Total knee arthroplasty in patients with severe haemophilia

We reviewed the perioperative records of haemophiliac patients who underwent total knee replacement (TKR) over the period 1990-1999 and followed up the surviving patients. Nine knees were replaced in eight patients. Seven of the nine patients did not require blood transfusion. Mean perioperative haemoglobin drop was 2.9 g/dl. There were no significant complications. All surviving patients (eight TKRs) were reviewed clinically using a standard scoring system. The mean follow-up period was 51 months. All patients scored excellent (>90/100) in the functional category. The frequency of haemarthroses fell significantly from the rate experienced prior to TKR, and pain scores were zero.

Benign cementoblastoma: a case report

Benign cementoblastoma is an odontogenic tumour of mesenchymal origin. It usually presents as a distinct lesion with characteristic radiographic and histopathologic features. The tumour is attached to the roots of the teeth and commonly occurs in the posterior mandible. The case of a 19-year old female with a benign cementoblastoma is presented. The clinical histopathologic and therapeutic aspects of the tumour are described.

HIV prevention community planning and communities of color: do resources track the epidemic?

The Centers for Disease Control and Prevention (CDC) funds provided to state, local, and territorial health departments for HIV-prevention activities are prioritized with the substantial involvement of HIV-prevention community planning groups (CPGs). This article examines whether or not these funds (more than $261 million in fiscal year 1998) are allocated in a way that mirrors the HIV/AIDS epidemic in terms of race/ethnicity. AIDS prevalence data were used to reflect disease burden, and were compared to budget data submitted by health departments to the CDC. The budget data report expenditures by race/ethnicity for two major types of activities: (1) health education and risk reduction (more than $104 million); and (2) counseling, testing, referral, and partner notification (more than $91 million). The rank order correlation between funding and AIDS prevalence data for the five specific racial/ethnic categories was .900 (n = 5, p < .05) for health education and risk reduction (HERR) activities, and 1.000 (n = 5, p < .05) for counseling, testing, referral, and partner notification (CTRPN) activities. From 1997 to 1998, the proportion of funds targeted and accounted for by race/ethnicity increased from 79 percent to 88 percent for HERR, and from 71 percent to 84 percent for CTRPN activities. With regard to race/ethnicity, health departments and CPGs appear to be actively targeting and accounting for HIV prevention resources, and we will argue that relatively small changes in counseling and testing resources for African-American and Latino/Latina communities would result in a close match between AIDS prevalence data and devoted resources.

An investigation of the correspondence between psychological problems diagnosed by GPs and those subsequently targeted for treatment by clinical psychologists

OBJECTIVES

1. To observe the level of concordance between problems identified by GPs in the referral letter, and primary treatment targets identified by Clinical Psychologists following assessment within an NHS Clinical Psychology Department. 2. To examine whether concordance between GP and Psychologist varies for different psychological problem areas. 3. To examine whether concordance between GP and Psychologist varies with time spent on the waiting list.

DESIGN

A retrospective review, and classification, of GP referral letters and Psychologists treatment targets.

SETTING

A Department of Clinical Psychology based in Scotland. Sixty five GPs based across fifteen GP practices refer to the department.

CASES

Four hundred and one patients consecutively referred by GPs to the Department of Clinical Psychology between April 1 1996 and March 31 1998, and subsequently assessed by one of the qualified Clinical Psychologists. Two hundred and seventy three cases were female (68.08%), 128 male (31.92%).

RESULTS

Overall agreement between GP referred problem and Psychologist treatment target, coded in terms of EPPIC 'reasons for care' categories, was 'fair', and observed for 59.6% of cases. High agreement for eating disorders, moderate agreement for anxiety and depression, and low agreement for relationship/social problems was observed. Analysis indicated one third of anxiety referrals and one half of depression referrals were treated differently. Agreement levels were high for short waiting times, and lower for long waiting times, although findings for intermediate waiting times were mixed.

CONCLUSIONS

Moderate agreement levels between GP and Clinical Psychologist in cases initially referred for anxiety and depression replicate previous findings. Low levels of agreement for relationship/social problems were not anticipated. The implications of results for future research and service provision are outlined.

The oral cavity in Crohn's disease

We assessed the utility of expert oral examination as a part of the diagnostic evaluation of patients with suspected Crohn's disease. Of 45 patients with newly diagnosed CD, 25 had been examined by a dentist. Twelve (48%) of these had oral CD lesions. Mucosal tags constituted the most frequent form of oral lesion (8/12). Of 8 oral biopsy specimens, 6 (75%) contained non-caseating granulomas. Patients with oral CD had more oral symptoms, presented for diagnosis sooner, and were more likely to have other upper gastrointestinal inflammation than those without oral lesions. Oral manifestations of CD are common in children; therefore, expert oral examination may be useful during diagnostic evaluation of children with suspected inflammatory bowel disease.

A rapid appraisal method for reviewing the effectiveness of workplace smoking policies in large and medium sized organisations

Workplace smoking policies have been developed in response to growing scientific evidence about the harmful effects of environmental tobacco smoke (ETS), increasing opposition from non-smokers, concern over escalating costs of health damage and productivity losses, and the emergence of relevant laws and codes of good practice. Much has been written on the development and implementation of workplace smoking policies, but little about their evaluation. This paper describes a rapid appraisal method for the evaluation of workplace smoking policies. The four-stage process involves rapid, focused consultation with policy makers in the workplace, appropriate risk assessment, rapid consultation with those affected by the policy and focused feedback of results for planning and ongoing monitoring. In the pilot site the existing health and safety committee members were effective informants for the identification of key issues in smoking policy. The risk assessment phase was incorporated into the main appraisal which involved a canvass of staff and others on ETS issues identified by the informants. In the final stage of the process the health and safety committee proved to be both responsive to identified need, and proactive in facilitating ongoing review of the smoking policy. It therefore proved possible to develop the rapid appraisal process for administration in a limited time frame, three months for the whole process, with the rapid canvass element being achieved within one week.

The KBG syndrome, characteristic dental findings: a case report

Short stature and developmental delay may be observed in many genetic conditions and well-defined syndromes. A 7-year-old girl presented with the non-specific findings of subtle dysmorphism, short stature and developmental delay. Although a genetic syndrome was suspected, a definitive diagnosis was not made until the dental findings of KBG syndrome were recognised, namely grossly enlarged maxillary permanent central incisors and hypodontia.

The health promotion implications of the knowledge and attitude of employees in relation to health and safety leaflets

Selected aspects of the efficacy of printed leaflets produced by a government health and safety agency and widely distributed by the enforcement bodies and other organisations to promote workplace health and safety are examined. It is based on a study of 30 small or medium-sized enterprises and examines the views of 120 employers and employees regarding the availability, attractiveness, relevance and usefulness of the leaflets and estimates the reader comprehension and readability of the selected leaflets. The results indicate that the selected leaflets are considered acceptable and comprehensible by the majority of respondents. As these are typical of the leaflets available in the health and safety field this is a positive outcome. The discussion focuses around the ability of the leaflets to engage and to inform and suggestions are made to encourage a wider debate on the criteria which contribute to these two aspects of leaflet use. It is contended that leaflets will continue to be important in the attempts of those involved in workplace health and safety to facilitate learning and to contribute to the overall process of behaviour change. This study raises a number of key issues regarding the future design and use of such leaflets.

Socio-demographic associations with digit and pacifier sucking at 15 months of age and possible associations with infant infection. The ALSPAC Study Team. Avon Longitudinal Study of Pregnancy and Childhood

AIMS

To assess the prevalence of pacifier and digit sucking at 15 months of age and to investigate whether this habit adversely affects the health of 18 month old infants.

STUDY DESIGN

Data collected via self-completion questionnaires from mothers forming part of the prospective, population based Avon Longitudinal Study of Pregnancy and Childhood.

SUBJECTS AND METHODS

The mothers of 10006 infants gave information on their child's use of a pacifier and of digit sucking at 15 months of age and the presence of specific health symptoms at 18 months of age. Adjusted logistic regression was performed to identify any statistically significant associations between pacifier use, digit sucking or a combination of the two with possible infection.

RESULTS

36.3% of infants sucked a pacifier, 21. 3% their thumb or finger and 2.7% sucked both at 15 months. Statistically significant differences were observed among various socio-demographic variables. Mothers were more likely to give their child a pacifier if they were younger, had lower levels of education, experienced greater financial difficulties or lived in council housing (compared to owned/mortgaged). The opposite was apparent for digit suckers. After allowing for these possible confounding factors, pacifier users had a higher incidence of earache and colic compared to children with no sucking habit, however digit suckers had a lower incidence of these symptoms. Children who sucked both were significantly more likely to have reported wheezing, earache, and poor health in the past month.

CONCLUSIONS

Significantly different sociodemographic characteristics were observed with pacifier suckers compared to those who sucked their thumb or finger. It is almost impossible to attribute the direction of causality between infection and a sucking habit. Further and more detailed studies are needed before any recommendations can be made based on the statistically significant associations found as they are unlikely to be of major clinical significance.

Drug safety during pregnancy and in infants. Lack of mortality related to mitochondrial dysfunction among perinatally HIV-exposed children in pediatric HIV surveillance

The objectives were to assess whether any deaths reported among perinatally exposed, uninfected, or indeterminate children were consistent with mitochondrial dysfunction, and to characterize perinatal exposure to antiretrovirals among children born in the last five years and reported to perinatal HIV surveillance. Population-based HIV/AIDS surveillance data on perinatally exposed children born in 1993 through 1998 from 32 states with HIV reporting and from a special HIV surveillance project in Los Angeles County and in 22 hospitals in New York City were used. The classifications of exposure and deaths were consistent with the investigation of deaths across all US cohorts. Deaths were ascertained from recent matches with death registries in each state. Causes of death were ascertained from death certificates, autopsy records when available, and medical records. None of the 98 deaths (1.1%) among 9067 perinatally exposed uninfected or indeterminate children born from 1993 through 1998 and reported through pediatric HIV surveillance died of conditions that were consistent with mitochondrial dysfunction. This included 679 children exposed to zidovudine (ZDV) and 3TC, 277 exposed to other antiretroviral combinations, 4512 exposed to ZDV alone, 927 with no antiretroviral exposure, and 2672 with unknown exposure--1128 of whom were born before March 1994 and were unlikely to have been exposed to ZDV. No deaths attributable to mitochondrial dysfunction were found through this evaluation of population-based HIV surveillance data. Long-term follow-up of antiretroviral-exposed children has been recommended by the Public Health Service. This evaluation highlights the contribution of population-based surveillance to the evaluation of potential toxicities associated with maternal antiretroviral use.

The geographic distribution of AIDS in the United States: is there a rural epidemic?

The goal of this study was to examine where people with acquired immune deficiency syndrome (AIDS) in the United States live and the degree to which AIDS is present in rural areas. AIDS cases reported to the Centers for Disease Control and Prevention (CDC) in 1996 were categorized by metropolitan statistical area (MSA) size and compared to the general population. Data were analyzed by region, race/ethnicity and risk exposure; AIDS incidence rates were compared over time by MSA size. Relative to the U.S. population, AIDS cases were disproportionately black (43 percent vs. 11 percent), male (80 percent vs. 48 percent), and from the Northeast (32 percent vs. 20 percent). In all regions, a greater proportion of AIDS cases reside in large MSAs compared with the general population. Risk exposures differ little by MSA size, except in the Northeast. The proportion of people with AIDS who reside in large MSAs exceeds the proportion of the population in those areas, especially when race/ethnicity is considered. AIDS rates have increased in non-MSAs relative to large MSAs, yet do not indicate that the epidemic is increasing rapidly in rural areas. Fewer AIDS cases are reported from smaller communities, yet require medical and social services that may burden the rural health care system.

A rapid appraisal method for the selection and pre-testing of environmental health leaflets

This paper presents a rapid appraisal method for the selection and pre-testing of printed leaflets on environmental health issues. The method combines a staff questionnaire, a readability test and a target population survey and is designed to aid leaflet selection in a way which is practically feasible yet retaining an acceptable level of face validity. A multiple, embedded case study was used to field-test the method and the feedback from this is discussed. The results suggest that the method has the potential to replace ad hoc arrangements by the gatekeepers and make the selection of leaflets more a matter of structured decision-making involving representatives of all the stake-holders.

Bladder calculi in children who perform clean intermittent catheterization

OBJECTIVE

To examine the role of clean intermittent catheterization (CIC) as a possible predisposing risk factor for bladder calculi, assessing risk factors in patients with and without bladder augmentation, and to evaluate management options for bladder calculi in these patients.

PATIENTS AND METHODS

The records of 403 patients who were using a regimen of CIC between January 1981 and March 1998 were reviewed to identify those forming bladder calculi; stones were diagnosed in 28 patients. The patients were categorized as: group 1, patients with no bladder augmentation who catheterized urethrally (227, group 1a) or via a Mitrofanoff conduit (18, group 1b); group 2, patients with augmented bladders who catheterized urethrally (100, group 2a) or via a Mitrofanoff conduit (58, group 2b). The incidence of bladder calculi in each group was determined and compared statistically where applicable. The success of the treatment options for stone management was reviewed.

RESULTS

Bladder calculi developed in 5% of patients in group 1a, 8% in group 2a, 11% in group 1b, and 10% in group 2b; the incidence of calculi was not significantly different among the groups. Of these patients, 18 (64%) were asymptomatic at the time of diagnosis and significant bacteriuria was found in 23 (88%). Difficulty in catheterizing either the Mitrofanoff conduit or the native urethra was reported in 14 (50%) of these patients. Calculi were more often solitary (71%) and typically composed of struvite or apatite. Calculi were managed by open cystolithotomy in 15 patients (54%) and endoscopically in 13 (46%). Stones recurred in nine patients (32%) after treatment, comprising four of six patients treated endoscopically with electrohydraulic lithotripsy and in five of 15 after open cystolithotomy. The mean interval to recurrence was 22.8 months.

CONCLUSION

These results suggest that patients on a regimen of CIC are at risk of developing bladder calculi but the incidence of calculi is not influenced by bladder augmentation. The presence of a Mitrofanoff conduit was associated with a slightly increased incidence of calculus formation. Open cystolithotomy was associated with a lower stone recurrence rate but there were too few patients to draw definitive conclusions.

The effect of the position of the limb on venous impulse foot pumps

Compression foot pumps are widely used for the prevention of postoperative venous thrombosis. We tested the efficiency of the pump in ten healthy subjects; the velocity of venous blood flow in the common femoral vein was measured in the horizontal, Trendelenberg (foot-up) and reverse-Trendelenberg (foot-down) positions. Application of the foot pump produced an increase in the venous velocity in all subjects. The mean increase in the horizontal position was 27.2% and in the Trendelenberg position 15.4%. In the reverse-Trendelenberg position, the foot pump produced a mean increase of 102.8%. The efficiency of the compression foot pump in increasing venous return is improved by adopting the reverse-Trendelenberg position. This may increase its thromboprophylactic effect.

The effect of the position of the limb on venous impulse foot pumps

Compression foot pumps are widely used for the prevention of postoperative venous thrombosis. We tested the efficiency of the pump in ten healthy subjects; the velocity of venous blood flow in the common femoral vein was measured in the horizontal, Trendelenberg (foot-up) and reverse-Trendelenberg (foot-down) positions.

Application of the foot pump produced an increase in the venous velocity in all subjects. The mean increase in the horizontal position was 27.2% and in the Trendelenberg position 15.4%. In the reverse-Trendelenberg position, the foot pump produced a mean increase of 102.8%.

The efficiency of the compression foot pump in increasing venous return is improved by adopting the reverse-Trendelenberg position. This may increase its thromboprophylactic effect.

Odontogenic keratocysts in a 5-year-old: initial manifestations of nevoid basal cell carcinoma syndrome

The purpose of this paper is to report the occurrence of odontogenic keratocysts in a young child. Odontogenic keratocysts are one of the principal features of nevoid basal cell carcinoma syndrome. Their occurrence in this syndrome is usually during the second or third decades of life. This report describes the occurrence of odontogenic keratocysts in a 5-year-old, which proved to be the initial presentation of nevoid basal cell carcinoma syndrome and highlights the need to consider this syndrome as a possible diagnosis in all cases of odontogenic keratocysts.

A case report of pre-eruptive coronal resorption in a mandibular canine

A case of intracoronal resorption in a recently erupted mandibular canine in an 11-year-old girl is presented. Possible aetiology and approaches to treatment of such lesions are discussed.

Night-time non-nutritive sucking in infants aged 1 to 5 months: relationship with infant state, breastfeeding, and bed-sharing versus room-sharing

AIM

Epidemiological studies suggest that pacifier use may be protective against SIDS but little is known of the relationship between pacifier use and other forms of non-nutritive sucking (NNS) in infancy, or of patterns of NNS during the night, when most SIDS deaths occur. We report the first longitudinal study of NNS by direct overnight observations in healthy infants in a sleep laboratory.

METHODS

Healthy, breast fed term infants (n = 10) were enrolled at birth, and sequential overnight polygraphic and infrared video recordings of infants with their mothers performed at monthly intervals from 1 to 5 months. Each month, mother baby pairs were randomized to 1 night bed-sharing (BN) then 1 room-sharing (RN), or vice versa. 'Episodes' of pacifier, own digit and mother's digit sucking (> 1 min) were identified and compared with state-matched control periods without sucking or feeding before and after each such episode.

RESULTS

329 episodes of NNS were identified in 749 h of video recording. The prevalence of pacifier sucking decreased with age, whilst digit sucking increased. Routine pacifier users rarely sucked their digits. There were temporal differences throughout the night in the distribution of different types of sucking and in infant state during and around sucking episodes. Sleeping in the 'non-routine' location was associated with a larger percentage of nights with sucking episodes and increased sleep latency. Bed sharing (routinely or on a given night) was associated with less sucking behavior and more breastfeeding. Non-nutritive sucking was not, however, associated with decreased total time breastfeeding per night or number of feeds per night.

CONCLUSION

Patterns of NNS during the night change with age and are affected by maternal proximity. Digit sucking has state modulating effects, and may be suppressed by pacifier use. Thus any benefits of pacifier use must be set against the potential loss of a self-directed ability to modulate state during the night, and possible shortening of breastfeeding duration.

Long-term outcome based on the initial surgical approach to ureterocele

PURPOSE

The management of extravesical ureterocele is controversial. Heminephrectomy and recently recommended primary incision or puncture have high reoperation rates. We reviewed and compared the long-term results of these procedures with those of primary lower tract reconstruction for ureterocele.

MATERIALS AND METHODS

We reviewed the records of 106 children with ureterocele treated between 1979 and 1997. Followup was available in 99 patients, including 72 with extravesical and 27 with intravesical ureterocele. Patients with extravesical ureterocele were divided based on initial management into group 1-13 who underwent transurethral incision or puncture, group 2-41 who underwent an upper tract approach, including partial or complete nephrectomy with partial ureterectomy or ureteroureterostomy and group 3-18 who underwent complete reconstruction, including ureterocelectomy and ureteral reconstruction with or without upper tract surgery.

RESULTS

Overall the reoperation rate in patients with intravesical ureterocele was 22% and 23% in those treated with initial endoscopic incision or puncture. In patients with extravesical ureterocele the reoperation rate was 100, 41 and 0% in groups 1 to 3, respectively. Differences in followup (overall mean 6 years) and the incidence of preoperative reflux in the 3 groups were not statistically significant. In group 2, the reoperation rate in patients with versus without preoperative reflux was 57 versus 20% (p = 0.08). Of the 25 prenatally diagnosed patients urinary tract infection developed preoperatively in 3 (12%) at ages 2, 3, and 6 months, respectively. Mean age at the time of the initial operation in all prenatally diagnosed patients was 3.1 months (range 5 days to 11 months).

CONCLUSIONS

Complete reconstruction appears to be safe and highly effective even in infancy for treating extravesical ureterocele. Although the primary upper tract approach is associated with a significantly higher reoperation rate, it is a favorable alternative in patients with no preoperative reflux. However, while transurethral decompression is effective in the majority of patients with intravesical ureterocele, it is not definitive therapy for extravesical ureterocele and it should have a limited role in initial management.

Ureteral reimplantation in infancy: evaluation of long-term voiding function

PURPOSE

The advisability of early ureteral reimplantation in neonates and infants is controversial and to our knowledge long-term results are not available. We evaluated long-term voiding function after ureteral reimplantation in infancy.

MATERIALS AND METHODS

Between 1984 and 1993, 32 children underwent ureteral reimplantation in year 1 of life at our institution. Long-term results were evaluated in regard to surgical outcome, voiding function, urinary tract infection and the need for prophylaxis. Analysis of voiding function included family interviews, uroflowmetry and post-void residual urine measurement.

RESULTS

Complete long-term data were available in 14 girls and 7 boys. The diagnosis was primary bilateral and unilateral vesicoureteral reflux, and ureterovesical junction obstruction in 11, 4 and 6 cases, respectively. Of the 26 refluxing renal units overall disease was grade II in 3, III in 6 and IV to V in 17. Patient age at surgery was 0.6 to 12 months (mean 5.4) and followup was 5 to 13 years (mean 9.5). Tapered reimplantation was performed in 8 renal units using excisional or infolding in 5 and 3, respectively. There were no complications in 19 patients (94%), while 2 had postoperative reflux for which 1 underwent reoperation. In 13 patients voiding habits were normal, while 8 reported infrequent voiding (3 or fewer voids daily). In 19 of the 20 patients tested voided volume was appropriate, and the flow rate of 10.8 to 52.7 cc per second (mean 20.9) and post-void residual urine volume of 0 to 40 cc (mean 11) were considered normal. One patient with normal uroflowmetry had incomplete vesical emptying.

CONCLUSIONS

Early reimplantation may result in a high technical success rate and low postoperative morbidity in infants. After long-term followup infrequent voiding was common but noninvasive assessment of bladder function revealed no significant abnormality in the majority of patients.

Long-term outcome based on the initial surgical approach to ureterocele

PURPOSE

The management of extravesical ureterocele is controversial. Heminephrectomy and recently recommended primary incision or puncture have high reoperation rates. We reviewed and compared the long-term results of these procedures with those of primary lower tract reconstruction for ureterocele.

MATERIALS AND METHODS

We reviewed the records of 106 children with ureterocele treated between 1979 and 1997. Followup was available in 99 patients, including 72 with extravesical and 27 with intravesical ureterocele. Patients with extravesical ureterocele were divided based on initial management into group 1-13 who underwent transurethral incision or puncture, group 2-41 who underwent an upper tract approach, including partial or complete nephrectomy with partial ureterectomy or ureteroureterostomy and group 3-18 who underwent complete reconstruction, including ureterocelectomy and ureteral reconstruction with or without upper tract surgery.

RESULTS

Overall the reoperation rate in patients with intravesical ureterocele was 22% and 23% in those treated with initial endoscopic incision or puncture. In patients with extravesical ureterocele the reoperation rate was 100, 41 and 0% in groups 1 to 3, respectively. Differences in followup (overall mean 6 years) and the incidence of preoperative reflux in the 3 groups were not statistically significant. In group 2, the reoperation rate in patients with versus without preoperative reflux was 57 versus 20% (p = 0.08). Of the 25 prenatally diagnosed patients urinary tract infection developed preoperatively in 3 (12%) at ages 2, 3, and 6 months, respectively. Mean age at the time of the initial operation in all prenatally diagnosed patients was 3.1 months (range 5 days to 11 months).

CONCLUSIONS

Complete reconstruction appears to be safe and highly effective even in infancy for treating extravesical ureterocele. Although the primary upper tract approach is associated with a significantly higher reoperation rate, it is a favorable alternative in patients with no preoperative reflux. However, while transurethral decompression is effective in the majority of patients with intravesical ureterocele, it is not definitive therapy for extravesical ureterocele and it should have a limited role in initial management.