Standardized Physical Examination Research Articles

Seroepidemiologic Study of Hepatitis B Virus, Hepatitis C Virus, Human Immunodeficiency Virus and Syphilis Infections in Iranian Blood Donors

To determine the frequency of hepatitis B, hepatitis C, Human Immunodeficiency Virus (HIV) and syphilis infections in Iranian blood donors. The prevalence of serological markers of hepatitis B, hepatitis C, HIV and syphilis infections were evaluated in 318029 consecutive volunteer blood donors attending to Tehran blood transfusion service from March 2005 to March 2006. Those positive for hepatitis B surface antigen, anti-HCV, anti-HIV1/2 and VDRL (venereal disease research laboratory) reactivity were analyzed with a second independent HBsAg enzyme immunoassay (EIA) and neutralization assay; an additional independent anti-HCV EIA and HCV-RIBA assay; second independent anti-HIV1/2 test, HIV western blot and fluorescent Treponemal Antibody Absorbed (FTA-ABS), respectively. In 318029 participants, prevalence of positive HBsAg, HCV RNA, HIV western blot and FTA-ABS was 1684 (0.487%), 323 (0.093%), 11 (0.003%) and 19 (0.005%), respectively. In 1014 subjects randomly selected from these 318029 participants, besides standard interview, physical exam and routine serologic tests; anthropometric and biochemical were studies. In this selected group frequency of HBsAg was 3 (0.29, 95% CI: 0-0.64%); frequency of anti-HCV was 21 (2.07%), but it was (0.09%, 95% CI: 0-0.30%) by confirmatory HCV RNA test; frequency of HIV-Abl, 2 was 8 (0.78%), but it was 2 (0.19%, 95% CI: 0-0.48%) by confirmatory test; frequency of RPR was 0 (0%, 95% CI: 0-0.30%). Despite excluding subjects with high-risk behaviors by standard interview and physical examination, still a few asymptomatic hepatitis B, hepatitis C, HIV-infected subjects existed among volunteer blood donors with demographic and biochemical findings similar to non-infected ones.

Associations Between Physical Examination and Self-Reported Physical Function in Older Community-Dwelling Adults With Knee Pain

Knee pain is a common disabling condition for which older people seek primary care. Clinicians depend on the history and physical examination to direct treatment. The purpose of this study was to examine the associations between simple physical examination tests and self-reported physical functional limitations. A population sample of 819 older adults underwent a standardized physical examination consisting of 24 tests. Associations between the tests and self-reported physical functional limitations (Western Ontario and McMaster Universities Osteoarthritis Index physical functioning subscale [WOMAC-PF] scores) were explored. Five of the tests showed correlations with WOMAC-PF scores, corresponding to an intermediate effect (r>or=.30). These were tenderness on palpation of the infrapatellar area, timed single-leg standing balance, maximal isometric quadriceps femoris muscle strength (force-generating capacity), reproduction of symptoms on patellofemoral compression, and degree of knee flexion. Each of these tests was able to account for between 7% and 13% of the variance in WOMAC-PF scores, after controlling for age, sex, and body mass index. Three of these tests are indicative of impairments that may be modifiable by exercise interventions. Self-reported physical functional limitations among older people with knee pain are associated with potentially modifiable physical impairments that can be identified by simple physical examination tests.

Physical Examination and Magnetic Resonance Imaging in the Diagnosis of Superior Labrum Anterior-Posterior Lesions of the Shoulder: A Sensitivity Analysis

The overall purpose of our study was to examine the sensitivity of physical examination, magnetic resonance imaging (MRI), and magnetic resonance (MR) arthrogram for the identification of arthroscopically confirmed SLAP lesions of the shoulder. An analysis of 51 consecutive patients with arthroscopically confirmed SLAP lesions and no history of shoulder dislocation was performed. Before undergoing surgery, all patients underwent a standardized physical examination and had either an MRI and/or MR arthrogram performed. Sensitivity analysis was then performed on the results of both the physical examination maneuvers and the radiologic imaging compared to the arthroscopic findings at surgery. The sensitivity of O'Brien's (active compression) test was 90%, whereas the Mayo (dynamic) shear was 80% and Jobe's relocation test was 76%. The sensitivity of a physical examination with any 1 of these 3 SLAP provocative tests being positive was 100%. Neer's sign (41%) and Hawkin's impingement tests (31%) each had low sensitivity for SLAP lesions. The sensitivity of MRI for SLAP lesions was 67% when interpreted by the performing surgeon, 53% when read by a radiologist. When the MR arthrograms were analyzed alone, the sensitivity was 72% (surgeon) and 50% (radiologist), respectively. All 3 physical examination maneuvers traditionally considered provocative for SLAP pathology (O'Brien's, Mayo shear, and Jobe's relocation) were sensitive for the diagnosis of SLAP lesions. MRI and MR arthrogram imaging had lower sensitivity than these physical examination tests in diagnosing SLAP lesions. Patient history, demographics, and the surgeon's physical examination should remain central to the diagnosis of SLAP lesions. Level II, development of diagnostic criteria on basis of consecutive patients with universally applied gold standard.

High Diagnostic Yield and Accuracy of History, Physical Examination, and ECG in Patients with Transient Loss of Consciousness in FAST: The Fainting Assessment Study

Transient loss of consciousness (TLOC) is a common clinical problem. The aim of this study was to assess the yield and accuracy of the initial evaluation, consisting of standardized history, physical examination, and ECG performed by attending physicians in patients with TLOC. Five hundred and three adult patients (mean age 53 +/- 19; 56% male) presenting with TLOC to the Academic Medical Center Amsterdam between February 2000 and May 2002 were included in this study. After initial evaluation, the physician made a certain, a highly likely (>80% certain), or no initial diagnosis. Initially undiagnosed patients received additional cardiological testing, additional history taking, and autonomic function tests. After 2 years of follow-up, an expert committee determined the final diagnoses. Two-year follow-up was obtained in 99% of the patients. The yield of certain diagnoses after the initial evaluation was 24%, increasing to 63% after including the highly likely diagnoses. The diagnostic accuracy of the initial certain diagnoses was 93% (95% CI 87-97%), decreasing to 88% (95% CI 84-91%) after inclusion of the initial highly likely diagnoses. Attending physicians can make a diagnosis based on initial evaluation in 63% of patients with TLOC, with an overall diagnostic accuracy of 88%. The use of additional testing, beyond history, physical examination, and ECG can be avoided in many patients with TLOC.

Alcoholism in women: is it different in onset and outcome compared to men?

Onset and course of alcohol dependence show gender related differences (telescoping effect) suggesting that women are more vulnerable to chronic alcohol consumption. This raises the question whether the differences are associated with a different treatment outcome as well. We hypothesized, that alcohol dependent women with a telescoping course show a less favourable treatment outcome compared to men. We investigated 212 alcohol dependent patients; matching 106 consecutively admitted women with 106 men drawn from a total sample of 343 male patients. The treatment program consisted of a 6 week inpatient treatment and 12 months of outpatient aftercare. We assessed milestone variables in development and course of alcoholism and carried out standardized diagnostic tests, physical and blood examinations to evaluate the course of the disease and treatment outcome. Overall, we confirm the telescoping effect, a faster progression in the course of alcoholism (developmental events and adverse consequences) in women compared to men ("telescoping effect"). However, despite the telescoping effect treatment outcome was similar in women and men. During the inpatient treatment program no alcohol relapse occurred. Throughout the 12 months outpatient treatment we found no significant differences in the survival analysis between women (283.29+/-11.26 days) and men (284.72+/-12.16 days). At the end of the 12 months both groups had an abstinence rate of approximately 50% and a drop-out rate of 33%.

Does delay matter? The restoration of objectively measured shoulder strength and patient-oriented outcome after immediate fixation versus delayed reconstruction of displaced midshaft fractures of the clavicle

Outcome after surgical treatment for nonunion and malunion of midshaft displaced clavicle fractures has generally been described as favorable and equal to results of acute repair. This assumption has been based on subjective criteria, however, and no direct comparison is available in the literature. This study used objective measurements of limb function to compare outcome in patients who underwent delayed operative intervention for nonunion and malunion with the outcome of patients who underwent immediate open reduction and internal fixation after displaced clavicle fracture. All patients had sustained completely displaced, closed, isolated midshaft clavicle fractures, of whom 15 had undergone acute open reduction and internal fixation with a compression plate at a mean of 0.6 months after injury (acute group). Another 15 patients had undergone delayed reconstruction with open reduction, bone grafting, and compression plate fixation for nonunion or malunion a mean of 63 months after injury (delayed group). The 2 groups were similar in age, gender, original fracture characteristics, and mechanism of injury. Complete assessment included standard history and physical examination, the Disabilities of the Arm, Shoulder and Hand (DASH) score and Constant Shoulder Score, subjective rating of outcome satisfaction, and objective muscle strength testing using a previously validated and published protocol on the Baltimore Therapeutic Equipment (BTE) work simulator. There were no significant differences between acute fixation and delayed reconstruction groups with regard to strength of shoulder flexion (acute, 94%; delayed, 93%; P = .82), shoulder abduction (acute, 97%; delayed, 97%; P = .92), external rotation (acute, 97%; delayed, 90%; P = .11), or internal rotation (acute, 98%; delayed, 96%; P = .55). Constant scores in the acute group were superior (acute, 95; delayed, 89; P = .02), but differences in DASH scores were not significant (acute, 3.0; delayed, 7.2; P = .15). Shoulder flexion muscle endurance was significantly decreased in the delayed group (acute, 109%; delayed, 80%; P = .05). Differences in muscle endurance in other planes were not significantly different (abduction endurance: acute, 107%; delayed, 81%; P = .24). Both groups rated their satisfaction with the procedure as excellent. Late reconstruction of nonunion and malunion after displaced midshaft fractures of the clavicle is a reliable and reproducible procedure that results in restoration of objective muscle strength similar to that seen with immediate fixation; however, there are subtle decreases in endurance strength and outcome compared with acute fracture repair. This information should not be used to justify primary operative repair in isolation but is useful in decision-making when counseling patients with displaced midshaft fractures of the clavicle.

Puppy behavior at the veterinary clinic: A pilot study

Abstract New owners usually have many questions regarding their puppy's behavior during the first physical examination. The aim of this pilot study was to investigate the expressed by puppies when exposed to a veterinary clinic environment. The puppies' response to physical examination was also studied. A total of 102 puppies, between 8 and 16 weeks of age and of various breeds, were filmed during a standardized physical examination at the veterinary clinic. The study included an observation of the puppy free on the floor (FF) followed by a physical examination on a table (PET) and various manipulations on the floor (MF). During FF, the behavioral categories recorded were: activity, exploration, facial expression, puppy solicitation of interaction with the veterinarian, vocalization, and others. During PET and MF, the type of interaction with the veterinarian, facial expression, and ear position were examined. The study revealed some significant differences between exhibited by puppies according to their sex, age, and estimated adult weight. Behaviors generally varied widely among puppies, but some individuals showed extreme behaviors (outliers) compared to the median puppy. These included more active avoidance, more locomotion, more panting, or more vocalization, which were often correlated across contexts. These findings suggest that even at a young age, some puppies can be differentiated from others by specific behaviors. Whether or not these individuals are at higher risk of developing behavioral disorders as adults remains to be investigated.

Functional and Aesthetic Outcome and Survival after Double Free Flap Reconstruction in Advanced Head and Neck Cancer Patients

Extensive composite defects in the head and neck area may require the use of double free flap reconstructions. These reconstructions are not only surgically challenging but also challenging to patients. A realistic perspective on general outcome for the patient seems important. From January of 2002 to August of 2003, double free flap reconstructions were used in 12 patients with extensive composite head and neck defects following malignant tumor (n = 7) and osteoradionecrosis (n = 5) resection. Six patients had a standardized interview, physical examination, and clinical photographs. All reconstructions were performed using an osteocutaneous fibula flap in combination with an anterolateral thigh flap (n = 8), a radial forearm flap (n = 1), or a lateral thigh flap (n = 1). The total flap survival rate was 96 percent. Mean mandibular bone defects were 10 cm. Mean skin island sizes of osteocutaneous fibula flaps were 67 cm. Mean external skin reconstruction flap sizes were 117 cm. Mean overall survival time was 20 months in patients with malignant tumors. Patients with osteoradionecrosis reconstruction survived free of disease for an average period of 38 months. Three patients (50 percent) were very satisfied, one was neutral, and two were very dissatisfied with their functional and aesthetic results. Objective evaluation of function showed mainly deteriorated speech (83 percent) and oral incontinence (67 percent). Objective evaluation of aesthetics showed mainly color mismatch (67 percent) and flap contracture of external flaps (50 percent). Reconstruction of these major composite through-and-through defects will often result in a modest functional and aesthetic outcome. Because selected patients require these procedures, the authors give information that matches with realistic expectations.

Physical Exam and Magnetic Resonance Imaging (MRI) in the Diagnosis of Superior Labrum Anterior-Posterior (SLAP) Lesions of the Shoulder (SS-50)

There is limited data comparing the sensitivity of physical examination and MR imaging in the diagnosis of arthroscopically confirmed glenoid labral lesions. A review of 50 consecutive patients with arthroscopically confirmed superior labrum anterior-posterior (SLAP) lesions and no history of shoulder dislocation was performed. The study was prospectively designed with IRB approval. All patients underwent a standardized physical examination that was compared to the official radiologist’s report of MR and/or MR arthrogram imaging. Sensitivity analysis was performed. To determine a difference in sensitivity of 8% between testing modalities, a pre-study power analysis determined that the minimal sample size was 25 patients (for a study with a power of 0.80 and an alpha of 0.05). The sensitivity of O’Brien’s active compression test was 90%, whereas the Mayo (dynamic) shear was 80% and Jobe’s relocation test was 76%. The sensitivity of a physical exam with any one of these three tests being positive was 100%; the sensitivity of requiring at least two positive tests ranged from 64% - 72%, and the sensitivity decreased to 58% if all three of these maneuvers was deemed necessary for the diagnosis. Neer (42%) and Hawkin’s impingement tests (32%) each had low sensitivity for SLAP lesions. The sensitivity of MRI for SLAP lesions was 68% when interpreted by the performing surgeon, 54% when read by a radiologist. When the gadolinium enhanced MRI’s were analyzed as a subset (performed in 17 patients), the sensitivity was 76% (surgeon) and 52% (radiologist), respectively. O’Brien’s test was highly sensitive while the Mayo shear and Jobe’s relocation tests had good sensitivity in the diagnosis of SLAP lesions. MR and MR arthrogram imaging had a lower sensitivity than these examination tests in diagnosing SLAP lesions. Patient history and physical examination remain central to the diagnosis of glenoid labral lesions. While MRI is not as sensitive, it remains an adjunct for the clinician in treating these patients.

Focused echocardiographic evaluation in resuscitation management: Concept of an advanced life support–conformed algorithm

Emergency ultrasound is suggested to be an important tool in critical care medicine. Time-dependent scenarios occur during preresuscitation care, during cardiopulmonary resuscitation, and in postresuscitation care. Suspected myocardial insufficiency due to acute global, left, or right heart failure, pericardial tamponade, and hypovolemia should be identified. These diagnoses cannot be made with standard physical examination or the electrocardiogram. Furthermore, the differential diagnosis of pulseless electrical activity is best elucidated with echocardiography. Therefore, we developed an algorithm of focused echocardiographic evaluation in resuscitation management, a structured process of an advanced life support-conformed transthoracic echocardiography protocol to be applied to point-of-care diagnosis. The new 2005 American Heart Association/European Resuscitation Council/International Liaison Committee on Resuscitation guidelines recommended high-quality cardiopulmonary resuscitation with minimal interruptions to reduce the no-flow intervals. However, they also recommended identification and treatment of reversible causes or complicating factors. Therefore, clinicians must be trained to use echocardiography within the brief interruptions of advanced life support, taking into account practical and theoretical considerations. Focused echocardiographic evaluation in resuscitation management was evaluated by emergency physicians with respect to incorporation into the cardiopulmonary resuscitation process, performance, and physicians' ability to recognize characteristic pathology. The aim of the focused echocardiographic evaluation in resuscitation management examination is to improve the outcomes of cardiopulmonary resuscitation.

Shoulder Pain and Dysfunction Among Collegiate Club Volleyball Players

Shoulder Pain and Dysfunction Among Collegiate Club Volleyball Players Although volleyball players commonly complain of shoulder pain, the epidemiology of volleyball-related shoulder pain - particularly among male athletes - is not well understood. PURPOSE: This study was designed to improve our understanding of shoulder problems among volleyball players. METHODS: Questionnaires incorporating the “Simple Shoulder Test” were distributed to the 2352 athletes participating in the 2006 NIRSA Collegiate Club Volleyball Championships in SLC, Utah. Respondents were invited to submit to a standardized shoulder physical examination, and complete a follow-up questionnaire. RESULTS: 422 athletes (18% participation rate) completed Part I questionnaires; 258 athletes completed a supplemental questionnaire and consented to a shoulder exam. Over half of the respondents had experienced volleyball-related shoulder problems, with over 40% reporting a shoulder problem during the current season. Nearly 50% of respondents lost time from training or competition as a result of their shoulder problem. Females had lower average shoulder functional scores, and tended to seek medical attention more frequently than did males, but scapular malposition and periscapular atrophy were more prevalent among males. Both males and females demonstrated increased external rotation combined with reduced internal rotation of the dominant shoulder compared to the non-dominant side. CONCLUSIONS: Our findings suggest that overuse injuries of the shoulder contribute significantly to the volleyball athlete's ability to participate in this overhead sport. Although both genders reported comparable rates of time-lost due to their shoulder problems, females seem to perceive greater associated functional loss than males. Our findings also suggest that gender may play a significant role in the pathophysiologic adaptation to chronic musculoskeletal overload at the shoulder joint. These data may facilitate identification of volleyball athletes at risk for shoulder pain and dysfunction, and might also lead to sport-specific interventions designed to reduce the prevalence of shoulder problems among volleyball enthusiasts.

Complications of Spinal Instrumentation

Despite tremendous technical advances in spine surgery in recent decades, patients may experience residual or recurrent pain and other symptoms after such surgery. The standard history and physical examination have only limited utility for assessing the postoperative anatomy, and radiologists can play an important role in diagnosing complications and guiding postoperative care. To do so effectively, they must be familiar with the imaging features of successful and unsuccessful fusion, instrumentation fracture and loosening, complications due to faulty hardware placement, and postoperative infection. A basic knowledge of spinal biomechanics and common approaches to surgical instrumentation also may help radiologists anticipate and identify complications.

Recommendations and Considerations Related to Preparticipation Screening for Cardiovascular Abnormalities in Competitive Athletes: 2007 Update

Sudden deaths of young competitive athletes are tragic events that continue to have a considerable impact on the lay and medical communities.1–17 These deaths are usually due to a variety of unsuspected cardiovascular diseases and have been reported with increasing frequency in both the United States and Europe.1,5 Such deaths often assume a high public profile because of the youth of the victims and the generally held perception that trained athletes constitute the healthiest segment of society, with the deaths of well-known elite athletes often exaggerating this visibility. These counterintuitive events strike to the core of our sensibilities, periodically galvanizing discussion and action, and in the process raise practical and ethical issues related to detection of the responsible cardiovascular conditions. Preparticipation cardiovascular screening is the systematic practice of medically evaluating large, general populations of athletes before participation in sports for the purpose of identifying (or raising suspicion of) abnormalities that could provoke disease progression or sudden death.13,16 Indeed, identification of the relevant diseases may well prevent some instances of sudden death after temporary or permanent withdrawal from sports or targeted treatment interventions.15,17–21 In addition, the increasing awareness that automated external defibrillators (AEDs) may not always prove successful in the secondary prevention of sudden death for athletes with cardiovascular disease22 underscores the importance of preparticipation screening for the prospective identification of at-risk athletes and the prophylactic prevention of cardiac events during sports by selective disqualification. Although some critics have questioned the effectiveness of cardiovascular screening,23,24 overwhelming support for the principle of this public health initiative exists in both the medical and lay communities.13–16,25 The efficacy of the various athlete screening strategies is not easily resolved in the context of evidence-based investigative medicine. Recently, recommendations of the European Society of Cardiology (ESC)16 and International …

Type 2 Deiodinase Thr92Ala Polymorphism Is Not Associated With Arterial Hypertension in Type 2 Diabetes Mellitus Patients

To the Editor: A single nucleotide polymorphism in Type 2 deodinase ( Dio2 ) gene (A/G) in humans, in which a threonine (Thr) changes to alanine (Ala) at codon 92 (Thr92Ala), has been associated with a lower glucose disposal rate and higher insulin resistance in type 2 diabetes (DM2) patients.1,2 Nevertheless, these findings were not replicated in larger studies.3,4 Recently, Gumieniak et al reported that the Ala allele increases the risk for development of arterial hypertension.5 Since insulin resistance can cause hypertension, we sought to extend …

Measures of Renal Function, BMD, Bone Loss, and Osteoporotic Fracture in Older Adults: The Rancho Bernardo Study

The association between bone and renal function in healthy seniors is not well studied. In this cross-sectional and longitudinal study in 1713 older men and women, creatinine clearance was significantly associated with hip BMD. If confirmed, this may warrant adding mild to moderate renal dysfunction as an indication for osteoporosis screening. This study determined the cross-sectional and longitudinal association between measures of renal function and BMD, bone loss, and osteoporotic fracture in older adults. It determined which measure of renal function--creatinine clearance by the Cockcroft-Gault (CG) equation, estimated glomerular filtration rate by the Modification of Diet in Renal Disease (MDRD) equation, or serum creatinine--is most strongly associated with BMD and osteoporotic fracture. This was a cross-sectional and prospective study in older community-dwelling men and women. Between 1992 and 1995, 1713 participants (average age, 71.3 +/- 11.1 years) completed standardized questionnaires, physical examinations, laboratory testing, and bone densitometry; 1023 participants returned for a follow-up visit in 1997-1999, an average of 4.1 +/- 0.9 years later. Calculated renal function declined with age (p < 0.001). Renal function was categorized by Kidney Disease Outcomes Quality Initiative (K/DOQI) chronic kidney disease (CKD) stage. By the CG equation, at baseline, 5.5% of participants had stage 1 CKD (glomerular filtration rate > or = 90 ml/min/1.73 m(2)), 43.0% had stage 2 CKD (60-89 ml/min/1.73 m(2)), 48.8% had stage 3 CKD (30-59 ml/min/1.73 m(2)), and 2.7% had stages 4 and 5 CKD (<30 ml/min/1.73 m(2)). Using the MDRD equation, these percents were 7.0%, 61.7%, 30.9%, and 0.5%, respectively. In cross-sectional analyses, there was a significant linear association between creatinine clearance by CG or glomerular filtration rate by MDRD and hip BMD. In prospective analyses, there was an average annual bone loss of 0.6% and a significant association between baseline CG and 4-year hip bone loss. There was no association between baseline MDRD or serum creatinine and bone loss. At baseline, 180 of 1713 participants (11%) reported at least one clinical fracture of the hip, femur, forearm, or wrist; 79 (8%) reported new clinical fractures during follow-up. Baseline renal function by any measure was not significantly associated with prevalent or incident clinical fractures. Although renal function measured by both CG and MDRD was associated with BMD in cross-sectional analyses, only creatinine clearance by CG predicted 4-year bone loss. If confirmed, this should be the preferred method for assessing the association between renal function and BMD. Cross-sectional associations between renal function and BMD were strongest at higher CKD stage. None of the baseline renal function estimates was associated with prevalent or incident fractures, perhaps reflecting the multifactorial etiology of fractures beyond BMD. If further studies in the elderly confirm renal function as an important predictor of bone loss and fracture, this may warrant adding mild to moderate renal dysfunction as an indication for osteoporosis screening.

Predictive Factors for Incident Musculoskeletal Disorders in an In-Plant Surveillance Program

A surveillance program for upper-limb work-related musculoskeletal disorders (UWMSD) based on assessment of health and risk factors was implemented between 1996 and 2000 in a large shoe factory with overall high levels for biomechanical exposure. The study aimed to identify workers with an increased risk of UWMSD incidence. In 1996, 1997 and 2000, 166 workers filled out a questionnaire and underwent a standardized physical examination. Factors from the 1996 questionnaire (general, personal and occupational factors) associated with UWMSD incidence in 1997 were selected. The predictive role of these variables was studied with a logistic model, taking into account also gender and age. The performance of a risk score based on this model was studied in 2000, using the Wilcoxon test and ROC curves. In 1997, 28 incident cases of UWMSD were observed (N = 107, 26.2%). Work pace and prior history of UWMSD were the only factors significantly associated with UWMSD incidence in 1997 (respectively 33% versus 13%, P = 0.02 and 58% versus 22%, P = 0.01). Psychological distress (36% versus 21%, P = 0.10), physical fatigue (35% versus 22%, P = 0.14), repetitiveness (30% versus 18%, P = 0.17) and task precision (33% versus 21%, P = 0.16) were also included in the logistic model for 1997 UWMSD incidence. Controlling for these variables, prior history of UWMSD remained associated with incidence in 1997 (OR = 5.5, 95% CI = 1.4-21.8). In the period from 1997 to 2000, 24 incident cases were observed (N = 102, 23.5%). The risk score, based on variables from the 1997 model, was significantly higher for incident cases (median = 6 in incident cases versus 4.5 for healthy subjects, P = 0.02). ROC curves indicated that the highest agreement reached 67% for sensitivity and 59% for specificity. Among subjects who did not change their task (N = 71, 18 incident cases), performance reached 66% for specificity with the same sensitivity. These results suggest that surveillance programs of UWMSD at a company level are possible even with overall high levels for biomechanical exposure and should take into account occupational and personal factors, including prior history of UWMSD.

Assessment of Health Issues and Concerns of Israeli Seventh Graders During School Physician Examinations: A Pilot Study

The AMA Guidelines for Adolescent Preventive Services (GAPS) recommends annual medical evaluations during adolescence, emphasizing screening and counseling regarding psychosocial issues. In Israel, seventh graders undergo medical examinations within the school health services, focusing on the detection of physical conditions. We addressed the psychosocial issues of these students by introducing an expanded school physician evaluation. Twelve school physicians performed structured expanded health evaluations for seventh graders in 11 schools. Each student completed a questionnaire (checklist) with 22 health topics "about which s/he may want to receive information." The physician then carried out a biomedical and psychosocial evaluation, physical examination, and offered counseling to the student. Two hundred and seventy-eight students were examined. The questionnaire required 1-2 minutes, and the physician's evaluation 20-25 minutes. Health behaviors revealed included: currently dieting (28%), no physical activity after school (35%), ever smoked cigarettes (3%), ever smoked a water pipe (9%), used alcoholic beverages (6%), and does not always use front (22%) or rear (55%) seat belt. Nine percent rated their mood as being less than 7 (on a scale from 1 to 10). The leading topics about which the students requested information were height (50%), acne (42%), weight (38%), nutrition/diet (37%), physical activity (35%), and menstrual period (29% of the girls). The physicians counseled the students on an average of 3.6 topics per visit. An expanded school physician examination identifies students with psychosocial problems otherwise undetected during standard physical examinations, and provides the opportunity to address their personal concerns.

Percutaneous treatment of displaced intra-articular calcaneal fractures

BackgroundThe outcome after displaced intra-articular calcaneal fractures is influenced by the condition of the surrounding soft tissues. To avoid secondary soft tissue complications after surgical treatment, several less-invasive procedures for reduction and fixation have been introduced. The percutaneous technique according to Forgon and Zadravecz is suitable for all types of displaced intra-articular calcaneal fractures and was therefore introduced in our clinic. The aim of this study was to evaluate the long-term outcome of percutaneous treatment according to Forgon and Zadravecz in patients with displaced intra-articular calcaneal fractures. MethodsA cohort of patients with displaced intra-articular calcaneal fractures treated with percutaneous surgery was retrospectively defined. Clinical outcome was evaluated by standardized physical examination, radiographs, three published outcome scores, and a visual analogue scale of patient satisfaction. ResultsFifty patients with 61 calcaneal fractures were included. After a mean follow-up period of 35 months, the mean values of the Maryland foot score, the Creighton-Nebraska score, and the American Orthopaedic Foot and Ankle Society score were 79, 76, and 83 points out of 100, respectively. The average visual analogue scale was 7.2 points out of 10. The average range of motion of the ankle joint was 90% of normal and subtalar joint movements were almost 70% compared with the healthy side or normal values. Superficial wound complications occurred in seven cases (11%) and deep infections in two (3%). A secondary arthrodesis of the subtalar joint was performed in five patients and was scheduled in four patients (15%). ConclusionsCompared with the outcome of historic controls from randomized trials and meta-analyses, this study indicates favorable results for the percutaneous technique compared with the open technique. Despite similar rates of postoperative infection and secondary arthrodesis, the total outcome scores and preserved subtalar motion are overall good to excellent.

A Prospective Multicenter Study on Fever of Unknown Origin

We conducted a prospective study to update our knowledge of fever of unknown origin (FUO) and to explore the utility of a structured diagnostic protocol. From December 2003 to July 2005, 73 patients with FUO were recruited from 1 university hospital (n = 40) and 5 community hospitals (n = 33) in the same region in The Netherlands. FUO was defined as a febrile illness of >3 weeks' duration, a temperature of >38.3 degrees C on several occasions, without a diagnosis after standardized history-taking, physical examination, and certain obligatory investigations. Immunocompromised patients were excluded. A structured diagnostic protocol was used. Patients from the university hospital were characterized by more secondary referrals and a higher percentage of periodic fever than those referred to community hospitals. Infection was the cause in 16%, a neoplasm in 7%, noninfectious inflammatory diseases in 22%, miscellaneous causes in 4%, and in 51%, the cause of fever was not found (no differences between university and community hospitals). There were no differences regarding the number and type of investigations between university and community hospitals. Significant predictors for reaching a diagnosis included continuous fever; fever present for <180 days; elevated erythrocyte sedimentation rate, C-reactive protein, or lactate dehydrogenase; leukopenia; thrombocytosis; abnormal chest computed tomography (CT); and abnormal F-fluorodeoxyglucose positron emission tomography (FDG-PET). For future FUO studies, inclusion of outpatients and the use of a set of obligated investigations instead of a time-related criterion are recommended. Except for tests from the obligatory part of our protocol and cryoglobulins in an early stage, followed by FDG-PET, and in a later stage by abdominal and chest CT, temporal artery biopsy in patients aged 55 years or older, and possibly bone marrow biopsy, other tests should not be used as screening investigations.

Prevalence of Vitamin D Insufficiency in Obese Children and Adolescents

Recent studies have shown a broad prevalence of vitamin D deficiency in adults. Serum 25-hydroxyvitamin D (25-OHD) levels were reported to be inversely related to body mass index (BMI) and body fat content and correlated directly with hypertension, degree of insulin resistance and progression to diabetes mellitus. We sought to determine the prevalence of vitamin D insufficiency and markers of metabolic syndrome in an obese pediatric population. Charts of 217 obese (weight >95th percentile for age and sex) children (118 females, 99 males; mean BMI 32.2 +/- 6.4 kg/m2; mean age 12.9 2 5.5; age range 7-18 years) who had received a standard physical examination at the pediatric endocrine clinic of the Infants and Children's Hospital of Brooklyn at Maimonides, Brooklyn, NY, were retrospectively analyzed. Data obtained included age, sex, weight, BMI, height and systolic and diastolic blood pressure. The routine bloodwork panel for obesity at our pediatric endocrine facility includes fasting 25-OHD, total cholesterol, high density lipoprotein-cholesterol (HDL-C), low density lipoprotein-cholesterol (LDL-C), triglycerides, ALT, AST, thyroid stimulating hormone (TSH), total T4, and insulin and glucose. Insulin sensitivity as calculated by quantitative insulin-sensitivity check index (QUICKI = 1/[log(I0) + log(G0)], where I0 is fasting insulin and G0 is fasting glucose) was computed following the visit. Overall, 55.2% of patients were vitamin D insufficient (25-OHD <20 ng/ml). Severely low vitamin D levels (25-OHD < or =10 ng/ml) were seen in 21.6% of 217 patients, which represents almost half of the insufficient group. In the 25-OHD <20 ng/ml group age, BMI, and SBP were significantly higher than in the 25-OHD 220 ng/ml group, while QUICKI (<0.35 is consistent with insulin resistance) was borderline low in the <20 ng/ml group. HDL-C was significantly lower in the 25-OHD < or =10 ng/ml group. The 25-OHD levels correlated negatively with BMI and positively with HDL-C. No other findings were significant. More than half of the obese children had vitamin D levels <20 ng/ml with equal gender distribution. Vitamin D insufficiency was associated with increased age, BMI, and SBP, and decreased HDL-C.