Ultrasound-guided extracorporeal shock wave therapy for plantar fasciitis: a randomized controlled trial

Context  Extracorporeal shock wave therapy (ESWT) is increasingly used for plantar fasciitis, but limited evidence supports its use. Objective  To determine whether ultrasound-guided ESWT reduces pain and improves function in patients with plantar fasciitis. Design  Double-blind, randomized, placebo-controlled trial conducted between April 1999 and June 2001. Setting  Participants were recruited from the community-based referring physicians (primary care physicians, rheumatologists, orthopedic surgeons, and sports physicians) of a radiology group in Melbourne, Australia. Participants  We screened 178 patients and enrolled 166; 160 completed the 15-week protocol. Entry criteria included age at least 18 years with plantar fasciitis, defined as heel pain maximal over the plantar aspect of the foot of at least 6 weeks' duration, and an ultrasound-confirmed lesion, defined as thickening of the origin of the plantar fascia of at least 4 mm, hypoechogenicity, and alterations in the normal fibrillary pattern. Interventions  Patients were randomly assigned to receive either ultrasound-guided ESWT given weekly for 3 weeks to a total dose of at least 1000 mJ/mm² (n = 81), or identical placebo to a total dose of 6.0 mJ/mm² (n = 85). Main Outcome Measures  Overall, morning, and activity pain, measured on a visual analog scale; Maryland Foot Score; walking ability; Short-Form–36 Health Survey (SF-36) score; and Problem Elicitation Technique score, measured at 6 and 12 weeks after treatment completion. Results  At 6 and 12 weeks, there were significant improvements in overall pain in both the active group and placebo group (mean [SD] improvement, 18.1 [30.6] and 19.8 [33.7] at 6 weeks [P = .74 for between-group difference], and 26.3 [34.8] and 25.7 [34.9] at 12 weeks [P = .99], respectively). Similar improvements in both groups were also observed for morning and activity pain, walking ability, Maryland Foot Score, Problem Elicitation Technique, and SF-36. There were no statistically significant differences in the degree of improvement between treatment groups for any measured outcomes. Conclusion  We found no evidence to support a beneficial effect on pain, function, and quality of life of ultrasound-guided ESWT over placebo in patients with ultrasound-proven plantar fasciitis 6 and 12 weeks following treatment.      

Should Orbscan pachometry be performed before or after Goldmann applanation tonometry?

PURPOSE: To compare the Orbscan central corneal thickness (CCT) values before and after intraocular pressure (IOP) measurement with Goldmann applanation tonometry in young normal adults. MATERIALS AND METHODS: Fifty-three eyes of 53 subjects who were free from any ocular problems were studied. The measurements included optical pachometry by the Orbscan II system, followed by Goldmann applanation tonometry, and finally Orbscan optical pachometry again. Standard Goldmann technique was adopted with the application of one drop of 0.4% benoxinate and fluorescein sodium prior to the measurement. The same operator was involved in the Orbscan pachometry before and after Goldmann tonometry. Another investigator was responsible for Goldmann tonometry. Three readings were obtained in each case, and the means were used for analysis. RESULTS: The mean IOP of the sample was 14.6 +/- 2.6 mmHg. There was no significant difference (paired t-test: p = 0.50) in the mean CCT values before and after the Goldmann tonometry (551 +/- 32 and 552 +/- 35 microm respectively). CONCLUSION: Standard Goldmann applanation tonometry does not affect the Orbscan CCT values. Measurement of CCT for the adjustment of true IOP can be carried out either before or after Goldmann tonometry.     

Perimenopausal and Postmenopausal Hormone Replacement Therapy; Part 1. An Update of the Literature on Benefits and Risks*

As life expectancy increases and members of the postwar generation settle into their fifth decade of life, hormone replacement therapy—estrogen or an estrogen-progestin combination—has become a major research interest. An extensive, but often confusing and even contradictory, literature exists on the uses of hormone replacement for the treatment and prevention of a multitude of difficulties that may be associated with the perimenopausal and postmenopausal periods. These include hot flushes, vaginal changes, urinary tract changes, changes in sexuality, affective or emotional symptoms, changes in the oral mucosa and skin, loss of memory and Alzheimer's disease, bone loss and osteoporosis, and cardiovascular disease. This article reviews the literature in each of these areas. It also reviews studies relating to possible side effects of hormone therapy, including endometrial cancer, gall bladder disease, and breast cancer. The article outlines principles for practitioners to follow in assisting women to make informed and individualized decisions about this therapy. Part II of this article, which will appear in the May/June 1996 issue of the Journal of Nurse-Midwifery, will cover specific therapeutic regimens and their management, as well as alternative therapies and preventive measures.     

A content validity analysis of neoplastic items of the national board of medical examiners part II examination

As part of its evaluation of the Clinical Cancer Education Program (CCEP) at the Albert Einstein College of Medicine, the Office of Educational Research and Evaluation analyzed student performance on neoplastic items of the National Board of Medical Examiners (NBME) Examination Part II. The evaluation provided a successful application of the American Association for Cancer Education (AACE) coding schema for analysis of neoplastic items. Two examinations were analyzed in order to determine the frequency with which specific disease sites, treatment modalities, and question emphasis items appeared. With reference to disease site, the greatest number of questions on both examinations dealt with gynecological issues while the fewest dealt with lung and hematologic-related disease. A breakdown of questions into various treatment modalities indicated that of items that could be categorized, most dealt with surgical treatment, while other therapeutic modalities were given little or no emphasis. Looking at question emphases, the most frequently asked questions referred to diagnostic tests and stratagems, whereas the least amount of emphasis was placed on rehabilitative and psychosocial aspects of the disease. These findings corroborate those reported by Ruckdeschel and his associates and point out several limitations to the content validity of the neoplastic items on NBME Part II.     

Critical appraisal of the clinical and pathologic predictors of survival after resection of large hepatocellular carcinoma

HYPOTHESIS: A subset of patients with hepatocellular carcinoma (HCC) with a diameter of 10 cm or larger may benefit from hepatic resection. DESIGN: Retrospective study of a multi-institutional database. SETTING: Five major hepatobiliary centers. PATIENTS: We identified 300 patients who underwent hepatic resection for HCC 10 cm or larger. MAIN OUTCOME MEASURES: Clinical and pathologic data were collected, and prognostic factors were evaluated by univariate and multivariate analyses. Patient survival was stratified according to a clinical scoring system and pathologic T classification. RESULTS: The perioperative mortality rate was 5%. At a median follow-up of 32 months, the median survival was 20.3 months, and the 5-year actuarial survival rate was 27%. Four clinical factors-alpha-fetoprotein of 1000 ng/mL or higher, multiple tumor nodules, the presence of major vascular invasion, and the presence of severe fibrosis-were significant predictors of poor survival (all P<.05). Patients were assigned a clinical score according to the following risk factors: 1, no factor; 2, one or two factors; or 3, three or four factors. On the basis of the clinical score, patients could be stratified into only 2 distinct prognostic groups: no factor (score of 1) vs 1 or more factors (score of 2 or 3) (P<.001). In contrast, when patients were stratified according to pathologic T classification, 3 distinct groups were identified: T1 vs T2 vs T3 and T4 combined (P<.001). Fifty-six percent of the patients with a clinical score of 2 and 20% of patients with a clinical score of 3 actually had T1 or T2 disease on pathologic examination. CONCLUSIONS: Patients with large HCCs should be considered for liver resection as this treatment is associated with a 5-year survival rate exceeding 25%. Clinical predictors should not be used to exclude patients from surgical resection because these factors do not reliably predict outcome.