Teres minor denervation on routine magnetic resonance imaging of the shoulder

Objective To try to define an association between clinical history and the finding of isolated teres minor denervation on routine magnetic resonance (MR) examination of the shoulder.Design A retrospective review of all shoulder MR examinations performed at our institution over a 2-year period (n=2,563)Patients All patients and MR examinations demonstrating isolated denervation of the teres minor muscle as determined by review of this subset of patients (n=61)Results A 3% incidence of isolated teres minor denervation was found. No patient had a clinical history concerning the classic quadrilateral space syndrome, and no patient had a structural lesion in the quadrilateral space.Conclusions Isolated teres minor denervation is not an uncommon finding on routine shoulder MR imaging and may be associated with pathology other than a structural lesion in and about the axillary neurovascular structures, such as rotator cuff injuries and traction injury on the axillary nerve sustained during a glenohumeral joint translational event.     

Assessment of dietary vitamin D requirements during pregnancy and lactation

Concerns about vitamin D have resurfaced in medical and scientific literature because the prevalence of vitamin D deficiency in the United States, particularly among darkly pigmented persons, has increased. The primary goals of this review were to discuss past and current literature and to reassess the dietary reference intake for vitamin D in adults, with particular focus on women during pregnancy and lactation. The appropriate dose of vitamin D during pregnancy and lactation is unknown, although it appears to be greater than the current dietary reference intake of 200-400 IU/d (5-10 microg/d). Doses of < or =10 000 IU vitamin D/d (250 microg/d) for up to 5 mo do not elevate circulating 25-hydroxyvitamin D to concentrations > 90 ng/mL, whereas doses < 1000 IU/d appear, in many cases, to be inadequate for maintaining normal circulating 25-hydroxyvitamin D concentrations of between 15 and 80 ng/mL. Vitamin D plays no etiologic role in cardiac valvular disease, such as that observed in Williams syndrome, and, as such, animal models involving vitamin D intoxication that show an effect on cardiac disease are flawed and offer no insight into normal human physiology. Higher doses of vitamin D are necessary for a large segment of Americans to achieve concentrations equivalent to those in persons who live and work in sun-rich environments. Further studies are necessary to determine optimal vitamin D intakes for pregnant and lactating women as a function of latitude and race.     

Assessment of Ankle-Subtalar-Joint-Complex Laxity Using an Instrumented Ankle Arthrometer: An Experimental Cadaveric Investigation

OBJECTIVE: To show the relationship between direct measurements of tibial-calcaneal bone motion and instrumented measurements of ankle-subtalar-joint-complex laxity using a portable ankle arthrometer; to assess within and between-tester measurement reliability; and to determine if the ankle arthrometer can detect increased mechanical laxity of the ankle-subtalar-joint-complex after simulated injury of the lateral ankle ligaments. DESIGN AND SETTING: We used linear regression analysis to examine the relationship between direct measurements of tibial-calcaneal bone motion and instrumented measurements of ankle-subtalar-joint-complex laxity. An intraclass correlation coefficient (2,1) was calculated to determine intratester and intertester reliability for instrumented measurements of ankle-subtalar-joint-complex laxity. In addition, 2 separate, one-way, repeated-measures analyses of variance were used to compare instrumented measures of anteroposterior displacement and inversion-eversion rotation among the intact ankles after sectioning the anterior talofibular ligament and both the anterior talofibular and calcaneofibular ligaments. Data were collected in a biomechanics laboratory setting. SUBJECTS: Six fresh-frozen human-cadaver ankle specimens were studied. MEASUREMENTS: Testing involved the concurrent measurement of tibial-calcaneal bone motion and ankle-subtalar-joint-complex motion during the application of external loads. An instrumented ankle arthrometer was used to load the ankle in a controlled manner. Two spatial kinematic linkages measured the 3-dimensional motion of the calcaneus relative to the tibia and the motion of the arthrometer's footplate relative to the tibia. RESULTS: The correlation between tibial-calcaneal bone motion and instrumented measurement for anterior-posterior displacement was.878 (P =.0001). Its linear relationship with bone motion accounted for approximately 77% of the variance of the instrumented measurement. The correlation between tibial-calcaneal bone motion and instrumented measurement for inversion-eversion rotation was.858 (P =.0001), with approximately 74% of the variance of the instrumented measurement accounted for by its linear relationship with bone motion. High intratester and intertester reliability coefficients (ICC [2,1] =.80 to.97) were observed for instrumented measurements of ankle-subtalar-joint-complex laxity. In addition, ligamentous sectioning resulted in significantly increased ankle-subtalar-joint-complex laxity. When compared with the intact condition, sectioning both the anterior talofibular and calcaneofibular ligaments produced significant increases in anterior-posterior displacement (P =.0001) and inversion-eversion rotation (P =.002). CONCLUSIONS: We found a strong relationship between tibial-calcaneal bone motion and arthrometric measurements of ankle-subtalar-joint-complex laxity. The instrumented ankle arthrometer may be suitable as a diagnostic tool for the evaluation of lateral ankle-ligament laxity.     

Developing and testing new smoking measures for the Health Plan Employer Data and Information Set

OBJECTIVE: To develop and test items for the Health Plan Employee Data and Information Set (HEDIS) that assess delivery of the full range of provider-delivered tobacco interventions. MATERIALS AND METHODS: The authors identified potential items via literature review; items were reviewed by national experts. Face validity of candidate items was tested in focus groups. The final survey was sent to a random sample of 1711 adult primary care patients; the re-test survey was sent to self-identified smokers. RESULTS: The process identified reliable items to capture provider assessment of motivation and provision of assistance and follow-up. CONCLUSIONS: One can reliably assess patient self-report of provider delivery of the full range of brief tobacco interventions. Such assessment and feedback to health plans and providers may increase use of evidence-based brief interventions.     

Improving typeability of multiple bacterial species using pulsed-field gel electrophoresis and thiourea

Although pulsed-field gel electrophoresis is considered the "gold standard" technique for molecular typing, typeability may not be excellent for some bacterial species because of DNA degradation. Previous reports suggest that the addition of thiourea in the gel buffer can improved the typeability for some species. In the present study, 66 Gram-negative strains (seven species) known to be affected by DNA degradation and four control strains were evaluated by PFGE with and without the addition of 50 microg/M of thiourea to the buffer used in the electrophoresis. Macrorestriction patterns were obtained for all K. pneumoniae, S. marcescens, P. aeruginosa, and Salmonella spp., for 95.4% of E. coli, and for 50% of E. cloacae strains from the gels performed in the buffer with throurea. However, typeability was not improved for Acinetobacter spp. The range of non-typeable species for which thiourea can limit the problem of DNA degradation is considerably wider than described in previous publications.     

Intraopertive radiation therapy for breast cancer

The rapid patient accrual observed in the European breast IORT studies reported since 2000 indicates that surgeons, radiation oncologists, and women who have breast cancer are no longer content to continue to travel down the well-worn path of disfiguring ablative treatment. Breast conservation is currently viewed as the preferred mode of therapy for early-stage breast cancer in most clinical situations. Determination of the optimal combination of whole breast EBRT and localized IORT, for dose and fractionation, is a critical issue that only recently has been addressed [20,21]. Clearly, such clinical investigative endeavors should be regarded as high priority. The very low incidence of local in-breast recurrence of cancer to date suggests that another avenue for investigation might be the determination of the extent to which the lumpectomy procedure can be safely minimized when used in conjunction with IORT. For example, physicians might ask, "Are microscopically negative surgical margins still mandatory when IORT is applied at the time of lumpectomy?" If the answer to that question should turn out to be "no," then it should be much easier for surgeons to achieve the desired excellent cosmetic results when dealing with early-stage breast cancer. Another question remaining to be addressed pertains to the utility of IORT in the management of in-breast recurrence of cancer following conservative therapy. The incidence of local failure after organ-conserving treatment is generally reported to be approximately 5% to 10%. Currently, the preferred mode of salvage therapy in such a clinical situation is mastectomy. The proven efficacy of IORT concurrent with lumpectomy in the primary treatment of early-stage breast cancer suggests that even local recurrences following conventional conservative treatment might be dealt with effectively and expeditiously by means of local excision plus IORT. Such treatment, if safe and effective, could prove to be much less disfiguring than mastectomy. Because breast irradiation routinely produces a desmoplastic tissue response in the breast, there seems to be an opportunity here to address local recurrences of breast cancer with local surgical extirpation enhanced by IORT. Because there are currently few data regarding the use of IORT in this clinical situation, pilot studies would seem to be justified. The remarkably low incidence of local recurrence of breast malignancy observed in every breast IORT study reported to date may portend an important advancement in physicians' ability to better achieve local control of mammary carcinoma. It is hoped that such a putative improvement in the local control of breast cancer will soon translate into improved patient survival rates for this common malignancy.     

Intraoperative radiation therapy in surgical oncology

This is the first publication about intraoperative radiation therapy (IORT) to be written for surgeons through a collaborative effort of surgeons and radiation therapists. This article introduces the basic concepts of radiation therapy and the rationale of its use in the operating room, and presents the advantages for the surgeon and radiation therapist to work together for the benefit of our patients.