Neutral View Research Articles

Investigating the contribution of physician assistants to primary care in England: a mixed-methods study

BackgroundPrimary health care is changing as it responds to demographic shifts, technological changes and fiscal constraints. This, and predicted pressures on medical and nursing workforces, raises questions about staffing configurations. Physician assistants (PAs) are mid-level practitioners, trained in a medical model over 2 years at postgraduate level to work under a supervising doctor. A small number of general practices in England have employed PAs.ObjectiveTo investigate the contribution of PAs to the delivery of patient care in primary care services in England.DesignA mixed-methods study conducted at macro, meso and micro organisational levels in two phases: (1) a rapid review, a scoping survey of key national and regional informants, a policy review, and a survey of PAs and (2) comparative case studies in 12 general practices (six employing PAs). The latter incorporated clinical record reviews, a patient satisfaction survey, video observations of consultations and interviews with patients and professionals.ResultsThe rapid review found 49 published studies, mainly from the USA, which showed increased numbers of PAs in general practice settings but weak evidence for impact on processes and patient outcomes. The scoping survey found mainly positive or neutral views about PAs, but there was no mention of their role in workforce policy and planning documents. The survey of PAs in primary care (n = 16) found that they were mainly deployed to provide same-day appointments. The comparative case studies found that physician assistants were consulted by a wide range of patients, but these patients tended to be younger, with less medically acute or complex problems than those consulting general practitioners (GPs). Patients reported high levels of satisfaction with both PAs and GPs. The majority were willing or very willing to consult a PA again but wanted choice in which type of professional they consulted. There was no significant difference between PAs and GPs in the primary outcome of patient reconsultation for the same problem within 2 weeks, investigations/tests ordered, referrals to secondary care or prescriptions issued. GPs, blinded to the type of clinician, judged the documented activities in the initial consultation of patients who reconsulted for the same problem to be appropriate in 80% (n = 223) PA and 50% (n = 252) GP records. PAs were judged to be competent and safe from observed consultations. The average consultation with a physician assistant is significantly longer than that with a GP: 5.8 minutes for patients of average age for this sample (38 years). Costs per consultation were £34.36 for GPs and £28.14 for PAs. Costs could not be apportioned to GPs for interruptions, supervision or training of PAs.ConclusionsPAs were found to be acceptable, effective and efficient in complementing the work of GPs. PAs can provide a flexible addition to the primary care workforce. They offer another labour pool to consider in health professional workforce and education planning at local, regional and national levels. However, in order to maximise the contribution of PAs in primary care settings, consideration needs to be given to the appropriate level of regulation and the potential for authority to prescribe medicines. Future research is required to investigate the contribution of PAs to other first contact services as well as secondary services; the contribution and impact of all types of mid-level practitioners (including nurse practitioners) in first contact services; the factors and influences on general practitioner and practice manager decision-making as to staffing and skill mix; and the reliability and validity of classification systems for both primary care patients and their presenting condition and their consequences for health resource utilisation.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Hold-Over Admissions: Are They Educational for Residents?

Since implementation of resident duty-hour restrictions, many academic medical centers utilize night-float teams to admit patients during off hours. Patients are transferred to other resident physicians the subsequent morning as "hold-over admissions." Despite the increase of hold-over admissions, there are limited data on resident perceptions of their educational value. This study investigated resident perceptions of hold-over admissions, and whether they approach hold-over admissions differently than new admissions. Survey of internal medicine residents at an academic medical center. A total of 111 residents responded with a response rate of 71 %. Residents reported spending 56.2 min (standard deviation [SD] 18.9) compared to 80.0 min (SD 25.8) admitting new patients (p < 0.01). Residents reported spending significantly (p < 0.01) less time reviewing the medical record, performing histories, examining patients, devising care plans and writing orders in hold-over admissions compared to new admissions. Residents had neutral views on the educational value of hold-over admissions. Features that significantly (p < 0.01) increased the educational value of admissions included severe illness, patient complexity, and being able to write the initial patient care orders. Residents estimated 42.5 % (SD 14) of their admissions were hold-over patients. Residents spend less time in all aspects of admitting hold-over patients. Despite less time spent admitting hold-over patients, residents had neutral views on the educational value of such admissions.

Anteroposterior translation of the glenohumeral joint in various pathologies: differences between shoulder MRI in the adducted neutral rotation and abducted externally rotated positions

The present study was performed to determine the translation of the glenohumeral joint in patients with and without shoulder lesions by comparing the magnetic resonance images obtained in the conventional adducted neutral rotation position with those obtained in the abducted externally rotated position. Two hundred and eighty-five consecutive shoulders without rotator cuff tears that had been subjected to magnetic resonance imaging (MRI) without arthrography in the abducted externally rotated position were reviewed retrospectively. Among them, 50 shoulders without pathology were selected at random to be compared with three shoulder pathology groups, comprising shoulders with superior labrum, anterior-to-posterior (SLAP) lesions without range of motion (ROM) limitation (group I, 47 shoulders), with massive rotator cuff tears without ROM limitation (group II, 20 shoulders), and with full-thickness subscapularis tendon tears without ROM limitation (group III, 20 shoulders). Glenohumeral translation in the anterior-to-posterior direction relative to the glenoid face was evaluated using a method based on the glenohumeral contact point (CP) and humeral head centre (HHC) in the adducted neutral rotation and abducted externally rotated views, which were measured by three orthopaedic surgeons. For each shoulder, the differences in translation for the glenohumeral CP and HHC between the adducted neutral rotation and abducted externally rotated views were calculated as relative posterior translation in millimetres. The differences in ΔCP and ΔHHC between group I and the normal control group were not statistically significant. The differences in ΔCP (P = 0.001) and ΔHHC (P = 0.001) between group II and the normal control group were statistically significant. Additionally, the differences in ΔCP and ΔHHC between group III and the normal control group were not statistically significant. The MRI in abducted externally rotated view in patients with SLAP lesions or full-thickness subscapularis tendon tears diagnosed by conventional MRI alone showed no significant glenohumeral posterior translation relative to the adducted neutral rotation view in the present study. However, the abducted externally rotated view in patients with massive rotator cuff tears showed significant glenohumeral anterior translation relative to the adducted neutral rotation view.

Kong Girls and Lang Mo: teen perceptions of emergent gender stereotypes in Hong Kong

The aim of this study was to explore how young people perceive and evaluate two emergent gender stereotypes in Hong Kong. It examines how the young population defines and negotiates the meanings of two media labels, Kong Girls (Hong Kong Girls) and Lang Mo (teenage models), which have become a part of daily usage. Moving beyond the debates about misrepresentations in the media, the paper discusses the functions and influences of stereotypes. A survey was conducted with 920 secondary school students. The findings were mixed. On the one hand, respondents expressed either favourable or neutral views towards the two labels with pejorative meanings. On the other hand, their evaluations of the characteristics of the two subtypes revealed the traces of many existing gender expectations. Both benevolent and hostile sexism were noticeable, which also suggests that the respondents' views were based on normalised judgments. The study highlights how fashionable terms that are coined and circulated by the mass media become new labels for specific social groups, and how they can form into more solid impressions in young people's minds. The results draw attention to the power and limits of the mass media in perpetuating gender stereotypes. The discussion considers the roles of sexism, new forms of femininity and the changing media environment in teen perceptions.

The semantics and verification of timed service choreography

As a service composition and coordination language, the service choreography gives the global and neutral view on the collaboration among a collection of highly distributed services involving multiple different organizations or heterogeneous independent processes. In this paper, we extend the service choreography by introducing the explicit time activity, which can be used to specify and reason about the timed behaviour of Web service choreography. Then we explore an execution model for the proposed timed service choreography which possesses several novel features, such as timed activity, choreography composition, exception handling and finalization. Furthermore, a set of mapping rules is elaborately designed to translate the timed choreography into communicating sequential programs processes, thus the corresponding simulation and verification of Web services choreographies with timing restrictions can be carried out in the model checker process analysis toolkit. The case study shows that our approach is both effective and practical.

Does the Post-Acquisition Performance of Bidding Firms Depend on the Organizational Form of Targets Acquired?

A number of theoretical arguments such as corporate monitoring hypothesis, liquidity hypothesis and managerial motive hypothesis propose that the acquisitions of private targets are more value creating than the acquisitions of public targets. Using two large samples of acquirers of public targets and acquirers of private targets, we examine the post-acquisition operating performance of Australian bidders. The excess returns earned by these two samples during the announcement period reveal that the market perceives the acquisitions of private targets as value creating decisions while having a neutral view on the acquisitions of public targets. These findings corroborate existing evidence in the area while providing support for the relevant theories. An analysis of acquisition year financial profiles reveals that the acquirers of public targets are much larger in size, highly profitable and cash rich than the acquirers of private targets. Compared with acquisition-year performance, acquirers of public targets were able to maintain their performance in the post-acquisition years while the acquirers of private targets were able to show a significant improvement. However, when the industry-adjusted abnormal performance was analyzed, it was found that the former group outperformed their industry peers as well as the latter group by a significant margin. A number of bid and firm characteristics were found to have differential influences on the performance of two types of acquirers. Our sensitivity analyses revealed that the influences of bid and firm characteristics are somewhat sensitive to the benchmark used to generate abnormal performance and the scaling factor used to calculate performance measures.

ACDF Using the Solis Cage with Iliac Bone Graft in Single Level: Clinical and Radiological Outcomes in Average 36 months Follow-up.

ObjectiveTo evaluate the utility of anterior cervical discectomy and fusion (ACDF) with polyetheretherketone (PEEK) cage and autograft through long term(average 36 months) follow-up.MethodsThirty selected patients (male:20/female:10) who suffered from cervical radiculopathy, myelopathy or radiculomyelopathy underwent a single level ACDF with PEEK cage and autograft from iliac crest from March 2006 to July 2008 in single institute. We followed patients for an average 36.4±8.1 months (ranged from 23 to 49 months). The Japanese Orthopedic Association (JOA) score for evaluation of myelopathy and visual analogue scale (VAS) for radiating pain was used to estimate postoperative clinical outcome. Plain x-ray on true lateral standing flexion, extension and neutral position view and 3D CT scan were used every 6 months after surgery during follow-up period.ResultsThe mean VAS and JOA scoring improved significantly after the surgery and radiological fusion rate was accomplished by 100% 36 months after the surgery. We had no complication related with the surgery except one case of osteomyelitis. There was one case of Grade I fusion, four cases of grade II, and 25 cases of grade III by radiologic evaluation.ConclusionThis long term follow-up study for ACDF with PEEK cage shows that this surgical method is comparable with other anterior cervical fusion methods in terms of clinical outcomes and radiologic fusion rate.

Hemilaminectomy and vertebral stabilization for thoracolumbar intervertebral disc associated dynamic compression in 11 dogs

To describe the diagnostic findings, surgical technique and outcome in dogs with thoracolumbar intervertebral disc-associated dynamic compression. Retrospective case series. Client owned dogs (n = 11). Medical records (2005-2010) of dogs with a stress myelographic diagnosis of spinal cord injury due to thoracolumbar intervertebral disc-associated dynamic compression with inconclusive compression in the neutral myelographic views that had hemilaminectomy and vertebral stabilization were reviewed. Data on pre- and postoperative neurologic status, diagnostic findings, surgical techniques and outcomes were retrieved. Follow-up clinical and radiographic evaluations were performed immediately, and at approximately one, two, and six months postoperatively as well as at annual follow-up examinations. The stress myelography demonstrated distinct ventral dynamic compression due to bulging of the disc and additional dorsal compression due to infolding of the ligamentum flavum in some cases. The median percentage of post-stress reduction in spinal cord height on the lateral view was 18.0% (9.8-27.2%). All dogs recovered after surgery and at follow-up examinations were still ambulatory (median: 45 months, range: 7 to 94 months). Thoracolumbar intervertebral disc degeneration may result in disc-associated dynamic compression. Stress myelography was an effective means of diagnosing this condition and hemilaminectomy with vertebral stabilization was an effective treatment resulting in long-term neurological improvement in all dogs.

Engaged or Not? Perceptions of Australian Influence among Asian Publics

AbstractDespite Australia's increasing economic ties with Asia, little is known about how it is perceived by the typical citizen in the region. This paper seeks to contribute to the Australian discussion on ‘Asian engagement’, as well as to a general understanding of the structure of foreign policy beliefs, by examining perceptions of Australia's influence among the mass publics of 14 Asian polities. Despite some anxiety in Australia on national op-ed pages and among political leaders over how the country is perceived, we find that the average person in Asia probably does not have a strong or meaningful opinion about Australia's foreign policy. Using survey data covering the years 2006 through 2008 from the AsiaBarometer project, we find that, on average, far more people view Australia's influence on their country favorably (40.5%) than view it unfavorably (6.1%). A similar percentage (41.5%), however, have neutral views of Australia's influence, and 12% of people in Asian nations express no opinion on the topic. We suggest these high frequencies of neutral perceptions and non-response are evidence of considerable indifference towards Australia. Furthermore, we investigate the correlates of perceptions of Australia's influence and find that in almost all cases citizens’ views about US and Chinese influence on their country are much better predictors of their views of Australia's influence than core values, identity, information, and demographic characteristics. We posit that opinions about Australia, even those that are favorable, may have less to do with perceptions of Australia specifically, and more to do with respondents’ general internationalist sentiment or perceptions of major powers.

Cervical Alignment and Range of Motion After Laminoplasty

A large-scale analysis of radiographical results of patients with cervical spondylotic myelopathy and a review of the literature. To identify changes in sagittal alignment and range of motion (ROM) after cervical laminoplasty. Cervical laminoplasty is an effective procedure for decompressing multilevel spinal cord compression. It often induces postoperative complications such as loss of lordotic alignment and restriction of neck motion. Although numerous studies have reported the loss of flexion-extension ROM after laminoplasty, no large-scale study has been reported. Five hundred twenty consecutive patients with cervical spondylotic myelopathy (331 male and 189 female; mean age, 62.2 yr) who underwent modified double-door laminoplasty were enrolled. The average follow-up period was 33.3 months. All patients were allowed to sit up and walk on the first postoperative day using an orthosis, which could be removed within the first 2 weeks, even if long. Early cervical ROM exercises were performed as a part of the rehabilitation schedule. Radiography was performed before surgery and at the final follow-up. Cervical alignment in the neutral and flexion-extension view were measured by the Cobb method at C2-C7. The ROM was assessed by measuring the difference in alignment between flexion and extension. The mean C2-C7 alignment in the neutral position was 11.9° lordotic preoperatively and 13.6° lordotic postoperatively; the alignment increased by 1.8° in lordosis. The mean total ROM decreased from a preoperative value of 40.1° to 33.5° at the final follow-up, showing a significant difference of 6.6°. The mean total ROM preservation after laminoplasty was 87.9%. Sagittal alignment was slightly changed, with only a 1.8° increase in lordosis. The ROM of the cervical spine was preserved by 87.9%. This preservation of alignment and ROM might be attributable to improvements including early removal of the cervical orthosis, postoperative neck exercises, and some surgical modifications.

Trends in Food Attitudes and Behaviors Among Adults with 6–11‐Year‐Old Children

This study presents an analysis of survey data measuring food attitudes and behaviors among a nationally representative sample of adults with 6–11‐year‐old children for 2002–2010 from Experian Simmons Market Research. Results show numerous significantly positive improvements in attitudes and behaviors regarding healthier diets. In general, parents report increasing fiber intake, thinking about calories, and reducing sweets consumption as well as a generic effort to eat healthier. However, some areas still needing improvement include relatively neutral views that their diet is “very healthy” and that they only snack on healthy foods. While there are a number of improvements in parents' attitudes and behaviors regarding a healthy diet, the majority of the ground gained was early, from 2002 to between 2003 and 2006. This study's results suggest that a better understanding of the parental “snacking mindset” and indulgence‐healthy diet paradox might further assist in addressing childhood obesity.

Modern soldiery interrogated: cataloguing the local military's tasks and their perception of local civilian actors

The recent expansion of the Philippine military's tasks into areas not related to security and combat has had repercussions on their interface with local civilian actors. Through a survey of 93 soldiers from two communist front-line units in Western Visayas, the article examines the nature of tasks, civilian–military engagements and the soldiers' perception of local civilians. The soldiers perform predominantly non-combat tasks. They have more engagements with other local security forces and elected civilian authorities. These engagements are neither robust nor dense, with civilians providing material assistance to military-instigated activities. The soldiers have neutral views about elected authorities, civil society organizations and government agencies, and a moderately negative outlook towards the Commission on Human Rights, the media, the police and ex-rebels. The general skepticism over local government frameworks and capacity is tempered with the practical necessity of working with these local stru...

The Pyhäjärvi Cataract Study II. Criteria for cataract surgery

It is necessary to develop tools for patient selection to target cataract surgery to patients with the best expected outcomes. We used visual acuity, visual functioning 14 (VF-14) test, the 15-dimension health-related quality-of-life questionnaire (15D) and the New Zealand priority criteria to evaluate the criteria for cataract surgery in a post hoc setting. Ninety-three consecutive patients living in a defined rural area in Finland had cataract surgery as a part of the Pyhäjärvi Cataract Study in 2003. Success of cataract surgery was defined as improvement of visual acuity by at least 2 lines and/or improvement of visual function measured by questionnaires. The patients with a visual acuity of 0.30 logMAR (0.5 Snellen decimal) or worse in the better eye and/or 0.52 logMAR (0.3 Snellen decimal) in the worse eye had successful surgery in 59-83% of cases depending on the definition of success. When subjective judgement was added, the success rates varied between 63% and 91%. Setting indication criteria, it seems sufficient to use two global questions in addition to visual acuity: one on the subjective view on disability, and one on a more neutral view on visual function, such as the 15D item on vision. The VF-14 did not perform any better than the single item counterparts.

The face in congenital melanocytic nevus syndrome

Congenital melanocytic nevi (CMN) are known to be associated with neurological abnormalities and melanoma, but have not been considered to be part of a developmental syndrome. The objective of this study was to test our clinical observation that children with CMN show more facial similarities than might be expected by coincidence. We selected facial photographs of 95 white Caucasian children with CMN from our database only on the basis of good neutral views, allowing careful evaluation of facial morphology. These were scored independently by two clinical geneticists using standardized categories and definitions for facial morphology. Prevalence of age-independent features was compared to established norms in a large population, and associations with cutaneous phenotype were investigated. CMN were found to be associated with characteristic facies, and 74% of children in this series had at least three typical features. The characteristic features were: wide or prominent forehead, apparent hypertelorism, eyebrow variants, periorbital fullness, small/short nose, narrow nasal ridge, broad nasal tip, broad or round face, full cheeks, prominent pre-maxilla, prominent/long philtrum, and everted lower lip. No association was found with the severity of cutaneous phenotype. We conclude that children with CMN often have a characteristic face. We propose the term "congenital melanocytic nevus syndrome" to describe this association.

Card sort methodology: An objective measure in rehabilitation research

Haitham Jahrami, PhD Card sort clinical tests such as the Wisconsin Card Sort Test and Activity Card Sort are well known in several clinical practices, including psychiatry, neurology, neuropsychology, and learning disabilities. However, card sort methodology is less famous as a research methodology. This editorial attempts to shed light on the novelty of the card sort methodology and its relevance to rehabilitation research. Card sort methodology, commonly referred to as the card sort method, was introduced in 1935 by William Stephenson, a physicist and psychologist who served as the last assistant to Charles Spearman, the inventor of factor analysis [1]. In the card sort method, the researcher initially selects a set of items that are placed on individual cards. Collectively, the cards are called the card sort set and may be composed of a series of statements, words, pictures, instructing tasks, etc. [2]. Participants are then asked to sort the cards according to certain instructions such as approval versus disapproval, most like me versus least like me, or lowest versus highest priority. Denzine provides the example of a researcher who is seeking student perceptions on the most desirable place to study in a university campus [3]. A card sort set would have to include all of the possible study locations (e.g., library, computer laboratory, student union); students would be asked to rank the cards using a desirability continuum. Thus, the middle cards are likely to contain the neutral views and extreme cards will contain the strongest views. The strongest views most likely contain the most important information. In questionnaire format, each question is independent of the others. The card sort method involves an “ipsative” approach, which means that each item in the card sort set is dependent and interrelated. The participants are less likely to respond to an item that is inconsistent with the previous item because their choice is likely to be guided by the previous response. Denzine points out that in a forced sort situation, a normal statistical distribution will occur because of the ranking procedure that results in fewer cards being selected to represent the strongest held views of the participants. The method could therefore be used to understand relationships between items, to group items into categories, and to understand the subject’s mental models of item organization. Using the working example of patients’ perceptions on the factors affecting quality of life, the major advantage of using the card sort method would be the generation of a systematic and comprehensive view of the patients’ perceptions on these factors by examining how patients will subjectively rank the various factors, e.g., pain, activities of daily living, and leisure activities. Another advantage of this method is that it merges qualitative and

Public support for neonatal screening for Pompe disease, a broad-phenotype condition

BackgroundNeonatal screening for Pompe disease has been introduced in Taiwan and a few U.S. states, while other jurisdictions including some European countries are piloting or considering this screening. First-tier screening flags both classic infantile and late-onset Pompe disease, which challenges current screening criteria. Previously, advocacy groups have sometimes supported expanded neonatal screening more than professional experts, while neutral citizens' views were unknown. This study aimed to measure support for neonatal screening for Pompe disease in the general public and to compare it to support among (parents of) patients with this condition. The study was done in the Netherlands, where newborns are not currently screened for Pompe disease. Newborn screening is not mandatory in the Netherlands but current uptake is almost universal.MethodsA consumer panel (neutral group) and (parents of) patients with Pompe disease (Pompe group) were sent information and a questionnaire. Responses were analyzed of 555 neutral and 58 Pompe-experienced informants who had demonstrated sufficient understanding.Results87% of the neutral group and 88% of the Pompe group supported the introduction of screening (95% CI of difference -10 to 7%). The groups were similar in their moral reasoning about screening and acceptance of false positives, but the Pompe-experienced group expected greater benefit from neonatal detection of late-onset disease. Multivariate regression analysis controlling for demographics confirmed that approval of the introduction of screening was independent of having (a child with) Pompe disease. Furthermore, respondents with university education, regardless of whether they have (a child with) Pompe disease, were more likely to be reluctant about the introduction of screening than those with less education, OR for approval 0.29 (95% CI 0.18 to 0.49, p < 0.001).ConclusionsThis survey suggests a rather high level of support for newborn screening for Pompe disease, not only among those who have personal experience of the disease but also among the general public in the Netherlands. Optional screening on the basis of informed parental consent is probably unrealistic, underlining the need for new guidelines to help policymakers in their consideration of newborn screening for broad phenotype conditions.

A radiographic analysis of degenerative spondylolisthesis at the L4–5 level

Lumbar degenerative spondylolisthesis (LDS) is common and has generally been characterized as a homogeneous disease entity in the literature and in clinical practice. Because disease variability has not been carefully characterized, stratification of treatment recommendations based on scientific evidence is currently lacking. In this study, the authors analyzed radiographic parameters of patients with LDS at the L4-5 level to better characterize this entity. Demographic data were collected from 304 patients (200 women and 104 men) with LDS at the L4-5 level. Plain radiographs including anteroposterior, lateral, and flexion-extension lateral radiographs were analyzed for disc height, segmental angulation, segmental translation, and osteophyte formation. Correlations were sought between the variables of age, sex, disc height, segmental angulation, segmental translation, and osteophyte formation. The mean patient age was 63.8 years (range 40-86 years). The mean mid-disc height was 7 mm (range 0-14 mm) on the neutral lateral view. The mean angulation between the superior endplate of L-5 and the inferior endplate of L-4 was 6° of lordosis (range 13° of kyphosis to 23° lordosis) on the neutral lateral view. The mean angular change between flexion and extension lateral radiographs was 5° (range 0°-17°). The mean translation on the neutral lateral view was 6 mm (range 0-15 mm). The mean change in translational between flexion and extension was 2 mm (range 0-11 mm). Twenty patients (7%) exhibited spondylolisthesis only on the flexion view. A significant positive correlation was found between the change in angulation and the change in translation on flexion and extension views (ρ = 0.18, p = 0.001). No significant correlation was found between anterior osteophyte size and mobility with flexion-extension radiographs. The wide range in all radiographic parameters for LDS confirms the heterogeneous nature of this condition and suggests that a grading system to subclassify LDS may be clinically useful. On flexion and extension radiographs, increased translational motion correlated with increased angular motion. Anterior osteophyte size was not found to be predictive of segmental stability. This data set should prove beneficial to those seeking to subcategorize LDS in the future.

Estimation of Stellate Ganglion Block Injection Point Using the Cricoid Cartilage as Landmark Through X-ray Review

BackgroundStellate ganglion block is usually performed at the transverse process of C6, because the vertebral artery is located anterior to the transverse process of C7. The purpose of this study is to estimate the location of the transverse process of C6 using the cricoid cartilage in the performance of stellate ganglion block.MethodsWe reviewed cervical lateral neutral-flexion-extension views of 48 patients who visited our pain clinic between January and June of 2010. We drew a horizontal line at the surface of the cricoid cartilage in the neutral and extension views of cervical lateral x-rays. We then measured the change in the shortest distance from this horizontal line to the lowest point of the transverse process of C6 between the neutral and extension views.ResultsThere was a statistically significant difference in the shortest distance from the horizontal line at the surface of the cricoid cartilage to the lowest point of transverse process of C6 between neutral position and neck extension position in both males and females, and between males and females in both neutral position and neck extension position. The cricoid cartilage level was 4.8 mm lower in males and 14.4 mm higher in females than the lowest point of transverse process of C6 in neck extension position.ConclusionsPractitioners should recognize that the cricoid cartilage has cephalad movement in neck extension. In this way, the cricoid cartilage can be still useful as a landmark for stellate ganglion block.

Congenital atlantoaxial dislocation: a dynamic process and role of facets in irreducibility

Patient age at presentation with congenital atlantoaxial dislocation (CAAD) is variable. In addition, the factors determining irreducibility or reducibility in these patients remain unclear. The facets appear to contribute to the stability of the joint, albeit to an unknown extent. The objective of this paper was to study the characteristics of C1-2 facets in these patients and their bearing on the clinicoradiological presentation and management. Twenty-four patients with CAAD were studied. Fifteen patients had irreducible CAAD (IrAAD); 3 of these patients experienced incomplete reduction after traction, and 9 had reducible CAAD (RAAD). The images (CT scans of the craniovertebral junction in a neutral position) obtained in the parasagittal, axial, and coronal planes were studied with respect to the C1-2 facets and were compared with 32 control scans. The inferior sagittal and coronal C-1 facet angles were measured. The lordosis of the cervical spine (cervical spine angle calculated on radiographs of the cervical spine, neutral view) in these patients was compared with normal. The management of these patients is described. The inferior sagittal C-1 facet angle and at least one coronal angle in patients with IrAAD were significantly acute compared with those in patients with RAAD and the control population. A significant correlation was found between age and the acuteness of the inferior sagittal C-1 facet angle (that is, the more acute the angle, the earlier the presentation). The lordosis of the cervical spine was exaggerated in patients with IrAAD. Three patients with IrAAD who had smaller acute angles experienced a partial reduction after traction and a complete reduction after intraoperative distraction of the facets, thereby avoiding a transoral procedure. An inferior sagittal C-1 facet angle of more than 150° in the sagittal plane predicted reducibility. Drilling a wedge off the facet in the sagittal plane to make the inferior sagittal C-1 facet angle 150° can reduce the C1-2 joint intraoperatively by posterior approach alone. The acuteness of the inferior C-1 sagittal facet angles possibly determines the age at presentation and reducibility. The coronal angles determine the telescoping of C-2 within C-1. Patients with IrAAD can be treated using a posterior approach alone with the exception of those with extremely acute angles or a retroflexed dens. The exaggerated lordosis of the cervical spine in these patients is a compensatory phenomenon.

Do rebuttals affect future science?

In theory, rebuttals play a vital role in the progression of science, pointing out flaws in published articles, and ensuring that science self-corrects. However, the effect of rebuttals has not been tested in practice. We examined seven high-profile original articles and their rebuttals, finding that original articles were cited 17 times more than rebuttals, and that annual citation numbers were unaffected by rebuttals. When citations did not mention rebuttals, 95% accepted the thesis of the original article uncritically, and support remained high over time. On the rare occasions when rebuttals were cited, the citing papers on average had neutral views of the original article, and 8% actually believed that the rebuttal agreed with the original article. Overall, only 5% of all citations were critical of the original paper. Our results point to an urgent need to change current publishing models to ensure that rebuttals are prominently linked to original articles.