Power of narrative: a case study about documenting private insightful experiences while dealing with pain and associated disability.

Objective: People adjusting to living with a chronic disability, such as chronic pain, seek support and resources from societal systems, including health systems, to help them cope with this reality. This case study describes the use of a digital health platform designed to help in that quest. Method: MyHealthMyRecord (MHMR), is being developed to record, register and curate personal private experiences of a chronic condition. MHMR allows users to record and log short (30-90s) personal and private audio-videos of their accommodation-seeking journey in a way that can be encrypted, registered, curated and shared privately. This case study describes the use of a prototype version of the platform by a participant co-designer who experienced a sudden onset of a chronic pain condition, of undetermined origin. System use began three months after the onset of the condition and just after being discharged from several months of hospitalization without any definitive diagnosis. Result: During a three-month period, 65 short unstructured contributions were authored and logged. This paper presents a qualitative analysis of that content. The clips used various communication styles that documented experiences, concerns, issues, positive and negative interactions and pain episodes. Using thematic analysis with open coding, three domains (person-facing, accessibility and system-facing) and eight themes (pain, joy, therapy, environmental, recommendations, technical, culture and communication) were identified. Comments about pain, stress, etc., were the most common and occurred in 75% of all videos while technical and therapy/physio related comments were the fewest and occurred in 3 and 9% of the videos, respectively. Conclusion: We conclude that it is possible to create recordings of events, thoughts, reflections and issues on different aspects affecting an individual's health and well-being impact, including effects of the chronic condition as well as tangential outcomes such as accessibility (or lack of it), using MHMR over a longer period of time. The next steps will be to develop functionality to annotate the recordings, automatically analyze and summarize collections of recordings to make them consumable, useful and understandable to the individual and others, and then to share those analyses and summaries with others. In addition, evaluate this functionality longitudinally with more users.

Injury to the brachial plexus in neck dissections.

Injury to the brachial plexus is a rare complication of neck dissection. We present a case of a 65-year-old man who developed a lesion of the nerve root of C5 and C6 as a result of radical neck dissection.

Immediate repair and early mobilization of the extensor pollicis longus tendon in zones 1 to 4.

We present the results of repair and early mobilization of 100 extensor pollicis longus (EPL) tendon injuries in zones 1 to 4 in 100 patients using a dynamic outrigger splint which controlled metacarpophalangeal joint movements but allowed free movement of the interphalangeal joint. Eighty-two were complete divisions of the tendon and 18 were 80% to 99% tendon divisions. Analysis of measurements obtained routinely at 8 weeks showed 81% excellent and good results using the TAM system. There were 90% excellent and good results in the 72 patients, who were followed-up and received therapy for 12 weeks. Except on the rare occasion when the repair rupture, loss of thumb extension was not a common functional problem, but scar tethering of the repaired tendon could result in loss of thumb flexion. While loss of metacarpophalangeal joint flexion appeared to have little functional importance, loss of interphalangeal joint flexion and slowing of the movements of this joint could cause functional problems. When interphalangeal joint hyperextension is present before the injury, it is frequently lost but this generally goes unnoticed by the patients. The problems of analysing the EPL injury using the methods of assessment available are discussed.

Management of iatrogenic lower limb ischaemia in children.

An acutely ischaemic lower limb following femoral artery cannulation in children is a problem infrequently encountered by plastic surgeons in the UK. When such a case presented to us, we performed a search of published literature to guide us to the optimum treatment. This included methods for extraperitoneal exposure of the common iliac artery and vein. We describe the surgical technique that we used to salvage an acutely ischaemic lower limb following femoral puncture and a review of the literature.

The use of Acufex wedge tag tissue anchors in hand surgery.

Over a period of 4 years, in various circumstances commonly seen in hand surgery, 100 patients underwent 127 soft tissue attachments to bone using the Acufex wedge tag system (Acufex Microsurgical, Inc, Mansfield, MA), a non-metallic bone anchor. No failures to maintain the attachment of the desired soft tissue to bone were identified. While less robust than the Mitek anchor, the other commonly available system of bone anchoring, and therefore possibly inappropriate for general orthopaedics, the Acufex wedge tag proved adequate for the smaller forces of hand surgery.

The flexor digitorum profundus "demi-tendon"--a new technique for passage of the flexor profundus tendon through the A4 pulley.

The flexor digitorum profundus (FDP) tendon may retract after avulsion or division in Zone 1. When treatment has been delayed, the oedematous tendon can be too swollen to pass freely through the A4 pulley. We present a new technique for dealing with this situation which depends on the "double-barrelled" nature of the distal part of the FDP tendon. One half of the tendon is excised longitudinally and the remaining "demi-tendon" is passed through the intact A4 pulley to allow tendon repair or re-attachment. This technique has been used in six cases in which passage of the FDP tendon through the A4 pulley would otherwise have been impossible.

Venous augmentation of the free TRAM flap.

Venous congestion in a free TRAM or DIEP flap when the main pedicle is still patent (both the artery and the vein) is an occasional dire situation. Here, we describe ways of salvaging the free TRAM or DIEP flap from imminent loss. In the last 4 years, we have had three patients who developed venous congestion after the use of the TRAM or DIEP flap for breast reconstruction. This was detected as late as the third postoperative day in our first patient. On exploration, patent arterial and venous anastomoses were found. Fortunately, the opposite pedicle had been dissected and preserved with the flap. The patent congested vein in this pedicle was anastomosed to the cephalic vein using an interpositional vein graft, relieving the congestion. In the other two patients congestion was detected earlier and relieved using the superficial inferior epigastric vein. It has been our policy to dissect a length of the opposite pedicle and/or preserve a length of the superficial inferior epigastric vein or the superficial circumflex iliac vein. These can then be used to augment venous drainage if inadequacy is noted at the end of the operation or during the postoperative period.

A comparison of dynamic extension splinting and controlled active mobilization of complete divisions of extensor tendons in zones 5 and 6.

We present a prospective randomized trial of two groups of 50 patients each having complete zone 5 and 6 extensor tendon injuries. These were rehabilitated by the use of either a dynamic outrigger splint or a palmar blocking splint. The results were analysed using the Miller and TAM assessments. Good and excellent results were achieved in 95 and 98% of cases following dynamic outrigger mobilization and 93 and 95% of cases using palmar blocking splint mobilization, using the Miller and TAM assessments respectively. There was no statistical difference in the results obtained between the two groups. Therefore, we prefer the latter technique which is simple, cheap, more convenient and requires less therapy time.

Anomalies of the flexor digitorum superficialis muscle.

Three anomalies of the human flexor digitorum superficialis are presented. The normal development of this muscle from the amphibian to the human is discussed and the described anomalies of the muscle in humans classified.

A double blind, randomized, placebo-controlled phase II study to assess the safety and efficacy of orally administered SP-303 for the symptomatic treatment of diarrhea in patients with AIDS.

OBJECTIVE: The aim of this study was to investigate the safety and effectiveness of orally administered SP-303 in patients with AIDS and diarrhea. METHODS: This is a multicenter, phase II, randomized, double blind, placebo-controlled study. HIV-positive subjects with a history of a CD4 count <200 or an AIDS-defining illness were admitted to an inpatient study unit and screened for diarrhea defined as at least three abnormal (i.e., soft or watery) stools and >200 g of abnormal stool weight over a 24-h period. Subjects discontinued all antidiarrheal agents >24 h before enrollment. Stool samples were studied for routine pathogens. Subjects received 500 mg p.o. of SP-303 or placebo every 6 h for 96 h (4 days). Stool frequency and weights were recorded. Subjects were monitored for symptoms and side effects and were seen 1 wk later in follow-up. RESULTS: A total of 26 subjects received SP-303, and 25 received placebo. There were no significant demographic differences between treatment arms. A total of 41 subjects (80%) were receiving antiretroviral therapy and 39 subjects (77%) were receiving at least one protease inhibitor. Stool studies revealed no pathogens in 48 of 51 patients (94%). There were no serious adverse events or laboratory abnormalities. The SP-303 treatment group demonstrated a mean reduction from baseline stool weight of 451 g/24 h versus 150 g/24 h with placebo on day 4 of treatment (p = 0.14), and a mean reduction in abnormal stool frequency of three abnormal stools in 24 h versus two in 24 h in the placebo group (p = 0.30). Daily measures analysis over 4 days of treatment demonstrated that SP-303 subjects had a significant reduction in stool weight (p = 0.008) and abnormal stool frequency (p = 0.04) when compared to placebo-treated subjects. CONCLUSIONS: SP-303 is safe and well tolerated. These results suggest that SP-303 may be effective in reducing stool weight and frequency in patients with AIDS and diarrhea.

Effect of masoprocol on carbohydrate and lipid metabolism in a rat model of Type II diabetes.

Extracts of the creosote bush (Larrea tridentata, family Zygophyllaceae) have long been used as a folk remedy for Type II (non-insulin-dependent) diabetes by native Americans in southwestern North America. In this study we have evaluated the metabolic effects of masoprocol, a pure compound isolated from the creosote bush, in a rat model of Type II diabetes. Animals were fed a 20% fat (by weight) diet for 2 weeks prior to intravenous injection with streptozotocin (STZ, 0.19 mmol/kg). Diabetic animals (glucose 16-33 mmol/l) were treated with vehicle, metformin (0.83 mmol/kg body weight) or masoprocol (0.83 mmol/kg body weight) twice a day for 4 days. Masoprocol treatment lowered glucose concentrations an average of 35% compared with vehicle (14.2+/-1.1 vs 21.7+/-1.0 mmol/l, p < 0.001), a reduction similar to metformin treatment (12.8+/-0.9 mmol/l), without any change in insulin concentration. Masoprocol treatment also lowered triglyceride concentrations 80% compared with vehicle (1.0+/-0.1 vs 4.8+/-0.3 mmol/l, p < 0.001), a reduction far greater than following metformin treatment (3.6+/-0.3 mmol/l). Non-esterified fatty acid and glycerol concentration were decreased by approximately 65% by masoprocol compared with vehicle, a reduction approximately twice as great as seen with metformin (p < 0.001). The effect of masoprocol on in vivo insulin-mediated glucose disposal was evaluated by infusing fat-fed/STZ rats with glucose (0.22 mmol kg x min(-1)) and insulin (30 pmol x kg x min(-1)) for 5 h. In response to the infusion, steady-state plasma glucose concentrations were reduced 30% in masoprocol-treated animals compared with vehicle controls (p < 0.05) with no change noted in rats treated with metformin. The effect of masoprocol treatment was also tested in primary adipocytes isolated from normal animals. Adipocytes treated with masoprocol (30 micromol/l) had higher basal and insulin-stimulated glucose clearance than did adipocytes treated with vehicle (p <0.05). These data show that masoprocol decreases both plasma glucose and triglyceride concentrations in fat-fed/STZ rats, presumably as a result of its ability to both increase glucose disposal and decrease lipolysis.

5% amlexanox oral paste, a new treatment for recurrent minor aphthous ulcers: II. Pharmacokinetics and demonstration of clinical safety.

The safety of 5% Amlexanox paste was demonstrated in the following clinical studies: vehicle-controlled safety and efficacy studies; dermal irritation and sensitization studies; single and multiple dose pharmacokinetic studies; and a 28-day in use safety study. Minimal adverse experiences were observed with the 991 subjects that were exposed to 5% Amlexanox paste. No significant irritation or sensitization was associated with 5% Amlexanox paste. Pharmacokinetic studies indicated that systemic levels of Amlexanox are most likely due to normal gastrointestinal absorption with only limited absorption directly through the ulcer. After a 100 mg dose of 5% Amlexanox paste the average maximum concentration of Amlexanox in the serum was 120 ng/ml, occurring 2.4 hours after application. The half-life for elimination of Amlexanox was 3.5 hours, and there was no evidence of accumulation with multiple applications. Overall, the data indicate that 5% Amlexanox paste (Aphthasol) is safe for the treatment of recurrent minor aphthous ulcers.

5% amlexanox oral paste, a new treatment for recurrent minor aphthous ulcers: I. Clinical demonstration of acceleration of healing and resolution of pain.

5% Amlexanox oral paste (Aphthasol) was studied in four vehicle-controlled, randomized, double-blind, parallel group, multicenter, clinical studies involving 1335 subjects who had 1 to 3 aphthous ulcers less than 48 hours old at enrollment. Subjects applied study pastes directly to ulcers four times a day until ulcers healed or for the duration of the study, whichever occurred first. Ulcer size was measured by the investigator and pain was evaluated by the subject; the primary determinant of efficacy was the percentage of subjects with complete healing of ulcers and complete resolution of ulcer pain. The vehicle had marginal beneficial effects as would be expected from a covering material, but statistical significance over no treatment was inconsistent. However, these studies, both individually and collectively, clearly demonstrated in a highly significant and consistent manner that in comparison to both Vehicle and No Treatment 5% Amlexanox oral paste accelerates the resolution of pain and healing of aphthous ulcers.

Amlexanox oral paste: a novel treatment that accelerates the healing of aphthous ulcers.

Five percent Amlexanox oral paste is a novel treatment for aphthous ulcers. In 3 controlled clinical studies that evaluated 1,124 immunocompetent patients with mild to moderate aphthous ulcers, 5% Amlexanox oral paste (Aphthasol) was shown to accelerate healing of these ulcers. Treatment with Aphthasol reduced the median time to ulcer healing and to complete pain resolution in a statistically significant manner. This was true both when treatment with 5% Amlexanox oral paste was compared to treatment with a vehicle and when treatment with the Amlexanox paste was compared to no treatment. Study results after 3 days comparing treatment with the paste and no treatment indicated complete healing of ulcers for 21% and 8% of patients, respectively. Complete resolution of pain after 3 days was reported for 44% and 20% of patients, respectively.

A double-blind study of topically applied 5% amlexanox in the treatment of aphthous ulcers.

A double-blind trial of amlexanox (C16H14N2O4) was carried out in 32 patients with recurrent oral aphthous ulcerations. During the treatment period, which lasted for 3 days, patients received either placebo topical paste or 5% amlexanox paste. The paste was applied by the investigator twice per day for 3 days and once on the fourth day. Efficacy was assessed by the following parameters: 1) pain measured by the patients marking a 15-cm line between poles connoting no pain versus severe pain; 2) erythema evaluated by the investigator on a four-point scale ranging from none to strong; 3) size determined by investigator measurement of the perpendicular dimensions of the ulcer; and 4) an investigator's improvement scale consisting of six rank-ordered points from -1 for worsening of the ulcer with respect to previously described criteria to +4 when the ulcer had healed completely. All evaluations were based on a comparison with the day 1 visit of the patient. Outcomes for patients receiving the active ingredient were superior on all four criteria of effectiveness. Group differences for all criteria but pain reduction were statistically significant (P < .05). No side effects were reported. It was concluded that amlexanox is effective in reducing aphthous ulcer erythema, pain, and lesional size.

REV 5901: an orally effective peptidoleukotriene antagonist, detailed biochemical/pharmacological profile.

REV 5901 [alpha-pentyl-3-(2-quinolinylmethoxy)-benzene-methanol] has been shown to be a competitive antagonist of peptidoleukotrienes. In vitro it has a Ki value of 0.7 microM vs. [3H]leukotriene D4 ([3H]-LTD4) binding to membranes from guinea pig lung. Against LTC4-, LTD4- and LTE4-induced contractions of guinea pig parenchymal strips, it has Kb values of ca 3 microM and was relatively ineffective against contractions induced by other spasmogens. The peptiodoleukotriene-antagonist activity is also demonstrable against the hemodynamic and vasoconstriction effects of LTD4 in isolated guinea pig hearts. Oral antagonist activity has been shown with an LTD4-induced bronchoconstriction model and with an LTD4-induced wheal response model in guinea pigs. Unlike other reported antagonists, REV 5901 is ineffective against the multiple forms of cyclic nucleotide phosphodiesterases. Thus, in addition to its previously reported activity as a 5-lipoxygenase inhibitor, REV 5901 is a p.o. active antagonist of peptidoleukotrienes and represents a good tool for understanding the role of peptidoleukotrienes in disease.

REV 2871 (CHBZ): a potent antiallergic agent with a novel mechanism of action. II. Studies on the mechanism of action.

REV 2871 (CHBZ) was taken up by rat mast cells and human leukocytes in a specific and saturable manner. The compound can be hydrolyzed by a granule-associated enzyme in the mast cell to an ionic metabolite (REV 3579) whose in vitro profile is identical to that of disodium cromoglycate (DSCG). REV 3579, although achieving millimolar concentrations inside cells incubated with CHBZ, was not itself taken up by rat mast cells or human leukocytes. The unusual in vitro activity of CHBZ is postulated to arise from the fact that it is a prodrug for delivering a DSCG-like drug to the interior of a secretory cell. The internalized drug apparently exerts a more general and longer-lived inhibition of the secretory process than it can by acting on exterior membrane receptors. CHBZ thus represents a novel drug for studying anaphylactic responses in vitro.

REV 2871 (CHBZ): a potent antiallergic agent with a novel mechanism of action. I. Activity profile as an inhibitor of mediator release.

REV 2871 (CHBZ) and its putative metabolite REV 3579-Z (also designated in the literature as RHC 3579-Z) were shown to be potent and orally effective inhibitors of passive cutaneous anaphylaxis (PCA) in the rat (ED50 = 12 mg/kg). The activity profiles of CHBZ, REV 3579-Z and disodium cromoglycate (DSCG) were compared as inhibitors of histamine release (HR) in vitro from rat mast cells, human basophils, and guinea pig lung slices. CHBZ was a potent inhibitor of both immunologic and non-immunologic HR (I50 2-20 microM from rat mast cells). The activity profile of CHBZ as an inhibitor of HR from rat mast cells differed from that of DSCG and REV 3579-Z in the following respects: increasing inhibition of HR with increasing preincubation time; irreversibility of the inhibition; lack of tachyphylaxis and cross-tachyphylaxis to DSCG; potentiation of the inhibition of antigen-induced release of histamine (AIR) by DSCG; and inhibition of HR induced by dextran + phosphatidyl serine, compound 48/80, ionophore A23187 and platelet activating factor (PAF). In the human basophil model, CHBZ was: a potent inhibitor (I50 = 25 microM) of anti-IgE-induced release (AbIR), whereas DSCG and REV 3579-Z had no effect on AbIR; more potent as an inhibitor of AbIR than ionophore-induced release, whereas the reverse was true for proxicromil; an inhibitor of PAF-induced release, whereas proximcromil stimulated it; and potentiative with proxicromil for inhibition of AbIR. In the guinea pig lung slice model, CHBZ inhibited AIR (I50 = 800 microM) whereas DSCG and REV 3579-Z did not (I50 greater than 300 microM). We conclude that CHBZ is an orally effective antiallergic agent whose mechanism of action as an inhibitor of mediator release is different from DSCG and proxicromil.