[Regional anesthesia practice in Chile: an online survey]

OBJECTIVE

To conduct a survey to profile the practice of regional anesthesia in Chile and determine the limitations on its use.

MATERIAL AND METHODS

A link to an online questionnaire was sent by e-mail to anesthesiologists who were members of their national professional association (Sociedad Chilena de Anestesiologia). The survey was processed anonymously. Multiple choice items elicited responses concerning general demographic information, professional experience as an anesthetist, academic degree, hospital size, and the use of regional anesthesia in clinical practice (number of procedures and types of techniques). Finally, the questionnaire focused on the use of nerve and plexus blocks.

RESULTS

A total of 209 completed questionnaires were received, for a response rate of 54%. Regional anesthesia was part of routine practice for 97% of the respondents; 68% reported that regional techniques were used in more than 30% of their caseload. Most performed neuraxial techniques: 98.1% were spinal blocks, 96.2% lumbar epidural blocks, and 66.9% thoracic epidural blocks. Routine use of peripheral nerve blockade was reported by 73.7%. Upper limb anesthesia was provided significantly more often than lower limb anesthesia (P =.011). The most common technique involved use of a peripheral nerve stimulator (64%). Skills were mainly acquired through residency programs (68.9%) and self-teaching (20.1%). Peripheral nerve blocks were never performed by 26.3% of the respondents; the reason given most often was lack of training.

CONCLUSIONS

Although regional anesthesia is commonly used in Chile, neuraxial blocks remain the most frequently used types. Peripheral nerve blocks are used fairly often, mostly on an upper limb. Training should stimulate attempts to promote more widespread use of all forms of regional anesthesia.

Integrative health coaching for patients with type 2 diabetes: a randomized clinical trial

PURPOSE

The purpose of this study was to evaluate the effectiveness of integrative health (IH) coaching on psychosocial factors, behavior change, and glycemic control in patients with type 2 diabetes.

METHODS

Fifty-six patients with type 2 diabetes were randomized to either 6 months of IH coaching or usual care (control group). Coaching was conducted by telephone for fourteen 30-minute sessions. Patients were guided in creating an individualized vision of health, and goals were self-chosen to align with personal values. The coaching agenda, discussion topics, and goals were those of the patient, not the provider. Preintervention and postintervention assessments measured medication adherence, exercise frequency, patient engagement, psychosocial variables, and A1C.

RESULTS

Perceived barriers to medication adherence decreased, while patient activation, perceived social support, and benefit finding all increased in the IH coaching group compared with those in the control group. Improvements in the coaching group alone were also observed for self-reported adherence, exercise frequency, stress, and perceived health status. Coaching participants with elevated baseline A1C (>/=7%) significantly reduced their A1C.

CONCLUSIONS

A coaching intervention focused on patients' values and sense of purpose may provide added benefit to traditional diabetes education programs. Fundamentals of IH coaching may be applied by diabetes educators to improve patient self-efficacy, accountability, and clinical outcomes.

Measuring the salivary testosterone and cortisol concentrations of weightlifters using an enzyme-immunoassay kit

This study assessed an enzyme-immunoassay (EIA) kit for measuring the salivary testosterone (T) and cortisol (C) concentrations of weightlifters. Saliva samples (n=64) were collected from male and female weightlifters during normal training procedures and analysed for T and C using a commercial EIA kit and a criterion radioimmunoassay (RIA) method. Significant correlations were demonstrated between the EIA and RIA measurements of salivary T (r=0.72) and C (r=0.96) [corrected] concentrations (P<0.001). Further examination by sample and gender revealed similar relationships. The EIA concentrations of salivary T and C were found to be slightly greater (10-13%) than the RIA values. Similar discrepancies were noted when gender comparisons were made, although the relative information on T (males > females) and C (males=females) were consistent for both assay methods. In conclusion, a commercially available EIA kit provided valid measures of the salivary T and C concentrations of male and female weightlifters. Factors to consider when using an EIA kit include the hormone(s) of interest, the magnitude of the correlations, as well as the descriptive information gained (e. g. absolute, relative) and its uses within sport.

When headaches are not neurological: an unusual presentation of Ebstein's anomaly

A 16-year-old male was admitted following a loss of vision. Baseline observations demonstrated SpO2 80% on air, tachycardia of 180 beats per minute (bpm) and hypotension of 90/50 mmHg. He reported bilateral visual disturbance while sitting in bed together with breathlessness, chest discomfort and dizziness but had not had palpitation or syncope. He had been prescribed propranolol for recurrent migraines of increasing frequency with similar visual disturbances, nausea and vomiting but with no perceived benefit. He was otherwise well, a non-smoker who drank minimally and denied recreational drug use.

On examination, the jugular venous pressure was elevated but there were no other cardiorespiratory findings of note. Arterial blood gas analysis revealed profound hypoxia and a compensated metabolic acidosis. A 12-lead electrocardiogram demonstrated a supraventricular tachycardia with broad QRS (Figure 1). Carotid sinus massage and intravenous adenosine had no effect. Electrolyte levels were abnormal (potassium 2.7 mmol/litre, magnesium 0.45 mmol/litre, corrected calcium 1.60 mmol/litre) and a central venous line was inserted to allow electrolyte replacement. During this procedure, he spontaneously reverted to sinus rhythm at a rate of 70 bpm.

A repeat electrocardiogram showed sinus rhythm with normal axis but T wave inversion in the inferior leads and evidence of pre-excitation with a short PR interval and classical delta waves (Figure 2). As a result, Wolff–Parkinson–White syndrome was diagnosed. The chest radiograph showed an abnormal, globular cardiac silhouette (Figure 3).

Following return to sinus rhythm, the blood pressure and acid–base status normalized. Routine transthoracic echocardiography demonstrated Ebstein's anomaly with an associated atrial septal defect and small membranous ventricular septal defect.

PROMAXX inhaled insulin: safe and efficacious administration with a commercially available dry powder inhaler

OBJECTIVES

We investigated the pharmacokinetic (PK) and pharmacodynamic (PD) properties of recombinant human insulin inhalation powder (RHIIP), manufactured with PROMAXX technology, which allows formation of uniform protein microspheres.

METHODS

Thirty healthy male subjects [age 30 +/- 1 years (mean +/- s.e.), body mass index 24.2 +/- 0.3 kg/m(2)] in a randomized crossover study received 10 IU subcutaneous regular human insulin (SCIns) and 6.5 mg of RHIIP [187 IU, Cyclohaler dry powder inhaler (DPI)] under euglycaemic glucose clamp conditions. Subjects were trained to inhale RHIIP with a flow rate of 90 +/- 30 l/min prior to dosing.

RESULTS

Inhalation of RHIIP was well tolerated with no episode of cough or shortness of breath. RHIIP showed a faster onset of action than SCIns [time to reach 10% of total area under the glucose infusion rate (GIR) curves 73 +/- 2 vs. 95 +/- 3 min, time to maximal metabolic effect (T(max)GIR) 173 +/- 13 vs. 218 +/- 9 min, both p < 0.0001]. Duration of action (371 +/- 11 vs. 366 +/- 7 min) and total metabolic effect (AUCGIR0-10 h 2734 +/- 274 vs. 2482 +/- 155 mg/kg) were comparable. PK results were in accordance with the PD findings. Relative bioavailability (BA) of RHIIP was 12 +/- 2%, and relative biopotency (BP) was 6 +/- 1%.

CONCLUSIONS

PROMAXX technology allowed for safe and efficacious administration of RHIIP to the deep lung with an off-the-shelf DPI. RHIIP showed a fast onset of action and BA/BP comparable to that reported for other inhaled insulin formulations using specifically designed inhalers. Improvements in the insulin delivery technique might allow to optimize drug application in all cases with even higher BA/BP with RHIIP.

Complications of hysterectomy in women with von Willebrand disease

Case reports and small case series suggest that women with von Willebrand disease (VWD) are at a very high risk of bleeding complications with hysterectomy. As the procedure may be beneficial to women who suffer from heavy menstrual bleeding and have completed childbearing, an understanding of the true risks involved is essential for appropriate decision making. To estimate the incidence of bleeding and other complications in women with VWD who undergo hysterectomy. The United States Nationwide Inpatient Sample (NIS) from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality for the years 1988-2004 was queried for all hysterectomies for non-malignant conditions. Data were analysed based on the NIS sampling design. Bivariate analyses were used to examine the differences between women with and without VWD. Multivariate analysis was used to adjust for potential confounders among women who underwent hysterectomy for heavy menstrual bleeding. 545 of the 1 358 133 hysterectomies were to women with VWD. Women with VWD were significantly more likely to experience intraoperative and postoperative bleeding (2.75% vs. 0.89%, P < 0.001) and require transfusion (7.34% vs. 2.13%, P < 0.001) than women without VWD. One woman with VWD died. While the risk of bleeding complications from hysterectomy in women with VWD is smaller than previously reported, women with VWD did experience significantly more bleeding complications than women without VWD. Nonetheless, for women who have completed childbearing, the risks of hysterectomy may be acceptable.

Correlates of paid sex among men who have sex with men in Chennai, India

OBJECTIVES

To assess correlates of paid sex among men who have sex with men (MSM) in Chennai, India.

METHODS

A randomised survey was conducted among 200 MSM recruited from public sex environments using time-space sampling. The association of predictors with paid sex was assessed with chi(2) tests and multiple logistic regression.

RESULTS

Participants' mean age was 28.5 years (SD 8.7). Most (71.5%) were kothis; 60% had less than high school education and two-thirds had a monthly income less than 2000 Indian rupees. More than one-third (35.0%) reported daily/weekly harassment; 40.5% reported forced sex in the past year. The prevalence of paid sex was 59.5% (95% CI 52.7% to 66.3%). Univariate analyses indicated that paid sex was associated with kothi identity (chi(2) = 14.46; p<0.01), less than high school education (chi(2) = 4.79; p<0.05), harassment (chi(2) = 11.75; p<0.01) and forced sex (chi(2) = 3.98; p<0.05). Adjusted analyses revealed that paid sex was associated with kothi identity (adjusted odds ratio (AOR) 2.62, 95% CI 1.34 to 5.10) and harassment (AOR 2.34, 95% CI 1.16 to 4.72). MSM who engaged in paid sex (versus no paid sex) had a mean of 31 partners in the past month (versus 4, t = 6.17, p<0.001) and 71.2% used condoms consistently (versus 46.4%, chi(2) = 18.34; p<0.01). Overall, 32.5% were never tested for HIV.

CONCLUSIONS

Epidemic rates of harassment and sexual violence against MSM who engage in paid sex, predominantly kothis, suggest that interventions should target structural factors placing these men at increased risk of HIV/sexually transmitted infections and other health-compromising conditions. The effectiveness of individual-level, knowledge-based and condom-focused preventive interventions may be constrained in the context of poverty, low education, harassment and sexual violence.

Acute and long-term effects of exposure to sodium monofluoroacetate (1080) in sheep

Acute and long-term effects of a single, relatively high oral dose (0.25 and 0.30 mg/kg) of sodium monofluoroacetate (1080) on the survival and productivity of sheep were evaluated to establish a better understanding of 1080 poisoning and identify more specific changes diagnostic of toxicosis. In survivors, clinical signs of acute 1080 toxicosis such as salivation and lethargy were generally very mild. Fasted animals were more prone to 1080 toxicity. In animals that died, more severe signs, including tachypnoea, dyspnoea, and tremors occurred for 15-20 min prior to death. 1080 concentrations were highest in the blood > heart > skeletal muscle > liver. 1080 could not be detected in any of these organs of the animals that survived. Serum citrate concentrations were elevated for 4 days after dosing. No clinical or biochemical abnormalities were found in any animal after 4 days. Histopathological lesions were most marked in the heart and lung with inflammation, necrosis, and scattered foci of fibrous tissue in the myocardium, pulmonary oedema and inflammation of the lung. No adverse long-term effects on general health or reproductive performance were observed in any sheep that survived the first 4 days following exposure to 1080. The most reliable diagnostic indicators of 1080 exposure in sheep were measurement of its residues in blood, skeletal muscle and ruminal contents, increased serum citrate concentration, elevated heart rate, and characteristic electrocardiograph changes (up to 4 days after exposure). Death from 1080 is most likely to occur within 96 h, and animals that survived this period appeared normal.

Continental variations in preoperative and postoperative management of patients with anterior cruciate ligament repair

AIM

Surgeon decision making for non-operative anterior cruciate ligament (ACL) treatment and postoperative rehabilitation is influenced by a myriad of factors. The aim of this study was to investigate intercontinental differences in surgeon decision making for care of the ACL deficient patient. The authors hypothesized that significant variation in clinical decision of ACL deficient patients existed among surgeons in different continents.

METHODS

This study involved a survey design, which met the checklist for reporting results of internet e-surveys (CHERRIES) guidelines. The survey was administered to orthopedic surgeons in 15 countries and involved standardized follow up and design. Questions related to non-operative care management and postoperative/rehabilitative management were provided to each respondent. Statistical analyses included multivariate comparisons among continents and regression findings for likelihood of targeting longer term non-operative treatment.

RESULTS

Over six hundred (634) surgeons completed the survey, representing six continents. Continental variations were found in non-operative surgical decision making and postoperative/rehabilitative management. Significant differences were noted in nearly all clinical decision making categories.

CONCLUSION

Variations do exist across continents in the non-operative and postoperative/rehabilitative management of patients with an ACL tear. Continental variations and disparate emphases such as activity level, age during injury, and bracing influenced treatment decision making, which could lead to variations in outcomes, costs, and appropriate care.

Retinopathy of prematurity in South Africa: an assessment of needs, resources and requirements for screening programmes

AIMS

Retinopathy of prematurity (ROP) is a major cause of blindness in children in middle-income countries. In 1995, it accounted for 10.6% of blindness in children in schools for the blind in South Africa. This study was undertaken to estimate the number of premature babies at risk and to investigate policies, practices and screening programmes.

MATERIALS AND METHODS

17 level 1-3 neonatal units were visited in four provinces. Published literature reports were reviewed and staff interviewed.

RESULTS

13,000-15,000 surviving premature babies are at risk of ROP each year. Shortage of equipment precluded continuous oxygen monitoring in public units. Nursing levels were often below recommendations, and most nurses were unaware of target oxygen saturations. Private units were well staffed and adequately equipped. Ophthalmologists were only visiting four units on a regular basis for screening, using the birth weight criterion of <1500 g for ROP screening. ROP needing treatment rates were low (1.6-2.9%), as were rates of follow-up.

CONCLUSIONS

Primary prevention of ROP requires meticulous neonatal care and adequately equipped and staffed units. Secondary prevention requires efficient screening and treatment programmes. Competing demands and limited resources in the public sector in South Africa have precluded prioritizing the prevention of ROP. This should be re-evaluated.

Effect of the Deyo score on outcomes and costs in shoulder arthroplasty patients

PURPOSE

To evaluate the effect of preoperative comorbidity status (defined by the Deyo index) on hospital mortality, postoperative complications, length of hospital stay, and hospital costs for shoulder arthroplasty patients.

METHODS

The overall mean hospital mortality and postoperative complication rates, and length of hospital stay and hospital costs stratified by the Deyo score were compared using the Pearson Chi squared test and the F-test, respectively. The effects of the Deyo score on hospital mortality and postoperative complications were estimated using multiple logistic regression. The length of hospital stay and hospital costs were estimated using multiple linear regression. The magnitude of the estimated effects of the Deyo score on the 4 outcomes were expressed as crude odds ratios (ORs) and adjusted ORs for age, race, gender, surgeon volume, and hospital volume.

RESULTS

Higher Deyo scores tended to be associated with higher hospital mortality, length of hospital stay, postoperative complications, and hospital costs. Compared with the referent group (Deyo score=0), patients with the highest Deyo scores (5-36) exhibited adjusted ORs of 11.8 for hospital mortality (p=0.011) and 1.1 for developing postoperative complications (p=0.098), and had the highest length of hospital stay (mean, 4.1 days) and hospital costs (mean, US$18,549).

CONCLUSION

The Deyo score was a predictor of outcomes and costs in the shoulder arthroplasty population. By identifying relevant factors, health care providers can better determine who should be referred for shoulder arthroplasty and what should be considered when assessing risks and benefits.

Pneumocephalus as a complication of diverticulitis

We report a case of pneumocephalus, as a complication of diverticulitis, in a 48-year-old man who presented with back pain and mild disorientation. There are no previous reports of diverticulitis causing this phenomenon.

Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests

OBJECTIVE

To compile and critique research on the diagnostic accuracy of individual orthopaedic physical examination tests in a manner that would allow clinicians to judge whether these tests are valuable to their practice.

METHODS

A computer-assisted literature search of MEDLINE, CINAHL, and SPORTDiscus databases (1966 to October 2006) using keywords related to diagnostic accuracy of physical examination tests of the shoulder. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool was used to critique the quality of each paper. Meta-analysis through meta-regression of the diagnostic odds ratio (DOR) was performed on the Neer test for impingement, the Hawkins-Kennedy test for impingement, and the Speed test for superior labral pathology.

RESULTS

Forty-five studies were critiqued with only half demonstrating acceptable high quality and only two having adequate sample size. For impingement, the meta-analysis revealed that the pooled sensitivity and specificity for the Neer test was 79% and 53%, respectively, and for the Hawkins-Kennedy test was 79% and 59%, respectively. For superior labral (SLAP) tears, the summary sensitivity and specificity of the Speed test was 32% and 61%, respectively. Regarding orthopaedic special tests (OSTs) where meta-analysis was not possible either due to lack of sufficient studies or heterogeneity between studies, the list that demonstrates both high sensitivity and high specificity is short: hornblowers's sign and the external rotation lag sign for tears of the rotator cuff, biceps load II for superior labral anterior to posterior (SLAP) lesions, and apprehension, relocation and anterior release for anterior instability. Even these tests have been under-studied or are from lower quality studies or both. No tests for impingement or acromioclavicular (AC) joint pathology demonstrated significant diagnostic accuracy.

CONCLUSION

Based on pooled data, the diagnostic accuracy of the Neer test for impingement, the Hawkins-Kennedy test for impingement and the Speed test for labral pathology is limited. There is a great need for large, prospective, well-designed studies that examine the diagnostic accuracy of the numerous physical examination tests of the shoulder. Currently, almost without exception, there is a lack of clarity with regard to whether common OSTs used in clinical examination are useful in differentially diagnosing pathologies of the shoulder.

A novel radiographic method to facilitate measurement of the tibial plateau angle in dogs. A prospective clinical study

The tibial plateau levelling osteotomy (TPLO) is commonly performed for treatment of cranial cruciate ligament deficiency in dogs. In order to be performed as described, this procedure relies on consistent measurement of the tibial plateau angle (TPA) on radiographs. This prospective study compared two radiographic methods for subsequent TPA measurement with respect to measured angle and ease of determining landmarks for measurement as determined by four observers. One method was the accepted standard radiographic protocol outlined in the TPLO training seminars. The other method involved a novel split image radiographic protocol not yet described in the literature. Participants' subjective scores as to ease of identifying landmarks and determining TPA on radiographs for each method were evaluated. Inter-observer TPA measurement variability was also assessed for each method. The novel radiographic method was judged to be significantly better in terms of ease of measuring TPA. Inter-observer measurement variability was considered appropriate for recommending use of this novel method for radiographing patients for TPA measurements.

MR imaging volumetry of subcortical structures and cerebellar hemispheres in temporal lobe epilepsy

BACKGROUND AND PURPOSE

There is mounting evidence of extratemporal volume changes associated with medically refractory temporal lobe epilepsy (TLE). This MR imaging study aimed to characterize volume changes in subcortical structures and cerebellar hemispheres with respect to lateralization of the seizure focus, onset and duration of epilepsy, and frequency of generalized tonic-clonic seizures (GTCS).

METHODS

Amygdalar, hippocampal, thalamic, caudate head, and cerebellar volume measurements were obtained in the preoperative MR images of 40 patients with TLE (20 right, 20 left), who underwent temporal lobe resection with good outcome, and in 20 right-handed control participants. All 3D MR images were spatially aligned and normalized before measurements were obtained. Standardized volumes and right-to-left volume ratios (VRs) were compared between control participants and right and left TLE groups. Multiple regression analyses were performed to study the effects of epilepsy onset and duration and GTCS frequency on ipsilateral-to-contralateral VRs with respect to the resected seizure focus.

RESULTS

Thalamic volumes were smaller bilaterally in patients with TLE. Hippocampal volumes were smaller ipsilateral to the seizure focus, but there was no significant volume loss involving the amygdala, caudate, or cerebellum. Hippocampal and amygdalar right-to-left VRs differed significantly between right and left TLE groups and controls, whereas thalamic right-to-left VRs differed only between the TLE groups. Thalamic ipsilateral-to-contralateral VRs were correlated positively with epilepsy onset and negatively with epilepsy duration. Caudate ipsilateral-to-contralateral VRs were positively, whereas amygdalar and cerebellar VRs were negatively, correlated with GTCS frequency.

CONCLUSIONS

Unilateral amygdalar and bilateral thalamic volume loss, in the absence of caudate head atrophy, is likely to reflect seizure-induced injury due to TLE. Correlations of VRs affecting the amygdala, caudate, and cerebellum with GTCS frequency may also reflect injury or a prediposition for secondary generalization. Potential effects of complex partial seizures, febrile seizures, or antiepileptic medications on subcortical structures need to be evaluated in future studies.

Does stretching increase ankle dorsiflexion range of motion? A systematic review

BACKGROUND

Many lower limb disorders are related to calf muscle tightness and reduced dorsiflexion of the ankle. To treat such disorders, stretches of the calf muscles are commonly prescribed to increase available dorsiflexion of the ankle joint.

HYPOTHESIS

To determine the effect of static calf muscle stretching on ankle joint dorsiflexion range of motion.

STUDY DESIGN

A systematic review with meta-analyses.

METHODS

A systematic review of randomised trials examining static calf muscle stretches compared with no stretching. Trials were identified by searching Cinahl, Embase, Medline, SportDiscus, and Central and by recursive checking of bibliographies. Data were extracted from trial publications, and meta-analyses performed that calculated a weighted mean difference (WMD) for the continuous outcome of ankle dorsiflexion. Sensitivity analyses excluded poorer quality trials. Statistical heterogeneity was assessed using the quantity I2.

RESULTS

Five trials met inclusion criteria and reported sufficient data on ankle dorsiflexion to be included in the meta-analyses. The meta-analyses showed that calf muscle stretching increases ankle dorsiflexion after stretching for < or = 15 minutes (WMD 2.07 degrees; 95% confidence interval 0.86 to 3.27), > 15-30 minutes (WMD 3.03 degrees; 95% confidence interval 0.31 to 5.75), and > 30 minutes (WMD 2.49 degrees; 95% confidence interval 0.16 to 4.82). There was a very low to moderate statistical heterogeneity between trials. The meta-analysis results for < or = 15 minutes and > 15-30 minutes of stretching were considered robust when compared with sensitivity analyses that excluded lower quality trials.

CONCLUSIONS

Calf muscle stretching provides a small and statistically significant increase in ankle dorsiflexion. However, it is unclear whether the change is clinically important.

Effectiveness of post-match recovery strategies in rugby players

OBJECTIVES

To examine the effectiveness of four interventions on the rate and magnitude of muscle damage recovery, as measured by creatine kinase (CK).

METHODS

23 elite male rugby players were monitored transdermally before, immediately after, 36 hours after, and 84 hours after competitive rugby matches. Players were randomly assigned to complete one of four post-match strategies: contrast water therapy (CWT), compression garment (GAR), low intensity active exercise (ACT), and passive recovery (PAS).

RESULTS

Significant increases in CK activity in transdermal exudate were observed as a result of the rugby match (p<0.01). The magnitude of recovery in the PAS intervention was significantly worse than in the ACT, CWT, and GAR interventions at the 36 and 84 hour time points (p<0.05).

CONCLUSIONS

An enhanced rate and magnitude of recovery was observed in the ACT, CWT, and GAR treatment groups when compared with the PAS group. Low impact exercise immediately post-competition, wearing compression garments, or carrying out contrast water therapy enhanced CK clearance more than passive recovery in young male athletes.

Incidence of diagnosed polymyalgia rheumatica and temporal arteritis in the United Kingdom, 1990-2001

OBJECTIVE

To investigate time trends, geographical variation, and seasonality in the incidence of diagnosis of polymyalgia rheumatica (PMR) and temporal arteritis (TA) in the United Kingdom.

METHODS

Analysis of computerised medical records from UK general practices. Participants were registered with a practice contributing to the General Practice Research Database during the period 1990-2001. The main outcome measures were rates of diagnosis by year, age, sex, geographical region, and calendar month.

RESULTS

15 013 people had a first diagnosis of PMR and 3928 a first diagnosis of TA during 17 830 028 person-years of observation. The age adjusted incidence rate of PMR was 8.4/10 000 person-years (95% CI 8.3 to 8.6), rising from 6.9/10 000 person-years in 1990 to 9.3/10 000 in 2001. The age adjusted incidence rate of TA was 2.2/10 000 person-years (95% CI 2.1 to 2.3) with no increase observed. Both PMR and TA were more common in the south than in the north of the UK, and both were more commonly diagnosed in the summer months.

CONCLUSIONS

The explanation for the findings is unclear. Variations in diagnostic practice and accuracy are likely to have contributed in part to the patterns seen. However, the findings are also likely to reflect, at least in part, variations in the incidence of disease. The striking geographical pattern may be partly attributable to a risk factor which is more prevalent in the south and east of the United Kingdom.

A case control study of age related macular degeneration and use of statins

AIMS

Age related macular degeneration (AMD) is the leading cause of blindness in industrialised countries. Previous studies have suggested that statins may have a protective effect against the disease; however, existing studies have had limited power to reliably detect or exclude an effect and have produced conflicting results. The authors assessed the risk of AMD associated with the use of statins.

METHODS

Population based case control study using the United Kingdom General Practice Research Database. 18 007 people with diagnosed AMD were compared with 86 169 controls matched on age, sex, and general practice. The primary outcome was the odds ratio for the association between exposure to statins and AMD.

RESULTS

The crude odds ratio for the association between any recorded exposure to statins and AMD was 1.32 (95% CI 1.17 to 1.48), but this reduced to 0.93 (95% CI 0.81 to 1.07, p=0.33) after adjustment for consultation rate, smoking, alcohol intake, body mass index, atherosclerotic disease, hyperlipidaemia, heart failure, diabetes mellitus, hypertension, use of other cardiovascular drugs, and use of fibrates. There was no evidence that the risk varied by dose of statin, duration of use, or that the risk varied for individual statins.

CONCLUSION

In the short and medium term statin use is not associated with a decreased risk of AMD. Whether subgroups of patients with specific forms of AMD (particularly choroidal neovascularisation) benefit from statin therapy remains a possibility.

The cost-effectiveness of technology transfer using telemedicine

The high burden of disease in developing countries often makes it difficult for health systems in these countries to attain the same level of specialist skills as industrialized countries. Technology transfer is one way to improve specialist skills whilst at the same time reducing the burden of disease. This paper describes the use of teleophthalmology, a form of telemedicine, as a mode of technology transfer between the United Kingdom and South Africa. As the burden of eye disease in South Africa is high, the country cannot afford the level of ophthalmic specialization achieved in the UK. The paper estimates the cost-effectiveness of the technology transfer project in terms of a cost per Disability Adjusted Life Year (DALY) averted. We found the technology transfer project to be cost-effective in reducing the burden of eye disease, and that practitioners in South Africa also learned novel procedures that could help future patients and improve cost-effectiveness. Technology transfer using telemedicine is a cost-effective method that richer countries can employ to aid capacity building in the health care systems of poorer countries.

Complications of the orbital floor and maxillary sinus 30 years after Coe-Pak misplacement in the management of pan-facial fractures

We present the case of a woman who had sustained pan-facial fractures in a road traffic accident 30 years previously, and describe the ensuing unusual problems with the orbital floor and maxillary sinus as a consequence of unrecognised misplacement of a dental periodontal dressing material into the sinus. The subsequent management is discussed.

Lower extremity neuromuscular recovery following anterior cruciate ligament reconstruction; a 2-week case study

The lower extremity neuromuscular recovery of a 31-year-old male physical therapy student during the initial 2-weeks following anterior cruciate ligament reconstruction was evaluated by measuring involved side vastus medialis (VM), gluteus maximus (GMAX) and gastrocnemius (GASTROC) electromyographic (EMG) signals (1000 Hz), plantar forces (50 Hz), and knee pain as the subject performed a series of volitional, maximal effort unilateral, isometric leg presses (6 sec) in a modified continuous passive motion device. Data were standardized to pre-operative values and graphically plotted for split middle technique, celeration line assessment. From 1-8 hours post-surgery, EMG amplitudes and plantar forces decreased, pain increased, and plantar force location shifted toward the forefoot. From 9-12 hours post-surgery, EMG amplitudes and plantar forces increased and pain decreased. By 24 hours post-surgery, pain decreased to pre-operative levels. From 24-72 hours post-surgery, EMG amplitudes and plantar forces increased. From 1-2 weeks post-surgery, EMG amplitudes and plantar forces increased. From 9 hours-2 weeks post-surgery, plantar force location shifted toward the pre-operative location. Sequential increases were observed for GMAX, GASTROC, and VM EMG amplitudes. By 2 weeks post-surgery, plantar forces and VM EMG amplitudes remained reduced. Reduced plantar forces and VM EMG amplitude at 2 weeks post-surgery suggest a need for greater focus on restoring VM function before attempting closed kinetic chain exercises that require the full shock absorption capabilities of the quadriceps femoris muscle group.

The abdominal radiograph: a pictorial review

The plain abdominal radiograph is one of the most frequently requested X-ray examinations by junior surgical and accident and emergency staff. Interpretation is often difficult, but this review outlines normal appearances, suggests a strategy for evaluation, and covers the common pathological appearances seen in hospital practice.

The use of life review to enhance quality of life of people living with AIDS: a feasibility study

People living with AIDS (PLWA) are confronted with uncertainty and their own mortality at an earlier than expected age. Life review, an intervention that has the potential to increase life satisfaction in the elderly experiencing transition points in their lives, may have a similar effect when used with PLWA. Therefore, the purpose of this feasibility study was to explore the use of life review in a sample of 20 PLWA through a randomized controlled trial of its effectiveness in decreasing depressive symptoms and in increasing self esteem, quality of life, and purpose in life. Compared to the control group, the treatment group had an improved overall quality of life and self-esteem over 12 months, less depressive symptoms over 12 months, and a greater purpose in life at 3 months. The effects that were seen were mainly small to medium effects. The findings from this feasibility study suggest the potential value of life review to enhance quality of life, purpose in life, and self-esteem, and to decrease depressive symptoms in PLWA. Further research is needed with a larger sample and with other groups such as PLWA experiencing virologic failure.

Low molecular weight heparin and the risk of haemorrhage following percutaneous biopsy, despite a normal standard clotting screen

There has been an increase of the use of low molecular weight heparin in the treatment of thrombotic events. This case report describes a complication of a pelvic mass biopsy performed whilst the patient was being treated with low molecular weight heparin (LMWH). Despite an uncomplicated biopsy procedure and confirmation of normal clotting screen, INR (International normalised ratio), APTR (Activated partial thromboplastin ratio) and platelet levels, the biopsy was complicated by severe haemorrhage.

Utilization and practical aspects of tele-ophthalmology between South Africa and the UK

A tele-ophthalmology service was established between a regional hospital in South Africa and a specialist eye hospital in the UK. The aim of the service was to provide secondary specialist advice in the diagnosis and treatment of difficult ophthalmology cases in South Africa. Over 12 months, the South African medical officers saw 16,458 ophthalmology patients and would have liked a second opinion in 5.7% of these cases. Case discussions conducted by videoconferencing at 384 kbit/s were carried out in 0.5% of cases. No significant connection problems were experienced during the 12-month study period. On 4% of occasions, the case discussions were conducted at a bandwidth of 256 kbit/s, but this did not affect the quality of the still images. The South African medical officers valued the educational benefits gained from the case discussions with the UK specialists.

Ultrasound and fluoroscopic-guided angioplasty over the aortic bifurcation in a patient with previous severe reaction to contrast medium

PURPOSE

To describe a case of ultrasound and fluoroscopic-guided angioplasty necessitated by a patient history of allergic reaction to contrast medium.

CASE REPORT

A 60-year-old man with intermittent right leg claudication had a focal >70% stenosis in the right external iliac artery that was amenable to balloon dilation; however, the patient reported a severe reaction to radiographic contrast medium 10 years previously. Angioplasty was begun with transaortic access to the iliac artery lesion under fluoroscopic guidance only. On-table duplex imaging confirmed the lesion site and reference diameters for balloon selection. The balloon was filled with contrast medium to provide rapid positioning under fluoroscopy. An on-table postangioplasty duplex scan showed improvement in the lumen contour and confirmed a reduction in the peak systolic velocity. At the 1-year follow-up, the patient reports no symptoms referable to the treated segment.

CONCLUSIONS

The combination of ultrasound and fluoroscopy facilitated quick and efficient balloon dilation of an isolated iliac lesion without the use of any contrast medium.

Pre-operative electrocardiograph examination

The leading cause of death following surgery is a cardiac event, and an electrocardiogram is the most common pre-operative test to investigate coronary artery disease. Fifty adults, who required an electrocardiogram, undergoing general surgical procedures, were recruited into this pilot study, which investigated the examination rate of electrocardiographs by doctors pre-operatively. Each tracing was folded in one corner and a paperclip prevented full pre-operative viewing without its removal. Results suggest that 30% of ECGs were not opened and the records of 58% patients overall had no mention of the ECG having been performed. Further analysis showed no correlation with the examination rate of the electrocardiograph with patient age or fitness. If this reflects normal clinical practice, it is sub-optimal use of resources and warrants further audit.

Improving the oral hygiene of institutionalized mentally retarded clients

PURPOSE

The quality of oral health care of persons with mental retardation has been reported in the literature to be less than that of their normal peers. The purpose of this study, set in a Midwest institution for persons with developmental retardation, was to determine if a change in policy followed by staff training and monitored by an interested third party would improve the oral hygiene of clients living on wards.

METHODS

Methods used to train staff in proper toothbrushing were developed. Three living units were randomly selected for study: control, training plus accountability (experimental group I), and training without accountability (experimental group II). The direct care staff of both experimental groups were trained in proper toothbrushing techniques. Staff of the control group received no training. A dental hygienist visited the living unit periodically to evaluate and provide feedback on the plaque index scores taken by the caregivers in both experimental groups.

RESULTS

The plaque indexes of group I showed significant improvement over the control group and group II.

CONCLUSION

The results of this pilot study support the other findings of higher plaque indexes for residents with mental retardation and that modifying toothbrushing policies and staff training are not as critical to the improvement of the clients' oral hygiene as is the presence of an involved, interested third party.

Changing risk behaviours for non-communicable disease in New Zealand working men--is workplace intervention effective?

AIMS

To evaluate the effectiveness of a health promotion programme targeting dietary behaviours and physical activity among male hourly-paid workers and to explore demographic and attitudinal influences on dietary patterns at baseline.

METHODS

A controlled field trial compared workers at one intervention and one control worksite. The intervention comprised nutrition displays in the cafeteria and monthly 30-minute workshops for six months. Key outcome measures at six and twelve-months were self-reported dietary and lifestyle behaviours, nutrition knowledge, body mass index (BMI), waist circumference and blood pressure.

RESULTS

132 men at the intervention site and 121 men at the control site participated in the study and a high retention rate (94% at 6-months and 89% at 12-months) was achieved. At baseline, 40% of the total sample (253) were obese, 30% had elevated blood pressure, 59% indicated an excessive fat intake and 92% did not meet the recommended vegetable and fruit intake. The intervention reduced fat intake, increased vegetable intake and physical activity, improved nutrition knowledge and reduced systolic blood pressure when compared to the control site. There was no difference in change in mean BMI or waist circumference. Reduction in BMI was associated with reduction in fat intake.

DISCUSSION

Low intensity workplace intervention can significantly improve reported health behaviours and nutrition knowledge although the impact on more objective measures of risk was variable. A longer duration or more intensive intervention may be required to achieve further reduction in risk factors.

Telemedicine techniques can be used to facilitate the conduct of multicentre trials

A multicentre randomized controlled trial was established in Pretoria, Bloemfontein and Edendale in South Africa, and coordinated from London. The purpose of the trial was to determine the efficacy of low-dose beta irradiation of glaucoma. Five communication modalities (telephone, fax, e-mail, videoconferencing and face-to-face meetings) were examined in terms of their benefits in a multicentre trial. The eight stages of the multicentre trial examined were: set-up and training, recruitment, standardization, patient management, data transmission, update and data dissemination, clinical follow-up and monitoring, and publication. On four-point Likert scales for rating the usefulness of the communication modalities at each of the eight stages of the trial (from 0 = not useful to 3 = very useful; maximum score 24) the telephone was given a total score of 10, fax 9, e-mail 13, videoconferencing 15 and face-to-face meetings 9. Telemedicine techniques offer considerable benefits in the coordination of multicentre trials by improving data collection, maintaining the efficacy and monitoring of trials, while potentially offering reduced costs in terms of travel and time. The realtime scrutiny of patient records helps to ensure data uniformity and completeness of data collection. Videoconferencing was most useful when considered as one of several communication tools that can be used to improve the effectiveness of a service or process.