Major lower limb amputation – what,why and how to achieve the best results

This article is intended as an overview of rehabilitation following major lower limb amputation; which surgical techniques can improve outcomes, why they should be considered and how the rehabilitation team works once patients have left the care of the surgical team. It is aimed primarily at orthopaedic and trauma surgeons, but also contains references to dysvascular patients, as this is the primary cause of lower limb amputation in the UK. The different aspects of rehabilitation after an amputation will be presented using the World Health Organization’s international classification of functioning, disability and health. The domain of health condition includes the aetiology of amputation and a brief history of prosthetic provision. The impairment section covers surgical techniques and how they can help improve outcomes for patients along with pre and post-operative pain management. An activity section contains an introduction to physiotherapy and early walking aids, with an overview of prosthetic assessment and the common component types. The participation section goes into appropriate goal setting and realistic outcomes that patients can expect. The final section on social and environmental factors briefly covers psychology and motivation. A vignette of key learning points concludes the article.     

Congenital cutaneous lymphadenoma

Cutaneous lymphadenoma is an uncommon benign neoplasm often considered to be an adamantinoid variant of trichoblastoma. Lesions present in both sexes, between 14 and 87 years of age, and are mainly located on the head and neck. Cases in children are rare and there is only 1 previous case of a congenital lymphadenoma. An 8‐year‐old Asian girl presented with a congenital lesion on her forehead comprising 4 pink papules, the largest 5 mm in diameter. Microscopy revealed a well‐circumscribed tumor within the dermis and subcutis comprising well‐demarcated epithelial lobules of basaloid and clear cells with subtle peripheral palisading, growing in a collagenous stroma but lacking retraction artefact. A relatively dense accompanying predominantly lymphocytic inflammatory cell infiltrate including both T‐cells (CD3+) and B‐cells (CD20+) permeated the nodules and spilled into the stroma. CD68+ histiocytes and CD1a+ Langerhans cells were moderately numerous. This is the second case of congenital lymphadenoma which—in spite of its rarity in childhood—widens the diagnostic possibilities of cutaneous lymphoepithelial tumors in children.     

Use of parenteral iron products and serious anaphylactic‐type reactions

Controversy exists about the safety of the parenteral iron dextran products, Dexferrum and INFeD, which have been associated with rare, serious anaphylactic‐type reactions. In the United States, their product labels carry boxed warnings of this adverse event; some have called for the withdrawal from marketing of the higher molecular weight Dexferrum. Between 2002 and 2007, sales of Dexferrum, INFeD, and iron gluconate Ferrlecit declined 32.5%, 21%, and 4.8%, respectively, while sales of iron sucrose Venofer increased 160%. Voluntary reports submitted to the Food and Drug Administration show anaphylactic reactions and symptoms for the four parenteral iron products. Because of underreporting, possible differential reporting, absence of iron dextran brand names, and incomplete use (denominator) data, incidence rates and relative risk estimates cannot be calculated. U.S. death certificate data show that for most years from 1979 through 2006, no more than 3 deaths per year were coded to “adverse events in therapeutic use of iron preparations;” brand names were not consistently recorded. Emergency department data show small numbers of visits for treatment of allergic reactions with intravenous iron preparations. The data presented herein show that allergic reactions are possible with all four parenteral iron products, and it is difficult to determine which product has the largest risk based on sales data, voluntarily submitted adverse event reports, death certificates, ED visits, and observational studies performed to date. To help differentiate risk among the parenteral iron products, the brand name of the product always should be provided on medical records, death certificates, and adverse drug reaction reports. Am. J. Hematol., 2010. Published 2010 Wiley‐Liss, Inc.     

Hepatitis B awareness,knowledge, and screening among Asian Americans

BACKGROUND: Due to the high prevalence of hepatitis B, Asian Americans have high rates of liver cancer. Screening for hepatitis B leads to monitoring and treatment and prevent further infection through vaccination of contacts. METHODS: We reviewed the published literature up to 2006 on hepatitis B awareness, knowledge, and screening among Asian Americans. RESULTS: Many Asian Americans lack knowledge about hepatitis B and have not been screened. Sociodemographics, knowledge, beliefs, and health care variables are associated with screening. CONCLUSIONS: Further research and health policy changes are needed to address the problem of hepatitis B and liver cancer among Asian Americans.     

Investigation into the subambient behavior of aqueous mannitol solutions using temperature-controlled Raman microscopy.

The aim was twofold; to demonstrate the ability of temperature-controlled Raman microscopy (TRM) to locate mannitol within a frozen system and determine its form; to investigate the annealing behavior of mannitol solutions at -30 degrees C. The different polymorphic forms of anhydrous mannitol as well as the hemihydrate and amorphous form were prepared and characterized using crystal or powder X-ray diffractometry (XRD) as appropriate and Raman microscopy. Mannitol solutions (3% w/v) were cooled before annealing at -30 degrees C. TRM was used to map the frozen systems during annealing and was able to differentiate between the different forms of mannitol and revealed the location of both beta and delta polymorphic forms within the structure of the frozen material for the first time. TRM also confirmed that the crystalline mannitol is preferentially deposited at the edge of the frozen drop, forming a rim that thickens upon annealing. While there is no preference for one form initially, the study has revealed that the mannitol preferentially transforms to the beta form with time. TRM has enabled observation of spatially resolved behavior of mannitol during the annealing process for the first time. The technique has clear potential for studying other crystallization processes, with particular advantage for frozen systems.     

Changes in food intake and body weight associated with basic combat training

This research project evaluated changes in food selections, food intake, and body weight during 8 weeks of basic combat training (BCT). During the first week of BCT, 139 soldiers from two companies volunteered for participation in the study. In the eighth week of BCT, 92 soldiers were available for retesting. A digital photography method for measuring food selections and food intake was developed for this study. Fruit intake of soldiers was very low at the beginning and end of BCT. Food intake for grains and milk products was low during the first week of BCT but improved by the end of BCT. Average body weight decreased during the 8 weeks of BCT, but heavier soldiers tended to lose weight and thinner soldiers tended to gain weight. These findings suggest that the overall effect of BCT was a trend toward improvement of healthy eating and healthy body weight.     

Functional outcome of burst fractures of the thoracolumbar spine managed non-operatively,with early ambulation,evaluated using the load sharing classification

The purpose of this prospective study was to assess the functional outcome of conservative treatment with early ambulation of thoracolumbar burst fractures, using the Load Sharing classification. From 1997 to 2001, 60 consecutive patients with single-level thoracolumbar spinal injury, with no neurological impairment, were classified according to the Load Sharing scoring and were managed non-operatively. A custom-made thoracolumbosacral orthosis was worn by all patients for six months, and early ambulation was recommended. Several radiological parameters were evaluated; the Denis Pain and Work Scale was used to assess the clinical outcome. The average follow-up period was 42 months (range, 24 to 55 months). During this period the spinal canal occupation was significantly reduced. Other radiological parameters, such as Cobb's angle and anterior vertebral body compression, showed loss of fracture reduction, which was not statistically significant. However, the functional outcome was satisfactory in 55 of 60 patients with no complications recorded on completion of treatment. Load Sharing scoring is a reliable and easy-to-use classification for the conservative treatment and prognosis of thoracolumbar spinal fractures. Because of the three characteristics of the fracture site this classification can also predict the structural results of spinal injury, such as posttraumatic kyphosis, as well as the functional outcome in conservatively treated patients.     

Ovarian cancer: patterns of care in Victoria during 1993-1995

OBJECTIVE: To describe the management of and outcomes in patients with newly diagnosed ovarian cancer during 1993, 1994 and 1995 in Victoria. DESIGN AND SETTING: Retrospective cohort study conducted by surveying doctors involved in managing incident ovarian cancer cases identified from the population-based Victorian Cancer Registry. The survey was conducted in 1997 and the cohort was followed up until the end of 1999 to obtain at least four years of follow-up data on all patients. PATIENTS: All women with invasive epithelial ovarian cancer diagnosed during 1993, 1994 and 1995. MAIN OUTCOME MEASURES: Reported management in terms of staging, treatment and survival. RESULTS: Management details were obtained for 84.5% (562/665) of eligible patients. Median age at diagnosis was 66 years (range, 22-98 years). Surgery was the primary therapy in 77.2% of women (434/562). Only one in three women had adequate surgery, which was less likely to be performed by general gynaecologists and general surgeons than gynaecological oncologists (21.3% [35/164] v 13.3% [8/60] v 52% [105/202]). After surgery 78.6% of women (341/434) received chemotherapy, usually with platinum-based regimens. The overall five-year relative survival was 46% for women treated surgically; poor survival was related to increasing age, later tumour stage, presence of ascites, residual disease > 2 cm and poorer histological differentiation of the tumour. CONCLUSIONS: For optimal care a preoperative carcinoma antigen (CA)-125 assay, chest x-ray and pelvic ultrasound should be performed, and early referral to a multi-disciplinary unit for definitive surgery is advised. Every effort should be made to adequately stage or debulk the tumour. Women with high-risk early-stage and advanced disease should be considered for platinum-based chemotherapy.     

“It’s a Balancing Act!”: Exploring School/Work/Family Interface Issues Among Bilingual,Rural Nebraska,Paraprofessional Educators

Abstract: Nebraska’s rural school districts have a rapidly growing Spanish‐speaking student body and few qualified instructors to meet their educational needs. This investigation examined factors that promote and challenge the ability of rural Nebraska paraprofessional educators to complete an online B.S. program in elementary education, with a K‐12 English as a second language endorsement. Interviews focused on the interface between school, work, and family, with special attention on family system change and adaptation. Twenty‐six bilingual paraprofessional educators enrolled (or formerly enrolled) in the education program were interviewed. Twenty were first‐ (n= 15) or second‐generation (n= 5) immigrant Latino/as. Influences of program involvement on the marital and parent‐child relationships are discussed, as are implications for future work with unique populations.