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R A Rubinstein

Publications and source records attributed to R A Rubinstein.

16 recordsLinked to original sources
PubMed2000

Towards a public health approach to bioethics.

In this paper we examine the central commitments of bioethical enquiry and reasoning from a public health perspective. We argue that a core element of American national culture is individualism, which resonates in scholarly and popular debates. Our contention is that the habitus of bioethical debate is in large measure animated by an overriding concern with the individual, and the resulting social practice of the community has been to downplay the importance and legitimacy of group-level health care dilemmas. This paper calls for re-focusing of bioethics by employing a public health perspective, which would include a population focus, evidence-based research topics, and engagement of the ethical dilemmas that arise from decisions concerning prevention. Racial and ethnic health disparities throughout the life span of a population in central New York State are used to illustrate the need for a public health focus in bioethics.

Bioethics↗
PubMed1998

"Breaking the bureaucracy": drug registration and neocolonial relations in Egypt.

According to the Egyptian Ministry of Health, the per capita use of prescription drugs in Egypt is amongst the highest in the world. Multinational pharmaceutical companies license their proprietary products for manufacture and sale in Egypt through their Egyptian subsidiaries. A Ministry of Health Committee reviews and approves for sale all drugs marketed in the country. Aside from being an extremely lucrative market itself, approval of a drug for sale and manufacture in Egypt also opens to the pharmaceutical companies other markets in the Arab world. The Egyptian drug approval process is thus both important for assuring the health of Egyptian nationals and a high-stakes activity for the pharmaceutical companies. This paper examines the social relations and interactions of multinational pharmaceutical representatives in Egypt with Egyptian researchers in relation to the Ministry of Health's drug approval process. From time-to-time events focus attention on the huge financial rewards reaped by multinational pharmaceutical companies from their activities in lesser developed countries. This attention not infrequently has revealed the "drugging of the Third World" as a result of actions by expatriate multinational pharmaceutical officials. Indigenous review procedures such as those established by the Egyptian Ministry of Health might guard against such external exploitation. This paper shows how in place of external exploitation, indigenous pharmaceutical company officials have manipulated local patterns of social interaction to construct a system of reciprocal obligations which may frustrate intended safeguards, and by reconstructing colonial institutional structures, creates a pattern of neocolonialism in Egypt.

Drug Approval↗
PubMed1997

A comparison of oral azithromycin with topical oxytetracycline/polymyxin for the treatment of trachoma in children.

Trachoma, an infectious keratoconjunctivitis caused by Chlamydia trachomatis, is a leading cause of preventable blindness in developing countries. In this study we compared oral azithromycin with oxytetracycline/polymyxin eye ointment (once daily for 5 days every 4 weeks; total of six treatment cycles) for the treatment of active endemic trachoma in 168 rural Egyptian children. A suspension of azithromycin was administered to children as a dose of 20 mg/kg by one of three schedules: a single dose, one dose a week for 3 weeks, and one dose every 4 weeks for a total of six doses. The children's clinical status and chlamydial infection rates were evaluated for 1 year. The clinical cure rates were 35% 2 months after initial treatment, 16% at 8 months (during the annual autumn epidemic of purulent conjunctivitis), and 47% at 1 year. The pretreatment chlamydial infection rate of 33% (determined by direct immunofluorescence) decreased to 5% at 2 months and was 9% at 12 months. There were no significant clinical or laboratory differences among the four treatment groups. Thus, 1-6 doses of azithromycin were equivalent to 30 days of topical oxytetracycline/polymyxin ointment and may offer an effective alternative means of controlling endemic trachoma.

Administration, Oral↗
PubMed1996

Uncemented total knee arthroplasty: report of 109 titanium knees with cancellous-structured porous coating.

One hundred twenty-three uncemented total knee arthroplasties were performed between November 1986 and November 1989. The implants were pure titanium with porous coating for bony ingrowth. One hundred nine of these knees were followed for 2 to 5 years (average: 31.5 months). Clinical evaluation of the results, using the Hospital for Special Surgery Knee Rating Scale, revealed an increase in the average knee score from 62.9 preoperatively to 92.5 postoperatively, with excellent or good results in 94.5% of the cases. Thirteen knees (12%) had 26 radiolucent lines or areas. There was no complete lucency underneath any implant, and no knees were revised for loosening. One knee required replacement of the tibial insert for instability. While titanium implants were successful in achieving secure fixation and high knee scores in the short term, longer follow up will be necessary for more definitive conclusions, especially in regard to the potential problems with titanium wear debris.

Adult↗
PubMed1996

The effect of bone quality on the outcome of ingrowth total knee arthroplasty.

Bone quality generally is felt to be an important consideration when planning total knee arthroplasty (TKA). This prospective study was conducted to see if bone quality, as assessed intraoperatively in 346 knees, affects the outcome of ingrowth TKA. Group A consisted of 272 knees with good or excellent bone quality in all areas and Group B consisted of 74 knees with fair or poor bone in at least one area. The average follow-up was 48 months, with 301 knees (87%) available for follow-up. Group A knees had more males, were heavier, had fewer patients with rheumatoid arthritis, and exhibited more varus. Preoperatively, Groups A and B had modified Hospital for Special Surgery (HSS) knee scores that averaged 55 and 48, respectively. At 4 years post-surgery, Groups A and B had HSS scores of 92 and 90, respectively. Fluoroscopic radiographs of the bone-prosthesis interfaces showed 13% incomplete radiolucencies in Group A and 7% in Group B. A complete radiolucency was seen in one patient in Group A. Based on these results, it can be concluded that bone quality as determined by gross intraoperative inspection had little effect on the 4-year outcome of this ingrowth TKA.

Aged↗
PubMed1995

Assessment of patellar height after autogenous patellar tendon anterior cruciate ligament reconstruction.

In this study, we sought to determine if a significant change in patellar height occurs after autogenous patellar tendon anterior cruciate ligament (ACL) reconstruction at our clinic. In a series of 71 patients (52 males and 18 females; average age: 22 years; range: 12 to 41) randomly selected, all had undergone an identical autogenous patellar tendon ACL reconstruction, by the same surgeon, and followed the same postoperative accelerated rehabilitation program. All patients had standardized preoperative and postoperative lateral knee radiographs. The patellar tendon length as well as the patellar height and ratio of Blackburne and Peel were measured by the same person for all subjects. The length of the patellar tendon shortened by an average of 0.4 mm (range: 6% lengthening to 12% shortening) which is less than 1% and not statistically significant (P = .068). The Blackburne and Peel ratio for patellar height decreased by 1%, which was also not statistically significant (P = .060). The evidence obtained from this study indicated no significant change in patellar height after autogenous patellar tendon ACL reconstruction combined with postoperative accelerated rehabilitation and no correlations with postoperative complications, secondary surgeries, timing of surgery, age, or anterior knee symptoms.

Adolescent↗
PubMed1995

Nonreamed interlocked intramedullary tibial nailing. One community's experience.

Forty-nine acute displaced tibial fractures (31 closed, 18 open: 5 Grade I, 7 Grade II, 4 Grade IIIA, and 2 Grade IIIB) were treated in 1 community with a standard operative protocol using a distractor without a fracture table, and an unreamed interlocked tibial nail. Forty-six fractures healed (94%). Complications included 3 nonunions (6%), 2 deep infections (4%), 9 delayed unions (18%), 4 angular malunions (8%), 2 rotatory malunions (4%), and 12 interlocking screws bent or broke (24%). Twenty-eight patients (57%) required at least 1 additional operation to obtain union, most commonly dynamization of a statically locked nail. The authors conclude that unreamed tibial nails provide adequate stabilization of displaced tibial fractures and can be used in the management of most open or closed tibial fractures. However, static locking is required in axially unstable fractures. Early dynamization or exchange nailing and bone grafting should be considered to hasten union and avoid screw failure. The distractor is an excellent adjunctive technique for reduction and alignment of tibial shaft fractures during intramedullary nailing.

Adolescent↗
PubMed1994

Methodist Sports Medicine Center's experience with acute and chronic isolated posterior cruciate ligament injuries.

The treatment of isolated PCL tears remains controversial. Potential exists for long-term subjective and radiographic deterioration with non-operative treatment. The general consensus for treating combined instabilities that involve the PCL is a surgical reconstruction. The authors would also consider a reconstruction in the isolated grade 2 or greater PCL tear for the high demand patient. Because the results of reconstruction are not as certain or predictable for posterior laxity as they are for anterior laxity, caution is in order, however. Patient selection remains critical and may warrant an attempt at nonoperative treatment initially with continued close follow-up to locate those patients, whether subjectively or radiographically, who do poorly. It is these latter patients who would most likely benefit from an autogenous patellar tendon PCL reconstruction for their isolated laxity. Continued follow-up of both non-operative and operative treatments are needed so we can further refine our current recommendations. Future research should include both prospective natural history studies of acute isolated PCL tears treated non-operatively as well as the long-term results of different operative treatments. Sufficient patient numbers and an objective methodology for patient evaluation must be included in studies of these treatments.

Acute Disease↗
PubMed1993

The results of treatment of posttraumatic avascular necrosis of the femoral head in young adults: report of 31 patients.

A series of 31 adult patients less than 42 years of age who were treated for avascular necrosis (AVN) following a healed femoral neck fracture were followed for an average of 14.6 years, and the results of their treatment were analyzed. The average age at fracture was 26.3 years (range: 12.2 to 41.4 years). The mechanism of injury was a motor vehicle accident in 18 and a fall in 13. Sixteen patients had multiple injuries. The average time from fracture to diagnosis of AVN was 19.1 months. The management of AVN included one or a combination of the following: non-weightbearing ambulation, decompression and bone grafting, electrical stimulation, femoral osteotomy, cup arthroplasty, resurface arthroplasty, arthrodesis, hemiarthroplasty, and total hip arthroplasty (THA). The average number of hip operations after initial fracture treatment was 2.9 per patient (range: 0-7). Current follow-up was possible in 97% (30 out of 31) of the patients. THA was performed either primarily or following other treatment in 23 patients at an average age of 31.9 years (range: 16.9-55.3 years). The survivorship of these THAs was 89% at five years and 49% at ten years. Revisions have been done for aseptic loosening of cemented components with the exception of two infections and one loose metal-on-metal press-fit THA. The results of this study indicate that total hip arthroplasty has a high long-term failure rate in this population, and alternate treatment should be considered in order to improve the long-term results.

Adolescent↗
PubMed1992

Intramedullary interlocked tibia nailing: a new technique (preliminary report).

This paper presents a modified surgical technique for interlocked intramedullary stabilization of tibia fractures. An external distractor is used to achieve an indirect fracture reduction on a fluoroscopy table. This method avoids the potential traction complications associated with conventional fracture tables. The fluoroscopy unit remains in one position during the entire operation. This technique decreases set-up time, provides complete control over the involved extremity, facilitates an accurate reduction, allows for compression at the fracture site, and simplifies the interlocking procedure. Twenty patients with 20 tibia shaft fractures were treated with this technique. No complications occurred during acute fracture care. Alignment was anatomic or near anatomic in all cases and physician satisfaction was 100%. At follow-up, averaging 5.2 months, there has been no change in fracture alignment, and most tibias are demonstrating clinical and radiographic healing. Distraction at the fracture site with a statically locked tibia nail may impede healing. The external distractor can be used to compress the fracture site prior to static interlocking, and this may facilitate healing. Dynamization of the nail should be considered when early signs of healing are absent. This technique is simple, accurate, and safe, and should be considered when treating an unstable tibia shaft fracture with a locked intramedullary nail.

Adolescent↗
PubMedDate not supplied

Isolated autogenous bone-patellar tendon-bone graft site morbidity.

To distinguish between morbidity caused by the isolated patellar tendon graft harvest and morbidity associated with anterior cruciate ligament reconstruction when the graft is harvested from the involved knee, we studied 20 patients who had an isolated contralateral graft harvest for anterior cruciate ligament reconstruction in the opposite knee. We defined and quantitated the morbidity by evaluating the uninjured knee from preoperative studies to current followup (range, 0.5 to 5 years; average, 2 years). All graft harvest surgeries were performed in an identical fashion. Rehabilitation of the harvest knee included immediate range of motion, weightbearing, and closed chain kinetic exercises with a emphasis on early strengthening. All patients regained full knee range of motion by 3 weeks. At final followup, there was no clinical or radiographic evidence of patella contracture or baja. Quadriceps strength averaged 69% at 6 weeks and returned to 93% at 1 year and 95% at 2 years. Activity-related soreness at the donor site (patellar tendinitis) was rarely restricting and resolved after the 1st year. No patient complained of patellofemoral joint pain in the donor knee. The modified Noyes subjective questionnaire score averaged 97 of 100 at last followup. The morbidity of an isolated autogenous patellar tendon graft harvest appears to be of short duration and largely reversible.

Adolescent↗
PubMedDate not supplied

The accuracy of the clinical examination in the setting of posterior cruciate ligament injuries.

Thirty-nine subjects volunteered for this blinded, randomized, and controlled study to assess the clinical examination skills of orthopaedic surgeons with fellowship training in sports medicine. Eighteen of the patients had 19 chronic isolated posterior cruciate ligament tears. The controls were 9 patients with 9 anterior cruciate ligament-deficient knees, 12 subjects with normal knees, and the contralateral normal knees of the ligament-deficient patients. To eliminate preexamination bias, all examiners were blinded from the examinee's history, identity, and diagnosis. The overall clinical examination accuracy for all orthopaedic surgeons was 96%. The accuracy for detecting a posterior cruciate ligament tear was 96%, with a 90% sensitivity and a 99% specificity. The examination accuracy was higher for grade II and III posterior laxity than for grade I laxity. Eighty-one percent of the time, the examiners agreed on the grade of the posterior cruciate ligament tear for any given patient. The posterior drawer test, which included palpation of the tibia-femur step-off, was the most sensitive and specific clinical test. A thorough and precise physical examination, coupled with a patient history, can be considered diagnostic in the majority of isolated posterior cruciate ligament injuries. With this accuracy level known, the natural history of isolated posterior cruciate ligament tears can be reliably documented and studied.

Adolescent↗
PubMedDate not supplied

Correlation of remaining patellar tendon width with quadriceps strength after autogenous bone-patellar tendon-bone anterior cruciate ligament reconstruction.

One hundred twenty-one patients were prospectively studied to determine whether the different remaining patellar tendon widths after central 10-mm bone-patellar tendon-bone graft harvest influenced the rate and level of quadriceps strength achieved during rehabilitation. Size of the patellar tendon width, measured at the same location in each patient, ranged from 24 to 35 mm. For this study, patients were grouped according to their remaining tendon size into small (14 to 17 mm; mean, 15.8), medium (18 to 20 mm; mean, 19.2), and large (21 to 25 mm; mean, 22.5) widths. Postoperatively, the patient's isokinetic quadriceps scores were determined at 6 weeks, 3 months, 6 months, and 1 year. At 6 weeks, the small- and medium-width tendon groups were significantly weaker than the large-width tendon group. At 3 months, only the small-width tendon group continued to be significantly weaker than the large-width tendon group. At and beyond 6 months, no statistically significant differences were seen between remaining patellar tendon width groups and their isokinetic quadriceps scores. A constant-sized autogenous patellar tendon graft may be harvested for anterior cruciate ligament reconstruction without compromising ultimate postoperative quadriceps strength recovery.

Adolescent↗
PubMedDate not supplied

Effect on knee stability if full hyperextension is restored immediately after autogenous bone-patellar tendon-bone anterior cruciate ligament reconstruction.

We sought to determine if knee stability after autogenous bone-patellar tendon-bone anterior cruciate ligament reconstruction was adversely affected by obtaining immediate full hyperextension. We selected patients based on degree of knee hyperextension. Group 1 (46 men and 51 women), with an average of 10 degrees (range, 8 degrees to 15 degrees) hyperextension, was compared with the randomly selected control Group 2 (70 men and 27 women), which had an average of 2 degrees (range, 0 degrees to 5 degrees) hyperextension. The operative knee in both groups, which underwent similar reconstruction of the injured knee, achieved full passive extension equal to the non-involved knee during the immediate postoperative course. The average KT-1000 arthrometer manual maximum side-to-side differences were 2.4 mm for Group 1 and 2.1 mm for Group 2 (P = 0.13). Seventy-nine patients in Group 1 had KT-1000 arthrometer differences of < or = 3 mm as compared with 85 patients in Group 2. Fourteen patients in Group 1 had KT-1000 arthrometer differences of 4 or 5 mm as compared with eight patients in Group 2. Four patients in each group had KT-1000 arthrometer differences > 5 mm. Evidence suggests that restoring and maintaining immediate full knee hyperextension after this type of reconstruction does not adversely affect the ultimate stability of the knee.

Adult↗