Wrist pain: a systematic approach to diagnosis

Numerous radiographic procedures are now available to help determine the cause of wrist pain. This paper presents a wrist-pain algorithm that defines the relative roles of various radiographic techniques in the evaluation of patients with wrist pain. Practical application of the algorithm is demonstrated through illustrative cases.     

Developing a systematic approach to the diagnosis and classification of mitochondrial disease

The accurate diagnosis and classification of mitochondrial diseases are essential first steps in understanding the natural history and true health care burden imposed by these protean and devastating disorders. Epidemiologic studies place the incidence of genetic forms of mitochondrial disease between 1 in 2000 and 1 in 5000 live births. Symptoms may not appear for years after birth, even when inherited. Once they occur, however, the course is often relentlessly progressive. Diagnosis requires a combination of clinical and laboratory studies that are applied systematically. DNA analysis and respiratory chain studies remain the mainstays of diagnosis, but several other disciplines may contribute to achieving diagnostic confidence when a single study is suggestive but inconclusive. A comprehensive classification system for mitochondrial diseases has not yet been developed. The current International Classification of Diseases, 10th Revision (ICD-10) includes just 10 codes for mitochondrial disorders. Supplementary data of 347 proposed ICD-10 codes is included to assist with the development of a more comprehensive system for the diagnosis and classification of mitochondrial disease.     

Aspergillosis: Mechanisms of pathogenicity implicated and approach to laboratory diagnosis.

Aspergillosis comprises a wide range of clinical conditions, of which the most serious is invasive aspergillosis, which particularly affects immunodeficient individuals. In the present work we present a review centred on three main aspects of this disease: 1) Possibility of differentiation of strains of Aspergillus fumigatus by phenotyphic and genotypic methods, 2) Mechanisms of pathogenicity of this species and especially the relationships of elastase activity, and 3) Laboratory diagnosis of aspergillosis, principaly in terms of determination of circulating antigens and DNA sequences in the blood and urine of patients.     

The universal tip: a systematic approach to aesthetic problems of the lower lateral cartilages

A systematic approach to the various common aesthetic problems of the lower lateral cartilages is presented. Since this approach and technique may be applied to a wide variety of problems, we have taken the liberty of calling this the universal tip. These concepts have emerged from study of the literature and have evolved over the past thousand rhinoplasties. A classification of lower lateral cartilage problems includes five basic variations: (1) the wide, amphorous, ill-defined tip, (2) insufficient projection of the tip, (3) overprojection of the tip, (4) dependent tip with lack of definition, and (5) asymmetrical tip. It is important to realize that any of these five categories may be found in various combinations with each other. The details and fundamental steps of this universal tip technique are presented along with illustrative case examples in each of the five basic variations. In approximately 4 percent of patients there is a postoperative asymmetry in the position of cartilaginous flaps in the region of the dome of the lower lateral cartilage. These abnormalities plus abnormal ridges or bossa can usually be corrected at the time of secondary surgery under local anesthesia.     

Biochemical characterization of detergent-resistant membranes: a systematic approach

Lateral segregation of cholesterol- and sphingomyelin-rich rafts and glycerophospholipid-containing non-raft microdomains has been proposed to play a role in a variety of biological processes. The most compelling evidence for membrane segregation is based on the observation that extraction with non-ionic detergents leads to solubilization of a subset of membrane components only. However, one decade later, a large body of inconsistent detergent-extraction data is threatening the very concept of membrane segregation. We have assessed the validity of the existing paradigms and we show the following. (i) The localization of a membrane component within a particular fraction of a sucrose gradient cannot be taken as a yardstick for its solubility: a variable localization of the DRMs (detergent-resistant membranes) in sucrose gradients is the result of complex associations between the membrane skeleton and the lipid bilayer. (ii) DRMs of variable composition can be generated by using a single detergent, the increasing concentration of which gradually extracts one protein/lipid after another. Therefore any extraction pattern obtained by a single concentration experiment is bound to be 'investigator-specific'. It follows that comparison of DRMs obtained by different detergents in a single concentration experiment is prone to misinterpretations. (iii) Depletion of cholesterol has a graded effect on membrane solubility. (iv) Differences in detergent solubility of the members of the annexin protein family arise from their association with chemically different membrane compartments; however, these cannot be attributed to the 'brick-like' raft-building blocks of fixed size and chemical composition. Our findings demonstrate a need for critical re-evaluation of the accumulated detergent-extraction data.     

Antigen-antibody dissociation in Alzheimer disease: a novel approach to diagnosis

With the ever-increasing population of aged individuals at risk of developing Alzheimer's disease (AD), there is an urgent need for a sensitive, specific, non-invasive, and diagnostic standard. The majority of efforts have focused on auto-antibodies against amyloid-β (Aβ) protein, both as a potential treatment, and a reliable biomarker of AD pathology. Naturally occurring antibodies against Aβ are found in the CSF and plasma of patients with AD as well as healthy control subjects. To date, differences between diseased and control subjects have been highly variable. However, some of the antibody will be in preformed antigen–antibody complexes and the extent and nature of such complexes may provide a potential explanation for the variable results reported in human studies. Thus, measuring total amounts of antigen or antibody following unmasking is critical. Here, using a technique for dissociating antibody–antigen complexes, we found significant differences in serum antibodies to Aβ between AD and aged-matched control subjects. While the current study demonstrates the relevance of measuring total antibody, bound and unbound, against Aβ in AD, this technique may be applicable to diseases such as acquired immune deficiency syndrome and hepatitis B where determination of antigen and antibody levels are important for disease diagnosis and assessing disease progression.     

The effects of care bundles on patient outcomes: a systematic review and meta-analysis

Background

Care bundles are a set of three to five evidence-informed practices performed collectively and reliably to improve the quality of care. Care bundles are used widely across healthcare settings with the aim of preventing and managing different health conditions. This is the first systematic review designed to determine the effects of care bundles on patient outcomes and the behaviour of healthcare workers in relation to fidelity with care bundles.

Methods

This systematic review is reported in line with the PRISMA statement for reporting systematic reviews and meta-analyses. A total of 5796 abstracts were retrieved through a systematic search for articles published between January 1, 2001, to February 4, 2017, in the Cochrane Central Register for Controlled Trials, MEDLINE, EMBASE, British Nursing Index, CINAHL, PsychInfo, British Library, Conference Proceeding Citation Index, OpenGrey trials (including cluster-randomised trials) and non-randomised studies (comprising controlled before-after studies, interrupted time series, cohort studies) of care bundles for any health condition and any healthcare settings were considered. Following the removal of duplicated studies, two reviewers independently screen 3134 records. Three authors performed data extraction independently. We compared the care bundles with usual care to evaluate the effects of care bundles on the risk of negative patient outcomes. Random-effect models were used to further explore the effects of subgroups.

Results

In total, 37 studies (6 randomised trials, 31 controlled before-after studies) were eligible for inclusion. The effect of care bundles on patient outcomes is uncertain. For randomised trial data, the pooled relative risk of negative effects between care bundle and control groups was 0.97 [95% CI 0.71 to 1.34; 2049 participants]. The relative risk of negative patient outcomes from controlled before-after studies favoured the care bundle treated groups (0.66 [95% CI 0.59 to 0.75; 119,178 participants]). However, using GRADE, we assessed the certainty of all of the evidence to be very low (downgraded for risk of bias, inconsistency, indirectness).

Conclusions

Very low quality evidence from controlled before-after studies suggests that care bundles may reduce the risk of negative outcomes when compared with usual care. By contrast, the better quality evidence from six randomised trials is more uncertain.

Trial registration

PROSPERO, CRD42016033175

     

Blood glucose monitors: a laboratory and patient assessment.

The four blood glucose monitors available in the United Kingdom were compared by asking the opinions of 24 patients who used each monitor for two weeks, by correlating their blood glucose results with those obtained in the laboratory, and by having the monitors examined by an electronics engineer. Of the battery-operated monitors, patients preferred the Hypocount (15) to the Glucochek (9). The mains-operated units were less popular, with little to choose between Eyetone and Reflomat. Under field conditions the blood glucose results obtained with the Glucochek correlated poorly with the standard reference method. In contrast the Hypocount, Eyetone, and Reflomat machines produced good correlations. Poor results with the Glucochek were mainly due to faulty timing systems. The patients'' preference for the Hypocount was supported by tests of performance under laboratory conditions and by the electronics engineer''s report.     

The laboratory diagnosis of campylobacteriosis today

Different conditions necessary for the successful isolation and cultivation of Campylobacter (culture media, inoculation techniques, gas mixtures, etc.) are described. Of these, the most effective conditions and methods, as well as those available for practical health service, have been determined. The main trends in further improvement of the laboratory diagnosis of Campylobacter infection is presented.     

From principles to practice: a spatial approach to systematic conservation planning in the deep sea

Increases in the demand and price for industrial metals, combined with advances in technological capabilities have now made deep-sea mining more feasible and economically viable. In order to balance economic interests with the conservation of abyssal plain ecosystems, it is becoming increasingly important to develop a systematic approach to spatial management and zoning of the deep sea. Here, we describe an expert-driven systematic conservation planning process applied to inform science-based recommendations to the International Seabed Authority for a system of deep-sea marine protected areas (MPAs) to safeguard biodiversity and ecosystem function in an abyssal Pacific region targeted for nodule mining (e.g. the Clarion–Clipperton fracture zone, CCZ). Our use of geospatial analysis and expert opinion in forming the recommendations allowed us to stratify the proposed network by biophysical gradients, maximize the number of biologically unique seamounts within each subregion, and minimize socioeconomic impacts. The resulting proposal for an MPA network (nine replicate 400 × 400 km MPAs) covers 24% (1 440 000 km²) of the total CCZ planning region and serves as example of swift and pre-emptive conservation planning across an unprecedented area in the deep sea. As pressure from resource extraction increases in the future, the scientific guiding principles outlined in this research can serve as a basis for collaborative international approaches to ocean management.     

A biometric approach to laboratory rodent identification

Individual identification of laboratory rodents typically involves invasive methods, such as tattoos, ear clips, and implanted transponders. Beyond the ethical dilemmas they may present, these methods may cause pain or distress that confounds research results. The authors describe a prototype device for biometric identification of laboratory rodents that would allow researchers to identify rodents without the complications of other methods. The device, which uses the rodent's ear blood vessel pattern as the identifier, is fast, automatic, noninvasive, and painless.     

Depression screening and patient outcomes in cancer: a systematic review

Background

Several practice guidelines recommend screening for depression in cancer care, but no systematic reviews have examined whether there is evidence that depression screening benefits cancer patients. The objective was to evaluate the potential benefits of depression screening in cancer patients by assessing the (1) accuracy of depression screening tools; (2) effectiveness of depression treatment; and (3) effect of depression screening, either alone or in the context of comprehensive depression care, on depression outcomes.

Methods

Data sources were CINAHL, Cochrane, EMBASE, ISI, MEDLINE, PsycINFO and SCOPUS databases through January 24, 2011; manual journal searches; reference lists; citation tracking; trial registry reviews. Articles on cancer patients were included if they (1) compared a depression screening instrument to a valid criterion for major depressive disorder (MDD); (2) compared depression treatment with placebo or usual care in a randomized controlled trial (RCT); (3) assessed the effect of screening on depression outcomes in a RCT.

Results

There were 19 studies of screening accuracy, 1 MDD treatment RCT, but no RCTs that investigated effects of screening on depression outcomes. Screening accuracy studies generally had small sample sizes (median = 17 depression cases) and used exploratory methods to set sample-specific cutoff scores that varied substantially across studies. A nurse-delivered intervention for MDD reduced depressive symptoms moderately (effect size = 0.37).

Conclusions

The one treatment study reviewed reported modest improvement in depressive symptoms, but no evidence was found on whether or not depression screening in cancer patients, either alone or in the context of optimal depression care, improves depression outcomes compared to usual care. Depression screening in cancer should be evaluated in a RCT in which all patients identified as depressed, either through screening or via physician recognition and referral in a control group, have access to comprehensive depression care.