Dermatological postoperative patient information leaflets: is it time for more uniformity?

INTRODUCTION: Patient information leaflets (PILs) are an important source of information for patients postoperatively. There are currently no nationally agreed standards by dermatologists for postoperative advice following skin surgery. AIM: To assess the common themes and areas of variation in advice given in PILs after skin surgery across all National Health Service (NHS) hospitals in England and Wales. METHODS: All acute trusts in England (n = 159) and local health boards in Wales (n = 7) were requested to provide their postoperative dermatological PILs for general sutured wound care or excision biopsy. Eight preselected parameters were assessed: minimum dressing duration, duration of pressing on a bleeding wound, postoperative analgesia, explanation of infection signs, application of petroleum jelly, scarring, whom to contact if there is a problem, and the recommended postoperative time for abstaining from active exercise. RESULTS: PILs were received from 137 different dermatology departments belonging to 127/166 (76.5%) organisations across England and Wales. Of these, 102 PILs gave a specific duration for dressings: 45/102 (44.1%) advised a minimum of 48 h, but 28/102 (27.5%) recommended leaving dressings in place until suture removal. Regarding duration of pressing on a bleeding wound, 117 PILs gave advice, with the most common recommendation being 15 min (30/117, 25.6%), followed closely by 10 min (26/117, 22.2%). Of the 137 PILs received, 125 gave advice regarding postoperative analgesia, with paracetamol alone being the most common recommendation (24/125, 19.2%). For the remaining parameters, 111/137 (81.0%) PILs described ≥ 2 signs of infection, 42/137 (30.7%) recommended the application of petroleum jelly, 65/137 (47.4%) mentioned scarring, 137/137 (100%) highlighted whom to contact if there were postoperative problems and 87/137 (63.5%) PILs gave advice regarding postoperative abstinence from active exercise. CONCLUSIONS: The advice given in dermatology postoperative PILs across England and Wales is highly variable. A nationally agreed template or set of postoperative advice should be considered to improve consistency.

A prospective trial of the effects of isotretinoin on quality of life and depressive symptoms.

BACKGROUND: Isotretinoin is an efficacious treatment for acne, but has been controversially linked with depression. OBJECTIVES: This study aimed to examine the effects of isotretinoin on quality of life(QoL) and depression using a prospective design. METHODS: The WHOQOL-BREF QoL measure and Centre for Epidemiological Studies Depression Scale were administered to consecutive outpatients with acne who were prescribed either isotretinoin (n = 65) or antibiotic treatment (n = 31).Patients and physicians rated acne severity independently. Groups were compared at baseline with a matched community sample (n = 94) and measurements repeated at 3 months for treatment groups. RESULTS: There were no differences between the three groups at baseline in terms of age, gender, depression or overall QoL. Acne was more severe in the treatment groups (P < 0·001). Depression was negatively correlated with QoL (P < 0·001)and hence was included as a covariate in repeated-measures analyses of QoL.Acne improved over time in both treatment groups (F = 48·2, P < 0·001). There was no detectable deterioration in depression score in either group (F = 1·1, not significant). QoL in the physical and social domains improved (P < 0·001) while psychological and environmental QoL was unchanged over time. The improvement in social QoL was greater in the isotretinoin group (P < 0·05). Those patients with higher baseline depression scores showed greater improvements in physical, psychological and social QoL (P < 0·001). CONCLUSIONS: Treatment of acne improves QoL, particularly in those with more depressive symptoms at the outset. Mood deterioration was not detected, but the possibility of subtle or rare mood effects of isotretinoin cannot be ruled out.

Quantification of wound oedema after dermatological surgery.

BACKGROUND: Postoperative wound oedema causing increased suture tension is thought to be a possible cause of scars known as suture marks. Quantification of such oedema has not previously been reported in the literature. Measures to accommodate wound oedema may include the adoption of alternative suture techniques and the use of more elastic suture materials. OBJECTIVES: To quantify wound expansion after skin surgery and to identify any contributory factors, and to determine the ability of eight commonly used skin suture materials to stretch under increasing tension. METHODS: Forty consecutive adult patients attending a dermatology department for routine skin surgery in December 2002 were recruited. Details including body site, nature of the lesion excised and dimensions of the open wound were recorded. The distance between entry and exit points of an untied suture at the time of skin surgery was measured and then repeated 24 h postoperatively. The ability of eight different suture materials to stretch when an increasing force was applied was measured by hanging standard weights from the sutures and measuring the suture length for each force applied. RESULTS: Thirty-nine patients completed the study. All wounds expanded postoperatively, with a mean lateral expansion of 1.0 mm. There was a strong association between the width of the unsutured wound after excision and the subsequent wound expansion. Commonly used sutures in skin surgery were found to be relatively inelastic at forces under 0.2 kg. The monofilament Novofil (Davis & Geck, Danbury, CT, U.S.A.) exhibited the greatest degree of stretch of those tested. CONCLUSIONS: There is considerable oedema in the first 24 h after skin surgery, particularly with wider excisions. This needs to be considered when choosing suturing materials and techniques to avoid excessive suture tension.

Standardized diagnosis of pneumonia in developing countries.

The World Health Organization recommends the use of raised respiratory rate and chest wall indrawing to enable health workers in developing countries to diagnose pneumonia. We evaluated the current World Health Organization guidelines for management of the child with cough or difficult breathing in Manila, Philippines and Mbabane, Swaziland using an identical protocol in both countries. Raised respiratory rate was defined as greater than or equal to 50/minute for children ages 2 to 12 months and greater than or equal to 40/minute for children 12 months to 5 years. Chest wall indrawing was defined as inward movement of the bony structures of the lower chest wall with inspiration. In the Philippines raised respiratory rate or chest wall indrawing, when applied by a pediatrician, was found to have a sensitivity of 0.81 and specificity of 0.77 for predicting pneumonia as determined by a pediatrician with the aid of a chest roentgenogram. In Swaziland the sensitivity was 0.77 and the specificity was 0.80. When applied by health workers the sensitivity was similar but the specificity was lower. The current World Health Organization ARI case management guidelines predicted pneumonia with similar sensitivity and specificity in two very different developing countries, the Philippines and Swaziland.

[Implantation of a "pan-cameral" intraocular lens in Africa].

In modern medicine, extraction of the cataractous lens is followed by implantation of an artificial intraocular lens. The 2 main types of intraocular lenses, the anterior and the posterior chamber types, are essentially different in design. We present here 11 cases in which, due to lack of facilities, we were compelled to implant posterior chamber intraocular lenses in the anterior chamber of the eye. Postoperatively, visual acuity improved in 82% of the operated eyes.

How appropriate is the WHOQOL-BREF for assessing the quality of life of adolescents?

BACKGROUND: Using mixed-methods research, we investigated whether the adult version of the WHOQOL-BREF was acceptable and feasible to use with adolescents (13-19), and what features might need to be changed to develop it. Differences from young adults quality of life (QoL) (20-30 years) could add justification. METHODS: Preliminary psychometric properties of the adult WHOQOL-BREF were examined in 208 adolescents and 204 young adults. Unhealthy adolescents diagnosed with acne or elevated depressive symptoms (CES-D) were compared with healthy adolescents. Cognitive interviewing used 'think aloud' techniques with six healthy adolescents during WHOQOL-BREF completion. Concepts and wording were thematically analysed for relevance, comprehension and comprehensiveness. RESULTS: Little data were missing from the WHOQOL-BREF suggesting some feasibility and acceptability to adolescents. Compared with adults, adolescents perceived greater access to information, a better home environment, worse pain, and medication dependency. Internal consistency reliability for adolescents was good (α = .89), especially psychological and environmental QoL. Content validity especially for social and environment domains was supported. Domains validly discriminated between high- and low-depressive symptoms but not acne groups. Additional new facets on autonomy, altruism and physical fitness and changed item contents are proposed. CONCLUSION: The evidence indicates that developing a new adolescent version is justifiable. Cross-cultural research should build on these preliminary findings.

Recognition of pneumonia by primary health care workers in Swaziland with a simple clinical algorithm.

In developing countries primary health care workers are being trained to manage and treat acute respiratory infections with a protocol developed by the WHO. We tested the ability of nurses and nursing assistants in Swaziland to recognise the signs and symptoms of pneumonia; with the results of a paediatrician's examination as "gold standard", sensitivities and specificities were calculated. Danger signs of stridor and abnormal sleepiness were poorly recognised (sensitivity 0-50%) by the health care workers, as was audible wheeze. Severe undernutrition, tachypnoea, and chest wall indrawing were well recognised. Overall, the recognition of pneumonia was good (sensitivity 71-83%, specificity 84-85%). These findings highlight topics for emphasis in training.

PIP: In July-August 1989, 2 primary health care (PHC) workers (nurses and nurse's assistants) and a pediatrician used WHO case management protocol to assess the conditions of 362 2-59 month old children who came to Mbabane Government Hospital and the Salvation Army Clinic in Mbabane, Swaziland, with coughing (99%) and difficulty in breathing (29%). The PHC workers had earlier undergone a 5-day training period on identifying signs and symptoms of pneumonia. A consulting pediatrician and a public health official conducted this study to compare the ability of the PHC workers to recognize the clinical signs of pneumonia with that of the pediatrician (gold standard). 64% of the children had a history of fever, but only 12% had a fever (38.3 degrees Celsius) at admission. 4 children had had convulsions. The PHC workers did not do well at recognizing the danger signs of stridor and abnormal sleepiness (sensitivity 50% and 0-14%, respectively). They were able to correctly recognize the danger sign of severe undernutrition in 2 children, however. They correctly identified most children with true fever (sensitivity 73-76%), yet they also claimed that many children with normal temperature had a fever (specificity 62-78%). Thus they would have administered antipyretics to 2-3 times too many children. The nursing assistants detected audible wheeze in only 4 of 14 children with audible wheeze (sensitivity 29%), while the nurses only detected 2 such children (sensitivity 14%). Further, they diagnosed audible wheeze in 18 children who actually had blocked nostrils. They correctly identified fast breathing in almost 75% of cases. Nurses were more likely to correctly diagnose chest wall indrawing than the nursing assistants (sensitivity 68% vs. 34%; p = .0048). Overall, the training helped the PHC workers to diagnose pneumonia quit well (sensitivity 71-83%, specificity 84-85%). Future training programs must focus on recognition of 2 danger signs, stridor and abnormal sleepiness, however.