The Impact of Chronic Obstructive Pulmonary Disease and Smoking on Mortality and Kidney Transplantation in End-Stage Kidney Disease

Background: Chronic obstructive pulmonary disease (COPD) and tobacco use are leading causes of morbidity and mortality. The prevalence and clinical impact of COPD on mortality and kidney transplantation among patients who begin dialysis therapy is unclear. Methods: We explored the clinical impact of COPD and continued tobacco use on overall mortality and kidney transplantation in a national cohort study of US dialysis patients. National data on all dialysis patients (n = 769,984), incident between May 1995 and December 2004 and followed until October 31, 2006, were analyzed from the United States Renal Data System. Prevalence and period trends were determined while multivariable Cox regression evaluated relative hazard ratios (RR) for death and kidney transplantation. Results: The prevalence of COPD was 7.5% overall and increased from 6.7 to 8.1% from 1995-2004. COPD correlated significantly with older age, cardiovascular conditions, cancer, malnutrition, poor functional status, and tobacco use. Adjusted mortality risks were significantly higher for patients with COPD (RR = 1.20, 95% CI 1.18-1.21), especially among current smokers (RR = 1.28, 95% CI 1.25-1.32), and varied inversely with advancing age. In contrast, the adjusted risks of kidney transplantation were significantly lower for patients with COPD (RR = 0.47, 95% CI 0.41-0.54, for smokers and RR = 0.54, 95% CI 0.50-0.58, for non-smokers) than without COPD [RR = 0.72, 95% CI 0.70-0.75, for smokers and RR = 1.00 for non-smokers (referent category)]. Conclusions: Patients with COPD who begin dialysis therapy in the US experience higher mortality and lower rates of kidney transplantation, outcomes that are far worse among current smokers.     

Aromatherapy massage seems to enhance relaxation in children with burns: an observational pilot study

Objective

This observational pilot study investigated effects of aromatherapy massage in paediatric burn patients.

Methods

The setting was a 17 beds level I burn unit in Cape Town, South Africa. Between January and October 2009 heart rates and respiratory rates of patients who underwent aromatherapy massage sessions were read before and after the sessions. Primary outcomes were decline in heart rates and respiratory rates, a sign of relaxation. Behavioural responses (sleep/awake state, facial expression, body posture) were documented as secondary outcomes.

Results

A convenience sample of 71 paediatric burn patients (median age 3 years) underwent a total of 126 massage sessions. Mean heart rate decreased significantly from 118 (SD 20) to 109 (SD 21), t = 9.8, p < 0.001. Mean respiratory rate decreased significantly from 34 (SD 8) to 30 (SD 8), t = 10.2, p < 0.001. Most massage sessions (92.8%) elicited positive behaviour to the massage, e.g. the child fell asleep, calmed or asked to continue. Nine patients (7.2%) with a median age of 15 months who underwent a single massage session did not show positive behaviour but cried, wriggled or were distressed.

Conclusions

Aromatherapy massage seems to be a helpful nonpharmacological approach to reduce hospitalized paediatric burn patients’ distress. Future studies with better research designs and validated outcome measures should confirm our findings.     

The role of diagnostic block in the management of Morton’s neuroma

Objective

To determine the outcome of surgical excision of Morton’s neuroma after a local anesthetic diagnostic block into the neuroma has relieved symptoms.

Design

A cohort study.

Setting

A university affiliated hospital.

Patients

A sequential series of 37 patients who underwent 41 excisions with at least 2 years’ follow-up. Seven patients had undergone repeat excision of a neuroma, and 34 primary excisions were performed. Surgery was performed by a specialist in orthopedic surgery of the foot and ankle.

Intervention

Excision of the Morton’s neuroma after a positive diagnostic block.

Main outcome measures

Grade of symptoms at follow-up done by independent review on a 4-point scale.

Results

Of 41 procedures, 11 had an unfavourable outcome: 4 procedures were graded 3, and 7 procedures were graded 4. Eight (24%) of the 34 primary procedures were reported as failures, and 3 (43%) of the 7 revision procedures were reported as failures. Most patients reported poor results owing to persistent pain.

Conclusions

Diagnostic blocks do not improve the results of surgery for excision of Morton’s neuroma and are not recommended. Because failure rates are greater than 20%, surgery for Morton’s neuroma should only be offered after a full course of nonoperative management.     

Survey of tourniquet use in orthopaedic foot and ankle surgery

BACKGROUND: Tourniquet technique varies among foot and ankle surgeons, and to establish a standard practice guideline the current standard of care should be examined. METHODS: One hundred and forty responses were received after 253 surveys were mailed to American Orthopaedic Foot and Ankle Society (AOFAS) members, concerning type of tourniquets, location, and pressures used. RESULTS: Cuff pressures most commonly used were 301 to 350 mmHg for thigh cuffs (49% of thigh cuff users) and 201 to 250 mmHG for calf and ankle cuffs (52% of calf cuff users, 66% of ankle cuff users). A substantial number of foot and ankle surgeons who use calf and ankle cuffs frequently use pressures above 250 mmHg (41% of calf cuff users, 19% of ankle cuff users). Only 9% use limb occlusion pressure when determining cuff pressure. CONCLUSION: Based on the existing evidence-based literature these pressures may be higher than necessary for many patients, and increased adoption of optimal pressure setting techniques as reported in the literature may help reduce tourniquet pressures used and risk of tourniquet injury. Respondents reported experiencing or hearing reports of breakthrough bleeding, nerve injury, and skin injuries under the cuff.     

Arthrodesis or total replacement arthroplasty for hallux rigidus: a randomized controlled trial

BACKGROUND: Arthrodesis is the current treatment for end-stage hallux rigidus, although there are many reports advocating total joint replacement arthroplasty. The aim of this randomized controlled trial was to evaluate clinical outcomes after first metatarsophalangeal joint (MTPJ) arthrodesis and replacement arthroplasty. METHODS: Between November, 1998, and January 2001, 63 patients between the ages of 34 and 77 years, with unilateral or bilateral MTPJ arthritis were recruited and randomly selected to have either MTPJ arthrodesis or arthroplasty. Twenty-two patients (38 toes) had arthrodesis and 27 patients (39 toes) had arthroplasty. A single surgeon performed all surgery. The primary outcome measure determining successful surgery was a decrease in pain as measured on a Visual Analogue Scale (VAS). Functional outcome was assessed at 6 months and 1 and 2 years. Cost data were simultaneously collected. RESULTS: At 24 months, pain improved in both groups (p < 0.001), but there were significantly greater improvements after arthrodesis (p = 0.01). All 38 arthrodeses united at a mean dorsiflexion angle of 26 degrees, with few complications. In contrast, in the arthroplasty group, six of the 39 inserted implants had to be removed because of phalangeal component loosening. In the remainder the range of motion gained was poor, and the patients tended to bear weight on the outer border of their foot. The cost ratio was 2:1 in favor of arthrodesis. CONCLUSIONS: Outcomes after arthrodesis were better than those after arthroplasty. The results were partially attributable to an unacceptably high incidence of loosening of the phalangeal components, which resulted in removal of the implants. However, even when data from the failures were excluded, arthrodesis was clearly preferred by most patients.     

Single-Center, Double-Blind, Randomized Study to Evaluate the Efficacy of 4% Lidocaine Cream versus Vehicle Cream During Botulinum Toxin Type A Treatments

BACKGROUND: Botulinum toxin type A (BTX-A) injections are overwhelmingly safe and effective treatment in cosmetic treatment, but some patients are apprehensive about pain associated with injection. OBJECTIVE: To determine whether preprocedural application of lidocaine 4% topical anesthetic cream to the injection site will reduce pain on injection of BTX-A for the treatment of crow's feet. METHODS: Twenty-four participants receiving bilateral injections for crow's feet were enrolled. Subjects were randomized to one of four study groups. Prior to BTX-A injection, group 1 (n = 6) received lidocaine 4% cream on the right side of the face and vehicle cream on the left side of the face; group 2 (n = 6) received vehicle cream on the right side and lidocaine 4% on the left side; group 3 (n = 6) received lidocaine 4% on both sides; and group 4 (n = 6) received vehicle cream on both sides. RESULTS: We observed a statistically significant reduction in subject-reported procedural pain in participants pretreated with lidocaine 4% on both sides of the face compared with controls. CONCLUSION: Lidocaine 4% cream is effective in reducing the pain associated with BTX-A injection for crow's feet. We encourage further study to clarify the optimal use of topical anesthetics in the practice of cosmetic dermatology.     

Actinomycosis of the sigmoid colon: A case report

Abdominal actinomycosis is a chronic suppurative infection caused by Actinomyces species. The ileo-cecal region is most commonly affected, while the left side of the colon is more rarely involved. The infection has a tendency to infiltrate adjacent tissues and is therefore rarely confined to a single organ. Presentation may vary from non specific symptoms and signs to an acute abdomen. A computed tomography scan is helpful in identifying the inflammatory process and the organs involved. It also allows visual guidance for percutaneous drainage of abscesses, thus aiding diagnosis. Culture is difficult because of the anaerobic character and slow growth of actinomycetes. Colonoscopy is usually normal, but may shows signs of external compression. Preoperative diagnosis is rare and is established only in less than 10% of cases. In uncomplicated disease, high dose antibiotic therapy is the mainstay of treatment. Surgery is often performed because of a difficulty in diagnosis. Surgery and antibiotics are required in the case of complicated disease. Combined medical and surgical treatment achieves a cure in about 90% of cases. The authors report a case of sigmoid actinomycosis where diagnosis was made from the histology, and a review of the literature is presented.     

Bilateral Total Joint Arthroplasty : The Early Results from the New Zealand National Joint Registry

This study evaluated the mortality rate, major complications, and early outcomes of single anesthetic bilateral total hip and knee arthroplasty compared with unilateral and staged procedures. A total of 37 828 total hip and knee arthroplasties were evaluated with 6-month Oxford 12 scores. Major complications and mortality rates were recorded. Analysis of variance tables were used for statistical analysis. The single anesthetic bilateral group were significantly younger (P < .001), with their age-adjusted postoperative Oxford 12 scores significantly better (P < .001) than the other 2 groups. The surgeons involved, in general, performed more than 25 total knee and hip arthroplasties per year. There was 1 death within the first 6 months occurring in the staged bilateral group and was unrelated to the surgery. The complication rate as reported by patients was low in all groups, and there was no significant difference. The results show that, in selected patients, single anesthetic bilateral total knee or hip arthroplasty is a safe, low-risk procedure with very good patient-generated outcome scores at 6 months when performed by an experienced surgeon.