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Objectives: To determine the prevalence and nature of rock-climbing injuries, and the factors associated with these injuries. Design: A retrospective cross-sectional study. Setting: Rock climbers were recruited at five outdoor and six indoor climbing venues in the UK. Participants: 201 active rock climbers (163 male, 38 female climbers) aged 16-62 years. Assessment of risk factors: Rock climbing behaviours and key demographics. Main outcome measures: Injuries requiring medical attention or withdrawal from participation for ⩾1 day. Results: Around 50% of climbers had sustained ⩾1 injury in the past 12 months, causing a total of 275 distinct anatomical injuries. 21 climbers (10%) had sustained acute climbing injuries as a result of a fall, 67(33%) had chronic overuse injuries, and 57(28%) had acute injuries caused by strenuous climbing moves. Dedicated climbers participating in different forms of rock climbing more often and at a higher level of technical difficulty may be more prone to injury, particularly overuse injuries of the finger and shoulder. The principal sources of treatment or advice sought by climbers were physiotherapists (18%), other climbers (14%) and doctors (11%). Conclusions: Climbing frequency and technical difficulty are associated with climbing injuries occurring at both indoor and outdoor venues, particularly cumulative trauma to the upper extremities. [ABSTRACT FROM AUTHOR]

It has been estimated that over 80% of the population will report low back pain (LBP) at some point in life, and each year 7% of the adult population consult their GP with symptoms. Prevalence increases with age, reaching a peak during the sixth decade of life. Until recently little was known about LBP at young ages. Clinically it was perceived to be uncommon-with few children consulting because of LBP in primary care. Large prospective epidemiological studies have shown that, in those free of LBP at baseline, the best predictor of future onset is a previous history of LBP. Therefore, to understand the epidemiology of LBP, and what predisposes someone to a trajectory of LBP in adult life, it is important to examine the condition at young ages, to determine factors responsible for onset of initial episodes, and to examine whether LBP in childhood is related to symptoms in adulthood. [ABSTRACT FROM AUTHOR]

Estimates the incidence of congenital brachial palsy in the United Kingdom. Causes and outcome of congenital brachial palsy; Factors associated with the occurrence of congenital brachial palsy.

Investigates the rates of change in bone mineral density of elderly people in New South Wales. Continuance of bone loss at the femoral neck of elderly people; Influence of cohort effects on the results; Relationship between smoking and bone loss.

Prevention of intracranial stent thrombosis with dual-antiplatelet therapy is widely used in neuroendovascular procedures. However, the rising incidence of inadequate platelet inhibition with clopidogrel may increase complications following stent placement, especially with newer devices that possess a larger total metal surface area. While there are recent reports of prasugrel as an alternative to clopidogrel, there is no clinical evidence in neurointerventional patients regarding the use of a lower maintenance dose as an alternative strategy to gain adequate platelet inhibition while possibly reducing the risk of bleeding. We present 6-month efficacy and safety outcomes of two patients undergoing elective pipeline embolisation that were found to have inadequate platelet response to clopidogrel and subsequently transitioned to prasugrel 5 mg daily for the prevention of stent thrombosis. [ABSTRACT FROM AUTHOR]

The article presents a case study of a couple that was referred for genetics assessment following an intrauterine fetal demise at 41 weeks gestation following an unremarkable antenatal course. A discussion of a postmortem examination which was conducted on the couple's deceased child, and resulted in the child receiving a diagnosis of a novel mutation in NIPBL3 in a case of Cornelia de Lange syndrome, is presented.

The article presents an obituary for associate specialist in obstetrics and gynaecology Prafulla Mangalore.

Background: Before the publication of the M40-A standard by the United States National Committee for Clinical Laboratory Standards (NCCIS), no quality control data for swab transport systems (STSs) had been available. Aims: To compare three commercially available STSs against the published standard to ascertain bacterial survival after a set holding time. Method: Charcoal and non-charcoal containing swabs were inoculated with standard volumes and numbers of a range of bacteria commonly isolated from clinical material. Bacterial counts were taken at time zero, six, 24, and 48 hours, with the results being compared against the NCCLS standard. Results: The standard clearly differentiated between the three STSs tested, with one product being superior to the other two products in providing better survival. Conclusion: The standard now provides manufacturers and users of STSs with meaningful data to provide, purchase, and compare an STS for routine clinical use. [ABSTRACT FROM AUTHOR]

Reports that metformin may reduce cardiovascular risks in patients with type 2 diabetes. Discussion of a United Kingdom diabetes study indicating metformin produced similar degrees of glycemic control and significantly reduced microvascular end points as did sulphonylurea and insulin; Results indicating that group tested with metformin had no hypoglycemia and less weight gain than groups tested with sulphonylurea and insulin; How metformin reduced the risk in mortality, diabetes-related deaths and diabetes-related end points.

Objectives: To determine the incidence and study the causes and outcome of congenital brachial palsy (CBP).Design: Active surveillance of newborn infants using the British Paediatric Surveillance Unit notification system and follow up study of outcome at 6 months of age.Setting: The United Kingdom and Republic of Ireland.Participants: Newborn infants presenting with a flaccid paresis of the arm (usually one, rarely both) born between April 1998 and March 1999.Main Outcome Measures: Extent of the lesion at birth and degree of recovery at 6 months of age.Findings: There were 323 confirmed cases giving an incidence of 0.42 per 1000 live births (1 in 2300). Significant associated risk factors in comparison with the normal population were shoulder dystocia (60% v 0.3%), high birth weight with 53% infants weighing more than the 90th centile, and assisted delivery (relative risk (RR) 3.4, 95% confidence interval (CI) 2.9 to 3.9, p = 0.0001). There was a considerably lower risk of CBP in infants delivered by caesarean section (RR 7, 95% CI 2 to 56, p = 0.002). At about 6 months of age, about half of the infants had recovered fully, but the remainder showed incomplete recovery including 2% with no recovery. The relative risk of partial or no recovery in infants with extensive lesions soon after birth compared with those with less extensive lesions was 11.28 (95% CI 2.38 to 63.66, p = 0.000005).Conclusions: The incidence of CBP in the United Kingdom and Republic of Ireland is strikingly similar to that previously reported nearly 40 years ago. Most cases are due to trauma at delivery, which is not necessarily excessive or inappropriate. Given the uncertainty about the appropriate management of these infants, serious consideration should be given to a formal clinical trial of microsurgical nerve repair. [ABSTRACT FROM AUTHOR]

Introduction It is imperative that laboratories receive uncontaminated urine samples to avoid giving falsepositive results and reduce antimicrobial use. Aim The aim of the study was to investigate a novel urine collection device (Peezy) in a renal outpatient clinic to determine whether it reduced contamination of urine samples. Methods The novel device was used in 420 renal transplant recipients and the results were compared with 424 matched historical controls, who used the standard method of urine collection. High epithelial cell counts on microscopy and mixed urine cultures were used to identify contaminated samples. Results Peezy increased the rates of both epithelial cells and mixed growths in the urine samples when compared with the historical controls. Conclusions Further randomised studies in other more generalisable populations need to be performed. [ABSTRACT FROM AUTHOR]

Objective: Brain amyloid imaging using positron emission tomography (PET) is of increasing importance in the premortem evaluation of dementias, particularly in relation to Alzheimer disease (AD). The purpose of this study was to explore the premortem diagnostic utility of (11)C-PiB PET in sporadic Creutzfeldt-Jakob disease (CJD).Methods: Two patients, 72 and 59 years old, underwent evaluation for rapidly progressive cognitive decline, dying after illness durations of 5 and 7 months, respectively. As part of their comprehensive assessment, (18)F-FDG PET and (11)C-PiB PET studies were performed approximately 2-4 weeks prior to death, and the brain regional distributions compared with those from cohorts of healthy controls (HC) and AD patients.Results: Routine investigations, including brain MRI scans, revealed changes typical of sporadic CJD, with the diagnosis confirmed at autopsy in both patients. The (18)F-FDG PET showed global hypometabolism in one patient and thalamic and frontal hypometabolism with unexpected hypermetabolism in the dentate nuclei of the cerebellum in the other. Neither patient displayed cerebral cortical (11)C-PiB PET retention above the levels observed in HC.Conclusions: No grey-matter (11)C-PiB retention was observed in two pathologically confirmed cases of typical sporadic CJD. We speculate that low PrP plaque density and small plaque size, as well as a relatively low affinity of the radioligand, explain the absence of (11)C-PiB retention. More studies to validate this hypothesis are warranted. [ABSTRACT FROM AUTHOR]

BACKGROUND: Gluten ataxia is an immune mediated disease, part of the spectrum of gluten sensitivity, and accounts for up to 40% of cases of idiopathic sporadic ataxia. No systematic study of the effect of gluten-free diet on gluten ataxia has ever been undertaken. OBJECTIVE: To study the effect of gluten-free diet on patients presenting with ataxia caused by gluten sensitivity. METHODS: 43 patients with gluten ataxia were studied. All were offered a gluten-free diet and monitored every six months. All patients underwent a battery of tests to assess their ataxia at baseline and after one year on diet. Twenty six patients (treatment group) adhered to the gluten-free diet and had evidence of elimination of antigliadin antibodies by one year. Fourteen patients refused the diet (control group). Three patients had persistently raised antigliadin antibodies despite adherence to the diet and were therefore excluded from the analysis. RESULTS: After one year there was improvement in ataxia reflected in all of the ataxia tests in the treatment group. This was significant when compared with the control group. The diet associated improvement was apparent irrespective of the presence of an enteropathy. CONCLUSIONS: Gluten ataxia responds to a strict gluten-free diet even in the absence of an enteropathy. The diagnosis of gluten ataxia is vital as it is one of the very few treatable causes of sporadic ataxia. [ABSTRACT FROM AUTHOR]

Presents a letter to the editor about mycobacterial infection published in the January 2001 issue of the journal "Thorax."

Focuses on the evidence for familial immune defect in meningococcal meningitis. Vaccination of patients with Group C meningococcal polysaccharide and tetanus toxoid; Measurement of hemagglutinating antibody response; Presence of defective response to meningococcal polysaccharide.

Focuses on the welfare of children. Proposals for an extension of human rights to the baby and to the minors; Passage of the Congenital Disabilities Act; Provisions of the bill.

OBJECTIVE: Brain amyloid imaging using positron emission tomography (PET) is of increasing importance in the premortem evaluation of dementias, particularly in relation to Alzheimer disease (AD). The purpose of this study was to explore the premortem diagnostic utility of 11C-PiB PET in sporadic Creutzfeldt–Jakob disease (CJD). METHODS: Two patients, 72 and 59 years old, underwent evaluation for rapidly progressive cognitive decline, dying after illness durations of 5 and 7 months, respectively. As part of their comprehensive assessment, 18F-FDG PET and 11C-PiB PET studies were performed approximately 2–4 weeks prior to death, and the brain regional distributions compared with those from cohorts of healthy controls (HC) and AD patients. RESULTS: Routine investigations, including brain MRI scans, revealed changes typical of sporadic CJD, with the diagnosis confirmed at autopsy in both patients. The 18F-FDG PET showed global hypometabolism in one patient and thalamic and frontal hypometabolism with unexpected hypermetabolism in the dentate nuclei of the cerebellum in the other. Neither patient displayed cerebral cortical 11C-PiB PET retention above the levels observed in HC. CONCLUSIONS: No grey-matter 11C-PiB retention was observed in two pathologically confirmed cases of typical sporadic CJD. We speculate that low PrP plaque density and small plaque size, as well as a relatively low affinity of the radioligand, explain the absence of 11C-PiB retention. More studies to validate this hypothesis are warranted. [ABSTRACT FROM AUTHOR]

Background: Chronic abdominal pain (CAP) is common among schoolchildren, but risk factors for its onset are still largely unknown. Aims: To determine the frequency of onset of CAP in schoolchildren and investigate risk factors for its development. Methods: 1411 schoolchildren aged 11-14 years were recruited from schools in North West England. Information was collected on recent pain symptoms and potential risk factors for developing CAP. Participants were followed up 1 and 4 years later and new episodes of CAP were identified. Results: 22% reported new-onset abdominal pain at 1-year follow-up which persisted at 4-year follow-up (CAP). CAP was almost three times higher in girls than boys (34% vs 13%; χ2: 26.0; p<0.001). In girls, reporting headache at baseline was the only predictive factor for CAP onset: those reporting headaches experienced a doubling in the risk of symptom onset (relative risk: 2.1 ; 95% confidence interval: 0.95 to 4.7). In contrast, in boys, development of CAP was independently predicted by daytime tiredness (3.0; 1.2 to 7.6), lack of school enjoyment (2.0; 0.95 to 4.2), adverse psychosocial exposures (2.3; 1.2 to 4.5) and taller stature (1.9; 0.8 to 4.5). Conclusion: Our results suggest that over 20% of adolescent schoolchildren experience new-onset non-self-limiting abdominal pain over a 1-year period. Future abdominal pain is predicted by previous somatic symptom reporting in girls and both somatic symptom reporting and psychosocial factors in boys. These risk factors indicate a possible mechanism for understanding the development of CAP, and might have important implications for both primary and secondary preventive strategies. [ABSTRACT FROM AUTHOR]

Objective: To determine whether the marks in the third year Objective Structured Clinical Examination (OSCE) were affected by the collusion reported by the students themselves on an electronic discussion board. Design: A review of the student discussion, examiners' feedback and a comparison of the marks obtained on the 2 days of the OSCE. Participants: 255 third year medical students. Setting: An OSCE consisting of 15 stations, administered on three sites over 2 days at a UK medical school. Results: 40 students contributed to the discussion on the electronic discussion board. The main points raised were perceived inequity between students who did, or did not, have prior knowledge of the station content, and the lack of honesty and professionalism of their peers. Most contributors claimed to have received, or knew of others receiving, prior knowledge, but none confessed to passing on information. No significant difference (p = 0.16) was observed in the overall mark for the OSCE on day 1 (mean 390 (SD 37)) and day 2 (mean 397 (38)). On day 2, marks were considerably greater for four stations and markedly lower for three stations. It was not obvious why collusion should affect these station marks. A clear indication of the effects of collusion could only be obtained from a single subsection of an individual station (pathology) where 82 students on day 2 incorrectly gave the diagnosis from day 1. Conclusion: Marks do not provide a sound inference of student collusion in an OSCE and may mask the aspects of professional development of students. [ABSTRACT FROM AUTHOR]

Objectives: To prospectively study the clinical, neurophysiological and neuropathological characteristics of axonal neuropathies associated with positive antigliadin antibodies and the prevalence of such neuropathies in a cohort of patients with sporadic axonal neuropathy. Methods: Prospective screening (using antigliadin, antiendomysium and tissue transglutaminase antibodies) of patients with peripheral neuropathy attending a neurology clinic. Results: 215 patients with axonal neuropathy were screened. 141 patients had symmetrical sensorimotor neuropathy, 47 had mononeuropathy multiplex, 17 had motor neuropathy and 10 had small-fibre neuropathy. Despite extensive investigations of the 215 patients, 140 had idiopathic neuropathy. Positive immunoglobulin (Ig)G with or without IgA antigliadin antibodies was found in 34% (47/140) of the patients with idiopathic neuropathy. This compares with 12% prevalence of these antibodies in the healthy controls. The prevalence of coeliac disease as shown by biopsy in the idiopathic group was at least 9% as compared with 1% in the controls. The clinical features of 100 patients (47 from the prevalence study and 53 referred from elsewhere) with gluten neuropathy included a mean age at onset of 55 (range 24–77) years and a mean duration of neuropathy of 9 (range 1–33) years. Gluten-sensitive enteropathy was present in 29% of patients. The human leucocyte antigen types associated with coeliac disease were found in 80% of patients. Conclusions: Gluten sensitivity may be aetiologically linked to a substantial number of idiopathic axonal neuropathies. [ABSTRACT FROM AUTHOR]

Presents letters related to medicine. Importance of medical staff awareness about major incident planning; Comments about drug treatment of hypertension; Difficulties faced in the identification of malnourished children by the World Health Organization.

Aims: To assess the impact of two pediatric intensive care unit retrieval teams on the performance of three mortality risk scoring systems: pre-ICU PRISM, PIM, and PRISM II. Methods: A total of 928 critically ill children retrieved for intensive care from district general hospitals in the south east of England (crude mortality 7.8%) were studied. Results: Risk stratification was similar between the two retrieval teams for scores utilising data primarily prior to ICU admission (pre-ICU PRISM, PIM), despite differences in case mix. The fewer variables required for calculation of PIM resulted in complete data collection in 88% of patients, compared to pre-ICU PRISM (24%) and PRISM II (60%). Overall, all scoring systems discriminated well between survival and non-survival (area under receiver operating characteristic curve 0.83-0.87), with no differences between the two hospitals. There was a tendency towards better discrimination in all scores for children compared to infants and neonates, and a poor discrimination for respiratory disease using pre-ICU PRISM and PRISM II but not PIM. All showed suboptimal calibration, primarily as a consequence of mortality over prediction among the medium (10-30%) mortality risk bands. Conclusions: PIM appears to offer advantages over the other two scores in terms of being less affected by the retrieval process and easier to collect. Recalibration of all scoring systems is needed. [ABSTRACT FROM AUTHOR]

Editorial. Focuses on coeliac disease or gluten sensitivity enteropathy. History of the treatment of coeliac disease; Association between neurological disorders and adult coeliac disease; Typical clinical manifestation of a patient with gluten sensitivity.

Presents several letters related to medicine in Great Britain. Risks of total hip replacement; Medical implications of prostaglandins and asthma; Application of the declaration of the President of the General Dental Council on operator and anesthetists.

Introduction Manual muscle testing, in the form of the Medical Research Council sumscore (MRC-SS) is a widely accepted clinical tool for diagnosing intensive care unit-acquired weakness (ICU-AW). Although MRC-SS is a simple bedside test, the nature of the test is volitional limiting its ability to distinguish poor motivation and impaired cognition from actual loss of muscle function. The clinical predictive value of the MRC-SS therefore needs to be assessed. Method Unselected adult ICU patients (=18 years) ventilated for =48 h were eligible. The conscious level of the patients was determined using the Richmond Agitation Sedation Scale; a score -1 to +1 was indicative of awakening. Testing comprised of a two-stage process. Stage 1: Patients at awakening were required to follow 4 simple, one-stage commands. Stage 2: If all 4 one-stage commands were successfully completed, MRC-SS testing was performed by a specialist ICU rehabilitation clinician. ICU-AW was defined as MRC-SS <48. ICU and hospital mortality and length of stay (LOS) were recorded in all the patients. Results 94 sequential awakening patients were recruited; 68.1% males (n=64), with a mean age for the whole cohort of 64.5±15.3 years. 29 patients were unable to successfully complete the 4 one-stage commands as a result of cognitive impairment. 65 patients completed the MRC-SS of whom 73.9% demonstrated ICU-AW at awakening. Results are shown in Abstract P67 table 1. Conclusion Almost a third of critically ill patients, from a sequential cohort, were unable to complete 4 one-stage commands and thus could not perform the MRC-SS. Although inability to successfully complete the one-stage commands conferred limited predictive value, those patients that could perform this task were more likely to survive ICU. Similarly an MRC-SS <48 at awakening, presumed indicative of ICU-AW, conferred limited predictive value. However an MRC-SS =48 predicted ICU and hospital survival as well as an ICU LOS <2 weeks. These data highlight the limitations of volitional tests in critically ill patients. It clearly challenges the current view that ICU-AW, as measured by volitional tests, is a predictor of poor outcome. These data confirm that preserved peripheral strength predicts a good outcome. [ABSTRACT FROM AUTHOR]

An abstract of the article "Panhypopituitarism After Tuberculosis Meningitis With Suprasellar Abscess," by D. Iyer and colleagues is presented.

Objectives Riding racehorses is a hazardous occupation but, to date, there has not been a study of risk factors for falls to thoroughbred racing jockeys riding in flat races. Methods Data on race-day falls were extracted from stewards' reports. Denominator data were provided by Racing Information Services Australia on races conducted in Australia from August 2002 until July 2006. Incidence rate ratios (IRRs) were estimated using Poisson regression. Analyses were stratified by race grade (maiden, class, open/restricted). Results In multivariable analyses, factors associated with falls were female jockeys (IRR 1.11; 95% CI 1.00 to 1.23), apprentice jockeys (1.51; 1.39 to 1.63), amateur jockeys (1.44; 1.11 to 1.86), drier tracks, younger horse age, shorter race distance, lower field size and lower race grade (all p<0.05). The IRR's for five factors associated with falls differed by category of race grade: those for apprentice jockey, higher prize money and shorter race distance were greater in lower race grades, while those for fewer previous rides this meeting and drier track rating were greater in higher race grades. Female jockeys had a significantly higher incidence of falls when riding horses under 4 years of age in open/restricted races, and the effects of lower field size in maiden races, and of shorter races, were more pronounced for falls occurring prerace. Conclusions We identified a range of factors associated with falls to thoroughbred racing jockeys riding in flat races that adds to the evidence base for formulating strategies to improve occupational health and safety standards in the thoroughbred racing industry. [ABSTRACT FROM PUBLISHER]

Examines the delayed detection of congenital hearing loss in high risk infants in Great Britain. Effects of the introduction of evoked response audiometry on the mean age of the identification of hearing loss; Failure to arrange auditory evoked response testing in early infancy; Awareness of health service personnel of the risk criteria of infants.

The article discusses the case of a newborn infant who was diagnosed with a depressed skull fracture in the right parietal bone. She was delivered via emergency ceasarean section due to failure to progress with an unstable lie. The baby experienced good postoperative recovery following neurosurgical elevation of the fracture. Information on the incidence of bone injuries in infants is provided, as well as the types of obstetric depressed skull fractures.