The aetiology of rickets-like lower limb deformities in Malawian children.

UNLABELLED: Debilitating rickets-like lower limb deformities are common in children throughout the world, particularly in Malawi, Africa where the causes are unknown. We have identified that Blount disease and calcium deficiency rickets are the likely causes of these deformities and propose calcium supplementation as a potential treatment of Malawian rickets. INTRODUCTION: Surgical correction of rickets-like lower limb deformities is the most common paediatric operation performed at Beit Cure Orthopaedic Hospital, Malawi. The aim of this study was to investigate the aetiology of these deformities. METHODS: Children with a tibio-femoral angle of deformity >20° were enrolled (n = 42, 3.0-15.0 years). Anthropometric and early life and well-being data were collected. Early morning serum and urine samples were collected on the morning of the operation for markers of calcium and phosphate homeostasis. Knee radiographs were obtained, and the children were diagnosed with either Blount (BD, n = 22) or evidence of rickets disease (RD, n = 20). As BD is a mechanical rather than metabolic disease, BD were assumed to be biochemically representative of the local population and thus used as a local reference for RD. RESULTS: There were no differences in anthropometry or early life experiences between BD and RD. Parathyroid hormone (PTH), 1,25-dihydroxyvitamin D, total alkaline phosphatase and urinary phosphate were significantly higher and serum phosphate, 25-hydroxyvitamin D (25OHD) and tubular maximal reabsorption of phosphate significantly lower in RD than BD. There was no difference in serum calcium, fibroblast growth factor 23 or markers of iron status between groups. All children had 25OHD > 25 nmol/L. CONCLUSIONS: Vitamin D deficiency is not implicated in the aetiology of RD or BD in Malawian children. The cause of RD in Malawi is likely to be dietary calcium deficiency leading to elevated PTH resulting in increased losses of phosphate from the bone and glomerular filtrate. The causes of BD remain unclear; there was no evidence in support of previously suggested risk factors such as being overweight or starting to walk early. Prior to surgical intervention, supplementation with calcium should be considered for children with RD.

Proactive integrated care improves quality of life in patients with COPD.

Self-management strategies improve a variety of health-related outcomes for patients with chronic obstructive pulmonary disease (COPD). These strategies, however, are primarily designed to improve chronic disease management and have not focused on early detection and early treatment of exacerbations. In COPD, the majority of exacerbations go unreported and treatment is frequently delayed, resulting in worsened outcomes. Therefore, a randomised clinical trial was designed to determine whether integration of self-management education with proactive remote disease monitoring would improve health-related outcomes. A total of 40 Global Initiative for Chronic Obstructive Lung Disease stage 3 or 4 COPD patients were randomised to receive proactive integrated care (PIC) or usual care (UC) over a 3-month period. The primary and secondary outcomes were change in quality of life, measured by the St George's Respiratory Questionnaire (SGRQ), and change in healthcare costs. PIC dramatically improved SGRQ by 10.3 units, compared to 0.6 units in the UC group. Healthcare costs declined in the PIC group by US$1,401, compared with an increase of US$1,709 in the UC group, but this was not statistically significant. PIC uncovered nine exacerbations, seven of which were unreported. Therefore, proactive integrated care has the potential to improve outcomes in chronic obstructive pulmonary disease patients through effects of self-management, as well as early detection and treatment of exacerbations.

Jenny's story: reinventing oneself through occupation and narrative configuration.

Two life history interviews were conducted to discover how one women, Jenny, experienced a traumatic head injury, rehabilitation, and recovery. Narrative analysis of the transcribed interviews revealed a rich story of how Jenny had fashioned her identity and character through childhood occupations, including studying classical literature and music, and of how she drew upon resources developed in childhood to engineer her recovery. It also illustrated how Jenny used a recursive process of narrative construction and engagement in self-devised graduated occupations, including studying, playing music, writing, computer graphics, and theater production, to create a new identity and develop capacities to process complex information and exercise creativity. Jenny's story illustrates the usefulness of gaining a perspective on patients as occupational beings through the gathering of life histories focused on occupation, the importance of collaborative patient-therapist goal setting, and the necessity for considering both the doing (practic) and the meaning (narrative) aspects of occupation. Her story supports many scholars' arguments that the therapeutic relationship, and thus occupational therapy practice, may be enhanced through the use of life history interviewing in occupational therapy evaluation and treatment.

Pain relief after major gynaecological surgery.

The effect of Voltarol, administered routinely, in reducing the postoperative requirement for opioid drugs was monitored using patient-controlled analgesia. Omnopon consumption was recorded together with pain scores. The significance of the results is discussed with reference to the dosage and timing of analgesia and to nursing practice.

Lipid peroxidation does not appear to be a factor in late radiation injury of the cervical spinal cord of rats.

PURPOSE: We tested the role of lipid peroxidation in the demyelination and white matter necrosis associated with radiation injury of the central nervous system. METHODS AND MATERIALS: We irradiated the cervical spinal cords of female F344 rats (23 Gy) and assayed for the accumulation of the peroxidation byproducts malondialdehyde and hydroxyeicosatetraenoic acids, and for the consumption of the endogenous free radical scavengers vitamins E and C. We further tested the role of lipid peroxidation in radiation injury of the central nervous system by determining the sensitivity of the cervical spinal cord to radiation in rats on diets containing deficient, normal, and supplemental levels of the antioxidant vitamin E. Rats were placed on these diets at 4 weeks of age and irradiated (18.5-21.5 Gy) 16 weeks later. RESULTS: During the 5 months between irradiation and the onset of paralysis, no accumulation of peroxidation byproducts or consumption of endogenous scavengers was seen in the cervical spinal cords of the irradiated rats. The cervical spinal cords of some of the rats placed on the diets with deficient, normal, and supplemental levels of vitamin E were analyzed at the time of irradiation and contained 197 +/- 57, 501 +/- 19, and 717 +/- 35 pmol vitamin E/mg protein, respectively. Despite the statistical differences in these levels, the radiation sensitivity of the cervical spinal cord (ED50 for white matter necrosis) in rats receiving the three diets was not different (20.4, 20.7, and 20.6 Gy). CONCLUSION: These data do not support a role for free radical-induced lipid peroxidation in the white matter damage seen in radiation injury of the central nervous system.

Effects of long term 2% fish oil supplements on tissue fatty acids, phospholipids, cholesterol, and arterial histology in Japanese quail (Coturnix coturnix japonica).

The effects of 2% olive oil (OO) or fish oil (FO) (Super epa500) dietary supplementation (9 months) on Japanese "SEA" quail was investigated. The animals were examined for tissue biochemical changes and possible blood vessel fatty deposition. The fatty acids of blood and tissue extracts from heart, liver and fat were analyzed by gas-chromatography/mass spectrometry. The ratio of arachidonic acid to eicosapentaenoic or docosahexaenoic acid was markedly decreased in FO treated animals compared to OO or control diet treated animals. Tissue cholesterol and total phospholipids were present in elevated amounts in the heart and liver of FO treated animals. After the 9-month regimen many animals had residual atherosclerotic lesions but the FO treated birds had considerably more fatty streaks and fatty deposition in their large vessels compared to control or OO treated animals. Although the lipid composition of tissues of FO treated animals would indicate that the purported cardioprotective omega-3 fatty acids are enriched in the various tissues examined compared to olive oil and control diet treated animals, the possible detrimental effect of saturated fat, cholesterol, or some other component of the fish oil preparations is suggested from the histological appearance of fatty deposition in the blood vessels (aortae) of these inbred animals. These results in quail are strikingly similar to that seen in the omega-3 FA treated WHHL rabbit (15).

Comparison of infusions of morphine and lysine acetyl salicylate for the relief of pain following thoracic surgery.

A double-blind study comparing the effectiveness of a continuous infusion i.v. of lysine acetyl salicylate (LAS) with an infusion of morphine for the treatment of pain following pulmonary surgery is described. Mean pain scores in the two groups were not significantly different at any stage during the 24-h period of study. LAS was not associated with any significantly greater blood loss in the period after operation. The incidence of drowsiness, nausea and vomiting, and the need for antiemetic medication were similar in both groups.