BSACI guideline for the diagnosis and management of cow's milk allergy.

This guideline advises on the management of patients with cow's milk allergy. Cow's milk allergy presents in the first year of life with estimated population prevalence between 2% and 3%. The clinical manifestations of cow's milk allergy are very variable in type and severity making it the most difficult food allergy to diagnose. A careful age- and disease-specific history with relevant allergy tests including detection of milk-specific IgE (by skin prick test or serum assay), diagnostic elimination diet, and oral challenge will aid in diagnosis in most cases. Treatment is advice on cow's milk avoidance and suitable substitute milks. Cow's milk allergy often resolves. Reintroduction can be achieved by the graded exposure, either at home or supervised in hospital depending on severity, using a milk ladder. Where cow's milk allergy persists, novel treatment options may include oral tolerance induction, although most authors do not currently recommend it for routine clinical practice. Cow's milk allergy must be distinguished from primary lactose intolerance. This guideline was prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI) and is intended for clinicians in secondary and tertiary care. The recommendations are evidence based, but where evidence is lacking the panel of experts in the committee reached consensus. Grades of recommendation are shown throughout. The document encompasses epidemiology, natural history, clinical presentations, diagnosis, and treatment.

Early results of autologous chondrocyte implantation in the talus.

Autologous chondrocyte implantation (ACI) has been used most commonly as a treatment for cartilage defects in the knee and there are few studies of its use in other joints. We describe ten patients with an osteochondral lesion of the talus who underwent ACI using cartilage taken from the knee and were prospectively reviewed with a mean follow-up of 23 months. In nine patients the satisfaction score was 'pleased' or 'extremely pleased', which was sustained at four years. The mean Mazur ankle score increased by 23 points at a mean follow-up of 23 months. The Lysholm knee score returned to the pre-operative level at one year in three patients, with the remaining seven showing a reduction of 15% at 12 months, suggesting donor-site morbidity. Nine patients underwent arthroscopic examination at one year and all were shown to have filled defects and stable cartilage. Biopsies taken from graft sites showed mostly fibrocartilage with some hyaline cartilage. The short-term results of ACI for osteochondral lesions of the talus are good despite some morbidity at the donor site.

Can rock climbing lead to Dupuytren's disease?

OBJECTIVES: To determine if rock climbing is a significant factor in the development of Dupuytren's disease in men, and, if so, what is the most likely related factor. METHODS: Questionnaires were distributed to all 1100 members of the Climbers' Club of Great Britain. These detailed basic information about the climber, the presence of Dupuytren's disease, and any known risk factors for its development. RESULTS: About half (51%) of the questionnaires were returned. The respondents were almost entirely male. It was revealed that 19.5% of male climbers had developed Dupuytren's disease. There was a significantly higher life time intensity of climbing activity in those with the disease. An earlier age of onset of the disease was found in climbers compared with the general population. CONCLUSIONS: This study further strengthens the hypothesis that repetitive trauma to the palmar fascia predisposes to the development of Dupuytren's disease in men.

Outcome after conservatively managed intracapsular fractures of the femoral neck.

INTRODUCTION: In 2012, 2.6% of hip-fracture patients in the UK were treated conservatively. There is little data on outcome for these patients. However, one study demonstrated that though 30-day mortality is higher, mortality over the rest of the year is comparable with that in surgical groups. Therefore, we assessed conservatively managed patients in our unit. METHODS: Patients with intracapsular fractures of the femoral neck treated by conservative means between 2010 and 2012 inclusive were identified. Data were collected: American Society of Anaesthesiologists (ASA) grade, Nottingham Hip Fracture Score (NHFS), mobility, mortality (30 days and one year) and pain levels. RESULTS: Thirty-two patients formed the study cohort. Mean age was 85.6 years. Median ASA grade was 4. Mortality at 30 days and one year was 31.3% and 56.3%, respectively. There was one case of pneumonia and one of infection. Pressure sores or venous thromboembolism were not documented. Three patients underwent surgery once their health improved. In general, mobility was decreased, but 30.8% of patients could mobilise with two aids or a frame. Only two cases had ongoing problems with pain. CONCLUSIONS: Our data are similar to those published previously. Our patients were likely to have higher mortality data due to selection bias. Thirty-day mortality was significantly higher than the national average, but patients surviving 30 days had a prevalence of mortality similar to those managed by surgical means. Despite mobility decreasing from the pre-admission status, a considerable number of patients were free of pain and could mobilise. These data suggest that conservative management of intracapsular fractures of the femoral neck can produce acceptable results.

Meningitis without a petechial rash in children in the Hib vaccine era.

AIMS: (1) To determine the causes of meningitis in children immunized with Hib vaccine, presenting without a non-blanching rash; (2) to review the use of dexamethasone in this group. METHOD: Retrospective review of all children with more then 10 white cells/mm(3) in their cerebrospinal fluid (CSF), admitted between January 1998 and August 2002. Children were excluded if they had a non-blanching rash on admission or if their discharge diagnosis was not meningitis. Local guidelines recommended dexamethasone to be given before antibiotics for children with meningitis and no rash. RESULTS: One hundred and eight children were identified. Causes of proven meningitis were: viral 41 (enterovirus 40), bacterial 22. CSF culture or PCR was the only diagnostic test in 31 children. Dexamethasone was given to 16 children. Length of admission was shorter in children with viral compared with bacterial meningitis (4 vs 8 days; P < 0.0001). SUMMARY: Viral meningitis is the commonest cause of meningitis without rash. Enteroviral PCR was the most useful test and needs to be widely available. Confirmation of enteroviral meningitis allowed early discharge. Few children were given dexamethasone, but only 5/108 may have benefited. CONCLUSIONS: The most common cause of meningitis without a rash in British children is enterovirus. The use of dexamethasone in children with meningitis without a rash should be reconsidered or, at least, individualised.

Unusual complication of a central venous line in a neonate.

The placement of a central venous line in a low birthweight neonate led to a complication that highlights the need for continued vigilance after the position of the line is checked and thought satisfactory.

Conservative versus operative treatment for displaced ankle fractures in patients over 55 years of age. A prospective, randomised study.

Forty-seven patients over the age of 55 years with a displaced fracture of the ankle were entered into a prospective, randomised study in order to compare open reduction and internal fixation with closed treatment in a plaster cast; 36 were reviewed after a mean of 27 months. The outcome was assessed clinically, radiologically and functionally using the Olerud score. The results showed that anatomical reduction was significantly less reliable (p = 0.03) and loss of reduction significantly more common (p = 0.001) in the group with closed treatment. Those managed by open reduction and internal fixation had a significantly higher functional outcome score (p = 0.03) and a significantly better range of movement of the ankle (p = 0.044) at review.

Acute hand and wrist injuries in experienced rock climbers.

BACKGROUND: The sport of rock climbing has its own spectrum of injuries, almost half of which involve the wrist and hand. OBJECTIVE: To examine the incidence of acute wrist and hand injuries in 545 members of The Climbers' Club of Great Britain. METHOD: A total of 1100 questionnaires were sent to current members of The Climbers' Club of Great Britain for them to detail any hand and wrist injuries sustained to date. In decade years, the climbing grades and time spent climbing at each grade were determined. From these results a total and historic climbing intensity score for each climber could be calculated. RESULTS: Half of the questionnaires were returned complete. The respondents were almost entirely male. There were 235 wrist and hand injuries in 155 climbers (28%). The climbing intensity scores were significantly higher in the injury group than in those who had not suffered a wrist or hand injury (p<0.05). Finger tendon injuries were the most common injury, followed by abrasions/lacerations and fractures. DISCUSSION: The most common injuries found in rock climbing involve the wrist and hand. The predominant injury to the hand involves the finger tendons or pulleys. The greater the climbing intensity calculated over a climber's career, the greater the likelihood of sustaining these injuries.

Ankle effusions following acute ankle injury.

We prospectively studied 56 patients with an acute ankle injury and an effusion to determine the significance of the ankle effusion to functional outcome. The average size of effusion was 15 mm. Most injuries occurred following a fall (73%) and most (73%) were inversion injuries. At 6 months all but two patients had returned to their normal activities with no further problems. No correlation was found with size of effusion and the functional and clinical outcome. We conclude that an ankle effusion does not reliably distinguish which injuries require further investigations and unless there are clinical indications further investigations are not indicated.

The effect of leg length discrepancy on foot loading patterns and contact times.

The effect of a simulated leg length discrepancy on foot loading patterns and gait cycle times in normal individuals was investigated. Thirty feet of 15 normal volunteers were evaluated. Leg length discrepancy was simulated using flexible polyurethane soles. As leg length discrepancy increased, the total loading increased from 35.31 to 37.99 kg/cm2/sec, forefoot loading increased from 15.58 to 19 kg/cm2/sec, hindfoot loading remained the same. All subjects, except females with middle loading patterns, demonstrated increased hallux loading. The contact phase of gait decreased from 22% to 13%, the midstance phase remained the same, the propulsion phase increased from 44% to 50%. All findings were statistically significant. Leg length discrepancy has significant effects on the foot. Different adaptive loading patterns amongst subsets of individuals are seen.

Osteotomy of the hallux proximal phalanx.

Osteotomy of the proximal phalanx appears to be used more frequently and with increasing indications. It rarely is indicated as the only surgical procedure and often is combined with a secondary procedure. In hallux valgus surgery, a proximal or distal metatarsal osteotomy often is used, and in hallux rigidus, a cheilectomy usually is added. The advantage of a proximal phalanx osteotomy is that it enables an extra-articular correction, which avoids breaching the metatarsophalangeal joint. This extra-articular correction may prevent joint stiffness and long-term joint changes.

Effect of cotton padding on the setting properties of plaster slabs.

INTRODUCTION: Plaster of Paris (PoP) impregnated bandages have been used to maintain the position of bones and joints for over a century. Classically, wool dressing is applied to the limb before the PoP, which can then be moulded to the desired shape. A modification of this practice is to wrap the PoP bandages circumferentially in cotton before wetting and applying to the patient in an attempt to reduce inhalation of plaster dust and reduce mess. However, this may affect the water content of the cast and therefore also its setting properties and strength. This study compared the setting properties of PoP casts when used with and without cotton wrapping. METHODS: Sixty specimens, compliant with the American Society for Testing and Materials standards for three-point bending tests, were prepared, with thirty wrapped in cotton. All were weighed before and after water immersion, and wrapped around a plastic cylinder to mimic limb application. Bending stiffness and yield strength was measured on a servohydraulic materials testing machine at 2, 6, 12, 24, 48 and 72 hours. RESULTS: The water content of cotton-wrapped plaster was significantly higher (50%) than that of standard plaster. It had significantly lower strength up to 24 hours and significantly lower stiffness up to 72 hours. CONCLUSIONS: The initial decrease in strength and stiffness of the cast wrapped in cotton may comprise the ability of the backslab to hold the joint or bone in an optimal position. Any modification of the standard plaster slab application technique should allow for the potential adverse effects on the plaster setting properties.

The sentinel vein: an anatomical guide to localisation of the dorsomedial cutaneous nerve in hallux surgery.

Damage to the dorsomedial branch of the medial dorsal cutaneous nerve is not uncommon in surgery of the hallux. The resultant morbidity can be disabling. In the light of the senior author's operative observation of a sentinel vein, we undertook a cadaver study to investigate the anatomical relationships of the dorsomedial branch of the medial dorsal cutaneous nerve. This established that in 14 of 16 cadaver great toes exposed via a modified medial incision, there is an easily identified vein which runs transversely superficial and proximal to the nerve. In a prospective clinical study of 171 operations on the great toe using this approach, we confirmed this anatomical relationship in 142 procedures (83%), with no complaint of numbness or pain in the scar at follow-up. We attribute this to careful identification of the 'sentinel' vein and the subjacent sensory nerve, which had been successfully protected from damage. We recommend this technique when operating on the great toe.

Myocardial dysfunction in meningococcal septic shock.

PURPOSE OF REVIEW: The underlying pathophysiology of sepsis has long been disputed. Systemic vasodilatation is important in the development of shock and, in septic critically ill adults who have been volume resuscitated, the systemic pressure is often low and the cardiac output high. In septic children however, and especially in those with meningococcal septic shock, poor cardiac output as a consequence of depressed myocardial function seems to be important, often being the cause of death in these patients. There is much evidence for disturbance of myocardial performance, yet despite the literature, there is still no consensus on how best to manage this complication of meningococcal disease. RECENT FINDINGS: Many mediators have been proposed as the cause of the reduced myocardial performance, most recently interleukin-6 has emerged as a possible candidate involved in the pathophysiology of the myocardial dysfunction. Cardiac troponin I has been shown to be a marker of myocardial injury and may be used to monitor left ventricular function. Newer treatments emerging to manage the dysfunction include reports of success with phosphodiesterase inhibitors. SUMMARY: Accepting that myocardial dysfunction may be an important cause of the shock state in overwhelming meningococcal disease, the approach to management may need to be tailored appropriately. Although presently there is no targeted treatment, it may be that therapy focused on inhibiting or antagonising interleukin-6 will be helpful in the future. Regardless of the importance of myocardial depression, fluid resuscitation remains a cornerstone in the management of severe meningococcal disease.

Prospective study of community needlestick injuries.

Fifty three children were referred following community needlestick injuries, August 1995 to September 2003. Twenty five attended for serology six months later. None were positive for HIV, or hepatitis B or C. Routine follow up after community needlestick injury is unnecessary. HIV post-exposure prophylaxis should only be considered in high risk children.

Sledging related spinal injuries and fracture patterns: a report on five cases.

The cases are reported of five patients who presented to The Queens Medical Centre, Nottingham after a sledging accident. All five patients presented consecutively during the first weekend in 1997 having sustained the accident in the same public park. The mechanism and subsequent fracture type is described for each. These injuries are preventable, and increasing public awareness of the risk of sledging in public places may reduce the incidence.

Skip metastases in Ewing's sarcoma: a report of three cases.

The accurate pre-operative staging of all potentially malignant tumours of bone is essential. We report three cases of Ewing's sarcoma of bone in which MR imaging identified skip metastases not visualized on either contemporary radiographs or bone scintigraphy. The implications for patient management and possible reasons for the other imaging modalities failing to reveal the skip metastases are discussed.