Gastrointestinal bleeding caused by epitheloid sarcoma: A case report.

Epithelioid sarcoma (ES) of the small bowel is a rare gastrointestinal tumour. We report a case of gastrointestinal bleeding secondary to small bowel ES in a 55-year-old gentleman. After gastroscopy and colonoscopy failed to identify the source of bleeding, we proceeded with computed tomography angiogram of the mesentery, which revealed intraluminal blood clot in the distal jejunum with features of obstruction. This is a rare cause of obscure gastrointestinal bleeding and emphasises the need for additional evaluation in the presence of negative endoscopic findings.

Idiopathic duodenal varix presenting as a massive upper gastrointestinal bleeding: A case report.

Ectopic variceal bleeding is both a diagnostic dilemma and a therapeutic challenge, especially when it is located in the third part of the duodenum. Varix is rare in the absence of cirrhosis or portal hypertension. Because the diagnosis of this condition is usually delayed, treatment is administered late resulting in high morbidity and mortality rate. We report a case of a 61-year-old lady with an idiopathic duodenal varix presenting as an upper gastrointestinal bleeding.

Axillary accessory breast carcinoma masquerading as axillary abscess: a case report.

Accessory breast is a frequently seen developmental breast abnormality, commoner among Asians than Caucasians. This ectopic breast tissue shares many similarities as the normal breast tissue, and although subjected to the same pathological processes, accessory breast carcinoma is rare. As locations of the accessory breast may be variable, detection of pathological lesions through clinical examinations and standard diagnostic tools (i.e., mammogram) can be difficult. Staging and management should be tailored-made according to the location of the accessory breast as well as its known pattern of lymphatic drainage. We report a case of an intra-ductal carcinoma occurring in an axillary accessory breast.

Combined Laparoscopic and Thoracoscopic Repair of A Large Traumatic Diaphragmatic Hernia: A Case Report.

Traumatic diaphragmatic hernia is a well known complication of blunt trauma to the abdomen and thorax. In the acute setting, laparotomy is mandatory. In this current era, this condition can be managed with minimally invasive surgery. We hereby report a case of delayed large left diaphragmatic hernia that was repaired with a combination of laparoscopic and thoracoscopic approach.

Combined laparoscopic and thoracoscopic repair of a large traumatic diaphragmatic hernia: a case report.

Traumatic diaphragmatic hernia is a well known complication of blunt trauma to the abdomen and thorax. In the acute setting, laparotomy is mandatory. In this current era, this condition can be managed with minimally invasive surgery. We hereby report a case of delayed large left diaphragmatic hernia that was repaired with a combination of laparoscopic and thoracoscopic approach.

Ano-coccygeal support in the treatment of idiopathic chronic posterior anal fissure: a prospective non-randomised controlled pilot trial.

BACKGROUND: Idiopathic chronic anal fissure is believed to be a consequence of a traumatic acute anodermal tear followed by recurrent inflammation and poor healing due to relative tissue ischaemia secondary to internal sphincter spasm. This pilot trial compared the efficacy of a novel manufactured ano-coccygeal support attached to a standard toilet seat (Colorec) to the standard procedure of lateral internal sphincterotomy (LIS) for chronic anal fissure. METHODS: Fifty-three patients with confirmed chronic anal fissures were enrolled and assigned, based on their preference, to the test group and the control group. Each patient was reviewed after therapy, and follow-up was scheduled at 4, 6 and 8 weeks and at 6 months. RESULTS: The fissure healing rate was 100% in both groups. There were no statistically significant differences between the test group (n = 30, median age 42 years; range 20-71 years) and the control group (n = 22, median age 38 years; range 23-60 years) with regards to resolution of rectal bleeding at defaecation after 4 weeks (86.6 vs. 72.7%, p = 0.698), and by week 6, bleeding had resolved in 100% of patients in both groups. There was no statistically significant difference between the test group and the control group with regards to pain scores at 4, 6 and 8 weeks (4.30 ± 0.79, 2.03 ± 0.80, 0.43 ± 0.50 vs. 3.50 ± 0.74, 1.68 ± 0.56, 0.50 ± 0.51, p = 0.054) and to time until complete healing of fissures (5.60 ± 1.52 weeks vs. 5.91 ± 1.57 weeks, p = 0.479). After continuous use of the ano-coccygeal support over 6 months, no patients in the test group had recurrent fissures. No complications were observed during the trial. CONCLUSIONS: Results of both methods were comparable and demonstrated that the ano-coccygeal support is at least as effective as LIS, without any short-term complications. Larger and randomised trials on the use of ano-coccygeal support for chronic anal fissures are awaited.

A survey of contemporary opinions and practices of surgical and intensive care specialists towards peri-operative venous thromboembolism prophylaxis in Asia.

AIM: This survey was conducted to determine the opinions and practices of peri-operative venous thromboembolism (VTE) prophylaxis among surgical and intensive care specialists in Asia. METHODS: A set of questionnaire was distributed to surgeons and intensivists from different countries in Asia. The specialties included were general surgery and its sub-specialties, orthopaedic surgery, gynaecological surgery and intensive care unit. This survey involved teaching institutions, general hospitals and private hospitals. To gauge if the respondents were from hospitals that would likely encounter VTE cases, the hospital's bed-strength, intensive care facility and sub-specialty services were recorded. Over a period of six months, questionnaires and feedbacks were collected and analyzed. RESULTS: One hundred and ninety-one responses were received from 8 countries throughout Asia. Fifty-six percent of these were from large hospitals (800 bedded or more) and 62% of these hospitals have large intensive care facility (20 or more beds). Only half of the respondents practice routine thromboprophylaxis in moderate and high risk surgeries. Thirty six percent of them practices selective thromboprophylaxis and only 3% do not believe in any thromboprophylaxis. A third prescribed thromboprophylaxis for 3 to 5 days; another third extended it until patient is mobile. About 48.6% of the respondents do not have VTE guidelines in their institutions. Majority of the respondents agreed that more evidence is needed in the form of multi-centre randomized controlled trials to influence their decision on thromboprophylaxis. CONCLUSION: Despite the availability of strong epidemiological data, randomized controlled trials and multicentre case-controlled studies, perioperative VTE prophylactic practices are still suboptimal in Asia.

Data warehousing methods and processing infrastructure for brain recovery research.

In order to accelerate translational neuroscience with the goal of improving clinical care it has become important to support rapid accumulation and analysis of large, heterogeneous neuroimaging samples and their metadata from both normal control and patient groups. We propose a multi-centre, multinational approach to accelerate the data mining of large samples and facilitate data-led clinical translation of neuroimaging results in stroke. Such data-driven approaches are likely to have an early impact on clinically relevant brain recovery while we simultaneously pursue the much more challenging model-based approaches that depend on a deep understanding of the complex neural circuitry and physiological processes that support brain function and recovery. We present a brief overview of three (potentially converging) approaches to neuroimaging data warehousing and processing that aim to support these diverse methods for facilitating prediction of cognitive and behavioral recovery after stroke, or other types of brain injury or disease.

Alpha neurofeedback improves the maintaining ability of alpha activity.

The effects of alpha-neurofeedback (ANF) on electroencephalographic alpha-activity were investigated. Each session consisted of a 2.5-min eye-opened state and 17.5-min of ANF, which was divided into 16 1.25-min bins. Alpha amplitudes were gradually increased as the session was repeated. The maximum value at the start of ANF gradually decreased as time passed, but the slowdown of alpha-activity during each session was decreased as the session was repeated. The correlation between alpha-activity at the end of ANF and at the following session's eye-opened state was highly significant. These results showed that ANF enhances the ability of alpha-activity to maintain itself rather than the increase of alpha-amplitude during intrasession and that the maintained alpha-activity during former training remained until the next session.

Differences between systematic reviews/meta-analyses of hyaluronic acid/hyaluronan/hylan in osteoarthritis of the knee.

OBJECTIVE: To explore reasons for discrepant results between systematic reviews (SR)/meta-analyses (MA) of the efficacy and safety of hyaluronic acid/hyaluronan/hylan (HA) therapy in the treatment of osteoarthritis (OA) of the knee. METHODS: A decision algorithm was utilised to identify reasons for discordance among six SR. Sources of discordance such as clinical question, trial selection and inclusion, data extraction, assessment of study quality, assessment of the ability to combine trials, and statistical methods for data synthesis were examined. RESULTS: A similar question was asked in all six SR. Different trials were selected for inclusion in the reviews mainly because of differences in the search strategies and selection criteria. Although similar methods for data extraction were utilised, differences were found both in the outcome measures and time-points selected for extraction. Methodological quality was not always formally assessed. Different statistical methods for data synthesis resulted in conflicting estimates of therapeutic effect. CONCLUSIONS: Reasons for the inconsistency of results reported in the six SR were identified. Using the principles of the GRADE approach for estimating the therapeutic effect of HA in the treatment of OA of the knee, there is moderate evidence suggesting that further research is unlikely to change our confidence in the estimate of the effect. In the balance of benefit to harm, the trade-off is probable benefit with respect to pain reduction and physical function improvement with low risk of harm.

Intraarticular corticosteroid for treatment of osteoarthritis of the knee.

BACKGROUND: Osteoarthritis (OA) is a common joint disorder. In the knee, injections of corticosteroids into the joint (intraarticular (IA)) may relieve inflammation, and reduce pain and disability. OBJECTIVES: To evaluate the efficacy and safety of IA corticosteroids in treatment of OA of the knee. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 2, 2003), MEDLINE (to January (week 1) 2006 for update), EMBASE, PREMEDLINE (all to July 2003), and Current Contents (Sept 2000). Specialised journals, trial reference lists and review articles were handsearched. SELECTION CRITERIA: Randomised controlled trials of IA corticosteroids for patients with OA of the knee: single/double blind, placebo-based/comparative studies, reporting at least one core OMERACT III outcome measure. DATA COLLECTION AND ANALYSIS: Methodological quality of trials was assessed, and data were extracted in duplicate. Fixed effect and random effects models, giving weighted mean differences (WMD), were used for continuous variables. Dichotomous outcomes were analysed by relative risk (RR). MAIN RESULTS: Twenty-eight trials (1973 participants) comparing IA corticosteroid against placebo, against IA hyaluronan/hylan (HA products), against joint lavage, and against other IA corticosteroids, were included.IA corticosteroid was more effective than IA placebo for pain reduction (WMD -21.91; 95% confidence interval (CI) -29.93 to -13.89) and patient global assessment (the RR was 1.44 (95% CI 1.13 to 1.82)) at one week post injection with an NNT of 3 to 4 for both, based on n=185 for pain on 100 mm visual analogue scale (VAS) and n=158 for patient global assessment. Data on function were sparse at one week post injection and neither statistically significant nor clinically important differences were detected. There was evidence of pain reduction between two weeks (the RR was 1.81 (95% CI 1.09 to 3.00)) to three weeks (the RR was 3.11 (95% CI 1.61 to 6.01), but a lack of evidence for efficacy in functional improvement. At four to 24 weeks post injection, there was lack of evidence of effect on pain and function (small studies showed benefits which did not reach statistical or clinical importance, i.e. less than 20% risk difference). For patient global, there were three studies which consistently showed lack of effect longer than one week post injection. However, all were fairly small sample sizes (less than 50 patients per group). This was supported by another study which did not find statistically significant differences, at any time point, on a continuous measure of patient global assessment (100 mm VAS).In comparisons of corticosteroids and HA products, no statistically significant differences were in general detected at one to four weeks post injection. Between five and 13 weeks post injection, HA products were more effective than corticosteroids for one or more of the following variables: WOMAC OA Index, Lequesne Index, pain, range of motion (flexion), and number of responders. One study showed a difference in function between 14 to 26 weeks, but no differences in efficacy were detected at 45 to 52 weeks. In general, the onset of effect was similar with IA corticosteroids, but was less durable than with HA products. Comparisons of IA corticosteroids showed triamcinolone hexacetonide was superior to betamethasone for number of patients reporting pain reduction up to four weeks post injection (the RR was 2.00 (95% CI 1.10 to 3.63). Comparisons between IA corticosteroid and joint lavage showed no differences in any of the efficacy or safety outcome measures. AUTHORS' CONCLUSIONS: The short-term benefit of IA corticosteroids in treatment of knee OA is well established, and few side effects have been reported. Longer term benefits have not been confirmed based on the RevMan analysis. The response to HA products appears more durable. In this review, some discrepancies were observed between the RevMan 4.2 analysis and the original publication. These are likely the result of using secondary rather than primary data and the statistical methods available in RevMan 4.2. Future trials should have standardised outcome measures and assessment times, run longer, investigate different patient subgroups, and clinical predictors of response (those associated with inflammation and structural damage).

Viscosupplementation for the treatment of osteoarthritis of the knee.

BACKGROUND: Osteoarthritis (OA) is the most prevalent chronic joint disorder worldwide and is associated with significant pain and disability. OBJECTIVES: To assess the effects of viscosupplementation in the treatment of OA of the knee. The products were hyaluronan and hylan derivatives (Adant, Arthrum H, Artz (Artzal, Supartz), BioHy (Arthrease, Euflexxa, Nuflexxa), Durolane, Fermathron, Go-On, Hyalgan, Hylan G-F 20 (Synvisc Hylan G-F 20), Hyruan, NRD-101 (Suvenyl), Orthovisc, Ostenil, Replasyn, SLM-10, Suplasyn, Synject and Zeel compositum). SEARCH STRATEGY: MEDLINE (up to January (week 1) 2006 for update), EMBASE, PREMEDLINE, Current Contents up to July 2003, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched. Specialised journals and reference lists of identified randomised controlled trials (RCTs) and pertinent review articles up to December 2005 were handsearched. SELECTION CRITERIA: RCTs of viscosupplementation for the treatment of people with a diagnosis of OA of the knee were eligible. Single and double-blinded studies, placebo-based and comparative studies were eligible. At least one of the four OMERACT III core set outcome measures had to be reported (Bellamy 1997). DATA COLLECTION AND ANALYSIS: Each trial was assessed independently by two reviewers for its methodological quality using a validated tool. All data were extracted by one reviewer and verified by a second reviewer . Continuous outcome measures were analysed as weighted mean differences (WMD) with 95% confidence intervals (CI). However, where different scales were used to measure the same outcome, standardized mean differences (SMD) were used. Dichotomous outcomes were analyzed by relative risk (RR). MAIN RESULTS: Seventy-six trials with a median quality score of 3 (range 1 to 5) were identified. Follow-up periods varied between day of last injection and eighteen months. Forty trials included comparisons of hyaluronan/hylan and placebo (saline or arthrocentesis), ten trials included comparisons of intra-articular (IA) corticosteroids, six trials included comparisons of nonsteroidal anti-inflammatory drugs (NSAIDs), three trials included comparisons of physical therapy, two trials included comparisons of exercise, two trials included comparisons of arthroscopy, two trials included comparisons of conventional treatment, and fifteen trials included comparisons of other hyaluronans/hylan. The pooled analyses of the effects of viscosupplements against 'placebo' controls generally supported the efficacy of this class of intervention. In these same analyses, differential efficacy effects were observed for different products on different variables and at different timepoints. Of note is the 5 to 13 week post injection period which showed a percent improvement from baseline of 28 to 54% for pain and 9 to 32% for function. In general, comparable efficacy was noted against NSAIDs and longer-term benefits were noted in comparisons against IA corticosteroids. In general, few adverse events were reported in the hyaluronan/hylan trials included in these analyses. AUTHORS' CONCLUSIONS: Based on the aforementioned analyses, viscosupplementation is an effective treatment for OA of the knee with beneficial effects: on pain, function and patient global assessment; and at different post injection periods but especially at the 5 to 13 week post injection period. It is of note that the magnitude of the clinical effect, as expressed by the WMD and standardised mean difference (SMD) from the RevMan 4.2 output, is different for different products, comparisons, timepoints, variables and trial designs. However, there are few randomised head-to-head comparisons of different viscosupplements and readers should be cautious, therefore, in drawing conclusions regarding the relative value of different products. The clinical effect for some products, against placebo, on some variables at some timepoints is in the moderate to large effect-size range. Readers should refer to relevant tables to review specific detail given the heterogeneity in effects across the product class and some discrepancies observed between the RevMan 4.2 analyses and the original publications. Overall, the analyses performed are positive for the HA class and particularly positive for some products with respect to certain variables and timepoints, such as pain on weight bearing at 5 to 13 weeks postinjection. In general, sample-size restrictions preclude any definitive comment on the safety of the HA class of products; however, within the constraints of the trial designs employed no major safety issues were detected. In some analyses viscosupplements were comparable in efficacy to systemic forms of active intervention, with more local reactions but fewer systemic adverse events. In other analyses HA products had more prolonged effects than IA corticosteroids. Overall, the aforementioned analyses support the use of the HA class of products in the treatment of knee OA.

Antibiotic prophylaxis in patients with valvular heart defects undergoing dermatological surgery remains a confusing issue despite apparently clear guidelines.

The guidelines pertaining to prescription of prophylactic antibiotics to prevent endocarditis during dermatological surgery appear clear and well-documented. The British Society for Dermatological Surgery, in agreement with the British Society for Antimicrobial Chemotherapy, state that antibiotic prophylaxis for endocarditis is not required for routine dermatological surgery procedures even in the presence of a pre-existing heart lesion. Pre-existing cardiac lesions include prosthetic valves, history of bacterial endocarditis, congenital cardiac malformation, rheumatic or other acquired valvular dysfunction, hypertrophic cardiomyopathy or mitral valve prolapse with regurgitation. It is important to distinguish between antibiotic prophylaxis for wound infection and that for bacterial endocarditis. Routine procedures, such as punches, shaves, curettage and simple excisions, performed on clean intact skin have an extremely low risk of wound infection (1-4%). The risk of wound infection increases to 5-15% with clean-contaminated skin surgery that includes procedures involving eroded or ulcerated skin, respiratory or buccal mucosa, flexural areas and protracted procedures such as Mohs' micrographic surgery. In such cases, antibiotic prophylaxis may be considered in patients with a cardiac lesion because a wound infection may result in bacteraemia and subsequent endocarditis. This should therefore not be considered 'routine' dermatological surgery. In contaminated, dirty and/or infected classes of wounds the risk of wound infection is higher (> 25%). Elective skin surgery should be postponed if possible until the wound infection is treated with therapeutic antibiotics.

Viscosupplementation for the treatment of osteoarthritis of the knee.

BACKGROUND: Osteoarthritis (OA) is the most prevalent chronic joint disorder worldwide and is associated with significant pain and disability. OBJECTIVES: To assess the effects of viscosupplementation in the treatment of OA of the knee. The products were hyaluronan and hylan derivatives (Adant, Arthrum H, Artz (Artzal, Supartz), BioHy (Arthrease), Durolane, Fermathron, Go-On, Hyalgan, Hylan G-F 20 (Synvisc Hylan G-F 20), NRD-101, Orthovisc, Ostenil, Replasyn, SLM-10, Suplasyn, Synject and Zeel compositum). SEARCH STRATEGY: MEDLINE, EMBASE, PREMEDLINE, Current Contents up to July 2003, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched. Specialised journals and reference lists of identified randomised controlled trials (RCTs) and pertinent review articles up to April 2004 were handsearched. SELECTION CRITERIA: RCTs of viscosupplementation for the treatment of people with a diagnosis of OA of the knee were eligible. Single and double-blinded studies, placebo-based and comparative studies were eligible. At least one of the four OMERACT III core set outcome measures had to be reported (Bellamy 1997). DATA COLLECTION AND ANALYSIS: Each trial was assessed independently by two reviewers (NB, JC) for its methodological quality using a validated tool. All data were extracted by one reviewer (JC) and verified by a second reviewer (VR). Continuous outcome measures were analysed as weighted mean differences (WMD) with 95% confidence intervals (CI). Dichotomous outcomes were analyzed by relative risk (RR). MAIN RESULTS: Sixty-three trials with a median quality score of 3 (range 1 to 5) were identified. Follow-up periods varied between day of last injection and one year. Thirty-seven trials included comparisons of hyaluronan/hylan and placebo, nine trials included comparisons of intra-articular (IA) corticosteroids, and five trials included comparisons of nonsteroidal anti-inflammatory drugs (NSAIDs). The pooled analyses of the effects of viscosupplements against 'placebo' controls generally supported the efficacy of this class of intervention. In these same analyses, differential efficacy effects were observed for different products on different variables and at different timepoints. Of note is the 5 to 13 week post injection period which showed a percent improvement from baseline of 11 to 54% for pain and 9 to 15% for function. In general, comparable efficacy was noted against NSAIDs and longer-term benefits were noted in comparisons against IA corticosteroids. In general, few adverse events were reported in the hyaluronan/hylan trials included in these analyses. AUTHORS' CONCLUSIONS: Based on the aforementioned analyses, viscosupplementation is an effective treatment for OA of the knee with beneficial effects: on pain, function and patient global assessment; and at different post injection periods but especially at the 5 to 13 week post injection period. It is of note that based on non-randomised groups, the magnitude of the clinical effect, as expressed by the WMD and standardised mean difference (SMD) from the RevMan 4.1 output, is different for different products, comparisons, timepoints, variables and trial designs. However, there are few randomised head-to-head comparisons of different viscosupplements and readers should be cautious, therefore, in drawing conclusions regarding the relative value of different products. The clinical effect for some products, against placebo, on some variables at some timepoints is in the moderate to large effect-size range. Readers should refer to relevant tables to review specific detail given the heterogeneity in effects across the product class and some discrepancies observed between the RevMan 4.1 analyses and the original publications. Overall, the analyses performed are positive for the HA class and particularly positive for some products with respect to certain variables and timepoints, such as pain on weight bearing at 5 to 13 weeks postinjection. In general, sample-size restrictions preclude any definitive comment on the safety of the HA class of products; however, within the constraints of the trial designs employed no major safety issues were detected. In some analyses viscosupplements were comparable in efficacy to systemic forms of active intervention, with more local reactions but fewer systemic adverse events. In other analyses HA products had more prolonged effects than IA corticosteroids. Overall, the aforementioned analyses support the use of the HA class of products in the treatment of knee OA.

Intraarticular corticosteroid for treatment of osteoarthritis of the knee.

BACKGROUND: Osteoarthritis (OA) is a common joint disorder. In the knee, injections of corticosteroids into the joint (intra-articular (IA)) may relieve inflammation, and reduce pain and disability. OBJECTIVES: To evaluate the efficacy and safety of IA corticosteroids in treatment of OA of the knee. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 2, 2003), MEDLINE, EMBASE, PREMEDLINE (all to July 2003), and Current Contents (Sept 2000). Specialised journals, trial reference lists and review articles were handsearched. SELECTION CRITERIA: Randomised controlled trials of IA corticosteroids for patients with OA of the knee: single/double blind, placebo-based/comparative studies, reporting at least one core OMERACT III outcome measure. DATA COLLECTION AND ANALYSIS: Methodological quality of trials was assessed, and data were extracted in duplicate. Fixed effect and random effects models, giving weighted mean differences (WMD), were used for continuous variables. Dichotomous outcomes were analysed by relative risk (RR). MAIN RESULTS: Twenty-six trials (1721 participants) comparing IA corticosteroid against placebo, against IA hyaluronan/hylan (HA products), against joint lavage, and against other IA corticosteroids, were included.IA corticosteroid was more effective than IA placebo for pain reduction (WMD -17.79; 95% confidence interval (CI) -25.02 to -10.55) and patient global assessment (the RR was 1.44 (95% CI 1.13 to 1.82)) at one week post injection with an NNT of 3 to 4 for both, based on n=185 for pain on 100 mm visual analogue scale (VAS) and n=158 for patient global assessment. Data on function were sparse at one week post injection and neither statistically significant nor clinically important differences were detected. There was evidence of pain reduction between two weeks (the RR was 1.81 (95% CI 1.09 to 3.00)) to three weeks (the RR was 3.11 (95% CI 1.61 to 6.01), but a lack of evidence for efficacy in functional improvement. At four to 24 weeks post injection, there was lack of evidence of effect on pain and function (small studies showed benefits which did not reach statistical or clinical importance, i.e. less than 20% risk difference). For patient global, there were three studies which consistently showed lack of effect longer than one week post injection. However, all were fairly small sample sizes (less than 50 patients per group). This was supported by another study which did not find statistically significant differences, at any time point, on a continuous measure of patient global assessment (100 mm VAS). In comparisons of corticosteroids and HA products, no statistically significant differences were in general detected at one to four weeks post injection. Between five and 13 weeks post injection, HA products were more effective than corticosteroids for one or more of the following variables: WOMAC OA Index, Lequesne Index, pain, range of motion (flexion), and number of responders. One study showed a difference in function between 14 to 26 weeks, but no differences in efficacy were detected at 45 to 52 weeks. In general, the onset of effect was similar with IA corticosteroids, but was less durable than with HA products. Comparisons of IA corticosteroids showed triamcinolone hexacetonide was superior to betamethasone for number of patients reporting pain reduction up to four weeks post injection (the RR was 2.00 (95% CI 1.10 to 3.63). Comparisons between IA corticosteroid and joint lavage showed no differences in any of the efficacy or safety outcome measures. AUTHORS' CONCLUSIONS: The short-term benefit of IA corticosteroids in treatment of knee OA is well established, and few side effects have been reported. Longer term benefits have not been confirmed based on the RevMan analysis. The response to HA products appears more durable. In this review, some discrepancies were observed between the RevMan 4.1 analysis and the original publication. These are likely the result of using secondary rather than primary data and the statistical methods available in RevMan 4.1. Future trials should have standardised outcome measures and assessment times, run longer, investigate different patient subgroups, and clinical predictors of response (those associated with inflammation and structural damage).

Barium peritonitis--following barium enema of the proximal colon through a colostomy

Perforation with extravasation of barium is a rare complication of contrast enema examination of the large bowel with a high associated mortality rate. The experience of performing a re-laparotomy in a patient previously exposed to barium peritonitis is even less common. We describe an elderly male patient with a Hartmann's procedure performed a year previously, presenting with peritonitis following barium enema evaluation of the proximal colon via an end descending colon stoma. Emergency laparotomy, segmental bowel resection and liberal peritoneal toilet resulted in a satisfactory outcome. The patient had a subsequent successful reversal of his Hartmann's procedure nine months later despite the presence of dense barium induced adhesions. This potentially preventable iatrogenic complication is discussed in this report, which is supplemented by a brief review of the English literature.

Pharmacokinetics and inflammatory fluid penetration of intravenous daptomycin in volunteers.

The lipopeptide antimicrobial daptomycin was administered intravenously at a dose of 4 mg/kg of body weight to seven healthy male volunteers. The concentrations of daptomycin in plasma, cantharidin-induced inflammatory fluid, and urine were measured by a microbiological assay. The mean +/- standard deviation peak concentrations in plasma and inflammatory fluid were 77.5 +/- 8.3 and 27.6 +/- 9.5 microg/ml, respectively; the mean terminal elimination half-lives were 7.74 and 13.2 h, respectively. The overall penetration of total drug into the inflammatory fluid (measured by ratio of the area under the concentration-time curve from 0 to 24 h for inflammatory fluid compared with that for plasma) was 68.4%. The mean urinary recovery over 24 h was 59.7%.

Single-dose pharmacokinetics and penetration of BMS 284756 into an inflammatory exudate.

The pharmacokinetics of a single dose of BMS 284756 were determined following oral administration of a 600-mg dose to eight healthy male volunteers. Concentrations of the drug were measured in plasma and a cantharidine-induced inflammatory exudate by a microbiological assay. The mean peak concentration in plasma of 10.4 microg/ml (standard deviation [SD], 1.3 microg/ml) was attained at a mean time of 1.2 h (SD, 0.5 h) after the dose. The penetration into the inflammatory exudate was 82% (SD, 15.7%). A mean peak concentration of 7.2 microg/ml (SD, 2.4 microg/ml) was attained in the inflammatory exudate at 5.3 h (SD, 1.5 h). The elimination half-lives from plasma and inflammatory fluid were 9.8 h (SD, 1.1 h) and 8.5 h (SD, 1.9 h), respectively. The areas under the concentration-time curves for plasma and inflammatory fluid were 96.7 microg x h/ml (SD, 10.3 microg x h/ml) and 77.9 microg x h/ml (SD, 19.2 microg x h/ml), respectively.