Publication December Research Articles

Neo-Ossification of the Cricothyroid Joint After Elective Cricothyroidotomy: A Case Report and Discussion on the Merits of This Procedure

From the Fauquier Ear, Nose, and Throat Consultants, PLC (C.Y.C.), Warrenton, Virginia; and James P. Thomas, MD, LLC (J.P.T.), Portland, Oregon. Submitted for publication September 19, 2005. Accepted for publication December 15, 2005. Address for reprints: James P. Thomas, MD, 909 NW 18th Avenue, Portland, OR 97209; email: [email protected].

The Iowa Belt Lipectomy Technique

Coralville, Iowa From Iowa City Plastic Surgery. Received for publication December 4, 2007; accepted January 7, 2008. Disclosure:Dr. Aly is an Ethicon consultant, has a financial interest in Insorb Stapler, receives a royalty from Quality Medical Publishing for books, and conducts research for Medicis. Dr. Cram is an Ethicon consultant. Video Plus content is available for this article. A direct URL citation appears in the printed text; simply type the URL address into any web browser to access this content. Clickable links to the material are provided in the HTML text and PDF of this article on the Journal’s Web site (www.PRSJournal.com). Al Aly, M.D., Iowa City Plastic Surgery, 501 12th Avenue, Suite 102, Coralville, Iowa 52241, [email protected]

An evidence‐informed, integrated framework for rheumatoid arthritis care

Introduction Providing adequate care for persons with rheumatoid arthritis (RA) is an ongoing challenge. Although the current evidence supports the use of disease-modifying antirheumatic drugs (DMARDs) within the first 3 months of symptoms appearing (1–3), delay in DMARD use and other gaps in care have been reported across communities (4–9). The situation has worsened due to the shortage of specialists (10). The process of seeking medical treatment begins with the person’s recognition of the symptoms and the action of visiting a family physician (FP) (Figure 1, levels A and B). The FP then performs the appropriate investigations, and if RA is suspected, the FP refers the person to a rheumatologist (levels B and C) who then conducts further tests, provides a diagnosis, and prescribes DMARDs and other appropriate medications (level D). Next, the person may be referred to the available community resources and/or rehabilitation programs that enable self-management (levels E1–E4), and will be periodically assessed by a rheumatologist (level F). Successful delivery of these interventions is largely dependent on the availability of local programs and the coordination among the rheumatologist, the FP, and other health professionals. In the case of severe joint damage, the person is referred for an orthopedic consultation and surgery may be considered (levels G1–G4). Moving from one level to the next involves a potential wait period, which may be caused by, for example, delays in patients’ and health professionals’ recognition of RA symptoms, delays in referral to rheumatologists, lack of access to specialist care or community resources, or patients’ own choices. Delays may occur at any of the following periods (Figure 1): Wait 1: the time between a person’s development and awareness of the seriousness of the symptoms and the first visit with an FP; Wait 2: the time between the first visit with an FP and the first visit with a rheumatologist; Wait 3: from the first rheumatology visit to the date the patient starts the appropriate therapy; Wait 4: from a patient starting medication to the date when he or she has access to adequate resources that enable self-management; andWait 5: from the decision date for an orthopedic consultation to the date of the patient’s first visit with a surgeon and, subsequently, the date of surgery. The delay between symptom onset and DMARD prescription for individuals with RA is a problem across countries (Waits 1–3), with a median lag time ranging from 6.5 to 19 months (5–9). A few studies have attempted to estimate the length of Wait 1, but the findings are inconsistent. Two studies, a retrospective cohort from the US (11) and a prospective study from Norway (12), estimated a median delay of 4 weeks for the first FP visit. However, more recent research from the UK estimated 12 weeks (13), with 38% of people waiting more than 3 months before seeing an FP (14). The lag time from FP visit to rheumatologist consultation is believed to be a major source of the delay (Wait 2). In a UK study, 44% waited more than 3 months for a specialist referral (14). Recent research from Canada also found a median lag time of 79 days between the FP visit and the first rheumatologist visit (15). In contrast, the Linda C. Li, PT, PhD: University of British Columbia and Arthritis Research Centre of Canada, Vancouver, British Columbia, Canada; Elizabeth M. Badley, DPhil: Arthritis Community Research and Evaluation Unit, Toronto Western Research Institute and University of Toronto, Toronto, Ontario, Canada; Crystal MacKay, PT, MHSc: Arthritis Community Research and Evaluation Unit, Toronto Western Research Institute, Toronto, Ontario, Canada; Dianne Mosher, MD, FRCP(C): Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada; Shahin (Walji) Jamal, MD, FRCP(C): St. Michael’s Hospital and University of Toronto, Toronto, Ontario, Canada; Anamaria Jones, PT, PhD(Candidate): Arthritis Research Centre of Canada, Vancouver, British Columbia, Canada, and Federal University of Sao Paulo, Sao Paulo, Brazil; Claire Bombardier, MD, FRCP(C): University Health Network, University of Toronto, Institute for Work & Health, and Mount Sinai Hospital, Toronto, Ontario, Canada. Dr. Mosher has received honoraria (less than $10,000) from serving on the advisory board for Pfizer, and has received speaking fees (less than $10,000 each) from Schering, Amgen, and Wyeth. Address correspondence to Linda C. Li, PT, PhD, Arthritis Research Centre of Canada, 895 West 10th Avenue, Room 324, Vancouver, British Columbia V5Z 1L7, Canada. E-mail: lli@arthritisresearch.ca. Submitted for publication December 27, 2007; accepted in revised form April 22, 2008. Arthritis & Rheumatism (Arthritis Care & Research) Vol. 59, No. 8, August 15, 2008, pp 1171–1183 DOI 10.1002/art.23931 © 2008, American College of Rheumatology

Otoplasty

New York, N.Y. Received for publication December 19, 2007; accepted January 2, 2008. Charles H. Thorne, M.D.; Department of Plastic Surgery; New York University School of Medicine; 812 Park Avenue; New York, N.Y. 10021-2759; [email protected] Disclosure:The author has no financial interests in any of the products, devices, or drugs described in this article or its corresponding video. Video Plus content is available for this article. A direct URL citation appears in the printed text; simply type the URL address into any web browser to access this content. Clickable links to the material are provided in the HTML text and PDF of this article on the Journal’s Web site (www.PRSJournal.com).

COMMENTARY ON “SMALL CELL NEUROENDOCRINE CARCINOMA OF EYELID”

University of South Florida College of Medicine; Tampa, Florida, U.S.A. Accepted for publication December 31, 2007.

Regulatory B lymphocytes in humans: A potential role in autoimmunity

The physiology of B cells has been revolutionized by the attribution of a number of new functions to their already established role in antibody production. Subpopulations of B cells have consequently been delineated, and Breg cells have been identified in mice, but not yet in humans. These Breg cells have the capacity to restrain immune responses and thus prevent pathogenic autoimmunity. Alteration of their function might signal an increased likelihood of disturbed immune homeostasis, making Breg cells an appealing target for immunotherapy, provided a confident characterization can be made. Recent experiments have rekindled the debate on the many alternative functions of B lymphocytes (1), which are no longer thought to have the production of antibodies as their only function. Studies initiated in genetically engineered mice and currently being extended in humans point to their role in antigen presentation (2) in the synovium of patients with rheumatoid arthritis (RA) and to their production of cytokines (3) in the blood of patients with systemic lupus erythematosus (SLE). In addition, their control of lymphoid organogenesis (4) and their function in association with dendritic cells (DCs) in ectopic germinal centers in the salivary glands of patients with primary Sjogren’s syndrome (SS) is consistent with a regulatory role of B lymphocytes. These observations revealed that autoimmune diseases could therefore all be mediated via the longterm activation of B cells (5) and that these cells may play a key role in autoimmunity. This has provided a rationale for therapeutic strategies that alter B cell survival (for review, see refs. 6 and 7). Furthermore, the diversity of their new properties has yielded the delineation of B cell populations into phenotypically unique and functionally distinct subsets. The distribution of these subsets is altered in the blood of patients with autoimmune disease (for review, see ref. 8), and the sequence of their return after therapeutic B cell depletion is abnormal (9). These studies implicate B cell subsets in the pathogenesis and/or maintenance of autoimmune diseases. Wolf and colleagues (10) have suggested a supplemental protective function of B cells against experimental autoimmune encephalomyelitis (EAE), a surrogate model of human multiple sclerosis, in B10.PL mice. The B cell–deficient B10.PL MT mice were unexpectedly unable to recover from EAE (Figure 1). Other mouse models have since confirmed that B cell depletion does not alleviate, but instead exaggerates, autoimmune traits. These findings have engendered, at least in the mouse, the concept of Breg cells, and evidence of their dominant role in immune regulation has been accumulating. Several mouse studies have allowed the dissection of mechanisms that underlie this B cell– induced regulation (for review, see ref. 11). That B cells are involved in some autoimmune conditions is not negated by such a new property. In this review, we critically describe some murine models of autoimmune rheumatic diseases and discuss some clues that suggest the existence of a human Christophe Jamin, PhD, Ahsen Morva, BSc, Sebastien Lemoine, BSc, Capucine Daridon, PhD, Pierre Youinou, MD, DSc, MACR: Brest University Medical School Hospital, Brest, France; Agnes Revol de Mendoza, PhD: Autonomous University of Nuevo Leon, Monterrey, Mexico. Dr. Youinou has received consulting fees, speaking fees, and/or honoraria (less than $10,000) from GlaxoSmithKline. Address correspondence and reprint requests to Pierre Youinou, MD, DSc, MACR, Laboratory of Immunology, Brest University Medical School Hospital, BP824, F29609 Brest, France. E-mail: youinou@univ-brest.fr. Submitted for publication December 19, 2007; accepted in revised form March 5, 2008.

The Meaning of Electroconvulsive Therapy

From the George Warren Brown School of Social Work, Washington University, St Louis, MO. Received for publication December 6, 2007; accepted December 11, 2007. Reprints: Melissa A. Hensley, MSW, MHA, Campus Box 1196, One Brookings Drive, St Louis, MO 63130 (e-mail: [email protected]).

Potential bias in studies of accidental needle sticks

There are many types of bias in clinical and epidemiologic studies that may distort the results. In his classic paper, Sackett1 cataloged 35 biases in analytic research. Others have suggested useful subclassifications of these biases.2 The most common type of bias is confounding of the association between exposure or intervention and the outcome by external factors. Equally critical biases in comparative studies, particularly those using retrospectively collected data, are selection, recall, and nonresponse bias. Selection bias is often created by erroneous sampling and selection by design or self-selection of study participants. Nonresponse bias, a form of selection bias, may exist in studies in which the response rate is low and the exposure and/or outcome among respondents is not representative of that in the study population. Recall bias may affect the study results when the ability of recalling past experiences and exposures in the groups of study participants is unequal. Case-control studies often suffer from recall bias because all data on risk factors are collected retrospectively. For example, cases of a disease tend to recall history of exposures and other illnesses much better than the control subjects. We chose 2 recently published studies of accidental needle sticks (ANSs) in allergy practices as examples for a discussion of how potential selection, recall, and nonresponse bias can affect the results of retrospective, survey-based studies. In response to continued concern about the risk of bloodborne diseases from ANSs, the National Institute of Occupational Safety and Health released needle stick guidelines,3 which advised employers to use safer devices, particularly needles with safety features (described hereafter as safety needles). Subsequently, the US Congress passed a bill that became the Needlestick Safety and Prevention Act of 2000.4 It authorized the Occupational Safety and Health Administration (OSHA) to revise its Bloodborne Pathogens Standard, redefine the engineering controls, and require employers to use this newer technology and maintain a log of the number of needle sticks and similar cutaneous injuries.5,6 Enforcement of this law began July 17, 2001. Considerable variation exists in the previously reported ANS incidence (between 14 and 839 ANSs per 1,000 population per year) among health care workers, and recent, reliable estimates for all health care facilities in the United States are not known.7 Although claims of safety needle use resulting in significant declines in the incidence of ANSs have been documented,8,9 the data were of questionable quality, the studies were restricted to 1 or a few selected hospitals (some outside the United States), and no randomized controlled trials were conducted. In particular, the tracking and recording of injury events by respondents have been problematic. For example, in a study of phlebotomy procedures using safety needles vs conventional needles in 6 teaching hospitals, 46% of all ANSs had not been reported.10 To determine the incidence of ANSs in allergy practices, Kanter and Siegel11 conducted a study of 400 selected practices in the United States, mostly in California. They collected data on ANSs by conducting a 2-year retrospective survey. The time frame of their survey and the details of the type (mail, telephone, or e-mail) and methods of their survey were not provided. The survey response rate was 30%. Kanter and Siegel found an incidence of 6.4 ANSs per million injections, which was much lower than the ANS incidence in general medical practices. (The source of data on general medical practices was not described.) In a subset of their data, the ANS incidence using safety needles was reported to be much higher than that using conventional needles. However, they acknowledged that these data were unreliable in establishing whether safety needles were actually less safe than traditional needles and were only an “initial step in what should be an ongoing process of evaluation.”11 Even though this study found 45 cases of ANSs, they mention that there have been no known reported cases of disease transmission in allergy practices and so argue that there is “no real risk to nursing personnel in the allergy setting.”11 In 2004, Wolf et al12 conducted a similar e-mail survey of 250 allergy practices. Seventy practices (28%) responded to the survey, and 29% and 59% of the respondents had switched to using safety needles for intradermal testing and allergy injections, respectively. The ANS incidence in the use of safety needles for allergy injections was higher than that for conventional needle use (39.6 vs 17.8 ANSs per million Affiliations: * Department of Medicine, Division of Allergy & Inflammation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; † Department of Health Policy & Management, University of Kansas School of Medicine, Kansas City, Kansas. Disclosures: Authors have nothing to disclose. Received for publication December 16, 2007; Received in revised form February 26, 2008; Accepted for publication March 3, 2008.

Handbook of PTSD: Science and Practice

Back to table of contents Previous article Next article Book ForumFull AccessHandbook of PTSD: Science and PracticeJONATHAN I. BISSON D.M., F.R.C.Psych.,JONATHAN I. BISSON D.M., F.R.C.Psych.Search for more papers by this author,Published Online:1 Mar 2008https://doi.org/10.1176/appi.ajp.2007.07121921AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail The exponential growth of research and clinical experience regarding posttraumatic stress disorder (PTSD) since its inclusion as a diagnosis in DSM-III 27 years ago has made it increasingly difficult to keep pace with advances in knowledge about the disorder. The three highly respected editors of this book identified the need for a comprehensive textbook on PTSD and brought together a group of 60 strong contributors, predominantly from the United States (with one or two well chosen exceptions), to produce a highly readable volume that will undoubtedly be of great use to individuals specializing in traumatic stress.The chapters detailing the historical background of the disorder set the scene and the chapters concerning psychological theories, epidemiology, and neurobiological theories provide up-to-date discussions of current knowledge in these areas. One great strength of the book is the detailed consideration of memory in PTSD, trauma-induced dissociation, and gene-environment interactions. Work in these areas is increasing and our knowledge is improving, and the chapters provide readers with an opportunity to consolidate their knowledge in these important areas that are not fully covered in many other texts.The section on prevention and treatment of posttraumatic stress disorder comprehensively reviews the evidence for interventions and importantly includes a chapter on cultural issues and trauma, which are often forgotten.The final section of the book, “Uncharted Territory,” provides a helpful overview of PTSD and the law. Perhaps not surprisingly, the focus is on U.S. legislation, although many of the issues can be easily translated to other countries, particularly the more developed ones. The contributing authors sensibly write, “Healthy skepticism must be tempered with an ethical obligation to deal with PTSD claimants in an honest and empathic manner.” Many texts do not consider emerging and novel treatments that have not been subjected to extensive evaluation but are in some cases already widely used. It is very important that such approaches are considered and fairly assessed. The chapter dedicated to emerging treatments for PTSD provides a useful review and helpfully recommends capitalizing on social support because of its association with recovery. Given the limited evidence for blanket early intervention, the chapter on public mental health interventions provides some excellent points, with a focus on providing for basic needs and triage. The final chapter provides a fitting end to the book with a synthesis of key questions and an agenda for future research.Overall this is a very good overview of the traumatic stress field and a volume I am very pleased to have on my bookshelf. I suspect that others will feel the same.Cardiff, U.K.Book review accepted for publication December 2007 (doi:10.1176/appi.ajp.2007.07121921).Reprints are not available; however, Book Forum reviews can be downloaded at http://ajp.psychiatryonline.org. FiguresReferencesCited byDetailsCited byNone Volume 165Issue 3 March, 2008Pages 404-405THE AMERICAN JOURNAL OF PSYCHIATRY March 2008 Volume 165 Number 3 Metrics PDF download History Published online 1 March 2008 Published in print 1 March 2008

Divided Doses for Methadone Maintenance

Divided Doses for Methadone Maintenance

Treatment of Rapid-Cycling Bipolar Disorder: Are Antidepressants Mood Destabilizers?

Treatment of Rapid-Cycling Bipolar Disorder: Are Antidepressants Mood Destabilizers?

Ernest Gutmann (1910–1977)

The Denervated Muscle, a book written by Ernest Gutmann and collaborators, was published in 1962 and at that time, represented an excellent summary of the existing knowledge on nerve–muscle interactions. In addition, the book contained a large amount of novel results identifying Gutmann’s laboratory as a major research center for work on muscle denervation, atrophy and neurotrophic effects. For those not familiar with this book, it is still worthwhile to scan the table of contents. As reflected by the titles of the 12 chapters and their authors, the book illustrates the vast scope of a group of morphologists, muscle physiologists, neurophysiologists and biochemists working together under the guiding spirit of an extraordinary personality, Ernest Gutmann. Ernest Gutmann was a pioneer in his country. He had the ability to attract young scientists and to guide them by the warmth of his personality, his stimulating and artistic intellect, his wit and charm, and also because he respected them as independent specialists in their fields. His ability to infuse enthusiasm made him so successful in forming a team and founding an internationally renowned school. Ahead of others, he recognized relevant problems and opened new chapters. He had the ability to formulate precise questions which could be addressed by simple experiments, especially with the use of methods that were available to him under restricted conditions. He liked to play with ideas and assessed experimental findings in their wider biological context. In his work on skeletal muscle, he acknowledged the decisive importance of innervation and neuromuscular activity in determining skeletal muscle properties, but he also considered other regulatory factors. Indeed, he was one of the first scientists who suggested that trophic factors may regulate important events in muscle and motoneurone development and maintenance. Having noticed the tremendous importance of hormones on muscle survival in invertebrates, he turned his attention to the effects of hormones on mammalian muscles linked to sexual activity. He and his colleagues discovered that the survival of such muscles is hormone dependent. Hormones led to aging, and his work on changes of the motor unit with age is a lasting contribution in this field. Sidney Hilton and Pavel Hnik stated in their obituary that Professor Gutmann was one of those whose work has inspired many laboratories throughout the world to turn their attention to these non-impulse aspects of cellto-cell relationships. Early studies on denervation and nerve regeneration had directed Gutmann’s interest towards non-impulse neural effects on muscle, its functional specialization and maintenance of phenotypic properties, e.g. Refs. 8–12. The work of Drahota and Gutmann on long-term regulatory influence of the nervous system on some metabolic differences in muscles of different function was the first study confirming and extending the observations published by Buller, Eccles and Eccles 3 years before and thus, represented an important contribution to the newly opened chapter of muscle plasticity. In this context, it is noteworthy that John Eccles had used the term plasticity already in 1959 when he first reported on the effects of cross-reinnervation as ‘plasticity at the simplest levels of the nervous system’. This term, however, appears to have originated from Albrecht Bethe who first used it in an article entitled ‘Die plastizitat (anpassungsfahigkeit) des nervensystems’. All the people who knew him succumbed to his charm and loved him for it. Some anecdotes about Ernest’s behavior illustrate his modesty and charming naivety. There was a meeting of heads of divisions of the Institute of Physiology to discuss some questions of interdepartmental organisation of the Institute. This meeting coincided with one convened by the cleaners and maintenance workers of the Institute. For most of the heads of Divisions, the decision as to which meeting to attend was not a problem and all apart from Ernest attended the meeting of the heads of divisions. Ernest’s choice was quite unexpected: he attended the meeting of the cleaners and maintenance workers. At the time, this choice seemed quite inappropriate, but with hindsight, it became clear that the meeting Ernest attended was much more important for the smooth running of the Institute than that of the heads of Divisions. Ernest Gutmann was truly a renaissance man, with many interests ranging from sport to music, history of science and above all understanding nature. He was Correspondence and reprint requests to: Dirk Pette, Department of Biology, University of Konstanz, D-78457 Konstanz, Germany. [dirk.pette@uni-konstanz.de] Accepted for publication December 2007.

Psychotic Depression

Psychotic Depression

Scleral Patch Graft Calcification and Erosion Following Molteno Implant Surgery

A case of dystrophic calcification of a scleral patch graft and conjunctival tissue erosion 17 years following the implantation ofa Molteno drainage device is described.

Large Blunt Scleral Rupture Without Retinal Detachment

Eyes with scleral rupture after blunt trauma are often complicated by proliferative vitreoretinopathy. A 56-year-old man sustained blunt trauma to his left eye. Visual acuity was light perception. The fundus was obscured by hyphema. Computed tomography imaging and the presence of extensive subconjunctival hemorrhage suggested scleral rupture. Prompt primary surgery to repair a 25-mm scleral rupture was performed under general anesthesia. No retinal detachment developed. Two years postoperatively, visual acuity increased to 12/20. This case shows that retinal detachment and proliferative vitreoretinopathy may not complicate extensive scleral ruptures under certain circumstances.

Imaging of Endometrioid Adenocarcinoma of the Uterus Metastatic to the Ciliary Body

A 60-year-old woman with endometrioid adenocarcinoma (stage FIGO II) presented with left eye pain. A hysterectomy was to be preceded by pelvic radiation therapy (45 Gy). Ophthalmic examination with high frequency ultrasonography revealed a ciliary body tumor with iris extension. Positron emission tomography and computed tomography fusion revealed multifocal metastatic disease. A Finger iridectomy technique ciliary body tumor biopsy revealed metastatic endometrioid adenocarcinoma. Treatment with external beam radiation therapy (3,060 cGy in 17 daily fractions) resolved her ocular disease. Subsequent and rapidly evolving systemic carcinomatosis with brain involvement resulted in her death. This is the first reported case of endometrioid adenocarcinoma of the uterus metastatic to the uveal tract.

Successful Delayed Surgical Revision of a Dislocated LASIK Flap

A 53-year-old woman presented with decreased vision and light sensitivity in the left eye for 3 months' duration. The patient had injured her left eye 7 months after laser in situ keratomileusis (LASIK), causing a traumatic flap dislocation that had not been repositioned. Three months after the injury, the LASIK flap was successfully repositioned with extensive intraoperative epithelial debridement and the use of flap sutures. Uncorrected visual acuity improved from 20/200 and J12 preoperatively to 20/60 and J1 postoperatively. This case illustrates that, although immediate flap repositioning is always recommended, a dislocated LASIK flap can be successfully repositioned even months after the trauma with an excellent visual outcome.

Severe Anterior Capsular Phimosis Following Acrylic Intraocular Lens Implantation in a Patient With Pseudoexfoliation

A case of severe capsular phimosis following implantation of an acrylic intraocular lens (hydrophobic acrylic with polymethylmethacrylate haptics) in a patient with pseudoexfoliation is described.

Surgical Stabilization of a Rib Fracture using an Angle Stable Plate

From the Department of Surgery, OLV Hospital, Oost-Vlaanderen, Belgium. Submitted for publication December 3, 2004. Accepted for publication April 20, 2005. Address for reprints: Roel Beelen, MD, Department of Cardio-vascular and Thoracic Surgery, OLV Hospital, Moorselbaan 164, 9300 Aalst, Oost-Vlaanderen, Belgium; email: [email protected].

Discussion

Augusta, Ga. Received for publication December 14, 2005. Jack C. Yu, M.D., Section of Plastic Surgery, Medical College of Georgia, 1457 Harper Street, HB 5040, Augusta, Ga. 30912, [email protected]