Randomised controlled trial of preoperative information to improve satisfaction with cataract surgery.

AIM: To investigate the effects of an informational video on patient expectations and satisfaction with day-stay cataract surgery. METHODS: 141 patients undergoing day-stay cataract surgery were randomised into one of two video groups, explaining either what to expect from the cataract surgery or the anatomy of cataract. Patients were surveyed as to their expectations for visual outcome, anxiety, risk, and discomfort resulting from the surgery. After the operation, patients were again asked to rate their experience of anxiety, discomfort, risk, comprehension, overall satisfaction, and comparison with expectations. RESULTS: 84% of patients already thought they received enough or too much information. The expectations video group expected more risk and discomfort than the anatomy video group. Yet, after the surgery, the expectations video group was significantly more satisfied, understood better what was happening to them, and felt less anxious. There was no difference in the discomfort or risk actually experienced, or the expected visual outcomes. Patients with previous cataract surgery experience expected less anxiety and discomfort, and found the surgery closer to their expectations. None the less, previous cataract surgery experience did not negate the effects of the video. CONCLUSIONS: This study demonstrates that a simple, inexpensive videotape showing patients what to expect from cataract surgery results in significant increases in patient understanding of and satisfaction with the cataract surgery, as well as a decrease in anxiety. These effects were independent of patients' expected outcomes or previous experience with cataract surgery, and despite the fact that patients generally thought they had already received enough information.

Assessment of the accuracy of transrectal ultrasonography in anorectal neoplasia.

BACKGROUND: Accurate preoperative staging of anorectal neoplasia is required to identify patients for whom local excision or adjuvant therapy may be appropriate. The objectives of this study were to review the accuracy of endoluminal transrectal ultrasonography (TRUS) in the staging of rectal cancers and to determine the learning curve before optimal staging accuracy can be achieved. METHODS: The results of all TRUS examinations for the assessment of anorectal neoplasia performed by two colorectal surgeons at two teaching hospitals of the University of Sydney from 1991 to 2001 were collected prospectively. RESULTS: Of the 433 patients examined by TRUS, 356 were included, of whom 263 (73.9 per cent) had nodal status assessed histologically. Of the 77 patients excluded, 50 had undergone radiotherapy before operation. TRUS achieved excellent accuracy when compared with histopathology reports using kappa statistics for standard Union Internacional Contra la Cancrum (UICC) staging (kappa = 0.89), tumour wall penetration (kappa = 0.70), lymph node detection (kappa = 0.66) and a proposed new staging system (kappa = 0.94). In addition, the increase in TRUS accuracy with operator experience demonstrates the need to perform 50 or more procedures before optimal accuracy is achieved. CONCLUSION: TRUS provides an appropriate investigation with which to select patients with T1 tumours for local excision, and patients with T3 or T4 tumours for preoperative radiotherapy. The relative inaccuracy of staging T2 tumours by TRUS has led to a proposed alternative ultrasonographic staging system.

Anticipating rotavirus vaccines: epidemiology and surveillance of rotavirus in South Africa.

Rotavirus infection is associated with acute infantile gastroenteritis in infants and young children globally. In South Africa, rotavirus infection has been shown to be associated with approximately one-quarter of all diarrhoeal admissions to hospital. Rotavirus infection predominantly occurs in infants less than 12 months of age (75%) and has a peak of shedding during the cooler, drier months of the year. A secondary peak during the spring has been observed. Multiple infections with rotavirus and at least one other microbial agent are common. The circulating VP7 serotypes and VP4 genotypes have been determined in various regions of South Africa and show a geographic specific distribution. A decade previously, P[8]G1 or G4 strains predominated, and P[4]G2 strains occurred in an epidemic pattern in one region. More recently, rotavirus strains with P[6] genotype have become common and novel VP7/VP4 genotype combinations are occurring across the country. G9 strains have been reported from Cape Town to Vendaland. The circulating rotavirus types observed in this study add to the knowledge of the natural history of rotavirus infection and provide the groundwork to consider future vaccine strategies.

Epidemiology of astrovirus infection in Zaria, Nigeria.

Astrovirus has been shown to be an important aetiological agent associated with gastroenteritis in children, although few studies have been conducted in Africa. In this study, stool specimens were obtained from 375 young children less than 5 years of age with acute gastroenteritis presenting at Ahmadu Bello University Hospital, and from a control group of 122 children without diarrhoeal illness. The specimens were examined for the presence of human astroviruses using a monoclonal antibody-based ELISA (Astrovirus IDEIATM, Dako, UK). Negative staining electron microscopy was performed on specimens to confirm the presence of astrovirus particles. Astrovirus was detected in 6.7 per cent (25/375) of the diarrhoeal stools compared to 5.7 per cent (7/122) of the control specimens. Astrovirus seemed to infect older children and more than half the children were between 1 and 4 years of age (15/25). Only four children were less than 6 months old. A winter peak of shedding was observed.

Patient's perceptions of biofeedback therapy for obstructive defaecation.

OBJECTIVE: The aim of this study is to assess the long-term outcomes of a biofeedback treatment programme for obstructive defaecation up to five years after completion of treatment, reporting from the patients' perspective the subsequent progression of defaecation difficulties and the perceived usefulness of the biofeedback training and its components. METHODS: A biofeedback program for obstructive defaecation at a major hospital in Sydney provided 37 patients with reading material, taught defaecation techniques, and prescribed simulated defaecation and anal relaxation exercises to practice between their monthly biofeedback sessions. Twenty-nine of these patients were contacted by telephone an average of 23 months after last attending and asked to rate the present severity of their condition, changes since last attending biofeedback, and which aspects of the program they found most helpful. RESULTS: Of patients who completed the program, 70% achieved at least a 15% improvement in perceived symptom severity. Those who completed the program and achieved benefit were more likely to name the exercises as the most helpful program component. At the time of follow-up, however, there was no difference in perceived symptom severity between program completers and noncompleters. Program completers, and those followed up more than two years after last attending biofeedback, were more likely to report a worsening in symptom severity subsequent to their final treatment session. CONCLUSIONS: This study confirms the favourable short-term outcomes achieved by some patients completing biofeedback treatment for obstructive defaecation. The findings suggest that biofeedback equipment may be economically used in an educative and corrective role, and that other factors such as education, exercises and counselling alone play an important role. Finally, the benefits of biofeedback may not be maintained through long-term follow-up, raising questions as to the natural history of the disorder and the long-term effectiveness of biofeedback treatment.

Malattia leventinese presenting with subretinal neovascular membrane and hemorrhage.

PURPOSE: To report a case of malattia leventinese involving subretinal hemorrhage. METHODS: Case report. RESULTS: Two weeks after initial presentation, the visual acuity of this 34-year-old man decreased to LE: 20/100. Funduscopic evaluation revealed a subretinal hemorrhage involving the center of the foveal in the left eye that was interpreted as secondary to a neovascular membrane on fluorescein angiography. The patient did well after the removal of the submacular material by pars plana vitrectomy. CONCLUSION: Patients with malattia leventinese may occasionally present with submacular hemorrhage. Prompt diagnosis and intervention may enhance the patient's chance for visual improvement.

Prevalence of unusual human rotavirus strains in Ghanaian children.

Sixty-seven rotavirus-positive fecal samples, collected between January and April 1999, from children with diarrhea in the Upper East Region of Ghana were examined for rotavirus VP7 and VP4 types. Sufficient viral RNA could be obtained from 46 (68.7%) of the samples and all the isolates had short electrophoretic pattern and typed as subgroup I rotaviruses by subgroup ELISA. Three rotavirus strains with G8 specificity were identified for the first time in Ghana. G and P typing by PCR identified two distinct strains, P[6]G2 (50%) and P[6]G8 (4.3%). Eighty-two percent of the isolates (n = 38) were of the "putative" neonatal P[6] genotype. Two of these G8 isolates carried the VP4 P[6] genotype whereas the third could not be assigned a P type. Mixed infections of G1, G2, G3 and G8 were detected amongst the stool samples. The presence of these unusual strains, especially the high incidence of G2 rotavirus strains in Ghana, reinforces the need to put in place a surveillance system for the detection of new and exotic rotavirus strains, that will provide information on the spread of these strains in West Africa as well as useful data for the formulation of the next generation of rotavirus vaccines.

Streptokinase versus alteplase and other treatments for acute and delayed thrombolysis of blood stains in clothing.

OBJECTIVE: To assess the usefulness of heparin, alteplase, and streptokinase in removing blood stains. DESIGN: Randomised controlled trial. SETTING: Hospital laundry. INTERVENTIONS: Blood stains were allocated to treatment with alteplase, streptokinase, heparin, a commercial enzymatic stain remover, or no treatment at all after three or seven hours and then washed in hot or cold water two hours later. RESULTS: Both hot water and early treatment were strongly associated with improved stain removal. All four treatments were associated with a worse outcome than no treatment at all, although for streptokinase this trend did not reach significance. The commercial stain remover gave the worst results of all treatments tested. CONCLUSIONS: Contrary to popular wisdom, hot water is much more effective than cold in removing blood stains. Methodologically rigorous research and evidence based principles are needed within the laundry industry, and the role of thrombolytic drugs should be assessed further.

Distribution of rotavirus VP7 serotypes and VP4 genotypes circulating in Sousse, Tunisia, from 1995 to 1999: emergence of natural human reassortants.

Rotavirus strains circulating in Sousse, Tunisia, between 1995 and 1999 were characterized antigenically by monoclonal antibodies to the VP6 subgroup and the VP7 serotype. The VP4 genotype was determined by reverse transcription-PCR, as were the strains with untyped VP7. Only 17% of 375 children were shedding rotavirus as determined by latex agglutination assay. Most rotavirus strains were G1P[8] (50%), followed by G4P[8] and G4P[6]. Reassortant G1P[4] strains emerged in Sousse during the 1998-1999 season.

South African G4P[6] asymptomatic and symptomatic neonatal rotavirus strains differ in their NSP4, VP8*, and VP7 genes.

Over the past decade, a G4P[6] strain has been found to be circulating in different neonatal wards in the Pretoria area. This endemic strain was associated with both asymptomatic and symptomatic infection, providing the opportunity to undertake a molecular study of some of the putative "virulence" genes. The genes encoding NSP4, VP8*, and VP7 of two asymptomatic and two Symptomatic strains were sequenced and compared with ST3. Within each of these genes, amino acid substitutions unique to South African strains were recorded. Four conserved amino acid differences between asymptomatic and symptomatic strains at aa 82 (serine to leucine), aa 114 (aspartic acid to glutamic acid), aa 138 (proline to threonine), and aa 169 (leucine to serine) were identified within the NSP4 gene. The hypervariable region of VP8* exhibited 10 specific amino acid differences (at aa 73, 78, 98, 111, 116, 142, 145, 167, 169, and 188) between asymptomatic and symptomatic strains, while three amino acid substitutions within VP7 were noted. These changes to VP7 occurred within the glycosylation site at aa 70 (leucine to serine), at antigenic region A (aa 96, asparagine to threonine), and at aa 318 (aspartic acid to glycine). It may be speculated that these changes are specific to G4P[6] strains. Furthermore, the observed substitutions may also be particular to South African strains. NSP4, VP8*, and VP7 have been associated with virulence and the amino acid substitutions within these genes correlate with both asymptomatic and symptomatic infection observed in neonates.

Dying of a broken heart: ethics and law in a case of hypoplastic left heart syndrome.

The short life of Baby P is reviewed. Baby P was an infant girl who was born with hypoplastic left heart syndrome and died at the age of 30 days. Effective, aggressive surgical treatment for this condition is rapidly developing in some countries, but is rarely available or successful in most. Baby P died without intervention. After presenting the history and background, the legal and ethical issues raised by this case regarding decision-making, futility, and best interests are reviewed.

VP6 subgroup and VP7 serotype of human rotavirus in Zaria, northern Nigeria.

A survey of rotavirus infection in infants and young children with acute diarrhoea was undertaken in Zaria, northern Nigeria during 1997 and 1998. In total, 375 faecal specimens were collected from children aged between 1 and 60 months and 122 specimens from age-matched control children without diarrhoea. Fourteen specimens were collected from neonates in the University Teaching Hospital. Rotavirus antigen was detected in 61 diarrhoeal and four control specimens; four neonates were shedding rotavirus. Polyacrylamide gel electrophoresis of the viral genome showed the presence of five strains of rotavirus with long RNA electropherotypes and one short pattern. The rotavirus VP6 subgroup was determined by monoclonal antibodies specific ELISA and showed that subgroup II strains predominated (72 vs. 9.8 per cent), while eight strains could not be subgrouped and three did not react at all. Examination of the VP7 serotype showed G1 and G3 strains circulating at similar levels (29 and 25 per cent), but no serotype G2 nor G4 strains were identified. G1/G3 'mosaic' virus strains circulated commonly (10 per cent).

Comparative studies of human rotavirus serotype G8 strains recovered in South Africa and the United Kingdom.

Epidemiological studies on the VP7 serotype prevalence of human rotaviruses in South Africa and the United Kingdom identified several strains which could not be serotyped as G1-G4 by monoclonal antibodies. Further analysis of these strains with a G8-specific monoclonal antibody and with probes for human rotaviruses confirmed them as G8 rotaviruses. These G8 strains exhibited a high degree of sequence identity when compared with each other and with other rotavirus G8 strains. Five South African strains were further characterized as VP6 subgroup I, but with a long RNA electropherotype, which is similar to the G8 strains previously isolated in Finland. In the UK strains, one was VP6 subgroup II with a long RNA electropherotype (similar to the Italian G8 strain). The other two were subgroup I with a short RNA electropherotype. None of these strains exhibited the super-short RNA electropherotype described in the prototype G8 strains recovered from Indonesia (69M).