Central and peripheral mechanisms of pain in fibromyalgia: scoping review protocol.

Fibromyalgia is characterised by widespread musculoskeletal pain, which may present with fatigue, depression, anxiety, sleep and cognitive disturbances. It is the second most prevalent rheumatic disease. An accurate diagnosis is challenging, since its symptoms may resemble diverse conditions such as carpal tunnel syndrome, Raynaud syndrome, Sjögren syndrome, amongst others. Neuropathic pain and autonomic dysfunction in fibromyalgia suggest the involvement of the nervous system. Ion channels, neurotransmitters and neuromodulators may play a role. Small fibre neuropathy (SFN) may also cause chronic widespread pain. SFN may occur in 50% of fibromyalgia patients, but its role in the disease is unknown. Despite several efforts to synthesise the evidence on the mechanisms for pain in fibromyalgia, there are few studies applying an integrative perspective of neurochemical, immunological, and neuroanatomical characteristics, and their relevance to the disease. This protocol aims to clarify the mechanisms of the central and peripheral nervous system associated with pain in fibromyalgia. We will retrieve published studies from Web of Science, MEDLINE, Scopus, EBSCOhost, Ovid and Google Scholar. All clinical studies or experimental models of fibromyalgia reporting imaging, neurophysiological, anatomical, structural, neurochemical, or immunological characteristics of the central or peripheral nervous systems associated with pain will be included. Exclusion criteria will eliminate studies evaluating pain without a standardised measure, studies written in languages different from Spanish or English that could not be appropriately translated, and studies whose full-text files could not be retrieved after all efforts made. A narrative synthesis will be performed.

Antibody tests for identification of current and past infection with SARS-CoV-2.

BACKGROUND: The diagnostic challenges associated with the COVID-19 pandemic resulted in rapid development of diagnostic test methods for detecting SARS-CoV-2 infection. Serology tests to detect the presence of antibodies to SARS-CoV-2 enable detection of past infection and may detect cases of SARS-CoV-2 infection that were missed by earlier diagnostic tests. Understanding the diagnostic accuracy of serology tests for SARS-CoV-2 infection may enable development of effective diagnostic and management pathways, inform public health management decisions and understanding of SARS-CoV-2 epidemiology. OBJECTIVES: To assess the accuracy of antibody tests, firstly, to determine if a person presenting in the community, or in primary or secondary care has current SARS-CoV-2 infection according to time after onset of infection and, secondly, to determine if a person has previously been infected with SARS-CoV-2. Sources of heterogeneity investigated included: timing of test, test method, SARS-CoV-2 antigen used, test brand, and reference standard for non-SARS-CoV-2 cases. SEARCH METHODS: The COVID-19 Open Access Project living evidence database from the University of Bern (which includes daily updates from PubMed and Embase and preprints from medRxiv and bioRxiv) was searched on 30 September 2020. We included additional publications from the Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-Centre) 'COVID-19: Living map of the evidence' and the Norwegian Institute of Public Health 'NIPH systematic and living map on COVID-19 evidence'. We did not apply language restrictions. SELECTION CRITERIA: We included test accuracy studies of any design that evaluated commercially produced serology tests, targeting IgG, IgM, IgA alone, or in combination. Studies must have provided data for sensitivity, that could be allocated to a predefined time period after onset of symptoms, or after a positive RT-PCR test. Small studies with fewer than 25 SARS-CoV-2 infection cases were excluded. We included any reference standard to define the presence or absence of SARS-CoV-2 (including reverse transcription polymerase chain reaction tests (RT-PCR), clinical diagnostic criteria, and pre-pandemic samples). DATA COLLECTION AND ANALYSIS: We use standard screening procedures with three reviewers. Quality assessment (using the QUADAS-2 tool) and numeric study results were extracted independently by two people. Other study characteristics were extracted by one reviewer and checked by a second. We present sensitivity and specificity with 95% confidence intervals (CIs) for each test and, for meta-analysis, we fitted univariate random-effects logistic regression models for sensitivity by eligible time period and for specificity by reference standard group. Heterogeneity was investigated by including indicator variables in the random-effects logistic regression models. We tabulated results by test manufacturer and summarised results for tests that were evaluated in 200 or more samples and that met a modification of UK Medicines and Healthcare products Regulatory Agency (MHRA) target performance criteria. MAIN RESULTS: We included 178 separate studies (described in 177 study reports, with 45 as pre-prints) providing 527 test evaluations. The studies included 64,688 samples including 25,724 from people with confirmed SARS-CoV-2; most compared the accuracy of two or more assays (102/178, 57%). Participants with confirmed SARS-CoV-2 infection were most commonly hospital inpatients (78/178, 44%), and pre-pandemic samples were used by 45% (81/178) to estimate specificity. Over two-thirds of studies recruited participants based on known SARS-CoV-2 infection status (123/178, 69%). All studies were conducted prior to the introduction of SARS-CoV-2 vaccines and present data for naturally acquired antibody responses. Seventy-nine percent (141/178) of studies reported sensitivity by week after symptom onset and 66% (117/178) for convalescent phase infection. Studies evaluated enzyme-linked immunosorbent assays (ELISA) (165/527; 31%), chemiluminescent assays (CLIA) (167/527; 32%) or lateral flow assays (LFA) (188/527; 36%). Risk of bias was high because of participant selection (172, 97%); application and interpretation of the index test (35, 20%); weaknesses in the reference standard (38, 21%); and issues related to participant flow and timing (148, 82%). We judged that there were high concerns about the applicability of the evidence related to participants in 170 (96%) studies, and about the applicability of the reference standard in 162 (91%) studies. Average sensitivities for current SARS-CoV-2 infection increased by week after onset for all target antibodies. Average sensitivity for the combination of either IgG or IgM was 41.1% in week one (95% CI 38.1 to 44.2; 103 evaluations; 3881 samples, 1593 cases), 74.9% in week two (95% CI 72.4 to 77.3; 96 evaluations, 3948 samples, 2904 cases) and 88.0% by week three after onset of symptoms (95% CI 86.3 to 89.5; 103 evaluations, 2929 samples, 2571 cases). Average sensitivity during the convalescent phase of infection (up to a maximum of 100 days since onset of symptoms, where reported) was 89.8% for IgG (95% CI 88.5 to 90.9; 253 evaluations, 16,846 samples, 14,183 cases), 92.9% for IgG or IgM combined (95% CI 91.0 to 94.4; 108 evaluations, 3571 samples, 3206 cases) and 94.3% for total antibodies (95% CI 92.8 to 95.5; 58 evaluations, 7063 samples, 6652 cases). Average sensitivities for IgM alone followed a similar pattern but were of a lower test accuracy in every time slot. Average specificities were consistently high and precise, particularly for pre-pandemic samples which provide the least biased estimates of specificity (ranging from 98.6% for IgM to 99.8% for total antibodies). Subgroup analyses suggested small differences in sensitivity and specificity by test technology however heterogeneity in study results, timing of sample collection, and smaller sample numbers in some groups made comparisons difficult. For IgG, CLIAs were the most sensitive (convalescent-phase infection) and specific (pre-pandemic samples) compared to both ELISAs and LFAs (P < 0.001 for differences across test methods). The antigen(s) used (whether from the Spike-protein or nucleocapsid) appeared to have some effect on average sensitivity in the first weeks after onset but there was no clear evidence of an effect during convalescent-phase infection. Investigations of test performance by brand showed considerable variation in sensitivity between tests, and in results between studies evaluating the same test. For tests that were evaluated in 200 or more samples, the lower bound of the 95% CI for sensitivity was 90% or more for only a small number of tests (IgG, n = 5; IgG or IgM, n = 1; total antibodies, n = 4). More test brands met the MHRA minimum criteria for specificity of 98% or above (IgG, n = 16; IgG or IgM, n = 5; total antibodies, n = 7). Seven assays met the specified criteria for both sensitivity and specificity. In a low-prevalence (2%) setting, where antibody testing is used to diagnose COVID-19 in people with symptoms but who have had a negative PCR test, we would anticipate that 1 (1 to 2) case would be missed and 8 (5 to 15) would be falsely positive in 1000 people undergoing IgG or IgM testing in week three after onset of SARS-CoV-2 infection. In a seroprevalence survey, where prevalence of prior infection is 50%, we would anticipate that 51 (46 to 58) cases would be missed and 6 (5 to 7) would be falsely positive in 1000 people having IgG tests during the convalescent phase (21 to 100 days post-symptom onset or post-positive PCR) of SARS-CoV-2 infection. AUTHORS' CONCLUSIONS: Some antibody tests could be a useful diagnostic tool for those in whom molecular- or antigen-based tests have failed to detect the SARS-CoV-2 virus, including in those with ongoing symptoms of acute infection (from week three onwards) or those presenting with post-acute sequelae of COVID-19. However, antibody tests have an increasing likelihood of detecting an immune response to infection as time since onset of infection progresses and have demonstrated adequate performance for detection of prior infection for sero-epidemiological purposes. The applicability of results for detection of vaccination-induced antibodies is uncertain.

The Hsp70 chaperone system: distinct roles in erythrocyte formation and maintenance.

Erythropoiesis is a tightly regulated cell differentiation process in which specialized oxygen- and carbon dioxide-carrying red blood cells are generated in vertebrates. Extensive reorganization and depletion of the erythroblast proteome leading to the deterioration of general cellular protein quality control pathways and rapid hemoglobin biogenesis rates could generate misfolded/aggregated proteins and trigger proteotoxic stresses during erythropoiesis. Such cytotoxic conditions could prevent proper cell differentiation resulting in premature apoptosis of erythroblasts (ineffective erythropoiesis). The heat shock protein 70 (Hsp70) molecular chaperone system supports a plethora of functions that help maintain cellular protein homeostasis (proteostasis) and promote red blood cell differentiation and survival. Recent findings show that abnormalities in the expression, localization and function of the members of this chaperone system are linked to ineffective erythropoiesis in multiple hematological diseases in humans. In this review, we present latest advances in our understanding of the distinct functions of this chaperone system in differentiating erythroblasts and terminally differentiated mature erythrocytes. We present new insights into the protein repair-only function(s) of the Hsp70 system, perhaps to minimize protein degradation in mature erythrocytes to warrant their optimal function and survival in the vasculature under healthy conditions. The work also discusses the modulatory roles of this chaperone system in a wide range of hematological diseases and the therapeutic gain of targeting Hsp70.

Morphology of ejaculatory ducts: A systematic review.

The morphology of human ejaculatory ducts has not been well established. The objective of this study was to describe macroscopic and microscopic anatomy of ejaculatory ducts. We conducted a systematic review using MEDLINE, Scopus, PubMed, and Cochrane databases. Search terms were: "ejaculatory ducts," "seminal colliculus," "prostatic utricle," "anatomy," "histology," "radiology," and "embryology." We only included studies assessing adult (>18 years) humans published before November 1, 2019. We excluded studies describing pathological ducts and case reports. Independent authors extracted data using predefined criteria. Fourteen studies were included in the qualitative synthesis. Usually, the ejaculatory ducts entered the prostate by piercing the central part of its base. Most studies identified an anteromedial curve of the ducts at the outset within the prostate, their subsequent course being a straight path towards the seminal colliculus, their terminal parts diverging immediately before joining the prostatic urethra. However, the morphology of the terminal part of the ducts was inconsistent. The mean length of the ducts ranged from 1.4 to 2.2 cm. In conclusion, the luminal diameter gradually decreased as the ducts traveled towards the seminal colliculus. Ejaculatory ducts angulate anteromedially at their onset within the prostate and travel straight towards the seminal colliculus. Their terminal parts diverge immediately before joining the prostatic urethra. However, the reported dimensions of the ducts differ among studies.

Pathological characteristics of lung tumors in Sri Lanka 2017-2021.

The prevalence of lung cancer is steadily increasing globally, and it is projected to become the second most prevalent cancer in men by 2030. Lung cancer is the leading cause of cancer-related deaths worldwide, accounting for approximately 3.61% of total fatalities. Despite its significant impact, many Asian countries, including Sri Lanka, lack precise data on the epidemiological patterns of lung tumors. This study pioneers a comprehensive exploration in Sri Lanka, delving into the demographic and clinicopathological characteristics of lung cancer patients. The study included 733 consecutive patients with lung tumors from 2017 to 2021, with a median age of 59 years. The most common site of tumors was the right lower lobe and left upper lobes. Adenocarcinoma was the most prevalent histopathological type of primary malignant lung tumors, while colorectal adenocarcinomas were the most common cause of metastatic deposits in the lungs. The most common benign tumor was hamartoma. Significantly, our findings unveiled associations between patient demographics and tumor types, underscoring the importance of factoring in age and gender in diagnostic assessments. Notably, the absence of a dedicated lung cancer screening program in Sri Lanka underscores the critical reliance on clinical suspicion and accurate diagnostic methods.

Anatomic description of the distal great saphenous vein to facilitate peripheral venous access during resuscitation: a cadaveric study.

The distal great saphenous vein is a popular site for venous access by means of percutaneous cannulation or venous cutdown in a hemodynamically unstable patient. The aim of this study was to precisely define the surface anatomy and dimensions of the distal part of the great saphenous vein to facilitate the aforementioned procedures. Cross-sectional anatomy of the distal saphenous vein was studied in 24 cadaveric ankles sectioned at a horizontal plane across the most prominent points of the medial and lateral malleoli. The curvilinear distance from the most prominent point of the medial malleolus to the center of the saphenous vein, its widest collapsed diameter and skin depth were obtained. The great saphenous vein was located at a mean distance of 24.4 ± 7.9 mm anterior to the medial malleolus. The mean widest collapsed diameter was 3.8 ± 1.5 mm. The mean distance from the skin surface to the vein was 4.1 ± 1.2 mm. These measurements could be used to locate the saphenous vein accurately, particularly in hemodynamically unstable patients with visually indiscernible veins.

Pathological characteristics of mediastinal masses in Sri Lanka 2017-2021: a retrospective observational study.

The integration of patient demographic characteristics with clinical and radiological features helps establish accurate presumptive diagnosis of mediastinal masses, which, in turn, ensures timely initiation of treatment and improves prognosis https://bit.ly/3vB3zCw.

Health-related attitudes, behaviors and burnout in intern medical officers and their effects on self-reported patient care in a developing country.

BACKGROUND: Intern Medical Officers (IMOs) in Sri Lanka face significant challenges due to heavy patient load and scarcity of resources. AIMS: To assess IMOs' level of burnout, associated factors and the effects on self-reported patient care in comparison to post-intern Relief House Officers (RHOs). METHODS: A descriptive cross-sectional study was conducted among IMOs and RHOs in two leading tertiary care hospitals in Sri Lanka. The level of burnout was assessed using Maslach Burnout Index. The self-reported health-related attitudes, practices, level of burnout, and their associations with patient care were compared between IMOs and RHOs. RESULTS: We studied 114 participants (70 (61.4%) IMOs and 44 (38.6%) RHOs). IMOs were not involved in regular exercises (χ2(1) = 19.8, p = 0.000), skipped meals frequently (χ2(1) = 29.3, p = 0.000), and had a poor sleep quality (χ2(1) = 35.7, p = 0.000) compared to RHOs. Overall, 46.5%, 95.5%, and 86.7% of the participants were having moderate-to-high emotional exhaustion, depersonalization, and sense of poor personal achievement. The exhaustion and depersonalization levels were significantly higher among IMOs. Emotional exhaustion was significantly associated with poor sleep (U = 923.0, p = 0.014). Self-reported patient care negatively correlated with exhaustion (rs(112) = - 0.263, p = 0.005) and depersonalization (rs(112) = - 0.491, p = 0.000), while having positive attitudes correlated with better patient care (rs(112) = 0.208, p = 0.027). CONCLUSIONS: The prevalence of burnout in IMOs in Sri Lanka is high, which, in turn, negatively correlates with patient care. IMOs face significant challenges in self-care, while their poor sleep perturbs daytime activities and conceivably interferes with patient care. Therefore, we recommend introduction of preventive measures to mitigate burnout in early-career physicians, particularly IMOs, to improve both self and patient care.

Tuberculosis presenting as arthritis of the ankle: A case report.

Tuberculosis presenting as monoarticular involvement in immunocompetent patients is rare. Here, we report a Sri Lankan patient presenting with ankle swelling due to tuberculosis with no other extrapulmonary or pulmonary involvement. Magnetic resonance imaging showed destruction of articular cartilage of the ankle joint with chronic inflammation of the subtalar joint. The diagnosis was confirmed by synovial tissue culture which was positive for Mycobacterium tuberculosis. The patient recovered uneventfully with anti-tuberculosis treatment. Therefore, a high degree of suspicion is necessary to diagnose extrapulmonary tuberculosis when patients are presenting with atypical monoarthritis.

Demographic, Clinical Features and Outcome Determinants of Thoracic Trauma in Sri Lanka: A Multicentre Prospective Cohort Study.

Prognostic determinants in thoracic trauma are of major public health interest. We intended to describe patterns of thoracic trauma, demographic factors, clinical course, and predictors of outcome in selected tertiary care hospitals in Sri Lanka. A multicentre prospective cohort study was conducted in five leading teaching hospitals from June to September 2017. Patients with thoracic trauma were followed up during the hospital stay. A logistic regression analysis was conducted using in-hospital morbidity as the dichotomous outcome variable. One hundred seventy-one patients were included in the study yielding 1450 (median = 8.5) person-days of observation. Of them, 71.9% (n = 123) were males. The mean age was 45.8 ± 17.9 years. Majority (39.2%, n = 67) were recruited from the National Hospital of Sri Lanka. Automobile accidents were the commonest (62.6%, n = 107), followed by falls (26.9%, n = 46), assaults (8.8%, n = 15), and animal attacks (1.8%, n = 3). The ratio of blunt to penetrating trauma was 5.6 : 1. Injury patterns were rib fractures (80.7%, n = 138), haemothorax (44.4%, n = 76), pneumothorax (44.4%, n = 76), lung contusion (22.8%, n = 39), flail segment (15.8%, n = 27), tracheobronchial trauma (7.0%, n = 12), diaphragmatic injury (2.3%, n = 4), vascular injury (2.3%, n = 4), cardiac contusions (1.1%, n = 2), and oesophageal injury (0.6%, n = 1). Ninety nine (57.9%) had extrathoracic injuries. Majority (63.2%, n = 108) underwent operative management including intercostal tube insertion (60.8%, n = 104), wound exploration (6.4%, n = 11), thoracotomy (4.1%, n = 7), rib reconstruction (4.1%, n = 7), and video-assisted thoracoscopic surgery (2.9%, n = 5). Pneumonia (10.5%, n = 8), bronchopleural fistulae (2.3%, n = 4), tracheaoesophageal fistulae (1.8%, n = 3), empyema (1.2%, n = 2), and myocardial infarction (1.2%, n = 2) were the commonest postoperative complications. The mean hospital stay was 15.6 ± 18.0 days. The in-hospital mortality was 11 (6.4%). The binary logistic regression analysis with five predictors (age, gender, mechanism of injury (automobile/fall/assault), type of trauma (blunt/penetrating), and the presence of extrathoracic injuries) was statistically significant to predict in-hospital morbidity (X 2 (6, n = 168) = 13.1; p=0.041), explaining between 7.5% (Cox and Snell R 2) and 14.5% (Nagelkerke R 2) of variance. The automobile accidents (OR: 2.3, 95% CI = 0.2-26.2) and being males (OR: 2.3, 95% CI = 0.6-9.0) were the strongest predictors of morbidity.

Novel anthropometric parameters to define obesity and obesity-related disease in adults: a systematic review.

CONTEXT: Obesity is defined as an abnormal or excessive accumulation of body fat. Traditionally, it has been assessed using a wide range of anthropometric, biochemical, and radiological measurements, with each having its advantages and disadvantages. OBJECTIVE: A systematic review of the literature was conducted to identify novel anthropometric measurements of obesity in adults. DATA SOURCES: Using a combination of MeSH terms, the PubMed database was searched. DATA EXTRACTION: The current systematic review was conducted in accordance with the PRISMA guidelines. The data extracted from each study were (1) details of the study, (2) anthropometric parameter(s) evaluated, (3) study methods, (4) objectives of the study and/or comparisons, and (5) main findings/conclusions of the study. DATA ANALYSIS: The search yielded 2472 articles, of which 66 studies were deemed eligible to be included. The literature search identified 25 novel anthropometric parameters. Data on novel anthropometric parameters were derived from 26 countries. Majority were descriptive cross-sectional studies (n = 43), while 22 were cohort studies. Age range of the study populations was 17-103 years, while sample size varied from 45 to 384 612. CONCLUSIONS: The novel anthropometric parameters identified in the present study showed variable correlation with obesity and/or related metabolic risk factors. Some parameters involved complex calculations, while others were derived from traditional anthropometric measurements. Further research is required in order to determine the accuracy and precision.

Non-simulator-based techniques in teaching direct ophthalmoscopy for medical students: a systematic review.

Non-simulator-based examination methods of the fundal examination have shown to be cost-effective. We reviewed different non-simulator-based direct fundoscopy examination methods used in undergraduate curricula and their outcomes. PubMed (MEDLINE) and Cochrane Database of Systematic Reviews were searched using standard Medical Subject Heading (MeSH) terms ophthalmoscopy, medical education, undergraduate medical education, medical student, educational assessment and learning. The search included publications until 28th February 2019. We obtained 34 articles after screening abstracts; of them, 12 articles were included in the qualitative synthesis. The studies were comprised of diverse teaching methods which included fundal photograph matching with corresponding eye, continuous education using community-based eye clinics, formal instructions and demonstrations prior to skills training, ophthalmoscopy skills practice using eye pathologies, teaching versus conventional ophthalmoscopy and group-based teaching. We concluded that non-simulator-based techniques such as use of fundal photograph matching of an eye of a volunteer, introduction to eye pathologies, smaller student groups and formal instructions with video demonstrations prior to skills training were highly effective in teaching direct ophthalmoscopy for undergraduate medical students.

Location and Diameter of Intracranial Meningioma as Predictors of Peritumoral Brain Oedema and Mass Effect.

INTRODUCTION: The presence of peritumoral oedema or mass effect with intracranial meningiomas is associated with poor clinical outcomes. This study aimed to investigate magnetic resonance (MR) morphologic features of meningioma, which can predict peritumoral oedema and mass effect. METHODS: Data of 100 consecutive patients diagnosed with meningioma on MRI brain at the neurosurgical MRI unit, National Hospital of Sri Lanka, reported by a Consultant Radiologist were analysed in a retrospective study. Binary logistic regression models were fitted to identify predictors of perilesional oedema and mass effect. RESULTS: Female-to-male ratio was 5.8:1. Patients were aged 18-80 years. Majority (n = 78) were in supratentorial compartment with 16 at parasagittal location. Cerebellopontine angle was the commonest infratentorial site (n = 9). Size of meningiomas ranged from 1.1 to 9.1 cm (largest dimension). Mass effect (n = 68), perilesional oedema (n = 37), and midline deviation (n = 31) were the most commonly reported complications. Maximum diameter of meningioma and its location significantly predicted the presence of perilesional oedema [χ2(2,47) = 6.03, P = .049, Nagelkerke R2 = 18.2%] and mass effect [χ2(2,71) = 16.73, P = .000, Nagelkerke R2 = 39.4%] in two logistic regression models. CONCLUSION: The probability of mass effect and perilesional oedema increased with the maximum diameter. Meningioma extending to both supratentorial and infratentorial compartments had the highest risk of having concomitant perilesional oedema and mass effect.

In Situ Monitoring of Transiently Formed Molecular Chaperone Assemblies in Bacteria, Yeast, and Human Cells.

J-domain proteins (JDPs) form the largest and the most diverse co-chaperone family in eukaryotic cells. Recent findings show that specific members of the JDP family could form transient heterocomplexes in eukaryotes to fine-tune substrate selection for the 70 kDa heat shock protein (Hsp70) chaperone-based protein disaggregases. The JDP complexes target acute/chronic stress induced aggregated proteins and presumably help assemble the disaggregases by recruiting multiple Hsp70s to the surface of protein aggregates. The extent of the protein quality control (PQC) network formed by these physically interacting JDPs remains largely uncharacterized in vivo. Here, we describe a microscopy-based in situ protein interaction assay named the proximity ligation assay (PLA), which is able to robustly capture these transiently formed chaperone complexes in distinct cellular compartments of eukaryotic cells. Our work expands the employment of PLA from human cells to yeast (Saccharomyces cerevisiae) and bacteria (Escherichia coli), thus rendering an important tool to monitor the dynamics of transiently formed protein assemblies in both prokaryotic and eukaryotic cells.

Transient perivascular inflammation of the carotid artery; a rare cause of intense neck pain.

Carotidynia or Transient Perivascular Inflammation of the Carotid Artery (TIPIC) syndrome is a rare cause of atypical neck pain. Exact aetiopathogenesis of this clinical entity is poorly understood. A 43-year-old female presented with progressively increasing right side neck pain of 3 days duration associated with focal tenderness over the right carotid pulse corresponding to the level of upper border of thyroid cartilage. Her inflammatory markers were not elevated. An ultrasound scan revealed increased echogenicity surrounding the distal common carotid artery, obliteration of the perivascular tissue planes with preserved doppler flow pattern. MRI showed soft tissue thickening around the distal common carotid artery, carotid bulb and proximal external carotid artery on right side of the neck corresponding to sonographic findings with gadolinium enhancement. A diagnosis of TIPIC syndrome was made and she was started on celecoxib. Pain completely subsided within 2 weeks. In conclusion, TIPIC syndrome is a rare differential diagnosis of neck pain. It is caused by a transient perivascular inflammation of the carotid artery. A high degree of suspicion is necessary for the diagnosis. Imaging is the gold standard investigation for the diagnosis of TIPIC syndrome. It is a self-limiting pathology and often responds rapidly to nonsteroidal anti-inflammatory drugs.

Improving balance with wobble board exercises in stroke patients: single-blind, randomized clinical trial.

Background: A primary objective in stroke rehabilitation is to restore functional balance, in order to reduce falls.Objectives: To identify the efficacy and safety of wobble board exercises when combined with conventional physiotherapy, in improving balance in hemiplegic patients following ischemic strokes.Methods: A block-randomized, controlled, observer blinded, superiority trial was conducted on ambulatory hemiplegic patients following ischemic strokes of middle cerebral artery territory. Subjects in the control group received a conventional physiotherapy regime. Subjects in the intervention group received training on a wobble board combined with conventional physiotherapy. Main Outcome measures were the improvement of Four-Square Step Test (FSST) and the Berg Balance Scale (BBS), both of which assess functional balance at the end of 6 weeks.Results: Thirty patients were randomly assigned for intervention (n = 15) and control (n = 15) groups. One patient dropped out from the study, leaving 29 eligible for the analysis. Intervention and control groups were comparable in sociodemographic characteristics and pre-test scores of balance. A repeated-measures MANOVA showed a significant difference in improvement of balance between the two study groups after 6 weeks [F(1,28) = 32.6,p = .000; Wilk's lambda = .46]. The improvement of mean score of balance in interventional group was greater than in the control group [BBS:9.5 (intervention group),5.5 (control group); FSST:3.9 (intervention group),1.7 (control group)]. There were no injuries in both groups.Conclusions: Wobble board exercises, when combined with the conventional physiotherapy, are safe and effective in restoring functional balance in patients with hemiplegia following ischemic strokes.

Are predominantly western standards and expectations of informed consent in surgery applicable to all? A qualitative study in a tertiary care hospital in Sri Lanka.

OBJECTIVE: To identify the different perceptions on informed surgical consent in a group of Sri Lankan patients. METHODS: A qualitative study was conducted in a single surgical unit at a tertiary care hospital from January to May 2018. The protocol conformed to the Declaration of Helsinki. Patients undergoing elective major surgeries were recruited using initial purposive and later theoretical sampling. In-depth interviews were conducted in their native language based on the grounded theory. Initial codes were generated after analysing the transcripts. Constant comparative method was employed during intermediate and advanced coding. Data collection and analyses were conducted simultaneously, until the saturation of the themes. Finally, advanced coding was used for theoretical integrations. RESULTS: Thirty patients (male:female=12:18) were assessed. The mean age was 41±9 years. Sinhalese predominated (50.0%, n=15). Majority underwent thyroidectomy (36.7%, n=11). The generated theory categorises the process of obtaining informed consent in four phases: initial interaction phase, reasoning phase, convincing phase and decision-making phase. Giving consent for surgery was a dependent role between patient, family members and the surgeon, as opposed to an individual decision by the patient. Some patients abstained from asking questions from doctors since doctors were 'busy', 'short-tempered' or 'stressed out'. Some found nurses to be more approachable than doctors. Patients admitted that having a bystander while obtaining consent would relieve their stress. They needed doctors to emphasise more on postoperative lifestyle changes and preprocedure counselling at the clinic level. To educate patients about their procedure, some suggested leaflets or booklets to be distributed at the clinic before ward admission. The majority disliked watching educational videos because they were 'scared' to look at surgical dissections and blood. CONCLUSION: The informed consent process should include key elements that are non-culture specific along with elements or practices that consider the cultural norms of the society.

Retained Shrapnel from a Blast Injury as a Rare Cause of Secondary Osteoarthritis of the Hip Joint: A Case Report and Review of Literature.

BACKGROUND: Complications related to intra-articular retained shrapnel are rare and primarily depend on the anatomical location and the reaction with the surrounding tissue. Retained bodies causing severe osteoarthritis with bone destruction and limb shortening are extremely rare. We describe a rare occurrence of retained shrapnel, possibly iron nails causing a late presentation of grade 4 secondary osteoarthritis of the hip joint with destruction of the femoral head and limb shortening. CASE PRESENTATION: A 74-year-old otherwise healthy Sri Lankan male with a history of blast injury to the right hip 35 years ago presented with an isolated, right sided mild hip pain with a progressive limp for an 8-year duration. He had a true right limb shortening of 3.6 cm and limited range of motion. However, he had minimal functional disability. An X-ray of the pelvis and hip joints showed grade 4 osteoarthritis of the right hip joint with destruction of the right femoral head. There were three retained metallic nails (shrapnel) in the right hip joint of which two were intra-articular. Although he was offered a total hip arthroplasty, he opted for conservative management due to his minimal functional disability. Modified foot wear and simple analgesics were prescribed, and he had no worsening of symptoms at 6 months of follow up. CONCLUSION: Late presentation due to shrapnel-induced osteoarthritis with bone destruction and limb shortening is extremely rare. Initial assessment with radiographs is essential following blast injuries to exclude intra-articular or periarticular foreign bodies. Such foreign bodies should be removed to prevent the associated local and systemic complications.