Silicone? Silica? Scleroderma. A need to look further?
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Breast Implants↗
Biomedical subjects
L March
Publications and source records attributed to L March.
Scleroderma and silicone gel breast prostheses--the Sydney study revisited.
BACKGROUND: Silicone augmentation mammoplasty has been postulated as a cause of environmentally-induced scleroderma. While representing a small proportion of all alleged causes of scleroderma, the issue has huge social, ethical and medicolegal ramifications. The hypothesis, however, has been recently questioned in results of comparative studies. We have previously reported no association between augmentation mammoplasty and scleroderma. However, all information was self-reported including augmentation mammoplasty status, and the prosthesis type was not identified. In addition, data were not available from untraceable cases. The current study addresses these issues. AIMS: To validate self-reported augmentation mammoplasty status, re-analyse rates of exposure to silicone gel breast prostheses in 556 scleroderma patients and 289 general practice controls and evaluate whether silicone gel breast prostheses are causally linked to scleroderma. METHODS: Study design-population-based case-control study; Cases-scleroderma patients resident in Sydney for at least six consecutive months between 1974-1988; Controls-patients from 29 randomly selected Sydney general practices, age- and gender-group-matched with cases. Validation of augmentation mammoplasty exposure was ascertained from the general medical practitioner of each interviewed case and control, or from the medical records of each deceased or untraceable case. Validation of the date of surgery and prosthesis type was from the relevant plastic surgeon. For each augmentation mammoplasty-positive case, validation of both the date and nature of the scleroderma onset was from the patient's medical records. Controls were given a "control date' for disease onset to adjust for duration of potential exposure. RESULTS: Validation of augmentation mammoplasty status was possible in 252 (87.2%) living controls, and 532 (95.7%) cases, of whom 287 were living. Self-reported augmentation mammoplasty status was highly reliable in living non-senile cases (kappa = 1), and living validated controls (kappa = 0.86). No association was identified between silicone gel augmentation mammoplasty and scleroderma with unadjusted odds ratios of 1.33 (95% CI: 0.26-6.71), and 1.00 (95% CI: 0.16-6.16) following adjustment for potential confounders of age, socioeconomic status and ethnicity. CONCLUSIONS: This validates the self-reported augmentation mammoplasty status previously reported and does not support the hypothesis that silicone gel augmentation mammoplasty is an environmental inducer of scleroderma in females.
Adult↗
Prevalence of domestic violence among patients attending a hospital emergency department.
A cross-sectional study was conducted to determine the prevalence of domestic violence victims among patients using emergency services at Sydney's Royal North Shore Hospital, in an affluent urban area of New South Wales. This study used a self-administered questionnaire (used in a similar study at the Royal Brisbane Hospital) to investigate the history of domestic violence among patients attending the emergency department during 64 randomly selected nursing shifts in October-November 1994. Adult domestic violence was reported by 19.3 per cent of females and 8.5 per cent of males, confirming the results of the Brisbane study. Evidence for underreporting was found: 4 per cent of females and 6.3 per cent of males who did not report being victims revealed experiences of abuse on nine measures of types of violence, including six taken from the Conflict Tactics Scale. Results supported evidence from other studies suggesting that experience of abuse as a child is a risk factor for being in abusive relationships as an adult. In the past, comparison of results has been limited because of variation in definitions of domestic violence; this has been overcome by intentional replication of the Brisbane study. The study was enhanced by inclusion of patients from non-English-speaking backgrounds and a cohort of parents of children attending. Similar prevalence estimates were found in these groups. Results have implications for the detection and treatment of victims of domestic violence across all strata of society and have potential to raise awareness and affect attitudes towards this significant community problem.
Adolescent↗
Can occupational therapy intervention play a part in maintaining independence and quality of life in older people? A randomised controlled trial.
The main objective of this study was to see if older people could maintain their quality of life and independence after their homes had been modified and they were using community services as recommended by an occupational therapist. There were 167 study participants aged 69 to 94 years from the Northern Sydney Area. After being assessed at home by an occupational therapist, 105 were randomly allocated to one of two groups, to either have or not have the occupational therapist's recommendations carried out. They were assessed again after six months. A third group did not require any intervention. This group was followed up by telephone and postal questionnaire at six months. The main outcome measures used were the Sickness Impact Profile, the Philadelphia Geriatric Center Morale Scale, the Life Satisfaction Index, assessment of Activities of Daily Living, the Health Assessment Questionnaire and change in residence. After six months there were no difference in outcomes among the three groups. Most study participants remained at a satisfactory level on each measure. Three people had died. One had moved to hostel care and one had moved to a nursing home. A further 14 from the group having no intervention had withdrawn from the study. A secondary objective of this study was to indicate the responsiveness of these outcome measures to change in the short term (over six months) in an elderly population. Twelve-month assessments are in progress and may indicate what to expect from these outcome measures in the medium term.
Activities of Daily Living↗
Ethics of n-of-1 trials.
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Clinical Trials as Topic↗
A retrospective cohort study of childhood immunisation status in northern Sydney.
A survey of their children's immunisation status was conducted among mothers of babies from a three-month birth cohort (January to March 1990) in the Northern Sydney Area in 1992. Its aims were to determine the uptake of immunisation in the area, to examine factors associated with immunisation status, and to assess agreement between the parent's reporting of this status and records of councils and general practitioners. Fifty-eight per cent of the questionnaires (1004) were returned. The full immunisation rate was 86 per cent, 14 per cent were partially immunised and only four children had received no immunisations. Between 74 per cent and 82 per cent of vaccinations were on time at two, four and six months; the rate dropped to 21 per cent at 12 months. Logistic regression analysis showed that premature babies are significantly more likely to be fully immunised, whereas children who have had a serious childhood illness, those with a single mother, or whose mothers are more highly educated, are significantly less likely to be fully immunised. There was 60 per cent agreement between the parent's report of immunisation status and a subgroup of 197 council and 82 general practitioner records. Although all councils in the Northern Sydney Area have a reminder system, most immunisations were found to be done in general practices (64 per cent), where reminder systems are not common.
Child, Preschool↗
Health status instruments / utilities.
Rheumatologists and other interested professionals at the OMERACT II conference formed small groups to discuss whether it was sensible to use a generic health status instrument in musculoskeletal disease trials. These instruments promise the possibility of comparison of health status between disease states. However, data is lacking on validity of the current generation of instruments to support their use. Participants had little personal experience with these instruments. After inspection, many voiced strong concerns over comprehensiveness and responsiveness. Many dimensions of health relevant for patients with this group of diseases were felt to be underrepresented. The dimension of adverse effects was universally absent, although this is more a problem of state of the art in trial methodology than a problem of these measures. Although there is little data, the small number of response categories in the dimensions covered, plus the lack of comprehensiveness, make it likely that responsiveness will be low. Further research, especially the adoption of one or more generic measures alongside specific measures, both in trials and in observational studies, is necessary to validate and improve the current generic measures. Until that time, valid conclusions and health policy regarding musculoskeletal diseases cannot be based on generic measures of health status.
Health Status↗
n of 1 trials comparing a non-steroidal anti-inflammatory drug with paracetamol in osteoarthritis.
OBJECTIVE: To evaluate the efficacy of paracetamol and a non-steroidal anti-inflammatory drug for symptom relief in osteoarthritis. DESIGN: Double blind, randomised, controlled trials in individual patients (n of 1 trials). Three treatment cycles with two weeks' each of paracetamol (1 g twice daily) and diclofenac (50 mg twice daily) prepared in identical gelatin capsules. SETTING: General practices in metropolitan Sydney, Australia. SUBJECTS: 25 patients (median age 64 years) with pain of osteoarthritis (median duration of disease eight years) considered by their general practitioners to require regular treatment. 20 were already taking non-steroidal anti-inflammatory drugs. MAIN OUTCOME MEASURES: Diary of pain and stiffness, function, and side effects. RESULTS: 15 patients completed the study, five withdrew early but had made a therapeutic decision, and five dropped out very early. Results from 20 patients were analysed. Several patterns of response evolved. Eight of the 20 patients found no clear difference, symptoms being adequately controlled by paracetamol; five indicated a clear preference for the non-steroidal anti-inflammatory drug; two showed control of symptoms after their initial two weeks of the non-steroidal anti-inflammatory drug which continued throughout subsequent treatment changes; in five the non-steroidal anti-inflammatory drug may have been better but neither agent gave satisfactory control. After three months nine of the 20 patients had adequate symptom control with paracetamol alone. CONCLUSIONS: Of 1 studies--that is, randomised trials in individual patients--are clinically useful in deciding treatment in heterogeneous conditions which require long term symptomatic relief. In osteoarthritis many patients currently receiving or being considered for non-steroidal anti-inflammatory drugs may achieve adequate control with paracetamol.
Acetaminophen↗
Immunisation practices of general practitioners in metropolitan Sydney.
An anonymous postal survey of all known general practitioners in the Northern Sydney Health Area (N = 987) examined the provision of immunisation services in general practice. Questions were asked about knowledge of storage of vaccines, the ages of patients administered measles-mumps-rubella vaccine, the use of reminder systems for subsequent vaccinations and whether maternal and family health was discussed at immunisation visits. There were 394 (40 per cent) respondents. Only 30 per cent used temperature monitors in their vaccine refrigerators, and 26 per cent correctly identified the period after opening that Sabin may be used (eight hours). Forty-one percent correctly injected infants in the anterolateral aspect of the thigh and 40 per cent administered measles-mumps-rubella vaccine by the recommended age of 12 months. Forty-one percent of respondents always used visits for immunisation to discuss other issues of maternal and child health and 16 per cent used reminder systems for follow-up. Sixty-six per cent of general practitioners stated that they were more likely to review the immunisation status of adolescents routinely, compared to 55 per cent who reviewed adults and 44 per cent who reviewed senior citizens. Routine review of all three groups was carried out by 43 per cent. These results must be interpreted with caution because of low response rates, and cannot necessarily be generalised to all general practitioners providing immunisation services. Nevertheless, important deficiencies in knowledge and practice of immunisation have been identified.
Adult↗
Joint hyperlaxity: is there a case for screening?
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Humans↗
Tarsal tunnel syndrome and "burning feet".
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Biomechanical Phenomena↗
Failure of Klebsiella pneumoniae antibodies to cross-react with peripheral blood mononuclear cells from patients with ankylosing spondylitis.
Cross-reactivity between antibodies to 2 strains of Klebsiella pneumoniae (K43 and F77) and the peripheral blood lymphocytes of patients with ankylosing spondylitis (AS) was examined in 3 separate antibody binding and cytotoxicity assays. Using K pneumoniae antisera in a chromium release cytotoxicity assay, we found no difference in the reactions of cells from AS patients and those from control subjects. This result contrasts with the results of previous studies. Similarly, using an enzyme-linked immunosorbent assay, we detected no significant increase in antibody binding to peripheral blood mononuclear cells (PBMC) in HLA-B27 positive patients with AS. Low levels of antibody binding were detected by a fluoresceinated antibody binding assay; however, normal rabbit serum, which was used as a control, was shown to have a binding affinity for PBMC that was significantly greater than that of specific K pneumoniae antisera. The results of our present study do not support the concept of a specific cross-reactivity between antibodies to K pneumoniae and the PBMC of patients with AS who are HLA-B27 positive.
Adult↗
Benign joint hypermobility with neuropathy: documentation and mechanism of tarsal tunnel syndrome.
Eleven consecutive patients with tarsal tunnel syndrome were reviewed. All had pes planus, 8 had calcaneal valgus hindfoot, and generalized benign joint hypermobility syndrome was evident in 9. Detailed enquiry was necessary to identify apparently trivial precipitating events. In 6 patients there was superimposed secondary reflex sympathetic dystrophy which tended to obscure symptoms of the causative tarsal tunnel syndrome. Wider recognition of this cause-effect mechanism and early management with orthotic footwear and intrinsic foot muscle exercises may obviate the need for surgical intervention in many cases.
Exercise Therapy↗
Streptococcus group G septic polyarthritis.
A case of streptococcus group G polyarthritis has been identified from blood and synovial fluid cultures and was sensitive to penicillin G. The clinical tendency to polyarticular infection by this organism and its discordant response to the antibiotics indicated by in vitro studies are discussed.
Arthritis, Infectious↗
Etodolac, aspirin, and gastrointestinal microbleeding.
The effects of etodolac, a new nonsteroidal anti-inflammatory drug, on gastrointestinal (GI) microbleeding were quantitatively assessed in two studies in healthy adult men. The first was a two-group, open-label, parallel comparison of etodolac, 600 mg/day, aspirin, 2600 mg/day, and placebo in 20 subjects; the second was a four-group, double-blind, parallel comparison of etodolac, 600, 800, and 1200 mg/day, aspirin, 2600 mg/day, and placebo in 41 subjects. Subjects in both studies received a single-blind placebo on days 1 through 7, either etodolac or aspirin on days 8 through 14, and a single-blind placebo on days 15 through 19. GI blood loss (milliliters per day) was estimated by the radiolabeled (51Cr) erythrocyte method and was based on daily radioactivity counts of stool specimens and regression-estimated daily blood radioactivity. Etodolac, 600 mg/day, induced no significant GI blood loss at any time during the experiments, nor was there significant blood loss after 800 and 1200 mg/day in experiment 2. Blood loss was noted after aspirin in both.
Acetates↗
The neck-tongue syndrome: occurrence with cervical arthritis as well as normals.
The syndrome of unilateral occipital pain with simultaneous ipsilateral tongue dysesthesia on sharp turning of the neck, recently reported in 4 otherwise normal young adults, is now described in 3 additional instances; one without disease and one each having degenerative spondylosis and ankylosing spondylitis. The originally proposed anatomical explanation for the syndrome, interconnections between the lingual and hypoglossal nerves and the C2, C3 nerve roots, is consistent with this syndrome complex arising from arthritis affecting the C1-C2-C3 articulation.
Adult↗
The painful shoulder.
Although a common symptom, shoulder pain is not always due to intrinsic disorders of the joint; it can be referred from lesions of the cervical spine or from visceral disease.
Adult↗
Human pharmacologic trials with iohexol.
Injections of iohexol in two series of volunteers, 20 in 1980 and 16 in 1982 are briefly reported. Intravenous injections of iohexol in doses from 125 to 1500 mg I/kg body weight were well tolerated. Iohexol was completely excreted in unchanged form. The results indicate that iohexol may safely be used in clinical trials.
Adult↗