Your attitude changes your reality.

We have all heard that you should keep a positive attitude or perhaps that “you need to change your attitude!”. That is a nice piece of advice I suppose, but without any more reasons to do it is very easy to just brush such suggestions off and continue using your old attitude.

But the thing that I’ve discovered the last few years is that if you change your attitude, you actually change your reality. When you for instance use a positive attitude instead of a negative one you start to see things and viewpoints that were invisible to you before. You may think to yourself “why haven’t I thought about things this way before?”.

When you change your attitude you change what you focus on. And all things in your world can now be seen in a different light.

This is of course very similar to the previous tip but I wanted to give this one some space. Because changing your attitude can create an insane change in your world. It might not look like it if you just think about it though. Pessimism might seem like realism. But that is mostly because your R.A.S is tuned into seeing all the negative things you want to see. And that makes you “right” a lot of the time. And perhaps that is what you want. On the other hand, there are more fun things than being right all the time.

If you try changing your attitude for real – instead of analysing such a concept in your mind - you’ll be surprised.

You may want to read more about this topic in Take the Positivity Challenge!

Mistakes and failures are good.

When you are young you just try things and fail until you learn. As you grow a bit older, you learn from - for example - school to not make mistakes. And you try less and less things.

This may cause you to stop being proactive and to fall into a habit of being reactive, of waiting for someone else to do something. I mean, what if you actually tried something and failed? Perhaps people would laugh at you?

Perhaps they would. But when you experience that you soon realize that it is seldom the end of the world. And a lot of the time people don’t care that much. They have their own challenges and lives to worry about.

And success in life often comes from not giving up despite mistakes and failure. It comes from being persistent.

When you first learn to ride your bike you may fall over and over. Bruise a knee and cry a bit. But you get up, brush yourself off and get on the saddle again. And eventually you learn how to ride a bike. If you can just reconnect to your 5 year old self and do things that way - instead of giving up after a try/failure or two as grown-ups often do – you would probably experience a lot more interesting things, learn valuable lessons and have quite a bit more success.

Don’t beat yourself up.

Why do people give up after just few mistakes or failures? Well, I think one big reason is because they beat themselves up way too much. But it’s a kinda pointless habit. It only creates additional and unnecessary pain inside you and wastes your precious time. It’s best to try to drop this habit as much as you can.

A 3-Year-Old Girl With Fever and a Limp

Background

3-year-old girl is brought to the emergency department (ED) by her parents with a fever and refusal to walk secondary to pain in her right leg. The pain is associated with thigh and back pain on the same side as the limp. The day before presentation, the child's mother picked her up from her babysitter, where she noticed that the child was irritable and crying. At that time, the child was pointing at and trying to touch her back, and she was walking with a noticeable limp. The parents called the patient's pediatrician, who recommended an antipyretic with follow-up the next day. The review of symptoms is only remarkable for a 1-week history of a "cold" with a runny nose and a cough. The mother denies any history of trauma to the affected extremity, and there is no prior history of similar problems. The patient's past medical history is unremarkable. The child is well-appearing and has been regularly observed by the outpatient pediatric department. The patient's immunization schedule is up to date. The child's developmental milestones are appropriate for her age. The family history is noncontributory.

On physical examination, the patient's vital signs are stable, with a blood pressure of 103/66 mm Hg, pulse rate of 115 bpm, respiratory rate of 24 breaths/min, and an oxygen saturation of 100% while breathing room air. Her temperature is 97.5°F (36.4°C).The patient initially refuses to bear weight on the right leg and is unwilling to walk. She is tearful and uncooperative as a result of the pain. The respiratory and cardiac portions of the physical examination are normal. The abdominal examination is also normal, with no palpable masses or tenderness to deep palpation. There is localized exquisite tenderness over the L1-2 region of the back, with slight induration noted in the overlying tissue. The lower extremities are well-perfused, with intact peripheral pulses; no external evidence of trauma is found. There is no limitation in the range of motion at the hip and knee joints bilaterally, with unremarkable obturator and psoas signs. The neurologic examination is normal. No lymphadenopathy is detected.

The initial laboratory investigations reveal an elevated white blood cell (WBC) count of 20.5 × 10³/μL (20.5 × 10⁹/L; neutrophils, 66.5% [0.66]; lymphocytes, 21% [0.21]; monocytes, 11.3% [0.11]), an elevated erythrocyte sedimentation rate of 87 mm/h, a C-reactive protein (CRP) level of 49.5 mg/L, a creatine kinase of 69 units/L (69 U/L), and a lactate dehydrogenase of 247 units/L (247 U/L). The urinalysis is normal, with no evidence of infection or hematuria. Plain radiographs of the lumbar spine are obtained (see Figures 1 and 2) and are essentially unremarkable. Since there is a high suspicion for serious pathology based on the clinical presentation and the results of the laboratory investigations, urgent magnetic resonance imaging (MRI) scans of the spine are also obtained (see Figures 3 and 4).

Figure 1. (Click to enlarge)	Figure 2. (Click to enlarge)
Figure 3. (Click to enlarge)	Figure 4. (Click to enlarge)

Question


What diagnosis do the findings on the MRI scan suggest?

Psoas abscess

Spinal epidural abscess

Retroperitoneal schwannoma

Retroperitoneal hematoma

Please try to answer first before you scroll down

Hint: Look closely at the area of the psoas muscle.

Answer

			Your Colleagues Responded:
	Psoas abscess	Correct Answer	70%
	Spinal epidural abscess		14%
	Retroperitoneal schwannoma		6%
	Retroperitoneal hematoma		8%

Discussion

As previously mentioned, the lumbosacral plain films were essentially unrevealing (see Figures 1 and 2). The MRI scan of the lumbosacral region, however, revealed a right multiloculated psoas abscess, with paraspinal extension in the region of L3-4 (see Figures 3 and 4) and possible involvement of the ipsilateral pedicle of L3 (not shown in the images provided). Osteomyelitis could not be ruled out based on the images. The abscess measured 1.1×0.6×2.5 cm.

A psoas abscess may be classified as primary or secondary, depending on the presence or absence of an underlying cause. In cases of primary psoas abscess, there is no identifiable source of infection. The psoas muscle is a single structure ("psoas major") in 70% of people, but the remaining 30% also have a smaller "psoas minor", which lies anterior to the psoas major and along the same course. In the lower half of the psoas muscle's course, it runs alongside the iliacus muscle, with a common tendon insertion into the lesser trochanter. Together, they are referred to as the iliopsoas. It lies in close proximity to many organs, such as the sigmoid colon, jejunum, appendix, ureters, aorta, renal pelvis, pancreas, iliac lymph nodes, and the spine. Infections in these organs can contiguously spread to the psoas muscle. A rich vascular supply is believed to predispose it to hematogenous spread from sites of occult infection.^[2,3,5,7]

A psoas abscess in children classically presents as a triad of fever, limp, and hip pain. It is important to differentiate between primary disease of the hip and a psoas abscess, as close proximity of a psoas abscess to the hip capsule can result in a similar presentation. This contributes to its extreme clinical variability. Passive rotation of the hip joint in flexion is possible in cases of psoas abscess, whereas in primary disease of the hip, resistance would be likely. Dysfunction of this joint, however, is extremely variable, ranging from complete pseudoparalysis to normal range of motion. In our case, the child presented with the additional finding of tenderness localized to the lower back, which led to an initial incorrect working diagnosis of diskitis. The differential diagnoses in this patient included psoas abscess, pyelonephritis (ruled out by the urine analysis), osteomyelitis, and a neoplastic process. Garner et al has suggested that the incidence of psoas abscess is probably underreported.^[11] Primary psoas abscess has a better prognosis than secondary psoas abscess, with a mortality rate of 2.4% (18.9% for secondary abscesses). The median time of diagnosis is 3 days, and the median hospital stay is 27 days. The major cause of death is delayed or inadequate therapy.^[6,13,14]

The appropriate imaging studies are important to accurately diagnose this uncommon clinical presentation. Ultrasonography has been recognized as the quickest and least expensive diagnostic imaging modality, as well as being a safe one. It can also differentiate between solids and liquids but, unfortunately, has a low sensitivity. Plain films of the abdomen may show enlargement or loss of definition of the psoas muscle or gas shadows in the soft tissue. Even though findings on plain films correlate poorly with a lesion, especially given the frequent presence of overlying bowel and stool, studies have shown that plain films should be performed before other imaging modalities in patients with suspected psoas abscesses (but may not be necessary if a computed tomography [CT] scan is already planned). CT scans done with intravenous (IV) contrast will show rim-enhancing hypodense areas, with secondary findings of inflammation obliterating surrounding tissue, gas bubbles, and bone destruction when present. There may be marked wall thickening, rim thickening, or multiple cavities, which suggest tuberculous rather than pyogenic infection. CT scans are also useful in recognizing potential etiologies such as Crohn disease and appendicitis. MRI (which was the diagnostic study in this case) has been reported to be more sensitive than CT scanning in displaying tissue contrast resolution and in screening out bone interference, as well as showing the extent of disease. A study by Yin et al recommended the use of a bone scan, especially in patients presenting with low back pain and an established fever of unknown origin, as it allows detection of unexpected concomitant infections.^[1,2,3,4,10]

A review of the literature published from 1881 through 1990 revealed that the incidence of psoas abscesses approximates 4 cases per 100,000 population per year, with a more recent Taiwanese study reporting that the rate of occurrence was 2.5 cases annually.^[4] These incidences reflect adult patients. In Asia and Africa, 99.5% of all psoas abscesses are primary, compared with 61% in the United States and Canada and 18.7% in Europe. The causes of psoas abscess in the Western world have changed since the beginning of the 20th century. Primary psoas abscesses caused by hematogenous spread from an occult source is common, especially in immunocompromised individuals.

In the past, psoas abscess was mainly caused by tuberculosis of the spine (Pott disease), but with the decline in the prevalence of infections caused by Mycobacterium tuberculosis, major pathogens associated with psoas abscesses are those related to diseases of the digestive tract. This is reflective of the role of contiguous sites of infection in the development of a psoas abscess. Common secondary causes of psoas abscess include Crohn disease (60%), appendicitis (16%), ulcerative colitis, diverticulitis, colon cancer (11%), and vertebral osteomyelitis (10%). In secondary psoas abscesses, cultures are often mixed with Escherichia coli and BacteriodesStaphylococcus aureus is the most common isolated organism in primary disease. Leukocytosis is the most common laboratory finding.^[2,3,7,9] species predominating.

Without localizing tenderness, the presentation of fever and irritable hip could be attributed to primary diseases of the hip and, therefore, it is important that the clinician know how to distinguish between psoas abscesses and primary hip diseases. In psoas abscess, the posterior part of the hip joint is not tender, and a fully flexed hip can be rotated without pain; this would be difficult in patients with hip problems. Digital rectal examinations produce tenderness in psoas muscle disease.

Percutaneous drainage and antibiotics are the first line of treatment, but there is a high recurrence rate. In the past, open drainage of the abscess through a McBurney or iliac crest incision was performed. Open surgical drainage allows simultaneous treatment of the underlying pathology in secondary abscess. The duration of antibiotic therapy must be individualized and graded by the clinical signs and any involvement of other sites.^{[2,6,8,11,13]}

The patient in this case was started on empiric intravenous antibiotic therapy, initially on ceftriaxone 75mg/kg/day. An ultrasonogram obtained shortly after admission was read as a "negative study of the upper abdomen, perirenal and perivertebral lower thoracic lumbar area". Following consultation with the infectious disease service, the antibiotic regimen was changed to cefepime to provide better broad-spectrum coverage. A review of the MRI findings with the interventional radiology department led to the decision that an invasive drainage procedure for a relatively small collection would not be immediately warranted, and a "wait-and-see" approach to determine the response to the intravenous antibiotics would be the best course of action. After 3 days of intravenous antibiotic therapy, the child's fever subsided, and she was noted to be moving around without limping and with no residual tenderness on examination. If fact, her mother described her as "back to her old self." A consultation with the neurology service found no neurologic deficits, and the initial limp was attributed to pain. A repeat CRP level was obtained, with a result of 34.5mg/L. The final results of the blood and urine cultures, as well as a purified protein derivative (PPD), were all negative.

As the child was doing well clinically (running and jumping up and down) and had a compliant parent, the patient was discharged on hospital day 5 with a combination antibiotic regimen of rifampin and amoxicillin/clavulanic acid for 4 weeks, along with appropriate outpatient follow-up with her primary pediatrician and an infectious disease specialist. Repeat MRI scans performed at 1 month and again at 3 months after discharge demonstrated complete resolution of the collections, except for a residual "abnormal signal intensity in the right pedicle of L3", which persisted with no identifiable clinical impact; the patient was noted to have complete resolution of her symptoms. It should be noted that the use of IV antibiotics as the sole modality of therapy in our case was unusual for the management of a psoas abscesses.

Questions

Which of the following statements about psoas abscess imaging is true?

MRI has been reported to be more sensitive than CT scanning

Ultrasonography is more sensitive than CT

A negative plain film of the area can rule out psoas abscess

CT scanning is the least expensive and quickest imaging modality

Which of the following statements about the psoas muscle's anatomy is true?

The psoas muscle together with the iliacus muscle is referred to as the iliopsoas.

Seventy percent of individuals have a smaller secondary psoas muscle.

The psoas muscle is relatively isolated from other organs.

A poor vascular supply can cause hematogenous spread from sites of occult infection.

Please try to answer first before you scroll down

























Answer

Which of the following statements about psoas abscess imaging is true?

			Your Colleagues Responded:
	MRI has been reported to be more sensitive than CT scanning	Correct Answer	86%
	Ultrasonography is more sensitive than CT		4%
	A negative plain film of the area can rule out psoas abscess		2%
	CT scanning is the least expensive and quickest imaging modality		6%

Which of the following statements about the psoas muscle's anatomy is true?

			Your Colleagues Responded:
	The psoas muscle together with the iliacus muscle is referred to as the iliopsoas.	Correct Answer	84%
	Seventy percent of individuals have a smaller secondary psoas muscle.		5%
	The psoas muscle is relatively isolated from other organs.		5%
	A poor vascular supply can cause hematogenous spread from sites of occult infection.		5%

• The psoas muscle is a single structure ("psoas major") in 70% of people, but the remaining 30% also have a smaller "psoas minor", which lies anterior to the psoas major and along the same course. In the lower half of the psoas minor's course, it runs alongside the iliacus muscle, with a common tendon insertion into the lesser trochanter. Together, they are referred to as the iliopsoas. It lies in close proximity to many organs, such as the sigmoid colon, jejunum, appendix, ureters, aorta, renal pelvis, pancreas, iliac lymph nodes, and the spine. Infections in these organs can contiguously spread to the psoas muscle. A rich vascular supply is believed to predispose it to hematogenous spread from sites of occult infection.

			Source: http://cme.medscape.com

Orthopaedic Information Technology

Author : Myles Clough, MD

Published: 03/29/2001

Introduction

Signs of the growing integration of the Internet into the mainstream of orthopaedic academic activity were evident at the 68th Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS). Queues at the email kiosks, standing room only at the AAOS "Create Your Own Website" display, and packed attendance at the Digital Imaging Instructional Courses all tell their own tale. However, few formal presentations were delivered on this topic, indicating a lack of scientific studies on the impact of information technology on orthopaedic surgery. Areas of particular interest included patient information on the Internet, sites for orthopaedic surgeons, digital imaging, and other uses of the Internet for such things as evaluating outcomes and maintaining databases.

Patient Information on the Internet

One of the most popular areas of investigation is the impact and quality of orthopaedic patient information. Several studies have been conducted to examine how many patients use the Internet to get information on orthopaedic care and to evaluate the quality of that information.

Dr. Terry Messer and colleagues^[1] undertook a 2-part study. In the first part, they evaluated patient information sites on anterior cruciate ligament (ACL) reconstruction and total knee arthroplasty (TKA). They found bias in 59 of 116 sites evaluated and inaccurate information in 25 of the 116 sites. They concluded that 60% of these sites were biased, inaccurate, or both.

The second part of the study involved a survey of Internet use of 200 patients (100 patients with ACL reconstruction, 100 with TKA). Forty percent of the ACL patients used the Internet for information about their condition, as did 14% of the TKA patients. This reflected the age-related differences in Internet use. Patients generally found that information on the Internet was helpful and did not conflict much with the information they received from their surgeons. The study concluded that orthopaedic surgeons should be aware of patients' use of the Internet and should be prepared to guide their patients to sites that are accurate, reliable, and free from bias. Unfortunately, the authors of this study did not give an indication of where such sites are to be found.

Dr. Charles K. Lim and colleagues^[2] presented another survey on how patients use the Internet. They surveyed 500 patients in a general orthopaedic practice and found that up to 77% of younger patients and 16% of older patients used the Internet. Of these, 56.5% use the Internet to obtain orthopaedic health information.

The team also conducted a survey to find out what patients would like to access through the Internet. They found that high numbers of patients would like to be able to email their physicians, and more than 80% would like to access their physicians' Web sites. Concerns were expressed by patients about the privacy and security of their medical information on the Internet.

The authors noted that their study population represented only a small sample in a specific community. In addition, the survey was conducted before January 2000, so Internet use may have changed since then. Despite these limitations, Dr. Lim and colleagues were able to conclude from the studythat patients are increasingly using the Internet for orthopaedic information and are expecting better quality and access to useful information. They urge orthopaedic surgeons to adopt the Internet and integrate it into their patient information strategies.

Dr. Robert B. Koch and associates^[3] gave a presentation entitled "Shoulder Information Available on the Internet: Is It Accurate?" They reported on a study of 120 statements, 30 each about 4 common shoulder problems, that were collected from randomly selected Web sites by a nonmedical person. Five fellowship-trained shoulder surgeons were asked to rank the validity of the statements on a scale of 1 (strongly disagree) to 5 (strongly agree).

The mean validity score was 3.79, with minor differences between the 4 shoulder problems selected (frozen shoulder, 3.41; osteoarthritis, 3.81; shoulder instability, 4.07; and rotator cuff, 3.85).

Examples of statements that were rated as "highly valid" included "Frozen shoulder is often associated with thyroid disease," or "Rotator cuff tears normally occur through areas that are not normal to begin with." Examples of statements rated as "highly invalid" included "Shoulder magnets help pain, swelling, and inflammation and increase the blood flow to the shoulder" (in reference to osteoarthritis), or, "Usually a test called an arthrogram, in which dye is injected into the shoulder, is required" (in reference to rotator cuff tears).

Koch and associates concluded that 20% of the information about management of shoulder problems found on the Internet is misleading and invalid. Physicians should be aware of these inaccuracies to counsel their patients better.

To put these studies in perspective, it is important to apply the same standards and criteria that are applied to the information found on the Internet to the information surgeons normally give their patients. None of the studies presented did this or referred to studies in which this has been done. It is natural to assume that information provided by surgeons is more complete and accurate than that found on the Internet, but this has not been tested and should be.

Improving Orthopaedic Informatics: The Orthopaedic Gateway

Dr. David L. Nelson and colleagues ^[4] presented the "Expanded Orthopaedist's Guide to the Internet." This is part of the Orthogate Project, an attempt to form a clearinghouse for orthopaedic surgery on the Internet sponsored by the Internet Society of Orthopaedic Surgery and Trauma (ISOST). The Guide contains modules on searching the Internet, improving your use of email, setting up your office Web site, imaging, finding commercial orthopaedic information, discussion forums and an appendix of additional reading.

The Internet Society of Orthopaedic Surgery and Trauma is a nonprofit academic society founded in 1999 to improve orthopaedic informatics. It has over 400 members worldwide. Through its Orthogate site, it pursues these aims by providing a collection of links to orthopaedic sites of interest and access to Web-based mailing list archives that promote communication among orthopaedic surgeons on a variety of topics.

Digital Imaging

Digital imaging is an area of keen interest in orthopaedic surgery. Several presentations were devoted to this topic. At the Instructional Course Lecture (ICL) on "Digital Imaging and Computer Presentation,"^[5] moderators J.W. Brodsky and R.W. Sanders presented useful information on image capture using digital cameras and other devices, but information was lacking on editing of digital images after they have been captured. The focus was on using images for presentations, whereas most orthopaedic surgeons can expect to use images more often for clinical records and for sending them to colleagues. Nevertheless, the introduction to the PowerPoint program for presentation and the tips and pointers shared with the audience were valuable. About half of the participants brought their laptops so they could participate more fully in the workshop.

The presentation on "Computer-based Multimedia Presentations - the Essentials"^[6] also demonstrated the techniques for PowerPoint presentations. About 50% of the podium presentations at the meeting used PowerPoint rather than slides.

Dr. Brett M. Andres and associates^[7] presented a review of results that can be expected from using a digital camera for clinical imaging. They compared 4 cameras and assessed their effectiveness with regard to plain radiographs, cross-sectional images (eg, CT), operative specimens, and a knee simulator. The quality of the output was compared, and they concluded that the image should contain at least 2.1 megapixels to provide sufficient resolution; storage medium should be removable and have space for at least 20-30 images; the zoom system should be optical, not digital; macro mode should have a focus of less than 12 cm (5 in); and high-speed transfer of images to a computer is best achieved using a USB port or Flash cards. However, for sharing images with others, transfer by floppy disk is a good option because it doesn't require special programs or hardware.

Dr. Troy Watson^[8] presented a scientific exhibit on digital imaging. He also compared several systems and concluded that use of a digital camera is the most suitable method. He reviewed a number of topics, including how to choose a camera, how to use a digital camera, computer needs, mechanisms of image transfer from camera to computer, image storage media, and archiving systems. Dr. Watson also provided a review of resources available in print and on the Internet. Unlike most of the other displays on imaging, his presentation emphasized the need to edit the image before storing it, and his focus was on using images for everyday clinical practice rather than for academic presentations.

The ISOST Guide describes 5 ways of capturing images: video capture, use of a scanner, digital camera, digital arthroscopy systems, and digital radiology. Use of a digital camera is probably the optimal choice if the budget allows because it is the most versatile.

Gomoll and Thornhill^[9] presented a solution to the problem of storing and indexing scanned and digital images, documents, presentations, and video segments in a teaching and research environment. The image database they described is accessible to contributing members over the Internet and has greatly facilitated the preparation of talks and presentations.

Other Uses of the Internet

Dr. Diana L. Hauser and associates^[10] presented a discussion of the Massachusetts Total Hip Registry, a multisourced, Internet-based database of patient information, surgeons' assessments, operative and follow-up reports, and radiology images. This system reduces to a few minutes the time it takes to collect a cohort of patients who satisfy certain inclusion data.

Strain and Kurzon^[11] identified a rich source of outcomes data that has been largely overlooked. Physicians input volumes of data into billing systems. So far only invoices and other financial reports have been generated from these data. With some additional effort, these data can be transformed into information on outcomes and performance measurements, specifically operation and reoperation rates for certain diagnoses, requirements for postoperative physiotherapy, number of visits related to diagnosis, referral rates, and requirements for other services. The authors have set up templates of commonly used database and spreadsheet programs that clinicians can use to obtain comparative information on their own practices.

Mohtadi and colleagues^[12] wanted to determine whether outcomes questionnaires administered through a computer system displayed any inherent bias, and how well they were tolerated by patients. They found that there were more problems with the paper format (eg, unanswered questions, which were not permitted with the computer system). No significant differences in the scores were found for most groups, and there was no evidence of a patient preference for paper, although the study lacked sufficient power to prove that the lack of difference found between the groups was statistically significant (see Tornetta and associates^[13]). Despite this limitation, the study concluded that computerized questionnaires for quality-of-life measurement can replace paper without loss of accuracy.

AAOS Web Site

The AAOS had a special display area at the meeting to acquaint members and other attendees with services available on their Web site. This display was staffed by orthopaedic surgeons from the AAOS Internet Committee and from ISOST. One feature was a facility where attendees could create a Web site for their own practice. This is available, free of charge, to all AAOS fellows, members, and international affiliates. The site, which is password protected, is template-based and allows the surgeon to describe his or her practice under the headings of Educational Background, Board Certification and Focus, Office Location & Hours, and Affiliations. The AAOS site has been recently upgraded to facilitate navigation to the enormous variety of information on the site. A series of pop-up menus on the front page allow immediate access to the Patient Information Site (which contains information about hand, neck, shoulder, spine, hip, arm, knee, and foot fractures), Medical Education, Annual Meetings, Academy Journals, Orthopaedic Yellow Pages, and an Educational Resources Catalog.

General Comments

The focus of orthopaedic informatics research on patient information is highly appropriate and needed. Orthopaedic surgeons who are trained to evaluate the quality of information obviously need less guidance than their patients do. A letter to the editor that appeared in JAMA ^[14] pointed out that patients who use search engines to access orthopaedic information on the Internet are likely to find a very mixed collection. Unfortunately, none of the current studies have advanced much beyond this conclusion. The studies presented did not, for the most part, refer to Rose and colleagues or other similar published papers. Although they all concluded that orthopaedic surgeons need to guide their patients, they did not, in fact, provide such guidance or offer links to sites where orthopaedic patients can find information that has been vetted by an orthopaedic surgeon.

The next generation of studies should investigate solutions to the problem, compare the quality of information on the Internet to that obtained from the treating surgeon, and propose mechanisms for securing quality assurance on the Internet. The field is small yet. A MEDLINE search for "Orthopedics [MeSH] AND Internet [MeSH]" yielded only 25 citations on March 7, 2001.

Currently, 2 not-for-profit organizations are offering "solutions" to the problem of quality information on the Internet: AAOS and ISOST. The AAOS provides a very comprehensive database of patient information and encourages its members to use it. Patients and orthopaedic surgeons can be assured that this information is of exceptional quality. ISOST believes that patients will not be satisfied with information from a single source. By assembling links to patient information sites that have been collected by orthopaedic surgeons, ISOST anticipates becoming the clearinghouse for orthopaedic information. If that goal can be realized, reviews by the orthopaedic community that makes up ISOST will carry some weight.

References

1. Messer TM, Stern SH, Patel AA, Edwards SL. Evaluation and patient utilization of Internet Web sites related to anterior cruciate ligament reconstruction and total knee arthroplasty. Program and abstracts of the AAOS 68th Annual Meeting; February 28-March 4, 2001; San Francisco, California. Abstract 067.
2. Lim CK, Parekh SG, Nazarian DG, Booth RE. Orthopaedic patients on the Internet. Program and abstracts of the AAOS 68th Annual Meeting; February 28-March 4, 2001; San Francisco, California. Abstract 070. Available at: http://www.aaos.org/wordhtml/anmt2001/sciprog/070.htm
3. Koch RB, Lazarus MD, Romeo AA, Williams GR Jr, Jensen KL. Shoulder information available on the Internet: is it accurate? Program and abstracts of the AAOS 68th Annual Meeting; February 28-March 4, 2001; San Francisco, California. Poster 028. Available at: http://www.aaos.org/wordhtml/anmt2001/poster/pe028.htm
4. Nelson DL, Clough JFM, Sechrest RC, Eaton C. An expanded orthopedists' guide to the Inernet. Program and abstracts of the AAOS 68th Annual Meeting; February 28-March 4, 2001; San Francisco, California. Exhibit SE45.
5. Sanders RW, Brodsky JW, moderators. Digital imaging and computer presentation. Program and abstracts of the AAOS 68th Annual Meeting; February 28-March 4, 2001; San Francisco, California. Course 315. Available at: http://www.aaos.org/wordhtml/anmt2001/icl/315.htm
6. Weil CE, Rooks MD, moderators. Computer-based multimedia presentations -- the essentials. Program and abstracts of the AAOS 68th Annual Meeting; February 28-March 4, 2001; San Francisco, California. Course 243.
7. Andres BM, Khanna J, Wenz JF, Frassica FJ. Digital imaging for the orthopaedic surgeon: current applications and recommended equipment for optimal results. Program and abstracts of the AAOS 68th Annual Meeting; February 28-March 4, 2001; San Francisco, California. Poster PE150.
8. Watson T. Digital photography for the orthopaedic surgeon. Program and abstracts of the AAOS 68th Annual Meeting; February 28-March 4, 2001; San Francisco, California. Scientific Exhibit 44.
9. Gomoll AH. Introduction of a distributed asset management system: an image database for surgeons accessible over the Intra-/Internet. Program and abstracts of the AAOS 68th Annual Meeting; February 28-March 4, 2001; San Francisco, California. Poster 153.
10. Hauser DL, Hoeffel DP, Condon RH, et al. Advanced Web-based Internet site documentation center for outcome studies. Program and abstracts of the AAOS 68th Annual Meeting; February 28-March 4, 2001; San Francisco, California. Poster 151. Available at: http://www.aaos.org/wordhtml/anmt2001/poster/pe151.htm
11. Strain RE Jr, Kurzon JD. Claims data from an outcome database you already have. Program and abstracts of the AAOS 68th Annual Meeting; February 28-March 4, 2001; San Francisco, California. Poster 152.
12. Mohtadi N, Sasyniuk TM, Hollinshead RL. Development and evaluation of preference for a computerized outcome system for prospective outcome assessment. Program and abstracts of the AAOS 68th Annual Meeting; February 28-March 4, 2001; San Francisco, California. Poster 154.
13. Tornetta P, Lochner H, Bhandari M. Type II error rates (beta errors) of randomized trials in orthopaedic trauma. Program and abstracts of the AAOS 68th Annual Meeting; February 28-March 4, 2001; San Francisco, California. Paper No. 066.
14. Rose S, Bruce J, Maffuli N. Accessing the Internet for patient information about orthopedics [letter]. JAMA. 1998;280(15).

Suggested Links

Evaluation And Patient Utilization Of Internet Websites Related To Anterior Cruciate Ligament Reconstruction And Total Knee Arthroplasty Messer TM, Stern SH, Patel AA, Edwards SL
www.aaos.org/wordhtml/anmt2001/sciprog/067.htm

An Expanded Orthopaedist's Guide to the Internet Nelson DL, Clough JFM, Sechrest RC, Eaton CJ
Guide site D.L.Nelson (ed)
www.aaos.org/wordhtml/anmt2001/sciexh/se45.htm
www.orthogate.com/guide

Guide to e-mail J.F.M.Clough (ed)
www.orthogate.com/ortho_resources/guide/chapter2.html

Guide to searching J.F.M.Clough (ed)
www.orthogate.com/ortho_resources/guide/chpt3_searching/chapter3.html

Guide to setting up a practice website D.L.Nelson (ed)
www.orthogate.com/ortho_resources/guide/chpt4_websites/chapter4.html

Guide to imaging J.F.M.Clough (ed)
www.orthogate.com/ortho_resources/guide/chap5/chap5.htm

Guide to orthopaedic corporate information L.Lada (ed)
www.orthogate.com/ortho_resources/guide/chpt6/chapter6.html

Guide to orthopaedic discussion forums C.J.Eaton
www.orthogate.com/ortho_resources/guide/chpt7/chapt7.html

Guide to webpage editing J.F.M.Clough (ed)
www.orthogate.com/ortho_resources/guide/chpt8/chpt8.html

Reviews of major orthopaedic Internet sites D.L.Nelson (ed)
www.orthogate.com/ortho_resources/guide/appx1/appdx1.html

Orthopaedic Web Links J.F.M.Clough (ed)
owl.orthogate.com

Orthopod family of mailing lists R.C.Sechrest (ed)
www.orthogate.com/mailing list stuff/index.html

Orthogate Project (ISOST)
www.orthogate.com

Internet Society of Orthopaedic Surgery and Trauma (ISOST)
www.isost.org

Computer-based Multimedia Presentations - the Essentials Weil CE Rooks MD (Instructional Course Lecture)
www.aaos.org/wordhtml/anmt2001/icl/243.htm

Digital Imaging For The Orthopaedic Surgeon: Current Applications And Recommended Equipment For Optimal Results Andres BM, Khanna J, Wenz JF, Frassica FJ
www.aaos.org/wordhtml/anmt2001/poster/pe150.htm

Digital Photography for the Orthopaedic Surgeon Watson T
www.aaos.org/wordhtml/anmt2001/sciexh/se44.htm

Introduction Of A Distributed Asset Management System: An Image Database For Surgeons Accessible Over The Intra-/Internet. Gomoll AH, Thornhill TS
www.aaos.org/wordhtml/anmt2001/poster/pe153.htm

Claims Data From An Outcome Database You Already Have Strain RE Jr, Kurzon JD
www.aaos.org/wordhtml/anmt2001/poster/pe152.htm

Development And Evaluation Of Preference For A Computerized Outcome System For Prospective Outcome Assessment Mohtadi NGH, Sasyniuk TM, Hollinshead RL
www.aaos.org/wordhtml/anmt2001/poster/pe154.htm

American Academy of Orthopaedic Surgeons Home Page
www.aaos.org

Example of the AAOS Practice Website
orthodoc.aaos.org/MylesClough

Page for AAOS members to create their own practice website

Your Orthopaedic Connection (AAOS Patient Information)

AAOS Annual Meeting page

AAOS Educational Resources

Journal of the American Academy of Orthopaedic Surgeons
www.jaaos.org/

Archives of present and previous AAOS meetings
www.aaos.org/wordhtml/libscip.htm

Search the AAOS site

Accessing the Internet for patient information about orthopedics.
Rose S, Bruce J, Maffulli N JAMA 1998 Oct 21;280(15):1309

Survey of patient-oriented total hip replacement information on the World Wide Web. Mabrey JDClin Orthop. 2000 Dec;(381):106-13.
Link to PubMed Abstract

Evaluating the source and content of orthopaedic information on the Internet. The case of carpal tunnel syndrome. Beredjiklian PK, Bozentka DJ, Steinberg DR, Bernstein J.J Bone Joint Surg Am. 2000 Nov;82-A(11):1540-3.
Link to PubMed Abstract

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Authors and Disclosures

Author(s)

Myles Clough, MD

Clinical Instructor, Department of Orthopaedic Surgery, University of British Columbia; Orthopaedic Surgeon, Kamloops, British Columbia, Canada.

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CME Information

CME Released: 03/29/2001; Valid for credit through 03/29/2002

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This activity is intended for physicians.

Goal

The goal of this activity is to provide expert commentary on the clinical applications of "state-of-the-art" treatment protocols and strategies for the diagnosis and management of bone and joint disorders, to enhance the care of patients with arthritis and degenerative diseases, and to support quality clinical practice of orthopaedic surgeons involved in their care.

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Upon completion of this self-study activity, participants will be able to:

1. Critique presentations of surgical techniques and demonstrations of treatment options.
2. Discuss management of patients who present with musculoskeletal injuries.
3. Determine indications and complications in arthroscopy, arthroplasty, and other surgical interventions.
4. Update basic knowledge and skills through clinical research findings.

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Physicians - maximum of 1.5 AMA PRA Category 1 Credit(s)™

All other healthcare professionals completing continuing education credit for this activity will be issued a certificate of participation.

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Contents of Emerging Technologies

1. MSTS Examines New and Conventional Technologies for Diagnosis of Tumors
2. Orthopaedic Information Technology
3. Osteoporosis and Prevention of Fractures: Practical Approaches for Orthopaedic Surgeons
4. Strategies in Contemporary Tissue Engineering
5. Spine Associations Debate New Research and Technology
6. Personal Digital Assistants in Clinical Practice: The Wave of the Future?

Case Study - A Young Man With Lower Back Pain and Low-Grade Fever

Background

A 19-year-old man presents to his primary care provider with a 2-month history of lower back pain and stiffness. The pain is intermittent, achy, and usually worse in the morning than it is later in the day or evening. He has also noticed a progressive inability to perform activities that require flexibility in the back, such as bending down to pull on his pants or tying his shoelaces. The pain sometimes awakens him at night. It is improved with exercise. He also reports a several-month history of low-grade fever, malaise, and anorexia, as well as an unintended weight loss of 10 lb (4.5 kg). He has not noted any masses on his testicles with self-examination. The patient has no history of rash. He does not have any known chronic medical conditions. He takes one multivitamin per day. He has never smoked, but he does drink an occasional glass of wine with dinner. There is no significant family history of disease.

On physical examination, the patient has a blood pressure of 125/67 mm Hg and a heart rate of 60 bpm. His respiratory rate is 8 breaths/min and his temperature is normal at 98.0°F (36.7°C). The cardiovascular and respiratory portions of the examination are normal; specifically, no murmurs or rubs are detected. The patient has no photophobia, eye redness, or decreased visual acuity. On examination of the back, flexion of the lumbar spine is clearly decreased when the patient attempts to bend down to touch his toes. He also has pain and limited range of motion with rotation and lateral flexion at the lumbar spine. His chest expansion is mildly diminished. The remainder of the physical examination is within normal limits.

As part of the initial workup of the findings on physical examination, routine laboratory investigations, including a complete blood cell (CBC) count and a basic electrolyte panel, as well as plain radiographs of the back, are performed. The chemistry panel is unremarkable, and the CBC reveals a white blood cell (WBC) count of 4.6 × 10³/μL (4.6 × 10⁹/L), a hemoglobin of 13.7 g/dL (137 g/L), a hematocrit of 43% (0.43), and a platelet count of 120 × 10³/μL (120 × 10⁹/L). The electrolytes are within normal limits. A rheumatoid factor test is negative, and the erythrocyte sedimentation rate is 64 mm/hr (normal range, <10>

Anteroposterior and lateral radiographs of the lumbar spine are obtained (see Figure 1).

Questions

What is the underlying disease process for the radiographic abnormalities?

Ankylosing spondylitis

Spinal stenosis

Psoriatic arthritis

Diffuse idiopathic skeletal hyperostosis

Hint: The spine and sacroiliac joints show classic findings for the diagnosis.

Please try to answer first before you scroll down

Answer

			Your Colleagues Responded:
	Ankylosing spondylitis	Correct Answer	85%
	Spinal stenosis		4%
	Psoriatic arthritis		4%
	Diffuse idiopathic skeletal hyperostosis		5%

Discussion

The anteroposterior and lateral radiographs of the spine demonstrated the classic "bamboo-spine" finding seen in cases of ankylosing spondylitis. The images showed sclerosis and ankylosis of the vertebral bodies, without loss of disc space. Bone formation extended across the anterior and lateral margins of the intervertebral disks of the lower thoracic and lumbar spine (syndesmophytosis). The sacroiliac joints showed extensive periarticular sclerosis and focal ankylosis.

Ankylosing spondylitis is a chronic inflammatory disorder of multiple articular and para-articular structures that principally involves the axial skeleton. It usually affects the sacroiliac joints and the spinal facet joints of the vertebrae. It sometimes involves the appendicular skeleton as well, such as the joints of the greater trochanter, patella, and calcaneum. Other extraspinal manifestations include iritis/uveitis and pulmonary involvement. The basic pathologic lesion of ankylosing spondylitis occurs at the entheses, which are sites at which ligaments, tendons, and joint capsules attach to bone. In the outer layers of the annulus fibrosis of the intervertebral disks, the condition manifests as a formation of new bone. The name of the disease is derived from Greek; "ankylos" means stiffening of a joint, and "spondylos" means vertebra. The disease is classified as a chronic and progressive form of seronegative arthritis. Ankylosing spondylitis affects men 4-10 times more frequently than women, and the symptoms generally appear in those aged 15-35 years. More than 90% of whites with ankylosing spondylitis have the HLA-B27 gene, but 6-8% of those with this gene do not develop the disease.^[2,3]

Symptoms of ankylosing spondylitis include back pain and stiffness, peripheral joint and chest pain, sciatica, anorexia, weight loss, and low-grade fever. The back pain associated with this condition is typically transient at first, but it eventually becomes persistent. It is usually worse in the mornings and resolves with exercise. A typical patient may also complain of waking up with back pain at night. The pain is usually centered over the sacrum, but it may radiate to the groin, buttocks, and down the legs. With time, the back pain usually progresses up the spine and affects the rib cage, resulting in a restriction of chest expansion and diaphragmatic breathing (observed as ballooning of the abdomen during inspiration) as the costovertebral joints become affected. The cervical spine is ankylosed late in the course of the disease, leading to restriction in neck movement and head rotation. Without treatment, the spine eventually becomes completely rigid, with loss of the normal curvatures and movement.^[2,3]

On physical examination, the loss of lateral flexion of the lumbar spine is the earliest objective sign of spinal involvement. The sacroiliitis may be detected by eliciting a tenderness response during percussion over the sacroiliac joints. Objective tests to quantify spinal restriction include touching the toes, the Schober test, and measurement of chest expansion. Additional physical findings include restriction of motion in the peripheral joints and tenderness over the enthuses. The physical exam should also include evaluation for signs of potentially serious cardiovascular and pulmonary complications, such as aortic incompetence secondary to aortitis, conduction defects of the heart, cardiomyopathy, pericarditis, apical fibrosis of the lungs, bronchiectasis, cavitation of the chest, and development of a restrictive ventilatory pattern. Other associated conditions include the development of inflammatory bowel disease, uveitis (in up to 20% of patients), radiculitis secondary to inflamed nerves, and, rarely, amyloidosis.^[2,3]

Specific criteria for the diagnosis of ankylosing spondylitis include the Rome criteria (developed in 1963) and the New York criteria (developed in 1968). Although these criteria have been generally accepted as useful, limitations are recognized and overlaps exist among the clinical and radiologic features of various seronegative spondyloarthropathies. Sacroiliitis is the hallmark of ankylosing spondylitis and is a requisite for the diagnosis under both sets of criteria. Other conditions, such as psoriasis, Reiter disease, enteropathic arthropathy, hyperparathyroidism, and osteitis condensans ilii, may also result in bilateral symmetric sacroiliac joint disease and should be considered in the differential diagnosis. Ankylosing spondylitis may also present with asymmetric sacroiliitis, which may be more characteristic of other conditions, such as psoriasis, Reiter disease, rheumatoid arthritis, and gouty arthritis. Radiographically, diffuse idiopathic skeletal hyperostosis (DISH) has a similar appearance to ankylosing spondylitis; however, DISH typically occurs at a later age and does not involve the sacroiliac joint.^[2,3]

The radiographic changes usually first appear in the sacroiliac joints, followed by the thoracolumbar and lumbosacral spine; this is in line with the natural progression of the disease. The disease then proceeds cephalad up the spine; however, the cervical spine may also be affected without involvement of the thoracic or lumbar spine. Radiographically evident peripheral-joint abnormalities are seen in more than 50% of patients. Abnormalities can also be seen in the symphysis pubis and in the manubriosternal, sternoclavicular, and temporomandibular joints. Spinal findings include osteitis, syndesmophytosis, diskovertebral erosions and destruction (Romanus lesions), and disk calcification. Radiographically, joint involvement appears as joint-space narrowing, periostitis, osseous erosion, and minimal periarticular osteoporosis (less than that seen with rheumatoid arthritis). Sacroiliac joint involvement is usually bilateral and symmetric.^[1,3]

Common laboratory findings are an elevated erythrocyte sedimentation rate (during the acute phase), a positive HLA-B27 histocompatibility antigen, mild leukocytosis, normochromic normocytic anemia (anemia of chronic disease), and negative results for rheumatoid factor.^[2,3]

The general principles of managing chronic arthritis also apply to ankylosing spondylitis. Among the various nonsteroidal anti-inflammatory drugs (NSAIDs) available to treat the disease, indomethacin may be the most effective. The lowest dose that provides pain relief should be used in order to avoid potentially serious complications, such as gastritis, peptic ulcer disease, and renal insufficiency. Sulfasalazine can be useful if peripheral arthritis is substantial, but it may be less effective when spinal and sacroiliac pain are the most prominent symptoms. In the majority of patients, the symptoms persist for life, although in some cases remission does occur.^[5]

Physical therapy and exercise can help prevent axial immobility. Specifically, spinal extension and deep-breathing exercises maintain spinal mobility, encourage erect posture, and promote chest expansion. Maintaining an erect posture and sleeping on a firm mattress with a thin pillow can help reduce thoracic kyphosis. Severe hip or spinal involvement may require surgical repair. Antitumor necrosis factor (anti-TNF) agents, such as infliximab and etanercept, are relatively new but often very effective therapeutic agents that may be considered for patients with pain refractory to other interventions.^[4,5]

The patient in this case was started by his primary care provider on a low dose of indomethacin to reduce pain and decrease inflammation. He was referred by the primary care provider to a rheumatologist for further evaluation and management and ongoing medical treatment. He was also referred to a physical therapist to begin a proper exercise and stretching program. Information regarding support groups to provide further education on the disease process and available treatment options were also given to the patient.

Questions

Which of the following statements is true?

Ankylosing spondylitis is a chronic inflammatory disorder that principally involves the appendicular skeleton.

The disease affects women more frequently than men.

Symptoms generally appear in individuals aged 5-10 years.

More than 90% of white patients with the disease are positive for the HLA-B27 gene.

Which of the following statements about therapeutic modalities and treatments is/are accurate?

Indomethacin may be the most effective NSAID for managing arthritic pain.

Vigorous physical therapy such as spinal extension and chest expansion as well as regular exercise may help to prevent disability resulting from axial immobility.

Thoracic kyphosis may be reduced by maintaining an erect posture and sleeping on a firm mattress.

Severe spinal or hip involvement may require surgical repair.

All of the above

Please try to answer first before you scroll down

Answer

Which of the following statements is true?

			Your Colleagues Responded:
	Ankylosing spondylitis is a chronic inflammatory disorder that principally involves the appendicular skeleton.		20%
	The disease affects women more frequently than men.		2%
	Symptoms generally appear in individuals aged 5-10 years.		0%
	More than 90% of white patients with the disease are positive for the HLA-B27 gene.	CorrectAnswer	76%

Explanation

• Ankylosing spondylitis is a chronic inflammatory disorder of multiple articular and para-articular structures that principally involves the axial skeleton. It usually affects the sacroiliac joints and the spinal facet joints of the vertebrae. It sometimes involves the appendicular skeleton as well, such as the joints of the greater trochanter, patella, and calcaneum. Other extraspinal manifestations include iritis/uveitis and pulmonary involvement. The disease is classified as a chronic and progressive form of seronegative arthritis. Ankylosing spondylitis affects men 4-10 times more frequently than women, and the symptoms generally appear in those aged 15-35 years. More than 90% of whites with ankylosing spondylitis have the HLA-B27 gene, but 6-8% of those with this gene do not develop the disease.

Which of the following statements about therapeutic modalities and treatments is/are accurate?

			Your Colleagues Responded:
	Indomethacin may be the most effective NSAID for managing arthritic pain.		9%
	Vigorous physical therapy such as spinal extension and chest expansion as well as regular exercise may help to prevent disability resulting from axial immobility.		3%
	Thoracic kyphosis may be reduced by maintaining an erect posture and sleeping on a firm mattress.		1%
	Severe spinal or hip involvement may require surgical repair.		1%
	All of the above	Correct Answer	84% Source: http://cme.medscape.com