Noninvasive Evaluation of the Collateral Circulation to the Hand

Objective: To compare four methods of evaluating collateral blood flow to the hand.
Methods: The hands of 74 volunteers on the faculty or staff of a university hospital were studied prospectively. Only subjects without known peripheral vascular disease were included. Four tests were used in random order to assess radial and ulnar artery flow. Results of the assessments using the modified Allen's test, pulse oximetry, plethysmography, and laser Doppler perfusion monitoring were compared.
Results: No interrupted palmar arch was found. The modified Allen's test was normal in all cases. Pulse oximetry detected a 5% incidence of noticeably reduced blood flow in one artery compared with the other artery. This dominance of one artery was identified in 69% of the hands by plethysmography. The laser Doppler noted a dominant artery in 64% of the hands. Plethysmography and the laser Doppler disagreed in their findings in only 9% of the hands evaluated. Numerical values of blood flow, attainable only by the laser Doppler, were significantly lower upon occlusion of the radial vs the ulnar arteries (p < 0.05; paired t-test).
Conclusion: All of the tests provide information about the collateral circulation to the hand. Only the laser Doppler provides quantitative blood flow. Further studies involving subjects most at risk for post-cannulation ischemic injury are needed to guide the clinical application of these findings.     

The National Trend in Quality of Emergency Department Pain Management for Long Bone Fractures

Background
Despite national attention, there is little evidence that the quality of emergency department (ED) pain management is improving.
Objectives
To compare the quality of ED pain management before and after implementation of the Joint Commission on the Accreditation of Healthcare Organizations' standards in 2001.
Methods
The authors performed a retrospective cohort study by using the National Hospital Ambulatory Medical Care Survey from 1998–2003. Patients who presented to the ED with a long bone fracture (femur, humerus, tibia, fibula, radius, or ulna) were compared. The authors extracted data on patient, visit, and hospital characteristics. The primary outcomes were the proportion of patients who received assessment of pain severity and who received analgesic treatment.
Results
There were 2,064 patients with a qualifying fracture in the study period, 834 from 1998–2000 and 1,230 from 2001–2003. Compared with the early period, a higher proportion of patients in the late period had their pain assessed (74% vs. 57%), received opiates (56% vs. 50%), and received any analgesic (76% vs. 56%). Patients in the late period had higher odds of receiving any analgesia (adjusted odds ratio [OR], 1.43) and opioid analgesia (adjusted OR, 1.27) compared with the early period. Patients in the middle age group (adjusted OR, 2.28) or those seen by physician assistants (adjusted OR, 2.05) were more likely, whereas those with Medicaid (adjusted OR, 0.58) and those in the Northeast were less likely, to receive opiates.
Conclusions
Although the quality of ED pain management for acute fractures appears to be improving, there is still room for further improvement.     

Measuring the quality of documented care given by Swedish midwives during birth

Objectives

to measure the extent to which documented Swedish midwifery care for low-risk labour and birth followed the World Health Organization's (WHO) recommendations for care in normal birth, and to compare midwifery care given to women who’s labours were classified as low and high risk.

Study design

a retrospective examination of midwifery and medical records, 144 from women with low-risk births and 54 from women with high-risk births, for aspects of pregnancy, labour and birth using a validated instrument based on WHO’s recommendations.

Setting

southern Sweden.

Outcome measurements

care given in accordance with WHO’s four categories of practice and changes in risk group during the birth process.

Findings

care interventions not recommended by WHO, such as routine establishment of an intravenous route, routine amniotomy during the first stage, continuous electronic fetal monitoring and pharmacological methods of pain relief, were widespread in the records. Documented care differed little between the labours of women at low risk and high risk. The midwives at the unit under study did not routinely carry out risk assessment.

Key conclusions and implications for practice

the mode of care was one of readiness for medical intervention. The act of carrying out risk assessments at the time of the woman’s admission may affect awareness of the level of care offered to birthing women, and thus help to reduce the number and variety of practices not recommended by WHO.     

Association Between Serum 25(OH)D Level and Nonspecific Musculoskeletal Pain in Acute Rehabilitation Unit Patients

Objective: Nonspecific musculoskeletal pain can be difficult to manage in acute rehabilitation unit (ARU) patients. We investigated whether vitamin D status is a potential modifiable risk factor for nonspecific musculoskeletal pain in ARU patients. Materials and Methods: This cross‐sectional study focused on 414 adults from an inpatient ARU in Mission Viejo, California, between July 2011 and June 2012. On ARU admission, all patients had serum 25‐hydroxyvitamin D (25(OH)D) levels measured and were assessed for nonspecific musculoskeletal pain. We performed multivariable logistic regression to test the association of serum 25(OH)D level with nonspecific musculoskeletal pain while adjusting for clinically relevant covariates. Results: Among these 414 patients, mean (SD) 25(OH)D level was 29 (12) ng/mL, and 30% had nonspecific musculoskeletal pain. After adjustment for age, sex, race, body mass index, Functional Independence Measure score, Deyo‐Charlson Comorbidity Index, fractures, steroid use, history of osteoporosis/osteomalacia, and patient type (orthopedic, cardiac, neurological, spinal cord injury, or traumatic brain injury), serum 25(OH)D level was inversely associated with nonspecific musculoskeletal pain (odds ratio [OR] per 10 ng/mL, 0.67; 95% confidence interval [CI], 0.48–0.82). When 25(OH)D level was dichotomized, patients with levels <20 ng/mL had higher odds of nonspecific musculoskeletal pain (OR, 2.33; 95% CI, 1.23–4.17) compared with patients with levels ≥20 ng/mL. Conclusions: In adult patients, serum 25(OH)D level on admission to ARU was inversely associated with nonspecific musculoskeletal pain. These data support the need for randomized, controlled trials to test the role of vitamin D supplementation to improve nonspecific musculoskeletal pain in ARU patients.     

Ten‐Year Survey of Program Directors: Trends,Challenges, and Mentoring in Prosthodontics. Part 1

Purpose: This study consisted of two parts. Part 1 was a survey of US program directors, and Part 2 reports on the survey findings distributed to the deans of US dental schools. Both surveys evaluated observations of trends in prosthodontic education. The first survey (2005) of program directors and deans was published in 2007. This second survey was conducted in 2009. The 2009 survey provided 10‐year data on trends in prosthodontics as reported by program directors. Materials and Methods: A national e‐mail survey of 46 program directors was used to collect enrollment data for years 1 to 3 of prosthodontics training for US and international dental school graduates, the total number of applicants and applications considered, and the trends over time of applicants to prosthodontics for US dental school graduates and for international graduates. In addition, the program directors were asked to rank 13 key factors that may have contributed to any changes in the prosthodontic applicant pool. Program directors were also asked for information on student financial incentives and whether their programs were state or federally funded, and whether their sponsoring institution was a dental school. Results: Of the 46 program directors, 40 responded, for an 87% response rate. Respondents reported that 66% of their enrollees were graduates of US dental schools. Between 2000 and 2009 the applicant pool in prosthodontics nearly doubled, with 50% of the program directors reporting an increase in US‐trained applicants, 42.5% reporting no change, and only 7.5% reporting a decrease. Using the Spearman correlation for the 10‐year survey, there was a positive, statistically significant correlation that society's demand for a higher level of training and credentialing and interest in prosthodontics among dental students contributed to an increase in the number of US dental graduates applying to prosthodontic programs. Only four programs offered no financial packages to offset tuition. The remaining 36 respondents reported some financial package. Among the respondents, there were 23 state‐sponsored programs and 6 sponsored by private universities; the remaining 9 were sponsored by hospitals or federal agencies. Conclusions: A nearly doubled applicant pool and more US‐trained applicants to prosthodontics ensure a much more competitive applicant pool for our specialty. In the 2009 survey, program directors reported that factors such as society's demand for a higher level of training and credentialing, interest in prosthodontics among US dental students, advances in implant, esthetic, and reconstructive dentistry, literature pertaining to the need of prosthodontists for the future, marketing of prosthodontics as a career, and the dollar value of prosthodontic training have all had some impact on increasing the mentored applicant pool to prosthodontic training in the United States.