Achilles tendon ruptures during summer show the lowest incidence, but exhibit an increased risk of re-rupture.

PURPOSE: Achilles tendon rupture (ATR) is a common injury. The knowledge of seasonal factors´ impact is incomplete, but may provide means for preventive approaches for Achilles tendon related morbidity. The aim of this study was to investigate seasonal variations in ATR incidence in relation to injury mechanism, adverse events including risk of re-rupture, and patient-reported outcome in adults in Stockholm, Sweden. METHODS: In total, 349 patients with unilateral acute Achilles tendon rupture, prospectively treated with standardized surgical techniques, were retrospectively assessed. Date of injury was assigned to one of the four internationally defined meteorological seasons in the northern hemisphere. Injury mechanism and the rate of adverse events; deep venous thrombosis, infection and re-rupture in relation to per-operative complications. Patient-reported outcome at 1 year was assessed with the validated Achilles tendon Total Rupture Score. RESULTS: ATR incidence was significantly highest during winter and spring, and lowest during summer (p < 0.05). The most common sporting activities associated with ATR were badminton, floorball and soccer (> 50%). The rate of soccer-related ATR was highest during summer (p < 0.05). Patients sustaining an ATR during summer, compared to other seasons, exhibited more per-operative complications (p < 0.05), a significantly higher risk of re-rupture (p < 0.05) and a lower rate of good outcome (n.s.). The risk of other adverse events after ATR did not differ between the seasons. CONCLUSION: Winter and spring are the high risk seasons for sports-related ATR and the risk sports are badminton, soccer and floorball. The reason for the higher risk of re-rupture after ATR repair during summer should be further investigated. LEVEL OF EVIDENCE: III.

Microcirculation after Achilles tendon rupture correlates with functional and patient-reported outcomes.

Patients with acute Achilles tendon rupture (ATR) display an extended healing process with varying clinical outcome. Poor microcirculatory blood flow has been suggested to be a significant factor for the healing process. However, whether microcirculation may predict healing outcome has been mostly unknown. Therefore, we investigated whether blood flow in the Achilles tendon may be associated with patient-reported and functional outcomes after ATR. In vivo laser-Doppler flowmetry was used to assess microvascular blood flow bilateral in the Achilles tendons, during post-occlusive reactive hyperemia, of nine patients with acute total ATR at 2 weeks post-operatively. At 3 months post-operatively, patient-reported outcome was assessed using Achilles tendon Total Rupture Score (ATRS). At 1 year a uniform outcome score, Achilles Combined Outcome Score (ACOS), was obtained by combining validated, independent, patient-reported (ATRS), and functional outcome (heel-rise test) measures. An improved combined patient-reported and functional outcome, ACOS, at 1 year was significantly correlated with higher maximum blood flow (r=.777, P=.040) in the injured limb. Furthermore, enhanced patient-reported outcome, ATRS, at 3 months, was associated with an elevated ratio of maximum to resting blood flow (r=.809, P=.015) in the uninjured limb. Blood flow in early tendon healing is associated with long-term patient-reported and functional outcomes after ATR. The microcirculatory blood flow of both the healing and contralateral Achilles tendon seems to determine the healing potential after injury.

Intensive care admissions due to poisoning.

BACKGROUND: Poisoning represents a significant part of admissions to intensive care units. The aim of this nationwide study was to describe recent national quality register data of demographics and mortality for these patients. METHOD: A retrospective national observational study including all patients over 19 years admitted to an ICU in Sweden, between 1 January 2010 and 31 December 2011, with an ICD-10 code for poisoning. The data were collected from three national registers (The Swedish Intensive Care Register, The National Patient Register, and The Cause of Death Register). RESULTS: The incidence of ICU-treated poisonings was 43/100,000. Twenty-one per cent (n = 8155) of all poisoned patients seeking medical care were admitted to the ICU. Their median age was 38 years (q1-q3: 26-51), as many men as women and 46.5% (n = 3790) had a previous registered poisoning. A mix of different substances was the most common type of suspected poisoning (29.7%, n = 2424). The in-hospital mortality was 1.9% and was correlated to invasive mechanical ventilation (OR 6.91 CI 95% 4.59-10.42), age > 40 (OR 4.54 CI 95% 2.86-7.21) and no previous hospitalisation for poisoning (OR 3.23 CI 95% 2.06-5.07). For 78.3% (n = 119) of the deceased patients, the fatal poisoning was their first diagnosed poisoning. The 30-day mortality was 2.7%, a majority died from poisoning (P < 0.01). CONCLUSION: In Sweden, patients treated in the ICU due to poisoning represent a fifth of all poisoned patients seeking medical care. Older men with no previous poisoning were considered a high-risk group.

Metabolic activity in early tendon repair can be enhanced by intermittent pneumatic compression.

Since Achilles tendon healing is protracted, more knowledge of metabolites known to meet the demands for biosynthesis and proliferation is needed. We hypothesized that essential metabolites, glutamate, glucose, lactate, pyruvate and glycerol, are present and upregulated in healing Achilles tendons. We moreover hypothesized that adjuvant intermittent pneumatic compression (IPC), which increases blood flow, upregulates metabolite concentrations. Twenty patients with acute Achilles tendon rupture were recruited, operated, and included. The control group, 15 patients, received plaster cast immobilization, while five patients received adjuvant foot IPC beneath the plaster cast. At 2 weeks postoperatively, microdialysis of the healing and contralateral intact Achilles tendons was followed by quantification of metabolites. Healing compared to intact tendons of the controls exhibited significantly increased concentrations (mM) of glutamate (60 ± 14 vs 20 ± 11), lactate (1.15 ± 0.60 vs 0.64 ± 0.35), and pyruvate (81 ± 29 vs 35 ± 25, µM). Healing tendons of the IPC vs control group displayed higher levels of glutamate (84 ± 15 vs 62 ± 16) and glucose (3.44 ± 0.62 vs 2.62 ± 0.72); (P < 0.05) and trends toward higher concentrations of pyruvate, lactate, and glycerol (P < 0.10). The present study demonstrates that early Achilles tendon repair entails and upregulates local essential metabolites. This metabolic response can, during tendon healing with plaster cast immobilization, be promoted by adjuvant IPC.

Expectation and experiences of childbirth in primiparae with caesarean section.

OBJECTIVE: The aim of this study was to examine the expectations and experiences in women undergoing a caesarean section on maternal request and compare these with women undergoing caesarean section with breech presentation as the indication and women who intended to have vaginal delivery acting as a control group. A second aim was to study whether assisted delivery and emergency caesarean section in the control group affected the birth experience. DESIGN: A prospective group-comparison cohort study. SETTING: Danderyd Hospital, Stockholm, Sweden. SAMPLE: First-time mothers (n= 496) were recruited to the study in week 37-39 of gestation and follow up was carried out 3 months after delivery. Comparisons were made between 'caesarean section on maternal request', 'caesarean section due to breech presentation' and 'controls planning a vaginal delivery'. METHODS: The instrument used was the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ). MAIN OUTCOME MEASURES: Expectations prior to delivery and experiences at 3 months after birth. RESULTS: Mothers requesting a caesarean section had more negative expectations of a vaginal delivery (P < 0.001) and 43.4% in this group showed a clinically significant fear of delivery. Mothers in the two groups expecting a vaginal delivery, but having an emergency caesarean section or an assisted vaginal delivery had more negative experiences of childbirth (P < 0.001). CONCLUSIONS: Women requesting caesarean section did not always suffer from clinically significant fear of childbirth. The finding that women subjected to complicated deliveries had a negative birth experience emphasises the importance of postnatal support.

No support for lipid rescue in oral poisoning: A systematic review and analysis of 160 published cases.

Lipid rescue is used as treatment of various poisonings despite weak scientific evidence. Some experimental studies have indicated a positive effect, but others have not. Clinical studies are lacking, wherefore a systematic review of virtually all published human case reports is presented. The case reports were searched for in PubMed and Web of Science and examined by two experts according to an assessment form grading the probability for a causal connection between lipid rescue and improved symptoms. A total of 160 cases were finally included, of which 30 had no positive effect of lipid rescue. Among the 130 included cases with alleged positive effect, 94 were oral poisonings and 36 were cases with local anesthetic systemic toxicity (LAST). The experts' assessment resulted in a "certain" causal connection in three cases with LAST but not in oral poisoning. Moreover, the mean assessment score among the oral poisonings was significantly worse than the corresponding score in the cases with LAST. The average log p-value of the main toxins among the oral poisonings was significantly lower than the corresponding p-value in the cases with LAST. Among the oral poisonings, 91% had received some other resuscitative treatment more or less simultaneously with lipid rescue. Considering the findings of this study and the increasingly reported adverse effects of lipid rescue, it's reasonable to strictly limit its use in clinical practice. We would not recommend it in oral poisonings.

Ageing, deep vein thrombosis and male gender predict poor outcome after acute Achilles tendon rupture.

AIMS: Patients with an acute Achilles tendon rupture (ATR) take a long time to heal, have a high incidence of deep vein thrombosis (DVT) and widely variable functional outcomes. This variation in outcome may be explained by a lack of knowledge of adverse factors, and a subsequent shortage of appropriate interventions. PATIENTS AND METHODS: A total of 111 patients (95 men, 16 women; mean age 40.3, standard deviation 8.4) with an acute total ATR were prospectively assessed. At one year post-operatively a uniform outcome score, Achilles Combined Outcome Score (ACOS), was obtained by combining three validated, independent, outcome measures: Achilles tendon Total Rupture Score, heel-rise height test, and limb symmetry heel-rise height. Predictors of ACOS included treatment; gender; age; smoking; body mass index; time to surgery; physical activity level pre- and post-injury; symptoms; quality of life and incidence of DVT. RESULTS: There were three independent variables that correlated significantly with the dichotomised outcome score (ACOS), while there was no correlation with other factors. An age of less than 40 years old was the strongest independent predictor of a good outcome one year after ATR (odds ratio (OR) 0.20, 95% confidence interval (CI) 0.08 to 0.51), followed by female gender (OR) 4.18, 95% CI 1.01 to 17.24). Notably, patients who did not have a DVT while immobilised post-operatively had a better outcome (OR 0.31, 95% CI 0.12 to 0.80). CONCLUSION: Over the age of 40 years, male gender and having a DVT while immobilised are independent negative predictors of outcome in patients with an acute ATR. Cite this article: Bone Joint J 2016;98-B:1635-41.

Skin conductance habituation and cerebrospinal fluid 5-hydroxyindoleacetic acid in suicidal patients.

The concentration of 5-hydroxyindoleacetic acid (5-HIAA) in the cerebrospinal fluid (CSF) and psychophysiologic variables, such as habituation of the skin conductance response, were measured in 35 drug-free, suicidal inpatients. Twenty-four patients were hospitalized after a suicide attempt, and another 11 had suicidal ideation. The suicide attempters were classified into nonviolent (drug overdoses taken orally, or a single wrist cut) and violent (all other methods). As in previous studies, the suicide attempters had significantly lower CSF concentrations of 5-HIAA compared with healthy, matched controls. The distribution of habituation rate was bimodal (slow and fast habituators). All violent attempters were fast habituators, as were all four patients who in a one-year follow-up were found to have completed a suicide (all by violent methods). The lowest frequency of fast habituators was found in the group of patients with suicidal ideation. There was no correlation between CSF 5-HIAA and habituation rate. A combination of these two variables yielded a highly significant correlation with type of suicide behavior, both retrospectively and prospectively.

Aberrant tyrosine transport across the cell membrane in patients with schizophrenia.

BACKGROUND: There is evidence that patients with schizophrenia exhibit abnormalities, not only in the brain but also in peripheral organs. An abnormal cell membrane composition has been suggested to be a common denominator, supported by findings of alterations in membrane phospholipid levels. In a previous study, the transport of amino acids across the plasma membrane was investigated with fibroblasts from patients with schizophrenia and controls. An isolated decrease in the maximal transport capacity (V(max)) of tyrosine was observed in the cells from patients. In this context, tyrosine transport across the fibroblast membrane was investigated in patients with schizophrenia and healthy control subjects. METHODS: Skin fibroblasts were obtained from 36 patients with schizophrenia (15 first episode and 21 chronic) and 10 healthy controls. Tyrosine transport across the cell membrane was studied in cultivated fibroblasts. The V(max) and the affinity of the tyrosine binding sites (K(m)) were determined. RESULTS: Significantly lower V(max) (F(1,41) = 12.80; P =.001; effect size = 1.36) and K(m) (F(1,41) = 24.85; P<.001; effect size = 1.00) were observed in fibroblasts from the patients. The findings were present in both neuroleptic-naive patients with their first episode and patients with chronic schizophrenia. CONCLUSIONS: The lower V(max) and K(m) are compatible with a cell membrane disturbance and support the view of schizophrenia as a systemic disorder. The decreased V(max) and K(m) observed in cells from schizophrenic patients probably reflect a genetic trait, as the changes were transmitted through several cell generations of cultured fibroblast.

Intermittent pneumatic compression reduces the risk of deep vein thrombosis during post-operative lower limb immobilisation: a prospective randomised trial of acute ruptures of the Achilles tendon.

Deep vein thrombosis is a common complication of immobilising the lower limb after surgery. We hypothesised that intermittent pneumatic compression (IPC) therapy in outpatients who had undergone surgical repair of acute ruptures of the Achilles tendon could reduce the incidence of this problem. A total of 150 patients who had undergone surgical repair of the Achilles tendon were randomised to either treatment with IPC for six hours per day (n = 74) under an orthosis or treatment as usual (n = 74) in a plaster cast without IPC. At two weeks post-operatively, the incidence of deep vein thrombosis was assessed using blinded, double-reported compression duplex ultrasound. At this point, IPC was discontinued and all patients were immobilised in an orthosis for a further four weeks. At six weeks post-operatively, a second compression duplex ultrasound scan was performed. At two weeks, the incidence of deep vein thrombosis was 21% in the treated group and 37% in the control group (p = 0.042). Age over 39 years was found to be a strong risk factor for deep vein thrombosis (odds ratio (OR) = 4.84, 95% confidence interval (CI) 2.14 to 10.96). Treatment with IPC, corrected for age differences between groups, reduced the risk of deep vein thrombosis at the two-week point (OR = 2.60; 95% CI 1.15 to 5.91; p =0.022). At six weeks, the incidence of deep vein thrombosis was 52% in the treated group and 48% in the control group (OR 0.94, 95% CI 0.49 to 1.83). IPC appears to be an effective method of reducing the risk of deep vein thrombosis in the early stages of post-operative immobilisation of outpatients. Further research is necessary to elucidate whether it can confer similar benefits over longer periods of immobilisation and in a more heterogeneous group of patients.

Muscle biopsy, macro EMG, and clinical characteristics in patients with schizophrenia.

BACKGROUND: In a previous study of motor unit properties in patients with schizophrenia, muscle fiber histologic and electrophysiologic abnormalities were observed. The present study was designed to compare patients with schizophrenia with healthy control subjects with regard to muscle fiber histology and motor unit function. A second objective was to relate these variables to clinical characteristics. METHODS: Twelve patients with first-episode schizophrenia and fifteen patients with chronic schizophrenia (DSM-III-R) and 27 matched control subjects were included in the study. Muscle biopsies were performed either in m. tibialis anterior or m. vastus lateralis. Electromyographic recordings (macro EMG) were made from the m. tibialis anterior motor units. Psychiatric ratings included the PANSS and extrapyramidal side effects. RESULTS: Seven of the muscle biopsy specimens from the patients and one from the control subjects were classified as abnormal (p =.049). The most frequent abnormality was atrophic muscle fibers. Eight patients and no control subjects exhibited pathological macro EMG (p =.032). The findings were present in chronic as well as in first-episode patients with schizophrenia. CONCLUSIONS: In approximately 50% of the patients, neuromuscular abnormalities were found either in the muscle biopsy or the macro EMG investigations. The results indicate that either a common pathologic process or different pathological processes are at hand in the neuromuscular system in patients with schizophrenia. The findings are compatible with a disturbed cell membrane function.

Personality characteristics and platelet MAO activity in women with congenital adrenal hyperplasia (CAH).

Personality traits and platelet monoamine oxidase (MAO) activity were studied in 22 women, 17-34 years old, with prenatal virilization due to congenital adrenal hyperplasia (CAH) (21-hydroxylase deficiency) and 22 healthy controls. The CAH group differed significantly on two of the eight scales of the Karolinska Scales of Personality (KSP), which have earlier shown significant gender differences. Both differences were in the masculine direction, with a high, male level, score for Detachment and a lower score for Indirect Aggression. The Detachment scale reflects distance in social relations, and has earlier been shown to be strongly gender differentiating. There was no significant difference in platelet MAO activity between the CAH group and the controls. Although an influence of psychosocial factors cannot be excluded, the results suggest a possible association between prenatal androgen exposure and the high Detachment score for the CAH group. Gender differences in empathy, affiliation motivation, intimacy and maternal behavior may be relevant parallels.

Smoking, pain tolerance, and physiological activation.

The effects of tobacco smoking and beta-blockade on psychophysiological measures, i.e., heart rate (HR), blood pressure (BP), skin conductance (SC), and sensitivity to electrical pain stimulation was studied in a group of 33 male moderate smokers. Using a method of limits threshold determination technique, measures of pain threshold (PT), and tolerance level (TL) were obtained. The results were analyzed in relation to smoking habits, personality measures, and subjective effects. There was no significant effect of smoking on pain sensitivity. Smoking caused a physiological activation as indicated by an increase in HR and systolic BP. beta-Blockade counteracted the smoking-induced increase in HR and systolic BP, but did not influence PT or TL. Subjective effects of smoking were not affected by beta-blockade. The findings suggest that physiological activation is not related to effects of smoking on pain.

Clinical and biochemical effects of citalopram, a selective 5-HT reuptake inhibitor--a dose-response study in depressed patients.

Citalopram is a bicyclic phtalane derivative. In animal experiments, citalopram has been demonstrated to possess a potent and highly selective inhibitory effect on serotonin reuptake. Several studies in man have indicated that citalopram given in daily doses of 40-60 mg has antidepressant properties and few side effects. The present double-blind study investigated the effects of three doses of citalopram (5 mg, 25 mg, and 50 mg) on depressive symptoms and various biochemical variables in 26 depressive patients. A significant reduction of the clinical ratings of depressive symptoms occurred at all dose levels. In endogenously depressed patients, a dose of 25 or 50 mg daily seemed to have the most pronounced antidepressive effect. The side effects were few and not related to dose level. A highly significant decrease in 5-HIAA in the CSF was found. MO-PEG in the CSF was also significantly decreased, while HVA in the CSF was increased. In addition, a significant decrease in the plasma concentrations of valine, leucine, tyrosine, and histidine was found. None of the biochemical effects was dose-dependent. The complex pattern of biochemical effects indicate that the amelioration of depressive symptoms might be related to effects of citalopram on central monoaminergic mechanisms and peripheral amino acid concentrations.

Concentrations of monoamine metabolites in the cerebrospinal fluid of twins and unrelated individuals--a genetic study.

The concentrations of the major monoamine metabolites, homovanillic acid (HVA), 3-methoxy-4-hydroxyphenylethylene glycol (MOPEG), and 5-hydroxyindoleacetic acid (5-HIAA) in the cerebrospinal fluid (CSF), of platelet monoamine oxidase (MAO) and of dopamine beta-hydroxylase (DBH)-activity in serum and CSF were determined in pairs of healthy mono- and dizygotic twins, brothers and unrelated individuals. Intraclass correlations were calculated for each category of pairs. Of the monoamine metabolites, only MOPEG was found to be under any major genetic influence. Genetic heritability for MOPEG was 0.74 with no evidence of cultural heritability or environment common to twins. For HVA and 5-HIAA, a familial influence was found, where the cultural heritability was higher than the genetic. As in previous studies of MAO in blood platelets and of DBH activity in serum, there was strong evidence for a genetic component. The genetic heritability for MAO was 0.78. For DBH in serum the genetic component was 0.98, and for DBH in CSF, 0.83. The demonstration of a familial influence on 5-HIAA and HVA in CSF requires a more detailed analysis of the character of such environmental and genetic influences, using more direct techniques.

Neuromuscular and psychomotor abnormalities in patients with schizophrenia and their first-degree relatives.

In previous studies of schizophrenic patients, neuromuscular (histopathological and electrophysiological) and psychomotor (finger tapping) abnormalities were found. The present study was designed to investigate relationships between these abnormalities and a family history of psychosis in 14 schizophrenic patients and 25 unaffected first-degree relatives compared to 14 healthy controls. Muscle biopsies were performed in either m. tibialis anterior or m. lateralis. Macro EMG recordings were made from m. tibialis anterior. A finger tapping test was used to investigate psychomotor performance. Neuromuscular abnormalities (muscle biopsies and/or macro EMG) and/or aberrant psychomotor performance (finger tapping test) were found in 13 (93%) patients, 14 (56%) first-degree relatives and in three (21%) controls. A statistically significant relationship for the psychomotor, but not neuromuscular changes to a family history of psychosis was found using a logistic regression method. The percentage of patients, relatives and healthy controls exhibiting were 36/40/7% in the muscle biopsy, 50/20/0% in the macro EMG, and 71/82/14% in the finger tapping investigations. A higher frequency of neuromuscular and psychomotor abnormalities was found in patients with schizophrenia and their first-degree relatives compared to healthy controls. The relationship between psychomotor findings and a family history of psychosis indicate that central aspects of motor aberrations are associated with a hereditary disposition of psychosis. The neuromuscular as well as psychomotor changes indicate that schizophrenia may be a systemic disease involving the central nervous system as well as peripheral organs. An altered cell membrane is suggested to be an underlying factor based on the type of neuromuscular findings.

A twin study of amino acid concentrations in cerebrospinal fluid.

The concentrations of amino acids in the cerebrospinal fluid (CSF) were measured in pairs of healthy mono- and dizygotic twins. Intraclass correlations were calculated. Genetic and cultural heritabilities were estimated using a path analytical model. CSF levels of glycine, tyrosine and arginine were shown to be influenced by genetic factors. Genetic variation was also shown for serine, alpha-aminobutyrate and leucine. The results were compared with results from a genetic analysis of the amino acids in serum.

Interaction effects of extraversion and neuroticism on detection thresholds.

Detection thresholds for electrocutaneous stimulation were measured in young male subjects by two different methods - a method of limits and a forced-choice method - the latter assumed to be less influenced by decision processes. Relations between the threshold measures and scores in the EPI extraversion (E) and neuroticism (N) scales were studied. High N-low E ("unstable introvert") subjects had the lowest thresholds. The result is in line with the predictions made on the basis of Eysenck's personality theory.

Bilateral skin conductance activity, clinical symptoms and CSF monoamine metabolite levels in unmedicated schizophrenics, differing in rate of habituation.

Bilateral skin conductance (SC) and heart rate (HR) were recorded for 18 RDC-diagnosed unmedicated recently admitted psychotic patients (13 schizophrenic and 5 paranoid) and for age- and sex-matched controls, during rest and tone stimulation (85 dBA, 1000 Hz, 1 sec duration and 0.25 msec rise time). Schizophrenics had more SC spontaneous fluctuations and faster HR, indicating higher arousal. SC spontaneous fluctuations were more frequent in left hand and showed an increasing trend over the session. Several SC measures indicated higher responsivity and a more irregular responding pattern in schizophrenics. These patients had higher levels of the noradrenaline metabolite (MHPG). Paranoid psychotic patients had a more stable SC habituation course than controls, and higher levels of the dopamine (HVA) and serotonin metabolites (5-HIAA). Schizophrenic nonhabituators had fewer positive psychotic symptoms than habituators, suggesting that poor habituation is not due to interference by symptoms. It may be related to higher arousal, or to deficient information processing.