ASCIA guidelines for prevention of food anaphylactic reactions in schools, preschools and child-care centres

These guidelines have been developed by the anaphylaxis working party of the Australasian Society of Clinical Immunology and Allergy to provide advice for minimizing the risk of food-induced anaphylaxis in schools, preschools and child-care centres. The guidelines outline four steps for the prevention of food anaphylactic reactions in children at risk and food policy measures specific to school age and preschool age children.     

Frontal lobe epilepsy in childhood

Frontal lobe epilepsy is poorly understood and often unrecognized by health care workers caring for children. We sought to better characterize frontal lobe epilepsy in childhood and help delineate this condition from other nonepileptic events. We reviewed pediatric patients admitted to the Comprehensive Epilepsy Program at the University of Alberta Hospitals with a proven diagnosis of frontal lobe epilepsy. Twenty-two patients, 13 males and 9 females, were studied. Age of onset was variable from 10 months to 16 years (mean 7.5 years). Seizures were brief (30 seconds to 2 minutes), stereotypic, nocturnal (17/21), and frequent (3-22/night). Clinical features included explosive onset, screaming, agitation, stiffening, kicking or bicycling of the legs, and incontinence. The diagnosis of frontal lobe epilepsy was not made in any child before referral. The referring diagnosis was sleep disturbance (10), psychiatric problems (6), or other seizure types (6). Interictal electroencephalogram was usually normal (18/21). Long-term video electroencephalographic monitoring demonstrated frontal (9) or bifrontal (13) epileptic discharges. Magnetic resonance imaging was normal in most patients (18/21). Seizure control was difficult, with only half (11/21) the patients being controlled on medication. Three intractable patients went on to epilepsy surgery and became seizure-free. Frontal lobe epilepsy in childhood is a distinct epilepsy syndrome with characteristic features. The seizures are brief, stereotypic, nocturnal, and frequent. Electroencephalogram and magnetic resonance imaging are usually normal. The condition is often misdiagnosed as a sleep disorder or psychiatric problem. Seizures are difficult to control but may respond to carbamazepine, valproic acid, or epilepsy surgery.     

Stridor: unusual presentation of multiple myeloma

We present a patient with multiple myeloma whose only presenting symptom was stridor caused by a subglottic stenosis. Biopsy suggested the presence of amyloid which prompted immunological investigations that showed hypogammaglobulinaemia and the presence of Bence Jones proteinuria at 0.93 g/24 hours. Further investigation demonstrated a 15 per cent plasma cell infiltrate into the bone marrow and a lytic lesion in the mid-shaft of the right femur. Chemotherapy and localized radiotherapy were commenced. This is a most unusual presentation of multiple myeloma and shows that immunoglobulin profiles should be properly investigated in such cases.     

Anastomotic leakage after curative anterior resection results in a higher prevalence of local recurrence

BACKGROUND: The aim of this study was to determine whether leakage from a colorectal anastomosis following potentially curative anterior resection for rectal cancer is an independent risk factor for local recurrence. METHODS: The study included all patients who had a potentially curative anterior resection with anastomosis for adenocarcinoma of the rectum between 1971 and 1991 at Concord Hospital. The data were collected prospectively, with complete follow-up for at least 5 years. The Kaplan-Meier method was used to compare time to recurrence between strata of categorical variables. Proportional hazards regression was used in multivariate modelling. RESULTS: There were 403 patients in the study. After adjustment for lymph node metastases, the distal resection margin of resection, non-total anatomical dissection of the rectum and the level of anastomosis, multivariate analysis identified a significant association between anastomotic leakage and local recurrence (hazard ratio 3.8, 95 per cent confidence interval 1.8 to 7.9). CONCLUSION: Leakage following a colorectal anastomosis after potentially curative resection for adenocarcinoma of the rectum is an independent predictor of local recurrence.     

Impact of an interdisciplinary low vision service on the quality of life of low vision patients

AIM: To investigate the impact of an interdisciplinary low vision service on the vision related quality of life of service users. METHODS: 71 patients were interviewed 2 weeks before their appointment with the service and again 6 months later to assess any changes in their vision related quality of life. The majority of these patients had age related macular degeneration. RESULTS: After contact with the service the majority of patients indicated a reduction in concern about most quality of life issues. They were significantly less anxious about deterioration of their vision, safety within the home, and coping with everyday life. CONCLUSION: Improvements in many areas of their vision related quality of life indicate that this interdisciplinary low vision service has a positive impact on the lives of service users. However many patients were still unable to carry out their preferred everyday activities, and feelings of loneliness and isolation were unchanged. The identification of issues unrelieved by input from the service will be important in planning future service delivery.     

Visual perception during phacoemulsification cataract surgery under topical and regional anaesthesia

PURPOSE: To compare the subjective visual experiences of patients during phacoemulsification and intraocular lens (IOL) implantation using regional and topical anaesthesia. DESIGN: A prospective, cohort, questionnaire-based study. METHODS: The study cohort consisted of 247 patients without pre-existing ocular pathology who underwent routine phacoemulsification and IOL implantation. The mean age of the subjects was 75.4 +/- 9.4 years and 34.5% of them had a history of cataract surgery. Three different methods of local anaesthesia were used: 66 (26.7%) of the patients were given topical anaesthesia (TA); 74 (30.0%) were given sub-Tenon's anaesthesia (SA), and 107(43.3%) were given peribulbar anaesthesia (PA). The patients were interviewed immediately after surgery by theatre staff using a standardized questionnaire that investigated their intraoperative visual experiences. RESULTS: There was no significant difference between the three methods of anaesthesia regarding light perception during the surgery. However, patients undergoing surgery under TA experienced brighter light intensity levels (78.3%) than those given SA (50.0%) and PA (55.7%) (p = 0.02). A total of 69.6% of subjects who received TA reported visual perception of colours during surgery, as opposed to 56.8% of SA recipients and 49.0% of PA recipients (p = 0.02). In addition, patients under TA were more aware of surgical instruments (26.1%) than those under SA (10.8%) and PA (15.9%) (p = 0.08). The vast majority of patients in all three groups found the visual experience to be non-frightening. There were no associations between intraoperative visual impression and age or sex. Although not statistically significant (p = 0.06), prior cataract surgery appeared to alleviate some of the anxiety associated with the visual experience. CONCLUSION: Patients undergoing regional and topical anaesthesia experience a wide variety of visual sensations during surgery. The differences in visual impressions between the groups may reflect the varying degrees of optic nerve blockade that result from the different anaesthetics.     

Anti-inflammatory properties of local anesthetics and their present and potential clinical implications

Development of new local anesthetic agents has been focused on the potency of their nerve-blocking effects, duration of action and safety and has resulted in a substantial number of agents in clinical use. It is well established and well documented that the nerve blocking effects of local anesthetics are secondary to their interaction with the Na+ channels thereby blocking nerve membrane excitability and the generation of action potentials. Accumulating data suggest however that local anesthetics also possess a wide range of anti-inflammatory actions through their effects on cells of the immune system, as well as on other cells, e.g. microorganisms, thrombocytes and erythrocytes. The potent anti-inflammatory properties of local anesthetics, superior in several aspects to traditional anti-inflammatory agents of the NSAID and steroid groups and with fewer side-effects, has prompted clinicians to introduce them in the treatment of various inflammation-related conditions and diseases. They have proved successful in the treatment of burn injuries, interstitial cystitis, ulcerative proctitis, arthritis and herpes simplex infections. The detailed mechanisms of action are not fully understood but seem to involve a reversible interaction with membrane proteins and lipids thus regulating cell metabolic activity, migration, exocytosis and phagocytosis.