A multicentre, randomized, double-blind trial of the safety and efficacy of mannose-6-phosphate in patients having Zone II flexor tendon repairs.

The safety, tolerability and preliminary efficacy of mannose 6-phosphate in enhancing the outcome in Zone II flexor tendon repair was studied in a multicentre parallel double-blinded randomized controlled trial. Eight UK teaching hospitals were involved in treating repaired flexor tendons with a single intraoperative intrathecal dose of 600 mM mannose 6-phosphate, with follow-up over 26 weeks. A total of 39 patients (mannose 6-phosphate, n = 20; standard care, n = 19) were randomized. Seven were excluded from the safety and tolerability analysis because of intraoperative findings and eight were excluded due to early dropout (n = 4) or tendon rupture (n = 4), leaving 24 (mannose 6-phosphate, n = 13; standard care, n = 11) for assessment of total active motion. The safety, tolerability and other side effects were comparable between the groups. There was no significant difference between the two groups in the total active motion at Week 26. We concluded that mannose 6-phosphate, although safe and tolerable, had no beneficial effect on finger range of motion after Zone II tendon division.Level of evidence 1b.

The results of pollicization for congenital thumb hypoplasia.

We assessed pollicizations performed by one surgeon; compared function of the pollicized digit in patients with and without forearm/wrist anomalies; and determined if hand function changed with age. A total of 42 hands were assessed an average of 5.7 years post-operatively, 21 with a forearm/wrist anomaly (Group 1) and 21 without (Group 2). Fourteen patients with 16 pollicizations were assessed on two occasions 3.5 years apart. Carpometacarpal joint motion was near normal in both groups (decreased retropulsion in Group 1). Metacarpophalangeal and interphalangeal joint flexion, grip, thumb lateral and tip pinch strengths, and Jebsen timed test were superior in Group 2. Subjective assessment by patients/parents found 72% excellent/good results for function and 94% for appearance. Doctor excellent/good assessments were 60% and 70%, respectively. Forearm/wrist anomalies significantly compromised results but are not a contraindication for pollicization. Strength and Jebsen timed test measurements improved at the second assessment of 16 thumbs, but this was consistent with age-related improvement. LEVEL OF EVIDENCE 4.

Zone 1 flexor tendon injuries: a review of the current treatment options for acute injuries.

Zone 1 flexor tendon avulsion and laceration injuries are commonly managed by plastic surgeons. These injuries are traditionally repaired using the button pullout technique originally described by Bunnell in 1940. The morbidity related to this method is well documented and this has lead to the development of alternative repair methods. These include modifications of the pullout button technique, internal suture techniques and more recently techniques using bone anchors. However, at present no one technique has been shown to be superior to the others either in terms of outcome or low complication rates. This review examines the published techniques for dealing with these injuries with a view to providing the reader with the available outcome data for each repair type.

The outcomes of zone 1 flexor tendon injuries treated using micro bone suture anchors.

This article evaluates the outcome of 42 consecutive zone 1 flexor tendon injuries treated by using micro bone anchors during the period 2003-2008. Patients were rehabilitated using the modified Belfast Regime. The range of motion at the distal interphalangeal joint was assessed using Moiemen's classification. A total of 56% of patients achieved excellent or good results for range of motion at the distal interphalangeal joint and 23% had a poor outcome. The mean distal interphalangeal joint and proximal interphalangeal joint range of motion were 48° and 96°, respectively. A total of 94% of patients returned back to work by 12 weeks. One patient sustained a tendon rupture and one developed osteomyelitis. The mean QuickDASH score was 13.5 and 81% of patients were satisfied with their outcomes. This is the largest clinical study on the use of bone anchors for zone 1 tendon injuries. Our study demonstrated a low rate of complications and outcomes that compare favourably with other published techniques.

The oldest reported mirror hand? The curse of the coal-house frog!

Despite being one of the rarest congenital upper limb abnormalities, a wide spectrum of the typical mirror hand has been described in the literature. We report a very interesting case of a new variant of mirror hand presenting in a 78-year-old man. The unique features of the case include the age at diagnosis, the anatomical features present and the acquired function despite no form of reconstructive surgery.

A quick and effective method of limb preparation with health, safety and efficiency benefits.

INTRODUCTION: Pre-operative limb preparation (PLP) usually involves lifting the limb and holding it in a fixed 'static' posture for several minutes. This is hazardous to theatre staff. Furthermore, 'painting' the limb can be time consuming and difficult areas such as between toes and fingers may remain unsterile. We demonstrate the time efficiency and asepsis achieved using the 'sterile bag' preparation technique. An additional advantage is the ability to prepare and anaesthetise a limb prior to theatre, increasing efficiency substantially for units with a large throughput of cases, such as day-case hand surgery lists. METHODS: We monitored the duration of PLP in 20 patients using the 'sterile bag' technique compared to 20 patients using a conventional 'painting' method. Additionally, microbiology samples acquired from prepared upper limbs of 27 sequential patients operated on by a single surgeon over a two-month period were sent for culture immediately prior to commencement of surgery. RESULTS: The mean duration of the 'sterile bag' PLP was significantly lower than that of the conventional method (24 seconds vs 85 seconds, p=0.045). The technique can take as little as ten seconds (n=1). Final microbiology reports showed no growth for any of the 27 patients from whom a culture sample was taken. CONCLUSIONS: The sterile bag technique is effective in achieving asepsis, has the potential to increase theatre efficiency and reduces manual handling hazards compared to the conventional method. It is now taught to all theatre staff in our hospital during manual handling training. It can be undertaken in approximately ten seconds with practice for the upper limb.

Change in operative workload for rheumatoid disease of the hand: 1,109 procedures over 13 years.

Orthopaedic literature regarding lower limb joints reports a decline in operative management of rheumatoid arthritis since the 1980s. We investigated whether the demand for hand surgery for rheumatoid disease had changed over the last 13 years in our unit. Data for all patients undergoing operative treatment for rheumatoid arthritis of the hand and wrist over a 13-year period were analysed. Between 1996 and 2009, 1,069 patients with rheumatoid disease (182 men, 887 women) underwent a total of 1,109 hand surgery procedures. The operations were synovectomy (430, 39%), arthroplasty (252, 23%), arthrodesis (194, 18%) and tendon surgery (233, 21.0%). Linear regression analysis showed a statistically significant decrease in the number of synovectomies, arthroplasties and arthrodeses between 1996 and 2009, but no decrease in tendon surgery. We explore possible factors responsible for this change in operative workload.

Intra-abdominal femoral nerve reconstruction following excision during right hemicolectomy.

Iatrogenic femoral nerve injury is an uncommon but recognised complication of abdominal and gynaecological surgery. There have been several reported cases following colorectal surgery which specifically report transient femoral nerve neuropathies with variable but often full recovery. To our knowledge, this is the first documented case of femoral nerve reconstruction after iatrogenic resection during right hemicolectomy. We present a case report of complete femoral nerve transection following abdominal surgery and discuss our management.

Outcomes of hospitalisation for right heart failure in pulmonary arterial hypertension.

The aim of this study was to examine the causes and outcomes of hospitalisation in patients with pulmonary arterial hypertension (PAH). 205 consecutive hospitalisations occurring between 2000 and 2009 in 90 PAH patients were studied. The leading causes for hospitalisation were right heart failure (RHF; 56%), infection (16%) and bleeding disorders (8%). For patients with RHF, in-hospital mortality was 14% overall, 46% for patients receiving inotropes and 48% for those admitted to the intensive care unit. The predictors for in-hospital mortality were the presence of connective tissue disease (CTD) (OR 4.92), systolic blood pressure <100 mmHg (OR 4.32) and Na ≤ 136 mEq · L(-1) (OR 4.29). Mortality after discharge was 13, 26 and 35% at 3, 6 and 12 months, respectively. World Health Organization functional class prior to admission, renal dysfunction, Charlson comorbidity index, and the presence of CTD were all predictors of mortality after discharge. Hyponatraemia and low systolic blood pressure upon admission and underlying CTD are the main prognostic factors for in-hospital mortality in patients with PAH admitted for RHF. The short-term outcomes after discharge are poor and remarkably worse in patients with underlying CTD or renal impairment. Early recognition of these factors may guide decisions regarding more aggressive therapy, including consideration for lung transplantation.

Disproportionate elevation of N-terminal pro-brain natriuretic peptide in scleroderma-related pulmonary hypertension.

N-terminal pro-brain natriuretic peptide (NT-proBNP) is a marker of neurohormonal activation that is useful in the diagnosis and prognosis of various forms of pulmonary arterial hypertension (PAH). We sought to characterise and compare NT-proBNP in a cohort of PAH related to systemic sclerosis (PAH-SSc) and idiopathic PAH (IPAH) patients. NT-proBNP levels, collected from PAH-SSc and IPAH patients followed prospectively, were compared and correlated with haemodynamic variables. Cox proportional hazard models were created to assess the predictive value of NT-proBNP. 98 patients (55 PAH-SSc, 43 IPAH) were included. Haemodynamics were similar, except for lower mean pulmonary arterial pressure in PAH-SSc. NT-proBNP levels were significantly higher in PAH-SSc (3,419+/-3,784 versus 1,393+/-1,633 pg x mL(-1); p<0.01) and were more closely related to haemodynamics in PAH-SSc than IPAH. 28 patients died. NT-proBNP predicted survival (hazard ratio (HR) 3.18; p<0.01) in the overall cohort; however, when stratified by group, predicted survival only in PAH-SSc (HR 3.07, p<0.01 versus 2.02, p = 0.29 in IPAH). This is the first description showing NT-proBNP levels are 1) significantly higher in PAH-SSc than IPAH despite less severe haemodynamic perturbations, and 2) stronger predictors of survival in PAH-SSc, suggesting that neurohormonal regulation may differ between PAH-SSc and IPAH. Future studies to define pertinent mechanisms are warranted.

Sting-ray injuries to the hand: case report, literature review and a suggested algorithm for management.

Sting-ray injuries have recently had high profile media coverage following a rare fatality. However, minor injuries to the hands and feet are common. We present a case of a sting-ray injury to the hand. This was washed out under local anaesthetic at the local emergency department and was a delayed presentation to a specialist hand surgeon, 1 month post injury with severe pain. Ultrasound scan showed synovitis of the palm, confirmed at synovectomy the following day, along with frankly necrotic lumbrical muscles. Histology showed extensive low grade chronic inflammation. At 1 month follow up the patient was pain free and making good progress with a full and functional range of movement. We review the available literature and discuss the circumstances and pathophysiology of the sting-ray sting, the most appropriate first aid management, need for prompt surgical exploration and wound debridement and the possible complications. We would also like to suggest an algorithm for the management of sting-ray injuries to the hand.

Epidermal growth factor therapy and wound healing--past, present and future perspectives.

The role ofepidermal growth factor (EGF) has been extensively investigated in normal and pathological wound healing. It is implicated in keratinocyte migration, fibroblast function and the formation of granulation tissue. Since the discovery of EGF, the first growth factor to be isolated, over 45 years ago, growth factor therapy has progressed into clinical practice in the treatment ofwounds. The investigation EGF in wound healing has progressed from the treatment of acute wounds, to its limited effect in chronic wounds. EGF is readily degraded in the chronic wound environment, but with the recent focus of research in new drug delivery systems that are able to protect and stabilise the protein, the potential healing effects of EGF are at the forefront of research. In this review, the history of EGF and wound healing research is considered, as are current and future therapeutic options.

Mu-opioid antagonists for opioid-induced bowel dysfunction.

BACKGROUND: Opioid-induced bowel dysfunction (OBD) is characterized by constipation, incomplete evacuation, bloating, and increased gastric reflux. OBD occurs both acutely and chronically, in multiple disease states, resulting in increased morbidity and reduced quality of life. OBJECTIVES: To compare the efficacy and safety of traditional and peripherally active opioid antagonists versus conventional interventions for OBD. SEARCH STRATEGY: We searched MEDLINE, the Cochrane Central Register of Controlled Trials and EMBASE in January 2007. Additional reports were identified from the reference lists of retrieved papers. SELECTION CRITERIA: Studies were included if they were randomized controlled trials that investigated the efficacy of mu-opioid antagonists for OBD. DATA COLLECTION AND ANALYSIS: Data were extracted by two independent review authors and included demographic variables, diagnoses, interventions, efficacy, and adverse events. MAIN RESULTS: Twenty-three studies met inclusion criteria and provided data on 2871 opioid antagonist-treated patients. The opioid antagonists investigated were alvimopan (nine studies), methylnaltrexone (six), naloxone (seven), and nalbuphine (one). Meta-analysis demonstrated that methylnaltrexone and alvimopan were better than placebo in reversing opioid-induced increased gastrointestinal transit time and constipation, and that alvimopan appears to be safe and efficacious in treating postoperative ileus. The incidence of adverse events with opioid antagonists was similar to placebo and generally reported as mild-to-moderate. AUTHORS' CONCLUSIONS: Insufficient evidence exists for the safety or efficacy of naloxone or nalbuphine in the treatment of OBD. Long-term efficacy and safety of any of the opioid antagonists is unknown, as is the incidence or nature of rare adverse events. Alvimopan and methylnaltrexone both show promise in treating OBD, but further data will be required to fully assess their place in therapy.

An analysis of 1361 aesthetic procedures from 2000 to 2005 in a large regional plastic surgery unit: implications for cosmetic surgery training.

One of the challenges facing our profession is the adequate training of plastic surgeons in the subspeciality of aesthetic surgery, in addition to covering the rest of the large curriculum. The UK's Chief Medical Officer, Professor Sir Liam Donaldson, has recently called for better training for doctors, better information for patients, and a touger regulatory structure for private cosmetic surgery. In this study, we show that the training of cosmetic procedures in our unit has risen steadily over the 6 year period studied. As part of our committment to improving training, our unit has recently organised a 3 month block soely dedicated to aesthetic surgery, allowing increasing exposure to cosmetic clinics and theatre sessions. It is clear that as a group, we must continue to develop robust training schemes to produce plastic surgeons able to cope with the demands of 21st Century healthcare, and ensure that the public does not fall prey to practitioners in unregulated clinics.

Dorsal Dupuytren's disease causing a swan-neck deformity.

A previously undescribed lesion of Dupuytren's disease is presented. An oblique cord coursed parallel to the oblique retinacular ligament of Landsmeer, but inserted proximal to the proximal interphalangeal joint, tethering the central slip and radial lateral band across the intervening transverse retinacular ligament. Contraction of this cord caused a rigid swan-neck deformity. Excision of the cord resulted in complete resolution of the deformity and a full range of motion in the affected digit.

A comparison between optimal and actuarial health care costs of adolescents with diabetes.

OBJECTIVE: To assess actuarial cost and cost of optimal standards of care for adolescents with type 1 diabetes in a tertiary, hospital-based care setting. To also assess actuarial costs of diabetic adolescents in psychosocial crisis. METHODS: Contact diaries were maintained over a 1-year period (June 1999-June 2000). Contacts recorded included both structured and non-structured clinical encounters with contact times recorded. In addition, optimal or 'ideal' hospital-based support and contact times for adolescents were estimated and recorded in minutes per year. Three illustrative cases of adolescents in psychosocial crisis were also assessed in terms of actuarial health care professional contact times. Costs were then calculated according to Victorian hospital pay structures per professional for 1999-2000. RESULTS: The mean and median actuarial costs of caring for patients aged between 10 and 19 years were 1307 Australian dollars per year and 515 Australian dollars per year, respectively. The cost of optimal care for an adolescent was estimated at 2817 Australian dollars per year after the first year of diagnosis. The costs per year of the three adolescents in crisis ranged from 10,137 Australian dollars per year to 30,524 Australian dollars per year. CONCLUSIONS: Cost benefits may be seen in the short term by reducing the number of adolescents who end up in psychosocial crisis. Current actuarial costs of diabetic care for adolescents falls short of an optimal standard of care. Diabetic adolescents who fall into psychosocial crisis consume a disproportionate share of a limited clinical resource.

Regional and urban Victorian diabetic youth: clinical and quality-of-life outcomes.

OBJECTIVES: To compare groups of urban and regional Victorian diabetic children and assess their quality of life, diabetes knowledge, access to services and metabolic control. METHODS: Forty-seven children from three regional Victorian communities (Horsham, Warrnambool and Sale; n = 16, 18 and 13, respectively) were compared with 120 age-, sex- and duration of diabetes-matched children attending the Royal Children's Hospital (RCH) diabetes clinic in Melbourne. Quality of life, diabetes knowledge, use of services, and metabolic control were assessed using the child health questionnaire (CHQ PF-50/CF-80); a diabetes-knowledge questionnaire; access to a diabetes nurse educator (DNE), dietitian and complication screening; and indices of mean HbA1C (values are taken every 3 months in the 'yearly HbA1C'), respectively. RESULTS: Comparisons of CHQ data showed that regional diabetic youth scored significantly lower on most subscales. The greatest deficits were seen in areas of mental health, self-esteem, parent impact (emotional) and family cohesion. Diabetes knowledge and median yearly HbA1C for patients were not significantly different between the regional and urban centres (8.1%, 8.9%, 8.4% and 8.6% at RCH, Horsham, Warrnambool and Sale, respectively). Patients in regional centres had reportedly less access to team-based diabetes care. CONCLUSIONS: Regional youth in Victoria, with similar levels of metabolic control and diabetes knowledge as their urban counterparts, have a markedly lower quality of life, implying a negative synergy between diabetes and the demands of regional lifestyles.

Current pharmacotherapy for hepatitis B infection.

Chronic infection with the hepatitis B virus (HBV) affects 350 million people worldwide, or approximately 5% of the global population, and commonly results in cirrhosis and hepatocellular carcinoma. Until recently, the only available treatment was injectable interferon alpha and response rates were suboptimal. Moreover, this expensive and toxic therapy had little applicability in the endemic regions of the world, i.e., Asia and Africa. The realisation that orally available nucleoside and nucleotide agents may effectively control this infection opened a new era in the management of chronic hepatitis B. Oral lamivudine recently became approved for treatment of hepatitis B worldwide. It is free of significant toxicity, improves liver histology and rapidly diminishes HBV DNA levels; lamivudine is expected to become the first-line therapy of choice. Nevertheless, the consistent emergence of lamivudine-resistant variants mandates the need to develop additional therapeutic agents. Adefovir dipivoxil, a nucleotide, and entecavir, a nucleoside agent, are promising new drugs that might eventually be used in combination with lamivudine and therefore reduce the incidence of drug resistance. There is a critical need to advance the research of hepatitis B antiviral agents so that effective combination therapies can become widely available.

Inflammatory-cell subpopulations in keloid scars.

The aim of this study was to investigate the contribution of lymphocytes and macrophages to keloid scarring by morphologically characterising inflammatory cell subpopulations in keloid scars in comparison with normal skin. We took 3mm punch biopsies from the anterior forearms of eight normal healthy volunteers. Eight keloid scars were excised using an intralesional technique. All tissue was snap frozen in liquid nitrogen and serial sections were stained with a panel of anti-inflammatory cell monoclonal antibodies. The numbers of macrophages and lymphocytes and the proportions of the subpopulations were compared. Higher numbers of both macrophages and lymphocytes were found in keloid dermis (P=0.01 and P=0.02, respectively (Mann-Whitney U -test)). There was no significant increase in the expression of the lymphocyte-activation markers, CD25 and CD27. However, there was a significantly higher CD4(+):CD8(+)(Th:Ts) ratio (P= 0.046) in keloid tissue. This suggests that an imbalance in these inflammatory cell subpopulations may contribute to keloid scarring in man.