The Anatomic Position of the Sciatic Nerve During Percutaneous Retrograde Posterior Column Fixation Is Determined by Hip Position

OBJECTIVES

There are multiple established patient positions for placement of a percutaneous retrograde posterior column screw for fixation of acetabulum fractures. The sciatic nerve is at risk of injury during this procedure because it lies adjacent to the start point at the ischial tuberosity. The purpose of this study was to define how the position of the sciatic nerve, relative to the ischial tuberosity, changes regarding the patient's hip position.

METHODS

In a cohort of 11 healthy volunteers, ultrasound was used to measure the absolute distance between the ischial tuberosity and the sciatic nerve. Measurements were made with the hip and knee flexed to 90 degrees to simulate supine and lateral positioning and with the hip extended to simulate prone positioning. In both positions, the hip was kept in neutral abduction and neutral rotation.

RESULTS

The distance from the lateral border of the ischial tuberosity to the medial border of the sciatic nerve was greater in all subjects in the hip-flexed position versus the extended position. The mean distance was 17 mm (range, 14-27 mm) in the hip-extended position and 39 mm (range, 26-56 mm) in the hip-flexed position ( P < 0.001).

CONCLUSIONS

The sciatic nerve demonstrates marked excursion away from the ischial tuberosity when the hip is flexed compared with when it is extended. The safest patient position for percutaneous placement of a retrograde posterior column screw is lateral or supine with the hip flexed to 90 degrees.

Long-term follow-up of patients with hypoparathyroidism

CONTEXT

Despite tremendous interest in hypoparathyroidism, large cohort studies describing typical treatment patterns, laboratory parameters, and rates of complications are lacking.

OBJECTIVE

Our objective was to characterize the course of disease in a large cohort of hypoparathyroid patients.

DESIGN AND SETTING

We conducted a chart review of patients with permanent hypoparathyroidism identified via a clinical patient data registry. Patients were seen at a Boston tertiary-care hospital system between 1988 and 2009.

PATIENTS

We identified 120 patients. Diagnosis was confirmed by documented hypocalcemia with a simultaneous low or inappropriately normal PTH level for at least 1 yr. Mean age at the end of the observation period was 52 ± 19 (range 2-87) yr, and the cohort was 73% female.

MAIN OUTCOME MEASURE

We evaluated serum and urine laboratory results and renal and brain imaging.

RESULTS

We calculated time-weighted average serum calcium measurements for all patients. The time-weighted average for calcium was between 7.5 and 9.5 mg/dl for the majority (88%) of patients. Using linear interpolation, we estimated the proportion of time within the target calcium range for each patient with a median of 86% (interquartile range 67-98%). Of those with a 24-h urine collection for calcium (n = 53), 38% had at least one measurement over 300 mg/d. Of those with renal imaging (n = 54), 31% had renal calcifications, and 52% of those with head imaging (n = 31) had basal ganglia calcifications. Rates of chronic kidney disease stage 3 or higher were 2- to 17-fold greater than age-appropriate norms.

CONCLUSIONS

Hypoparathyroidism and its treatment carry a large burden of disease. Renal abnormalities are particularly common.

Clinical pathway after hip fracture

PURPOSE

Hip fracture occurs frequently, resulting in considerable morbidity, mortality and utilization of healthcare resources. Technical advances in fracture fixation and surgical treatment have improved outcomes following hip fracture in the elderly. However, further improvement in outcomes of hip fracture patients may be possible with utilization of a clinical pathway designed to enhance outcomes in a standardized, cost-effective manner. This paper presents a clinical pathway for the treatment of hip fractures in the elderly with the above aims.

METHOD

The clinical pathway presented is based on personal experience and literature pertaining to the treatment of the elderly hip fracture patient. It outlines a suggested algorithmic approach to the patient that begins with the initial evaluation, progresses on through pre-operative and operative management, and ends with post-operative rehabilitation and treatment.

RESULTS

The clinical pathway for the hip fracture patient in this paper is a working treatment algorithm that has been successful in personal experience.

CONCLUSION

This treatment algorithm has been utilized successfully in personal experience. Further input from healthcare professionals may prove to enhance outcomes in a cost-effective, standardized manner.

Assessing community violence: the children's report of exposure to violence

OBJECTIVE

To describe the development and initial psychometric features of a brief self-report instrument for assessing exposure to community violence, the Children's Report of Exposure to Violence (CREV).

METHOD

The CREV was administered to 228 schoolchildren between the ages of 9 and 15 years. A subset (n = 42) was retested 2 weeks later.

RESULTS

The CREV has good test-retest reliability, internal consistency, and construct validity. Analyses performed by race and gender revealed no differences in frequency of exposure to community violence as assessed by the CREV.

CONCLUSIONS

This initial report suggests that the CREV has promise as a self-report questionnaire, and its construction represents a significant advance in the development of psychometrically sound instruments for use in community violence research.

A multicomponent behavioral treatment for social phobia: social effectiveness therapy

The development of a new, comprehensive and multicomponent treatment for social phobia is described. Initial results of a pilot study with the new treatment also are reported. The treatment was found to be effective with severe (generalized) social phobics, most of whom had co-occurring Axis I and/or II conditions. In addition to significant change on a host of outcome variables, a normative-based endstate functioning index was used to determine treatment efficacy. The results are discussed with respect to the implementation of the treatment and in terms of the need for a comprehensive approach to treating social phobia.

Assessing reliable and clinically significant change in social phobia: validity of the social phobia and anxiety inventory

The ability of the Social Phobia and Anxiety Inventory (SPAI) to measure change as a function of treatment for social phobia was assessed. In addition to determining treatment sensitivity of the SPAI, changes over the course of treatment were examined to determine if they were reliable and clinically significant. The results indicated that although a number of measures showed statistically significant change, only on the SPAI was that change reliable and clinically significant. The use of outcome measures that are reliable and clinically significant for social phobia as well as other disorders is discussed.