Experimental Referred Pain Extends Toward Previously Injured Location: An Explorative Study

Facilitated pain mechanisms have been demonstrated in musculoskeletal pain, but it is unclear whether a recent painful injury leaves the pain system sensitized. Pain characteristics were assessed in individuals who recently recovered from ankle pain (recovered pain group; n?=?25) and sex-matched control subjects (n?=?25) in response to tonic pressure pain and saline-induced pain applied at the shin muscle. Pain intensity and pain referral patterns were recorded bilaterally after the painful muscle stimulus. Pressure pain thresholds were measured at the lower legs and shoulder. Cuff pressure algometry on the lower leg was used to assess pain detection threshold, pressure evoking 6-cm pain score on a 10-cm visual analog scale, pain tolerance, temporal summation of pain, and conditioned pain modulation. Compared with in control subjects, saline-induced and pressure-induced pain in the shin muscle were more frequently felt as referred pain in the previously painful ankle (P < .05), and the pain area within the previously affected ankle was larger after saline-induced pain (P < .05). In the recovered pain group, conditioned pain modulation responses and the cuff pressure needed to reach a 6-cm pain score on a 10-cm visual analog scale was higher in the previously painful leg compared with in the contralateral leg (P < .05). No group differences were found in pressure pain threshold, pain detection threshold, pain tolerance, and temporal summation of pain.

Accuracy of ICD-9 codes to identify nonunion and malunion and developing algorithms to improve case-finding of nonunion and malunion

ObjectiveTo evaluate the accuracy of using ICD-9 codes to identify nonunions (NU) and malunions (MU) among adults with a prior fracture code and to explore case-finding algorithms.Study designMedical chart review of potential NU (N = 300) and MU (N = 288) cases. True NU cases had evidence of NU and no evidence of MU in the chart (and vice versa for MUs) or were confirmed by the study clinician. Positive predictive values (PPV) were calculated for ICD-9 codes. Case-finding algorithms were developed by a classification and regression tree analysis using additional automated data, and these algorithms were compared to true case status.SettingGroup Health Cooperative.ResultsCompared to true cases as determined from chart review, the PPV of ICD-9 codes for NU and MU were 89% (95% CI, 85–92%) and 47% (95% CI, 41–53%), respectively. A higher proportion of true cases (NU: 95%; 95% CI, 90–98%; MU: 56%; 95% CI, 47–66%) were found among subjects with 1 + additional codes occurring in the 12 months following the initial code. There was no case-finding algorithm for NU developed given the high PPV of ICD-9 codes. For MU, the best case-finding algorithm classified people as an MU case if they had a fracture in the forearm, hand, or skull and had no visit with an NU diagnosis code in the 12-month post MU diagnosis. PPV for this MU case-finding algorithm increased to 84%.ConclusionsIdentifying NUs with its ICD-9 code is reasonable. Identifying MUs with automated data can be improved by using a case-finding algorithm that uses additional information. Further validation of the MU algorithms in different populations is needed, as well as exploration of its performance in a larger sample.     

Views of teenage children about the effects of a Parent's mobility disability

Background

Few U.S. studies have explored how children experience a parent's mobility disability and its effects on their daily lives.

Primary Prevention of Falls: Effectiveness of a Statewide Program

Objectives. We examined a population-wide program, Pennsylvania’s Healthy Steps for Older Adults (HSOA), designed to reduce the incidence of falls among older adults. Older adults completing HSOA are screened and educated regarding fall risk, and those identified as being at high risk are referred to primary care providers and home safety resources.Methods. From 2010 to 2011, older adults who completed HSOA at various senior center sites (n = 814) and a comparison group of older adults from the same sites who did not complete the program (n = 1019) were recruited and followed monthly. Although participants were not randomly allocated to study conditions, the 2 groups did not differ in fall risk at baseline or attrition. We used a telephone interactive voice response system to ascertain the number of falls that occurred each month.Results. In multivariate models, adjusted fall incidence rate ratios (IRRs) were lower in the HSOA group than in the comparison group for both total (IRR = 0.83; 95% confidence interval [CI] = 0.72, 0.96) and activity-adjusted (IRR = 0.81; 95% CI = 0.70, 0.93) months of follow-up.Conclusions. Use of existing aging services in primary prevention of falls is feasible, resulting in a 17% reduction in our sample in the rate of falls over the follow-up period.The public health significance of falls among older adults is clear. As noted by the National Council on Aging,

falls are the leading cause of injury related deaths of older adults, the primary reason for older adult injury emergency department visits, and the most common cause of hospital admissions for trauma.1

In 2011, the rate of nonfatal fall injuries requiring emergency department care was 2301 per 100 000 among people aged 50 to 54 years but 14 159 per 100 000 among people 85 years or older.2Self-report measures from health surveys confirm that there is a high prevalence of falls (30%–40%) among people 65 years or older and that the prevalence increases with age (40%–50% among those 80 years or older), as does the inability to get up from falls.3,4 Even noninjurious falls are disabling in that they are associated with activity restriction, isolation, deconditioning, and depression.5–8 In 2005, medical care costs associated with falls in the United States among people 50 years or older totaled about $13.5 billion (including deaths, hospital care, and emergency department admissions).2 A challenge for public health is to decrease the risk of falls without encouraging reduced physical activity, which carries other risks.Risk factors for falls include sedative use, cognitive impairment, lower extremity weakness, poor reflexes, balance and gait abnormalities, foot problems, and environmental hazards.9,10 Community-level efforts have adapted clinical interventions in addressing such risk factors. A review of 5 prospective but nonrandomized community trials involving matched control communities suggested that fall-related fractures could potentially be reduced by 6% to 33%,11 and meta-analyses and systematic reviews provide support for the effectiveness of multifactorial assessments and management of fall risk.12 The Centers for Disease Control and Prevention (CDC) has compiled a compendium of successful interventions that can be used by public health practitioners and community-based organizations.13,14Recommendations for optimal means of preventing falls are still evolving.15,16 A Cochrane review reported that exercise and home safety programs reduce the rate of falls and risk of falling but did not reveal any benefits of interventions that increase knowledge regarding fall prevention without additional components.3Pennsylvania’s Department of Aging has opted for a hybrid program in which older adults can take advantage of an intervention that offers, within the current aging service infrastructure, risk screening for falls and education regarding prevention. This voluntary program, Healthy Steps for Older Adults (HSOA), is available to all adults 50 years or older. Those identified as having a high risk for falls are referred to primary care providers and encouraged to complete home safety assessments. Because it relies on referrals to physician care rather than direct clinical interventions, the program may be less effective among people at high risk for falls; however, it is scalable across the state and reaches large numbers of people. In the case of some public health challenges, such a strategy may be more effective than more intensive interventions targeting high-risk individuals.17There is a lack of evidence regarding the effectiveness of this short-term, low-cost, population-wide program in reducing the incidence of falls among its participants, however. Here we report the results of a statewide evaluation of HSOA, which uses the state’s network of providers of aging services in its primary prevention efforts.     

Preliminary characterization of ribosomes of Entamoeba invadens

The ribosomes of Entamoeba invadens trophozoites have sedimentation coefficients of 77, 53 and 36 S. Most of the ribosomal proteins are basic and their one- and two-dimensional electrophoretic patterns differ from the corresponding patterns of Escherichia coli and Saccharomyces cerevisiae. Two dozen bands were observed in the 10 000 to 100 000 molecular weight range following sodium dodecylsulfate-gel electrophoresis of amoebal ribosomal proteins. Long, thin pronase-sensitive structures were seen in electron micrographs of E. invadens ribosomal preparations.     

Use of tuf sequences for genus-specific PCR detection and phylogenetic analysis of 28 streptococcal species

A 761-bp portion of the tuf gene (encoding the elongation factor Tu) from 28 clinically relevant streptococcal species was obtained by sequencing amplicons generated using broad-range PCR primers. These tuf sequences were used to select Streptococcus-specific PCR primers and to perform phylogenetic analysis. The specificity of the PCR assay was verified using 102 different bacterial species, including the 28 streptococcal species. Genomic DNA purified from all streptococcal species was efficiently detected, whereas there was no amplification with DNA from 72 of the 74 nonstreptococcal bacterial species tested. There was cross-amplification with DNAs from Enterococcus durans and Lactococcus lactis. However, the 15 to 31% nucleotide sequence divergence in the 761-bp tuf portion of these two species compared to any streptococcal tuf sequence provides ample sequence divergence to allow the development of internal probes specific to streptococci. The Streptococcus-specific assay was highly sensitive for all 28 streptococcal species tested (i.e., detection limit of 1 to 10 genome copies per PCR). The tuf sequence data was also used to perform extensive phylogenetic analysis, which was generally in agreement with phylogeny determined on the basis of 16S rRNA gene data. However, the tuf gene provided a better discrimination at the streptococcal species level that should be particularly useful for the identification of very closely related species. In conclusion, tuf appears more suitable than the 16S ribosomal RNA gene for the development of diagnostic assays for the detection and identification of streptococcal species because of its higher level of species-specific genetic divergence.     

Development of a real-time PCR assay for the specific detection and identification of Streptococcus pseudopneumoniae using the recA gene

We sequenced the evolutionarily conserved genes 16S rRNA, atpD, tuf, and recA from Streptococcus pseudopneumoniae, Streptococcus pneumoniae, Streptococcus mitis, and Streptococcus oralis. Phylogenetic analysis revealed that recA provided good resolution between these species, including discrimination of the novel species S. pseudopneumoniae. By contrast, the more conserved 16S rRNA, tuf and atpD are not sufficiently discriminatory. Therefore, recA sequences were used to develop a real-time PCR assay with a locked nucleic acid-mediated TaqMan probe for the specific detection and identification of S. pseudopneumoniae. The PCR assay showed excellent specificity and a detection limit of <10 genome copies for the detection and identification of S. pseudopneumoniae strains, which makes it a promising tool for molecular identification and epidemiological studies. In conclusion, this article describes for the first time a PCR assay for the specific identification of S. pseudopneumoniae.     

Parent satisfaction with the electronic medical record in an academic pediatric rheumatology practice

Background

Patient satisfaction has not been widely studied with respect to implementation of the electronic medical record (EMR). There are few reports of the impact of the EMR in pediatrics.

Objective

The objective of this study was to assess the impact of implementation of an electronic medical record system on families in an academic pediatric rheumatology practice.

Methods

Families were surveyed 1 month pre-EMR implementation and 3 months post-EMR implementation.

Results

Overall, EMR was well received by families. Compared with the paper chart, parents agreed the EMR improved the quality of doctor care (55% or 59/107 vs 26% or 26/99, P < .001). More parents indicated they would prefer their pediatric physicians to use an EMR (68% or 73/107 vs 51% or 50/99, P = .01).

Conclusions

Transitioning an academic pediatric rheumatology practice to an EMR can increase family satisfaction with the office visit.