RESUMO
Context The osteopathic cranial field suggests that cranial rhythmic impulse (CRI) can be used to examine distal segments. However, there is a lack of research on the reliability of using CRI to diagnose other distal segments. This study aims to evaluate the effectiveness of using the cranial vault hold compared to traditional osteopathic diagnostic techniques to diagnose somatic dysfunctions at the following segments: atlantooccipital joint (OA), atlantoaxial joint (AA), cervical-4 (C4), cervical-7 (C7), thoracic-6 (T6), thoracic-12 (T12), lumbar-3 (L3), sacrum, left innominate, right fibular head, and left radial head. Objective To determine if palpation of CRI can reliably detect somatic dysfunctions in multiple distal segments. Methods The study compared osteopathic physicians' diagnoses of specific segments (OA, AA, C4, C7, T6, T12, L3, sacrum, left innominate, right fibular head, and left radial head) using the cranial vault hold and direct palpation. Two osteopathic neuromusculoskeletal medicine experts (cranial group) diagnosed distal segments via the cranial vault hold, while board-certified osteopathic physicians (confirmatory group) used direct palpation. We recruited 44 second-year osteopathic medical students and osteopathic physicians via a school-wide email. Each participant lay supine on a massage table for diagnosis. A neuromusculoskeletal expert, with a scribe, diagnosed the segments using the cranial vault hold. The process was repeated by a second neuromusculoskeletal expert with another scribe. Two osteopathic physicians then diagnosed the same subjects using direct palpatory techniques. Both osteopathic physicians had to agree on a diagnosis for the segment, or it was excluded from comparison. Cohen's kappa coefficient measured inter-rater reliability between the cranial and confirmatory groups. Results Cranial physician 1 provided all 484 diagnoses, while cranial physician 2 provided 152. Cranial physician 1 showed positive agreement with the confirmatory group (κ>0) in 2/11 (18.2%) segments: T12 and left innominate (κ=0.009 and 0.007). Cranial physician 2 showed positive agreement (κ>0) in 4/11 (36.4%) segments: OA, AA, C4, and left innominate (κ=0.050, 0.031, 0.130, and 0.154). Inter-rater reliability between cranial physicians showed positive agreement in 6/11 (54.5%) segments: OA, AA, C4, sacrum, left innominate, and right fibular head (κ=0.125, 0.022, 0.048, 0.036, 0.154, and 0.0261). Conclusion The positive kappa values, all between 0 and 0.2, indicate the inter-rater reliability for diagnosis with the vault hold is above random chance but has none to slight reliability. The kappa coefficients comparing both cranial physicians indicate positive agreement in six segments, supporting palpation of the same phenomena in six out of 11 (54.5%) segments. However, none of the positive kappa values were statistically significant (p>0.05) and the effect sizes were small, likely due to shared bias among the evaluators. We conclude our experiment suggests palpation of the cranium may not reliably diagnose distal segments. However, our experiment may support a connection between CRI and distal segment somatic dysfunctions. Considering diagnoses of certain segments are above random chance, more research is needed to confirm whether there is a connection between palpation of the CRI and the diagnosis of a distal somatic dysfunction.
RESUMO
Encapsulating peritoneal sclerosis (EPS) is a serious complication of chronic peritoneal dialysis (PD) that results in encapsulation of the bowel in a thick, fibrocollagenous membrane. Given its rare and complex nature, diagnosis of EPS often arises late in the disease process or intraoperatively. We report the case of an 86-year-old male with a history of renal failure managed with PD who presented with multiple hospital admissions for recurrent abdominal pain and symptoms of small bowel obstruction. Open laparotomy revealed encasement of the entire abdominal cavity in a cocoon-like membrane, consistent with EPS, which was successfully managed with extensive excision and adhesiolysis. This discussion, enriched by unique radiographic insights and delineation of a surgical strategy, seeks to enhance the understanding of this underreported disease characterized by a lack of definitive treatment and an enigmatic pathophysiology.
RESUMO
BACKGROUND: The purpose of this study was to compare the outcomes of pediatric patients who were surgically treated for a supracondylar humerus fracture by pediatric fellowship-trained orthopaedic surgeons (PFT) to the outcomes of those surgically treated by orthopaedic surgeons without pediatric fellowship training (NPFT). We hypothesized that there would be no differences in patient outcomes. METHODS: A retrospective review of pediatric patients who underwent surgical treatment for a supracondylar humerus fracture with closed reduction and percutaneous pinning (CRPP) or open reduction and percutaneous pinning (ORPP) at a regional level 1 trauma center over a 5-year period was performed. Exclusion criteria were inadequate follow up or absence of postoperative radiographs. RESULTS: A total of 201 patients met the inclusion criteria. Pediatric-fellowship trained orthopaedic surgeons treated 15.9% of patients. There was no statistically significant difference in carrying angle, Baumann's angle, or lateral rotation percentage at final follow up between PFT and NPFT groups. There was no permanent neurovascular compromise in either group. Patients treated by NPFT were more likely to return to the operating room for pin removal. CONCLUSION: In this study, there was no difference in radiographic outcomes for patients with supracondylar humerus fractures surgically treated by either group. This suggests that pediatric supracondylar humerus fractures may be appropriately treated in communities without a pediatric-fellowship trained orthopaedic surgeon without compromised outcomes.Level of Evidence: III.