Improving the transition between paediatric and adult healthcare: a systematic review.

INTRODUCTION: The transition between paediatric and adult care for young people with chronic illness or disability is often poorly managed, with adverse consequences for health. Although many agree that adolescent services need to be improved, there is little empirical data on which policies can be based. OBJECTIVES: To systematically review the evidence of effectiveness of transitional care programmes in young people aged 11-25 with chronic illness (physical or mental) or disability, and identify their successful components. DESIGN: A systematic literature review in July 2010 of studies which consistently evaluated health outcomes following transition programmes, either by comparison with a control group or by measurement pre-intervention and post-intervention. RESULTS: 10 studies met the inclusion criteria, six of which showed statistically significant improvements in outcomes. Descriptive analysis identified three broad categories of intervention, directed at: the patient (educational programmes, skills training); staffing (named transition co-ordinators, joint clinics run by paediatric and adult physicians); and service delivery (separate young adult clinics, out of hours phone support, enhanced follow-up). The conditions involved varied (eg, cystic fibrosis, diabetes mellitus), and outcome measures varied accordingly. All six interventions that resulted in significant improvements were in studies of patients with diabetes mellitus, with glycosylated haemoglobin level, acute and chronic complications, and rates of follow-up and screening used as outcome measures. CONCLUSIONS: The most commonly used strategies in successful programmes were patient education and specific transition clinics (either jointly staffed by paediatric and adult physicians or dedicated young adult clinics within adult services). It is not clear how generalisable these successful studies in diabetes mellitus will be to other conditions.

Newborns develop a Th1-type immune response to Mycobacterium bovis bacillus Calmette-Guérin vaccination.

Data obtained in animals indicate that neonatal immune responses are biased toward Th2. This could reduce the efficacy of vaccines against viral and mycobacterial diseases. The ability of human newborns to develop a Th1 immune response upon immunization has not been studied. Since the vaccine Mycobacterium bovis bacillus Calmette-Guérin (BCG) triggers a Th1-type response in adults, we investigated whether it induces a similar response in newborns and whether age at vaccination influences immunogenicity. We found that BCG vaccination at birth induces a memory Th1-type response of similar magnitude to that when given later in life. This study demonstrates that human newborns can be immunized against pathogens controlled by a Th1 immune response.

Transfer of the levator scapulae, rhomboid major, and rhomboid minor for paralysis of the trapezius.

Twenty-two patients who had paralysis of the trapezius muscle secondary to injury of the spinal accessory nerve had transfer of the levator scapulae and rhomboid major and minor muscles. In each patient, function of the trapezius had failed to improve with either physical therapy or an operative attempt at neurolysis or reconstruction of the spinal accessory nerve. The etiology of the injury was biopsy of a cervical node in thirteen patients, trauma in seven, and radical dissection in the neck in two. All patients had pain, visible deformity, and dysfunction of the shoulder girdle. Physical examination revealed asymmetry of the neckline, drooping of the shoulder girdle with lateral displacement of the scapula, and weakness of active elevation. Fourteen patients had had an incorrect clinical diagnosis, and twelve patients had had an inaccurate or incomplete electromyographic examination. A long thoracic nerve palsy developed in three patients. At an average of seven and a half years (range, two to fourteen years), the result of the operative procedure, as determined with the American Shoulder and Elbow Surgeons Shoulder Evaluation Form, was excellent for thirteen patients, satisfactory for six, and unsatisfactory for three. All but three patients had adequate relief of pain and demonstrable functional improvement.

An electromyographic analysis of the shoulder during a medicine ball rehabilitation program.

We used dynamic electromyography and a motion analysis system to describe the muscle firing patterns in 10 shoulder muscles and the basic kinematics of a two-handed overhead medicine ball throw. Ten healthy male subjects with no history of shoulder injury were evaluated. The two-handed medicine ball throw was divided into three phases for analysis: cocking, acceleration, and deceleration. The average duration of the throw was 1.92 seconds; the cocking phase represented 56%, the acceleration phase 15.5%, and the deceleration phase 28.5% of the throw. In the cocking phase, the upper trapezius, pectoralis major, and anterior deltoid muscles showed high activity ( > 40% to 60% maximum manual test), and the rotator cuff muscles had moderate activity ( > 20% to 40%). In the acceleration phase, five of the muscles demonstrated high levels of activity ( > 40% to 60%) and the upper trapezius and lower subscapularis muscles had very high levels of activity ( > 60%). Analysis of the deceleration phase revealed high activity in the upper trapezius muscle and moderate activity in all other muscles except the pectoralis major. Our findings support the use of medicine ball training as a bridge between static resistive training and dynamic throwing in the rehabilitation of the overhead athlete. This training technique provides a protective method of strengthening that closely simulates portions of the throwing motion.

Inferior capsular shift procedure for anterior-inferior shoulder instability in athletes.

Sixty-eight shoulders in 63 athletic patients with anterior-inferior glenohumeral instability underwent an anterior-inferior capsular shift procedure. Shoulders with glenoid fractures, predominantly posterior instability, or routine, unidirectional anterior instability were not included in this study. There were 42 men and 21 women, with an average age of 23 years. Forty-two repairs were performed on the dominant arm. All 31 overhead throwing athletes had their dominant arms repaired. Forty-six shoulders had histories of recurrent anterior dislocations, while 22 shoulders had recurrent subluxation. All 68 shoulders had an anterior-inferior capsular shift, tailored to the degree of laxity found; in addition, 21 had repair of a Bankart lesion. Forty-two patients were rated excellent (67%), 17 good (27%), 2 fair (3%), and 1 poor (3%). Fifty-eight of 63 (92%) patients returned to their major sports, 47 (75%) at the same competitive levels. Only 5 of 10 elite throwing athletes returned to their prior competitive levels. Loss of external rotation averaged 7 degrees. Two patients (2.9%) re-dislocated postoperatively, after violent falls.

Repair of rotator cuff tears in tennis players.

Twenty-three tennis players with a symptomatic full-thickness rotator cuff tear underwent anterior acromioplasty and rotator cuff repair. There were 8 small tears (less than 1 cm), 5 moderate tears (1 to 3 cm), 2 large tears (3 to 5 cm), and 8 massive tears (greater than 5 cm). The dominant shoulder was involved in all patients and all were unable to play tennis before surgery. Eleven patients experienced a traumatic event that caused an injury, 6 while playing tennis, and 12 patients had a gradual onset of symptoms. At average follow-up of 42 months, 19 patients (83%) achieved a good result, were pain-free, and were able to play tennis at their presymptomatic competitive level. Three patients (13%), all with massive tears, had a satisfactory result and were able to play tennis, although at a lower competitive level secondary to weakness. One patient (4%), who also had a massive tear, had an unsatisfactory result and was unable to play tennis.

Multicentric reticulohistiocytosis and Sjögren's syndrome.

A 66-year-old man with an 18-year history of cutaneous multicentric reticulohistiocytosis (MRH) developed a chronic destructive symmetrical arthritis and xerostomia. Biopsies of synovium and minor salivary glands established a diagnosis of MRH polyarthritis and lymphocytic infiltrative Sjögren's syndrome, respectively. Anti-Ro(SSA) antibody was present. Hypothyroidism was also identified. This report of Sjögren's syndrome in MRH may enlarge the spectrum of autoimmune diseases associated with MRH.

Treatment of trapezius paralysis.

Trapezius paralysis is a painful, disabling problem. Eighteen patients with trapezius paralysis were evaluated and initially treated conservatively. Nine patients had had a misdiagnosis prior to evaluation and only one patient was successfully treated conservatively. Ten patients underwent operative reconstruction, consisting of transfer of the levator scapulae and rhomboid muscles. Seven patients were followed for more than two years, and they had five excellent results, one satisfactory result, and one unsatisfactory result. All patients had improved function and correction of deformity, and six patients had good pain relief.

Minocycline hyperpigmentation: skin, tooth, nail, and bone involvement.

The association of bone, tooth, nail and scleral pigmentation in a patient treated for acne with minocycline was noted. Hyperpigmentation appeared in old scar tissue, but not that present from recent surgical procedures.

Epithelioma cuniculatum.

The cases of epithelioma cuniculatum in this report illustrate the unusual appearance and diagnostic difficulty of the lesion. Early diagnosis resulted in apparent cure with adequate local excision in some cases, whereas amputation was necessary for advanced or recurrent tumors. Distant metastasis may occur. Superficial biopsy specimens may yield inadequate tissue for proper diagnosis. Verrucous carcinoma should be considered as a diagnostic possibility in any atypical or recurrent "wart" on the sole.

Cutaneous protothecosis in a patient receiving immunosuppressive therapy.

A 30-year-old recipient of a renal transplant, who was receiving immunosuppressive therapy, developed cutaneous abscesses from which an organism of the genus Prototheca was cultured. The patient died of Klebsiella septicemia. At the time of death, pure cultures of Prototheca and Candida organisms were grown from separate skin lesions. Prototheca is a genus of achloric algae. Cultural, microscopical, and staining characteristics separate these organisms from the yeast and fungi. Cutaneous protothecosis was first described in 1964 by Davies et al in an otherwise healthy African rice farmer. Since that time, nine other cases have been reported. However, only a single case has been described in a patient receiving immunosuppressive drugs, a woman with carcinoma of the breast who was receiving chemotherapy with multiple agents.