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1.  The Outcomes of Manipulation or Mobilization Therapy Compared with Physical Therapy or Exercise for Neck Pain: A Systematic Review 
Study Design Systematic review.
Study Rationale Neck pain is a prevalent condition. Spinal manipulation and mobilization procedures are becoming an accepted treatment for neck pain. However, data on the effectiveness of these treatments have not been summarized.
Objective To compare manipulation or mobilization of the cervical spine to physical therapy or exercise for symptom improvement in patients with neck pain.
Methods A systematic review of the literature was performed using PubMed, the National Guideline Clearinghouse Database, and bibliographies of key articles, which compared spinal manipulation or mobilization therapy with physical therapy or exercise in patients with neck pain. Articles were included based on predetermined criteria and were appraised using a predefined quality rating scheme.
Results From 197 citations, 7 articles met all inclusion and exclusion criteria. There were no differences in pain improvement when comparing spinal manipulation to exercise, and there were inconsistent reports of pain improvement in subjects who underwent mobilization therapy versus physical therapy. No disability improvement was reported between treatment groups in studies of acute or chronic neck pain patients. No functional improvement was found with manipulation therapy compared with exercise treatment or mobilization therapy compared with physical therapy groups in patients with acute pain. In chronic neck pain subjects who underwent spinal manipulation therapy compared to exercise treatment, results for short-term functional improvement were inconsistent.
Conclusion The data available suggest that there are minimal short- and long-term treatment differences in pain, disability, patient-rated treatment improvement, treatment satisfaction, health status, or functional improvement when comparing manipulation or mobilization therapy to physical therapy or exercise in patients with neck pain. This systematic review is limited by the variability of treatment interventions and lack of standardized outcomes to assess treatment benefit.
doi:10.1055/s-0033-1341605
PMCID: PMC3699243  PMID: 24436697
neck pain; spinal manipulation; physical therapy; exercise; mobilization therapy
2.  Modular ‘Click-in-Emulsion’ Bone-Targeted Nanogels 
Advanced materials (Deerfield Beach, Fla.)  2012;25(10):10.1002/adma.201202881.
A new class of nanogel demonstrates modular biodistribution and affinity for bone. Nanogels, 67 nm in diameter and synthesized via an astoichiometric click-chemistry-inemulsion method, controllably display residual, free click-able functional groups. Functionalization with a bisphosphonate ligand results in significant binding to bone on the inner walls of marrow cavities, liver avoidance, and anti-osteoporotic effects.
doi:10.1002/adma.201202881
PMCID: PMC3815631  PMID: 23280931
Nanotechnology; Drug delivery; Polymers; Nanogel; Bone
3.  Israeli medical students’ perceptions of six key medical specialties 
Background
Choosing a medical specialty requires medical students to match their interests and social-cultural situations with their perceptions of the various specialties.
Objectives
Examine Israeli 6th-year medical students’ perceptions of six key specialties: pediatrics, orthopedic surgery, anesthesiology, obstetrics/gynecology, general surgery and family medicine.
Methods
Questionnaires distributed to 355 6th-year students from three successive classes (2008–2010) of 6th-year students at the Hebrew University – Hadassah School of Medicine, Jerusalem, Israel and the 2010 class of the Ben Gurion University School of Medicine, Be’er Sheva, Israel.
Results
Responses were obtained from 234 students, for a response rate of 66%. Pediatrics and obstetrics/gynecology were the specialties most often under positive career consideration by individual students. Anesthesiology and general surgery were least often under positive career consideration and were viewed as being in a workforce crisis. Pediatrics and family medicine, found to be especially popular among women, were perceived by 58% and 78% of respondents, respectively, as providing reasonable ratios of lifestyle to income. None of the students thought the same about general surgery and only 28% thought so about anesthesiology. Pediatrics and obstetrics/gynecology were reported to afford a controllable lifestyle by 63% and 8%, respectively, With respect to positive career considerations and lifestyle perceptions, there were no differences between the opinions of men and women students. Differences between genders arose in responses to queries of whether a specialty was interesting and challenging. Women were more likely than men to perceive pediatrics and family medicine as interesting and challenging while men were more likely to think that general and orthopedic surgery are interesting and challenging.
Conclusions
Knowing the medical students’ perceptions of the various specialties should help in understanding the maldistribution of physicians among the various specialties. Such data can also be an important input into the efforts of the healthcare leadership to promote a specialty distribution that matches the population’s evolving needs.
doi:10.1186/2045-4015-2-19
PMCID: PMC3668158  PMID: 23692660
Medical education; Residency; Medical specialties; Medical students; Marketing research
4.  Disc degeneration after disc herniation: are we accelerating the process? 
Study design: Systematic review.
Study rationale: Disc degeneration is a common process starting early in life. Often disc herniation is an early step in disc degeneration, which may cause pain or stenosis. How quickly this subsequent disc degeneration occurs following a disc herniation and subsequent surgical treatment and whether certain spinal procedures increase the rate of degeneration remain unclear.
Objectives: To investigate the risk of subsequent radiographic disc degeneration following discectomy, discography, and conservative care in patients with a first-time diagnosed herniated nucleus pulpous (HNP) and to ascertain whether this risk in these defined groups changes over time.
Methods: A systematic review of pertinent articles published up to June 2012. Key articles were searched to identify studies evaluating the risk of subsequent radiographic disc degeneration following treatment for HNP. Studies that included patients undergoing secondary surgery for disc herniation or that did not use a validated classification system to measure the severity of disc degeneration were excluded. Two independent reviewers assessed the strength of evidence using the GRADE criteria and disagreements were resolved by consensus.
Results: From a total of 147 possible citations, three cohort studies (class of evidence III) met our inclusion criteria and form the basis for this report. The risk of subsequent lumbar disc degeneration following standard discectomy was significantly greater compared with both microdiscectomy (48.7% vs 9.1%) and asymptomatic controls (90% vs 68%) in two studies with mean follow-ups of 5.5 and 25.3 years, respectively. Following conservative care for first-time HNP in the third study, the risk of progression of lumbar disc degeneration was 47.6% over the first 2 years of follow-up and 95.2% over the next 6 years of follow-up. In the same study, the risk of lumbar disc degeneration was shown to increase incrementally over the course of the 8-year follow-up, with all patients showing signs of degeneration at final examination.
Conclusion: Standard discectomy in first-time lumbar HNP may increase the risk of subsequent same-level lumbar disc degeneration compared with microdiscectomy as seen in one low-quality study. However, disc degeneration is likely a natural, temporal consequence following HNP, as demonstrated in a second low-quality study. The overall strength of evidence for the conclusions is very low.
doi:10.1055/s-0032-1328141
PMCID: PMC3592777  PMID: 23526910
5.  Does pregnancy increase curve progression in women with scoliosis treated without surgery? 
Study design: Systematic review.
Study rationale: It is commonly believed that scoliosis treated nonoperatively does not worsen in pregnancy; however, at times patients with scoliosis progress rapidly during these months.
Objective or clinical question: What is the level of evidence to support or deny the claim that scoliosis treated nonoperatively does not worsen in pregnancy?
Methods: A systematic review of the literature was undertaken for articles published through March 2011. PubMed, Cochrane, National Guideline Clearinghouse Databases as well as bibliographies of key articles were searched. Two independent authors reviewed articles. Inclusion and exclusion criteria were set and each article was subject to a predefined quality-rating scheme.
Results: We identified two articles meeting our inclusion criteria. There was no difference in risk of curve progression > 5° or > 10° between women who had one or more pregnancies compared with those who had never been pregnant. However, among women who had been treated with an orthosis, those with one or more pregnancies had a higher risk of curve progression > 5° compared with never-pregnant women: relative risk = 8.1 (95% confidence interval: 1.8–35.8) in one study and 1.9 (95% confidence interval: 0.8–4.3) in the other. While women with more severe curves had a higher risk of curve progression, having one or more pregnancies did not appear to modify the effect of curve severity.
Conclusions: Having one or more pregnancies does not appear to affect curve progression in scoliosis. However, among patients who had prior orthotic treatment, there is some evidence to suggest that women experiencing one or more pregnancies had a higher risk of curve progression compared with never-pregnant women. The overall strength of evidence for this conclusion is low.
doi:10.1055/s-0030-1267112
PMCID: PMC3604750  PMID: 23526896
6.  Cement augmentation in spinal tumors: a systematic review comparing vertebroplasty and kyphoplasty 
Study design: Comparative effectiveness review.
Study rationale: The spine is among the most common location for bony metastases. In many cases these metastases cause fractures leading to increased morbidity. Percutaneous cement augmentation techniques have been developed over the past decades for the treatment of these fractures; however, there are little data comparing these interventions.
Clinical question: Do comparative studies of vertebral cement augmentation for fractures caused by spinal tumors provide evidence of improved patient outcomes?
Methods: A systematic search and review of the literature was undertaken to identify studies published through June 8, 2011. Two individuals independently reviewed articles based on inclusion and exclusion criteria which were set a priori. Each article was evaluated using a predefined quality-rating system and an overall strength of evidence determined.
Results: The literature consists primarily of case series. Only two studies comparing vertebroplasty with kyphoplasty were found. Pain scores in both treatment groups were significantly decreased relative to preoperative scores and appear to have been sustained at follow-up times to 1 year. It is unclear whether one treatment provided superior pain relief than the other. Both studies reported decreased analgesic use after both treatments but neither study compared use between treatment groups. Balloon rupture occurred in one kyphoplasty patient in one study and extravasation of polymethylmethacrylate (PMMA) cement into the anterior perivertebral soft tissue was seen in another patient in the vertebroplasty group and no patients in the kyphoplasty group in the other study. No other intraoperative or postoperative complications occurred.
Conclusions: There is only limited evidence from comparative studies (two small retrospective cohort studies) regarding the benefits of vertebroplasty versus kyphoplasty in patients with spinal fractures caused by tumors. Both appear to be effective in reducing pain with relatively few complications. Whether one method provides superior results over the other cannot be determined from the available evidence. Study limitations preclude making definitive conclusions. The overall strength of evidenced is very low.
doi:10.1055/s-0031-1274755
PMCID: PMC3506144  PMID: 23230404
7.  Interspinous devices: are they as attractive as they seem? An intermediate-term follow-up 
Study design: A retrospective cohort of 68 patients who underwent insertion of the DIAM (Medtronic Sofamor Danek, Switzerland) interspinous device (ISD) during 2006–2008 at one medical center.
Objectives: To assess the short- and intermediate-term outcomes and complications associated with ISD.
Methods: Evaluation of files and all patients who underwent insertion of a DIAM ISD was performed. Patients walking distances and pain (visual analog scale score) were compared with data gathered before surgery. Outcome and all complications related to ISD have been identified and analyzed.
Results: All 68 patients were available for follow-up. Mean follow-up was 34 months (23–52 months). The average age was 57 (±13) years. Walking distance increased by 890% and patient's pain score improved by 3.27 points on visual analog scale. Twenty-one (32%) of the 68 patients had perioperative or late complications. Nine complications (75%) were unrelated to ISD and included 5 dura tears, 3 wound-related complications, and 1 transient ischemic attack. Spinous process fractures occurred in 5 cases, leading to revision in 2 cases. In total, 7 of the patients required revision surgery. These patients were older, with an average age of 69 years.
Conclusion: The outcome of patients who had an implantation of the DIAM ISD is good. In this cohort, 6% developed recurrent claudication symptoms in the second postoperative year. In an older population, the combination of softer bone and rigid stenosis increase the risk of spinous process fracture, resulting in failure and leading to revision surgery. Other solutions should be sought for these patients.
The definiton of the different classes of evidence is available on page 55.
doi:10.1055/s-0030-1267101
PMCID: PMC3621856  PMID: 23637678
8.  Medical specialty considerations by medical students early in their clinical experience 
Background
Specialty selection by medical students determines the future composition of the physician workforce. Selection of career specialties begins in earnest during the clinical rotations with exposure to the clinical and intellectual environments of various specialties. Career specialty selection is followed by choosing a residency program. This is the period where insight into the decision process might help healthcare leaders ascertain whether, when, and how to intervene and attempt to influence students' decisions. The criteria students consider important in selecting a specialty and a residency program during the early phases of their clinical rotations were examined.
Methods
Questionnaires distributed to fifth-year medical students at two Israeli medical schools.
Results
229 of 275 (83%) questionnaires were returned. 80% of the students had considered specialties; 62% considered one specialty, 25% two, the remainder 3-5 specialties. Students took a long-range view; 55% considered working conditions after residency more important than those during residency, another 42% considered both equally important. More than two-thirds wanted an interesting and challenging bedside specialty affording control over lifestyle and providing a reasonable relationship between salary and lifestyle. Men were more interested in well-remunerated procedure-oriented specialties that allowed for private practice. Most students rated as important selecting a challenging and interesting residency program characterized by good relationships between staff members, with positive treatment by the institution, and that provided much teaching. More women wanted short residencies with few on-calls and limited hours. More men rated as important residencies affording much responsibility for making clinical decisions and providing research opportunities. More than 50% of the students considered it important that their residency be in a leading department, and in a large university medical center. Only 5% considered it important to do their residency in the country's peripheral areas, while 30% reported interest in a residency in the country's center.
Conclusions
The fifth year of a six-year medical school is an opportune time to provide students with information and guidance on the various specialties and selecting a residency program as they begin to solidify their perceptions and ideas about the various specialties. This study serves as an impetus to medical educators and healthcare leaders to become interested in students' career selection.
doi:10.1186/2045-4015-1-13
PMCID: PMC3424828  PMID: 22913658
Medical students; medical specialties; specialty selection; residency; healthcare system; physician workforce
9.  Reinforcing the role of the conventional C-arm - a novel method for simplified distal interlocking 
Background
The common practice for insertion of distal locking screws of intramedullary nails is a freehand technique under fluoroscopic control. The process is technically demanding, time-consuming and afflicted to considerable radiation exposure of the patient and the surgical personnel. A new concept is introduced utilizing information from within conventional radiographic images to help accurately guide the surgeon to place the interlocking bolt into the interlocking hole. The newly developed technique was compared to conventional freehand in an operating room (OR) like setting on human cadaveric lower legs in terms of operating time and radiation exposure.
Methods
The proposed concept (guided freehand), generally based on the freehand gold standard, additionally guides the surgeon by means of visible landmarks projected into the C-arm image. A computer program plans the correct drilling trajectory by processing the lens-shaped hole projections of the interlocking holes from a single image. Holes can be drilled by visually aligning the drill to the planned trajectory. Besides a conventional C-arm, no additional tracking or navigation equipment is required.
Ten fresh frozen human below-knee specimens were instrumented with an Expert Tibial Nail (Synthes GmbH, Switzerland). The implants were distally locked by performing the newly proposed technique as well as the conventional freehand technique on each specimen. An orthopedic resident surgeon inserted four distal screws per procedure. Operating time, number of images and radiation time were recorded and statistically compared between interlocking techniques using non-parametric tests.
Results
A 58% reduction in number of taken images per screw was found for the guided freehand technique (7.4 ± 3.4) (mean ± SD) compared to the freehand technique (17.6 ± 10.3) (p < 0.001). Total radiation time (all 4 screws) was 55% lower for the guided freehand technique compared to conventional freehand (p = 0.001). Operating time per screw (from first shot to screw tightened) was on average 22% reduced by guided freehand (p = 0.018).
Conclusions
In an experimental setting, the newly developed guided freehand technique for distal interlocking has proven to markedly reduce radiation exposure when compared to the conventional freehand technique. The method utilizes established clinical workflows and does not require cost intensive add-on devices or extensive training. The underlying principle carries potential to assist implant positioning in numerous other applications within orthopedics and trauma from screw insertions to placement of plates, nails or prostheses.
doi:10.1186/1471-2474-13-8
PMCID: PMC3305668  PMID: 22276698
Distal interlocking; Distal targeting; Nailing; Free-hand locking; Computer aided surgery
10.  Long-term outcome of surgical correction of congenital kyphosis in patients with myelomeningocele (MMC) with segmental spino-pelvic fixation 
Study design: A retrospective case series of patients with myelomeningocele (MMC) who underwent kyphectomy and posterior segmental fixation using Luque rods and 16-gauge wires.
Objective: To assess outcomes after posterior kyphectomy and segmental fixation for kyphosis in patients with MMC.
Methods: Thirteen consecutive patients who underwent posterior kyphectomy for transforaminal fixation contiguous to “everted lamina.” Fusion rates, time to fusion, change in Cobb angle, complications, and improvement in activities of daily living using the Katz score were measured.
Results: Average age at time of surgery was 9.2 (range, 4.5–17) years. Average time to follow-up was 120 (range, 20–310) months. Solid fusion was achieved in 9 patients (69%) with a mean time to fusion of 12 months. The mean postoperative kyphotic curve was 22° with an average correction of 90°. Five patients (38%) experienced a postoperative complication. The mean improvement in activities of daily living score was 1.6 points and all patients achieved independent sitting balance.
Conclusion: Segmental spino-pelvic fixation is a solid alternative mode of fixation in patients with MMC with congenital kyphosis. Patient selection, proper perioperative multidisciplinary assessment, and surgeons' expertise are significant in the success of this complex surgery.
doi:10.1055/s-0030-1267082
PMCID: PMC3427965  PMID: 22956932

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