Ophthalmological outcome after orbital entry during anterior and anterolateral skull base surgery

OBJECT: Partial resection of the orbital bones is not uncommon during the excision of anterior and anterolateral skull base tumors. Controversy exists regarding the need for and extent of reconstruction after this procedure. The authors studied this factor in a series of patients. METHODS: The authors conducted a retrospective review of 56 patients in whom resection of 57 anterior or anterolateral skull base tumors and partial excision of the orbital bone were performed. Adverse ophthalmological outcomes were noted in 16 patients, in nine of whom adverse outcomes were believed to be directly related to resection of the orbital walls. Some degree of orbital reconstruction was performed during 23 of the 57 procedures. An adverse orbital outcome was strongly associated with resection of the orbital floor and resection of two thirds or more of two or more orbital walls, but not with the presence or absence of orbital reconstruction. The later finding, however, is likely a function of selection bias. CONCLUSIONS: In most patients elaborate orbital reconstruction is not necessary after partial excision of the orbital bones. Isolated medial and lateral orbital wall defects, or combined superior and lateral orbital wall defects, especially in cases in which the periorbita is intact, probably do not require primary reconstruction. In cases of orbital floor defects, whether isolated or part of a multiple-wall resection, primary reconstruction is recommended.     

Genetic aberrations detected by comparative genomic hybridisation in vulvar cancers

Squamous cell carcinoma of the vulva is a disease of significant clinical importance, which arises in the presence or absence of human papillomavirus. We used comparative genomic hybridisation to document non-random chromosomal gains and losses within human papillomavirus positive and negative vulvar cancers. Gain of 3q was significantly more common in human papillomavirus-positive cancers compared to human papillomavirus-negative cancers. The smallest area of gain was 3q22-25, a chromosome region which is frequently gained in other human papillomavirus-related cancers. Chromosome 8q was more commonly gained in human papillomavirus-negative compared to human papillomavirus-positive cancers. 8q21 was the smallest region of gain, which has been identified in other, non-human papillomavirus-related cancers. Chromosome arms 3p and 11q were lost in both categories of vulvar cancer. This study has demonstrated chromosome locations important in the development of vulvar squamous cell carcinoma. Additionally, taken together with previous studies of human papillomavirus-positive cancers of other anogenital sites, the data indicate that one or more oncogenes important in the development and progression of human papillomavirus-induced carcinomas are located on 3q. The different genetic changes seen in human papillomavirus-positive and negative vulvar squamous cell carcinomas support the clinicopathological data indicating that these are different cancer types.     

Infectious diseases. 6: Sexually transmitted infections: new diagnostic approaches and treatments

1. Commercially available nucleic acid amplification assays (eg, polymerase or ligase chain reaction) are now the "gold standard" tests for genital chlamydial infection and also have a role in screening for gonococcal infection. 2. Single-dose oral antibiotics are available for treatment of Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis infections. 3. Strains of N. gonorrhoeae in urban Australia are often penicillin resistant, while strains from South East Asia and those in homosexually active men may show high-level resistance to quinolones. 4. Imiquimod, a novel immune-response modifier, is now available for effective, safe, self-administered treatment of genital warts. 5. The Pap smear remains the cornerstone of screening for precursor lesions of cervical cancer, but human papillomavirus genotyping may have a role in clinical decision-making for women with equivocal or early precancerous lesions. 6. Treatment of primary genital herpes changes the clinical course, and long-term suppressive therapy is effective for those with multiple recurrences. New technologies have made diagnosis and screening easier for patients and clinicians     

Availability of Diagnostic and Treatment Services for Acute Stroke in Frontier Counties in Montana and Northern Wyoming

CONTEXT: Rapid diagnosis and treatment of ischemic stroke can lead to improved patient outcomes. Hospitals in rural and frontier counties, however, face unique challenges in providing diagnostic and treatment services for acute stroke. PURPOSE: The aim of this study was to assess the availability of key diagnostic technology and programs for acute stroke evaluation and treatment in Montana and northern Wyoming. METHODS: In 2004, hospital medical directors or their designees were mailed a survey about the availability of diagnostic technology, programs, and personnel for acute stroke care. FINDINGS: Fifty-eight of 67 (87%) hospitals responded to the survey. Seventy-nine percent (46/58) of responding hospitals were located in frontier counties, with an average bed size of 18 (11 SD). Of the hospitals in frontier counties, 44% reported emergency medical services prehospital stroke identification programs, 39% had 24-hour computed tomography capability, 44% had an emergency department stroke protocol, and 61% had a recombinant tissue plasminogen activator protocol. Thirty percent of hospitals in frontier counties reported that they met 6-10 of the criteria established by the Brain Attack Coalition to improve acute stroke care compared to 67% of hospitals in the nonfrontier counties. CONCLUSION: A stroke network model could enhance care and improve outcomes for stroke victims in frontier counties.     

Critical realism as emancipatory action: the case for realistic evaluation in practice development

Abstract  To provide rigour when preparing a research design, the researcher needs to carefully consider not only the methodology but also the philosophical intent of the study. This, however, is often absent from reported research and provides the reader with little evidence by which to judge the merits of the chosen methodology and its influence on the study. The purpose of this paper is to set out the case for critical realism as a framework to guide appropriate action in practice development and realistic evaluation for understanding the consequences of those actions.
It is evident that critical realism and critical social science share common ground. Emancipatory practice development (ePD) is based on the philosophy of critical social science and therefore by virtue is linked to the tenets of critical realism. Until now, the evaluation of ePD programme has been well served by 4th-generation evaluation. However, this paper outlines the need for a different approach to evaluation, one that is based on critical realism, that is concerned with emancipation, and that can be used in the ever-changing environment of clinical practice. Realistic evaluation not only links strongly to ePD programmes, but also serves as the basis for effective research questions that will test the outcomes of the research and inform the transferability of ePD mechanisms into differing contexts.     

A randomized clinical trial of beta carotene vs placebo for the treatment of cervical HPV infection

The objective of the study was to determine if oral beta carotene would improve abnormalities observed in Papanicolaou smears or reduce the amount of HPV DNA in genital samples. A randomized double blind placebo controlled trial was designed for 117 women with abnormal cervical morphology, not undergoing laser ablative therapy, at The Royal Women's Hospital, Victoria. Thirty milligrams of oral beta carotene were administered daily for 12 months. Post-intervention cervical cytology and the amount of HPV DNA present on tampon specimens as determined by polymerase chain reaction and Hybrid Capture were the main outcome measures. After 12 months therapy there was no difference between the beta carotene and placebo groups in Papanicolaou smear results (58% and 62% normal) and HPV positivity (42% and 46% positive) ( P > 0.86). Women taking beta carotene were not more likely to have improved cervical cytology or a decrease in the amount of HPV DNA ( P > 0.2). The median post-intervention beta carotene level was 0.63 µm ml⁻¹ (range 0.04–1.6) for the beta carotene group and 0.15 µm ml⁻¹ (range 0.02–1.51) for the lecithin group ( P < 0.0001). This clinical trial did not identify a beneficial effect of 30 mg of oral beta carotene on cervical cytology, or on the amount of HPV DNA present from tampon specimens.     

Phenotypic variation and detection of carrier status in the partial androgen insensitivity syndrome

The partial androgen insensitivity syndrome occurs in 46,XY subjects with phenotypes ranging from perineoscrotal hypospadias with cryptorchidism and micropenis (mild undervirilisation) to clitoromegaly and partial labial fusion (marked undervirilisation). Within an affected family, wide variation in the degree of genital ambiguity between individuals can be seen. Two cousins of a previously reported subject who had severe genital ambiguity and partial androgen insensitivity were investigated. Neither of the cousins had genital abnormalities as marked as the index case, who also had qualitatively abnormal androgen binding and two mutations of the androgen receptor gene. Despite marked phenotypic differences between the index case and his cousins, similar androgen binding and the same androgen receptor mutations were shown in the cousins. Furthermore, one of the androgen receptor gene mutations has been shown in the mother and sister of one of the boys indicating that they are carriers. Thus phenotypic variation in families affected by partial androgen insensitivity is dependent on factors other than abnormalities of the androgen receptor gene alone. Although carrier status in partial androgen insensitivity can be determined, the severity of genital abnormalities in an affected offspring cannot be reliably predicted.