Diabetes Mellitus is known to have many complications and one of the most distressing is diabetic... more Diabetes Mellitus is known to have many complications and one of the most distressing is diabetic foot ulcer which affects 15% of people with diabetes. It puts enormous financial burden on the patient and the health care services, even though it is preventable. Diabetic foot ulcer is characterized by a classical triad of neuropathy, ischemia, and infection. Each of these has a multifactorial aetiopathogenesis. These factors are compounded by mechanical stress created by foot deformities. The most commonly used classification systems are the Wagner-Ulcer Classification system and the University of Texas Wound Classification. These classifications help to predict the outcome of this condition. Prevention of this condition is paramount to prevent long term morbidity and sometimes mortality. This can be achieved by patient self-awareness and emphasis on regular foot examinations during follow-up. Care of the diabetic foot should be multidisciplinary. Debridement, dressings and offloading are the pillars of local management. Simultaneous glycemic and infection control is also essential. Amputations are usually the treatment of last resort but occasionally can be considered early to allow for faster mobilization and rehabilitation. Causative factors like peripheral vasculopathy and neuropathy must also be appropriately treated.
Chronic wounds are very distressing for the patient and a difficult problem to manage. Many treat... more Chronic wounds are very distressing for the patient and a difficult problem to manage. Many treatment modalities exist for this condition, making it difficult for the health care professionals to choose the appropriate treatment. This article deals mainly with the definition and local management of these wounds, and has been subdivided into debridement techniques, techniques to stimulate the healing process and dressing methods available. A mention has been made of the recent advances in the management of these wounds.
Sickle cell disease is a group of disorders that affects haemoglobin, which causes distorted sick... more Sickle cell disease is a group of disorders that affects haemoglobin, which causes distorted sickle- or crescent-shaped red blood cells. It is characterized by anaemia, increased susceptibility to infections and episodes of pain. The disease is acquired by inheriting abnormal genes from both parents, the combination giving rise to different forms of the disease. Due to increased erythropoiesis in people with sickle cell disease, it is hypothesized that they are at an increased risk for folate deficiency. For this reason, children and adults with sickle cell disease, particularly those with sickle cell anaemia, commonly take 1 mg of folic acid orally every day on the premise that this will replace depleted folate stores and reduce the symptoms of anaemia. It is thus important to evaluate the role of folate supplementation in treating sickle cell disease. To analyse the efficacy and possible adverse effects of folate supplementation (folate occurring naturally in foods, provided as fortified foods or additional supplements such as tablets) in people with sickle cell disease. We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Haemoglobinopathies Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. We also conducted additional searches in both electronic databases and clinical trial registries.Date of last search: 07 December 2015. Randomised, placebo-controlled trials of folate supplementation for sickle cell disease. Four review authors assessed the eligibility and risk of bias of the included trials and extracted and analysed the data included in the review. We used the standard Cochrane-defined methodological procedures. One trial, undertaken in 1983, was eligible for inclusion in the review. This was a double-blind placebo-controlled quasi-randomised triaI of supplementation of folic acid in people with sickle cell disease. A total of 117 children with homozygous sickle cell (SS) disease aged six months to four years of age participated over a one-year period (analysis was restricted to 115 children).Serum folate measures, obtained after trial entry at six and 12 months, were available in 80 of 115 (70%) participants. There were significant differences between the folic acid and placebo groups with regards to serum folate values above 18 µg/l and values below 5 µg/l. In the folic acid group, values above 18 µg/l were observed in 33 of 41 (81 %) compared to six of 39 (15%) participants in the placebo (calcium lactate) group. Additionally, there were no participants in the folic acid group with serum folate levels below 5 µg/l, whereas in the placebo group, 15 of 39 (39%) participants had levels below this threshold. Haematological indices were measured in 100 of 115 (87%) participants at baseline and at one year. After adjusting for sex and age group, the investigators reported no significant differences between the trial groups with regards to total haemoglobin concentrations, either at baseline or at one year. It is important to note that none of the raw data for the outcomes listed above were available for analysis.The proportions of participants who experienced certain clinical events were analysed in all 115 participants, for which raw data were available. There were no statistically significant differences noted; however, the trial was not powered to investigate differences between the folic acid and placebo groups with regards to: minor infections, risk ratio 0.99 (95% confidence interval 0.85 to 1.15); major infections, risk ratio 0.89 (95% confidence interval 0.47 to 1.66); dactylitis, risk ratio 0.67 (95% confidence interval 0.35 to 1.27); acute splenic sequestration, risk ratio 1.07 (95% confidence interval 0.44 to 2.57); or episodes of pain, risk ratio 1.16 (95% confidence interval 0.70 to 1.92). However, the investigators reported a higher proportion of repeat dactylitis episodes in the placebo group, with two or more attacks occurring in 10 of 56 participants compared to two of 59 in the folic acid group (P < 0.05).Growth, determined by height-for-age and weight-for-age, as well as height and growth velocity, was measured in 103 of the 115 participants (90%), for which raw data were not available. The investigators reported no significant differences in growth between the two groups.The trial had a high risk of bias with regards to random sequence generation and incomplete outcome data. There was an unclear risk of bias in relation to allocation concealment, outcome assessment, and selective reporting. Finally, There was a low risk of bias with regards to blinding of participants and personnel. Overall the quality of the evidence in the review was low.There were no trials identified for other eligible comparisons, namely: folate supplementation…
It is known that simulation training is associated with stress for the trainees, at all levels of... more It is known that simulation training is associated with stress for the trainees, at all levels of trainee experience. We explored the factors which were perceived by the trainees to cause them the maximum stress related to their simulation experience and their temporal changes over three simulation sessions. Ninety-seven final year medical students were administered a Likert-type questionnaire on perceived stressors after trauma simulation training. These stressors were classified as intrapsychic (relating to internal feelings); interpersonal (relating to interaction with others) and interactive (related to interaction with the simulated patient). Non-parametric tests were used for statistical analysis. Death of the simulated patient scored highest of all stressors. When the median scores for intrapsychic, interpersonal or interactive items were plotted session-wise, three distinct types of graphs were obtained. Eight of 13 items had a decrease in perceived stress scores from the fi...
Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare, 2014
Arthroscopy uses a completely different skill set compared with open orthopedic surgery. Hitherto... more Arthroscopy uses a completely different skill set compared with open orthopedic surgery. Hitherto, arthroscopy had not been given enough emphasis in the core orthopedic curricula. Simulation has been seen as an excellent way to teach the skills required in arthroscopy. The simulators used for arthroscopy training can be broadly classified into physical simulators such as cadavers, animals, models and box trainers, virtual-reality simulators, and hybrid simulators that combine virtual-reality simulation with physical components that allow real tactile feedback. The advantages and disadvantages of each of these types have been described in this article. The factors that determine skill acquisition using these simulators have been highlighted. In conclusion, simulation seems to be a valuable tool for arthroscopy training, although further studies are needed to state whether this translates into better operative skill on real patients.
Charcot neuroarthropathy (CN) is a rare, progressive, deforming disease of bone and joints, espec... more Charcot neuroarthropathy (CN) is a rare, progressive, deforming disease of bone and joints, especially affecting the foot and ankle and leading to considerable morbidity. It can also affect other joints such as the wrist, knee, spine and shoulder. This disease, described originally in reference to syphilis, is now one of the most common associates of diabetes mellitus. As the number of diabetics increase, the incidence of CN is bound to rise. Faster initial diagnosis and prompt institution of treatment may help to reduce its sequelae. There should be a low threshold for ordering investigations to assist coming to this diagnosis. No single investigation is the gold standard. Recent studies on pathogenesis and development of newer investigation modalities have helped to clarify the mystery of its pathogenesis and of its diagnosis in the acute phase. Various complementary investigations together allow the correct diagnosis to be made. Osteomyelitis continues to be confused with acute CN. Hybrid positron emission tomography has shown some promise in differentiating these conditions. A multispecialty approach involving diabetologists, orthopaedists and podiatrists should be used to tackle this difficult problem. The aim of this article is to describe current knowledge about CN with particular reference to the status of diagnostic indicators and management options.
Injury of the ulnar collateral ligament (UCL) of thumb can be incapacitating if untreated or not ... more Injury of the ulnar collateral ligament (UCL) of thumb can be incapacitating if untreated or not treated properly. This injury is notorious for frequently being missed by inexperienced health care personnel in emergency departments. It has frequently been described in skiers, but also occurs in other sports such as rugby, soccer, handball, basketball, volleyball and even after a handshake. The UCL of the thumb acts as a primary restraint to valgus stress and is injured if hyperabduction and hyperextension forces are applied to the first metacarpophalangeal joint. The diagnosis is best established clinically, though MRI is the imaging modality of choice. Many treatment options exist, surgical treatment being offered depending on various factors, including timing of presentation (acute or chronic), grade (severity of injury), displacement (Stener lesion), location of tear (mid-substance or peripheral), associated or concomitant surrounding tissue injury (bone, volar plate, etc.), and patient-related factors (occupational demands, etc.). This review aims to identify the optimal diagnostic techniques and management options for UCL injury available thus far.
Diabetes Mellitus is known to have many complications and one of the most distressing is diabetic... more Diabetes Mellitus is known to have many complications and one of the most distressing is diabetic foot ulcer which affects 15% of people with diabetes. It puts enormous financial burden on the patient and the health care services, even though it is preventable. Diabetic foot ulcer is characterized by a classical triad of neuropathy, ischemia, and infection. Each of these has a multifactorial aetiopathogenesis. These factors are compounded by mechanical stress created by foot deformities. The most commonly used classification systems are the Wagner-Ulcer Classification system and the University of Texas Wound Classification. These classifications help to predict the outcome of this condition. Prevention of this condition is paramount to prevent long term morbidity and sometimes mortality. This can be achieved by patient self-awareness and emphasis on regular foot examinations during follow-up. Care of the diabetic foot should be multidisciplinary. Debridement, dressings and offloading are the pillars of local management. Simultaneous glycemic and infection control is also essential. Amputations are usually the treatment of last resort but occasionally can be considered early to allow for faster mobilization and rehabilitation. Causative factors like peripheral vasculopathy and neuropathy must also be appropriately treated.
Chronic wounds are very distressing for the patient and a difficult problem to manage. Many treat... more Chronic wounds are very distressing for the patient and a difficult problem to manage. Many treatment modalities exist for this condition, making it difficult for the health care professionals to choose the appropriate treatment. This article deals mainly with the definition and local management of these wounds, and has been subdivided into debridement techniques, techniques to stimulate the healing process and dressing methods available. A mention has been made of the recent advances in the management of these wounds.
Sickle cell disease is a group of disorders that affects haemoglobin, which causes distorted sick... more Sickle cell disease is a group of disorders that affects haemoglobin, which causes distorted sickle- or crescent-shaped red blood cells. It is characterized by anaemia, increased susceptibility to infections and episodes of pain. The disease is acquired by inheriting abnormal genes from both parents, the combination giving rise to different forms of the disease. Due to increased erythropoiesis in people with sickle cell disease, it is hypothesized that they are at an increased risk for folate deficiency. For this reason, children and adults with sickle cell disease, particularly those with sickle cell anaemia, commonly take 1 mg of folic acid orally every day on the premise that this will replace depleted folate stores and reduce the symptoms of anaemia. It is thus important to evaluate the role of folate supplementation in treating sickle cell disease. To analyse the efficacy and possible adverse effects of folate supplementation (folate occurring naturally in foods, provided as fortified foods or additional supplements such as tablets) in people with sickle cell disease. We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Haemoglobinopathies Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. We also conducted additional searches in both electronic databases and clinical trial registries.Date of last search: 07 December 2015. Randomised, placebo-controlled trials of folate supplementation for sickle cell disease. Four review authors assessed the eligibility and risk of bias of the included trials and extracted and analysed the data included in the review. We used the standard Cochrane-defined methodological procedures. One trial, undertaken in 1983, was eligible for inclusion in the review. This was a double-blind placebo-controlled quasi-randomised triaI of supplementation of folic acid in people with sickle cell disease. A total of 117 children with homozygous sickle cell (SS) disease aged six months to four years of age participated over a one-year period (analysis was restricted to 115 children).Serum folate measures, obtained after trial entry at six and 12 months, were available in 80 of 115 (70%) participants. There were significant differences between the folic acid and placebo groups with regards to serum folate values above 18 µg/l and values below 5 µg/l. In the folic acid group, values above 18 µg/l were observed in 33 of 41 (81 %) compared to six of 39 (15%) participants in the placebo (calcium lactate) group. Additionally, there were no participants in the folic acid group with serum folate levels below 5 µg/l, whereas in the placebo group, 15 of 39 (39%) participants had levels below this threshold. Haematological indices were measured in 100 of 115 (87%) participants at baseline and at one year. After adjusting for sex and age group, the investigators reported no significant differences between the trial groups with regards to total haemoglobin concentrations, either at baseline or at one year. It is important to note that none of the raw data for the outcomes listed above were available for analysis.The proportions of participants who experienced certain clinical events were analysed in all 115 participants, for which raw data were available. There were no statistically significant differences noted; however, the trial was not powered to investigate differences between the folic acid and placebo groups with regards to: minor infections, risk ratio 0.99 (95% confidence interval 0.85 to 1.15); major infections, risk ratio 0.89 (95% confidence interval 0.47 to 1.66); dactylitis, risk ratio 0.67 (95% confidence interval 0.35 to 1.27); acute splenic sequestration, risk ratio 1.07 (95% confidence interval 0.44 to 2.57); or episodes of pain, risk ratio 1.16 (95% confidence interval 0.70 to 1.92). However, the investigators reported a higher proportion of repeat dactylitis episodes in the placebo group, with two or more attacks occurring in 10 of 56 participants compared to two of 59 in the folic acid group (P < 0.05).Growth, determined by height-for-age and weight-for-age, as well as height and growth velocity, was measured in 103 of the 115 participants (90%), for which raw data were not available. The investigators reported no significant differences in growth between the two groups.The trial had a high risk of bias with regards to random sequence generation and incomplete outcome data. There was an unclear risk of bias in relation to allocation concealment, outcome assessment, and selective reporting. Finally, There was a low risk of bias with regards to blinding of participants and personnel. Overall the quality of the evidence in the review was low.There were no trials identified for other eligible comparisons, namely: folate supplementation…
It is known that simulation training is associated with stress for the trainees, at all levels of... more It is known that simulation training is associated with stress for the trainees, at all levels of trainee experience. We explored the factors which were perceived by the trainees to cause them the maximum stress related to their simulation experience and their temporal changes over three simulation sessions. Ninety-seven final year medical students were administered a Likert-type questionnaire on perceived stressors after trauma simulation training. These stressors were classified as intrapsychic (relating to internal feelings); interpersonal (relating to interaction with others) and interactive (related to interaction with the simulated patient). Non-parametric tests were used for statistical analysis. Death of the simulated patient scored highest of all stressors. When the median scores for intrapsychic, interpersonal or interactive items were plotted session-wise, three distinct types of graphs were obtained. Eight of 13 items had a decrease in perceived stress scores from the fi...
Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare, 2014
Arthroscopy uses a completely different skill set compared with open orthopedic surgery. Hitherto... more Arthroscopy uses a completely different skill set compared with open orthopedic surgery. Hitherto, arthroscopy had not been given enough emphasis in the core orthopedic curricula. Simulation has been seen as an excellent way to teach the skills required in arthroscopy. The simulators used for arthroscopy training can be broadly classified into physical simulators such as cadavers, animals, models and box trainers, virtual-reality simulators, and hybrid simulators that combine virtual-reality simulation with physical components that allow real tactile feedback. The advantages and disadvantages of each of these types have been described in this article. The factors that determine skill acquisition using these simulators have been highlighted. In conclusion, simulation seems to be a valuable tool for arthroscopy training, although further studies are needed to state whether this translates into better operative skill on real patients.
Charcot neuroarthropathy (CN) is a rare, progressive, deforming disease of bone and joints, espec... more Charcot neuroarthropathy (CN) is a rare, progressive, deforming disease of bone and joints, especially affecting the foot and ankle and leading to considerable morbidity. It can also affect other joints such as the wrist, knee, spine and shoulder. This disease, described originally in reference to syphilis, is now one of the most common associates of diabetes mellitus. As the number of diabetics increase, the incidence of CN is bound to rise. Faster initial diagnosis and prompt institution of treatment may help to reduce its sequelae. There should be a low threshold for ordering investigations to assist coming to this diagnosis. No single investigation is the gold standard. Recent studies on pathogenesis and development of newer investigation modalities have helped to clarify the mystery of its pathogenesis and of its diagnosis in the acute phase. Various complementary investigations together allow the correct diagnosis to be made. Osteomyelitis continues to be confused with acute CN. Hybrid positron emission tomography has shown some promise in differentiating these conditions. A multispecialty approach involving diabetologists, orthopaedists and podiatrists should be used to tackle this difficult problem. The aim of this article is to describe current knowledge about CN with particular reference to the status of diagnostic indicators and management options.
Injury of the ulnar collateral ligament (UCL) of thumb can be incapacitating if untreated or not ... more Injury of the ulnar collateral ligament (UCL) of thumb can be incapacitating if untreated or not treated properly. This injury is notorious for frequently being missed by inexperienced health care personnel in emergency departments. It has frequently been described in skiers, but also occurs in other sports such as rugby, soccer, handball, basketball, volleyball and even after a handshake. The UCL of the thumb acts as a primary restraint to valgus stress and is injured if hyperabduction and hyperextension forces are applied to the first metacarpophalangeal joint. The diagnosis is best established clinically, though MRI is the imaging modality of choice. Many treatment options exist, surgical treatment being offered depending on various factors, including timing of presentation (acute or chronic), grade (severity of injury), displacement (Stener lesion), location of tear (mid-substance or peripheral), associated or concomitant surrounding tissue injury (bone, volar plate, etc.), and patient-related factors (occupational demands, etc.). This review aims to identify the optimal diagnostic techniques and management options for UCL injury available thus far.
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