Magnetic targeting to enhance microbubble delivery in an occluded microarterial bifurcation.

Ultrasound and microbubbles have been shown to accelerate the breakdown of blood clots both in vitro and in vivo. Clinical translation of this technology is still limited, however, in part by inefficient microbubble delivery to the thrombus. This study examines the obstacles to delivery posed by fluid dynamic conditions in occluded vasculature and investigates whether magnetic targeting can improve microbubble delivery. A 2D computational fluid dynamic model of a fully occluded Y-shaped microarterial bifurcation was developed to determine: (i) the fluid dynamic field in the vessel with inlet velocities from 1-100 mm s-1 (corresponding to Reynolds numbers 0.25-25); (ii) the transport dynamics of fibrinolytic drugs; and (iii) the flow behavior of microbubbles with diameters in the clinically-relevant range (0.6-5 µm). In vitro experiments were carried out in a custom-built microfluidic device. The flow field was characterized using tracer particles, and fibrinolytic drug transport was assessed using fluorescence microscopy. Lipid-shelled magnetic microbubbles were fluorescently labelled to determine their spatial distribution within the microvascular model. In both the simulations and experiments, the formation of laminar vortices and an abrupt reduction of fluid velocity were observed in the occluded branch of the bifurcation, severely limiting drug transport towards the occlusion. In the absence of a magnetic field, no microbubbles reached the occlusion, remaining trapped in the first vortex, within 350 µm from the bifurcation center. The number of microbubbles trapped within the vortex decreased as the inlet velocity increased, but was independent of microbubble size. Application of a magnetic field (magnetic flux density of 76 mT, magnetic flux density gradient of 10.90 T m-1 at the centre of the bifurcation) enabled delivery of microbubbles to the occlusion and the number of microbubbles delivered increased with bubble size and with decreasing inlet velocity.

Asymmetric reversal in aged high concentration CuMn alloy.

The magnetic hysteresis loops of an aged Cu(81.2)Mn(18.8) alloy sample exhibit significant asymmetric reversal at low temperatures, with high sensitivity to the cooling field. Much of the observed behaviour was explained by considering an ensemble of coherent, ferromagnetically aligned clusters interacting with a randomized spin glass component. A modified Stoner-Wohlfarth model was successfully applied to the data using Monte Carlo simulations, in order to gain insight into the dependence of the cluster shape anisotropy and exchange anisotropy on the cooling field. This model suggested that ferromagnetic clusters grow as the cooling field increases.

Metastatic prostatic carcinoma mimicking a unilateral sacroiliitis.

We describe a 65-year-old male who presented with unilateral sacroiliitis as the first manifestation of metastatic prostatic carcinoma. When progressive symptoms are unresponsive to conventional therapy, a reconsideration of the diagnosis is necessary with appropriate further imaging studies. We discuss the differential diagnosis of sacroiliitis including, mechanisms of joint involvement in malignancy, and present a review of the literature.

Shock wave therapy for lateral elbow pain.

BACKGROUND: This review is one in a series of reviews of interventions for lateral elbow pain. OBJECTIVES: To determine the effectiveness and safety of extracorporeal shock wave therapy (ESWT) for lateral elbow pain. SEARCH STRATEGY: Searches of the Cochrane Controlled Trials Register (Cochrane Library Issue 2, 2004), MEDLINE, EMBASE, CINAHL, and Science Citation Index (SCISEARCH) were conducted in February 2005, unrestricted by date. SELECTION CRITERIA: We included nine trials that randomised 1006 participants to ESWT or placebo and one trial that randomised 93 participants to ESWT or steroid injection. DATA COLLECTION AND ANALYSIS: For each trial two independent reviewers assessed the methodological quality and extracted data. Methodological quality criteria included appropriate randomisation, allocation concealment, blinding, number lost to follow up and intention to treat analysis. Where appropriate, pooled analyses were performed. If there was significant heterogeneity between studies or the data reported did not allow statistical pooling, individual trial results were described in the text. MAIN RESULTS: Eleven of the 13 pooled analyses found no significant benefit of ESWT over placebo. For example, the weighted mean difference for improvement in pain (on a 100-point scale) from baseline to 4-6 weeks from a pooled analysis of three trials (446 participants) was -9.42 (95% CI -20.70 to 1.86) and the weighted mean difference for improvement in pain (on a 100-point scale) provoked by resisted wrist extension (Thomsen test) from baseline to 12 weeks from a pooled analysis of three trials (455 participants) was -9.04 (95% CI -19.37 to 1.28). Two pooled results favoured ESWT. For example, the pooled relative risk of treatment success (at least 50% improvement in pain with resisted wrist extension at 12 weeks) for ESWT in comparison to placebo from a pooled analysis of two trials (192 participants) was 2.2 (95% CI 1.55 to 3.12). However this finding was not supported by the results of four other individual trials that were unable to be pooled. Steroid injection was more effective than ESWT at 3 months after the end of treatment assessed by a reduction of pain of 50% from baseline (21/25 (84%) versus 29/48 (60%), p<0.05). Minimal adverse effects of ESWT were reported. Most commonly these were transient pain, reddening of the skin and nausea and in most cases did not require treatment discontinuation or dosage adjustment. AUTHORS' CONCLUSIONS: Based upon systematic review of nine placebo-controlled trials involving 1006 participants, there is "Platinum" level evidence that shock wave therapy provides little or no benefit in terms of pain and function in lateral elbow pain. There is "Silver" level evidence based upon one trial involving 93 participants that steroid injection may be more effective than ESWT.

Acupuncture and electroacupuncture for the treatment of rheumatoid arthritis.

BACKGROUND: Acupuncture has been used by rehabilitation specialists as an adjunct therapy for the symptomatic treatment of rheumatoid arthritis (RA). Acupuncture is a traditional Chinese medicine where thin needles are inserted in specific documented points believed to represent concentration of body energies. In some cases a small electrical impulse is added to the needles. Once the needles are inserted in some of the appropriate points, endorphins, morphine-like substances, have been shown to be released in the patient's system, thus inducing local or generalised analgesia (pain relief). This review is an update of the original review published in July 2002. OBJECTIVES: To evaluate the effects of acupuncture or electroacupuncture on the objective and subjective measures of disease activity in patients with RA. SEARCH STRATEGY: A comprehensive search of MEDLINE, EMBASE, PEDro, Current Contents , Sports Discus and CINAHL, initially done in September 2001, was updated in May 2005. The Cochrane Field of Rehabilitation and Related Therapies and the Cochrane Musculoskeletal Review Group were also contacted for a search of their specialized registries. Handsearching was conducted on all retrieved papers and content experts were contacted to identify additional studies. SELECTION CRITERIA: Comparative controlled studies, such as randomized controlled trials and controlled clinical trials in patients with RA were eligible. Trials published in languages other than French and English were not analyzed. Abstracts were excluded unless further data could be obtained from the authors. DATA COLLECTION AND ANALYSIS: Two independent reviewers identified potential articles from the literature search and extracted data using pre-defined extraction forms. Consensus was reached on all the extracted data. Quality was assessed by two reviewers using a five point validated tool that measured the quality of randomization, double-blinding and description of withdrawals. MAIN RESULTS: After the updated searches were conducted, five further potential articles were identified; however, these did not meet the inclusion criteria. Two studies involving a total of 84 people were included. One study used acupuncture while the other used electroacupuncture. In the acupuncture study, no statistically significant difference was found between groups for erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), visual analogue scale for patient's global assessment (VAS G), number of swollen joints and tender joints, general health questionnaire (GHQ), modified disease activity scale (DAS) or for the decrease in analgesic intake. Although not statistically significant, pain in the treatment group improved by 4 points on a 0-100mm visual analogue scale versus no improvement in the placebo group. In the second study, using electroacupuncture, a significant decrease in knee pain was reported in the experimental group, 24 hours post treatment, when compared to the placebo group (WMD: -2.0 with 95% CI -3.6,-4.0). A significant decrease was found also at four months post-treatment (WMD -0.2, 95% CI: -0.36, -0.04) AUTHORS' CONCLUSIONS: Although the results of the study on electroacupuncture show that electroacupuncture may be beneficial to reduce symptomatic knee pain in patients with RA 24 hours and 4 months post treatment, the reviewers concluded that the poor quality of the trial, including the small sample size preclude its recommendation. The reviewers further conclude that acupuncture has no effect on ESR, CRP, pain, patient's global assessment, number of swollen joints, number of tender joints, general health, disease activity and reduction of analgesics. These conclusions are limited by methodological considerations such as the type of acupuncture (acupuncture vs electroacupuncture), the site of intervention, the low number of clinical trials and the small sample size of the included studies.

Hypermobility and sports injuries in junior netball players.

OBJECTIVE: To evaluate the incidence of hypermobility in young female netball players and to determine the relation between hypermobility, previous injuries sustained in netball or other sports, and the use of protective equipment. METHODS: Under 16 year old female netball players from a local suburban netball association were assessed for joint hypermobility using the validated Beighton score (0-9, with higher scores indicating increasing hypermobility). Player profiles and details of sporting injuries, both netball and non-netball, and the use of protective equipment were gathered by means of a self completed questionnaire. Parental and child consent was obtained. RESULTS: Two hundred netball players were recruited for the study. Twenty one percent of the subjects with a Beighton hypermobility score of 0-2 had sustained previous netball injuries compared with 37% with Beighton scores of 3-4, and 43% with scores of 5-9. These differences were significant (p<0.025). Injuries were most common in the ankle (42%), knee (27%), and fingers (15%). Thirty nine players (19%) wore protective equipment, and within this group 30 (77%) had sustained previous injuries. No association was detected between hypermobile joints and non-netball sporting injuries. CONCLUSIONS: In this study hypermobility was significantly associated with an increased prevalence of injuries in junior netball players. A targeted interventional approach may help to reduce injuries in this susceptible group.

Long term outcomes of inversion ankle injuries.

BACKGROUND: Ankle sprains are common sporting injuries generally believed to be benign and self limiting. However, some studies report a significant proportion of patients with ankle sprains having persistent symptoms for months or even years. AIMS: To determine the proportion of patients presenting to an Australian sports medicine clinic who had long term symptoms after a sports related inversion ankle sprain. METHODS: Consecutive patients referred to the NSW Institute of Sports Medicine from August 1999 to August 2002 with inversion ankle sprain were included. Exclusion criteria were fracture, ankle surgery, or concurrent lower limb problems. A control group, matched for age and sex, was recruited from patients attending the clinic for upper limb injuries in the same time period. Current ankle symptoms, ankle related disability, and current health status were ascertained through a structured telephone interview. RESULTS: Nineteen patients and matched controls were recruited and interviewed. The mean age in the ankle group was 20 (range 13-28). Twelve patients (63%) were male. Average follow up was 29 months. Only five (26%) ankle injured patients had recovered fully, with no pain, swelling, giving way, or weakness at follow up. None of the control group reported these symptoms (p<0.0001). Assessments of quality of life using short form-36 questionnaires (SF36) revealed a difference in the general health subscale between the two groups, favouring the control arm (p<0.05). There were no significant differences in the other SF36 subscales between the two groups. CONCLUSION: Most patients who sustained an inversion ankle injury at sport and who were subsequently referred to a sports medicine clinic had persistent symptoms for at least two years after their injury. This reinforces the importance of prevention and early effective treatment.

Rheumatological prescribing in athletes: a review of the new World Anti-Doping Agency guidelines.

Rheumatologists, with their musculoskeletal background, often care for athletes. The effect of a positive anti-doping test, whether through illegitimate use or accidental prescribing of banned drugs, is devastating to an athlete's career. It is therefore incumbent upon rheumatologists to be aware of issues relating to drugs in sport. This involves both therapeutic drugs and doping. It is vital to ensure that any substance prescribed should be approved for use and should not adversely affect (or benefit) the athlete's performance. In March 2004, 5 months prior to the 2004 Olympic Games in Athens, the joint World Anti-Doping Agency/International Olympic Committee published the revised list of banned substances in athletes. This article aims to provide an overview of the current status of medications commonly prescribed in rheumatological practice.

Non-steroidal anti-inflammatory drugs (NSAIDs) for treating lateral elbow pain in adults.

BACKGROUND: Lateral elbow pain, or tennis elbow, is a common condition causing pain in the elbow and forearm and lack of strength and function of the elbow and wrist. It is often treated with non-steroidal anti-inflammatory drugs (NSAIDs), either orally or by topical application. OBJECTIVES: To assess effectiveness of NSAIDs (oral or topical) in the treatment of adults with lateral elbow pain with respect to symptom (pain) reduction, improvement in function, grip strength and adverse effects. SEARCH STRATEGY: We searched the Musculoskeletal Review Group's trials register database, the Cochrane Clinical Trials Register (Cochrane Library issue 2, 2001), MEDLINE, CINAHL, EMBASE and SCISEARCH up to June 2001. SELECTION CRITERIA: Randomised and pseudo randomised trials in all languages of NSAIDs (oral or topical) compared to placebo or another intervention, or comparing two NSAIDs (oral or topical) to each other, in adults with lateral elbow pain (tennis elbow). Outcomes of interest were pain, function, disability and quality of life, strength, participant satisfaction with treatment and adverse effect. DATA COLLECTION AND ANALYSIS: Two reviewers independently applied selection criteria and assessed study quality. MAIN RESULTS: Fourteen trials were included in the review. Few trials used intention to treat analysis, and the sample size of most was small. The median follow up was 2 weeks (range 1-12 weeks). There is evidence that topical NSAIDs are significantly more effective than placebo with respect to pain [weighted main difference= -1.88, (95% confidence intervals -2.54 to -1.21)] and participant satisfaction [relative risk 0.39, (95% confidence intervals 0.23 to 0.66)] in the short term, and this finding is robust against the possible bias introduced by the inclusion of unblinded trials and publication bias. The adverse effects reported were minor. Only two included trials assessed the effect of oral NSAID and these were not able to be pooled. There is some evidence for short term benefit with respect to pain and function from oral NSAIDs, but this benefit was not sustained. Significantly more gastrointestinal adverse effects were reported by those taking oral NSAIDs [relative risk = 3.17, (95% confidence intervals 1.35 to 7.41)]. In the short term there may be some advantage in steroid injection over oral NSAID [patient's perception of benefit relative risk = 3.06, (95% confidence intervals 1.55 to 6.06)], but this was not sustained in the longer term. REVIEWER'S CONCLUSIONS: There is some support for the use of topical NSAIDs to relieve lateral elbow pain at least in the short term. There remains insufficient evidence to recommend or discourage the use of oral NSAID, although it appears injection may be more effective than oral NSAID in the short term. A direct comparison between topical and oral NSAID has not been made and so no conclusions can be drawn regarding the best method of administration.

Shock wave therapy for lateral elbow pain.

BACKGROUND: This review is one in a series of reviews of interventions for lateral elbow pain. Lateral elbow pain, or tennis elbow, is a common condition causing pain in the elbow and forearm and lack of strength and function of the elbow and wrist. Shock wave therapy (ESWT) involves the application of single pulsed acoustic wave. Since the 1990's reports of benefit of ESWT in the treatment of tendon disorders have been appearing in the literature. A systematic review published in the German language appeared in 2000 (Boddeker 2000) OBJECTIVES: To determine the effectiveness and safety of ESWT in the treatment of adults with lateral elbow pain. SEARCH STRATEGY: Comprehensive electronic searches of MEDLINE, CINAHL, EMBASE and SCISEARCH were combined with searches of the Cochrane Clinical Trails Registrar and the Musculoskeletal Review Group's specialist trial database. Identified keywords and authors were searched again in an effort to identify as many trials as possible. SELECTION CRITERIA: Two independent reviewers assessed all identified trials against pre-determined inclusion criteria. Randomised and pseudo randomised trials in all languages were evaluated for inclusion in the review provided they described individuals with lateral elbow pain and were comparing the use of ESWT as a treatment strategy. DATA COLLECTION AND ANALYSIS: For continuous variables means and standard deviations were extracted or imputed to allow the analysis of weighted mean difference. Weighted mean difference using a random effects model was selected when outcomes were measured on standard scales. A fixed effects model was used to interpret results and assess heterogeneity. For binary data numbers of events and total population were analysed and interpreted as relative risk. MAIN RESULTS: Two trials of ESWT versus placebo are included in this review (~~Rompe 1996~~, ~~Haake 2001~~). Both trials included similar study populations consisting of participants with chronic symptoms who had failed other conservative treatment. The frequency of ESWT application and the doses and techniques used were similar in both trials. The first trial demonstrated highly significant differences in favour of ESWT whereas the second trial found no benefits of ESWT over placebo. When the data from the two trials were pooled, the benefits observed in the first trial were no longer statistically significant. The relative risk for treatment failure (defined as Roles-Maudsley score of 4) of ESWT over placebo was 0.40 (95% CI, 0.08 to 1.91) at six weeks and 0.44 (95% CI, 0.09 to 2.17) at one year. After 6 weeks, there was no statistically significant improvement in pain at rest [WMD pain out of 100 = - 11.40 (95% CI, -26.10 to 3.30)], pain with resisted wrist extension [WMD pain out of 100 = -16.20 (95% CI, -47.75 to 15.36)] or pain with resisted middle finger extension [WMD pain out of 100 = -20.51(95% CI, -56.57 to 15.56)]. Results after 12 or 24 weeks were similar. REVIEWER'S CONCLUSIONS: The two trials included in this review yielded conflicting results. Further trials are needed to clarify the value of ESWT for lateral elbow pain.

Surgery for lateral elbow pain.

BACKGROUND: This review is one in a series of reviews of interventions for lateral elbow pain. Lateral elbow pain, or tennis elbow, is a common condition causing pain in the lateral elbow and forearm and lack of strength and function of the elbow and wrist. Surgery is sometimes recommended in treating chronic cases of lateral elbow pain where other less invasive interventions have failed. Various operations have been described based upon the surgeon's concept of the pathological entity. The most described surgical procedures involve release of the extensor carpi radialis brevis (ECRB) from the lateral epicondyle region based upon the premise that there is pathology in the attachment of ECRB to the lateral epicondyle. No systematic review has previously been published assessing the effect of surgical interventions for lateral elbow pain. OBJECTIVES: To determine the effectiveness of surgical interventions in the treatment of adults with lateral elbow pain. SEARCH STRATEGY: Comprehensive electronic searches of MEDLINE, CINAHL, EMBASE and SCISEARCH were combined with searches of the Cochrane Clinical Trials Registrar and the Musculoskeletal Review Group's specialist trial database. Identified keywords and authors were researched in an effort to identify as many trials as possible. Searches were conducted up to October 2001. SELECTION CRITERIA: Two independent reviewers assessed all identified studies against pre-determined inclusion criteria. Randomised and pseudo randomised trials in all languages were to be included in the review provided they were studying the effects of a surgical intervention and included a control as treatment for adults with lateral elbow pain. The control intervention could comprise no treatment or another intervention including an alternate surgical intervention. Outcomes of interest included pain, function, disability and quality of life, strength and adverse effects. DATA COLLECTION AND ANALYSIS: The planned collection and analysis of data is described. MAIN RESULTS: Our search did not identify any controlled trials investigating the effect of surgery on lateral elbow pain. REVIEWER'S CONCLUSIONS: At this time there are no published controlled trials of surgery for lateral elbow pain. Without a control group, it is not possible to draw any conclusions about the value of this modality of treatment.

Acupuncture for lateral elbow pain.

BACKGROUND: This review is one in a series of reviews of interventions for lateral elbow pain. Lateral elbow pain, or tennis elbow, is a common condition causing pain in the elbow and forearm and lack of strength and function of the elbow and wrist. Acupuncture has long been used to treat lateral elbow pain in China and in Western countries practitioners and consumers are increasingly exploring acupuncture as a first line treatment for musculoskeletal disorders. No previous systematic review of the available evidence has been conducted to determine whether acupuncture is efficacious in the treatment lateral elbow pain. OBJECTIVES: To determine the effectiveness of acupuncture in the treatment of adults with lateral elbow pain with respect to pain reduction, improvement in function, grip strength and adverse effects. SEARCH STRATEGY: We searched MEDLINE, CINAHL, EMBASE and SCISEARCH and the Cochrane Clinical Trials Register and the Musculoskeletal Review Group's specialist trial database from 1966 to June 2001. Identified keywords and authors were searched in an effort to retrieve as many trials as possible. SELECTION CRITERIA: Two independent reviewers assessed all identified trials against pre-determined inclusion criteria. Randomised and pseudo randomised trials in all languages were included in the review provided they were testing acupuncture compared to placebo or another intervention in adults with lateral elbow pain (tennis elbow). Outcomes of interest were pain, function, disability, quality of life, strength, participant satisfaction with treatment and adverse effect. DATA COLLECTION AND ANALYSIS: For continuous variables means and standard deviations were extracted or imputed to allow the analysis of weighted mean difference, while for binary data numbers of events and total population were analysed and interpreted as relative risks. Trial results were combined only in the absence of clinical and statistical heterogeneity. MAIN RESULTS: Four small randomized controlled trials were included but due to flaws in study designs (particularly small populations, uncertain allocation concealment and substantial loss to follow up) and clinical differences between trials, data from trials could not be combined in a meta-analysis. One randomised controlled trial found that needle acupuncture results in relief of pain for significantly longer than placebo (WMD = 18.8 hours, 95%CI 10.1 to 27.5) and is more likely to result in a 50% or greater reduction in pain after 1 treatment (RR 0.33, 95%CI 0.16 to 0.69) (Molsberger 1994). A second randomized controlled trial demonstrated needle acupuncture to be more likely to result in overall participant reported improvement than placebo in the short term (RR = 0.09 95% CI 0.01 to 0.64) (Haker 1990a). No significant differences were found in the longer term (after 3 or 12 months). A randomized controlled trial of laser acupuncture versus placebo demonstrated no differences between laser acupuncture and placebo with respect to overall benefit (Haker 1990b). A fourth included trial published in Chinese demonstrated no difference between Vitamin B12 injection plus acupuncture, and Vitamin B12 injection alone (Wang 1997). REVIEWER'S CONCLUSIONS: There is insufficient evidence to either support or refute the use of acupuncture (either needle or laser) in the treatment of lateral elbow pain. This review has demonstrated needle acupuncture to be of short term benefit with respect to pain, but this finding is based on the results of 2 small trials, the results of which were not able to be combined in meta-analysis. No benefit lasting more than 24 hours following treatment has been demonstrated. No trial assessed or commented on potential adverse effect. Further trials, utilising appropriate methods and adequate sample sizes, are needed before conclusions can be drawn regarding the effect of acupuncture on tennis elbow.

Pain referral from the sternoclavicular joint: a study in normal volunteers.

OBJECTIVE: The sternoclavicular joint (SCJ) is commonly affected by rheumatological conditions. Case reports suggest that it may refer pain to distant areas, potentially leading to delays in diagnosis and inappropriately targeted investigations. Therefore, we studied the patterns of pain referral from the SCJ of nine healthy volunteers. METHODS: Hypertonic saline was injected into the SCJ of nine normal volunteers and the location of any resulting pain was noted, as was the effect of resisted shoulder abduction and flexion. Composite pain maps were then constructed from individual pain diagrams. RESULTS: An unpleasant, deep aching pain was produced locally in eight subjects and referred to distant sites in all subjects. Tests of shoulder movement had varied and inconstant effects. CONCLUSIONS: We demonstrated that the SCJ is capable of referring pain to areas distant from the joint. Knowledge of these referral patterns will enable the SCJ to be considered in patients with pain in these areas.

Hypertrophic pulmonary osteoarthropathy without clubbing of the digits.

Hypertrophic osteoarthropathy (HOA) typically occurs concurrently with clubbing of the digits, with isolated HOA being reported only rarely. We report two patients with intra-thoracic malignancy in whom HOA, demonstrated on bone scintigraphy, developed in the absence of clubbing. We also report the novel observation of involvement of the metatarsal and metacarpal bones by HOA.

Clinical skills in early postgraduate medical trainees: patterns of acquisition of confidence and experience among junior doctors in a university teaching hospital.

BACKGROUND: Little is known about patterns of clinical skills acquisition among junior doctors undertaking clinical training in the early postgraduate period. A better understanding would assist in the design of effective educational interventions for this group. METHODS: We conducted a cross-sectional survey of the levels of confidence and experience with a broad raft of clinical skills among early PGY1 trainees (interns), PGY2s and PGY3s within a university teaching hospital network in Sydney at the beginning of the clinical year in 1999. The instrument was a new validated 69 item questionnaire. A total of 92 respondents took part, representing 100% of the PGY1 (n=36), PGY2 (n=31) and PGY3 (n=25) cohorts. RESULTS: Commencing interns reported high confidence levels with a small group of practical skills but less confidence with clinical management skills. Significant positive differences were found for confidence with all skill areas between early PGY1 and PGY3. We identified three patterns for skills acquisition. Pattern A was the most common, with a significant difference in levels of confidence and experience between PGY1 and PGY2 but not between PGY2 and PGY3 (e.g. suturing a simple laceration). In Pattern B, significant differences were found in levels of confidence and experience between PGY1 and PGY2 as well as between PGY2 and PGY3 (e.g. cardiopulmonary resuscitation). In Pattern C, significant differences were found in levels of experience between PGY2 and PGY3 but not between PGY1 and PGY2 (e.g. endotracheal intubation). There was a significant correlation between reported confidence and experience for all skill areas. CONCLUSIONS: Early postgraduate medical trainees in a Sydney teaching hospital acquire high levels of confidence and experience in most skill areas after two years of training. The first postgraduate year is particularly significant for the development of clinical skills.

The psychological profiles of patients with whiplash-associated headache.

Headache often compounds chronic neck pain following whiplash injury. To better understand post-traumatic headache, the SCL-90-R symptom checklist was used to determine the psychological profiles of patients with whiplash-associated headache and of patients with whiplash-associated neck pain without headache. The psychological profiles of these patients were compared with previously published SCL-90-R profiles of patients with post-traumatic and nontraumatic headache, and of the normal population. Patients with whiplash-associated headache were not significantly different from those with other forms of post-traumatic headache or with whiplash-associated neck pain without headache. However, when patients with whiplash-associated headache and patients with nontraumatic headache were compared to normal data, significant differences emerged. Patients with nontraumatic headache exhibited higher scores on all subscales, whereas patients with whiplash-associated headache differed from the normal sample only on somatization, obsessive-compulsive, depression and hostility subscales, and the global severity index. These differences imply that patients with whiplash-associated headache suffer psychological distress secondary to chronic pain and not from tension headache and generalized psychological distress.