Intraoperative computed tomography for orbital reconstruction: a systematic review.

Orbital reconstruction is a common procedure with inherent challenges and important consequences. Intraoperative use of computed tomography (CT) is an emerging application that facilitates accurate intraoperative evaluation to improve clinical outcomes. This review aims to investigate the intraoperative and postoperative outcomes of intraoperative CT use in orbital reconstruction. PubMed and Scopus databases were systematically searched. Inclusion criteria were: clinical studies investigating intraoperative CT use in orbital reconstruction. Exclusion criteria were: duplicates; non-English publications; non-full-text publications; studies with insufficient data. Of the 1022 articles identified, seven eligible articles representing 256 cases were included. The mean age was 39 years. Most cases were male (69.9%). With regards to intraoperative outcomes, the mean revision rate was 34.1%, with plate repositioning being the most common type (51.1%). Intraoperative time was variably reported. With regards to postoperative outcomes, there were no revisions, and only one case that had a complication (transient exophthalmos). Mean volumetric difference between the repaired and contralateral orbits was reported in two studies. The findings of this review present an updated evidence-based summary of the intraoperative and postoperative outcomes of intraoperative CT use in orbital reconstruction. Robust longitudinal comparisons of clinical outcomes between intraoperative and non-intraoperative CT cases are required.

Analysis of Trauma Characteristics Between the Older and Younger Adult Patient from the Pan Asian Trauma Outcome Study Registry (PATOS).

OBJECTIVE: Asia is experiencing a demographic shift toward an aging population at an unrivaled rate. This can influence the characteristics and outcomes of trauma. We aim to examine different characteristics of older adult trauma patients compared to younger adult trauma patients and describe factors that affect the outcomes in Asian countries. METHODS: This is a retrospective, international, multicenter study of trauma across participating centers in the Pan Asian Trauma Outcome Study (PATOS) registry, which included trauma cases aged ≥18 years, brought to the emergency department (ED) by emergency medical services (EMS) from October 2015 to November 2018. Data of older adults (≥65 years) and younger adults (<65 years) were analyzed and compared. The primary outcome measure was in-hospital mortality, and secondary outcomes were disability at discharge and hospital and intensive care unit (ICU) length of stays. RESULTS: Of 39,804 trauma patients, 10,770 (27.1%) were older adults. Trauma occurred more among older adult women (54.7% vs 33.2%, p < 0.001). Falls were more frequent in older adults (66.3% vs 24.9%, p < 0.001) who also had higher mean Injury Severity Score (ISS) compared to the younger adult trauma patient (5.4 ± 6.78 vs 4.76 ± 8.60, p < 0.001). Older adult trauma patients had a greater incidence of poor Glasgow Outcome Scale (GOS) (13.4% vs 4.1%, p < 0.001), higher hospital mortality (1.5% vs 0.9%, p < 0.001) and longer median hospital length of stay (12.8 vs 9.8, p < 0.001). Multiple logistic regression revealed age (adjusted odds ratio [AOR] 1.06, 95%CI 1.02-1.04, p < 0.001), male sex (AOR 1.60, 95%CI 1.04-2.46, p = 0.032), head and face injuries (AOR 3.25, 95%CI 2.06-5.11, p < 0.001), abdominal and pelvic injuries (AOR 2.78, 95%CI 1.48-5.23, p = 0.002), cardiovascular (AOR 2.71, 95%CI 1.40-5.22, p = 0.003), pulmonary (AOR 3.13, 95%CI 1.30-7.53, p = 0.011) and cancer (AOR 2.03, 95%CI 1.02-4.06, p = 0.045) comorbidities, severe ISS (AOR 2.06, 95%CI 1.23-3.45, p = 0.006), and Glasgow Coma Scale (GCS) ≤8 (AOR 12.50, 95%CI 6.95-22.48, p < 0.001) were significant predictors of hospital mortality. CONCLUSIONS: Older trauma patients in the Asian region have a higher mortality rate than their younger counterparts, with many significant predictors. These findings illustrate the different characteristics of older trauma patients and their potential to influence the outcome. Preventive measures for elderly trauma should be targeted based on these factors.

Evaluating Quality-of-Life, Length of Stay and Cost-Effectiveness of a Front-Door Geriatrics Program: An Exploratory Proof-of-Concept Study.

BACKGROUND: The Emergency Department Interventions for Frailty (EDIFY) program was developed to deliver early geriatric specialist interventions at the Emergency Department (ED). EDIFY has been successful in reducing acute admissions among older adults. OBJECTIVES: We aimed to examine the effectiveness of EDIFY in improving health-related quality-of-life (HRQOL) and length of stay (LOS), and evaluate EDIFY's cost-effectiveness. DESIGN: A quasi-experiment study. SETTING: The ED of a 1700-bed tertiary hospital. PARTICIPANTS: Patients (≥85 years) pending acute hospital admission and screened by the EDIFY team to be potentially suitable for discharge or transfer to low-acuity care areas. INTERVENTION: EDIFY versus standard-care. MEASUREMENTS: Data on demographics, comorbidities, premorbid function, and frailty status were gathered. HRQOL was measured using EQ-5D-5L over 6 months. We used a crosswalk methodology to compute Singapore-specific index scores from EQ-5D-5L responses and calculated quality-adjusted life-years (QALYs) gained. LOS and bills in Singapore-dollars (SGD) before subsidy from ED attendances (including admissions, if applicable) were obtained. We estimated average programmatic EDIFY cost and performed multiple imputation (MI) for missing data. QALYs gained, LOS and cost were compared. Potential uncertainties were also examined. RESULTS: Among 100 participants (EDIFY=43; standard-care=57), 61 provided complete data. For complete cases, there were significant QALYs gained at 3-month (coefficient=0.032, p=0.004) and overall (coefficient=0.096, p=0.002) for EDIFY, whilst treatment cost was similar between-groups. For MI, we observed only overall QALYs gained for EDIFY (coefficient=0.102, p=0.001). EDIFY reduced LOS by 17% (Incident risk ratio=0.83, p=0.015). In a deterministic sensitivity analysis, EDIFY's cost-threshold was SGD$2,500, and main conclusions were consistent in other uncertainty scenarios. Mean bills were: EDIFY=SGD$4562.70; standard-care=SGD$5530.90. EDIFY's average programmatic cost approximated SGD$469.30. CONCLUSIONS: This exploratory proof-of-concept study found that EDIFY benefits QALYs and LOS, with equivalent cost, and is potentially cost-effective. The program has now been established as standard-care for older adults attending the ED at our center.

Anti-hypertensive prescription practices in private hospitals in Malaysia: a prospective, non-interventional, observational study.

INTRODUCTION: In managing hypertension, monotherapy and sometimes a combination of more than one agent are used to achieve blood pressure (BP) control. The objective of this prospective, observational, multi-centre study was to assess the level of BP control in patients receiving one or more anti-hypertensive drugs in private medical centres in Malaysia according to the treatment regimens (monotherapy, free drug combinations and single pill combinations). MATERIALS AND METHODS: Data were collected through medical records and interview sessions with patients on current pharmacotherapy for hypertension management at baseline and 2-3 months later. Results are expressed as mean ± SD for continuous data and as frequencies and percentages for categorical data. RESULTS: Among 182 recruited patients, 89 (49%) achieved BP control by the end of the study. Majority (62/89) patients were on single-pill (monotherapy or SPC) antihypertensives. Majority (63/89) required more than two antihypertensives to achieve BP control. CONCLUSION: Both SPC and free drug combination antihypertensives reduced BPs, but physicians preferred SPC to improve BP control and increase treatment compliance.

E-scooters and maxillofacial fractures: a seven-year multi-centre retrospective review.

BACKGROUND: Standing electric scooters (e-scooters) are a cost-effective and environmentally-friendly transport alternative, but also elicit substantial concern regarding associated craniofacial injuries. This study aims to describe the patient factors, procedural factors and post-operative outcomes of maxillofacial fractures caused by e-scooter accidents. METHODS: Retrospective chart review of patients aged 18 years or older who were surgically treated for these injuries in 2014-2020 at two Australian tertiary hospitals. RESULTS: There were 18 cases included. Most cases were male (66%). The mean age was 35 years. Common risk factors were alcohol use (86%) and lack of helmet use (62%). The most common fracture pattern was zygomatico-maxillary complex (ZMC) fractures (50%). There were no associated systemic injuries. Mean operation timing was 12 days post-injury for ZMC fractures and 3 days post-injury for condyle fractures. For ZMC fractures, the most common method of fixation was 2-point fixation (66%). For condyle fractures, the most common surgical approach was arch bars only (83%). Post-operative complications were reported in six cases, with malocclusion being the most common (n = 3). Revision surgeries were performed in two cases. CONCLUSIONS: Maxillofacial fractures associated with e-scooter accidents appear to be increasing in incidence. Robust longitudinal evaluations with larger sample sizes are required to better understand associated presentations, surgical approaches and post-operative complications.

Vitamin D and smell impairment: a systematic literature review.

OBJECTIVE: Smell impairment affects 60-80 per cent of individuals aged over 80 years. This review aimed to identify any association between vitamin D deficiency and smell impairment, and determine the efficacy of vitamin D to treat smell impairment. METHODS: A literature search was conducted across four databases between the years 2000 and 2022. The literature screen was performed by two independent reviewers. RESULTS: Seven articles were included in this review. Four studies examined the association between vitamin D deficiency and smell impairment, with three studies identifying a significant relationship. Three studies investigated the use of vitamin D as treatment for smell impairment, which found complete resolution or significant symptom improvement after vitamin D deficiency was treated. CONCLUSION: This review identified limited studies on this topic. As vitamin D supplementation is relatively cost-efficient, further large-scale studies should be carried out to investigate the efficacy of vitamin D for treating anosmia.

The moderating role of trajectories of family hardiness in the relationship between trajectories of economic hardship and mental health of mothers and children.

Trajectories of perceived economic hardship are related to clinical levels of mental health issues in mothers and children from low-income families. Cross-sectionally, family hardiness has been found to have a moderating effect on the relationship between stressors and mental health severity. Recent advances in family resilience theory highlight the importance of considering trajectories of family resilience. Trajectories of family hardiness and their moderating effect on the relationship between trajectories of perceived economic hardship and symptoms of depression and anxiety in low-income mothers and children were investigated in 511 mother-child dyads in Singapore. Three trajectories of family hardiness were delineated, namely the high stable, low rapidly increasing and moderate increasing group. The trajectories of family hardiness were found to moderate the relationship between trajectories of perceived economic hardship and symptoms of mental health in low-income mothers and children. The same moderation effect was not found when perceived economic hardship and family hardiness were investigated cross-sectionally. These findings highlight the importance of considering the family's trajectory of hardiness over time when working with low-income families. In addition, given that different trajectories of family hardiness were protective for different aspects of mental health, further studies to understand these relations are necessary.

Trajectories of perceived economic hardship: Relations with mother's and child's mental health and the role of self-esteem.

Trajectories of poverty influence the mental health of mothers and children. Previous studies utilize objective measures despite the importance of subjective measures of poverty. Furthermore, chronic economic hardship may erode personal resources such as self-esteem which increases vulnerability to mental health issues. Trajectories of perceived family economic hardship and their relationship with common mental health disorders, as mediated by self-esteem, were investigated in 511 mother-child dyads from Singapore. Three distinct groups of economic hardship trajectories were delineated, namely the low stable, high stable and moderate decreasing group. The high stable group was found to be associated with a greater likelihood of mother's depression, mother's anxiety and child's anxiety when compared to the low stable group. The moderate decreasing group was found to be associated with a greater likelihood of mother's anxiety when compared to the low stable group. Mother's self-esteem was found to mediate all the significant relations found. These findings indicate the existence of distinct trajectories of perceived economic hardship within low-income families and their relation with mental health outcomes in mothers and children. The mediation of these relations by mother's self-esteem suggests the importance of enhancing self-esteem in mothers from low-income backgrounds.

Impact of sepsis education for healthcare professionals and students on learning and patient outcomes: a systematic review.

BACKGROUND: Sepsis is an important global healthcare problem that is a key challenge faced by healthcare professionals face worldwide. One key effort aimed at reducing the global burden of sepsis is educating healthcare professionals about early identification and management of sepsis. AIM: To provide a comprehensive evaluation of sepsis education among healthcare professionals and students. METHODS: Six databases (PubMed, CINAHL, Embase, MEDLINE, Cochrane Central Register of Controlled Trials, and Scopus) were searched. We included studies that described and evaluated any form of education or training on sepsis delivered to healthcare professionals and students. Study outcomes were summarized according to the adapted Kirkpatrick model of training evaluation. RESULTS: Thirty-two studies were included in the review. The learning contents were reported to be in accordance with the Surviving Sepsis Campaign guidelines. Seven studies included the topic of interprofessional teamwork and communication in their sepsis education content. Most educational programmes were effective and reported positive effects on immediate knowledge outcomes. Interventions that were delivered through an active learning approach such as simulation and game-based learning generally produced greater gains than didactic teaching. Improvements in patient care processes and patient outcomes were associated with the concomitant existence or implementation of a hospital sepsis care bundle. CONCLUSION: Incorporating active learning strategies into sepsis education interventions has the potential to improve learners' long-term outcomes. In addition, sepsis education and a protocol-based sepsis care bundle act in synergy to augment greater improvements in care processes and patient benefits.

Disruptive behavior in a high-power distance culture and a three-dimensional framework for curbing it.

BACKGROUND: Disruptive behavior can harm high-quality care and is prevalent in many Western public health systems despite increasing spotlight on it. Comparatively less knowledge about it is available in Asia, a region commonly associated with high-power distance, which may limit its effectiveness in addressing disruptive behavior. PURPOSE: The aim of this study was to develop a comprehensive framework for tackling disruptive behavior among health care professionals in a public health system. METHODOLOGY: A nationwide cross-sectional study relying on the Nurse-Physician Relationship Survey was conducted in Singapore. Four hundred eighty-six public health care professionals responded. RESULTS: Two hundred ninety-eight doctors (95.5%) and 163 nurses (93.7%) had witnessed a form of disruptive behavior. Doctors observed disruptive behavior committed by other doctors and nurses much more frequently than did nurses. Doctors made stronger associations between disruptive behavior and negative employee outcomes and between disruptive behavior and negative patient outcomes. Qualitative analyses of participants' open-ended answers produced a multipronged three-dimensional approach for tackling disruptive behavior: (a) deterrent measures, (b) development of knowledge and skills, and (c) demonstration of organizational commitment through proper norms, empathizing with staff, and structural reforms. PRACTICE IMPLICATIONS: Disruptive behavior is a multifaceted problem requiring a multipronged approach. Our three-dimensional framework is a comprehensive approach for giving health care professionals the capability, opportunity, and motivation to address disruptive behavior effectively.

SARC-F at the Emergency Department: Diagnostic Performance for Frailty and Predictive Performance for Reattendances and Acute Hospitalizations.

OBJECTIVES: Sarcopenia is associated with adverse health outcomes including mortality, functional loss, falls, and poorer quality of life. However, the value of screening sarcopenia at the Emergency Department (ED) remains unclear. We aimed to examine the SARC-F questionnaire for its (1) diagnostic ability in identifying frailty, and (2) predictive ability for adverse health outcomes. DESIGN: A secondary analysis of a quasi-experimental study. SETTING: An ED within a 1700-bed tertiary hospital. PARTICIPANTS: ED patients aged ≥85 years (mean age 90.0 years) recruited into the Emergency Department Interventions of Frailty (EDIFY) study. MEASUREMENTS: Data of demographics, premorbid function, frailty status [Frailty Index (FI), Clinical Frailty Scale (CFS), FRAIL], comorbidities, medications, and cognitive status were gathered. We also captured outcomes of mortality, acute hospitalization, and ED reattendance at 1-, 3-, and 6-month. We then compared area under the operating characteristic curves (AUCs) for the abovementioned measures against the FI (reference) for diagnosis of frailty. Lastly, we performed univariate analyses and logistic regression to compare SARC-F and other measures against the adverse outcomes of interest. RESULTS: Amongst the various instruments, the SARC-F (AUC 0.92, 95% Confidence Interval (CI) 0.86-0.98, P<0.001; Sensitivity 79.0%, and Specificity 88.9%) performed best for frailty detection as defined by FI. Optimal cutoff was ≥3 (Sensitivity 91.4%, Specificity 83.3%, and Negative Predictive Value 68.2%). Only SARC-F was predictive of acute hospitalization [Adjusted Odds Ratio (OR) 4.00, 95% CI 1.47-10.94, P=0.007] and ED-reattendance [Adjusted OR 3.29, 95% CI 1.26-8.56, P=0.015] at 3-month. CONCLUSIONS: The SARC-F demonstrated excellent diagnostic ability for frailty detection and predictive validity for ED reattendance and acute hospitalization at 3 months. Lowering cutoff score to ≥3 may improve case-finding at the ED to facilitate early identification and management of sarcopenia. Further studies are required to validate the diagnostic and predictive performance of SARC-F at ED settings.

Multifaceted Functions of Rab23 on Primary Cilium-Mediated and Hedgehog Signaling-Mediated Cerebellar Granule Cell Proliferation.

Sonic hedgehog (Shh) signaling from the primary cilium drives cerebellar granule cell precursor (GCP) proliferation. Mutations of hedgehog (Hh) pathway repressors commonly cause medulloblastoma, the most prevalent and malignant childhood brain tumor that arises from aberrant GCP proliferation. We demonstrate that Nestin Cre-driven conditional knock-out (CKO) of a Shh pathway repressor-Rab23 in the mouse brain of both genders caused mis-patterning of cerebellar folia and elevated GCP proliferation during early development, but with no prevalent occurrence of medulloblastoma at adult stage. Strikingly, Rab23-depleted GCPs exhibited upregulated basal level of Shh pathway activities despite showing an abnormal ciliogenesis of primary cilia. In line with the compromised ciliation, Rab23-depleted GCPs were desensitized against Hh pathway activity stimulations by Shh ligand and Smoothened (Smo) agonist-SAG, and exhibited attenuated stimulation of Smo-localization on the primary cilium in response to SAG. These results implicate multidimensional actions of Rab23 on Hh signaling cascade. Rab23 represses the basal level of Shh signaling, while facilitating primary cilium-dependent extrinsic Shh signaling activation. Collectively, our findings unravel instrumental roles of Rab23 in GCP proliferation and ciliogenesis. Furthermore, Rab23's potentiation of Shh signaling pathway through the primary cilium and Smo suggests a potential new therapeutic strategy for Smo/primary cilium-driven medulloblastoma.SIGNIFICANCE STATEMENT Primary cilium and Sonic hedgehog (Shh) signaling are known to regulate granule cell precursor (GCP) proliferation. Aberrant overactivation of Shh signaling pathway ectopically increases GCP proliferation and causes malignant childhood tumor called medulloblastoma. However, the genetic and molecular regulatory cascade of GCP tumorigenesis remains incompletely understood. Our finding uncovers Rab23 as a novel regulator of hedgehog (Hh) signaling pathway activity and cell proliferation in GCP. Intriguingly, we demonstrated that Rab23 confers dual functions in regulating Shh signaling; it potentiates primary cilium and Shh/Smoothened (Smo)-dependent signaling activation, while antagonizes basal level Hh activity. Our data present a previously underappreciated aspect of Rab23 in mediating extrinsic Shh signaling upstream of Smo. This study sheds new light on the mechanistic insights underpinning Shh signaling-mediated GCP proliferation and tumorigenesis.

Traumatic maxillofacial and brain injuries: a systematic review.

Concomitant traumatic brain injury (TBI) and maxillofacial fractures carry the risk of significant morbidity and mortality. The aim of this review was to explore the demographics, types of injury, and complications of traumatic maxillofacial and brain injuries, in order to contribute to comprehensive health strategies. The PubMed and Scopus databases were systematically searched. Inclusion criteria were clinical studies investigating combined traumatic maxillofacial and brain injuries. Exclusion criteria were duplicates, non-English publications, non-full-text publications, publication date before 1990, and studies with insufficient data. Of the 754 articles identified, 15 eligible articles representing 1421 cases were included. The mean age was 38.3 years. Most cases were male (79%). The most common mechanism of injury was traffic accidents (53.4%). The most common fracture pattern was middle third fractures (52.4%). Seven studies had an explicit definition for TBI, using the Glasgow Coma Score (GCS), radiological evidence, and/or specific symptoms. There were 147 complications reported in 62 of 253 cases (24.5%), with the most common being infection (n=54, 36.7%). Significant risk factors for complications included delayed surgical repair, low GCS, and upper third fractures. Robust longitudinal evaluations with clear definitions of TBI are required. Gaps in knowledge include risk factors for complications and fracture pattern-GCS correlations.

Submental intubation in oral and maxillofacial surgery: a systematic review 1986-2018.

Submental intubation is a low-risk alternative to tracheostomy when nasotracheal or orotracheal intubation is not appropriate. To improve the selection of patients and clinical outcomes we have explored published papers on submental intubation in oral and maxillofacial surgery, and included a proposal for a decision pathway. Systematic searches of PubMed, Scopus, and Cochrane databases for papers published between 1986 and 2018 yielded 116 eligible articles (one randomised controlled trial, 61 case series, 40 case reports, six surgical techniques, and eight letters) that included 2 229 patients. Measured outcomes were the indications, techniques, devices used, time taken to complete the procedure, and complications. Indications were trauma (81%), orthognathic surgery (15%), disease (2%), and cosmetic surgery (1%). Technical preferences were for a one-tube (84%) over a two-tube technique (6%), and a paramedian (52%) over a median incision (33%). The preferred device was a reinforced endotracheal tube (85%). The mean (range) intubation time was 10 (2-37) minutes. The complication rate was 7% (n=152), the most common being superficial skin infection (n=54), hypertrophic scarring (n=18), and damage to the tube apparatus (n=15). Submental intubation has minimal complications, takes a short time to do, and it is a useful alternative to tracheostomy in some oral and maxillofacial operations. More robust evidence regarding the selection of patients, modifications to the technique, and a comparison of risk with that of tracheostomy, are needed for further evaluation of its feasibility.

Comparison of trauma systems in Asian countries: a cross-sectional study.

OBJECTIVE: This study aimed to compare the demographic characteristics and trauma service structures and processes of hospitals in 15 countries across the Asia Pacific, and to provide baseline data for the integrated trauma database: the Pan-Asian Trauma Outcomes Study (PATOS). METHODS: Medical directors and emergency physicians at PATOS-participating hospitals in countries across the Asia Pacific were surveyed through a standardized questionnaire. General information, trauma care system data, and trauma emergency department (ED) outcomes at each hospital were collected by email and analyzed using descriptive statistics. RESULTS: Survey data from 35 hospitals across 15 countries were collected from archived data between June 2014 and July 2015. Designated trauma centers were identified as the highest hospital level for trauma patients in 70% of surveyed countries. Half of the hospitals surveyed had special teams for trauma care, and almost all prepared activation protocol documents for these teams. Most hospitals offered specialized trauma education programs, and 72.7% of hospitals had a hospital-based trauma registry. The total number of trauma patients visiting the ED across 25 of the hospitals was 300,376. The overall survival-to-discharge rate was 97.2%; however, it varied greatly between 85.1% and 99.7%. The difference between survival-to-discharge rates of moderate and severe injury groups was highest in Taiwan (41.8%) and lowest in Thailand (18.6%). CONCLUSION: Trauma care systems and ED outcomes vary widely among surveyed hospitals and countries. This information is useful to build further detailed, systematic platforms for trauma surveillance and evidence-based trauma care policies.

Pan-Asian Trauma Outcomes Study (PATOS): Rationale and Methodology of an International and Multicenter Trauma Registry.

BACKGROUND: Trauma is a major health burden and a time-dependent critical emergency condition among developing and developed countries. In Asia, trauma has become a rapidly expanding epidemic and has spread out to many underdeveloped and developing countries through rapid urbanization and industrialization. Most casualties of severe trauma, which results in significant mortality and disability are assessed and transported by prehospital providers including physicians, professional providers, and volunteer providers. Trauma registries have been developed in mostly developed countries and measure care quality, process, and outcomes. In general, existing registries tend to focus on inhospital care rather than prehospital care. METHODS: The Pan-Asia Trauma Outcomes Study (PATOS) was proposed in 2013 and initiated in November, 2015 in order to establish a collaborative standardized study to measure the capabilities, processes and outcomes of trauma care throughout Asia. The PATOS is an international, multicenter, and observational research network to collect trauma cases transported by emergency medical services (EMS) providers. Data are collected from the participating hospital emergency departments in various countries in Asia which receive trauma patients from EMS. Data variables collected include 1) injury epidemiologic factors, 2) EMS factors, 3) emergency department care factors, 4) hospital care factors, and 5) trauma system factors. The authors expect to achieve a sample size of 67,230 cases over the next 2 years of data collection to analyze the association between potential risks and outcomes of trauma. CONCLUSION: The PATOS network is expected to provide comparison of the trauma EMS systems and to benchmark best practice with participating communities.

Incision-sparing management of canaliculitis: an efficacious alternative to surgical management.

OBJECTIVE: The aim of this study was to describe the outcomes of conservative (punctal dilation, manual expression, microcurettage, and canalicular irrigation with antibiotics) and surgical (punctoplasty) modalities for the management of canaliculitis in an Asian population. METHODS: The medical records of 11 consecutive patients (12 eyes) presenting with canaliculitis to one surgeon from August 2010 to January 2014 were reviewed. The clinical presentation, findings, management, microbiology, and treatment outcomes were studied. RESULTS: The mean age was 70.6 years (57-91 years), 8 (72.7%) patients were females, and all 11(100%) were Chinese. The majority had unilateral canaliculitis-8 (66.7%) right eye only and 4 (33.3%) left eye only (1 patient had consecutive right canaliculitis followed by left canaliculitis)-involving the lower canaliculi (75%). Ten (83.3%) eyes had primary canaliculitis, and 2 (16.7%) eyes had secondary canaliculitis from punctal plug insertion. Common presenting symptoms included eye discharge (75%) and eyelid swelling/redness (50%). Common clinical signs included mucopurulent punctal regurgitation (75%) and pouting punctum (58.3%). Facultative anaerobes (56.3%) formed the majority of organisms, and the most common bacteria isolated were Streptococcus spp. (18.8%). Mean duration to definitive treatment was 35 days (0-126 days). Ten (83.3%) eyes were successfully treated with incision-sparing modalities, and 2 (16.7%) eyes were treated surgically. No recurrences were observed at 3, 6, and 12 months, and only 1 (10.0%) of the 10 conservatively managed eyes had a recurrence of canaliculitis after 3.8 years. CONCLUSIONS: Surgical modalities remain effective for the treatment of canaliculitis. However, they are not without disadvantages, such as scarring, discomfort, infection, and recurrence of punctal stenosis. In our experience, incision-sparing modalities are effective in the treatment of canaliculitis and have low recurrence rates.

Review article: pharmacotherapy for alcohol dependence - the why, the what and the wherefore.

BACKGROUND: The development of alcohol dependence is associated with significant morbidity and mortality. For the majority of affected people the most appropriate goal, in terms of drinking behaviour, is abstinence from alcohol. Psychosocial intervention is the mainstay of the treatment but adjuvant pharmacotherapy is also available and its use recommended. AIM: To provide an updated analysis of current and potential pharmacotherapeutic options for the management of alcohol dependence. In addition, factors predictive of therapeutic outcome, including compliance and pharmacogenetics, and the current barriers to treatment, including doctors' unwillingness to prescribe these agents, will be explored. METHODS: Relevant papers were selected for review following extensive, language- and date-unrestricted, electronic and manual searches of the literature. RESULTS: Acamprosate and naltrexone have a substantial evidence base for overall efficacy, safety and cost-effectiveness while the risks associated with the use of disulfiram are well-known and can be minimised with appropriate patient selection and supervision. Acamprosate can be used safely in patients with liver disease and in those with comorbid mental health issues and co-occurring drug-related problems. A number of other agents are being investigated for potential use for this indication including: baclofen, topiramate and metadoxine. CONCLUSION: Pharmacotherapy for alcohol dependence has been shown to be moderately efficacious with few safety concerns, but it is substantially underutilised. Concerted efforts must be made to remove the barriers to treatment in order to optimise the management of people with this condition.