Alberic Fiennes

Reported sexual abuse and cognitive content in the morbidly obese

This study investigated whether a reported history of childhood sexual abuse (CSA) in morbidly obese adults is associated with a higher level of negative core beliefs (unconditional, schema-level representations regarding the self, the world, and others), and whether those beliefs are significantly associated with weight levels and weight fluctuation. A cross-sectional design was used, with comparative and correlational elements. The participants were 30 morbidly obese patients (age range=27-61years; body mass index [BMI] range=40.8-73.5), awaiting surgical intervention. Each completed standardized self-report measures of childhood traumatic experiences, core beliefs, and weight history. BMI was obtained from clinical interview. In terms of weight variables, the individuals with a reported history of sexual abuse (n=10) did not differ from those with no such history (n=20). However, those with a reported abuse history had higher levels of specific negative core beliefs. This group also showed more extensive associations between their BMI and their core beliefs than the nonabused group. Core beliefs, which are often associated with personality disorder pathology, were associated with the reported presence of a history of sexual abuse among the morbidly obese. The group differences (in levels of core beliefs and in their association with weight variables) suggest that there might be different mechanisms to explain weight levels in those obese patients who do or do not have a history of CSA. When psychological interventions are used in support of other treatments (e.g., surgery), they might be most productively targeted on those with such an abuse history.

Growth rate of human tumour xenografts measured in nude mice by in vivo cast-modelling

Caliper measurement of xenograft tumour volume incurs shape-dependent errors of up to 230 per cent. A more sensitive and accurate method is described for repeated in vivo measurement of tumour volume by cast modelling. The technique can provide electronic data for further analysis and its accuracy and limitations can themselves be determined. Week-on-week changes in tumour volume may be detected with up to 99 per cent confidence.

Adolescent Bariatric Surgery — Thoughts and Perspectives from the UK

Opinions of healthcare professionals in the United Kingdom regarding bariatric surgery in adolescents are largely unknown. This study aims to explore the perspectives of medical professionals regarding adolescent bariatric surgery. Members of the British Obesity and Metabolic Surgery Society and groups of primary care practitioners based in London were contacted by electronic mail and invited to complete an anonymous online survey consisting of 21 questions. Ninety-four out of 324 questionnaires were completed. 66% of professionals felt that adolescents with a body mass index (BMI) >40 or BMI >35 with significant co-morbidities can be offered surgery. Amongst pre-requisites, parental psychological counseling was chosen most frequently. 58% stated 12 months as an appropriate period for weight management programs, with 24% regarding 6 months as sufficient. Most participants believed bariatric surgery should only be offered ≥16 years of age. However, 17% of bariatric surgeons marked no minimum age limit. Over 80% of the healthcare professionals surveyed consider bariatric surgery in adolescents to be acceptable practice. Most healthcare professionals surveyed feel that adolescent bariatric surgery is an acceptable therapeutic option for adolescent obesity. These views can guide towards a consensus opinion and further development of selection criteria and care pathways.

Can glucose make you faint

In April, 2008, a 27-year-old woman came to the emergency department of her local hospital, with a 3-week history of dizziness, low appetite, and occasional vomiting. 2 months before, she had undergone an uncomplicated laparoscopic proximal gastric bypass for obesity; on discharge, she was prescribed multi vitamins and lansoprazole. She had sinus tachycardia, and was dehydrated. Doctors provisionally diagnosed gastric outfl ow obstruction. The patient was transferred to our unit for oesophagogastroduodenoscopy—which showed nothing of note. Her total weight loss since surgery was 18∙9 kg. Blood tests showed sodium, urea, and creatinine concentrations of 155 mmol/L, 10∙4 mmol/L, and 155 μmol/L respectively, consistent with dehydration. We therefore administered intravenous fl uids, including 5% glucose. Additionally, the patient drank high-sugar energy drinks. The next day, she said she felt light-headed; she fell in the shower. We found severe postural hypotension (blood pressure 122/79 mm Hg lying down, 75/35 mm Hg standing), and bilateral ankle oedema. An electrocardiogram (ECG) showed sinus rhythm, and inverted T waves in the lateral leads (fi gure); the serum concentration of troponin T was 0∙23 μg/L (normal range <0·01 μg/L). The patient rapidly developed nystagmus on lateral gaze, diplopia on central gaze, hyper-refl exia of the arms, weakness of the thighs, and patchy hypoaesthesia. She was not ataxic or confused. We diagnosed thiamine defi ciency, and administered intravenous thiamine (500 mg, 8-hourly). Echo cardiography showed a left ventricular (LV) ejection fraction of 32%, moderately to severely impaired LV systolic function, diastolic dysfunction, and widespread marked hypokinesia. Within 24 h of thiamine being given, the diplopia, nystagmus, postural hypotension, and inversion of T waves resolved. We continued to administer thiamine intravenously for a further 3 days, before prescribing oral thiamine (100 mg, 8 hourly). In a blood sample taken before treatment began, the concentration of thiamine pyrophosphate (TPP), measured by high-performance liquid chromatography, was 41 nmol/L (normal concentration 66–200 nmol/L). The patient admitted that she had not taken her multivitamins. We discharged her with a prescription for thiamine and multivitamins. 4 weeks later, echocardiography revealed a normal LV ejection fraction of 63%, with restoration of LV and diastolic function; the thiamine concentration in the blood was 218 nmol/L. When last seen, in August, 2008, the patient was well, with a body-mass index of 25∙2 kg/m2. She was taking multivitamins. Thiamine is converted by the liver to TPP, an essential cofactor in carbohydrate metabolism. The CNS requires thiamine to maintain myelin, and synthesise acetylcholine, γ-aminobutyrate, and glutamate. Total body thiamine stores last 18–60 days; data on stores in obese patients are limited. Thiamine defi ciency can cause wet beriberi, characterised by cardiovascular dysfunction; dry beriberi, of which peripheral neuropathy is the main feature; and Wernicke’s encephalopathy, an acute neurological disorder characterised by nystagmus, diplopia, ophthalmoplegia (all three ocular signs are present in only 16% of patients), ataxia, and confusion. Worldwide, thiamine-fortifi cation programmes have reduced the incidence of thiamine defi ciency; however, outbreaks still occur among refugee populations. In economically developed countries, thiamine defi ciency is most commonly associated with chronic alcoholism, but also occurs in people with habitually restricted diets, hyper emesis gravidarum, gastrointestinal disorders, malignancy, AIDS, severe infection, kidney disease—and after surgery for obesity. Wernicke’s encephalopathy most commonly occurs 4–12 weeks after surgery, mainly in people who have lost more than 7 kg per month. Glucose administration can cause thiamine defi ciency to manifest acutely, perhaps by using up remaining thiamine stores. If thiamine defi ciency is suspected, thiamine should be administered before a patient is given glucose.

Human tumour cell lines established in vitro from tumours after long-term passage as nude mouse xenografts. Comparative fingerprinting of their concanavalin-A acceptor glycoproteins.

Two human colon cancer xenografts (EC and AC) were established in tissue culture only after long-term passage in nude mice. Earlier attempts to establish cell lines were unsuccessful. The epithelioid cells retain their tumourigenicity after in vitro growth, giving rise to tumours with a take rate of 60-80%. After reimplantation, the xenografts retain a similar morphology to that of the original human tumours. Both cell lines show human karyology. Comparative mapping of Concanavalin-A acceptor glycoproteins provides a fingerprint characteristic of each cell line. These glycoprotein patterns are similar to those shown by HT-29, an established colon cancer cell line.

The totally extraperitoneal laparoscopic hernia repair.

We read with interest the paper by Vanclooster and colleagues [11] and commend their contribution to this procedure. However, we would offer three comments: First, totally extraperitoneal laparoscopic hernia repair was developed by Dulucq [1–3] in 1989/90 and by McKernan [7] not a great deal later. While it seems legitimate for others to publish their own technical variations, developments, and outcomes, we strongly support recent reminders [6] that journal editors and their peer referees owe the reader a duty of diligence: they should insist that authors exercise proper scholarship by giving credit where it is due. Otherwise the uninformed reader may assume originality and the informed may infer plagiarism, where the author intended neither. Second, the mesh configuration suggested by Vanclooster et al. was presented by one of us several years ago [4, 10]. However, the concept of amputating the inferior and lateral corner ‘‘so the mesh fits better on the iliac vessels and the psoas muscle’’ is flawed, since it has subsequently been reported [12] that recurrences may occur dorsal/ inferior to this inferolateral corner. The most extensive possible coverage of the psoas muscle belly is therefore appropriate. Third, the need for mesh fixation remains debatable. However, to fix the cranial border to ‘‘prevent early migration or slipping’’ is illogical: In our joint experience of over 1,000 cases and, to our knowledge in all reports in the world literature, recurrences pass uniformly caudal to the inferior border of the prosthesis. Fixation of the inferior medial part of the mesh to Astley Cooper’s ligament alone [5] may not offend against the original tension-free notion of Stoppa [8, 9] nor interfere with the mechanics of prosthesis retention. To fix the superior border to points that move relative to one another within a musculofascial structure contravenes both principles. Finally, on a minor point, if the structure annotated as ‘‘D’’ in Fig. 1 is the testicular vascular bundle, where is the vas deferens? Despite these comments we congratulate the authors on their low complication rate. References

Registering refugee and asylum-seeking doctors

647grew in part as a consequence of the strict regulations,which allowed attachments at main teaching hospitals butnot at district general hospitals.Of the 420 on the register in December, 1997, 54 wererefugees or asylum seekers. 60% of the remainder hadindefinite leave to remain in the UK. Our experience isthat once such a doctor is attached to a medical school heor she is likely to be ready to qualify through the UEB injust under a year. Once they have passed the examination(which is inspected by the GMC) doctors can obtainprovisional registration; full registration follows aftersatisfactory completion of the preregistration year.The PLAB test is run by the GMC. Successfulexaminees obtain limited registration (for up to 5 years)once they start working in a recognised post and many ofthem return to their own countries after completing theirtraining. Others apply for full registration when they haveobtained suitable NHS experience; often they have ahigher qualification. 4047 doctors obtained fullregistration by this route in 1996 and there were 2039exemptions from the PLAB test.

Computer analysis of upper gastrointestinal endoscope images.

Gastro‐oesophageal reflux disease (GORD) occurs in up to 40% of adults in the West. Oesophagitis is a major determinant in the treatment of GORD but its current classification systems are subjective. In order to help to provide objective interpretation of upper gastro‐intestinal (GI) endoscope examination and reduce inter‐observer variability, we developed a computer image analysis system. Digital video recordings were made on patients with clinical evidence of reflux oesophagitis. Cross‐sectional profiles of hue and saturation data were analysed on images from seven patients with grade B or C oesophagitis (LA grading). This analysis showed clear changes in hue (p = 0.01) and saturation (p = 0.001). These results suggest that quantification of upper GI endoscopic images is feasible and may help in objective assessment.