Review of police inquiries to an accident and emergency department.

OBJECTIVE: To assess the workload generated by police inquiries to an accident and emergency (A&E) department and the adherence of medical staff to departmental guidelines relating to these inquiries. DESIGN: Prospective analysis of the number, nature, and timing of police inquiries and the information released by medical staff. SETTING: A&E department of an inner city teaching hospital. OUTCOME MEASURES: Number of personal and telephone requests for information from police; completion of a form of inquiry; record of patient consent for release of information. RESULTS: A daily average of 8.7 police inquiries were made, but in only 10% of cases was a form of inquiry completed. The patient's consent for release of information to the police was recorded in 4% of cases. CONCLUSIONS: Police inquiries generate a significant workload for an A&E department, often at clinically busy times. Medical staff need further education to ensure that patient confidentiality is respected while assisting the police with their investigations.     

Speaking of which: dissecting the neurocognitive network of language production in picture naming

The noninvasive methods of cognitive neuroscience offer new possibilities to study language. We used neuronavigated multisite transcranial magnetic stimulation (TMS) to determine the functional relevance of 1) the posterior part of left superior temporal gyrus (Wernicke's area), 2) a midportion of Broca's area (slightly posterior/superior to apex of vertical ascending ramus), and 3) the midsection of the left middle temporal gyrus (MTG), during overt picture naming. Our chronometric TMS design enabled us to chart the time points at which neural activity in each of these regions functionally contributes to overt speech production. Our findings demonstrate that the midsection of left MTG becomes functionally relevant at 225 ms after picture onset, followed by Broca's area at 300 ms and Wernicke's area at 400 ms. Interestingly, during this late time window, the left MTG shows a second peak of functional relevance. Each area thus contributed during the speech production process at different stages, suggesting distinct underlying functional roles within this complex multicomponential skill. These findings are discussed and framed in the context of psycholinguistic models of speech production according to which successful speaking relies on intact, spatiotemporally specific feed forward and recurrent feedback loops within a left-hemispheric fronto-temporal brain connectivity network.     

Comparison between amputation-induced demineralization and age-related bone loss using digital X-ray radiogrammetry

Digital X-ray radiogrammetry (DXR) is a computer-assisted automatic osteodensitometric tool. This study was performed to compare DXR measurements between bone changes following amputation trauma and age-related bone loss. Thirty-five men, who had undergone finger amputations, received a baseline examination and 2--3 serial measurements. As a second group, 215 males older than 70yr were enrolled. All patients obtained standardized hand radiographs. The following DXR parameters evaluating metacarpals were considered: cortical bone mineral density (DXR-BMD), cortical thickness (DXR-CT), metacarpal index (DXR-MCI), outer bone diameter (width; DXR-W), and inner medullary diameter (DXR-MD). In the amputation group, the DXR parameters showed an accentuated initial decrease between first and second measurements (DRX-BMD--12.7%, DXR-CT--14.2%, DXR-W--8.6%, DXR-MCI--6.1%; p<0.001) followed by a less pronounced reduction between second and third radiographs (DRX-BMD--0.5%, DXR-CT--1.5%, DXR-W--0.1%, DXR-MCI--1.3%). DXR-MD revealed a reduction of--3.6% (p<0.05) between first and second estimates and a non-significant increase (+1.1%) between second and third measurements. When compared with the second and third estimates in the amputation group, men older than 70yr presented lower DXR-BMD, DXR-CT, and DXR-MCI values (p<0.001), but larger metacarpal outer and inner bone diameters (DXR-W and DXR-MD; p<0.001). DXR-MD of the elderly men group was also more extended when compared with the baseline measurements of the amputation cohort (p<0.001). The early accentuated cortical bone loss and particularly the pronounced decrease of the outer bone width seem to be characteristic for amputation-induced osteoporosis, suggesting that this might be a distinct secondary osteoporosis entity. When compared with amputation-associated osteoporosis, where the bone loss occurs to a higher extent in the outer bone diameter than in the medullary cavity, the age-related bone changes lead more to an increase of the medullary diameter than of the outer bone width.     

Which patients are at the highest risk of dying from competing causes ≤10 years after radical prostatectomy?

Study Type – Outcomes (cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Several comorbidity classifications have been investigated for their suitability to assist treatment decision‐making in men with early prostate cancer. In unselected patients, some serious comorbidities have been shown to be associated with a 10‐year competing mortality rate clearly superseding the 50% level. The present study shows that it is hardly possible to discern meaningful subsets of patients with a 10‐year risk of competing mortality of >50% by using comorbidity classifications. This finding suggests that the selecting clinicians did well in estimating the medium‐term survival probability in men referred for radical prostatectomy.

OBJECTIVE

• ? To identify subsets of patients who are most likely to die from competing causes ≤10 years after radical prostatectomy (RP).

PATIENTS AND METHODS

• ? In all, 2205 consecutive patients who underwent RP for clinically localized prostate cancer between 1992 and 2005 were studied. The 10‐year cumulative competing mortality rates were determined in several worst‐case scenarios formed by using comorbidity classifications and combinations of them.

RESULTS

• ? In this sample of men selected for RP, even those with the most severe comorbidity level had a competing mortality risk of <50% ≤10 years after RP.
• ? Depending on the comorbidity classification used, the 10‐year cumulative competing mortality rates differed between 16 and 39% in the whole sample and between 18 and 48% in men aged ≥65 years.

CONCLUSION

• ? Clinicians do well in estimating the further life span in candidates for RP. Comorbidity classifications may assist treatment choice in this population but are not able to discern meaningful subsets to be excluded from curative treatment because of a life expectancy falling below a limit of 10 years.

     

Attentional systems in target and distractor processing: a combined ERP and fMRI study

The interplay of "top-down" and "bottom-up" regulated mechanisms is of particular relevance for the rapid (re-)focusing of attention to environmental changes. The purpose of the study was to explore the differential contributions of frontoparietal attentional networks involved in top-down and stimulus-driven processing to the detection of "target" and "distractor" events in a visual three-stimulus oddball paradigm. Thirteen healthy subjects underwent separate event-related potential (ERP) and whole-brain functional magnetic resonance imaging (fMRI) measurements during the oddball task. The targets, which were difficult to detect, elicited a classical posterior P3b whereas the distractor stimuli were followed by a centro-frontal P3a ERP. The fMRI data showed activation of the temporoparietal junction (TPJ) bilaterally and right prefrontal cortex associated with both the target and distractor conditions. This network has previously been described as an attentional system that is predominantly stimulus driven and that responds to rare events. Furthermore, target processing produced bilateral perisylvian activity, which has been related to the "retrieval mode". Processing of the distractors activated the frontal eye fields (FEFs) and bilateral superior parietal cortex, areas engaged in attention switching and voluntary allocation of attention. Additional left prefrontal activation suggested an involvement of the cortical system for working memory encoding. Our results thus demonstrate that distractor and target processing engage a common neuronal system for the detection of rare events, but also task-specific subsystems related to attention and memory processes.     

Efficacy of pregabalin in neuropathic pain evaluated in a 12-week, randomised, double-blind, multicentre, placebo-controlled trial of flexible- and fixed-dose regimens

Pregabalin binds with high affinity to the alpha2-delta subunit protein of voltage-gated calcium channels and, thereby, reduces release of excitatory neurotransmitters. This 12-week randomised, double-blind, multicentre, placebo-controlled, parallel-group study evaluated the efficacy and safety of pregabalin in patients with chronic postherpetic neuralgia (PHN) or painful diabetic peripheral neuropathy (DPN). Patients were randomised to placebo (n=65) or to one of two pregabalin regimens: a flexible schedule of 150, 300, 450, and 600 mg/day with weekly dose escalation based on patients' individual responses and tolerability (n=141) or a fixed schedule of 300 mg/day for 1 week followed by 600 mg/day for 11 weeks (n=132). Both flexible- and fixed-dose pregabalin significantly reduced endpoint mean pain score (primary outcome) versus placebo (P=0.002, P<0.001) and were significantly superior to placebo in improving pain-related sleep interference (P<0.001). The most common adverse events (AEs) for pregabalin-treated patients were dizziness, peripheral oedema, weight gain (not affecting diabetes control), and somnolence. These results are consistent with previous studies' demonstrating pregabalin's efficacy, tolerability, and safety for treatment of chronic neuropathic pain associated with DPN or PHN. Pregabalin dosing aimed at optimal balance of efficacy and tolerability provides significant pain relief and may reduce risks for AEs and therapy discontinuation.     

Role of angiogenic growth factors in transplant coronary artery disease

Transplant coronary artery disease (TxCAD) as a manifestation of chronic rejection is a major limitation to long-term survival of heart transplant recipients. Although the exact molecular and cellular mechanisms contributing to neointimal formation are unknown, it has been generally believed that smooth muscle cells (SMC) of donor origin migrate from the media into the subendothelial layer of the vascular wall, where SMC proliferate and synthesize extracellular matrix resulting in intimal thickening. However, recent observations indicate that hematopoietic and vascular progenitor cells derived from recipient bone marrow may contribute to the arteriosclerotic lesion formation in the coronary arteries of the transplant. On the other hand, studies on postnatal hematopoiesis indicate that angiogenic growth factors such as vascular endothelial growth factor (VEGF) and angiopoietin-1 (Ang1) may regulate the recruitment of these cells into distant organs. Furthermore, embryonic VEGFR-2 /CD34+ stem cells may serve as vascular progenitor cells and their differentiation into endothelial cells and SMC may be regulated by VEGF and platelet-derived growth factor (PDGF), respectively. In this review, we discuss the role of angiogenic growth factors such as VEGF, Ang, and PDGF in the recruitment of hematopoietic and vascular progenitor cells in TxCAD and suggest novel therapies targeted at homing, differentiation and proliferation of these cells in the allograft.