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Fibromyalgia is characterized by widespread pain and tenderness; however, comorbid cognitive difficulties are a common complaint among patients. Known as fibro fog or dyscognition, this symptom comprises difficulties with complex cognitive processes including memory, executive function, concentration and attention. While the mechanisms that initiate and maintain these cognitive deficits are still largely unknown, recent research has increased the understanding of subjective symptoms and objectively-determined deficits in cognitive performance. Treatments have also improved to include complementary cognitive and physical strategies. This review focuses on issues of dyscognition in fibromyalgia. Details of objective testing methods are not within the scope of this paper.

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We report the case of a gentleman referred with apparent worsening function in a hydronephrotic left-sided pelvic kidney. Imaging with Tc-99m-Mercaptoacetyltriglycine (MAG 3) in 1999, showed that the left kidney contributed 46% of renal function with no evidence of obstruction. Three years later, repeat scanning showed ectopic kidney function had decreased to 20% and with worsening pain, nephrectomy had been suggested. Review of the second MAG 3 scan revealed that only posterior images had been obtained. With pelvic kidneys, the pelvis forms a barrier between the radioactively labelled tracer and the gamma camera, thus, reducing the amount of radiation detected and underestimating function. A subsequent Dimercaptosuccinic acid scan (DMSA) was carried out with posterior and anterior images, the latter showing split renal function was identical to that seen on the initial scan. In patients with pelvic kidneys, anterior views must be obtained during radionuclide scanning if unnecessary nephrectomy is to be avoided.

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The surgical treatment of distal ureteric strictures depends on their length and aetiology. Laparoscopic procedures in this setting are uncommon. We describe a laparoscopic non-refluxing ureteroneocystostomy for a symptomatic distal ureteric stricture performed on a 26-year-old man. The operation was carried out successfully without complication. Blood loss was 100 ml with an operating time of 250 min. He was discharged on the fourth day and returned to work after 11 days. Retrograde ureterography and cystography after 1 month showed no evidence of obstruction or reflux. At 3 months, an intravenous urogram showed excellent drainage and at 6 months the patient remained asymptomatic. We advocate the use of laparoscopic ureteroneocystostomy for benign distal ureteric stricture refractory to endoscopic procedures. In symptomatic patients, it is a feasible, safe, minimally invasive procedure with all the added benefits of laparoscopy compared with open repair. A non-refluxing anastomosis is preferable. Reconstructive and intracorporeal suturing skills are needed to carry out this procedure.

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The lifespan of medical equipment must be maximised to ensure cost-effectiveness. Flexible ureterorenoscopes have become widely used in the diagnosis and treatment of urolithiasis. They are relatively expensive and current literature shows that they require frequent repair and replacement. We have analysed our data for the number of procedures and repairs required for each new instrument we have used. So far we have used four new flexible ureteroscopes, which have been used for a total of 375 procedures, an average of 94 procedures each. On average each required repair twice. We believe that a few simple precautions taken during use and storage help to maximise the lifespan of the flexible ureterorenoscope and our results would appear to support this.

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OBJECTIVE: To report our outcomes with small diameter, actively deflectable flexible ureterorenoscopy from a prospective database. PATIENTS AND METHODS: 114 flexible ureterorenoscopies were performed in 105 patients (mean age, 49.5 years; range, 19-85 years; 71 males, 34 females) over a 9-month period. Of these, 101 were for refractory stones following failed ESWL and 13 for diagnostic reasons. An Olympus URF P3 flexible ureteroscope with pressure irrigation was used. Electrohydraulic lithotripsy was used to fragment stones and the fragments were retrieved with Graspit, triradiate graspers or tipless baskets. RESULTS: Stents had previously been placed in 53% and dilatation of the ureteric orifice was necessary in 15%. In the stone group, the median operating time was 55 min (range, 15-210 min) and the median screening time 2.2 min (range, 0.3-9.1 min). Success was defined as complete stone clearance or good fragmentation to 2 mm or less. Overall success in this group was 72.3%. There was no statistically significant difference between lower and other calyces (P=0.83 Chi-square test). Successful outcome was achieved in 72% for stone size 10 mm or less, 80% for 11-20 mm and 50% for greater than 20 mm. Two or more procedures were needed in 8 patients. In the diagnostic group, the median operating time was 45 min (range, 20-60 min) and the median screening time 2 min (range, 0.3-8.3 min). The majority were for upper tract filling defects. Access and successful diagnosis was achieved in all cases. The major complication rate was 2.6%. The ureteroscope needed repair once during this series. CONCLUSIONS: Flexible ureterorenoscopy is an effective diagnostic and therapeutic tool in a select group of patients. It should be considered for ESWL-resistant upper tract stones but the results are poor in stones larger than 20 mm and percutaneous nephrolithotomy may be a better option in these patients.

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OBJECTIVE: To evaluate fibromyalgia (FM) patients for the presence of cognitive deficits and to test the hypothesis that abnormalities would fit a model of cognitive aging. METHODS: We studied 3 groups of patients: FM patients without concomitant depression and in the absence of medications known to affect cognitive function (n = 23), age- and education-matched controls (n = 23), and education-matched older controls who were individually matched to be 20 years older (+/- 3 years) than the FM patients (n = 22). We measured speed of information processing, working memory function, free recall, recognition memory, verbal fluency, and vocabulary. We correlated performance on cognitive tasks with FM symptoms, including depression, anxiety, pain, and fatigue. We also determined if memory complaints were correlated with cognitive performance. RESULTS: As expected, older controls performed more poorly than younger controls on speed of processing, working memory, free recall, and verbal fluency. FM patients performed more poorly than age-matched controls on all measures, with the exception of processing speed. FM patients performed much like older controls, except that they showed better speed of processing and poorer vocabulary. Impaired cognitive performance in FM patients correlated with pain complaints, but not with depressive or anxiety symptoms. FM patients reported more memory problems than did the older and younger controls, and these complaints correlated with poor cognitive performance. CONCLUSION: Cognitive impairment in FM patients, particularly memory and vocabulary deficits, are documented in the study. Nevertheless, the intact performance on measures of information processing speed suggests that the cognitive deficits are not global. FM patients' complaints about their memory are likely to be legitimate, since their memory function is not age appropriate.

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A 13-year-old girl experienced a fall during gym class that caused immediate unresponsiveness and death. The lone witness reported that the decedent lost her balance as she approached a hurdle and fell, striking her head on a crossbar of the hurdle near the ground. Autopsy revealed no external injury. Internal injury that could be demonstrated anatomically was confined to a contusion within the right semicapitis muscle at the base of the skull. In the absence of an anatomic cause of death, possible explanations of the death include a cardiac dysrhythmia, a vasovagal stimulus, and diffuse axonal injury caused by a concussive force to the junction of the medulla and spinal cord. Animal studies have shown that severe concussion can cause death via profound autonomic dysfunction without leaving anatomic evidence of injury, and that the essential component of concussion is an element of rotational injury to the brain. The authors believe that the blow to the neck caused this death by the transmission of a concussive force through the reticular activating system. The prompt work of police in distinguishing the lone witness from several people in the area who thought they knew what had happened was essential for diagnosis. On reaching our conclusions, the authors notified first the family, then the superintendent of the school system, and finally the news media. The authors told each party in turn that they would be contacting the others.

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A fundamental issue for psychological science concerns the extent to which people can simultaneously perform two perceptual-motor tasks. Some theorists have hypothesized that such dual-task performance is severely and persistently constrained by a central cognitive "bottle-neck," whereas others have hypothesized that skilled procedural decision making and response selection for two or more tasks can proceed at the same time under adaptive executive control. The three experiments reported here support this latter hypothesis. Their results show that after relatively modest amounts of practice, at least some participants achieve virtually perfect time sharing in the dual-task performance of basic choice reaction tasks. The results also show that observed interference between tasks can be modulated by instructions about differential task priorities and personal preferences for daring (concurrent) or cautious (successive) scheduling of tasks. Given this outcome, future research should investigate exactly when and how such sophisticated skills in dual-task performance are acquired.

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Fibromyalgia is a puzzling syndrome of widespread musculoskeletal pain. In addition to pain, patients with fibromyalgia frequently report that cognitive function, memory, and mental alertness have declined. A small body of literature suggests that there is cognitive dysfunction in fibromyalgia. This article addresses several questions that physicians may have regarding cognitive function in their patients. These questions concern the types of cognitive tasks that are problematic for patients with fibromyalgia, the role of psychological factors such as depression and anxiety, the role of physical factors such as pain and fatigue, the nature of patients' perceptions of their cognitive abilities, and whether patients can be tested for cognitive dysfunction. Critical areas for further investigation are highlighted.

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The apparently deleterious effect of aging on dual-task performance is well established, but there is little agreement about the source of this effect. Studies of the psychological refractory period (PRP) indicate that young adults can flexibly control dual-task performance through task-coordination strategies. Thus, the performance of older adults might differ from young adults because older adults use different task-coordination strategies. To test this hypothesis, the executive-process interactive control (EPIC) architecture was applied to quantify the reaction time data from two PRP experiments conducted with young (age 18-26) and older (age 60-70) adults. The results show that participants' ability to coordinate the processing of two tasks did not decline with age. However, dual-task time costs were greater in the older adults. Three sources for this increase were found: generalized slowing, process-specific slowing, and the use of more cautious task-coordination strategies by the older adults.

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OBJECTIVE: To determine the long-term therapeutic value of transurethral microwave thermotherapy (TUMT) in the treatment of bladder outflow obstruction secondary to benign prostatic hyperplasia (BPH). PATIENTS AND METHODS: A total of 67 patients with BPH, assessed using symptom scores and measurements of urinary flow rate, underwent TUMT using the Leo Microthermer system (Laser Electro Optics Ltd, London, UK) between October 1990 and June 1992. Follow-up information was obtained on 60 patients (90%). If they had undergone no further treatment for their BPH, they were re-assessed with symptom scores and measurements of flow rate. RESULTS: The mean follow-up was 52.4 months; eight of the 6 7 patients had died and seven were lost to follow-up. Sixteen of the remaining 52 (31%) had undergone another treatment for BPH; one patient developed prostatitis and one developed localized carcinoma of the prostate. Thirty-four patients had had no further treatment, 29 of whom attended for assessment. In these patients, a statistically significant improvement in both the symptom score and flow rate was maintained at 4 years. No patients developed retrograde ejaculation. CONCLUSION: This is the first study to report a follow-up of at least 4 years after TUMT with any device. Treatment with the Leo Microthermer provided at least a 50% symptomatic improvement in 16 of 50 patients treated at 4 years. However, 30% of the patients needed further treatment for their BPH. TUMT is safe and effective in patients not wanting anaesthesia and in young patients concerned about retrograde ejaculation.

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Renal cell carcinomas show a variety of histological features. A case of a renal tumour arising in a 44 year old African man is reported. The tumour was composed of a cobweb-like pattern of narrow anastomising tubules lined by cuboidal cells separated by a hypocellular myxoid stroma. Immunohistochemical stains were consistent with a renal cell origin. The differential diagnosis in these cases includes sarcoma.

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Splenectomy is often performed in patients with malignant disease or trauma who are at a high risk of complications. In the long term, it increases the risk of infection by encapsulated bacteria. An audit was performed to determine the reasons for splenectomy in a district general hospital, to review the results and complications of surgery, and to see how often the patients were prescribed antibacterial prophylaxis. Twenty-eight patients underwent splenectomy in 3 years. The indication was haematological disease in 13 and trauma in four. In the remaining nine the spleen was removed either as part of a radical gastrectomy or during some other abdominal procedure. Six of the 28 patients had died, one within 30 days from disseminated intravascular coagulopathy following an emergency gastrectomy and splenectomy for haematemesis, two from progressive haematological malignant disease, two from non-haematological malignancy, and one from bronchopneumonia. Of the nine patients (32%) with complications, three required a further laparotomy. Most patients had been prescribed pneumococcal vaccine (85%) and prophylactic antibiotics (93%).

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OBJECTIVES: To determine whether the measurement of penile blood flow by colour Doppler imaging (CDI) and the subjective impressions generated from CDI correlate with the results of measuring isotope penile blood flow (IPBF), and thus determine if CDI is a useful screening investigation for vasculogenic impotence. PATIENTS AND METHODS: The study comprised 37 men with impotence of > 6 months duration. All patients underwent CDI of the penis; the maximum systolic (vmax) and minimum diastolic velocity (vmin) were recorded. Video recordings of the CDI were reviewed subsequently with no knowledge of the erectile response. Twenty-seven patients then underwent measurement of IPBF. RESULTS: There was no relationship between the results obtained from IPBF and those from CDI, nor was there a significant difference between the vmax of patients identified as having arteriogenic impotence on IPBF and that of normal men or those with venous leakage on IPBF. There was no relationship between the subjective impressions from CDI and the results from IPBF, or with erectile response. CONCLUSIONS: There was no correlation between the results obtained on IPBF and those obtained from CDI; the latter is not useful in differentiating between venogenic and arteriogenic impotence in men who have failed to have a full response to papaverine.

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