The Manitoba Youth Justice Program: empowering and supporting youth with FASD in conflict with the law.

Fetal alcohol spectrum disorder (FASD) describes a constellation of physical, cognitive, neurologic, and behavioral impairments resulting from prenatal exposure to alcohol. FASD is recognized as being one of the most common causes of preventable brain injury in children. There had long been concerns that some youth in conflict with the law may be affected with FASD given repetitive patterns of offending and apparent lack of understanding of the consequences of their actions. In 2004, funding was received from Justice Canada for a pilot project with a cross-departmental steering committee working together to determine a best way of working across systems to provide FASD assessments to these youth. It was recognized that provision of timely FASD assessments would allow the court to provide more meaningful sentences taking into account the youth's strengths and challenges and enhance the changes of decreased recidivism and increased changes of rehabilitation. This paper describes the basic science around FASD and its diagnosis, provides a history of the FASD Youth Justice Program, and reports on legal issues, structure, statistics, accomplishments, and ongoing future challenges.

Understanding continuous professional development participation and choice of mid-career general dental practitioners.

OBJECTIVE: Participating in continuing professional development (CPD) activities is a requirement for dental practitioners to keep their skills and knowledge up to date. Understanding the ways dental practitioners engage with professional development and the impact on practice is not fully known (Eaton et al. 2011, http://www.gdc-uk.org/Aboutus/policy/Documents/Impact%20Of%20CPD%20In%20Dentistry.pdf). The aim of this study was to gain insights into the ways that dentists reflect on their professional development and what may be influencing their choices. METHOD: Empirical qualitative data were collected by semi-structured interviewing of five mid-career dentists. Using grounded theory, the data were analysed for themes about CPD choice and participation. RESULTS: Three themes were identified as influences to dentists' choices of CPD with pragmatic considerations of how new learning could benefit their patients and their practices. Dental practitioners were influenced by the requirements of external regulatory bodies which they did not consider to necessarily improve practice. CONCLUSION: Dentists working in primary care in the UK are undertaking CPD which is influenced by the pragmatic requirements of running a small business and to meet regulatory requirements. In this sample, dentists are not critically reflecting on their education needs when choosing their CPD activity. Protected learning time and organisational feedback and support are recommended as a way to promote more meaningful reflection on learning and to improve professional development.

Successful renal transplant in a patient with non-Herlitz junctional epidermolysis bullosa.

Non-Herlitz junctional epidermolysis bullosa (NH-JEB) is a very rare inherited disorder, with an array of complications. We present the case of a 33-year-old patient of Chinese origin, diagnosed with NH-JEB in childhood, who developed severe IgA nephropathy. His renal impairment was initially treated by haemodialysis. He underwent successful renal transplantation, resulting in normalization of his renal function. To our knowledge, this is the first report of renal transplantation in a patient with epidermolysis bullosa, which should support use of this intervention in other similar cases.

Using a wiki platform to promote guidelines internationally and maintain their currency: evidence-based guidelines for the nutritional management of adult patients with head and neck cancer.

BACKGROUND: The present study describes the development of evidence-based practice guidelines for the nutritional management of adult patients with head and neck cancer using a wiki platform to enable wide international stakeholder consultation and maintain currency. METHODS: A dietitian steering committee and a multidisciplinary steering committee were established for consultation. Traditional methods of evidence-based guideline development were utilised to perform the literature review, assess the evidence and produce a draft document. This was transferred to a wiki platform for stakeholder consultation and international endorsement processes in Australia, New Zealand and the UK. Data were collected on website traffic utilising Google Analytics. RESULTS: In addition to broad stakeholder consultation through the steering committees, an additional twenty comments were received via the wiki by twelve individuals covering six different professions from three different countries, compared to four comments by e-mail. The guidelines were subsequently endorsed by the dietetic associations of Australia, New Zealand and the UK. During a 4-month period monitoring the use of the guidelines, there were 2303 page views to the landing page from 33 countries. The average number of pages accessed per visit was five and the duration of time spent on the website was approximately 6 min. CONCLUSIONS: Using a wiki platform for guideline development and dissemination is a successful method for producing high-quality resources that can undergo wide international stakeholder review and include open public consultation. This can replace conventional methods whereby guidelines can quickly become outdated.

Introduction of an enhanced recovery protocol into a laparoscopic living donor nephrectomy programme.

INTRODUCTION: Living-donor renal transplantation is the optimal treatment for patients with end-stage renal disease. The rate of living donation in the UK is sub-optimal, and potential donor concerns regarding postoperative recovery may be contributory. Enhanced recovery programmes are well described for a number of surgical procedures, but experience in living-donor surgery is sparse. This study reports the impact of introducing an enhanced recovery protocol into a living-donor renal transplant programme. MATERIALS AND METHODS: All consecutive patients undergoing laparoscopic living-donor nephrectomy over a 25-month period were included. The principles of enhanced recovery were fluid restriction, morphine sparing and expectation management. Outcome measures were postoperative pain scores and complications for donor and recipients. RESULTS: Standard care was provided for 24 (30%) patients and 57 (70%) followed an enhanced recovery pathway. The latter group received significantly less preoperative intravenous fluid (0ml vs 841ml p < 000.1) and opiate medication (14.83mg vs 23.85mg p = 0.001). Pain scores, postoperative complications and recipient transplant outcomes were comparable in both groups. CONCLUSIONS: Enhanced recovery for living-donor nephrectomy is a safe approach for donors and recipients. Application of these techniques and further refinement should be pursued to enhance the experience of living donors.

A review of the current evidence for maintenance therapy in ovarian cancer.

OBJECTIVES: Ovarian cancer (OC) typically is diagnosed at advanced stages, in which the primary goal of therapy is to prolong progression-free survival (PFS) and overall survival (OS). In recent years, maintenance therapy has been tested for this purpose in advanced OC (AOC). Literature on maintenance therapy in AOC was systematically reviewed to assess current knowledge regarding the impact of this therapeutic approach. METHODS: A MEDLINE search was performed 2/2009 for articles published 1/2001-1/2009 pertaining to OC maintenance therapy guidelines, patterns, and outcomes. A second search used keywords specific to maintenance and included primary studies published in the last 10 years. Of 406 sources identified, 36 primary studies and 16 review articles were included in this systematic review. A third search used the keyword "consolidation" to find maintenance articles not identified through other searches; of 48 additional sources, 13 primary studies and 6 reviews were included. A fourth search of non-MEDLINE-indexed sources yielded 14 additional relevant publications from the same time period. RESULTS: Among practice guidelines identified, only the National Comprehensive Cancer Network (NCCN) 2008 guidelines provide recommendations regarding maintenance therapy, assigning it a category 2B recommendation. No studies were identified that reported current treatment patterns or economic outcomes in maintenance therapy; quality of life data were reported in one study. A variety of agents have been tested for maintenance, with paclitaxel the most commonly evaluated. The Southwest Oncology Group-Gynecologic Oncology Group 178 trial has found that 12 cycles of paclitaxel extend PFS (by 7 months) compared to 3 months paclitaxel, but could not adequately evaluate OS. CONCLUSIONS: Maintenance therapy may improve clinical outcomes in AOC, but additional research is needed to demonstrate an OS advantage. Future studies should investigate the long-term clinical benefit of maintenance treatment and its impact on resource utilization and health-related quality of life.

Soldier-relevant body borne load impacts minimum foot clearance during obstacle negotiation.

Soldiers often trip and fall on duty, resulting in injury. This study examined ten male soldiers' ability to negotiate an obstacle. Participants had lead and trail foot minimum foot clearance (MFC) parameters quantified while crossing a low (305 mm) and high (457 mm) obstacle with (19.4 kg) and without (6 kg) body borne load. To minimize tripping risk, participants increased lead foot MFC (p = 0.028) and reduced lead (p = 0.044) and trail (p = 0.035) foot variability when negotiating an obstacle with body borne load. While obstacle height had no effect on MFC (p = 0.273 and p = 0.126), placing the trail foot closer to the high obstacle when crossing with body borne load, resulted in greater lead (R = 0.640, b = 0.241, p = 0.046) and trail (R = 0.636, b = 0.287, p = 0.048) MFC. Soldiers, when carrying typical military loads, may be able to minimize their risk of tripping over an obstacle by creating a safety margin via greater foot clearance with reduced variability.

A Phase I and pharmacological study of the glutamine antagonist acivicin with the amino acid solution aminosyn in patients with advanced solid malignancies.

Acivicin is a glutamine analogue antimetabolite that inhibits several glutamate-dependent synthetic enzymes. Previous studies of this agent administered on a 72-h continuous i.v. infusion schedule every 3 weeks demonstrated a high rate of severe, albeit reversible, central nervous system (CNS) toxicity at the 30 mg/m2/day dose level. Animal studies have shown that the CNS toxicity of acivicin can be prevented by a concomitant infusion of amino acids postulated to block drug uptake in the CNS by a saturable transport system that is common to endogenous amino acids. This study evaluated the feasibility of escalating acivicin doses in cancer patients by administering acivicin with a concomitant 96-h i.v. infusion of a mixture of 16 amino acids (Aminosyn, 10%). Twenty-three patients with advanced malignancies were treated with acivicin on a 72-h continuous infusion schedule at doses ranging from 25 to 60 mg/m2/day every 3 weeks. Reversible, dose-limiting CNS toxicity, characterized by lethargy, confusion, and decreased mental status, occurred in the two patients enrolled at the 60 mg/m2/day dose level, precluding further dose escalation. The maximum tolerated dose (MTD) and recommended dose for additional evaluation of acivicin on this schedule is 50 mg/m2/day. Other toxicities observed were dose-related neutropenia that was grade 4 in four patients (four courses), complicated with fever in three of those patients, and grade 3-4 thrombocytopenia in three patients (three courses). Pharmacokinetics studies performed in 15 patients revealed that the acivicin plasma Css increased from 0.44 microg/ml (range, 0.28-0.59 microg/ml) at the 25 mg/m2/day to 1.06 microg/ml (0.64-1.5 microg/ml) at the 50 mg/m2/dose level. Acivicin Css at the MTD was not significantly higher than previously reported values with single-agent acivicin on the same schedule of administration at the MTD of 25 mg/m2/day dose level (0.60 microg/ml; range, 0.43-0.81 microg/ml). Neurotoxicity did not correlate with acivicin Css, but relationships between exposure to acivicin and the occurrence of both neutropenia and thrombocytopenia were well described by a sigmoidal Emax model. This trial demonstrated that concomitant infusions of amino acid can prevent acivicin-induced CNS toxicity, which allows the dose of acivicin to be escalated 2-fold above previously tolerable doses; however, this effect did not translate in a significant increment in acivicin Css.

Outcome after surgical repair of junctional epidermolysis bullosa-pyloric atresia syndrome: a report of 3 cases and review of the literature.

BACKGROUND: Junctional epidermolysis bullosa-pyloric atresia syndrome is recognized as a distinct autosomal recessive entity. Affected infants present with skin fragility and inability to feed due to intestinal obstruction. Despite successful surgical repair of the anatomical defect, the outcome is poor owing to poor feeding, malabsorption, failure to thrive, and sepsis. OBSERVATIONS: In 70 cases of intestinal obstruction and epidermolysis bullosa reported in the medical literature and the 3 reported here, surgical intervention was attempted 51 times. In all except 16 infants, death occurred before age 11 months (mean age, 70 days). Renal involvement and continued failure to thrive accompanied the skin disease in survivors, who ranged in age from 30 days to 16 years (mean age, 4.0 years). CONCLUSIONS: The poor prognosis of this condition must be considered when decisions are made regarding surgical correction. Attempting surgical correction may be warranted in individual circumstances, but withholding surgical intervention and providing palliative support is an acceptable alternative.

Rationale for estrogen with interrupted progestin as a new low-dose hormonal replacement therapy.

OBJECTIVE: This review outlines the basic principles of a novel interrupted progestin hormone replacement therapy (HRT) regimen in which estrogen is given continuously but the progestin is administered in a 3-days-on and 3-days-off schedule. The rationale for this regimen is to prevent receptor down-regulation and allow estrogen to increase estrogen and progestin sensitivity during the progestin-free periods. METHODS: The reasons for poor patient acceptance of HRT are reviewed. The association of HRT with breast and endometrial cancer is discussed, as are the potential benefits of HRT on the skeleton and the cardiovascular system. Basic research studies in the rat are described that provide supporting evidence for the interrupted progestin regimen. Clinically, we review a pilot study examining symptom control, bleeding rates, and safety of the interrupted progestin regimen as well as preliminary results of the usefulness of this regimen for add-back therapy in GnRH agonist-treated patients. RESULTS: Estrogen and progestin receptor measurements in the rat uterus demonstrate a clear up- and down-regulation in response to estrogen and interrupted progestin but not to the continuous administration of estrogen and progestin or estrogen alone. In addition, we found a significant beneficial effect of a low-dose interrupted HRT regimen on bone mineral content and density in an aged rat model of osteopenia, compared with continuous estrogen and progestin or estrogen alone. These results support the hypothesis that the interrupted progestin HRT increases tissue sensitivity to both estrogen and progestin. Clinical studies demonstrated good symptom control, low bleeding rates, endometrial protection, and excellent patient acceptance. CONCLUSION: The combination of continuous estrogen with interrupted progestin appears to result in increased sensitivity to estrogen and progestin in estrogen-responsive tissues. As a result, lower doses of estrogen and progestin may be used for HRT with good biological effects. Further clinical studies, preferably in prospective randomized trials, are required to demonstrate reduced bleeding and improved patient acceptance of this new regimen compared to continuous combined HRT.

Transferring hospital sponsorship of a family practice residency: financial implications.

Family practice residency programs close each year, many in which there is a perception by the sponsoring institution that the program was too costly. Upon the imminent closure of a program's sponsoring hospital, we analyzed and projected the residency's budget and revenues to convince another community hospital to accept transfer of the sponsorship of the program. Revenues directly attributable to the residency (family practice center, grants, Medicare graduate medical education reimbursement) were identified. In addition, we identified that portion of new inpatient revenues necessary to offset the balance of the residency budget. We found that the program could account for reimbursement of 51.8% of its budget through patient care services, requiring 5.2% to be subsidized through state grants and 43.1% through federal graduate medical education reimbursement. Consistent with studies by several authors, family practice residency programs continue to require financial subsidy to balance their budgets. The nation's need for family physicians can only be ensured if state and federal priorities for needed primary health manpower are translated into continued and enhanced financial support.

London's burning: recovering other geographies of health.

In the opening to this paper we concern ourselves with the concept of health as it is currently understood in the now reformulated 'geography of health'. We focus on countering the assumption that the desire for health is the main drive behind individual patterns of consumption. To this end, we turn to a more culturally informed analysis which identifies the importance of understanding the complex relations between the body, identity, consumption and risk. To illustrate our ideas and arguments, we draw on current anti-smoking debates, particularly those relating to passive smoking, and what we see as evidence of alternatives to such health-related or 'healthist' rhetoric: the rise of cigar smoking and cigar bars in London, England.

Emergency physicians in critical care: a consultant's experience.

There is a growing interest in the interface between emergency medicine and critical care medicine. Previous articles in this journal have looked at the opportunities and advantages of training in critical care medicine for emergency medicine trainees. In the UK there are a small number of emergency physicians who also have a commitment to critical care medicine. This article describes a personal experience of such a job, looking at the advantages and disadvantages. Depending upon future developments in the role of emergency medicine in the UK, together with the proposed expansion in critical care medicine, such posts may become more common.

The prevention of softball injuries: the experience at Yokota.

Softball injuries occur in a predictable pattern. Review of Emergency Room records at Yokota AB Hospital for three summers showed a high incidence of ankle injuries. Sliding is the cause of many of these injuries. Common sense interventions should reduce the incidence of softball injury. Use of low profile bases or the outlawing of sliding are reasonable interventions that should be considered by policy makers.

Anxiety disorders seen in primary care.

This paper presents a clinical overview of syndromal anxiety and its treatment as seen in a family practice setting, where many patients with anxiety disorders are first seen. Panic disorder, social phobia, agoraphobia, and generalized anxiety disorder are the ones most often seen by such physicians. Treatment options include psychotherapy, behavioral-cognitive therapy, and pharmacotherapy. The primary care physician may choose from the benzodiazepines or the heterocyclic antidepressants or both. The monoamine oxidase inhibitors have also proved very useful in the treatment of panic disorder and social phobia, but probably should be used only by physicians with experience with this type of medication.

Middle ear symptoms while flying. Ways to prevent a severe outcome.

In an era when air travel is commonplace, middle ear block is not unusual. Educating patients about the simple techniques they can perform at the first signs of a problem may save a business trip or vacation from becoming a trip to the emergency department and a train ride home. The most important preventive measure is to avoid flying when symptoms of upper respiratory tract infection are present. When this is not possible, passengers should yawn, swallow, or chew to relieve pressure in the middle ear. Use of the Valsalva maneuver and decongestants or antihistamines may be helpful. Serve or unremitting ear block may require the use of the Politzer bag or a myringotomy.

Learning modules as a supplement to existing audiovisual aids.

The development and use of supplementary learning modules for audiovisual aids designed for wider audiences was found to be a feasible approach for the education of family practice residents. This approach allows programs to direct learner attention to areas of greatest interest in family practice. It was not excessively time consuming to develop the two modules and extensive technical expertise with media was not required. It was found that the modules were adaptable to individual or group use. This teaching method appears to be an excellent learning tool for residents. Supplementary learning modules may be useful for medical students and other health-care providers in family practice. Further economy of time and other innovations using this basic approach could result from recruiting family practice residents and other students to develop their own learning modules on topics of individual interest.

A network model for decentralized family practice residency training.

The organization of departments and divisions of family practice in a majority of medical schools in the United States has facilitated a recent trend toward increasing numbers of university affiliations with family practice residency programs in community hospitals. Many difficult issues arise when such affiliations are explored and developed. To date, the literature is meager on this important subject. This paper describes the elements of a network model for decentralized family practice residency training which has been in operation at the University of California Davis for over four years. Common issues are outlined, together with the various advantages of affiliation to the community hospital and the university. An active partnership between the medical school and community through a network of affiliated residency programs can effectively contribute to the quality of medical education and patient care on a regional basis and at the same time directly address the problem of physician maldistribution.