The treatment of late post-traumatic orbital deformities

Trauma to the orbital region may result in fractures of the bony orbit, displacement of which gives rise to malposition of the eye and diplopia. If initial treatment is not feasible or is unsuccessful, later correction may be achieved by osteotomy or reduction and stabilisation of the bony fragments, often with bone grafts. Displaced medial or lateral canthi may need to be repositioned, where feasible in an overcorrected position. Where bone grafts are necessary, the skull is now favoured as the best donor site.     

Cases of antiretroviral-associated gynaecomastia reported to the National HIV & Tuberculosis Health Care Worker Hotline in South Africa

Background

Gynaecomastia is associated with exposure to antiretroviral therapy (ART), in particular efavirenz. There is limited data on clinical characteristics of patients with ART-associated gynaecomastia in resource-limited settings and little guidance on the optimal management of this adverse drug reaction (ADR). We describe the clinical characteristics, management and outcomes of gynaecomastia cases reported to the National HIV & Tuberculosis Health Care Worker Hotline in South Africa.

Methods

We identified all gynaecomastia cases in adolescent boys and men on ART reported to the hotline between June 2013 and July 2014. We collected follow up data telephonically at monthly intervals to document clinical management and outcomes.

Results

We received 51 reports of gynaecomastia between June 2013 and July 2014; 11% of the 475 patient-specific ADR queries to the hotline. All patients were on efavirenz-based ART. Mean age was 34 years (standard deviation 12) and seven were adolescents. The median onset of gynaecomastia was 15 months after efavirenz initiation (interquartile range 6–42). Gynaecomastia was bilateral in 29 patients (57%) and unilateral in 16 (31%). Serum testosterone was quantified in 25 of 35 patients with follow up data, and was low in 2 (8%). Efavirenz was replaced with an alternative antiretroviral in 29/35 patients (83%) and gynaecomastia improved in 20/29 (69%).

Conclusions

Gynaecomastia was a frequently reported ADR in our setting, occurring with prolonged efavirenz exposure. Testosterone was low in the minority of tested cases. Most clinicians elected to switch patients off efavirenz, and gynaecomastia improved in the majority.

     

Mutations in human complement regulator, membrane cofactor protein (CD46), predispose to development of familial hemolytic uremic syndrome

Membrane cofactor protein (MCP; CD46) is a widely expressed transmembrane complement regulator. Like factor H it inhibits complement activation by regulating C3b deposition on targets. Factor H mutations occur in 10-20% of patients with hemolytic uremic syndrome (HUS). We hypothesized that MCP mutations could predispose to HUS, and we sequenced MCP coding exons in affected individuals from 30 families. MCP mutations were detected in affected individuals of three families: a deletion of two amino acids (D237/S238) in family 1 (heterozygous) and a substitution, S206P, in families 2 (heterozygous) and 3 (homozygous). We evaluated protein expression and function in peripheral blood mononuclear cells from these individuals. An individual with the D237/S238 deletion had reduced MCP levels and approximately 50% C3b binding compared with normal controls. Individuals with the S206P change expressed normal quantities of protein, but demonstrated approximately 50% reduction in C3b binding in heterozygotes and complete lack of C3b binding in homozygotes. MCP expression and function was evaluated in transfectants reproducing these mutations. The deletion mutant was retained intracellularly. S206P protein was expressed on the cell surface but had a reduced ability to prevent complement activation, consistent with its reduced C3b binding and cofactor activity. This study presents further evidence that complement dysregulation predisposes to development of thrombotic microangiopathy and that screening patients for such defects could provide informed treatment strategies.     

Clinical association of acute lateral ankle sprain with syndesmotic involvement: a stress radiography and magnetic resonance imaging study

BACKGROUND: Information concerning the clinical association between syndesmosis injury and grade of lateral ankle ligament damage would aid in the diagnosis and treatment of ankle sprains. HYPOTHESIS: Evaluation of lateral ligament injury in terms of percentage tear of both the anterior talofibular and calcaneofibular ligaments can provide information on the extent of syndesmotic involvement. STUDY DESIGN: Prospective cohort study. METHODS: Twenty-five patients volunteered to have magnetic resonance imaging examinations performed and 21 volunteered to undergo graded stress radiographs. Talar tilt angles were measured from radiographs taken with 0, 6, 9, 12, and 15 daN of force applied medially just above the ankle joint, and the percentage of ligament tear and grade of injury were determined. Scans were obtained with the foot in neutral and plantar flexion to image the anterior talofibular and calcaneofibular ligaments. RESULTS: Grades of lateral ligament injury determined by magnetic resonance imaging and graded stress radiography were the same. The extent of syndesmotic injury could be assessed for all patients. CONCLUSIONS: Intact tibiofibular ligaments were found equally frequently among patients with normal or any grade of lateral ligament damage, but the more severe injuries to the syndesmotic ligaments were associated with normal or minimally traumatized lateral ligaments. The inverse correlation can be explained on the basis of the difference between the mechanisms that precipitate these injuries.     

Malaria. A challenge for the haemodialysis and intensive care nurse

Malaria is the world's most important tropical parasitic disease. In many developing countries, and Africa in particular, malaria exacts an enormous toll in lives, medical costs, and days of lost labour. Through the use of case studies, this paper explores the effects of malaria and the patient management by the haemodialysis and intensive care nurse. All malaria cases admitted to an intensive care unit, and treated by means of haemodialysis or continuous-veno-veno-haemodiafiltration were analysed. Specific problems identified were impaired fluid and biochemical control, acid-base imbalance, disseminated intra vascular coagulation, adult respiratory distress syndrome, and haemodynamic instability. Guidelines were compiled for the nursing management of these complicated malaria cases.     

Detection and management of depression and/or anxiety for people with epilepsy in primary health care settings in Zambia

PurposeAmong the 50 million people with epilepsy (PWE) worldwide ～15 to 60% likely also suffer from depression and/or anxiety and 80% reside in low-income regions where human and technological resources for care are extremely limited.MethodsIn Zambia, we carried out a retrospective chart review of 200 randomly selected files of PWE using a structured abstraction form to systematically collect socio-demographic data and clinical details on the detection and treatment of depression and/or anxiety.ResultsOnly 2 PWE (1%) had depression diagnosed and none were given a diagnosis of an anxiety disorder. Complaints suggestive of underlying depressive and/or anxiety disorders were documented in 120 (60%), but no diagnoses were made and no referrals, investigations or treatment were offered.ConclusionsFurther research is required to establish the prevalence of depression and anxiety among PWE in sub-Saharan Africa and efforts are needed to improve screening and treatment for common, treatable psychiatric comorbidities in PWE in resource limited settings.