Lancinating lumbar facet syndrome: a congenitally absent facet joint

Congenitally absent or hypoplastic L5-S1 facet (zygapophyseal) joints are an aberrated rarity, with less than 30 reported cases. This absence of facet joint and contralateral hypertrophic facet provides a continuum of presentations that can complicate low back pain diagnoses and management. A broad differential including lumbar facet syndrome, disc degeneration, spinal stenosis, herniated radiculopathy, spondyloarthropathies and sacroiliac joint pain should be considered initially, with the flexibility for other diagnoses. Understanding the effects of different anatomical, biomechanical and physiological changes on spinal health is essential for patient care. We report a progression of lumbar radiculopathy complicated by the presence of a congenitally absent left L5-S1 facet joint and hypertrophic right L5-S1 facet joint. Furthermore, our discussion concentrates on pathophysiology, differential diagnoses and management of congenitally absent facet joints and the impact they can have on low back pain and spinal health.

Information seeking behaviors and attitudes of wives of former football players regarding chronic traumatic encephalopathy

This study examines CTE-related knowledge and information-seeking behaviors of caregivers of persons who are at high risk of CTE. Online survey responses were collected from 64 females, ages 18-74, who were married to former college, semiprofessional, or professional football players and were fluent in English. Ranging from 0 to 18, a score was calculated to represent level of CTE knowledge. Participants were classified into groups based on their spouse's reported symptoms and diagnosis. Approximately 87% of participants reported that their spouses have been diagnosed with a football-related concussion and were significantly more likely to seek out information from a healthcare provider, a scientific journal or article, and post/comment on social media compared to spouses of symptomatic/undiagnosed and non-symptomatic groups. Participants reported 77% of available information as probably true, with social media thought to be highly credible. Highest levels of dissatisfaction were reported for league-sponsored websites and physicians/healthcare providers. Although the majority of participants sought CTE related information on regular or social media, and the internet, information sources differed amongst the groups. These findings may help healthcare providers and organizations develop more effective health-related educational programs that will help the wives make informed decisions regarding care for their spouses with respect to CTE.

A survey study investigating perceptions and acceptance of the whole-body imaging techniques used for the diagnosis of myeloma

INTRODUCTION

The purpose of this study was to investigate patient perceptions and acceptance of the three whole-body imaging (WBI) modalities used for diagnosing myeloma; radiographic skeletal survey (RSS), low-dose whole-body computed tomography (LD-WBCT) and whole-body magnetic resonance imaging (WB-MRI). The secondary aim was to explore the factors affecting the acceptance of whole-body imaging for myeloma.

METHODS

60 participants (median age = 58.5 years old) recruited from three NHS trusts and social media completed a survey in which they scored their experiences of each WBI modality on nine 5-point rating scales. Spearman's correlation coefficient, Kruskal-Wallis, Mann-Whitney and Wilcoxon signed-rank tests were used to compare scores between different WBI techniques. Participants were invited to provide additional open text responses for interpretation using thematic analysis.

RESULTS

All modalities demonstrated high levels of acceptability (median score = 4). WB-MRI was perceived as more stressful (p=<0.01) and claustrophobic (p=<0.01) than RSS and LD-WBCT. Thematic analysis showed patients understood the importance of imaging but had concerns about exacerbated pain and the results. WB-MRI was difficult to tolerate due to its duration. Respondents were averse to the physical manipulation required for RSS while remaining stationary was perceived as a benefit of LD-WBCT and WB-MRI. Staff interactions had both positive and negative effects on acceptance.

CONCLUSIONS

Despite the psychological and physical burdens of WBI, patients accepted its role in facilitating diagnosis. Staff support is vital for facilitating a positive whole-body imaging experience. Healthcare practitioners can improve WBI acceptance by understanding the burdens imposed by WBI and adopting the personalised care model.

IMPLICATIONS FOR PRACTICE

Patient experience can be improved by tailoring examinations to individual needs. RSS can be as burdensome as other WBI techniques and could be superseded by LD-WBCT or WB-MRI.

Systematic review: psychological morbidity in young people with inflammatory bowel disease - risk factors and impacts

BACKGROUND

Psychological morbidity in young people aged 10-24 years, with inflammatory bowel disease (IBD) is increased, but risk factors for and impacts of this are unclear.

AIM

To undertake a systematic literature review of the risk factors for and impact of psychological morbidity in young people with IBD.

METHODS

Electronic searches for English-language articles were performed with keywords relating to psychological morbidity according to DSM-IV and subsequent criteria; young people; and IBD in the MEDLINE, PsychInfo, Web of Science and CINAHL databases for studies published from 1994 to September 2014.

RESULTS

One thousand four hundred and forty-four studies were identified, of which 30 met the inclusion criteria. The majority measured depression and anxiety symptoms, with a small proportion examining externalising behaviours. Identifiable risk factors for psychological morbidity included: increased disease severity (r(2) = 0.152, P < 0.001), lower socioeconomic status (r(2) = 0.046, P < 0.001), corticosteroids (P ≤ 0.001), parental stress (r = 0.35, P < 0.001) and older age at diagnosis (r = 0.28, P = 0.0006). Impacts of psychological morbidity in young people with IBD were wide-ranging and included abdominal pain (r = 0.33; P < 0.001), sleep dysfunction (P < 0.05), psychotropic drug use (HR 4.16, 95% CI 2.76-6.27), non-adherence to medication (12.6% reduction) and negative illness perceptions (r = -0.43).

CONCLUSIONS

Psychological morbidity affects young people with IBD in a range of ways, highlighting the need for psychological interventions to improve outcomes. Identified risk factors provide an opportunity to develop targeted therapies for a vulnerable group. Further research is required to examine groups under-represented in this review, such as those with severe IBD and those from ethnic minorities.

An on-farm evaluation of the capability of saline land for livestock production in southern Australia

Grazing livestock on revegetated saline land is one of few profitable options to continue using this class of agricultural land. However, there has been little research conducted to assess the capability of saline land to support livestock production based on the soil and water characteristics at a particular site. In this study, data from 11 grazing studies collected from eight commercial farms across southern Australia were used to estimate metabolisable energy (ME) utilised/ha, as well as total ME produced/ha. All data were from the autumn (March–May) period, when feed is normally in short supply and of limited quality. Site characteristics indicative of the severity of salinisation varied across the sites. Topsoil electrical conductivity (ECe) ranged from 1 to 33 dS/m and groundwater EC from 14 to 60 dS/m (equivalent to sea water). Feed on offer before grazing varied from 700 kg dry matter/ha to 9000 kg dry matter/ha between sites. Thinopyrum ponticum and Puccinellia ciliata featured prominently in the less saline revegetated sites, with Atriplex spp. present on the more saline sites and some lucerne and rhodes grass on the less saline, well drained sites. Grazing days per ha for sheep (ME-adjusted dry sheep equivalent) on autumn pastures across the sites ranged from 41 to 3600, and liveweight gains ranged from –95 to 314 g/sheep.day. The grazing value of the highest producing saltland was at least as high as that expected on adjacent areas that were not salt affected. The major advantage of establishing saltland pastures included an out-of-season feed supply high in crude protein and micronutrients that possessed the ability to capture summer and autumn rain. This should represent a substantial reduction in supplementary feed costs and increases the flexibility of methods for feeding livestock through periods of low annual pasture availability. The value of the ME produced on the highest yielding saltland pasture was estimated to be $360/ha based on substituting the best alternative strategy of purchasing lupin grain as a supplement. A quadratic relationship (R2 = 0.62, P = 0.024) was found between soil ECe and ME produced across the sites. Significant relationships were not found between other saline site characteristics and ME production, which partly reflects the complexity of these systems as well as limitations with site characterisation.

One-Pot Synthesis of Fluorescent 2,5-Dihydro-1,2,3-triazine Derivatives from a Cascade Rearrangement Sequence in the Reactions of 1,2,3-Triazolium-1-aminide 1,3-Dipoles with Propiolate Esters

The reactions of 1,2,3-triazolium-1-aminides 1 (readily available from benzil bishydrazones) with propiolate esters leads to fluorescent 2,5-dihydro-1,2,3-triazine derivatives 2, 3 in one pot. These synthetic reactions can be carried out in acetone, in water, or under solvent-free conditions. The reactions involve a Huisgen cycloaddition followed by a sequence of rearrangements. The final ring-expansion step was blocked by linking a six-methylene hydrocarbon chain between the prospective 1,2,3-triazine C-4 and C-6 atoms, using substrate 8 which gave the fused tricyclic azapropellane product 9 exclusively. X-ray crystal structures were determined for two 2,5-dihydro-1,2,3-triazine derivatives and for compound 9. The UV absorption of the 1,2,3-triazine derivatives showed a dual absorption at ca. 310 and ca. 390 nm with fluorescent emission at ca. 480 and 528 nm (for excitation at 317 nm). The significant Stokes shift of ca. 200 nm shows the potential for biological fluorescent labeling experiments.

Coronary blood flow during variation in coronary perfusion pressure

It is demonstrated that severe dysfunction occurs in the myocardial segment supplied by a critically stenosed coronary artery during hypotension, while in contrast an increase in coronary perfusion pressure (to the extent used in this experimental model) is not detrimental to regional myocardial function. If the results of these experiments are applied to clinical practice, it appears to be of primary importance to maintain normal blood pressure in patients with ischaemic heart disease, and it may even be preferable to increase the blood pressure slightly during the peri-operative period.

Myocardial ischaemia during tachycardia--not due to an increase in myocardial oxygen demand

It is generally believed that an increase in heart rate will be accompanied by an increase in myocardial oxygen demand (MVO2), but in a recent publication this concept has been challenged; we present data supporting the view that an increase in heart rate is not necessarily accompanied by an increase in MVO2. Our data are based on studies on dogs in five phases: (a) normal coronary arteries; (i) with normal heart rate; (ii) with tachycardia induced by a pacemaker; and (iii) with normal heart rate; and (b) with a constricted left anterior descending coronary artery: (i) with normal heart rate; and (ii) with induced tachycardia. MVO2 remained unchanged both per beat and per unit of time. Neither global nor regional myocardial function in the area supplied by the constricted artery changed during tachycardia. The reason for myocardial ischaemia should therefore not be attributed to an increase in MVO2 if the diameter of the heart is not increased, and attention should rather be focused on inadequate diastolic perfusion time and possible redistribution of blood from the potentially ischaemic zone.

Effect of hypoxia on the normal and ischemic myocardium

This study investigated the effect of hypoxia on global and regional myocardial function in the normal heart and in the heart with a critically constricted coronary artery. Eight dogs under halothane anesthesia were subjected to progressive degrees of hypoxia while global and segmental heart function as well as general hemodynamics were evaluated. In the control phase of the experiment, the coronary circulation was undisturbed. A decrease in the inspired oxygen fraction from 0.3 to 0.1 was associated with significant increases in the heart rate, cardiac output, left ventricular minute work and coronary blood flow, and significant decreases in systemic vascular resistance. regional myocardial function (measured by endocardial fiber shortening) did not change. In dogs with a critical constriction applied to the left anterior descending coronary artery (LAD), hypoxia significantly increased heart rate and decreased stroke volume. Indices of global myocardial function did not change, but regional function in the area supplied by constricted LAD was depressed during severe hypoxia. This study implies that measured indices of global heart function bear little relation to regional function when a compromised segment of the myocardium is subjected to hypoxia.

The effect of hypocapnia on coronary blood flow and myocardial function in the dog

The effect of hypocapnia on global and regional myocardial function and coronary blood flow (CBF) was studied in dogs anesthetized with halothane before and after critical constriction of the left anterior descending (LAD) coronary artery. Coronary blood flow decreased 29% (P less than 0.05) when hypocapnia was induced in dogs with a normal LAD artery. Critical constriction reduced CBF by 42% (P less than 0.05). In the critically constricted LAD artery, hypocapnia did not reduce CBF. During hypocapnia and with a normal LAD artery, oxygen extraction by the myocardium increased 16% (P less than 0.01) and oxygen tension in the coronary sinus was reduced by 19% (P less than 0.001). After critical constriction of the LAD, hypocapnia was associated with an increase in oxygen extraction of 14% (P less than 0.01) and the coronary sinus oxygen tension was reduced by 21% (P less than 0.001). CBF of the left circumflex coronary artery (LC) increased 36% (P less than 0.05) after critical constriction to the LAD when compared with control values of the preconstriction phase. However, LC flow did not change during hypocapnia when critical stenosis had been applied to the LAD artery. Although oxygen supply (product of CBF and arterial oxygen content) to the myocardium was reduced during hypocapnia, regional myocardial function did not change from control values. Regional function was similarly maintained during hypocapnia and critical constriction of the LAD.