Management of Gartland's type III supracondylar fractures of the humerus in children: the role audit and practice guidelines

In 1995, we audited the outcome following Gartland's type III supracondylar fractures of the humerus in children. Closed reduction under anaesthesia (MUA) and cast immobilisation was the treatment of choice, with the treatment changed whenever displacement occurred. The result of the audit showed that 86% of cases were treated with this method. The rate of re-operation was 45.6%. Cubitus varus deformity developed in 50% of cases. Guidelines were introduced in order to abandon the use of MUA and cast immobilisation for type III fractures. The guidelines recommended treating these fractures with rigid fixation using Kirchner (K) wires. A re-audit was conducted in the year 2000 to study the impact of introducing the guidelines. The rate of compliance was 64%. The re-audit showed a significant drop in the rate of re-operations from 45.6 to 17.7% (P = 0.0043), and a significant drop in the incidence of cubitus varus from 50 to 6.6% ( P < 0.0001). The results of the re-audit suggest that practice guidelines can have a major impact on clinical practice.

Increasing incidence of resistance to nalidixic acid in shigellas from humans in England and Wales: implications for therapy

Among shigellas isolated from patients in England and Wales in 2002, 10% of subgroups A, B and C, and 13% of subgroup D (Shigella sonnei), were resistant to nalidixic acid. As a consequence, should antimicrobial therapy be indicated, the efficacy of nalidixic acid as the preferred treatment for children with bacillary dysentery has been jeopardised.

A potentially useful distribution model for dietary intake data

BACKGROUND

Conventional mixed models for the analysis of diet diary data have introduced several simplifying assumptions, such as that of a single standard deviation for within-person day-to-day variation which is common to all individuals.

OBJECTIVE

We developed a model in which the within-person standard deviation was allowed to differ from person to person.

DESIGN

The model was demonstrated using data on daily retinol intake from the Dietary and Nutritional Survey of British Adults. The data were from 7-day weighed dietary diaries. Estimation was performed by Markov chain Monte Carlo. Reliability of the model was assessed from the accuracy of estimation of the percentage of days on which various intakes were exceeded. For levels above the median retinol intake, estimation of percentages of days with excessive intakes was most accurate using the model with varying within-person standard deviation.

SETTING

A survey of British adults aged 16-64 years.

SUBJECTS

In total 2197 adults living in the UK, 1087 males and 1110 females.

RESULTS

Under the traditional model, estimated daily intake ranged from 716.4 to 1421.8 microg depending on age and sex, with a within-person standard deviation of 4298.9 microg. Under the new model, estimated average daily intake ranged from 388.9 to 518.3 microg depending on age and sex, but with a within-person standard deviation varying between subjects with a 95% range of 29 to 8384 microg. The new model was shown to predict the percentage of days of exceeding large intakes more successfully than the traditional model. For example, the percentage of days of exceeding the maximum recommended intake (9000 microg for men and 7500 microg for women) was 2.4%. The traditional model predicted no excessive intakes, whereas the new model predicted 2.9%.

CONCLUSIONS

This model is potentially useful in dietary research in general and for analysis of data on chemical contaminants in foods, in particular.

Glutamate-receptor-mediated encoding and retrieval of paired-associate learning

Paired-associate learning is often used to examine episodic memory in humans. Animal models include the recall of food-cache locations by scrub jays and sequential memory. Here we report a model in which rats encode, during successive sample trials, two paired associates (flavours of food and their spatial locations) and display better-than-chance recall of one item when cued by the other. In a first study, pairings of a particular foodstuff and its location were never repeated, so ensuring unique 'what-where' attributes. Blocking N-methyl-d-aspartate receptors in the hippocampus--crucial for the induction of certain forms of activity-dependent synaptic plasticity--impaired memory encoding but had no effect on recall. Inactivating hippocampal neural activity by blocking alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid (AMPA) receptors impaired both encoding and recall. In a second study, two paired associates were trained repeatedly over 8 weeks in new pairs, but blocking of hippocampal AMPA receptors did not affect their recall. Thus we conclude that unique what-where paired associates depend on encoding and retrieval within a hippocampal memory space, with consolidation of the memory traces representing repeated paired associates in circuits elsewhere.

Elements of a neurobiological theory of the hippocampus: the role of activity-dependent synaptic plasticity in memory

The hypothesis that synaptic plasticity is a critical component of the neural mechanisms underlying learning and memory is now widely accepted. In this article, we begin by outlining four criteria for evaluating the 'synaptic plasticity and memory (SPM)' hypothesis. We then attempt to lay the foundations for a specific neurobiological theory of hippocampal (HPC) function in which activity-dependent synaptic plasticity, such as long-term potentiation (LTP), plays a key part in the forms of memory mediated by this brain structure. HPC memory can, like other forms of memory, be divided into four processes: encoding, storage, consolidation and retrieval. We argue that synaptic plasticity is critical for the encoding and intermediate storage of memory traces that are automatically recorded in the hippocampus. These traces decay, but are sometimes retained by a process of cellular consolidation. However, we also argue that HPC synaptic plasticity is not involved in memory retrieval, and is unlikely to be involved in systems-level consolidation that depends on HPC-neocortical interactions, although neocortical synaptic plasticity does play a part. The information that has emerged from the worldwide focus on the mechanisms of induction and expression of plasticity at individual synapses has been very valuable in functional studies. Progress towards a comprehensive understanding of memory processing will also depend on the analysis of these synaptic changes within the context of a wider range of systems-level and cellular mechanisms of neuronal transmission and plasticity.

Mental health in older adult recipients of primary care services: is depression the key issue? Identification, treatment and the general practitioner

OBJECTIVES

Mental health services for older people in primary care are relatively underdeveloped. This study has sought to determine the nature and extent of mental health problems in older people presenting to primary care and to compare this with the detection and management of mental health problems by the primary health care team (PHCT).

METHOD

Participants were patients aged 65 years and above attending a representative inner city general practice. Screening tools included the General Health Questionnaire (GHQ-28), Hospital Anxiety and Depression Scale (HADS), Mini Mental State Examination (MMSE). The PHCT used a brief checklist to rate participants for the presence of mental health problems. Follow-up interviews using the Geriatric Mental State (GMSA), Cambridge Examination for Mental Disorders in the Elderly (CAMDEX)-cognitive subscale (CAMCOG), National Adult Reading Test (NART), were carried out.

RESULTS

A high level of psychological morbidity was identified at screening (48.1%). There was a considerable degree of agreement between the HADS and GMSA, and the MMSE and GMSA at follow-up. Agreement rates between the PHCT and initial screening tools were low suggesting under-recognition of mental health problems at primary care level by the PHCT. Contributory factors included: short consultation times with a concentration on physical symptoms; few patients presenting explicitly with mental health problems; few decisions to treat or refer patients; and the general practitioners tended to monitor, or defer decisions.

CONCLUSIONS

This study found lower levels of severe mental health problems, especially depression, than reported elsewhere, but higher prevalence of psychological distress. High levels of physical and mental health co-morbidity were found. These findings suggest that planning for primary care services needs to adopt a flexible assessment model. The development of effective, time-limited protocols and screening tools to assist the PHCT in improving their identification rates is recommended. This needs to be supported by the availability of appropriate treatments for the psychological distress.

Subdural Blood Patch for the Treatment of Persistent CSF Leak After Permanent Intrathecal Catheter Implantation: A Report of Two Cases

A CSF leak that persists despite conservative therapy may significantly increase the morbidity associated with implantable intrathecal drug delivery systems. This report presents 2 cases where the application of a subdural blood patch led to the satisfactory resolution of a persistent CSF leak after previous epidural blood patches had failed.

Bladder injection of "naked" hSlo/pcDNA3 ameliorates detrusor hyperactivity in obstructed rats in vivo

The goal of these studies was to examine the potential utility of bladder instilled K+ channel gene therapy with hSlo cDNA (i.e., the maxi-K channel) to ameliorate bladder overactivity in a rat model of partial urinary outlet obstruction. Twenty-two female Sprague-Dawley rats were subjected to partial urethral (i.e., outlet) obstruction, with 17 sham-operated control rats run in parallel. After 6 wk of obstruction, suprapubic catheters were surgically placed in the dome of the bladder in all rats. Twelve obstructed rats received bladder instillation of 100 microg of hSlo/pcDNA in 1 ml PBS during catheterization, and another 10 obstructed rats received 1 ml PBS (7 rats) or 1 ml PBS containing pcDNA only (3 rats). Two days after surgery cystometry was performed on all animals to examine the characteristics of the micturition reflex in conscious and unrestrained rats. Obstruction was associated with a three- to fourfold increase in bladder weight and alterations in virtually every micturition parameter estimate. PBS-injected obstructed rats routinely displayed spontaneous bladder contractions between micturitions. In contrast, hSlo injection eliminated the obstruction-associated bladder hyperactivity, without detectably affecting any other cystometric parameter. Presumably, expression of hSlo in rat bladder functionally antagonizes the increased contractility normally observed in obstructed animals and thereby ameliorates bladder overactivity. These initial observations indicate a potential utility of gene therapy for urinary incontinence.

Neurolysis of the Trigeminal and Sphenopalatine Ganglions

Facial pain of trigeminal and sphenopalatine ganglion origin is the bain of existence for thousands of people. Treatment protocols typically begin with oral medication, usually anticonvulsants, and may progress to percutaneous and open surgical procedures. Several new medications show promise as alternatives to carbamazepine, which has been the standard first-line treatment (trigeminal neuralgia), while electromagnetic pulsed radiofrequency and gamma knife surgery are new options when the surgical route is warranted. This article will examine the anatomy of the trigeminal and sphenopalatine ganglions. Indications for neurolysis and neurolytic options will be discussed. Efficacy of the various neurolytic techniques will be thoroughly reviewed.

Developing benchmarks for prior learning assessment. Part 2: Practitioners

Part 1 of this article examined a study into the use of benchmarking for prior learning assessment (PLA). This article outlines the benchmarks and practitioner guidelines that emerged from the study. The guidance is based on the benchmarks for practice and is intended to encourage PLA practitioners and adult learners to purposefully apply proven assessment theory to a variety of personal and professional goals and needs, by developing a portfolio. The basic principles and processes necessary for effective, systematic assessment of prior learning are identified and discussed.

Developing benchmarks for prior learning assessment. Part 1: Research

AIM

The aim of the study was to develop and promote national benchmarks for those engaged in accreditation of prior learning (APL) termed 'prior learning assessment and recognition' (PLAR) assessment in Canada, in all sectors and communities. The study objectives were to gain practitioner consensus on the development of benchmarks for APL (PLAR) across Canada; produce a guide to support the implementation of national benchmarks; make recommendations for the promotion of the national benchmarks; and distribute the guide. The study also investigated the feasibility of developing a system to confirm the competence of APL (PLAR) practitioners, based on nationally agreed benchmarks for practice.

METHOD

A qualitative research strategy was developed, which used a benchmarking survey and focus groups as the primary research tools. These were applied to a purposive sample of APL practitioners (n = 91). The participants were identified through the use of an initial screening survey.

RESULTS

Respondents indicated that in Canada, PLAR is used in a variety of ways to assist with individual and personal growth for human resource development, the preparation of professionals and the achievement of academic credit. The findings of the focus groups are summarised using a SWOT analysis

CONCLUSION

The study identified that the main functions of the PLAR practitioners are to prepare individuals for assessment and conduct assessments. Although practitioners should be made aware of the potential conflicts in undertaking combined roles, they should be encouraged to develop confidence in both functions.

Three-dimensional magnetic resonance spectroscopic imaging of histologically confirmed brain tumors

The goal of this study was to determine whether presurgical metabolite levels measured by 3D MR Spectroscopic Imaging (MRSI) can accurately detect viable cancer within human brain tumor masses. A total of 31 patients (33 exams, 39 pathology correlations) with brain tumors were studied prior to surgical biopsy and/or resection. The 3D MRSI was obtained with a spatial resolution of 0.2 to 1 cc throughout the majority of the mass and adjacent brain tissue using PRESS-CSI localization. Levels of choline, creatine and NAA were estimated from the locations of the resected tissue and normalized to normal appearing brain tissue. The data were correlated with subsequent histologic analysis of the biopsy tissue samples. Although there were large variations in the metabolite ratios, all regions of confirmed cancer demonstrated significant choline levels and a mean choline/NAA ratio of 5.84 + 2.58 with the lowest value being 1.3. This lowest value is greater than 4 standard deviations above the mean (0.52 +/- 0.13) found in 8 normal volunteers. The choline signal intensities in confirmed cancers were significantly elevated compared to normal appearing brain tissue with a mean ratio of 1.71 +/- 0.69. Spectra with no significant metabolite levels were observed in the non-enhancing necrotic core of the tumor masses. The results of this study indicate that 3D MRSI of brain tumors can detect abnormal metabolite levels in regions of viable cancer and grades and can differentiate cancer from necrosis and/or normal brain tissue.

Identifying and prioritizing gaming workers' health and safety concerns using mapping for data collection

BACKGROUND

This research was prompted by the clinical presentation of workers from a variety of gaming occupations with injuries and illnesses and multiple health and safety concerns.

METHODS

Using participatory action research principles, 51 gaming workers in Ontario and 20 gaming workers in Manitoba were consulted during a series of focus group sessions. Mapping exercises were used to survey the participants about their health concerns, perceived occupational hazards and the impact of working conditions on their personal lives. Participants were then asked to prioritize their concerns and make recommendations for improvements.

RESULTS

Gaming workers from both provinces identified similar health, hazard and psycho-social concerns. They prioritized the issues of stress, ergonomics, indoor air quality (including second-hand smoke and temperature), biological hazards, physical hazards and noise.

CONCLUSIONS

This study points to a need to more fully investigate and address health and safety issues in the gaming industry. It also demonstrates the effectiveness of a worker-driven, participatory consultation.

Etiology and management of coagulation abnormalities in the pain management patient

Coagulation abnormalities and bleeding disorders are frequently encountered in patients undergoing invasive procedures. These are of particular importance in the pain management setting where even small amounts of excessive bleeding can result in devastating complications. It is imperative that physicians treating those patients under-stand the basic concepts of coagulation and be able to identify and manage the common bleeding disorders. This article provides a brief overview of the coagulation system and describes the use of appropriate screening tests and management strategies to limit bleeding in pain management procedures.

Neuromodulation: spinal cord and peripheral nerve stimulation

Spinal cord and peripheral nerve stimulation for relief of chronic intractable pain have been used since the mid-1960s. Multiple mechanisms of action have been theorized without a clear-cut winner. The early frustrations with patient selection criteria and equipment difficulties have diminished secondary to carefully controlled studies and improvements in equipment designs. Efficacy studies consistently show an overall 50% improvement in long-term pain control in patients who have failed conservative or other invasive modalities. With improvements in today's technology, one hopes that better analgesia will be attainable.

Cyclical changes in endogenous levels of oestrogen modulate the induction of LTD and LTP in the hippocampal CA1 region

The present study investigated the effects of naturally fluctuating endogenous levels of oestrogen on the induction and maintenance of long-term potentiation (LTP) and long-term depression (LTD) in the CA1 region of the hippocampus. Using an anaesthetized in vivo preparation, the results showed that the induction of LTP was augmented during the pro-oestrous stage of the oestrous cycle. In contrast to LTP, however, the induction of paired-pulse LTD was severely attenuated during pro-oestrous, but was clearly manifested by rats during met/dioestrous and oestrous stages of the cycle. These findings are discussed with reference to: (i) the modulatory effects of oestrogen on N-methyl-D-aspartate (NMDA) receptor function and gamma-aminobutyric acid (GABA) neurotransmission in the hippocampus; and (ii) the functional implications that such cyclical changes in synaptic plasticity have for learning and memory processes supported by the hippocampus.

"Best friends": the construction of a teenage friendship

A case study of a friendship between two high school students with disabilities was reported. The study was part of a research project on the social relationships of children and youth with disabilities. Ethnographic interviews and participant observations were used to accomplish two goals: (a) delineating the features of a spontaneous friendship between two young women in a self-contained high school class and (b) assisting them in pursuing social activities together outside of school. The "insider perspectives" of the participants regarding their friendship is presented as is an interpretation of factors that supported and constrained the relationship. The importance of professionals encouraging the formation of networks among the families of youth with disabilities and of respecting families' cultural perspectives is emphasized.