Similar views on rehabilitation following hip arthroscopy among physiotherapists and surgeons in Scandinavia: a specialized care survey.

PURPOSE: The rising number of hip arthroscopies (HA) is leading to increasing numbers of patients requiring post-surgical rehabilitation; however, evidence regarding post-operative rehabilitation is currently limited. The purpose of the study was to describe and compare current rehabilitation strategies and views among surgeons and physiotherapists in Scandinavia. METHODS: Scandinavian surgeons and physiotherapists experienced with HA and post-surgical rehabilitation were asked to complete an online survey. Ninety clinicians (28 surgeons, 62 physiotherapists) responded. RESULTS: Both professions mostly rated physiotherapy as very or extremely important in the rehabilitation process. The majority advocated criteria-based or combined criteria- and time-based progression. Expected rehabilitation timelines were reported with large intra-professional variation but general inter-professional agreement. However, compared with physiotherapists surgeons expected fewer weeks on crutches and faster return to competitive sport. Surgeons more often reported use of evidence-based self-reported outcomes while physiotherapists more often evaluated readiness for return to play. CONCLUSIONS: Among surgeons and physiotherapists, physiotherapy is considered very important following HA. Generally, very similar views were held between professions. Surgeons expected reduced time on crutches and to return to competitive sports than physiotherapists. Surgeons also used evidence-based self-reported outcomes to a higher degree than physiotherapists. Being the first study to provide an overview on currently applied rehabilitation strategies following HA, results of this study may guide much needed, future research on the rehabilitation process following HA. LEVEL OF EVIDENCE: IV.

[fMRI and DTI in delayed development of number processing]. / fMRT und DTI bei Entwicklungsverzögerung der Zahlenverarbeitung.

The neuronal correlate of the current cultural performance arose from developmental processes that can be observed by functional and anatomical magnetic resonance imaging. The velocity of these maturation processes occurs differently between adolescents, causing implications for both school career and academic performance. Regarding spatial-numerical cognition the myelinization of the superior longitudinal bundle appears to be crucial because this fiber connection intermediates between the linguistic nature of number words and conception of their spatial-numerical magnitude. The neuroscientific observation of anatomical brain maturation and its influence on school-relevant number processing may be helpful for educational purposes as well as for school psychology.

Evaluation of changes in forgoing life-sustaining treatment in Israeli ICU patients.

INTRODUCTION: Over the last several years, there have been legal decisions and changes in medical directives concerning end-of-life decisions in Israel. METHODS: The data were compared to evaluate the changes in the frequency and types of forgoing of life-sustaining treatment (FLST) in patients who were admitted to the ICU during period I (November 1994 to July 1995) and period II (January 1998 to January 1999). RESULTS: During period I, there were 385 ICU admissions, and during period II there were 627 ICU admissions. In period I, FLST or death occurred in 13.5% of patients, and in 12% in period II. There was no significant difference in cardiopulmonary resuscitation (9% vs 13%, respectively), withholding therapy (90% vs 91%, respectively), or withdrawing therapy (0% vs 0%, respectively) between the two study periods. CONCLUSIONS: There was no significant change in the frequency or types of FLST in an Israeli ICU between 1994 and 1998, despite passage of a new Patients' Rights Law and the issuing of a Ministry of Health directive on the treatment of the terminally ill, both of which occurred in 1996, and recent district court decisions favoring the termination of life-sustaining therapies.

End-of-life intensive care unit decisions, communication, and documentation: an evaluation of physician training.

PURPOSE: The majority of patients dying in intensive care units (ICUs) do so after the forgoing of life-sustaining therapies (FLST). Communication between physicians, patients, and their families regarding the decision to FLST has not been evaluated in Israel. MATERIALS AND METHODS: All patients who had FLST in a general ICU were enrolled in the study. We evaluated whether physicians communicated and documented the FLST decisions with patients or the patients' families. We also assessed the effect of the physician's geographic place of training on communication behavior. RESULTS: Over a period of 8.5 months, 385 patients were admitted to a general ICU in Israel. Fifty-seven patients died or had FLST. Twelve of these 57 were excluded from the study. Thus, 45 (79%) patients had FLST and were enrolled in the study. All patients were deemed medically incompetent to make FLST decisions. In 24 (53%) patients, FLST was discussed with the family before the decision to forgo therapy. Discussion occurred later with 6 other families, who were unavailable at the time the FLST decision was made. In 15 patients, there were no discussions with families. American-trained physicians discussed FLST with 22 of 29 families initially and 5 other families later (93%), whereas the Eastern European-trained physicians discussed FLST with only 3 of 16 (19%) families (P <.001). Documentation of FLST was present in 26 (90%) patients of American-trained physicians and 8 (50%) patients of Eastern European-trained physicians (P <.001). CONCLUSIONS: FLST is common in an Israeli ICU. Patients are not medically competent to make FLST decisions. American-trained physicians discuss and document FLST more often than Eastern European-trained physicians.

Screening mammography: a missed opportunity.

By age 80, 1/10 women will be diagnosed with breast cancer. Both positive and negative associations have been reported between alcohol consumption and breast cancer. Minority women are less likely to undergo breast cancer screening. All women admitted for alcohol detoxification in an urban setting with a high minority population were offered screening mammography, using American Cancer guidelines. Women with previously diagnosed breast cancer were excluded from the study. The mammograms were performed by standard technique in the hospital radiology department. The subjects with positive mammograms were referred for further diagnostic studies, as determined by the internist managing the patient's care. Of the 117 women admitted, 28 were excluded due to age. Only one woman, previously treated for breast cancer, was also excluded. Of the 88 women screened, abnormalities were detected in 32. The women with normal mammograms did not differ from those with abnormal studies in: (1) age; (2) years of alcohol consumption; (3) age at menarche; (4) parity; (5) age at first full term pregnancy; and (6) personal history of benign breast disease or family history of breast cancer. The alcohol detoxification unit provides a unique opportunity to screen women for breast cancer. Compliance with initial screening is high but resistance is encountered if further diagnostic studies are required to evaluate suspicious lesions. Surprisingly, in this study, the number of suspicious lesions detected was not higher than expected.

Second surgical opinion programs: dead or alive?

BACKGROUND: In the 1970s, second surgical opinion programs were established in an effort to improve medical care and to control health care costs. The cost-effectiveness of these programs has been questioned recently. STUDY DESIGN: A retrospective review was conducted of elective second-opinion surgical consultations for members of Local 32B-J of the International Service Employees Union for the years 1993-1994. Nonconfirmed consultations were reviewed against claims history data for the subsequent 2 years. Data were analyzed for rates of nonconfirmation by diagnosis and surgical specialty and for cost-effectiveness benefit. RESULTS: Of the 5,601 second surgical consultations performed, 490 procedures were not confirmed as medically necessary (9%). Claims history survey for these 490 patients for the 2 years following the consultation revealed that no operation was performed in 62%. The highest nonconfirmation rate (41%) was in plastic and reconstructive surgery, followed by gynecology (22%). The cost-benefit ratio for the program was calculated to be 1.34. CONCLUSIONS: A second surgical opinion program confers both cognitive and psychologic beneficial effects on Joint Trust Fund members and their dependents who are advised to undergo elective operations. Our current second surgical opinion nonconfirmation rate is 9%, with hysterectomy, prostatectomy, and bunionectomy among the procedures most frequently nonconfirmed. The cost-benefit ratio was estimated at 1.34.

Relative kindling effect of readmissions in alcoholics.

To determine if there is an increase in the risk of seizure activity when patients experience recurrent alcohol detoxification, the histories of 360 alcoholics who had at least two admissions for alcohol detoxification, between November 1987 and August 1992, were reviewed retrospectively. All subjects were treated with tapering doses of chlordiazepoxide as required, to control symptoms/signs of alcohol withdrawal. Subjects with a seizure history were prophylactically treated with tapering doses of chlordiazepoxide. No seizures were observed during detoxification in any of these subjects. In this group of readmitted subjects, there was no correlation between self-reported duration of alcohol consumption or average daily intake of alcohol. A significant correlation was observed between seizure history and number of detoxification admissions and neurological admissions, but not for other medical/surgical admissions, nor for admissions for rehabilitation. At the time of initial admission, laboratory parameters did not distinguish those subjects with seizures from those without. At the time of readmission, mean corpuscular volume and gamma-glutamyl transpeptidase, both markers of alcohol consumption, were higher in the group with seizures.

Hepatotoxicity is not increased in alcoholics with positive urinary cocaine metabolites.

Cocaine hepatotoxicity in mice has been reported by numerous investigators. Such hepatotoxicity in other animal models has been more difficult to produce. We prospectively assessed 1212 alcoholics admitted for detoxification for historical, clinical and laboratory evidence of concomitant cocaine/crack use and evidence of liver disease. The 470 cocaine positive subjects had both longer durations and higher average daily costs of cocaine/crack use than the 742 cocaine negative subjects, but had a shorter duration of alcohol use. Serum transaminases were higher in the cocaine negative group. There were no clinically severe cases of liver disease or rhabdomyolysis in either group. Serum hepatitis B surface antibody and hepatitis A antibody were more frequent in the cocaine positive subjects. In conclusion, in this large sample of alcoholics abusing cocaine, severe hepatotoxicity was not at all evident. The previous reports of hepatotoxicity may represent co-morbidity. Some possibilities include infection with a hepatitis or other virus, the presence of an adulterant, an idiosyncratic reaction or an enzymatic abnormality.

Propranolol versus diazepam in the management of the alcohol withdrawal syndrome: double-blind controlled trial.

Thirty-seven male alcoholics admitted electively for detoxification were randomized to treatment with either diazepam or propranolol. Subjects were comparable both in age and in duration and quantity of alcohol consumed. Admission laboratory parameters did not distinguish between the groups. Eleven subjects required no medication to control withdrawal signs/symptoms. Both groups showed improvement in blood pressure, pulse, and withdrawal tremor. None of the subjects randomized to diazepam manifested withdrawal seizures or hallucinations. By contrast, one subject in the propranolol group had a single withdrawal seizure. Another subject manifested increasing withdrawal that required parenteral paraldehyde treatment. Thus, this study confirms that a significant number of subjects admitted electively for alcohol withdrawal can be managed without medication. Minor tranquilizers still remain the "gold standard" for management of the withdrawal syndrome.

An analysis of substance abuse patterns, medical expenses and effectiveness of treatment in the workplace: long-term followup.

This study of workplace substance abuse programs indicates that they are effective for many participants and also shows that these programs can significantly lower medical expenses for those who successfully complete them.

Acupuncture fails to improve treatment outcome in alcoholics.

Fifty-six alcoholics (49 male, 7 female) of lower socioeconomic class attending an outpatient treatment program in Brooklyn, New York were prospectively randomized to one of three treatment group: point-specific acupuncture, sham transdermal stimulation or standard care (control). One third of the subjects reported a history of drug use in addition to alcohol. Results in this small sample showed no significant differences in attendance at Alcoholics Anonymous meetings, number of outpatients sessions attended, number of weeks in either the study or in the outpatient program, number of persons completing treatment or in the number of relapses. It is therefore concluded that in this small racially mixed sample of urban outpatient alcoholics, fixed point-specific standardized acupuncture did not improve outcome. We caution against the routine use of this treatment until more randomized controlled trials demonstrate a beneficial effect.

Total ethanol consumption as a seizure risk factor in alcoholics.

Population studies suggest that seizures occur in chronic alcoholics as an effect of ethanol withdrawal or ethanol toxicity. Our own studies of individuals undergoing inpatient alcohol detoxification revealed a correlation between the number of detoxifications conducted and the probability that the individual will have a seizure disorder. To establish the basis for this association we studied drinking histories, drug use, and related characteristics of 500 individuals, 83 of whom were women, who enrolled in an inpatient detoxification program. Discriminant analyses revealed a direct correlation between average daily alcohol consumption and the prevalence of seizures in the alcoholic individuals studied. This correlation was significant, but it was not as strong as that between seizure prevalence and the number of times an individual underwent inpatient detoxification. This data supports the hypothesis that seizures occur in alcoholics because of a long-term kindling effect of recurrent detoxifications and a more short-term effect of ethanol exposure.

Human immunodeficiency virus and hepatitis B virus infections in a New York City alcoholic population.

Alcoholics have previously been reported to have an increased susceptibility to hepatitis B virus (HBV) infection. Since human immunodeficiency virus (HIV) is transmitted in a similar fashion, we studied 143 consecutive in- and outpatient alcoholics residing in New York City for HIV and HBV prevalence and associated risk factors. Of these alcoholics, 19 (13%) individuals were HIV positive, 57 (40%) were hepatitis B seropositive. Intravenous drug use and sexual contact with an IV drug user were the most important risk behaviors for HIV acquisition, with large numbers of partners and anal heterosexual intercourse being lesser factors. The only significant risk behavior determined for hepatitis B infection was IV drug use. These high-risk behaviors did not appear to be related to episodes of alcoholic intoxication. However, it is conceivable that alcoholism may, in other ways, affect susceptibility to HIV infection.

Effect of gender on neurologic findings in alcoholics.

We examined 340 men and 60 women admitted for alcohol detoxification to determine if there was a difference in the neurologic effects of alcohol on men and women with similar alcohol, drug, and medical histories. Focal neurologic deficits, seizure histories, and electroencephalographic abnormalities were assessed. Confounding factors, such as illicit drug use, head trauma, neurosurgery, and repeated detoxifications were monitored in both male and female populations. Our findings reveal no excess focal neurologic deficits in women compared to men. EEG recordings revealed more abnormalities in women than men, but there was no excess seizure activity reported for the women. For men, the prevalence of seizure histories is correlated with the number of inpatient detoxifications to which the patient submitted. For women, the correlation of seizure prevalence with detoxification admissions does not hold.

Relative kindling effect of detoxification and non-detoxification admissions in alcoholics.

We reviewed the histories of 340 men and 60 women who were admitted for alcohol detoxification to determine if hospitalizations unrelated to detoxification increased the prevalence of seizures observed in these patients. Previous investigations on this cohort suggested that recurrent detoxification admissions increased the probability of seizure histories. Detoxification and non-detoxification hospitalizations were calculated from patient reports and chart reviews on patients admitted for alcohol detoxification. Discriminant analysis of each type of hospitalization and total hospitalizations for each sex revealed an increased risk of seizure activity correlating with non-detoxification hospitalizations, but the correlation was weaker than that observed for detoxification admissions and for total admissions. This correlation between hospitalizations and seizure prevalence supports the hypothesis that recurrent alcohol withdrawal may have a kindling effect.

Seizure risk with recurrent alcohol detoxification.

To determine if there is an increase in the risk of seizure activity when patients experience recurrent alcohol detoxifications, we reviewed the detoxification and seizure histories of 256 men and 45 women voluntarily admitted to a 5-day in-patient detoxification program. Structural brain damage, focal neurologic deficits, epileptogenic findings on electroencephalograms, and provocative drug use were all considered pertinent variables for seizure risk. Seizures did not occur during alcohol detoxification in any of the study patients, despite a high incidence of antecedent seizures and provocative drug use. Oral chlordiazepoxide use during detoxification was associated with the elimination of withdrawal seizures. Of all 301 patients, 64 had a history of seizures, 42 had significantly abnormal electroencephalograms during detoxification, and 30 had focal slowing on the electroencephalogram. There was no correlation between the duration of alcohol abuse or lifetime consumption of alcohol and seizure activity. There was, however, a significant correlation between the number of inpatient alcohol detoxifications and the prevalence of seizure disorders. This correlation held true even when provocative drug use was taken into consideration.