Hospitalization trends in adult ocular trauma at the University Hospital of the West Indies

OBJECTIVE

To assess the epidemiology of ocular trauma in adult patients admitted to the University Hospital of the West Indies (UHWI), Jamaica, between January 2000 and December 2005.

METHODS

Retrospective review of all adult patients admitted with ocular trauma in the UHWI trauma database.

RESULTS

Three hundred and ninety-seven patients were admitted with ocular trauma during the study period; 35.8% of admissions with ocular trauma were < or = 16 years of age. There were 252 adults (> 17 years old), 21.4% (54/252) were females and 78.6% (198/252) were males. The ratio of males to females was 3.7:1. The median age of the females and males was 32 years (95% CI 27, 35.9) and 33 years (95% CI 30, 35.0), respectively. The hospitalization period ranged from 1-283 days, mean 8.8 days in the males; and ranged from 1-39 days, mean six days in the females. March had the highest mean admissions over the six years. Severe chemical burns were the cause of the longest admissions. The most commonplace of injury was the home (30.2%) followed by in the street (28.2%); only 2% were from recreation. The most common cause of ocular injury was motor vehicle accident in 18.6%. The second most common cause was from nail hammering (14.3%); of this, 97.2% were male. Females (14.8%) were more commonly admitted from chemical injuries than males (11.1%). Of the females, 50% were due to domestic dispute and 50% were accidental bleach spills.

CONCLUSION

The most common cause of ocular injury was motor vehicle accidents, nail hammering in males and chemical injuries in females. Epidemiological information is important in determining the burden of ocular disease on the population. It is essential in planning improvement in health services and patient education for prevention of serious eye injuries.

Paediatric ocular trauma admissions to the University Hospital of the West Indies 2000-2005

PURPOSE

To assess the epidemiology of paediatric ocular trauma presenting to the University Hospital of the West Indies (UHWI), Jamaica, between January 2000 and December 2005.

METHODS

Retrospective review of all paediatric patients (< or = 16 years old) admitted with ocular trauma in the UHWI trauma database.

RESULTS

Three hundred and ninety-seven patients were admitted with ocular trauma during the study period, 36.5% of admissions were < or = 16 years old. Males comprised 69.6% (101/145) of the paediatric admissions. The mean age was 8.3 years (95% CI 7.2, 9.4) and 8.7 years (95% CI 7.9, 9.4) for the females and males, respectively. The commonest place of injury was in the home: 47.5% and 50% in males and females, respectively Females were more likely to be involved in domestic disputes (4.8%). Stones (20.3%) were the most common causative agent of eye injury in children, only occurring in the 4-16-year old age group. The highest incidence for hospitalization of paediatric eye injury occurred in March and May, with the least admissions occurring in February. Contusions (48.3%) were the most common type of injury. Open globe injuries occurred in 35.9% of cases. Chemical burns were the least common type of injury. The admission period ranged from 1-58 days. The median hospitalization period was five days (95% CI 4.5, 6.0).

CONCLUSION

Paediatric ocular injury can be age specific. Contusion was the most common ocular injury and males were more likely to be hospitalized than females. Epidemiological information is important in determining the burden of ocular disease in the population. It is also essential in planning improvement in health services and patient education for prevention of serious eye injuries.

Guidelines for the treatment of myelodysplastic syndromes (MDS) in South Africa

INTRODUCTION

Myelodysplastic syndromes (MDS) encompass a heterogeneous group of clonal haematopoietic disorders characterised by chronic and progressive cytopenias resulting from ineffective haematopoiesis. Treatment is complicated by differences in disease mechanisms in different subgroups, variable clinical phenotypes and risk of progression to acute myeloid leukaemia.

RATIONALE

Changes in disease classification, prognostic scoring systems, the availability of novel treatment options and the absence of South African guidelines for the diagnosis and management of these complex disorders underpinned the need for the development of these recommendations.

METHODS

These recommendations are based on the opinion of a number of experts in the field from the laboratory as well as clinical settings and came from both the private and institutional academic environments. The most recent literature as well as available guidelines from other countries were discussed and debated at a number of different meetings held over a 2-year period.

RESULTS

A comprehensive set of recommendations was developed focusing on risk stratification, supportive management and specific treatment. Novel agents and their indications are discussed and recommendations are made based on best available evidence and taking into account the availability of treatments in South Africa.

CONCLUSION

Correct diagnosis, risk stratification and appropriate therapeutic choices are the cornerstones of success in the management of patients with myelodysplastic syndromes.

Conservative treatment for urinary incontinence in Men After Prostate Surgery (MAPS): two parallel randomised controlled trials

OBJECTIVE

To determine the clinical effectiveness and cost-effectiveness of active conservative treatment, compared with standard management, in regaining urinary continence at 12 months in men with urinary incontinence at 6 weeks after a radical prostatectomy or a transurethral resection of the prostate (TURP).

BACKGROUND

Urinary incontinence after radical prostate surgery is common immediately after surgery, although the chance of incontinence is less after TURP than following radical prostatectomy.

DESIGN

Two multicentre, UK, parallel randomised controlled trials (RCTs) comparing active conservative treatment [pelvic floor muscle training (PFMT) delivered by a specialist continence physiotherapist or a specialist continence nurse] with standard management in men after radial prostatectomy and TURP.

SETTING

Men having prostate surgery were identified in 34 centres across the UK. If they had urinary incontinence, they were invited to enroll in the RCT.

PARTICIPANTS

Men with urinary incontinence at 6 weeks after prostate surgery were eligible to be randomised if they consented and were able to comply with the intervention.

INTERVENTIONS

Eligible men were randomised to attend four sessions with a therapist over a 3-month period. The therapists provided standardised PFMT and bladder training for male urinary incontinence and erectile dysfunction. The control group continued with standard management.

MAIN OUTCOME MEASURES

The primary outcome of clinical effectiveness was urinary incontinence at 12 months after randomisation, and the primary measure of cost-effectiveness was incremental cost per quality-adjusted life-year (QALY). Outcome data were collected by postal questionnaires at 3, 6, 9 and 12 months.

RESULTS

Within the radical group (n = 411), 92% of the men in the intervention group attended at least one therapy visit and were more likely than those in the control group to be carrying out any PFMT at 12 months {adjusted risk ratio (RR) 1.30 [95% confidence interval (CI) 1.09 to 1.53]}. The absolute risk difference in urinary incontinence rates at 12 months between the intervention (75.5%) and control (77.4%) groups was -1.9% (95% CI -10% to 6%). NHS costs were higher in the intervention group [£ 181.02 (95% CI £ 107 to £ 255)] but there was no evidence of a difference in societal costs, and QALYs were virtually identical for both groups. Within the TURP group (n = 442), over 85% of men in the intervention group attended at least one therapy visit and were more likely to be carrying out any PFMT at 12 months after randomisation [adjusted RR 3.20 (95% CI 2.37 to 4.32)]. The absolute risk difference in urinary incontinence rates at 12 months between the intervention (64.9%) and control (61.5%) groups for the unadjusted intention-to-treat analysis was 3.4% (95% CI -6% to 13%). NHS costs [£ 209 (95% CI £ 147 to £ 271)] and societal costs [£ 420 (95% CI £ 54 to £ 785)] were statistically significantly higher in the intervention group but QALYs were virtually identical.

CONCLUSIONS

The provision of one-to-one conservative physical therapy for men with urinary incontinence after prostate surgery is unlikely to be effective or cost-effective compared with standard care that includes the provision of information about conducting PFMT. Future work should include research into the value of different surgical options in controlling urinary incontinence.

Is criminal violence a non-communicable disease? Exploring the epidemiology of violence in Jamaica

There is a high level of criminal violence that afflicts the Jamaican society. While it is certainly noncommunicable in the context of medicine and public health, the concepts of social contagion and the well-established fact of the intergenerational transfer of effects of trauma raise questions as to whether or not it is non-communicable in a social sense. Historically, scholars have linked Jamaican criminal violence to three main roots: poverty and urban decay, political patronage, garrisonisation and more recently to a fourth, the growth in transnational organized crime (TOC). Traditionally as well, policymakers have brought the three discrete perspectives of criminology, criminal justice and public health to bear on the problem. This paper applies a conceptual framework derived from a combination of epidemiology and the behavioural sciences to argue that a sustainable resolution to this looming and intractable social problem must take the form of a cocktail of policies that encompasses all three approaches at levels ranging from the community to the international.

A sewer ventilation model applying conservation of momentum

The work presented herein was completed in an effort to characterize the forces influencing ventilation in gravity sewers and to develop a mathematical model, based on conservation of momentum, capable of accounting for friction at the headspace/pipe interface, drag at the air/water interface, and buoyancy caused by air density differences between a sewer headspace and ambient. Experiments were completed on two full scale sewer reaches in Australia. A carbon monoxide-based tracer technique was used to measure the ventilation rate within the sewer headspaces. Additionally, measurements of pressure, relative humidity, and temperature were measured in the ambient air and sewer headspace. The first location was a five kilometre long sewer outfall beginning at a wastewater treatment plant and terminating at the ocean. The second location was a large gravity sewer reach fitted with ventilation fans. At the first location the headspace was entirely sealed except for openings that were controlled during the experiments. In this situation forces acting on the headspace air manifested mostly as a pressure distribution within the reach, effectively eliminating friction at the pipe wall. At the second location, air was forced to move near the same velocity as the wastewater, effectively eliminating drag at the air/water interface. These experiments allowed individual terms of the momentum equation to be evaluated. Experimental results were compared to the proposed mathematical model. Conclusions regarding model accuracy are provided along with model application guidance and assumptions.

Priority water research questions as determined by UK practitioners and policy makers

Several recent studies have emphasised the need for a more integrated process in which researchers, policy makers and practitioners interact to identify research priorities. This paper discusses such a process with respect to the UK water sector, detailing how questions were developed through inter-disciplinary collaboration using online questionnaires and a stakeholder workshop. The paper details the 94 key questions arising, and provides commentary on their scale and scope. Prioritization voting divided the nine research themes into three categories: (1) extreme events (primarily flooding), valuing freshwater services, and water supply, treatment and distribution [each >150/1109 votes]; (2) freshwater pollution and integrated catchment management [100-150 votes] and; (3) freshwater biodiversity, water industry governance, understanding and managing demand and communicating water research [50-100 votes]. The biggest demand was for research to improve understanding of intervention impacts in the water environment, while a need for improved understanding of basic processes was also clearly expressed, particularly with respect to impacts of pollution and aquatic ecosystems. Questions that addressed aspects of appraisal, particularly incorporation of ecological service values into decision making, were also strongly represented. The findings revealed that sustainability has entered the lexicon of the UK water sector, but much remains to be done to embed the concept operationally, with key sustainability issues such as resilience and interaction with related key sectors, such as energy and agriculture, relatively poorly addressed. However, the exercise also revealed that a necessary condition for sustainable development, effective communication between scientists, practitioners and policy makers, already appears to be relatively well established in the UK water sector.

Ablation of AMP-activated protein kinase alpha1 and alpha2 from mouse pancreatic beta cells and RIP2.Cre neurons suppresses insulin release in vivo

AIMS/HYPOTHESIS

AMP-activated protein kinase (AMPK) is an evolutionarily conserved enzyme and a target of glucose-lowering agents, including metformin. However, the precise role or roles of the enzyme in controlling insulin secretion remain uncertain.

METHODS

The catalytic alpha1 and alpha2 subunits of AMPK were ablated selectively in mouse pancreatic beta cells and hypothalamic neurons by breeding Ampkalpha1 [also known as Prkaa1]-knockout mice, bearing floxed Ampkalpha2 [also known as Prkaa2] alleles (Ampkalpha1 ( -/- ),alpha2( fl/fl ),), with mice expressing Cre recombinase under the rat insulin promoter (RIP2). RIP2 was used to express constitutively activated AMPK selectively in beta cells in transgenic mice. Food intake, body weight and urinary catecholamines were measured using metabolic cages. Glucose and insulin tolerance were determined after intraperitoneal injection. Beta cell mass and morphology were analysed by optical projection tomography and confocal immunofluorescence microscopy, respectively. Granule docking, insulin secretion, membrane potential and intracellular free Ca(2+) were measured with standard techniques.

RESULTS

Trigenic Ampkalpha1 ( -/- ),alpha2( fl/fl ) expressing Cre recombinase and lacking both AMPKalpha subunits in the beta cell, displayed normal body weight and increased insulin sensitivity, but were profoundly insulin-deficient. Secreted catecholamine levels were unchanged. Total beta cell mass was unaltered, while mean islet and beta cell volume were reduced. AMPK-deficient beta cells displayed normal glucose-induced changes in membrane potential and intracellular free Ca(2+), while granule docking and insulin secretion were enhanced. Conversely, betaAMPK transgenic mice were glucose-intolerant and displayed defective insulin secretion.

CONCLUSIONS/INTERPRETATION

Inhibition of AMPK activity within the beta cell is necessary, but not sufficient for stimulation of insulin secretion by glucose to occur. AMPK activation in extrapancreatic RIP2.Cre-expressing cells might also influence insulin secretion in vivo.

Increasing HIV transmission through male homosexual and heterosexual contact in Australia: results from an extended back-projection approach

OBJECTIVES

The aim of the study was to reconstruct the HIV epidemic in Australia for selected populations categorized by exposure route; namely, transmission among men who have sex with men (MSM), transmission among injecting drug users (IDUs), and transmission among heterosexual men and women in Australia.

DESIGN

Statistical back-projection techniques were extended to reconstruct the historical HIV infection curve using surveillance data. Methods We developed and used a novel modified back-projection modelling technique that makes maximal use of all available surveillance data sources in Australia, namely, (1) newly diagnosed HIV infections, (2) newly acquired HIV infections and (3) AIDS diagnoses.

RESULTS

The analyses suggest a peak HIV incidence in Australian MSM of approximately 2000 new infections per year in the late 1980s, followed by a rapid decline to a low of <500 in the early 1990s. We estimate that, by 2007, cumulatively approximately 20 000 MSM were infected with HIV, of whom 13% were not diagnosed with HIV infection. Similarly, a total of approximately 1050 and approximately 2600 individuals were infected through sharing needles and heterosexual contact, respectively, and in 12% and 23% of these individuals, respectively, the infection remained undetected.

DISCUSSION

Male homosexual contact accounts for the majority of new HIV infections in Australia. However, the transmission route distribution of new HIV infections has changed over time. The number of HIV infections is increasing substantially among MSM, increasing moderately in those infected via heterosexual exposure, and decreasing in IDUs.

Clinical role of flow cytometry in redefining bone marrow involvement in diffuse large B-cell lymphoma (DLBCL) - a new perspective

AIMS

The clinical role of flow cytometry in staging bone marrow in diffuse large B-cell lymphoma (DLBCL), especially its impact on outcome, remains uncertain. The aim was to determine the contribution of flow cytometry to conventional staging, and to study the impact of this revised staging on survival.

METHODS AND RESULTS

One hundred and thirteen cases of DLBCL diagnosed at The Canberra Hospital from 1996 to 2005 were identified. Blinded analysis of bone marrow (BM) morphology and flow cytometric data showed involvement on morphology (M) in 25 (22.1%) cases, on flow cytometry (F) in 21 (18.6%) cases and overall (M + F) in 32 cases (28.3%); discordance was noted in 16 cases (16.1%). Cases with and without marrow involvement on conventional staging alone (M) had no significant difference in survival (P = NS). However, when BM involvement was defined as positivity on morphology and/or flow cytometry (M + F), the median survival of patients with involvement was significantly worse than patients without involvement (P = 0.026).

CONCLUSIONS

Flow cytometry-positive cases should be included with those positive on morphology in a summative model to define BM involvement in DLBCL, as it may have a potential impact on predicting outcome.

Restoring hemostatic thrombin generation at the time of cutaneous wounding does not normalize healing in hemophilia B

BACKGROUND

We recently reported that wound healing is abnormal in hemophilia B (HB) mice [1]. The wounds show abnormal histology: s.c. hematoma formation; delayed re-epithelialization; delayed macrophage influx; and an increase in wound site angiogenesis.

OBJECTIVE

To test the hypothesis that restoring a hemostatic level of thrombin generation at the time of wounding would allow formation of an adequate platelet/fibrin plug and correct abnormalities of wound healing in HB.

METHODS

We placed a 3-mm cutaneous wound on the back of each HB or wild-type (WT) mouse. Some HB mice were treated just prior to wounding with either human factor IX (FIX) or FVIIa in a dose sufficient to normalize bleeding in a tail bleed model.

RESULTS

The average wound size over time in treated HB animals was intermediate between those in WT and untreated HB mice. However, the time to complete skin closure was not improved by treatment. Hematoma formation was decreased and macrophage influx began earlier in treated than in untreated HB animals. However, treated HB mice had evidence of ongoing low-level bleeding near the wound site, even after closure of the skin defect. Treatment also did not normalize the increased angiogenesis observed in HB mice.

CONCLUSIONS

Restoring initial hemostasis can modulate some of the parameters of wound healing. However, an extended period of adequate hemostatic function is necessary to achieve normal healing, probably because the risk of hemorrhage is increased by vascular remodeling and angiogenesis during the healing process.

A nurse-/pharmacy-led capecitabine clinic for colorectal cancer: Results of a prospective audit and retrospective survey of patient experiences

Oral chemotherapy agents provide patients with choice and home-based therapy but demand greater emphasis on patient support and education to minimise toxicities. To meet this demand, a nurse-/pharmacy-led clinic was established at the Beatson Oncology Centre in 2003 for the provision of oral capecitabine to metastatic colorectal cancer patients to provide a controlled and supportive environment. We conducted a prospective audit of 52 patients attending the clinic from March 2003 to June 2004 and a retrospective survey of patient experiences to assess clinic effectiveness. Of 52 patients, 79% completed at least 3 cycles of treatment (mean 3.5). Capecitabine was well tolerated. The dose was reduced on at least one occasion in 15 (29%) patients and 17 (30%) patients experienced at least one delay. Patient satisfaction, indicated by questionnaire responses (n=27), was high. Most patients (> or =85%) thought that the service provision was useful and well organised. The results indicate that a nurse-/pharmacy-led clinic for the provision of home-based oral capecitabine is safe, effective and acceptable to most patients. The success of this clinic can provide a model for use in other centres and in other types of cancer, such as breast cancer, where oral chemotherapy is a treatment option.