Biomedical subjects
Publications and source records attributed to R G Marx.
Several overuse injuries can affect the upper extremity of tennis players. A thorough understanding of anatomy and knowledge of these common conditions and their treatment facilitates the management of these athletes.
The purpose of this study was to determine whether individual items in a disability questionnaire were answered differently depending on whether or not the questions were attributed to the upper limb (i.e., "do you have difficulty eating due to your arm or hand problem?" or "do you have difficulty eating?", respectively). The a priori hypothesis was that the same or more disability would be detected by nonattributed items. Four hundred sixty-seven patients with upper extremity disorders completed the SF-36 general health survey, which does not attribute health problems to affected areas. Patients also completed six additional questions, modified from the SF-36, regarding work (four questions) and social function with friends and family (two questions), which attributed their disability to their affected upper extremity. Of 467 patients, 419-431 (89-92%) responded to both versions of the questions. Although we demonstrated a significant order effect (Generalized Estimating Equation; P=.003), comparison of the responses to the six questions showed that for five of the six questions (Generalized Estimating Equation; P< or = .001) patients reported more disability when the questions were worded with attribution to the upper extremity. Even considering the order effect, patients demonstrated a counterintuitive result by reporting more disability when questions were attributed to their affected area. Thus, both the wording of questions and order of questions can significantly affect patients' responses about their disability and raises questions about the validity of patients' reports of their disability.
In this study, we assessed the validity of a subjective histological-histochemical scoring system as compared to an automated histomorphometry program for analyzing cartilage repair tissue. In the first part of the study, we assessed the ability of the human eye to estimate the percent cartilage in a histological section. Twenty-nine rabbit periosteal explants that had been cultured in agarose transforming growth factor-beta (TGF-beta) were selected so that the percentage of cartilage in the specimens was distributed equally from 0% to 100%. Color photomicrographs were evaluated by 5 expert observers who gave a visual estimate of the percent cartilage. There was a strong correlation between the estimated and actual percent cartilage (R(2) = 0.92, p < 0.0001) and among the observers (I.C.C. = 0.89). On average, the estimated percent cartilage was within ten percent of the actual percent measured. In the second part, we compared the data derived using a simple cartilage score with those obtained by automated image analysis. The histological slides from 159 explants cultured under various experimental conditions (14 treatment groups) in two different experiments were analyzed. The cartilage content was estimated visually and a score from 0 to 3 was assigned. A previously validated, computerized image analysis system was used to measure the actual percent cartilage. Statistical analyses revealed a good linear regression (R(2) = 0.84, p = 0.0001), and even better polynomial correlation between the actual measurement and the score (R(2) = 0.88, p = 0.0001). These data demonstrate the validity of a simple histological-histochemical subjective scoring system. A computerized automated program such as the one employed in this study is preferable due to its many advantages. However, a subjective scoring system may be appropriate to use when the funding and expertise required for a computerized image analysis program are not available.
OBJECTIVE: The study tested the hypothesis that females who sustain stress fractures of cancellous bone have decreased bone density. DESIGN: A retrospective, controlled, cross-sectional study. SETTING: The setting of the study was a tertiary care center for Women's Sports Medicine. PATIENTS: 20 female patients under the age of 40 who had suffered a stress fracture and who had a positive diagnostic study (radiograph, bone scan, or magnetic resonance imaging) were included in the study. INTERVENTIONS: Patients who had a positive diagnostic study (radiograph, bone scan, or magnetic resonance imaging) for the diagnosis of stress fracture also underwent dual energy X-ray absorptiometry (DEXA) scans. MAIN OUTCOME MEASURE: Bone density measured by the DEXA scan, as defined by the World Health Organization criteria for osteopenia (greater than one standard deviation from the standard age-matched control). RESULTS: 8 of 9 patients with cancellous stress fractures had DEXA scans indicating osteopenia while only 3 of 11 patients with stress fractures of cortical bone had a scan indicating osteopenia (p = 0.01). CONCLUSIONS: A cancellous stress fracture in a female may be a warning sign of early onset osteopenia. We recommend that young females who have documented stress fractures of cancellous bone or cortical bone (with risk factors for osteopenia) undergo bone density evaluation.
BACKGROUND: Many patient-based knee-rating scales are available for the evaluation of athletic patients. However, there is little information on the measurement properties of these instruments and therefore no evidence to support the use of one questionnaire rather than another. The goal of the present study was to determine the reliability, validity, and responsiveness of four knee-rating scales commonly used for the evaluation of athletic patients: the Lysholm scale, the subjective components of the Cincinnati knee-rating system, the American Academy of Orthopaedic Surgeons sports knee-rating scale, and the Activities of Daily Living scale of the Knee Outcome Survey. METHODS: All patients in the study had a disorder of the knee and were active in sports (a Tegner score of 4 points). Forty-one patients who had a knee disorder that had stabilized and who were not receiving treatment were administered all four questionnaires at baseline and again at a mean of 5.2 days (range, two to fourteen days) later to test reliability. Forty-two patients were administered the scales at baseline and at a minimum of three months after treatment to test responsiveness. The responses of 133 patients at baseline were studied to test construct validity. RESULTS: The reliability was high for all scales, with the intraclass correlation coefficient ranging from 0.88 to 0.95. As for construct validity, the correlations among the knee scales ranged from 0.70 to 0.85 and those between the knee scales and the physical component scale of the Short Form-36 (SF-36) and the patient and clinician severity ratings ranged from 0.59 to 0.77. Responsiveness, measured with the standardized response mean, ranged from 0.8 for the Cincinnati knee-rating system to 1.1 for the Activities of Daily Living scale. CONCLUSIONS: All four scales satisfied our criteria for reliability, validity, and responsiveness, and all are acceptable for use in clinical research.
Percutaneous transluminal coronary angioplasty (PTCA) of a native coronary artery via internal thoracic artery (ITA) graft after bypass surgery is a relatively rare procedure. Our current study evaluates the flow velocity patterns of the graft before and after PTCA. After intervention the mean diastolic flow velocity increased under rest and stress conditions. In addition, the graft patency was proved not before control angiography after 6 months. It could be verified that the measurement of flow velocity patterns under rest and stress conditions is a useful non-invasive procedure for monitoring long-term patency and PTCA-results of this vessel.
This case report presents chondral damage associated with a resorbable meniscal repair implant. Although the devices may not have been inserted properly, surgeons using these implants should be aware of the potential severe chondral injury that may occur.
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Standard arthroscopic assessment of the anterior cruciate ligament (ACL) injury through an anterior view can be sub-optimal for evaluation of the femoral origin, particularly the posterior component. The figure-of-four view provides increased exposure to the posterolateral aspect of the intercondylar notch, thereby facilitating diagnosis of proximal ACL injury and avulsions of the ACL origin.
There are many factors to consider when treating an active individual with a known or suspected meniscal tear. The athlete with a meniscal tear sometimes can return to competition, temporarily delaying surgery until after the season. If an athlete remains symptomatic and is unable to return, however, then arthroscopic surgery generally is effective to allow the athlete to resume participation. The decision of meniscal repair versus excision must be carefully thought out and discussed with the athlete before surgery. Either treatment can allow the athlete to return to their sport. It is controversial whether or not an athlete should be allowed early return to play after meniscal repair. Further prospective randomized studies would provide useful information in deciding which type of treatment and which type of rehabilitation is best suited for the active individual.
Clinimetrics and psychometrics, two accepted methods for developing multiitem health measurement scales, have fundamentally different aims and methods that have seldom been compared and never prospectively. The purpose of this study was to determine whether these two methodologies provided comparable scales in the development of an upper extremity disability measure. Psychometric analysis involved field testing a 70-item questionnaire on 407 patients. Equidiscriminatory item total correlation (EITC) was used to select the top 30 items. Clinimetric testing used the mean importance and severity ratings of the 70 items by 76 patients to select the top 30 items. Clinimetric and psychometric analyses were performed independently. Cronbach's alpha was 0.97 for the top 30 items selected by EITC and 0.96 for the items selected based on patient's ratings. The two scales (after clinician modification to improve face validity) shared 16 items in common (P=0.10). The intraclass correlation coefficient of the patient scores on the two 30-item scales was 0.93 before clinician input and 0.97 after. The mean (and standard deviation) difference between scales was 9.1 (8.8) before and 1.7 (5.2) after clinician input. A scale developed with a clinimetric strategy can measure a complex (so-called heterogeneous) clinical phenomenon (thought to be composed of several patient attributes) but still fulfill psychometric criteria for "homogeneity." Thus, these strategies for the development of health measurement scales, which have been considered potentially opposite or conflicting, may be complementary.
Patients' ratings of the severity and importance of items are often used to select items for health status instruments. The purpose of this study was to compare six different methods of combining severity-importance ratings. Two different patient groups separately rated the importance and severity of their complaints; (i) 76 patients with upper-extremity disorders rated 70 upper-extremity-related questions; and (ii) 86 patients with hip arthrosis rated 22 questions relating to their hip problem. The rank ordering of the items using the six different methods in the two populations were very similar (tau(bi) = 0.91 and 0.87, respectively). Furthermore, the six methods when used to choose 30 upper-extremity items shared 25 items in common and shared 9 (of 10) hip items in the second group. In conclusion, the results of item reduction were not affected by the method of creating importance-severity ratings.
The literature regarding the reliability and validity of commonly used clinical tests for disorders of the upper extremity was reviewed. Formal literature search, standard texts, and experts in the field of upper extremity were consulted to locate relevant articles. Range of motion and strength testing of the upper limb have been shown to be reliable, while various tests used for the diagnosis of conditions in the upper limb, such as carpal tunnel syndrome and rotator cuff tendinopathy, have been shown to have varying degrees of validity. Overall, however, we determined that there is little evidence regarding the reliability and validity of physical examination for the upper extremity and specifically less information available regarding the reliability of diagnostic physical examination tests and the validity of impairment measures used for the upper limb. Further studies in this area are warranted in view of the impact of these findings on the treatment of patients.
We have developed and tested a color-based method for automated computerized histomorphometric analysis of cartilage. Histological sections stained with safranin O from 29 rabbit periosteal agarose-cultured explants were selected with various amounts of cartilage (0-100%). Color photomicrographs of these sections were visually assessed by five expert observers who estimated the percent area occupied by cartilage and outlined (in pen) the areas they considered to be cartilage. Manual histomorphometry was performed by cutting out and weighing the outlined areas. The average area for each of the five observers ranged from 31% to 43% (intraclass correlation coefficient = 0.70). The average of these values was used as a "gold standard" against which to compare the computer measurements. When point counting histomorphometry was performed on the 29 sections, the data agreed with the measurements made by the other five cartilage experts (r2 = 0.96; p < 0.0001). The analysis of cartilage is based on safranin O stain, using a custom-designed Vidas 2.1 Image Analysis Program (Zeiss). The computer-based results correlated very closely with those obtained by manual (p = 0.0001; r2 = 0.92) and point counting (r2 = 0.92; p < 0.0001) histomorphometry. The mean percentage of the sections occupied by cartilage measured in the automated mode was only 6% higher than that using the gold standard. Histological complexity had only a minor effect on the computerized values. The automated computerized image analysis system has the advantages of objectivity, accuracy, repeatability, and ease of use.
OBJECTIVE: To compare self-perception between a group of competitive, elite female collegiate athletes (participating in gymnastics, cross country, and track and field) and a group of female political science students (nonathletic control subjects). We hypothesized that the athletic group would rate athletics as more important than would the nonathletic group, that the perception of athletic competence would correlate positively with self-worth for athletes only, and that the perception of athletic competence would have a stronger influence on self-worth in the athletic group. SUBJECTS AND METHODS: The Self-perception Profile for College Students was completed by 32 athletes and 13 nonathletes. This profile measures 12 subscales plus Global Self-worth independently and generates scores that reflect the subject's perceived importance of and competence in each of the subscale areas. RESULTS: The athletes rated athletics as more important than did nonathletes, although this trend was nonsignificant when adjusted for age. As age increased, the importance of athletics decreased for both groups. There was a direct relationship between perceived athletic competence and self-worth for the athletes but not for the nonathletes. Variables that accounted for the Global Self-worth score in athletes were perceptions of Competence subscales for Appearance, Social Acceptance, Friendship, and Job. Variables that accounted for the Global Self-worth scores in the nonathletes were perceptions of Competence subscales for Romance, Morality, Humor, and Appearance. The athletic group had significantly lower Global Self-worth scores than the nonathletic group. CONCLUSIONS: The female athletes in this study derived a large component of their self-worth from their perceived athletic competence. Clinicians should bear in mind the relative importance of athletics to young female athletes and the relationship of perceived athletic ability to self-worth when treating these individuals.
Septic arthritis of the hip must be managed promptly to avoid the serious complications associated with the condition. In the case reported here, the diagnosis was delayed and was complicated by a slipped capital femoral epiphysis. The patient, an adolescent boy previously in good health, presented with a 2-week history of hip pain and systemic illness. Septic arthritis was diagnosed and was managed by incision and drainage and antibiotic therapy. Two weeks later he presented with a subcutaneous abscess and a slipped capital femoral epiphysis, which was pinned in situ. There was a 2.5-cm leg-length discrepancy. Avascular necrosis of the femoral head subsequently developed leaving the boy with a permanent disability.
The goal of this study was to determine the interobserver and intraobserver reliability of static and moving two-point discrimination, Semmes-Weinstein monofilament testing, Tinel's test, manual motor testing of abductor pollicis brevis, vibration and Phalen's test in the diagnosis of carpal tunnel syndrome. Twelve patients with suspected carpal tunnel syndrome were examined in an outpatient setting. The interobserver reliability was satisfactory for all tests except for Semmes-Weinstein monofilament testing. Intraobserver reliability was also satisfactory for all tests. Static two point discrimination had higher reliability than moving two-point discrimination. Seven tests for the diagnosis of carpal tunnel syndrome were reliable in the hands of skilled health care professionals. Hand surgeons and hand therapists examined patients more reliably than occupational health workers.