Management of osteoarthritis of the wrist and hand

Osteoarthritis of the wrist and hand can cause significant functional impairment and disability. Its management is as much an art as it is science, as one has to consider increasing patient expectations, functional demands, pain relief and preserving motion. A sound knowledge of the wrist and hand anatomy, biomechanics, appreciation of the specific location and grade of wrist and hand joints arthritis and various treatment options and their pros and cons is important to successfully manage patients with this condition. Wrist osteoarthritis can be idiopathic, however more commonly it is secondary to distal radius and/or carpal fractures and ligamentous injuries. A small proportion still can occur due to avascular necrosis of carpus or congenital and developmental causes. Osteoarthritis of the hand is often idiopathic with a high familial tendency, especially in younger patients but can be secondary to other causes such as trauma, gout and ligamentous laxity. Once the non-surgical management options such as analgesia, activity modifications, steroid injections and splints have been exhausted, then there are various surgical options available for wrist and hand osteoarthritis. These are tailored to the exact location of arthritis and patient factors. For the wrist, these include anterior and posterior interosseous nerve neurectomy, arthroscopic debridement, selective bony excisions, wrist arthroplasty and focal or total fusion. Whilst for finger osteoarthritis, surgical options include arthroplasty and arthrodesis. This article aims to describe the pathology of wrist and hand arthritis and various treatment options available.     

Hair analysis does not allow to discriminate between acute and chronic administrations of a drug in young children

There are many differences between the hair from children and that of adult subjects, the hair being thinner, more porous with a different growth rate from the usual 1 cm/month observed in adults. In order to determine whether hair analysis could discriminate between chronic use and acute administration of a drug in children like in adults, we analyzed hair from 18 children aged between 1 day and 15 years in whom the administration of different drugs was known (single therapeutic administration or acute intoxication). A strand of hair was sampled within 1 to 45 days after treatment or intoxication. Analysis was conducted using LC/MS/MS. In the 10 youngest children, aged between 1 day and 29 months, the compounds administered in hospital or responsible for intoxication (lidocaine, ropivacaine, diazepam, midazolam, levetiracetam, morphine, ketamine, methadone, buprenorphine, THC, MDMA) were found in all segments of the hair independently of the time of sampling (1–45 days after ingestion). The concentrations detected were similar along the hair shaft, showing a radial diffusion and incorporation of the analytes in the hair of young children from the sebum. Concentrations could be very high when sampled shortly after administration (72 ng/mg for methadone, 75 ng/mg for MDMA after 3 days) and lower when sampling later (1.2 ng/mg for MDMA after 45 days). In these cases, hair analysis allowed to highlight the compounds responsible for intoxication even when they had disappeared from the blood or urine but should not be used to discriminate long-term exposure to a drug. In the eight remaining children aged from 34 months to 15 years, the drugs used in hospital (lidocaine, diazepam, morphine) or responsible for intoxication (THC, codeine, buprenorphine) were not found in any analyzed segments sampled 1 to 5 days after administration of the drugs, in agreement with the non-incorporation of the drugs from the sebum into the hair. For those children aged over 34 months, hair analysis allows to determine the chronic administration of a drug, like in adults.

     

Genetic analysis of the STR system D20S161 in Japanese and Bangladeshi

The allele distributions of the STR locus D20S161 have been investigated in Japanese and Bangladeshi people. No deviation from the Hardy-Weinberg equilibrium was observed in either population. D20S161 was found to be a polymorphic STR with seven alleles in Japanese and with six alleles in Bangladeshi. The distribution of allele frequencies in Japanese was very similar to that in Bangladeshi. The D20S161 system can be a potential marker for medicolegal individualization and paternity testing.     

MDG 5: how close are we to success?

Only 6 years are left until 2015, the target date for achieving the Millennium Development Goals (MDG), yet improving maternal health (MDG 5) continues to lag behind. At the global level, maternal mortality still remains high in sub-Saharan Africa and Southeast Asian countries. Most deaths are preventable and occur due to unavailability of and/or poor quality of service.
Skilled care at facilities ensures safety, cleanliness, the availability of supplies and equipment, and it makes management and supervision easier. With the mixture of professionals in a facility, life-saving emergency care can be provided quickly. Wherever childbirth takes place, it is essential that the person who helps has the core competencies for safe delivery, has the necessary equipment and supplies, and has the option to refer to a functioning facility offering emergency obstetric and newborn care.
The continuing high incidence of maternal and perinatal mortality and morbidity is unacceptable precisely because it is solvable. We know how to make pregnancy and childbirth safe. The task is enormous but not insurmountable. Our efforts of investment need to be equal to the tasks and must be intensified if maternal and perinatal morbidity and mortality is to be reduced.     

Effects of atrial natriuretic peptide and sodium nitroprusside on epidermal growth factor-stimulated wound repair in rabbit corneal epithelial cells

PURPOSE: Treatment of rabbit corneal epithelial cells (RCEC) with epidermal growth factor (EGF) stimulates cell proliferation and wound repair in a cell culture model system. Studies have also shown that atrial natriuretic peptide (ANP) and sodium nitroprusside (SNP), a nitric oxide-generating agent, inhibit proliferation of a variety of cell types. The aim of the present work was to examine whether ANP or SNP has any effect on EGF-stimulated proliferation of RCEC involved in wound repair. METHODS: The SV-40 immortalized RCEC were cultured in 24-well plates until they became confluent. Wounds of uniform size (8 mm diameter) were created and the cells allowed to grow in the presence and absence of EGF and/or other agents. At prescribed time intervals, the cells were stained by Giemsa and the wound areas digitized and quantified by Sigma Image Scan System. The cGMP contents in RCEC, treated with or without ANP or SNP, were measured by radioimmunoassay. RESULTS: Addition of EGF (1-100 ng/ml) to RCEC stimulated cell proliferation which significantly reduced the time required for wound closure. Addition of ANP (1 nM to 10 microM) or SNP (10 microM to 1 mM), in the presence of EGF, dose-dependently inhibited the growth factor-stimulated wound closure in RCEC. When added alone to the cells, ANP or SNP increased cGMP accumulation in a dose-dependent manner. Addition of ANP (1 microM) or SNP (1 mM) to primary corneal epithelial cells, in the presence and absence of EGF, also inhibited the wound closure with a corresponding increase in cGMP contents. Treatment of the cells with ODQ (10 nM to 10 microM), a soluble guanylate cyclase inhibitor, dose-dependently decreased the SNP-induced accumulation of cGMP, and reversed the inhibitory effect of SNP on EGF-stimulated wound closure. Addition of membrane-permeable cGMP analog, 8-bromo-cGMP, to RCEC inhibited the EGF-stimulated wound closure in a dose-dependent manner. Treatment of RCEC with mitomycin C (5 microM) exerted a marked inhibitory effect on wound closure in the presence and absence of EGF, and also abrogated the inhibitory effect of 8-bromo-cGMP on wound closure in the EGF-treated and untreated cells. CONCLUSIONS: The results demonstrate that ANP and SNP inhibit the EGF-stimulated wound repair in RCEC. The effect of these agents is mediated via activation of guanylate cyclases that generate cGMP. Cyclic GMP appears to exert its inhibitory effect at the level of cell proliferation and not cell migration. The data suggest an important role for cGMP-dependent protein kinase in proliferation of RCEC stimulated by EGF.     

Pineal region tumor manifesting initially as hearing impairment

An 18-year-old male presented with a pineal region germinoma with hearing impairment as the chief complaint. Magnetic resonance image demonstrated a well-enhanced multi-cystic tumor extending into the upper fourth ventricle and wall of the bilateral lateral ventricles. Audiometry revealed bilateral mild hearing impairment in the low frequencies. Auditory brainstem response recording showed low amplitudes in all waves (IV-V/I ratio < 1) with prolong latencies (I-V and III-V) on the right but no discernable wave at 60 dB clicks on left. Hearing impairment and audiometric findings were improved after ventriculoperitoneal shunt operation. The hearing impairment appeared to be a mixed (conductive and sensorineural) type. The tumor was responsible for the sensorineural deafness because of invasion and compression of the central auditory structures. The inferior brachium was maximally compressed anterolaterally by the dilated bilateral lateral ventricles and posteromedially by the tumor. Hydrocephalus caused conductive deafness by halting or arresting the footplate of stapes movement, as a consequence of high-pressure transmission through the cochlear aqueduct.     

A randomised,prospective study comparing trabeculectomy augmented with antimetabolites with a viscocanalostomy technique for the management of open angle glaucoma uncontrolled by medical therapy

AIMS: To compare trabeculectomy with viscocanalostomy for the control of intraocular pressure (IOP) in open angle glaucoma (OAG) uncontrolled by medical therapy. METHODS: 48 patients (50 eyes) with uncontrolled OAG were randomised to either trabeculectomy (25 eyes) or a viscocanalostomy technique (25 eyes). Preoperatively, eyes were graded in terms of risk factors for drainage failure. Those undergoing trabeculectomy were given intraoperative antimetabolites (5-fluorouracil 25 mg/ml (5-FU), mitomycin C (MMC) 0.2 mg/ml and 0.4 mg/ml) according to a standard protocol. Antimetabolites were not used intraoperatively in eyes undergoing viscocanalostomy, but they were randomised to the use of viscoelastic (Healonid GV) for intraoperative intracanalicular injection. RESULTS: There were no significant differences between the groups in age, sex, type of OAG, preoperative medications, risk factors for drainage failure, and preoperative IOP. Mean follow up was 19 months (range 6-24 months). It was 12 months or longer in all eyes, except one lost to follow up at 6 months. At 12 months, complete success (IOP <21 mm Hg without antiglaucoma medications) was seen in all eyes undergoing trabeculectomy (100%), but in only 64% of eyes undergoing viscocanalostomy (p<0.001). The mean IOP was lower at 12 months (p<0.001) with trabeculectomy and the number of eyes with IOPs of 15 mm Hg or less was greater (p<0.05). The mean IOP at 12 months was lower in eyes that had undergone viscocanalostomy using intraoperative intracanalicular Healonid GV injection compared to those where only balanced saline solution had been used (p<0.01). However, in terms of complete success there was no difference between the viscocanalostomy groups (p<0.1). With the exception of measurements at 1 week, visual recovery (logMAR acuity) was similar and laser flare and cell values showed little differences between the groups. Corneal topography and keratometry at 12 months were little different from preoperative values. Postoperative interventions (subconjunctival 5-FU and needling procedures) were similar between the groups. Transient complications such as early bleb leak and hyphaema were more common in the trabeculectomy group (p<0.05). Postoperative cataract formation was more common after trabeculectomy (p<0.05). CONCLUSIONS: IOP control appears to be better with trabeculectomy. Viscocanalostomy is associated with fewer postoperative complications, although significant complications permanently impairing vision did not occur with either technique.