FUSION OF THE FIRST METACARPOPHALANGEAL JOINT FOR POST-TRAUMATIC CONDITIONS

Fusion of the metarcarpophalangeal joint of the thumb is an accepted treatment in the management of instability or osteoarthritis following trauma to this joint. A review was made of the literature and 30 of the senior author's (RH) patients who had had this operation, in order to determine what effect the operation had on the pain in their thumb, any symptoms of instability, interference with work and daily activities, and strength in the hand. All of the patients achieved bony union and the average angle of fusion was 7.6 degrees of flexion. All of the patients were either satisfied or very satisfied with the results of the operation, and had an average increase of 6.3 points on a 12 point rating scale. However, 48% of patients had some mild intermittent pain and 43% complained of some difficulty with fine motor tasks. Twelve patients were able to attend for formal evaluation including the Jebson and Crawford Hand Function Tests which revealed some decrease in hand function in all of those tested. It was concluded that this method of arthrodesis of the metacarpophalangeal joint of the thumb gives reliable results, with high patient acceptance, but does not result in an entirely normal thumb or hand function.     

Free vascularized fascial flap in oral cavity reconstruction

Our experience with the free vascularized fascial flap based on the radial artery used for intraoral reconstruction is described. Thirteen patients underwent primary or secondary reconstruction following major resections for malignant disease. The osseofascial flap incorporating radial bone proved to be ideal when reconstruction of composite mandibular or maxillary defects was undertaken. The flaps rapidly underwent surface epithelialization, and submucosal fibrosis provided the ideal attached mucosal lining for prosthetic rehabilitation. © 1994 John Wiley & Sons, Inc.     

Expression profiling of metalloproteinases and inhibitors in cartilage

Objective   To profile the expression of all known members of the matrix metalloproteinase ( MMP ), a disintegrin and metalloproteinase with thrombospondin motifs ( ADAMTS ), and tissue inhibitor of metalloproteinases ( TIMP s) gene families in normal cartilage and that from patients with osteoarthritis (OA).
Methods   Human cartilage was obtained from femoral heads at joint replacement for either osteoarthritis or following fracture to the neck of femur. Total RNA was purified and expression of genes assayed using quantitative real-time PCR.
Results   Several members of the above gene families were regulated in OA. Genes increasing in expression in OA were: at P  < 0.001, MMP-13 , MMP-28 , ADAMTS-16 ; at P  < 0.01, MMP-9 , MMP-16 , ADAMTS-2 , ADAMTS-14 and at P  < 0.05, MMP-2 , TIMP-3 , ADAMTS-12 . Genes decreasing in expression in OA were: at P  < 0.001, MMP-1 , MMP-3 , ADAMTS-1 ; at P  < 0.01, MMP-10 , TIMP-1 , ADAMTS-9 and at P  < 0.05, TIMP-4 , ADAMTS-5 , ADAMTS-15 . Correlation analysis revealed that groups of genes across the gene families are co-expressed in cartilage.
Conclusion   This is the first comprehensive expression profile of all known MMP , ADAMTS and TIMP genes in cartilage. Patterns of expression provide a foundation on which to understand mechanisms of gene regulation in OA and potentially for refining the specificity of anti-proteolytic therapies.     

The management of bile duct stones.

Bile duct stones are almost always associated with gallbladder stones and coexist with gallbladder stones in approximately 10% of patients. The frequency of coexisting bile duct stones increases with advancing age. In patients with stones in both the gallbladder and bile duct, therapeutic options for the latter include laparoscopic or open exploration of the bile duct, and pre-operative and post-operative endoscopic sphincterotomy and stone extraction. Endoscopic sphincterotomy remains the treatment of choice for bile duct stones after cholecystectomy. However, management algorithms in individual institutions will be influenced by surgical and endoscopic expertise and by other factors such as overall costs. After surgical or endoscopic removal of bile duct stones, estimates of the lifetime risk of recurrent stones range from 5%-20%. Increased life expectancy and the apparent absence of simple preventative measures indicate that the burden of bile duct stones on health expenditure is likely to increase in many countries.     

Improved documentation of wound care with a structured encounter form in the pediatric emergency department.

OBJECTIVE: Accurate and complete documentation may enhance reimbursement and compliance with financial intermediary regulations, protect against litigation, and improve patient care. We measured the effect of introduction of a structured encounter form on the completeness of documentation of pediatric wound management in a teaching hospital. METHODS: The Children's Hospital Emergency Department introduced a structured encounter form for use in the documentation of wound care in place of the existing free-text dictation method. Attending physicians and trainees, all unaware of the study, had the option of using the form in place of free-text dictation for patients with lacerations requiring closure. We abstracted 100 consecutive free-text dictations from patients treated before the form's introduction. Following a 3-month run-in period, we abstracted 100 consecutive structured wound records. We compared the 2 chart types for completeness of documentation based on 20 predetermined criteria relevant to pediatric wound care. RESULTS: Overall completeness of documentation improved with structured forms (80% vs 68% for free text, P < .001), with significant improvements in 6 of 20 individual criteria. Trainees demonstrated improvement in documentation with the structured form, with the greatest improvements among senior-level residents. Documentation of the general physical examination worsened with structured charting. DISCUSSION: In an academic pediatric emergency department, the use of a structured complaint-specific form improved overall completeness of wound-care documentation. Structured encounter forms may provide for more standardized documentation for a variety of pediatric chief complaints, thereby facilitating communication and ultimately transition to template-driven systems in anticipation of an electronic medical record.     

The effect of simulator training on clinical skills acquisition, retention and transfer

Context  Prior research has demonstrated that residents have poor clinical skills in cardiology and respirology. It is not clear how these skills can be improved because the number of patients with suitable clinical findings whose cooperation might help residents to better develop these clinical skills is limited.
Objectives  Our objective was to evaluate the effect of training on a cardiorespiratory simulator (CRS) on skills acquisition, retention and transfer.
Methods  We randomly allocated 146 students to CRS training in either chest pain or dyspnoea and compared each student's performance on the clinical presentation in which he or she had received CRS training with performance on the control presentation.
Results  Immediately after training, students were more accurate in identifying abnormal clinical findings on the CRS (70.0% versus 52.2%; d = 7.6, P  < 0.0001) and showed improved diagnostic performance (72.1% versus 55.6%; d = 4.3, P  = 0.0007) on the training clinical presentation. At the end of the course they were still better at identifying abnormal findings (57.1% versus 51.7%; d = 2.5, P  = 0.004) and diagnosing correctly (50.0% versus 38.1%; d = 3.0, P  = 0.002) on problems included in the training clinical presentation. However, they showed no difference between training and control presentations in diagnostic performance when required to transfer their skills between problems (45.9% versus 43.8%; P  = 0.5) or in performance on multiple-choice questions (64.1% versus 63.6%; P  = 0.8).
Conclusions  Students can acquire and retain clinical skills with CRS training, but demonstrate limited ability to transfer these to other problems. Further studies are needed to explore ways of improving learning and transfer with CRS training.     

Rotigotine transdermal patch in early Parkinson's disease: a randomized, double-blind, controlled study versus placebo and ropinirole.

Rotigotine is a new, non-ergot dopamine agonist formulated in a transdermal delivery system. The present study was to investigate the efficacy and safety of the rotigotine transdermal patch in the treatment of early Parkinson's disease. Patients (n = 561) were randomized to rotigotine, ropinirole, or placebo. The titration period was up to 13 weeks, and there was a minimum dose-maintenance period of 24 weeks for ropinirole and 33 weeks for rotigotine. The primary endpoint was the proportion of patients with a minimum of 20% decrease in the combined Unified Parkinson's Disease Rating Scale Part II and Part III scores. The responder rate in the rotigotine group was significantly higher than in the placebo group (52% vs. 30%, P < 0.0001). Transdermal rotigotine at doses < or =8 mg/24 h did not show noninferiority to ropinirole at doses < or =24 mg/day. In a post-hoc subgroup analysis, rotigotine < or =8 mg/24 hours had a similar efficacy to ropinirole at doses < or =12 mg/day. The rotigotine transdermal patch was well tolerated. The most common adverse events were application-site reactions, nausea, and somnolence. Application-site reactions were predominantly mild or moderate in intensity. In conclusion, the rotigotine transdermal patch represents an effective and safe option for the treatment of patients with early Parkinson's disease.     

The psychological and social characteristics of patients referred for NHS cosmetic surgery: quantifying clinical need.

PURPOSE: Elective cosmetic surgery is expanding in the UK in both the public and private sectors. Because resources are constrained, many cosmetic procedures are being excluded within the National Health Service. If guidelines on who can receive such surgery are to be evidence-based, information is needed about the level of dysfunction in patients referred for elective surgery and whether this is related to their degree of physical abnormality. METHOD: Consecutive patients referred to a regional plastic surgery and burns unit for assessment for elective cosmetic surgery completed standardised measures of physical and psychosocial dysfunction, and indicated their perception of the degree of their abnormality and their preoccupation with it. We distinguished between patients referred for physical reasons or appearance reasons only, and compared levels of physical and psychosocial dysfunction in each with published values for community and clinical samples. Surgeons indicated patients' degree of objective abnormality, and we identified the relationship of dysfunction with perceived and objective abnormality and preoccupation. RESULTS: Whether patients sought surgery for physical or appearance reasons, physical function was normal. Those seeking surgery for appearance reasons only had moderate psychosocial dysfunction, but were not as impaired as clinical groups with psychological problems. Patients seeking the correction of minor skin lesions for purely appearance reasons reported excellent physical and psychosocial function. Level of function was related (negatively) to patients' preoccupation with abnormality rather than to their perceived or objective abnormality. CONCLUSIONS: In general, patients referred for elective cosmetic surgery did not present with significant levels of dysfunction. Moreover, levels of functioning were related to preoccupation rather than to objective abnormality. Therefore, for most patients, whether surgical treatment is generally appropriate is questionable. Future guidelines must seek to identify the small minority who do have a clinical need for surgery.