A 65-year-old white man with a history of multiple myeloma presented with thick, leathery, gray skin of the torso and extremities. Panel A shows the left axilla. The patient reported intense pruritus and thickening of . . .
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Saturday, October 24, 2009
Pachyderma
Pachyderma: ""
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Keratoconus Complicated by Acute Corneal Hydrops
Keratoconus Complicated by Acute Corneal Hydrops: "
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A 21-year-old woman with a history of myopia presented with the acute onset of foggy vision in her right eye and associated photophobia and mild sensation of the presence of a foreign body. Visual acuity . . .
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National Pain Summit - www.painsummit.org.au
Pain strategy launched
Experts are calling for chronic pain to be recognised as a disease in its own right, saying it should be included as a fifth vital sign that should be recorded alongside as BP, heart rate, temperature and breathing rate.
Older Drivers in Australia: Trends in Driving Status and Cognitive and Visual Impairment
Older Drivers in Australia: Trends in Driving Status and Cognitive and Visual Impairment
KEYWORDS
driving • DYNOPTA • alternative transportation • older adults • visual and cognitive impairments
ABSTRACT
OBJECTIVES: To investigate self-reported driving status within three Australian states; associations between demographic, health, and functional factors and driving status; and the extent to which remaining a driver in spite of cognitive and visual impairments varies as a function of sex.
DESIGN: Secondary data analysis of a pooled data set.
SETTING: Australian communities.
PARTICIPANTS: Adults aged 65 to 103 (N=5,206) from the Dynamic Analyses to Optimise Ageing (DYNOPTA) project. DYNOPTA is a unique data set created through the harmonization and pooling of data across nine separate Australian longitudinal studies of aging conducted between 1990 and 2007 (N=50,652).
MEASUREMENTS: Driving status, demographic characteristics, Mini-Mental State Examination score, visual acuity, physical activity, and occupation.
RESULTS: Men and participants with higher-level occupations had greater odds of driving. Older age, more medical conditions, and poorer vision increased the odds of not driving. Persons who were divorced, widowed, or never married were at a greater risk than married adults of not driving. Descriptive analyses revealed a large proportion of men with probable visual or cognitive impairments who reported driving. Subsequent comparative analyses between the DYNOPTA sample and other published U.S. and Canadian data revealed lower proportions of current drivers among Australian women and those at older ages, although there were consistently lower proportions of drivers within Australia and Canada than in the United States.
CONCLUSION: The rate of men with probable dementia or visual impairments who reported driving is of particular concern. Research and policy need to focus on evidence-based assessment of older drivers and development of appropriate interventions and programs to maintain the mobility and independence of older adults
Friday, October 23, 2009
Spinal surgery debate erupts - ABC Online
Spinal surgery debate erupts - ABC Online: "
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Spinal surgery debate erupts ABC Online The Prime Minister has referred to the procedure in his call for a national review of treatments on the Medicare Benefits Scheme but doctors who perform the ... |
http://www.bmj.com/cgi/content/abstract/339/oct06_2/b3829
http://www.bmj.com/cgi/content/abstract/339/oct06_2/b3829
Objectives To describe the course of chronic low back pain in an inception cohort and to identify prognostic markers at the onset of chronicity.
Prognosis for patients with chronic low back pain: inception cohort study
Luciola da C Menezes Costa, PhD candidate1, Christopher G Maher, director of division1, James H McAuley, research manager1,2, Mark J Hancock,lecturer2, Robert D Herbert, associate professor1, Kathryn M Refshauge,professor2, Nicholas Henschke, postdoctoral fellow1
1 George Institute for International Health, University of Sydney, 2 Back Pain Research Group, Faculty of Health Sciences, University of Sydney
Correspondence to: L da C Menezes Costa, PO Box M201, Missenden Road, NSW 2050, Australia lmenezes@george.org.au
Design Inception cohort study with one year follow-up.
Setting Primary care clinics in Sydney, Australia.
Participants The study sample was a subcohort of an inception cohort of 973 consecutive patients presenting to primary care with acute low back pain (<2 weeks' duration). 406 participants whose pain persisted for three months formed the inception cohort of patients with chronic low back pain.
Main outcome measures Outcomes and putative predictors measured at initial presentation, onset of chronicity (study entry), and follow-up at nine and 12 months. Recovery was determined from measures of pain intensity, disability, and work status. The association between potential prognostic factors and time to recovery was modelled with Cox regression.
Results Completeness of follow-up was 97% of total person time for all outcomes. The cumulative probability of being pain-free was 35% at nine months and 42% at 12 months and for complete recovery was 35% at nine months and 41% at 12 months. Of the 259 participants who had not recovered from pain related disability at entry to the chronic study, 47% had recovered by 12 months. Previous sick leave due to low back pain, high disability levels or high pain intensity at onset of chronicity, low levels of education, greater perceived risk of persistent pain, and being born outside Australia were associated with delayed recovery.
Conclusion More than one third of patients with recent onset, non-radicular chronic low back pain recover within 12 months. The prognosis is less favourable for those who have taken previous sick leave for low back pain, have high disability levels or high pain intensity at onset of chronic low back pain, have lower education, perceive themselves as having a high risk ofpersistent pain, and were born outside Australia.
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ andhttp://creativecommons.org/licenses/by-nc/2.0/legalcode.
Diabetes drug 'trumps fat pill'
Diabetes drug 'trumps fat pill': "A diabetes injection appears more effective at promoting weight loss than one of the leading obesity drugs, trials suggest."
Fungal exposure endocrinopathy in sinusitis with growth hormone deficiency: Dennis-Robertson syndrome
Fungal exposure endocrinopathy in sinusitis with growth hormone deficiency: Dennis-Robertson syndrome: "
A retrospective study was carried out on 79 patients with a history of mold exposure, fatigue, and chronic rhinosinusitis (CRS) to determine whether there is a causal relationship between fungal exposure and chronic sinusitis, fatigue, and anterior hypopituitarism, especially growth hormone deficiency (GHD). Of the patients, 94% had a history of CRS, endoscopically and/or computed tomography (CT) confirmed; 100% had chronic fatigue and 100% had either significant history of indoor mold exposure and/or positive mold plate testing as measured by settle plates, with an average colony count of 21 (0-4 normal). A total of 62 had positive mold plate testing and 17 had positive history of mold exposure. Of 75, 73 (97.3%) had positive serum immunoglobulin G (IgG)-specific antibodies to fungal antigens. Out of 8, 7 were positive for urinary trichothecenes. Resting levels of insulin-like growth factor 1 (IGF-1) averaged 123 ng/mL (range 43-285, normal 88-249 ng/mL). Despite normal resting levels of IGF-1, significant deficiency of serum human growth hormone (GH) was confirmed by insulin tolerance test (ITT) in 40 of 50 tested. In all, 51% (40/79) were GH deficient. Primary or secondary hypothyroidism in T3 and/or T4 was seen in 81% (64/79) patients; 75% (59/79) had adrenocorticotrophic hormone (ACTH) deficiency. Fungal exposure endocrinopathy likely represents the major cause of GHD, affecting approximately 4.8 million people compared to approximately known 60,000 cases from all other causes. A literature review indicates a possible mechanism of GHD in fungal exposure is that the fungal glucan receptors in the lenticulostellate cells of the anterior pituitary bind to fungal cells wall glucans and activate the innate immune system, which activates macrophages that destroy the fungus and lenticulostellate tissue. Treatment of patients included normal saline nasal irrigations, antifungal and antibiotic nasal sprays, appropriate use of oral antibiotics and antifungals, facial steamer with CitriDrops. Thymate and/or Intramax vitamin supplements, hormone replacement, and reduction of indoor mold levels. Resolution of rhinosinusitis was seen in 93% (41 of 45) of the patients who achieved a mold count by settling plates of 0-4 colonies. Thirty patients were unable to lower their mold counts below four colonies and had various degrees of mucosal disease and fatigue remaining. Fatigue was improved in all 37 patients who received GH and cortisol and/or thyroid hormone, which were deficient. Fatigue was partially relieved in 7 of the 37 who did not achieve mold counts of fewer than four colonies.
"Molds, mycotoxins, and sick building syndrome
Molds, mycotoxins, and sick building syndrome: "
The following is a review of some of the work we have done since 2004 regarding the importance of molds and their mycotoxins in the phenomenon of sick building syndrome (SBS). In these studies we showed that the macrocyclic trichothecene mycotoxins (MTM) of Stachybotrys chartarum (SC) are easily dissociated from the surface of the organism as it grows and could therefore be consequently spread in buildings as the fungus experiences additional water events. We then showed that SC and Penicillium chrysogenum (PC) colonies remain viable long after a water source has been removed, and the MTM produced by SC remain toxic over extended periods of time. We next showed that PC when inhaled, can release in vivo, a protease allergen that can cause a significant allergic inflammatory reaction in the lungs of mice. We then showed, in a laboratory study, that the MTM of SC can become airborne attached to spores or SC particulates smaller than spores. Following that study, we next showed that the same phenomenon actually occurred in SC infested buildings where people were complaining of health problems potentially associated with SBS. Finally, we were able to demonstrate the presence of MTM in the sera of individuals who had been exposed to SC in indoor environments. This last study was done with enough mold exposed individuals to allow for the statistical significance of SC exposure to be evaluated.
"The biocontaminants and complexity of damp indoor spaces: more than what meets the eyes
The biocontaminants and complexity of damp indoor spaces: more than what meets the eyes: "
Nine types of biocontaminants in damp indoor environments from microbial growth are discussed: (1) indicator molds; (2) Gram negative and positive bacteria; (3) microbial particulates; (4) mycotoxins; (5) volatile organic compounds, both microbial (MVOCs) and non-microbial (VOCs); (6) proteins; (7) galactomannans; (8) 1-3-β-D-glucans (glucans) and (9) lipopolysaccharides (LPS — endotoxins). When mold species exceed those outdoors contamination is deduced. Gram negative bacterial endotoxins, LPS in indoor environments, synergize with mycotoxins. The gram positive Bacillus species, Actinomycetes (Streptomyces, Nocardia and Mycobacterium), produce exotoxins. The Actinomycetes are associated with hypersensitivity pneumonitis, lung and invasive infections. Mycobacterial mycobacterium infections not from M. tuberculosis are increasing in immunocompetent individuals. In animal models, LPS enhance the toxicity of roridin A, satratoxins G and aflatoxin B1 to damage the olfactory epithelium, tract and bulbs (roridin A, satratoxin G) and liver (aflatoxin B1). Aflatoxin B1 and probably trichothecenes are transported along the olfactory tract to the temporal lobe. Co-cultured Streptomyces californicus and Stachybotrys chartarum produce a cytotoxin similar to doxorubicin and actinomycin D (chemotherapeutic agents). Trichothecenes, aflatoxins, gliotoxin and other mycotoxins are found in dust, bulk samples, air and ventilation systems of infested buildings. Macrocyclic trichothecenes are present in airborne particles <2 µm. Trichothecenes and stachylysin are present in the sera of individuals exposed to S. chartarum in contaminated indoor environments. Haemolysins are produced by S. chartarum, Memnoniella echinata and several species of Aspergillus and Penicillium. Galactomannans, glucans and LPS are upper and lower respiratory tract irritants. Gliotoxin, an immunosuppressive mycotoxin, was identified in the lung secretions and sera of cancer patients with aspergillosis produced by A. fumigatus, A. terreus, A. niger and A. flavus.
"Mold remediation in a hospital
Mold remediation in a hospital: "
As occupants in a hospital, patients are susceptible to air contaminants that can include biological agents dispersed throughout the premise. An exposed patient can become ill and require medical intervention. A consideration for patients is that they may have become environmentally sensitive and require placement in an environment that does not compromise their health. Unfortunately, the hospital environment often contains more biological substances than can be expected in an office or home environment. When a hospital also experiences water intrusion such as flooding or water leaks, resulting mold growth can seriously compromise the health of patients and others such as nursing staff and physicians (Burge, Indoor Air and Infectious Disease. Occupational Medicine: State of the Art Reviews, 1980; Lutz et al., Clinical Infectious Diseases 37: 786—793, 2003). Micro-organism growth can propagate if the water is not addressed quickly and effectively. Immunocompromised patients are particularly at risk when subjected to fungal infection such that the US Center for Disease Control issued guideline for building mold in health care facilities (Centers for Disease and Control [CDC], Centers for Disease and Control: Questions and Answers on Stachybotrys chartarum and Other Molds, 2000). This paper is based on mold remediation of one portion of a hospital unit due to water from construction activity and inadequate maintenance, resulting in mold growth. A large proportion of the hospital staff, primarily nurses in the dialysis unit, exhibited health symptoms consistent with mold exposure. Unfortunately, the hospital administrators did not consider the mold risk to be serious and refused an independent consultant retained by the nurse’s union to examine the premise (Canadian Broadcasting Corporation [CBC], Nurses file complaints over mold at Foothills. Canadian Broadcasting Corporation, 2003). The nurse’s union managed to have the premise examined by submitting a court order of detention and inspection and for an interlocutory injunction to allow their consultants to undertake air quality testing. Mold remediation procedures are readily available and are not to be discussed here (Silicato, http://www.nibs.org/BETEC/M6/ 13-Silicato_Mold-Remediation.pdf, 2004). However, the difficulty of determining the qualifications of consultants, contactors and project managers are discussed. It also describes the need and importance of a buffer zone between the occupied areas and the mold abatement containment area.
"Neurologic and neuropsychiatric syndrome features of mold and mycotoxin exposure
Neurologic and neuropsychiatric syndrome features of mold and mycotoxin exposure: "
Human exposure to molds, mycotoxins, and water-damaged buildings can cause neurologic and neuropsychiatric signs and symptoms. Many of these clinical features can partly mimic or be similar to classic neurologic disorders including pain syndromes, movement disorders, delirium, dementia, and disorders of balance and coordination. In this article, the author delineates the signs and symptoms of a syndrome precipitated by mold and mycotoxin exposure and contrasts and separates these findings neurodiagnostically from known neurologic diseases. This clinical process is designed to further the scientific exploration of the underlying neuropathophysiologic processes and to promote better understanding of effects of mold/mycotoxin/water-damaged buildings on the human nervous system and diseases of the nervous system. It is clear that mycotoxins can affect sensitive individuals, and possibly accelerate underlying neurologic/pathologic processes, but it is crucial to separate known neurologic and neuropsychiatric disorders from mycotoxin effects in order to study it properly.
"Sunday, October 18, 2009
Hydroxypyrene in urine of football players after playing on artificial sports field with tire crumb infill
Hydroxypyrene in urine of football players after playing on artificial sports field with tire crumb infill: "
Background Artificial sports fields are increasingly being used for sports. Recycled rubber from automotive and truck scrap rubber tires are used as an infill material for football grounds. There are concerns that football players may be at risk due to exposure from released compounds from rubber infill. Compounds from crumb infill may be inhaled and dermal exposure may occur. A study was performed to assess the exposure of football players to polycyclic aromatic hydrocarbons due to sporting on synthetic ground with rubber crumb infill.
Methods In this study, football players were trained and had a match on the artificial turf pitch during 2.5 h. They had an intensive skin contact with rubber infill. All urine of seven nonsmoking football players was collected over a 3-day period, the day before sporting, the day of sporting and the day after sporting. Urine samples were analyzed for 1-hydroxypyrene. Confounding exposure from environmental sources and diet was controlled for.
Results The individual increase of the amount of excretion over time was used as a measure to assess the uptake of PAH. It appeared that the baseline of excreted 1-hydroxypyrene in 4 of 7 volunteers was sufficient stable and that 1 volunteer out of 4 showed after the 2.5-h period of training and match on the playground an increase in hydroxypyrene in urine. However, concomitant dietary uptake of PAH by this volunteer was observed.
Conclusions This study provides evidence that uptake of PAH by football players active on artificial grounds with rubber crumb infill is minimal. If there is any exposure, than the uptake is very limited and within the range of uptake of PAH from environmental sources and/or diet."
An analysis of MRI and ultrasound imaging in patients with gout who have normal plain radiographs
An analysis of MRI and ultrasound imaging in patients with gout who have normal plain radiographs: "
Objective. The aim of this study was to analyse the prevalence of occult destructive arthropathy in subjects with gout and normal plain radiographs by utilizing MRI and ultrasound (US).
Methods. The study consisted of two visits. At Visit 1, a plain radiograph of the ‘index joint’ was obtained. The ‘index joint’ was defined as a joint that has had the most acute attacks of gout historically. The index joint plain radiograph had to be free of erosive damage in order for the subject to qualify for Visit 2. At Visit 2, the subject had an MRI with contrast and an US of the index joint. Each subject also had an MRI and US of an ‘asymptomatic joint’. The ‘asymptomatic joint’ was defined as a joint that had never experienced an acute attack of gout (determined by standard protocol). The primary endpoint was erosive changes on the MRI and/or US of the index joint. Secondary endpoints included erosive changes on the asymptomatic joint as well as bone marrow oedema (BME) (on MRI), synovial pannus (SP), soft tissue tophi (STT) or oedema (STE) on either the index or asymptomatic joint.
Results. Twenty-seven subjects (26 males; 1 female) completed both visits. Their average age and disease duration were 55.1 years (range 21–75 years) and 6.8 years (range 0.25–25 years), respectively. The subjects’ average serum uric acid level over the past 5 years was 8.09 mg/dl (range 4.1–12.8 mg/dl); their average on the day of Visit 1 was 7.96 mg/dl (range 4.6–13.9 mg/dl). The first MTP was the most common index joint (17) followed by the ankle (5), mid-tarsal (2), knee (2) and wrist (1). The knee was the most common asymptomatic joint (21) followed by the wrist (3), MTP (2) and ankle (1). All subjects had both MRIs; one subject refused the US. Out of 27 subjects, 15 (56%) had erosions on MRI of their index joint (P < 0.0001); only 1 subject (4%) had erosions identified in the index joint by US (P = NS). Regarding the secondary endpoints on the index joint, the MRI detected SP (13), BME (4), STE (3) and STT (0); the US detected SP (1), STT (1) and STE (0). Regarding the MRI of the asymptomatic joint, positive findings included SP (3), BME (3), STE (2) and erosions (1). There were no positive findings by US in the asymptomatic joint.
Conclusions. A large percentage of patients with gout and normal plain radiographs have occult destructive arthropathy that is only detected by advanced imaging such as MRI and/or US. However, MRI appears to be much more sensitive than US at detecting these findings."
Hand deformities are important signs of disease severity in patients with early rheumatoid arthritis
Hand deformities are important signs of disease severity in patients with early rheumatoid arthritis: "
Objectives. The aim of this study was to investigate the occurrence and significance of hand deformities during the first 10 years of RA.
Methods. One hundred and eighty-three early RA patients were included in the study during 1985–89. Mean ± s.d. of age at onset was 51.4 ± 12.4 years, and mean duration of symptoms before inclusion 12 ± 7 months; 64% were women. The patients were followed annually. Assessment of hand deformities was standardized. Hand mobility was measured by signals of functional impairment (SOFI), disability by HAQ and hand HAQ, disease activity by ESR and radiographic changes by the Larsen method.
Results. One hundred and eight (59%) patients developed at least one hand deformity during the study time. The majority occurred during the first years. After 10 years, the rate of ulnar deviation, button hole deformity and swan neck deformity was 44, 24 and 23.5%, respectively. The deformity group showed significantly higher disease activity during the first 5 years, and significantly more hand impairment, more disability and more severe radiographic changes throughout the study. Presence of a deformity after 1 year increased the risk of developing a Larsen score above median after 5 years. Odds ratio (95% CI) was 2.1 (1.023, 4.385).
Conclusions. More than half of the patients in this early RA cohort had developed hand deformities after 10 years. Most deformities occurred during the first year of the disease. Presence of hand deformities had an impact on daily life function and added useful prognostic information, being an early sign of a more severe disease."
Ultrasound lung comets in systemic sclerosis: a chest sonography hallmark of pulmonary interstitial fibrosis
Ultrasound lung comets in systemic sclerosis: a chest sonography hallmark of pulmonary interstitial fibrosis: "
Objective. To assess the correlation between ultrasound lung comets (ULCs, a recently described echographic sign of interstitial lung fibrosis) and the current undisputed gold-standard high-resolution CT (HRCT) to detect pulmonary fibrosis in patients with SSc.
Methods. We enrolled 33 consecutive SSc patients (mean age 54 ± 13 years, 30 females) in the Rheumatology Clinic of the University of Pisa. We assessed ULCs and chest HRCT within 1 week independently in all the patients. ULC score was obtained by summing the number of lung comets on the anterior and posterior chest. Pulmonary fibrosis was quantified by HRCT with a previously described 30-point Warrick score.
Results. Presence of ULCs (defined as a total number more than 10) was observed in 17 (51%) SSc patients. Mean ULC score was 37 ± 50, higher in the diffuse than in the limited form (73 ± 66 vs 21 ± 35; P < 0.05). A significant positive linear correlation was found between ULCs and Warrick scores (r = 0.72; P < 0.001).
Conclusions. ULCs are often found in SSc, are more frequent in the diffuse than the limited form and are reasonably well correlated with HRCT-derived assessment of lung fibrosis. They represent a simple, bedside, radiation-free hallmark of pulmonary fibrosis of potential diagnostic and prognostic value.
"Vital Signs: Awareness: Prodding People to Wash Their Hands in Restrooms
Vital Signs: Awareness: Prodding People to Wash Their Hands in Restrooms: "Signs with simple reminders seem to induce men and women to clean with soap and water, a British study found.
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