Direct Clinical Observation Research Articles

Using Eulerian video magnification to enhance detection of fasciculations in people with amyotrophic lateral sclerosis.

This study seeks to determine whether the use of Eulerian video magnification (EVM) increases the detection of muscle fasciculations in people with amyotrophic lateral sclerosis (PALS) compared with direct clinical observation (DCO). Thirty-second-long video recordings were taken of 9 body regions of 7 PALS and 7 controls, and fasciculations were counted by DCO during the same 30-s period. The video recordings were then motion magnified and reviewed by 2 independent assessors. In PALS, median fasciculation count per body region was 1 by DCO (range 0-10) and 3 in the EVM recordings (range 0-15; P < 0.0001). EVM revealed more fasciculations than DCO in 61% of recordings. In controls, median fasciculation count was 0 for both DCO and EVM. Compared with DCO, EVM significantly increased the detection of fasciculations in body regions of PALS. When it is used to supplement clinical examination, EVM has the potential to facilitate the diagnosis of ALS. Muscle Nerve 56: 1063-1067, 2017.

A developmental approach to dimensional expression of psychopathology in child and adolescent offspring of parents with bipolar disorder.

The aim of this is to describe psychopathology, functioning and symptom dimensions accounting for subthreshold manifestations and developmental status in child and adolescent offspring of parents with bipolar disorder ("high-risk offspring"). The study population comprised 90 high-risk offspring (HR-offspring) and 107 offspring of community control parents (CC-offspring). Direct clinical observations and parental and offspring reports based on selected standardized clinical scales were used to assess offspring threshold and subthreshold diagnoses, symptoms and functioning. All outcomes were compared between the whole HR-offspring and CC-offspring samples and then by developmental status. After controlling for potential confounders, HR-offspring showed significantly poorer adjustment for childhood (r=0.18, p=0.014) and adolescence (r=0.21, p=0.048) than CC-offspring, as well as more emotional problems (r=0.24, p=0.001) and higher depression scores (r=0.16, p=0.021). As for differences in lifetime categorical diagnoses (threshold and subthreshold) between HR-offspring and CC-offspring, the prevalence of disruptive disorders was higher in pre-pubertal HR-offspring (OR 12.78 [1.45-112.42]), while prevalence of mood disorders was higher in post-pubertal HR-offspring (OR 3.39 [1.14-10.06]). Post-pubertal HR-offspring presented more prodromal (r=0.40, p=0.001), negative (r=0.38, p=0.002), manic (r=0.22, p=0.035) and depressive (r=0.23, p=0.015) symptoms than pre-pubertal HR-offspring, as well as more peer relationship problems (r=0.31, p=0.004), poorer childhood adjustment (r=0.22, p=0.044) and worse current psychosocial functioning (r=0.27, p=0.04). Externalizing psychopathology is more prevalent in pre-pubertal HR-offspring, while depressive and prodromal symptoms leading to functional impairment are more prominent in post-pubertal HR-offspring. Developmental approaches and dimensional measures may be useful for identifying children at high risk of developing bipolar disorder and help guide specific preventive strategies.

Diphasic dyskinesias during levodopa-carbidopa intestinal gel (LCIG) infusion in Parkinson's disease

ObjectivesLevodopa-carbidopa intestinal gel infusion (LCIG) is indicated in patients with advanced levodopa-responsive Parkinson's disease (PD) for the treatment of motor fluctuations and dyskinesias. Here we describe 4 PD patients who developed disabling diphasic dyskinesias after LCIG initiation. MethodsThe clinical data of 33 PD patients consecutively treated with LCIG therapy were obtained through direct clinical observation and detailed review of medical records. ResultsWithin 10 days, after LCIG introduction, we identified 4 subjects (12.1%) with persistent and disabling diphasic dyskinesia (DD). We tried to manage these symptoms by increasing morning LCIG flow and adding “extended-release” formulations of dopamine-agonists and levodopa/carbidopa during bedtime. Within 1 month, all patients presented a gradual reduction in the duration and severity of DD. ConclusionsTo our knowledge, this is the first report describing the occurrence of DD in a small cohort of advanced PD patients after LCIG initiation. We wish to draw the attention of clinicians to the risk of developing disabling DD in PD patients switched to the LCIG monotherapy.

What do health workers in Timor-Leste want, know and do? Findings from a national health labour market survey.

BackgroundThe objectives of this study were to understand the labour market dynamics among health workers, including their preferences and concerns, and to assess the skills, competence and performance (i.e. the ‘know–do gap’) of doctors working in Timor-Leste.MethodsThis cross-sectional survey was implemented in all 13 districts of Timor-Leste in 2014. We surveyed 443 health workers, including 175 doctors, 150 nurses and 118 midwives (about 20% of the health workers in the country). We also observed 632 clinical consultations with doctors, including 442 direct clinical observations, and tested 190 vignettes.ResultsThe study highlights some positive findings, including the gender balance of health workers overall, the concentration of doctors in rural areas, the high overall reported satisfaction of staff with their work and high motivation, the positive intention to stay in the public sector, the feeling of being well prepared by training for work, the relatively frequent and satisfactory supervisions, and the good attitudes towards patients as identified in observations and vignettes. However, some areas require more investigations and investments. The overall clinical performance of the doctors was very good in terms of attitude and moderate in regard to history taking, health education and treatment. However, the average physical examination performance score was low. Doctors performed better with simulated cases than the real cases in general, which means they have better knowledge and skills than they actually demonstrated. The factors that were significantly associated with the clinical performance of doctors were location of the health facility (urban doctors were better) and consultation time (cases with more consultation time were better). Regression analysis suggests that lack of knowledge was significantly associated with lack of performance, while lack of motivation and equipment were not significant.ConclusionsThe survey provides essential information for workforce planning and for developing training policies and terms and conditions that will attract and retain health workers in rural service. Improving the work environment and performance of doctors working in rural health facilities and ensuring compliance with clinical protocols are two priority areas needed to improve the performance of doctors in Timor-Leste.

Evaluation Methods of Bone Graft Materials

Bone graft substitute materials play an important role in oral rehabilitation and understanding the biological effects of these materials is important for an optimum use. Many bone graft substitutes have been approved for clinical use but this large variability make it hard to select a graft materials. The present study aimed to evaluate the methods that we can today use to assess the degree of osseointegration of the synthetic bone augmentation materials.For this study we made three study groups, each of them consisting of six laboratory rats. On the maxilla of this animals 3-mm diameter experimental cavities were carried out. For the first study group the cavities were augmented with the collagen fleece Alveoprotect, for the second group with the synthetic bone graft Ossceram nano, and in the third group the experimental cavities were left unaugmented. The obtained samples were subjected to three examination methods: clinical and radiological examination, Optical Coherence Tomography (OCT), and a histological study.The evaluation methods of bone graft materials may be divided in two categories: in vivo and in vitro methods. In vivo methods include clinical evaluation and imagistic such as radiological or computer tomography (CT) evaluation. Even a minimal but careful direct clinical observation allows observing the appearance of the bone defect healing at its different stages. CBCT scan is the imaging method of choice in the graft materials repairment of the osseous defects because provides 3D volumetric measurements of newly formed hard tissues.Optical Coherence Tomography (OCT) is a constantly growing imaging method characterized by high spatial resolution and noninvasive subsurface detection. The OCT allowed us to evaluate the surface and subsurface of the ongoing healing bone defects in a non-destructive manner.For the in vitro methods histological methods represents the classical evaluation of the bone graft materials biological integration. On the histological samples we generally noticed the experimental defects filling with connective tissuewith various bone ingrowths from the surrounding bone tissue.However new emerging methods give new opportunities to a more accurate research of this materials. The microcomputed tomography analysis may determine the relationships and differences in three-dimensional bone mineral density and microtrabecular structures between bone grafts and their adjacent native boneTo design and produce an efficient bone graft, the researchers and clinicians should have sufficient knowledge of the characteristics of grafts such as osteogenesis, osteoinductivity, and osteoconductivity, and their other advantages and disadvantages.

Retention of class V restorations placed by dental students: a retrospective evaluation

Objective: The aim of this study was to evaluate the clinical performance of class V restorations made by undergraduate students and determine the factors that might influence retention of restorations. Material and Methods: A survey of the clinical records created between 2007 and 2009 was used to collect data on patients with dental restorations. The USPHS (United States Public Health Service) criteria were used to perform evaluations by direct clinical observation. Statistical analyses were performed using Fisher’s exact test, Chi-square test, and Logistic regression analysis. Results: Clinical records were analyzed, of which 282 (21.3%) described class V restorations performed on a total of 781 teeth. These patients were contacted, and 67 (23.76%) attended the clinic for assessment. Out of the 221 (28.3%) evaluated teeth, 37 restorations were replaced and 184 were analyzed. The logistic regression analysis showed that gingival bleeding index (GBI), decay-missing-filled teeth (DMFT) index, and pulpal protection influenced the retention of the restorations. The association tests demonstrated superiority of the composite resin over the glass ionomer cement with regard to retention, wear, and anatomical form. Conclusion: In this study, retention of cervical composite resin restorations was higher than that of the glass ionomer cement restorations when performed by undergraduate students.Key Words: Composite resins; Glass ionomer cements; Retrospective study.

A novel mentorship programme for residents integrating academic development, clinical teaching and graduate medical education assessment.

IntroductionMentorship fosters career development and growth. During residency training, mentorship should support clinical development along with intellectual and academic interests. Reported resident mentoring programmes do not typically include clinical components. We designed a programme that combines academic development with clinical feedback and assessment in a four-year emergency medicine residency programme.MethodsIncoming interns were assigned an advisor. At the conclusion of the intern year, residents actively participated in selecting a mentor for the duration of residency. The programme consisted of quarterly meetings, direct clinical observation and specific competency assessment, assistance with lecture preparation, real-time feedback on presentations, simulation coaching sessions, and discussions related to career development. Faculty participation was recognized as a valuable component of the annual review process. Residents were surveyed about the overall programme and individual components.ResultsOver 88 % of the respondents said that the programme was valuable and should be continued. Senior residents most valued the quarterly meetings and presentation help and feedback. Junior residents strongly valued the clinical observation and simulation sessions.ConclusionsA comprehensive mentorship programme integrating clinical, professional and academic development provides residents individualized feedback and coaching and is valued by trainees. Individualized assessment of clinical competencies can be conducted through such a programme.

Inter-Rater Agreement between Trachoma Graders: Comparison of Grades Given in Field Conditions versus Grades from Photographic Review

ABSTRACTPurpose: Trachoma surveillance is most commonly performed by direct observation, usually by non-ophthalmologists using the World Health Organization (WHO) simplified grading system. However, conjunctival photographs may offer several benefits over direct clinical observation, including the potential for greater inter-rater agreement. This study assesses whether inter-rater agreement of trachoma grading differs when trained graders review conjunctival photographs compared to when they perform conjunctival examinations in the field.Methods: Three trained trachoma graders each performed an independent examination of the everted right tarsal conjunctiva of 269 children aged 0–9 years, and then reviewed photographs of these same conjunctivae in a random order. For each eye, the grader documented the presence or absence of follicular trachoma (TF) and intense trachomatous inflammation (TI) according to the WHO simplified grading system.Results: Inter-rater agreement for the grade of TF was significantly higher in the field (kappa coefficient, κ, 0.73, 95% confidence interval, CI 0.67–0.80) than by photographic review (κ = 0.55, 95% CI 0.49–0.63; difference in κ between field grading and photo grading 0.18, 95% CI 0.09–0.26). When field and photographic grades were each assessed as the consensus grade from the three graders, agreement between in-field and photographic graders was high for TF (κ = 0.75, 95% CI 0.68–0.84).Conclusions: In an area with hyperendemic trachoma, inter-rater agreement was lower for photographic assessment of trachoma than for in-field assessment. However, the trachoma grade reached by a consensus of photographic graders agreed well with the grade given by a consensus of in-field graders.

Abstract P3-07-35: Findings from the first prospective womb to breast cancer study: New gestational biomarkers support proof of concept that gestation is a window of susceptibility for the breast

Abstract Rationale. Here we provide the first prospective evidence for proof of concept that gestation is an important window of susceptibility for breast cancer. These findings could open the field to interdisciplinary investigation of mechanisms, and interventions via clinical and experimental science. Objective. We tested the hypothesis that biomarkers in gestation predict early-onset breast cancer. Data were prospectively collected including maternal and paternal peri-conceptual body mass, tobacco and alcohol use, maternal pregnancy weight gain, pregnancy complications and outcomes, placental morphology assessed by a standardized examination at birth, and environmental chemicals recently assayed in archived maternal perinatal serum samples. This investigation was based on the observation of 20,000 pregnancies beginning in 1959, with surveillance for both maternal (F0) and offspring (F1) cancer in the Child Health and Development Studies pregnancy cohort. This report is based on the first 133 breast cancer cases in F1 that occurred from 1992-2012, diagnosed at ages 32 to 52. Results. We observed gestational biomarkers of breast cancer risk which were independent of maternal history of breast cancer and race. Highlights of significant findings include independent, higher risk for women who: were born to mothers who lost weight during pregnancy (3-fold increase in risk, p&amp;lt;0.03), were growth retarded in utero (3-fold increased risk, p&amp;lt;0.01), were born with thick (p&amp;lt;0.01), but small diameter placentas (p&amp;lt;0.04), whose mothers had higher perinatal serum levels of environmental chemicals including o,p'-DDT (2.5-fold increase in risk for upper quartile, p&amp;lt;0.03), perfluorooctanesulfonic acid (PFOS) precursors (p&amp;lt;0.03) and total cholesterol (p&amp;lt;0.04). Maternal floor infarction of the placenta was a protective factor both for mothers and their daughters. In ancillary studies we observed that F1 breast density at mid-life is also impacted by placental morphology during F1 gestation. Conclusions. Here we provide a high level of evidence for the existence of gestational biomarkers for breast cancer. Prospective design and direct clinical observation of pregnancies eliminates reporting and misclassification bias. Findings extend the discussion of gestational biomarkers beyond birthweight and pre-eclampsia which have been previously reported. The importance of the gestation window for breast cancer in humans is in line with toxicological evidence in animal models and strongly suggests the existence of opportunities for primary prevention beginning before birth. Citation Format: Barbara Cohn, Nickilou Krigbaum, Lauren Zimmermann, Piera Cirillo. Findings from the first prospective womb to breast cancer study: New gestational biomarkers support proof of concept that gestation is a window of susceptibility for the breast [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P3-07-35.

Misguided guidelines for managing labor

In a recent review we expressed concerns about new guidelines for the assessment and management of labor recommended jointly by the American Congress of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM). These guidelines are based heavily on a new concept of how cervical dilatation and fetal descent progress, derived from the work of Zhang etal. In their Viewpoint article they have addressed, but not allayed, the concerns we described in our review. We assert that the dilatation curve promulgated by Zhang etal cannot be reconciled with direct clinical observation. Even if they were correct, however, it still does not follow that the ACOG/SMFM guidelines should recommend replacing the coherent system of identifying and managing labor aberrations described by Friedman. That system is grounded in well-established clinical principles based on decades of use and the objectively documented association of some labor abnormalities with poor fetal and maternal outcomes. Recommendations for new clinical management protocols should require the demonstration of superior outcomes through extensive, preferably prospective, assessment. Using untested guidelines for the management of labor may adversely affect women and children. Even if those guidelines were to reduce the currently excessive cesarean delivery rate, the price of that benefit is likely to be a trade-off in harm to parturients and their offspring. The nature and degree of that harm needs to be documented before considering adoption of the guidelines.

Does the MCAT predict medical school and PGY-1 performance?

The Medical College Admissions Test (MCAT) is a high-stakes test required for entry to most U. S. medical schools; admissions committees use this test to predict future accomplishment. Although there is evidence that the MCAT predicts success on multiple choice-based assessments, there is little information on whether the MCAT predicts clinical-based assessments of undergraduate and graduate medical education performance. This study looked at associations between the MCAT and medical school grade point average (GPA), Medical Licensing Examination (USMLE) scores, observed patient care encounters, and residency performance assessments. This study used data collected as part of the Long-Term Career Outcome Study to determine associations between MCAT scores, USMLE Step 1, Step 2 clinical knowledge and clinical skill, and Step 3 scores, Objective Structured Clinical Examination performance, medical school GPA, and PGY-1 program director (PD) assessment of physician performance for students graduating 2010 and 2011. MCAT data were available for all students, and the PGY PD evaluation response rate was 86.2% (N = 340). All permutations of MCAT scores (first, last, highest, average) were weakly associated with GPA, Step 2 clinical knowledge scores, and Step 3 scores. MCAT scores were weakly to moderately associated with Step 1 scores. MCAT scores were not significantly associated with Step 2 clinical skills Integrated Clinical Encounter and Communication and Interpersonal Skills subscores, Objective Structured Clinical Examination performance or PGY-1 PD evaluations. MCAT scores were weakly to moderately associated with assessments that rely on multiple choice testing. The association is somewhat stronger for assessments occurring earlier in medical school, such as USMLE Step 1. The MCAT was not able to predict assessments relying on direct clinical observation, nor was it able to predict PD assessment of PGY-1 performance.

Direct Versus Remote Clinical Observation: Assessing Learners' Milestones While Addressing Adolescent Patients' Needs.

Direct clinical observation is an essential component of medical trainee assessment, particularly in the era of milestone-based competencies. However, the adolescent patient's perspective on this practice is missing from the literature. Quality health care is patient centered, yet we did not know if our educational practices align with this clinical goal. We sought to better understand our adolescent/young adult patients' perspectives of the direct observation of our medical trainees in the outpatient clinical setting. As a quality improvement initiative, we surveyed adolescent/young adult patients, medical trainees, and physician observers in our outpatient clinical practice regarding their experience following a direct observation encounter. We performed descriptive analyses of the data. During a 1-year period, responses were received from 23 adolescent/young adult patients, 8 family members, 14 trainees, and 6 faculty observers. Nearly all adolescent/young adult patients (n=22) and all surveyed family members (n=8) expressed comfort with direct observation, and all respondents felt the care they received was the same or better. All patient/family respondents preferred direct observation to the idea of remote observation, and most, but not all, trainees and faculty observers expressed similar opinions. Adolescent/young adult patients and their family members found direct observation of their trainee providers to be comfortable and beneficial. Despite adolescent and young adults' facility and comfort with modern technologies, there was an expressed preference for direct versus remote observation.

PP164-SUN: How Good are Health Professionals at Assessing Nutritional Status and Growth in Hospitalized Children by Direct Clinical Observation Alone?

PP164-SUN: How Good are Health Professionals at Assessing Nutritional Status and Growth in Hospitalized Children by Direct Clinical Observation Alone?

The first Smartphone application for microsurgery monitoring: SilpaRamanitor.

Postoperative monitoring of free flap tissue perfusion is vital. Devices available are expensive and complex to operate. Most surgeons rely on direct clinical observation. A monitoring system that is reliable, inexpensive, and easy to operate is needed. Using mobile phone technology, the authors developed and evaluated a new free flap monitoring system: SilpaRamanitor. Software was developed for Android-operated mobile phones. Forty-two normal subjects were recruited to assess its effectiveness. Varying degrees of pressure were applied around the index finger to produce partial venous occlusion, partial arterial occlusion, complete venous occlusion, and complete arterial occlusion sequentially. Photographs of each subject's index and middle fingers were taken using the smartphone camera. To detect the abnormal perfusion presented on the index finger, the application was instructed to analyze photographs for color difference, with the unoccluded middle finger serving as the control. The sensitivity, specificity, accuracy, false-negative results, and false-positive results were 94, 98, 95, 6, and 1 percent, respectively. The accuracy of the application in grading occlusion severity was also evaluated. Thirty-nine cases (93 percent) were correctly identified as venous occlusion. The occlusion severity was correctly identified in 33 cases (85 percent). Likewise, for the 40 cases (95 percent) correctly identified as arterial occlusion, the method correctly categorized its severity in 33 cases (83 percent). The authors developed a new, accurate, and reliable diagnostic system for postoperative microsurgery monitoring using a smartphone application. SilpaRamanitor is inexpensive and easy to use, making it applicable in many microsurgical settings. Diagnostic, IV.

Using direct clinical observation to assess the quality of cesarean delivery in Afghanistan: an exploratory study.

BackgroundAs part of a National Emergency Obstetric and Newborn Care (EmONC) Needs Assessment, a special study was undertaken in July 2010 to examine the quality of cesarean deliveries in Afghanistan and examine the utility of direct clinical observation as an assessment method in low-resource settings.MethodsThis cross-sectional assessment of the quality of cesareans at 14 facilities in Afghanistan included a survey of surgeons regarding their routine cesarean practices, direct observation of 29 cesarean deliveries and comparison of observations with facility records for 34 additional cesareans conducted during the 3 days prior to the observation period at each facility. For both observed cases and record reviews, we assessed time intervals between specified points of care-arrival to the ward, first evaluation, detection of a complication, decision for cesarean, incision, and birth.ResultsAll time intervals with the exception of “decision to skin incision” were longer in the record reviews than in observed cases. Prior cesarean was the most common primary indication for all cases. All mothers in both groups observed survived through one hour postpartum. Among newborns there were two stillbirths (7%) in observed births and seven (21%) record reviews. Although our sample is too small to show statistical significance, the difference is noteworthy. In six of the reviewed cesareans resulting in stillbirth, a fetal heart rate was recorded in the operating theater, although four were recorded as macerated. For the two fresh stillbirths, the cesarean surgeries were recorded as scheduled and not urgent.ConclusionsDirect observation of cesarean deliveries enabled us to assess a number of preoperative, postoperative, and intraoperative procedures that are often not described in medical records in low resource settings. Comparison of observations with findings from provider interviews and facility records allowed us to infer whether observed practices were typical of providers and facilities and detect potential Hawthorne effects.

Bénéfices secondaires d’une réhabilitation cognitive réalisée chez un patient souffrant d’un éthylisme chronique : effets sur la conscience des troubles, la motivation, et la coopération globale aux soins

Alcoholism causes psychological, behavioral and cognitive symptoms that need to be addressed together. The neuropsychological alterations among alcohol-dependent people are considered to make the therapeutic work complex and longer. A cognitive rehabilitation program is sometimes difficult to achieve with these patients. Functional results are often difficult to anticipate. However, the consequences of this therapeutic approach are multiple and there are many interactions between psycho-affective, behavioral and cognitive components. A neuropsychological approach can be used like a tool to improve metacognition. A bad contribution to treatment programs is often secondary to the illusion of a satisfying intellectual functioning. Patients' motivation for the therapeutic work is very changeable. A complete consciousness of impairments can help them to stay involved. The following case shows the cognitive effects and secondary benefits associated with a neuropsychological work, which was carried out by a chronic ethylic patient with severe physical and cognitive symptoms. The patient aged 50, with a good qualification level (scientific section in the final year of secondary school, with no diploma, then attended a training program to become a croupier) was suffering from chronic alcoholism since his adolescence. He arrived in the closed unit after many hospitalizations in psychiatric and hepato-gastroenterology units. He had been showing mental confusion. He presented a frontal and subcortical profile of alcohol-related dementia according to Oslin's criteria. MRI revealed global cerebral atrophy, more pronounced on the fronto-parietal cortex with cerebellar leukoencephalopathy, but no pontine central myelinolysis. The neurocognitive program had two main lines: reducing attentional, executive and graphical deficits with training exercises (individual and group sessions) and compensating memory, and executive disorders with an external aid. The cognitive program had been assessed by means of repeated psychometric measures, behavior and metacognition estimated by direct clinical observations. The cognitive remediation was carried out during a 10-month hospitalization, and then in an outpatient rehabilitation setting over a 12-month period. The external individual sessions were associated with medical consultations and support for reintegration at home provided by the mobile psychiatric team. The test results showed a significant improvement in attentional processes and executive functions. On graphic level, his writing was recovered after 10 months. Impairment within episodic memory processes-encoding was observed, and prospective memory was reinforced by external aids. At the end of the program, the use of an agenda proved to be effective even if updating was difficult once back home. Although a part of these effects could be expected, their psychological influence on the patient must be underlined: his perception of the alcohol related problem had been modified with more consciousness of the neurobiological consequences and a strong desire of personal implication. He worked a lot on his own (always under supervision) on cognitive exercises and succeeded in remaining abstinent for nearly 2 years. He died of complications of acute hepatitis. All the cognitive assessments and rehabilitation results seem to have increased his participation in the global therapeutic care. Therapeutic tools used for cognitive work give a concrete picture of the consequences of alcohol consumption and the necessary time to retrieve brain capacities. Visible improvements in terms of reduction in disability-handicaps encouraged the patient, valued his efforts, and increased his determination to solve his alcohol related problem. Thus, cognitive programs can help to reduce passiveness and develop activeness. This patient regarded therapeutic difficulties as a challenge, not as an obstacle. We can reasonably assume the effect of the cognitive rehabilitation on the Persistence of the Cloninger's biosocial model. This increase in temperament corresponds to a certain form of tenacity, which would facilitate abstinence.

Suprastomal Cutaneous Monitoring Paddle for Free Flap Reconstruction of Laryngopharyngectomy Defects

Method of direct clinical monitoring of tissue perfusion in free tissue reconstruction of pharyngeal defects. To describe a novel and effective method of incorporating a cutaneous skin paddle into laryngopharyngectomy reconstruction for direct clinical monitoring of anterolateral thigh free flaps. Retrospective review of pharyngoesophageal reconstruction for laryngopharyngectomy defects performed between August 1, 2008, and March 1, 2011, using the anterolateral thigh flap. Tertiary care academic medical center. Consecutive patients undergoing laryngopharyngectomy where free tissue transfer is indicated. Anterolateral thigh free flap reconstruction with suprastomal cutaneous monitoring paddle. Postoperative complications, including flap failure, fistula, and stricture. Postoperative functional outcomes of swallowing and vocal capability were also measured. Twenty-one patients (mean age, 62.2 years; range, 39-81 years) underwent total laryngectomy with near-total or total pharyngectomy and immediate reconstruction with an anterolateral thigh free flap. The reconstructions included a cutaneous monitor paddle distal to the pharyngoesophageal anastomosis. Twenty patients were treated for squamous cell carcinoma and received either adjuvant or neoadjuvant radiation therapy. There were no partial or total flap losses. A late pharyngocutaneous fistula occurred at 6 weeks in 1 patient (5%), requiring exploration, and anastomotic stricture occurred in 4 patients (19%). All patients except 1 were able to swallow solid foods at a mean follow-up of 11.1 months. Nineteen patients (90%) underwent tracheoesophageal puncture and attained an intelligible voice. One patient (5%) had stomal stenosis requiring surgical management. The suprastomal cutaneous monitoring paddle enables direct monitoring of an otherwise buried reconstructive flap. This method allows direct clinical observation for microvascular compromise without a need for further procedures and without any increase in morbidity or compromise of speech and swallow functions. 4.

AB1114 Juvenile idiopathic arthritis: Can mother mood be a determinant factor in the child illness management?

BackgroundJuvenile Idiopathic Arthritis (JIA) is a chronic disease that causes children to have swelling, pain, and stiffness in their joints. JIA occurs before the age of 16. In particular child’s...

Editorial

Periprosthetic infection is a common and challenging problem in current orthopaedic surgery practice. It can result in a devastating clinical outcome and be very costly to treat. In some cases, infection is lifelong. Any implant for arthroplasty or osteosynthesis may be subject to infection [1]. However, the frequency and nature of such infection remain to be accurately characterised. Proposed definitions take into account only the objective criteria obtained from direct clinical observation or by diagnostic tools [2]. Nevertheless, it is well known that months or even years after the apparent disappearance of infection, a new episode of local clinical sepsis can develop spontaneously. Prevention, on the one hand, and careful epidemiological surveillance on the other, of infections in the orthopaedic department can maintain the incidence of infection within a “tolerable” range. Despite this, diagnosis remains most solidly grounded by a retrospective review of clinical history, when the infection has already become apparent [3]. Microbiological tests to confirm the existence of infection can fail due to false positive contamination, false negative (difficult to culture) microorganisms or antibiotic treatment. New developments in the diagnosis of infection are continually being presented, but none has yet proven infallible [4-6]. Even retrospective epidemiological short or medium-term follow up can fail to detect whether a patient will suffer in the future from periprosthetic infection, because this may develop at any time after the primary operation, either as a result of silent infection or due to newly-developed bacteraemia. The majority of these patients need more than one surgical debridement. An aggressive approach, meticulously removing necrotic or ischaemic infected soft tissue, together with peri-implant vascularisation enhancement, is the most effective basis for pharmacological treatment. Antibiotic administration consists of a single or, more frequently, a combination of antibiotics determined in accordance with the findings of a positive culture. It is currently accepted that treatment must be conducted by an orthopaedic surgeon in collaboration with a physician specialised in infectious diseases and in antibiotic management [1]. Nevertheless, early or late antibiotic resistance may require treatment changes. If the infection continues, implant removal may be necessary, followed, in due course, by the insertion of a new implant. Nevertheless, the soundness of this procedure, known as two-stage revision, has yet to be fully established. The advantages and problems of medical and surgical techniques for the diagnosis and treatment of periprosthetic infection are analysed in this issue of the Open Orthopaedic Journal.

Recognition Memory for High and Low Associative Stimuli in Autistic Individuals with Outstanding Memory Skill.

Individuals with autism exhibit typical recognition memory performance, but they show a reduced use of context and relational processing in more complex memory tasks. It is unclear whether the same is true for autistic individuals with exceptional memory skill for whom superior rote memory skill has been assumed. In this study, we investigated recognition memory for high and low associative stimuli in autistic memory experts. In accord with the rote memory notion, we expected an equal recognition performance for high and low associative stimuli and superior memorizing of nonsense material compared to control participants. Seven autistic memory experts and seven typically developed control subjects, matched according to age, sex, handedness, and full-scale intelligence quotient (IQ), were examined on a continuous old-new recognition paradigm, including high or low associative pseudowords and shapes. Memory expertise was characterized as a currently present outstanding memory skill above the subject's general level of ability and above the general population and was validated through direct clinical observation or some form of credible evidence. Our hypotheses were partially corroborated with autistic memory experts recognizing high and low associative shapes equally well in contrast to control participants who showed superior recognition of high associative shapes. However, memory experts did not outperform control participants in the recognition of low associative shapes. There were no differences for the recognition of pseudowords. Findings do not indicate enhanced memory for nonsense material, but a failure to make use of semantic features of abstract stimuli as assumed for autism as a whole.