Strategic Development of the Public Health Workforce: A Unified Logic Model for a Multifaceted Program at the Centers for Disease Control and Prevention

CONTEXT

Public health has a responsibility to ensure the ability of its workforce to deliver essential services, including mastering the core public health competencies.

PROGRAM

The Division of Scientific Education and Professional Development (DSEPD) of the Centers for Disease Control and Prevention has a mission to improve health outcomes through a competent, sustainable, and empowered public health workforce. The DSEPD programs offer fellowships and other training opportunities, develop and disseminate quality public health training, and advance public health workforce development science.

EVALUATION

The DSEPD developed a unified division logic model to describe the combined activities and intended outcomes of all DSEPD programs and their intended contribution to a robust public health workforce and to support ongoing program planning and evaluation. The logic model has 4 streams of work that include (1) producing and disseminating quality learning products; (2) implementing and managing fellowship programs that support learning; (3) providing public health service through fellows; and (4) advancing workforce development science through collaboration with other public health leaders.The underlying program theory is that a robust workforce has sufficient workforce, organizational, and systems capacity to deliver public health essential services and, therefore, to protect the public's health. Three scientific theories support the program theory: the quality of learning; the accepted practice of competency-based programs and the service-learning model; and use of evidence-guided decision making in workforce development programs.

DISCUSSION

A unified division logic model allows DSEPD to describe its combined approaches to workforce development as a coherent portfolio with well-defined goals and measureable outcomes. The logic model effectively communicates the relationship among division programs, their shared outcomes, and their combined contributions to developing and maintaining a robust public health workforce. A unified logic model can serve as effective frame of reference for division evaluation and as evidence in public health workforce development science.

A Novel Approach for Workforce Surveillance at the US Department of Health and Human Services

BACKGROUND

Expert groups have recommended ongoing monitoring of the public health workforce to determine its ability to execute designated objectives. Resource- and time-intensive surveys have been a primary data source to monitor the workforce. We evaluated an administrative data source containing US Department of Health and Human Services (HHS) aggregate federal civil service workforce-related data to determine its potential as a workforce surveillance system for this component of the workforce.

METHODS

We accessed FedScope, a publicly available online database containing federal administrative civilian HHS personnel data. Using established guidelines for evaluating surveillance systems and identified workforce characteristics, we evaluated FedScope attributes for workforce surveillance purposes.

RESULTS

We determined FedScope to be a simple, highly accepted, flexible, stable, and timely system to support analyses of federal civil service workforce-related data. Data can be easily accessed, analyzed, and monitored for changes across years and draw conclusions about the workforce. FedScope data can be used to calculate demographics (eg, sex, race or ethnicity, age group, and education level), employment characteristics (ie, supervisory status, work schedule, and appointment type), retirement projections, and characterize the federal workforce into standard occupational categories.

CONCLUSIONS

This study indicates that an administrative data source containing HHS personnel data can function as a workforce surveillance system valuable to researchers, public health leaders, and decision makers interested in the federal civil service public health workforce. Using administrative data for workforce development is a model that can be applicable to federal and nonfederal public health agencies and ultimately support improvements in public health.

An exploratory review of the literature evaluating nonclinical fellowship programs

Fellowship programs offer career development opportunities, provide experiential training, and can be used to recruit personnel to address specific challenges facing the public health workforce. Given the potential influence fellowships have on the future public health workforce, it is important to understand and articulate the results of such programs and to identify areas of improvement to meet current workforce needs. The purpose of this literature review was to identify common practices used to evaluate nonclinical fellowship programs. After a search of the internet and selected databases, we screened titles and abstracts using predetermined selection criteria. We then conducted a detailed review of selected papers to extract information about program characteristics (program description, sector, and program length) and evaluation characteristics (primary evaluation type, framework for evaluation, data collection methods, and respondent populations) from 33 papers. We found a limited number of published papers on the evaluation of nonclinical fellowship programs, and most focused on outcomes associated with fellows or alumni. The most useful papers for our purposes clearly described the evaluation framework that guided the evaluation.

Rapid HIV testing, pregnancy, antiretroviral prophylaxis and infant abandonment in St Petersburg

In St Petersburg, Russia, a rapid HIV-testing programme was implemented in April 2004 for high-risk women giving birth. Among 670 women without prenatal care who received rapid HIV testing, 6.4% (43) had positive results. Among HIV-positive mothers, receipt of intrapartum antiretroviral prophylaxis increased significantly compared to pre-programme levels (76 versus 41%). Additionally, infant abandonment increased significantly (50% versus 26%), and was 10 times greater in women with unintended versus intended pregnancies (73% versus 7%).

Perspectives on One Health: a survey of national Delegates to the World Organisation for Animal Health, 2012

In 2012, the World Organisation for Animal Health (OIE) surveyed all 178 national Delegates to better understand the perceptions and priorities of Veterinary Services with respect to One Health efforts and to guide future work in that area. For the purposes of this survey, the concept or practice of One Health was defined as 'the intersectoral collaborative approach to preventing, detecting, and controlling diseases among animals and humans, including the collaboration among the institutions and systems that support their prevention, detection and control'. A total of 120 OlE Delegates, representing countries from all five OIE regions, responded to the survey. Delegates identified zoonoses, rabies and influenza as high-priority disease areas and disease reporting and food safety as high-priority programme areas for One Health approaches. Veterinary Services participated in joint programmes, involving these priority disease and programme areas, with national intersectoral partners. Delegates reported barriers to implementing One Health approaches, including a lack of resources, the complexity of collaboration, inadequate capacity within their Veterinary Services, and a lack of adequate legislation, policy, guidance and political will for One Health activities. Delegates supported OIE efforts to enhance One Health activities, and requested that the OIE and partners provide technical information and advice and conduct training and capacity-building seminars for One Health. Veterinary Services cannot effectively apply One Health approaches at the national level without effective partnerships across sectors. The OlE can serve as a model for countries by continuing its commitment to these intersectoral partnerships at the international level.

Opening the window on public health to veterinary students

Veterinary public health is defined by the World Health Organization as: 'the sum of all contributions to the physical, mental, and social well-being of humans through an understanding and application of veterinary science'. The role of animals and wildlife as sources of human diseases continues to increase. As demand for public health veterinarians will similarly continue to increase, the veterinary profession must make a concentrated effort to encourage veterinary students to pursue careers in this field, and increase the opportunities for training and experience in this area for both veterinary students and graduates. In this paper, the authors describe the existing opportunities for training in or practising as a public health veterinarian, with a particular focus on the United States of America.

Rapid HIV testing and prevention of perinatal HIV transmission in high-risk maternity hospitals in St. Petersburg, Russia

OBJECTIVE

The purpose of this study was to evaluate the effectiveness of a human immunodeficiency virus (HIV) rapid testing (RT) program.

STUDY DESIGN

From April 13, 2004, to April 13, 2005, pregnant women at 2 high-risk maternity hospitals with no or incomplete HIV testing results (negative tests at <34 weeks, none thereafter) were offered point-of-care RT, with antiretroviral prophylaxis for RT-positive women and their infants.

RESULTS

Overall, 89.2% of eligible women (3671/4117) underwent RT, of whom 90.4% received results before delivery. HIV seroprevalence among all women who underwent RT was 2.7% (100/3671 women); among previously untested women, seroprevalence was 6.5% (90/1375 women); the incidence of HIV seroconversion among women with previous negative tests during pregnancy was 0.4% (10/2296 women). After adjustment, the main predictor of receiving RT results after delivery was late admission. Among HIV-exposed infants, 97.9% (92/94) received prophylaxis; 61.7% (58/94) had available follow-up data, and 8.6% (5/58) met criteria for definitive or presumptive HIV infection.

CONCLUSION

The RT program achieved timely detection of HIV-infected women in labor with unknown HIV status and effectively prevented perinatal HIV transmission.

Handbook of Zoonoses: Identification and Prevention

Handbook of Zoonoses: Identification and Prevention

The status of national HIV case surveillance, United States 2006

Since the height of HIV incidence in the mid-1980s, advances in treatment have delayed progression of HIV infection. As a result, surveillance of AIDS cases alone is no longer sufficient to monitor the current status of the HIV epidemic. At the national level, new HIV diagnoses and progression of these cases to AIDS are used to describe the epidemic. The capacity to monitor the national HIV epidemic has consistently improved over the last several years. An increasing number of states report diagnosed HIV cases to the national surveillance system, allowing data from this system to better represent the national picture. Monitoring the national HIV epidemic depends on a nationwide system using standardized methods of data collection, and establishing such a comprehensive system remains one of the highest priorities for national HIV case surveillance.

Prior antimicrobial agent use increases the risk of sporadic infections with multidrug-resistant Salmonella enterica serotype Typhimurium: a FoodNet case-control study, 1996-1997

Several strains of multidrug-resistant (MDR) Salmonella serotype Typhimurium, including MDR S. Typhimurium definitive type 104, cause almost 10% of Salmonella infections among humans in the United States. To determine the risk factors for acquiring sporadic MDR S. Typhimurium infection, we conducted a population-based, case-control study using data from the Foodborne Diseases Active Surveillance Network (FoodNet) during 1996-1997. S. Typhimurium isolates from 5 FoodNet surveillance areas (California, Connecticut, Georgia, Minnesota, and Oregon) were tested for antimicrobial resistance and phage typing. Telephone interviews were conducted with ill persons and matched control subjects. Compared with both control subjects and patients infected with pansensitive strains of S. Typhimurium, patients with MDR S. Typhimurium infection were significantly more likely to have received an antimicrobial agent, particularly an agent to which the Salmonella isolate was resistant, during the 4 weeks preceding illness onset. Prudent antimicrobial agent use among humans and among veterinarians and food-animal producers is necessary to reduce the burden of drug-resistant salmonellosis in humans.

Endemic, notifiable bioterrorism-related diseases, United States, 1992-1999

Little information is available in the United States regarding the incidence and distribution of diseases caused by critical microbiologic agents with the potential for use in acts of terrorism. We describe disease-specific, demographic, geographic, and seasonal distribution of selected bioterrorism-related conditions (anthrax, botulism, brucellosis, cholera, plague, tularemia, and viral encephalitides) reported to the National Notifiable Diseases Surveillance System in 1992 to 1999. Tularemia and brucellosis were the most frequently reported diseases. Anthrax, plague, western equine encephalitis, and eastern equine encephalitis were rare. Higher incidence rates for cholera and plague were noted in the western United States and for tularemia in the central United States. Overall, the incidence of conditions caused by these critical agents in the United States is low. Individual case reports should be considered sentinel events. For potential bioterrorism-related conditions that are endemic and have low incidence, the use of nontraditional surveillance methods and complementary data sources may enhance our ability to rapidly detect changes in disease incidence.

Veterinarians and public health: the Epidemic Intelligence Service of the Centers for Disease Control and Prevention, 1951-2002

Public health affords important and exciting career opportunities for veterinarians. The Epidemic Intelligence Service Program (EIS) of the Centers for Disease Prevention and Control (CDC) is a two-year post-graduate program of service and on-the-job training for health professionals, including veterinarians, who are interested in careers in epidemiology and public health. EIS serves as a major point of entry into the public health arena. Veterinarians applying to the program must have a Master of Public Health or equivalent degree, or demonstrated public health experience or course work. EIS officers are assigned to positions at CDC headquarters or in state and local health departments. During two-year assignments, they are trained in applied epidemiology, biostatistics, conducting outbreak investigations, emergency preparedness and response, and scientific communications. They conduct epidemiologic outbreak and other investigations, perform applied research and public health surveillance, serve the epidemiologic needs of state health departments, present at scientific and medical conferences, publish in the scientific literature, and disseminate vital public health information to the media and the public. EIS officers apply their training and skills to actual public health problems and issues, establish mentorships with recognized experts from CDC and other national and international health agencies, and travel domestically and internationally. Since 1951, 195 veterinarians have graduated from the program and gone on to make substantial contributions to public health in positions with federal, state, or local governments, academia, industry, and non-governmental organizations.

Seroincidence of Helicobacter pylori infection in a cohort of rural Bolivian children: acquisition and analysis of possible risk factors

High seroprevalence rates for Helicobacter pylori are reported in developing countries, yet few seroincidence studies exist that determine age of initial acquisition and risk factors for H. pylori seroconversion. Two H. pylori serosurveys were conducted in August 1996 and November 1997. Of 188 children aged 21 months to 6 years who were seronegative in the first survey, 44 (23%) had seroconverted at follow-up, yielding an 18% annual seroincidence. The largest increase in seroincidence occurred between children aged 2 years (10%) and children aged 3 years (32%). Use of a lidded, narrow-mouthed water vessel was protective against seroconversion (odds ratio [OR], 0.3; 95% confidence interval [CI], 0.1-0.8), and the presence of another H. pylori-seropositive sibling in the household was a risk factor for seroconversion (OR, 3.1; 95% CI, 1.3-8.7). Although not a randomized intervention trial, this study suggests that the use of a narrow-mouthed water vessel may prevent the transmission of H. pylori in households in developing countries.

Completeness of notifiable infectious disease reporting in the United States: an analytical literature review

Despite state and local laws requiring medical providers to report notifiable infectious diseases to public health authorities, reporting is believed to be incomplete. Through means of an analytical literature review, the authors synthesize current knowledge on the completeness of disease reporting and identify factors associated with reporting completeness. The review was limited to published studies, conducted in the United States between 1970 and 1999, that quantitatively assessed infectious disease reporting completeness. Thirty-three studies met the inclusion criteria. Reporting completeness, expressed between 0% and 100%, was treated as the dependent outcome variable in statistical analysis; disease, study location, time period, study design, and study size were treated as independent variables. Fifty-six distinct measures of reporting completeness were identified for 21 diseases. Reporting completeness varied from 9% to 99% and was most strongly associated with the disease being reported. The mean reporting completeness for acquired immunodeficiency syndrome, sexually transmitted diseases, and tuberculosis as a group was significantly higher (79%) than for all other diseases combined (49%) (p < 0.01).

A multistate outbreak of Escherichia coli O157:H7 infections associated with consumption of mesclun lettuce

BACKGROUND

An outbreak of Escherichia coli O157:H7 infections in Connecticut and Illinois during May 28 to June 27, 1996, was investigated to determine the source of infections.

METHODS

Independent case-control studies were performed in both states. Pulsed-field gel electrophoresis (PFGE) was performed on E. coli O157:H7 isolates. A case-patient was defined as a Connecticut or northern Illinois resident with diarrhea whose stool culture yielded E. coli O157:H7 of the outbreak-associated PFGE subtype. Controls were town-, age-, and sex-matched to case-patients. We traced implicated lettuce to the farm level and performed environmental investigations to identify unsafe lettuce production practices.

RESULTS

In Connecticut and Illinois, infection was associated with consumption of mesclun lettuce (Connecticut matched odds ratio [MOR], undefined; 95% confidence interval [CI], 3.4 to infinity; and Illinois MOR, undefined; 95% CI, 1.4 to infinity). We traced implicated lettuce to a single grower-processor. Cattle, a known E. coli O157:H7 reservoir, were found near the lettuce fields. Escherichia coli (an indicator of fecal contamination) was cultured from wash water and finished lettuce. A trace-forward investigation identified 3 additional states that received implicated lettuce; E. coli O157:H7 isolates from patients in 1 of these states matched the outbreak-associated PFGE subtype.

CONCLUSIONS

This multistate outbreak of E. coli O157:H7 infections was associated with consumption of mesclun lettuce from a single producer. Molecular subtyping facilitated the epidemiological investigation. This investigation increased the knowledge about current production practices that may contribute to the contamination of lettuce by microbial pathogens. Lettuce production practices should be monitored for microbiological safety.

An outbreak of Escherichia coli O157:H7 infection from unpasteurized commercial apple juice

BACKGROUND

Escherichia coli O157:H7 infections have traditionally been associated with animal products, but outbreaks associated with produce have been reported with increasing frequency. In fall 1996, a small cluster of E. coli O157:H7 infections was epidemiologically linked to a particular brand (brand A) of unpasteurized apple juice.

OBJECTIVE

To define the extent of the outbreak, confirm the source, and determine how the apple juice became contaminated.

DESIGN

Descriptive epidemiologic study and traceback investigation.

SETTING

Western United States and British Columbia, Canada.

PATIENTS

Patients with E. coli O157:H7 infection who were exposed to brand A apple juice.

MEASUREMENTS

Clinical outcome and juice exposure histories of case-patients, pulsed-field gel electrophoresis of case and juice isolates, and juice production practices.

RESULTS

Seventy persons with E. coli O157:H7 infection and exposure to brand A unpasteurized apple juice were identified. Of these persons, 25 (36%) were hospitalized, 14 (20%) developed the hemolytic uremic syndrome, and 1 (1%) died. Recalled apple juice that was produced on 7 October 1996 grew E. coli O157:H7 with a pulsed-field gel electrophoresis pattern indistinguishable from that of case isolates. Apple juice produced on 7 October 1996 accounted for almost all of the cases, and the source of contamination was suspected to be incoming apples. Three lots of apples could explain contamination of the juice: Two lots originated from an orchard frequented by deer that were subsequently shown to carry E. coli O157:H7, and one lot contained decayed apples that had been waxed.

CONCLUSIONS

Standard procedures at a state-of-the-art plant that produced unpasteurized juices were inadequate to eliminate contamination with E. coli O157:H7. This outbreak demonstrated that unpasteurized juices must be considered a potentially hazardous food and led to widespread changes in the fresh juice industry.

Emergence of multidrug-resistant Salmonella enterica serotype typhimurium DT104 infections in the United States

BACKGROUND

Strains of salmonella that are resistant to antimicrobial agents have become a worldwide health problem. A distinct strain of Salmonella enterica serotype typhimurium, known as definitive type 104 (DT104), is resistant to ampicillin, chloramphenicol, streptomycin, sulfonamides, and tetracycline and has become a major cause of illness in humans and animals in Europe, especially the United Kingdom.

METHODS

To characterize typhimurium DT104 infections in the United States, we analyzed data collected by local and state health departments and public health laboratories between 1979 and 1996 in national surveys of the antimicrobial-drug resistance of salmonella. Selected typhimurium isolates with the five-drug pattern of resistance were phage typed.

RESULTS

The prevalence of typhimurium isolates with the five-drug pattern of resistance increased from 0.6 percent in 1979-1980 to 34 percent in 1996. In 1994-1995, such isolates were identified in samples from 36 of the 46 surveillance sites (78 percent). Thirty-nine of 43 typhimurium isolates with the five-drug pattern of resistance identified in 1994-1995 and 1996 were phage type DT104 or a closely related phage type.

CONCLUSIONS

Multidrug-resistant typhimurium DT104 has become a widespread pathogen in the United States. More prudent use of antimicrobial agents in farm animals and more effective disease prevention on farms are necessary to reduce the dissemination of multidrug-resistant typhimurium DT104 and to slow the emergence of resistance to additional agents in this and other strains of salmonella.

Management of the upper-limb-deficient child with a powered prosthetic device

A long-term survey of a large number of children fitted with an electrically powered upper-limb prosthesis seems not to have been reported in the literature. Children with upper-limb deficiencies (congenital or traumatic) were fitted with an electrically powered upper-limb prosthesis in Ontario during the 18-year period of 1965-1983. Seventy-eight patients responded to a questionnaire or were interviewed by telephone. The dropout rate in children with a below-elbow amputation was similar to that reported in below-elbow child amputees wearing a conventional body-powered prosthesis (10% vs. 13%). The acceptance rate in children with above-elbow amputations was higher in those wearing an electrically powered prosthesis than in those using the conventional prosthesis, testifying for improved prosthetic function in the former group.

Popliteal artery entrapment

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The management of nonunions following high tibial osteotomies

Nonunion is an uncommon complication of high tibial osteotomy. Reported techniques of treating such a complication include resection of the pseudarthrosis and cast immobilization with risk of joint stiffness and loss of alignment. The special AO/ASIF threaded external fixator with double clamps was used to treat three patients with nonunions following high tibial osteotomy for medial compartment osteoarthritis. The pseudarthrosis was not resected in any instance. All were allowed full unrestricted joint motion postoperation. Rapid healing of the osteotomy ensued. The external fixator achieved excellent stability and rapid union while maintaining joint motion.

The significance of asymptomatic bacteriuria in patients undergoing hip/knee arthroplasty

The urinary tract has received a great deal of attention as a possible source of infection following arthroplasty. The incidence and significance of asymptomatic bacteriuria in patients admitted for arthroplasty is obscure. The occurrence of bacteriuria was therefore analyzed retrospectively in 299 patients admitted for hip/knee arthroplasty to determine its incidence and relation to the age of the patient and the result of the operation. There was a high incidence of bacteriuria in patients 65 years of age or older and an abnormally high incidence of asymptomatic bacteriuria in younger patients of both sexes who were to undergo hip/knee arthroplasty. However, there was no correlation between bacteriuria and surgical infection in these patients. Bacteriuria is common in patients admitted to the hospital for arthroplasty and should not be considered a cause for postponement of surgical treatment in the absence of other signs of cystitis or pyelonephritis.

A preliminary review of the Müller acetabular and Burch-Schneider antiprotrusio support rings

A high incidence of acetabular loosening following total hip arthroplasty is emerging as long term follow-up studies become available. The Müller and Burch-Schneider acetabular supports are indicated for acetabular deficiencies which are frequently present during revision hip arthroplasty. The Burch-Schneider support is indicated where the deficiencies are of such magnitude that the Müller ring does not have stable seating prior to screw fixation. These devices bring the resultant of forces across the hip joint under the acetabular roof and provide metal backing for the acetabular cup. They have the additional advantage of screw fixation which in the Müller ring is in line with the resultant of forces across the hip joint. In a one to three year follow-up of twenty-five hip replacements in twenty-four patients, the Müller support ring was used in twenty hips and the Burch-Schneider in five hips. The results were satisfactory and indicate that these supports are valuable in the treatment of patients with acetabular deficiencies.

Fusion of the cervical spine for instability

The orthopedic and neurosurgical literature is neither clear nor consistent in describing an unstable cervical spine. In a series of 25 patients treated by arthrodesis of the cervical spine for instability, 12 had Gallie fusions at the atlantoaxial level. Eight of those fusions were performed for rheumatoid arthritis. In three patients persistent subluxation of the atlas on the axis occurred because the wires were not fully tightened in areas of poor-quality bone. Stable fixation with relief of symptoms was achieved in all patients who had fusions at the subaxial level. Several of these patients had had prolonged nonsurgical treatment. With rheumatoid bone of poor quality, the surgeon must be very careful to tighten the wires only enough to secure a stable reduction for treatment of subaxial cervical instability. Since stability achieved by healing of soft tissue is generally unreliable, prolonged periods of nonsurgical treatment are not justified for traumatic instability.

An analysis of the causes of deep infection after hip and knee arthroplasties

Infection is a dreaded complication of joint arthroplasty. Deep infection may arise by contamination during operation, by secondary contamination of a discharging hematoma during the post-operative phase, or by the hematogenous route. Sixteen suspected cases of early and late deep infection in 1500 primary hip and knee arthroplasties performed during a ten-year period are reviewed. The operations were all performed by one of the authors (J.M.S.) in a Charnley Howarth sterile-air enclosure. No prophylactic antibiotic therapy was used, and the minimum follow-up period in all patients was one year. Suspected causes of infection were noted in six patients: the infection was considered to be hematogenous in three and to result from hematomas in two, and in the sixth patient a suspected rheumatoid cyst may have been a Brodie's abscess. Ten patients had no apparent predisposing source of infection, and breach of sterility technique was the most likely cause of infection in this group. Only two patients have required revision surgery to date. Although hematogenous infection of joint arthroplasty is possible, early, intermediate, or late infections generally are introduced during surgery either from the air or by direct contamination.

Surgical treatment of Osgood-Schlatter's disease

This report reflects the evolution of the operative treatment of Osgood-Schlatter's disease as practiced in Our Lady's Hospital for Sick Children. In the earlier portion of the series patients were treated by drilling of the tibial tubercle with or without removal of the prominence (Group A--22 operations). In the latter portion of the series loose pieces of cartilage or bone were excised without removal of the prominent tubercle or drilling (Group B--22 operations). The results showed a much higher incidence of excellent or good results in Group B. These patients had a short simple operation followed by rapid mobilization and return to full activity. We would, therefore, recommend this procedure for those who have significant symptoms from osteochondritis of the tibial tubercle.

Eight lateral compression injuries of the pelvis treated by the hoop apparatus of Lardennois

The pelvic hoop apparatus was used to treat 8 patients with severe lateral compression injuries to the pelvis. Each patient had an initially satisfactory reduction of the fracture or central dislocation. The advantages of this over other conservative methods of treating such injuries are discussed.

The Mitchell distal metatarsal osteotomy for hallux valgus

Seventy-two Mitchell distal metatarsal osteotomies for hallux valgus performed over a period of 10 years have been reviewed. Sixty-six (92 per cent) were graded as excellent or good. Retrospective radiographic analysis of 29 of these cases showed that the operation had reduced the intermetatarsal angles to within normal anatomical limits. No patient experienced a worsening of symptoms as a result of the operation.