The prevalence and risk factors for phantom limb pain: a cross-sectional survey

BACKGROUND

We previously performed a systematic review and meta-analysis which revealed a Phantom Limb Pain (PLP) prevalence estimate of 64% [95% CI: 60.01-68.1]. The prevalence estimates varied significantly between developed and developing countries. Remarkably, there is limited evidence on the prevalence of PLP and associated risk factors in African populations.

METHODS

Adults who had undergone limb amputations between January 2018 and October 2022 were recruited from healthcare facilities in the Western and Eastern Cape Provinces. We excluded individuals with auditory or speech impairments that hindered clear communication via telephone. Data on the prevalence and risk factors for PLP were collected telephonically from consenting and eligible participants. The prevalence of PLP was expressed as a percentage with a 95% confidence interval. The associations between PLP and risk factors for PLP were tested using univariate and multivariable logistic regression analyses. The strength of association was calculated using the Odds Ratio where association was confirmed.

RESULTS

The overall PLP prevalence was 71.73% [95% CI: 65.45-77.46]. Persistent pre-operative pain, residual limb pain, and non-painful phantom limb sensations were identified as risk factors for PLP.

CONCLUSION

This study revealed a high prevalence of PLP. The use of effective treatments targeting pre-amputation pain may yield more effective and targeted pre-amputation care, leading to improved quality of life after amputation.

LSD and psilocybin for chronic nociplastic pain: A narrative review of the literature supporting the use of classic psychedelic agents in chronic pain

Healthcare providers face the challenging task of managing patients who suffer from chronic nociplastic pain conditions. Pain is a multidimensional experience, and the current approach to managing people in chronic pain often fails to meet the needs of these patients. Novel ways of treating people who suffer from chronic nociplastic pain with classic psychedelic agents may offer a new lens through which to approach their pain. Lysergic acid diethylamide (LSD) and psilocybin are both serotonergic agents with a long history of use in treating people with chronic pain and mental health disorders. The new wave of research into psychedelics for major depressive disorder provides an opportunity to investigate and understand the potential for incorporating these drugs into chronic pain management pathways. This narrative review presents healthcare workers with a framework to understand the method of action of these drugs in chronic nociplastic pain pathways and a brief history into their use. We conducted an online search using Pubmed with keywords 'chronic pain' AND/OR 'psilocybin' AND/OR 'lysergic acid diethylamide' AND/OR 'psychedelics' with no date limit applied. We identified further articles that contained information on the neuroscience of psychedelics and the serotonergic system using Google Scholar. During the final stages of writing the article, the latest publications on psychedelics and chronic pain in leading pain journals were again included to update the information.

The Global Task Force for Chronic Pain in People with HIV (PWH): Developing a research agenda in an emerging field

Chronic pain is a common comorbidity in people with HIV (PWH), with prevalence estimates of 25-85%. Research in this area is growing, but significant gaps remain. A Global Task Force of HIV experts was organized to brainstorm a scientific agenda and identify measurement domains critical to advancing research in this field. Experts were identified through literature searches and snowball sampling. Two online questionnaires were developed by Task Force members. Questionnaire 1 asked participants to identify knowledge gaps in the field of HIV and chronic pain and identify measurement domains in studies of chronic pain in PWH. Responses were ranked in order of importance in Questionnaire 2, which was followed by a group discussion. 29 experts completed Questionnaire 1, 25 completed Questionnaire 2, and 21 participated in the group. Many important clinical and research priorities emerged, including the need to examine etiologies of chronic pain in PWH. Pain-related measurement domains were discussed, with a primary focus on domains that could be assessed in a standardized manner across various cohorts that include PWH in different countries. We collaboratively identified clinical and research priorities, as well as gaps in standardization of measurement domains, that can be used to move the field forward.

Effects of Integrated Vector Management in the Control of Malaria Infection: An Intervention Study in a Malaria Endemic Community in Nigeria

BACKGROUND/AIM

Malaria is a vector borne disease with high morbidity and mortality in endemic regions. In view to eliminating the disease, integrated vector and environmental hygiene practices have been advocated. There is paucity of studies on the effect of vector control measures on asymptomatic malaria infection which has been observed to be a reflection of malaria transmission.

METHODS

Longitudinal community-based intervention study carried out from October to December 2017. Study participants were 477 individuals living in 100 households selected by snow-balling sampling methods. Pre-intervention period included training of all heads of households on vector control methods. During the intervention period, each household received waste bins, two long lasting insecticide bed nets and had wire screen on their doors and windows; every household member was screened for malaria (antigen) using the pf rapid diagnostic test kits. Each household were monitored to ensure they comply with the environmental hygiene practices they were taught. Post-intervention malaria infection was obtained at 8 week being end of the intervention period.

RESULTS

Of the 100 households selected, 54.0% were from the lower social class, 45.0% middle class and only 1.0% upper class. Mean age [±] of the heads of the households was 37.1 ± 11.0 (range 16-68) years. There were 477 individuals recruited in the study from the 100 households; 234 (49.0%) females and 243 (51.0%) males; median age was 20.0 (range 1-100) years. Prevalence of malaria infection using mRDT during pre-intervention was 16.8% and an incidence of 1.3% post-intervention. There was 92.0% reduction in asymptomatic malaria infection showing marked reduction in malaria transmission in the study locale.

CONCLUSION

Some integrated vector control measures such as use of insecticide-treated net and sanitation were found effective methods for reducing malaria infection and transmission in endemic region.

Managing ethical issues in community-based adolescent self-harm research. ethical practice in an adolescent self-harm preventative intervention research project with pupils in secondary schools in wales

Introduction

Adolescent self-harm in Europe is a major public health challenge and shares a risk continuum with suicide. Recent research demonstrates a strong risk correlation with attempting suicide in the community-based adolescent self-harm population group, similar to research findings for populations in health setting-based research. In the UK increasing rates in hospital admissions represent the “tip of the iceberg” within the community, with potentially two thirds of the population group not accessing health services for support. This brings many health risks, including an increased suicide risk. Finding a solution to these issues requires a preventative intervention approach for young people, including community-based delivery to address service access barriers. Secondary schools are posited as key settings where this type of support could be delivered. But emerging UK research demonstrates challenges in completing adolescent self-harm research with young people in schools.

Objectives

This paper centres on a current adolescent self-harm preventative intervention research project in Cardiff University. It focuses on ethical research practice in community-based adolescent self-harm research.

Methods

This paper appraises some of the core ethical issues, challenges and their management in completing adolescent self-harm prevention intervention research in secondary school settings in Wales. It also provides an overview of the project’s innovative safety protocol design.

Results

This project was successful in managing the potential risks to the school-based adolescent research participants.

Conclusions

This work helps address some of the current research barriers to completing adolescent self-harm prevention intervention research in schools, to facilitate shared solutions to the urgent public health challenge of adolescent self-harm.

Are Groote Schuur Hospital anaesthesiologists burnt out? A cross-sectional study of prevalence and risk

Background: Burnout and physician wellness are becoming increasingly topical. While some surveys have been performed with South African anaesthesiologists, these have been conducted in limited samples. While burnout is often measured, there is a paucity of research on contributory risk and protective factors. Method: A contextual, prospective, cross-sectional study was conducted. The Maslach Burnout Inventory-Human Services Survey (MBI-HSS) and the Areas of Worklife Survey (AWS) were used to assess burnout and contributory organisational risk factors amongst state-employed anaesthesiologists working at Groote Schuur Hospital. Results: Out of a possible 127 members of staff (medical officers, registrars and consultants), 81 responded with 75 completing the full survey (59% response rate). Only 4% of respondents were classified as “burnt out”, defined as scoring high in all three domains of burnout: high emotional exhaustion and depersonalisation and low personal accomplishment. However, 67% of respondents scored high for at least one of the components of burnout, indicating the majority of the respondents are at risk for developing clinically significant burnout. The AWS showed that respondents found their workload inappropriate. However, responses for the categories of control, reward, community, fairness and values were all in the acceptable range. Conclusion: While the overall rate of burnout was low, the majority of respondents were at risk for developing burnout. High perceived workload appeared to be a particular contributory factor. Protection against burnout in this group may be provided by a combination of few organisational risk factors together with feelings of personal accomplishment.

The whole blood phagocytosis assay: a clinically relevant test of neutrophil function and dysfunction in community-acquired pneumonia

Objective

To refine and validate a neutrophil function assay with clinical relevance for patients with community-acquired pneumonia (CAP).

Design

Two phase cross-sectional study to standardise and refine the assay in blood from healthy volunteers and test neutrophil phagocytic function in hospital patients with CAP.

Participants

Phase one: Healthy adult volunteers (n = 30). Phase two: Critical care patients with severe CAP (n = 16), ward-level patients with moderate CAP (n = 15) and respiratory outpatients (no acute disease, n = 15).

Results

Our full standard operating procedure for the assay is provided. Patients with severe CAP had significantly decreased neutrophil function compared to moderate severity disease (median phagocytic index 2.8 vs. 18.0, p = 0.014). Moderate severity pneumonia neutrophil function was significantly higher than control samples (median 18.0 vs. 1.6, p = 0.015). There was no significant difference between critical care and control neutrophil function (median 2.8 vs. 1.6, p = 0.752).

Conclusions

Our whole blood neutrophil assay is simple, reproducible and clinically relevant. Changes in neutrophil function measured in this pneumonia cohort is in agreement with previous studies. The assay has potential to be used to identify individuals for clinical trials of immunomodulatory therapies, to risk-stratify patients with pneumonia, and to refine our understanding of ‘normal’ neutrophil function in infection.

Reactivities of an anti-CEA peptide monoclonal antibody

Synthetic peptides representing different areas of the CEA molecule were used as immunogens for the development of anti-CEA antibodies. Both polyclonal and monoclonal antibodies were generated using peptides composed of CEA amino acid positions 99–128 and 585–613, respectively. One MAb, designated CP4, generated using the CEA peptide 99–128, was chosen for a more detailed analysis of reactivity. MAb CP4 reacts in solid phase RIAs with CEA peptide 99–128 immunogen and purified native CEA. CP4 did not react with purified non- specific cross reacting antigen (NCA), even though there were two single amino acid differences between NCA and CEA in the 29 amino acid peptide. The affinity constants of CP4 for the CEA peptide 99–128 and native CEA are 4.07 × 109M−1and 5.75 × 108M−1, respectively. When CP4 was reacted with purified CEA in Western blotting experiments, the Mr 180,000 glycoprotein characteristic of CEA was detected, but CP4 reacted to various size entities in tumor cell extracts. The results of liquid competition RIAs showed that the epitope that MAb CP4 recognized on native CEA is not available for binding when CEA is in solution. Physical (adsorption to a solid matrix) or chemical (deglycosylation or formalin-fixation) alteration of CEA is required for binding of CP4 to CEA. MAb CP4 reacted approximately 1,000-fold greater to deglycosylated CEA than native CEA. Immunohistochemical studies using formalin-fixed paraffin-embedded tissue sections demonstrated that, among carcinomas, CP4 reacts selectively with colorectal carcinomas, while normal colon is negative. Although stomach carcinoma is negative, dysplastic lesions and areas of intestinal metaplasia are reactive. Two of 7 normal stomach tissues showed focal cytoplasmic reactivity of the surface epithelium. CP4, therefore, appears to react with an epitope with highly restricted expression in colorectal carcinoma. These studies demonstrate the complexities in dealing with an anti-peptide MAb with reactivity to an epitope which is accessible only under certain conditions.

Utility of HbA1c assessment in people with diabetes awaiting liver transplantation

AIMS

To investigate the relationship between HbA_1c and glucose in people with co-existing liver disease and diabetes awaiting transplant, and in those with diabetes but no liver disease.

METHODS

HbA_1c and random plasma glucose data were collected for 125 people with diabetes without liver disease and for 29 people awaiting liver transplant with diabetes and cirrhosis. Cirrhosis was caused by non-alcoholic fatty liver disease, hepatitis C, alcoholic liver disease, hereditary haemochromatosis, polycystic liver/kidneys, cryptogenic/non-cirrhotic portal hypertension and α-1-antitrypsin-related disease.

RESULTS

The median (interquartile range) age of the diabetes with cirrhosis group was 55 (49-63) years compared to 60 (50-71) years (P=0.13) in the group without cirrhosis. In the diabetes with cirrhosis group there were 21 men (72%) compared with 86 men (69%) in the group with diabetes and no cirrhosis (P=0.82). Of the group with diabetes and cirrhosis, 27 people (93%) were of white European ethnicity, two (7%) were South Asian and none was of Afro-Caribbean/other ethnicity compared with 94 (75%), 16 (13%), 10 (8%)/5 (4%), respectively, in the group with diabetes and no cirrhosis (P=0.20). Median (interquartile range) HbA_1c was 41 (32-56) mmol/mol [5.9 (5.1-7.3)%] vs 61 (52-70) mmol/mol [7.7 (6.9-8.6)%] (P<0.001), respectively, in the diabetes with cirrhosis group vs the diabetes without cirrhosis group. The glucose concentrations were 8.4 (7.0-11.2) mmol/l vs 7.3 (5.2-11.5) mmol/l (P=0.17). HbA_1c was depressed by 20 mmol/mol (1.8%; P<0.001) in 28 participants with cirrhosis but elevated by 28 mmol/mol (2.6%) in the participant with α-1-antitrypsin disorder. Those with cirrhosis and depressed HbA_1c had fewer larger erythrocytes, and higher red cell distribution width and reticulocyte count. This was reflected in the positive association of glucose with mean cell volume (r=0.39) and haemoglobin level (r=0.49) and the negative association for HbA_1c (r=-0.28 and r=-0.26, respectively) in the diabetes group with cirrhosis.

CONCLUSION

HbA_1c is not an appropriate test for blood glucose in people with cirrhosis and diabetes awaiting transplant as it reflects altered erythrocyte presentation.

Gabapentinoids for treatment of neuropathic pain: a medicines usage evaluation at the Groote Schuur Hospital Chronic Pain Management Clinic

Background: Neuropathic pain (NP), defined as pain caused by a lesion or disease of the somatosensory system, affects 6.9–10% of people worldwide. Pregabalin is currently recommended as a first line drug for NP in South Africa. Methods: A cross-sectional, retrospective, descriptive medicines usage evaluation (MUE) of pregabalin at Groote Schuur Hospital (GSH) Chronic Pain Management Clinic for the year 2017 was conducted. A MUE using a standardised data collection form was performed on 100 randomly selected patient folders. Data was summarised using descriptive statistics. Results: The majority of cases were women (76) with a mean age of 55.9 years (SD12.49). A diagnosis of NP was recorded in 58 folders and a “possible” diagnosis recorded in 7 folders. In 79 cases there was no mention of a tool/method used to diagnose NP. The most common condition diagnosed was chronic postsurgical pain with a neuropathic component (n = 16), followed by NP (n = 15). The most common initiating and current dose of pregabalin was 75 mg twice daily. In 56 patients, pregabalin was prescribed in conjunction with a tricyclic antidepressant (TCA) or selective noradrenaline reuptake inhibitor (SNRI). Patient education was documented as having taken place in 76 of cases. Conclusions: Based on this MUE we recommend the use of screening tools for the diagnosis of neuropathic pain, and a focus on the initiating dose of pregabalin. The use of a standardised assessment document and the interdisciplinary team input at this clinic appears to optimise prescribing of pregabalin in line with practice guidelines.

Interaction Effects between Blade Rows in Turbomachines

The paper discusses the mechanisms of interaction between blade rows in turbomachines due to the relative motion between the rows. Interaction occurs due to potential flow effects and because each blade produces a viscous wake.

In spite of extensive investigations of various aspects of interaction there is very little information available in a form which can be applied by a designer to minimize the noise and vibration excitation due to blade row interaction.

Experimental research is hampered by the extreme difficulty of separating the types of excitation and many theoretical analyses are of limited value because reliable experimental verification has not been obtained.

Optimising perioperative care for hip and knee arthroplasty in South Africa: a Delphi consensus study

Background

A structured approach to perioperative patient management based on an enhanced recovery pathway protocol facilitates early recovery and reduces morbidity in high income countries. However, in low- and middle-income countries (LMICs), the feasibility of implementing enhanced recovery pathways and its influence on patient outcomes is scarcely investigated. To inform similar practice in LMICs for total hip and knee arthroplasty, it is necessary to identify potential factors for inclusion in such a programme, appropriate for LMICs.

Methods

Applying a Delphi method, 33 stakeholders (13 arthroplasty surgeons, 12 anaesthetists and 8 physiotherapists) from 10 state hospitals representing 4 South African provinces identified and prioritised i) risk factors associated with poor outcomes, ii) perioperative interventions to improve outcomes and iii) patient and clinical outcomes necessary to benchmark practice for patients scheduled for primary elective unilateral total hip and knee arthroplasty.

Results

Thirty of the thirty-three stakeholders completed the 3 months Delphi study. The first round yielded i) 36 suggestions to preoperative risk factors, ii) 14 (preoperative), 18 (intraoperative) and 23 (postoperative) suggestions to best practices for perioperative interventions to improve outcomes and iii) 25 suggestions to important postsurgical outcomes. These items were prioritised by the group in the consecutive rounds and consensus was reached for the top ten priorities for each category.

Conclusion

The consensus derived risk factors, perioperative interventions and important outcomes will inform the development of a structured, perioperative multidisciplinary enhanced patient care protocol for total hip and knee arthroplasty. It is anticipated that this study will provide the construct necessary for developing pragmatic enhanced care pathways aimed at improving patient outcomes after arthroplasty in LMICs.

Creation of Realistic Appearing Simulated Patient Cases Using the INTERNIST-1/QMR Knowledge Base and Interrelationship Properties of Manifestations

The Internist-1/0uick Medical Reference (OMR) knowledge base (KB) describes the clinical manifestations of some 600 diseases in the domain of internal medicine. This KB, while not representing deep causal modelling of disease processes, is nonetheless effective iri providing medical diagnostic assistance through the OMR medical decision support system. One potential application ofthis extensive KB is the generation of simulated patient cases for use in educating health professionals. However, the “flat” KB is not adequate for this because the clinical manifestations used in the disease descriptions are not mutually independent. While it is theoretically possible to construct disease descriptions which embody pathophysiologic mechanisms of disease causality, it is not practical from the standpoint of resource utilization. Short of constructing a causal knowledge base, the authors herein describe the generation of realistic appearing simulated patient case data using existing information in the knowledge base. This existing information in the KB is in the form of properties which represent a shallow form of interrelationships of the manifestations. The authors conclude that this ability to generate simulated cases represents another view in which to look at an extensive knowledge base, as well as having application to constructing intelligent tutoring systems for health professionals in training.

Fracture of the medial intercondylar eminence of the tibia in horses treated by arthroscopic fragment removal (21 horses)

BACKGROUND

Fractures of the medial intercondylar eminence of the tibia (MICET) are scarcely reported in horses.

OBJECTIVES

To report the clinical and diagnostic findings, surgical treatment and outcome in a series of horses presented with MICET fracture and treated with arthroscopic fragment removal.

STUDY DESIGN

Multicentre retrospective case series.

METHODS

Case records of horses diagnosed with MICET fractures that had undergone surgical treatment were reviewed. Follow-up information was obtained from re-examination visits and/or owners.

RESULTS

Twenty-one cases were identified at 9 equine hospitals between 2004 and 2016. A history of trauma and acute onset of lameness was reported in 12 horses. All cases underwent fracture removal via arthroscopy of the medial femorotibial joint. The cranial cruciate ligament was intact in 6 horses and damaged in 15 horses (damage was ≤25% [n = 9], 25-50% [n = 4] or ≥50% [n = 2] of the cross-sectional area). The cranial ligament of the medial meniscus was damaged in 11 horses (≤25% [n = 8], 25-50% [n = 3]). The medial meniscus was damaged in 5 horses and articular cartilage damage was identified in 14 horses (mild [n = 8], moderate [n = 6]). Follow-up information (median 14 months; 4 months-6 years) was available for 20 cases; 2 horses were sound but convalescing; 13 horses were sound and returned to their previous or expected use. Of the 4 horses with the most severe changes to the articular soft tissue structures, 2 remained lame and 2 were subjected to euthanasia because of persistent lameness.

MAIN LIMITATIONS

The retrospective, multicentre nature of this study and the limited number of horses are the main limitations.

CONCLUSIONS

Fractures of the MICET are commonly associated with a traumatic event. Prompt diagnosis and early arthroscopic removal of the fracture are recommended.

The Excitation and Consequences of Acoustic Resonances in Enclosed Fluid Flow Around Solid Bodies

A survey is made of enclosed flow systems in which acoustic and/or mechanical oscillations can be excited by vortex shedding from bodies immersed in the flow which becomes ‘locked’ to an acoustic resonance.

Significant improvements in pain after a six-week physiotherapist-led exercise and education intervention, in patients with osteoarthritis awaiting arthroplasty, in South Africa: a randomised controlled trial

Background

A major challenge facing those with late stage osteoarthritis is delayed surgery due to waiting lists. In South Africa patients wait years for a hip/knee arthroplasty. Affected patients require effective management to address their pain, especially while awaiting surgery. Existing literature is mostly available from high income countries exploring effects of interventions during short waiting periods. Research is warranted in low income countries where long waiting periods are common. This study explored the effects of a six-week physiotherapist-led exercise and education intervention on pain in this population.

Methods

A randomised controlled trial was performed at two public hospitals in South Africa. Ethical approval and informed consent was obtained. 74 participants from arthroplasty waiting lists were randomly allocated to an intervention (n = 35) or control group (n = 39). The intervention included six physiotherapist-led group-based sessions (two hours/week of education, exercise and relaxation). The control group received usual care. Data collection was conducted by blinded physiotherapists at baseline, week six, 12 and month six. The primary outcome was pain, measured by the Brief Pain Inventory. Additionally, participants completed an open-ended questionnaire at month six, to gain insight regarding the intervention. Analysis was by intention to treat using two-way analysis of variance and post-hoc Tukey comparisons. Answers to subjective questions were analysed according to common themes that emerged.

Results

The intervention group had significant improvements compared with the control group with moderate to large effect sizes (ES) on pain severity [week 6: p < 0.01, ES = 0.94, 95 % CI (0.45,1.41), month 6: p = 0.02. ES = 0.74, 95 % CI (0.26,1.2)] and moderate to large effects on pain interference [week 6: p < 0.01, ES = 1.2, 95 % CI (0.70,1.69), week 12: p = 0.04, ES = 0.68, 95 % CI (0.20,1.14), month 6: p < 0.01, ES = 0.98, 95 % CI (0.49,1.45)]. 53 % of participants reported that the intervention improved their pain.

Conclusions

The intervention resulted in sustained significant improvements in pain severity and interference in patients with hip/knee osteoarthritis, awaiting arthroplasty compared with a control group. Additionally, participants’ individual feedback supported observed significant improvements in pain. Such an intervention appears to be effective in managing pain in this population and should be incorporated into practice for appropriate patients. Further research is being conducted to explore long term and postoperative outcomes.

Clinical trial registration

Pan African Clinical Trial Registry, PACTR201409000885765, PACTR201507001186115.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-016-1088-6) contains supplementary material, which is available to authorized users.

Extended right hemicolectomy and left hemicolectomy for colorectal cancers between the distal transverse and proximal descending colon

INTRODUCTION

We report our experience with extended right hemicolectomy (ERH) and left hemicolectomy (LH) for the treatment of cancers located between the distal transverse and the proximal descending colon, and compare postoperative morbidity, mortality, pathological results and survival for the two techniques.

METHODS

A retrospective review was performed of a single institution series over ten years. Patients who underwent different operations, had benign disease or received palliative resections were excluded. Data collected were patient demographics, type and duration of surgery, tumour site, postoperative complications and histology results.

RESULTS

Ninety-eight patients were analysed (64 ERHs, 34 LHs). ERH was conducted using an open approach in 93.8% of cases compared with 73.5% for LH. The anastomotic leak rate was similar for both groups (ERH: 6.3%, LH: 5.9%). This was also the case for other postoperative complications, mortality (ERH: 1.6%, LH: 2.9%) and overall survival (ERH: 50.4 months, LH: 51.8 months). All but one patient in the ERH cohort had clear surgical margins. Nodal evaluation for staging was adequate in 78.1% of ERH cases and 58.8% of LH cases.

CONCLUSIONS

In our experience, both ERH and LH are adequate for tumours located between the distal transverse and the proximal descending colon.

Ultrasound v. sham ultrasound for experimentally induced delayed-onset muscle soreness: A double-blind, randomised controlled trial

Background. Therapeutic ultrasound (US) is an electrophysical therapy that is commonly used by sports physiotherapists, but its mechanismof action is unclear. There is little evidence that US therapy is more effective than sham US therapy, and any clinical benefits may be dueto a placebo effect.Objective. To investigate whether US has a specific effect that renders it effective in its own right, or whether its effect is placebo driven.Methods. In a double-blind controlled trial, delayed-onset muscle soreness (DOMS) was experimentally induced in both bicep musclesof 15 females. Sham US was applied to one bicep (n=15 biceps) and pulsed active US to the other bicep (n=15 biceps) of each participant,48 and 72 h after induction of DOMS. Primary and secondary outcomes were pain reported on the McGill Pain Questionnaire (MPQ) andrange of movement (ROM) (elbow extension) measured by goniometry, respectively.Results. Results showed significant improvements in pain and ROM over the intervention periods, but there was no difference betweeninterventions.Conclusion. US and sham US therapy improve pain equally when treating DOMS of the biceps in the context of a therapeutic encounter.This analgesic effect is placebo driven. Clinicians can influence the analgesic effect of US by managing the therapeutic context. Managementof patients’ anxiety may also boost the analgesic effect of US.

Spontaneous splenic rupture four days after an open appendicectomy

INTRODUCTION

Spontaneous splenic rupture is a rare but dangerous event that requires prompt diagnosis and frequently an emergency splenectomy. Previous case reports have described the occurrence in patients with medical conditions, anticoagulant treatments, endoscopic procedures, laparoscopic surgery or no particular predisposing factor. Our report is the first to describe the occurrence of spontaneous spleen rupture following a laparotomy conducted in the lower abdomen.

CASE HISTORY

A 62-year-old woman presented with a 10-day history of right iliac fossa pain radiating to the right leg and associated vomiting. Following a routine blood check and computed tomography (CT), she underwent an open appendicectomy through a lower midline laparotomy for an appendicular abscess. Four days later, she experienced haemorrhagic shock and a second CT scan diagnosed a spontaneous splenic rupture that required a prompt splenectomy.

CONCLUSIONS

Our case is the first that describes the spontaneous rupture of the spleen following an open procedure conducted in the lower quadrants. This entity must still be considered as a rare but potential cause for postoperative bleeding when no other obvious sources are identified.

Feasibility and acceptability of web-based enhanced relapse prevention for bipolar disorder (ERPonline): trial protocol

BACKGROUND

Relapse prevention interventions for Bipolar Disorder are effective but implementation in routine clinical services is poor. Web-based approaches offer a way to offer easily accessible access to evidence based interventions at low cost, and have been shown to be effective for other mood disorders.

METHODS/DESIGN

This protocol describes the development and feasibility testing of the ERPonline web-based intervention using a single blind randomised controlled trial. Data will include the extent to which the site was used, detailed feedback from users about their experiences of the site, reported benefits and costs to mental health and wellbeing of users, and costs and savings to health services. We will gain an estimate of the likely effect size of ERPonline on a range of important outcomes including mood, functioning, quality of life and recovery. We will explore potential mechanisms of change, giving us a greater understanding of the underlying processes of change, and consequently how the site could be made more effective. We will be able to determine rates of recruitment and retention, and identify what factors could improve these rates.

DISCUSSION

The findings will be used to improve the site in accordance with user needs, and inform the design of a large scale evaluation of the clinical and cost effectiveness of ERPonline. They will further contribute to the growing evidence base for web-based interventions designed to support people with mental health problems.