Patient-directed follow-up for the clinical scaphoid fracture.

Aims: Occult (clinical) injuries represent 15% of all scaphoid fractures, posing significant challenges to the clinician. MRI has been suggested as the gold standard for diagnosis, but remains expensive, time-consuming, and is in high demand. Conventional management with immobilization and serial radiography typically results in multiple follow-up attendances to clinic, radiation exposure, and delays return to work. Suboptimal management can result in significant disability and, frequently, litigation. Methods: We present a service evaluation report following the introduction of a quality-improvement themed, streamlined, clinical scaphoid pathway. Patients are offered a removable wrist splint with verbal and written instructions to remove it two weeks following injury, for self-assessment. The persistence of pain is the patient's guide to 'opt-in' and to self-refer for a follow-up appointment with a senior emergency physician. On confirmation of ongoing signs of clinical scaphoid injury, an urgent outpatient 'fast'-wrist protocol MRI scan is ordered, with instructions to maintain wrist immobilization. Patients with positive scan results are referred for specialist orthopaedic assessment via a virtual fracture clinic. Results: From February 2018 to January 2019, there were 442 patients diagnosed as clinical scaphoid fractures. 122 patients (28%) self-referred back to the emergency department at two weeks. Following clinical review, 53 patients were discharged; MRI was booked for 69 patients (16%). Overall, six patients (< 2% of total; 10% of those scanned) had positive scans for a scaphoid fracture. There were no known missed fractures, long-term non-unions or malunions resulting from this pathway. Costs were saved by avoiding face-to-face clinical review and MRI scanning. Conclusion: A patient-focused opt-in approach is safe and effective to managing the suspected occult (clinical) scaphoid fracture.

Medium term effects of including manual therapy in a pulmonary rehabilitation program for chronic obstructive pulmonary disease (COPD): a randomized controlled pilot trial.

STUDY DESIGN: Randomized clinical trial. OBJECTIVE: To investigate the effect of including manual therapy (MT) in a pulmonary rehabilitation program for patients with chronic obstructive pulmonary disease (COPD). BACKGROUND: The primary source of exercise limitation in people with COPD is dyspnea. The dyspnea is partly caused by changes in chest wall mechanics, with an increase in chest wall rigidity (CWR) contributing to a decrease in lung function. As MT is known to increase joint mobility, administering MT to people with COPD carries with it the potential to influence CWR and lung function. METHODS: Thirty-three participants with COPD, aged between 55 and 70 years (mean = 65·5±4 years), were randomly assigned to three groups: pulmonary rehabilitation (PR) only, soft tissue therapy (ST) and PR, and ST, spinal manipulative therapy (SM), and PR. Outcome measures including forced expiratory volume in the 1st second (FEV1), forced vital capacity (FVC), 6-minute walking test (6MWT), St. George's respiratory questionnaire (SGRQ), and the hospital anxiety and depression (HAD) scale were recorded at 0, 8, 16, and 24 weeks. RESULTS: There was a significant difference in FVC between the three groups at 24 weeks (P = 0·04). For the ST+SM+PR group versus PR only the increase was 0·40 l (CI: 0·02, 0·79; P = 0·03). No major or moderate adverse events (AE) were reported following the administration of 131 ST and 272 SM interventions. DISCUSSION: The increase in FVC is a unique finding. Although the underlying mechanisms responsible for this outcome are not yet understood, the most likely explanation is the synergistic effect resulting from the combination of interventions. These results support the call for a larger clinical trial in the use of MT for COPD.

CT enterography: Mannitol versus VoLumen.

INTRODUCTION: Several different neutral oral contrast agents have been trialled in magnetic resonance and CT enterography (CTE). In the Auckland region, Mannitol 2.5% and VoLumen are both used in CTE. This study compares the performance of these two neutral oral contrast agents in CTE. METHODS: Computed tomography enterography data were collected from 25 consecutive studies that used either Mannitol or VoLumen in 2014. All images were reviewed by three radiologists blinded to the type of oral contrast. Each quadrant was assessed for maximum distension, proportion of bowel loops distended, presence of inhomogeneous content and bowel wall visibility. Assessment also included whether the contrast agent reached the caecum and an overall subjective quality assessment. Patients were invited to answer a questionnaire regarding tolerability of the preparations. RESULTS: Mannitol achieves better wall visibility in the right upper quadrant, left upper quadrant and left lower quadrant (P < 0.01). Overall differences in study quality favours Mannitol (P < 0.01) with 48% of the Mannitol studies being considered excellent compared with 4% of the VoLumen studies. There was no difference in maximal distension or proportion of loops distended. CONCLUSION: Mannitol in CTE achieves studies of a better quality than and is a viable alternative to VoLumen.

Path Analysis Identifies Receptor Activator of Nuclear Factor-κB Ligand, Osteoprotegerin, and Sclerostin as Potential Mediators of the Tophus-bone Erosion Relationship in Gout.

OBJECTIVE: To determine the relationship between tophus, erosion and bone remodeling factors in gout. METHODS: Computed tomography bone erosion and circulating bone factors were measured in adults with tophaceous gout. Multiple regression modeling and path analysis were used to determine predictors of erosion. RESULTS: Tophus number, Maori or Pacific ethnicity, creatinine, receptor activator of nuclear factor-κB ligand (RANKL), osteoprotegerin (OPG), and sclerostin were independently associated with erosion. Path analysis showed a direct effect of tophus number on erosion, partially mediated through OPG, RANKL, and sclerostin. CONCLUSION: Tophus number is strongly associated with bone erosion in gout. Circulating RANKL, OPG, and sclerostin are potential mediators of tophus-related erosion.

A Little Bit of Sugar Helps the Pill Go Down: Resilience, Peace, and Family Planning: Comment on "The Pill Is Mightier Than the Sword".

The article by Potts et al, "The Pill is Mightier than the Sword," points out that family planning has an important role to play in building peace by increasing women's empowerment and their agency, ultimately helping peacebuilding efforts. Evidence has demonstrated that family planning programs are cost effective, produce quick results, help women and couples meet their desired fertility levels, and produce a multitude of benefits around economic productivity, community engagement, conservation, resilience, and peacebuilding. In order for policy audiences from a variety of sectors, including conflict and peacebuilding, to appreciate these benefits, it is important to find common ground and articulate co-benefits that will help them appreciate and value the role of family planning, as it were, give them sugar to help the pill go down. This commentary examines how resilience, peacebuilding and family planning efforts need to focus on co-benefits in order to build on the successful interventions and opportunities that Potts et al highlight.

Performance of two neutral oral contrast agents in CT enterography.

INTRODUCTION: This study compares the performance of two neutral oral contrast agents in CT enterography (CTE). Mannitol 2.5%, an oral osmotic agent, is compared with psyllium fibre (Metamucil). Both these agents are commonly used, but to our knowledge, they have not been compared in CTE. METHODS: CTE data were collected from 25 consecutive studies for both mannitol and psyllium fibre between 2011 and 2013. All images were reviewed by two radiologists and one registrar blinded to the oral contrast used. Each quadrant was assessed for maximum distension, proportion of bowel loops distended, presence of inhomogeneous content and bowel wall visibility. Overall subjective quality and whether the contrast agent reached the caecum were also assessed. Patients were invited to answer a questionnaire regarding tolerability of the preparations. RESULTS: Wall visibility was rated good in 100% of the mannitol studies, compared with 71% of the psyllium fibre studies, in the right lower quadrant (P = 0.01). No statistically significant difference between groups was observed in either maximal distension or proportion of loops distended in any quadrant. Inhomogeneous material was observed in 12% of the mannitol cases and 86% of the psyllium fibre cases (P < 0.0001). In all mannitol cases, the contrast reached the caecum, compared with 50% of psyllium fibre cases (P < 0.0001), and 36% of the mannitol studies were considered excellent, compared with 20% of the psyllium fibre studies (P = 0.03). CONCLUSION: Mannitol achieves studies of better quality and is now the preferred oral contrast for CTE studies at Auckland City Hospital.

Resilience, integrated development and family planning: building long-term solutions.

For the many individuals and communities experiencing natural disasters and environmental degradation, building resilience means becoming more proficient at anticipating, preventing, recovering, and rebuilding following negative shocks and stresses. Development practitioners have been working to build this proficiency in vulnerable communities around the world for several decades. This article first examines the meaning of resilience as a component of responding to disasters and some of the key components of building resilience. It then summarises approaches to resilience developed by the Rockefeller and Packard Foundations, the Intergovernmental Panel on Climate Change, USAID and DFID, which show how family planning services can contribute to resilience. Next, it gives some examples of how family planning has been integrated into some current environment and development programmes. Finally, it describes how these integrated programmes have succeeded in helping communities to diversify livelihoods, bolster community engagement and resilience, build new governance structures, and position women as agents of change.

Zoledronate for prevention of bone erosion in tophaceous gout: a randomised, double-blind, placebo-controlled trial.

OBJECTIVES: The osteoclast has been implicated in development of bone erosion in gout. The aim of this study was to determine whether zoledronate, a potent antiosteoclast drug, influences bone erosion in people with tophaceous gout. METHODS: This was a 2-year, randomised, double-blind, placebo-controlled trial of 100 people with tophaceous gout. Participants were randomised to annual administration of 5 mg intravenous zoledronate or placebo. The primary endpoint was change in the foot CT bone erosion score from baseline. Secondary endpoint was change in plain radiographic damage scores. Other endpoints were change in bone mineral density (BMD), bone turnover markers and the OMERACT-endorsed core domains for chronic gout studies. RESULTS: There was no change in CT erosion scores over 2 years, and no difference between the two treatment groups at Year 1 or 2 (p(treat)=0.10, p(time)=0.47, p(treat*time)=0.23). Similarly, there was no change in plain radiographic scores over 2 years, and no difference between the two groups at Year 1 or 2. By contrast, zoledronate increased spine, neck of femur, total hip and total body BMD. Zoledronate therapy also reduced the bone turnover markers P1NP and ß-CTX compared with placebo. There was no difference between treatment groups in OMERACT-endorsed core domains. CONCLUSIONS: Despite improvements in BMD and suppression of bone turnover markers, antiosteoclast therapy with zoledronate did not influence bone erosion in people with tophaceous gout. These findings suggest a disconnect between responses in the healthy skeleton and at sites of focal bone erosion in tophaceous gout.

Accelerating the transit time of barium sulphate suspensions in small bowel examinations.

PURPOSE: To determine whether hyperosmolar and effervescent agents proven individually to accelerate transit time in the barium small bowel examination have an additive effect when combined, surpassing that of either agent alone. MATERIALS AND METHODS: One hundred and forty-nine patients were randomised to four groups. Three hundred milliliters of barium sulphate alone was given to the first group. Fifteen milliliters of iodinated hyperosmolar contrast agent (Gastrografin, meglumine/sodium diatrizoate, Schering) was given in addition to barium sulphate to the second group while six packets of effervescent granules (Carbex, Ferring) were added for the third group. The final group was given a combination of both additives and barium sulphate. The time taken following ingestion for the contrast column to reach the caecum, as assessed by frequent interval fluoroscopy, was recorded. A subgroup of 32 patients were selected randomly from the four groups, 8 from each and assessed for quality of examination. Statistical assessments were made using Kruskal-Wallis and Mann-Whitney tests. RESULTS: One hundred and nineteen patients were analysed after exclusions. The addition of accelerant to barium sulphate, both individually and in combination significantly reduced the small bowel transit time (p<0.001). No significant difference existed between the additives when used with barium alone. The combined group had significantly faster transit times compared to the hyperosmolar group (p=0.02). Differences between combined and effervescent groups tended towards significance (p=0.09). No significant difference existed between groups when examination quality was assessed. CONCLUSION: These results suggest that the addition of combined effervescent and hyperosmolar agents to the barium suspension may significantly shorten the small bowel transit time without adversely affecting examination quality. This has implications for patient acceptability of the examination as well as potentially reducing screening time and therefore radiation dose.

Creating windows of opportunity for policy change: Incorporating evidence into decentralized planning in Kenya.

PROBLEM: Because researchers and policy-makers work in different spheres, policy decisions in the health arena are often not based on available scientific evidence. APPROACH: We describe a model that illustrates the policy process and how to work strategically to translate knowledge into policy actions. Several types of activity--agenda-setting, coalition building and policy learning--together can create a window of opportunity for policy change. LOCAL SETTING: Activities were undertaken as part of the Kenyan Ministry of Health's new decentralized planning-process. The objective was to ensure that the results of a national assessment of health services were used in the preparation of district-level health plans. RELEVANT CHANGES: Following the intervention, 70 district-level, evidence-based work plans were developed and approved by the Kenyan Ministry of Health. LESSONS LEARNED: Substantial investment and effort are needed to bring stakeholders together to work towards policy change. More in-depth evaluation of these efforts can aid understanding of how systematic approaches to policy change can be replicated elsewhere.

Cystoscopic and DMSA findings in relation to types of reflux demonstrated on percutaneous direct radionuclide cystography in children.

BACKGROUND: The new technique of percutaneous direct radionuclide cystography (PDRC) allows the accurate demonstration of vesicorenal reflux under physiological conditions during resting and micturition phases. Five types of reflux have been described, the clinical relevance of which is uncertain. OBJECTIVE: To determine whether a relationship exists between the type of reflux identified on PDRC and the appearance of the ureteric orifice at cystoscopy or the prevalence of renal abnormalities. MATERIALS AND METHODS: The reports of 281 PDRC examinations were reviewed and 76 children with reflux formed the population of this study. Studies of these children were reviewed to classify the reflux as types 1-5, and patient records were searched for cystoscopy and DMSA scan reports. RESULTS: Regardless of the type of reflux, the ureteric orifices were found to be open at cystoscopy in 60-66% of refluxing units. DMSA scan abnormalities were present in 68% of units with reflux at rest, 61% of units with reflux on micturition and 86% of units with reflux on both resting and micturition phases. In comparison with contralateral units that did not reflux, the presence of reflux had a significant association with openness of the ureteric orifice ( p<0.00001) and DMSA abnormality ( p<0.005). CONCLUSIONS: Reflux of any type is strongly associated with an open ureteric orifice. Units that reflux during both resting and micturition phases had a higher incidence of DMSA abnormality than those refluxing during one phase only, but this was not statistically significant.