Management of complex orbital fractures.

The treatment of orbital injuries has evolved considerably over the last two decades. We describe strategies involved in the emergency management of orbital injuries, the use of imaging, preformed and customised materials for reconstruction, and endoscopic techniques.

Case series of extra pulmonary tuberculosis presenting as facial swelling.

In England there were 7,290 cases of tuberculosis (TB) reported in 2013. The area with the highest incidence of the disease in England is London, with hotspots in other urban areas. TB affecting the head and neck is rare. We present three such cases of TB presenting as pre-auricular swelling. Two of the patients were initially misdiagnosed as having dental infection, demonstrating the importance of taking a good history and considering the differential diagnosis of TB when appropriate. TB remains a potentially fatal disease that should be considered in patients presenting with facial swelling where common causes have been excluded.

Piezoelectric surgery--primary bone grafting in craniofacial trauma revisited.

Reconstruction of the frontal bar following complex craniofacial fractures involving the frontal sinus is a central strategic element, and inaccurate reduction can result in contour defects and non-union. Such defects can be reconstructed using autogenous bone from the inner table of a calvarial graft. Traditionally this is done with rotary instruments and osteotomes. In this article, we describe the use of piezoelectric surgery to harvest the graft. This technique allows for more precise and less destructive harvesting of autogenous bone with the additional benefit of reducing the risk of injury to the surgeon.

Is there a therapeutic role for cranioplasty?

Cranioplasty is often undertaken as a joint neurosurgical and maxillofacial procedure. The principal aims remain to improve cosmesis and to protect the underlying brain. We report two cases of cranioplasty with subsequent improvement in neurological function and discuss the possible therapeutic role of cranioplasty.

Development and delivery of an exercise intervention for rheumatoid arthritis: strengthening and stretching for rheumatoid arthritis of the hand (SARAH) trial.

This paper describes the development and implementation of a hand exercise intervention for rheumatoid arthritis (RA) as part of a large multi-centred randomised controlled trial in a U.K. National Health Service (NHS) setting. Participants are eligible if diagnosed with RA according to American College of Rheumatology criteria, have a history of disease activity, functional deficit or impairment in the hand and/or wrist, and have been on a stable medication regime for at least 3 months. The intervention development was informed by the current evidence base, published guidelines, clinician and expert opinion, and a pilot study. The exercise programme targets known, potentially modifiable physical impairments of the hand with 5 exercise sessions and a home exercise component over a 12 week period. The intervention will be provided to 240 participants along with usual care. A further 240 will receive usual care only as part of the control arm. Specific details of the treatments delivered are described. [ISRCTN no: 89936343].

Cutaneous sinuses of dental origin.

We report a case of a cutaneous sinus related to a non-vital lower premolar. The case was misdiagnosed by non-dentally trained medical staff and subsequent treatment proved ineffective. Following referral to an Oral and Maxillofacial clinic the correct cause was established. Correct treatment was followed by rapid resolution of signs and symptoms. This case highlights the need for healthcare professionals dealing with such patients to be aware of the dentition as a cause for cutaneous sinuses in the head and neck region. Those professionals not dentally qualified should enquire about dental pain and consider referral to the dental practitioner or a specialist department for further evaluation. Even those with a dental background can be fooled and a through history and examination is paramount, supplemented by special investigations were appropriate.

Low-income groups and behaviour change interventions: a review of intervention content, effectiveness and theoretical frameworks.

BACKGROUND: Interventions to change health-related behaviours have potential to increase health inequalities. METHODS: This review investigated the effectiveness of interventions targeting low-income groups to reduce smoking or increase physical activity and/or healthy eating. Of 9766 papers identified by the search strategy, 13 met the inclusion criteria. Intervention content was coded into component technique and theoretical basis, and examined as a potential source of effect heterogeneity. RESULTS: Interventions were heterogeneous, comprising 4-19 techniques. Nine interventions had positive effects, seven resulted in no change and one had an adverse effect. Effective interventions had a tendency to have fewer techniques than ineffective interventions, with no evidence for any technique being generally effective or ineffective. Only six studies cited theory relative to intervention development, with little information about how theory was used and no obvious association with intervention content or effect. CONCLUSION: This review shows that behaviour change interventions, particularly those with fewer techniques, can be effective in low-income groups, but highlights the lack of evidence to draw on in informing the design of interventions for disadvantaged groups.

A rapid and systematic review and economic evaluation of the clinical and cost-effectiveness of newer drugs for treatment of mania associated with bipolar affective disorder.

OBJECTIVES: To evaluate the clinical and cost-effectiveness of quetiapine, olanzapine and valproate semisodium in the treatment of mania associated with bipolar disorder. DATA SOURCES: Electronic databases; industry submissions made to the National Institute for Clinical Excellence. REVIEW METHODS: Randomised trials and economic evaluations that evaluated the effectiveness of quetiapine, olanzapine or valproate semisodium in the treatment of mania associated with bipolar disorder were selected for inclusion. Data were extracted by one reviewer into a Microsoft Access database and checked for quality and accuracy by a second. The quality of the cost-effectiveness studies was assessed using a checklist updated from that developed by Drummond and colleagues. Relative risk and mean difference data were presented as Forest plots but only pooled where this made sense clinically and statistically. Studies were grouped by drug and, within each drug, by comparator used. Chi-squared tests of heterogeneity were performed for the outcomes if pooling was indicated. A probabilistic model was developed to estimate costs from the perspective of the NHS, and health outcomes in terms of response rate, based on an improvement of at least 50% in a patient's baseline manic symptoms derived from an interview-based mania assessment scale. The model evaluated the cost-effectiveness of the alternative drugs when used as part of treatment for the acute manic episode only. RESULTS: Eighteen randomised trials met the inclusion criteria. Aspects of three of the quetiapine studies were commercial-in-confidence. The quality of the included trials was limited and overall, key methodological criteria were not met in most trials. Quetiapine, olanzapine and valproate semisodium appear superior to placebo in reducing manic symptoms, but may cause side-effects. There appears to be little difference between these treatments and lithium in terms of effectiveness, but quetiapine is associated with somnolence and weight gain, whereas lithium is associated with tremor. Olanzapine as adjunct therapy to mood stabilisers may be more effective than placebo in reducing mania and improving global health, but it is associated with more dry mouth, somnolence, weight gain, increased appetite, tremor and speech disorder. There was little difference between these treatments and haloperidol in reducing mania, but haloperidol was associated with more extrapyramidal side-effects and negative implications for health-related quality of life. Intramuscular olanzapine and lorazepam were equally effective and safe in one very short (24 hour) trial. Valproate semisodium and carbamazepine were equally effective and safe in one small trial in children. Olanzapine may be more effective than valproate semisodium in reducing mania, but was associated with more dry mouth, increased appetite, oedema, somnolence, speech disorder, Parkinson-like symptoms and weight gain. Valproate semisodium was associated with more nausea than olanzapine. The results from the base-case analysis demonstrate that choice of optimal strategy is dependent on the maximum that the health service is prepared to pay per additional responder. For a figure of less than 7179 British pounds per additional responder, haloperidol is the optimal decision; for a spend in excess of this, it would be olanzapine. Under the most favourable scenario in relation to the costs of responders and non-responders beyond the 3-week period considered in the base-case analysis, the incremental cost-effectiveness ratio of olanzapine is reduced to 1236 British pounds. CONCLUSIONS: In comparison with placebo, quetiapine, olanzapine and valproate semisodium appear superior in reducing manic symptoms, but all drugs are associated with adverse events. In comparison with lithium, no significant differences were found between the three drugs in terms of effectiveness, and all were associated with adverse events. Several limitations of the cost-effectiveness analysis exist, which inevitably means that the results should be treated with some caution. There remains a need for well-conducted, randomised, double-blind head-to-head comparisons of drugs used in the treatment of mania associated with bipolar disorder and their cost-effectiveness. Participant demographic, diagnostic characteristics, the treatment of mania in children, the use of adjunctive therapy and long-term safety issues in the elderly population, and acute and long-term treatment are also subjects for further study.