Parecoxib: a shift in pain management?

Parecoxib (Dynastat) is a parenteral cyclooxygenase-2 inhibitor available in Europe. Clinical trials have reported a benefit in reducing pain following oral, orthopedic, gynecologic and cardiac surgeries. The overall efficacy was dose-related and similar to ketorolac (Toradol). Several trials reported an opioid-sparing effect with parecoxib. No trials have reported significantly fewer opioid-related gastrointestinal side effects (e.g., nausea, vomiting, constipation and intestinal ileus) when opioids were administered with parecoxib versus placebo. Gastroduodenal ulcers, gastric ulcers and duodenal ulcers or erosions were less common with parecoxib than ketorolac. Parecoxib does not affect platelet aggregation, interfere with the antiplatelet affect of aspirin, affect prothrombin and partial thromboplastin time or platelet counts when administered with heparin.

First measurement of the form factors in the decays D0 → ρ- e+ ν(e) and D+ → ρ0 e+ ν(e)

The beauty to up quark coupling constant |V(ub)| can be extracted from B → ρ e+ ν(e) combined with the form factors for D → K* e+ ν(e) and B → V ℓ+ ℓ- and D → ρ e+ ν(e). Using the entire CLEO-c ψ(3770) → DD event sample, corresponding to an integrated luminosity of 818  pb(-1) and approximately 5.4×10(6) DD events, we measure the form factors for the decays D0 → ρ- e+ ν(e) and D+ → ρ0 e+ ν(e) for the first time and the branching fractions with improved precision. A four-dimensional unbinned maximum likelihood fit determines the form factor ratios to be V(0)/A1(0)=1.48±0.15±0.05 and A2(0)/A1(0)=0.83±0.11±0.04. Assuming Cabibbo-Kobayashi-Maskawa unitarity, the known D meson lifetimes, and our measured branching fractions we obtain the form factor normalizations A1(0), A2(0), and V(0). We also present a measurement of the branching fraction for D+ → ω e+ ν(e) with improved precision.

Development and psychometric evaluation of an evidence-based practice questionnaire for a chiropractic curriculum

OBJECTIVE

The purposes of this study were to describe the questionnaire development process for evaluating elements of an evidence-based practice (EBP) curriculum in a chiropractic program and to report on initial reliability and validity testing for the EBP knowledge examination component of the questionnaire.

METHODS

The EBP knowledge test was evaluated with students enrolled in a doctor of chiropractic program in the University of Western States. The initial version was tested with a sample of 374 and a revised version with a sample of 196 students. Item performance and reliability were assessed using item difficulty, item discrimination, and internal consistency. An expert panel assessed face and content validity.

RESULTS

The first version of the knowledge examination demonstrated a low internal consistency (Kuder-Richardson 20 = 0.55), and a few items had poor item difficulty and discrimination. This resulted in an expansion in the number of items from 20 to 40, as well as a revision of the poorly performing items from the initial version. The Kuder-Richardson 20 of the second version was 0.68; 32 items had item difficulties of between 0.20 and 0.80, and 26 items had item discrimination values of 0.20 or greater.

CONCLUSIONS

A questionnaire for evaluating a revised EBP-integrated curriculum was developed and evaluated. Psychometric testing of the EBP knowledge component provided some initial evidence for acceptable reliability and validity.

Observation of the h(c)(1P) Using e+ e- collisions above the DD threshold

Using 586  pb(-1) of e+ e- collision data at E(c.m.) = 4170  MeV, produced at the Cornell Electron Storage Ring collider and collected with the CLEO-c detector, we observe the process e+ e- → π+ π- h(c)(1P). We measure its cross section to be 15.6±2.3±1.9±3.0  pb, where the third error is due to the external uncertainty on the branching fraction of ψ(2S) → π0 h(c)(1P), which we use for normalization. We also find evidence for e+ e- → ηh(c)(1P) at 4170 MeV at the 3σ level and see hints of a rise in the e+ e- → π+ π- h(c)(1P) cross section at 4260 MeV.

Severe orthostatic hypotension in a diabetic patient may not be due to diabetic autonomic neuropathy

This lesson describes an unusual case of a man who was recently diagnosed with type 1 diabetes and who presented with severe orthostatic hypotension. As his diabetes was recent in onset, well controlled, and he had no other signs of microvascular disease, other causes of orthostatic hypotension were sought. His serum and cerebrospinal fluid were strongly positive for Borrelia burgdorferi IgG, suggesting a diagnosis of Lyme neuroborreliosis. Autonomic instability in Lyme, while rare, has been previously reported.

Levetiracetam for the management of levodopa-induced dyskinesias in Parkinson's disease

The efficacy and safety of levetiracetam (LEV), administered for management of levodopa-induced dyskinesias (LID) in Parkinson's disease (PD), was examined using a multicenter, double-blind, placebo-controlled, parallel groups, crossover trial. Because of having a period effect, data after crossover point was excluded from analysis. Levodopa-treated PD participants with LID (n = 38) received LEV 500 mg/day, were assessed, titrated to 1,000 mg/day and reassessed, before and after crossover. The placebo group followed the same routine. Primary efficacy was defined from percent change in "On with LID" time from patient diaries. Secondary efficacy assessment used "On without LID," "Off" time, unified PD rating scale (UPDRS), clinical global impression (CGI), and Goetz dyskinesia scale after levodopa challenge. Safety measures were also performed. On with LID time decreased 37 minutes (95% confidence interval [CI] 0.59, 7.15; P = 0.02) at 500 mg/day, 7.85% 75 minutes (95% CI 3.3, 12.4; P = 0.002) at 1,000 mg/day. On without LID time increased by 46 minutes (95% CI -1.55, -0.03; P = 0.04) at 500 mg/day and 55 minutes (95% CI -10.39, -1.14; P = 0.018) at 1,000 mg/day. UPDRS 32 showed decreased dyskinesia duration mean change 0.35 (95% CI 0.09, 0.5; P = 0.009) at 1,000 mg/day. CGI showed LID decreased by 0.7 (95% CI 0.21, 1.18; P = 0.006) at 1,000 mg/day. Patient diaries and UPDRS show no increase in Off time. This exploratory trial provides evidence that LEV in 1,000 mg/day, slowly titrated, could be useful in improving LID as was assessed with patient diaries, UPDRS, and CGI scales, safely, with minimal side effects.

Metabolism of Common Substrates by the Reiter Strain of Treponema pallidum

The utilization of glucose, amino acids, fatty acids, bicarbonate, purines, and pyrimidines by the Reiter treponeme was studied by using carbon 14-labeled substrates. The distribution of carbon from the substrates into various cell components was determined. Radioactivity from labeled bicarbonate in the cellular protein was restricted to aspartic acid. The Reiter treponeme is capable of synthesizing glycine, serine, alanine, aspartic acid, glutamic acid, proline, and possibly ornithine. Phenylalanine, arginine, lysine, leucine, isoleucine, valine, threonine, and histidine do not appear to be synthesized by this treponeme. The Reiter treponeme cannot synthesize fatty acids, and thymine is not incorporated. Glucose is a major carbon and energy source. Arginine, histidine, serine, threonine, and glutamic acid are degraded by the Reiter treponeme and may serve as energy sources. It was calculated that exogenously supplied amino acids contribute 41 to 54% of the cellular material; fatty acids, 18%; and glucose, 28 to 43%.

Physical examination and self-reported pain outcomes from a randomized trial on chronic cervicogenic headache

OBJECTIVE

Objective clinical measures for use as surrogate markers of cervicogenic headache (CGH) pain have not been established. In this analysis, we investigate relationships between objective physical examination (PE) measures with self-reported CGH outcomes.

METHODS

This is an exploratory analysis of data generated by attention control PE from an open-label randomized clinical trial. Of 80 subjects, 40 were randomized to 8 treatments (spinal manipulative therapy or light massage control) and 8 PE over 8 weeks. The remaining subjects received no PE. Physical examination included motion palpation of the cervical and upper thoracic regions, active cervical range of motion (ROM) and associated pain, and algometric pain threshold evaluated over articular pillars. Self-reported outcomes included CGH and neck pain and disability, number of CGH headaches, and related disability days. Associations between PE and self-reported outcomes were evaluated using generalized linear models, adjusting for sociodemographic differences and study group.

RESULTS

At baseline, number of CGH and disability days were strongly associated with cervical active ROM (P < .001 to .037). Neck pain and disability were strongly associated with ROM-elicited pain (P < .001 to .035) but not later in the study. After the final treatment, pain thresholds were strongly associated with week 12 neck pain and disability and CGH disability and disability days (P < or = .001 to .048).

CONCLUSIONS

Cervical ROM was most associated with the baseline headache experience. However, 4 weeks after treatment, algometric pain thresholds were most associated. No one PE measure remained associated with the self-reported headache outcomes over time.

Neurosurgery as a first foundation year training post

Neurosurgery has traditionally been regarded as a surgical speciality unsuitable for doctors in their first clinical year after graduation with limited prior experience of such patients. However, the advent of UK Modernising Medical Careers' Foundation Year training and the European Working Time Directive mean neurosurgery is now available as a clinical placement for newly qualified doctors. The authors describe the development of such a post, first implemented in August 2008, which both facilitated safe and effective care of neurosurgical patients and enabled the trainee to achieve many of the goals of UK Foundation training. Suggestions are made for the implementation of further similar posts.

Haemangioblastoma: a rare cause of a cerebellar mass in the elderly

In the elderly, cerebellar lesions are commonly metastatic tumours with poor prognosis. We describe two octogenarians who presented with obstructive hydrocephalus, secondary to posterior fossa tumours that, on computed tomography, were thought to be cerebellar metastases. Both lesions were excised and the histology proved them to be cerebellar haemangioblastomas, primary benign tumours of the posterior fossa, which are rare in the elderly.

Observation of D+ --> etae + nue

Using a 281 pb-1 data sample collected at the psi(3770) resonance with the CLEO-c detector at the Cornell Electron Storage Ring, we report the first observation of D+ --> etae + nue. We also set upper limits for D+ --> eta'e + nue and D + --> varphie + nue that are about 2 orders of magnitude more restrictive than those obtained by previous experiments.

Observation of eta' decays to pi+pi-pi0 and pi+pi-e+e-

Using psi(2S)-->pi;{+}pi;{-}J/psi, J/psi-->gammaeta;{'} events acquired with the CLEO-c detector at the CESR e;{+}e;{-} collider, we make the first observations of the decays eta;{'}-->pi;{+}pi;{-}pi;{0} and eta;{'}-->pi;{+}pi;{-}e;{+}e;{-}, measuring absolute branching fractions (37_{-9};{+11}+/-4)x10;{-4} and (25_{-9};{+12}+/-5)x10;{-4}, respectively. For eta;{'}-->pi;{+}pi;{-}pi;{0}, this result probes the mechanism of isospin violation and the roles of pi;{0}/eta/eta;{'}-mixing and final state rescattering in strong decays. We also set upper limits on branching fractions for eta;{'} decays to pi;{+}pi;{-}micro;{+}micro;{-}, 2(pi;{+}pi;{-}), pi;{+}pi;{-}2pi;{0}, 2(pi;{+}pi;{-})pi;{0}, 3(pi;{+}pi;{-}), and invisible final states.