Towards a uniform definition for the centralisation phenomenon

The focus of this PhD project is on symptom centralisation. Its primary objectives were to establish a standard operational definition of centralisation and evaluate its inter-rater reliability in neck pain. Two systematic reviews on the reliability and prognostic value of clinically induced symptom responses in spinal pain (Chapters 2 and 3) showed that although the potential usefulness of centralisation has been demonstrated in low back pain, concern has been expressed about the observed inconsistency in reported definitions, and the scarcity of studies in neck pain. A Delphi survey of experts (Chapter 4) assisted in the development of a uniform operational definition for centralisation and the identification of future research questions. Centralisation was generally defined as the progressive and stable reduction of the most distal presenting pain towards the spine midline in response to standardised spinal loading strategies. The support by the Delphi panel of a broader definition allowed for a multitude of different ways of testing to be included in the assessment procedure which may offer some flexibility to clinicians assessing, classifying and managing different spinal pain presentations across different countries. Although the reliability of identifying centralisation was acceptable, high levels of reliability were not demonstrated (Chapter 5). However, reliability was greater for the pair of physiotherapists with prior experience and formal extensive training in symptom response assessment. Therefore, the optimal type and amount of training for eliciting and interpreting centralisation and the effect of procedural variations on testing the outcomes of individuals who centralise require urgent investigation. The prognostic and management value of centralisation are also unknown. This investigation may pave the way for the standardisation of centralisation as a physical sign and stimulate interest for further study of potential sub-groups and classification of spinal syndromes

Towards a uniform definition for the centralisation phenomenon

The focus of this PhD project is on symptom centralisation. Its primary objectives were to establish a standard operational definition of centralisation and evaluate its inter-rater reliability in neck pain. Two systematic reviews on the reliability and prognostic value of clinically induced symptom responses in spinal pain (Chapters 2 and 3) showed that although the potential usefulness of centralisation has been demonstrated in low back pain, concern has been expressed about the observed inconsistency in reported definitions, and the scarcity of studies in neck pain. A Delphi survey of experts (Chapter 4) assisted in the development of a uniform operational definition for centralisation and the identification of future research questions. Centralisation was generally defined as the progressive and stable reduction of the most distal presenting pain towards the spine midline in response to standardised spinal loading strategies. The support by the Delphi panel of a broader definition allowed for a multitude of different ways of testing to be included in the assessment procedure which may offer some flexibility to clinicians assessing, classifying and managing different spinal pain presentations across different countries. Although the reliability of identifying centralisation was acceptable, high levels of reliability were not demonstrated (Chapter 5). However, reliability was greater for the pair of physiotherapists with prior experience and formal extensive training in symptom response assessment. Therefore, the optimal type and amount of training for eliciting and interpreting centralisation and the effect of procedural variations on testing the outcomes of individuals who centralise require urgent investigation. The prognostic and management value of centralisation are also unknown. This investigation may pave the way for the standardisation of centralisation as a physical sign and stimulate interest for further study of potential sub-groups and classification of spinal syndromes.EThOS - Electronic Theses Online ServiceHellenic State Scholarships FoundationUniversity of WarwickGBUnited Kingdo

Towards a uniform definition for the centralisation phenomenon

The focus of this PhD project is on symptom centralisation. Its primary objectives were to establish a standard operational definition of centralisation and evaluate its inter-rater reliability in neck pain. Two systematic reviews on the reliability and prognostic value of clinically induced symptom responses in spinal pain (Chapters 2 and 3) showed that although the potential usefulness of centralisation has been demonstrated in low back pain, concern has been expressed about the observed inconsistency in reported definitions, and the scarcity of studies in neck pain. A Delphi survey of experts (Chapter 4) assisted in the development of a uniform operational definition for centralisation and the identification of future research questions. Centralisation was generally defined as the progressive and stable reduction of the most distal presenting pain towards the spine midline in response to standardised spinal loading strategies. The support by the Delphi panel of a broader definition allowed for a multitude of different ways of testing to be included in the assessment procedure which may offer some flexibility to clinicians assessing, classifying and managing different spinal pain presentations across different countries. Although the reliability of identifying centralisation was acceptable, high levels of reliability were not demonstrated (Chapter 5). However, reliability was greater for the pair of physiotherapists with prior experience and formal extensive training in symptom response assessment. Therefore, the optimal type and amount of training for eliciting and interpreting centralisation and the effect of procedural variations on testing the outcomes of individuals who centralise require urgent investigation. The prognostic and management value of centralisation are also unknown. This investigation may pave the way for the standardisation of centralisation as a physical sign and stimulate interest for further study of potential sub-groups and classification of spinal syndromes.EThOS - Electronic Theses Online ServiceHellenic State Scholarships FoundationUniversity of WarwickGBUnited Kingdo

A pilot study of the association of rs6127099 polymorphism with primary hyperparathyroidism

Primary hyperparathyroidism (PHPT) is the third most common endocrine disorder characterized by autonomous parathyroid hormone (PTH) secretion by one or more parathyroid glands and increased serum calcium concentration. A recent genome wide association study showed that the rs6127099 polymorphism, which is located upstream the CYP24A1 (Cytochrome P450, family 24, subfamily A, polypeptide 1) gene, is associated strongly with elevated serum PTH levels. CYP24A1 gene encodes an enzyme of cytochrome P450, which is responsible for inactivating vitamin D metabolites. As PTH hypersecretion is a common clinical sign of PHPT, the aim of the present study was to investigate the role of the polymorphism rs6127099 as a genetic predisposing factor for PHPT manifestation. Thirty-nine unrelated patients with sporadic PHPT and an equal number of healthy volunteers were enrolled in the study.Polymerase chain reaction and restriction fragment length polymorphism assays were used for rs6127099 genotyping in both groups. No statistically significant difference was observed comparing CYP24A1 rs6127099 A>T genotypes (p = 0.836) and A vs T allele (p = 0.383) distribution between PHPT patients and controls. In conclusion, rs6127099 polymorphism seems not to be associated with PHPT predisposition. Further independent studies, as the present one, are necessary to evaluate the strong association of rs6127099 polymorphism with PTH levels and its prognostic role in PHPT predisposition

Virtual and Augmented Reality in Medical Education

Virtual reality (VR) and augmented reality (AR) are two contemporary simulation models that are currently upgrading medical education. VR provides a 3D and dynamic view of structures and the ability of the user to interact with them. The recent technological advances in haptics, display systems, and motion detection allow the user to have a realistic and interactive experience, enabling VR to be ideal for training in hands-on procedures. Consequently, surgical and other interventional procedures are the main fields of application of VR. AR provides the ability of projecting virtual information and structures over physical objects, thus enhancing or altering the real environment. The integration of AR applications in the understanding of anatomical structures and physiological mechanisms seems to be beneficial. Studies have tried to demonstrate the validity and educational effect of many VR and AR applications, in many different areas, employed via various hardware platforms. Some of them even propose a curriculum that integrates these methods. This chapter provides a brief history of VR and AR in medicine, as well as the principles and standards of their function. Finally, the studies that show the effect of the implementation of these methods in different fields of medical training are summarized and presented

Genetic pathways in pathogenesis of parathyroid adenoma

Parathyroid gland plays a significant role in regulatory homeostasis of calcium, magnesium and phosphorus, as they secrete parathormone. Parathyroid adenoma constitutes the most common cause of primary hyperparathyroidism, overproducing parathormone and oversecreting calcium. The aim of the present study is to evaluate the potential role of ANXA2, MED12, CALM1, MAPK1 and VDR genes in pathogenesis of parathyroid adenoma. Sixty patients with parathyroid adenoma and 60 healthy individuals without history of carcinoma or autoimmune disease took part in our study. Blood samples from both groups (patients and control) were collected, from which genomic DNA was extracted. Genotyping was performed with polymerase chain reaction (PCR) and restriction fragment length polymorphism assay (RFLP). For the immunohistochemical study, tissue samples after parathyroidectomy were collected and prepared for the antigen retrieval, the antigen-antibody interaction and staining evaluation. Fifty patients and 50 healthy volunteers were enrolled in the study. VDR gene TaqI polymorphism was found to have statistical significant distribution among these two groups, whereas no association was detected for FokI, ApaI and BsmI (VDR) , rs7170178 (ANXA2), rs 1057519912 (MED12), rs12885713(CALM1) και rs1057519911 (MAPK1) polymorphisms and parathyroid adenoma pathogenesis. ANXA2, MAPK1, MED12 and VDR proteins were stained positive in parathyroid adenoma tissue, ranging from mild to intense intensity, while CALM1 protein was not evaluated due to technical difficulties and failure during immunohistochemical preparation. The genetics of parathyroid adenoma is a novel research field that gain ground nowadays. The awareness of the genetic pathways involved in parathyroid adenoma pathogenesis may give new opportunities to the diagnosis and treatment of this disease. VDR, ANXA2, MED12 and MAPK1 proteins could be applied as biomarkers during the diagnosis of parathyroid adenoma, in the differential diagnosis of parathyroid tumors (hyperplasia or carcinoma), while they can be correlated to the clinical symptoms.Οι παραθυρεοειδείς αδένες είναι βασικά λειτουργικά όργανα που έχουν καθοριστικό ρόλο στη ρύθμιση της ομοιόστασης του ασβεστίου, μαγνησίου και φωσφόρου στον οργανισμό, παράγοντας την παραθορμόνη. Το αδένωμα παραθυρεοειδή αδένα αποτελεί τη συχνότερη αιτία πρωτοπαθή υπερπαραθυρεοειδισμού και προκαλεί υπερπαραγωγή παραθορμόνης και υπερέκκριση ασβεστίου. Σκοπός την παρούσας μελέτης είναι η μελέτη του πρωτεϊνικού προφίλ σε ιστολογικά δείγματα αδενώματος του παραθυρεοειδή αδένα των πρωτεϊνών CALM1, ANXA2, MED12, MAPK1και VDR και περαιτέρω η διερεύνηση γενετικών αλλαγών στα υπό μελέτη αυτά γονίδια για το ρόλο τους στο εν λόγω πρωτέωμα. Στη μελέτη έλαβαν μέρος 60 ασθενείς με αδένωμα παραθυρεοειδή αδένα προς χειρουργική αντιμετώπιση και 60 υγιή άτομα νοσηλευόμενα για άλλη πάθηση χωρίς ιστορικό κακοήθειας ή αυτοάνοσης νόσου. Διενεργήθηκε λήψη δείγματος περιφερικού αίματος των ασθενών και των υγιών ατόμων, από το οποίο απομονώθηκε ολικό γονιδιωματικό DNA, ακολούθησε PCR και ηλεκτροφόρηση σε πηκτή αγαρόζης και μελέτη με την τεχνική πολυμορφισμών μήκους θραυσμάτων περιορισμού (RFLP). Για την ανοσοϊστοχημική μελέτη, χρησιμοποιήθηκε υλικό από την ιστολογική εξέταση των χειρουργικών παρασκευασμάτων, το οποίο μετά την διαδικασία αντιγονικής ανάκτησης και επώασης, εξετάσθηκε στο μικροσκόπιο. Πενήντα ασθενείς και 50 υγιή άτομα συμπεριλήφθηκαν στην γονιδιακή μελέτη. Ο πολυμορφισμός TaqI του γονιδίου VDR αναγνωρίσθηκε ως προδιαθεσικός παράγοντας για την ανάπτυξη αδενώματος παραθυρεοειδή αδένα. Οι λοιποί πολυμορφισμοί FokI, ApaI and BsmI (VDR) καθώς και rs7170178 (ANXA2), rs 1057519912 (MED12), rs12885713(CALM1) και rs1057519911 (MAPK1) δεν βρέθηκε να έχουν θετική συσχέτιση με το αδένωμα παραθυρεοειδή αδένα. Από την ανοσοϊστοχημική μελέτη, οι πρωτεΐνες ΑΝΧΑ2, ΜΑΡΚ1, MED12 και VDR αναγνώρισθηκαν με ήπια έως έντονη έκφραση στο αδένωμα παραθυρεοειδή αδένα, ενώ η πρωτεΐνη CALM1 δεν κατέστη δυνατό να αξιολογηθεί λόγω τεχνικών δυσκολιών και αποτυχιών στη διαδικασία της χρώσης. Η μελέτη της γονιδιακής βάσης του σποραδικού αδενώματος παραθυρεοειδή αδένα αποτελεί πεδίο αιχμής στην έρευνα με σκοπό την αναγνώριση των γενετικών μονοπατιών που εμπλέκονται στην παθογένεση της νόσου. Οι πρωτεΐνες VDR, ANXA2, MED12 και MAPK1 μπορούν να χρησιμοποιηθούν ως βιοδείκτες στη διάγνωση της νόσου, στη διαφοροδιάγνωση από την υπερπλασία και το καρκίνωμα παραθυρεοειδή αδένα καθώς και να συσχετισθούν με την κλινική συμπτωματολογία της νόσου

Richter’s hernia in a 5-mm trocar site

We present an unusual case of a trocar site incision hernia at a 5-mm trocar port occurring approximately 2 weeks post-operatively after a laparoscopic cholecystectomy. The patient, in her mid-60s, reported diffuse abdominal pain, constipation, nausea and vomiting. An abdominal X-ray demonstrated dilated small bowel loops with gas-fluid levels. Abdominal computed tomography revealed the small bowel herniation through the 5-mm port site. Laparotomy confirmed a Richter’s hernia of the small bowel in the fascia defect. This case highlights the necessity to examine and investigate any complaint post-operatively and deliberate its possible significance. Furthermore, it demonstrates that, even during a normal recovery period for a patient without any underlying disease or risk factors, a rare complication could still develop in a delayed fashion multiple days post-operatively from a laparoscopic procedure. High clinical suspicion is essential in order to avoid further deterioration of the patient condition and optimal treatment

Sporadic parathyroid adenoma: an updated review of molecular genetics

IntroductionPrimary HPT (PHPT) is a common disorder, affecting approximately 1% of the general population. Parathyroid adenomas emerge as non-familial sporadic in 90% of cases. The aim of this review is to give a detailed update of molecular genetics of sporadic parathyroid adenoma reported in international literature.MethodsA bibliographic research was conducted in PubMed, Google Scholar, and Scopus.ResultsSeventy-eight articles were included in our review. CaSR, MEN1, CCND1/PRAD, CDKI, angiogenic factors like VEGF, FGF, TGFβ, and IGF1, and apoptotic factors are important genes in parathyroid adenomas pathogenesis that have been established by several studies. A huge list of proteins is differently expressed in parathyroid adenomas measured by Western Blotting, MALDI/TOF, MS spectrometry, and immunohistochemistry. These proteins take part in several cell processes such as cell metabolism, cytoskeleton structural stability, cell oxidative stress regulation, cell death, transcription, translation, cell connection, and cell signaling transmission, while they can be found over- or underexpressed in abnormal tissues.ConclusionThis review gives a detailed analysis of all reported data on genomics and proteomics of parathyroid adenoma. Further studies should be applied on understanding parathyroid adenoma pathogenesis and introducing new biomarkers for early detection of primary hyperparathyroidism

The prognostic value of symptom responses in the conservative management of spinal pain : a systematic review

Study Design. Systematic review. Objective. To investigate the prognostic value of clinically induced changes in spinal symptoms (i.e., symptom response) in the conservative management of spinal pain. Summary of Background Data. Symptom response is used by clinicians to inform management decisions. Understanding the prognostic value of symptom response can aid in this decision-making process. Methods. A search of Ovid-Medline, Ovid-Embase, Ovid-Cinahl, Ovid-Amed, reference lists and citation tracking was performed. Methodologic quality was assessed independently by 2 raters. Results. We included 22 articles reporting 18 different cohorts. The evidence was limited and mainly involved low back pain. We found no association between most symptom responses and clinical outcomes. Only for changes in pain location and/or intensity with repeated spinal movement testing or as a response to treatment did the data provide support for use of symptom response to inform management. Further work is needed to confirm these findings. Limited evidence of an association with disability was found for the prone instability test in low back pain patients attending a stabilization program. The evidence for neurodynamic testing was conflicting for low back pain. The strength of identified associations and the extent of confounding between investigated prognostic factors remain uncertain. Conclusion. Further investigation of symptom responses in spinal pain is needed before their use can be recommended

A systematic review of reliability and validity studies of methods for measuring active and passive cervical range of motion

Objective: The purpose of this study was to systematically review the literature evaluating the reliability and validity of all available methods for measuring active and passive cervical range of motion (CROM). Methods: Electronic databases (PubMed, MEDLINE, CINAHL, EMBASE, and AMED) were searched through OVID from their inception to January 2008. Articles were selected according to a priori defined criteria. Data were extracted regarding publication details, type of study, movements and device evaluated, subject and observer characteristics, and measurement protocol including blinding and statistical analysis methods. Quality assessment was undertaken using developed criteria to assess internal validity, external validity, and statistical methods. An estimate of the level of reliability and validity was calculated and used to categorize studies as good, moderate, or poor. Results: A total of 56 articles fulfilled the selection criteria and were included in the review. Forty-six of these articles described 66 reliability studies and 21 described 21 concurrent criterion validity studies. Twelve different methods were evaluated. Although it was the intention of this review to conduct meta-analysis, this was deemed inappropriate due to studies being too heterogeneous. Most of the reliability and validity studies involved asymptomatic subjects measured by allied health professionals investigating active ROM. Devices that were deemed to have "good" reliability and validity were the CROM device, the Spin-T goniometer, and the single inclinometer. Conclusions: A considerable number of reliability and concurrent validity studies have been published for CROM. The CROM device has undergone most evaluation and has been shown to be clinimetrically sound. Further research with significantly improved methodology and reporting is warranted for all devices. (J Manipulative Physiol Ther 2010;33:138-155