Significant analgesic effects of one session of postoperative left prefrontal cortex repetitive transcranial magnetic stimulation: a replication study

BACKGROUND

In a recent preliminary trial in 20 patients after gastric bypass surgery, 20 minutes of repetitive transcranial magnetic stimulation (TMS) over the left prefrontal cortex was associated with a 40% reduction in postoperative patient-controlled morphine use. As is the case with all novel scientific findings, and especially those that might have an impact on clinical practice, replicability is paramount. This study sought to test this finding for replication and to more accurately estimate the effect size of this brief intervention on postoperative morphine use and postoperative pain and mood ratings.

METHODS

Twenty participants who underwent gastric bypass surgery completed this replication and extension study. Beck Depression Inventory and Center for Epidemiological Studies Depression scale scores were collected before surgery and at the time of discharge from the hospital. Immediately after surgery, participants were randomly assigned to receive 20 minutes of real or sham repetitive TMS (rTMS) (10 Hz, 10 seconds-ON, 20 seconds-OFF for a total of 4000 pulses). Patient-controlled morphine pump usage was tracked throughout each participant's postoperative hospital stay. In addition, pain and mood ratings were collected via visual analogue scales twice per day.

RESULTS

Findings from the original postoperative TMS trial were replicated, as cumulative morphine usage curves were significantly steeper among patients receiving sham TMS, and participants receiving real TMS had used 35% less morphine at the time of discharge than participants receiving sham TMS. At the time of discharge, subjects who had received real TMS had used 42.50 mg of morphine, whereas subjects receiving sham TMS had used an average of 64.88 mg. When the data from the original preliminary trial were combined with the data from this replication trial, a significant difference in cumulative morphine usage was observed between subjects receiving real and sham TMS. Overall, participants who received real TMS used 36% less morphine and had significantly lower ratings of postoperative pain-on-average, and pain-at-its-worst than participants receiving sham. In addition, participants who received real TMS rated their mood-at-its-worst as significantly better than participants receiving sham. The effect of a single 20-minute session of TMS on postoperative pain and morphine use appears to be large (Cohen's d = 0.70) and clinically meaningful. Lastly, cross-lag correlational analyses indicate that improvements in mood follow improvements in pain by approximately 12 hours, supporting the notion that postoperative analgesic TMS effects are not driven by antidepressant effects.

CONCLUSIONS

Although more research is needed to verify these observed effects independently, findings from the original postoperative TMS trial were replicated. TMS may have the potential to significantly improve current standards of postoperative care among gastric bypass patients, and further studies may be warranted on other surgical populations. Future investigations should use methodology that permits more definitive conclusions about causal effects of TMS on postoperative pain (for example, double-blinding, sham stimulation that is matched with real TMS with respect to scalp discomfort).

A rapid and efficient method for DNA extraction from paraffin wax embedded tissue for PCR amplification

DNA from archival, formaldehyde fixed, paraffin wax embedded human tissue, suitable for amplification by the polymerase chain reaction (PCR), was obtained using a microwave method based on the capture of DNA by magnetic beads. Fragments of the alpha-1-antitrypsin gene (AAT) and the apolipoprotein E gene (APOE) were amplified successfully from human liver and brain tissue, respectively. This procedure provides a more rapid, simple and efficient method for reproducibly obtaining DNA from preserved tissue that has been kept in storage for up to 30 years.

Not just for trauma patients: damage control laparotomy in pancreatic surgery

BACKGROUND

Damage control laparotomy (DCL) has been a major advance in modern trauma care. The principles of damage control which include truncation of operation to correct acidosis, hypothermia, and coagulopathy with subsequent planned definitive repair are applicable in managing patients undergoing abdominal operations. In order to define indications, technique, and outcome, we undertook a retrospective review and analysis of pancreatic surgery patients in whom DCL was utilized.

METHODS

In a cohort of 835 patients who underwent elective pancreatic operations at the Medical University of South Carolina from 2001 to 2007, eight patients were identified who required DCL. Under Institutional Review Board approval, records were reviewed to define intraoperative blood loss, acidosis, hypothermia, coagulopathy, operative techniques, timing of definitive operation, and hospital outcome.

RESULTS

There were five men and three women with a mean age of 51 years. The diagnosis was chronic pancreatitis in seven patients and cancer in one. The index operation was pancreatoduodenectomy in four patients, distal pancreatectomy in three, and total pancreatectomy in one. In four patients undergoing elective pancreatic resection intraoperative portal vein hemorrhage initiated damage control laparotomy. Four patients had damage control utilized at reoperation for abdominal sepsis (two) and hemorrhage (two). DCL techniques included external tube drainage (eight), abdominal packing (seven), staple closure of open bowel (four), and rapid abdominal closure (four). Operative blood loss ranged from 300 to 12,000 cc. Operative transfusions ranged from 0 to 44 U of packed red cells. Intraoperative INR was greater than 1.5 in four patients, pH ranged from 7.08 to 7.45, and temperature ranged from 34.8 to 38.8 degrees C. Laparotomy for pack removal and intestinal reconstruction was undertaken 1 to 7 days after DCL. Length of hospital stay ranged from 7 to 80 days. Hospital mortality was zero.

CONCLUSIONS

Patients with exsanguinating hemorrhage and severe sepsis related to pancreatic surgery can be successfully managed with principles of DCL. Truncation of operation with abdominal packing, bowel closure, external drainage of bile and pancreatic ducts, and rapid abdominal closure with planned subsequent completion laparotomy should be considered in pancreatic operations when patients risk intraoperative acidosis, hypothermia, and coagulopathy due to sepsis or hemorrhage.

Natural orifice transluminal endoscopic surgery versus laparoscopic surgery for inadvertent colon injury repair: feasibility, risk of abdominal adhesions, and peritoneal contamination in a porcine survival model

BACKGROUND

Adhesions are common after conventional surgery; natural orifice transluminal endoscopic surgery (NOTES) avoids peritoneal disruption and may reduce adhesions.

OBJECTIVES

To determine whether adhesions (and peritoneal contamination) are less common with NOTES transgastric colon injury and repair (TGCR) than with laparoscopic colon repair (LCR).

DESIGN/SETTING

Porcine survival study.

INTERVENTIONS

After colon preparation and administration of antibiotics, forty 25-kg male pigs were randomly assigned to either TGCR or LCR. TGCR involved an endoscopic gastrotomy (needle-knife plus balloon dilation), CO(2) pneumoperitoneum, and a 2-cm needle-knife transmural incision of spiral colon. Colotomies were repaired with clips; gastrotomies were closed with clips and a detachable snare.

MAIN OUTCOME MEASUREMENTS

Adhesions were assessed at necropsy at 21 days; biopsy specimens were blindly reviewed. A 9-point adhesion score (density/vascularity, width, and extent) was averaged from 3 reviewers. Peritoneal lavage was sent for cell count and culture.

RESULTS

Two of 20 TGCR pigs died immediately (unrecognized preoperative autopsy-proven pneumonia). The median procedure times were 70.5 and 19.0 minutes for TGCR and LCR, respectively; weight gains were 7.1 and 8.2 kg, respectively. The median adhesion scores were 4.3 and 3.7, respectively (P = .26); subscores were similar (1.9, 1.5, 1.3 vs 1.7, 1.1, 1.0, respectively (P = .3-.6)). Peritoneal lavage bacterial growth was nonsignificantly lower after TGCR than after LCR (38.9% vs 60.0%, respectively; P = .30); administration of intragastric antibiotics did not decrease contamination. Three TGCR (vs no LCR) pigs had histologic peritonitis.

LIMITATIONS

Animal model, colon prepped, injury immediately recognized.

CONCLUSION

NOTES colon repair is feasible after transmural injury. Adhesions, histologic peritonitis, and contamination were similar to those with laparoscopy and were not helped by intragastric antibiotics.

Gene expression levels as endophenotypes in genome-wide association studies of Alzheimer disease

BACKGROUND

Late-onset Alzheimer disease (LOAD) is a common disorder with a substantial genetic component. We postulate that many disease susceptibility variants act by altering gene expression levels.

METHODS

We measured messenger RNA (mRNA) expression levels of 12 LOAD candidate genes in the cerebella of 200 subjects with LOAD. Using the genotypes from our LOAD genome-wide association study for the cis-single nucleotide polymorphisms (SNPs) (n = 619) of these 12 LOAD candidate genes, we tested for associations with expression levels as endophenotypes. The strongest expression cis-SNP was tested for AD association in 7 independent case-control series (2,280 AD and 2,396 controls).

RESULTS

We identified 3 SNPs that associated significantly with IDE (insulin degrading enzyme) expression levels. A single copy of the minor allele for each significant SNP was associated with approximately twofold higher IDE expression levels. The most significant SNP, rs7910977, is 4.2 kb beyond the 3' end of IDE. The association observed with this SNP was significant even at the genome-wide level (p = 2.7 x 10(-8)). Furthermore, the minor allele of rs7910977 associated significantly (p = 0.0046) with reduced LOAD risk (OR = 0.81 with a 95% CI of 0.70-0.94), as expected biologically from its association with elevated IDE expression.

CONCLUSIONS

These results provide strong evidence that IDE is a late-onset Alzheimer disease (LOAD) gene with variants that modify risk of LOAD by influencing IDE expression. They also suggest that the use of expression levels as endophenotypes in genome-wide association studies may provide a powerful approach for the identification of disease susceptibility alleles.

Critical roles of kisspeptins in female puberty and preovulatory gonadotropin surges as revealed by a novel antagonist

Kisspeptins (Kp) have recently emerged as master regulators of the reproductive axis and among the most potent elicitors of GnRH-gonadotropin secretion. Despite their paramount importance in reproductive physiology and their potential therapeutic implications, development of Kp antagonists has remained elusive, and only recently has the first compound with the ability to block Kp actions in vitro and in vivo, namely p234, been reported. However, previous in vivo studies all used acute central injections, whereas characterization of the effects of the antagonist after continuous or systemic administration, which poses pharmacological challenges, is still pending. We report herein a comprehensive series of analyses on the impact of continuous intracerebroventricular infusion of p234 on puberty onset and the preovulatory surge of gonadotropins in the female rat. In addition, the effects of systemic (ip) administration of a tagged p234-penetratin, with a predicted higher permeability at the blood-brain barrier, on Kp-10 induced gonadotropin secretion were evaluated. Central infusion of p234 to pubertal females delayed vaginal opening and decreased uterine and ovarian weights at the expected time of puberty, without affecting body weight. Likewise, chronic intracerebroventricular administration of p234 for 4 d prevented the preovulatory surges of LH and FSH. In addition, systemic (ip) administration of p234-penetratin significantly attenuated acute LH and FSH responses to Kp-10, either after intracerebroventricular or ip injection of Kp. Our data document the validity of p234 for antagonizing Kp actions in vivo and provide direct experimental evidence for the important role of Kp signaling in the key events of female reproduction, such as puberty onset and the preovulatory surge of gonadotropins.

Combining dimensional and categorical representation of psychosis: the way forward for DSM-V and ICD-11?

BACKGROUND

There is good evidence that psychotic symptoms segregate into symptom dimensions. However, it is still unclear how these dimensions are associated with risk indicators and other clinical variables, and whether they have advantages over categorical diagnosis in clinical practice. We investigated symptom dimensions in a first-onset psychosis sample and examined their associations with risk indicators and clinical variables. We then examined the relationship of categorical diagnoses to the same variables.

METHOD

We recruited 536 patients as part of a population-based, incidence study of psychosis. Psychopathology was assessed using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN). A principal axis factor analysis was performed on symptom scores. The relationship of dimension scores with risk indicators and with clinical variables was then examined employing regression analyses. Finally, regression models were compared to assess the contribution of dimensions versus diagnosis in explaining these variables.

RESULTS

Factor analysis gave rise to a five-factor solution of manic, reality distortion, negative, depressive and disorganization symptom dimensions. The scores of identified dimensions were differentially associated with specific variables. The manic dimension had the highest number of significant associations; strong correlations were observed with shorter duration of untreated psychosis, acute mode of onset and compulsory admission. Adding dimensional scores to diagnostic categories significantly increased the amount of variability explained in predicting these variables; the reverse was also true but to a lesser extent.

CONCLUSIONS

Categorical and dimensional representations of psychosis are complementary. Using both appears to be a promising strategy in conceptualising psychotic illnesses.

The role of the sports and exercise medicine physician in the National Health Service: a questionnaire-based survey

OBJECTIVES

To investigate the opinions of general practitioners, orthopaedic surgeons, rheumatologists, sport and exercise medicine (SEM) registrars and public health consultants on training, caseload, the most appropriate setting and the position of SEM within the National Health Service (NHS) in the UK.

METHOD

A cross-sectional questionnaire-based survey investigated the opinions of the above professionals from three primary care trusts and associated hospitals in London and Birmingham.

RESULTS

With a 50% response rate (n = 226), 93% (208/224) of participants felt that there was a role for SEM in the NHS. 56% (124/223) agreed that this role should be in both primary and secondary care. 64% (136/212) of participants felt that their practice would benefit from the input of a SEM physician and 95% (191/202) would consider referring patients to SEM services. 74% (165/222) agreed that SEM should have a public health role, and 63% (140/222) believed that these responsibilities should be evenly balanced with the treatment of sports injuries. Despite the emphasis on public health work from SEM policy makers, none of the SEM registrars selected public health as an important training area. 31% (44/140) of participants felt that a lack of education in the medical profession regarding SEM represented the greatest hindrance to its development in the NHS.

CONCLUSION

Several areas of agreement were demonstrated across the specialties, many of which matched the views of policy makers. This study involved participants from a range of cognate disciplines and was the first to investigate this issue since SEM was recognised as a specialty in 2005.

Examining evidence for neighbourhood variation in the duration of untreated psychosis

Background

Family involvement in help-seeking is associated with a shorter duration of untreated psychoses [DUP], but it is unknown whether neighbourhood-level factors are also important.

Methods

DUP was estimated for all cases of first-episode psychoses identified over 2 years in 33 Southeast London neighbourhoods (n=329). DUP was positively skewed and transformed to the natural logarithm scale. We fitted various hierarchical models, adopting different assumptions with regard to spatial variability of DUP, to assess whether there was evidence of neighbourhood heterogeneity in DUP, having accounted for a priori individual-level confounders.

Results

Neighbourhood-level variation in DUP was negligible compared to overall variability. A non-hierarchical model with age, sex and ethnicity covariates, but without area-level random effects, provided the best fit to the data.

Discussion

Neighbourhood factors do not appear to be associated with DUP, suggesting its predictors lie at individual and family levels. Our results inform mental healthcare planning, suggesting that in one urbanised area of Southeast London, where you live does not affect duration of untreated psychosis.

Culture change initiatives in the procurement of organs in the United kingdom

In 2004, the United Kingdom began for the first time a systematic, countrywide initiative to increase organ donations. The approach, based on international research and with consultation from the United States, entailed encouraging the early identification and referral of potential donors, training critical care physicians in breaking bad news and in collaborating with donor coordinators, training coordinators in donation conversation skills, and getting them in to speak with families. The strategy represented a large culture change in the procurement of organs in the United Kingdom and has met resistance. However, the change has started to take hold and, despite a dramatic and unexpected 21% reduction in potential brain stem death donors over a 4-year period, is showing positive results. Herein we have described the historical model for procuring organs in the United Kingdom, the development of the new strategy, its components, and the results of its implementation, in terms of earlier referrals, the identification of non-heart-beating donors, the collaboration between physicians and coordinators in speaking with families and in converted donors.

Interleukin 10 (IL-10) gene variants and susceptibility for paediatric onset Crohn's disease

BACKGROUND

A recent genome-wide association study in adult patients with ulcerative colitis (UC) has implicated the interleukin 10 (IL-10) gene as an important candidate gene. Moreover, a UC-associated single nucleotide polymorphism (SNP) rs3024405 was also significantly associated with adult Crohn's disease (CD).

AIMS

To examine whether IL-10-CD associations extended to paediatric-onset CD.

METHODS

We implemented the case-control design at three paediatric gastroenterology clinics in Canada. CD patients (<or=20 years) were recruited along with healthy controls. DNA samples were genotyped for tag-single nucleotide polymorphisms (tag-SNPs) in the IL-10 gene. Allelic, genotype and haplotype associations with CD were studied.

RESULTS

A total of 270 patients and 336 controls were studied. The mean age (+/-s.d.) at diagnosis was 12.1 (+/-3.5). There were a slightly higher proportion of male patients (56.3%). Of the five IL-10 tag-SNPs, rs2222202 (C/T) (P = 0.03) and rs1800871 (C/T) (P = 0.05) showed significant allelic associations with CD. Specific IL-10 SNPs were associated with CD disease location and/or disease behaviour.

CONCLUSIONS

Our gene-wide analysis replicates recent findings of associations between IL-10 and adult CD, and suggests that these associations extend to paediatric-onset CD as well.

Ethnicity, social disadvantage and psychotic-like experiences in a healthy population based sample

OBJECTIVE

We sought to investigate the prevalence and social correlates of psychotic-like experiences in a general population sample of Black and White British subjects.

METHOD

Data were collected from randomly selected community control subjects, recruited as part of the AESOP study, a three-centre population based study of first-episode psychosis.

RESULTS

The proportion of subjects reporting one or more psychotic-like experience was 19% (n = 72/372). These were more common in Black Caribbean (OR 2.08) and Black African subjects (OR 4.59), compared with White British. In addition, a number of indicators of childhood and adult disadvantage were associated with psychotic-like experiences. When these variables were simultaneously entered into a regression model, Black African ethnicity, concentrated adult disadvantage, and separation from parents retained a significant effect.

CONCLUSION

The higher prevalence of psychotic-like experiences in the Black Caribbean, but not Black African, group was explained by high levels of social disadvantage over the life course.

Cumulative social disadvantage, ethnicity and first-episode psychosis: a case-control study

BACKGROUND

Numerous studies have reported high rates of psychosis in the Black Caribbean population in the UK. Recent speculation about the reasons for these high rates has focused on social factors. However, there have been few empirical studies. We sought to compare the prevalence of specific indicators of social disadvantage and isolation, and variations by ethnicity, in subjects with a first episode of psychosis and a series of healthy controls.

METHOD

All cases with a first episode of psychosis who made contact with psychiatric services in defined catchment areas in London and Nottingham, UK and a series of community controls were recruited over a 3-year period. Data relating to clinical and social variables were collected from cases and controls.

RESULTS

On all indicators, cases were more socially disadvantaged and isolated than controls, after controlling for potential confounders. These associations held when the sample was restricted to those with an affective diagnosis and to those with a short prodrome and short duration of untreated psychosis. There was a clear linear relationship between concentrated disadvantage and odds of psychosis. Similar patterns were evident in the two main ethnic groups, White British and Black Caribbean. However, indicators of social disadvantage and isolation were more common in Black Caribbean subjects than White British subjects.

CONCLUSIONS

We found strong associations between indicators of disadvantage and psychosis. If these variables index exposure to factors that increase risk of psychosis, their greater prevalence in the Black Caribbean population may contribute to the reported high rates of psychosis in this population.

Pilot comparison of adhesion formation following colonic perforation and repair in a pig model using a transgastric, laparoscopic, or open surgical technique

BACKGROUND AND STUDY AIM

Postoperative adhesions create significant morbidity and mortality. Natural orifice transluminal endoscopic surgery (NOTES) procedures may reduce or eliminate adhesions by avoiding disruption of the parietal peritoneum. The primary aim of this pilot study was to compare adhesion formation after performance and subsequent repair of colonic perforation via transgastric, laparoscopic, or open surgical techniques. The secondary aim was to test the feasibility and outcome of transgastric management of bowel perforation in a prepared model.

MATERIAL AND METHODS

15 Yorkshire pigs were divided into three groups of five: transgastric (needle-knife entry with balloon dilation over a wire), laparoscopic, and open surgical. Aspects of adhesion formation (density/vascularity, width of bands, and number of organ pairs involved) were compared after perforation and repair during the same procedure. Intra- and postoperative complications were documented during the 21-day survival period.

RESULTS

All 15 pigs recovered fully with no immediate procedural complications. After 21 days, there was a trend towards a lower adhesion burden regarding density/vascularity and number of organ pairs involved, and a significant reduction in the width of the adhesive bands, when the transgastric group was compared with the surgical groups. Additionally, there was a trend towards decreased adhesions to the peritoneum in the transgastric group.

CONCLUSIONS

Repair of colonic perforation during transgastric (NOTES) procedures appear feasible and safe in a porcine model. There appears to be a trend towards a lower rate of adhesion formation with the transgastric approach compared with laparoscopic or open surgery.