Noninvasive neuromodulation techniques for the management of phantom limb pain: a systematic review of randomized controlled trials

Neuromodulation techniques work by modulating pain perception by inducing changes in polarity of the neuronal membrane and thereby cortical excitability. The aim of this review is to evaluate the efficiency and safety of noninvasive neuromodulation techniques for phantom limb pain (PLP). A systematic literature search in the PubMed, Scopus, Web of Science, and Cochrane Library databases was performed to identify studies investigating the effects of noninvasive neuromodulation for PLP. The included journal articles were assessed with Furlan et al.'s method for examining the risk of bias to assess methodologic quality, and evidence was graded using the GRADE approach. The literature search identified 239 studies. Of these 239, four studies fulfilled the inclusion criteria and were included for data extraction. Two of the studies focused on repetitive transcranial magnetic stimulation (rTMS) whereas two other concentrated on transcranial direct current stimulation (tDCS). The present review showed that there is conflicting evidence to support the use of tDCS in short term and moderate evidence to support the use of rTMS in immediate and short term. It is important to recognize that this evidence comes from a very small sample size. No serious adverse effects were reported. Further information from randomized controlled trials with larger sample size investigating immediate and short-term and long-term effects are needed to clarify the best effective stimulation parameters and number of sessions of tDCS and rTMS for PLP. Correspondence to Gulseren Akyuz, MD, Department of Physical Medicine and Rehabilitation and Division of Pain Medicine, Marmara University School of Medicine, Istanbul, Turkey Tel: +90 216 625 4657; fax: +90 216 450 0077; e-mail: gulserena@gmail.com Received July 17, 2018 Accepted August 31, 2018 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Medical Catastrophe: Confessions of an Anesthesiologist

No abstract available

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Temporal Changes in Ventilator Settings in Patients With Uninjured Lungs: A Systematic Review

In patients with uninjured lungs, increasing evidence indicates that tidal volume (VT) reduction improves outcomes in the intensive care unit (ICU) and in the operating room (OR). However, the degree to which this evidence has translated to clinical changes in ventilator settings for patients with uninjured lungs is unknown. To clarify whether ventilator settings have changed, we searched MEDLINE, Cochrane Central Register of Controlled Trials, and Web of Science for publications on invasive ventilation in ICUs or ORs, excluding those on patients 25% of patients with acute respiratory distress syndrome (ARDS). Our primary end point was temporal change in VT over time. Secondary end points were changes in maximum airway pressure, mean airway pressure, positive end-expiratory pressure, inspiratory oxygen fraction, development of ARDS (ICU studies only), and postoperative pulmonary complications (OR studies only) determined using correlation analysis and linear regression. We identified 96 ICU and 96 OR studies comprising 130,316 patients from 1975 to 2014 and observed that in the ICU, VT size decreased annually by 0.16 mL/kg (−0.19 to −0.12 mL/kg) (P

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Teaching Medical Students Clinical Anesthesia: A View From the United Kingdom

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Anesthetics and Trauma: A Complex Interaction

No abstract available

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Vertical and Horizontal Pathways: Intersection and Integration of Enhanced Recovery After Surgery and the Perioperative Surgical Home

No abstract available

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Surveying the Literature: Synopsis of Recent Key Publications

No abstract available

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In Response

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Perioperative Outcomes and Surgical Case Volume in Pediatric Complex Cranial Vault Reconstruction: A Multicenter Observational Study From the Pediatric Craniofacial Collaborative Group

BACKGROUND: Complex cranial vault reconstruction (CCVR) performed to treat craniosynostosis can be associated with significant blood loss, transfusion, and perioperative complications. The aim of this study was to examine the effect of CCVR surgical case volume on perioperative outcomes. We hypothesized that surgical case volume is not associated with differences in perioperative outcomes. The study primary outcome was total perioperative blood donor exposures. Secondary outcomes included the total perioperative transfusion volume, major complications, and intensive care unit and hospital length of stay. METHODS: The multicenter Pediatric Surgery Perioperative Registry was queried for infants and children undergoing CCVR between June 2012 and September 2016. Institutions were categorized into low, middle, or high surgical case volume groups based on tertiles of the average number of cases performed per month. Primary and secondary outcomes were analyzed with respect to these groupings. RESULTS: The query yielded 1814 CCVR cases from 33 institutions. Demographics were similar among the 3 study groups. An inverse relationship between surgical case volume and total perioperative blood donor exposures was observed (P

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Point-of-Care Ultrasound Abnormalities in Late-Onset Severe Preeclampsia: Prevalence and Association With Serum Albumin and Brain Natriuretic Peptide

BACKGROUND: Pilot studies applying point-of-care ultrasound (POCUS) in preeclampsia indicate the presence of pulmonary interstitial edema, cerebral edema, and cardiac dysfunction. Laboratory markers of oncotic pressure (albumin) and cardiac dysfunction (brain natriuretic peptide [BNP]) may be abnormal, but the clinical application remains unclear. We investigated the prevalence of pulmonary interstitial syndrome (PIS), cardiac dysfunction, and increased optic nerve sheath diameter (ONSD) in late-onset preeclampsia with severe features. The primary aim was to examine the association between PIS or ONSD and maternal serum albumin level. The secondary aims were to explore the association between cardiac dysfunction and PIS, ONSD, BNP, and serum albumin level and between POCUS-derived parameters and a suspicious or pathological cardiotocograph. METHODS: Ninety-five women were enrolled in this prospective observational cohort study. A POCUS examination of lungs, heart, and ONSD was performed. PIS was defined as a bilateral B-line pattern on lung ultrasound and diastolic dysfunction according to an algorithm of the American Society of Echocardiography. ONSD >5.8 mm was interpreted as compatible with raised intracranial pressure (>20 mm Hg). Serum BNP and albumin levels were also measured. RESULTS: PIS, diastolic dysfunction, systolic dysfunction, and raised left ventricular end-diastolic pressure (LVEDP) were present in 23 (24%), 31 (33%), 9 (10%), and 20 (25%) women, respectively. ONSD was increased in 27 (28%) women. Concerning the primary outcome, there was no association between albumin level and PIS (P = .4) or ONSD (P = .63). With respect to secondary outcomes, there was no association between albumin level and systolic dysfunction (P = .21) or raised LVEDP (P = .44). PIS was associated with diastolic dysfunction (P = .02) and raised LVEDP (P = .009; negative predictive value, 85%). BNP level was associated with systolic (P

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The Association Between Training Load and Performance in Team Sports: A Systematic Review

Abstract

Background

Adequate training loads promote favorable physical and physiological adaptations, reduce the likelihood of illness and injury, and, therefore, increase the possibility of success during competition.

Objectives

Our objective was to systematically examine the association between training load and performance outcomes in team sports.

Methods

We systematically searched the PubMed, SPORTDiscus, and PsycINFO databases for original research published before July 2018. The search included terms relevant to training load, performance, and team sports. Articles were screened using pre-defined selection criteria, and methodological quality was assessed independently by two authors before data were extracted by the lead author.

Results

The electronic search yielded 5848 articles, 2373 of which were duplicates. A further 17 articles were retrieved from additional sources. In total, 26 articles met the inclusion criteria for this review, with quality scores ranging from 6 to 10 out of 11. Training exposure was more strongly associated with aerobic performance than other external training load measures. High-intensity activity (≥ 90% of maximum heart rate) was strongly associated with aerobic performance. The individualized training impulse model was strongly associated with aerobic performance, whereas various other training impulse models and perceptual training load measures showed weak associations with aerobic performance. There were no clear associations between training load and neuromuscular variables or game-related statistics.

Conclusion

We found no consistent associations between external training load measures and performance. High-intensity internal training load appears to be the most prominent indicator of aerobic performance.

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An investigation of pressure profiles and wearer comfort during walking with a transtibial hydrocast socket

Objective to conduct an investigation of the transtibial hydrocast socket interface pressures during walking and explore potential relationships between pressures experienced and resultant wearer comfort. Design In this cross-sectional study, pressure data at the limb and hydrocast socket interface during walking were collected from sixteen users of the hydrocast socket. The pressures at this interface were described by location, magnitude and duration for all participants and were compared between the most and least comfortable participants. Results High pressures were found about the bony prominences of the residual limb, especially the tibial crest of the anterior distal region. Factors identified as potentially causing discomfort (p0.80) were high peak pressures at the anterior proximal region, and longer durations of submaximal loading at the lateral proximal region and the anterior and medial distal regions. High pressure variability at the anterior proximal region may also contribute to discomfort (p=0.106, d=0.88). Conclusions The hydrocast socket interface pressures have been described for a cohort of users. A number of differences were found in the pressure profiles of the most and least comfortable participants. These differences suggest trends between the identified pressure parameters and resultant wearer comfort. Future studies should confirm these exploratory results. *Corresponding author: Email: pvlee@unimelb.edu.au Competing Interests: The authors have no competing interests Funding: This work was funded by the CASS Foundation (Australia), the Rotary Club of Richmond, (Australia), the Promobilia Foundation (Sweden) and the Australian Government Research Training Program. Acknowledgements: The authors wish to thank Mr. Nguyen Hai Thanh, Mr. Dao Hong Duc and Mr. Pham Hung Cuong from the Vietnamese Training Centre for Orthopaedic Technologists for their contributions to the study. Author Contributions: SL collected the pressure data, completed the data analysis and drafted the manuscript. PL and NL conceived of and secured funding for the study, designed the study, coordinated the study and reviewed the manuscript. JL contributed to the study design, assessed the participants' limbs, supervised the production of the prostheses and reviewed the manuscript. All authors gave final approval for publication. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Quiz: COPD exacerbations: 5 things EMS providers need to know

How familiar are you with the symptoms and concerns that accompany COPD exacerbations?

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Transcription factor Zbtb38 downregulates the expression of anti-inflammatory IL1r2 in mouse model of rheumatoid arthritis

Publication date: Available online 15 September 2018

Source: Biochimica et Biophysica Acta (BBA) - Gene Regulatory Mechanisms

Author(s): Tímea Ocskó, Dániel M. Tóth, Gyula Hoffmann, Vilmos Tubak, Tibor T. Glant, Tibor A. Rauch

Abstract

DNA methylation is a decisive regulator of gene expression. Differentially methylated promoters were described in rheumatoid arthritis (RA), but we do not know how these epimutations can trigger a proinflammatory cytokine milieu. B cell-focused DNA methylome studies identified a group of genes that had undergone disease-associated changes in a murine model of RA. An arthritis-specific epimutation (hypomethylation) was detected in the promoter region of the Zbtb38 gene, which encodes a transcriptional repressor. Gene expression studies revealed that hypomethylation of the Zbtb38 promoter was accompanied by disease-specific repressor expression, and two anti-inflammatory factors interleukin 1 receptor 2 gene (IL1r2) and interleukin-1 receptor antagonist (IL1rn) were among the downregulated genes. We hypothesized that Zbtb38 repressor could induce downregulated expression of these anti-inflammatory genes and that this could significantly contribute to arthritis pathogenesis. Our studies demonstrate that Zbtb38 forms a molecular bridge between an arthritis-associated epimutation (DNA hypomethylation in Zbtb38 promoter) and transcriptional silencing of the IL1r2 gene in B cells. In this way, disease-associated DNA hypomethylation can support autoimmune arthritis by interfering with an anti-inflammatory pathway.

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Impaired performance of patients with writer’s cramp in complex fine motor tasks

Publication date: Available online 15 September 2018

Source: Clinical Neurophysiology

Author(s): Kathrin Allgöwer, Waltraud Fürholzer, Joachim Hermsdörfer

Abstract

Objective

Writer's cramp (WC) is a task-specific focal dystonia. WC is characterized by involuntary contractions of muscles of the hand and arm during handwriting, resulting in impaired writing with exaggerated finger forces. The generalization of symptoms to other fine motor tasks is widely discussed. The aim of the study was to determine affected fine motor aspects with an extensive testing battery.

Methods

Twelve people with WC and twelve healthy controls were examined. Performance in the Jebsen-Taylor Hand Function Test, Nine-Hole-Peg Test and 2-point discrimination was evaluated. To analyze object manipulation skills, we examined grip forces, temporal measures and other aspects of force control during (1) lifting actions with variations of weight and surface (2) cyclic movements (3) visuomotor tracking (4) fast force changes and (5) grip strength. In addition, correlation between the dependent variables of the fine motor tasks and the handwriting deficits was assessed.

Results

WC patients had impaired performance in the visuomotor tracking task (root mean square error (RMSE), p=.03 and time lag, p=.05) and the fast force changes (frequency, p=.01). There were no statistically significant group differences in the other tasks. We found a correlation between the RMSE of the tracking task and the time needed to write the test sentence (r=.643, p=.01).

Conclusion

WC patients revealed abnormalities in complex fine motor performance in tasks with high demands on coordination and visual components, specifically in tracking and fast force changes.

Significance

This suggests a deficit in visuomotor integration, coordination and cognitive aspects related to movement processing particularly with respect to low forces. These insights may prove useful in the development of targeted training approaches.

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The study of exercise tests in paroxysmal kinesigenic dyskinesia

Publication date: Available online 15 September 2018

Source: Clinical Neurophysiology

Author(s): Hai-Yan Zhou, Fei-Xia Zhan, Wo-Tu Tian, Chao Zhang, Yan Wang, Ze-Yu Zhu, Xiao-Li Liu, Yang-Qi Xu, Xing-Hua Luan, Xiao-Jun Huang, Sheng-Di Chen, Li Cao

Abstract

Objective

To unravel if there was muscular ion channel dysfunction in paroxysmal kinesigenic dyskinesia (PKD) patients using the exercises tests (ET).

Methods

Sixty PKD patients including 28 PRRT2 mutations carriers were enrolled in this study, as well as 19 hypokalaemic periodic paralysis (HypoPP) patients as the positive controls and 45 healthy subjects as the negative controls. ET including long exercise test (LET) and short exercise test (SET) was performed in the corresponding subjects.

Results

In the LET, both the overall PKD patients and HypoPP patients had greater CMAP amplitude and area increments during exercise than healthy controls. At most 25% of PKD patients were identified from the normality with greater amplitude increment than the area. On the contrary, 50% of HypoPP patients were differentiated with greater area increment than the amplitude. More percentage of PRRT2- patients than PRRT2+ patients had abnormal average amplitude increment. Unexpectedly, five PKD patients had abnormal maximum CMAP amplitude decrements after exercise in the LET, and one had abnormal maximum immediate amplitude decrement in the SET.

Conclusions

Distinct ET manifestations were found in PKD patients compared to normal controls and HypoPP patients.

Significance

Abnormal muscle membrane excitability might be involved in the mechanisms responsible for PKD.

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Table of Contents

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Postoperative pain management for tracheoesophageal fistula repair using transverse, in-plane, ultrasound guided paravertebral technique in a 2 kg neonate

We read with interest the recent paper discussing an ultrasound guided oblique intercostal approach for paravertebral catheters placement in 2 neonates scheduled for tracheoesophageal fistula repair [1]. While we applaud the author's choice of using for paravertebral catheters (PVBCs) in such small neonates, we question the technique used; an ultrasound image was not presented, and the figure and block details do not seem to be in concordance with the approach used. The depth of paravertebral space with intercostal approach is only few millimiters, making this approach extremely challenging, with a high risk of pneumothorax and intrapleural catheter placement.

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Editorial Board w/barcode

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Why don't mice lacking the mitochondrial Ca2+ uniporter experience an energy crisis?

The Journal of Physiology, Volume 0, Issue ja, -Not available-.


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Nicotine modulates human brain plasticity via calcium‐dependent mechanisms

The Journal of Physiology, Volume 0, Issue ja, -Not available-.


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Issue Information

The Journal of Physiology, Volume 596, Issue 18, Page 4285-4286, 15 September 2018.


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