Status Cataplecticus Following Abrupt Withdrawal of Clomipramine

Presentation This is a case of a 31 year old gentleman who suffered an attack of status cataplecticus following abrupt withdrawal of clomipramine. Diagnosis Clomipramine was temporarily discontinued in order to confirm a suspected diagnosis of narcolepsy using Multiple Sleep Latency Testing. This precipitated an episode of status cataplecticus which resolved with re-introduction of therapy. A diagnosis of narcolepsy was later confirmed with undetectable levels of hypocretin/orexin in the CSF. Treatment Re-introduction of clomipramine led to resolution of status cataplecticus. The patient now remains stable with regards to his cataplexy on clomipramine 30mg. Discussion There have been a total of 4 case reports of status cataplecticus following withdrawal of antidepressant therapy. In all cases, reintroduction of anti-cataplectic therapy led to resolution of attacks. The abrupt discontinuation of an SSRI is believed to precipitate cataplexy attacks due to reduction in noradrenergic tone.

Influence of parallel vs. perpendicular source geometry on cathodic: arc efficiency and film quality for generation of ZnO thin films.

ZnO films have been grown on Si (111) substrates using a modified PAMBD (pulsed arc molecular beam deposition) reactive cathodic arc source employing either O2, N2, or NH3 as carrier gas. Utilizing new source geometry, a two to three fold improvement in source efficiency has been realized. Scanning electron microscopy analysis confirms that this new source configuration gives a significant reduction in marcoparticle contamination and exhibits good crystalline properties for room temperature deposition. ZnO films were grown with this new source and characterized using X-ray diffraction and X-ray photoelectron spectroscopy.

Sports hernia or groin disruption injury? Chronic athletic groin pain: a retrospective study of 100 patients with long-term follow-up.

INTRODUCTION AND OBJECTIVES: Chronic groin pain (athletic pubalgia) is a common problem in sports such as football, hockey, cricket, baseball and athletics. Multiple co-existing pathologies are often present which commonly include posterior inguinal canal wall deficiency, conjoint tendinopathy, adductor tendinopathy, osteitis pubis and peripheral nerve entrapment. The mechanism of injury remains unclear but sports that involve either pivoting on a single leg (e.g. kicking) or a sudden change in direction at speed are most often associated with athletic pubalgia. These manoeuvres place large forces across the bony pelvis and its soft tissue supports, accounting for the usual clinical presentation of multiple symptomatic abnormalities forming one pattern of injury. RESULTS: The diagnoses encountered in this series of 100 patients included rectus abdominis muscle atrophy/asymmetry (22), conjoint tendinopathy (16), sports (occult, incipient) hernia (16), groin disruption injury (16), classical hernia (11) traumatic osteitis pubis (5), and avulsion fracture of the pubic bone (4). Surgical management was generally undertaken only after failed conservative therapy of 3-6 months, but some professionals who have physiotherapy during the football season went directly to surgery at the end of the football season. A variety of operations were performed including groin reconstruction (15), open hernia repair with or without mesh (11), sports hernia repair (Gilmore) (7) laparoscopic repair (3), conjoint tendon repair (3) and adductor tenotomy (3). Sixty-six patients were available for follow at an average of 13 years after initial consultation and the combined success rate for both conservative treatment and surgery was 94%. CONCLUSION: The authors believe that athletic pubalgia or sports hernia should be considered as a 'groin disruption injury', the result of functional instability of the pelvis. The surgical approach is aimed at strengthening the anterior pelvic soft tissues that support and stabilise the symphysis pubis.

Computed tomography scan diagnosis of occult groin hernia.

BACKGROUND: The value of computed tomography (CT) for the diagnosis of clinically occult (hidden) groin hernia was assessed in a series of patients presenting with undiagnosed groin pain. METHODS: A total of 158 consecutive patients presenting over a period of 5 years with undiagnosed groin pain or lower abdominal pain and negative or equivocal clinical findings were radiologically assessed with non-contrast CT. The decision to manage operatively or conservatively was then based on a combination of the clinical and CT findings. Outcomes were assessed at 10 years follow-up. RESULTS: The study cohort comprised 158 patients presenting with groin or lower abdominal pain and/or swelling, and was studied prospectively. Seven of these patients were re-investigated at a later date after developing new pain on either the ipsilateral or contralateral side, giving a total of 165 CT examinations. One-third of cases (54) had clinically occult groin hernias and most of the remaining cases had diagnoses that could be managed non-operatively. Of those who came to surgery, the pre-operative CT diagnosis of hernia had a positive predictive value (PPV) of 92% and a negative predictive value (NPV) of 96% (overall accuracy 94%). Lipoma of the spermatic cord was responsible for three of five false-positive CT results. The concept of sports hernia/groin disruption injury (GDI) was encountered, and this entity is discussed in this paper. In the group of patients without hernia findings on CT, the most common diagnoses were rectus abdominis and/or pyramidalis muscle injury which could be treated by physiotherapy (22%), GDI (16%), post-surgical problems (14%), miscellaneous (20%) and 'no abnormality' was identified in 15%. Overall, there were 111 patients with a 'non-hernia' CT diagnosis, of which urological, gynaecological, gastrointestinal and neuralgia contributed to the non-musculoskeletal diagnosis. CONCLUSION: This prospective non-contrast CT study of patients with undiagnosed chronic groin pain detected the majority of occult hernias requiring surgical intervention. These results suggest that CT can be a useful adjunct to the evaluation of patients presenting with chronic undiagnosed groin pain, but that experienced clinical judgment remains a critical element in the diagnostic pathway.

Sportsman hernia: what can we do?

INTRODUCTION: Sportsman (sports) hernia is a medially located bulge in the posterior wall of the inguinal canal that is common in football players. About 90% of cases occur in males. The injury is also found in the general population. CLINICAL PRESENTATION: The presenting symptom is chronic groin pain which develops during exercise, aggravated by sudden movements, accompanied by subtle physical examination findings and a medial inguinal bulge on ultrasound. Pain persists after a game, abates during a period of lay-off, but returns on the resumption of sport. Frequently, sports hernia is one component of a more extensive pattern of injury known as 'groin disruption injury' consisting of osteitis pubis, conjoint tendinopathy, adductor tendinopathy and obturator nerve entrapment. RISK FACTORS: Certain risk factors have been identified, including reduced hip range of motion and poor muscle balance around the pelvis, limb length discrepancy and pelvic instability. The suggested aetiology of the injury is repetitive athletic loading of the symphysis pubis disc, leading to accelerated disc degeneration with consequent pelvic instability and vulnerability to micro-fracturing along the pubic osteochondral junction, periosteal stripping of the pubic ligaments and para-symphyseal tendon tears, causing tendon dysfunction. RADIOLOGY: Diagnostic imaging includes an erect pelvic radiograph (X-ray) with flamingo stress views of the symphysis pubis, real-time ultrasound and, occasionally, computed tomography (CT) scanning and magnetic resonance imaging (MRI), but seldom contrast herniography. Other imaging tests occasionally performed can include nuclear bone scan, limb leg measurement and test injections of local anaesthetic/corticosteroid. PREVENTION AND TREATMENT: The injury may be prevented by the detection and monitoring of players at risk and by correcting significant limb length inequality. Groin reconstruction operation consists of a Maloney darn hernia repair technique, repair of the conjoint tendon, transverse adductor tenotomy and obturator nerve release. Rehabilitation involves core stabilisation exercises and the maintenance of muscle control and strength around the pelvis. OUTCOME: Using this regimen of groin reconstruction and post-operative rehabilitation, a player would be anticipated to return to their pre-injury level of activity approximately 3 months after surgery.

Cardiovascular disease in obstructive sleep apnoea syndrome: the role of intermittent hypoxia and inflammation.

There is increasing evidence that intermittent hypoxia plays a role in the development of cardiovascular risk in obstructive sleep apnoea syndrome (OSAS) through the activation of inflammatory pathways. The development of translational models of intermittent hypoxia has allowed investigation of its role in the activation of inflammatory mechanisms and promotion of cardiovascular disease in OSAS. There are noticeable differences in the response to intermittent hypoxia between body tissues but the hypoxia-sensitive transcription factors hypoxia-inducible factor-1 and nuclear factor-kappaB appear to play a key role in mediating the inflammatory and cardiovascular consequences of OSAS. Expanding our understanding of these pathways, the cross-talk between them and the activation of inflammatory mechanisms by intermittent hypoxia in OSAS will provide new avenues of therapeutic opportunity for the disease.

Adverse reaction to Bacille-Calmette-Guérin vaccine in a HIV positive healthcare worker.

BACKGROUND: The Bacille-Calmette-Guérin (BCG) vaccine is used in Mycobacterium tuberculosis prophylaxis in at risk tuberculin-negative healthcare workers. Its use is contraindicated however in individuals with HIV infection. AIMS: We herein highlight the case of a healthcare worker who developed a localised reaction at a BCG vaccination site and who was subsequently found to be HIV positive. CONCLUSION: This case emphasises the importance of eliciting risk factors for immunocompromise in individuals for whom BCG vaccination is being considered.

Malignant fibrous histiocytoma of the pancreas.

A case of fibrous histiocytoma of low grade malignancy arising from the uncinate lobe of the pancreas is reported. This is an unusual site for these extremely rare tumours. Survival up to 4 years has been achieved in our patient following surgical resection.

Long-term canine duct-occluded segmental pancreatic autografts: endocrine function.

This study examines the endocrine function of duct-obliterated canine segmental autografts for periods up to 5 years posttransplant. Overall the response profile of autografted animals was subnormal. After intravenous glucose tolerance tests K-values in transplanted animals (2.8 +/- 0.9%/min) were significantly lower than normal (4.6 +/- 1.2% min, p less than 0.001). After oral glucose stimulation, blood glucose in the autografted dogs reached a mean peak of 10.6 +/- 2.8 mmol/L whereas in normal dogs the peak value was 6.0 +/- 1.0 mmol/L (p less than 0.002). The mean insulin response in autografted dogs showed lower insulin concentrations in the early stages of the test, whereas insulin secretion after glucagon stimulation was significantly reduced in autografted dogs. Intravenous glucose tolerance tests were analyzed by calculating K value or measuring a single blood glucose concentration 40 min after glucose injection. This value had a high correlation with the K value (r = 0.967). No progressive deterioration of graft function up to 5 years was found. Glycosylated hemoglobin levels were measured in autografted (646 +/- 59 pmol/mg) and normal dogs (620 +/- 85 pmol/mg) and no significant difference was found. In conclusion, duct-occluded segmental pancreatic autografts were shown to have a reduced functional capacity but there was no deterioration of function up to 5 years after duct-occlusion and grafting. The degree of metabolic control may be sufficient to prevent diabetic complications.

The grafted fetal rat pancreas: features of development and rejection.

Pancreata from 17-18-day gestational rat embryos have been transplanted between related and unrelated adult rats rendered diabetic with streptozotocin. In separate experiments allograft recipients were given the immunosuppressive agent cyclosporin A. The morphologic changes in most of these grafts were followed during the first 2 weeks after transplantation. The endocrine, but not the exocrine, tissue developed fully in the isografts and did so at a rate corresponding to that reported for in vitro cultures. Within the allografted pancreata there was no maturation of the exocrine components, and endocrine tissue only reached full maturity if immunosuppression was used. Allograft rejection was similar morphologically to that of other tissues, involving cellular and humoral factors. The cells within the graft evoking rejection were not identified. These studies indicate that if rejection could be adequately suppressed, the endocrine parts of the fetal pancreas would survive and develop.