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European Spine Journal - Depression, anxiety, catastrophising, and fear-avoidance beliefs are key "yellow flags" (YFs) that predict a poor outcome in back patients. Most surgeons...     

Validity of a single-item measure to assess leg or back pain as the predominant symptom in patients with degenerative disorders of the lumbar spine

Purpose

Recent studies suggest that the location of predominant pain (back or leg) can be a significant predictor of the outcome of surgery for degenerative spinal disorders. However, others challenge the notion that the predominant symptom can be reliably identified. This study examined the validity of a single item used to determine the most troublesome symptom.

Methods

A total of 2,778 patients with degenerative disorders of the lumbar spine scheduled for surgery with the goal of pain relief completed a questionnaire enquiring as to their most troublesome symptom [“main symptom”; back pain (BACK) or leg/buttock pain (LEG)]. They also completed separate 0–10 graphic rating scales for back pain (LBP) and leg/buttock pain (LP) intensity. Receiver operating characteristics (ROC) analysis was used to determine the accuracy with which the “LP minus LBP” score was able to classify patients into their declared “main symptom” group. Sub-studies evaluated the test–retest reliability of the patients’ self-rated pain scores (N = 45) and the agreement between the main symptom declared by the patient in the questionnaire and that documented by the surgeon after the clinical consultation (N = 118).

Results

Test–retest reliability of the back and leg pain scores was good (ICC_2,1 of 0.8 for each), as was patient–surgeon agreement regarding the main symptom (BACK or LEG) (κ value 0.79). In the BACK group, the mean values for pain intensity were 7.3 ± 2.0 (LBP) and 5.2 ± 2.9 (LP); in the LEG group, they were 4.3 ± 2.9 (LBP) and 7.5 ± 1.9 (LP). The area under the curve for the ROC was 0.95 (95 % CI 0.94–0.95), indicating excellent discrimination between the BACK and LEG groups based on the “LP minus LBP” scores. A cutoff score >0.0 for “LP minus LBP” score gave optimal sensitivity and specificity for indicating membership of the LEG group (sensitivity 79.1 %, specificity 95.7 %).

Conclusions

The responses on the single item for the “main symptom” were in good agreement with the differential ratings on the 0–10 pain scales for LBP and LP intensity. The cutoff >0 for “LP minus LBP” for classifying patients as LEG pain predominant seemed appropriate and suggests good concurrent validity for the single-item measure. The single item may be of use in sub-grouping patients with the same disorder (e.g. spondylolisthesis) or as an indication in surgical decision-making.     

Expression of protocadherin-γC4 protein in the rat brain

It has been proposed that the combinatorial expression of γ-protocadherins (Pcdh-γs) and other clustered protocadherins (Pcdhs) provides a code of molecular identity and individuality to neurons, which plays a major role in the establishment of specific synaptic connectivity and formation of neuronal circuits. Particular attention has been directed to the Pcdh-γ family, for which experimental evidence derived from Pcdh-γ-deficient mice shows that they are involved in dendrite self-avoidance, synapse development, dendritic arborization, spine maturation, and prevention of apoptosis of some neurons. Moreover, a triple-mutant mouse deficient in the three C-type members of the Pcdh-γ family (Pcdh-γC3, Pcdh-γC4, and Pcdh-γC5) shows a phenotype similar to the mouse deficient in whole Pcdh-γ family, indicating that the latter is largely due to the absence of C-type Pcdh-γs. The role of each individual C-type Pcdh-γ is not known. We have developed a specific antibody to Pcdh-γC4 to reveal the expression of this protein in the rat brain. The results show that although Pcdh-γC4 is expressed at higher levels in the embryo and earlier postnatal weeks, it is also expressed in the adult rat brain. Pcdh-γC4 is expressed in both neurons and astrocytes. In the adult brain, the regional distribution of Pcdh-γC4 immunoreactivity is similar to that of Pcdh-γC4 mRNA, being highest in the olfactory bulb, dentate gyrus, and cerebellum. Pcdh-γC4 forms puncta that are frequently apposed to glutamatergic and GABAergic synapses. They are also frequently associated with neuron-astrocyte contacts. The results provide new insights into the cell recognition function of Pcdh-γC4 in neurons and astrocytes.     

Suicide attempt and melancholic depression in a male with erotomania: case report.

Erotomania is a delusional disorder, which is more common among women. A case of erotomania in a 34-year-old male associated with depression and suicidal behavior is presented. At the time he attempted suicide his erotomania fulfilled the diagnostic criteria of "pure" erotomania, described by de Clérambault. A depressive picture with melancholic features emerged four months later. Antidepressant medication was given and two months later he became euthymic. The erotomanic delusion disappeared in the third month of the euthymic state. In this case primary erotomania was associated with a depressive illness, presumably unipolar depression. The patient developed delusional guilt and suicidal ideation before the unequivocal change in his mood. To the authors' knowledge this is the first reported case where the erotomanic symptomatology led to suicidal attempt.     

A comparative study of hemorheological parameters in transient ischemic attack and acute ischemic stroke patients: possible predictive value

A complete neurological and laboratory assessment was made of 31 transient ischemic attack (TIA) and 33 acute ischemic stroke patients. Laboratory parameters were compared with 33 age- and sex-matched controls. Erythrocyte deformability was characterised by determining the relative cell transit time (RCTT) with a St. George filtrometer. Plasma viscosity was measured with a Haake microviscosimeter. In comparison with controls, fibrinogen content, erythrocyte sedimentation rate (ESR), platelet and leukocyte count, erythrocyte RCTT and plasma viscosity were found to be significantly higher in stroke patients. In TIA patients the elevation of these values was not significant with the exception of platelet count. Our results suggest that the hemorheological alterations observed in TIA and stroke are largely non-specific findings and associated with the atherosclerotic disease of patients. The significant elevation of leukocytes, fibrinogen and plasma viscosity in acute stroke versus TIA probably reflects the systemic acute phase response of organism to cerebral infarction.     

Survival and Implantation of Escherichia coli in the Intestinal Tract

Preliminary experiments established that a 0.5-ml inoculum that is introduced directly into the stomach of mice was cleared rapidly into the small intestine. Bicarbonate buffer, but not skim milk, protected such an inoculum from stomach acid until at least 90% of it had entered the small intestine. Passage and survival of various Escherichia coli strains through the mouse gut were tested by introducing a buffered bacterial inoculum directly into the stomach, together with the following two intestinal tracers: Cr(51)Cl(3) and spores of a thermophilic Bacillus sp. Quantitative recovery of excreted bacteria was accomplished by collecting the feces overnight in a refrigerated cage pan. The data show that wild-type E. coli strains and E. coli K-12 are excreted rapidly (98 to 100% within 18 h) in the feces without overall multiplication or death. E. coli varkappa1776 and DP50supF, i.e., strains certified for recombinant DNA experiments underwent rapid death in vivo, such that their excretion in the feces was reduced to approximately 1.1 and 4.7% of the inoculum, respectively. The acidity of the stomach had little bactericidal effect on the E. coli K-12 strain tested, but significantly reduced the survival of more acidsensitive bacteria (Vibrio cholerae) under these conditions. Long-term implantation of E. coli strains into continuous-flow cultures of mouse cecal flora or into conventional mice was difficult to accomplish. In contrast, when the E. coli strain was first inoculated into sterile continuous-flow cultures or into germfree mice, which were subsequently associated with conventional mouse cecal flora, the E. coli strains persisted in a large proportion of the animals at levels resembling E. coli populations in conventional mice. Metabolic adaptation contributed only partially to the success of an E. coli inoculum that was introduced first. A mathematical model is described which explains this phenomenon on the basis of competition for adhesion sites in which an advantage accrues to the bacterium which occupies those sites first. The mathematical model predicts that two or more bacterial strains that compete in the gut for the same limiting nutrient can coexist, if the metabolically less efficient strains have specific adhesion sites available. The specific rate constant of E. coli growth in monoassociated gnotobiotic mice was 2.0 h(-1), whereas the excretion rate in conventional animals was -0.23 h(-1). Consequently, limitation of growth must be regarded as the primary mechanism controlling bacterial populations in the large intestine. The beginnings of a general hypothesis of the ecology of the large intestine are proposed, in which the effects of the competitive metabolic interactions described earlier are modified by the effects of bacterial association with the intestinal wall.