Inclusion body myositis: The interplay between ageing, muscle degeneration and autoimmunity

Inclusion body myositis (IBM) is a slowly progressive muscle disease affecting ageing individuals. IBM presents with a distinctive pattern of weakness involving the quadriceps and finger flexor muscles, although other muscles including pharyngeal muscles become affected over time. Pathological hallmarks of IBM include autoimmune features, including endomysial infiltration by highly differentiated T cells, as well as degenerative features marked by intramyofibre protein aggregates organised into inclusion bodies. Despite some progress in understanding the cellular pathways involved in IBM, it remains untreatable, and the progression of the disease leads to progressive weakness, disability, wheelchair dependency and loss of independence. Therefore, there is an urgent need to improve our understanding of the underlying mechanisms and pathways involved in this disease to identify new treatment targets. Here, we discuss the current understanding of aetiopathogenesis, the interrelationship between autoimmunity and degeneration, and how ageing is a major influencer of both these features.

Management of complex ventral hernias: results of an international survey

Background

The surgical treatment of patients with complex ventral hernias is challenging. The aim of this study was to present an international overview of expert opinions on current practice.

Methods

A survey questionnaire was designed to investigate preoperative risk management, surgical approach and mesh choice in patients undergoing complex hernias repair, and treatment strategies for infected meshes. Geographical location of practice, experience and annual volumes of the surgeons were compared.

Results

Of 408 surgeons, 234 (57.4 per cent) were practising in the USA, 116 (28.4 per cent) in Europe, and 58 (14.2 per cent) in other countries. Some 412 of 418 surgeons (98.6 per cent) performed open repair and 322 of 416 (77.4 per cent) performed laparoscopic repair. Most recommended preoperative work-up/lifestyle changes such as smoking cessation (319 of 398, 80.2 per cent) and weight loss (254 of 399, 63.7 per cent), but the consequences of these strategies varied. American surgeons and less experienced surgeons were stricter. Antibiotics were given at least 1 h before surgery by 295 of 414 respondents (71.3 per cent). Synthetic and biological meshes were used equally in contaminated primary hernia repair, whereas for recurrent hernia repair synthetic mesh was used in a clean environment and biological or no mesh in a contaminated environment. American surgeons and surgeons with less experience preferred biological mesh in contaminated environments significantly more often. Percutaneous drainage and antibiotics were the first steps recommended in treating mesh infection. In the presence of sepsis, most surgeons favoured synthetic mesh explantation and further repair with biological mesh.

Conclusion

There remains a paucity of good-quality evidence in dealing with these hernias, leading to variations in management. Patient optimization and issues related to mesh choice and infections require well designed prospective studies.

Treating a subtotal degloving ring avulsion with leeches: an unusual case report with review of the literature

Subtotal deglovement injuries with delayed presentation give rise to the question: how to treat the mangled soft tissue to best keep the digit alive and functioning. We hereby present a case of a 59-year-old woman who was referred to our clinic 7 h after initial trauma from a peripheral hospital where an instant repositioning of a subtotal degloved skin envelop of her left middle finger had taken place with only minimal adhesion and circulation at the top of the finger left intact. On X-ray, a small avulsion fracture of her distal interphalangeal joint was visible but flexion and extension was intact at proximal interphalangeal (PIP) joint level on examination. On arrival, we saw a finger with minimal reconstituted blood circulation and livid skin. Further treatment consisted of onsite debridement and primary suturing of the involved skin, followed by leech therapy the next week, and consecutive split-skin grafting 6 weeks later to cover minor residual defects. Further clinical course was uneventful and showed good clinical and esthetic results. We hereby present the patient’s clinical outcome and review of the literature for further evidence of our treatment regime.

Level of evidence: Level V, therapeutic study.

Sleep and circadian rhythm disturbance in bipolar disorder

BACKGROUND

Subjective reports of insomnia and hypersomnia are common in bipolar disorder (BD). It is unclear to what extent these relate to underlying circadian rhythm disturbance (CRD). In this study we aimed to objectively assess sleep and circadian rhythm in a cohort of patients with BD compared to matched controls.

METHOD

Forty-six patients with BD and 42 controls had comprehensive sleep/circadian rhythm assessment with respiratory sleep studies, prolonged accelerometry over 3 weeks, sleep questionnaires and diaries, melatonin levels, alongside mood, psychosocial functioning and quality of life (QoL) questionnaires.

RESULTS

Twenty-three (50%) patients with BD had abnormal sleep, of whom 12 (52%) had CRD and 29% had obstructive sleep apnoea. Patients with abnormal sleep had lower 24-h melatonin secretion compared to controls and patients with normal sleep. Abnormal sleep/CRD in BD was associated with impaired functioning and worse QoL.

CONCLUSIONS

BD is associated with high rates of abnormal sleep and CRD. The association between these disorders, mood and functioning, and the direction of causality, warrants further investigation.

Abdominal Aortic Aneurysm Surgery in a District General Hospital: A 15-Years Experience

The incidence of patients presenting with both ruptured abdominal aortic aneurysm (RAAA) and elective abdominal aortic aneurysm (EAAA) increases with age. The aim of our study was to find out the incidence of RAAA, age and sex groups of patients at risk, and 30-day all-cause perioperative mortality associated with RAAA as well as EAAA repair in a busy district general hospital over a 15-year time period. All patients operated for AAA during 1989-2003, both elective and ruptured, were included in the study. Patients who died in the community from RAAA were also included. The data were collected from the hospital information system, theater logbooks, intensive therapy unit records, postmortem register, and patients' medical notes. We divided the data for RAAA into two groups of 7.5 years each to see if there was any improvement over time in 30-day postoperative mortality. There were 816 cases of AAA, which included 468 RAAAs (57%) and 348 EAAAs (43%). Out of 468 RAAAs, 243 patients had emergency repair, of whom 213 were males. There were 201 patients who had RAAA postmortem (43%). Median age (range) was 73 (54-94) years in males and 77 (52-99) years in females, with a male-to-female ratio of 7:1. The peak incidence of RAAA was over 60 years of age in males and 70 years in females. Incidence of RAAA was 7.3/100,000/year in males and 5/100,000/year in females. For RAAA, 30-day perioperative mortality was 43% (105/243) while overall mortality was 70% (330/468), which includes deaths in the community. There was no improvement in 30-day mortality over time after comparing data for the first 7.5 years (50/115, 43.5%) with those for the second set of 7.5 years (55/128, 43%). There were 348 patients who had EAAA repair over the same period, comprising 282 males, with a male:female ratio of 4.3:1. The 30-day mortality in the elective group was 7.75%. Incidence and mortality of RAAA remain high. A high proportion of patients with AAA remain undiagnosed and die in the community. More lives may be saved if a screening program is started for AAA.

Pressure monitoring of the femoral nerve during total hip replacement: an explanation for iatropathic palsy

Pressure changes around the femoral nerve were monitored throughout 10 consecutive primary total hip replacements to identify any surgical steps that might raise pressure around the nerve and be implicated in iatropathic palsy. The only notable variable was the patient himself/herself. The only step that consistently raised pressure around the nerve, sometimes to alarming levels, was use of a retractor sited on the anterior lip of the acetabulum. Pressure changes were modest in patients with an endomorphic body type suggesting relative protection from this injury by a thicker soft cushion.

Ankle fractures in diabetics

Ankle fractures are common and good results are expected. Insulin dependent diabetes mellitus is also common, and long-standing disease is associated with peripheral neuropathy. A trauma unit will inevitably receive patients with both problems. We describe two salutary lessons and suggest how our experience with diabetic neuroarthropathy might be avoided.

Civilian parachute injuries; 10 years on and no lessons learned

The Maidstone Hospital provides trauma services to one of the largest parachute clubs in the United Kingdom. We studied injuries sustained at the club in 1994 and compared results with equivalent data from 1984. The injury rate for first time jumpers in the current study was 1.2%; half of these cases required admission for an average of 10 d. Individual morbidity and loss of productivity lasted far longer. No lessons had been learned from the first study. We question parachuting as a fund-raising venture and suggest re-evaluating the training of novice parachutists, perhaps with mandatory use of the safer rectangular parachute. At a time when healthcare rationing is an issue, individuals engaging in activities such as these might be required to indemnify themselves against the medical costs of injury currently met by the state.

A randomised prospective study of outpatient haemodilution for central retinal vein obstruction

PURPOSE

Central retinal vein obstruction (CRVO) has significant visual morbidity. We prospectively evaluated an outpatient haemodilution (HD) regimen for CRVO.

METHODS

We recruited 59 patients with CRVO of less than three months' duration and visual acuity (VA) worse than or equal to 6/9.5. Thirty patients underwent HD (packed cell volume of <0.35, 12 weeks); there were 29 controls and follow-up was for six months.

RESULTS

Incidence rates for VA improvement (P = 0.708) and rubeosis iridis (P = 0.619) between the two groups were not different. The incidence rate of VA deterioration was 5.315 times higher with HD (P = 0.035, Cox Proportional analysis).

CONCLUSION

This data does not support the previous studies on haemodilution.

Survey of colourings and preservatives in drugs

OBJECTIVE

To assess the prevalence of colourings and preservatives in drug formulations in the United Kingdom.

DESIGN

Postal survey.

PARTICIPANTS

All pharmaceutical manufacturers in the United Kingdom were requested to supply data on drug formulations with particular regard to the content of colourings and preservatives.

MAIN OUTCOME MEASURE

Prevalence in proprietary drugs of colourings or preservatives, or both, that have been implicated in adverse reactions. Computation of a list of formulations of bronchodilators, antihistamines, and antibiotics that are free of such additives.

RESULTS

A total of 118 out of 120 pharmaceutical companies supplied the data requested. In all, 2204 drug formulations were analysed and found to contain 419 different additives, of which 52 were colourings and preservatives that have been implicated in adverse reactions; 930 formulations contained such an additive. Tartrazine was the fourth most commonly occurring colouring, being present in 124 drug formulations.

CONCLUSION

Many drugs contain additives that help to identify them and prolong their shelf life but are implicated in adverse reactions in some people. Some form of labelling of drug additives would enable these people to avoid drugs containing such additives.

Trial of ganglioside therapy for diabetic neuropathy

The efficacy of daily intramuscular injection of mixed gangliosides (Cronassial) for highly symptomatic diabetic neuropathy was investigated in a randomized double-blind trial. There were 37 patients treated with 40 mg of gangliosides or placebo for 12 weeks and studied with physical examination, symptom scales, and electrophysiologic parameters. There was no demonstrated benefit of therapy. Given the spontaneous variation in the measurements employed, larger numbers of patients would have been needed to identify a significant change of 10% owing to therapy.

Testicular torsion does not cause autoimmunization in man

Forty-seven patients have been reviewed 2-10 years after torsion of the testicle. Thirty-six (77 per cent) were found to have abnormalities of exocrine or endocrine gonadal function. None showed evidence of testicular autoimmunization using standard assays of sperm agglutination and immobilization by serum or seminal plasma, and the serum mixed agglutination reaction (MAR) test. In addition, 11 cases of acute torsion were followed at intervals for 3-6 months after surgery, but no evidence was observed of the transient development of sperm antibodies. Our findings confirm poor gonadal function after torsion, but do not support the recent suggestion that it is caused by autoimmunization.

Trials of ganglioside therapy for amyotrophic lateral sclerosis and diabetic neuropathy

Double blind placebo controlled trials of dialy intramuscular injections of 40 mg of mixed gangliosides were carried out in ALS and diabetic neuropathy. Forty patients with ALS were treated for six months and monitored with tests of strength and pulmonary function. No effect of gangliosides was found. Forty patients with symptomatic diabetic neuropathy will be treated for three months. Some of the data from the first 25 patients to complete the study were analyzed in a preliminary fashion. While no difference in nerve conduction studies was found in the treated group compared to the control group, there was greater symptomatic improvement in the patients treated with gangliosides.