Assessment of fibromyalgia & chronic fatigue syndrome: a new protocol designed to determine work capability--chronic pain abilities determination (CPAD)

The objective was to design a protocol to assess work ability in people suffering ill-defined painful and disabling disorders, the outstanding prototype of which is fibromyalgia/chronic fatigue syndrome (FM/CSF).Following an extensive literature search, the mos appropriate components of current methods of assessment of physical and cognitive abilities were incorporated into the protocol, occasionally with appropriate modification to suit the specific requirements of the individual. The initial part of the assessment consists of a standard history taking, principally focusing on the patient's self-reported physical and cognitive abilities and disabilities, as well as the completion of established pain and fatigue scales, and relevant disability questionnaires. Following this, physical and cognitive abilities are objectively assessed on two separate occasions, utilizing computerized hand-held dynamometers, inclinometers, algometers, and force dynamometers. Specific work simulation tests using the industrial standards Methods-Time-Measurement testing are availed of, as is aerobic testing using the Canadian Aerobic Fitness Test (CAFT). Objective computerised neuro-cognitive testing are also utilised as an integral component of the assessment. All results are then subject to specific computerized analysis and compared to normative and standardised work-based databases. The designed system produces reliable, consistent and reproducible results. It also proves capable of detecting any inconsistencies in patient input and results, in addition to being independent of any possible assessor bias. A new protocol has been designed to determine the working capability of individuals who suffer from various chronic disabling conditions, and represents a significant step forward in a difficult but rapidly expanding area of medical practice.

Pyruvate dehydrogenase deficiency presenting as intermittent isolated acute ataxia

OBJECTIVE

The aim of this study is to report and emphasize unusual presentations of pyruvate dehydrogenase (PDH) deficiency (OMIM 312170).

METHODS

PDH activity and PDHA1 gene were studied in two siblings presenting with intermittent ataxia in childhood. Similar presentations in reported PDH-deficient patients were searched for using the Medline database.

RESULTS

Both patients had PDH deficiency caused by a new mutation (G585C) in the PDHA1 gene, which is predicted to replace a highly conserved glycine at codon 195 by alanine. Although this mutation lies within the thiamine pyrophosphate binding domain, there was no thiamine responsiveness IN VIVO. The patients presented recurrent episodes of acute isolated ataxia in infancy. Both had normal blood and CSF lactate levels. Although symptoms initially resolved between episodes during the first decade, both patients subsequently worsened and developed progressive and severe encephalopathy, leading to death in their twenties. The spectrum of intermittent presentations in PDH deficiency includes episodic ataxia, intermittent peripheral weakness, recurrent dystonia and extrapyramidal movement disorders.

CONCLUSIONS

PDH deficiency should be considered in patients with unexplained intermittent and recurrent acute neurological symptoms. Long-term prognosis and outcome remain uncertain. PDH deficiency can occur even with normal CSF lactate concentration.

Impact of a preceptor education board and computer network to engage community faculty at Dartmouth Medical School

In 1994, as part of the Generalist Physician Initiative of The Robert Wood Johnson Foundation, Dartmouth Medical School established two programs to support and engage community-based teaching. The Preceptor Education Board and Community Computer Network were established to support a network of community-based preceptors and to facilitate communication between course directors at the school and community-based teachers. The board's mission is to organize, develop, and support a network of community-based primary care faculty, and to create and review community-based curricula. Through the board, community faculty members have made substantial contributions to curriculum, evaluation, faculty development, governance, and financing in community-based teaching. The Community Computer Network provides hardware, software, network systems, and support. Course directors and students have reported improved community-based educational experiences as a direct result of the Network. These two initiatives are dynamic and effective ways to improve the quality of community-based education and preceptors' morale. These efforts have strengthened the community faculty and their connection to the academic medical center.

Referrals for depression by primary care physicians. A pilot study

BACKGROUND

Communication between primary care physicians (PCPs) and mental health providers (MHPs) is integral to the management of depressive disorders. Our study investigated referrals from PCPs to MHPs in a rural research network.

METHODS

From April 1997 to September 1997, 5 family physicians tracked 6 weeks of referrals for depression and non-mental health problems and assessed the outcomes of these referrals after 3 months. The referrals were characterized by the nature and extent of communication between the PCP and the MHP and by the effectiveness of the consultation.

RESULTS

Sixty-seven patients (44 with non-mental health disorders and 23 with depressive disorders) were identified and followed. Analysis of the initial referral process showed that the referring physicians felt a greater sense of urgency for the referrals for depression. Written evidence of the referral in the patient's chart at the 3-month survey was more common for non-mental health disorders.

CONCLUSIONS

This pilot study demonstrates that there are communication barriers between PCPs and their mental health colleagues. Enhanced communication might improve satisfaction with the referral process. The details of the referral process need further study.

Recommended specifications for new mammography equipment: report of the ACR-CDC Focus Group on mammography equipment

The American College of Radiology has published a report that describes desirable features for new mammography x-ray units that will contribute to high-quality imaging. It encompasses all aspects of x-ray equipment performance including mechanical considerations, the x-ray tube focal spot and spectrum, generator performance, collimation, scatter rejection, and the automatic exposure control. The report is intended to provide guidance to equipment manufacturers and to purchasers of mammography systems with regard to basic performance levels that should be expected.

Canadian multicenter randomized clinical trial of chorion villus sampling and amniocentesis. chromosome mosaicism in CVS and amniocentesis samples

Data on 1040 chorionic villus and 969 amniotic fluid samples were collected from women studied in the Canadian Multicentre Randomized Clinical Trial of Chorion Villus Sampling and Amniocentesis. Cytogenetic results were obtained from 98.0 per cent of chorionic villus samples and from 99.9 per cent of amniotic fluid samples. Level I mosaicism (a single cell with an abnormal karyotype) occurred frequently in both chorionic villus and amniotic fluid samples and appeared to have no clinical significance. Level II mosaicism occurred in 0.9 per cent of CVS mesenchyme and 1.5 per cent of amniotic fluid cultures and in general was not perceived to be of sufficient concern to warrant cytogenetic follow-up studies. Level III mosaicism was reported in 18 CVS cases (15 cytotrophoblast, 1 mesenchyme, and 2 with both cell methods) and in one amniotic fluid case. In all cases but one (fetus with trisomy 18), level III mosaicism was confined to the placenta. Maternal cell contamination occurring with a frequency of 6.4 per cent in the mesenchyme analyses was a concern. This study supports the final report of the Canadian Multicentre Randomized Clinical Trial of Chorion Villus Sampling and Amniocentesis. Cytogenetic analysis of chorionic villus samples appears to be an acceptable alternative to the analysis of amniotic fluid samples. However, because of mosaicism and maternal cell contamination concerns, the examination of both cytotrophoblast preparations and mesenchyme cultures from chorionic villus samples is recommended.

[Corneal changes in Scheie disease. (Mucopolysaccharidosis type I S) (author's transl)]

Bilateral keratoplasty performed on a 39-year-old patient with Scheie disease gave the opportunity to study the histological, histochemical and ultrastructural lesions of both corneas. The patient showed all the characteristics signs of Scheie disease with bilateral corneal opacities, thick face, synophrys, mitral and aortic valve stenosis, bilateral carpal tunnel syndrome, stiff joints, and was of normal intelligence. 24 hours urines revealed a marked excretion of mucopolysaccharides. Histology showed scarring of the superficial stroma. Histochemistry revealed an accumulation of acid mucopolysaccharides in the keratocytes throughout the stroma. Electron microscopy showed vacuoles or pleomorphic inclusions in the keratocytes compabible with abnormal lysosomes deficient in alpha-L-iduronidase.

Morphology of the fluorescent interphase body demonstrated by quinacrine in man

In man, the distal part of the long arms of the Y chromosome and a corresponding interphase body fluoresce brightly when stained by quinacrine, an acridine derivative. We confirmed these observations, but we have found that this interphase body varies in size from one individual to another and that a multicorpuscular structure is often seen, which may correspond to a functional state.