Impact of diabetes on outcomes in hand surgery.

Diabetes mellitus is associated with the development of several pathologic conditions of the hand, including carpal tunnel syndrome, Dupuytren disease, trigger digits, and limited joint mobility or cheiroarthropathy. In recent years, across a variety of surgical disciplines, increased emphasis has been placed on the impact of diabetes on treatment outcomes. This review provides an overview of the current literature regarding the effect of diabetes on outcomes of hand surgery for these common diabetes-related conditions. Taken as a whole, the best current evidence supports the efficacy of surgical interventions for the management of these conditions in diabetic individuals; however, additional research is required to determine whether the treatment outcomes are equivalent to those of nondiabetic patients, and whether diabetes is associated with an increased risk of complications.

Pathogen yield and antimicrobial resistance patterns of chronic rhinosinusitis patients presenting to a tertiary rhinology centre.

OBJECTIVES: To examine the yield and resistance profile of pathogens in chronic rhinosinusitis (CRS) patients receiving culture-directed management and to pay particular attention to the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in this population. STUDY DESIGN: Retrospective review of a CRS microbiology database. PARTICIPANTS: Consecutive CRS patients seen at the St. Paul's Sinus Centre between June 2007 and August 2008. SETTING: Canadian tertiary sinus centre. MAIN OUTCOME MEASURE: To determine the pathogens isolated, the frequency of these pathogens, and their resistance profiles. RESULTS: The most common bacterial pathogens isolated were Staphylococcus aureus, accounting for 39% of cultured samples, followed by Haemophilus influenzae (29%), Pseudomonas aeruginosa (15%), Streptococcus pneumoniae (12%), and Moraxella catarrhalis (11%). Only three cases of MRSA were found, one in a patient with cystic fibrosis. CONCLUSION: MRSA does not appear to pose a significant risk of morbidity in our patient population. However, ongoing concern regarding the increasing prevalence of S. aureus and antimicrobial resistance in chronic sinonasal disease highlights the importance of using culture-directed antimicrobial therapy with the goal of minimizing future resistance patterns.

Reinfection with hepatitis C virus following sustained virological response in injection drug users.

BACKGROUND AND AIM: Despite that 60-90% of injection drug users (IDUs) are infected with hepatitis C virus (HCV) infection, IDUs are often denied therapy based on concerns of reinfection following treatment. However, there are little data in this regard. We evaluated HCV re-infection following sustained virologic response (SVR) among HCV-infected IDUs having received HCV treatment in a multidisciplinary program. METHODS: Following treatment, participants were encouraged to return at follow-up intervals of 1 year and illicit drug use histories were obtained. In those with SVR, HCV RNA testing by PCR was performed to determine if relapse or reinfection occurred. RESULTS: Among 58 receiving HCV treatment between January 2002 and December 2006, 60% (35 of 58) achieved an SVR. Patients were followed for a median of 2.0 years following SVR (range, 0.4-5.0 years), with ongoing illicit and injection drug use reported in 54% (19 of 35) and 46% (16 of 35). Of the 35 with SVR, 28 remained HCV RNA negative during follow-up (80%), with four lost to follow-up and one dying of hepatocellular carcinoma and two cases of reinfection were observed (2 of 35). The rates of reinfection were 3.2 per 100 p-y (95% CI:0.4, 11.5) overall and 5.3 per 100 p-y (95% CI:0.6, 19.0) among those reporting injecting following SVR (n = 16). One of two participants with HCV re-infection spontaneously cleared virus following reinfection. CONCLUSION: The rate of reinfection following treatment for HCV infection among current and former IDUs engaged in a multidisciplinary program is low.

Optimizing assessment and treatment for hepatitis C virus infection in illicit drug users: a novel model incorporating multidisciplinary care and peer support.

OBJECTIVES: We evaluated assessment and treatment for hepatitis C virus (HCV) among illicit drug users accepting referral to a weekly HCV peer-support group at a multidisciplinary community health centre. METHODS: From March 2005 to 2008, HCV-infected individuals were referred to a weekly peer-support group and assessed for HCV infection. A retrospective chart review of outcomes 3 years after the initiation of the group was conducted (including HCV assessment and treatment). RESULTS: Two hundred and four HCV antibody-positive illicit drug users accepted referral to a weekly HCV peer-support group. Assessment for HCV occurred in 53% of patients(n= 109), with 13% (n= 14) having initiated or completed treatment for HCV infection before attending the support group, evaluation ongoing in 10% (n= 11) and treatment deferred/not indicated in 25% (n= 27). The major reasons for HCV treatment deferral included early disease (30%),drug dependence (37%), other medical (11%) or psychiatric comorbidities (4%). Sixty-eight percent of those deferred for reasons other than early liver disease showed multiple reasons for treatment deferral. The first 4 weeks of support group attendance predicted successful HCV assessment (odds ratio: 6.03, 95% confidence interval:3.27-11.12, P < 0.001). Overall, 28% (n= 57) received treatment. Among individuals having completed pegylated-interferon and ribavirin therapy with appropriate follow-up (n =19), the rate of sustained virologic response was 63% (12/19), despite illicit drug use in 53%. CONCLUSION: A high proportion of illicit drug users accepting referral to a weekly HCV peer-support group at a multidisciplinary health centre were assessed and treated for HCV infection. Peer support coupled with multidisciplinary care is an effective strategy for engaging illicit drug users in HCV care.

Image-guided endoscopic transsphenoidal removal of pituitary tumours.

BACKGROUND: With continuing advancements in minimally invasive endoscopic nasal and sinus surgical techniques, image-guided endoscopic transsphenoidal approaches to the pituitary gland and anterior skull base have progressively become more popular. METHODS: Clinical records were reviewed retrospectively from 2001 to 2006. Twenty-nine consecutive patients with pituitary tumours underwent transnasal endoscopic surgery. RESULTS: We outlined our endoscopic surgical technique with the use of image guidance. The duration of surgery, complications, and hospital stay were also reviewed. CONCLUSIONS: Image guidance can be applied during transnasal transsphenoidal endoscopic surgery and requires a minimal amount of time. It can reduce morbidity and allow for a more complete and safer operation with minimal postoperative discomfort. It can significantly reduce postoperative hospital stay, resulting in a reduced cost to the medical system.

Effectiveness of itraconazole in the management of refractory allergic fungal rhinosinusitis.

OBJECTIVES: Conventional management of allergic fungal rhinosinusitis (AFRS) after surgery consists of the use of steroids to immunomodulate the body's response to fungi. However, there are many side effects to prolonged steroid use, and some patients are unresponsive to standard treatment. The role of systemic antifungal drugs in AFRS is still largely unknown. This was a pilot study to evaluate the effectiveness of itraconazole, an oral antifungal drug, in the treatment of refractory AFRS. METHOD: Thirty-two patients with AFRS who had had surgery and were refractory to prednisone, steroid, and amphotericin B nasal sprays were treated with itraconazole for at least 3 months. They were evaluated with pre- and posttreatment endoscopic examinations, serum immunoglobulin E (IgE), and the 31-Item Rhinosinusitis Outcome Measure (RSOM-31) questionnaires. Monthly liver function tests were done to monitor for the hepatic side effects of itraconazole. RESULTS: Twelve cases had endoscopic improvement. Fifteen had no difference, and five had a worse endoscopic stage after 3 months. One patient had to stop treatment due to abnormal liver function tests. The mean pre- and posttreatment IgE levels were 581 microg/L and 766 microg/L, respectively. Subjectively, 9 patients (28%) reported a significant improvement, 9 (28%) had moderate improvements, and 14 (44%) reported little or no change. There was no correlation between the subjective and the endoscopic changes. CONCLUSION: Itraconazole may be useful as an adjunct in the management of AFRS. However, more studies, including a prospective randomized clinical trial, are required to determine if itraconazole is effective in the management of AFRS.

Barriers associated with the treatment of hepatitis C virus infection among illicit drug users.

BACKGROUND: Illicit drug users account for the majority of cases of HCV infection in the developed world, but few have received treatment. METHODS: We evaluated barriers to initiating HCV treatment -- including general treatment willingness -- and factors associated with these among HCV infected illicit drug users. Participants were recruited via convenience sampling from two community clinics in Canada. Individuals age >18 years with a history of illicit drug use completed interviewer-administered surveys. Those reporting positive HCV testing underwent additional questioning on willingness, uptake and barriers to treatment for HCV. RESULTS: Of 188 HCV positive illicit drug users, 16% (n=30) had received treatment for HCV. Factors associated with a decreased treatment uptake included current heroin use and HIV/HCV co-infection. Among those not having received therapy, 77% (117/153) indicated a willingness to receive HCV treatment. Factors associated with treatment willingness included not being infected with HIV, having not recently used drugs by injection and having reported physical health problems. Among those not having sought HCV treatment (n=107), the major reasons for not doing so were: lack of information about HCV or knowledge that treatment was available (23%), the absence of symptoms (20%) and the perceived side effects of treatment (14%). CONCLUSIONS: Among illicit drug users attending inner city clinics, we have observed a low uptake of HCV treatment, but a high willingness to receive therapy. An increased focus on improving education about the long-term consequences of HCV and the availability of effective treatment are important components for expanding HCV treatment among illicit drug users.

Directly observed therapy for the treatment of hepatitis C virus infection in current and former injection drug users.

BACKGROUND AND AIM: There are few studies investigating the treatment of hepatitis C virus (HCV) infection in current and former drug users. With this in mind, we sought to evaluate the antiviral efficacy of interferon alpha-2b (IFN alpha-2b) or pegylated-interferon alpha-2b (PEG-IFN alpha-2b) and ribavirin (RBV) in injection drug users (IDU) enrolled in a directly observed therapy (DOT) program, as measured by sustained virologic response (SVR). METHODS: Viremic HCV-infected IDU, with alanine aminotransferase (ALT) >1.5x upper limit of normal (ULN) were offered 24-48 week (based on HCV genotype) therapy with RBV (800-1200 mg/day, based on weight) along with IFN alpha-2b (3 million IU thrice weekly) replaced by PEG-IFN alpha-2b (1.5 ìg/kg once weekly) as it became available. All injections were directly observed. The primary endpoint was SVR. RESULTS: Overall, 40 patients (33 males) received IFN alpha-2b (12) or PEG-IFN alpha-2b (28), 55% with HCV genotypes 2 or 3. Only 14 discontinued therapy, 5 due to toxicity, 6 due to illicit drug use and 3 did not achieve an early virologic response. In an intent-to-treat analysis, the overall SVR was 55% (22/40), 64% (14/22) in subjects with genotypes 2/3. There was no significant difference in response rates among those with >6 (50%) or

Fungal cultures in patients with allergic fungal rhinosinusitis: improving the recovery of potential fungal pathogens in the Canadian laboratory.

BACKGROUND: There is no uniform consensus on how to grow fungi from sinus aspirates in the Canadian setting. Protocols vary between institutions, and the positivity rate for fungal cultures ranges between 10 and 20% even when endoscopically obvious allergic mucin is being sent to the laboratory. The aim of this study was to compare the occurrence of positive fungal cultures obtained by our institution's fungal culture method with the occurrence obtained by the Mayo Clinic's fungal culture method. The ultimate aim was to propose a modified, feasible, standardized protocol for culturing fungi from sinus aspirates in the Canadian laboratory setting. METHODS: Twenty-five allergic mucin aspirates were collected in 23 consecutive patients meeting the clinical diagnosis of allergic fungal rhinosinusitis. These samples were sent to the microbiology laboratory, where half of them were subject to our conventional laboratory protocol and the other half to the modified Mayo Clinic protocol. RESULTS: Positive fungal cultures were obtained in 16 of 25 (64%) specimens when the modified Mayo Clinic culture technique was used, with 12 cultures (48%) growing pathogenic fungus. Using our standard culture technique, 4 of 25 (16%) specimens resulted in a positive fungal culture, of which 3 grew pathogenic fungus (12%). A significantly greater fungal culture yield was obtained by the modified Mayo Clinic fungal culture technique than with our culturing technique. CONCLUSION: The modified Mayo Clinic fungal culture technique, although more costly, is a highly sensitive and effective technique for growing fungi from nasal specimens when compared with our traditional culture technique.

Effectiveness of intraoperative mitomycin C in maintaining the patency of a frontal sinusotomy: a preliminary report of a double-blind randomized placebo-controlled trial.

BACKGROUND: Postoperative scarring in the frontal recess is the most common cause of iatrogenic frontal sinusitis. Topical mitomycin-C (MMC) is an antifibroblastic agent that has been shown to reduce clinical scarring. This is a preliminary report of a double-blind, randomized, placebo-controlled trial using MMC to determine its effectiveness in reducing frontal recess stenosis after frontal sinusotomy. METHODS: All patients with chronic rhinosinusitis undergoing primary or revision bilateral image-guided endoscopic sinus surgery were enrolled. Patients requiring frontal sinus stents and those with allergic fungal sinusitis were excluded. After completion of the frontal sinusotomy, dimensions of the frontal recess were measured using curved Frazer suction diameters. A neuropattie soaked in 0.5 mg/mL of MMC was then placed into one frontal recess for 4 minutes in a randomized manner. A saline control was used for the other side. The primary surgeon was blinded to the medicated side intraoperatively and throughout the follow-up period. Measurements of the frontal recess were repeated at 1, 3, and 6 months. RESULTS: There was no difference in the degree of frontal recess stenosis between the MMC and control sides at 1, 3, and 6 months postoperatively for both primary and revision cases. CONCLUSION: One-time intraoperative topical MMC is not effective in reducing postoperative frontal recess stenosis in both primary and revision cases.

Patient quality of life improvements with and without computer assistance in sinus surgery: outcomes study.

BACKGROUND: Chronic rhinosinusitis affects millions of North Americans and has been increasing annually since 1991. This study aimed to evaluate the effectiveness of functional endoscopic sinus surgery (FESS) done with the use of computer assistance (CASS) and without the use of computer assistance on patient quality of life. As of this writing, there is no published study that measures the difference in patient quality of life with and without image guidance in endoscopic sinus surgery. METHODS: A nonrandomized prospective study was performed on 95 patients. A 31-item quality of life (Rhinosinusitis Outcome Measures Form [RSOM-31]) questionnaire was administered to patients prior to surgery and 6 months following surgery during a 3-year enrollment period. Patients assessed both rhinologic and nonrhinologic symptoms using a statistically validated scoring system. Statistical analysis was performed using both equal and unequal variance sample t-tests when appropriate. RESULTS: Statistically significant improvement in mean score analysis between preoperative and postoperative results for all symptom subgroups was reported when the entire study population was included. When the improvement in quality of life was compared between the CASS and FESS surgical groups, the CASS group demonstrated an overall greater improvement in quality of life. CONCLUSION: Quality of life restrictions in patients with chronic rhinosinusitis were greatest in the areas of nasal symptoms and sleep deprivation, which were significantly improved by endoscopic sinus surgery. Although the long-term effect of CASS as measured by patient quality of life remains relatively unknown, there appears to be a significant trend indicating greater quality of life improvement in the short- term over non-computer-assisted FESS techniques.