Responses to the "freestanding stories".
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Contract Services↗
Biomedical subjects
L Burton
Publications and source records attributed to L Burton.
Nonhealing foot ulcer.
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Amputation, Surgical↗
Reactive neuromuscular training for the anterior cruciate ligament-deficient knee: a case report.
OBJECTIVE: To demonstrate the response to a proprioceptive training model during a 1-week rehabilitation regime. The techniques were demonstrated on a college-aged female basketball player who had injured her anterior cruciate ligament (ACL) several weeks earlier. The athlete was tested, trained, and then retested during her semester break. BACKGROUND: The ACL injury has become a fairly common occurrence in the world of athletics. Knowing this, the athletic trainer is constantly searching for ways to improve the rehabilitative process. New research demonstrates that rehabilitation should be based on proprioception. The ACL not only serves a mechanical role by limiting passive knee mobility but also serves a sensory role through the mechanoreceptors deep in its tissue, which communicate with the neuromuscular system to provide proprioceptive feedback during training and competition. DIFFERENTIAL DIAGNOSIS: Partial or complete tear of the ACL. TREATMENT: The athlete was treated with a rehabilitation protocol based on proprioception, which uses reactive neuromuscular training. UNIQUENESS: Our rehabilitation focused on the muscular imbalances about the hip, knee, and ankle. The athlete achieved dramatic decreases in muscular imbalances about the hip and knee in only 1 week of rehabilitation through reactive neuromuscular training. CONCLUSIONS: The athlete had significant gains in strength over her brief period of therapy. However, these gains can be viewed only as neuromuscular changes and not strictly as gains in strength. The athlete returned to postseason competition under the supervision of her surgeon, who later recommended surgical reconstruction at the completion of the basketball season with rehabilitation during the offseason.
Journal Article↗
Health effects of caregiving: the caregiver health effects study: an ancillary study of the Cardiovascular Health Study.
We propose that two related sources of variability in studies of caregiving health effects contribute to an inconsistent pattern of findings: the sampling strategy used and the definition of what constitutes caregiving. Samples are often recruited through self-referral and are typically comprised of caregivers experiencing considerable distress. In this study, we examine the health effects of caregiving in large population-based samples of spousal caregivers and controls using a wide array of objective and self-report physical and mental health outcome measures. By applying different definitions of caregiving, we show that the magnitude of health effects attributable to caregiving can vary substantially, with the largest negative health effects observed among caregivers who characterize themselves as being strained. From an epidemiological perspective, our data show that approximately 80% of persons living with a spouse with a disability provide care to their spouse, but only half of care providers report mental or physical strain associated with caregiving.
Activities of Daily Living↗
Effects of omeprazole versus placebo in treatment of noncardiac chest pain and gastroesophageal reflux.
Gastroesophageal reflux (GER) occurs in 22-66% of patients with noncardiac chest pain (NCCP). Although open-label investigations have shown beneficial effects of antireflux therapy in NCCP, no double-blind, prospective, placebo-controlled studies have been conducted. The purpose of this study was to evaluate the effects of omeprazole compared to placebo in a prospective, double-blind, randomized trial of patients with NCCP and GER. Thirty-six consecutive patients with NCCP and GER documented by 24-hr ambulatory pH testing entered this study. The subjects were randomized to omeprazole, 20 mg by mouth twice a day (17 patients), or placebo (19 patients) for eight weeks. Patients on omeprazole obtained significantly more improvement in the fraction of chest pain days (P = 0.006) and severity (P = 0.032) when compared to placebo. More patients in the omeprazole group reported improvement in individual daily pain scores (81% vs 44%, P = 0.03) and individual severity scores (81% vs 50%, P = 0.057). Thirteen (81%) of the subjects in the treatment arm reported overall symptomatic improvement versus one (6%) in the placebo group (P = 0.001). The results of this study indicate that acid suppression with omeprazole effectively improves chest pain in patients with NCCP and GER.
Chest Pain↗
Hemangioma of the temporal bone in a patient presumed to have Ménière's syndrome.
This case report describes a patient with a facial nerve hemangioma of 8 years' duration that initially caused most of the symptoms of Ménière's syndrome: fullness, sensorineural hearing loss, dizziness, tinnitus, and disruption of balance. The hearing loss was in the high-frequency range (> or = 3,000 Hz); typically, the initial hearing loss in Ménière's syndrome is in the low-frequency range. Mild facial nerve weakness and punctate keratitis due to corneal exposure appeared 8 years later. Contrast-enhanced magnetic resonance imaging and high-resolution computed tomography depicted the lesion and made preoperative diagnosis possible. With meticulous surgical removal of the tumor, which was intertwined with the facial nerve, facial nerve function was preserved.
Cranial Nerve Neoplasms↗
Prospective evaluation of clinical criteria to select older persons with acute medical illness for care in a hypothetical home hospital.
OBJECTIVE: To evaluate criteria to select older persons who need hospitalization for common acute medical illnesses for care in a hypothetical home hospital. DESIGN: Prospective record review. SETTING AND PARTICIPANTS: Patients aged 65 and older admitted to the general medical service of a community-based university hospital. MEASUREMENTS: We developed illness-specific selection criteria to identify older persons with certain acute medical conditions for treatment in a hypothetical home hospital. The selection criteria were reviewed prospectively against all community-dwelling older patients admitted to the general medical service of a community-based university hospital over a 2-month period. We determined eligibility for home hospital admission based on information available at the time of admission and then tracked the patient's hospital course. RESULTS: One hundred fifty-seven admissions of 143 patients were reviewed. The selection criteria identified 33% of patients admitted to the acute hospital with one of the three target diagnoses as eligible for a home hospital model of care had it been available. Eligible patients experienced shorter lengths of stay (3.7 vs 5.4 days, P = .012), fewer mean number of procedures performed (0.98 vs 1.70, P = .001), fewer mean number of complications (0.17 vs 0.56, P = .010), and fewer events that could be handled only in the acute hospital setting (P = .036). In addition, in logistic regression analysis, three criteria for home hospital ineligibility, pulmonary congestion associated with ischemic chest pain (odds ratio 6.85, 95% CI 2.64, 17.81), the presence of an acute coexisting illness requiring hospitalization independent of the target conditions (odds ratio 2.66, 95% CI 1.11, 6.41), and significant pulmonary congestion after initial treatment (odds ratio 14.4, 95% CI 1.77, 117.41) were significantly associated with items difficult to accomplish at home. CONCLUSIONS: Criteria can be delineated that identify older persons with acute medical illnesses who may be suitable for treatment in a home hospital.
Acute Disease↗
Ascertaining dementia by expert panel in epidemiologic studies of nursing home residents.
A new method for ascertaining dementia in epidemiologic research and the results of a study to evaluate it are described. The method relies on an expert panel of clinicians reviewing clinically relevant information collected by lay evaluators to arrive at a diagnosis based on DSM-III-R criteria. The approach was developed to study dementia in a statewide sample of over 2400 new admissions to 59 nursing homes in Maryland. Expert panel ascertainment of dementia was compared to that obtained by direct clinical evaluation for 100 nursing home residents. Agreement between the panel and direct assessment was 76% (kappa = 0.59) using a three-category classification of dementia, no dementia, and indeterminate. This ascertainment strategy provides an alternative to methods currently in use and is particularly well-suited for populations with a high prevalence, in those dispersed over large geographic areas, and when timely, cost-effective evaluations are required.
Aged↗
The ethical dilemmas of the Oregon health plan.
Escalating health care costs place our country at an economic disadvantage in the world marketplace. Currently, a mixture of rationing methods in the health care system limits access to control costs. Federal and state moneys fund the state Medicaid programs. States on limited budgets often tighten eligibility to far below the poverty level; those with benefits get unlimited care and those without get none. The state of Oregon has a different idea: Medicaid covers everyone below the poverty level but limits services to those with the "best cost-to-benefit ratio." Many people consider the distribution and finance of health care an ethical issue. The Oregon plan raises some ethical concerns and several arguments. The federal government waived Title XIX of the Social Security Act to allow implementation of the plan. Many providers believe universal access is important; however, the drive to see more patients may limit visit time.
Decision Making, Organizational↗
Views of pediatric emergency fellows and fellowship directors concerning training experiences in child abuse and neglect.
BACKGROUND: Emergency physicians are an important part of the teams responsible for the management of victims of child abuse and neglect. As the number of fellowship-trained pediatric emergency physicians working in these emergency departments increases, their influence on the field of child abuse will increase. An evaluation of the experiences and possible weakness in the child abuse training of pediatric emergency fellows will assist in improving their fellowship experience. METHODS: A survey was conducted to evaluate the view of pediatric emergency medicine fellows in training and directors of pediatric fellowship training programs regarding their respective program's structure and adequacy of child abuse training. RESULTS: Thirty-eight percent of all respondents reported that a specific rotation in child abuse management was a part of their training program requirements. A majority (51%) of surveyed fellows reported their training in child abuse was less than adequate, while 23% of fellowship directors believe the experience of their fellows was less than adequate. CONCLUSIONS: Child abuse training is an important part of the fellowship experience of pediatric emergency fellows. Because a majority of pediatric emergency medicine fellows report that their respective programs are providing less than adequate training in child abuse management, further evaluation of fellowship curriculums and training experiences is required. The establishment and utilization of regional or national child abuse training centers is one option for improving this situation.
Administrative Personnel↗
The structure of informal care: are there differences by race?
This study investigated whether there are race differences in the structure of informal caregiving networks. Data on 3,793 functionally impaired persons age 65 and over from the 1989 National Long-Term Care Survey were analyzed. The size of the total caregiver network and the unpaid network did not differ by race, but the likelihood of there being a non-immediate family member among unpaid caregivers was higher among disabled older blacks. These findings raise questions about whether race differences in nursing home utilization and paid long-term care services, documented in other studies, can be explained by differences in caregiving arrangements.
Activities of Daily Living↗
Focal suppression-burst on electrocorticography after temporal lobectomy.
Of 40 patients with cortical resections for epilepsy, three had focal suppression-burst (S-B) on postresection intraoperative electrocorticography (ECoG). Eighteen to 24 months later, two patients were seizure-free and one had rare seizures. Follow-up neuropsychological testing and MRI did not reveal unexpected postoperative abnormalities. Follow-up scalp surface EEGs did not show S-B. Although S-B on postresection ECoG suggests severe localized cortical damage, this pattern near anterior temporal lobectomy resection margins was not associated with postoperative deficits.
Cerebral Cortex↗
Fetal alcohol effects on the postnatal development of the rat myocardium: an ultrastructural and morphometric analysis.
Heart disease is an entity frequently seen in the fetal alcohol syndrome. This paper describes the effect of in utero ethanol exposure on the postnatal ultrastructural development of rat cardiac muscle. To determine this time-pregnant Sprague-Dawley rats were fed either a nutritionally balanced protein- and vitamin-enriched liquid ethanol diet (with 36% of the calories derived from ethanol) or a liquid diet with maltose-dextrins isocalorically substituted for ethanol. The latter group was designated the pairfed control group. At birth, pups of both the groups were surrogate-fostered by normal dams. Body weights and crown-rump lengths were significantly less in the rat pups exposed to ethanol in utero at 21 days postnatal. Ultrastructural analysis of the cardiac muscle was performed at 7, 14, and 21 days postnatal in ethanol and pairfed groups. Several morphological features of myocyte damage were observed in ethanol-exposed pups, predominantly at 7 days postnatal, with nearly total absence of myocyte damage by 21 days postnatal. The most outstanding changes were observed in the myofibrils, which showed dysplastic changes at 7 days postnatal, a delay in M-band structural development at 14 days postnatal, and a significantly smaller myofibril volume density per tissue volume at 21 days postnatal in the ethanol rat pups compared to the pairfed controls.
Animals↗
A comparison of the effectiveness and patient tolerance of oral sodium phosphate, castor oil, and standard electrolyte lavage for colonoscopy or sigmoidoscopy preparation.
One hundred thirteen patients were randomized to receive either oral sodium phosphate (Fleet Phospho-Soda), lemon-flavored castor oil (Purge), or standard polyethylene glycol-based lavage solution (GoLYTELY) before elective colonoscopy. The study purpose was to confirm the efficacy of oral sodium phosphate and extend observations to include castor oil. Overall, patients reported that sodium phosphate and castor oil were easier to complete (p < 0.05). Scores for cleansing the entire colon as determined by endoscopists who were blinded to the cathartic agent were highest in patients receiving sodium phosphate (p < 0.02). Scores of left-colon cleansing for flexible sigmoidoscopy were equally high for the three methods. Scores for taste and symptom side effects were similar for each preparation. There were no recognized signs or symptoms of hypocalcemia in the sodium phosphate group. Because of the low cost of oral sodium phosphate combined with the lowest repeat endoscopy rate for inadequate cleansing, patient savings were projected to be $5000 per 100 patients at this center. Oral sodium phosphate is a cost-effective colonoscopy preparation that is better tolerated and more effective than the polyethylene glycol-electrolyte lavage solution or castor oil.
Administration, Oral↗
Chest pain associated with nutcracker esophagus: a preliminary study of the role of gastroesophageal reflux.
A review of our 402 motility records of patients undergoing evaluation of noncardiac chest pain identified 40 patients with the diagnosis of nutcracker esophagus. Gastroesophageal reflux was found in 13 of 20 patients (65%) who underwent pH studies, and endoscopy detected one patient with erosive esophagitis. Thus, at least 14 (35%) of our nutcracker esophagus patients had evidence of reflux. Twelve of these subjects agreed to enter an open-label therapeutic trial. After 8 wk of intensive antireflux treatment with high doses of ranitidine or omeprazole, repeat 24-h pH studies and endoscopy demonstrated normalization of pH parameters and healing of esophagitis in all patients. Ten (83%) patients obtained significant symptomatic improvement in frequency of pain episodes, number of days with pain, and pain severity. However, repeat manometry showed normalization of motor findings in only two (18%) patients. These observations warrant further placebo-controlled trials. Until more information is available, the results of this study suggest that gastroesophageal reflux should be excluded in patients with noncardiac chest pain and nutcracker esophagus before initiation of smooth muscle relaxant therapy.
Adult↗
Segmental versus diffuse nutcracker esophagus: an intermittent motility pattern.
The most common esophageal motility abnormality in patients with noncardiac chest pain is nutcracker esophagus. Most investigators regard nutcracker esophagus as a diffuse process involving the distal esophagus. Others consider it a segmental disturbance affecting isolated regions of the distal esophageal smooth muscle. This study compared the prevalence, clinical features, consistency, and manometric course of patients with either segmental high-amplitude peristaltic contractions (SHAPC) or those with the traditional diffuse contraction abnormalities termed nutcracker esophagus (NE). We particularly sought to determine whether patients with SHAPC represent an early spectrum evolving into a more diffuse contraction disorder--NE. The prevalence and clinical features of patients with either motility disturbance were similar. Thirty-nine percent of our patients had abnormally high peristaltic amplitude in locations of the proximal esophagus not previously described. Follow-up manometric studies demonstrated that only 53% of patients in the NE and 20% with SHAPC retained the same manometric diagnosis. In addition, 33% of patients in the NE group and 40% of the SHAPC group permutated into each other. These findings indicate that patients with SHAPC do not represent an early process subsequently evolving into a more diffuse contraction abnormality. Rather, the motility pattern of high-amplitude peristaltic contractions--segmental or diffuse--constitutes a labile marker associated with noncardiac chest pain.
Chest Pain↗
Tom was a big challenge.
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Amputation, Surgical↗
Long-term clinical and manometric follow-up of patients with nonspecific esophageal motor disorders.
In the manometric evaluation of patients complaining of chest pain, a nonspecific esophageal motor disorder is commonly identified. Yet, the clinical characteristics of these patients and stability of the manometric pattern with time have not been previously described. This study reports a 3.2-yr clinical and manometric follow-up of 23 patients with nonspecific esophageal motor disorder. These subjects were most commonly middle-aged women with long-standing, persistent, and debilitating clinical symptoms. Ninety-six percent (22/23) of our patients complained of chest pain; 65% (15/23) had dysphagia. In addition, 15 (65%) had evidence of reflux during ambulatory pH studies. Symptoms caused such concern that the patients frequently sought medical assistance to exclude serious diseases. Although the symptoms tended to persist, the motility patterns changed in some patients. Follow-up manometric studies were normal in 29%, and nonspecific esophageal motor disorder persisted in 57% of the patients. In three patients (14%), the pattern evolved into diffuse esophageal spasm. When symptoms were compared with these changes in follow-up manometric patterns, the correlation was poor. This observation suggests that additional mechanism(s) other than disturbed esophageal motility may be responsible for the symptoms seen in these individuals.
Adult↗