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Evaluation of spinal missile injuries with respect to bullet trajectory, surgical indications and timing of surgical intervention: a new guideline.

Spine. 2008 Sep 15;33(20):E746-53

Authors: Duz B, Cansever T, Secer HI, Kahraman S, Daneyemez MK, Gonul E

STUDY DESIGN: Analysis of the patients with spinal missile injury (SMI). OBJECTIVE: Choosing the optimum treatment for SMI with respect to bullet trajectory, evaluation of surgical indications, and timing of surgical intervention. SUMMARY OF BACKGROUND DATA: A few guidelines were reported for the management of SMI. But there is still no consensus about the indication and timing of the surgery. The relationship between the surgery and bullet trajectory was not reported previously. METHODS: One hundred twenty-nine patients with spinal missile injury were admitted to our department from 1994 to 2006 and 122 of them could be functionally monitored. Functional recovery and complications in surgical and conservative treatment groups were evaluated. Surgical indications were discussed. The injuries were classified with respect to the bullet’s trajectory. Seventy-four patients were treated surgically, of whom 60 (81%) had incomplete injuries. All 17 patients whose vertebral column was injured with side-to-side trajectory were operated on because of instability. RESULTS: In the surgical group, 33 (56.9%) showed improvement, 20 (34.5%) showed no change, and 5 (8.6%) worsened. The best results were obtained by the patients who received operations because of rapid neurologic decline, compression, and instability in the spinal canal (P < 0.0001). Twenty-three (31%) complications and associated injuries were seen in the surgically treated patients and 18 (34.6%) were seen in the conservatively treated patients. CONCLUSION: Anteroposterior and oblique trajectories [Gulhane Military Medical Academy (GATA)-SMI I and GATA-SMI II] of SMI must be recognized as highly infective in the lumbar region. A side-to-side trajectory (GATA-SMI III) missile causing spinal cord injury is unstable and needs further stabilization. The spinal cord is not injured by the GATA-SMI IV trajectory, and thus, the best approach in this case is conservative. The best results from neurosurgical interventions may be achieved after rapid neurologic deteriorations because of spinal compression and/or instability.

PMID: 18794750 [PubMed - in process]

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Guidelines for medical care of children evaluated for suspected sexual abuse: an update for 2008.

Curr Opin Obstet Gynecol. 2008 Oct;20(5):435-41

Authors: Adams JA

PURPOSE OF REVIEW: Child sexual abuse is a common problem in our society and medical professionals who provide evaluations of children who may have been abused need to be updated as to recent research findings and recommendations for conducting examinations and interpreting results. RECENT FINDINGS: Research studies have provided important new information regarding the qualifications of examiners, the recovery of forensic evidence in children, the frequency of abnormal findings in children and adolescents, the healing of genital injuries, and the interpretation of medical findings and sexually transmissible infections with respect to abuse. SUMMARY: The recommendations for the timing and type of examinations for prepubertal children, in contrast to adolescent sexual assault victims, may need to be changed. Studies showing that partial tears of the hymen, as well as abrasions and contusions, may heal to leave very little or no sign of previous injury emphasize the importance of urgent evaluations. There is a need for standardization of the training of medical professionals who perform child sexual abuse evaluations to ensure continuing competence.

PMID: 18797265 [PubMed - in process]

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Guideline for the investigation and initial therapy of diarrhea-negative hemolytic uremic syndrome.

Pediatr Nephrol. 2008 Sep 18;

Authors: Ariceta G, Besbas N, Johnson S, Karpman D, Landau D, Licht C, Loirat C, Pecoraro C, Taylor CM, Van de Kar N, Vandewalle J, Zimmerhackl LB,

This guideline for the investigation and initial treatment of atypical hemolytic uremic syndrome (HUS) is intended to offer an approach based on opinion, as evidence is lacking. It builds on the current ability to identify the etiology of specific diagnostic sub-groups of HUS. HUS in children is mostly due to infection, enterohemorrhagic Escherichia coli (EHEC), Shigella dysenteriae type 1 in some geographic regions, and invasive Streptococcus pneumoniae. These sub-groups are relatively straightforward to diagnose. Their management, which is outside the remit of this guideline, is related to control of infection where that is necessary and supportive measures for the anemia and acute renal failure. A thorough investigation of the remainder of childhood HUS cases, commonly referred to as “atypical” HUS, will reveal a risk factor for the syndrome in approximately 60% of cases. Disorders of complement regulation are, numerically, the most important. The outcome for children with atypical HUS is poor, and, because of the rarity of these disorders, clinical experience is scanty. Some cases of complement dysfunction appear to respond to plasma therapy. The therapeutic part of this guideline is the consensus of the contributing authors and is based on limited information from uncontrolled studies. The guideline proposes urgent and empirical plasmapheresis replacement with whole plasma fraction for the first month after diagnosis. This should only be undertaken in specialized pediatric nephrology centers where appropriate medical and nursing skills are available. The guideline includes defined terminology and audit points so that the early clinical effectiveness of the strategy can be evaluated.

PMID: 18800230 [PubMed - as supplied by publisher]

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Effect of Physical Activity Guidelines on Physical Function in Older Adults.

J Am Geriatr Soc. 2008 Sep 17;

Authors: Morey MC, Sloane R, Pieper CF, Peterson MJ, Pearson MP, Ekelund CC, Crowley GM, Demark-Wahnefried W, Snyder DC, Clipp EC, Cohen HJ

OBJECTIVES: To determine whether elderly people who meet national guidelines have higher physical function (PF) scores than those who do not and the effect on functional trajectory when physical activity (PA) levels change from above to below this threshold, or vice versa. DESIGN: Pooled data. SETTING: Two 6-month randomized controlled trials aimed at increasing PA in adults. PARTICIPANTS: Adults aged 65 to 94 (N=357). INTERVENTION: PA counseling over the telephone and through mailed materials. MEASUREMENTS: Self-reported PA dichotomized at 150 minutes/week and PF using the Medical Outcomes Study 36-item Short Form Questionnaire PF subscale. RESULTS: At baseline, individuals reporting 150 minutes or more of moderate PA/week had mean PF scores that were 20.3 points higher than those who did not (P< .001). Change in PA minutes from above threshold to below threshold or from below threshold to above threshold from baseline to 6 months resulted in an average change in PF of -11.18 (P<.001) and +5.10 (P=.05), respectively. CONCLUSION: These findings suggest that PA is an important predictor of functional status. Older sedentary adults can improve PF by meeting recommended PA levels. Conversely, dropping below recommended PA levels has a deleterious effect on PF. Given the importance of PF in maintenance of independence and quality of life in older adults, adherence to recommended PA guidelines should be endorsed.

PMID: 18800990 [PubMed - as supplied by publisher]

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Adherence to, and results of, physical therapy programs in patients with hip or knee osteoarthritis. Development of French clinical practice guidelines.

Joint Bone Spine. 2008 Sep 18;

Authors: Mazières B, Thevenon A, Coudeyre E, Chevalier X, Revel M, Rannou F

OBJECTIVE: To develop recommendations regarding adherence to physical therapy programs by patients with hip or knee osteoarthritis. METHODS: We used the method recommended by the French Society for Physical and Rehabilitation Therapy (SOFMER), which combines a systematic literature review, a practice survey, and validation by a multidisciplinary panel of experts. RESULTS: When setting up exercise programs for patients with lower limb osteoarthritis, measures should be taken to increase effectiveness by optimizing adherence. Patient selection is among these measures, as exercise programs are more likely to succeed in patients with a history of being physically active, a positive view of the suggested program, and/or favorable social and material conditions. Regardless of the type of exercise, the program should be tailored to exercise capacity and pain level (professional consensus). Patient adherence can be improved by explaining the expected results to the patient, asking the patient to keep a self-evaluation diary, conducting long-term evaluations (by phone or mail), and providing follow-up visits. CONCLUSION: Studies of adherence according to the type of exercise are needed. The relevance of widely used incentives in patients with hip or knee osteoarthritis should be evaluated in new therapeutic trials.

PMID: 18805033 [PubMed - as supplied by publisher]

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Recommended guidelines for reporting on emergency medical dispatch when conducting research in emergency medicine: The Utstein style.

Resuscitation. 2008 Sep 19;

Authors: Castrén M, Karlsten R, Lippert F, Christensen EF, Bovim E, Kvam AM, Robertson-Steel I, Overton J, Kraft T, Engerstrom L, Garcia-Castrill Riego L,

OBJECTIVES: To establish a uniform framework describing the system and organisation of emergency medical response centres and the process of emergency medical dispatching (EMD) when reporting results from studies in emergency medicine and prehospital care. DESIGN AND RESULTS: In September 2005 a task force of 22 experts from 12 countries met in Stavanger; Norway at the Utstein Abbey to review data and establish a common terminology for medical dispatch centres including core and optional data to be used for health monitoring, benchmarking and future research.

PMID: 18805620 [PubMed - as supplied by publisher]

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A Proposed Set of Ethical Practice Guidelines in the Assessment and Treatment of Pelvic Floor Disorders.

Appl Psychophysiol Biofeedback. 2008 Sep 19;

Authors: Striefel S, Glazer HI

The treatment of pelvic floor disorders using biofeedback, behavioral therapies, and other applied psychophysiological treatments has been well documented as effective. Practitioners must take due care to ensure that they practice within the boundaries of what is common practice for their discipline and within the scope of practice allowed by their professional license as outlined by the appropriate state licensing law(s), the ethical principles and practice guidelines and standards for their discipline, and those of the Association of Applied Psychophysiology and Biofeedback if using a biofeedback assessment or treatment. Being competent to provide a particular treatment does not necessarily make it legal and/or ethical. This paper provides a set of recommended practice guidelines for use in the assessment and treatment of pelvic floor disorders. Please note that they have not at this time been endorsed as an official position of the Association of Applied Psychophysiology and Biofeedback or any other professional organization.

PMID: 18807176 [PubMed - as supplied by publisher]

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[Clinical Practice Guideline on Diagnosis and Treatment of Crohn's Disease.]

Z Gastroenterol. 2008 Sep;46(9):1094-1146

Authors: Hoffmann JC, Preiß JC, Autschbach F, Buhr HJ, Häuser W, Herrlinger K, Höhne W, Koletzko S, Krieglstein CF, Kruis W, Matthes H, Moser G, Reinshagen M, Rogler G, Schreiber S, Schreyer AG, Sido B, Siegmund B, Stallmach A, Bokemeyer B, Stange EF, Zeitz M

PMID: 18810679 [PubMed - as supplied by publisher]

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The impact of the current epidemiology of pediatric musculoskeletal infection on evaluation and treatment guidelines.

J Pediatr Orthop. 2008 Oct-Nov;28(7):777-85

Authors: Gafur OA, Copley LA, Hollmig ST, Browne RH, Thornton LA, Crawford SE

BACKGROUND: Methicillin-resistant Staphylococcus aureus is thought to have led to an increase in the incidence of severe musculoskeletal infection in children. Our purpose was (1) to compare the current epidemiology of musculoskeletal infection with historical data at the same institution 20 years prior and (2) to evaluate the spectrum of the severity of this disease process within the current epidemiology. METHODS: Children with musculoskeletal infection, treated between January 2002 and December 2004, were studied retrospectively. Diagnoses of osteomyelitis, septic arthritis, pyomyositis, and abscess were established for each child based on overall clinical impression, laboratory indices, culture results, radiology studies, and intraoperative findings. Comparison was made with the experience reported at the same institution in 1982. Children within each diagnostic category were compared with respect to mean values of C-reactive protein and erythrocyte sedimentation rate at admission, number of surgical procedures, intensive care unit admissions, identification of deep venous thrombosis, and length of hospitalization. RESULTS: Five hundred fifty-four children were studied (osteomyelitis, n = 212; septic arthritis, n = 118; pyomyositis, n = 20; and deep abscess, n = 204). The annualized per capita incidence of osteomyelitis increased 2.8-fold, whereas that of septic arthritis was unchanged when compared with historical data from 20 years prior. Methicillin-resistant Staphylococcus aureus was isolated as the causative organism in 30% of the children. We identified increasing severity of illness according to a hierarchy of tissue involvement (osteomyelitis > septic arthritis > pyomyositis > abscess) and according to the identification of contiguous infections within in each primary diagnostic category. CONCLUSIONS: The incidence of musculoskeletal infection appears to have increased within our community. We found that a more comprehensive diagnostic classification of this disease is useful in understanding the spectrum of the severity of illness and identifying those who require the greatest amount of resources. Magnetic resonance imaging is useful early in the diagnostic process to enable a more detailed disease classification and to expedite surgical decisions. The recognition of the incidence of methicillin-resistant Staphylococcus aureus within our community has also led to a change in empirical antibiotic selection.

PMID: 18812907 [PubMed - in process]

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A consensus approach to the formulation of guidelines for laboratory testing and reporting of antiphospholipid antibody assays.

Semin Thromb Hemost. 2008 Jun;34(4):361-72

Authors: Wong RC, Favaloro EJ

Despite numerous past and ongoing efforts, there remains significant variation in results from assays for the major antiphospholipid antibodies (aPL), namely anticardiolipin (aCL), anti-beta2 glycoprotein I (anti-beta2GPI), and lupus anticoagulant (LA). There is therefore a need to produce comprehensive guidelines on laboratory testing and reporting of aPL assays. However, because of the paucity of good-quality published evidence, there is a heavy reliance on expert opinion, and thus the existing consensus guidelines for aPL testing and reporting are largely eminence based rather than evidence based. This may potentially bias recommendations to reflect the personal preferences of those who have the greatest influence during the guideline formulation process. This article largely details the experience of the Australasian Anticardiolipin Working Party in undertaking a consensus approach to formulation of guidelines on aCL and anti-beta2GPI testing and reporting, including measures taken to minimize these issues. Despite the time-consuming nature of the process, given the paucity of good-quality published evidence, formulation of guidelines by the consensus process remains an important initiative to improve the standardization of aPL testing and reporting.

PMID: 18814070 [PubMed - in process]

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