Increase in weight induced by muraglitazar, a dual PPARalpha/gamma agonist, in db/db mice: adipogenesis/or oedema?

BACKGROUND AND PURPOSE

Muraglitazar, a dual PPARalpha/gamma agonist, caused a robust increase in body weight in db/db mice. The purpose of the study was to see if this increase in weight was due to oedema and/or adipogenesis.

EXPERIMENTAL APPROACH

The affinity of muraglitazar at PPARalpha/gamma receptors was characterized using transactivation assays. Pre-adipocyte differentiation, expression of genes for adipogenesis (aP2), fatty acid oxidation (ACO) and sodium reabsorption (ENaCgamma and Na+, K+-ATPase); haemodilution parameters and serum electrolytes were measured to delineate the role of muraglitazar in causing weight gain vis a vis rosiglitazone.

KEY RESULTS

Treatment with muraglitazar (10 mg kg(-1)) for 14 days significantly reduced plasma glucose and triglycerides. Reduction in plasma glucose was significantly greater than after similar treatment with rosiglitazone (10 mg kg(-1)). A marked increase in weight was also observed with muraglitazar that was significantly greater than with rosiglitazone. Muraglitazar increased aP2 mRNA and caused adipocyte differentiation in 3T3-L1 cells similar to rosiglitazone. It also caused a marked increase in ACO mRNA in the liver of the treated mice. Expression of mRNA for ENaCgamma and Na+, K+-ATPase in kidneys was up-regulated after either treatment. Increased serum electrolytes and decreased RBC count, haemoglobin and haematocrit were observed with both muraglitazar and rosiglitazone.

CONCLUSIONS AND IMPLICATIONS

Although muraglitazar has a better glucose lowering profile, it also has a greater potential for weight gain than rosiglitazone. In conclusion, muraglitazar causes both robust adipogenesis and oedema in a 14-day treatment of db/db mice as observed in humans.

Relevance of rodent models of intravenous MDMA self-administration to human MDMA consumption patterns

RATIONALE

Despite decades of research specifying harmful effects produced by 3,4-methylenedioxymethamphetamine (MDMA; a principal component of 'ecstasy' pills), young people (and adults) continue to use it. In an attempt to model human MDMA consumption patterns, preclinical investigators have sought to establish reliable patterns of intravenous MDMA self-administration in rodents.

OBJECTIVE

The objective of this report is to offer a critical review of published data (including our own novel findings) that reveal MDMA self-administration in rodents.

RESULTS

The data indicate that MDMA serves as a reinforcer in rodents, though the responses are not similar to those previously reported for psychostimulants (i.e., cocaine). Important differences between rodent models and human use patterns include frequency of dosing and dosage exposure, routes of administration, tolerance that develops to MDMA after repeated exposure, polydrug use in humans but not by rodents, limits on the repertoire of behaviors that can be exhibited by rodents undergoing IV self-administration procedures, and the question of neurotoxicity as it relates to models of self-administration.

CONCLUSIONS

While MDMA is not as potent a reinforcer as other drugs of abuse, the fact remains that young people and adults continue to use the drug, and therefore, additional research is needed to determine why drugs with low reinforcing effects continue to be abused.

Perioperative Erythropoietin Efficacy in Renal Transplantation

BACKGROUND

There is no consensus on the usage of erythropoietin in the immediate postoperative period to prevent anemia and delayed graft function.

METHODS

A retrospective case note audit of renal transplants included hemoglobin (Hb) and serum creatinine (Scr) values preoperatively as well as at days 7, 14, 30, 60, and 90. Patients were categorized as those receiving erythropoietin during the first 6 months posttransplant (Epo+ve) and those not receiving any erythropoietin (Epo-ve).

RESULTS

Hb decreased from 12.4 +/- 1.6 g/L preoperatively to 9.5 +/- 1.5 g/L at day 14 and then rose to 10.5 +/- 1.6 g/L at 1 month and 12.4 +/- 1.7 g/L at 3 months. There was no difference in absolute Hb values in three transplant groups. Scr decreased from 597.0 +/- 200.1 mmol/L preoperatively to 254.1 +/- 196.9 mmol/L at day 14 and continued to fall to 163.8 +/- 98.9 mmol/L at 1 month and 147.8 +/- 66.9 mmol/L at 3 months. There was no difference in absolute Hb values and delayed graft function in the three transplant groups.

CONCLUSION

With respect to anemia and delayed graft function, the use of erythropoietin in the first 3 months had little impact. We suggest that such an expensive medication may be safely omitted in the immediate postoperative period.

Reconstruction of iliac crest with rib to prevent donor site complications: A prospective study of 26 cases

BACKGROUND

The tricortical bone graft from the iliac crest are used to reconstruct the post corpectomy spinal defects. The donor iliac area defect is large and may give rise to pain at donor site, instability of pelvis, fracture of ilium, donor site muscle herniation or abdominal content herniation. Rib removed during thoracotomy was used by us to reconstruct the iliac crest defect.

MATERIALS AND METHODS

Twenty-six patients who underwent thoracotomy for dorsal spine corpectomy or curettage for various spinal pathologies from June 2002 to May 2004 were included in the study. After adequate decompression the spine was reconstructed by tricortical bone graft from iliac crest and reconstruction of the iliac crest was done with the rib removed for exposure during thoracotomy.

RESULTS

The mean follow up was 15 months. All patients had good graft incorporation which was evaluated on the basis of local tenderness and radiographs. One patient had graft displacement.

CONCLUSION

The reconstruction of iliac crest by rib is a simple and effective procedure to prevent donor site complications.

Treatment of Postcraniotomy Tension Pneumocephalus via Endoscopic Closure of the Nasofrontal Recess

Tension pneumocephalus can be a life-threatening complication following cranial surgery. We report a 14-year-old female who developed tension pneumocephalus following her most recent external approach to a recurrent pilocytic astrocytoma of the skull base and clivus. Because the risk of devascularization of the recently placed bone grafts was a concern, an endoscopic approach was chosen instead of a cramotomy. Endoseopic decompression was accomplished by opening the anterior ethmoid and frontal recess air cells after performing an uncinectomy. The nasofrontal recess areas were then packed from below with grafts of muscle and fascia lata. Follow-up magnetic resonance imaging (MRI) at three and eight months showed complete resolution of the intracranial air. At two-year follow-up, the patient is still asymptomatic. This case report presents treatment of tension pneumocephalus through endoscopic decompression and closure of the nasofrontal recess as a viable option if significant risks are associated with craniotomy and the status of the mucosa of the nasal frontal recess is known.

Pain relief following breast augmentation surgery: a comparison between incisional patient-controlled regional analgesia and traditional oral analgesia

BACKGROUND AND OBJECTIVES

Postoperative pain is a common problem following ambulatory breast augmentation surgery. This study was performed to compare standard of care (oral analgesics) with patient-controlled incisional regional analgesia (PCRA) for postoperative pain management at home for 48 h. A second aim was to compare the analgesic efficacy of ropivacaine 0.25% vs. 0.5%.

METHODS

Surgery was performed under local anaesthesia and monitored anesthesia care. Sixty adults (ASA 1-2) were randomized to one of two groups. Patients in Group PCRA could self-administer ropivacaine 0.25% 10 mL in the left breast and ropivacaine 0.5% in the right breast. Patients in Group T (tablets) received our standard of care treatment, i.e. oral paracetamol 1 g four times a day and oral ibuprofen 500 mg three times a day. Parameters measured included: analgesic requirements (in post-anesthesia care unit, PACU and post-discharge), pain intensity (visual analogue scale), patient satisfaction, global analgesia, side-effects, and quality of recovery.

RESULTS

Pain scores were significantly lower in Group PCRA compared to Group T at all time periods (P < 0.05). No differences were found in pain scores between the right and left breasts. Significantly more patients in Group T requested analgesics in the recovery unit (27 vs. 7; P = 0.001) and also at home (20 vs. 11; P < 0.02). More patients in the tablet group had nausea and vomiting (10 vs. 3; P < 0.05). Global analgesia on day 2 was significantly better in PCRA group; however, patient satisfaction was similar in both groups. More patients in the tablet group had sleep disturbance and woke up at night due to pain.

CONCLUSIONS

Pain relief after ambulatory breast augmentation is superior with incisional PCRA when compared to oral analgesic combination of paracetamol and ibuprofen. Incisional PCRA was associated with minimal side-effects and less sleep disturbance. There was no difference in the analgesic efficacy between ropivacaine 0.25% and 0.5%.

Serial quantitative diffusion tensor MRI of the term neonates with hypoxic-ischemic encephalopathy (HIE)

AIM

To determine the altered pattern of fractional anisotropy (FA) and mean diffusivity (MD) change in brain parenchyma in serially studied neonates with mild or moderate hypoxic ischemic injury (HIE) within 7 days after birth and again at the age of three months.

METHODS

Serial diffusion tensor imaging (DTI) was performed at two-time points in term neonates with mild (n = 7) and moderate (n = 10) HIE and age/sex-matched controls (n = 7). Neurodevelopmental outcome was assessed at the time of the 2nd study.

RESULTS

On comparing FA and MD changes over time using two-way analysis of variance between neonates with HIE and controls, we observed significant differences in age-related FA increase (p < 0.05) in anterior limb of internal capsule and periventricular white matter of parietal, occipital, and temporal lobes. Significant differences in age-related MD decrease (p < 0.05) was observed in the caudate nuclei, and temporal white matter among these groups. Significant positive correlation was observed between neurodevelopmental outcome and FA.

CONCLUSION

The results suggest that abnormal FA and MD values help in early and more accurate assessment of microstructural damage in HIE that may have predictive value for long-term neurofunctional outcome in these neonates.

Evidence-based review of treatment and follow up of pediatric patients with differentiated thyroid carcinoma

Childhood onset differentiated thyroid cancer (DTC) is distinct from the adult-onset disease being more aggressive at the time of initial evaluation with a higher risk category for disease recurrence; however, it is ultimately less lethal. International groups have outlined consensus statements detailing follow up and management guidelines for adult DTC, but since disease progression and markers are significantly different in childhood DTC compared to adults, management protocols may differ. Unfortunately, there is no consensus regarding the means of follow up, timing and management strategy regarding pediatric DTC. We performed an evidence-based review of DTC in children targeted to address the following questions: What is the most appropriate initial treatment? What is the goal of thyroid hormone replacement management? What is the approach to follow-up of childhood DTC? and, How should tumor recurrence/persistence be assessed and treated? We conducted a literature search using PubMed, Cochrane databases, guidelines from various international groups, and studies pertaining to pediatric DTC management and outcome in order to answer these questions. We suggest a pre-set algorithm and approach for the management of children with DTC according to our review.

Lower energy levels adequate for effective transcleral diode laser cyclophotocoagulation in Asian eyes with refractory glaucoma

PURPOSE

To study the treatment parameters for diode laser cyclophotocoagulation (DLCP) in Asian Indian eyes using laser energy titrated to clinical response.

METHODS

This prospective interventional longitudinal study included 66 eyes of 66 patients with varied aetiology refractory glaucoma, no previous cycloablation, and minimum 1 year follow-up. DLCP was performed using the Oculight Diode laser system IRIS( Medical Instruments Inc., CA, USA). Power used per spot was titrated according to the audible 'pops' indicating tissue microexplosion. The mean laser energy delivered, post-laser intraocular pressure (IOP) reduction, complications, and requirement of re-treatment in various subgroups were analyzed. Differences in energy delivered in each subgroup were assessed by analysis of variance with post hocBonferroni corrections. Linear regression analysis was used to identify possible predictive factors for failure of cyclodiode therapy.

RESULTS

The mean total energy delivered per eye was 87.80+/-31.8 J (range 105.4+/-36.8 J in neovascular glaucoma (NVG) to 61.5+/-8.8 J in uveitic glaucoma (P=0.134)). Mean pre treatment IOP was 36.4+/-10.7 mmHg, which reduced to 19.4+/-9.8 mmHg (P<0.001) at 1 week, and 15.6+/-6.6 mmHg at 1 year. At 1 year, 58 of 66 patients had IOP<22.0 mmHg (response rate 87.8%), and six patients had hypotony (success rate 78.8%). The uveitic glaucoma group had 100% success rate. NVG group required maximum re-treatments.

CONCLUSIONS

DLCP with a titrated energy protocol needs resulted in lower energy in Asian Indian eyes compared to that reported in literature, and different energy levels are needed for different diseases. 'Standard treatment parameters' for DLCP may be inappropriate for all diseases and all races.

Raman scattering from high-frequency phonons in supported n-graphene layer films

Results of room-temperature Raman scattering studies of ultrathin graphitic films supported on Si (100)/SiO2 substrates are reported. The results are significantly different from those known for graphite. Spectra were collected using 514.5 nm radiation on films containing from n = 1 to 20 graphene layers, as determined by atomic force microscopy. Both the first- and second-order Raman spectra show unique signatures of the number of layers in the film. The nGL film analogue of the Raman G-band in graphite exhibits a Lorentzian line shape whose center frequency shifts linearly relative to graphite as approximately 1/n (for n = 1 omegaG approximately 1587 cm-1). Three weak bands, identified with disorder-induced first-order scattering, are observed at approximately 1350, 1450, and 1500 cm-1. The approximately 1500 cm-1 band is weak but relatively sharp and exhibits an interesting n-dependence. In general, the intensity of these D-bands decreases dramatically with increasing n. Three second-order bands are also observed (approximately 2450, approximately 2700, and 3248 cm-1). They are analogues to those observed in graphite. However, the approximately 2700 cm-1 band exhibits an interesting and dramatic change of shape with n. Interestingly, for n < 5 this second-order band is more intense than the G-band.

Expression of CD34 as a novel marker for glioneuronal lesions associated with chronic intractable epilepsy

The spectrum of glioneuronal lesions underlying intractable epilepsies includes malformative pathologies like focal cortical dysplasia (FCD); and neoplastic lesions like gangliogliomas (GG) and dysembryoplastic neuroepithelial tumours (DNT). These may occur either singly or as dual lesions, having simultaneous presence of both elements. Currently, the relationship between the malformative and neoplastic glioneuronal lesions is poorly understood. Recently, CD34, a stem cell marker transiently expressed during early neurulation, has been identified in these tumours. This study was undertaken to (i) evaluate the role of CD34 as a diagnostic marker for glioneuronal lesions of epilepsy, namely, GG, DNT and FCD, and (ii) attempt to define the relationship among these lesions, using CD34 as a marker. Tissues resected from 47 patients with intractable epilepsy due to glioneuronal lesions (GG, FCD, DNT) were studied. These were evaluated for CD34 expression, using immunohistochemistry. Dysplastic or atypically differentiated neural precursors which could not be identified on routine haematoxylin and eosin (H&E) staining were highlighted by CD34 immunostaining. The pattern of immunostaining was diffuse in GGs, unlike FCDs, wherein cells were present singly or in small clusters. However, cases of DNT and control tissue were largely CD34-immunonegative. Based on these findings, we propose a possible common origin of GG and FCD, from a bipotent precursor that undergoes abnormal glioneuronal development, while DNTs possibly have a different origin. The CD34-immunoreactive cells represent dysplastic or undifferentiated neural precursors, which may signify a valuable marker for the diagnostic evaluation of neoplastic and/or malformative pathologies in patients with intractable epilepsy.

The role of psychosocial factors in predicting the onset of chronic widespread pain: results from a prospective population-based study

OBJECTIVE

Chronic widespread pain (CWP) is strongly associated with psychosocial distress both in a clinical setting and in the community. The aim of this study was to determine the contribution of measures of psychosocial distress, health-seeking behaviour, sleep problems and traumatic life events to the development of new cases of CWP in the community.

METHODS

In a population-based prospective study, 3171 adults aged 25-65 yrs free of CWP were followed-up 15 months later to identify those with new CWP. Baseline data were available on their scores from a number of psychological scales including Illness Attitude Scales (IAS), Somatic Symptom Checklist (SSC), Hospital Anxiety & Depression Scale, Sleep Problems Scale, and Life Events Inventory.

RESULTS

324 subjects [10%, 95% confidence interval (CI) 9.2, 11.3] developed new CWP at follow-up. After adjustment for age and sex, three factors independently predicted the development of CWP: scoring three or more on the SSC [odds ratio (OR) 1.8, 95% CI 1.1, 3.1], scoring eight or more on the Illness Behaviour subscale of the IAS (OR 3.3, 95% CI 2.3, 4.8), and nine or more on the Sleep Problem Scale (OR 2.7, 95% CI 1.6, 3.2). Subjects exposed to all three factors were at 12 times the odds of new CWP than those with low scores on all scales.

CONCLUSION

Subjects are at substantial increased odds of developing CWP if they display features of somatization, health-seeking behaviour and poor sleep. Psychosocial distress has a strong aetiological influence on CWP.

Chronic hepatitis C virus infection in renal transplant: treatment and outcome

BACKGROUND

Chronic hepatitis C virus (HCV) infection is a common cause of liver disease in post-renal transplant period and causes poor patient and graft survival. We analyzed the effects of antiviral therapy using ribavirin monotherapy or ribavirin in combination with interferon (IFN)-alpha in our kidney transplant recipients with chronic hepatitis C.

METHODS

Total of 14 patients received antiviral therapy, all of whom had stable graft function, raised aminotransferases and positive HCV viremia at the start of treatment. Eight patients received ribavirin alone for a period of six months to two yr, in doses of 400-800 mg daily. Five patients received IFN-alpha therapy for a period of two months to 1.5 yr, in doses of 1.5 million units daily or three million units thrice weekly with ribavirin. One patient received pegylated IFN 50 microg once weekly in combination with ribavirin. The response was seen in terms of biochemical and virological improvement at the end of study period.

RESULTS

In patients treated with ribavirin alone (n = 8), mean alanine aminotransferase (ALT) levels before and after treatment were significantly different (198.4 +/- 147.6 and 104.8 +/- 66.5 IU/L respectively; p < 0.05). ALT levels normalized completely in three patients at the end of treatment, improved in three patients and deteriorated in two. Only in one of eight patients on ribavirin alone, HCV-RNA became negative after six months of treatment while in the rest (n = 7) HCV-RNA continued to be positive. In subjects on IFN plus ribavirin (n = 6), the mean ALT levels decreased significantly (from 280.2 +/- 114.9 IU/L at baseline to 71 +/- 49 IU/L at end of therapy; p < 0.05). Two patients had sustained remission (33.3%) on IFN plus ribavirin (persistently negative HCV-RNA), two patients relapsed after initial remission and in two patients treatment was stopped after two months because of graft dysfunction. Totally four patients developed graft dysfunction at some time during the course of IFN therapy (66.6%), but it was discontinued in only two (33.3%). All patients regained normal creatinine levels after discontinuation of IFN, although one patient developed chronic allograft nephropathy as shown by kidney biopsy. Four patients in IFN group developed leucopenia. Two patients developed severe anemia one of whom required blood transfusion and one developed severe flu-like syndrome requiring stoppage of therapy.

CONCLUSION

Ribavirin monotherapy in renal transplant recipients with chronic hepatitis C infection results in good biochemical response but is not associated with virological clearance. IFN in combination with ribavirin is effective in two-thirds of patients after a minimum therapy of six months, but it is poorly tolerated, results in graft dysfunction in significant number of patients, and relapse can occur after stopping treatment.

Umbilical CSF fistula: a rare complication of ventriculoperitoneal shunt

An umbilical CSF fistula following a ventriculoperitoneal shunt is an extremely rare complication. We report a 28-year-old man who presented with leak of clear fluid from the umbilicus, one month after a ventriculo-peritoneal shunt revision. Shuntogram revealed communication between umbilicus and abdominal end of the catheter. He was managed successfully with shunt exteriorization, antimeningitic treatment, and later shunt re-insertion.

Salicylate for the treatment of Kawasaki disease in children

BACKGROUND

Kawasaki disease is the most common cause of acquired heart disease in children in developed countries. The coronary arteries supplying the heart can be damaged in Kawasaki disease. The principal advantage of timely diagnosis is the potential to prevent this complication with early treatment. Salicylate (acetyl salicylate acid (ASA), aspirin) and intravenous immunoglobulin (IVIG) are widely used for this purpose. Salicylate is largely otherwise avoided in children because of concerns about serious side effects, particularly the risk of Reyes syndrome.

OBJECTIVES

The objective of this review was to evaluate the effectiveness of salicylate in treating and preventing cardiac consequences of Kawasaki disease in children.

SEARCH STRATEGY

The Cochrane Peripheral Vascular Disease Group searched their trials register (last searched July 2006) and the Cochrane Central Register of Controlled Trials (CENTRAL) (last searched Issue 3, 2006). We searched MEDLINE (January 1966 to July 2006), EMBASE (January 1980 to July 2006), and CINAHL (1982 to July 2006), and reference list of articles. In addition we contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of salicylate to treat Kawasaki disease in children were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. Study authors were contacted for additional information.

MAIN RESULTS

We found one trial involving 102 children which was described as randomised, but it was not possible to confirm the method of treatment allocation. A second comparative study, possibly with a randomised treatment allocation, was also identified. The one randomised trial reported no association between the addition of ASA to IVIG treatment on the rate of coronary artery abnormalities at follow up, but with wide confidence limits. The second, possibly randomised trial did demonstrate a reduction in duration of fever with high dose ASA compared to low dose ASA, but was insufficiently powered to establish the effect on coronary artery abnormalities at follow up.

AUTHORS' CONCLUSIONS

Until good quality RCTs are carried out, there is insufficient evidence to indicate whether children with Kawasaki disease should continue to receive salicylate as part of their treatment regimen.

Development of computational models for the purpose of conducting individual livestock and premises traceback investigations utilizing National Animal Identification System-compliant data

Many of the efforts surrounding the development of the National Animal Identification System have encompassed the identification of livestock production and handling premises as well as individuals or herds of animals, whereas little effort has been directed toward the ultimate goal of animal traceback within 48 h. A mock data set representative of the Colorado cattle population was created for modeling of cattle traceability. Using this data set, algorithms were developed to complete rapid and accurate traceback and traceforward of animals or premises or both. On July 19, 2005, the Colorado Department of Public Health and Environment, in conjunction with the Colorado Department of Agriculture, conducted a test exercise pertaining to homeland security. The exercise team randomly identified animal number 926,583 (of the 2 million total animals) as a potentially infected animal of interest and requested a traceback of this animal. Traceback was accomplished in 215 s, and 540 primary coresident animals were identified. However, due to animal movements, the number of coresidents (animals exposed, directly or indirectly, to the animal of interest) expanded with coresidency level (level 1 = direct contact; level 2 = direct contact with an animal that had direct contact with the animal of interest; level 3 = direct contact with an animal that had contact with an animal that had direct contact with the animal of interest, etc.) to more than 1.2 million coresidents at level 4, and more than 90% of all animals identified as a coresident at some level. In addition to the coresidency results, the premises containing the coresidents were identified and sorted by the number of coresidents. Because of animal movement, all 19,391 premises included in the data set had coresidents at some level. This exercise demonstrated the capability of the developed algorithms to complete rapid traceback and the complexity of the resulting animal traceback output.

Forward neutral pion production in p + p and d + Au collisions at square root sNN=200 GeV

Measurements of the production of forward pi0 mesons from p + p and d + Au collisions at square root sNN=200 GeV are reported. The p + p yield generally agrees with next-to-leading order perturbative QCD calculations. The d + Au yield per binary collision is suppressed as eta increases, decreasing to approximately 30% of the p + p yield at eta =4.00, well below shadowing expectations. Exploratory measurements of azimuthal correlations of the forward pi0 with charged hadrons at eta approximately 0 show a recoil peak in p + p that is suppressed in d + Au at low pion energy. These observations are qualitatively consistent with a saturation picture of the low-x gluon structure of heavy nuclei.

A knee-sparing distal femoral endoprosthesis using hydroxyapatite-coated extracortical plates

We used a knee-sparing distal femoral endoprosthesis in young patients with malignant bone tumours of the distal femur in whom it was possible to resect the tumour and to preserve the distal femoral condyles. The proximal shaft of the endoprosthesis had a coated hydroxyapatite collar, while the distal end had hydroxyapatite-coated extracortical plates to secure it to the small residual femoral condylar fragment. We reviewed the preliminary results of this endoprosthesis in eight patients with primary bone tumours of the distal femur. Their mean age at surgery was 17.years (14 to 21). The mean follow-up was 24 months (20 to 31). At final follow-up the mean flexion at the knee was 102° (20° to 120°) and the mean Musculoskeletal Tumour Society score was 80% (57% to 96.7%).

There was excellent osteointegration at the prosthesis-proximal bone interface with formation of new bone around the hydroxyapatite collar. The prosthesis allowed preservation of the knee and achieved a good functional result. Formation of new bone and remodelling at the interface make the implant more secure. Further follow-up is required to determine the long-term structural integrity of the prosthesis.

Pressure pain thresholds and tender point counts as predictors of new chronic widespread pain in somatising subjects

BACKGROUND

Tender points are a general measure of distress both in the community and in clinic subjects. It has been suggested that multiple tender points should be regarded as the early stages of somatisation of distress. Similarly, recent evidence suggests that chronic widespread pain (CWP) is one manifestation of the somatisation of distress.

OBJECTIVE

Given that a high tender point count and CWP are clinical hallmarks of the fibromyalgia syndrome, it was hypothesised that in somatising subjects, a high tender point count or a low pain threshold would predict the development of CWP in the future.

METHODS

In this population-based prospective study, 245 adults aged 25-65 years, free of CWP, were identified on the basis of a detailed questionnaire on pain and a psychosocial questionnaire comprising the Somatic Symptom Checklist and the Illness Behaviour subscale of the Illness Attitude Scales. These subjects took part in a pain threshold examination with a Fischer pressure algometer. Tender point counts were computed by including all areas with a pain threshold<4 kg/cm2. Individuals were followed up at 15 months, at which time 231 (93% of subjects still living at their baseline address) provided data on pain status, using the same instruments.

RESULTS

At follow-up, 26 (11%) subjects developed new CWP. Although subjects with a low baseline pain threshold were not at increased risk of developing symptoms, a high tender point count, adjusted for age, sex, baseline pain status and other confounding factors, predicted the development of new CWP.

CONCLUSION

Subjects free of CWP are at an increased risk of its development if they have a high tender point count. However, a low-pressure pain threshold does not predict the onset of symptoms. Data from this population-based prospective study suggest that a low pain threshold in subjects with CWP is likely to be a secondary phenomenon as a result of pain or associated distress rather than the antecedent of symptoms.

Subcortical white matter abnormalities related to drug resistance in Wilson disease

Wilson disease (WD) produces typical lesions in the brain, which can aid in diagnosis and therapy. The authors present a drug-resistant WD case with atypical cerebral lesions with marked involvement of white matter as visualized on MRI scans. The diagnosis was confirmed by identification of mutations in the ATP7B gene. The case demonstrates an uncommon pathology-related cerebral copper accumulation and emphasizes the importance of genetic screening in the diagnosis of WD.

Amyand's hernia: a report of 18 consecutive patients over a 15-year period

AIM

The presence of a vermiform appendix in an inguinal hernia sac is termed Amyand's hernia. It may present as a tender inguinal or inguino-scrotal swelling and is often misdiagnosed as an incarcerated or strangulated hernia. The purpose of this study was to review the management of Amyand's hernia at a single institution since 1991.

MATERIAL AND METHODS

A retrospective analysis was undertaken of 18 consecutive patients with an Amyand's hernia operated upon at our institution from 1991 to 2005. Patients' demographics, treatment and postoperative outcome were analysed.

RESULTS

There were 17 men and one woman. Their median age was 42 years. None of the patients was diagnosed preoperatively. The commonest presenting symptom was painful inguinal or inguino-scrotal swelling (83%). All patients, therefore, underwent emergency surgery with a presumptive diagnosis of either incarcerated or strangulated inguinal hernia. Operative findings included 11 normal appendices, four inflamed appendices and three perforated appendices in the inguinal hernial sac. Patients with a normal appendix (n = 11) had a mesh hernia repair without an appendicectomy. The rest of the patients (n = 7) with an abnormal appendix underwent emergency open appendicectomy followed by Bassini's sutured hernia repair. One patient died in the postoperative period of pneumonia. Only one recurrent hernia has been detected, with a median follow-up time of 6.4 years.

CONCLUSION

The inflammatory status of the appendix determines the type of hernia repair and the surgical approach. Incidental appendicectomy in the case of a normal appendix is not favoured.