Multimodal imaging demonstrates concomitant changes in bone and cartilage after destabilisation of the medial meniscus and increased joint laxity.

OBJECTIVE: Alterations in joint mechanics can cause osteoarthritis, which results in degeneration of both cartilage and bone tissue. The objective of this work is to measure changes in the laxity of the mouse knee joint after destabilisation of the medial meniscus (DMM) and to visualise and quantify the resulting three-dimensional changes in the bone and cartilage. METHODS: Skeletally mature C57Bl6 male mice underwent DMM surgery in the right leg. Animals were sacrificed immediately 0 weeks (n=15), 4 weeks (n=11) or 8 weeks (n=12) after surgery. For the 0-week group, the anterior-posterior (AP) and varus-valgus laxity of the DMM limb were compared to the contralateral limb. For 4 and 8-week groups, tibiae were scanned with micro-computed tomography (µCT) to quantify and visualise bone changes and with confocal scanning laser microscopy (CSLM) to measure changes in cartilage. RESULTS: Laxity testing measured an increase in AP range of motion, particularly in the anterior direction. The DMM limbs showed a decrease in epiphyseal trabecular bone at 8 weeks and a decrease in cartilage volume, primarily on the posterior medial plateau, compared to the contralateral limb. Significant bone remodelling was observed at the periphery of the joint and in severe cases, osteolysis extended through the growth plate. CONCLUSION: Multimodal imaging allowed quantifiable 3D assessment of bone and cartilage and indicated extensive changes in the tissues. The increase in AP laxity suggests that DMM surgery redistributes loading posteriorly on the medial plateau, resulting in bone and cartilage loss primarily on the posterior portion of the medial plateau.

Early bleb leak after trabeculectomy and prognosis for bleb failure.

AIM: To determine whether early bleb leak after MMC trabeculectomy affects intermediate intraocular pressure (IOP) outcome. METHODS: Retrospective case note review. All cases of MMC trabeculectomy with at least 1-year follow-up were included. Cases where a bleb leak occurred within the first month were identified. All cases without an early bleb leak formed the control group. Patient demographics and clinical factors were analysed to determine any factors predisposing to bleb leakage. IOPs were compared for 1 year postoperatively and final follow-up. RESULTS: A total of 119 trabeculectomies were included. Of these 27 (22.7%) had an early bleb leak. The remaining 92 cases formed the control group. Mean age of cases was 70.7 years. Mean follow-up time was 19.5 months. Mean time of detection of the bleb leak was 9 days (range 1-21 days). Four cases (14.8%) were managed by primary resuturing. Thirteen cases (48.1%) were managed conservatively with a bandage contact lens. Ten cases (37.0%) resolved with expectant management. There was no statistically significant difference between the two groups with regards to IOP measurement at any time point. Intervention rates were similar with regards to bleb massage, 5-fluorouracil injection, and needling revision. No factors were identified between the two groups that predisposed to bleb leaks occurring. CONCLUSION: Our data suggest that early bleb leak is not a poor prognostic indicator for intermediate bleb survival and IOP control in patients undergoing MMC trabeculectomy. No additional bleb manipulations compared with the control group were required to achieve a satisfactory IOP outcome.

Injuries to the acromioclavicular joint.

Injuries to the acromioclavicular joint are common but underdiagnosed. Sprains and minor subluxations are best managed conservatively, but there is debate concerning the treatment of complete dislocations and the more complex combined injuries in which other elements of the shoulder girdle are damaged. Confusion has been caused by existing systems for classification of these injuries, the plethora of available operative techniques and the lack of well-designed clinical trials comparing alternative methods of management. Recent advances in arthroscopic surgery have produced an even greater variety of surgical options for which, as yet, there are no objective data on outcome of high quality. We review the current concepts of the treatment of these injuries.

Patients' attitudes towards trainee surgeons performing cataract surgery at a teaching hospital.

AIM: To evaluate patients' preferences of surgeon to perform their cataract surgery if given a choice between consultant and trainee. METHODS: A questionnaire based patient satisfaction survey was conducted in a large University Teaching Hospital in the UK. One hundred and eighty patients undergoing first eye cataract surgery between January and March 2006 were asked a number of set questions on their preferences regarding the surgeon performing the operation. Primary outcome measure was the patient's preference for who would perform their cataract surgery (consultant or trainee). RESULTS: Overall, 126 (70%) accepted that trainee surgeons should operate as part of their training. Only 102 (81%) of these (57% of the total) would be happy to be operated on themselves by a supervised surgical trainee. Ninety-eight (78%) patients objected to being operated on by a trainee if they were to be unsupervised. One hundred and forty-two (79%) patients stated they would choose to wait longer for their surgery if it meant that a consultant would perform their operation. This preference was held significantly more strongly among patients who had been listed for surgery from a consultant's clinic rather than from the pooled 'cataract clinic' (P=0.048). One hundred and forty-four (80%) patients thought they should be told the name and designation of the surgeon who was to perform their operation. CONCLUSIONS: Patients undergoing their first cataract procedure appear to have a preference for their named consultant to perform their surgery. If 'patient choice' extends to the choice of operating surgeon, then there are clear implications for the training of future UK ophthalmologists.

Frequency of bleb manipulations after trabeculectomy surgery.

AIM: To quantify the type and frequency of postoperative bleb manipulations undertaken after modern glaucoma surgery. METHODS: Bleb manipulations were recorded after trabeculectomy surgery on 119 consecutive patients with at least 1 year of follow-up. The type of intervention and time after surgery were recorded. Statistical analysis identified success rates at various intraocular pressure (IOP) cut-off definitions and identified factors that increased the risk for bleb manipulation. RESULTS: In all, 78.2% of trabeculectomies were followed by some form of bleb manipulation. Almost 49% of blebs underwent massage and a similar number required at least one suture removal, 31.1% required at least one 5-fluorouracil (5-FU) injection and 25.2% required at least one needling and 5-FU injection. The median time to the first intervention for massage, suture removal, 5-FU injection, and needling and 5-FU injection were 1, 14, 14 and 43 days, respectively. IOP measurements were higher at all follow-up time points in the intervention group. Failure to achieve specific IOP target pressures was also generally poorer in the 5-FU, and needling and 5-FU intervention groups. CONCLUSIONS: Postoperative intervention is a frequent occurrence after modern glaucoma surgery. This requires intensive postoperative follow-up and is a labour-intensive undertaking. Despite interventions in our group of patients, IOP in the intervention group was always higher than in the group that required no intervention.

Otago Diagnostic Laboratories' (ODL) Method for the detection of beta-lactamases in Enterobacteriaceae.

AIM: The rapid evolvement of beta-lactamases in Enterobacteriaceae is an important concern and the clinical microbiology laboratory is required to detect them, where possible, using a rapid, reliable, simple and low cost methodology. MATERIALS AND METHODS: A disc diffusion method using NCCLS breakpoints, Jarlier's principle and cefoxitin test for AmpC was carried out. It incorporated seven antimicrobial discs in one agar plate: cefotaxime, aztreonam, amoxicillin-clavulanate, ceftazidime, cefpodoxime, cefepime and cefoxitin. NCCLS disc confirmation test for extended-spectrum beta-lactamase (ESBL) was carried out simultaneously. RESULTS: AmpC, ESBL, CTX-M, and K1 were detected using these tests. The prevalence of ESBL was <1% in the hospital. CONCLUSION: The method is recommended for the phenotypic detection of beta-lactamases in Enterobacteriaceae or for confirmation after the results are obtained by conventional automated systems.

The effect of Edmonston-Zagreb and Schwarz measles vaccines on immune response in infants.

The effects of measles immunization on immune responses in infants and the roles of vaccine strain and age of immunization are not known. Eighty-eight children were immunized at 6 or 9 months of age with the Edmonston-Zagreb (EZ) or Schwarz (SW6, SW9) strain of measles vaccine. Children were studied before and 2 weeks and 3 months after immunization. Seroconversion was similar, but geometric mean neutralizing titers at 3 months differed by vaccine group: SW9, 1367 mIU/mL; SW6, 982; and EZ, 303 (P = .003). Mitogen-induced lymphoproliferation was decreased at 2 weeks in the SW9 group and at 3 months in all groups and was negatively correlated with measles antibody level at 3 months (r = -.387, P = .003). CD8 T cells, soluble CD8, neopterin, and beta2-microglobulin were increased at 2 weeks in the SW9 group, and soluble CD8 and beta2-microglobulin remained elevated at 3 months. Therefore, measles immunization resulted in suppression of lymphoproliferation, which was most evident in infants with the highest antibody responses and most immune activation.

Evaluation of intravenous ketorolac administered by bolus or infusion for treatment of postoperative pain. A double-blind, placebo-controlled, multicenter study.

BACKGROUND: Ketorolac is a nonsteroidal analgesic that may provide postoperative analgesia without opioid-related side effects. This double-blind, randomized, multicenter study evaluated the analgesic efficacy and safety of intravenous ketorolac in 207 patients during the first 24 h after major surgery. METHODS: Subjects were assigned to receive one of three analgesic regimens: a ketorolac infusion, ketorolac boluses, or placebo. All subjects had access to intravenous morphine via patient-controlled analgesia (PCA). Evaluations included PCA morphine used, pain assessment (categorical pain intensity scores and visual analogue pain scores), pain relief (categorical pain relief scores), sedation, presence of adverse events, and overall rating of regimens by study observers and patients. RESULTS: Patients in the ketorolac infusion group (but not the ketorolac bolus group) used less morphine (average 33 mg) than did the placebo group (44 mg) (P = 0.009). Significant differences favoring both ketorolac groups were seen in the pain intensity and the categorical pain relief scores at various time points during the study. At the termination of the study, compared with the placebo group, categorical pain intensity scores were lower in the ketorolac bolus group; visual analogue pain scores were lower in both ketorolac groups; and pain relief scores were higher in the ketorolac bolus group. The incidence of vomiting was significantly greater in the placebo group (27%) than in the ketorolac infusion group (12%) or bolus group (9%) (P = 0.032 and P = 0.005, respectively). The incidence of postoperative fever was 10% in the ketorolac bolus group and 25% in the placebo group (P = 0.013). Study observers noted less nursing difficulty while caring for patients in the ketorolac infusion group (P = 0.015). Study observers and patients in both ketorolac groups reported statistically significant overall drug superiority compared with placebo. CONCLUSIONS: It is concluded that intravenous boluses or infusions of ketorolac in conjunction with PCA morphine provide effective, safe analgesia after major surgery and improve on the response to PCA morphine alone.

A general practice study to compare the efficacy and tolerability of a spray ('Otomize') versus a standard drop formulation ('Sofradex') in the treatment of patients with otitis externa.

In an open, multi-centre study in general practice, a comparison was made of the efficacy, tolerability and acceptability of a neomycin/dexamethasone preparation administered by metered-dose spray ('Otomize') and a framycetin/gramicidin/dexamethasone preparation ('Sofradex') administered as drops in 60 patients with otitis externa. Patients were allocated at random to receive one or other preparations 3-times daily for 10 days and were followed-up again 14 days after cessation of therapy. Clinical assessments were carried out under observer blind conditions on entry (Day 0) and on Days 10 and 24 of the severity of erythema, swelling and debris in the affected ear(s). A global assessment of clinical outcome was made by the doctor on Day 10. There were no significant differences in the two groups at the start of treatment. Significant improvement occurred in both groups from Day 0 to Day 10 and from Day 10 to Day 24 in all symptoms, with the proportion symptom-free in the 'Otomize' group significantly greater than in the 'Sofradex' group at 24 days, and approaching significance at 10 days. Significantly more patients in the 'Otomize' group were rated as having a good clinical outcome by the physician, and fewer patients experienced discomfort on application. Few side-effects were reported by either treatment group, none necessitating discontinuation of therapy.

Comparative efficacy and tolerability of two antibacterial/anti-inflammatory formulations ('Otomize' spray and 'Otosporin' drops) in the treatment of otitis externa in general practice.

An open, multi-centre study was carried out in general practice to compare the efficacy, tolerability and acceptability of a neomycin/dexamethasone preparation administered by spray ('Otomize') and neomycin/polymyxin B/hydrocortisone administered as drops ('Otosporin') in the treatment of 187 patients with otitis externa. Patients were allocated at random to receive one or other preparation 3-times daily for 10 days irrespective of response and were followed up again 14 days after cessation of therapy. Assessments were made on entry and at Days 10 and 24 of the severity of erythema, swelling and debris. A global assessment of clinical outcome was made by the doctor on Day 10. There were no significant differences between the two groups at the start of treatment. Significant improvement occurred in both groups from Day 0 to Day 10 and from Day 10 to Day 24 in all symptoms, but no statistically significant differences were recorded between the two drugs. However, significantly more patients in the 'Otomize' group were rated as having a good clinical outcome by the physicians, and a highly significant number of patients, with previous experience of the use of ear drops, expressed a preference for the spray preparation. Few side-effects were reported by either treatment group, none necessitating discontinuation of therapy.

Comparison of intravenous ketorolac tromethamine and morphine sulfate in the treatment of postoperative pain.

This study compared the efficacy and safety of ketorolac tromethamine and morphine sulfate in alleviating moderate or severe pain immediately after major surgery. One hundred twenty-two patients were randomly assigned to receive single intravenous injections of ketorolac 10 mg, ketorolac 30 mg, morphine 2 mg, or morphine 4 mg; patients could receive a second dose 15 minutes thereafter, upon request, and most received both available doses. Analgesic efficacy was measured by interviewing patients and assessing pain intensity and pain relief for 6 hours after the first medication administration. The two drugs showed a similar onset of action, peaking 1 hour after administration. When placed in order of descending efficacy, the mean scores for most efficacy measures fell into the following sequence: ketorolac 30 mg, ketorolac 10 mg, morphine 4 mg, and morphine 2 mg. There were no statistically significant differences among the two ketorolac doses and the high dose of morphine, but all three of these treatments were significantly superior to the low morphine dose. One patient who took morphine 4 mg withdrew because of drowsiness; other common adverse events reported included nausea, vomiting, somnolence, and dyspepsia. There were no statistically significant differences in the frequency of adverse events among the treatment groups. Intravenous ketorolac is effective for the treatment of postoperative pain.

Analgesic efficacy and safety of single-dose oral and intramuscular ketorolac tromethamine for postoperative pain.

The efficacy and safety of the analgesic drug ketorolac tromethamine in the treatment of moderate to very severe postoperative pain was assessed in five dose-ranging studies with single-dose, double-blind, randomized, parallel-group designs. The drug was administered orally (2.5-200 mg, 352 patients in three trials) and intramuscularly (5-90 mg, 395 patients in two trials), and compared with placebo and reference drugs. Patients subjectively evaluated pain intensity and relief using verbal categoric and visual analog scales; efficacy values included pain intensity difference (PID), summed PID, and total pain relief. Oral ketorolac 10, 12.5, 100, and 200 mg were each statistically significantly superior to placebo in all efficacy measurements, and 10 mg was equivalent to intramuscular morphine 10 mg. Intramuscular ketorolac 90 mg was superior to and 10 and 30 mg were similar to intramuscular morphine 12 mg, and all of these ketorolac doses were superior to intramuscular morphine 6 mg. Intramuscular ketorolac 10 and 30 mg were superior to intramuscular meperidine 50 and 100 mg. Ketorolac was well tolerated, with rates of adverse events generally lower than those of the opiate comparators. Ketorolac doses of 2.5 and 5 mg were less effective than higher doses; 10 mg or more resulted in faster onset of action and greater peak efficacy; 90 mg or more gave more prolonged analgesic effects.

Virological studies of water from the Cape Flats reclamation plant.

The virological quality of sewage effluent treated by a pilot reclamation plant on the Cape Flats was evaluated. The potable water produced by the treatment was repeatedly shown to be free of virus contamination.

Comparative efficacy and tolerability of two ointment and suppository preparations ('Uniroid' and 'Proctosedyl') in the treatment of second degree haemorrhoids in general practice.

A multi-centre general practice, open study was carried out in 89 patients with second degree haemorrhoids to compare the efficacy and tolerability of two antibiotic-corticosteroid combinations ('Uniroid' and 'Proctosedyl') in ointment and suppository formulations. Patients were allocated at random into 4 groups and received treatment with one of the trial preparations for 1, 2 or 3 weeks, as required, with weekly assessments of response. There were no significant differences between the various groups at the start of treatment. Significant improvement occurred in all groups during treatment. Both suppository and ointment formulations were broadly comparable and control of symptoms was achieved from Week 2 onwards, building up to levels in excess of 90% after 3 weeks of therapy. With regard to the symptoms of pain and itching, suppositories gave marginally greater relief in the early stages of treatment, while both ointment and suppositories were associated with similar reduction in bleeding from haemorrhoids. Whereas both suppository formulations were about equal in reducing anal discharge, 'Uniroid' ointment was clinically superior to 'Proctosedyl' ointment in controlling this symptom over the 3-week trial period. No unwanted effects were experienced attributable to treatment. No statistically significant differences between the two ointment and the two suppository formulations were identified in this study and all four preparations were found to be efficacious in the majority of patients studied.

The morphology of human immunodeficiency virus particles by negative staining electron microscopy.

Negative staining electron microscopy was used to examine culture fluids from the H9/HTLV-III cell line after concentration by centrifugation. Characteristic retrovirus-like particles bearing distinctive envelope projections were seen. The virion envelope was frequently extended in the form of a bleb or a tail. These particles were morphologically virtually indistinguishable from similar preparations of Friend murine leukaemia virus. H9/HTLV-III culture fluids contained, in addition, numerous comet-shaped particles with a dense head and flared tail. These particles were clumped by the addition of anti-HTLV-III-positive serum suggesting that they may represent intermediate forms of the virus.

Meningitis in Cape Town children.

A prospective clinical and microbiological survey of 213 children who presented to the teaching hospitals of the Cape Peninsula with meningitis was performed during a winter month. The predominant bacterium isolated was Neisseria meningitidis and this survey uncovered an outbreak of viral meningitis due to echovirus 4 of the Du Toit strain. In comparison with previous studies, the absence of fever in 20% of the cases of meningococcal disease and the isolation of N. meningitidis group B organisms which were resistant to sulphonamides are noted. Cases of N. meningitidis meningitis with initial clinical and cerebrospinal fluid findings indistinguishable from those in echovirus 4 meningitis are presented to emphasize the difficulties encountered in making a differential diagnosis. We recommend that in endemic areas all children with meningitis should be observed in hospital for at least 48 hours until the diagnosis of N. meningitidis has been excluded bacteriologically.