Tetra disseminated microsporidiosis: a novel disease in ornamental fish caused by Fusasporis stethaprioni n. gen. n. sp.

A novel microsporidial disease was documented in two ornamental fish species, black tetra Gymnocorymbus ternetzi Boulenger 1895 and cardinal tetra Paracheirodon axelrodi Schultz 1956. The non-xenoma-forming microsporidium occurred diffusely in most internal organs and the gill, thus referring to the condition as tetra disseminated microsporidiosis (TDM). The occurrence of TDM in black tetra was associated with chronic mortality in a domestic farmed population, while the case in cardinal tetra occurred in moribund fish while in quarantine at a public aquarium. Histology showed that coelomic visceral organs were frequently necrotic and severely disrupted by extensive infiltrates of macrophages. Infected macrophages were presumed responsible for the dissemination of spores throughout the body. Ultrastructural characteristics of the parasite developmental cycle included uninucleate meronts directly in the host cell cytoplasm. Sporonts were bi-nucleated as a result of karyokinesis and a parasite-produced sporophorous vesicle (SPV) became apparent at this stage. Cytokinesis resulted in two spores forming within each SPV. Spores were uniform in size, measuring about 3.9 ± 0.33 long by 2.0 ± 0.2 µm wide. Ultrastructure demonstrated two spore types, one with 9-12 polar filament coils and a double-layered exospore and a second type with 4-7 polar filament coils and a homogenously electron-dense exospore, with differences perhaps related to parasite transmission mechanisms. The 16S rDNA sequences showed closest identity to the genus Glugea (≈ 92%), though the developmental cycle, specifically being a non-xenoma-forming species and having two spores forming within a SPV, did not fit within the genus. Based on combined phylogenetic and ultrastructural characteristics, a new genus (Fusasporis) is proposed, with F. stethaprioni n. gen. n. sp. as the type species.

Modified matched ulnar resection for arthrosis of distal radioulnar joint in rheumatoid arthritis.

The pain of distal radioulnar arthrosis in rheumatoid patients is often due to disease largely confined to the radioulnar rather than the ulnocarpal articulation. This is a retrospective study of 14 patients (14 wrists) who underwent selective shaving of the radial articulation of the ulnar head leaving the ulnocarpal articulation intact. The ulnar head is reduced to the circumference of its shaft and a dorsal retinacular flap is interposed between it and the distal radius. Average age of the patients and follow-up were 63.5 years and 31 months, respectively. All patients had rheumatoid arthritis. Pain improved in 14 out of 15 wrists. Overall results were 67% good to excellent and 33% fair based on the modified Mayo's wrist score. This novel procedure for DRUJ arthrosis produces predictable pain relief in low demand rheumatoid patient.

Scaphoid non-union: the role of vascularized grafting in recalcitrant non-unions of the scaphoid.

Achieving union using conventional grafts has a high chance of failure in patients with recalcitrant non-union (persistent pseudarthrosis) of the scaphoid bone, an avascular proximal fragment and previous failed surgeries because of poor host bed vascularity. Eleven patients with long-standing non-union were treated with vascularized pedicle bone grafting and supplementary corticocancellous grafting. Five had screw fixation and six were fixed with K-wires. The average age of the patients was 28 years, average duration of the non-union was 39 months and mean radiological follow-up was 32 months. There were no significant skeletal complications, although two patients developed neuromata. At review, only six of the 11 non-unions were united. Whilst this is a difficult clinical problem and achieving union is a formidable challenge, we believe that there is a role for such extensive surgery in order to achieve good postoperative function.

Tenodesis of the extensor carpi ulnaris for chronic, post-traumatic lunotriquetral instability.

We describe a technique of soft-tissue reconstruction which is effective for the treatment of chronic lunotriquetral instability. Part of extensor carpi ulnaris is harvested with its distal attachment preserved. It is passed through two drill holes in the triquetrum and sutured to itself. This stabilises the ulnar side of the wrist. We have reviewed 46 patients who underwent this procedure for post-traumatic lunotriquetral instability with clinical signs suggestive of ulnar-sided carpal instability. Standard radiographs were normal. All patients had pre-operative arthroscopy of the wrist at which dynamic lunotriquetral instability was demonstrated. A clinical rating system for the wrist by the Mayo clinic was used to measure the outcome. In 19 patients the result was excellent, in ten good, in 11 satisfactory and in six poor. On questioning, 40 (87%) patients said that surgery had substantially improved the condition and that they would recommend the operation. However, six (13%) were unhappy with the outcome and would not undergo the procedure again for a similar problem. There were six complications, five of which related to pisotriquetral problems. The mean follow-up was 39.1 months (6 to 100). We believe that tenodesis of extensor carpi ulnaris is a very satisfactory procedure for isolated, chronic post-traumatic lunotriquetral instability in selected patients. In those with associated pathology, the symptoms were improved, but the results were less predictable.

Multiple plexiform schwannoma of the hand and forearm: a long-term follow-up.

We present a case report to illustrate the differential diagnosis and management of a multiple plexiform schwannoma involving the main nerve trunks of the upper limb in a 4 year-old boy. The tumour was diagnosed by MRI scan and histological examination. A 12 year follow-up is presented in which, despite multiple recurrences, the condition has been controlled by surgical means and the limb salvaged.

Sequence-specific identification of 18 pathogenic microorganisms using microarray technology.

We have developed a Multi-Pathogen Identification (MPID) microarray for high confidence identification of eighteen pathogenic prokaryotes, eukaryotes and viruses. Analysis of amplified products from pathogen genomic DNA using microarray hybridization allows for highly specific and sensitive detection, and allows the discrimination between true amplification products and false positive amplification products that might be derived from primers annealing to non-target sequences. Species-specific primer sets were used to amplify multiple diagnostic regions unique to each individual pathogen. Amplified products were washed over the surface of the microarray, and labelled with phycoerythrin-streptavidin for fluorescence detection. A series of overlapping 20-mer oligonucleotide probes hybridize to the entire diagnostic region, while parallel hybridizations on the same surface allow simultaneous screening for all organisms. Comparison to probes that differ by a single mismatch at the central position reduced the contribution of non-specific hybridization. Samples containing individual pathogens were analyzed in separate experiments and the corresponding species-specific diagnostic regions were identified by fluorescence among their highly redundant probe sets. On average, 91% of the 53 660 pathogen probes on the MPID microarray performed as predicted. The limit of detection was found to be as little as 10 fg of B. anthracis DNA in samples that were amplified with six diagnostic primer-pairs. In contrast, PCR products were not observed at this concentration when identical samples were prepared and visualized by agarose gel electrophoresis.

Bizarre parosteal osteochondromatous proliferation with cortical invasion.

A 15-year-old male presented with an 18-month history of increasing swelling on the radial aspect of his left forearm. Radiographs and MR images showed a partly calcified mass on the lateral border of the radius with erosion of the underlying cortex. Following a CT-guided needle biopsy, the mass was excised by segmental resection of the radial shaft with replacement by a vascularised fibular graft. Histological examination of the resected specimen showed many features typical of a bizarre parosteal osteochondromatous proliferation (BPOP) but with destruction of the underlying cortical bone by cellular spindle cell tissue. Although there were no cytological signs of malignancy, we believe that this unusual disease should be regarded as a particularly aggressive form of BPOP and treated by wide excision. Clinical follow-up of our patient at 2 years shows no sign of local recurrence or metastasis.

The value of crossed intrinsic transfer after metacarpophalangeal silastic arthroplasty: a comparative study.

Seventy three hands in patients with rheumatoid arthritis undergoing primary index to small finger metacarpophalangeal joint replacements were studied retrospectively. In twenty eight hands a crossed intrinsic transfer was performed and in forty five hands it was not. A similar splintage and rehabilitation programme was followed in each group. The two treatment groups had similar preoperative ulnar drift (crossed intrinsic transfer group mean 27 degrees, comparative group 29 degrees). At a mean follow up of 50 months the crossed intrinsic transfer group had statistically less ulnar drift (crossed intrinsic transfer group mean 6 degrees, comparative group mean 14 degrees, P=0.01). There were no other significant differences at follow up.

Did Project 2000 nurse training change recruitment patterns or career expectations?

In the UK, Project 2000 nurse education, introduced over the last eight years, aimed to increase the professional status of nurses and enhance skills, focusing on wider community care. This paper reports some of the results from a research project conducted between 1994 and 1996, funded by the Department of Health (Project 2000 Fitness for Purpose 1996). It was hypothesized that the changes in Project 2000 training might attract those more academically qualified and lead to more rapid career progression. The results found in this study did not support either of these hypotheses and suggestions are made about the reasons for the negative findings.

A patient-reported comparison of trapeziectomy with Swanson Silastic implant or sling ligament reconstruction.

A retrospective review of two types of operations for carpometacarpal osteoarthritis of the thumb was done for patients operated on between 1991 and 1996. Follow-up ranged from 18 to 90 months (mean 62 months). Fifty-eight Swanson Silastic arthroplasties and 56 sling excision arthoplasties were reviewed. Eight patients with Swanson arthroplasties underwent removal of the implant. Eight patients in the sling excision group required further surgery. These patients were excluded from further analysis. Questionnaires about pain, general satisfaction and function were sent to the other patients and 87 responses were received (sling 45, implant 42). In the implant group significantly better results were obtained for pain at 1 year, carrying a milk bottle and taking a handbrake off a car, and overall function. We conclude that trapeziectomy combined with Swanson implant gives better results in the short term if there are no complications of the operation.

Suicidal ideation and attempts: a longitudinal investigation of children of depressed and well mothers.

OBJECTIVE: This study uses a prospective longitudinal design to examine suicidality (ideation, plans, attempts, and completions) in children and adolescents, to compare suicidality in the offspring of depressed and well mothers, and to identify correlates and predictors of suicidality. METHOD: Two children (n = 192) from each of the families in an ongoing longitudinal study of the offspring of mothers with major depressive disorder (n = 42), with bipolar disorder (n = 26), or without past or current psychiatric diagnosis (n = 30) were studied. Assessment of suicidality, based on diagnostic interviews, was made when the younger of the sibling pairs were approximately 6, 9, and 14 years of age and older siblings were approximately 6, 9, 13, and 18 years of age. RESULTS: Children of depressed mothers were more likely to report suicidal thoughts or behaviors than were children of well mothers (particularly the older sibling cohort). Developmental trajectories of suicidality differed for offspring of mothers with major depressive disorder and bipolar disorder. Links were found between lifetime reports of suicidality and the adolescent's mood problems (e.g., hypomanic behavior), coping strategies, and parental rejection. Also, child's and mother's suicidality were related. CONCLUSIONS: These findings have implications for planning interventions targeted at preventing suicide in youth.

Skills competency in nurse education: nurse managers' perceptions of diploma level preparation.

This paper reports on part of a national study conducted between 1994 and 1996, the overall aim of which was to examine the 'fitness for purpose' of the Project 2000 nursing education reforms. The study used multiple methods of data collection, including an individual and group interview study of nurse managers (n = 132) and a national survey of Project 2000 diplomates and traditionally prepared registered nurses (n = 5417). Findings in relation to the managers' expectations and experiences of diplomates are presented. This includes views on the level of skills achievement and skills acquisition of diploma level education. The qualities of the diplomates are discussed and this includes those areas where the skills of the diplomates are felt to achieve what is required of the role. Also included is an exploration of those skills which the managers felt fell short of expectations. Managers raised the long-standing concerns of clinical skills and competencies and discussed these in relation to the changing health care environment and the relative roles of other health care workers. The conclusions highlight the need to identify what could be seen as the 'core skills' required of a registered nurse and the need to explore the environment in which the diplomate takes up first appointment.

"Ready to quit chew? " Smokeless tobacco cessation in rural Nebraska.

A quit-chew media campaign was conducted in a 10-county region of south-central Nebraska. The campaign involved television and radio appearances, newspaper articles, and paid billboard advertisements. Smokeless tobacco users who called a toll-free helpline were provided quitting resources. Twelve months after the campaign ended, follow-up contact was completed with 104/205 (51%) of chewers who received the quit kits. A majority (70%) reported making some change, such as using less or switching brands, and 49% had made a quit attempt. The point prevalence quit rate was 11.5%.

Measuring outcome in community-based rehabilitation services for people who have suffered traumatic brain injury: the Community Outcome Scale.

OBJECTIVE: To develop a way of measuring long-term outcomes after traumatic brain injury (TBI) that takes account of individual circumstances. DESIGN: Reports by head-injured people and their families about problems and coping strategies were elicited via semi-structured interviews. Specially designed computer software was used to record problems and strengths and to measure their impact for the individual on four handicap dimensions. SETTING: Interviews took place in the respondents' homes. SUBJECTS: Between 1992 and 1997 the services at 10 rehabilitation centres in England were evaluated. Subjects were men and women aged between 16 and 65 who had suffered TBI and who had been referred for treatment to one of the centres under study. INTERVENTIONS: Head-injured people and their families were interviewed three months, 18 months and in some cases 36 months after recruitment. MAIN OUTCOME MEASURES: The Hospital Anxiety and Depression Scale (HAD) and the Functional Independence/Assessment Measure (FIM/FAM) were used to validate relevant dimensions of the new scale. RESULTS: A measure of long-term outcome was developed and called the Community Outcome Scale. Relevant dimensions of the scale showed significant correlation with the HAD and with items of the FIM/FAM. CONCLUSION: The scale captures information which no other instrument does, and merits further validation.

Near patient testing in general practice: attitudes of general practitioners and practice nurses, and quality assurance procedures carried out.

BACKGROUND: The evaluation of near patient testing in British general practice has largely been confined to studies examining individual tests or comparing equipment. AIM: This study set out to determine the attitudes of practice staff to near patient testing, and the extent to which staff undertook quality assessment. METHOD: Four types of near patient testing machines were introduced into 12 general practices in two regions of England, south west Thames and west Midlands. General practitioner and practice nurse attitudes to near patient testing were assessed by semi-structured interview before and six months after the introduction of the machines. The extent to which routine quality assurance procedures were carried out within the surgery and as part of local and national schemes was examined. RESULTS: Although 80% of general practitioners anticipated changing patient management with near patient testing, only two fifths reported having done so after six months. Nurses generally were enthusiastic at the outset, although one third were unhappy about incorporating near patient testing into their work schedules. Time pressure was the most important factor restricting uptake of near patient testing. Nurses performed quality control regularly but complete local external quality assurance procedures were established in only half the practices. All the practices participated in a national scheme for cholesterol assays. CONCLUSION: General practitioners in this study did not find near patient testing a very useful addition to their resources. Pressure on nurses' time was the most frequently reported limitation.

Lower limb trauma: a review of 40 cases treated at the regional burns and plastic surgery unit, Merseyside, England.

This is a review of 40 patients with lower limb trauma that required reconstruction, treated at Mersey Regional Plastic Surgery and Burns Centre during the year 1989. 73% had bone involvement while there was soft tissue injury only, in 27%. Seven patients (18%) had the affected limb amputated. Of the rest, 6 were treated with skin grafts only, 13 with local flaps and 14 with free flap reconstruction. The soft tissue healing time was least in patients who had free flaps. The time taken by skin and bone to heal and the average duration of hospitalisation was also less in cases that had early management compared to those who had delayed and late treatment. Early reconstruction in severe lower limb trauma is desirable and cost effective.

Use of silastic sheet in Apert's syndactyly.

Patients with Apert's syndrome usually have severe complex syndactyly affecting both hands. Surgical separation of the distal digital bony fusion often exposes bone and cartilage which can cause problems with graft take. A case is presented where the bare divided bone between two digits was kept apart with a silastic sheet. On its removal 4 weeks later, the previously bare bone was covered with a membrane. This was covered with a full thickness skin graft with a complete graft take.

Impact of introducing near patient testing for standard investigations in general practice.

OBJECTIVE: To assess the clinical and economic impact of surgery based near patient testing in general practice for six commonly used biochemical and bacteriological tests. DESIGN: After four months' monitoring, equipment for two bacteriological and four biochemical tests was introduced without cost into 12 practices using a crossover design. Structured request forms were used to monitor laboratory investigations. SETTING: 12 general practices in west midlands and south west Thames with list sizes above 9000. MAIN OUTCOME MEASURES: Investigation rates per 1000 consultations. Changes from baseline rates. Reasons for requesting investigations and provisional diagnoses. Cost per test and sensitivity of costs to rate of use. RESULTS: Investigation rates for the six tests rose by 16.5% (from 78.6/1000 consultations to 91.6/1000) when equipment was available in the surgery and reverted to baseline rates when it was withdrawn. The average weekly number of tests when equipment was available ranged from 0.5 to 10.5 (mean 9.0). Cholesterol tests were used as an addition to laboratory testing, usually for screening. Midstream urine analysis was often done in the surgery instead of in the laboratory, although 30% of samples were tested by both methods. Doctors' reasons for investigation and conditions tested were largely unaffected by availability of surgery tests. Costs for surgery tests were higher for all tests except midstream urine. CONCLUSIONS: Availability of surgery based testing increased the number of tests performed. It was cost effective only for midstream urine analysis.