Estimating the location of the posterior interosseus nerve during an extensor digitorum communis-splitting approach: a comparison of methods using the transepicondylar distance.

Background: The posterior interosseus nerve (PIN) may be encountered when using the extensile extensor digitorum communis (EDC)-splitting approach to the elbow. An accurate means of estimating its location remains elusive. The purpose of this investigation is to identify whether the methods described in previous studies can be improved upon to more accurately estimate the PIN's location using the transepicondylar distance (TED). Methods: Forty-five fresh-frozen cadavers were dissected using the EDC-splitting approach. Method A (N = 39) used an electronic caliper measuring along the midlateral border of the radius from the lateral epicondyle (LE) and radiocapitellar joint in supination, neutral position, and pronation. Method B (N = 16) used a sterile tape measure, measuring from the LE in pronation only along an axis from the LE to Lister's tubercle passing through the center capitellum. Results: In method A, the mean TED was 63.4 ± 6.1 mm. Of the 6 measurements, the TED was most correlated to the actual distance to the PIN from the LE in pronation (68.3 ± 7.3 mm; R2 = 0.266). The median difference between the estimated and actual distances was -5.6 mm (-19.3 mm to 7.6 mm). In method B, the mean TED was 68.4 ± 8.7 mm, and the mean measured distance from the LE in pronation was 68.7 ± 9.4 mm. The TED closely correlated with the measured distance to the PIN (R2 = 0.95, P < .001). The mean difference between the estimated and actual distances was ±2.0 mm (range -4.0 mm to 2.0 mm), significantly more precise than method A (P = .007). Conclusion: Using a tape measure, the TED predicted the PIN's location within a mean ±2 mm in pronation along an axis from the LE to Lister's tubercle, using an EDC-splitting approach. This technique is simple and comparatively more accurate than those used previously.

Ultrasound of the Median Nerve in the Surgical Treatment of Severe Carpal Tunnel Syndrome.

BACKGROUND: High-resolution ultrasound (HRU) has demonstrated utility in the diagnosis and treatment of carpal tunnel syndrome (CTS) by measuring the cross-sectional area (CSA) of the median nerve. We investigated whether HRU could be helpful in evaluating outcomes of carpal tunnel release in patients with severe CTS. METHODS: Patients greater than 18 years of age with severe CTS on electrodiagnostic (EDX) studies and scheduled to have carpal tunnel release were enrolled. At baseline visit within 6 weeks preoperatively, HRU was used to measure median nerve CSA at the carpal tunnel inlet and forearm, and the wrist/forearm ratio (WFR) was calculated. Patients also completed the Boston Carpal Tunnel Questionnaire (BCTQ). Ultrasound and BCTQ were repeated at 6 weeks and 6 months postoperatively. RESULTS: Twelve patients completed the study (average age, 69 years; range, 52-80 years). The WFR improved significantly at 6 weeks and reached normal levels at 6 months. The CSA at the wrist also improved at 6 months, although this did not reach statistical significance (P = .059). Boston Carpal Tunnel Questionnaire symptoms and function scores improved significantly at 6 weeks and 6 months. CONCLUSIONS: High-resolution ultrasound provides an objective assessment of surgical outcomes in cases of severe CTS, demonstrating normalization of WFR in our series of successful cases. Future study of poor outcomes may help determine whether improvement in WFR and CSA can provide reassurance and support for observation rather than reoperation. Ultrasound also provides anatomical evaluation and may be helpful in cases with medicolegal or psychosocial issues while potentially being less costly and better tolerated than EDX or magnetic resonance imaging.

Clozapine-induced stercoral colitis: a surgical perspective.

We describe a case of a 46-year-old man with schizophrenia treated with clozapine who presented as an emergency with abdominal pain on the background of a 1 month history of constipation. The initial presenting symptoms were vague and a diagnosis was difficult to establish. Initial CT of the abdomen and pelvis demonstrated only minor abnormalities. He continued to deteriorate until a further CT scan revealed worsening stercoral colitis. He subsequently underwent an emergency total colectomy and ileostomy formation and had a complicated prolonged postoperative recovery. This case highlights the risks that clozapine can have on slowing bowel transit and the dangerous consequences that can occur if not identified early.

Orthopaedic Resident Remediation: Frequency, Interventions, and Outcomes.

BACKGROUND: Despite multiple studies in other areas of surgical resident education, there is no current literature regarding orthopaedic resident remediation. The goal of the present study was to use a survey format to determine the frequency of remediation, the underlying etiology, the intervention strategies utilized, and the outcomes. METHODS: The program directors of all current 159 Accreditation Council for Graduate Medical Education-recognized orthopaedic residency programs in the United States were e-mailed a non-identifying digital survey. Follow-up e-mails were sent monthly for a 3-month period. The data remained anonymous, with no identifying information. The data are reported with use of descriptive statistics. RESULTS: Seventy (44%) of 159 program directors responded; most were from academic institutions with 4 to 5 residents per class. One hundred and fifty-eight residents were remediated, with the greatest number being remediated during the third postgraduate year (PGY-3). Professionalism, patient care, and communication were the most common deficiencies requiring remediation. Mentorship, feedback, and probation were the most common interventions. Of the 117 residents for which the outcome was reported, 58 graduated on time, 14 graduated from another program, 25 graduated from another specialty, 14 were terminated, 3 pursued litigation, and 3 chose a non-medical career. Rehabilitation, didactics, feedback, and mentorship were associated with the highest rates of on-time graduation. CONCLUSIONS: Most remediated residents were PGY-3, suggesting increased scrutiny as residents moved from junior to senior responsibilities. The greatest number of deficiencies requiring remediation pertained to the affective domain, which highlights the importance of screening measures such as away rotations and interviews. The relationships formed during increased feedback sessions and mentorships can help problem residents to graduate on time.

#ChoosePsychiatry #the60secondchallenge - a thematic analysis of videos published on Twitter about reasons for choosing psychiatry.

This article was migrated. The article was marked as recommended. Aims and Method #ChoosePsychiatry is the Royal College of Psychiatrist's social media campaign aimed at medical students and foundation doctors to encourage recruitment into psychiatry.  This study explored the reasons given for choosing psychiatry in videos uploaded by psychiatrists to Twitter alongside the campaign, through the use of thematic analysis.  Results Each psychiatrist gave different reasons for choosing psychiatry but four main themes were identified: prior experience of psychiatry, career factors, patient factors and knowledge factors.  Both undergraduate and postgraduate experiences were influential in choosing psychiatry.  In particular, perceived job satisfaction, an opportunity to deliver holistic care and a sense of making a difference were also influential in choosing psychiatry. Clinical Implications Findings here support efforts to improve the undergraduate experience and to increase foundation posts, as well as maintaining some of the current key messages of the campaign.  However, whilst engagement with the videos on Twitter was observed, further consideration of the most appropriate social media platform to ensure engagement with the target audience is needed.

Calling on a million minds for community annotation in WikiProteins.

WikiProteins enables community annotation in a Wiki-based system. Extracts of major data sources have been fused into an editable environment that links out to the original sources. Data from community edits create automatic copies of the original data. Semantic technology captures concepts co-occurring in one sentence and thus potential factual statements. In addition, indirect associations between concepts have been calculated. We call on a 'million minds' to annotate a 'million concepts' and to collect facts from the literature with the reward of collaborative knowledge discovery. The system is available for beta testing at http://www.wikiprofessional.org.