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Background Comparing cohorts with similar functional and motor status at admission to inpatient rehabilitation may delineate demographics or impairments associated with recovery from lateropulsion, also known as "pusher syndrome," after stroke based on lesion side. The aim of this case–control study was to determine how demographics and severity of stroke impairments at admission to inpatient rehabilitation distinguish patients who recover from lateropulsion from those who do not. Methods Patients with admission motor Functional Independence Measure (FIM) scores less than 31 and contralesional lower extremity Fugl-Meyer motor scores less than 19 out of 34 were included. Burke Lateropulsion Scales score of 2 or higher at the time of discharge from inpatient rehabilitation indicated persistent lateropulsion; a score of 0 or 1 indicated resolved lateropulsion. Logistic regression tests included age, gender, admission Motricity Index score, limb placement error, and cognitive FIM score. χ 2 analyses compared groups for neglect. Results For patients with left brain lesion, older age and worse admission motor status distinguished those with persistent lateropulsion at discharge. For right brain lesion, related factors were older age, greater admission limb placement error, and lower cognitive FIM scores. Visuospatial neglect did not influence recovery from lateropulsion. Conclusions Older age and severe impairments were associated with delayed recovery from lateropulsion in a manner specific to lesion side in a sample with motor and functional deficits. The study provides evidence that lesion side and admission characteristics are useful in early decision making for the duration of rehabilitation, selection of interventions, and discharge planning.

Background. Lateropulsion, a postural control disorder, delays recovery following hemispheric stroke. The number of stroke impairments may lead to differential recovery rates, depending on the intact systems available for recovery from lateropulsion. Objective. To study the impact of key postural control deficits on lateropulsion rate of recovery following stroke. Methods. Through retrospective analysis: 169 patients with hemispheric stroke in an in-patient rehabilitation facility were divided into 3 groups: (1) motor deficits only; (2) motor and hemianopic or visual–spatial deficits or motor and proprioceptive deficits; and (3) motor, proprioceptive, and hemianopic or visual–spatial deficits. Kaplan–Meier survival analysis determined if time to recovery from lateropulsion (achieving a score of 0 or 1 on the Burke Lateropulsion Scale) differed by group. Results. Log rank tests showed that time to recovery from lateropulsion differed based on the number of deficits (group, P = .012). Post hoc analyses by lesion side showed that group differences only occurred in right brain lesion ( P < .05) as compared with left brain lesions ( P = .34). Patients recovered from lateropulsion during in-patient rehabilitation if they had only motor deficits; those with all 3 postural control deficits showed the most protracted recovery. Conclusions. Rate of recovery from lateropulsion after stroke is dependent on the side of lesion, and number of key motor, proprioceptive, and/or hemianopic or visual–spatial deficits. The more postural control systems affected, the slower the recovery. Our data identify patients likely to need protracted rehabilitation targeting key postural control deficits.

Aims: To identify disease management-related activities that could pose a burden to patients with systemic lupus erythematosus (SLE) and their families. Methods: The rheumatology charts of 20 pediatric patients diagnosed with SLE were retrospectively reviewed. One patient evolved into a connective tissue disease picture and was thus excluded from the analysis. The charts were examined to identify the following disease management activities that are required of patients and families during the first 2.5 years after diagnosis: medications used, pediatric rheumatology clinic appointments, laboratory tests, and out- and in-patient diagnostic tests completed. Results: Nineteen children had a median age of 14 years (range: 9–17 years). An average of seven medications per interval was used in the first two intervals and did not vary significantly in the third, fourth and fifth intervals. The most common immunomodulating agent prescribed was hydrocholorquine. Mycophenolate mofetil use increased after the first in...

Systemic lupus erythematosus in children is a multisystem disease with extensive organ involvement characterized by its chronic, fluctuating and unpredictable course. The physical, emotional and social effects of systemic lupus erythematosus significantly impact the health-related quality of life (HRQOL) of patients. In the last several years, the need for addressing HRQOL in children with systemic lupus erythematosus has been recognized and there has been significant progress. The current tools offer significantly greater advantages compared with the older scales used to measure HRQOL in these children. The relationship between HRQOL and disease activity and damage has been examined. Research is underway to examine HRQOL globally across different countries and cultures.

Understanding the events preceding emergency department (ED) asthma visits can guide patient education regarding managing exacerbations and seeking timely care. The objectives of this analysis were to assess time to seeking ED care, self-management of asthma exacerbations, and clinical status on presentation.A total of 296 patients was grouped according to time to seeking ED care: ≤1 day (22%), 2-5 days (44%), and5 days (34%) and was compared for clinical and psychosocial characteristics. Asthma severity at presentation was obtained from patient report with the Asthma Control Questionnaire (ACQ) and the Asthma Quality of Life Questionnaire (AQLQ) and from physicians' ratings using decision to hospitalize as an indicator of worse status. RESULTS. Mean age was 44 years, 72% were women, 10% had been in the ED in the prior week, and 28% came to the ED by ambulance. Patients who waited longer were more likely to be older, have more depressive symptoms, and have been in the ED in the prior week. They also were more likely to have taken more medications, but they were not more likely to have visited or consulted their outpatient physicians. Patients who waited longer reported worse ACQ (p.0001) and AQLQ (p = .0002) scores and were more likely to be hospitalized for the current exacerbation (odds ratio 1.9, 95% CI 1.1, 3.2, p = .03).Patients who waited longer to come to the ED had worse asthma on presentation, had more functional limitations, and were more likely to be hospitalized. The ability to gauge severity of exacerbations and the use of the ED in a timely manner are important but often overlooked are self-management skills that patients should be taught.

Literature is lacking on partial IgA deficiency. In this study, the authors propose to describe the clinical manifestations of patients with partial IgA deficiency. Methods. The authors conducted a retrospective chart review of 13 patients with partial IgA deficiency followed at the pediatric rheumatology clinic at Robert Wood Johnson Medical School. They looked for the presence of rashes, joint pain, joint swelling, and morning stiffness. The authors also examined charts for a history of frequent infections, allergies, and the presence of elevated antinuclear antibody. Results. Eleven out of the 13 patients complained of joint pain, joint swelling, or morning stiffness. Six patients carried a diagnosis of a definitive rheumatic disease. Four patients suffered from frequent infections and 2 patients reported allergies. Conclusion. Partial IgA deficiency appears to be associated with rheumatic diseases and complaints of joint pain, joint swelling, and morning stiffness. A larger study is needed to confirm these results.

Compilation of worldwide data regarding the incidence and prevalence of pediatric-onset systemic lupus erythematosus (SLE) is needed in order to evaluate the scope of the disease in the pediatric population. A literature review was performed to unify the current data available on the global incidence and prevalence of pediatric-onset SLE. We examined 13 available epidemiological studies concentrated on the incidence and prevalence of pediatric-onset SLE. The available reports were predominantly from North America, Europe and Asia. The limited amount of studies available highlights the need for more epidemiological research in order to better comprehend the global scope of this disease.

Patients using the emergency department (ED) for asthma may benefit from self-management education. Our goal is to test an educational intervention in 296 asthma ED patients.This was a randomized controlled trial with concealed allocation. Controls received instruction from an asthma knowledge test, peak flowmeter training, and asthma brochures. Intervention patients received these plus a self-management workbook, a behavioral contract, inhaler training, and telephone reinforcements. The main outcome was change in Asthma Quality of Life Questionnaire (AQLQ) score at 8 weeks (a change of 1.5 is a marked clinically important difference). Secondary outcomes were repeated ED visits and change in AQLQ scores at 4, 12, and 16 weeks and 1 year.Mean age of patients was 44 years, and 93% had the 8-week follow-up. Enrollment AQLQ scores were comparable and increased at 8 weeks by more than a marked clinically important difference in both groups. For controls, the change in score was 1.95 (95% confidence interval [CI] 1.74 to 2.16; P.001), for intervention patients the change in score was 1.83 (95% CI 1.64 to 2.03; P.001), and the difference between groups was 0.11 (95% CI -0.17 to 0.40; P=.43). Patients who improved more (ie, change was above the group mean) were more likely to be high school graduates (odds ratio=1.9; 95% CI 1.0 to 3.8), previous or current smokers at enrollment (odds ratio=2.2; 95% CI 1.3 to 3.5), and to have been admitted to the hospital from the ED (odds ratio=1.7; 95% CI 1.0 to 2.8). Similar variables were associated with AQLQ outcomes in hierarchic analyses during 16 weeks. Repeated ED visits occurred for 12% of patients at 8 weeks and in multivariate analysis were associated with no hospitalization for the index ED visit, difficult access to outpatient care, and previous ED visits. Fewer patients (16%) had an ED visit at 12 weeks compared with a similar time before enrollment (36%).Patients in both groups had marked sustained improvements in clinical status 16 weeks after an ED visit for asthma. A self-management education intervention delivered in the ED and reinforced by telephone was successfully implemented, with high retention rates, but did not provide incremental benefit for quality of life and short-term repeated ED visit outcomes.

The duration of treatment and appropriate guidelines for antibiotic prophylaxis for children with poststreptococcal reactive arthritis (PSRA) have not been determined. The authors performed a retrospective chart review of 40 children with PSRA and examined their clinical features at initial evaluation and at 6, 12, and 24months. At baseline, 18% (n = 7) had a finding noted on the echocardiogram. Although most patients developed cardiac findings early on in the course of their disease, 2 patients with a normal baseline echocardiogram may have developed findings after 12 months of follow-up. The mean duration of prophylaxis was 22 months. During the follow-up period, there was improvement in Physician's Global Assessment, number of patients with arthralgia, tender and swollen joints, erythrocyte sedimentation rate, anti—streptolysin O, and anti—DNAse B antibody titers. The authors conclude that marked improvement in clinical features and laboratory values was seen over time. Patients may benefit with long-term cardiac follow-up.

As a consequence of newly elevated standards for normal vitamin D levels, there is a renewed interest in vitamin D insufficiency and deficiency (

Homocystinuria and Marfan syndrome represent distinct genetic conditions that share phenotypically similar skeletal features. An overview of the current understanding of genetic and physiologic contributing to the etiology of these conditions is summarized. The focus of this review is to explore the present understanding of the pathophysiology of Marfan syndrome and homocystinuria relative to the occurrence of osteoporosis in both conditions. Osteoporosis has been reported in association with homocystinuria. However, evidence supporting an association of osteoporosis with Marfan syndrome is equivocal and sources of ambiguity are critically reviewed. Advisability and approaches to bone mineral density monitoring in patients with Marfan syndrome or homocystinuria to inform clinical management are discussed. Finally, future research foci are proposed which will improve understanding of association of osteoporosis with Marfan syndrome or homocystinuria.

Falls are a common occurrence in stroke patients admitted to a rehabilitation unit. This study evaluates the effect of current fall risk screening and prevention strategies on the number of falls in stroke patients admitted to an acute rehabilitation facility. All stroke patients admitted to a designated acute rehabilitation unit were considered at risk for falls by virtue of their diagnosis. These patients were studied retrospectively during a 24-month period. Wheelchair lap belts and bedrails were provided to all patients admitted to the unit. Further measures consisting of bed and chair alarms, enclosed beds, and placement in rooms close to the nursing station were implemented with high-fall risk patients. One hundred seventeen (15.5%) of the 754 patients in this study fell. The fall index rate was 8.2 falls, based on patient care days during the study period. No injury was observed in 143 of 159 fall cases (90%). In 13 cases (8%) there were only minor injuries, and 3 falls (2%) resulted in serious injuries. Current preventive strategies decrease the number of falls and the severity of fall-related injuries. Patients who do fall are cognitively impaired on admission and have lower ambulation speed.

Rabadi MH, Rabadi FM, Edelstein L, Peterson M. Cognitively impaired stroke patients do benefit from admission to an acute rehabilitation unit. Objective To determine whether cognitively impaired stroke patients benefit (defined as having an improved level of functional independence and capable of being discharged home) from admission to an acute rehabilitation unit. Design Retrospective analysis of data from a historical cohort of patients with acute stroke within the last 4 weeks or less. Setting Acute stroke rehabilitation unit. Participants The study sample was divided into 4 distinct groups based on admission Mini-Mental State Examination (MMSE) scores: cognitively intact (MMSE score range, ≥25 points), mild cognitive impairment (MMSE score range, 21–24), moderate cognitive impairment (MMSE score range, 10–20), and severe cognitive impairment (MMSE score range, ≤9 points). Interventions Not applicable. Main Outcome Measures Primary outcome measures were: change in total FIM instrument score, cognitive FIM subscore, length of stay (LOS), FIM efficiency, and discharge disposition (home vs not-to-home). Results Based on the MMSE cut scores, there were 233 cognitively intact patients and 435 cognitively impaired (mild, n=139; moderate, n=165; severe, n=131) patients. The cognitively intact and the 3 cognitively impaired groups were similar in age, sex, and ethnicity. The data show that the 3 cognitively impaired groups of patients had delayed onset to acute rehabilitation admission and greater stroke severity and disability. The change in FIM total score and FIM efficiency was similar between the cognitively intact and the 3 cognitively impaired groups ( P =.058). There were, however, statistically significant changes in the FIM cognitive subscore favoring the cognitively impaired groups ( P P P Conclusions Our results suggest that despite severe neurologic impairment(s) and disability, cognitively impaired stroke patients make significant functional gains while undergoing rehabilitation and many can be discharged home. Based on these results, stroke patients with cognitive impairments benefit from rehabilitation and should be given the same access to acute rehabilitation services as stroke patients who are cognitively intact.

It is widely acknowledged that genetic factors play a significant role in the pathogenesis of systemic lupus erythematosus (SLE). However, the female preponderance remains unexplained. We hypothesized that the female preponderance in childhood SLE results from selection early in the course of conception against male fetuses bearing genetic material predisposing to SLE. If this hypothesis is accurate, there should be a decreased number of male children in families with a child with SLE. Alternatively, children with SLE would have fewer male siblings. Further, this hypothesis may apply to other diseases with a female predominance such as pauciarticular onset juvenile rheumatoid arthritis (PaJRA), and not apply to diseases without female preponderance such as systemic onset juvenile rheumatoid arthritis (SoJRA). Chart review of patients with childhood onset SLE and PaJRA revealed a greater number of female children in these families compared with families of patients with SoJRA. Large-scale epidemiologic studies with precise counting of miscarriages and abortions could help to confirm these findings. Detailed studies of genetic and maternal intrauterine factors are required to conclusively prove this hypothesis. Lupus (2008) 17, 128—131.

Our aim in this study was to evaluate the prevalence of patella baja after total knee arthroplasty (TKA) using 2 different surgical techniques. Postoperative changes in patella height were measured on serial radiographs of 74 TKAs implanted using a mini-midvastus capsular approach without patella eversion (group 1) and 57 TKAs implanted using a standard medial parapatellar capsular approach with patella eversion (group 2). Preoperative and postoperative Knee Society scores, operative data, and complications were compared. With a cutoff level of 5% shortening, the prevalence was 12% in group 1 and 37% in group 2 (P = .001). The presence of patella baja was related to reduced flexion and increased pain as early as 1 year after TKA.

Phosphorylation of the organic matrix proteins of dentin is important for the initiation of mineralization, but its relevance in later mineralization stages is controversial. The objective of this study was to analyze changes in the total matrix phosphate content during dentin development and to identify their origin. Amino acid and total matrix phosphate analyses of microdissected developing mantle and circumpulpal fetal bovine dentin specimens were performed. The amino acid composition showed few changes during mantle and circumpulpal dentin maturation. However, the total matrix phosphate content showed a significant, positive correlation with tissue maturation in both mantle and circumpulpal dentin, with a two- and a three-fold increase, respectively, being observed. The data indicate that changes occur in the pattern of phosphorylation of matrix proteins during dentin maturation, which we suggest may play a functional role in later stages of tooth mineralization.

Objective To determine the efficacy of a daily dose of 81 mg aspirin in primary thrombosis prevention in asymptomatic, persistently antiphospholipid antibody (aPL)–positive individuals (those with positive aPL but no vascular and/or pregnancy events). Methods The Antiphospholipid Antibody Acetylsalicylic Acid (APLASA) study was a multicenter, randomized, double-blind, placebo-controlled clinical trial in which asymptomatic, persistently aPL-positive individuals were randomized to receive a daily dose of 81 mg of aspirin or placebo. In a separate observational and parallel study, asymptomatic, persistently aPL-positive individuals who were taking aspirin or declined randomization were followed up prospectively. Results In the APLASA study, 98 individuals were randomized to receive aspirin or placebo (mean ± SD followup period 2.30 ± 0.95 years), of whom 48 received aspirin and 50 received placebo. In the observational study, 74 nonrandomized individuals were followed up prospectively (mean ± SD followup period 2.46 ± 0.76 years); 61 received aspirin and 13 did not. In the APLASA study, the acute thrombosis incidence rates were 2.75 per 100 patient-years for aspirin-treated subjects and 0 per 100 patient-years for the placebo-treated subjects (hazard ratio 1.04, 95% confidence interval 0.69–1.56) (P = 0.83). Similarly, in the observational study, the acute thrombosis incidence rates were 2.70 per 100 patient-years for aspirin-treated subjects and 0 per 100 patient-years for those not treated with aspirin. All but 1 patient with thrombosis in either study had concomitant thrombosis risk factors and/or systemic autoimmune disease at the time of thrombosis. Conclusion Our results suggest that asymptomatic, persistently aPL-positive individuals do not benefit from low-dose aspirin for primary thrombosis prophylaxis, have a low overall annual incidence rate of acute thrombosis, and develop vascular events when additional thrombosis risk factors are present.

Reduced bone mineral density (BMD) was sporadically reported in patients with Marfan syndrome. This may or may not place the Marfan patient at increased risk for bone fracture. In comparing the BMDs of our patients with those reported in the literature, it seemed that agreement between values, and hence the degree of osteoporosis or osteopenia reported, was dependent on the instrumentation used. The objective of this study was to statistically assess this impression. Bone mineral density measurements from our previously published study of 30 adults with Marfan syndrome performed on a Lunar DPXL machine were compared with studies published between 1993–2000 measured using either Lunar or Hologic bone densitometry instruments. The differences of our measurements compared with those made on other Lunar machines were not statistically significant, but did differ significantly with published results from Hologic machines (P

Background Delayed union or nonunion of a fracture of the humerus is an infrequent but debilitating complication. Open reduction and internal fixation combined with autologous bone-grafting can result in reliable healing of the fracture; however, there is morbidity associated with the bone-graft donor site. This study was designed to evaluate healing of ununited fractures of the humeral shaft treated by one surgeon at one institution with a strict and consistent surgical protocol but with the use of two different types of bone graft: autologous iliac crest bone graft and demineralized bone matrix. Methods A consecutive retrospective cohort series was analyzed. From 1992 to 1999, forty-five patients with an aseptic, atrophic delayed union or nonunion of a humeral shaft fracture were treated with open reduction and internal fixation with a plate and autologous iliac crest bone graft. The mean time from the fracture to the surgery was 14.0 months, and the mean duration of follow-up was 32.8 months. From 2000 to 2003, thirty-three patients with the same condition were treated with the same protocol with the exception that demineralized bone matrix was used instead of autologous iliac crest bone graft. The mean time from the fracture to the surgery in that group was 22.6 months, and the mean duration of follow-up was 20.4 months. All patients in both groups were assessed clinically and radiographically. Results Osseous union was noted clinically and radiographically following the index surgery in 100% of the forty-five patients treated with autologous bone graft and 97% (thirty-two) of the thirty-three patients treated with demineralized bone matrix. The mean time to union was 4.5 months in the group treated with autologous bone graft and 4.2 months in the group treated with demineralized bone matrix. The overall functional outcome did not differ between the groups; however, twenty (44%) of the autologous bone-graft recipients had donor site morbidity, including a prolonged pain in the majority and a superficial infection requiring irrigation and debridement in one patient. Conclusions Healing of an ununited humeral shaft fracture can be achieved consistently with rigid plate fixation and lag-screw compression augmented with either autologous cancellous bone graft or commercially available demineralized bone matrix. The harvest of the autologous bone graft is frequently associated with complications. Level of evidence Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

Single-stage bilateral total hip arthroplasty can be performed with a completely new sterile setup for the second side or with the same instruments for both sides. The latter could theoretically lead to a higher prevalence of infection in the second side. We retrospectively determined the prevalence of deep infection during the first postoperative year in 271 consecutive patients operated on with different sterile setups (group 1) and 289 patients operated on with the same setup (group 2). There was one deep infection affecting the first side of a patient in group 1. In group 2, there were no deep infections (P ∼ 1.0) and one developed a superficial infection on the second side requiring readmission and intravenous antibiotics. Given the very low prevalence of deep infection of the first and second side (0.2% and 0%, respectively), it would be necessary to analyze more than 2300 patients in each group to achieve statistical significance. Based on this experience, the use of the same set of instruments for the second side in the operating conditions described in this study appears safe.

Systemic lupus erythematosus (SLE) in children is a chronic multi-system disease with wide ranging effects on their quality of life (QOL). While SLE’s impact on different arenas of life and well-being has been extensively examined in the adult population, its effect on children has not received adequate attention. This paper briefly discusses the multi-dimensional aspect of QOL, the biopsychosocial implica-tions of SLE, factors complicating QOL measurement in the affected population, and the different generic and disease-specific scales used for measuring QOL and related constructs, and it also highlights the need for SLE-specific pediatric QOL instruments.

Life events have been shown to be associated with health and illness.We studied the number of life events experienced by hip fracture patients, nonfracture rheumatology patients, and community-dwelling asymptomatic residents in the year before interview. Fifty-four hip fracture patients, 63 ambulatory patients, and 115 community-dwelling residents participated in the study. All were older than 65 years. Descriptive statistics and nonparametric analyses were performed.The number of events reported in the previous 12 months was higher for hip fracture patients than for community participants (p = 0.02). At least one bereavement was reported by 32% of hip fracture patients, 27% of ambulatory patients, and 26% of community dwellers (p = 0.8). Ten percent of all respondents reported experiencing more than one bereavement.This has important consequences when considering the care of these patients and the mental distress they may be experiencing, especially in the aftermath of local disasters or trauma. Medications may not always be the best treatment, and better psychosocial assessments and delivery systems are needed.

Impingement can damage the acetabular liner, create polyethylene wear, and cause dislocation. We determined the prevalence of impingement, its relation with dislocation, and the influence of patient, surgical, and design factors in 162 components randomly selected from a larger group retrieved between 1990 and 1999. Impingement arc, severity, and wear damage were measured; patient data were obtained from medical records, and component position was determined from radiographs. More than half (56%) showed impingement, including 94% of those removed for dislocation. The occurrence of impingement was significantly increased if the revision diagnosis was dislocation, if the component had a large outer diameter or an elevated rim, and if the femoral component had an extended flanged neck. Implant design, in particular head/neck ratio, can help reduce the prevalence of impingement.

The purpose of this study was to evaluate the relationship between increasing hospital volume and the following outcomes for total shoulder arthroplasties done in the state of New York: length of stay, hospital costs, readmission within 60 days, revision surgery within 24 months, and death within 60 days. The Statewide Planning and Research Cooperative System (SPARCS) database from the New York State Department of Health, a census of all hospital discharges in the state, was used to evaluate the relationship between hospital volume and outcomes for total shoulder arthroplasties for 1996 to 1999. One thousand three hundred seven total shoulder arthroplasties were done in New York from 1996 to 1999. Nearly (1/2) were done at the five highest-volume hospitals. Middle-volume hospitals has the least lengths of stay and hospital costs. Independent of age and comorbidities, patients at hospitals with greater volumes of total shoulder arthroplasties were at reduced risk of patients being readmitted within 60 days. No other outcomes were significantly associated with hospital volume. The finding that greater hospital volume decreases risk of readmission may have important public health implications, but additional research is needed before implementing policy changes.

Background: First-generation cementless modular cups reproducibly achieved fixation to bone but were associated with unacceptable rates of pelvic osteolysis and mechanical failure. Consequently, second-generation cups were developed with shells that had a limited number of holes (or no holes) as well as improved locking mechanisms, a polished inner surface, and increased conformity with the liner. The purpose of the present study was to evaluate the clinical and radiographic results associated with the use of a second-generation acetabular component for primary total hip arthroplasty. Methods: Two hundred and ninety-seven patients underwent 335 consecutive primary total hip arthroplasties that were performed by a single surgeon with a second-generation modular acetabular component. All cups were implanted with a press-fit technique. Ten patients were lost to follow-up, and sixteen died from unrelated causes. The remaining 271 patients (308 hips) were followed clinically (with the Hospital for Special Surgery hip-scoring system) and radiographically for four to seven years. Results: One cup was revised because of aseptic loosening. There were seven additional revisions: five were performed because of aseptic loosening of the stem with a well-fixed cup, and two were performed because of deep infection. Among the 271 patients who were alive at the time of the last follow-up, 266 (98%) had retention of the cup and 264 (97%) had retention of both components with a good or excellent clinical result. In the group of 229 patients (262 hips) with complete radiographic follow-up, 259 cups were well fixed and the average wear rate (for the 246 hips for which this rate could be calculated) was 0.09 mm/yr. Osteolysis was detected in twelve hips (5%) and was associated with male gender (p = 0.001) and the annual wear rate (p = 0.004). The extent of calcar resorption was also associated with the annual wear rate (p < 0.001). Conclusions: This second-generation acetabular cup design predictably achieved bone fixation and was associated with low rates of revision for loosening and osteolysis after intermediate-term follow-up. Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

The amount of lengthening or shortening that can be detected by patients before and after total hip arthroplasty has not been yet quantified. We studied the ability to detect limb length inequality in 194 patients with and without a total hip arthroplasty, match-paired for age and sex. None of the participants had clinical signs of lumbosacral pathology, spinal deformity, or fixed pelvic obliquity; and all had equal functional and actual limb length. The participants walked with shoes, with and without the addition of fixed insoles, to simulate 2.5, 5, 10 and 15 millimeters of shortening and lengthening of the tested limb. Lengthening and shortening were similarly detected. Younger individuals detected the differences better than older ones (p=0.001), and there was a significant correlation between the decade of life and the ability to detect a limb length discrepancy (r=-0.22; p=0.002). This study demonstrates that perception of limb length is affected by the age, with older individuals having less awareness of changes in limb length than younger ones. (Hip International 2004; 14: 249-53).

Background and Objective Serial measurements obtained during observational longitudinal studies offer the opportunity to describe the effects of chronic diseases on patient-centered outcomes such as quality of life. The purpose of this study was to assess serial Asthma Quality of Life Questionnaire (AQLQ) and SF-36 scores against a transition item using three methods of data analysis—final minus initial scores, maximum minus minimum scores, and regression line slopes through all scores. Methods Using receiver operating characteristic (ROC) curves, each method of analysis was compared against patients’ responses to a global transition question about change in asthma status with responses dichotomized as “stayed the same or got worse” or “improved.” A total of 185 patients, mean age 41±11 years, 83% women, completed the AQLQ and SF-36 three to seven times at approximately 8-month intervals over a mean of 24.8±3.9 months. For the AQLQ, all three methods of data analysis performed well against the transition item with ROC areas highest for the symptoms, activities, and the summary AQLQ scores (0.74–0.78). Results Overall, ROC areas increased as the number of observations increased, ranging from 0.78 to 0.93 for the AQLQ summary score for patients with three to six or more assessments, respectively ( P = .02). As part of the AQLQ, patients cited specific activities in which they were limited because of asthma. A total of 66 different activities were cited, including limitations in stair climbing, walking, interacting with others, sleeping, and working. In ROC analysis, serial measurements of these items also performed well against the transition item with areas ranging from 0.72 to 0.75 for all three methods of analysis. In contrast, ROC areas for the SF-36 Physical and Mental Component Summary scores were significantly lower, ranging from 0.59 to 0.66 compared to the AQLQ areas, indicating that the generic scale was less responsive than the disease-specific scale ( P ⩽.01). The three different methods of analysis also provided unique information about the cohort. The final minus initial analysis showed that 63% of patients had clinically important improvements, the maximum minus minimum analysis showed that over 90% of patients had fluctuations in scores that were clinically important, and the slope analysis showed that 79% of patients had an overall trend of improvement. Conclusions This study described possible methods to analyze and present serial data. Additional techniques to assess and interpret serial longitudinal data are needed to comprehensively describe long-term effects of chronic diseases on quality of life.

OBJECTIVE To determine if acupuncture is an effective, safe adjunctive treatment to standard therapy for chronic low back pain (LBP) in older patients. METHODS The inclusion criteria for subjects were: (i) LBP > or =12 weeks and (ii) age > or =60 yr; the exclusion criteria were (i) spinal tumour, infection or fracture and (ii) associated neurological symptoms. The subjects were randomized to two groups. The control group of subjects continued their usual care as directed by their physicians, i.e. NSAIDs, muscle relaxants, paracetamol and back exercises. Subjects in the acupuncture group in addition received biweekly acupuncture with electrical stimulation for 5 weeks. Outcome was measured by the modified Roland Disability Questionnaire (RDQ) at weeks 0, 2, 6 and 9. The primary outcome measure was change in RDQ score between weeks 0 and 6. RESULTS Fifty-five patients were enrolled, with eight drop-outs. Twenty-four subjects were randomized to the acupuncture group and 23 were randomized to the control group. Acupuncture subjects had a significant decrease in RDQ score of 4.1 +/- 3.9 at week 6, compared with a mean decrease of 0.7 +/- 2.8 in the control group (P = 0.001). This effect was maintained for up to 4 weeks after treatment at week 9, with a decrease in RDQ of 3.5 +/- 4.4 from baseline, compared with 0.43 +/- 2.7 in the control group (P = 0.007). The mean global transition score was higher in the acupuncture group, 3.7 +/- 1.2, indicating greater improvement, compared with the score in the control group, 2.5 +/- 0.9 (P < 0.001). Fewer acupuncture subjects had medication-related side-effects compared with the control group. CONCLUSIONS Acupuncture is an effective, safe adjunctive treatment for chronic LBP in older patients.

This is a report on 11 years (1990-2000) of total hip arthroplasty cases and days of discharge from one large city hospital. In 1990, patients stayed an average of 9.7 days after surgery. By 2000, patients stayed only 5.3 days. In general, women stayed longer than men, but this gap had nearly disappeared by 2000. The patients discharged in 2000 achieved fewer functional milestones during their hospital stay than those discharged in 1990.

This prospective study examined the kinematic and temporal/spatial effects of proximal femoral varus rotation osteotomy (VRO) on the gait of individuals with cerebral palsy from preoperative to 1-year postoperative status. Participants were a consecutive sample of 37 individuals (14 males, 23 females). The analysis consisted of three-dimensional kinematics, temporal/spatial measures, and functional status. A curve representing the difference between the preoperative and 12-month postoperative conditions was calculated for each joint motion. Ninety-five percent confidence intervals were calculated about the mean difference curves using a bootstrapping technique. VRO resulted in improved cosmesis and objective improvement in gait, including a statistically significant increase in hip external rotation and hip extension, a decrease in anterior pelvic tilt, and an increase in knee extension strength. The use of confidence bands to identify surgical outcomes with respect to kinematic variables has enormous value for patients and professionals. Long-term follow-up is needed to see if the aforementioned gains improve.

The purpose of this prospective randomized clinical study was to investigate the enhanced systemic fibrinolysis mechanism of venous thrombosis prevention by pneumatic compression after total hip arthroplasty. Fifty patients were randomized into one of two groups (one with pneumatic compression [n=25] and one without [n=25]). Blood was drawn from a radial arterial line immediately preoperatively (baseline), at skin closure, and 8 hours and 22 hours after the baseline sample. Serum determinations of antigen of tissue plasminogen activator and plasminogen activator inhibitor-1 were done using enzyme-linked immunosorbent assays. These data do not support the enhancement of systemic fibrinolysis mechanism for lowering thromboembolic risk after total hip arthroplasty by pneumatic compression devices. The results of this study showed no differences that were statistically significant between the two groups. The greatest difference was observed 8 hours after surgery for the plasminogen activator inhibitor-1 marker, (28.12 with compression versus 22.07 ng/mL without); however, this result was not statistically significant. The beneficial effect of mechanical compression is more likely achieved through increased flow, local fibrinolytic effects, or both.

Six thousand four hundred eighty-nine knee replacements were done in 6120 patients at the authors' institution between 1993 and 1999. Operations were done in a theater with vertical laminar flow and with the surgical team using body exhaust suits. Of these knee replacements, 116 knees became infected and 113 were available for followup. One hundred of the infections occurred in patients undergoing primary knee replacement, whereas the remaining infections occurred in patients undergoing revision knee replacement. Ninety-seven of these knees (86%) had deep periprosthetic infections and the remaining 16 knees had superficial wound infections. One third of the deep infections occurred within the first 3 months after surgery and the remaining % occurred after 3 months. The overall early deep infection rate for patients undergoing a primary knee replacement was 0.39%, whereas the rate for patients undergoing a revision knee replacement was 0.97%. A cohort of noninfected knee replacements from patients matched for gender, age, and month of surgery was used as a control group. Those comorbidities that were statistically significant in increasing the risk of infection were prior open surgical procedures, immunosuppressive therapy, poor nutrition, hypokalemia, diabetes mellitus, obesity, and a history of smoking. Patients undergoing revision procedures had a statistically higher risk of infection than did patients undergoing primary surgeries. If the surgery took longer than 2.5 hours, the risk of infection was increased significantly. There was no change in the infection rate when the perioperative antibiotic prophylaxis was decreased from 48 to 24 hours after surgery. The predominant infectious organisms were gram-positive (Staphylococcus aureus, Staphylococcus epidermidis, and Streptococcus Group B). Twenty percent of the knees that were infected clinically had no organisms that could be identified. In each case, the patient had been treated empirically at another institution with antibiotics before a culture of the joint was obtained.

Objective To assess osteoporosis knowledge, beliefs, and preventive behaviors among young adult women and to identify sources that they would mostly likely utilize to learn more about the disease. Methods Information was gathered through a cross-sectional survey of 321 women (mean age 21.6 years; 63.5% were white, 29.2% were black) enrolled in a required undergraduate health course at a southeastern state university. Results Two hundred seventy-seven (86%) of the survey participants had heard about osteoporosis, but only 3.8% of respondents reported getting both adequate exercise and the recommended 1,200 mg of calcium per day. Respondents believed that they were unlikely to develop osteoporosis and that osteoporosis is less serious than other common causes of morbidity and mortality in women, such as heart disease and breast cancer (P < 0.0001). Brochures, magazines, and short counseling sessions were preferred information sources for learning about osteoporosis. Conclusions The majority of young women studied are at risk for developing premature osteoporosis. They prefer brochures, magazines, and short counseling sessions during medical office visits to learn about osteoporosis. Arthritis Care Res 45:28–34, 2001. © 2001 by the American College of Rheumatology.

Objective To examine the relationship between allelic polymorphisms of IgG receptors (FcγR) and the development of lupus nephritis in a prospective study, and to determine the distribution of FcγR haplotypes (FcγRIIA and FcγRIIIA genotypes) in lupus patients and disease-free control subjects. Methods We studied 67 Hispanic systemic lupus erythematosus (SLE) patients from a prospective study of outcome and 53 disease-free control subjects. Patients were followed up longitudinally for 3 years. FcγRIIA and FcγRIIIA genotypes were determined using allele-specific polymerase chain reaction. Results Nephritis was present in 28% of patients at entry into the study and in 69% at the end of 3 years. In the nephritis group (n = 46), as well as the entire SLE cohort, there was a predominance of genotypes with low-binding alleles (FcγRIIa-R131 and FcγRIIIa-F176) at both loci (SLE nephritis patients 89% versus controls 62%; P < 0.002; odds ratio 0.20 [95% confidence interval 0.05–0.6] for risk of nephritis in individuals homozygous for either FcγRIIa-H131 or FcγRIIIa-V176). The frequency of individuals homozygous for high-binding alleles at either locus decreased as the burden of disease increased (P < 0.002, by Mann-Whitney test). There was no linkage disequilibrium between FcγRIIA and FcγRIIIA in Hispanics, yet in the SLE patients, there was a clear overrepresentation of the FcγRIIa-R131;FcγRIIIa-F176 haplotype (SLE patients 48% versus controls 30%) and a decrease in the frequency of the high-binding haplotype (4% versus 23%) (P < 0.002). Conclusion We observed an increase in the frequency of low-binding FcγR alleles in an SLE population with a high prevalence of renal disease. The apparent selection for the FcγRIIa-R131;FcγRIIIa-F176 haplotype in Hispanic patients suggests that low-binding alleles of both FcγRIIa and FcγRIIIa confer risk for SLE and may act additively in the pathogenesis of disease, whereas the high-binding haplotype FcγRIIa-H131;FcγRIIIa-V176 is protective, particularly in the homozygous state.

We performed a crossover study to evaluate the haemodynamic effect of active dorsal to plantar flexion and seven pneumatic compression devices in ten patients who had a total knee arthroplasty. Using the Acuson 128XP/10 duplex ultrasound unit with a 5MHz linear array probe, we assessed the augmentation of peak venous velocity and venous volume above and below the junction of the greater saphenous and common femoral veins in order to study both the deep and superficial venous systems. The pneumatic compression devices evaluated included two foot pumps (A-V Impulse System and PlexiPulse Foot), a foot-calf pump (PlexiPulse Foot-Calf), a calf pump (VenaFlow System) and three calf-thigh pumps (SCD System, Flowtron DVT and Jobst Athrombic Pump). The devices differed in a number of ways, including the length and location of the sleeve and bladder, the frequency and duration of activation, the rate of pressure rise, and the maximum pressure achieved. A randomisation table was used to determine the order of the test conditions for each patient. The enhancement of peak venous velocity occurred primarily in the deep venous system below the level of the saphenofemoral junction. The increases in peak venous velocity were as follows: active dorsal to plantar flexion 175%; foot pumps, A-V Impulse System 29% and PlexiPulse 65%; foot-calf pump, PlexiPulse, 221%; calf pump, VenaFlow, 302% and calf-thigh pumps, Flowtron DVT 87%, SCD System 116% and Jobst Athrombic Pump 263%. All the devices augmented venous volume, the greatest effect being seen with those incorporating calf compression. The increases in ml/min were found in the deep venous system as follows: foot pumps, A-V Impulse System 9.6 and PlexiPulse Foot 16.7; foot-calf pump, PlexiPulse, 38.1; calf pump, VenaFlow, 26.2; calf-thigh pumps, Flowtron DVT 61.5, SCD System 34.7 and Jobst Athrombic Pump 82.3. Active dorsal to plantar flexion generated 8.5 ml for a single calf contraction.

Objective. To determine whether gains in functioning observed immediately following participation in an 8-week program of supervised fitness walking for patients with knee osteoarthritis were sustained at 1-year followup. Methods. Twenty-nine (61.1%) of 47 original intervention program patients and 23 (51.1%) of 45 original control patients were interviewed by telephone at 1-year followup. Patients completed the Arthritis Impact Measurement Scales physical activity, arthritis impact, pain, medication use, and general health perceptions subscales, as well as a separate visual analog pain scale and measures of perceived self-efficacy to cope with arthritis pain and other symptoms. Results. Adherence to walking was low, and there were no statistically significant differences between intervention and control patients at one year. Conclusions. The failure of intervention patients to maintain regular walking resulted in loss of functional benefits that were observed at 8 weeks in the original study. Long-term adherence to walking is critical to maintenance of initial gains in functional outcomes.

Accurate inclination and anteversion of the acetabular component is paramount to achieve a stable total hip arthroplasty, prevent prosthetic dislocation and minimize long- term wear. We present and evaluate a simple new technique to improve consistency in cup inclination during primary total hip arthroplasty, based on information available from the preoperative plan. The technique consists of assessing the distance and relationship between the inferomedial border of the acetabular cup and the inferomedial margin of the teardrop, with the use of a measuring probe. This simple surgical gesture improved consistency in cup inclination during total hip arthroplasty.

We performed a prospective study in order to assess the utility of high-resolution magnetic resonance imaging in the detection and specific localization of tears of the triangular fibrocartilage complex. Seventy-seven patients who had pain in the wrist were studied with use of a dedicated surface coil and three-dimensional gradient-recalled techniques with a field of view of eight centimeters and a slice thickness of one millimeter. The patients had pain on the ulnar side of the wrist, ligamentous instability, occult ganglia, or a combination of these. Magnetic resonance images were assessed for radial or ulnar avulsion, or both; central defects; degenerative intrasubstance changes; and complex tears of the triangular fibrocartilage complex. Partial tears were differentiated from complete tears. The findings on the magnetic resonance images were then compared with the arthroscopic findings. Fifty-seven of the fifty-nine tears that were suspected on magnetic resonance images were confirmed with arthroscopy; the two suspected tears that were not confirmed had been interpreted as small partial tears on the magnetic resonance images. With use of arthroscopy as the standard, magnetic resonance imaging had a sensitivity of 100 per cent (fifty-seven of fifty-seven), a specificity of 90 per cent (eighteen of twenty), and an accuracy of 97 per cent (seventy-five of seventy-seven) for the detection of a tear (kappa = 0.93, p < 0.00001). Fifty-three of the fifty-seven tears were localized correctly with use of magnetic resonance imaging. With regard to the location of the tear, magnetic resonance imaging had a sensitivity of 100 per cent (fifty-three of fifty-three), a specificity of 75 per cent (eighteen of twenty-four), and an accuracy of 92 per cent (seventy-one of seventy-seven) (kappa = 0.9, p < 0.0001). We concluded that high-resolution magnetic resonance imaging permits accurate depiction and localization of tears of the triangular fibrocartilage complex. When the appropriate pulse sequence is used, magnetic resonance imaging is an accurate and effective method for the non-invasive evaluation of pain in the wrist.

Objective. To assess the impact of LupusLine during its pilot phase of operation by determining patterns of utilization and user satisfaction. LupusLine is a peer counseling service designed to provide ongoing emotional support from home to home by telephone appointment. Methods. One hundred fifty-three respondents were surveyed, using a 72-item structured questionnaire administered over the telephone by interviewers separately trained and hired specifically for this purpose. The questionnaire was pilot tested on 10 volunteers with systemic lupus erythematosus (SLE), and a panel of related health professionals reviewed the questionnaire for face validity. Results. Most users were women (94.5%) who had SLE themselves (87.5%) and who called the service because of recent changes in their physical functioning and reported feelings of depression and anxiety about their illness. Forty-one percent of respondents made 6 or more calls to their assigned peer counselor. Respondents reported high levels of satisfaction across 5 highly correlated measures, with 92% of callers reporting at least moderate satisfaction with the service. Over 60% of respondents who reported a change in 6 “feeling” categories attributed this change to using LupusLine. Fewer users reported a change in 4 specific behaviors since using the service, but more respondents attributed changes, when they occurred, to LupusLine. Conclusions. Based on these initial findings, we believe that telephone networks similar to the LupusLine model maybe able to offer substantial benefit to people coping with the complex, ongoing psychosocial challenges of SLE. Further, the at-home accessibility and low cost of such volunteer-based interventions may play an ever more needed role in the present health care environment.

Although there have been many studies focusing on the increasingly important assessment of patients' satisfaction, few studies have specifically addressed this tissue for total hip arthroplasty (THA). The goals of this study were to measure patients' satisfaction with THA and to evaluate the relationships of expectations and outcome to patients' satisfaction. A total of 180 patients were surveyed 2 to 3 years after THA about their experiences with THA. Patients cited 45 different expectations, which were grouped into five categories reflecting improvement in pain, walking, psychological state, essential activities, and nonessential activities. Overall, 89% of patients were satisfied with the results of surgery. Lower rates of satisfaction were found in patients who had a better preoperative condition (as measured by the surgeons with The Hospital for Special Surgery Hip Scale), in patients who expected improvement in nonessential activities, and in patients who reported worse postoperative condition (as measured by self-assessment with the Hip Rating Questionnaire and the Medical Outcomes Study Short-form General Health Survey). Patients were also asked how they came to THA. Nearly 50% of patients were first referred to an orthopaedist by family or friends or based on their own knowledge. Seventy-four percent either had subsequently referred others for THA or would have done so if they knew someone with hip pain. This study demonstrates that satisfaction with THA is a complex phenomenon, affected by expectations, outcome, and what patients know about the procedure from their community network. A better understanding of THA satisfaction will enable better future selection of patients and an additional dimension of outcome, both of which are important to patients and payers.

A self-administered questionnaire was designed to assess the severity of symptoms related to and the functional status of the shoulder. It includes domains of global assessment, pain, daily activities, recreational and athletic activities, work, satisfaction, and areas for improvement. Each domain is graded separately and is weighted to arrive at the total score. The over-all scale and each domain were prospectively tested for validity, reliability, and responsiveness to clinical change. One hundred patients who were seen for evaluation of the shoulder were enrolled in the study. The validity of the scale was demonstrated by moderate-to-high correlation of the domains and individual questions of the Shoulder Rating Questionnaire with those of the Arthritis Impact Measurement Scales 2. Validity was supported further by significant correlation of the scores in each domain with the level of satisfaction in that domain and by significantly lower scores in domains that patients selected as areas important for improvement. The over-all scale and each domain were internally consistent (Cronbach alpha, 0.71 to 0.90). Reproducibility was evaluated by repeated administration of the questionnaire after a mean of three days to forty patients whose condition was clinically stable. Reproducibility of the over-all questionnaire and individual domains was excellent (Spearman-Brown index, 0.94 to 0.98). Individual questions were reproducible, with a weighted kappa value of more than 0.7 for each. Responsiveness was evaluated by comparison of the preoperative and postoperative scores of thirty patients who had a satisfactory result one year after an operation on the shoulder. The over-all Shoulder Rating Questionnaire and each domain were responsive to clinical change as demonstrated by favorable standardized response means (range, 1.1 to 1.9) and indices of responsiveness (range, 1.1 to 2.0). Similar analysis performed for individual diagnostic groups supported the validity, reliability, and responsiveness of the questionnaire in each group. The self-administered shoulder questionnaire was found to be valid, reliable, and responsive to clinical change. These qualities should make it a useful instrument for the prospective assessment of the outcome of treatment of disorders related to the shoulder.

Objective To assess the general use of all non-steroidal anti-inflammatory drugs (NSAID) and their relation to upper gastrointestinal bleeding in view of National Institute for Clinical Excellence guidelines published in July 2001 in the UK. Methods Cross sectional study on all patients who were referred for endoscopy for suspected upper gastrointestinal bleeding in six hospitals in Yorkshire region of the UK. Results One hundred and sixty three patients presented for endoscopy for suspected upper gastrointestinal bleeding, 43 patients were taking at least one ulcerogenic drug, and 120 were not. The mean age difference between these two groups was eight years (p Conclusions Elderly patients are being inappropriately prescribed conventional NSAIDs. NSAIDs with or without aspirin use are still associated with a significant risk of upper gastrointestinal bleeding in the era of cyclo-oxygenase 2 selective agents. Substitution with cyclo-oxygenase 2 selective NSAIDs is not without risk of upper gastrointestinal bleeding.

Background Combined spinal-epidural anesthesia (CSE) may offer theoretic advantages for outpatient surgery, because it produces the rapid onset of spinal anesthesia, with the option to extend the blockade with an epidural catheter. In this study, the authors attempted to determine an appropriate initial dose of a short-acting local anesthetic, 2% lidocaine, to administer for outpatient knee arthroscopy using CSE. Methods Data were collected from 90 patients undergoing outpatient knee arthroscopy. Using a double-blinded, prospective study design, patients were randomly assigned to receive CSE with an initial dose of intrathecal 2% lidocaine of 40, 60, or 80 mg. A 27-G 4 11/16-inch Whitacre needle was placed through a 17-G Weiss needle. Onset and regression of sensory anesthesia and motor blockade were measured by a blinded observer at frequent intervals. Results All 90 patients had adequate anesthesia. Durations of thoracic and lumbar sensory and lower limb motor blockade were significantly shorter in the 40-mg group compared with the 60- or 80-mg groups (P < 0.0002 Mantel-Cox, Survivorship Analysis). Indices of neural blockade resolved 30-40 min more rapidly in the 40-mg group than in either the 60- or 80-mg group. Times to urinate, site upright in a chair, take oral fluids, and be discharged were all significantly shorter (between 30 and 60 min) in the 40-mg group compared with the 60- and 80-mg groups (P < 0.01). Seven patients required intraoperative epidural supplementation: three in the 40-mg group, three in the 60-mg group, and one in the 80-mg group. Conclusions Combined spinal-epidural anesthesia with a 40-mg initial intrathecal dose of lidocaine provided reliable anesthesia for knee arthroscopy. Duration of spinal anesthesia with lidocaine was dose related.

Soluble adhesion protein intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1), and endothelial leukocyte adhesion molecule (E-selectin) were measured in serum and cerebrospinal fluid (CSF) of patients with relapsing-remitting multiple sclerosis (RRMS) in remission and in exacerbation, as well as patients with chronic progressive MS, stable MS, and in patients with other neurological and inflammatory diseases (ONDs). Serum ICAM-1 and E-selectin were significantly elevated in patients with MS over those with ONDs and controls. CSF VCAM-1 and E-selectin were found to be elevated over control and disease control samples. No increase in CSF ICAM-1 was observed. Results were analyzed longitudinally and by MS category. In paired CSF and serum samples from patients in exacerbation, elevated VCAM-1 correlated with increased serum VCAM-1 in 5 of 7 patients. Elevated CSF E-selectin did not correlate with elevations in serum E-selectin.

Background and Objective Simple Measure of the Impact of Lupus Erythematosus in Youngsters (SMILEY) is a health‐related quality of life (HRQOL) assessment tool for pediatric systemic lupus erythematosus (SLE), which has been translated into Portuguese for Brazil. We are reporting preliminary data on cross‐cultural validation and reliability of SMILEY in Portuguese (Brazil). Methods In this multi‐center cross‐sectional study, Brazilian children and adolescents 5–18 years of age with SLE and parents participated. Children and parents completed child and parent reports of Portuguese SMILEY and Portuguese Pediatric Quality of Life Inventory (PedsQL™) Generic and Rheumatology modules. Parents also completed the Childhood Health Assessment Questionnaire (CHAQ). Physicians completed the SLE disease activity index (SLEDAI), Physician’s Global Assessment of disease activity (PGA) and Systemic Lupus Erythematosus International Collaborating Clinics ACR Damage Index (SDI). Results 99 subjects (84 girls) were enrolled; 93 children and 97 parents filled out the SMILEY scale. Subjects found SMILEY relevant and easy to understand and completed SMILEY in 5–15 minutes. Brazilian SMILEY was found to have good psychometric properties (validity and reliability), and the child–parent agreement was moderate. Conclusion SMILEY may eventually be used routinely as a research/clinical tool in Brazil. It may be also adapted for other Portuguese-speaking nations offering critical information regarding the effect of SLE on HRQOL for children with SLE.

Understanding triggers is important for managing asthma particularly for patients who seek emergency department (ED) care for exacerbations. The objectives of this analysis were to delineate self-reported triggers in ED patients and to assess associations between triggers and asthma knowledge, severity, and quality of life.At the time of an ED visit, 296 patients were asked what were their usual asthma triggers based on a checklist of 25 potential items, and what they thought specifically precipitated their current ED visit. Using standardized scales, patients also were asked about asthma knowledge, severity, and quality of life.The mean age was 44 years and 72% were women. Patients cited a mean of 12 triggers; most patients had diverse triggers spanning respiratory infections, environmental irritants, emotions, allergens, weather, and exercise. Patients with more triggers were more likely to be women (odds ratio (OR) = 2.0, confidence interval (CI) = 1.3, 3.2, p = .002), obese (OR = 1.7, CI = 1.1, 2.5, p = .01), and to not have a smoking history (OR = 1.9, CI = 1.3, 2.9, p = .001). There were no associations between number of triggers and current age, age at diagnosis, education, socioeconomic status, or race/ethnicity. Patients who cited more triggers had more frequent flares (OR = 1.1, CI = 1.1, 1.2, p.0001), worse quality of life scores (OR 1.6, CI = 1.1, 2.4, p = .02), and were more likely to have been previously hospitalized for asthma (OR = 1.9, CI = 1.3, 2.9, p = .003) and to have previously required oral corticosteroids (OR = 2.9, CI = 1.6, 5.1, p = .003). There was little clustering of specific triggers according to the variables we considered except for more frequent animal allergy in patients diagnosed at a younger age (OR = 2.8, CI = 1.7, 4.5, p.0001) and worse quality of life in patients citing emotional stress as a trigger (OR = 2.5, CI = 1.5, 4.0, p = .0002). Patients attributed their current ED visit to multiple precipitants, particularly respiratory infections and weather, and these were concordant with what they reported were known triggers.Patients presenting to the ED for asthma reported multiple triggers spanning diverse classes of precipitants and having more triggers was associated with worse clinical status. ED patients should be instructed that although it may not be possible to eliminate all triggers, mitigating even some triggers can be helpful.

The behavior of the moment arms of the rotator cuff and deltoid muscles was studied during simple and combine movements of abduction and rotation about the glenohumeral joint. This was done by experimental measurement of excursions of the muscles in an in vitro cadaver model and by use of a multiple-regression analysis to delineate the changes in the moment arms as a function of abduction and rotation. The results demonstrated the potential of some rotator cuff muscles to contribute to both abduction and rotation, the sensitivity of the abductor moment-arm lengths to internal and external rotation and of the rotator moment-arm lengths to the degree of abduction, and the capacity of the abductor moment-arm lengths of the deltoid to increase with increasing abduction. Characterization of this behavior resulted in an increased understanding of the complex role of the rotator cuff and deltoid muscles about the gleno-humeral joint and provided quantitative descriptions of functional relationships. This study demonstrates the capacity of the infraspinatus and subscapularis muscles to contribute not only to external and internal rotation, respectively, but also to elevation of the arm in the plane of the scapula, a role for which these muscles have been given little or no consideration. Furthermore, it demonstrates that the contribution of the infraspinatus to abduction is enhanced with internal rotation while that of the subscapularis is enhanced with external rotation. Thus, dysfunction of the supraspinatus muscle need not preclude good elevation of the arm, and rehabilitation to reprogram and strengthen the remaining muscles becomes an important consideration.

The agreement between measurements and the relative performance reproducibility among different microcomputed tomography (microCT) systems, especially at voxel sizes close to the limit of the instruments, is not known. To compare this reproducibility 3D morphometric analyses of mouse cancellous bone from distal femoral epiphyses were performed using three different ex vivo microCT systems: GE eXplore Locus SP, Scanco μCT35 and Skyscan 1172. Scans were completed in triplicate at 12 μm and 8 μm voxel sizes and morphometry measurements, from which relative values and dependence on voxel size were examined. Global and individual visually assessed thresholds were compared. Variability from repeated scans at 12 μm voxel size was also examined. Bone volume fraction and trabecular separation values were similar, while values for relative bone surface, trabecular thickness and number varied significantly across the three systems. The greatest differences were measured in trabecular thickness (up to 236%) and number (up to 218%). The relative dependence of measurements on voxel size was highly variable for the trabecular number (from 0% to 20% relative difference between measurements from 12 μm and 8 μm voxel size scans, depending on the system). The intra-system reproducibility of all trabecular measurements was also highly variable across the systems and improved for BV/TV in all the systems when a smaller voxel size was used. It improved using a smaller voxel size in all the other parameters examined for the Scanco system, but not consistently so for the GE or the Skyscan system. Our results indicate trabecular morphometry measurements should not be directly compared across microCT systems. In addition, the conditions, including voxel size, for trabecular morphometry studies in mouse bone should be chosen based on the specific microCT system and the measurements of main interest.