The ‘antiphospholipid syndrome’ and the ‘lupus anticoagulant’

In recent years an association has been described between, on the one hand, an in vitro prolongation of phospholipid-dependent coagulation tests (the lupus anticoagulant) or the demonstration of antiphospholipid antibodies and, on the other, clinical events, particularly recurrent thrombosis (usually venous but sometimes arterial), thrombocytopenia, and also recurrent mid-term fetal loss. Other less well-documented associations with haemolytic anaemia, livedo reticularis, strokes and other neurological syndromes have been suggested. The antibodies are present temporarily in many infections, are usually of IgM isotype and thrombosis does not occur. However, they are persistently present and mainly of IgG isotype in a number of auto-immune disorders associated with thrombosis, in particular systemic lupus erythematosus, in which 50% of patients will show antibody of one isotype or another. The strongest association is with antinuclear factor-negative lupus and lupus-like disorders in which a full diagnosis of classical lupus cannot be made. The clotting test abnormality and antiphospholipid antibodies may be found also in otherwise normal individuals suffering thrombosis or fetal loss — the so-called primary antiphospholipid syndrome. These data raise important questions for management, but many details are controversial despite a decade's work; this review examines the present position and outlines some of the difficulties, particularly from the point of view of nephrology and paediatrics.     

Arthur Barker and the ‘glass spine’

Arthur Barker developed his glass spine (a glass tube bent to represent the space in the spinal column containing the spinal cord and the cerebrospinal fluid) to view the behaviour of different local anaesthetic solutions. He tested three solutions of local anaesthetic each with a different specific gravity. He is thought to have been the first person to use glucose with the local anaesthetic in the injection fluid.     

Biomechanical considerations in ‘biological’ femoral osteosynthesis: an experimental study of the ‘bridging’ and ‘wave’ plating techniques

Although traditional compression plate fixation aims to abolish interfragmentary movement and achieve primary bone healing, the more recent ‘biological’ plate fixation methods such as the ‘bridging’ and ‘wave’ plate techniques aim to maintain fracture alignment without absolute stability and promote union by callus formation. Furthermore, some mechanical advantages have been attributed to the ‘wave’ plate fixation. Since no data have been published on the mechanical characteristics of the ‘bridging’ and ‘wave’ plate fixation methods, the aim of this biomechanical comparative study was to investigate the rigidity of those fixation methods in various types of femoral diaphyseal fractures. Using a composite femoral model, the rigidity characteristics of three fixation methods (short DCP, ‘bridging’ and ‘wave’ plates) were investigated. The results showed that when cortical contact between the main fragments is present, a ‘bridging’ plate can be equally rigid to the ‘wave’ plate in mediolateral bending by displaying a similar tension-band effect. Furthermore, in the absence of cortical contact, the axial fixation rigidity of the long ‘bridging’ plate is superior to that of the ‘wave’ plate. Both methods showed a significant ‘stress-shielding’ effect on the intact femur. In conclusion, this in vitro study failed to show any significant mechanical advantages of the ‘wave’ plate technique over the ‘bridging’ plating method. It appears that the ‘bridging’ plate fixation may be the mechanically optimal ‘biological’ plating method for the femoral diaphysis. Received: 26 May 1999     

Overcoming placebo-related challenges in manual therapy trials: The ‘whats and hows’ and the ‘touch equality assumption’ proposals

Due to the significant increase in interest in placebos, biomedical scientists have incorporated placebo innovations into a modern methodological research scenario in order to increase the quality of clinical studies. Indeed, the randomised-controlled trial design has changed dramatically, and these changes have had an impact on manual therapy research as well. The present paper outlines the main difficulties that placebo-controlled trials pose for research in manual therapy, for example, designing ineffective sham protocols, the role of touch in triggering neurobiological responses, or the unique specificity of manual therapies. The paper then offers suggestions on how to overcome such challenges, for example by providing a definition of ‘specificity’ in the context of manual therapies, and specifically osteopathy, suggesting how to design adequate sham procedures, and by introducing the so-called ‘touch equality assumption'.     

Should the ‘normal’ and ‘ideal’ nipple position in a male influence the surgeon when planning severe gynaecomastia correction?

BackgroundThe ideal nipple areolar complex (NAC) position of the male chest following gynaecomastia surgery is well documented; however, with increased development of the chest muscles, the NAC placement can change, leading to the medial displacement of the nipple giving a poor aesthetic outcome. Therefore, we believe that these measurements need to be applied to the patients’ build and take into consideration the future fitness goals of the patients.MethodWe have analysed the photographs of three groups of men: super athletes, athletes and individuals with severe gynaecomastia. We have assessed the proportions of the chest in relation to the NAC, degree of ptosis and TAP index.ResultsThere was a wide variation between the athlete and the super athlete group, with minor variations within each group. The range of measurement in the severe gynaecomastia group was significantly larger than those in the other groups. We feel that based on this research study, surgeons should however be somewhat circumspect in their choice of nipple position as there is a wide variation in what can be considered as normal, and positioning of the NAC too early in the recovery process may lead to an abnormal aesthetic appearance following muscle development.ConclusionDespite the multitude of techniques available in the literature to determine the position of nipple, there is a lack of understanding on how the NAC position changes with muscle development. Adopting a dogmatic approach may result in a very aesthetically displeasing outcome, which can be very difficult to correct in men.