Spontaneous sensations reveal distorted body perception in complex regional pain syndrome (CRPS).

Distortions of body representation have been reported in Complex Regional Pain Syndrome (CRPS). The perception of sensations arising without external triggers (spontaneous sensations or SPS) was assessed here as a means of investigating distortions of body representation and awareness in CRPS. To avoid confounds between CRPS symptoms and SPS, lower-limb CRPS patients were included, whereas SPS were tested on the hands. Patients and controls were required to focus on their hands and to report the spatial and qualitative characteristics of SPS arising there. We found an ipsilateral decrease in the perception of thermal, pain-related and surface/mechanical SPS, as well as in the number of SPS-sensitive areas. The latter finding was predicted by decreased body awareness as assessed through questionnaires. A bilateral decrease in the perception of paresis-like SPS was also observed. Finally, the ipsilateral spatial distribution of SPS frequency and intensity underwent a shift from the fingers towards the lower parts of the palm. CRPS is likely to distort patient's body perception and awareness of the entire half-body ipsilateral to the affected limb, and even of both sides. Such disturbances are not manifested solely as a decrease in sensitivity, but sometimes as shifts in the spatial distribution of sensitivity.

Perspectives of laparoscopic donors toward a new procedure: transvaginal donor nephrectomy.

BACKGROUND: Interest in natural orifice transluminal endoscopic surgery (NOTES) is increasing. Transvaginal NOTES (TVNOTES) donor nephrectomy with subsequent removal of the kidney via the vagina is technically possible. This approach may minimize the surgical insult to the donor and allow improved cosmesis. The acceptability to patients of such a technique is, however, unknown. The aim of this article is to explore the attitudes of women who have previously undergone laparoscopic donor nephrectomy (LDN). METHODS: A 15-point questionnaire was designed by a multidisciplinary group of surgeons interested in minimally invasive surgery to obtain the views of women who had previously undergone LDN at the Queen Elizabeth Hospital, Adelaide. It was sent to 150 female donors, and their views with regard to the acceptability of a TV approach to the peritoneal cavity for donor nephrectomy were recorded. RESULTS: Forty-nine patients returned the completed questionnaire. The majority (90%) of these women did not have adverse feelings toward scars. Thirty-seven percent of women would consider a TVNOTES donor nephrectomy; however, this was increased to 51% if they could be reassured that TVNOTES was as safe as LDN. Concerns regarding a negative impact on sexual function after this procedure were raised by 33% of patients. The majority (88%) did not cite surgeon gender as an important factor when deciding for or against this procedure. CONCLUSIONS: This study demonstrates that less postoperative pain, better cosmesis, and safety are factors that may influence a patient's decision to choose TVNOTES donor nephrectomy. The majority, however, would still prefer LDN.

Cytoplasmic beta-catenin accumulation is a good prognostic marker in upper and lower gastrointestinal adenocarcinomas.

AIMS: beta-Catenin is an important molecule in cancer biology. Membranous beta-catenin enhances cellular differentiation and inhibits invasion by its action on E-cadherin. The aim was to ascertain whether the cellular expression of these molecules in colorectal and oesophageal cancer specimens is associated with survival in patients with gastrointestinal cancer. METHODS AND RESULTS: Tumour samples from 149 patients undergoing resection for colorectal adenocarcinoma and 147 patients undergoing resection for oesophageal adenocarcinoma were retrospectively analysed using immunohistochemical techniques to assess beta-catenin expression. Increasing beta-catenin expression in the cytoplasm was associated with improved survival for colorectal cancer cases on both univariate (P = 0.003) and multivariate (P = 0.01) analysis. In addition, increased expression in the most recent cohort of oesophageal adenocarcinoma patients was associated with improved TNM staging (P = 0.007). Membrane expression was weakly associated with survival in colorectal cancer on univariate analysis (P = 0.09), but not on multivariate analysis (P = 0.21). Complete absence of beta-catenin expression at all three sites was associated with reduced 5-year survival in colorectal cancer. CONCLUSIONS: This is one of the largest prognostic studies of beta-catenin in gastrointestinal adenocarcinoma. It shows that low levels of cytoplasmic beta-catenin expression are associated with reduced survival in patients with colorectal cancer as well as worse TNM staging in oesophageal adenocarcinoma (a recognized surrogate end-point for survival). We believe this is the first time that this has been reported. This finding should be tested prospectively in oncological trials to validate whether the presence of cytoplasmic beta-catenin could be used as a prognostic marker for less aggressive disease.

Transvaginal natural orifice translumenal endoscopic surgery (NOTES): a survey of women's views on a new technique.

BACKGROUND: Laparoscopic and minimally invasive surgery has changed the surgical landscape irrevocably. Natural orifice translumenal endoscopic surgery (NOTES) offers the possibility of surgery without visible scars. Transvaginal entry offers potential benefits because it gains access to the peritoneal cavity without the need to open an abdominal viscus. Much of the discussion pertaining to NOTES focuses on technical and training issues, with little attention to date paid to the opinions of women. The perceptions of female health care workers and patients were sought in relation to their views on transvaginal NOTES. METHODS: This study surveyed 300 women using a 12-point questionnaire devised by a multidisciplinary group of surgeons interested in minimally invasive surgery. The questionnaire was designed to establish the opinions of women with respect to NOTES surgery versus standard laparoscopic procedures. Responses were de-identified. RESULTS: Three-fourths of the women surveyed were neutral or unhappy about the prospect of a NOTES procedure, and this remained constant even when it was stipulated that laparoscopic cholecystectomy and NOTES had equivalent safety and efficacy. Younger nulliparous women were most concerned about the potential negative effect of NOTES on sexual function. A minority were concerned about the cosmetic effect of surgery, although surgical scars were perceived as more important to younger respondents. CONCLUSIONS: Potentially, NOTES surgery offers women a scarless operation with the possibility of less pain than experienced in standard laparoscopic surgery. Few women, however, were troubled about the cosmetic effect of surgery. The effect of NOTES on sexual function was expressed as a particular concern by younger women. In all groups and across all ages, peritoneal access using the transvaginal route was met by significant scepticism. In Australia, women remain to be convinced about the potential advantages of the emerging NOTES technology.

Efficacy and safety of ursodeoxycholic acid in primary, type IIa or IIb hypercholesterolemia: a multicenter, randomized, double-blind clinical trial.

BACKGROUND: Ursodeoxycholic acid (UDCA) is a therapeutic bile acid used in dissolution of gallstones and treatment of several cholestatic liver diseases. Results obtained from primary biliary cirrhosis patients treated with UDCA suggested that this agent exerts significant cholesterol-lowering effects and justifies evaluation in primary hypercholesterolemic patients without liver disease. Purpose of this study was to determine whether UDCA had potential to be an effective, safe cholesterol-lowering agent in primary type IIa or IIb hypercholesterolemia. METHODS: This was a multicenter randomized, double blind, placebo-controlled trial. After a 6-week placebo lead-in period during which two qualifying lipid profiles were obtained, patients with a mean serum LDL-cholesterol (LDL-C) between 130 and 190mg/dL, triglycerides <400mg/dL and HDL-cholesterol >30mg/dL were randomized to UDCA or matching placebo for 24 weeks. RESULTS: Seven sites screened 200 patients with 134 patients meeting the entry criteria who were randomized to the two treatments. There were 125 patients meeting the efficacy evaluation criteria, 57 on UDCA and 68 on placebo. LDL-C change from weeks 0 to 24 showed no significant difference between groups. No significant differences in changes for total cholesterol, HDL-cholesterol and triglycerides were observed. Both groups had similar adverse event profiles. CONCLUSIONS: UDCA did not show intrinsic cholesterol-lowering properties and therefore is not a useful therapy in treating type IIa or type IIb hypercholesterolemic patients. UDCA was confirmed as a well tolerated and safe drug in this population.

Attentional capture in schizophrenia: failure to resist interference from motion signals.

INTRODUCTION: Patients with schizophrenia show high susceptibility to distraction but the neural mechanisms underlying sensitivity to distraction are not clearly established. We designed a paradigm to assess whether sensitivity to distraction and dorsal stream dysfunction are related in schizophrenia. METHOD: 60 patients, 37 schizotypals, and 58 healthy controls were asked to locate a target square appearing above or below fixation and to ignore a distractor that either moved abruptly (in Experiments 1 and 3) or changed in colour (in Experiment 2). The distractor condition was compared to a baseline condition with no distractor. Resistance to interference was assessed by manipulating the probability of the distractor changing more frequently (50%, 75%, 100%) on one side of fixation. RESULTS: Patients, schizotypals, and controls showed attentional capture with longer response times when the distractor changed as compared to the baseline condition. In contrast to controls, the magnitude of interference from distractors remained stable for patients and schizotypals across all probability conditions and this was confined to attentional capture by motion, not by colour. CONCLUSION: We found a similar pattern of results in patients and in schizotypals. Our attentional capture paradigm could help to identify early cognitive impairments in populations at risk to develop schizophrenia. The data are interpreted in terms of dysfunction of frontal control on dorsal stream functions in schizophrenia.

Steroid injection for osteoarthritis of the hip: a randomized, double-blind, placebo-controlled trial.

OBJECTIVE: To determine the efficacy of fluoroscopically guided corticosteroid injection for hip osteoarthritis (OA) in a randomized, double-blind, placebo-controlled trial. METHODS: Fifty-two patients with symptomatic hip OA were randomly allocated to receive placebo (10 mg bipuvicaine, 2 ml saline) (n = 21) or corticosteroid treatment (10 mg bipuvicaine, 40 mg triamcinolone hexacetonide) (n = 31). Patients were followed up for 1, 2, 3, and 6 months. The primary outcome measure was the pain improvement response, defined as a 20% decrease in the Western Ontario and McMaster Universities OA Index (WOMAC) pain score (on 5 100-mm visual analog scales [VAS]) (WOMAC20) from baseline to 2 months postinjection. Secondary outcomes were a 50% decrease in the WOMAC pain score (WOMAC50), changes in other WOMAC subscale scores, patient's global assessment of health (on a 100-mm VAS), and Short Form 36 (SF-36) quality of life indices. Analyses were based on the intent-to-treat principle. RESULTS: The mean WOMAC pain score fell 49.2% (decreasing from 310.1 mm to 157.4 mm) at 2 months postinjection in patients receiving corticosteroid, compared with a decrease of 2.5% (from 314.3 mm to 306.5 mm) in the placebo group (P < 0.0001). The proportion of WOMAC20 responders at 2 months' followup was significantly higher in the corticosteroid group (67.7%) compared with the placebo group (23.8%) (P = 0.004); similar proportions of WOMAC50 responders were observed between groups (61.3% in the corticosteroid group versus 14.3% in the placebo group; P = 0.001). Response differences were maintained at 3 months' followup (58.1% responders in the corticosteroid group versus 9.5% responders in the placebo group; P = 0.004). Significant differences in the WOMAC stiffness and physical function scores (P < 0.0001), patient's global health scores (P = 0.005), and SF-36 physical component scores (P = 0.04) were observed, with patients in the corticosteroid group showing greater improvements. There were no differences in the frequency of adverse events between groups. CONCLUSION: This placebo-controlled trial confirms that corticosteroid injection can be an effective treatment of pain in hip OA, with benefits lasting up to 3 months in many cases. Future studies should address questions related to the benefits of repeated steroid injection and the effects of this treatment on disease modification.

Transverse morphology of the sacroiliac joint: effect of angulation and implications for fluoroscopically guided sacroiliac joint injection.

OBJECTIVE: Effects of angulation of computed tomography (CT) reconstruction plane on sacroiliac (SI) joint morphology were studied, and factors influencing the approach to fluoroscopically guided SI joint injection were assessed. DESIGN AND PATIENTS: CT scans of pelvises were reformatted on 41 subjects, aged 51.7 (+/-15.1) years. Transverse images were reconstructed at the caudal 3 cm of the SI joint tilting plane of reconstruction from -30 degrees to +30 degrees at 15 degrees increments. Anteroposterior diameter of joint (depth), angle from sagittal plane (orientation angle), and distance from skin were measured. Joint contour was classified, and presence of bone blocking access to the joint was recorded. Comparison between angles were analysed by t-test. Relationships between variables were assessed by a Pearson correlation test. RESULTS: Depth was shorter with angulation in the inferior direction (P<0.01). Orientation angle increased with superior angulation (P<0.01). Distance from skin increased (P<0.01) with angulation in either direction. Joint contour was significantly different from baseline at each angle (P<0.001) but highly variable. Inferior angulation resulted in interposition of ilium between skin and SI joint, and superior angulation caused bone block due to the lower sacrum. None of these features was identified without tilting of the reconstruction plane, and effects were more pronounced with steeper angulation. CONCLUSION: Angulation of the reconstruction plane considerably affects the appearance of the sacroiliac joints. By shortening joint depth, an inferiorly directed approach to SI joint injection may make fluoroscopic guidance easier, although associated bony interposition can prevent access to the synovial compartment. A superiorly directed approach is more likely to have adverse effects.

Photodynamic therapy with porfimer sodium for ablation of high-grade dysplasia in Barrett's esophagus: international, partially blinded, randomized phase III trial.

BACKGROUND: Barrett's esophagus (BE) may lead to high-grade dysplasia (HGD) and adenocarcinoma. The objective was to examine the impact of treating patients with BE and with HGD by using porfimer sodium (POR) and photodynamic therapy (PDT) for ablating HGD and reducing the incidence of esophageal adenocarcinoma. METHODS: The design was a multicenter, partially blinded (pathology), randomized clinical trial conducted in patients with BE who have HGD. There were 30 contributing centers. A total of 485 patients were screened, with 208 in the intent-to-treat population and 202 in the safety population. Patients were randomized on a 2:1 basis to compare PDT with POR plus omeprazole (PORPDT) with omeprazole only (OM). The main outcome measurement was complete HGD ablation occurring at any time during the study period. RESULTS: There was a significant difference (p < 0.0001) in favor of PORPDT (106/138 [77%]) compared with OM (27/70 [39%]) in complete ablation of HGD at any time during the study period. The occurrence of adenocarcinoma in the PORPDT group (13%) (n=18) was significantly lower (p < 0.006) compared with the OM group (28%) [corrected] (n=20). The safety profile showed 94% of patients in the PORPDT group and 13% of patients in the OM group had treatment-related adverse effects. The limitations of the study were that PDT therapy may have had to be applied more than once and that patients spent more time in treatment. The patients and the physicians were not blinded to the treatment. CONCLUSIONS: PORPDT in conjunction with omeprazole is an effective therapy for ablating HGD in patients with BE and in reducing the incidence of esophageal adenocarcinoma.

Evaluation of level 1 care facilities for vascular patients.

BACKGROUND: A surgical acute care unit (SACU) was established within our hospital to specifically provide level 1 care to surgical patients. We assess the impact that this has had on outcome in vascular patients. METHODS: All patients undergoing carotid endarterectomy (CEA) and elective abdominal aortic aneurysm repair (AAA) during the first year of SACU were included in the present study. A control group was compiled from patients undergoing the same two procedures in the year preceding the opening of the SACU. Data were collected on admission time, time spent in critical care, outcome and operative cancellations. RESULTS: During the first year of the SACU there were 28 CEA and 42 AAA repairs performed. In the control group there were 18 CEA and 34 AAA repairs performed. There were no significant differences in death rate or length of hospital stay between the two groups for either AAA repair or CEA. CEA patients in the study group had a significantly reduced level 2 stay (P < 0.001 Mann-Whitney U-test), with 71% of patients being admitted directly to the level 1 facility from theatre. There were less CEA cancelled because of critical care bed shortages among the cases (n = 0) compared to the control group (n = 2), although this did not reach statistical significance (P = 0.15 Fisher's exact test). CONCLUSIONS: Designated level 1 care has reduced the need for the postoperative admission of CEA patients to level 2 care facilities. It has had no discernible impact on admission time or mortality, but might reduce the number of cancelled operations caused by a lack of level 2 beds.

Recurrent herpes simplex labialis: selected therapeutic options.

Recurrent infection with herpes simplex virus 1 (HSV1), called herpes simplex labialis (HSL), is a global problem for patients with normal immune systems. An effective management program is needed for those with frequent HSL recurrences, particularly if associated morbidity and life-threatening factors are present and the patient's immune status is altered. Over the past 20 years, a variety of antiviral compounds (acyclovir, penciclovir, famciclovir, valacyclovir) have been introduced that may reduce healing time, lesion size and associated pain. Classical lesions are preceded by a prodrome, but others appear without warning, which makes them more difficult to treat. Various methods of application (intravenous, oral, topical) are used, depending on whether the patient is experiencing recurrent HSL infection or erythema multiforme or is scheduled to undergo a dental procedure, a surgical procedure or a dermatological face peel (the latter being known triggers for recurrence). This article outlines preferred treatment (including drugs and their modes of application) for adults and children in each situation, which should assist practitioners wishing to use antiviral therapy.

Controlling attentional priority by preventing changes in oculomotor programs: a job for the premotor cortex?

Abruptly presented items capture attention automatically so they constitute the first items to be examined [Yantis and Jonides, Journal of Experimental Psychology: Human Perception and Performance, 1984;10:601; Jonids and Yantis, Perception and Psychophysics, 1988;43:346; Theeuwes, Perception and Psychophysics, 1992;51:599; Theeuwes, Journal of Experimental Psychology: Human Perception and Performance, 1994;20:799]. This attentional priority can be controlled in a top-down manner by directing attention towards the locus of interest [Yantis and Johnson, Journal of Experimental Psychology: Human Perception and Performance, 1990;16:812; Theeuwes. Perception and Psychophysics, 1991;49:83; Miller, Perception and Psychophysics, 1989;45:567; Folk et al., Journal of Experimental Psychology: Human Perception and Performance, 1992; 18:1030]. The premotor theory of attention [Rizzolatti et al., Neuropsychologia 1987;25:31; Rizzolatti et al., Attention and Performance XV, 1994, p. 231] assumes that the mechanism responsible for the attentional shifts is strictly linked to that responsible for eye movements, and several studies [Corbetta et al., Society of Neuroscience Abstracts 1997;23:122.12; Nobre et al., Brain 1997;120:515; Theeuwes et al., Journal of Experimental Psychology: Human Perception and Performance, 1999;25:1595] suggested that the premotor cortex plays a role in the control of attention. However, the nature of this involvement is still unclear. We have been asking a patient (RJ) with a damage of the right premotor cortex to decide whether a target had a discontinuity on its right or left side. The absolute location of the target was pre-cued. In Section 2, an interference was observed when a sudden onset occurred in the visual space, suggesting that RJ was not able to control attentional capture. The possibility to attribute this interference to an insufficient focalization of attention or a grouping effect were discarded by Sections 3 and 4, respectively. Section 5 revealed that this interference followed exclusively the onset occurring in the hemifield opposite the one containing the target (meridian effect [Rizzolatti et al., Neuropsychologia 1987;25:31]). The results suggest that the control of attentional capture may be achieved by keeping constant the parameters of the appropriate oculomotor program.

The thalamus interrupts top-down attentional control for permitting exploratory shiftings to sensory signals.

When attention is involuntarily drawn in a direction different to that of the target, slower motor response times are observed (i.e. the meridian effect). Previous data suggested that the thalamus might participate in the generation of visual salience. What may be the role of the thalamus in the capture by luminance transients when attentional control is in action? A single experiment was administrated in a group of ten healthy volunteers as well as in a group of three patients with unilateral thalamic infarcts. Subjects participated in a task where attentional control was interrupted by a distractor. The meridian effect was present only in the performance of the healthy volunteers and when distractors occurred in the ipsilesional (intact) hemifield of the thalamic patients. These results suggest that when an important signal appears during attentional focalization, the thalamus interrupts current focalization and permits the compilation of an attentional program in the midbrain aiming at generating an orienting response towards the source of this signal.