Chief Complaints Of Patients Research Articles

Comprehensive Clinical Evaluation of Femoroacetabular Impingement: Part 1, Physical Examination

A thorough evaluation of the hip must include a comprehensive medical and surgical history focused on the hip joint, surrounding soft tissues, and the associated structures of the spine, pelvis, and lower extremities. These details can guide the physical examination and provide insight into the cause of the patient's chief complaints. A proper examination includes physical examination while the patient is in the upright, supine, prone, and lateral position, as well as an evaluation of gait. Guided by a thorough history, the physical examination enables the surgeon to distinguish between intra-articular and extra-articular contributors to hip pain, selection of appropriate imaging modalities, and ultimately supports medical decision making.

429 Assessment of Access to Firearms in Suicidal Patients in the Emergency Department

Suicide is the 10th leading cause of death in the United States. Suicidal ideation (SI) is a common chief complaint of patients presenting to the emergency department (ED). Nearly half of suicide deaths in the United States in 2014 were due to firearms. Despite these numbers, provider documentation on access to lethal means is lacking. Our primary objective was to quantify documentation of access to firearms in patients who presented to the ED with a chief complaint of SI. We performed a retrospective chart review of consecutive patients who presented to the ED with a chief complaint or diagnosis of SI during July 2014. This study was performed at an urban, academic ED. Charts were queried from the electronic medical record. Primary outcomes assessed included whether the ED physician team documented: 1) patient access to firearms, 2) access to firearms in the home, and 3) assessment of storage methods. Assessment and documentation by psychiatry, when consulted, was compared to that of emergency physicians. Secondary outcomes included demographics, preexisting psychiatric diagnoses, substance use, disposition at time of visit, and disposition upon return visit for SI within 30 days. 100 patient charts were reviewed. 54% of this patient population was aged 30-49; 64% were male, 53% were Caucasian, and 54% were single. In this patient cohort, we found that only 3% of the 100 charts included documentation regarding access to firearms by the emergency physician. Psychiatry was consulted on 81 patients; of these, 78% included documentation of access to firearms. 36% of our patients were transferred to another psychiatric facility, 32% were admitted, and 32% were discharged home. Emergency physicians rarely documented access to firearms in this patient cohort. Given the pivotal role emergency physicians play in caring for patients in suicidal crisis, there is a need for educational and quality improvement initiatives regarding counseling against lethal means in the ED. This study is limited in that not all verbal conversations regarding access to lethal means are later documented in the electronic medical record.

Syndromic Surveillance of Mental and Substance Use Disorders: A Validation Study Using Emergency Department Chief Complaints.

This study evaluated whether emergency department (ED) patient presentations for problems related to mental and substance use disorders could be validly monitored by a syndromic surveillance system that uses chief complaints to identify mental disorders. The study used syndromic surveillance data on 146,315 ED visits to participating Fresno County, California, hospitals between January 1 and December 31, 2013. Free-text patient chief complaints are automatically classified into syndromes based on the developer's algorithms. Agreement was assessed between the algorithm's syndrome classification of mental health and substance abuse (MHSA) disorders and ICD-9-CM discharge diagnostic codes. Diagnosis and ED utilization patterns among patients with at least one visit with an MHSA syndrome classification were also examined. Approximately 8% of ED visits during the study period received an MHSA syndrome classification. Overall agreement between MHSA syndrome classification and psychiatric- or substance use-related ICD-9 discharge diagnoses was high (κ=.92, 95% confidence interval=.91-.92). Sensitivity (100%) and specificity (98.6%) of the MHSA syndrome classification were also very high. MHSA syndrome-classified patients exhibited high levels of health care and morbidity burden compared with other patients. ED chief complaints can be utilized to reliably and validly ascertain the incidence of patient presentations for mental and substance use disorders in contexts in which discharge diagnoses are not routinely available. Wider adoption of MHSA-related syndrome algorithms by syndromic surveillance systems could be valuable for public mental health surveillance, service delivery, and resource planning efforts.

Mindful EM

Mindful EM

Assessment of Fungal Infection of Peritoneal Fluid in Cirrhotic Ascites

Background and study aim: Spontaneous peritonitis (SP) is the most important infectious complication of cirrhotic patients. The aim of this study is to evaluate the occurrence of fungal infection of peritoneal fluid in cirrhotic patients with ascites. Patients and Methods: Between September 2016 and April 2017, 50 Patients were classified into (SP group) and (non SP group) all patients were subjected to history taking, clinical examination, complete blood count, ESR,CRP, liver profile, kidney function tests, serological tests for viral hepatitis markers, abdominal ultrasonography and diagnostic abdominal paracentesis. The ascitic fluid was subjected to the following: microscobic examination, biochemical examination and microbiological cultures (bacterial and fungal). Results: MELD score was higher in SP group with Mean ± SD 23.08 ± 3.85. Analysis of the results showed that abdominal pain, hepatic encephalopathy and melena were the only significant clinical presentations (chief complaint) in patients with SP compared to non SP group (52%, 40% and 8% respectively). As regard risk factors of ascitic fluid infection, 40% had previous episodes of SP. In SP patients, mean PMN count in ascitic fluid was 675.20 ± 420.02 at the time of diagnosis. Ascitic fluid bacterial culture was positive in only 40% of SP patients. Ascitic fluid fungal culture was positive in only 2 patient (8%) of SP group and negative in all patients of non SP group. The isolated organism was Candida albicans. These 2 patient had proven spontaneous fungal peritonitis owing to the presence of Candida albicans as evidenced by clinical picture of spontaneous peritonitis, high ascitic fluid PMN count and. Conclusion: Spontaneous fungal peritonitis is less common than SBP but usually presented as a severe disease, so, clinical prediction and early detection helps in proper treatment and better prognosis.

Patient-provider concordance in the perception of illness and disease: a cross-sectional study among multimorbid patients and their general practitioners in Switzerland

BackgroundMultiple chronic health conditions are leading to multiple treatment procedures and polypharmacy. Prioritizing treatment according to patients’ needs and preferences may be helpful for deprescribing. Thus, for improving health care, it is crucial for general practitioners (GPs) to perceive the chief complaints (CCs) of patients. The primary aim of this study was to investigate the patient–provider concordance of CCs and the secondary aim was to investigate the concordance between CCs and diagnosis, in a sample of Swiss multimorbid patients.Materials and methodsA cross-sectional analysis based on a cluster randomized controlled trial (RCT) among 46 GPs, recruited between March 2015 to July 2016, and 334 multimorbid patients (≥60 years taking ≥5 drugs for at least 6 months) in Northern Switzerland was performed. CCs listed by GPs and by patients (n=128) were classified according to the International Classification of Primary Care, version 2 (ICPC-2) coding system on chapter and component level and defined as concordant if ICPC-2 codes of patients and GPs were identical. Concordance was classified into full, moderate or low, depending on the ranking of patients’ CCs on GPs’ list. As secondary outcome, we compared patients’ CCs to GPs’ diagnosis. Statistics included descriptive measures and a multivariate regression analysis of factors that are modifying concordance.ResultsThe mean age of patients was 76.9 (SD 8.1) years, where 38% were male, taking 7.9 (SD 2.6) drugs on the long term. The most frequent complaint was pain. Concordance of the CC was given in 101/128 (78.9%) on the ICPC-2 chapter level, whereby 86/128 (67.2%) showed full, 8/128 (6.3%) moderate and 7/128 (5.5%) low concordance; 27/128 (21.1%) were discordant. Concordance between CCs and diagnosis was 53.6%. Concordance increased with the intensity of the CC rated by patients (OR 1.48, CI 1.13–1.94, P<0.001). The younger age and higher intake of drugs were significantly associated with an increased concordance between CCs and diagnosis.ConclusionA majority of GPs perceive the CCs of the multimorbid patients correctly, but there is room for improvement.

Inflammatory and Noninflammatory Itch: Implications in Pathophysiology-Directed Treatments.

Itch is the main chief complaint in patients visiting dermatologic clinics and has the ability to deeply impair life quality. Itch results from activation of cutaneous nerve endings by noxious stimuli such as inflammatory mediators, neurotransmitters and neuropeptides, causing itch signal transduction from peripheral skin, through the spinal cord and thalamus, to the brain cortex. Primarily noninflammatory diseases, such as uremic pruritus, cause itch through certain pruritogens in the skin. In inflammatory skin diseases, atopic dermatitis (AD) is the prototypic disease causing intensive itch by aberrant skin inflammation and epidermal barrier disruption. Recent understanding of disease susceptibility, severity markers, and mechanisms have helped to develop targeted therapy for itch in AD, including monoclonal antibodies against IL-4, IL-13, thymic stromal lymphopoietin (TSLP), IgE and IL-31. Promising effects have been observed in some of them. In this review, we summarized targeted therapies for inflammatory itch in AD and for managing abnormal itch transductions in other common itching skin diseases.

Solving One of Graduate Medical Education's Problems: A Loss of Thoroughness

Solving One of Graduate Medical Education's Problems: A Loss of Thoroughness

Repeated Emergency Medical Services Use by Older Adults: Analysis of a Comprehensive Statewide Database

The objective of this study is to characterize repeated emergency medical services (EMS) transports among older adults across a large and socioeconomically diverse region. Using the North Carolina Prehospital Medical Information System, we analyzed the frequency of repeated EMS transports within 30 days of an index EMS transport among adults aged 65 years and older from 2010 to 2015. We used multivariable logistic regressions to determine characteristics associated with repeated EMS transport. During the 6-year period, EMS performed 1,711,669 transports for 689,664 unique older adults in North Carolina. Ofthese, 303,099 transports (17.7%) were followed by another transport of the same patient within 30 days. The key characteristics associated with an increased adjusted odds ratio of repeated transport within 30 days include transport from an institutionalized setting (odds ratio [OR] 1.42; 95% confidence interval [CI] 1.38 to 1.47), blacks compared with whites (OR 1.29; 95% CI 1.24 to 1.33), a dispatch complaint of psychiatric problems (OR 1.38; 95% CI 1.25 to 1.52), back pain (OR 1.35; 95% CI 1.26 to 1.45), breathing problems (OR 1.21; 95% CI 1.15 to 1.30), and diabetic problems (OR 1.14; 95% CI 1.06 to 1.22). Falls accounted for 15.6% of all transports and had a modest association with repeated transports (OR 1.07; 95% CI 1.00 to 1.14). More than 1 in 6 EMS transports of older adults in North Carolina are followed by a repeated transport of the same patient within 30 days. Patient characteristics and chief complaints may identify increased risk for repeated transport and suggest the potential for targeted interventions to improve outcomes and manage EMS use.

Using Syndromic Surveillance Alert Protocols for Epidemiologic Response in Georgia

ObjectiveDescribe how the Georgia Department of Public Health (DPH) usessyndromic surveillance to initiate review by District Epidemiologists(DEs) to events that may warrant a public health response (1).IntroductionDPH uses its State Electronic Notifiable Disease SurveillanceSystem (SendSS) Syndromic Surveillance (SS) Module to collect,analyze and display results of emergency department patient chiefcomplaint data from hospitals throughout Georgia.MethodsDPH prepares a daily SS report, based upon the analysis ofdaily visits to 112 Emergency Department (EDs). The visits areclassified in 33 syndromes. Queries of chief complaint and dischargediagnosis are done using the internal query capability of SendSS-SSand programming in SAS/BASE. Charting of the absolute countsor percentage of ED visits by syndromes is done using the internalcharting capability of SendSS-SS. A daily SS report includes thefollowing sections:Statewide Emergency Department Visitsby Priority Syndromes(Bioterrorism, BloodyRespiratory,FeverRespiratory, FeverChest, FeverFluAdmit, FeverFluDeaths,VeryIll, andPoxRashFever, Botulism, Poison, BloodyDiarrhea,BloodyVomit, FeverGI, ILI, FeverFlu, RashFever, Diarrhea,Vomit).Statewide Flag Analysis: Is intended to detect statewideflags, by using theChartscapability in SendSS SS.Possible caseswith presumptive diagnosis of potentially notifiable diseases: Isintended to provide early-warning to the DEs of possible cases thatare reportable to public health immediately or within 7 days usingqueries in the Chief Complaint and Preliminary Diagnosis fields ofSendSS-SS.Possible clusters of illness: Since any cluster of illnessmust be reported immediately to DPH, this analysis is aimed atquerying and identifying possible clusters of patients with similarsymptoms (2).Possible travel-related illness: Is intended to identifypatients with symptoms and recent travel history.Other events ofinterest: Exposures to ill patients in institutional settings (e.g. chiefcomplaint indicates that other children in the daycare have similarsymptoms).Trend Analysis: Weekly analysis of seasonality andtrends of 14 syndromes. Finally, specific events are notified to andreviewed by the 18 DEs, who follow up by contacting the InfectionPreventionists of the hospitals to identify the patients using medicalrecords or other hospital-specific identification numbers and followup on the laboratory test results.ResultsSince 05/15/2016, 12 travel-related illnesses, 29 vaccine-preventable diseases, 14 clusters, and 3 chemical exposures havebeen notified to DEs. For instance, a cluster of chickenpox in childrenwas identified after the DE contacted the Infection Preventionist ofa hospital, who provided the DE with the laboratory results and thephysician notes about the symptoms of the patients. These actionshave resulted in earlier awareness of single cases or cluster of illness,prompt reporting of notifiable diseases, and successful interactionbetween DEs and health care providers. In addition, SS continues totrack the onset, peak, and decline of seasonal illnesses.ConclusionsThe implementation of SS in the State of Georgia is helping withthe timely detection and early responses to disease events and couldprove useful in reducing the disease burden caused by a bioterroristattack.

Integrating Musculoskeletal Education and Patient Care at Medical Student−Run Free Clinics

BackgroundStudent-run free clinics (SRFCs) have emerged as an important educational component of United States (U.S.) medical schools. Despite the prevalence of musculoskeletal (MSK) problems presenting to SRFCs, students and clinics are often unprepared to diagnose and to treat common MSK complaints. ObjectiveWe sought to determine the scope of diagnosis and treatment at a medical student−run free clinic specializing in musculoskeletal care using physical medicine and rehabilitation (PM&R) residents. Secondary goals included reviewing student satisfaction and determining the appropriateness of the clinic in medical education. DesignRetrospective chart review, anonymous online survey. SettingPrimary care, free student clinic affiliated with tertiary academic medical center. ParticipantsA total of 20 medical student volunteers, 6 PM&R residents, and 91 community patients. MethodsWe established a musculoskeletal clinic as a specialty referral clinic for the 2 primary care SRFCs with institutional support from a partner medical school. We then reviewed clinical operations retrospectively using electronic medical records and student satisfaction based on an online survey. Main Outcome MeasurementsWe analyzed patient demographics and chief complaints, referrals provided, and medical services rendered. We also used a 5-point Likert scale to assess student satisfaction. ResultsA monthly musculoskeletal referral clinic was established with the oversight of PM&R attendings and residents. The clinic received 91 referrals and managed 61 unique patients over a 2.5-year study period. The most common presentations to the clinic involved knee pain (n = 17, 27.9%) and back pain (n = 16, 26.2%). Pro bono relationships with community and institutional partners enabled all patients to receive medical examinations, physical therapy visits, plain film radiographs, and insurance consultations free of charge. Student satisfaction with teaching and patient care was high, with 19 of 20 students reporting their experience as “good” or “excellent.” ConclusionsSRFCs represent an underused opportunity to enhance MSK education among medical students by treating a variety of common MSK complaints in an underserved population. Level of EvidenceNot applicable.

Association of Hospital Resources and Imaging Choice for Appendicitis in Pediatric Emergency Departments.

Abdominal pain and concern for appendicitis are common chief complaints in patients presenting to the pediatric emergency department (PED). Although many professional organizations recommend decreasing use of computed tomography (CT) and choosing ultrasound as first-line imaging for pediatric appendicitis, significant variability persists in imaging utilization. This study investigated practice variation across children's hospitals in the diagnostic imaging evaluation of appendicitis and determined hospital-level characteristics associated with the likelihood of ultrasound as the first imaging modality. This was a multicenter (seven children's hospitals) retrospective investigation. Data from chart review of 160 consecutive patients aged 3-18 years diagnosed with appendicitis from each site were compared with a survey of site medical directors regarding hospital resource availability, usual practices, and departmental-level demographics. In the diagnostic evaluation of 1,090 children with appendicitis, CT scan was performed first for 22.4% of patients, with a range across PEDs of 3.1% to 83.8%. Ultrasound was performed for 54.0% of patients with a range of 2.5% to 96.9%. The only hospital-level factor significantly associated with ultrasound as the first imaging modality was 24-hour availability of in-house ultrasound (odds ratio = 29.2, 95% confidence interval = 1.2-691.8). Across children's hospitals, significant practice variation exists regarding diagnostic imaging in the evaluation of patients with appendicitis. Variation in hospital-level resources may impact the diagnostic evaluation of patients with appendicitis. Availability of 24-hour in-house ultrasound significantly increases the likelihood of ultrasound as first imaging and decreases CT scans. Hospitals aiming to increase the use of ultrasound should consider adding 24-hour in-house coverage.

Randomized, placebo-controlled, phase IV pilot study of ramosetron to evaluate the co-primary end points in male patients with irritable bowel syndrome with diarrhea

BackgroundGlobal assessment allows patients to assess improvement in multiple irritable bowel syndrome (IBS) symptoms. However, it was deemed important to assess “clinically meaningful improvements, focusing on the patient’s chief complaint and the severity of major IBS symptoms” in addition to global assessment to show how ramosetron is effective for individual IBS symptoms. This is a pilot study to explore clinical endpoints focusing on the chief complaint of patients with IBS with diarrhea (IBS-D).MethodsThe same database was used in a previously reported post-marketing phase IV, randomized placebo-controlled pilot trial in male patients with IBS-D. The hypothesis is completely different from that of the other study. Patients with IBS-D diagnosed according to Rome III criteria were given either 5 μg of ramosetron (n = 47) or placebo (n = 51) once daily for 12 weeks after a one-week baseline period. To explore and examine endpoints that allow evaluation of “clinically meaningful improvements focusing on the patient’s chief complaint,” the chief complaint and its relief by this study drug were assessed in this exploratory study.ResultsRates of patients with abdominal pain/discomfort, stool form and stool frequency which patients had as a chief complaint before administration were 34.0, 19.1 and 25.5%, respectively, in the ramosetron 5 μg group and 42.0, 18.0, and 20.0% in the placebo group. Responder rates for improvement in symptoms of the chief complaint that patients had before administration were 53.2% in the ramosetron 5 μg group and 42.0% in the placebo group at the last point. The greatest symptomatic improvement in the chief complaint in the ramosetron 5 μg group compared to the placebo group was shown with respect to stool consistency. Bristol Stool Form Scale (BSFS) scores were significantly lower in the ramosetron group than in the placebo group (4.36 ± 1.195 vs 4.85 ± 0.890 at the last point, P = 0.027) throughout the treatment period, except at week 6.ConclusionsRamosetron acted most effectively on stool consistency. Improvement in stool consistency is considered to be a clinically meaningful endpoint in showing how ramosetron was effective for individual IBS symptoms. (Clinicaltrials.gov ID: NCT00918411. Registered 9 June 2009).

Preventing Returns to the Emergency Department FollowingBariatric Surgery.

Unnecessary emergency department (ED) visits following bariatric surgery represent a significant source of inefficient resource utilization. This study aimed to identify potential strategies aimed at preventing unnecessary returns to the ED following bariatric surgery. The study was conducted in University Hospital, USA. The electronic medical records of all patients who underwent bariatric surgery at our institution between January 2011 and October 2015 were retrospectively reviewed. Information regarding procedure, gender, age, preoperative BMI, obesity-related comorbid conditions, postoperative length of stay (LOS), and reasons for ED visits within 90 days of surgery were obtained. Six practitioners (four attending surgeons, one resident physician, and one physician assistant) independently reviewed patient chief complaint and clinical findings at the time of ED returns. Reasons for ED return were scored as either preventable or non-preventable. "Preventable" denoted that an ED return could potentially be avoided by means of a system change in our bariatric practice. Our institution performed 361 bariatric procedures during the study period. Of these, 65 patients had 91 ED visits, 23 of which resulted in readmissions, and two of which required operative interventions. The ≤90-day all-cause postoperative ED visit rate was 18% (n=65). Of the 91 ED visits, 47% were deemed preventable (n=43). The most common preventable reasons for ED returns were nausea, vomiting, dehydration (NVD) (27.9%), postoperative pain (25.6%), wound evaluations (20.9%), and compliance issues (14%). Postoperative ED visits following bariatric surgery are prevalent and costly. Many of these visits are potentially preventable. Implementing outpatient strategies to address these causes will likely attenuate inefficient resource utilization.

A Challenge to Diagnose Amalgam Associated Lichenoid Reaction in Elderly Patient

&lt;p class="AbstractContent"&gt;&lt;strong&gt;Introduction:&lt;/strong&gt; Several studies reported the association between erosive oral lichenoid reaction (OLR) and amalgam which often arises without symptoms and rarely becomes chief complaint of patient in contrast with its local inflammatory reaction. Amalgam filling was popular in elderly patients. A decline in the protective functions of the oral mucosa could expose elder people to a variety of chemicals and put them in the higher risk to suffer from OLR.&lt;/p&gt;&lt;p class="AbstractContent"&gt;&lt;strong&gt;Case Report&lt;/strong&gt;: A 70-year-old female patient has chief complaints of taste loss and dry mouth. In the next scheduled visit, operator found a non-scrapable reticular with a reddish inflamed area on buccal mucosa adjacent to amalgam fillings which was painful when being stretched. The Amalgam filling associated OLR diagnosis was established. The lesion was reduced significantly after replacing amalgam filling followed by topical application of steroid. Many factors may contribute as the challenging factors for undetected OLR lesion during the first visit such as elderly altering mental status and pain perception.&lt;/p&gt;&lt;strong&gt;Conclusion:&lt;/strong&gt; Although the Amalgam filling associated OLR was a relatively common lesion in the elderly, factors that contribute as challenging factors to diagnose OLR must be comprehended by the dentist, in order to have a precise diagnosis.

Antibiotic Drug Utilization and Evaluation in Pediatric Patients

OBJECTIVES: To estimate the use of antibiotics in pediatric patients and categorize them according to the pediatric population on the basis of age, gender, chief complaints received, disease diagnosed, commonly preferred dosage form, average amount antibiotics prescribed per patient. Methods: This prospective study was conducted between December 2016 to April 2017 at “Sri Baby clinic” in Chennai. All children between 0 and 18 years who were examined because of the infectious disease that were enrolled. The population study was categorized in to several categories. Based on gender, age, chief complaints, disease diagnosed, etc. The divided population in each category is further quantified and expressed as percentage of the population. The obtained statistical data is represented in the form of pi-chart. The percentage of population falling under each category is noted and reported. Reports: Total of 100patients. Majority of the pediatrics patient were male 53 (53%) In the study, the total percentages of male and female Pediatric patients were 53% and 47%. Study population the age was categorized into 4 groups such as Neonates (from birth-1 month), infant (1 month-24 month), child (2years- 11years), adolescent (12 years-18 years). most of the children’s Disease diagnosed with upper respiratory tract infections 46 (46%), and gastroenteritis 23 (23%). 4 antibiotics used 2patients (2%), 3 antibiotics used 2 patients (2%), 2 antibiotics used 29 patients (29%), 1 antibiotics used 67 patients (67%). Route of administration antibiotics, oral 84 patients (84%), parental 09 patients (9%), topical applications 12 patients (12%). Chief complaints of patients most commonly fever 47 patients (47%), cough 36 patients (36%), cold 51 patients (51%), vomiting 23 patients (23%). Most used antibiotics Cephalosporins 65%, Quinolones 16%, Beta lactam antibiotics 11% (Table 7). Conclusion: Narrow spectrum antibiotics were prescribed for upper respiratory tract infections, Gasteroentirities, etc. This study showed that most commonly prescribing narrow spectrum antibiotics was Cephalosporins. The study highlights the need for development and implementation of relevant, diagnosis-specific prescribing of the antibiotic as per the guideline for the pediatric patients.

Surgery-first Approach

ABSTRACT Aim This article is intended to provide an overview of the Surgery First Approach (SFA) mainly including case selection, diagnosis, treatment protocols, success rate and the potential problems encountered. Background The most important indication of the need for orthognathic surgery is usually the psychosocial effect resulting from the unaesthetic appearance of a dentofacial deformity. The conventional approach in treatment of such deformities till today has been an orthodontics-first approach. Review Results Available evidence suggest that both the SFA and the conventional approach had similar outcomes in dentofacial relationships however the relapse tendency was greater with the SFA but the total treatment duration was substantially shorter. Conclusion SFA treats facial aesthetics (and the skeletal malrelation) first and then occlusion, i.e. orthognathic surgery antecedes the orthodontic therapy. The concept of this technique is to utilize orthognathic surgery to eliminate the displeasing pre-surgical facial profile and promptly accomplish facial aesthetic enhancement that is usually the patient's chief complaint at the beginning of the treatment. SFA also facilitates accelerated orthodontic tooth movement thus reducing the length of post-surgical orthodontic therapy. Clinical Significance The optimal esthetic and functional results, significant reduction in total treatment time and high patient satisfaction led us to the postulation that SFA may represent a reasonable, cost-effective method to manage skeletal malocclusions in selected cases and that it has the potential to become a standard approach to orthognathic surgery in the future. How to cite this article Shah YA, Deshmukh SV, Patil AS. Surgery-first Approach. World J Dent 2017;8(4):343-350.

A COMBINED TREATMENT APPROACH EMPHASIZING IMPAIRMENT-BASED MANUAL THERAPY AND EXERCISE FOR HIP-RELATED COMPENSATORY INJURY IN ELITE ATHLETES: A CASE SERIES.

Athletes experiencing hip, groin, and low back pain often exhibit similar clinical characteristics. Individuals with hip, groin and low back pain may have the presence of multiple concurrent pathoanatomical diagnoses. Regardless, similar regional characteristics and dysfunction may contribute to the patient's chief complaint, potentially creating a sub-group of individuals that may be defined by lumbopelvic and hip mobility limitations, motor control impairments, and other shared clinical findings. The purpose of this case series is to describe the conservative management of elite athletes, within the identified aforementioned sub-group, that emphasized regional manual therapy interventions, and therapeutic exercise designed to improve lumbopelvic and hip mobility, stability and motor control. Five elite athletes were clinically diagnosed by a physical therapist with primary pathologies including adductor-related groin pain (ARGP), femoral acetabular impingement (FAI) with acetabular labral lesion and acute, mechanical low back pain (LBP). Similar subjective, objective findings and overall clinical profiles were identified among all subjects. Common findings aside from the chief complaint included, but were not limited to, decreased hip range of motion (ROM), impaired lumbopelvic motor control and strength, lumbar hypomobility in at least one segment, and a positive hip flexion-adduction-internal rotation (FADIR) special test. A three-phase impairment-based physical therapy program was implemented to resolve the primary complaints and return the subjects to their desired level of function. Acute phase rehabilitation consisted of manual therapy and fundamental motor control exercises. Progression to the sub-acute and terminal phases was based on improved subjective pain reports and progress with functional impairments. As the subjects progress through the rehabilitation phases, the delivery of physical therapy interventions were defined by decreased manual therapies and an increased emphasis and priority on graded exercise. Significant reductions in reported pain (>2 points Numeric Pain Rating Scale), improved reported function via functional outcome measures (Hip and Groin Outcome Score), and continued participation in sport occurred in all five cases without the need for surgical intervention. The athletes described in this case series make up a common clinical sub-group defined by hip and lumbopelvic mobility restrictions, lumbopelvic and lower extremity motor control impairments and potentially other shared clinical findings. Despite differences in pathoanatomic findings, similar objective findings were identified and similar treatment plans were applied, potentially affecting the movement system as a whole. Subjects were conservatively managed allowing continued participation in sport within their competitive seasons. Comprehensive conservative treatment of the athletes with shared impairments, as described in this case series, may be of clinical importance when managing athletes with hip, groin, and low back pain. Therapy, Level 4, Case Series.

Reasons to seek periodontal treatment in a libyan community

Background: Periodontitis is a persistent bacterial infection characterized by the progressive destruction of the tooth-supporting structures and can lead to tooth loss. By triggering inflammatory reactions, periodontitis can detrimentally affect systemic health. Periodontitis is a prevalent disease in developed countries like the USA, whereas none is known about its prevalence or the motivations to ask for periodontal treatment in Libya. Aim of the Study: The aim of this study is to understand and analyze the motivation factors to seek periodontal care in the Libyan community; we recorded the chief complaints (CCs) of Libyan patients seeking periodontal treatment in a dental clinic. To the best of our knowledge, this is the first attempt to gather data regarding periodontal disease and the associated CCs in the Libyan community. Materials and Methods: A total of 121 (20–80 years) Libyan patients with periodontitis who sought periodontal care in a private polyclinic were examined. Their CCs were recorded and grouped into true periodontal CC, emergency, esthetic, or referral based. Results: Most of the patients had moderate-to-severe chronic periodontitis. The examiner recorded 170 CCs. They were divided into 14 different CC groups. The most popular CC (32%) was “I was told that I have gum disease,” which is not a true periodontal CC. The second (31%) was “my gum bleeds when I brush my teeth,” which represents a true periodontal CC. Pain constituted only 3% of the patients' complaints. Other true periodontal CCs reported in descending order were: teeth mobility, recession, gum enlargement, bad odor, tooth sensitivity, and gum discoloration. All together constituted 20%. The rest presented for checkup and “cleaning” (9%) or were referred before commencing orthodontic treatment (4%) or implant placement (1%). Conclusion: The major motivation factor to seek periodontal care was found to be the information given to the patient that they had periodontal problems. This emphasizes the crucial role of health-care providers in determining patients with periodontal diseases and raises the awareness level of this silent disease among the Libyan population.

A Prospective and Retrospective Study of Acute Bronchitis in Hillah City-Iraq

Acute bronchitis is a clinical term implying a self-limited inflammation of the large airways of the lung that is characterized by cough without pneumonia. The purpose of this study is to study of acute bronchitis in Hillah City-Iraq and to identify factors that are, and are not, associated with these practices. A total of 127 patients fit this criterion, and were included in the study. Factors such as patient age, gender, residential area, chief complaint (cough, shortness of breath, sinus pain, chest pain and fever), heart rate, respiratory rate and medications prescribed during the visit were obtained from the database. During the study period, there were 127 cases of acute bronchitis. Distribution of acute bronchitis according to respiratory rate and gender that there were 97(76.38%) [male: 77(79.38%) and female: 20(20.62%)] less 20 and 30(23.62%) [male: 22(73.33%) and female: 8(26.67%)]. Also acute bronchitis cases had been distributed according to heart rate (more 100 and less 100) were 47(74.60%), 52(81.25%) respectively in male and 16(25.39%), 12(18.75%) respectively in female.