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.     

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'.     

The ‘clitoromotor’ reflex

The effect of glans clitoris (GC) stimulation on the vagina, uterus and pelvic floor muscles (levator ani (LA) or pubococcygeus, puborectalis (PR)) was studied in 16 healthy volunteers (mean age 34.9 years). The GC was stimulated mechanically and electrically while recording the vaginal and uterine pressures and the electromyographic activity of PR and LA. Stimulation caused a drop in the uterine (P<0.001) and upper vaginal (P<0.05) pressures (1.6 and 2.9 cmH₂O, respectively) and an increase in the middle (P<0.001) and lower (P<0.001) vaginal pressures (58.6 and 89.2 cmH₂O, respectively). It also effected an increase of EMG activity in the PR (P<0.01) and LA (P<0.01). Response was greater with electrical than with mechanical stimulation (P<0.05). No response occurred upon stimulation of the anesthetized GC or the anesthetized PR or LA. The reproducibility of the PR and LA contraction on GC stimulation postulates a reflex relationship which we call the clitoromotor reflex. This induces uterovaginal changes that enhance the sexual response of both partners, and also prepares the uterus and vagina for the reproductive process. LA contraction pulls open and reduces the pressure in the upper vagina as well as elevating the cervix uteri. PR contraction constricts the middle and lower vagina and increases their pressure.Editorial Comment: This article describes a reflex which is operative during coitus. It results in ballooning of the upper vagina (assuming lateral sidewall attachments are intact) and contraction of the paravaginal muscles. The study is nicely done and objectively establishes the existence of this physiological reflex.     

‘The Crown flap’: a modification to the keystone flap types I and IIA

The Crown flap is a modification of the keystone flap first described by Felix Behan in 2003. A third V-Y advancement limb is incorporated into the design in the central region of the flap where the line of maximum tension exists. This added V-Y closure utilizes surrounding tissue laxity and has been found to aid in closure of the defect centrally whilst not compromising the flap. The Crown flap is a useful modification to the keystone flap. Level of Evidence: Level V, therapeutic study.     

Differences Between Attendings’ and Residents’ Operative Notes for Laparoscopic Cholecystectomy

Background

Operative notes are the gold standard for detecting adverse events and near misses and form the basis for scientific research. In order to guarantee safe patient care, operative notes must be objective, complete, and accurate. This study explores the current routine of note writing for laparoscopic cholecystectomy (LC) and the differences between the notes of attendings and residents.

Methods

Attendings and residents were sent a DVD with footage of three LCs and were asked to “write” the corresponding notes and to complete a questionnaire. Dictation tapes were transcribed and items in the notes were analyzed for each procedure (“item described” or “item not described”). Fisher’s exact tests were performed using SPSS 16.0 for Mac.

Results

Thirteen sets of typewritten notes and 10 dictation tapes were returned. The results of the questionnaire showed that 16 of the 23 sets of notes were dictated. Eight participants found the current system for generating notes inadequate. 14 items (31 %) were included more often in the attendings’ notes and 25 items (56 %) were included more often in the residents’ notes. Overall, residents significantly more often described the location of the epigastric trocar (P = 0.018), the size of both working trocars (P = 0.019), the opening of the peritoneal envelope (P = 0.002), Critical View of Safety reached (P = 0.002), and the location for removing the gallbladder (P = 0.019). With the exception of “gallbladder perforation” (20 of 21 notes), complications were underreported.

Conclusions

In this study residents described more items than attendings. All notes lacked information concerning complications in the procedure, which makes the notes subjective and incomplete. A procedure-specific template or black-box-based operative notes based on established guidelines could improve the quality of the notes of both attendings and residents.     

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     

Impingement-free Hip Motion: The ‘Normal’ Angle Alpha after Osteochondroplasty

Femoroacetabular impingement is considered a cause of hip osteoarthrosis. In cam impingement, an aspherical head-neck junction is squeezed into the joint and causes acetabular cartilage damage. The anterior offset angle α, observed on a lateral crosstable radiograph, reflects the location where the femoral head becomes aspheric. Previous studies reported a mean angle α of 42° in asymptomatic patients. Currently, it is believed an angle α of 50° to 55° is normal. The aim of this study was to identify that angle α which allows impingement-free motion. In 45 patients who underwent surgical treatment for femoroacetabular impingement, we measured the angle α preoperatively, immediately postoperatively, and 1 year postoperatively. All hips underwent femoral correction and, if necessary, acetabular correction. The correction was considered sufficient when, in 90° hip flexion, an internal rotation of 20° to 25° was possible. The angle α was corrected from a preoperative mean of 66° (range, 45°–79°) to 43° (range, 34°–60°) postoperatively. Because the acetabulum is corrected to normal first, the femoral correction is tested against a normal acetabulum. We therefore concluded an angle α of 43° achieved surgically and with impingement-free motion, represents the normal angle α, an angle lower than that currently considered sufficient. Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. Each author certifies that his or her institution has approved the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.