1. Communication skills training in orthopaedics

Communication skills have been identified as a key component of medical education by the CanMEDS Project. The objectives of this study were to identify the perceived key components of communication skills from the perspectives of both orthopaedic residents and their program directors, and to understand how these skills are currently taught. This study utilized a mixed methods design. Quantitative data was collected using a 30-item questionnaire, which was distributed to all Canadian orthopaedic residents. Qualitative data was collected through focus groups with orthopaedic residents and semi-structured interviews with orthopaedic program directors. One hundred and nineteen out of three hundred and twenty-five questionnaires were completed (response rate = 37%), twelve residents participated in two focus groups, and 9/16 program directors from across the country were interviewed. The questionnaire reliability had an internal consistency of Cronbach’s alpha = 0.72. An ANOVA of the questionnaire data showed gender and International vs. Canadian medical graduate status to be independent variables to several item responses (P < 0.01). The factor analysis produced a five-factor model accounting for 50% of the variance. Both program directors and residents identified communication skills as being the accurate and appropriate use of language (ie, content skills), not how the communication was presented (ie, process skills). Perceived barriers to communication included time constraints and the need to adapt to the many personalities and types of people encountered daily in the hospital. Residents lack explicit communication skill training, but value developing communication skills in the clinical environment through experiential learning and role modeling. Resident education should focus on developing residents’ process skills in communication. Care should be taken to avoid large-group didactic teaching sessions, which are perceived as ineffective.

Management options for adenosine deaminase deficiency; proceedings of the EBMT satellite workshop (Hamburg, March 2006)

Adenosine deaminase (ADA) deficiency is a disorder of purine salvage that has its most devastating consequences in the immune system leading to severe combined immunodeficiency (SCID). Management options for ADA SCID include hematopoietic stem cell transplantation, enzyme replacement therapy and gene therapy. Formal data on the outcome following each of the three treatment modalities are limited, and this symposium was held in order to gather together the experience from major centers in Europe and the US. Transplantation for ADA-SCID is highly successful with survival rates of approximately 90% if a matched sibling or matched related donor is available but survival following matched unrelated donor or haploidentical procedures is 63% and 50% respectively with a significant rejection/non-engraftment rate in unconditioned procedures. Successfully transplanted patients demonstrated good immunological recovery with normal cellular and humoral function in the majority of cases. PEG-ADA has been used in over 150 patients worldwide either as an alternative to mismatched transplant or as a stabilizing measure prior to transplant. Overall, approximately two thirds of patients treated with PEG-ADA have survived with the majority of patients showing good clinical improvement. The level of immune recovery long term was less than that seen after transplant and approximately 50% of patients continued to receive immunoglobulin replacement. Gene therapy has been used as an experimental procedure in two centers in Europe. Early results from 9 patients suggest that the treatment is safe and that the majority have shown recovery of cellular immune function. Long-term follow-up of treated patients highlights a significant incidence of non-immunological problems with cognitive, neurological and audiological abnormalities most prominent.

Use of intravenous immunoglobulin in human disease: A review of evidence by members of the Primary Immunodeficiency Committee of the American Academy of Allergy, Asthma and Immunology

Human immunoglobulin prepared for intravenous administration (IGIV) has a number of important uses in the treatment of disease. Some of these are in diseases for which acceptable treatment alternatives do not exist. In this review we have evaluated the evidence underlying a wide variety of IGIV uses and make specific recommendations on the basis of these data. Given the potential risks and inherent scarcity of IGIV, careful consideration of the indications for and administration of IGIV is warranted.

Rotational malalignment of the tibia following reamed intramedullary nail fixation

OBJECTIVE

To determine the incidence and severity of tibial malrotation following reamed intramedullary nail fixation as measured by computerized tomography and to determine the repeatability of computed tomography measurement in the assessment of rotational malreduction.

DESIGN

Prospective cohort.

SETTINGS

Level 1 trauma center.

PARTICIPANTS

Twenty-five consecutive patients with 25 tibial shaft fractures.

INTERVENTION

All patients were treated with reamed intramedullary nailing. Appropriate radiographs and a postoperative lower extremity computed tomography scan were obtained for each patient who consented to the study.

MAIN OUTCOME MEASURE

Rotational alignment of affected tibia as compared to a version of the normal contralateral limb. Malrotation was defined as an internal/external rotation deformity greater than 10degrees.

RESULTS

Malrotation, comparing the fractured limb to normal limb, was determined using a similar measurement method previously described in the literature. Two patients declined inclusion, and in one case, the computed tomography was not acceptable for analysis. Malrotation, comparing the fractured limb to the normal limb, was determined using the measurements from axial computed tomography images. Results revealed a mean absolute rotational difference of 6.7degrees (SD +/-6.3degrees). Rotational malreduction ranged from 15degrees of internal rotation to 22degrees of external rotation. Five of the 22 tibia (22%) were malrotated greater than 10degrees. A larger degree of deformity was seen with certain injury patterns. The intraobserver and interobserver repeatability testing revealed a mean absolute difference between paired malrotation calculations of 3.4degrees and 3.9degrees, respectively, and a repeatability coefficient of 8degrees for both.

CONCLUSION

Computed tomography measurement is a repeatable method of assessing tibial torsion and in this study revealed a significantly higher incidence of rotational malreduction than that previously reported in the literature.

Mutations in genes required for T-cell development:IL7R, CD45, IL2RG, JAK3, RAG1, RAG2, ARTEMIS, and ADA and severe combined immunodeficiency: HuGE review

Severe combined immunodeficiency (SCID) is an inherited immune disorder characterized by T-cell lymphopenia (TCLP), a profound lack of cellular (T-cell) and humoral (B-cell) immunity and, in some cases, decreased NK-cell number and function. Affected children develop severe bacterial and viral infections within the first 6 months of life and die before 1 year of age without treatment. Mutations in any of eight known genes: IL2RG, ARTEMIS, RAG1, RAG2, ADA, CD45, JAK3, and IL7R cause SCID. Mutations in unidentified genes may also cause SCID. Population-based genotype and allelic frequencies of these gene defects have not been measured. Some minimal estimates of SCID prevalence are presented. Currently, hematopoietic stem cell transplants are the standard treatment. In clinical trials, gene therapy has been used to reconstitute immune function in patients with IL2RG and ADA defects. The availability of effective therapies, plus the short asymptomatic period after birth, (when stem-cell transplantation is most effective), make SCID a potentially good candidate for newborn screening. Dried blood spots are currently collected from all infants at birth for newborn metabolic screening. Tests for TCLP on dried blood spots could be developed as a screen for SCID. Because SCID may be unrecognized, with infant deaths from infection attributed to other causes, newborn screening is the only way to ascertain true birth prevalence. Validated tests and pilot population studies are necessary to determine newborn screening's potential for identifying infants with SCID.

Can the confidence in long range atmospheric transport models be increased? The pan-european experience of ensemble

Is atmospheric dispersion forecasting an important asset of the early-phase nuclear emergency response management? Is there a 'perfect atmospheric dispersion model'? Is there a way to make the results of dispersion models more reliable and trustworthy? While seeking to answer these questions the multi-model ensemble dispersion forecast system ENSEMBLE will be presented.

Complications following management of displaced intra-articular calcaneal fractures: a prospective randomized trial comparing open reduction internal fixation with nonoperative management

OBJECTIVE

To report on all complications experienced by patients with displaced intra-articular calcaneal fractures (DIACFs) following nonoperative management or open reduction internal fixation (ORIF).

DESIGN

Prospective, randomized, multicenter study.

SETTING

Four level I trauma centers.

PATIENTS

The patient population consisted of consecutive patients, age 17 to 65 at the time of injury, presenting to 1 of the centers with DIACFs between April 1991 and December 1998.

INTERVENTIONS

Patients were randomized to the nonoperative treatment group or to operative reduction using a lateral approach to the calcaneus.

MAIN OUTCOME MEASUREMENTS

Follow-up for patients was at 2 weeks, 6 weeks, 3 months, 12 months, 24 months, and once greater than 24 months following injury. At each follow-up interval, patients were assessed for the development of major and minor complications. After a minimum of 2-year follow-up, patients were asked to fill out a validated visual analogue scale questionnaire (VAS) and a general health review (SF-36).

RESULTS

There were 226 DIACFs (206 patients) in the ORIF group with 57 of 226 (25%) fractures (57 of 206 patients [28%]) having at least 1 major complication. Of 233 fractures (218 patients) nonoperatively managed, 42 (18%) (42 of 218 patients [19%]) developed at least 1 major complication (indirectly resulting in surgery).

CONCLUSION

Complications occur regardless of the management strategy chosen for DIACFs and despite management by experienced surgeons. Complications are a cause of significant morbidity for patients. Outcome scores in this study tend to support ORIF for calcaneal fractures. However, ORIF patients are more likely to develop complications. Certain patient populations (WCB and Sanders type IV) developed a high incidence of complications regardless of the management strategy chosen.

Assessment of osteoporosis using standard radiographs of the wrist

BACKGROUND

This study evaluated the ability of the orthopaedic surgeon to radiographically assess bone density in the wrist with sufficient accuracy to determine which patients require treatment for osteoporosis.

METHODS

Thirty-eight patients with unilateral distal radius fractures, 30 of whom were female, were included in this study. The mean age was 55 years (range 45 to 82). Standard radiographs of the fractured and normal wrists were taken. Dual energy x-ray absorptiometry was performed on the normal distal radius of all patients within 1 week of their injury. The radiographs were viewed in blinded randomized fashion on two separate occasions by three orthopaedic surgeons and once by a fourth. The participants were required to determine the presence of osteoporosis. Visual analog scales (VAS) were used to evaluate (1) porosity, (2) cortical thickness, (3) trabecular thickness, and (4) the number of trabeculae in the ultradistal radius.

RESULTS

Intraobserver agreement assessing osteoporosis averaged 81% (kappa of 0.5393). VAS assessment was unreliable for all four parameters. Radiographic determination of osteoporosis had a specificity of 61% and a sensitivity of 61% using x-rays of the uninjured wrist.

CONCLUSION

We conclude that orthopaedic surgeons cannot predict with sufficient accuracy using plain x-rays whether a patient is significantly osteoporotic.

Alterations of the X-linked lymphoproliferative disease gene SH2D1A in common variable immunodeficiency syndrome

X-linked lymphoproliferative (XLP) disease is a primary immunodeficiency caused by a defect in the SH2D1A gene. At least 3 major manifestations characterize its clinical presentation: fatal infectious mononucleosis (FIM), lymphomas, and immunoglobulin deficiencies. Common variable immunodeficiency (CVID) is a syndrome characterized by immunoglobulin deficiency leading to susceptibility to infection. In some patients with CVID, a defective btk or CD40-L gene has been found, but most often there is no clearly identified etiology. Here, 2 unrelated families in whom male members were affected by CVID were examined for a defect in the XLP gene. In one family previously reported in the literature as having progressive immunoglobulin deficiencies, 3 brothers were examined for recurrent respiratory infections, whereas female family members showed only elevated serum immunoglobulin A levels. A grandson of one of the brothers died of a severe Aspergillus infection secondary to progressive immunoglobulin deficiency, FIM, aplastic anemia, and B-cell lymphoma. In the second family, 2 brothers had B lymphocytopenia and immunoglobulin deficiencies. X-linked agammaglobulinemia syndrome was excluded genetically, and they were classified as having CVID. The occurrence of FIM in a male cousin of the brothers led to the XLP diagnosis. Because the SH2D1A gene was found altered in both families, these findings indicate that XLP must be considered when more than one male patient with CVID is encountered in the same family, and SH2D1A must be analyzed in all male patients with CVID. Moreover, these data link defects in the SH2D1A gene to abnormal B-lymphocyte development and to dysgammaglobulinemia in female members of families with XLP disease.

Age, gender, work capability, and worker's compensation in patients with displaced intraarticular calcaneal fractures

OBJECTIVES

To determine which demographic variables are linked with outcome in displaced intraarticular calcaneal fractures. The variables studied were age, gender, work capability, Workers' Compensation Board (WCB) support, and injury type.

DESIGN

A prospective cohort study with a minimum of two years of follow-up.

SETTING

A university-affiliated Level I trauma hospital.

PATIENTS

One hundred sixty-nine patients who required treatment for displaced intraarticular calcaneal fractures treated by a single surgeon. To be included in the study, patients had to be aged between fifteen and sixty-five years at the time of the injury, have closed injuries, and have posterior facet displacement greater than two millimeters.

INTERVENTION

Patients were treated nonoperatively or operatively, using a lateral approach to the calcaneus.

MAIN OUTCOME MEASUREMENTS

Outcome was measured by return of patients to full-time work, change in work capability after treatment, the SF-36 health survey, and visual analog scales.

RESULTS

Male gender, medium and heavy labor, presence of WCB support, and presence of bilateral intraarticular fractures all proved to be associated with a poorer prognosis. Female patients did well when treated nonoperatively and operatively, whereas male patients always were less able to return to work at the same level as before the injury. Operatively treated patients returned to work quicker (average, eighty-seven days).

CONCLUSIONS

Males, multiply injured patients, and heavy laborers may have better outcomes with operative treatment, whereas females and non-WCB patients may do better with nonoperative treatment.

Imiquimod therapy for molluscum contagiosum

BACKGROUND

Molluscum contagiosum virus (MCV) is a large double-stranded DNA virus that is a member of the family Poxviridae, and which has a worldwide distribution. As with other poxviruses, MCV does not appear to develop latency but evades the immune system through the production of viral specific proteins.

OBJECTIVE

To evaluate the therapeutic efficacy of imiquimod 5% cream for MCV.

METHODS

Thirteen children >5 and <10 years old, 19 immune-competent adults and four adults with advanced, but stable HIV-1 disease with >10 MCV lesions were treated with topical 5% imiquimod cream three times weekly for up to 16 weeks.

RESULTS

Fourteen of 19 immune-competent adults, four of four adults with HIV-1 disease, and six of 13 children had resolution of their MCV lesions in <16 weeks of imiquimod therapy. Children tended to have more pruritus and inflammatory reactions with imiquimod, although most treated lesions appeared to respond. The development of new MCV lesions resulted in a lower overall resolution of the lesions in children. Imiquimod appeared to be the most efficacious in patients with HIV-1 disease and in the genital area in immune-competent adults.

CONCLUSION

Although topical imiquimod appears to have some efficacy in the therapy of MCV, in children the pruritus correlated relatively well with the development of new lesions. In adults, areas that would be expected to have better penetration appeared to respond more consistently. Although the HIV-1-positive patients had the largest clinical lesions at the onset of therapy, as a group they had the best overall response to therapy.

Lamivudine (3TC)-induced contact dermatitis

The nucleoside analogue lamivudine (3TC) is commonly used in multidrug therapy of human immunodeficiency virus-1 disease because it not only potentiates the antiviral effects of other reverse transcriptase inhibitors, but it is also relatively nontoxic. We present a patient who developed a contact dermatitis to lamivudine after prolonged exposure.

Monitoring Diffuse Impacts: Australian Tourism Developments

/ The scientific quality of monitoring for diffuse environmental impacts has rarely been quantified. This paper presents an analysis of all formal environmental monitoring programs for Australian tourism developments over a 15-year period from 1980 to 1995. The tourism sector provides a good test bed for this study because tourism developments are (1) often adjacent to or even within conservation reserves and other relatively undisturbed natural environments, and (2) often clustered, with resulting cumulative impacts that require detection at an early stage. Here we analyze the precision and reliability with which monitoring programs as actually implemented can detect diffuse environmental impacts against natural variation. Of 175 Australian tourism developments subject to EIA from 1980 to 1993 inclusive, only 13 were subject to formal monitoring. Only 44 individual parameters, in total, were monitored for all these developments together. No baseline monitoring was conducted for nine of the 44 parameters. For the remaining 35, only one was monitored for a full year. Before, after, control, impact, paired sampling (BACIP) monitoring designs were used for 24 of the 44 parameters, and power analysis in 10. The scientific quality of monitoring was significantly better for developments subject to control by the Great Barrier Reef Marine Park Authority (GBRMPA). The key factor appears to be the way in which GBRMPA uses external referees and manages external consultants. The GBRMPA model merits wider adoption.

Generalized essential telangiectasia in a patient with Graves' disease: should the spectrum of autoimmune diseases associated with generalized telangiectasia be expanded?

Generalized essential telangiectasia (GET), as originally described, is not associated with any underlying disease. Although patients with GET lack the typical periungual telangiectases associated with autoimmune collagen vascular diseases, these patients may have an underlying autoimmune process. We present a patient with a history of Graves' disease and low-titer anti-nuclear antibodies, who developed rapidly progressive generalized telangiectases. The gender and age of the majority of patients with GET fit well within the demographics of most autoimmune diseases. The documented occurrence of an autoimmune disease in several of the limited number of patients previously diagnosed with GET provides additional evidence that GET may be associated with an underlying autoimmune disease.

Phenomenology and treatment of psychotic disorders in the psychiatric emergency service

The emergency evaluation of a psychotic patient calls on all of the skills of the psychiatrist. The immediate control of dangerous behavior takes place at the same time that clinicians evaluate patients for delirium. A screening physical examination, a brief mental status examination, and a high index of suspicion for medical diseases are essential tools in the first few minutes of a patient's stay in the psychiatric emergency service. Drugs of abuse are often part of a patient's presentation. Here, too, the first task is to rule out delirium, particularly from sedative or alcohol withdrawal. As soon as a patient's condition is stabilized, the psychiatrist should review all of the available information, develop a working diagnosis, and initiate definitive treatment of the presumed disorder. With fewer emergency patients being hospitalized and with shorter lengths of hospital stay, these initial decisions acquire increasing significance for patient outcome.

Bohler's angle: correlation with outcome in displaced intra-articular calcaneal fractures

OBJECTIVES

Bohler's tuber joint angle is commonly assessed when evaluating calcaneal fractures. A severe heel fracture will result in a significant decrease or loss of this angle. The purpose of this study was to evaluate the correlation between Bohler's angle and functional outcome in displaced intra-articular calcaneal fractures.

DESIGN

Prospective cohort study.

SETTING

Level I trauma center.

METHODS

Ninety-five fractures in eighty-eight patients were analyzed for clinical outcome as measured by previously validated visual analogue scale (VAS) and SF-36 Health Survey scores. Radiographic results were measurements of Bohler's angle on plain x-rays. Angles were measured twice by two observers working independently.

RESULTS

This prospective randomized cohort study indicates that patients initially presenting with a severely depressed Bohler's angle have a poor two-year outcome regardless of treatment. As well, fractures of lesser initial displacement, as measured by Bohler's angle, had higher functional scores on both VAS and SF-36 scoring scales.

CONCLUSION

In this study, Bohler's angle had significant prognostic value in terms of predicting morbidity. Fractures with a markedly diminished Bohler's angle demonstrated a much poorer two-year outcome regardless of treatment. It would seem that the initial Bohler's angle was highly prognostic, regardless of treatment modality.

Comparison of two regimens of beta-adrenergics in acute asthma

BACKGROUND AND METHODS

Inhaled adrenergics and steroids are the main agents used in acute asthma. Dosing recommendations for adrenergics, while generally becoming more aggressive, lack prospective validation. A double blind, randomized trial of two regimens of nebulized metaproterenol was conducted in patients presenting to an Emergency Department with an acute asthma exacerbation. Asthmatics age 16-55, with no other cardio-pulmonary disease, presenting with peak expiratory flow rate (PEFR) < 30% of predicted and greater than 80 L/m were enrolled. All patients received 125 mg of methylprednisolone and theophylline, if needed, to reach therapeutic levels. The experimental group received 0.3 cc metaproterenol in 2.5 cc of saline at times 0, 20", 40", 1', 2', 3', 4', 5', 6', and 7'. The control group received metaproterenol at times 0, 1 hr, and hours 3, 5, and 7. Placebo was given to control group patients at 20", 40", 2', 4', and 6'. PEFR and vital signs were measured 10 min after each treatment. Study end points included discharge upon reaching set criteria or admission if patients were not discharged following the hour 7 treatment.

RESULTS

Seventy one patients were enrolled, 40 in experimental group and 31 in the control group. The group characteristics did not differ at entry in any significant way, and the groups began with mean expected PEFR of 23.4% and 24.5%, respectively. There were no significant differences at any point in PEFR outcomes, time to discharge, or admission rate. The experimental group showed a greater increase in pulse rate and a reduced diastolic blood pressure at 20, 40 and 60 min. The experimental group had a 12- and 8-fold increase in the risk of a pulse rate > 140 at 40 and 60 min, respectively. This group also had two moderate complications, both near the 60-minute mark. These were an induction of atrial fibrillation in one patient and ischemic electrocardiographic changes in another.

CONCLUSION

Three treatments in the first hour, and hourly thereafter showed no benefit over treatments initially, at one hour, and every other hour in acute, moderate, or severe exacerbation of asthma. Side effects were markedly increased in the control group. Such dosing should not be recommended as routine therapy.

Diagnosis and treatment of prostatitis in Canada

OBJECTIVES

There is a general consensus among physicians that the present management of chronic prostatitis is dismal. We undertook a survey of Canadian primary care physicians (PCPs) and urologists to determine the degree and source of frustration and to analyze present practice patterns in this disease.

METHODS

Five thousand PCPs and all 545 Canadian urologists were asked to complete a comprehensive computer-assisted telephone survey that explored practice characteristics, attitudes, and diagnostic and treatment strategies in the management of prostatitis. Randomization of attribute banks, adherence to questionnaire routing, validation by on-site monitoring, and possible bias were addressed.

RESULTS

Completed interviews were obtained from 10% of PCPs and 28% of urologists. PCPs see on average 3.5 (median 2) patients with prostatitis per month and urologists see on average 21.8 (median 11) patients with prostatitis per month. All physicians experience significantly more frustration in treating prostatitis than they do in treating patients with benign prostatic hyperplasia (BPH) and prostate cancer, and they perceive that prostatitis affects patients' quality of life significantly more than BPH and almost as much as prostate cancer. The degree of frustration and unhappiness in dealing with prostatitis is driven by a lack of confidence and comfort in their ability to accurately diagnose and subsequently rationalize treatment. Most PCPs and urologists continue to employ steps in addition to history and physical examination to establish a diagnosis but only a few PCPs and a third of urologists use specific lower urinary tract cultures. Physicians tend to use trimethoprim or trimethoprim-sulfamethoxazole (TMP-SMX) or a fluoroquinolone as their usual first line therapy for chronic prostatitis. The most commonly used therapeutic strategy (40%) for chronic prostatitis was TMP-SMX as first line therapy and a fluoroquinolone as second line therapy.

CONCLUSIONS

There is widespread frustration, discomfort, and lack of confidence in both PCPs' and urologists' perceived ability to manage prostatitis. Physicians have expressed a desire for a better understanding of this disease, simpler and clearer diagnostic guidelines, and more rational treatment strategies.

Oral analogue scale as an outcome measure after displaced intra-articular calcaneal fractures

Functional outcome measures of displaced intra-articular calcaneal fractures have been documented using general health surveys (SF36) and disease-specific health surveys (Visual Analogue Scale). A simple oral analogue scale (OAS) was collected on 115 patients with 124 displaced intra-articular calcaneal fractures at 2 years or more after fractures. There was a high correlation (r = 0.72, P < 0.0001) between the verbal OAS and the written Visual Analogue Scale. We believe that the OAS may assist in follow-up outcome assessment and management in this difficult trauma patient population. Outcomes may be accomplished verbally rather than in written form.

Mycobacterium fortuitum infection occurring after a punch biopsy procedure

Mycobacterium fortuitum is a rapidly growing atypical mycobacterium frequently reported as a postsurgical wound complication from a major surgical procedure. We present a unique case of M. fortuitum infection occurring in a 4-year-old boy after a minor punch biopsy surgical procedure. As far as we know there has been no published case of M. fortuitum occurring after a punch biopsy procedure.

An accident and emergency nurse in the besieged city of Sarajevo

As war raged in Bosnia a team of doctors and nurses travelled into the besieged city of Sarajevo to treat some of the people injured by the war. More than half of the city's doctors had been killed or had escaped the city. This is the experience of one of the members of the team, an Accident and Emergency nurse.

A comparison of one versus two distal locking screws in tibial fractures treated with unreamed tibial nails: a prospective randomized clinical trial

The objective was to determine whether the number of interlocking screws have an impact on hardware failure. In a clinical prospective randomized study of skeletally mature patients with diaphyseal tibial fractures, 44 were randomized pre-operatively into the two treatment arms over a two-year period. Two patients, one from each group, were excluded later. Of eligible patients, 22 had one distal locking screw and 20 had two distal locking screws. One distal screw failed (59.1 per cent) significantly more often than two distal screws (5 per cent). Screw failure occurred more often in heavier patients and usually between six and 12 weeks. Proximal screw failure was seen in 17 per cent of patients. There was no significant difference between groups with respect to fracture union.

The role of the therapeutic contact lens in the management of recurrent corneal erosions: a review of treatment strategies

PURPOSE

Recurrent corneal erosion is a commonly encountered condition for which multiple treatment modalities are suggested. We discuss the role of the therapeutic contact lens in the management of this condition.

METHODS

We reviewed treatment strategies based on published literature and on personal experience.

RESULTS

Ocular lubricants are the standard treatment for recurrent corneal erosion. Where loose flaps of epithelium are present, they should be removed before prescribing lubricants. In some dystrophic cases, reduplicated basement membrane can be scraped off before lubricant treatment is resumed. Where conservatives measures fail, three treatment modalities may be employed: application of a therapeutic contact lens; anterior stromal puncture; and excimer laser phototherapeutic keratectomy (PTK). The choice of treatment is determined by: etiology; location of disease (axial or off-axis); coexisting ocular diseases; individual patient reliability; and availability of equipment. The therapeutic contact lens has a role in the management of difficult post-traumatic cases where the lesion is axial. The use of such a lens in dystrophic cases is often not very effective, and these cases may be most effectively treated with PTK. If a contact lens is used, the lens should be fit fairly tight and both physician and patient should be aware of the risk of microbial keratitis.

CONCLUSIONS

The guidelines in this paper should enable physicians to maximize success and minimize risks when managing patients with recurrent corneal erosions.

Risk factors for hepatitis C virus infection among injecting drug users in Sydney

OBJECTIVE

To study risk factors for hepatitis C virus (HCV) infection in injecting drug users (IDUs) from central Sydney.

SETTING AND SUBJECTS

All IDUs attending a primary health care facility in central Sydney between December 1991 and November 1992 who underwent HCV antibody testing.

METHODS

Information was obtained retrospectively from client forms routinely completed at the time of medical consultation. Additional information on injecting history and practice was obtained from the registration forms of subjects who also attended the needle syringe exchange programme at the same health care facility.

RESULTS

Of the 201 IDUs tested, 118 (59%) had HCV antibodies, which did not differ significantly between males and females. HCV prevalence increased significantly with age, being highest in IDUs who were aged 35 years or more (93%) and lowest in IDUs aged under 20 years (17%). HCV prevalence increased significantly with time since first injecting, from 26% for IDUs who had injected for less than 3 years to 94% for those who had injected for more than 10 years. HCV prevalence was also significantly higher in heterosexual IDUs as compared with homosexual male IDUs, and in opiate users as compared with stimulant users, even after adjustment for age and duration of injecting. HCV prevalence was strongly associated with exposure to hepatitis B virus, but was not associated with exposure to HIV.

CONCLUSION

Recent HCV transmission indicates ongoing injecting risk behaviour despite HIV prevention efforts, and underlies the potential for increased transmission of HIV through the sharing of injecting equipment. Within the population of IDUs, those who are heterosexual or inject heroin appear to be at increased risk of HCV infection.

Excimer laser superficial keratectomy for proud nebulae in keratoconus

Contact lens intolerance in keratoconus may be due to the formation of a proud nebula at or near the apex of the cone. Excimer laser superficial keratectomy was performed as an outpatients with proud nebulae as treatment patients with proud nebulae as treatment for their contact lens intolerance. The mean period of contact lens wear before the development of intolerance was 13.4 years (range 2 to 27 years). Following the development of intolerance, three patients abandoned contact lens wear in the affected eye while the remainder experienced a reduction in comfortable wearing time (mean = 3.75 hours; range: 0-14 hours). All patients had good potential Snellen visual acuity with a contact lens of 6/9 (nine eyes) and 6/12 (one eye). The proud nebulae were directly ablated with a 193 nm ArF excimer laser using a 1 mm diameter beam. Between 100-150 pulses were sufficient to ablate the raised area. Patients experienced no pain during the procedure and reported minimal discomfort postoperatively. In all cases flattening of the proud nebulae was achieved. Seven patients were able to resume regular contact lens wear (mean wearing time = 10.17 hours; range 8 to 16 hours). In three patients, resumption of contact lens wear was unsuccessful because of cone steepness. All patients achieved postoperative Snellen visual acuity of 6/12 or better with a contact lens. Four patients experienced a loss of one line in Snellen acuity. The mean follow up period was 8.3 months (range 2 to 17 months). Excimer laser superficial keratectomy is a useful technique for the treatment of contact lens intolerance caused by proud nebulae in patients with keratoconus. Penetrating keratoplasty is thus avoided.

The visual prognosis following HLA-matched keratoplasty for high-risk patients

We report the clinical details of 30 HLA-matched corneal grafts with a mean follow-up of 29 months. Few of the patients were immunologically naive as almost all had received previous unmatched grafts. The two-year survival rate was 77%, comparable with other series. A majority of patients obtained good vision, and this was statistically superior to a recent large series. Almost all remained on their topical medication indefinitely. The contralateral visual acuity was surprisingly good, but there are few published data for comparison. We were unable to document an enhanced prognosis with a higher degree of HLA-A, B or DR match, possibly because of the small numbers.

Limbal transplantation in the management of chronic contact-lens-associated epitheliopathy

We describe the clinical management of 6 patients who developed a chronic corneal epitheliopathy 1-18 years after commencing soft contact lens wear. All had a history of exposure to thiomersal in contact lens fluids. The corneal changes were characterised by epithelial haze and superficial stromal vascularisation which extended from the limbus towards the visual axis. Five patients were observed for a minimum of 18 months after stopping contact lens wear before undergoing limbal transplantation. A good result was obtained in 1 patient who had worn a contact lens in one eye only. Recurrent epithelial changes were observed on the recipient eyes of the remaining patients who had previously worn contact lenses bilaterally, and in 1 patient epithelial haze also developed adjacent to the donor site in the previously clinically normal donor eye. All 5 patients experienced an improvement in symptoms post-operatively but in 2 patients the visual acuity later deteriorated because of epithelial irregularity. The sixth patient has not had surgery. We conclude that limbal stem cell dysfunction in chronic contact-lens-associated epitheliopathy may be subclinical and that autograft transplantation in bilaterally exposed patients may fail to restore the epithelial phenotype of the host eye whilst jeopardising the epithelial integrity of the donor eye by depleting its stem cell reserve.

The Greater Vancouver Mental Health Service Society: 20 years' experience in urban community mental health

Caring for people in the community with persistent and disabling mental illnesses presents a major challenge to government, planners and mental health professionals. The success with which mentally disabled people are integrated into community life says much about the society in which we live. This article describes the experience of the Greater Vancouver Mental Health Service Society in offering community-based mental health services to persons with schizophrenia and other major mental disorders over the past 20 years. The key to its success lies in a decentralized, relatively non hierarchical organizational structure which allows committed and skilled multidisciplinary teams to work with patients and their families in their community. The resulting services are fully integrated within the fabric of the community and are responsive to local needs. Partnerships among professionals, patients, families and community agencies result in work that is creative, productive and effective.

Symptomatic bradycardia following the administration of sublingual nitroglycerin

A case of severe bradycardia with junctional escape immediately following sublingual nitroglycerin is described. Bradycardia is a rare, but well-documented, complication of nitroglycerin and is often reported in the setting of myocardial ischemia or infarction. This particular case reported was complicated by the presence of an angiographically documented congenital coronary anomaly, but did not have either electrocardiographic or enzymatic evidence of ischemia or infarction during this event. Previously reported cases were reviewed, as well as potential mechanisms for this phenomenon. All cases reported to date were easily corrected with passive leg elevation or atropine.

The multi-service network: reaching the unserved multi-problem individual

A small number of multi-problem, service-resistant individuals in every metropolitan community consume extraordinary amounts of human service at great cost to publicly-funded agencies with less than satisfactory benefit to the individual. This paper describes an innovative collaboration among mental health, alcohol/drug treatment, corrections, forensic, and social and housing agencies to provide more effective services at less cost. The theory of action was that (1) inter-agency communication and (2) external controls developed by core service agencies increase the efficacy of treatment and reduce the cost of caring for multi-problem clients. Agencies refer clients to the Multi-Service Network who are then screened for problematic multi-agency involvement. Case conferences result in individual service plans. Three illustrative cases are described and the results of two evaluative studies summarized. Cost of care for clients appears to have been reduced. Agencies appear to have benefited from improved information and communication. Clients' behavior was stabilized by external controls and more adequate attention to their needs.

Auditing the precision and accuracy of environmental impact predictions in Australia

Our understanding of natural ecosystems can be measured by our ability to predict their responses to external disturbances. Predictions made during environmental impact assessment (EIA) for major development projects are hypotheses about such responses, which can be tested with data collected in environmental monitoring programmes. The systematic comparison of predicted and actual impacts has been termed environmental impact audit. Ecosystem disturbances associated with major resource developments, though of lesser magnitude than those associated with natural cataclysms, are generally of far greater magnitude than those which can be applied experimentally. Environmental audit can hence provide critical tests of theory in a number of natural sciences. It is also needed to improve the scientific content of EIA. Audits of 4 and 29 EISs respectively have been carried out previously in the UK and USA, but this is the first national scale audit for any country. It is also the first attempt to select, from the many vague statements in EISs, only those predictions that are scientifically testable, and to determine and analyse their quantitative accuracies. Its principal results are as follows. The average accuracy of quantified, critical, testable predictions in environmental impact statements in Australia to date is 44%±5% s.e. Predictions where actual impacts proved more than expected were on average significantly (p<0.05) less accurate (33%±9%) than those where they proved as or less severe (53%±6%).

Perioperative cefazolin prophylaxis in hip fracture surgery

Antibiotics given perioperatively are thought to decrease the occurrence of postoperative wound infection. The duration of treatment for hip fracture surgery is empirical. This randomized, double-blind, single-hospital clinical study was carried out to assess the effect of both antibiotic use and duration of use on wound infections in hip fracture surgery. Wound infection rates in three groups of patients were compared: those who received four doses of cefazolin (108 patients), those who received one dose of cefazolin and three doses of placebo (83 patients) and those who received four placebo doses (121 patients). Results showed an infection rate of 1.6% for the four-dose group, 2.4% for the one-dose group and 3.7% for the placebo group. These differences were not statistically significant, even when both treatment groups were combined and compared with the placebo group. The authors conclude that until more patients are added, empirical use of antibiotics should be continued in patients who undergo hip fracture surgery.

Seronegative arthritis associated with serological evidence of Yersinia infection in Australia

Infection due to yersinia enterocolitica is a common antecedent illness in patients with reactive arthritis in Scandinavia, but appears to be less frequent in other countries. In order to examine the frequency of yersinia infection in patients with seronegative arthritis in Australia we examined 22 patients, 15 with ankylosing spondylitis (AS) and seven with Reiter's syndrome (RS). A sensitive ELISA assay was used to detect serum antibodies to the most common serotypes. Six patients (29%) had positive yersinia serology, all were HLA B27 and four had a history of diarrhea preceding the onset of their disease. Four patients with positive yersinia serology had AS and two had RS. Antibodies were directed against Y. enterocolitica biotype 0:3 in three cases, Y. enterocolitica 0:9 in two cases and Y. enterocolitica 0:8 in one subject. Twenty-nine control subjects (13 HLA B27) had no serum antibodies to yersinia. The results of this study indicate that preceding yersinia infection occurs in a significant (p less than 0.05; compared to controls) proportion of patients with HLA B27 related seronegative arthropathies.