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BACKGROUND: The lateral step-down test is used by physical therapists (PT) to identify movement faults in patients with patellofemoral pain (PFP). The FPPA is a measure of knee valgus and PTs have access to open source video analysis software and high quality smart phones and video cameras to implement 2D video analysis into practice. The purpose of our study was to determine the reliability of PTs measuring the frontal plane projection angle (FPPA) during the lateral step-down test, and to determine if the FPPA was associated with pain, self-reported knee function and fear of movement. METHODS: Twenty-two subjects (mean age[SD] = 27.8 [6.6] years, females n = 14, males n = 8) with PFP were analyzed by six PTs using 2D video analysis software. The FPPA was measured during the lateral step down test. Numeric Pain Rating Scale (NPRS), Anterior Knee Pain Scale (AKPS) and the Tampa Scale of Kinesiophobia (TSK) were collected. Intraclass correlation (ICC) was used to assess for PT measurement reliability. Correlations between outcomes were calculated using Spearman correlation coefficient and standard error of measurement (SEM) and minimal detectable change (MDC) were reported. RESULTS: Reliability amongst PTs measuring the FPPA was good (ICC [95 %CI] = 0.85 [0.72-0.93]; SEM = 3.33°, MDC = 9.20°). There were no significant correlations (p > 0.05) between FPPA and NPRS(ρ = -0.046), AKPS(ρ = 0.066), or TSK(ρ = -0.204). CONCLUSIONS: Although reliability measuring FPPA was good, the large SEM and MDC associated with this measurement may limit its clinical utility in those with PFP.

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Objective: When inserting a dry needle laterally into the upper lumbar spine (L1-L3) there is an increased risk of piercing the kidney; therefore, the objective of this study was to determine a zone of safety for practitioners to needle in the upper lumbar spine.Methods: Ten cadavers were screened for inclusion. L1 spinous process was identified and confirmed with ultrasound imaging. A digital caliper was used to measure laterally at 1.5 cm, 2.0 cm, and 2.5 cm. Dry needles were inserted maximally at each point and a binary decision, yes or no, was made to determine if bony contact was made. Needle depth and abdominal width measurements were also recorded. Safety of the dry needling procedure was interpreted as such if bony contact was made by the needle. If bony contact was made, then it was assumed that the needle cannot advance further into pleura or kidney.Results: Forty-four percent of needles did not make bony contact at 2.5 cm lateral of the L1 spinous process, whereas 22% did not make bony contact at 1.5 cm and 2.0 cm. There was a weak to moderate negative correlation between abdominal width measurements and needle depth at 1.5 cm (-0.48) and 2.0 cm (-0.45), and at 2.5 cm (-0.39).Conclusion: A safety zone of needling less than 2.5 cm is likely safe, but needs to be confirmed with future study. Dry needling 2.5 cm lateral appears more risky due to the higher frequency of not contacting a bony backdrop.

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OBJECTIVE: Our objective was to assess the occurrence of pediatric emergencies in the offices of family physicians and pediatricians, the preparedness to respond, and the perceived importance of being prepared. STUDY DESIGN: We performed a cross-sectional random mail survey of physicians. POPULATION: Surveys were sent to 187 family physicians and 129 pediatricians practicing in North Carolina with 75% and 86% response rates, respectively. The 169 total respondents were in community practices regularly treating children and were included for analysis. OUTCOMES MEASURED: We measured the incidence of 8 types of pediatric emergencies, the availability of 11 items for resuscitation and stabilization, whether the physician had Pediatric Advanced Life Support (PALS) training in the previous 2 years, whether the office ever conducted a mock emergency, and beliefs about the importance of preparing for and providing emergency care to children. RESULTS: Six types of pediatric emergencies were seen in one third or more of all practices during the year. The average practice saw 4 or more pediatric emergencies in a year (family physicians = 3.8 vs pediatricians = 4.9, P <.001). Family physicians had fewer resuscitation and stabilization items than pediatricians (5.7 vs 8.6 items, P <.001) and were less prepared in terms of PALS training (19% vs 51%, P <.001). Those with PALS training were more likely to have an intraosseous needle and Broselow tape and to have conducted a mock code. Family physicians considered it is less important than pediatricians to provide such care or to be prepared to do so. CONCLUSIONS: Pediatric emergencies in the office are likely for either specialty. Family physicians may be less prepared, and they discount the importance of the problem and need for preparation.

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OBJECTIVE: To estimate the cost-effectiveness of low-molecular-weight heparin (LMWH) in the treatment of proximal lower extremity deep venous thrombosis. DESIGN: Cost-effectiveness analysis that includes the treatment of the index case and simulated 3-month follow-up. SETTING: Acute care facility. PATIENTS AND PARTICIPANTS: Hypothetical cohorts of 1,000 patients who present with proximal deep venous thrombosis. INTERVENTIONS: Intravenous unfractionated heparin (UH), LMWH (40% at home, 60% in hospital), or selective UH/LMWH (UH for hospitalized patients and LMWH for patients treated at home). MEASUREMENTS AND MAIN RESULTS: The outcomes were recurrent thrombosis, mortality, direct medical costs, and marginal cost-effectiveness ratios from the payer's perspective. At the base-case and under most assumptions in the sensitivity analysis, the LMWH and the selective UH/LMWH strategies dominate the UH strategy i.e., they result in fewer cases of recurrent thrombosis and fewer deaths, and they save resources. The savings occur primarily by decreasing the length of stay. The LMWH strategy resulted in lower costs as compared with the UH strategy when the proportion of patients treated at home was more than 14%. Treating 1, 000 patients with the LMWH strategy as compared with the UH/LMWH strategy would result in 10 fewer cases of recurrent thrombosis, 1.2 fewer deaths, at an additional cost of $96,822; the cost-effectiveness ratio was $9,667 and $80,685 per recurrent thrombosis or death prevented, respectively. CONCLUSIONS: Treatment with LMWH leads to savings and better outcomes as compared with UH in patients with lower extremity deep venous thrombosis. The selective UH/LMWH strategy is an alternative option.

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OBJECTIVES: This study examined premature mortality by county in the United States and assessed its association with metro/urban/rural geographic location, socioeconomic status, household type, and availability of medical care. METHODS: Age-adjusted years of potential life lost before 75 years of age were calculated and mapped by county. Predictors of premature mortality were determined by multiple regression analysis. RESULTS: Premature mortality was greatest in rural counties in the Southeast and Southwest. In a model predicting 55% of variation across counties, community structure factors explained more than availability of medical care. The proportions of female-headed households and Black populations were the strongest predictors, followed by variables measuring low education, American Indian population, and chronic unemployment. Greater availability of generalist physicians predicted fewer years of life lost in metropolitan counties but more in rural counties. CONCLUSIONS: Community structure factors statistically explain much of the variation in premature mortality. The degree to which premature mortality is predicted by percentage of female-headed households is important for policy-making and delivery of medical care. The relationships described argue strongly for broadening the biomedical model.

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The Boston HAPPENS [Human immunodeficiency virus (HIV) Adolescent Provider and Peer Education Network for Services] Program is a project supported by Special Projects of National Significance (SPNS) Program, HIV/AIDS Bureau, Health Resources and Services Administration, which provides a network of care for homeless, at-risk, and HIV-positive youth (ages 12-24 years), involving eight agencies. The program has provided services to 1301 youth, including 46 who are HIV-positive. Boston HAPPENS provides a citywide network of culturally and developmentally appropriate adolescent-specific care, including: (a) outreach and risk-reduction counseling through professional and adult-supervised peer staff, (b) access to appropriate HIV counseling and testing support services, (c) life management counseling (mental health intake and visits as part of health care and at times of crisis), (d) health status screening and services needs assessment, (e) client-focused, comprehensive, multidisciplinary care and support, (f) follow-up and outreach to ensure continuing care, and (g) integrated care and communication among providers in the metropolitan Boston area. This innovative network of youth-specific care offers a continuum from street outreach to referral and HIV specialty care that crosses institutional barriers.

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BACKGROUND: Controversy exists regarding the efficacy of routine neonatal circumcision of male infants. Little is known about parental or provider characteristics or the use of medical resources associated with this procedure. METHODS: Records of 3703 male infants born during 1990 and 1991 at four US sites were analyzed to discern associations between circumcision and the above factors. Analyses were limited to healthy infants. RESULTS: Eighty-five percent of the infants in the study population were circumcised. White and African-American male infants were much more likely to be circumcised than those of other races (odds ratios [ORs], 7.3 and 7.1, respectively, P < .001). Compared with self-pay patients, those covered by private insurance were 2.5 times more likely to be circumcised (P < .001). Logistic regression showed that rates for obstetricians and family physicians were not significantly different. Increased odds of circumcision were found if the mother received an episiotomy (OR = 1.9, P < .001) or cesarean section (OR = 2.1, P < .001). Circumcised infants stayed in the hospital an average of one fourth of a day longer than did those who were not circumcised (mean difference, 0.26 days; 95% confidence interval, 0.16 to 0.36). CONCLUSIONS: Mother's insurance status and race as well as surgical interventions during delivery are related to circumcision. Associations with episiotomy and cesarean section suggest physician and/or parental preference for interventional approaches to health care. Generalizing the difference in hospital length of stay to the United States suggests an annual cost between $234 million and $527 million beyond charges for the procedure itself.

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BACKGROUND: Studies suggest that family physicians and other generalist physicians practice differently than specialists. This study was performed to determine whether practice patterns and outcomes differ for women with low-risk pregnancies who obtain maternity care from family physicians as compared with those who are cared for by obstetricians. METHODS: A retrospective chart review was performed at five sites across the United States. Women who presented for elective repeat cesarean section or who had any one of 14 high-risk conditions were excluded from the analysis. The final sample analyzed included 4865 women. Family physicians managed the labor of 2000 of these women, and obstetricians managed 2865. RESULTS: During intrapartum care, women managed by family physicians were less likely to have their labor induced (8.6% vs 10.4%, P = .03), receive oxytocin augmentation (14.9% vs 17.8%, P = .006), or receive epidural anesthesia (5.4% vs 17.0%, P < .001) as compared with those managed by obstetricians. Delivery outcomes showed that patients of family physicians were less likely to have an episiotomy during vaginal delivery (53.7% vs 74.5%, P < .001) and a lower frequency of cesarean section deliveries (9.3% vs 16.0%, P < .001), especially for cephalopelvic disproportion. When adjusted for potential confounders, rates for cesarean section and episiotomy for obstetricians were still significantly higher than those of family physicians. For neonatal outcomes (low 1-minute Apgar score, neonatal intensive care unit admission, birth trauma, or neonatal infection), no significant differences were found between the care delivered by obstetricians and family physicians. CONCLUSIONS: Women obtaining maternity care from family physicians were less likely to receive epidural anesthesia during labor or an episiotomy after vaginal births, and had a lower rate of cesarean section delivery rates, primarily because of a decreased frequency in the diagnosis of cephalopelvic disproportion. Differences between outcomes persisted after adjustment for potential confounders such as parity, previous cesarean delivery, and use of epidural anesthesia during labor. No differences between the two physician groups with respect to neonatal outcomes were found.

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OBJECTIVE: To evaluate the influence of socioeconomic factors and provider characteristics on the use of intrapartum epidural anesthesia. METHODS: A total of 8229 deliveries at five hospitals were reviewed retrospectively. Bivariate analysis was performed to identify potential biases in epidural use. Logistic regression was performed to control for confounding variables. RESULTS: Epidural use was predominantly related to parity, with nulliparous women more likely to use an epidural during labor. In hospitals where epidurals were used in a higher percentage of women, we found an association between the woman's insurance status and the specialty of the physician managing labor. Race also appeared to be associated with epidural use in the participating hospital that had a large non-white population. CONCLUSION: Use of intrapartum epidural analgesia varies considerably among sites and is associated with nulliparity, higher maternal age, and several nonclinical factors.

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Little is known about interventions in office practices aimed toward reducing behaviors that put adolescents at risk for human immunodeficiency virus (HIV) acquisition. We therefore targeted a pilot study of HIV education and counseling to high-risk adolescents. Ninety adolescent patients (mean age, 17.6 +/- 2.0 years) were interviewed in a hospital-based adolescent clinic by two physicians and randomized to two groups: 1) a standard care group that was interviewed about high-risk behaviors at 0 and 2 months; and 2) an intervention group that was similarly interviewed but was also given a detailed discussion about HIV risks and prevention. At follow-up (mean, 2.6 +/- 0.8 months), 25% of patients reported less sexual activity (standard care, 32%; intervention, 18%) toward a trend. The reduction in mean number of partners per month was 0.4 +/- 0.9, (p = 0.0001). Fifty-four percent of the patients reported that they used condoms more often than previously with no significant difference between the two groups. Use of condoms ("always use") increased in both groups significantly (p = 0.03 standard care, p = 0.02 intervention). Use of condoms at last intercourse increased in the intervention group (37% to 42%, p = 0.03). In the interval, there were no significant differences between the groups in the number of newly diagnosed sexually transmitted diseases or in the number of patients seeking HIV testing. The number of patients stating that they shared needles decreased from 3 to 0. Both the intervention and standard care groups reported a reduction in high-risk behaviors that was temporally related to the discussion of this subject in the clinic.(ABSTRACT TRUNCATED AT 250 WORDS)

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BACKGROUND: There are many risk factors associated with the occurrence of otitis media; cesarean section could be one of them. REPORT: Two hundred and eighty four children were treated during the first three years of life by the same pediatric service. 47% of these children were treated for otitis media and 53% were not. 41% were delivered by cesarean section, and 59% were vaginal births. The incidence of otitis media in the cesarean section group was 0.504, versus 0.449 in the vaginal birth group. RESULTS: These data indicate that the fraction of risk of having otitis media that is attributable to cesarean section is 11%; the relative risk is 1.12. CONCLUSION: The observed effect is not large enough to confirm that cesarean section is a risk factor, but suggests that a carefully controlled prospective study should be conducted.

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A case of respiratory obstruction caused by an armoured silicone rubber tracheal tube is reported and the literature reviewed. New silicone tubes have shown defects in design and manufacture formerly associated with those made of latex rubber. The authors found disposable polyvinyl chloride tubes to be more reliable.

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