Plastic surgical trainees' perspectives toward burn surgery in Australia and New Zealand: Changes in the last 17 years?

INTRODUCTION

An emerging amount of literature emphasises the ever-growing shortage of burn surgeons worldwide. Despite burn surgery being a fundamental competency in the Australia and New Zealand plastic and reconstructive surgery training curriculum, a perceived lack of interest amongst trainees exists. The aim of this study was to investigate Australasian plastic surgery trainees' interest in burn surgery as a career and compare with the Brown and Mills survey in 2004.

METHODS

An electronic survey was distributed to all Australian and New Zealand plastic and reconstructive surgery trainees during the March 2021 registrar trainee conference. This anonymous survey was adapted from the original survey conducted by Brown and Mills in 2004, with additional questions to determine the perceived importance of burns surgery as a subspecialty of plastic and reconstructive surgery, and to elicit possible solutions to the issue of workforce shortage. A reminder email was sent one month following the conference to improve the response rate. The survey was hosted by Survey Monkey (San Mateo, California, USA).

RESULTS

The survey was distributed to all 121 trainees and 71 (58.7%) responded. An increase in interest amongst trainees in pursuing a career in burn surgery was found, with 34 trainees (48.6% of respondents) interested, mostly on a half time or sessional basis. The three most common barriers to practising burn surgery remain unchanged, and were nature of burn operations, nature of burn care and on-call commitments; inadequacy of exposure or training ranked fourth. We found a strong overall response that burn surgery and burn care remained an important component of plastic and reconstructive surgery.

DISCUSSION

Inadequate exposure or training has evolved to present a bigger barrier in this study compared to a similar study conducted 17 years ago. Burn units and training bodies may offer additional job placements to address these feelings of insufficient exposure. Facilitating employment of burn surgeons on a half-time or sessional capacity is a sustainable model, and will arguably improve clinical service provision. Strong and early mentorship and allocation of commensurate resources and funding will help to address the high workload.

CONCLUSIONS

Interest in burn surgery has improved over the last 17 years and the most common deterrents persist, namely nature of burn operations, nature of burn care and on-call commitments. However, many of these issues are modifiable or amenable to change. The opportunity exists for relevant stakeholders to address some of these concerns raised, and thereby addressing the issue of burn surgeon shortage.

POS0753 SUBSPECIALTY LUPUS CLINIC CARE IS ASSOCIATED WITH HIGHER QUALITY FOR PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

Healthcare quality for systemic lupus erythematosus (SLE) is a modifiable target for improving patient outcomes. Disease-specific subspecialty clinics offer experienced healthcare professionals, collaborative multidisciplinary teams and streamlined care processes. A single centre study in the USA has suggested superior performance of the subspecialty lupus clinic in the provision of quality care (1), but this has not been examined outside the USA where access to care may be influential.

Objectives:

To assess the quality of SLE care provided in a subspecialty lupus clinic compared with hospital general rheumatology and private rheumatology clinics in a non-US, universal healthcare setting.

Methods:

Lupus patients (n = 258) were recruited in 2016 from various clinic settings in Australia, including a subspecialty lupus clinic (n = 147), two hospital general rheumatology clinics (n = 56) and two private clinics (n = 55). Quality of care was assessed using 31 validated SLE quality indicators (QI) encompassing diagnostic work-up, disease and comorbidities assessment, drug monitoring, preventative care and reproductive health (2,3). Data were collected from medical records and patient questionnaires. Overall and individual QI performance was calculated and compared between the three clinic settings, and multivariable regression was performed to adjust for sociodemographic, disease and healthcare factors.

Results:

Median [IQR] overall performance on eligible QIs was higher in the lupus clinic (66.7% [16.9]) than the hospital general rheumatology (52.7% [10.6]) and private rheumatology (50.00% [18.0]) clinics (p <0.01), and remained significant with multivariable adjustment. This trend was still observed when the overall performance was reassessed to include patient self-report (73.1% [14.8] vs 68.1% [11.5] vs 63.2% [13.4], p <0.01). This difference may be due to consistent formal assessments of disease activity (100% vs 0% vs 0%, p <0.01) and disease damage (95.9% vs 0% vs 0%, p <0.01) at the lupus clinic. Performance was high across all clinic settings for diagnostic work-up, comorbidity assessment, drug monitoring, prednisolone taper, osteoporosis management, lupus nephritis and pregnancy quality indicators. However, the lupus clinic significantly outperformed the other clinic settings on eligible quality indicators for new medication counselling, pre-immunosuppression hepatitis and tuberculosis screening, drug toxicity assessment, sun avoidance education, vaccinations, cardiovascular risk factor assessment and contraception counselling.

Conclusion:

SLE patients managed in a subspecialty lupus clinic received higher overall quality of care when compared to hospital general rheumatology and private rheumatology clinics. Regular assessment of QI performance can improve quality of care for patients in all clinic settings.

References:

[1]Arora, S et al. Does Systemic Lupus Erythematosus Care Provided in a Lupus Clinic Result in Higher Quality of Care Than That Provided in a General Rheumatology Clinic? Arthritis Care Res. 2018;70(12):1771-1777.

[2]Mosca, M et al. Development of quality indicators to evaluate the monitoring of SLE patients in routine clinical practice. Autoimmune Rev. 2011;10(7):383-8.

[3]Yazdany, J et al. A quality indicator set for systemic lupus erythematosus. Arthritis Rheum. 2009;61(3):370-7.

Disclosure of Interests:

None declared

Mental health attendances in Australia during the COVID-19 pandemic: A telehealth success story?

Introduction

The COVID-19 pandemic has significantly impacted the delivery of mental health services globally. Within Australia, the COVID-19 pandemic and subsequent containment measures have led to reduced face-to-face attendances. To maintain access to mental health consultations, new telehealth services were introduced by the Australian Government in late March 2020.

Objectives

We aimed to quantify the impact of the COVID-19 pandemic on patterns of mental health attendances in Australia using an interrupted time series model.

Methods

To characterise patterns of mental health service utilisation, monthly mental health attendances between January 2016 and June 2020 were extracted from the Medicare database, stratified by clinician type: general practitioner (GP), psychiatrist, and allied health. We used triple exponential smoothing to model attendances between January 2017 and December 2019. Observed and predicted attendances between January and June 2020 were compared with 95% confidence (p<0.05).

Results

Our models showed decreased mental health attendances in March and April, consistent with all healthcare services during this time. While uptake of telehealth was significant, it only partially covered the reduction in mental health attendances.

Conclusions

Our modelling highlights the significant impacts of the COVID-19 pandemic on mental health services in Australia, with telehealth only partially compensating for the reduction in face-to-face attendances. These results suggest that telehealth services may not be suitable for all individuals (e.g. those without reliable internet access). Given that telehealth will likely remain a feature of mental health service provision, outreach and face-to-face services should be considered for vulnerable groups

Disclosure

No significant relationships.

Cerebral white matter microstructural changes in isolated maxillofacial trauma and associated neuropsychological outcomes

Isolated traumatic maxillofacial injury without concomitant brain injury may cause delayed post-concussive symptoms. Early identification allows optimal diagnosis, prognostication, and therapeutic intervention. The aim of this prospective observational study was to investigate longitudinal microstructural changes of the white matter (WM) tracts based on diffusion tensor imaging (DTI) indices in patients with isolated maxillofacial injuries, immediately and 6 months post-trauma, and to correlate these DTI indices with neuropsychological changes observed. Twenty-one patients with isolated maxillofacial injuries and 21 age-matched controls were recruited. DTI was performed and indices were calculated for 50 WM tracts. The neuropsychological evaluation was done using the screening module of the Neuropsychological Assessment Battery. Patients were subjected to repeat DTI and neuropsychological evaluation at 6 months post-trauma. Reduced fractional anisotropy (FA) and increased median (MD) and radial diffusivity (RD) in the acute phase were seen in major association, projection, and commissural fibre bundles, indicative of vasogenic oedema. These changes correlated with attention and executive function deficits in the acute phase, as well as improvement in memory and visuospatial function in the chronic phase. Isolated maxillofacial trauma patients develop WM microstructural damage, which may impair cognitive performance acutely and over time. DTI indices can serve as predictive imaging biomarkers for long-term cognitive deficits in isolated maxillofacial injuries.

Small-scale (Phase II) evaluation of the efficacy and residual activity of SumiShield® 50 WG (clothianidin 50%, w/w) for indoor residual spraying in comparison to deltamethrin, bendiocarb and pirimiphos-methyl for malaria vector control in Karnataka state, India

Background & objectives

There is an urgent need of introducing new insecticide molecules with novel modes of action to counter the ever growing insecticide-resistance in mosquito vectors. In the present study, a new insecticide molecule, SumiShield 50 WG (clothianidin 50%, w/w) was investigated for its efficacy as an indoor residual spray along with its residual action in comparison to deltamethrin, pirimiphos-methyl and bendiocarb.

Methods

The study area included three villages in Almatti Dam catchment area in Bagalkot district, Karnataka, India. Spraying was done using Hudson sprayers with the following dosages-Clothianidin, 300 mg AI/m²; deltamethrin, 25 mg AI/m²; bendiocarb, 400 mg AI/m²; and pirimiphos-methyl, 1 g AI/m². Cone bioassays were conducted on cement and mud plastered surfaces at fortnightly intervals to assess the bioefficacy and residual activity. Mosquito densities in the sprayed houses were recorded at regular intervals for assessment of the insecticidal efficacy. Filter paper samples collected from the sprayed houses were analyzed for insecticide content sprayed on different wall surfaces at the Walloon Agricultural Research Institute, Gembloux, Belgium.

Results

Chemical content analysis of filter paper samples revealed that the applied to target ratios were in the acceptable range (1 + 0.5) for all the treatment types. Duration of persistence of effectiveness of bendiocarb (≥80% mortality in cone bioassays) was 19 to 21 wk on cement plastered surfaces and 15 to 19 wk on mud plastered surfaces. Duration of persistence of effectiveness of deltamethrin was 17 to 21 wk on both mud and cement plastered surfaces and that of pirimiphos-methyl was 15 to 19 wk. For SumiShield, it was 17 to 25 wk on both types of surfaces, indicating slow action of SumiShield. The densities of Anopheles culicifacies were lower in bendiocarb sprayed houses throughout the observation period, followed by pirimiphos methyl, deltamethrin and clothianidin sprayed houses. In case of other mosquitoes also, similar trend was observed.

Interpretation & conclusion

Considering the persistence of effectiveness of SumiShield on sprayed surfaces, effectiveness in reducing the density of mosquitoes, operational feasibility, safety and community acceptance, the formulation of clothianidin is a better option for IRS for the control of insecticide-resistant mosquito vectors.

Village-scale (Phase III) evaluation of the efficacy and residual activity of SumiShield® 50 WG (Clothianidin 50%, w/w) for indoor spraying for the control of pyrethroid-resistant Anopheles culicifacies Giles in Karnataka state, India

OBJECTIVE

There is an urgent need to test and incorporate new molecules with promising efficacy and novel mode of action to control insecticide-resistant mosquito vectors for disease control. We tested a new compound, clothianidin (SumiShield 50 WG), for its efficacy as an indoor residual spray (IRS) for the control of pyrethroid-resistant Anopheles culicifacies (Diptera: Culicidae) in comparison with pirimiphos methyl (Actellic CS) as a positive control.

METHODS

Ten villages were selected, five each for IRS with clothianidin (300 mg AI/m² ) and pirimiphos methyl (1000 mg AI/m² ) in Almatti Dam catchment area in Karnataka state, India. Entomological parameters were monitored in these sprayed villages using standard methods. Assessment of quality of spray was performed by analysing the insecticide content in the filter paper samples collected from sprayed houses. Perceptions of spray men and inhabitants were recorded post-spray on safety of these molecules.

RESULTS

The mean applied to target ratio of content was 1.7 (n = 29) for clothianidin and 1.8 (n = 50) for pirimiphos methyl on filter paper samples analysed. Residual activity (≥80% mortality in exposed mosquitoes) after 24 h post-exposure of SumiShield WG was 5 months and increased to 6 months when the holding period was extended to 120 h and that of Actellic CS was 3 months at 24-h holding period and extended to 4 months at 120-h extended holding period. The mean densities of An. culicifacies in both arms fell drastically post-spray. In light trap collections, density of mosquitoes collected indoors was lower than outdoors in both arms indicating effectiveness of IRS. SumiShield WG was more efficacious in reducing the per-structure density than Actellic CS. The proportion of nulliparous mosquitoes was higher than that of parous mosquitoes during post-spray collections in both arms. The majority of adverse events reported were transitory and subsided without medication.

CONCLUSION

Indoor residual spraying with SumiShield WG was found effective, operationally feasible and safe, and it is effective for up to 6 months.

A Study of Clinical Presentation and Correlative Histopathological Patterns in Renal Parenchymal Disease

Suspicion and subsequent detection of renal disease is by an assessment of the urinalysis and renal function in the clinical context. Our attempt in this study is to correlate initial presenting features of urinalysis and renal function to the final histopathological diagnosis. A retrospective analysis of 1059 native kidney biopsies performed from January 2002 to June 2015 at Amrita Institute of Medical Sciences was conducted. Correlative patterns between urinalysis, renal function, and final histopathological diagnosis were studied. Five hundred and eleven (48%) patients had nephrotic syndrome. Out of these, 193 (38%) had pure: nephrotic syndrome, 181 (35.8%) had associated microhematuria, 110 (21.7%) had microhematuria and renal failure, and 27 (5.3%) had only associated renal failure. Minimal change disease (MCD) (30%), membranous nephropathy (30%), and IgA nephropathy (29%) were the major diseases in the respective groups. Five hundred and five (47.6%) patients had subnephrotic proteinuria. Out of these, 29 (5.6%) had only subnephrotic proteinuria, 134 (27%) had additional microhematuria, 300 (59%) had subnephrotic proteinuria, microhematuria, and renal failure, and 42 (8%) had subnephrotic proteinuria with renal failure. Lupus Nephritis (45% and 40%) and IgA Nephropathy (32% and 21%) were the major disorders in the subgroups respectively. Forty-two patients (3.7%) were biopsied for isolated renal failure with bland urinary sediment. Cast nephropathy and acute interstitial nephritis were the major diseases. Out of 89 patients with diabetes who were biopsied, 15 (16.8%) had diabetic nephropathy, 45 (50.5%) had no diabetic nephropathy, and 29 (32.5%) had diabetic nephropathy along with a non-diabetic renal disease. Postinfectious glomerulonephritis was the major glomerular disease. IgA nephropathy (22.2%) and membranous nephropathy (15.5%) were the major diseases in patients with diabetes with no diabetic nephropathy. In our population, MCD and membranous nephropathy formed the majority of diseases in biopsied nephrotic syndrome. Added microhematuria did not seem to decrease the incidence of either disease on the whole. We found a significant number of patients with membranous nephropathy with nephrotic syndrome, microhematuria, and additional renal failure. IgA nephropathy formed a majority of cases with nephrotic syndrome, microhematuria, and renal failure. The presence of renal failure regardless of other abnormalities in urinalysis showed a trend toward IgA nephropathy. Membranous nephropathy may have a more varied presentation than was originally thought and IgA nephropathy presenting as nephrotic syndrome may not be uncommon. MCD is the major subgroup of diseases in the pediatric population and presents both as nephrotic syndrome as well as nephrotic syndrome with microhematuria. Thus, urinalysis and renal failure may be a valuable tool in assessing renal disease.

Family-led rehabilitation after stroke in India (ATTEND): a randomised controlled trial

BACKGROUND

Most people with stroke in India have no access to organised rehabilitation services. The effectiveness of training family members to provide stroke rehabilitation is uncertain. Our primary objective was to determine whether family-led stroke rehabilitation, initiated in hospital and continued at home, would be superior to usual care in a low-resource setting.

METHODS

The Family-led Rehabilitation after Stroke in India (ATTEND) trial was a prospectively randomised open trial with blinded endpoint done across 14 hospitals in India. Patients aged 18 years or older who had had a stroke within the past month, had residual disability and reasonable expectation of survival, and who had an informal family-nominated caregiver were randomly assigned to intervention or usual care by site coordinators using a secure web-based system with minimisation by site and stroke severity. The family members of participants in the intervention group received additional structured rehabilitation training-including information provision, joint goal setting, carer training, and task-specific training-that was started in hospital and continued at home for up to 2 months. The primary outcome was death or dependency at 6 months, defined by scores 3-6 on the modified Rankin scale (range, 0 [no symptoms] to 6 [death]) as assessed by masked observers. Analyses were by intention to treat. This trial is registered with Clinical Trials Registry-India (CTRI/2013/04/003557), Australian New Zealand Clinical Trials Registry (ACTRN12613000078752), and Universal Trial Number (U1111-1138-6707).

FINDINGS

Between Jan 13, 2014, and Feb 12, 2016, 1250 patients were randomly assigned to intervention (n=623) or control (n=627) groups. 33 patients were lost to follow-up (14 intervention, 19 control) and five patients withdrew (two intervention, three control). At 6 months, 285 (47%) of 607 patients in the intervention group and 287 (47%) of 605 controls were dead or dependent (odds ratio 0·98, 95% CI 0·78-1·23, p=0·87). 72 (12%) patients in the intervention group and 86 (14%) in the control group died (p=0·27), and we observed no difference in rehospitalisation (89 [14%]patients in the intervention group vs 82 [13%] in the control group; p=0·56). We also found no difference in total non-fatal events (112 events in 82 [13%] intervention patients vs 110 events in 79 [13%] control patients; p=0·80).

INTERPRETATION

Although task shifting is an attractive solution for health-care sustainability, our results do not support investment in new stroke rehabilitation services that shift tasks to family caregivers, unless new evidence emerges. A future avenue of research should be to investigate the effects of task shifting to health-care assistants or team-based community care.

FUNDING

The National Health and Medical Research Council of Australia.

Triquetral fracture with associated pisiform subluxation

We herein present a case of right triquetral fracture with associated pisiform and flexor carpi ulnaris subluxation in a 29-year-old man. Initial radiography showed a right triquetral fracture. Computed tomography and magnetic resonance imaging demonstrated a triquetral fracture with a subluxated pisiform. Open reduction and lag screw fixation of the right triquetrum was performed, with good subsequent recovery of function. Although triquetral fracture with subluxation of the pisotriquetral joint is uncommon, attending clinicians should bear in mind the possibility of such an injury when managing traumatic ulnar-sided wrist pain.

Combined volar and dorsal plating for complex comminuted distal radial fractures

PURPOSE

To review outcomes of combined volar and dorsal locked plating for AO type-C3 complex comminuted distal radial fractures.

METHODS

Records of 24 patients aged 17 to 77 (mean, 53.3) years who underwent combined volar and dorsal locked plating for AO type-C3 distal radial fractures with volar and dorsal metaphyseal and intra-articular comminution were reviewed. 21 were closed fractures, and 3 were Gustilo-Anderson type-1 open fractures. Bone union, volar tilt, radial inclination, radial height, range of motion, grip strength, and any complications were assessed by a single hand surgeon.

RESULTS

After a mean follow-up of 17 (range, 14-25) months, the mean palmar flexion was 49º (range, 30º-80º), dorsiflexion was 52º (range, 30º-80º), supination was 86º (range, 60º-90º), pronation was 77º (range, 30º-90º), radial deviation was 16º (range, 5º-30º), and ulnar deviation was 27º (range, 10º-50º). The mean grip strength of the injured hand was 69.2% of the uninjured side. The mean time to radiological union was 3.9 (range, 2.5-6.0) months; no patient had non-union. At the time of union, the mean volar tilt was 5º (-22º-14º), radial inclination was 18.6º (8º-28º), and radial height was 8.5 mm (5.0 mm-13.6 mm). One patient had collapse of the dorsal fragment resulting in a dorsal tilt of 22º and limited (30º) forearm pronation. The severity of dorsal metaphyseal comminution had not been recognised and bone grafting was not performed. The patient also had minor complications of little finger flexor tendon irritation and carpal tunnel syndrome. She underwent implant removal and carpal tunnel release at 8 months. One patient had implant-related extensor digitorum communis irritation. Another patient had non-specific chronic wrist pain, which was resolved at one year. No patient had infection, tendon rupture, or complex regional pain syndrome. Four patients underwent implant removal, including 2 who had no implant-related problems.

CONCLUSION

Combined volar and dorsal plating enables early mobilisation and good outcome for certain complex comminuted distal radial fractures.

Histiocytosis of the temporal bone

Histiocytosis is a rare disease of unknown aetiology which commonly affects the head and neck region. In the ear it can closely mimic acute and chronic ear disease leading to a confusion in diagnosis. It can be easily misdiagnosed unless a high index of clinical suspicion is maintained. We present a case of Letterer Siwe disease of the temporal bone which presented with bilateral mastoid abscesses.

Compound odontoma associated with impacted maxillary incisors

Odontomas are considered to be the most common odontogenic tumors of the oral cavity. Some authors consider it as malformations rather than true neoplasms. The exact etiology of odontomes is still not known. Most odontomes are asymptomatic and are discovered during routine radiographic investigations. Odontomes generally cause disturbances in the eruption of the teeth, most commonly delayed eruption or deflection. The present report describes the surgical management of a case of compound odontoma in a 10-year-old boy who presented with a complaint of swelling in the maxillary right anterior region and retained deciduous incisors. The related literature is also being reviewed in this article.

LINBURG-COMSTOCK PHENOMENON FOLLOWING FOREARM LACERATION

A 20-year-old man presented with an inability to flex the interphalangeal joint of the right thumb without simultaneous flexion of the distal interphalangeal joint of the index finger following a penetrating injury to the right forearm. With a clinical suspicion of intertendinous adhesions between the flexor pollicis longus and the flexor digitorum profundus to the index finger, surgical exploration under wide-awake anesthesia was performed. Intraoperatively, the intertendinous adhesions were identified and divided completely. Postoperatively, the patient achieved good, independent flexion of the interphalangeal joint of the thumb. This case demonstrates a clinical picture similar to that of Linburg-Comstock syndrome, which occurred following a forearm penetrating injury. We call this the Linburg-Comstock (LC) phenomenon.

SELF-REPORTED OUTCOME FOLLOWING ANTERIOR TRANSPOSITION OF ULNAR NERVE IN THE ELDERLY

Cubital tunnel syndrome is a common entrapment neuropathy of the upper limb. This condition can result in significant sensory disturbances and motor deficits in the distribution of the ulnar nerve. Surgical management of cubital tunnel syndrome is indicated when non-operative measures fail. However, in the elderly population, there may be a tendency to avoid surgery as nerve healing has been found to be poor. In our study, we reviewed the results of anterior transposition of ulnar nerve in patients 60 years of age and older. Our results were based on a self-reported outcome at a minimum of one year after surgery — 94.7% of our surgeries resulted in some improvement in symptoms experienced by the patients while there was an overall satisfaction rate of 83.3%. Based on our results, we recommend ulnar nerve transposition in the management of cubital tunnel syndrome in this group of patients if non-operative measures fail.

NEUROMA OF THE RADIAL DIGITAL NERVE OF THE MIDDLE FINGER FOLLOWING TRIGGER RELEASE

Trigger digit release is a common surgical procedure with a low complication rate. One of the potential complications is digital nerve injury. Though uncommon, digital nerve injury can be significantly symptomatic to the patient. We report a case of radial digital nerve neuroma formation following trigger release of the middle finger, which is considered to be safe, in terms of risk of digital nerve injury. We discuss our management of the complication, possible pitfalls which may have resulted in the complication in our case and offer possible means of overcoming these pitfalls.

Severe isolated trapezoid fracture: a case report

Isolated trapezoid fractures are rare. We present a case of severe isolated trapezoid fracture associated with bone loss and proximal migration of the second metacarpal, which was treated successfully by open reduction and internal fixation with bone grafting and joint fusion.

Rare causes of voice hoarseness: a case report

We report two contrasting and rare cases of voice hoarseness in young patients of tubercular aetiology. First case report is of isolated tubercular recurrent laryngeal nerve palsy in a patient who presented with hoarseness of voice. Chest radiograph showed a left hilar prominence and bronchial washings isolated acid-fast bacilli. Hoarseness of voice as an initial symptom due to isolated vocal cord palsy with no morphological lesions in the larynx and without obvious parenchymal infiltration often poses a diagnostic dilemma. Second case report highlights the possibilities of tuberculosis of the vocal cords mimicking tumour of the larynx. This patient had an ulcerative growth involving the vocal cord which was initially mistaken for malignancy. Patient also had concomitant miliary shadowing in the lungs and laryngoscopic biopsy revealed the growth to be tuberculosis. Early diagnosis and intervention with antitubercular treatment is vital as it results in complete recovery with reversal of vocal hoarseness.

Melanotic neuroectodermal tumour of infancy: a case report

A case of melanotic neuroectodermal tumor of infancy occurring in the maxilla in a 13 day old neonate is described. Computed tomography and histopathology confirmed the diagnosis and a submucosal excision was carried out when the infant was 30 days old. But three weeks later the patient reported back with a recurrence and a wide surgical excision was performed. The recurrence may have been caused by incomplete removal of the tumor cells and the initial surgical procedure may have stimulated tumour cell proliferation. Fortunately, 6 month follow up of the patient showed no recurrence.

Follicular thyroid carcinoma presenting as axial skeletal metastases

INTRODUCTION

Common modes of presentation of follicular thyroid carcinoma include a solitary thyroid nodule and cervical lymphadenopathy. We report four patients who presented with axial skeletal metastases rather than the usual neck lumps.

METHODS

A review of a database of 389 cases of thyroid cancer, managed by our department from 1990 to 2003, was perfomed. Based on each patient's presenting clinical feature, patients for the case series were selected.

RESULTS

Four of the 389 patients presented with axial skeletal metastases - three were in the scalp while the fourth was in the sacral region. The histology of all four cases was that of follicular thyroid carcinoma. Despite widespread metastases at presentation, the overall survival rates of these patients remained relatively good.

CONCLUSION

Patients presenting with lesions suspicious of secondary malignancy in the axial skeleton should be clinically evaluated for thyroid cancer. This is especially important if the patient belongs to a high risk age group and has highly vascular lesions.

Unicystic ameloblastoma of the maxilla: a case report

Unicystic ameloblastoma is believed to be less aggressive and responds more favorably to conservative surgery than the solid or multicystic ameloblastomas. This report is a rare case of unicystic ameloblastoma of the maxilla that was treated by enucleation under suspicion of a radicular cyst related to a dens in dente. The neoplastic nature of the lesion became evident only when the enucleated material was available for histologic examination. With this report, the authors illustrate the importance and complexity of a differential diagnosis of lesions with a cystic aspect in the anterior region of the maxilla, among them - inflammatory radicular cysts, odontogenic keratocysts, adenomatoid odontogenic and unicystic ameloblastoma. Relevant diagnostic problems and choice of treatment of unicystic ameloblastoma are presented along with a review of the literature.

Clinical spectrum and surgical management of acute mesenteric ischaemia in Singapore

INTRODUCTION

Acute mesenteric ischaemia (AMI) is a surgical emergency with a dismal prognosis. Much of the literature concerning this condition is from the West. This study aims to present a single-centre Asian experience of management of patients with AMI and the immediate outcome following surgical treatment.

METHODS

This is a retrospective study of patients managed for AMI in our department between 1990 and 2003. The data was obtained from a prospectively-collected surgical data base as well as from clinical case records.

RESULTS

65 patients were managed by our department for AMI over 14 years. The median age of this patient group was 69 years, with a high prevalence of cardiovascular diseases. The majority of patients presented with abdominal pain, distension and vomiting. The commonest subtype of AMI was caused by mesenteric arterial occlusion; this subtype also had the highest in-hospital mortality. Our overall in-hospital mortality for all 65 patients was 55.4 percent.

CONCLUSION

Clinical suspicion, especially in a patient with the relevant risk factors, remains the mainstay of appropriate early management of AMI. Our patient demographics, coexistent diseases and commonest subtype of AMI were similar to that reported in the Western literature. In this paper, we also suggest a management algorithm for patients with suspected AMI.

Tuberculosis in the head and neck: experience in India

OBJECTIVE

With improvement in economic and social conditions and the use of effective anti-tubercular therapy, the developed nations, and most developing nations, have enjoyed a decline in tuberculosis for several decades. It is now seen that extra-pulmonary presentations form a major proportion of new cases, especially since the advent of the acquired immunodeficiency syndrome epidemic. Therefore, it is important that otolaryngologists are aware of tuberculosis in the head and neck region and its varied manifestations. We report the increased incidence of isolated head and neck tuberculosis, its various presentations and clinical manifestations over a 10-year period.

MATERIALS AND METHODS

A 10-year (1995-2004), retrospective study was undertaken by the department of otolaryngology and head and neck surgery, Kasturba Medical College, and its allied hospitals, Mangalore, South India, involving a group of 165 patients with head and neck tuberculosis. Each patient underwent a detailed clinical examination and a battery of investigations. Most patients were treated with anti-tubercular therapy alone; others required surgical intervention followed by Anti-tubercular therapy (ATT). In addition, those with human immunodeficiency virus infection or malignancy were treated with anti-retroviral therapy and radiotherapy, respectively.

RESULTS

Of the 165 cases, 121 (73.3 per cent) had isolated tubercular lymphadenitis, 24 (14.5 per cent) had laryngeal tuberculosis, four (2.4 per cent) had tubercular otitis media, three (1.8 per cent) had tuberculosis of the cervical spine, three (1.8 per cent) had tuberculosis of the parotid, eight (5 per cent) had tuberculosis of the oral cavity, one had tuberculosis of the temporo-mandibular joint and one had tuberculosis of the nose. Fine needle aspiration cytology was highly effective in the diagnosis of tubercular lymphadenitis (92 per cent) but not so for other sites. The purified protein derivative (PPD) test was positive in only 20 per cent of cases. Pus for culture and sensitivity was positive only in caries of the spine and mandibular tuberculosis. Excision biopsy and histopathological examination were required to make a diagnosis in tuberculosis of the oral and nasal cavities, salivary glands, ear, temporo-mandibular joint, and mandible. There were 40 cases (24.2 per cent) with coexisting pulmonary tuberculosis and five cases (3 per cent) with coexisting malignancy. Of the 65 patients who were tested, 30 per cent were found to have coexisting human immunodeficiency virus infection.

CONCLUSION

In addition to cervical lymphadenitis, tuberculosis in the head and neck region can produce isolated disease in the oral cavity, ear, salivary glands, temporo-mandibular joint, nose and larynx. Seventy-five per cent of our head and neck tuberculosis patients did not have pulmonary involvement. Fine needle aspiration cytology was highly effective in the diagnosis of nodal tuberculosis, but histopathological examination was required to make the diagnosis in other head and neck sites. The PPD test was not effective as a diagnostic tool. If the otolaryngologist maintains a high index of suspicion, an early diagnosis can be made with the help of simple investigations. Successful outcome depends upon appropriate chemotherapy and timely surgical intervention when necessary.

Perichondritis of the auricle and its management

Objective: To conduct a study of patients presenting with perichondritis of the auricle and to analyse the possible aetiological factors responsible, the bacteriological agents involved, the treatment modalities and the complications of such infections.

Setting: Academic department of otolaryngology.

Design: A retrospective clinical study of patients treated over a five-year period.

Participants: Sixty-one patients with clinically proven perichondritis of the auricle, with or without diabetes mellitus (i.e. malignant otitis externa).

Results: Based on the severity of the disease, otherwise uncomplicated patients were assigned to group A and divided into three cohorts. Patients with perichondritis secondary to malignant otitis externa were analysed separately as group B. Men formed the majority of the patients and most were young (16–35 years). Trauma was the main cause (46 per cent) and Pseudomonas aeruginosa the most common micro-organism isolated. The condition was managed conservatively with antibiotics alone in 19 patients (31 per cent) and these cases had no residual deformity at follow up (group A, stage one). Incision and drainage was performed in a further 19 patients (31 per cent), resulting in minor residual deformity in one half (group A, stage two). Debridement was performed in 17 patients, and these patients had either gross (29 per cent) or minor residual deformity (71 per cent; group A, stage three). Six patients with perichondritis secondary to malignant otitis externa were managed by wound debridement via a post-auricular approach; all had minor residual deformities.

Conclusions: Perichondritis can be divided into two groups, depending on cartilage loss and on the presence or absence of malignant otitis externa. The treatment used and the residual deformity that will ensue are entirely dependent on the stage of disease.

Phase III trial of 5-fluorouracil and leucovorin plus either 3H1 anti-idiotype monoclonal antibody or placebo in patients with advanced colorectal cancer

BACKGROUND

The monoclonal antibody 3H1 mimics the external structure of the carcinoembryonic antigen (CEA). It therefore has the potential, via the anti-idiotypic network, to stimulate immune responses to CEA that may benefit colorectal cancer patients.

PATIENTS AND METHODS

A total of 630 patients with previously untreated metastatic colorectal cancer were randomised in a 2:1 fashion to receive bolus 5-fluorouracil (5-FU) and leucovorin (LV) plus either 3H1 (n = 422) or placebo (n = 208).

RESULTS

The addition of 3H1 to 5-FU and LV did not result in increased toxicity. Survival for the full intent-to-treat population was 14.7 months for the 3H1 arm and 15.2 months for the placebo arm (P = 0.80). Anti-CEA antibody responses were observed in 70% of patients treated with 3H1. Patients with a negative CEA response had a median survival of 8.3 months (95% CI 7.5-11.0) compared with patients with a strong response: median survival not reached (P <0.001).

CONCLUSION

3H1 is safe and effectively induces immune responses to CEA. Addition of 3H1 to 5-FU and LV was not shown to improve overall patient outcomes. However, improved survival in patients developing anti-CEA responses to 3H1 are provocative and should be studied in further clinical trials.

Diffuse idiopathic skeletal hyperostosis with cervical spinal cord injury -a report of 3 cases and a literature review

INTRODUCTION

Diffuse idiopathic skeletal hyperostosis (DISH), though common, is often asymptomatic. However, spinal hyperostosis can predispose the affected to chronic myelopathic symptoms and acute spinal cord injury.

CLINICAL PICTURE

We report on 3 patients with DISH, who sustained traumatic cervical cord injuries. Two were tetraplegic at presentation. The radiologic findings of the patients are also discussed.

TREATMENT

Both the tetraplegic patients were treated non-surgically in view of high surgical risk.

OUTCOME

Both the tetraplegic patients died due to mechanical respiratory failure.

CONCLUSIONS

The potential catastrophic neurological sequelae of DISH from relatively minor trauma must be understood. Further studies are needed to aid in evidence-based clinical management of asymptomatic patients with DISH.

The Internet as a source of health information among Singaporeans: prevalence, patterns of health surfing and impact on health behaviour

OBJECTIVE

The Internet is an increasingly popular source of healthcare information. This study describes the prevalence of health surfers in Singapore and their health-surfing patterns. It also assesses their confidence in online health information and the impact the Internet has on health-seeking behaviour.

MATERIALS AND METHODS

A cross-sectional survey using a standardised questionnaire was carried out among residents aged 13 to 55 years in 1852 units in Bishan North. These units were selected by single-stage simple random cluster sampling method.

RESULTS

The household response rate was 51% (n = 950) and the individual response rate was 69% (n = 1646). Responding and non-responding households were similar in terms of ethnicity and housing type. Of the responders, 62.9% surfed the Internet and 37.7% have surfed for health information. Health surfers tended to be younger (20 to 39 years) and have higher education status. Indians were also more likely than other ethnic groups to surf for health. Professional health-related sites comprised the majority (68%) of sites visited, and the most common search keywords concern chronic degenerative diseases, e.g. hypertension. The top preferred sources of health information were doctors (25.9%), the Internet (25.3%) and the traditional mass media (20.5%). Almost half (45.1%) considered online health information trustworthy if it was from a professional source or if the website displayed the source, while 10.6% trusted the information if it concurred with the doctors' advice. The vast majority (91.7%) had taken some action in response to the information.

CONCLUSION

The Internet is being used as an accessible source of health information by a substantial proportion of the lay public. While this can facilitate greater partnership in healthcare, it underlines the need for doctors to be pro-active in the practice of evidence-based medicine, and for guidelines to enable patients to use this tool in a discerning manner.

Enzymatically active papain preferentially induces an allergic response in mice

Human exposure to papain, a cysteine proteinase, is associated with hypersensitivity reactions. We demonstrate in mice that enzymatically active papain preferentially induces an IgG1 response and results in mast cell degranulation, both features typical of an allergic reaction. Inactive papain, blocked with E-64, appears to desensitize mice to subsequent challenge by active enzyme. These results suggest that the enzymatic activity of papain is critical in inducing an allergic response and that the use of inactive allergens may be a possible strategy for desensitizing allergic individuals.

DNA supercoiling and relaxation by ATP-dependent DNA topoisomerases

Bacterial DNA gyrase and the eukaryotic type II DNA topoisomerases are ATPases that catalyse the introduction or removal of DNA supercoils and the formation and resolution of DNA knots and catenanes. Gyrase is unique in using ATP to drive the energetically unfavourable negative supercoiling of DNA, an example of mechanochemical coupling: in contrast, eukaryotic topoisomerase II relaxes DNA in an ATP-requiring reaction. In each case, the enzyme-DNA complex acts as a ‘gate’ mediating the passage of a DNA segment through a transient enzyme-bridged double-strand DNA break. We are using a variety of genetic and enzymic approaches to probe the nature of these complexes and their mechanism of action. Recent studies will be described focusing on the role of DNA wrapping on the A 2 B 2 gyrase complex, subunit activities uncovered by using ATP analogues and the coumarin and quinolone inhibitors, and the identification and functions of discrete subunit domains. Homology between gyrase subunits and the A 2 homodimer of eukaryotic topo II suggests functional conservation between these proteins. The role of ATP hydrolysis by these topoisomerases will be discussed in regard to other energy coupling systems.

Prognostic factors in complicated and uncomplicated chronic otitis media

PURPOSE

The aim of the present study was to determine the factors that make a patient of chronic suppurative otitis media more susceptible to the development of a complication.

MATERIALS AND METHODS

A prospective study of 125 patients of both complicated and uncomplicated cases of chronic suppurative otitis media who underwent mastoid surgery was undertaken to study the percentage proportion of various complications and to correlate various variables, such as age, sex, duration of ear discharge, otoscopy, operative findings, state of pneumatization, and microbiology of the ear.

RESULTS

It was found that patients with complicated ear disease had ear discharge for a shorter duration compared with those without complications. The difference was statistically significant (P < .05). There was no significant difference in the otoscopic findings in both the groups. At surgery, presence of granulation tissue was significantly seen in the group with complications (P < .05). Radiologically, degree of mastoid pneumatization had no significant difference in the two groups, except the presence of lytic lesion in patients more than 15 years of age in the group with complications. Bacteriological examination showed significant isolation of anaerobes in patients with complications (P < .01).

CONCLUSION

A history of ear discharge for a short duration in a younger patient less than 15 years of age, the presence of anaerobes in the ear discharge, and granulation tissue at surgery increase the probability of development of a complication in patients with chronic suppurative otitis media.

NorA plasmid resistance to fluoroquinolones: role of copy number and norA frameshift mutations

Staphylococcus aureus NorA protein is a transmembrane multidrug efflux pump that confers low-level resistance to hydrophilic fluoroquinolones. The norA gene promoter is active in Escherichia coli HB101. We have examined the genetic basis of norA-mediated resistance in E. coli by introducing a wild-type norA gene into HB101 in plasmid pCL1921, pBR322, or pUC18 exhibiting copy numbers that spanned a 22-fold range. Increased ciprofloxacin resistance correlated with norA transcript levels seen by Northern (RNA) analysis. Thus, contrary to some reports, a wild-type norA gene confers fluoroquinolone resistance in E. coli in a copy-number-dependent fashion and does not require mutational activation. Interestingly, a multicopy pUC19norA derivative gave transformants exhibiting a range of resistance phenotypes. The norA gene of one transformant carried a single base deletion (ATACAAT to AACAAT; the deleted base is underlined) in the putative--10 Pribnow box resulting in a promoter down-regulatory mutation; a second plasmid had acquired a frameshift producing a null mutation at codon 112. These mutations override the dual resistance-growth-inhibitory phenotype of high-copy-number norA plasmids. The results have implications for using the standard E. coli HB101 system to assess NorA function and potentially for plasmid-borne transmission of norA-mediated drug resistance.

The house dust mite allergen Der p1 catalytically inactivates alpha 1-antitrypsin by specific reactive centre loop cleavage: a mechanism that promotes airway inflammation and asthma

Der p1, a cysteine proteinase derived from the house dust mite (HDM) Dermatophagoides pteronyssinus, is a major component of the allergic immune response in HDM atopic individuals. Recent evidence suggests that cysteine proteinase activity is important in the disease process as it increases the permeability of the allergen in the respiratory tract and disrupts the regulation of IgE synthesis. Der p1 is found in high concentrations in the faecal pellets of mites which are aerosolised and inhaled via the respiratory tract. The serine proteinase inhibitor, alpha 1-antitrypsin, protects the lower respiratory tract against damage by proteinases released in the lung during inflammation. Der p1 catalytically inactivates alpha 1-antitrypsin by a thiol-dependent mechanism involving specific cleavage of the reactive centre loop and we propose that this mechanism may be important in the pathogenesis of asthma.

Catalytic site targeted mutagenesis of the α-gingivain gene of Porphyromonas gingivalis using Tn-4351 to generate isogenic mutants

The extracellular proteinases of the anaerobe Porphyromonas gingivalis, are implicated in the destruction of host defence mechanisms in periodontitis. We have previously purified one of these enzymes, alpha-gingivain, and established that it belongs to the cysteine proteinase family of enzymes. In the present study, transposon Tn4351 was used to alter the open reading frame encoding a region that includes the catalytic site of alpha-gingivain by targeted mutagenesis. Escherichia coli HB101 which harbours R751 was used to introduce the transposon into P. gingivalis ATCC 33277 by conjugal transfer. E. coli was transformed using the altered plasmid with a Cla I site insertion of a sequence common to the catalytic site histidine or cysteine of many cysteine proteinases. The frequency of the transconjugation was 4.5 x 10(5) while the recipient viable counts comprised 60% of the original P. gingivalis. The result of this targeted mutagenesis was inactivation of gingivains such that some colonies on skimmed-milk agar plates showed no clear surrounding zones of hydrolysis and their normal catalytic activity towards L-BAPNA was destroyed.

Variation in the P2-S2 stereochemical selectivity towards the enantiomeric N-acetylphenylalanylglycine 4-nitroanilides among the cysteine proteinases papain, ficin and actinidin

1. Values of the kinetic specificity constant, kcat./Km, for the hydrolysis of N-acetyl-L-phenylalanylglycine 4-nitroanilide (I) and of its D-enantiomer (II) catalysed by ficin (EC 3.4.22.3) and by actinidin (EC 3.4.22.14) at pH 6.0, I 0.1 mol/l, 8.3% (v/v) NN-dimethylformamide and 25 degrees C were determined by using initial-rate data with [S] much less than Km and weighted nonlinear regression analysis as: for ficin, (kcat./Km)L = 271 +/- 6 M-1.s-1, (kcat./Km)D = 2.9 +/- 0.1 M-1.s-1, and for actinidin (kcat./Km)L = 13.3 +/- 0.7 M-1.s-1, (kcat/Km)D = 0.34 +/- 0.01 M-1.s-1.2. These data and analogous values for the corresponding reactions catalysed by papain (EC 3.4.22.2), (kcat./Km)L = 2064 +/- 31 M-1.s-1, (kcat./Km)D = 5.5 +/- 0.1 M-1.s-1, demonstrate marked variation in stereochemical selectivity for substrates (I) and (II) among the three cysteine proteinases with the following values for the index of stereochemical selectivity Iss = (kcat./Km)L/(kcat./Km)D: for papain, 375; for ficin 93; for actinidin 39. 3. Model building suggests ways in which, for the papain-catalysed reactions, binding interactions involving the extended acyl groups of the substrates may need to change as the reaction proceeds from adsorptive complex (ES) to tetrahedral intermediate (THI) before its rate-determining, general acid-catalysed collapse to acylenzyme intermediate. In particular, satisfactory alignment in the catalytic site at the THI stage of the acylation process appears to demand rotation of the substrate moiety about its long axis. 4. The different consequences of this rotation for the L- and D-enantiomers suggest that for closely related systems the greater the extent of this rotational adjustment the greater would be the value of Iss.5. For the actinidin-substrate combinations, model building suggests that even at the ES complex stage of catalysis it is not possible to approach optimized P2-S2 contacts and the three hydrogen-bonding interactions deduced for papain-ligand complexes in the absence of significant movement of protein conformation. Possible binding modes in which some of the interactions deduced for papain are relaxed are discussed. Consideration of postulated binding modes in the various transition states is shown to account for the order of reactivity reflected in values kcat./Km for the four reactions involving papain (Pap) and actinidin (Act) with the L- and D-enantiomeric substrates: Pap-L much greater than Act-L greater than Pap-D much greater than Act-D.(ABSTRACT TRUNCATED AT 400 WORDS)

gyrA mutations in ciprofloxacin-resistant, methicillin-resistant Staphylococcus aureus from Indiana, Minnesota, and Tennessee

Mutational changes occurring at amino acid codons 84 and 85 located in the gyrA gene of methicillin-resistant Staphylococcus aureus (MRSA) were studied using radiolabeled oligonucleotide probes to examine the incidence of these ciprofloxacin resistance determinants in 30 MRSA isolates from Indiana, Minnesota, and Tennessee. Four separate oligonucleotide probes, one each corresponding to the wild-type sequence, a mutation at codon 84 (nucleotide 251), a mutation at codon 85 (nucleotide 253), and mutations at both, were used to examine the total genomic DNA from each of the 30 isolates, which had been restricted, electrophoresed, and Southern blotted. The probes indicated that 15 of the 28 ciprofloxacin-resistant isolates gave results consistent with a single mutation at codon 84. Four of the 28 ciprofloxacin-resistant strains had results consistent with a mutation at codon 84 and possibly at codon 85. The two ciprofloxacin-sensitive isolates from Tennessee showed homology with the wild-type probe sequence. Five isolates (4, Minnesota; 1, Tennessee) had no homology with any probe. By oligonucleotide probes, ciprofloxacin-resistant MRSA from diverse geographic regions contained similar gyrA mutations at codons 84 or 85 in 19 of 28 ciprofloxacin-resistant isolates.

Ciprofloxacin resistance in coagulase-positive and -negative staphylococci: role of mutations at serine 84 in the DNA gyrase A protein of Staphylococcus aureus and Staphylococcus epidermidis

gyrA mutations in quinolone-resistant pathogenic isolates of Staphylococcus spp. have been detected by the direct HinfI digestion of polymerase chain reaction products. Homology among gyrA genes allowed rapid examination of both coagulase-positive and -negative isolates. DNA sequence analysis revealed that ciprofloxacin resistance in Staphylococcus epidermidis is associated with a novel Ser-84----Phe mutation in the DNA gyrase A protein, analogous to Ser-84----Leu changes observed in Staphylococcus aureus.

DNA gyrase gyrA mutations in ciprofloxacin-resistant strains of Staphylococcus aureus: close similarity with quinolone resistance mutations in Escherichia coli

The gyrA genes isolated from three ciprofloxacin-resistant clinical isolates of Staphylococcus aureus carried codon 84 (serine----leucine) and/or codon 85 (serine----proline) mutations that were absent in pretreatment susceptible strains. These substitutions occur in a region of the gyrase A protein wherein directly analogous mutations of serine 83----leucine and alanine 84----proline in Escherichia coli confer quinolone resistance. Thus, DNA gyrase A subunit mutations are implicated in resistance to ciprofloxacin in S. aureus.