'Physio's not going to repair a torn tendon': patient decision-making related to surgery for rotator cuff related shoulder pain.

BACKGROUND: Rotator cuff related shoulder pain (RCRSP) is a common and disabling shoulder condition and surgical management is becoming more common. The rates and costs of surgical interventions have been on the rise. Understanding decision-making related to surgery and providing adequate information to people with RCRSP may improve patient-centred care and potentially reduce rates of surgery. OBJECTIVES: To explore the decision-making processors of people who have undertaken surgery for RCRSP. DESIGN: An in-depth thematic analysis. METHOD: Interviews were conducted with patients from Melbourne who had had surgical management for RCRSP. Data were analysed using an inductive thematic approach. RESULTS: Fifteen participants were recruited. Six key themes emerged: (1) Needing to get it done: "It was necessary to remedy the dire situation"; (2) Non-surgical treatment experience:" I knew that I'd done all I could"; (3) Mechanical problem:" Physio's not going to repair a torn tendon"; (4) Trust in medical professionals "If they told me that I needed to swallow a thousand spiders, I would have done it."; (5) Varied information sources "Dr Google played a big part in it"; (6) Organisational barriers "It was absolutely useless, my insurance." CONCLUSION: Surgery appears to be commonly precipitated by unremitted severe symptoms and failed non-surgical treatment. While there was strong trust in highly trained surgeons, decision to undergo surgery also drew on questionable pathoanatomical beliefs and instances of inadequate patient information about treatment choices and risks that may be addressed by adopting a more patient-centred care approach.IMPLICATIONS FOR REHABILITATIONUnderstanding decision-making related to surgery and providing adequate information to people with rotator cuff related shoulder pain may improve patient-centred care.Surgery appears to be commonly precipitated by unremitted severe symptoms and failed non-surgical treatment.Decision to undergo surgery sometimes drew on questionable pathoanatomical beliefs.There was strong trust in highly trained surgeons but there were instances of inadequate patient information about treatment choices and risks.

Self-reported management among people with rotator cuff related shoulder pain: An observational study.

BACKGROUND: Rotator cuff related shoulder pain is the most common cause of shoulder pain. Whilst guidelines recommend conservative management prior to imaging, injection or surgical management, recent findings suggest that patients experience management contrary to guideline recommendations. OBJECTIVES: The aim of this study was to investigate self-reported management among people with rotator cuff related shoulder pain (RCRSP) and their beliefs towards management. MATERIALS AND METHODS: Cross-sectional survey of people with RCRSP recruited when referred for imaging (n = 120). Electronic survey about demographic factors, management people had had (including imaging, injections, surgery, exercise, adjuncts), and beliefs about treatments. The frequency of various treatments was reported (separately for each cohort and traumatic onset) as well as the timing of interventions related to first-line care. RESULTS: Most people had tried exercise (99/120, 82.5%) but only one in five people reported exercise was helpful, and one in six reported it was unhelpful or made their symptoms worse. Approximately a third of the cohort reported not receiving activity modification advice (34.2%, 41/120), those that did received inconsistent information. People with both traumatic (imaging 31/43, 72.1%; injections 13/24, 54.2%, surgery 8/21, 38.1%) and atraumatic onset pain (imaging 43/77, 55.8%; injections 31/51, 60.8%, surgery 4/19, 21.1%) had similarly high rates of intervention prior to trialling conservative management. Patient beliefs in regards to management showed trends towards interventionalist care. CONCLUSION: Patient reported management of RCRSP is often inconsistent with guideline recommended management.

Association of Vitamin D Levels and type 2 Diabetes Mellitus in Asian Indians is Independent of Obesity.

BACKGROUND: A large proportion of subjects with type 2 diabetes mellitus (T2DM) in India are non-obese. Asian-Indian subjects with diabetes have been shown to have low vitamin D levels. Whether low vitamin D levels and T2DM in Asian-Indians is attributable to the associated obesity as in caucasians is unclear. Hence we studied the association of vitamin D levels and T2DM in Asian-Indians with or without obesity. METHODS: Total of 213 subjects were recruited in four groups, group 1-Non-obese diabetic, group 2-Non-obese non-diabetic, group 3-Obese diabetic and group 4-Obese non-diabetic. Subjects recruited under various groups were matched for age and sex. Anthropometry, skin-fold thickness, fasting and postprandial plasma glucose, HbA1c, fasting insulin, lipids and vitamin D levels were measured in all study subjects and were compared between the groups. RESULTS: Mean age of study population was 41.23±7.43 years. Mean BMI in groups 1,2,3 and 4 was 21.34±1.41, 20.53±2.27, 27.72±2.94 and 27.62±3.37 kg/m2 respectively. Overall 64.3% study subjects had vitamin D deficiency and 27.7% had insufficient vitamin D levels. Significantly lower vitamin D levels were found in diabetic groups 1 and 3 compared to non-diabetic groups 2 and 4. No significant difference was observed in vitamin D levels between groups 1 and 3. Similarly, no significant difference was observed in vitamin D levels between groups 2 and 4. Vitamin D levels did not show any significant correlation with BMI, waist or body fat. CONCLUSION: Vitamin D levels do not appear to be related to obesity in diabetic as well non-diabetic Asian-Indian individuals.

Primary orbital Ewing sarcoma family of tumors: a study of 12 cases.

PurposeThe purpose of this study is to discuss the clinical presentation, management, and outcomes of patients with primary orbital Ewing sarcoma family of tumors (ESFTs).Patients and methodsRetrospective study of 12 patients with biopsy-proven primary orbital ESFT.ResultsThe mean age at presentation of primary orbital ESFT was 12 years (median, 8 years; range, 5 months to 28 years). There were seven (58%) females and five (42%) males. The presenting complaints included proptosis (n=10; 83%) and swelling in the upper eyelid (n=2; 17%). The mean duration of symptoms was 9 weeks (median, 5 weeks; range, 2-24 weeks). Tumor epicenter was located in the superior orbit (n=6; 50%), lateral orbit (n=3; 25%), inferior orbit (n=2; 17%), and medial orbit (n=1; 8%). Computed tomography of the orbits revealed predominant bony lesion (n=10; 83%) or isolated soft tissue/extraosseous lesion (n=2, 17%). At presentation, extraorbital extension was noticed in 10 patients including intra cranial extension (n=7; 58%), extension into temporal fossa (n=4; 33%), nasal cavity (n=2; 17%), maxillary sinus (n=2; 17%), and ethmoid sinus (n=1, 8%). Systemic metastases at presentation was detected in five (42%) patients involving the bone marrow (n=4; 33%), kidney (n=1; 8%), and retroperitoneal lymphnode (n=1; 8%). Multi-modal treatment including a combination of neoadjuvant chemotherapy, excision biopsy/debulking, and/or radiotherapy was given. Over a mean follow-up period of 21 months (median, 7 months; range, 1-152 months), disease-related death occurred in 11 (92%) cases.ConclusionPrimary orbital ESFT is aggressive at presentation and is associated with poor prognosis.

Summer Temperature and Spatial Variability of all-Cause Mortality in Surat City, India.

BACKGROUND: Ample information is available on extreme heat associated mortality for few Indian cities, but scant literature is available on effect of temperature on spatial variability of all-cause mortality for coastal cities. OBJECTIVE: To assess the effect of daily maximum temperature, relative humidity and heat index on spatial variability of all-cause mortality for summer months (March to May) from 2014 to 2015 for the urban population of Surat (coastal) city. MATERIALS AND METHODS: Retrospective analysis of the all-cause mortality data with temperature and humidity was performed on a total of 9,237 deaths for 184 summer days (2014-2015). Climatic and all-cause mortality data were obtained through Tutiempo website and Surat Municipal Corporation respectively. Bivariate analysis performed through SPSS. OBSERVATIONS: Mean daily mortality was estimated at 50.2 ± 8.5 for the study period with a rise of 20% all-cause mortality at temperature ≥ 40°C and rise of 10% deaths per day during extreme danger level (HI: > 54°C) days. Spatial (Zone wise) analysis revealed rise of 61% all-cause mortality for Southeast and 30% for East zones at temperature ≥ 40°C. CONCLUSIONS: All-cause mortality increased on high summer temperature days. Presence of spatial variation in all-cause mortality provided the evidence for high risk zones. Findings may be helpful in designing the interventions at micro level.

Measurement of the reaction 2H(e,e') at 180 degrees close to the deuteron breakup threshold.

Inclusive inelastic electron scattering off the deuteron under 180 degrees has been studied at the S-DALINAC close to the breakup threshold at momentum transfers q=0.27 fm;{-1} and 0.74 fm;{-1} with good energy resolution sufficient to map in detail the spin flip M1 response, which governs the starting reaction pn-->dgamma of big-bang nucleosynthesis over most of the relevant temperature region. Results from potential model calculations and (for q=0.27 fm;{-1}) from pionless nuclear effective field theory are in excellent agreement with the data.

Multi-organ failure due to Mycobacterium tuberculosis and Aspergillus flavus infection after allogeneic bone marrow transplantation.

Mycobacterium tuberculosis (MT) is a serious, but rare infectious complication after allogeneic bone marrow transplantation (BMT). We describe a case of fatal sepsis due to MT and Aspergillus flavus after allogeneic BMT for Aplastic Anemia. The diagnosis was made on bone marrow biopsy and asitic fluid culture. Broadspectrum antituberculous and Amphotericin B therapy was started immediately after diagnosis. The patient developed severe hypoxia and finally died of multi-organ failure. Rapid progression of mycobacterial infection as well as fungal infection should be considered in patients post BMT with unexplained fever, particularly in patients from endemic areas.

Cerebrotendinous xanthomatosis: a treatable cause of metabolic ataxia.

Cerebrotendinous xanthomatosis is an exceptionally rare condition in Indian subcontinent, however, it is potentially treatable if diagnosed. We present and discuss the clinical presentation and investigations in a case of cerebrotendinous xanthomatosis (CTX).

A chain-binomial model for intra-household spread of Mycobacterium tuberculosis in a low socio-economic setting in Pakistan.

A simulation study using Greenwood's chain-binomial model was carried out to elucidate the spread and control of Mycobacterium tuberculosis among the household contacts of infectious pulmonary tuberculosis (TB) patients. Based on the observed data, the maximum-likelihood estimates (+/-S.E.) of chain-binomial probabilities of intra-household M. tuberculosis transmission from an index case in 3-person and 4-person households were 0.313+/-0.008 and 0.325+/-0.009 respectively. The chi2 goodness-of-fit test of observed and simulated mean expected frequencies of cases revealed good fit for 3-person (P=0.979) and 4-person (P=0.546) households. With the assumption of varying risk of M. tuberculosis transmission across the households under beta-distribution, goodness-of-fit tests of observed and mean simulated expected frequencies revealed the inadequacy of Greenwood's chain-binomial model both for 3-person (P=0.0185) and 4-person (P<0.001) households. Simulated M. tuberculosis control strategy comprising efficient diagnosis, segregation and prompt antibiotic therapy of index pulmonary TB patients showed a substantial reduction of new cases among the household contacts in both household sizes. In conclusion, segregation coupled with prompt antibiotic therapy of the index case, chemoprophylaxis of M. tuberculosis-exposed household contacts, and the assessment of household environmental risks to devise and implement an educational programme may help reduce the TB burden in this and similar settings.

Plasma homocysteine and total thiol content in patients with exudative age-related macular degeneration.

PURPOSE: Exudative age-related macular degeneration (ARMD) is one of the debilitating ocular complications, which results in permanent blindness. Elevated homocysteine (Hcys) levels have been associated in the development of several vascular diseases. Vascular and oxidative stress theories have been implicated for the development of choroidal neovascularization in exudative ARMD. The aim of the present study was to investigate the possible role of plasma Hcys and thiol content (tSH) as a risk factor for the development of exudative ARMD. METHOD: A total of 16 patients with exudative ARMD and 20 age-matched controls were recruited for the study. Plasma Hcys levels were analysed using Reverse Phase High Performance Liquid Chromatography. Plasma glutathione (GSH) content was determined using o-phthalaldehyde (OPA) derivatization and subsequent detection by fluorimeter. Plasma tSH levels were determined by using thiol-specific reagent dithionitrobenzoic acid (DTNB) spectrophotometrically. RESULTS: Plasma Hcys levels in exudative ARMD were elevated three-fold (18+/-5.0 microM) when compared to healthy controls (6.7+/-1.8 microM). There was a two-fold decrease in the GSH and tSH in exudative ARMD when compared with controls. Negative correlation was observed between diminished tSH and Hcys levels (r=-0.4837, P=0.05). Similarly plasma Hcys levels negatively correlated with GSH content (r=-0.6620, P<0.05). CONCLUSION: Results from our present study revealed that there is an elevated Hcys level and diminished thiol pool content in exudative ARMD that are significant.

Caspofungin: a major breakthrough in treatment of systemic fungal infections.

Invasive fungal infections are difficult to eradicate especially in immuno-compromised host. Amphotericin B and voriconazole have been the mainstay of treatment but both have significant toxicity. Caspofungin belongs to a new class of antifungal agents, the echinocandins. It acts on the fungal cell wall by selective inhibition of beta-(1,3)-D-glucan syntheses, which is not present in mammalian cells. In vitro data and experimental studies have demonstrated that it has antifungal activity against yeasts of the genus Candida (including those resistant to amphotericin B and azoles), severe species of filamentous fungi, including aspergillosis and certain dimorphic fungi. As an empirical antifungal therapy in neutropenic patients, it has comparable clinical efficacy but superior tolerability compared with liposomal amphotericin B. In patients with invasive candidiasis, it is as effective as amphotericin B deoxycholate. In addition, it showed a significantly superior safety profile. Same has been shown in patients with oropharyngeal/oesophageal candidiasis. In patients with invasive aspergillosis refractory to or intolerant to other antifungal agents, 45% showed a partial or complete response to Caspofungin given as a salvage treatment. Caspofungin is cidal for all Candida species and is static against Aspergillus species. It also possesses activity against Pneumocystis jiroveci. In vitro and in animals, Caspofungin shows additive or synergic antifungal activity with amphotericin B and triazoles. Recently, it's use in paediatric patients, including after bone marrow transplantation, has also been shown to be safe. With compare to other antifungal agents known to be effective in systemic fungal infections, Caspofungin has the best safety profile, tolerability with very low potential for drug interactions. This makes Caspofungin an interesting and extremely valuable new antifungal agent that broadens the available therapeutic armamentarium for the treatment of systemic fungal infections.

Long-term results of orthotopic neobladder reconstruction after radical cystectomy.

OBJECTIVE: To assess, in a retrospective study, the long-term results of neobladder reconstruction after radical cystectomy, as this is the standard of care for muscle-invasive bladder cancer. PATIENTS AND METHODS: Data were retrieved for all patients with muscle-invasive transitional cell carcinoma of the bladder treated by radical cystectomy and orthotopic neobladder substitution between 1988 and 1998. All perioperative and long-term complications were recorded. The voiding pattern, frequency of micturition and continence were assessed, and a complete urodynamic profile recorded. RESULTS: In all, 102 patients underwent radical cystectomy with orthotopic neobladder reconstruction in the study period; their mean (range) follow-up was 73 (36-144) months. Neobladder substitution was with an ileocaecal segment in 35 patients, sigmoid colon in 34 and ileum in 33. Early complications occurred in 32 patients (31%) although open surgical intervention was required in only nine (9%). The death rate after surgery was 3.9%. Late complications occurred in 31 patients (30%) and were primarily caused by uretero-enteric and vesico-urethral strictures (9% each). Most patients had daytime (89%) and night-time (78%) continence. The mean maximum pouch capacity (mL) and pouch pressure at capacity (cmH2O) were 562.5 and 23 (ileocaecal), 542 and 17.8 (sigmoid) and 504 and 19.1 (ileal), respectively; the mean postvoid residual was 29, 44 and 23 mL, respectively. Nine patients with ileocaecal neobladders, and 20 and seven with sigmoid and ileal neobladders, required clean intermittent catheterization. Twenty-four patients had recurrence of disease, of whom 20 died. CONCLUSIONS: Orthotopic neobladder reconstruction requires complex surgery but has an acceptable early and late complication rate in properly selected patients. It provides satisfactory continence without compromising cure rates.

Ketoconazole 2% shampoo in pityriasis versicolor: an open trial.

Pityriasis versicolor is a common superficial fungal infection caused by a lipophilic yeast. The aim of the study was to evaluate the efficacy of ketoconazole 2% shampoo in the treatment of pityriasis versicolor, for which thirty patients were included. The shampoo was applied daily for 3 days and found to be very effective in clearing the signs and symptoms of the disease. There was no serious adverse effects.

Localized cutaneous sporotrichosis lasting for 10 years.

A case of localized cutaneous sporotrichosis lasting for 10 years is being reported. The fixed cutaneous variety creates diagnostic difficulty by mimicking other conditions, chiefly lupus vulgaris.