Diane W. Braza

The incidence of peripheral nerve injury in extremity trauma.

Taylor CA, Braza D, Rice JB, Dillingham T: The incidence of peripheral nerve injury in extremity trauma. Am J Phys Med Rehabil 2008;87:381–385. Objective:To examine the incidence of peripheral nerve injury within 90 days of a limb trauma diagnosis in patients who have presented to the hospital or outpatient clinic. Design:This study is a retrospective, descriptive study that uses the 1998 MarketScan Commercial Claims and Encounters Database (The MEDSTAT Group) to track peripheral nerve injuries in extremity trauma. We selected our sample by using ICD9 codes for limb trauma during the first 9 mos of 1998. Nerve injuries within 90 days after limb trauma were the main outcome measure. Finally, we report how the rates of trauma and accompanying nerve injuries were contrasted by gender and age group, using univariate and bivariate statistics. All data analyses were conducted using Stata 9.0 statistical software. Results:Out of 16 million insureds in the database, 220,593 (1.4%) were diagnosed with limb trauma. Eighty-three percent of the patients were less than 55 yrs old, and 50% were male. The total incidence of nerve injuries within 90 days of upper- or lower-limb trauma was 1.64%. The type of extremity trauma with the highest incidence of nerve injury within 90 days of the diagnosis was a crush injury at 1.9%. Approximately 50% of our sample was selected because of a dislocation, which had an associated nerve injury prevalence of 1.46%. Conclusions:When looking at the population sampled, rates for peripheral nerve injury in people incurring limb trauma are low. Crush injuries seem to have the highest rate of associated nerve injury. Further studies are needed to observe outcomes for people with nerve damage after trauma.

Meeting the Scholarly Project Requirement—Application of Scholarship Criteria beyond Research

Maintaining an environment of scholarly inquiry is highlighted in the Accreditation Council for Graduate Medical Education’s (ACGME) common program requirements. Faculty and trainees are expected to participate in scholarly activities, and present those findings to peers for review. Faculty and residents/fellows often lack a conceptual yet practical framework for guiding scholarly activities when they occur in the context of health care systems, clinical practice, quality improvement, education, or community partnerships.

Implementing a global integrative rehabilitation medicine rotation: a physical medicine and rehabilitation residency program's experience.

ABSTRACTAn innovative international rotation in integrative rehabilitation medicine was implemented as part of the physical medicine and rehabilitation residency program at the Medical College of Wisconsin. Rotation objectives were to introduce medical knowledge of integrative medicine treatments into physical medicine and rehabilitation practice and to initiate collaboration with international academic partners. Residents were approved based on their academic record, completion of prerequisites, and personal statement. During a 4-wk rotation located in Italy, residents developed an integrative treatment strategy for each patient using conventional medical care and other therapeutic options, including acupuncture, biofeedback, aquatic therapy, yoga, and others. Postrotation assessment included evaluations by Italian team and patients, residents’ evidence-based presentations, and postrotation self-reflection. Participating residents reported high achievement in clinical performance, improved application of integrative medicine, broader appreciation of cultural diversity in patient care, and increased personal and professional development. This reciprocal program model serves as an example for other programs interested in implementing similar international rotations.

Vertebral sarcoidosis masquerading as breast metastasis.

A 68-yr-old woman with a history of T1NOMO intraductal breast cancer and pulmonary sarcoidosis presented with a 2-mo history of worsening right buttock and lateral thigh pain. The pain was sharp, of variable severity, aggravated by standing and walking and lessened by sitting. Symptoms were worse at night. She denied constitutional symptoms and red flags. Her physical examination demonstrated no focal lower limb weakness; she had normal symmetric reflexes, intact light touch and pinprick sensation, and normal gait. There was no focal palpation tenderness over the spine or buttock. Lumbar spine magnetic resonance imaging showed severe L3Y4 spinal stenosis, with T1 and T2 magnetic resonance imaging (Fig. 1) revealing hypointense lesions in the lumbosacral spine, including the sacrum and iliac bones. These lesions were enhanced on postcontrast sequences, suggestive of metastatic disease. Whole-body bone scan showed increased uptake of the L1 and L3/L4 vertebral body levels, consistent with metastatic disease. Positron emission tomography scan results were normal, without any abnormal activity to indicate malignant disease. She eventually underwent bone marrow biopsies demonstrating noncaseating granulomatous inflammation, consistent with sarcoidosis. Clinically, her right buttock and leg pain was felt to be secondary to her severe lumbar spinal stenosis. Her pain symptoms responded to a flexion bias physical therapy exercise program and oral Gabapentin. Sarcoidosis, also called Morbus Boeck disease, is an idiopathic, inflammatory granulomatous condition occurring more commonly in women and black individuals. Sarcoidosis has a variable presentation and prognosis. It can involve one ormultiple organ systems and can be progressive or can resolve spontaneously. The lungs are involved in more than 90% of cases. Skeletal involvement is much less frequent; the prevalence has been reported to range from less than 1% to 13%. The small bones of the hands and feet are most often involved, whereas spinal disease is rare. 4 Spinal sarcoidosis usually involves the thoracolumbar region. The radiographic appearance of vertebral-based sarcoidosis has not been well defined. In one series, the lesions were generally lytic, with well-defined borders, but some of the lesions were mixed lytic and sclerotic. The posterior elements were usually spared, as were the intervertebral discs. Given that spine magnetic resonance imaging findings can be nonspecific, the differential diagnosis includes metastatic disease, myeloma, lymphoma, histoplasmosis, coccidioidomycosis, and tuberculosis. Biopsy is frequently required to confirm the diagnosis. The treatment of vertebral sarcoidosis depends on the clinical picture. In our patient, her vertebral lesions improved on subsequent lumbar magnetic resonance imaging, and no additional treatment was necessary.

Feasibility and Development of a PM&R Resident EMG OSCE

per thousand members to 7 per thousand, but t his change coincided with the increase in co-pay. Conclusions: Application of a value-based benefit design to rehabilitation therapy benefits appeared to lead to utilization of benefits that more closely matched the patients’ needs while remaining at least cost neutral. The benefit can have a simple design (e.g., two groups of diagnostic codes), minimizing additional administrative burden related to errors in coding an frequent review of requested exceptions.

Re: Alternative medicines: Yes; Alternatives to medicine: No

It is important to highlight three main points in our response. Our manuscript, BImplementing a Global Integrative Rehabilitation Medicine Rotation: A Physical Medicine and Rehabilitation Residency Program’s Experience[ describes first and foremost a global health resident experience and faculty teaching collaboration, with clearly defined resident learning goals and objectives based on ACGME competencies. Second, it describes resident exposure to integrative medicine, within an established successful group practice. Finally, the manuscript is descriptive, not a research article addressing the efficacy or safety of complementary and alternative medicine and, therefore, cannot be viewed in such a manner. A clear definition of integrative medicine and its tenets has been previously described and form an important component of Bpatient-centered care.[ The Veterans Health Administration is applying these concepts while embarking on a transformation of health care, to drive the current model that is primarily Bfind it, fix it[ disease care to a personalized, proactive approach that is driven by the individual needs of the Veteran. An in-depth study of each and all of these complementary and alternative medicine practices is not possible during a 4-week rotation and is not a rotation learning goal. Careful selections of the techniques and teachers who deliver them within the integrative group, as well as ongoing formation by means of in-service journal clubs, discussion groups, and cross-participation among the practices, are the cornerstones of our integrative medicine experience. The focus of both the outpatient and inpatient experiences is to create clarity of thought in prescribing comprehensive medical treatment, for an effective, precise prescription of pharmacologic agents, allopathic treatments, modalities, or exercise based on individualized patient assessment and goals. The integrative approach is a philosophy, not a series of techniques to be memorized and applied as mere protocol, reflecting the concept that Bthe whole is greater than the sum of its parts.[ We agree that the conventional standards of evidencebased medicine need to be applied equivalently to all areas of medical care, including complementary and alternative medicine. Further research addressing patient safety, efficacy, and cost effectiveness is needed and desired. Ongoing resident education must teach and practice critical review of the scientific literature, including the application of complementary and alternative medicine techniques.