The Use of Sonographically Guided Botulinum Toxin Type A (Dysport) Injections Into the Tensor Fasciae Latae for the Treatment of Lateral Patellofemoral Overload Syndrome.

BACKGROUND: Pain in the anterior and lateral parts of the knee during exercise is a common clinical problem for which current management strategies are often unsuccessful. PURPOSE: To investigate the effect of an ultrasound-guided botulinum toxin (BT) injection into the tensor fasciae latae (TFL), followed by physical therapy, in patients classified with lateral patellofemoral overload syndrome (LPOS) who failed to respond to conventional treatment. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 45 patients (mean ± SD age, 32.4 ± 8.6 years) who met the inclusion criteria of (1) activity-related anterolateral knee symptoms, (2) symptoms lasting longer than 3 months, (3) a pathological abnormality confirmed by magnetic resonance imaging, and (4) previous failed physical therapy received an ultrasound-guided injection of BT into the TFL followed by physical therapy. Patient-reported outcomes were collected at 5 intervals: before the injection; at 1, 4, and 12 weeks after the injection; and at a mean 5 years after the injection. In 42 patients, relative iliotibial band (ITB) length changes were assessed using the modified Ober test at the first 4 time points. A computational model was run to simulate the effect of TFL weakening on gluteus medius (GMed) activity. Statistical analysis was undertaken using 1-way analysis of variance and paired t tests with Bonferroni post hoc correction. RESULTS: There was a significant improvement in Anterior Knee Pain Scale scores from before the injection (61 ± 15) to 1 (67 ± 15), 4 (70 ± 16), and 12 weeks (76 ± 16) after the injection and in 87% of patients (39/45 patients available for follow-up) at approximately 5 years (from 62.9 ± 15.4 to 87.0 ± 12.5) after the injection (all P < .010). A significant effect on the modified Ober test was identified as a result of the intervention, with an increase in leg drop found at 1 (3° ± 5°), 4 (4° ± 5°), and 12 (7° ± 6°) weeks after the injection compared with before the injection (all P < .010). Simulating a progressive reduction in TFL strength resulted in corresponding increases in GMed activity during gait. CONCLUSION: An injection of BT into the TFL, combined with physical therapy, resulted in a significant improvement of symptoms in patients with LPOS, which was maintained at 5-year follow-up. This may result from reduced lateral TFL/ITB tension or to an increase in GMed activity in response to inhibition of the TFL.

Patient management in the emergency department by advanced care paramedics.

We describe an emergency department process using Advanced Care Paramedics in the management of patients identified as ambulatory and low acuity, or those able to be managed without an emergency nurse. Patients streamed in this way had shorter stays than other emergency patients, without affecting the care of the latter. The process was associated with improved patient flow indicators in spite of an increased patient burden.

Can we predict which patients with community-acquired pneumonia are likely to have positive blood cultures?

BACKGROUND: Blood cultures (BC) are commonly ordered during the initial assessment of patients with community-acquired pneumonia (CAP), yet their yield remains low. Selective use of BC would allow the opportunity to save healthcare resources and avoid patient discomfort. The study was to determine what demographic and clinical factors predict a greater likelihood of a positive blood culture result in patients diagnosed with CAP. METHODS: A structured retrospective systematic chart audit was performed to compare relevant demographic and clinical details of patients admitted with CAP, in whom blood culture results were positive, with those of age, sex, and date-matched control patients in whom blood culture results were negative. RESULTS: On univariate analysis, eight variables were associated with a positive BC result. After logistic regression analysis, however, the only variables statistically significantly associated with a positive BC were WBC less than 4.5 × 10(9)/L [likelihood ratio (LR): 7.75, 95% CI=2.89-30.39], creatinine >106 µmol/L (LR: 3.15, 95%CI=1.71-5.80), serum glucose<6.1 mmol/L (LR: 2.46, 95%CI=1.14-5.32), and temperature > 38 °C (LR: 2.25, 95% CI =1.21-4.20). A patient with all of these variables had a LR of having a positive BC of 135.53 (95% CI=25.28-726.8) compared to patients with none of these variables. CONCLUSIONS: Certain clinical variables in patients with CAP admitted to hospitals do appear to be associated with a higher probability of a positive yield of BC, with combinations of these variables increasing this likelihood. We have identified a subgroup of CAP patients in whom blood cultures are more likely to be useful.

Protein and mucin retention on oral mucosal surfaces in dry mouth patients.

Oral homeostasis depends largely on proteins and mucins present in saliva that coat all oral surfaces. The present study compared the protein composition of residual fluid on mucosal surfaces in subjects with normal salivary flow with that of patients with dry mouth caused by salivary hypofunction. Samples of residual mucosal fluid were collected using paper strips and then analysed by protein electrophoresis and immunoblotting. In both patients and controls, residual fluids on mucosal surfaces (except the anterior tongue in control subjects) had higher protein concentrations than unstimulated whole-mouth saliva. High-molecular-weight mucin (MUC5B) was present in greater amounts on the anterior tongue than on other surfaces in control subjects. In dry mouth patients who were unable to provide a measurable saliva sample, MUC5B was often still present on all mucosal surfaces but in reduced amounts on the anterior tongue. The membrane-bound mucin, MUC1, was prominent on buccal and labial surfaces in patients and controls. Statherin was still present on surfaces that were dried to remove salivary fluid, suggesting that it may be adsorbed as a protein pellicle. It is concluded that oral mucosal surfaces in dry mouth patients can retain MUC5B and other salivary proteins, although the functional integrity of these proteins is uncertain.

Procedural sedation and analgesia in a Canadian adult tertiary care emergency department: a case series.

OBJECTIVES: To examine the safety of emergency department (ED) procedural sedation and analgesia (PSA) and the patterns of use of pharmacologic agents at a Canadian adult teaching hospital. METHODS: Retrospective analysis of the PSA records of 979 patients, treated between Aug. 1, 2004, and July 31, 2005, with descriptive statistical analysis. This represents an inclusive consecutive case series of all PSAs performed during the study period. RESULTS: Hypotension (systolic blood pressure < or = 85 mm Hg) was documented during PSA in 13 of 979 patients (1.3%; 95% confidence interval [CI] 0.3%-2.3%), and desaturation (SaO2 < or = 90) in 14 of 979 (1.4%; Cl 0.1%-2.7%). No cases of aspiration, endotracheal intubation or death were recorded. The most common medication used was fentanyl (94.0% of cases), followed by propofol (61.2%), midazolam (42.5%) and then ketamine (2.7%). The most frequently used 2-medication combinations were propofol and fentanyl (P/F) followed by midazolam and fentanyl (M/F), used with similar frequencies 58.1% (569/979) and 41.0% (401/979) respectively. There was no significant difference in the incidence of hypotension or desaturation between the P/F and M/F treated groups. In these patients, 9.1% (90/979) of patients received more than 2 different drugs. CONCLUSIONS: Adverse events during ED PSA are rare and of doubtful clinical significance. Propofol/fentanyl and midazolam/fentanyl are used safely, and at similar frequencies for ED PSA in this tertiary hospital case series. The use of ketamine for adult PSA is unusual in our facility.

Review of the use of polymers in saliva substitutes for symptomatic relief of xerostomia.

It is clear from the many clinical studies carried out on currently available saliva substitutes, that the main factors limiting the success of polymers in treating xerostomia is their short duration of action and/or their lack of acceptability by users. The most effective formulations for severe sufferers of xerostomia contain relatively viscous, thixotropic polymers, which mild to moderate sufferers in particular tend to dislike. Relief can also be extended by increasing concentrations of non-thixotropic polymers; however, this also has to be balanced by the decrease in palatability resulting from higher polymer levels. In addition, gels rather than solutions tend to result from higher polymer concentrations, which are only employed by the most severe sufferers of xerostomia, and in fact, have been suggested to offer little improvement in efficacy over oral sprays. It would be highly advantageous to improve the duration of relief without impacting negatively on the sensory profile of the product. This would provide a longer lasting effect that is acceptable to all sufferers of xerostomia. The essential role of polymers in saliva substitutes is to provide lubrication, hydration, and protection of the oral mucosa, providing symptomatic relief to sufferers of xerostomia. However, saliva substitutes should also be of neutral or near neutral pH, to prevent demineralization of the oral hard tissues. These products should always be used in conjunction with a thorough oral health regimen, but may also contain appropriate levels of electrolytes for remineralization of enamel and dentine.

Evaluation of a combined polymer system for use in relieving the symptoms of xerostomia.

OBJECTIVE: The aim of this series of studies on rheological, sensory, and mucoadhesive properties was to evaluate the potential of using a combined polymer system to more closely represent the adaptive nature of saliva, while providing long lasting relief from the symptoms of xerostomia. METHODOLOGY: The rheological investigations were conducted on 1% polymer solutions 24 hours after preparation, during which time they were stored in sealed glass containers at room temperature. The rheometer was controlled via peltier to 35 degrees C +/- 0.1 degrees C, and a shear rate range of 0.1 to 300 s(-1) was applied; thirty measurements were taken during each run. Eight panelists were recruited from the in-house sensory panel at GlaxoSmithKline (GSK) Weybridge to take part in the sensory evaluation. A brief training session was conducted at the start of the study in order to standardize the panelists' responses to the sensory term "tacky." For each test, panelists were given 10 ml of the respective polymer solution and instructed to swirl this solution around their mouths for 20 seconds before expectorating. The panelists were then asked to evaluate the solution in terms of "tack," measured by tapping the tongue on the roof of the mouth. A new formulation, based upon the rheology and sensory testing, was evaluated versus other commercially available sprays for the relief of xerostomia. The new formulation, named OASIS, contains a combination of Xanthan gum, carboxymethyl cellulose and a polyvinyl pyrollidone backboned polymer. To evaluate mucoadhesion of this final product, a 16 mm diameter cylindrical aluminium probe was selected. The probe and the base platform were both coated with a thin layer of artificial polyurethane membrane to more closely mimic the oral mucosal surface. The probe was set to travel downward at 2.0 mm/sec until it made contact with the base platform with a force of 1000 g. The two surfaces were then left in contact for 30 seconds before the probe receded from the base platform at 0.5 mm/sec to a distance of 10 mm. A plot of force versus distance was obtained, and the area under the curve (defined as the Work of Adhesion, energy required to separate the two surfaces) was used as a measure of the mucoadhesion of the materials. RESULTS: For rheology, the Xanthan gum solution showed high initial viscosity of 32 Pa.s at 0.1 s(-1) with rapid shear thinning to 4.0 Pa.s. By 1.2 s(-1) the viscosity continued to drop with increasing shear rate to 0.05 Pa.s at 300 s(-1). For the sensory assessment, the CMC single solution was perceived to be significantly (p = 0.04) more tacky than the CMC + PVP solution. The Xanthan + PVP solution was perceived to be less tacky (slightly/moderately tacky) than the Xanthan solution (moderately tacky). The Xanthan + CMC + PVP solution was perceived to be less tacky (slightly tacky) than the Xanthan + CMC solution (moderately tacky). Overall, there was a significant difference in favor of the inclusion of PVP across the products (p = 0.038), which was also shown to be a consistent effect across the different polymer solutions. CONCLUSION: The sensory solution work indicates that the addition of a PVP backbone polymer within an anionic polymer solution (OASIS) enables higher concentrations of mucoadhesive polymer to be included within a dry mouth formulation, while at the same time giving improved mouth-feel due to reduced tack.

Agreement between emergency physician diagnosis and radiologist reports in patients discharged from an emergency department with community-acquired pneumonia.

To evaluate the level of concurrence between radiologist reports and the diagnosis of community-acquired pneumonia (CAP) in patients discharged from an emergency department (ED), a retrospective chart audit of patients discharged with a diagnosis of 'pneumonia' or 'possible pneumonia' from the ED during a 2-year period was conducted. Emergency physician (EP) and radiology report (RR) diagnoses were categorized as 'pneumonia', 'possible pneumonia', 'non-pneumonia' and 'normal', and categories from each were compared. 815 charts were analyzed. Of 671 EP diagnoses of 'pneumonia', 304 (45.3%) RR's reported 'pneumonia' and 82 (12.2%), 'possible pneumonia'. Of 815 EP diagnoses of 'pneumonia' or 'possible pneumonia', 426 (52.3%) RRs were in agreement, while 216(26.5%) were of diagnoses other than pneumonia and 173 (21.1%) were read as normal. EPs and radiologists frequently disagree on whether a patient has pneumonia or not. Perhaps it is time to revisit the gold standard status of plain chest X-ray.

Utility of follow-up recommendations for patients discharged with community-acquired pneumonia.

INTRODUCTION: The joint Canadian Infectious Diseases Society and Canadian Thoracic Society guidelines for community-acquired pneumonia (CAP) recommend 48-72 hour telephone follow-up of patients discharged from the emergency department (ED). The guidelines provide no evidence supporting this practice, and neither the clinical utility nor the effectiveness of such recommendations has been assessed. Our objective was to assess the utility of a 48-72 hour telephone follow-up protocol for patients discharged from the ED with CAP. METHODS: This was a retrospective chart audit covering a 2-year period (Jan. 3, 1999 to Jan. 3, 2001) after the introduction of a clinical practice guideline (CPG) that included routine 48-72 hour telephone follow-up of patients discharged from the ED with CAP. Eligible patients were identified in the ED database, rates of referral for telephone follow-up were recorded, and 30-day outcomes (death and readmission) for patients referred versus not referred were compared. RESULTS: During the study period, 867 patients were identified as being eligible for the study. The mean age was 55.7 years (range 16-98 yr), and mean pneumonia severity index (PSI) was 68.9 (range 6-187). Despite the CPG, only 148 patients (17.1%) were referred for telephone follow-up. Age, demographics, comorbidity, clinical status and pneumonia severity were similar for referred and non-referred patients. Thirty-day death (2.5%) and readmission rates (3%) were strongly related to PSI score, but did not differ significantly in the 2 comparison groups. CONCLUSION: In this setting, physicians were poorly compliant with a routine telephone follow-up protocol. The likelihood of referral for follow-up did not correlate with pneumonia severity, and follow-up referral did not appear to affect patient outcome. These findings do not support recommendations for routine early follow-up mechanisms beyond those already existing in the community.