive cancer care in Florida.

Socioeconomic and demographic factors associated with type of facility (cancer center vs non-cancer center) at which a child with cancer is seen were identified to suggest interventions to increase access to state-of-the-art care. The 2268 children with cancer in Florida (1981-1986) were classified as ever having been seen or not having been seen at a cancer center. Patients referred from one type of facility to another were compared to those not referred. Nineteen percent of children with cancer were never seen at a cancer center. These children were likely to be older (15-19 years of age), have Hodgkin's disease or a brain tumor, reside in a county without a cancer center, or have higher median income. Interventions extending state-of-the-art cancer care beyond cancer centers should target (1) physicians treating adolescent-aged children and (2) patients for whom private insurance may serve as a barrier to referral and protocol therapy.

Using a population-based registry to identify patterns of care in childhood cancer in Florida.

BACKGROUND: Unlike cancers occurring in adults, childhood cancers are distinguished by being primarily nonepithelial in origin and by their relative rarity. Even with the availability of registries such as the Surveillance, Epidemiology and End Results program of the National Cancer Institute or the Florida Cancer Data System for the State of Florida, there are potential biases that may affect the estimates of pediatric cancer incidence, studies related to elucidating patterns of care, and other epidemiologic studies. METHODS: To evaluate the magnitude of these potential biases and elucidate the settings (pediatric cancer center versus non-cancer center) in which childhood cancers are treated, the authors performed a retrospective study of childhood cancer in Florida. RESULTS: Approximately 19% of childhood cancer cases (in patients 0-19 years of age) in Florida diagnosed from 1981 to 1986 were treated outside of identified pediatric cancer centers in the state. Children with Hodgkin disease and brain tumors represented 43% of these cases. Among those cases treated in pediatric cancer centers, 23% were treated by physicians other than pediatric oncologists. Children with brain tumors represented 28% of these cases. Of those treated by pediatric oncologists, 65% were eligible for a cooperative group protocol and 55% of these were enrolled. CONCLUSIONS: Population-based registries are necessary for describing the full extent of childhood cancer, but they have limitations in demonstrating patterns of care. Consequently, generalization from the experience of pediatric cancer centers is questionable, and the opportunity to test and achieve advances in diagnosis and treatment may be subject to selection bias.

The incidence of pediatric cancer in Florida, 1981 to 1986.

Incidence rates for pediatric (ages, 0 to 14 years) cancer in the state of Florida were produced for the period 1981 to 1986 and compared with national data to investigate variations in pediatric cancer incidence. Overall, Florida had an incidence rate of 12.77 per 100,000; this was not significantly higher than expected based on national rates (standardized incidence ratio, 1.0; 95% confidence interval, 0.9 to 1.0). Compared with national rates, whites residing in Florida had an increased rate of acute lymphocytic leukemia and decreased rate for soft tissue sarcomas (other than rhabdomyosarcoma), "other leukemias," and "other" cancers. Nonwhites residing in Florida had increased rates for soft tissue sarcomas (other than rhabdomyosarcoma) and decreased rates of "other" cancers. Boys in Florida had increased rates for retinoblastoma and acute lymphocytic leukemia and decreased rates for "other leukemias" and "other" cancers. Rates for girls were decreased for neuroblastoma and "other leukemias."

National Study of Internal Medicine Manpower: XI. Internal medicine residency and fellowship training in the 1980s.

The number of residents beginning training in internal medicine continued to increase slightly in 1985-86. However, the total number of residents in internal residency training decreased slightly from the previous year due to a decrease in the number of second- and third-year residents. The proportion of first-year residents who were foreign-trained physicians decreased from 21% to 20%, and the proportion of residents who finished training and went on to subspecialty training in 1985 decreased substantially to 56%. The number of physicians entering residency and fellowship training in internal medicine considerably exceeds the number projected by the Graduate Medical Education National Advisory Committee. In this article, we discuss implications of these trends for medical education and practice.

National Study of Internal Medicine Manpower: X. Internal medicine residency and fellowship training: 1985 update.

The number of medical school graduates entering internal medicine residency training was at an all-time high in 1984-85. Although the number of first-year residents who were foreign-trained physicians did not differ greatly from the 1983-84 census, the number of first-year residents who were U.S. medical school graduates was much higher than the previous year largely because the number of graduates from U.S. medical schools increased substantially in 1984. The number of internal medicine fellowship programs and the number of fellows in 1984-85 were also at an all-time high. Foreign-trained physicians represent 22% of those in residency training and 20% of those in fellowship training. Of every 100 who completed residency training, 61 went on to a first year of subspecialty fellowship training, a number up slightly from the previous year. The increasing numbers of residents and fellows being trained in internal medicine, combined with the preference for subspecialization and the substantial proportion of foreign-trained physicians being trained, are discussed against the background of pending legislation to reduce federal assistance for graduate medical education.