Merging primary care practices with MSOs.

Primary care group practices need to merge to provide the community-wide access demanded by managed care companies. Unfortunately, merger costs are high; according to some estimates, creating large-scale access can demand $1 million in start-up costs alone. Creating and using a management service organization can make the process less trying by pooling resources and talent in a common organizational structure. It's important, though, also to recognize the personal and financial burdens of such a plan.

Tibial plateau leveling osteotomy for repair of cranial cruciate ligament rupture in the canine.

A new technique for correcting the cranial cruciate deficient stifle, the tibial plateau leveling osteotomy, is introduced by the author. The technique is described and illustrated. Clinical results of 394 cases are described.

Trochlear wedge recession for medial patellar luxation. An update.

Trochlear wedge recession, a surgical technique for correction of luxating patella, has been improved and simplified over the years. Modifications in the technique for the pathologic sulcus are described. Common problems with the osteotomy placement and wedge stability are defined with recommendations for correction.

Pelvic osteotomy for axial rotation of the acetabular segment in dogs with hip dysplasia.

Pelvic osteotomy has provided normal function and activity to dogs with hip dysplasia. Physical and radiographic examination and palpation under anesthesia permit evaluation of the degenerative process and provide the specific amount of axial rotation of the pelvis necessary for each dog. The technique consists of an osteotomy of the pubis, ischium, and ilium to reestablish acetabular support of the femoral head.

L7-S1 fixation-fusion for treatment of cauda equina compression in the dog.

The L7-S1 fixation-fusion technique for treatment of cauda equina compression was performed on 14 dogs, 13 of which were 6 years old or older, were severely lame, and had ventral bridging spondylitis at the L7-S1 vertebrae. One dog, 3 months old, had a congenital malformation of the L7 vertebra. The principles of the L7-S1 fusion technique were to expand the L7-S1 intervertebral foramina and spinal canal, remove pressure on the nerve roots, and provide stability to the L7-S1 vertebrae. This technique appeared to be applicable clinically for restoring normal function and activity to dogs with cauda equina compression.

Trochlear recession for correction of luxating patella in the dog.

Trochlear recession is a surgical technique for stabilizing luxating patellas by recessing the trochlear sulcus 1 to 2 mm. The smooth hyaline cartilage of the articulating trochlear surface is preserved. This technique has provided excellent results in 41 stifles of 28 dogs, as determined by a 6-month to 6-year follow-up, with an average follow-up period of 3.2 years.

Specialized nutrition support: patterns of care.

A prospectively studied series of 1072 patients who received specialized nutritional support are presented to evaluate the patterns of such care in a large nonuniversity teaching center. Age, service, materials used, routes of administration, complications, assessment parameters, duration of treatment, diagnoses, and survival statistics are presented. Such patterns are considered to be of importance to medical scientists, basic researchers, hospital administrators, governmental agencies, and members of the health care insurance industry.

Parenteral nutrition complications in a voluntary hospital.

A prospective study analyzing the complications in 307 patients who had specialized nutrition support administered by their private practitioners was performed and compared to other series in which a nutrition support service exclusively provided such care of patients. The mechanical complication rate of 4.6%, septic complication rate of 2.9%, and metabolic complication rate of 4.2% compared favorably with the reported literature. A new category of complications, the judgmental complication, is described and was 12.7% in the reported series. The Saint Barnabas Medical Center experience suggests that individual practitioners can satisfactorily administer intravenous specialized nutrition support if in fact an involved nutrition support service functions administratively and supportively in the background.

Cranial tibial wedge osteotomy: a technique for eliminating cranial tibial thrust in cranial cruciate ligament repair.

Cranial tibial wedge osteotomy, surgical technique for cranial cruciate ligament rupture, was performed on 19 stifles in dogs. This procedure leveled the tibial plateau, thus causing weight-bearing forces to be compressive and eliminating cranial tibial thrust. Without cranial tibial thrust, which was antagonistic to the cranial cruciate ligament and its surgical reconstruction, cruciate ligament repairs were allowed to heal without constant loads. This technique was meant to be used as an adjunct to other cranial cruciate ligament repair techniques.

Complications occurring during enteral nutrition support: a prospective study.

A review of 253 patients treated with enteral nutrition support via tube feedings is presented for the purpose of evaluating the incidence of complications. Thirty patients, (11.7%) experienced either gastrointestinal, (6.2%) mechanical (3.5%), or metabolic (2.0%) complications. The recognition and treatment of such complications are discussed and it is concluded that tube feedings are safely tolerated by most patients; however, constant attention must be exerted to either avoid or recognize such complications.

Cranial tibial thrust: a primary force in the canine stifle.

A cranially directed force identified within the canine stifle joint was termed cranial tibial thrust. It was generated during weight bearing by tibial compression, of which the tarsal tendon of the biceps femoris is a major contributor, and by the slope of the tibial plateau, found to have a mean cranially directed inclination of 22.6 degrees. This force may be an important factor in cranial cruciate ligament rupture and in generation of cranial drawer sign.

Wedge recession for treatment of recurrent luxation of the patella: a preliminary report.

Wedge recession is a method which utilizes the geometry of similar triangles to recess an articular wedge into the underlying bone. This concept has been applied to congenital luxating patellae in the dog. A trochlear wedge recession deepens the femoral trochlea and provides stability to the patella. Preliminary trials of the procedure in dogs produced excellent results.

Instant nutritional assessment in the intensive care unit.

Instant nutritional assessment of the critically ill patient using serum albumin level and total lymphocyte count is reported. When an intensive care unit population is compared to the general hospital population a 6-fold increase in albumin level depressions, a 2-fold increase in lymphocyte count depression, and an 11-fold increase in depression of both parameters was noted in the intensive care unit population. Surgical intensive care unit (SICU) patients with depressed albumin levels and total lymphocyte counts had twice the complication rate and 4.5 times the death rate of those SICU patients with normal albumin levels and lymphocyte counts. It is concluded that serum albumin levels and total lymphocyte count determinations are valuable tools for instant nutritional assessment of the critically ill patient.

Instant nutritional assessment.

Instant nutritional assessment of the hospitalized patient is described based upon admission serum albumin levels and total lymphocyte counts. Abnormalities of these parameters are associated with markedly increased morbidity and mortality in a series of 500 consecutively admitted patient. It is suggested that instant nutritional assessment be performed on all hospitalized patients with appropriate alterations and therapy being made to allow for nutritional repletion.