Functional somatic disorders: discussion paper for a new common classification for research and clinical use

Background Functional somatic symptoms and disorders are common and complex phenomena involving both bodily and brain processes. They pose major challenges across medical specialties. These disorders are common and have significant impacts on patients’ quality of life and healthcare costs. Main body We outline five problems pointing to the need for a new classification: (1) developments in understanding aetiological mechanisms; (2) the current division of disorders according to the treating specialist; (3) failure of current classifications to cover the variety of disorders and their severity (for example, patients with symptoms from multiple organs systems); (4) the need to find acceptable categories and labels for patients that promote therapeutic partnership; and (5) the need to develop clinical services and research for people with severe disorders. We propose ‘functional somatic disorders’ (FSD) as an umbrella term for various conditions characterised by persistent and troublesome physical symptoms. FSDs are diagnosed clinically, on the basis of characteristic symptom patterns. As with all diagnoses, a diagnosis of FSD should be made after considering other possible somatic and mental differential diagnoses. We propose that FSD should occupy a neutral space within disease classifications, favouring neither somatic disease aetiology, nor mental disorder. FSD should be subclassified as (a) multisystem, (b) single system, or (c) single symptom. While additional specifiers may be added to take account of psychological features or co-occurring diseases, neither of these is sufficient or necessary to make the diagnosis. We recommend that FSD criteria are written so as to harmonise with existing syndrome diagnoses. Where currently defined syndromes fall within the FSD spectrum – and also within organ system-specific chapters of a classification – they should be afforded dual parentage (for example, irritable bowel syndrome can belong to both gastrointestinal disorders and FSD). Conclusion We propose a new classification, ‘functional somatic disorder’, which is neither purely somatic nor purely mental, but occupies a neutral space between these two historical poles. This classification reflects both emerging aetiological evidence of the complex interactions between brain and body and the need to resolve the historical split between somatic and mental disorders

Radiographic Measurements Correlate to Isolated Posterolateral Corner (PLC) Injury in a Novel Cadaveric Model

Introduction: Injury to the posterolateral corner (PLC) of the knee often requires surgical reconstruction. There remains no consensus on treatment for PLC injury, and, therefore, it is imperative to have a reproducible injury model to improve the general knowledge of PLC injuries. A novel cadaveric model of isolated PLC injury is proposed and evaluated using radiographic parameters as well as gross dissection. Material and methods: All protocols were reviewed by the Human Investigation and Research Committee of the home institution and were approved. Translational force in a defined posterior and lateral direction was applied to cadaveric native knees to induce PLC injury. Varus and recurvatum stress fluoroscopic imaging was obtained of each specimen before and after the injury model. Lateral joint distance and recurvatum angle after stress was measured on each image via picture archiving and communication software (PACS) imaging software. After the injury model, injured structures were assessed via saline loading and gross dissection. Any specimens found to be fractured were excluded from the analysis of stress radiography. Results: A total of 12 knees underwent testing and 6/12 successfully induced PLC injury without fracture. The lateral capsule was torn in every specimen. The popliteofibular ligament (PFL) was torn in 83% of specimens and the fibular collateral ligament (FCL) in 66.7% of specimens. The median lateral gapping after injury under varus stress radiography was 5.39 mm and the median recurvatum angle after injury was 14.25°. Radiographic parameters had a direct relationship with a number of structures injured. Conclusions: This is the first successful cadaver model of PLC injury. The lateral capsule was injured in every specimen emphasizing the importance of this structure to the PLC

Primary Hemiarthroplasty for the Treatment of Basicervical Femoral Neck Fractures

Purpose Basicervical femoral neck fractures are uncommon injuries that occur at the extracapsular base of the femoral neck at its transition with the intertrochanteric line. Controversy remains in the orthopedic literature as to the optimal method of treatment for this fracture type given the inherent instability and greater rate of implant failure with traditional fixation constructs. The purpose of this study is to quantify the incidence and preferred treatment methods of basicervical hip fractures at a single, regional, Level 1 trauma center and to identify differences in postoperative complications between treatment options. Methods The present study is a retrospective case series from a single regional health network, including 316 patients with hip fractures. Basicervical femoral neck fractures were identified. Reoperation rates within 90 days, implant failures or nonunions, postoperative ambulation distances and range of motion, and discharge dispositions were compared across patients grouped by surgical treatment with either cephalomedullary nail, sliding hip screw, or hemiarthroplasty (HA). Results Basicervical femoral neck fractures represented 6.6% of this study population. The cephalomedullary nail group demonstrated rates of implant failure and return to the operating room within 90 days of 40% (4/10) and 20% (2/10), respectively. No patients who underwent hemiarthroplasty experienced a failure of fixation or return to the operating room. Conclusions This study suggests a much lower rate of fixation failure or need for reoperation with hemiarthroplasty treatment compared to cephalomedullary nail construct for basicervical femoral neck fractures and may be an underutilized treatment method for this fracture type. The promising results seen with this case series should encourage further investigation into HA as a primary treatment for these uncommon, yet challenging, fractures

DISTRIBUTION AND PREVALENCE OF ELAEOPHORA SCHNEIDERI IN MOOSE IN WYOMING

Elaeophora schneideri causes disease in aberrant hosts such as moose. Documented E. schneideri infections in moose are relatively rare, yet noteworthy enough that individual cases describing morbidity and mortality have been the norm for reporting. Surveillance efforts for E. schneideri in Wyoming moose in the 1970s found zero cases, but since 2000 several moose in Wyoming discovered dead or showing clinical signs of elaeophorosis have been found infected with E. schneideri. In 2009 we searched for worms in the carotid arteries of 168 hunter-harvested moose from across Wyoming to determine the prevalence and distribution of E. schneideri in moose; 82 (48.8%; 95% CI: 41.4-56.3%) were positive for E. schneideri. Prevalence did not differ between sexes or among age classes but there was difference in prevalence among herd units (range = 5-82.6%). Intensity of infection (range = 1-26 worms) did not differ between sexes, among age classes, or among herd units. Our findings indicate that moose do not succumb to the parasite to the extent previously thought. Prevalence and intensity were constant across age classes, suggesting that infected moose are surviving and an acquired, immunological resistance to further infection develops. In addition, moose might sometimes act as natural hosts to the parasite, as indicated by 1) high prevalence of infection in moose in areas where sympatric mule deer had much lower prevalence of infection, and 2) preliminary necropsy findings that revealed microfilariae in skin samples from 3 moose. However, negative impacts to moose and moose populations cannot be ruled out entirely, as this study was limited to apparently healthy hunter-harvested animals. While moose appear to often survive infection with E. schneideri, prevalence of ~50% is still cause for concern because it is unknown to what extent this parasite causes subclinical effects in moose that might impact recruitment or productivity. Subsequent research on moose herds where E. schneideri occurs should consider the effects of elaeophorosis and attempt to clarify its role

Depression and Anxiety Correlate Differently with Salivary Free Cortisol in the Morning in Patients with Functional Somatic Syndrome

Patients presenting with functional somatic syndrome (FSS) are common, and the symptoms are persistent and difficult to treat for doctors and costly for society. The aim of this study was to clarify the common pathophysiology of FSS, especially the relationship between hypothalamic-pituitary-adrenal (HPA) axis function and psychological characteristics of patients with FSS. The subjects were 45 patients with FSS and 29 healthy controls. Salivary free cortisol was measured in the morning, and psychological tests examining depression, anxiety and quality of life (QOL) were performed on the same day. In patients with FSS, depressive scores showed a significant negative correlation with salivary free cortisol in the morning, although in healthy controls, cortisol showed a significant positive correlation with depressive scores. In addition, the correlation between other psychological test scores and cortisol secretion in patients with FSS contrasted with that of controls. The relationship between cortisol and depression, anxiety or QOL, suggests that the HPA axis of patients with FSS is dysfunctional and does not function properly when patients with FSS are under stress. This dysfunction may explain the pathology of medically unexplained persistent symptoms of patients with FSS

Neutrinos below 100 TeV from the southern sky employing refined veto techniques to IceCube data

Many Galactic sources of gamma rays, such as supernova remnants, are expected to produce neutrinos with a typical energy cutoff well below 100 TeV. For the IceCube Neutrino Observatory located at the South Pole, the southern sky, containing the inner part of the Galactic plane and the Galactic Center, is a particularly challenging region at these energies, because of the large background of atmospheric muons. In this paper, we present recent advancements in data selection strategies for track-like muon neutrino events with energies below 100 TeV from the southern sky. The strategies utilize the outer detector regions as veto and features of the signal pattern to reduce the background of atmospheric muons to a level which, for the first time, allows IceCube searching for point-like sources of neutrinos in the southern sky at energies between 100 GeV and several TeV in the muon neutrino charged current channel. No significant clustering of neutrinos above background expectation was observed in four years of data recorded with the completed IceCube detector. Upper limits on the neutrino flux for a number of spectral hypotheses are reported for a list of astrophysical objects in the southern hemisphere.Comment: 19 pages, 17 figures, 2 table

Search for transient optical counterparts to high-energy IceCube neutrinos with Pan-STARRS1

In order to identify the sources of the observed diffuse high-energy neutrino flux, it is crucial to discover their electromagnetic counterparts. IceCube began releasing alerts for single high-energy ($E > 60$ TeV) neutrino detections with sky localisation regions of order 1 deg radius in 2016. We used Pan-STARRS1 to follow-up five of these alerts during 2016-2017 to search for any optical transients that may be related to the neutrinos. Typically 10-20 faint ($m < 22.5$ mag) extragalactic transients are found within the Pan-STARRS1 footprints and are generally consistent with being unrelated field supernovae (SNe) and AGN. We looked for unusual properties of the detected transients, such as temporal coincidence of explosion epoch with the IceCube timestamp. We found only one transient that had properties worthy of a specific follow-up. In the Pan-STARRS1 imaging for IceCube-160427A (probability to be of astrophysical origin of $\sim$50 %), we found a SN PS16cgx, located at 10.0' from the nominal IceCube direction. Spectroscopic observations of PS16cgx showed that it was an H-poor SN at z = 0.2895. The spectra and light curve resemble some high-energy Type Ic SNe, raising the possibility of a jet driven SN with an explosion epoch temporally coincident with the neutrino detection. However, distinguishing Type Ia and Type Ic SNe at this redshift is notoriously difficult. Based on all available data we conclude that the transient is more likely to be a Type Ia with relatively weak SiII absorption and a fairly normal rest-frame r-band light curve. If, as predicted, there is no high-energy neutrino emission from Type Ia SNe, then PS16cgx must be a random coincidence, and unrelated to the IceCube-160427A. We find no other plausible optical transient for any of the five IceCube events observed down to a 5$\sigma$ limiting magnitude of $m \sim 22$ mag, between 1 day and 25 days after detection.Comment: 20 pages, 6 figures, accepted to A&

Orbital redistribution in molecular nanostructures mediated by metal-organic bonds

Dicyanovinyl-quinquethiophene (DCV5T-Me) is a prototype conjugated oligomer for highly efficient organic solar cells. This class of oligothiophenes are built up by an electron-rich donor (D) backbone and terminal electron-deficient acceptor (A) moieties. Here, we investigated its structural and electronic properties when it is adsorbed on a Au(111) surface using low temperature scanning tunneling microscopy/spectroscopy (STM/STS) and atomic force microscopy (AFM). We find that DCV5T-Me self-assembles in extended chains, stabilized by intercalated Au atoms. The effect of metal-ligand hybridization with Au adatoms causes an energetic downshift of the DCV5T-Me lowest unoccupied molecular orbital (LUMO) with respect to the uncoordinated molecules on the surface. The asymmetric coordination of a gold atom to only one molecular end group leads to an asymmetric localization of the LUMO and LUMO+1 states at opposite sides. Using model density functional theory (DFT) calculations, we explain such orbital reshaping as a consequence of linear combinations of the original LUMO and LUMO+1 orbitals, mixed by the attachment of a bridging Au adatom. Our study shows that the alignment of molecular orbitals and their distribution within individual molecules can be modified by contacting them to metal atoms in specific sites