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Periorbital hemorrhage is a potentially sight threatening surgical complication. The effect of new oral anticoagulants (NOACs) on hemorrhagic events after periorbital surgery has not been investigated. We describe four cases of severe delayed postoperative hemorrhage associated with NOACs, in addition to three cases in patients on traditional antithrombotic agents. Time of delayed hemorrhage ranged from postoperative day 2 to 6. Six patients required surgical intervention to achieve control of bleeding, and two patients required transfusion of blood products. Risk factors and management of this rare complication are discussed.

Patients with syphilis can present with optic disc oedema (ODE) without visual compromise, which has been primarily attributed to papilloedema from raised intracranial pressure or optic perineuritis from optic nerve sheath inflammation. We report four cases of ODE in the setting of syphilis with preserved visual function, normal intracranial pressure, and no enhancement of the optic nerve or sheath on magnetic resonance imaging. We propose the term “incipient syphilitic papillitis” for cases presenting with ODE, preserved vision and absence of optic nerve sheath enhancement, which is likely a more common presentation than syphilitic optic perineuritis.

LGBTQ youth frequently experience bullying and harassment in the school setting. Teachers are in an ideal position to prevent student harassment, yet most don’t have adequate training. This study e...

Background: This study aims to compare the prevalence of dry eye symptoms following blepharoptosis surgery and surgical outcomes in patients ≥80 years old when compared to younger, case-matched con...

Histone deacetylase (Hdac3) inhibitors are emerging therapies for many diseases including cancers and neurological disorders; however, these drugs are teratogens to the developing skeleton. Hdac3 is essential for proper endochondral ossification as its deletion in chondrocytes increases cytokine signaling and the expression of matrix remodeling enzymes. Here we explored the mechanism by which Hdac3 controls matrix metalloproteinase (Mmp)-13 expression in chondrocytes. In Hdac3-depleted chondrocytes, extracellular signal-regulated kinase (Erk)1/2 as well as its downstream substrate, Runx2, were hyperphosphorylated as a result of decreased expression and activity of the Erk1/2 specific phosphatase, Dusp6. Erk1/2 kinase inhibitors and Dusp6 adenoviruses reduced Mmp13 expression and partially rescued matrix production in Hdac3-deficient chondrocytes. Postnatal chondrocyte-specific deletion of Hdac3 with an inducible Col2a1-Cre caused premature production of pErk1/2 and Mmp13 in the growth plate. Thus, Hdac3 controls the temporal and spatial expression of tissue-remodeling genes in chondrocytes to ensure proper endochondral ossification during development.

Mental disorders are disabling and economically costly health conditions. Given limited resources, mental health systems in low- and middle-income countries (LMICs) tend to focus on patients with the most severe conditions, for whom treatment usually relies on use of psychoactive medications; however, inconsistent patterns of use can be ineffective, wasteful, and potentially harmful. Therefore, a greater understanding of prescription practices and medication availability in LMIC is needed. We estimated associations between prescription practices and hospitals and medication availability for patients diagnosed with schizophrenia or delusional disorders (n = 7,296) and patients diagnosed with epilepsy (n = 1,807), the two most common mental and neurological disorders seen at Ghana’s psychiatric hospitals. Among patients with a primary diagnosis of schizophrenia or delusional disorders, 43% were prescribed an anti-psychotic or combination of anti-psychotics and anti-cholinergics. Among patients with...

Government-community partnerships are central to developing effective, sustainable models of primary health care in low-income countries; however, evidence about the nature of partnerships lacks the perspective of community members. Our objective was to characterise community perspectives regarding the respective roles and responsibilities of government and the community in efforts to strengthen primary health care in low-income settings. We conducted a qualitative study using focus groups (n=14 groups in each of seven primary health care units in Amhara and Oromia, Ethiopia, with a total of 140 participants) in the context of the Ethiopian Millennium Rural Initiative. Results indicated that community members defined important roles and responsibilities for both communities and governments. Community roles included promoting recommended health behaviours; influencing social norms regarding health; and contributing resources as feasible. Government roles included implementing oversight of health centres; providing human resources, infrastructure, equipment, medication and supplies; and demonstrating support for community health workers, who are seen as central to the rural health system. Renewed efforts in health system strengthening highlight the importance of community participation in initiatives to improve primary health care in rural settings. Community perspectives provide critical insights to defining, implementing and sustaining partnerships in these settings.

While nearly three-quarters of cancer mortalities occur in low- and middle-income countries, we know little about the factors contributing to patient delays in seeking care for cancer. Our study employs a multifactorial approach by examining three key areas: patient socio-demographic factors, structural factors of health-care access and cancer patients' beliefs about their illness and cancer in general as potential determinants of their delay in seeking care in Thailand. We conducted a cross-sectional study using a systematic sample of 264 patients with cancer treated during 2006-2007 at Prince Maha Vajiralongkorn Cancer Centre, a hospital of the National Cancer Institute of Thailand. We defined patient delay as when a patient waited more than 3 months after symptom onset to seek medical care. We used bivariate analysis and multivariate logistic regression to examine unadjusted and adjusted associations of patient delays in seeking care with: patient socio-demographic factors, structural factors of health-care access and patients' beliefs about their illness in particular and about cancer in general. We also obtained patient self-reports about their reasons for delaying care. In multivariate analysis, only patient-belief factors were significantly associated with delay. Patients who believed that the primary causes of cancer were non-medical (vs. medical) were more likely to delay seeking care (adjusted odds ratio (OR)=4.37, 95% confidence interval (CI)=2.27-8.67). Patients who believed that cancer was probably curable or was curable (vs. incurable) were significantly less likely to delay seeking care (adjusted OR=0.2, 95% CI=0.08-0.56; adjusted OR=0.18, 95% CI=0.07-0.49, respectively). Patient socio-demographic factors and structural factors of health-care access were not significantly associated (p>0.05). Our findings suggest that interventions to reduce delays in care seeking should address patient beliefs regarding cancer in order to effectively mitigate barriers to access.

In recent years, dozens of countries have introduced accreditation and other quality improvement initiatives. A great deal of information is available regarding best practices in high- and middle-income countries; however, little is available to guide developing nations seeking to introduce an accreditation programme. This paper describes the outputs and lessons learned in the first year of establishing an accreditation programme in Liberia, a developing nation in West Africa that in 2003 emerged from a brutal 14-year civil war. The Liberian experience of developing and implementing a government-sponsored, widespread accreditation programme may provide insight to other low-income and post-conflict countries seeking a way to drive rapid, system-wide reform in the health system, even with limited infrastructure and extremely challenging conditions.

Background To better understand what matters to African American elders who are faced with issues of death, dying, and end-of-life care, a qualitative study was conducted to elicit their perspective. Methods Focus groups were convened across the state of Connecticut. A total of 196 individuals participated in the 90-minute interview sessions. Using an interview guide, a trained moderator conducted the racially homogeneous discussion groups. Transcriptions of the group narratives with 22 older African Americans were coded to identify themes. Data were organized and analyzed using NUD-IST 4 and constant comparative method of qualitative data analysis. Results Five major themes emerged from the focus group data on older African Americans: (1) spirituality, (2) burden on family, (3) trust, (4) health insurance coverage, and (5) cultural concerns. Conclusion Recommendations are made for outreach education, involvement of informal helpers, and a level of acceptability in practice for diverse care needs.

Previous studies indicate that African American elders are less likely to use institutional long-term care than whites. The purpose of this study was to examine whether an individual's intention to use home care may mediate the effect of race on the actual use of home care. This study was a prospective, longitudinal study of 208 Connecticut residents over age 65. Findings indicated that African American elders' use of home care is associated with their intention to use services, while white elders' use of home care is associated with need. This suggests that the factors that predict long-term care use differ for African American and white elders. Therefore, the traditional models of health services use may need to be expanded in order to explain patterns of use among nonwhite populations.

Reflective practice in counselling and psychotherapy, by S. Bager-Charleson, Exeter, Learning Matters, 2010, 170 pp., 2010, £18.00, ISBN 9781844453603 Reviewed by Elizabeth F. Bradley, Careers Advi...