Using graded motor imagery for complex regional pain syndrome in clinical practice: failure to improve pain.

BACKGROUND: There is good evidence from studies conducted in a single-centre research setting for the efficacy of graded motor imagery (GMI) treatment, a complex physiotherapy intervention, to reduce pain in long-standing complex regional pain syndrome (CRPS). However, whether GMI is effective in clinical practice is not established. AIM: To establish whether GMI is effective in clinical practice. METHODS: We undertook a prospective audit of GMI treatment at two UK centres with a special interest in the management of patients with CRPS. All patients received GMI, in conjunction with a range of other 'best practice' physical and psychological interventions. RESULTS: The patients' average pain intensities did not improve with treatment [centre 1: n = 20, pre-post numeric rating scale (NRS) difference 0.6 [confidence interval (CI) -0.3 to 1.5]; centre 2: n = 12, pre-post NRS difference 0.2 (CI: -0.9 to 1.2)]. Patients at centre 1 reported significant functional improvement. Improved performance on left/right judgement replicated in both centres seen in the clinical trials. CONCLUSIONS: The failure of our real-world implementation of GMI suggests that better understanding of both the GMI methodology and its interaction with other treatment methods is required to ensure that GMI research results can be translated into clinical practice. Our results highlight challenges with the translation of complex interventions for chronic pain conditions into clinical practice.

Two million hours of science.

After over a quarter of a century, the doors of the world's first synchrotron radiation source have closed. Its contribution to materials science in the past and the future should not be underestimated.

A gas microstrip detector for XAS studies in the photon energy region 300-1500 eV.

The ability to perform X-ray absorption spectroscopy (XAS) in the 300-1500 eV energy range allows measurements to be made on transition metal compounds. This paper describes a detector and the technique used to perform fluorescent measurements on such materials. A variety of test sample results are shown to illustrate the low energy and energy-resolving capabilities of the detector (based on gas microstrip technology). Two possible applications are also demonstrated. The first shows how the detector can be used to gather X-ray absorption spectra for the L edges of transition metals and K edges of light elements (C, O and N). The other shows how the magnetic immunity of the detector can be exploited to study the magnetic properties of materials.

A novel application of silicon microstrip technology for energy-dispersive EXAFS studies.

A prototype X-ray detector for energy-dispersive EXAFS has been developed and tested to demonstrate the principle of using silicon microstrip detector technology for this application. Testing took place at the UK Synchrotron Radiation Source, where the absorption spectra of a 5 microm Ni foil and a 25 mM NiCl(2) solution were obtained.

Initial data from the 30-element ORTEC HPGe detector array and the XSPRESS pulse-processing electronics at the SRS, Daresbury Laboratory.

Following the completion of the collaborative project between CLRC Daresbury Laboratory and EG&G ORTEC to develop the world's first 30-element HPGe detector for fluorescence XAFS, it has now been tested and commissioned at the SRS. The system was commissioned with the XSPRESS digital pulse-processing electronics and this has demonstrated processed count rates in excess of 10 MHz. Initial data have been recorded and are presented.

The use of a PID controller to model vecuronium pharmacokinetics and pharmacodynamics during liver transplantation. Proportional-integral-derivative.

A four-phase proportional-integral-derivative (PID) controller was evaluated under the extremely unstable conditions of liver transplantation. Vecuronium was delivered to achieve 80%-90% neuromuscular blockade as measured by electromyogram (EMG). The first two controller phases delivered boluses and a constant infusion calculated to rapidly achieve setpoint, followed by a proportional-derivative (PD) phase at 35% from setpoint, and PID within 10% of the setpoint. During liver transplantation, the sources of system instability included large blood losses, temperature changes, and loss of hepatic drug metabolism during removal and replacement. During prolonged surgery, and when blood losses were not severe, the EMG remained within 10% of setpoint. Controller performance was more variable during system instability. Plasma sampling and two-compartment modelling of the infusion and response with a weighting factor for blood loss allowed estimation of the sources and degree of instability for improved design of future controllers.

A combined SAXS/WAXS investigation of the phase behaviour of di-polyenoic membrane lipids.

Real-time measurements of the SAXS/WAXS diffraction patterns of aqueous dispersions (1:1 wt/wt) of the di-polyenoic lipids di-18:2 PC, di-18:3 PC, di-18:2 PE and di-18:3 PE were made over the temperature range 10 degrees to about -80 degrees C. The results of these measurements were compared to similar measurements performed on the corresponding di-18:0 and di-18:1 derivatives. SAXS measurements of the temperature dependence of lamellar repeat distances show that the di-polyenoic lipids undergo broad second-order transitions between their gel and liquid-crystal lamellar phases spanning 30-40 degrees C. The di-18:1 and di-18:0 derivatives, in contrast, undergo abrupt first-order transitions. The gel phases of the di-18:0 derivatives are characterised by two-component WAXS patterns with a sharp component close to 0.42 nm and a broader component at narrower spacings. On cooling, these lipids appear to undergo an initial transition to an L beta, phase followed by a conversion to an Lc phase. The gel phases of the di-18:1 derivatives also show two-component patterns but with the sharp component centred closer to 0.44 nm. The di-polyenoic lipids, in contrast, are characterised by a single broad peak centred at a spacing of about 0.42 nm, close to that of conventional L beta phases. The changes in lamellar repeat distance accompanying the transitions in the di-monoenoic and di-polyenoic lipids, all of which occur in the frozen state, are very similar, indicating that the acyl chains of the polyenoic lipids are close to their maximum extension in the gel state. The WAXS patterns of the polyenoic lipids suggest that the saturated upper parts of the acyl chains are packed on a regular hexagonal lattice while their polyunsaturated termini remain relatively disordered.

Real-time simultaneous wide- and small-angle fibre diffraction.

A combination of two independent imaging area-detector systems controlled by a single data-acquisition system, provides a powerful system for X-ray diffraction studies of time-resolved phenomena over a wide q range, in samples with intrinsic or induced structural orientation. With this system we have observed a transient, tensile-stress-induced, orthorhombic-to-monoclinic transition in high-density polyethylene.

Simultaneous studies of reaction kinetics and structure development in polymer processing.

The simultaneous time-resolved study of structure development and reaction kinetics during polymer processing is an experimental method that has great potential in developing a deeper understanding of the parameters that govern the formation of structure and therefore polymer properties. A combination of synchrotron radiation small-angle x-ray scattering and Fourier-transform infrared spectroscopy experiments have been performed on a series of model segmented block copolyurethanes. These studies confirm that the driving force for structure development in polyurethanes is the thermodynamics of phase separation rather than hydrogen bonding.

Closed-loop infusion of atracurium with four different anesthetic techniques.

A new proportional-integral-derivative (PID) controller for the automated closed-loop delivery of atracurium was tested in 32 patients. Groups of 8 patients received halothane, enflurane, isoflurane, or N2O/morphine anesthesia. After induction of anesthesia with sodium thiopental 3-5 mg.kg-1, a bolus of atracurium 0.2 mg.kg-1 was delivered by the controller; this was followed by an infusion calculated by the controller to maintain the electromyogram (EMG) at a setpoint of 90% neuromuscular blockade. The average overshoot for the controller was 10.1% and the mean steady-state error 3.0%. The mean infusion rates for atracurium to maintain 90% blockade were calculated for each anesthetic group, with the inhalation anesthetics at 1 MAC. Infusion rates for N2O/morphine, halothane 0.8%, enflurane 1.7%, and isoflurane 1.4% at 90% blockade were 5.7 +/- 0.6, 4.9 +/- 0.3, 3.5 +/- 0.3, and 4.1 +/- 0.5 micrograms.kg-1.min-1, respectively (mean +/- SE). The infusion rate for atracurium at 90% blockade under N2O/morphine anesthesia was in general agreement with published values. The other infusion rates at 90% blockade have not been reported previously, but correspond to the known potencies of these inhalation anesthetics for augmentation of neuromuscular blockade. This controller performed well in comparison to previously developed controllers, and in addition was used as a research tool for rapid estimation of infusion rates.

Myopathy with hypophosphatasia.

Three children with hypophosphatasia also had muscle pains, stiffness, and symptoms of proximal lower limb muscle weakness that occurred early in the disorder and were the presenting features in two. A non-progressive myopathy may be an important sign of hypophosphatasia.

Thermally induced optical property changes in myocardium at 1.06 microns.

Light in the visible and near-infrared region is diffusely scattered in tissues by macromolecules. It was therefore hypothesized that tissue coagulation caused by high-power continuous wave laser irradiation might significantly alter tissue optical properties, resulting in a redistribution of laser energy during the laser ablation process. Infrared transmittance studies confirmed the hypothesis by demonstrating an irreversible decrease in light transmittance (45%) during heating of a 0.75 mm thick slice of tissue. Absorption and scattering coefficients were then determined from transmittance and reflectance measurements on thin slices of raw and coagulated myocardium irradiated with a Nd:YAG laser (1.06 microns). The scattering coefficient was found to increase fourfold (0.427 mm-1----1.74 mm-1) during tissue coagulation, while the absorption coefficient remained relatively unchanged (0.044 mm-1----0.051 mm-1). Calculations indicate that the coagulation-induced changes in tissue optical properties substantially increase surface back-scattering and reduce tissue penetration.