Reduced sperm concentration in a patient from a suspected post-operative infection: a case study.

A diagnostic semen analysis should be performed as part of a couple's routine fertility investigations in order to determine sperm quality prior to managing the treatment pathway. The semen analysis report should be considered alongside clinical discussions and a review of both patients' medical history. However, whilst it is part of the standard patient pathway, a regular up-to-date review at each clinical step of a patients' journey is not always performed, which may miss potential clinical changes that could impact the most effective management of the couple. This case study reports the impact on the semen quality of a post-operative infection and hospitalisation of a male patient on a fertility management pathway.

Systematic review of skills transfer after surgical simulation-based training.

BACKGROUND: Simulation-based training assumes that skills are directly transferable to the patient-based setting, but few studies have correlated simulated performance with surgical performance. METHODS: A systematic search strategy was undertaken to find studies published since the last systematic review, published in 2007. Inclusion of articles was determined using a predetermined protocol, independent assessment by two reviewers and a final consensus decision. Studies that reported on the use of surgical simulation-based training and assessed the transferability of the acquired skills to a patient-based setting were included. RESULTS: Twenty-seven randomized clinical trials and seven non-randomized comparative studies were included. Fourteen studies investigated laparoscopic procedures, 13 endoscopic procedures and seven other procedures. These studies provided strong evidence that participants who reached proficiency in simulation-based training performed better in the patient-based setting than their counterparts who did not have simulation-based training. Simulation-based training was equally as effective as patient-based training for colonoscopy, laparoscopic camera navigation and endoscopic sinus surgery in the patient-based setting. CONCLUSION: These studies strengthen the evidence that simulation-based training, as part of a structured programme and incorporating predetermined proficiency levels, results in skills transfer to the operative setting.

Uptake of tamoxifen in consecutive premenopausal women under surveillance in a high-risk breast cancer clinic.

BACKGROUND: Randomised trials of tamoxifen versus placebo indicate that tamoxifen reduces breast cancer risk by approximately 33%, yet uptake is low. Approximately 10% of women in our clinic entered the IBIS-I prevention trial. We assess the uptake of tamoxifen in a consecutive series of premenopausal women not in a trial and explore the reasons for uptake through interviews. METHODS: All eligible women between 33 and 46 years at ≥17% lifetime risk of breast cancer and undergoing annual mammography in our service were invited to take a 5-year course of tamoxifen. Reasons for accepting (n=15) or declining (n=15) were explored using semi-structured interviews. RESULTS: Of 1279 eligible women, 136 (10.6%) decided to take tamoxifen. Women >40 years (74 out of 553 (13.4%)) and those at higher non-BRCA-associated risk were more likely to accept tamoxifen (129 out of 1109 (11.6%)). Interviews highlighted four themes surrounding decision making: perceived impact of side effects, the impact of others' experience on beliefs about tamoxifen, tamoxifen as a 'cancer drug', and daily reminder of cancer risk. CONCLUSIONS: Tamoxifen uptake was similar to previously ascertained uptake in a randomised controlled trial (IBIS-I). Concerns were similar in women who did or did not accept tamoxifen. Decision making appeared to be embedded in the experience of significant others.

Atypical paraneoplastic pemphigus secondary to endometrial carcinoma with no mucosal involvement.

Paraneoplastic pemphigus (PNP) is a mucocutaneous immunobullous disease associated with several types of internal malignancy. We report a case of a 78-year-old woman presenting with an atypical form of PNP associated with a recurrence of endometrial cancer. There was no involvement of the mucous membranes. Although the macroscopic and histological appearances were typical for IgA pemphigus or Sneddon-Wilkinson disease, direct immunofluorescence was positive for intercellular IgG and C3 staining. Circulating antibodies were detected to periplakin and envoplakin, but not to desmogleins 1 or 3. This case therefore meets the modified criteria for PNP. A response was seen to a combination of topical and systemic corticosteroids and acitretin, although with cyclical recurrences. These ceased after resection of her recurrent endometrial carcinoma.

The reliability and validity of the Severity of Dependence Scale for detecting cannabis dependence in psychosis.

AIMS: To determine the reliability and validity of the Severity of Dependence Scale (SDS) for detecting cannabis dependence in a large sample of in-patients with a schizophrenia spectrum disorder. DESIGN: Cross-sectional study. PARTICIPANTS: Participants were 153 in-patients with a schizophrenia spectrum disorder in Brisbane, Australia. MEASUREMENTS: Participants were administered the SDS for cannabis dependence in the past 12 months. The presence of Diagnostic and Statistical Manual Version-IV (DSM-IV) cannabis dependence in the previous 12 months was assessed using the Comprehensive International Diagnostic Interview (CIDI). FINDINGS: The SDS had high levels of internal consistency and strong construct and concurrent validity. Individuals with a score of >or = 2 on the SDS were nearly 30 times more likely to have DSM-IV cannabis dependence. The SDS was the strongest predictor of DSM-IV cannabis dependence after controlling for other predictor variables. CONCLUSIONS: The SDS is a brief, valid and reliable screen for cannabis dependence among people with psychosis.

Psychotic symptom and cannabis relapse in recent-onset psychosis. Prospective study.

BACKGROUND: Cannabis use appears to exacerbate psychotic symptoms and increase risk of psychotic relapse. However, the relative contribution of cannabis use compared with other risk factors is unclear. The influence of psychotic symptoms on cannabis use has received little attention. AIMS: To examine the influence of cannabis use on psychotic symptom relapse and the influence of psychotic symptom severity on relapse in cannabis use in the 6 months following hospital admission. METHOD: At baseline, 84 participants with recent-onset psychosis were assessed and 81 were followed up weekly for 6 months, using telephone and face-to-face interviews. RESULTS: A higher frequency of cannabis use was predictive of psychotic relapse, after controlling for medication adherence, other substance use and duration of untreated psychosis. An increase in psychotic symptoms was predictive of relapse to cannabis use, and medication adherence reduced cannabis relapse risk. CONCLUSIONS: The relationship between cannabis use and psychosis may be bidirectional, highlighting the need for early intervention programmes to target cannabis use and psychotic symptom severity in this population.

Experimental infections with Lepeophtheirus salmonis (Krøyer) on threespine sticklebacks, Gasterosteus aculeatus L., and juvenile Pacific salmon, Oncorhynchus spp.

Experimental infections with Lepeophtheirus salmonis (Krøyer) were established on threespine sticklebacks, Gasterosteus aculeatus L., juvenile pink, Oncorhynchus gorbuscha (Walbaum), and chum, Oncorhynchus keta (Walbaum), salmon. The prevalence and abundance of infections were initially higher on sticklebacks than on either salmon species. The initial prevalence and intensity of infections on chum salmon were higher than those on pink salmon, and declined on both species during louse development. The rate of parasite development to adult stages was similar on all species although development beyond the preadult stage was not observed on sticklebacks. These results confirm previous field observations on the occurrence and development of L. salmonis on threespine sticklebacks.

Microscopic polyarteritis presenting with skin necrosis in a patient with sickle-cell disease.

A 20-year-old Caribbean woman with sickle cell anaemia was admitted with a 4-day history of fever and a painful swollen right ankle. She rapidly developed skin necrosis. The differential diagnosis is discussed. This case illustrates the difficulty in identifying the cause of cutaneous necrosis in an acutely ill patient. In our patient, histopathology implicated a vasculitic process, which was subsequently identified as a manifestation of microscopic polyarteritis.

A case of post-partum borderline tuberculoid leprosy complicated by a median nerve abscess, peptic ulceration and rifampicin-induced haemolytic renal failure.

We report a case of borderline tuberculoid leprosy complicated by a median nerve abscess, acute renal failure secondary to rifampicin-induced haemolysis and duodenal ulceration secondary to steroid use. Rifampicin induced hameolysis is a rare and probably under-reported complication of leprosy multi-drug therapy. It should be considered when patients complain of flu-like symptoms after taking their monthly rifampicin.

Congenital erythropoietic porphyria: dilemmas in present day management.

Congenital erythropoietic porphyria is a rare autosomal recessive disorder of haem biosynthesis caused by a deficiency of uroporphyrinogen III synthetase. There is resultant accumulation and hyperexcretion of porphyrinogens of the isomer I variety. These are converted by spontaneous oxidation into their corresponding photoactive porphyrins leading to photodamage. Accumulation of porphyrins results in haemolysis and extensive photosensitivity. The consequences of chronic haemolysis are splenomegaly, reactive erythroid hyperplasia, erythrodontia, bone fragility, extreme photosensitivity and photomutilation. We present a 35-year-old man who has the severe infantile form and illustrates the haematological and photodestructive complications despite attempts at treatment with hypertransfusion, oral charcoal therapy and beta-carotene. Allogenic bone marrow transplantation has been considered but because of the high associated mortality this procedure has been discounted at present in the management of our patient.

Xenoma formation during microsporidial gill disease of salmonids caused by Loma salmonae is affected by host species (Oncorhynchus tshawytscha, O. kisutch, O. mykiss) but not by salinity.

Host species and salinity often affect the development of disease in aquatic species. Eighty chinook salmon Oncorhynchus tshawytscha, 80 coho salmon O. kisutch and 80 rainbow trout O. mykiss were infected with Loma salmonae. Forty of each species were reared in seawater and 40 in freshwater. The mean number of xenomas per gill filament was 8 to 33 times greater in chinook salmon than in rainbow trout (RBT). Coho salmon had a mean xenoma intensity intermediate to that of chinook salmon and RBT. In contrast to the differences between species, salinity had no significant effect on xenoma intensity in any of these host species. The onset of xenoma formation occurred at Week 5 postexposure (PE) for chinook salmon and RBT, and at Week 6 PE for coho salmon. RBT had cleared all visible branchial xenomas by Week 9 PE, whereas xenomas persisted in coho and chinook salmon at Week 9 PE. Histologically, xenomas were visible in the filament arteries of the branchial arch in chinook and coho salmon gills but were absent from RBT gills. Fewer xenomas were seen in the central venous sinusoids of RBT than in chinook and coho salmon. The lower xenoma intensity, shorter duration of infection and pathological characteristics, common to microsporidial gill disease in RBT, suggest a degree of resistance to clinical disease that is not seen in coho and chinook salmon.

Alcohol abuse and dysfunctional eating in adolescent girls: the influence of individual differences in sensitivity to reward and punishment.

OBJECTIVE: An unusually high comorbidity of eating disorders and alcohol abuse has been found in clinical and community samples of young women. This paper proposes that individual differences in sensitivity to reward and punishment may influence the propensity of young women to engage in dysfunctional eating and drinking behaviour. METHOD: The Drive for Thinness scale, the Alcohol Use Disorders Identification Test and the BIS/BAS scales were administered to 232 high school girls. RESULTS: Heightened sensitivity to reward was the better predictor of alcohol misuse while heightened sensitivity to both reward and punishment was predictive of dysfunctional eating. When categorised by group, alcohol abusing, dysfunctional eating, and comorbid girls reported greater sensitivity to reward than non-disordered girls. Girls with dysfunctional eating with and without comorbid alcohol abuse reported greater sensitivity to punishment than alcohol abusing only girls. DISCUSSION: These findings suggest that girls who abuse alcohol and have dysfunctional eating may share a vulnerability to heightened sensitivity to reward, yet be differentiated by sensitivity to punishment.