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M. Lares, M.B. B.A.O., M.B.B.Ch., Ph.D.

Vice Chair, State University of New York Downstate Medical Center College of Medicine

The ischial tuberosity is the proximal attachment site for the hamstring muscles of the lower limb. The pubis is a useful bone with which to sex a skeleton in a forensic context (Bass 2005; Buikstra and Ubelaker 1994). The body tends to be rectangular in cross-section in females and triangular in males. The bony projection that unites the ischium and pubis anteriorly is called the ischiopubic ramus. Females tend to display a thin and sharp ramus on the medial surface while the surface in males tends to be broad and blunt. The joint that unites the two pubic bones in the front of the pelvis is called the pubic symphysis, which is a structure commonly used in age estimation. In young adults, the surface is billowed, but it transitions to being smooth and porous with increasing age. Finally, the large opening encircled by the pubis and ischium is called the obturator foramen. The shape of the foramen in females has been described as triangular while it is more likely to appear oval in males (Bass 2005). The ilium forms the large, fan-shaped superior portion, the ischium forms the posteroinferior portion, and the pubis forms the anteromedial portion. Lower Limb the bones of the lower limb skeleton include the femur, patella, tibia, fibula, seven tarsal (ankle) bones, five metatarsal (foot) bones, and 14 phalanges (toe bones). On the proximal epiphysis of the femur are attachment sites for major hip and thigh muscles on the greater trochanter, lesser trochanter, and gluteal tuberosity (Figure A. The raised ridge on the posterior aspect of the femoral diaphysis is called the linea aspera, and it is a major attachment site for the quadriceps femoris muscles and other muscles, and it terminates distally by splitting into medial and lateral epicondyles, additional sites of muscle attachment. The distal epiphysis of the femur is marked by two rounded condyles that articulate with the proximal part of the tibia. The anterior surface of the distal femur articulates with the patella (kneecap), a bone that develops within the tendon of the quadriceps femoris muscle to enhance the function of the muscle. The tibia is the robust, medial bone of the leg, and it is connected to the laterally positioned fibula by an interosseous membrane like in the forearm (Figure A. The proximal epiphysis of the tibia has two articular facets called tibial condyles that articulate with the femoral condyles. On the anterior surface of the proximal tibia is a raised projection called the tibial tuberosity, where the quadriceps muscle tendon attaches distally after containing the patella. On the distal epiphysis of the tibia is the medial malleolus, which articulates with the talus in the ankle joint. The lateral malleolus is a feature of the distal end of the fibula; the proximal end of the fibula articulates with the lateral portion of the proximal tibia. The talus is the most superior of the tarsals, and it articulates with the distal tibia and distal fibula superiorly and with the calcaneus inferiorly. On the posterior-most aspect of the calcaneus is the calcaneal tuberosity, which Osteology 659 is the attachment site for the Achilles tendon of the posterior leg. Distal to the talus is the medially positioned navicular, the three cuneiform bones (medial, intermediate, and lateral), and the laterally positioned cuboid. Distal to the tarsals are the digital rays, each of which contains a metatarsal (foot) bone and three phalanges (proximal, middle, and distal) or toe bones. The exception to this rule is the big toe, which has fewer phalanges (proximal and distal, but no middle) than the other digits. It also is reasonable that bioarchaeologists would want to estimate stature (height), because body size is one of the most important variables in assessing physiological processes like heart rate and metabolic rate. Stature estimation equations have been developed in bioarchaeological and forensic contexts that rely on measuring length of bones like the cranium, vertebrae, long bones of the limbs, and so forth. These measurements are then input into these equations and stature can be estimated from the resulting solution (Auerbach and Ruff 2010; Lundy 1988). It is estimated, then, that a baby is born with approximately 450 bones that grow from their centers of ossification and eventually become the 206 bones of the adult skeleton. In between epiphysis and diaphysis is an epiphyseal growth plate of cartilage that will remain unfused until postnatal growth is complete after puberty (and for some bones, well into adulthood).

In addition, assistance in lowering readmission rates is available from the Quality Improvement Organizations. Comment: Several commenters suggested that trauma hospitals and safety-net hospitals are at increased risk of being subject to a payment adjustment under the Hospital Readmissions Reduction Program because of insufficient risk-adjustment for ``case-mix' or the fact that their patients are sicker, lack access to appropriate post-discharge care, may suffer numerous chronic conditions, and may have substance abuse or behavioral problems. As noted above, our analyses suggest that trauma and safety net hospitals caring for high proportions of at-risk patients can, and frequently do, perform as well on the readmission measures as those hospitals with fewer at-risk patients (see: Medicare Hospital Quality Chartbook 2010, pp 14­19). We do not exclude hospice patients or those who have elected palliative care from the readmission measures because we do not believe that it is appropriate to differentiate, as to the appropriateness of care provided, between patients who have elected hospice or palliative care and those who have not. This provides substantially more data than a 1- or 2-year timeframe and increases the precision of the measure in distinguishing performance among hospitals. However, for purposes of the Hospital Readmissions Reduction Program, we will not be categorizing hospital performance in three categories; rather, we will be using the measures to calculate Excess Readmission Ratios for the three conditions. We indicated that we are currently conducting analyses to determine an appropriate data period (for example, 1 year, 2 years, 3 years) that will yield reliable Excess Readmission Ratios for the three proposed measures, and that we intend to consider both the positive and negative consequences of using longer or shorter data periods for this program. We also indicated that should our analysis or public comment indicate that a shorter data period yields Excess Readmission Ratios with acceptable reliability, we may consider finalizing a shorter time period. We proposed 3 years as the applicable period because we believe that this time period would ensure the proposed measures covers a sufficient number of applicable patients for hospital performance to be fairly portrayed. As stated above, we indicated that we are currently conducting analyses to determine if a different data period (for example, 1 or 2 years) might also yield reliable Excess Readmission Ratios for the three proposed measures. We intend to consider both the positive and negative consequences of using longer or shorter data periods for this program. If our analysis or public comments indicate that a shorter data period yields Excess Readmission Ratios with acceptable reliability, we may consider finalizing a shorter time period. However, we indicated that should our analysis or public comment indicate that a different minimum number of discharges would be more appropriate for this program, we would consider finalizing a different number. We invited public comment and suggestions on the topic of appropriate minimum number of discharges to consider for the three proposed readmission measures. Comment: Several commenters supported the proposed minimum number of 25 discharges. Other commenters stated that 25 discharges is too small a number to reliably profile hospitals. Response: We appreciate hearing from commenters regarding the proposed minimum number of discharges. We also proposed to use this threshold of 25 discharges for each of the three measures to calculate the Excess Readmission Ratios because we believe this number helps maximize hospital participation and at the same time ensures that we achieve reasonable reliability for profiling hospital performance. We note that analyses to determine appropriate sample size to yield reliable Excess Readmission Ratios for the three readmission measures are ongoing. If the results of our analyses suggest that a different minimum number of discharges would be more appropriate, we will propose to revise the minimum number accordingly through future rulemaking. We currently report information on the three readmission rates that we are finalizing in this rule on the Hospital Compare Web site for each subsection (d) hospital. We provide hospitals with an opportunity to preview their readmission rates for 30 days prior to posting on the Web site. We will review all such correction submissions and determine the appropriateness of any revisions. Two commenters requested more information about how the information will be presented on the Hospital Compare Web site. However, the Hospital Readmissions Reduction Program will include hospital-specific readmission rates. Comment: One commenter requested clarification on ``what grounds and with service population under part A. If the patient does not have any claims in the 12 months prior to the index hospitalization admission, only comorbidities from the included admission are used. The policies regarding what aspects of the readmission rates are subject to corrections, as well as specifics regarding the review and correction process will be proposed in future rulemaking. Section 1886(q)(8)(C) of the Act requires specified hospitals, or a State or an appropriate entity on behalf of the hospitals, to submit to the Secretary, in a form, manner and time specified by the Secretary, data and information determined necessary to calculate the all patient readmission rates. Section 1886(q)(8)(D) of the Act defines ``all patients' to mean patients who are treated on an inpatient basis and discharged from a specified hospital.

This will place increased demands for treatment services, and necessitate the incorporation of evidence-based medicine in treatment therein. Storage symptoms are experienced during the storage phase of the bladder and include daytime frequency and nocturia; voiding symptoms are experienced during the voiding phase. It is becoming widely accepted that the symptoms we relate in many older males may not have an etiology in prostate enlargement. Detrusor overactivity is a urodynamic observation characterized by involuntary detrusor contractions during the filling phase. The term "benign prostatic hyperplasia" is reserved for the histological pattern it describes. Benign prostatic enlargement is used when there is gland enlargement and is usually a presumptive diagnosis based on the size of the prostate. In addition to being responsible for the symptoms, these excluded clinical scenarios, diseases and/or conditions may affect treatment in a manner outside the purview of this Guideline. The full description of the methodology presented in Chapter 2 can be accessed at. What are the predictors of beneficial effects from Copyright ©2010 American Urological Association Education and Research, Inc. As in the previous Guideline, statements were graded using three levels with respect to the degree of flexibility in their application. A "standard" has the least flexibility as a treatment policy; a "recommendation" has significantly more flexibility; and an "option" is even more flexible. Standard: A guideline statement is a standard if: (1) the health outcomes of the alternative interventions are sufficiently well known to permit meaningful decisions and (2) there is virtual unanimity about which intervention is preferred. Diagnostic Evaluation the Panel decided that the diagnostic section of the 2003 Guideline required updating. After review of the recommendations for diagnosis published by the 2005 International Consultation of Urologic Diseases12 and reiterated in 2009 in an article by Abrams et al (2009), the Panel unanimously agreed that the contents were valid and reflected "best practices". A "recommended test" should be performed on every patient during the initial evaluation whereas an "optional test" is a test of proven value in the evaluation of select patients. In general, optional tests are performed during a detailed evaluation by a urologist. The physician can discuss with the patient treatment alternatives based on the results of the initial evaluation with no further tests being needed (See Figure 1. There should be a discussion of the benefits and risks involved with each of the recommended treatment alternatives. Then the choice of treatment is reached in a shared decision-making process between the physician and patient. If the patient has predominant significant nocturia and is awakened two or more times per night to void, it is recommended that the patient complete a frequency volume chart for two to three days. The frequency volume chart will show 24-hour polyuria or nocturnal polyuria when present, the first of which has been defined as greater than three liters total output over 24 hours. In practice, patients with bothersome symptoms are advised to aim for a urine output of one liter per 24 hours. Nocturnal polyuria is diagnosed when more than 33% of the 24-hour urine output occurs at night. If symptoms do not improve sufficiently, these patients can be managed similarly to those without predominant nocturia. If the patient has no polyuria and medical treatment is considered, the physician can proceed with therapy by focusing initially on modifiable factors such as concomitant drugs, regulation of fluid intake (especially in the evening), lifestyle (increasing activity) and diet (avoiding excess of alcohol and highly seasoned or irritative foods). The time from initiation of therapy to treatment assessment varies according to the pharmacological agent prescribed. If treatment is successful and the patient is satisfied, once yearly follow-up should include a repeat of the initial evaluation. The follow-up strategy will allow the physician to detect any changes Copyright ©2010 American Urological Association Education and Research, Inc.

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