Calcific myonecrosis: diagnostic dilemma.

Calcific myonecrosis is a rare benign condition affecting mainly the muscles of a single leg compartment. It is thought to follow a history of trauma with a latent period of years. Patients present with a slowly growing mass. Differential diagnosis from a malignant tumour can be made from the history and the distinctive radiographical features of a fusiform lesion with predominantly peripheral calcifications. Magnetic resonance imaging may be necessary to confirm the diagnosis; treatment is largely symptomatic.

Snapping Biceps Femoris: clinical demonstration and operative technique.

Snapping biceps femoris syndrome has been reported in the literature in a handful of case reports but not yet with a demonstration of clinical examination and intraoperative findings. We present an educational clinical video of snapping biceps femoris with intraoperative demonstration of findings and surgical repair.

Iliac crest apophyseal insufficiency avulsion fractures.

Iliac crest apophyseal avulsion fractures are rare injuries caused mainly through forceful contraction of attached muscles during high level sporting activities. We present the first case of a spontaneous iliac crest apophyseal avulsion insufficiency fracture in a patient with severe atopic eczema on oral steroids and review the relevant literature.

Sequential scapholunate and volar beak ligament reconstructions with flexor carpi radialis tendon grafts.

The flexor carpi radialis tendon is considered by many the workhorse tendon in hand and wrist surgery. Some have expressed concerns about altering the mechanics of the wrist by sacrificing part or all of the flexor carpi radialis tendon. We present an interesting case of sequential scapholunate and volar beak ligament reconstructions using a flexor carpi radialis tendon autograft where a slip of tendon was harvested twice within three years, achieving a satisfactory clinical outcome at five years following the initial surgery.

Management of joint dislocations of the lower limb in Larsen syndrome: practical approach.

INTRODUCTION Larsen syndrome is an autosomal-dominant osteochondrodysplasia characterised by large joint dislocations and craniofacial anomalies. CASE HISTORY We present a rare case of Larsen syndrome with bilateral dislocated hips and knees and severe clubfeet at 7-year follow-up. We undertook bilateral open reduction of both hips at age 8 months. This procedure was preceded by open reduction and left-knee V-Y quadricepsplasty at age 4 months following a failed trial of closed reduction of the left knee. Both feet had a severe deformity (Pirani score of 5.5 and 6.0) and were treated using the Ponseti method, but the left foot relapsed at 24 months and required posteromedial release. CONCLUSIONS We tried to address the difficult questions on the timing and sequence of surgical interventions by treating clubfeet and dislocated knees early using Ponseti casts which included the knees. Open reduction of hips was done later, and further interventions were guided by functional needs.

Correlation of 24-hour urinary protein quantification with spot urine protein:creatinine ratio in lupus nephritis.

OBJECTIVES: Twenty-four hour urine collection has been the foundation for monitoring patients with lupus nephritis. However, the use of protein to creatinine ratios in spot urine samples is now widely used. We aimed to evaluate the validity of this method cross-sectionally and longitudinally. METHODS: A cross-sectional retrospective study was conducted. Records of 486 lupus nephritis patients were searched for paired results of 24-h quantification of urinary protein and a random spot urine protein to creatinine ratio and were examined over a three-year period. RESULTS AND CONCLUSIONS: Ninety-five lupus nephritis patients had paired results and were included in the final analysis, male/female 14/81, mean age 36.5 years. Over a three-year period there were a total of 137 samples from 95 patients. For the entire dataset, there was a significant correlation between protein:creatinine ratio and 24-h urine collection protein (mg), Spearman Rho correlation coefficient was 0.869, p < 0.0001 with (R (2 )= 0.504). There was also a strong correlation for longitudinal data, n = 14 at two-years Rho 0.910, p < 0.0001 with (R (2 )= 0.878), n = 8 at three-years Rho 0.909, p < 0.0001 and (R (2 )= 0.73). We have shown for the first time in a UK population of lupus nephritis patients, well trained in producing 24-h collection, that the spot protein:creatinine ratio correlates well with 24-h urinary total protein excretion. Having a simple, reliable, reproducible and cost-effective test such as the spot urine protein:creatinine ratio is therefore a valuable tool with which to monitor disease progression.

Publications indexed in Medline and Embase originating from the Syrian Arab Republic: a survey.

Health research in the Syrian Arab Republic faces many difficulties, including limited funds, infrastructure and means of dissemination. In a search of Medline and Embase databases in March 2006 we extracted data on 386 biomedical papers originating from the Syrian Arab Republic. Embase had the superior coverage. A total of 64% were published in journals from Europe, 22% from North American journals and 12% in periodicals from the Middle East. Output of papers increased by 1.4 articles/year since 1979. The topics of 57% of papers were biomedical, with the remainder being pure science or agricultural/veterinarian issues. Dentistry, public health and surgery were the commonest subjects of the biomedical papers. Funding was largely from government.

Quality of life in patients with prostate cancer: development and application of a hybrid assessment method.

Investigator-derived quality of life (QoL) instruments such as the Functional Assessment of Cancer Therapy-Prostate (FACT-P) questionnaire do not allow participants to weight the relative importance of QoL domains. We investigated the effect of allowing patients the ability to weight the relative importance of the five areas included in the FACT-P (Physical, Social, Emotional and Functional well-being, and Additional concerns). Patients (n=150) completed the FACT-P and gauged the relative importance of each QoL domain using a direct-weighting approach. This was then used to provide an adjusted Hybrid QoL score. Patients also completed a Visual Analogue Scale. Patients considered Social well-being to be the most important domain and Additional concerns to be the least important. When patient weightings were taken into account overall QoL scores increased. The validity of the Hybrid score was supported by its ability to distinguish between patients with metastatic and locoregional disease and its ability to detect expected decreases in global QoL over time. Application of the direct-weighting approach to the FACT-P allows assessments to more accurately reflect individual QoL. Unadjusted QoL scores may lead researchers to incorrectly estimate the true QoL of respondents.

Publications indexed in Medline and Embase originating from the Syrian Arab Republic: a survey

Health research in the Syrian Arab Republic faces many difficulties, including limited funds, infrastructure and means of dissemination. In a search of Medline and Embase databases in March 2006 we extracted data on 386 biomedical papers originating from the Syrian Arab Republic. Embase had the superior coverage. A total of 64% were published in journals from Europe, 22% from North American journals and 12% in periodicals from the Middle East. Output of papers increased by 1.4 articles/year since 1979. The topics of 57% of papers were biomedical, with the remainder being pure science or agricultural/veterinarian issues. Dentistry, public health and surgery were the commonest subjects of the biomedical papers. Funding was largely from government

Cigarettes and waterpipe smoking among medical students in Syria: a cross-sectional study.

OBJECTIVES: To investigate tobacco use, beliefs and attitudes among medical students in Syria. METHODS: A cross-sectional study of a random sample of 570 medical students (first and fifth year) registered at the Damascus University Faculty of Medicine in 2006-2007. We used a self-administered questionnaire for demo-graphic information, smoking behaviour (cigarette, waterpipe), family and peer smoking, attitudes and beliefs about smoking and future role in advising patients to quit smoking. RESULTS: The overall prevalence of tobacco use was 10.9% for cigarettes (15.8% men, 3.3% women), 23.5% for waterpipe (30.3% men, 13.4% women) and 7.3% for both (10.1% men, 3.1% women). Both smoking methods were more popular among the fifth year students (15.4% and 27%) compared to their younger counterparts (6.6% and 19.7%). Regular smoking patterns predominated for cigarettes (62%), while occasional use patterns predominated for waterpipes (83%). More than two thirds of students (69%) thought they might not address or would have difficulty addressing smoking in their future patients. CONCLUSION: The level of tobacco use among Syrian medical students is alarming and highlights the rapidly changing patterns of waterpipe use, especially among female students. Medical schools should work harder to tackle this phenomenon and address it more efficiently in their curricula.

Measuring the individual quality of life of patients with prostate cancer.

Prostate cancer can have diverse effects on patients' quality of life (QoL). Standard QoL questionnaires do not address all of the concerns expressed by such patients. The primary purpose of this study was to identify those issues with the greatest influence on the QoL of patients with prostate cancer. A secondary aim was to compare the performance of the Schedule for the Evaluation of Individual Quality of Life-Direct Weighting (SEIQoL-DW) semi-structured interview with the Functional Assessment of Cancer Therapy-Prostate questionnaire (FACT-P). A mixed population of patients with prostate cancer (including those with localized and metastatic disease) completed the SEIQoL-DW and the FACT-P. The SEIQoL-DW was satisfactorily completed by 180 patients, including 93 patients with metastatic disease. Patients identified 144 separate QoL concerns, and these were then independently grouped by three of the authors into 13 distinct themes. The most frequently identified themes were 'leisure and hobbies', 'family' and 'health'. The themes that patients considered to be the most important were 'partner/spouse', 'family' and 'health'. Patients were most satisfied with their QoL in the domains of 'family', 'partner/spouse' and 'friends'. They were least satisfied with 'sexuality', 'mobility' and 'psychological factors'. Patients with metastatic disease rated their QoL significantly (P<0.0001) lower than other patients using the FACT-P, but not using the SEIQoL-DW (P=0.07). Patients with prostate cancer identified numerous QoL concerns that are not included (or are underrepresented) in standard health-related QoL questionnaires such as the FACT-P. Health-related QoL questionnaires may underestimate the QoL of patients with metastatic disease.

Cessation of medication for people with schizophrenia already stable on chlorpromazine.

BACKGROUND: Chlorpromazine, one of the first generation of antipsychotic drugs, is effective in the treatment of schizophrenia. For most people schizophrenia is a life-long disorder but about a quarter of those who have a first psychotic breakdown do not go on to experience further breakdowns. Most people with schizophrenia are prescribed antipsychotic drugs, although use is often intermittent. The effects of stopping medication are not well researched in the context of systematic reviews. OBJECTIVES: To quantify the effects of stopping chlorpromazine for people with schizophrenia stable on this drug. SEARCH STRATEGY: We supplemented an electronic search of the Cochrane Schizophrenia Group Trials Register (March 2006) with reference searching of all identified studies. SELECTION CRITERIA: We included all relevant randomised clinical trials. DATA COLLECTION AND ANALYSIS: We independently inspected citations and abstracts, ordered papers and re-inspected and quality assessed these. We independently extracted data and resolved disputes during regular meetings. We analysed dichotomous data using fixed effects relative risk (RR) and the 95% confidence interval (CI). For continuous data, where possible, we calculated the weighted mean difference (WMD). We excluded the data where more than 40% of people were lost to follow up. MAIN RESULTS: We included ten trials involving 1042 people with schizophrenia stable on chlorpromazine. Even in the short term, those who remained on chlorpromazine were less likely to experience a relapse compared to people who stopped taking chlorpromazine (n=376, 3 RCTs, RR 6.76 CI 3.37 to 13.54, NNH XX CI XX to XX). Medium term (n=850, 6 RCTs, RR 4.04 CI 2.81 to 5.8, NNH 4 CI 3 to 7) and long term data were similar (n=510, 3 RCTs, RR 1.70 CI 1.44 to 2.01, NNH XX CI XX to XX). People allocated to chlorpromazine withdrawal were not significantly more likely to stay in the study compared with those continuing chlorpromazine treatment (n=374, 1 RCT, RR 1.14 CI 0.55 to 2.35). In sensitivity analyses, there was a significant difference in the 'relapse' outcome between trials for those diagnosed according to checklist criteria compared to those with a clinical diagnosis. AUTHORS' CONCLUSIONS: This review confirms clinical experience and quantifies the risks of stopping chlorpromazine medication for a group of people with schizophrenia who are stable on this drug. With its moderate adverse effects, chlorpromazine is likely to remain one of the most widely prescribed treatments for schizophrenia.

Oral fluphenazine versus placebo for schizophrenia.

BACKGROUND: Fluphenazine is one of the first drugs to be classed as an 'antipsychotic' and has been widely available for five decades. OBJECTIVES: To evaluate the effects of oral fluphenazine for schizophrenia in comparison with placebo. SEARCH STRATEGY: We searched the Cochrane Schizophrenia Group's trials register (September 2006) which includes relevant randomised controlled trials from the bibliographic databases Biological Abstracts, CINAHL, The Cochrane Library, EMBASE, MEDLINE, PsycLIT, LILACS, PSYNDEX, Sociological Abstracts and Sociofile. References of all identified studies were searched for further trial citations. SELECTION CRITERIA: We sought all randomised controlled trials comparing oral fluphenazine with placebo relevant to people with schizophrenia. Primary outcomes of interest were global state and adverse effects. DATA COLLECTION AND ANALYSIS: We inspected citations and abstracts independently, ordered papers and re-inspected and quality assessed trials. We extracted data independently. Dichotomous data were analysed using fixed effects relative risk (RR) and the 95% confidence interval (CI). Continuous data were excluded if more than 50% of people were lost to follow up, but, where possible, weighted mean differences (WMD) were calculated. MAIN RESULTS: We found over 1200 electronic records for 415 studies, 47 of which were relevant but only seven could be included. Compared with placebo, in the short-term, global state outcomes for 'not improved' were not significantly different (n=75, 2 RCTs, RR 0.71 CI 0.5 to 1.1). There is evidence that oral fluphenazine, in the short term, increases a person's chances of experiencing extrapyramidal effects such as akathisia (n=227, 2 RCTs, RR 3.43 CI 1.2 to 9.6, NNH 13 CI 4 to 128) and rigidity (n=227, 2 RCTs, RR 3.54 CI 1.8 to 7.1, NNH 6 CI 3 to 17). We found study attrition to be lower in the oral fluphenazine group, but data were not statistically significant (n=227, 2 RCTs, RR 0.70 CI 0.4 to 1.1). AUTHORS' CONCLUSIONS: The findings in this review confirm much that clinicians and recipients of care already know, but they provide quantification to support clinical impression. Fluphenazine's global position as an effective treatment for psychoses is not threatened by the outcome of this review. However, fluphenazine is an imperfect treatment and If accessible, other inexpensive drugs less associated with adverse effects may be an equally effective choice for people with schizophrenia.