Surgery for obstructive sleep apnoea.

BACKGROUND: Obstructive sleep apnoea/hypopnoea syndrome(OSAHS) is the periodic reduction or cessation of airflow during sleep. The syndrome is associated with loud snoring, disrupted sleep and observed apnoeas. Surgery for obstructive sleep apnoea/hypopnoea syndrome aims to alleviate symptoms of daytime sleepiness, improve quality of life, and reduce the signs of sleep apnoea recorded by polysomnography. OBJECTIVES: The objective of this review was to assess the effects of any type of surgery for the treatment of the symptoms of obstructive sleep apnoea/hypopnoea syndrome in adults. SEARCH STRATEGY: We searched the Cochrane Airways Group Specialised Register and reference lists of articles. We contacted experts in the field, research dissemination bodies and other Cochrane Review Groups. Searches were current as of July 2005. SELECTION CRITERIA: Randomised trials comparing any surgical intervention for obstructive sleep apnoea/hypopnoea syndrome with other surgical or non-surgical interventions or no intervention. DATA COLLECTION AND ANALYSIS: Two reviewers assessed electronic literature search results for possibly relevant studies. Characteristics and data from studies meeting the inclusion criteria were extracted and entered into RevMan 4.2. MAIN RESULTS: In the 2005 update for this review eight studies (412 participants) of mixed quality met the inclusion criteria. Data from seven studies were eligible for assessment in the review. No data could be pooled. Uvulopalatopharyngoplasty (UPPP) versus conservative management (one trial): An un validated symptom score showed intermittent significant differences over a 12-month follow-up period. No differences in Polysomnography (PSG) outcomes were reported. Laser-assisted uvulopalatoplasty (LAUP) versus conservative management/placebo (two trials): One study recruited mixed a population, and separate data could not be obtained for this trial. In the other study no significant differences in Epworth scores or quality of life reported. A significant difference in favour of LAUP was reported in terms of apnoea hypopnoea index (AHI) and frequency and intensity of snoring. UPPP versus oral appliance (OA) (one trial): AHI was significantly lower with OA therapy than with UPPP. No significant differences were observed in quality of life. UPPP versus lateral pharyngoplasty (lateral PP) (one trial): No significant difference in Epworth scores, but a greater reduction in AHI with lateral PP was reported. Tongue advancement (mandibular osteotomy) + PPP versus tongue suspension + PPP (one trial): There was a significant reduction in symptoms in both groups, but no significant difference between the two surgery types. Complications reported with all surgical techniques included nasal regurgitation, pain and bleeding. These did not persist in the long term. An additional study assessed the effects of four different techniques. No data were available on between group comparisons. Multilevel temperature-controlled radiofrequency tissue ablation (TCRFTA) versus sham placebo and CPAP (one trial): There was an improvement in primary and secondary outcomes of TCRFTA over sham placebo and but no difference in symptomatic improvement when compared with CPAP. AUTHORS' CONCLUSIONS: There are now a small number of trials assessing different surgical techniques with inactive and active control treatments. The studies assembled in the review do not provide evidence to support the use of surgery in sleep apnoea/hypopnoea syndrome, as overall significant benefit has not been demonstrated. The participants recruited to the studies had mixed levels of AHI, but tended to suffer from moderate daytime sleepiness where this was measured. Short-term outcomes are unlikely to consistently identify suitable candidates for surgery. Long-term follow-up of patients who undergo surgical correction of upper airway obstruction is required. This would help to determine whether surgery is a curative intervention, or whether there is a tendency for the signs and symptoms of sleep apnoea to re-assert themselves, prompting patients to seek further treatment for sleep apnoea.

Population based epidemiology of ankle sprains attending accident and emergency units in the West Midlands of England, and a survey of UK practice for severe ankle sprains.

OBJECTIVES: To estimate the incidence of ankle sprains and severe ankle sprains attending accident and emergency (A&E) units; to describe current practice for severe ankle sprains in A&E units in the United Kingdom. METHODS: Crude age and sex specific incidence rates were calculated for four health districts from cases ascertained from data on seven A&E clinical information systems. Case records of patients with ankle sprains at an A&E unit in another health district were audited and the proportion of severe ankle sprains calculated. UK A&E units were surveyed about their usual treatment of patients with severe ankle sprains. RESULTS: The estimate of the crude incidence rate of ankle sprains was a minimum of 52.7 per 10 000, rising to 60.9 (95% CI 59.4 to 62.4) when figures were adjusted for the proportion of patients without a diagnostic code (13.7%). There were important age-sex differences with unadjusted rates observed from 127.8 per 10 000 (CI 115.5 to 140.0) in girls aged 10-14 years to 8.2 (CI 4.2 to 12.3) in men aged 70-74 years. As 14% of ankle sprains attending A&E were classed as severe, this would equate to 42 000 severe ankle sprains per year in the UK. In the UK wide survey, there was a response rate of 79% (211 of 266). Among the responders, Tubigrip was used routinely in 55%, below knee casts in 3%, and braces in 2%. Boots were not used routinely in any unit. CONCLUSION: While there is considerable variation in severe ankle sprain management in UK A&E units, most are treated with the minimal mechanical support of Tubigrip.

Orthopaedic fractures: trends in randomised controlled trials.

AIM: To ascertain and describe the number and epidemiology of randomised controlled trials (RCTs) focused on orthopaedic fractures. METHODS: A sensitive literature search was carried out for the period 1966-May 1999. Labels were applied to each identified RCT to indicate the fracture type, and the main type of intervention. RESULTS: 648 RCTs related to surgery of which 123 focused on adjuvant therapies and 88 related mainly to anaesthesia, analgesia, and radiography. The number of trials have increased exponentially with time so that the present decade has seen more RCTs published than all the other years added together. CONCLUSION: There is clearly an encouraging trend in the number of RCTs published. However there is a need to ensure that trials are on fracture types where there is most need for guidance. This growing evidence base should fuel systematic reviews and clinical guidelines within orthopaedics.

Acute health effects of a fire associated with asbestos-containing fallout.

BACKGROUND: In September 1994 in a disused leather factory in Tranmere, Wirral, England, there was a fire associated with asbestos-containing fallout in an urban area. This study aimed to describe the acute health effects of this acute environmental incident. METHODS: Descriptive epidemiology of acute health effects of the fire was based on solicitors' letters from compensation claimants, hospital admissions for asthma and other respiratory diseases, accident and emergency records, occupational health records of fire-fighters and police, reports of cases by general practitioners (GPs), and geographical location of calls for help and claimants. RESULTS: Sixteen thousand people lived in the area worst affected by fallout. There were 344 claimants. Eighty-six per cent of claimants had a health complaint, with a total of 728 symptoms or diseases reported to be a consequence of the fire. Seventy per cent of complaints related to the respiratory tract, with 33 per cent of claimants noting sore throat, 31 per cent cough, 9 per cent exacerbated asthma, 8 per cent breathing problems and 13 per cent headaches. The number of hospital admissions for asthma and other lung diseases 1 day, 2 days, 7 days and 28 days after the date of the incident tended to be lower in the year of the fire than in other years. Within 72 h of the fire no cases connected with the fire were seen in the local accident and emergency unit. The geographical location of calls for help to the environmental health department was different from that for compensation claimants. CONCLUSIONS: Hundreds of people sought compensation for the acute health consequences of the fire. Many symptoms or diseases in 344 people were attributed to the fire, but there is no hard evidence to suggest that these were directly due to the fire, although some may have been indirectly attributable to it.

Primary care perspective of prostate cancer screening after national guidance: a questionnaire survey.

National guidance (executive letter) EL(97)12 stated that population screening should not be provided by the NHS, or be offered to the public until there is effective screening technology for prostate cancer. The study set out to determine the views of general practitioners and, indirectly, their practice staff on prostate cancer screening in primary care upon receiving EL(97)12. This postal questionnaire survey reveals that 81% (95% CI 75% to 87%) of responding general practitioners in North Staffordshire agreed with EL(97)12 and one in ten said that the executive letter changed their views, suggesting that such national guidance has an effect.

Interventions for treating calcaneal fractures.

BACKGROUND: Fracture of the calcaneus (os calcis or heel bone) comprises one to two per cent of all fractures. OBJECTIVES: To identify and evaluate randomised trials of treatments for calcaneal fractures. SEARCH STRATEGY: MEDLINE, EMBASE, CINAHL, the Cochrane Controlled Trials Register, and the Cochrane Musculoskeletal Injuries Group Trials Register were searched. We checked reference lists of relevant articles and contacted trialists and experts in the field. Date of the most recent search: October 1998. SELECTION CRITERIA: Randomised and quasi-randomised trials comparing interventions for treating patients with calcaneal fractures. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality, using a 12 item scale, and extracted data. Wherever appropriate and possible, results were pooled. MAIN RESULTS: Of the six relevant randomised trials identified, four were included, one excluded and one is ongoing. All four included trials had methodological flaws. Three trials, involving 134 patients, compared open reduction and internal fixation with non-operative management of displaced intra-articular fractures. Pooled results showed no apparent difference in residual pain (24/40 versus 24/42; Peto odds ratio 0.90, 95% confidence interval 0.34 to 2.36), but a lower proportion of the operative group was unable to return to the same work (11/45 versus 23/45; Peto odds ratio 0.30, 95% confidence interval 0.13 to 0.71), and was unable to wear the same shoes as before (12/52 versus 24/54; Peto odds ratio 0.37, 95% confidence interval 0.17 to 0.84). One trial, involving 23 patients, evaluated impulse compression therapy. At one year there was a mean difference of 1.40 pain units on a visual analogue score (scale 0-10) (95% confidence interval 0.02 to 2.82) in favour of the treated group. The impulse compression group had greater subtalar movement (mean difference 14.0 degrees, 95% confidence interval 3.2 to 24.6) at three months. On average, patients in the impulse compression group returned to work three months earlier than those in the control group. REVIEWER'S CONCLUSIONS: Randomised trials of management of calcaneal fractures are few, small and generally of poor quality. Even where there is some evidence of benefit of operative compared with non-operative treatment, it remains unclear whether the possible advantages of surgery are worth its risks. Given this it seems best to wait for the results of one large ongoing trial on open reduction and internal fixation against conservative treatment. One very small trial suggests that impulse compression therapy for intra-articular calcaneal fractures may be beneficial. More large-scale, high quality randomised controlled trials are needed to confirm these results, and to test other interventions in the treatment of calcaneal fractures.

Surgery for obstructive sleep apnoea.

BACKGROUND: Obstructive sleep apnoea is the periodic reduction (hypopnoea) or cessation (apnoea) of airflow during sleep. The syndrome is associated with loud snoring, disrupted sleep and observed apnoeas. Beside conservative treatments there are a range of 8 broad categories of operative treatments for this condition. Surgical treatments aim to relieve the obstruction by either increasing the surface area OBJECTIVES: Surgery for obstructive sleep apnoea aims to relieve the obstruction by increasing the surface area of the airway, bypassing the pharyngeal airways or removing a lesion. The objective of this review was to assess the effects of any type of surgery for the treatment of obstructive sleep apnoea. SEARCH STRATEGY: We searched the Cochrane Airways Group trials register and reference lists of articles. We contacted experts in the field, research dissemination bodies and other Cochrane Review Groups. SELECTION CRITERIA: Randomised and quasi-randomised trials comparing any surgical intervention for obstructive sleep apnoea with other surgical or non-surgical interventions for obstructive sleep apnoea or no intervention. DATA COLLECTION AND ANALYSIS: No completed trials were identified. MAIN RESULTS: No studies fulfilled the inclusion criteria. REVIEWER'S CONCLUSIONS: There is an urgent need for high quality randomised controlled trials to be carried out in the field of surgery for obstructive sleep apnoea. More research should also be undertaken to identify and standardise techniques to determine the site of airways obstructions.

Has endometrial ablation replaced hysterectomy for the treatment of dysfunctional uterine bleeding? National figures.

OBJECTIVES: To describe trends in the use of endometrial ablation and hysterectomy for the treatment of dysfunctional uterine bleeding. DESIGN: Analysis of hospital admissions data. SETTING: National Health Service Hospitals in England. POPULATION: Women who underwent a hysterectomy or endometrial ablation for dysfunctional uterine bleeding between 1989 and 1996. MAIN OUTCOME MEASURES: Annual operation rates and standardised operation ratios for England and for the National Health Service Regions within it, and proportion of operations for dysfunctional uterine bleeding that were endometrial ablations or hysterectomies. RESULTS: There was an initial rise in operation rates for endometrial ablation until 1992/3, since when the rates have fallen. Hysterectomy rates have remained relatively steady since the introduction of endometrial ablation. The total operation rates for dysfunctional uterine bleeding initially increased but have tended to fall since 1992/3. The ratio of hysterectomy to endometrial ablation for dysfunctional uterine bleeding troughed at 3:1 in 1992/3, but by 1995/6 had increased to 4:1. CONCLUSIONS: Rather than replacing hysterectomy in the treatment of dysfunctional uterine bleeding, endometrial ablation appears to have added an alternative operative technique. This led to an increase in the total number of operations for this condition, perhaps by lowering the threshold for intervention.

Lessons learnt from a factory fire with asbestos-containing fallout.

BACKGROUND: Fallout containing asbestos from a factory fire at Tranmere, Wirral, England, landed on a highly populated urban area with an estimated 16000 people living in the area worst affected, which included a shipbuilding community. There was considerable public concern over the health impact of the acute environmental incident, and great media interest. METHODS: A descriptive study was carried out of the acute environmental incident and its management, and the difficulties encountered. RESULTS: Practical lessons learnt include need for: increased fire-fighter awareness of potential adverse health effects from asbestos in the structure of buildings; early involvement of both Local Authority environmental health and National Health Service public health departments; creation of a systematic local database of potential environmental health hazards in the structure of buildings as well as their contents; 24 hour on-call arrangements with laboratories expert in analyses of fire fallout; rapid quantitative analyses of multiple environmental samples; district written policy on handling asbestos incidents; systematic assessment of fright and media factors in public impact of an incident; dedicated public help-lines open long hours; consistent evidence-based public messages from all those communicating with the public; measurement of asbestos levels in the street and homes for public reassurance; local and health authorities' subscription to an environmental incident support service; formation of an acute environmental incident team to jointly manage and publicly report on airborne acute environmental incidents; clear government definition of responsibilities of different agencies. CONCLUSIONS: This paper provides a description of important lessons learnt during an acute environmental incident with asbestos-containing fallout. It will be helpful to those involved in the practical planning for and management of future incidents.

A novel method for the assessment of the accuracy of diagnostic codes in general surgery.

The aim of this study was to describe the accuracy of diagnostic coding in general surgery in a district general hospital, the North Staffordshire Hospital NHS Trust (NSHT), Stoke-on-Trent. An assessment was carried out by comparison between codes ascribed by hospital coders and expert external coders. Patients who had a finished consultant episode (FCE) in the specialty of general surgery at NSHT were included in the study. The sampling frame was general surgery FCEs at NSHT purchased by North Staffordshire Health Authority (NSHA) with an episode end date between 1 May 1995 and 31 December 1995. Every 15th record was sampled. Of 455 records sampled, 157 (35%) were in active use and were excluded but not replaced; therefore, 298 (65%) records were studied in detail. Outcome was measured by the accuracy of primary diagnostic codes ranked 1, 2, 3, 4, from highest to lowest levels of inaccuracy; a description of where errors occurred in the data cycle was recorded. Errors were found in 87/298 (29%) records; 25/298 (8%) records had an error at the highest level (i.e. wrong ICD-10 chapter), and 44/298 (15%) at the third level. Of the errors, 68/87 (78%) occurred between the medical record and the admission form. A substantial percentage (29%) of records had inaccurate diagnostic codes. It is concluded that coding should be carried out from the medical record rather than from the admission form (KMR1). The proportion of records with errors suggests that a routine data coding audit would be useful to improve the accuracy of routine diagnostic codes.

Outbreak of cryptosporidiosis associated with a disinfected groundwater supply.

In an outbreak of cryptosporidiosis in Warrington, a town in North-West England, 47 cases were recorded between November 1992 and February 1993, most within the first month. There was a strong statistical association between cases and residence in an area supplied from two groundwater sources. In a case-control study, a strong association between having drunk unboiled tap water from these sources, and a dose-response relationship were found. Oocysts were not detected in the water supply. During very heavy rainfall one source of water was found to drain surface water directly from a field containing livestock faeces, thereby bypassing natural sandstone filtration. Exceptionally heavy rainfall occurred at the probable time of infection. After withdrawal of the original water supply, the outbreak rapidly subsided. It was concluded that there was very strong evidence that this outbreak was waterborne. This, the second documented outbreak of cryptosporidiosis attributable to a groundwater supply, demonstrates that infection can be transmitted from a disinfected groundwater source despite apparently satisfactory treated water quality. We recommended that guidelines for protection of groundwater are implemented, raw groundwater should be routinely monitored for microbiological contamination, and the structure of all sources and waterworks should be assessed in risk surveys of water catchment areas.

The shoulder in sickle-cell disease.

Sickle-cell disease (SCD) is probably the commonest cause of avascular necrosis worldwide, and its prevalence appears to be rising in developed countries. Avascular necrosis of the humeral head is a common complication but has not been previously studied in detail. We have reviewed 138 patients with SCD for clinical, radiological and functional abnormalities of the shoulder, using a radiological classification designed for avascular necrosis of the shoulder. Radiographic lesions, frequently bilateral, were found in 28% and only 53% of patients had normal shoulder function. The management of this relatively common complication is difficult. Joint replacement is likely to fail and early diagnosis is important.

Leg lengthening.

The combined experience of the Royal Hospital for Sick Children, Glasgow and the Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry in lengthening 52 lower limb segments with the Orthofix device is reviewed. Forty-eight segments were lengthened by callotasis, 24 in patients with achondroplasia. Attempted lengthening with chondrodiatasis was performed in 4 patients with leg length discrepancy. With callotasis, planned lengthening was achieved in 43/48 (90%) of segments. There was a small number of significant complications. Angulation or buckling of the new bone was the commonest major complication, and was seen in 10% of segments. Pin tract infection was the predominant minor complication. Premature union was noted commonly in the femurs of achondroplastics, but could usually be overcome with manipulation under anaesthesia. We confirm that callotasis achieves its objectives with fewer complications and operations than the commonly used Wagner method which it should supersede. By contrast, we had major complications in all cases with chondrodiatasis and have abandoned this method.

Audit of closed tibial fractures: what is a satisfactory outcome?

We performed an audit of closed non-articular tibial fractures that presented to a teaching hospital during 1 year. A total of 52 fractures in 51 patients was seen. We found that the great majority of fractures occurred in the third quarter of the tibia. Standards are essential for audit, but on review of the literature we found wide discrepancy between the standards set to judge the outcome of tibial fractures. Depending on the standards selected, we can show that 4 per cent or 42 per cent of our patients can be said to have a suboptimal outcome. We found that there is little hard evidence to support the published standards. Long-term studies of tibial fractures are required to derive rational standards to allow the most effective and efficient treatment of each case and to enable surgeons to make a meaningful audit of their results.

Traumatic occipital condyle fracture, multiple cranial nerve palsies, and torticollis: a case report and review of the literature.

A 32-year-old man sustained a unique combination of injuries: an occipital condyle fracture, left tenth to twelfth cranial nerve palsies, and chronic torticollis secondary to atlantoaxial rotatory fixation. Computed tomography (CT) demonstrated a triangular fragment of bone in the posterior fossa, and three-dimensional CT-reconstructed images confirmed the bone fragment to be from the occipital condyle. The patient made a good recovery with conservative management. Few occipital condyle fractures have been reported, and they should be suspected in patients who sustain painful neck and lower cranial nerve palsy following trauma. CT and plain films are complementary in confirming the diagnosis.

Peripheral cold acclimatization in Antarctic scuba divers.

Peripheral acclimatization to cold in scuba divers stationed at the British Antarctic Survey's Signy Station was investigated during a year in Antarctica. Five divers and five non-diver controls underwent monthly laboratory tests of index finger immersion in cold water for 30 min. Index finger pulp temperature and time of onset of cold-induced vasodilatation (CIVD) were measured. Pain was recorded with verbal and numerical psychophysical subjective pain ratings. Average finger temperatures and median finger pain from 6-30 min of immersion, maximum finger temperatures during the first CIVD cycle, and finger temperatures at the onset of CIVD were calculated. Comparison of the variables recorded from divers and non-divers were performed with analysis of variance. No significant differences were found among the variables recorded from divers and non-divers. From a review of the literature, divers have responses typical of non-cold-adapted Caucasians. There is, therefore, no evidence that Signy divers peripherally acclimatized to cold. We suggest that these findings occur because either the whole body cooling which divers undergo inhibits peripheral acclimatization or because of insufficiently frequent or severe cold exposure while diving. Further basic studies on the duration, frequency and severity of cold exposure necessary to induce peripheral cold acclimatization are required before this question can be satisfactorily answered.

Thermal status of Antarctic divers.

I studied 5 wet-suited scuba divers studied on 26 dives in the Antarctic. The median duration of dives was 29 min, during which divers were usually involved in sampling or observations for marine biology or chemistry projects. Rectal temperature (Tre) and seven skin site temperatures were measured with thermistors, and mean skin temperature (Tsk) and heat loss estimated. Divers usually heated up during changing and transport to a dive. By the end of immersion, Tsk decreased to a median of 22 degrees C, and finger temperature decreased to a median of 10 degrees C, while the median heat loss during immersion was 850 kJ. Tre below 36 degrees C was not recorded. This study shows that divers do not become clinically hypothermic, but that they are subject to severe cooling, and skin temperatures reach levels at which manual and mental impairment may occur.