Τρίτη 19 Απριλίου 2016

Gut Microbiota of Nonalcoholic Fatty Liver Disease

Abstract

The prevalence of nonalcoholic fatty liver disease has been rapidly increasing worldwide. It has become a leading cause of liver transplantation. Accumulating evidence suggests a significant role for gut microbiota in its development and progression. Here we review the effect of gut microbiota on developing hepatic fatty infiltration and its progression. Current literature supports a possible role for gut microbiota in the development of liver steatosis, inflammation and fibrosis. We also review the literature on possible interventions for NAFLD that target the gut microbiota.



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Fibrosis Assessment in Nonalcoholic Fatty Liver Disease (NAFLD) in 2016

Abstract

Nonalcoholic fatty liver disease (NAFLD) is a spectrum of liver pathologies characterized by hepatic steatosis with a history of little to no alcohol consumption or secondary causes of hepatic steatosis. The prevalence of NAFLD is 20–25 % of the general population in the Western countries and is associated with metabolic risk factors such as obesity, diabetes mellitus, and dyslipidemia. The spectrum of disease ranges from simple steatosis to nonalcoholic steatohepatitis, fibrosis, and cirrhosis. Advanced fibrosis is the most significant predictor of mortality in NAFLD. It is crucial to assess for the presence and degree of hepatic fibrosis in order to make therapeutic decisions and predict clinical outcomes. Liver biopsy, the current gold standard to assess the liver fibrosis, has a number of drawbacks such as invasiveness, sampling error, cost, and inter-/intra-observer variability. There are currently available a number of noninvasive tests as an alternative to liver biopsy for fibrosis staging. These noninvasive fibrosis tests are increasingly used to rule out advanced fibrosis and help guide disease management. While these noninvasive tests perform relatively well for ruling out advanced fibrosis, they also have limitations. Understanding the strengths and limitations of liver biopsy and the noninvasive tests is necessary for deciding when to use the appropriate tests in the evaluation of patients with NAFLD.



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Role of nucleotide excision repair proteins in response to DNA damage induced by topoisomerase II inhibitors

Publication date: Available online 19 April 2016
Source:Mutation Research/Reviews in Mutation Research
Author(s): Jaqueline C. Rocha, Franciele F. Busatto, Temenouga N. Guecheva, Jenifer Saffi
In cancer treatment, chemotherapy is one of the main strategies used. The knowledge of the cellular and molecular characteristics of tumors allows the use of more specific drugs, making the removal of tumors more efficient. Among the drugs of choice in these treatments, topoisomerase inhibitors are widely used against different types of tumors. Topoisomerases are enzymes responsible for maintaining the structure of DNA, altering its topological state temporarily during the processes of replication and transcription, in order to avoid supercoiling and entanglements at the double helix. The DNA damage formed as a result of topoisomerase inhibition can be repaired by DNA repair mechanisms. Thus, DNA repair pathways can modulate the effectiveness of chemotherapy. Homologous recombination (HR) and non-homologous end joining (NHEJ) are the main pathways involved in the removal of double strand breaks (DSBs); while nucleotide excision repair (NER) is mainly characterized by the removal of lesions that lead to significant structural distortions in the DNA double helix. Evidence has shown that DSBs are the main type of damage resulting from the inhibition of the DNA topoisomerase II enzyme, and therefore the involvement of HR and NHEJ pathways in the repair process is well established. However, some topoisomerase II inhibitors induce other types of lesions, like DNA adducts, interstrand crosslinks and reactive oxygen species, and studies have shown that other DNA repair pathways might be participating in removing injury induced by these drugs. This review aims to correlate the involvement of proteins from different DNA repair pathways in response to these drugs, with an emphasis on NER.



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Florida father-of-two kills his entire family in murder-suicide



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Novel Pharmacotherapy Options for NASH

Abstract

While simple to recommend, diet and lifestyle measures as a first-line therapy for nonalcoholic steatohepatitis (NASH) are hardly a model of successful therapy, as most clinicians can testify. They can be complex to implement, hard to sustain, and of limited efficacy in advanced stages of the disease. The need for specific pharmacotherapy is now acknowledged by practitioners, the pharmaceutical industry, and regulators and is largely expected by patients. The result is a clear move away from products developed second hand for NASH (such as pioglitazone or metformin) or from generic, non-specific hepatoprotectors (such as pentoxifylline, ursodeoxycholic acid, or antioxidants) toward molecules developed and tested specifically for NASH that aim to correct one or several of the pathways of liver injury in this disease. The two most advanced molecules, obeticholic acid and elafibranor, have shown encouraging data on improving hepatic histology. Both compounds appear to clear NASH, with obeticholic acid improving liver fibrosis and elafibranor improving the glycemic and lipid profile. Much larger trials, currently ongoing, will need to confirm these preliminary data and better characterize the safety and tolerability profile. Meanwhile, other compounds are being tested, a few in phase 2b studies (cenicriviroc, aramchol for NASH, and simtuzumab for NASH fibrosis) and many more in earlier, smaller trials. Most of these drug candidates target different pathways, which speaks to the diversity and dynamism of the NASH pipeline.



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Global Epidemiology of Nonalcoholic Fatty Liver Disease and Perspectives on US Minority Populations

Abstract

Background

Non-alcoholic fatty liver disease (NAFLD) is a clinical syndrome predicted to be the next global epidemic affecting millions of people worldwide. The natural course of this disease including its subtype, non-alcoholic steatohepatitis (NASH), is not clearly defined especially in the African-American segment of the US population.

Aims

To conduct a review of the global epidemiology of NAFLD with emphasis on US minority populations.

Methods

A thorough search of evidence-based literature was conducted using the Pubmed database and commercial web sources such as Medscape and Google Scholar.

Results

NAFLD and its subtype NASH are becoming the principal cause of chronic liver disease across the world. In the US, Hispanics are the most disproportionately affected ethnic group with hepatic steatosis, and elevated aminotransferase levels, whereas African-Americans are the least affected. Genetic disparities involved in lipid metabolism seem to be the leading explanation for the lowest incidence and prevalence of both NAFLD and NASH in African-Americans.

Conclusions

The unprecedented rise in the prevalence of NAFLD globally requires an initiation of population cohort studies with long-term follow-up to determine the incidence and natural history of NAFLD and its underrepresentation in African-Americans. Future studies should also focus on the delineation of the interplay between genetic and environmental factors that trigger the development of NAFLD and NASH.



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Nonalcoholic Fatty Liver Disease: Key Considerations Before and After Liver Transplantation

Abstract

Nonalcoholic fatty liver disease (NAFLD) is the most common etiology of chronic liver disease in developed countries and is on trajectory to become the leading indication for liver transplantation in the USA and much of the world. Patients with NAFLD cirrhosis awaiting liver transplant face unique challenges and increased risk for waiting list stagnation and dropout due to burdensome comorbidities including obesity, diabetes, cardiovascular disease, and kidney disease. Thus far, patients transplanted for NAFLD cirrhosis have excellent mid- and long-term patient and graft survival, but concerns regarding short-term morbidity and mortality continue to exist. Post-liver transplantation, NAFLD occurs as both a recurrent and de novo manifestation, each with unique outcomes. NAFLD in the donor population is of concern given the growing demand for liver transplantation and mounting pressure to expand the donor pool. This review addresses key issues surrounding NAFLD as an indication for transplantation, including its increasing prevalence, unique patient demographics, outcomes related to liver transplantation, development of post-liver transplantation NAFLD, and NAFLD in the liver donor population. It also highlights exciting areas where further research is needed, such as the role of bariatric surgery and preconditioning of marginal donor grafts.



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Florida father-of-two kills his entire family in murder-suicide



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Florida father-of-two kills his entire family in murder-suicide



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Florida father-of-two kills his entire family in murder-suicide



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Selected Essential Oils as Antifungal Agents Against Antibiotic-Resistant Candida spp.: In Vitro Study on Clinical and Food-Borne Isolates

Microbial Drug Resistance , Vol. 0, No. 0.


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Heparin-Binding Epidermal Growth Factor-Like Growth Factor as a Potent Target for Breast Cancer Therapy

Cancer Biotherapy & Radiopharmaceuticals Apr 2016, Vol. 31, No. 3: 85-90.


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Efficacy Screening of Gloriosa Superba Extracts in a Murine Pancreatic Cancer Model Using 18F-FDG PET/CT for Monitoring Treatment Response

Cancer Biotherapy & Radiopharmaceuticals Apr 2016, Vol. 31, No. 3: 99-109.


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Exploring the Potential of 99mTc(CO)3-Labeled Triazolyl Peptides for Tumor Diagnosis

Cancer Biotherapy & Radiopharmaceuticals Apr 2016, Vol. 31, No. 3: 110-117.


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Correlating and Combining Genomic and Proteomic Assessment with In Vivo Molecular Functional Imaging: Will This Be the Future Roadmap for Personalized Cancer Management?

Cancer Biotherapy & Radiopharmaceuticals Apr 2016, Vol. 31, No. 3: 75-84.


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Long-Term Progression-Free and Overall Survival in Two Melanoma Patients Treated with Patient-Specific Therapeutic Vaccine Eltrapuldencel-T After Resection of a Solitary Liver Metastasis

Cancer Biotherapy & Radiopharmaceuticals Apr 2016, Vol. 31, No. 3: 71-74.


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Heparin-Binding Epidermal Growth Factor-Like Growth Factor as a Potent Target for Breast Cancer Therapy

Cancer Biotherapy & Radiopharmaceuticals Apr 2016, Vol. 31, No. 3: 85-90.


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Efficacy Screening of Gloriosa Superba Extracts in a Murine Pancreatic Cancer Model Using 18F-FDG PET/CT for Monitoring Treatment Response

Cancer Biotherapy & Radiopharmaceuticals Apr 2016, Vol. 31, No. 3: 99-109.


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Genotypic difference in 137Cs accumulation and transfer from the contaminated field in Fukushima to azuki bean (Vigna angularis)

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Publication date: July 2016
Source:Journal of Environmental Radioactivity, Volumes 158–159
Author(s): Khin Thuzar Win, Aung Zaw Oo, Katsuhiro Kojima, Djedidi Salem, Hiroko Yamaya, Sonoko Dorothea Bellingrath-Kimura, Norihiko Tomooka, Akito Kaga, Naoko Ohkama-Ohtsu, Tadashi Yokoyama
The screening of mini-core collection of azuki bean accessions (Vigna angularis (Willd.) Ohwi & Ohashi) for comparative uptake of 137Cs in their edible portions was done in field trials on land contaminated by the Fukushima Daiichi Nuclear Power Plant (FDNPP) accident. Ninety seven azuki bean accessions including their wild relatives from a Japanese gene bank, were grown in a field in the Fukushima prefecture, which is located approximately 51 km north of FDNPP. The contamination level of the soil was 3665 ± 480 Bq kg−1 dry weight (137Cs, average ± SD). The soil type comprised clay loam, where the sand: silt: clay proportion was 42:21:37.There was a significant varietal difference in the biomass production, radiocaesium accumulation and transfer factor (TF) of radiocaesium from the soil to edible portion. Under identical agricultural practice, the extent of 137Cs accumulation by seeds differed between the accessions by as much as 10-fold. Inter-varietal variation was expressed at the ratio of the maximum to minimum observed 137Cs transfer factor for seeds ranged from 0.092 to 0.009. The total biomass, time to flowering and maturity, and seed yield had negative relationship to 137Cs activity concentration in seeds. The results suggest that certain variety/varieties of azuki bean which accumulated less 137Cs in edible portion with preferable agronomic traits are suitable to reduce the 137Cs accumulation in food chain on contaminated land.



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Firefighter Paramedic - San Marino, San Gabriel and South Pasadena Fire Departments

SAN MARINO, SAN GABRIEL AND SOUTH PASADENA FIRE DEPARTMENTS South Pasadena Fire Department 817 Mound Ave. South Pasadena, CA 91030 http://ift.tt/1S8Mnus San Marino Fire Department 2200 Huntington Drive San Marino, CA 91108 http://ift.tt/1Thvxs7 San Gabriel Fire Department 115 North Del Mar Avenue San Gabriel, CA 91775 http://ift.tt/1S8MqpS Updated: April 14, 2016 Job Classification: ...

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Instructor, Emergency Medical Science - Texas Southmost College

Faculty are professional educators who have the primary responsibility of fulfilling the Texas Southmost College's (TSC) mission, vision, values and goals of providing a quality education, within a fully digital learning environment, for all students enrolled at the College. The relationship of the faculty member to the student is one of leader, teacher, advisor, and facilitator of learning. Faculty ...

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How medical device failures cause patient injuries

An EMS crew is transporting a 28-year-old pregnant patient to a high-risk labor and delivery unit. She will be a direct admission with a diagnosis of premature labor.

She has an IV pump running with normal saline and magnesium. During the transport, the IV pump's alarm continues to sound with multiple error messages. The attending paramedic attempts to troubleshoot the problem without success. Finally, the attendant shuts off the pump and the IV is maintained at a keep open rate.

The patient's labor intensifies and upon arrival at the hospital the crew is questioned by the receiving staff about shutting off the pump. The attending physician believes the device failure and subsequent decisions directly affected the patient's labor.

Alex Christgen, Project Manager at the Center for Patient Safety, states "health care has seen an influx of new technology and new devices, as well as improvements to current devices. Many of these innovations have improved the quality and safety for the patient and eased the workload for the provider, but as with any tool these devices may have weak points or may not be implemented into the system as expected."

Medical device adverse events
The CPS Patient Safety Organization receives regular reports of device failures. These range from operational error to the actual device failing during operation. These failures can be linked to a variety of factors.

Some of the most common factors include improper usage or stressing a device beyond its recommendations. Other reports include battery or power failure which is critical for many devices to function.

Stretcher drops and tips
Another common scenario that can happen anywhere: A crew reports placing a patient on the stretcher with three belts and shoulder straps and then moving the stretcher to the ambulance. The paramedic asks other providers at the scene to help load the patient and operate the stretcher.

The other providers agree to assist; one takes position at the head and another at the foot of the stretcher. The paramedic goes ahead of them to the front door of the home to open and hold the screen door. The other providers have not been fully trained on the stretcher including how to use the motorized lift, so they raise it to the high load position. While navigating the doorway they encounter an uneven surface area on the front porch.

The stretcher becomes top heavy and overturns. They try to quickly recover and slow the fall; however, the patient is injured in the fall.

Moving and lifting patients has inherent risks to the patient and provider. This includes stretcher related events where either a patient or provider is injured. Reports of stretchers tipping over and failing during the loading or unloading from the ambulance are not uncommon.

The causes for these events vary; however, common factors include inattention, over stressing the stretcher and lack of training. Due to the often extreme conditions and often unpredictable environment that EMS operates in, stretchers may be placed in situations where they can injure a provider and patient due to a failure.



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How medical device failures cause patient injuries

Improperly used or maintained patient care and devices can cause harm to patients and providers

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How to calculate heart rate with 6-second ECG strip



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Demonstration of 3 techniques for percutaneous translaryngeal ventilation after needle cricothyrotomy

How to perform and bag through a needle cricothyrotomy without a commercially available jet ventilation kit.

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How to calculate heart rate with 6-second ECG strip



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Demonstration of 3 techniques for percutaneous translaryngeal ventilation after needle cricothyrotomy

How to perform and bag through a needle cricothyrotomy without a commercially available jet ventilation kit.

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How to make EMS quality assurance and improvement people-oriented

By Drew Rinella

Six years ago, when I started at Bonner County EMS in Sandpoint, Idaho, the agency was still young and I had the exciting opportunity to help build an EMS system. I had a strong desire to develop a people-oriented approach to QA/QI that worked toward the betterment of EMS providers rather than the traditional approach of beating them into submission.

The traditional model of EMS Quality Assurance and Quality Improvement is a failed enterprise. I propose a more effective, people-oriented alternative. Traditional QA/QI relies on the equivalent of public flogging for improvement. The typical EMT or paramedic can count on having his worst chart, for his worst call, on his worst day, written at 4 a.m. on no sleep pulled for case review, blown up on a projector screen and being made to defend that chart against his peers.

Too often quality improvement is largely punitive, leading the provider to begin making decisions not based on what is clinically best for the patient, but what will look good enough on paper to keep from getting into trouble again.

In 10 years of service, having worked for a handful of agencies, I have seen these hostile QA/QI practices lead to patients being transported when they didn't need transport, intubated when they didn't need intubation, and forced onto backboards when didn't need to be immobilized. These interventions were not the result of clinical incompetence or inability, but the Pavlovian response to berating providers for their decisions. Any reasonable person can see that traditional methods of quality improvement lead to no improvement.

Efficient correction through education
Our first step was to draw a demarcation between education and punishment. We identified that the majority of EMS providers enter the field wanting to provide an excellent service to the community and their patients. Their inclination is to do well, and overall we found that if we treat our EMTs and paramedics with respect, they will seek out and be receptive to education and improvement without the need for discipline. This is not to say that some events should not be met with disciplinary action; that may be a very appropriate measure to take in some circumstances, but punishment is overall not an effective form of education.

This is especially true of more destructive forms of punishment, such as the verbal abuse characteristic of traditional case review meetings. Berating and humiliating people makes them feel small and does not build them up into confident, competent health care providers.

The goal of EMS quality improvement should be the efficient correction of inappropriate practices and behaviors, not to exact vengeance upon the employee. To encourage good clinical decision making abilities, EMS providers must be free to operate in good faith without the fear of being hauled over the coals in front of their colleagues.

Private, discreet correction
A critical component of correction through education is the need for privacy. In order to maintain positive employee morale, attention must be paid to maintaining the provider's dignity. For example, if a provider has a consistent problem with spelling and grammatical errors in his PCRs, that provider may simply need his supervisor to pull him into the office and teach him how to use a spell checker.

If the problem continues, that provider may be offered an opportunity to attend a writing class at a local community college, and it is unlikely his colleagues will ever find out any more information beyond what the provider tells them. If there is a widespread problem with spelling and grammar errors, attention could be paid to that area during agency trainings and individual providers with spelling issues would retain anonymity in the crowd. This type of discreet correction can be applied to most clinical or operational problems.

SOP for complaints
With the help of our medical director, we developed a standard operating procedure for clinical investigations to ensure the consistent and fair handling of internal and external complaints related to patient care. One important tenet of our investigative process is to notify involved parties of the investigation from the beginning, so that their first notification of a problem is not via the rumor mill. This reduces provider anxiety — maintaining their work efficiency while the investigation is occurring, increases cooperation, and creates an environment where the provider feels respected and is more receptive to any correction that must later take place.

Allow organic sharing of lessons learned
While clinical errors are investigated and corrected confidentially, experience has shown that this does not mean widespread learning among the providers of an agency is not taking place. We have found that, when left to their own devices, many providers are more than willing to voluntarily retell the mistakes they've made to their peers through so-called war stories. If one provider hears of a medication dosing error committed by another provider, the natural reaction is for both providers to become more alert to medication dosages. In sharing these mistakes, the provider retains his dignity while redeeming himself by helping to prevent the same mistake from happening again. This process should be allowed to happen organically in a healthy agency.

Criteria for case review
It became clear to us that the best function of a case review meeting is as an educational forum, rather than a means for correcting individual problems. When treated as an educational process, the case review meeting becomes a force multiplier for the war story sharing phenomenon. We began selecting cases for monthly review with the following criteria:

1. Never select charts with significant errors or complaints against them to prevent embarrassment to the provider and the agency.
2. Minor errors are acceptable if they are expected to create good discussion.
3. Calls with educational value, or which may stimulate good discussion, are sought out and selected. Examples are charts documenting rarely used procedures like cricothyrotomy or patients with rare medical conditions.
4. Calls that triggered a critical incident stress debriefing are not selected without permission from the providers involved.
5. Calls that caused mourning among the community, such as the death of a student at the local high school, are not selected. This is more important in a small community like ours.
6. Only four to five cases are selected per meeting in order to maximize actual learning.

Above all, our goal with using the above selection criteria was to create a meeting that EMS providers would want to attend, since we believe that better learning occurs when students actually want to be in the class. In our meeting, providers get to have a positive interaction with our medical director every month, which is quite a departure from the average EMS service.

Still, memories of negative experiences with past agencies linger, and it is not an uncommon response for a provider to ask what they did wrong when notified that one of their charts has been selected. We have observed this response fade significantly as trust was built between the providers and those performing QA/QI activities.

Our methods have been criticized as being too soft handed, but in practice our approach to QA/QI has never prevented us from correcting any problems. And while it would be difficult to produce hard numbers to definitively prove that our methods are more effective than the traditional approach, we do appreciate an almost nonexistent burnout-related turnover rate at Bonner County EMS.

People-oriented system benefits
We have created a people-oriented system of quality assurance and improvement wherein we work with providers rather than against them, giving each provider the educational tools they need to improve and grow within their profession, and we are observing success with our approach.

For true quality improvement to occur, the EMS industry must abandon the failed practices of the past and consider how our QA/QI activities affect field providers, and, in turn, how that affects patient care and the profession as a whole. EMS agencies may benefit from adopting a people-oriented approach to quality assurance and improvement modeled after the methods of Bonner County EMS.

About the author
Drew Rinella is the clinical coordinator for Bonner County EMS in rural North Idaho. He is a paramedic, public servant, and competition shooter. Drew is an advocate for quality in EMS and also blogs his crusade against bad EKGs in product advertising. 



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How to calculate heart rate with 6-second ECG strip



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Demonstration of 3 techniques for percutaneous translaryngeal ventilation after needle cricothyrotomy

How to perform and bag through a needle cricothyrotomy without a commercially available jet ventilation kit.

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Paramedics plan to make house calls to recovering overdose patients



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Esophageal motility after peroral endoscopic myotomy for achalasia

Abstract

Background

Peroral endoscopic myotomy (POEM) has been introduced as a novel endoscopic treatment for achalasia. The aim of this work is to assess the changes in esophageal motility caused by POEM in patients with achalasia.

Methods

Forty-one patients with achalasia underwent POEM from September 2012 to November 2014. Esophageal motility of all patients was evaluated preoperatively and 1 month after POEM utilizing high-resolution manometry, which was performed with ten water swallows, ten steamed bread swallows, and multiple rapid swallows (MRS).

Results

In single swallows, including liquid swallows and bread swallows, all the parameters of lower esophagus sphincter resting pressure (LESP), 4-s integrated relaxation pressure (4sIRP), and intra-bolus pressure (IBP) were decreased between pre- and post-POEM patients (all p < 0.05). Postoperatively, the trend of distal contractile integral (DCI) and distal esophageal peristaltic amplitude declined in subtype II and subtype III (subtype II: p < 0.05; subtype III: p > 0.05), but increased in subtype I (subtype I: p > 0.05). In liquid swallows, the Eckardt score of subtype II patients decreased with DCI, and distal esophageal peristaltic amplitude after POEM was significantly lower compared with those showing increased values of those two parameters (p < 0.05). In MRS, the rate of LES relaxation increased from 66.67 to 95.24 %, but without normal response in all achalasia patients.

Conclusions

POEM reduces LES pressure in achalasia, and partly restores esophageal motility. POEM displayed varying effect on esophageal motility in patients with different patterns of swallowing. In addition, the changes in parameters associated with esophageal peristalsis correlated with decreases in Eckardt score.



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Is a fecal occult blood test a useful tool for judging whether to perform capsule endoscopy in low-dose aspirin users with negative colonoscopy and esophagogastroduodenoscopy?

Abstract

Background

Aspirin use is reportedly not to be associated with fecal immunochemical occult blood test (FIT) false-positive results for the detection of colorectal cancer. The need for additional small bowel exploration in FIT-positive, low-dose aspirin users with a negative colonoscopy is controversial. The aim of this study was to assess the ability of FIT to judge whether capsule endoscopy (CE) should be performed in low-dose aspirin users with negative colonoscopy and esophagogastroduodenoscopy findings by comparing FIT results with CE findings.

Methods

A total of 264 consecutive low-dose aspirin users with negative colonoscopy and esophagogastroduodenoscopy who were scheduled to undergo CE at five hospitals in Japan were enrolled. Patients had been offered FIT prior to the CE. The association between the FIT results and the CE findings was then assessed.

Results

One hundred and fifty-seven patients were included in the final analysis. Eighty-four patients (53.5 %) had positive FIT results. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of positive FIT results for small bowel ulcers were 0.56, 0.47, 0.30, and 0.73, respectively. Furthermore, the NPV of positive FIT results for severe small bowel injury (Lewis score ≥790) was markedly high (0.90). When the analysis was performed only in low-dose aspirin users with anemia, the sensitivity of the positive FIT results was notably improved (0.72).

Conclusions

Small bowel evaluation using CE is not recommended for FIT-negative, low-dose aspirin users. However, small bowel evaluation using CE should be considered in both FIT-positive and anemic low-dose aspirin users.



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Paramedics plan to make house calls to recovering overdose patients



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Paramedics plan to make house calls to recovering overdose patients



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How to overcome your own self-doubt as an EMT, paramedic, student or leader

If you are an EMS teacher — or just an EMT needing a confidence boost — read on for tips in conquering professional obstacles encountered by first responders

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ERP C250 shows the elderly (cognitively normal, Alzheimer’s disease) store more stimuli in short-term memory than Young Adults do

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Publication date: June 2016
Source:Clinical Neurophysiology, Volume 127, Issue 6
Author(s): Robert M. Chapman, Margaret N. Gardner, Mark Mapstone, Rafael Klorman, Anton P. Porsteinsson, Haley M. Dupree, Inga M. Antonsdottir, Lily Kamalyan
ObjectiveTo determine how aging and dementia affect the brain's initial storing of task-relevant and irrelevant information in short-term memory.MethodsWe used brain Event-Related Potentials (ERPs) to measure short-term memory storage (ERP component C250) in 36 Young Adults, 36 Normal Elderly, and 36 early-stage AD subjects. Participants performed the Number–Letter task, a cognitive paradigm requiring memory storage of a first relevant stimulus to compare it with a second stimulus.ResultsIn Young Adults, C250 was more positive for the first task-relevant stimulus compared to all other stimuli. C250 in Normal Elderly and AD subjects was roughly the same to relevant and irrelevant stimuli in Intratrial Parts 1–3 but not 4. The AD group had lower C250 to relevant stimuli in part 1.ConclusionsBoth normal aging and dementia cause less differentiation of relevant from irrelevant information in initial storage. There was a large aging effect involving differences in the pattern of C250 responses of the Young Adult versus the Normal Elderly/AD groups. Also, a potential dementia effect was obtained.SignificanceC250 is a candidate tool for measuring short-term memory performance on a biological level, as well as a potential marker for memory changes due to normal aging and dementia.



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moviEEG: An animation toolbox for visualization of intracranial electroencephalography synchronization dynamics

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Publication date: June 2016
Source:Clinical Neurophysiology, Volume 127, Issue 6
Author(s): Simeon M. Wong, George M. Ibrahim, Ayako Ochi, Hiroshi Otsubo, James T. Rutka, O. Carter Snead, Sam M. Doesburg
ObjectiveWe introduce and describe the functions of moviEEG (Multiple Overlay Visualizations for Intracranial ElectroEncephaloGraphy), a novel MATLAB-based toolbox for spatiotemporal mapping of network synchronization dynamics in intracranial electroencephalography (iEEG) data.MethodsThe toolbox integrates visualizations of inter-electrode phase-locking relationships in peri-ictal epileptogenic networks with signal spectral properties and graph-theoretical network measures overlaid upon operating room images of the electrode grid. Functional connectivity between every electrode pair is evaluated over a sliding window indexed by phase synchrony.ResultsTwo case studies are presented to provide preliminary evidence for the application of the toolbox to guide network-based mapping of epileptogenic cortex and to distinguish these regions from eloquent brain networks. In both cases, epileptogenic cortex was visually distinct.ConclusionWe introduce moviEEG, a novel toolbox for animation of oscillatory network dynamics in iEEG data, and provide two case studies showing preliminary evidence for utility of the toolbox in delineating the epileptogenic zone.SignificanceDespite evidence that atypical network synchronization has shown to be altered in epileptogenic brain regions, network based techniques have yet to be incorporated into clinical pre-surgical mapping. moviEEG provides a set of functions to enable easy visualization with network based techniques.



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Early event-related potentials to emotional faces differ for adults with autism spectrum disorder and by serotonin transporter genotype

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Publication date: June 2016
Source:Clinical Neurophysiology, Volume 127, Issue 6
Author(s): Susan Faja, Geraldine Dawson, Elizabeth Aylward, Ellen M. Wijsman, Sara Jane Webb
ObjectiveTo test differences in neural sensitivity to facial expressions, including expressions with open versus closed mouths, exhibited by (1) adults with autism spectrum disorder (ASD) compared to neurotypical adults, and by (2) short versus long serotonin transporter allele (SLC6A4) carriers.MethodsEvent related potentials (ERPs) to happy, fearful, and neutral expressions were collected from neurotypical adults (n=25) and adults with ASD (n=27)–of whom 32 had short and 13 had homozygous long SLC6A4 alleles.ResultsIn the neurotypical group, we confirmed that the N170, VPP and EPN, but not the P1, were influenced by emotional expressions, and determined the EPN was the earliest component modulated by open mouth. Compared to the neurotypical group, individuals with ASD exhibited differences in EPN amplitude in response to open versus closed mouths and in hemispheric distribution. Across groups, short serotonin transporter allele carriers had reduced P1 amplitude compared to long allele carriers.ConclusionsIndividuals with ASD exhibited a different pattern of neural response when encoding and recognizing facial expressions at the EPN component. Across groups, SLC6A4 allele type modulated early sensory attention at the P1.SignificanceThese results provide insight into the nature of early responses to emotional information according to genetic variation and clinical condition.



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The relevance of attention in schizophrenia P50 paired stimulus studies

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Publication date: June 2016
Source:Clinical Neurophysiology, Volume 127, Issue 6
Author(s): Anna Dalecki, Amity E. Green, Stuart J. Johnstone, Rodney J. Croft
ObjectiveP50 suppression refers to the P50 ERP amplitude-reduction to the second (S2) relative to the first (S1) of identical brief auditory stimuli (SOA=500ms). Its reduction in schizophrenia is argued to represent impaired inhibitory input (II) mechanisms. Enhancing attention enhances II functionality (reducing S2P50 amplitude and increasing P50 difference) in healthy subjects. We determined whether the effect of attention on P50 suppression differs between schizophrenia patients (SCZ) and controls (CON) and thus is a confound in P50 schizophrenia research.MethodsWe manipulated the direction of attention (attention, non-attention) in 21 SCZ and 18 CON in the P50 suppression task.ResultsDirecting attention towards stimulus pairs (versus non-attention) increased P50 suppression (P50 difference). This effect differed between groups, with attention increasing S1P50, reducing S2P50 and increasing P50 suppression (P50 difference and reducing P50 ratio) in CON only. No group differences were found for P50 difference or ratio.ConclusionsAttention is a confound in schizophrenia P50 research and thus should be carefully controlled. When attention was controlled, P50 group differences were not found.SignificanceThe SCZ–CON P50 difference reported in the literature may be related to uncontrolled attention (and not impaired P50 suppression per se).



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Cortical correlates of susceptibility to upper limb freezing in Parkinson’s disease

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Publication date: June 2016
Source:Clinical Neurophysiology, Volume 127, Issue 6
Author(s): Marlieke Scholten, Rathinaswamy B. Govindan, Christoph Braun, Bastiaan R. Bloem, Christian Plewnia, Rejko Krüger, Alireza Gharabaghi, Daniel Weiss
ObjectiveFreezing behavior is an unmet symptom in Parkinson's disease (PD), which reflects its complex pathophysiology. Freezing behavior can emerge when attentional capacity is reduced, i.e. under dual task interference. In this study, we characterized the cortical network signatures underlying the susceptibility to freezing during continuous finger tapping.MethodsFourteen PD patients with STN-DBS and thirteen age- and gender-matched healthy controls performed continuous tapping with the index finger as single motor task and during dual tasking. Synchronized EEG and mechanogram of the finger tapping were recorded. Subsequently, we analyzed cortical activity and cortico-cortical phase synchronization. We correlated these spectral measures with the biomechanically confirmed numbers of freezing episodes during finger tapping.ResultsDuring dual tasking compared to the single motor task, PD patients showed an increase of cortico-cortical phase synchronization over the left prefrontal area from 13 to 30Hz. This correlated with increased occurrence of freezing episodes. Interestingly, PD patients lacked the increase of prefrontal cortico-cortical synchronization from 4 to 7Hz during dual tasking as observed in healthy controls.ConclusionDual task interference led to an increase of left prefrontal beta band synchronization (13–30Hz) in PD and this increment predicted the number of freezing episodes. This increment may underscore the relevance of prefrontal executive dysfunction in freezing susceptibility.SignificanceThese findings enhance our understanding of the pathological network mechanisms behind increased susceptibility to freezing behavior.



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Freezing of gait is associated with increased saccade latency and variability in Parkinson’s disease

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Publication date: June 2016
Source:Clinical Neurophysiology, Volume 127, Issue 6
Author(s): Samuel T. Nemanich, Gammon M. Earhart
ObjectiveFreezing of gait (FOG) is a locomotor disturbance in Parkinson disease (PD) related to impaired motor automaticity. In this study, we investigated the impact of freezing on automaticity in the oculomotor system using an anti-saccade paradigm.MethodsSubjects with PD with (PD–FOG, n=13) and without (PD–NON, n=13) FOG, and healthy age-matched controls (CTRL, n=12) completed automatic pro-saccades and non-automatic anti-saccades. Primary outcomes were saccade latency, velocity, and gain.ResultsPD–FOG (pro-saccade latency=271ms, anti-saccade latency=412ms) were slower to execute both types of saccades compared to PD–NON (253ms, 330ms) and CTRL (246ms, 327ms). Saccade velocity and gain variability was also increased in PD–FOG.ConclusionsSaccade performance was affected in PD–FOG for both types of saccades, indicating differences in automaticity and control in the oculomotor system related to freezing.SignificanceThese results and others show that FOG impacts non-gait motor functions, suggesting global motor impairment in PD–FOG.



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Transcranial direct current stimulation (tDCS) over primary motor cortex leg area promotes dynamic balance task performance

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Publication date: June 2016
Source:Clinical Neurophysiology, Volume 127, Issue 6
Author(s): Elisabeth Kaminski, Christopher J. Steele, Maike Hoff, Christopher Gundlach, Viola Rjosk, Bernhard Sehm, Arno Villringer, Patrick Ragert
ObjectiveThe aim of the study was to investigate the effects of facilitatory anodal tDCS (a-tDCS) applied over the leg area of the primary motor cortex on learning a complex whole-body dynamic balancing task (DBT). We hypothesized that a-tDCS during DBT enhances learning performance compared to sham tDCS (s-tDCS).MethodsIn a randomized, parallel design, we applied either a-tDCS (n=13) or s-tDCS (n=13) in a total of 26 young subjects while they perform the DBT. Task performance and error rates were compared between groups. Additionally, we investigated the effect of tDCS on the relationship between performance and kinematic variables capturing different aspects of task execution.ResultsA-tDCS over M1 leg area promotes balance performance in a DBT relative to s-tDCS, indicated by higher performance and smaller error scores. Furthermore, a-tDCS seems to mediate the relationship between DBT performance and the kinematic variable velocity.ConclusionsOur findings provide novel evidence for the ability of tDCS to improve dynamic balance learning, a fact, particularly important in the context of treating balance and gait disorders.SignificanceTDCS facilitates dynamic balance performance by strengthening the inverse relationship of performance and velocity, thus making tDCS one potential technique to improve walking ability or help to prevent falls in patients in the future.



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Do quiet standing centre of pressure measures within specific frequencies differ based on ability to recover balance in individuals with stroke?

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Publication date: June 2016
Source:Clinical Neurophysiology, Volume 127, Issue 6
Author(s): Alison Schinkel-Ivy, Jonathan C. Singer, Elizabeth L. Inness, Avril Mansfield
ObjectiveTo determine whether quiet standing measures at specific frequency levels (representative of reactive control) differed between individuals with stroke based on their ability to recover balance (Failed or Successful Responses to external perturbations).MethodsIndividuals with stroke completed a clinical assessment, including 30 s of quiet standing and lean-and-release postural perturbations, at admission to in-patient rehabilitation. Quiet standing centre of pressure (COP) signals were calculated and discrete wavelet decomposition was performed. Net COP amplitude, between-limb synchronization, and ratios of individual-limb COP were determined for each frequency level of interest, and for the non-decomposed signal (all frequency levels). Outcome measures were compared between individuals who exhibited Failed and Successful Responses during (a) unconstrained and (b) encouraged-use lean-and-release trials.ResultsIndividuals with Failed Responses during the unconstrained lean-and-release trials displayed greater net COP amplitude than those with Successful Responses, specifically within a frequency range of 0.40–3.20Hz.ConclusionsReduced ability to recover balance among individuals with stroke may be reflected in impaired reactive control of quiet standing.SignificanceThese results provide insight into the mechanism by which reactive control of quiet standing is impaired in individuals with stroke, and may inform assessment and rehabilitation strategies for post-stroke reactive balance control.



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Non-invasive cortical modulation of experimental pain in migraine

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Publication date: June 2016
Source:Clinical Neurophysiology, Volume 127, Issue 6
Author(s): M. Uglem, P.M. Omland, M. Engstrøm, G.B. Gravdahl, M. Linde, K. Hagen, T. Sand
ObjectiveTo test the hypothesis that secondary somatosensory cortex (S2) is involved in the migraine pathogenesis, by exploring the effect of navigated repetitive transcranial magnetic stimulation (rTMS) to S2 on thermal perception and pain.MethodsIn this blinded sham-controlled case-control study of 26 interictal migraineurs and 31 controls, we measured thermal detection and pain thresholds on the hand and forehead, and pain ratings to heat stimulation on the forearm and temple, after real and sham 10Hz rTMS.ResultsrTMS increased cold and heat pain thresholds in controls as compared to interictal migraineurs (p<0.026). rTMS decreased forehead and arm pain ratings (p<0.005) and increased hand cool detection thresholds (p<0.005) in both interictal migraineurs and controls.ConclusionsThe effects of rTMS to S2 on thermal pain measures differed significantly between migraine and control subjects, although the effects were generally low in magnitude and not present in pain ratings. However, the lack of cold and heat pain threshold increase in migraineurs may reflect a hypofunction of inhibitory pain modulation mechanisms.SignificanceThe expected rTMS-induced cold and heat hypoalgesia was not found among migraineurs, possibly a reflection of reduced intracortical inhibition.



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Maintenance of cutaneomuscular neuronal excitability after leg-cycling predicts lower limb muscle strength after incomplete spinal cord injury

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Publication date: June 2016
Source:Clinical Neurophysiology, Volume 127, Issue 6
Author(s): Stefano Piazza, Julio Gómez-Soriano, Elisabeth Bravo-Esteban, Diego Torricelli, Gerardo Avila-Martin, Iriana Galan-Arriero, José Luis Pons, Julian Taylor
ObjectiveControlled leg-cycling modulates H-reflex activity after spinal cord injury (SCI). Preserved cutaneomuscular reflex activity is also essential for recovery of residual motor function after SCI. Here the effect of a single leg-cycling session was assessed on cutaneomuscular-conditioned H-reflex excitability in relation to residual lower limb muscle function after incomplete SCI (iSCI).MethodsModulation of Soleus H-reflex activity was evaluated following ipsilateral plantar electrical stimulation applied at 25–100ms inter-stimulus intervals (ISI's), before and after leg-cycling in ten healthy individuals and nine subjects with iSCI.ResultsLeg-cycling in healthy subjects increased cutaneomuscular-conditioned H-reflex excitability between 25 and 75ms ISI (p<0.001), compared to a small loss of excitability at 75ms ISI after iSCI (p<0.05). In addition, change in cutaneomuscular-conditioned H-reflex excitability at 50ms and 75ms ISI in subjects with iSCI after leg-cycling predicted lower ankle joint hypertonia and higher Triceps Surae muscle strength, respectively.ConclusionLeg-cycling modulates cutaneomuscular-conditioned spinal neuronal excitability in healthy subjects and individuals with iSCI, and is related to residual lower limb muscle function.SignificanceCutaneomuscular-conditioned H reflex modulation could be used as a surrogate biomarker of both central neuroplasticity and lower limb muscle function, and could benchmark lower-limb rehabilitation programs in subjects with iSCI.



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Electroencephalogram signatures of ketamine anesthesia-induced unconsciousness

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Publication date: June 2016
Source:Clinical Neurophysiology, Volume 127, Issue 6
Author(s): Oluwaseun Akeju, Andrew H. Song, Allison E. Hamilos, Kara J. Pavone, Francisco J. Flores, Emery N. Brown, Patrick L. Purdon
ObjectivesKetamine is an N-methyl-d-aspartate (NMDA) receptor antagonist commonly administered as a general anesthetic. However, neural circuit mechanisms to explain ketamine anesthesia-induced unconsciousness in humans are yet to be clearly defined. Disruption of frontal–parietal network connectivity has been proposed as a mechanism to explain this brain state. However, this mechanism was recently demonstrated at subanesthetic doses of ketamine in awake-patients. Therefore, we investigated whether there is an electroencephalogram (EEG) signature specific for ketamine anesthesia-induced unconsciousness.MethodsWe retrospectively studied the EEG in 12 patients who received ketamine for the induction of general anesthesia. We analyzed the EEG dynamics using power spectral and coherence methods.ResultsFollowing the administration of a bolus dose of ketamine to induce unconsciousness, we observed a "gamma burst" EEG pattern that consisted of alternating slow-delta (0.1–4Hz) and gamma (∼27–40Hz) oscillations. This pattern was also associated with increased theta oscillations (∼4–8Hz) and decreased alpha/beta oscillations (∼10–24Hz).ConclusionsKetamine anesthesia-induced unconsciousness is associated with a gamma burst EEG pattern.SignificanceThe EEG signature of ketamine anesthesia-induced unconsciousness may offer new insights into NMDA circuit mechanisms for unconsciousness.



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Threshold tracking transcranial magnetic stimulation: Effects of age and gender on motor cortical function

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Publication date: June 2016
Source:Clinical Neurophysiology, Volume 127, Issue 6
Author(s): Kazumoto Shibuya, Susanna B. Park, Nimeshan Geevasinga, William Huynh, Neil G. Simon, Parvathi Menon, James Howells, Steve Vucic, Matthew C. Kiernan
ObjectiveRecently, the utility of threshold tracking paired-pulse transcranial magnetic stimulation (TTTMS), to measure changes in cortical excitabilitability, has been established for diagnostic purposes across a range of neurological diseases. However, the impact of healthy aging on the GABA-ergic intracortical inhibitory system remains unclear. To improve the clinical applicability, TTTMS was performed across an age spectrum.MethodsTTTMS, single-pulse TMS and nerve conduction studies (NCS) were performed in 113 healthy subjects aged between 20 and 83years (57 male and 56 female).ResultsProlonged motor evoked potential (MEP) latency, increased central motor conduction time, decreased compound muscle action potential (CMAP) amplitude, prolonged F-wave latency and decreased neurophysiological index (NI), calculated from CMAP amplitude, latency and F-wave frequency, were observed as subjects aged. In contrast, short interval intracortical inhibition (SICI) and facilitation did not change. Compared to females, males exhibited a reduced SICI and NI along with longer MEP, CMAP with prolonged F-wave latencies. Multivariate analyses revealed similar results.ConclusionUtilizing clinically applicable TTTMS protocols, findings suggest that GABA mediated intracortical inhibition may be greater in females but does not significantly change with age.SignificanceThese findings may better inform the interpretation of diagnostic TTTMS studies in the clinical setting.



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Medic soldiers learn to use ultrasound designed for battlefield

An ultrasound machine, while not an exact replacement, gives the soldiers something similar to a CT scan or X-ray machine

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Short latency afferent inhibition: Effects of ageing

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Publication date: June 2016
Source:Clinical Neurophysiology, Volume 127, Issue 6
Author(s): A.J. Yarnall, B.S.W. Ho, E. Eshun, R. David, L. Rochester, D.J. Burn, M.R. Baker




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