Whose wound is it anyway? Issues relating to wound photography

In this digital age it is easy to obtain images of wounds without permission from the owner or patient. A debate is needed to clarify who rightfully owns clinical images and the implications for patient consent of using them in different media.     

Chronic prostatitis and sensory urgency: Whose pain is it?

Difficulties encountered in diagnosing and effectively treating chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is frustrating for clinicians and patients. Scientific evidence cannot establish an exact relationship between the prostate and the symptoms of CP/CPPS, and the prostate continues to be the diagnosis of convenience in this complex syndrome in men. However, if the pain is not the prostate’s, whose pain is it? A heterogeneous group of insults can result in a common neurogenic pain response, resulting in recurring pain and voiding or sexual dysfunction. To add to this dilemma, certain life-threatening diagnoses, such as carcinoma-in-situ, is in the differential diagnosis and must be excluded. Urodynamics may be useful in evaluating and treating patients whose voiding symptoms predominate. However, many patients with CP/ CPPS will not have measurable abnormalities by conventional methods and likely suffer from a functional somatic syndrome that is best treated with a multimodality approach.     

Echogenicity of breast cancer: is it of prognostic value?

Echogenicity of colorectal metastases to the liver has been shown to correlate with prognosis. While there have been many studies looking at the echogenicity of breast cancer, there has been no study relating the issue of echogenicity to prognosis of breast cancer. In this study, we found that hyperechoic and mixed echogenicity breast cancers are rare compared to hypoechoic breast cancers. There was, however, no difference in the groups with respect to histological size, grade, axillary metastases, hormone receptor status and lymphovascular invasion.     

Fracture risk assessment after BMD examination: whose job is it,anyway?

Summary

Fracture risk assessments on bone mineral density reports guide family physicians’ treatment decisions but are subject to inaccuracy. Qualitative analysis of interviews with 22 family physicians illustrates their pervasive questioning of reported assessment accuracy and independent assumption of responsibility for assessment. Assumption of responsibility is common despite duplicating specialists’ work.

Introduction

Fracture risk is the basis for recommendations of treatment for osteoporosis, but assessments on bone mineral density (BMD) reports are subject to known inaccuracies. This creates a complex situation for referring physicians, who must rely on assessments to inform treatment decisions. This study was designed to broadly understand physicians’ current experiences with and preferences for BMD reporting; the present analysis focuses on their interpretation and use of the fracture risk assessments on reports, specifically

Methods

A qualitative, thematic analysis of one-on-one interviews with 22 family physicians in Ontario, Canada was performed.

Results

The first major theme identified in interview data reflects questioning by family physicians of reported fracture risk assessments’ accuracy. Several major subthemes related to this included questioning of: 1) accuracy in raw bone mineral density measures (e.g., g/cm²); 2) accurate inclusion of modifying risk factors; and 3) the fracture risk assessment methodology employed. A second major theme identified was family physicians’ independent assumption of responsibility for risk assessment and its interpretation. Many participants reported that they computed risk assessments in their practice to ensure accuracy, even when provided with assessments on reports.

Conclusions

Results indicate family physicians question accuracy of risk assessments on BMD reports and often assume responsibility both for revising and relating assessments to treatment recommendations. This assumption of responsibility is common despite the fact that it may duplicate the efforts of reading physicians. Better capture of risk information on BMD referrals, quality control standards for images and standardization of risk reporting may help attenuate some inefficiency.     

A third renal transplantation: is it relevant and is it worth it?

INTRODUCTION: The aim of this retrospective study was to determine the outcome of third cadaveric renal transplantations performed between 1989 and 2004 among a cohort of 35 patients whose immunosuppression included induction therapy and calcineurin inhibitors. Most patients were highly sensitized with 1 (0-4) HLA (classes I + II) incompatibility between donor and recipient. RESULTS: The median follow-up time was 57 months (range, 1-190). Fourteen patients experienced delayed graft function that required posttransplantation hemodialysis. The current patient and graft survival rates were 91.4% and 82.8%, respectively. At last follow-up, 6 grafts had been lost: 1 due to primary nonfunction; 1 due to an urinary leak (day 45); 2 deaths with functioning grafts; and 2 chronic allograft nephropathies (CAN) at 85 and 60 months posttransplantation, respectively. Among the 10 patients who experienced acute rejection episodes, half were steroid-sensitive, whereas the others required OKT3 therapy. Overall, when excluding the 2 patients who presented with early loss of their grafts, 13 of 33 patients (39.4%) developed CAN, which led to the graft loss in only 2 cases. The mean creatinine clearance was 57 +/- 23 mL/min at year 5. Of the 35 recipients, 12 (34.3%) developed graft/perigraft complications, among whom 10 (83.3%) required treatment. The most frequent complication was lymphocele (M = 4; 11.4%) or infections that led to rehospitalization (n = 17). CONCLUSION: Results from third transplantations were encouraging. Thus, despite the organ shortage, a third graft was worth it!     

Appendicitis, is it an emergency?

Prompt appendectomy has always been a standard of care because of the risk of progression in pathology. This time honored practice has been recently challenged by studies, suggesting that appendicitis can be operated on electively. The aim of this study is to examine whether delayed intervention in acute appendicitis is safe by correlating the interval from presentation to operation with the operative and postoperative complications. Retrospective review of patients who underwent appendectomy for acute appendicitis in 2009 was done. The following parameters were recorded: demographics, duration from presentation to evaluation by emergency room attending, performing CT scan, surgical consult, and operation. The pathology, post operative complications, and length of stay were also recorded. Patients were divided into two groups: incision time < 10 hours (early group) and incision time > 10 hours (delayed group). The end points chosen for comparison were: 1) laparoscopic to open conversion rate, 2) complications, 3) readmissions, and 4) length of stay. Number of cases totaled 201, with 76 in the < 10 hours group and 125 in the > 10 hours group. The male to female ratio for the < 10 hours group was 54:22 and for the > 10 hours group was 59:66 (P < 0.001). Length of stay for the early group was 75.52 hours and for the delayed group, 89.15 hours (P = 0.04). There was one intra-abdominal abscess in the early group and 10 in the delayed group (P = 0.04). The early group had 0.2 (2.6%) open conversions, and the delayed group had five (4.1%) conversions (P = 0.58). There were six (4.8%) readmissions in the delayed group and none in the early group (P = 0.05). Our study reveals that the complication rate, length of stay, and readmissions are more in the delayed group. Conversion rate was more in the delayed group, but the difference was not significant. We conclude that early surgical intervention is beneficial in acute appendicitis.     

Evidence-based orthopaedics: is it possible?

EBM is referred to as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. This article describes the history and practice of evidence-based medicine.