2016-05-06T22-33-52Z
Source: Medicine Science | International Medical Journal
Omer Karaca, Huseyin Ulas Pinar, Mehmet Vedat Caldir, Rafi Dogan.
We report a patient with amlodipine intoxication who presented to hospital 30 hours after suicidal intake of the drug. Admitted to the intensive care unit, the patient had profound hypotension and need for fluid replacement and infusion of dopamine and noradrenaline. The patient was also administered insulin and calcium gluconate. In addition to profound hypotension, massive non-cardiogenic pleural effusion also complicated the clinical picture. Bilateral pleurocans were placed and non-invasive ventilation was administered in continuous positive airway pressure (CPAP) mode. Hyperinsulinemic euglycemic therapy was also applied. Following the onset of insulin therapy mean blood pressure increased and need for vasopressors was reduced. Possible positive inotropic action of insulin therapy in this patient suffering calcium channel blocker intoxication is in accordance with previous reports. It has been suggested that hyperinsulinemic euglycemic therapy may be considered as a first-line therapy in amlodipine intoxication.
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Παρασκευή 6 Μαΐου 2016
Non-cardiogenic pleural effusion after amlodipine intoxication and hyperinsulinemic therapy
Is Period3 Genotype Associated With Sleep and Recovery in Patients With Disorders of Consciousness?
Background. Sleep evaluation is increasingly being used as prognostic tool in patients with disorders of consciousness, but, surprisingly, the role of Period3 (Per3) gene polymorphism has never been evaluated. Objective. The aim of this study was to investigate the contribution of Per3 genotype on sleep quantity and consciousness recovery level in patients with disorders of consciousness (DOC). Methods. In this observational study, we evaluated 71 patients with DOC classified as vegetative state/unresponsive wakefulness syndrome or minimally conscious state. Demographic and clinical data were collected and a standardised diagnostic workup, including a polysomnographic record, was applied. After informed consent provided by proxy, genomic DNA was obtained and Per3 polymorphism was analysed by polymerase chain reaction to identify 5/5, 4/5, or 4/4 genotype. Results. Per35/5 genotype was found in 12.7% of our DOC patients. The median total Coma Recovery Scale–revised score in Per35/5 carriers was significantly higher than 4/4 genotype (10, range 5-16 vs 7, range 4-11; post hoc P = .036). Moreover, total sleep time seemed to be higher in 5/5 genotype (5/5, 221 minutes, range 88-515 minutes; 4/4, 151.5 minutes, range 36-477 minutes; and 4/5, 188 minutes, range 44-422 minutes). Conclusion. For the first time we have shown a possible association between Per3 polymorphism and consciousness recovery level in DOC patients. Even though the exact molecular mechanism has not been defined, we speculate that its effect is mediated by higher total sleep time and slow wave sleep, which would improve the preservation of main cerebral connections.
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No Reduction of Severe Fatigue in Patients With Postpolio Syndrome by Exercise Therapy or Cognitive Behavioral Therapy: Results of an RCT
Background. People with postpolio syndrome (PPS) commonly experience severe fatigue that persists over time and negatively affects functioning and health-related quality of life (HRQoL). Objectives. To study the efficacy of exercise therapy (ET) and cognitive behavioral therapy (CBT) on reducing fatigue and improving activities and HRQoL in patients with PPS. Methods. We conducted a multicenter, single-blinded, randomized controlled trial. Over 4 months, severely fatigued patients with PPS received ET, CBT, or usual care (UC). The primary end point (fatigue) was assessed using the subscale fatigue severity of the Checklist Individual Strength (CIS20-F). Secondary end points included activities and HRQoL, which were assessed with the Sickness Impact Profile and the 36-Item Short-Form, respectively. End points were measured at baseline and at 4, 7, and 10 months. Results. A total of 68 patients were randomized. No differences were observed between the intervention groups and UC group for fatigue (mean differences in CIS20-F score = 1.47, 95%CI = –2.84 to 5.79, for ET versus UC; and 1.87, 95%CI = –2.24 to 5.98, for CBT versus UC), activities, or HRQoL. Conclusions. Our results demonstrate that neither ET nor CBT were superior to UC in reducing fatigue in severely fatigued PPS patients. Further research should investigate explanations for the lack of efficacy of these 2 currently advised approaches in clinical practice, which may provide clues to improving treatment aimed at reducing fatigue in PPS.
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Prediction of Balance Compensation After Vestibular Schwannoma Surgery
Background. Balance compensation after vestibular schwannoma (VS) surgery is under the influence of specific preoperative patient and tumor characteristics. Objective. To prospectively identify potential prognostic factors for balance recovery, we compared the respective influence of these preoperative characteristics on balance compensation after VS surgery. Methods. In 50 patients scheduled for VS surgical ablation, we measured postural control before surgery (BS), 8 (AS8) days after, and 90 (AS90) days after surgery. Based on factors found previously in the literature, we evaluated age, body mass index and preoperative physical activity (PA), tumor grade, vestibular status, and preference for visual cues to control balance as potential prognostic factors using stepwise multiple regression models. Results. An asymmetric vestibular function was the sole significant explanatory factor for impaired balance performance BS, whereas the preoperative PA alone significantly contributed to higher performance at AS8. An evaluation of patients' balance recovery over time showed that PA and vestibular status were the 2 significant predictive factors for short-term postural compensation (BS to AS8), whereas none of these preoperative factors was significantly predictive for medium-term postoperative postural recovery (AS8 to AS90). Conclusions. We identified specific preoperative patient and vestibular function characteristics that may predict postoperative balance recovery after VS surgery. Better preoperative characterization of these factors in each patient could inform more personalized presurgical and postsurgical management, leading to a better, more rapid balance recovery, earlier return to normal daily activities and work, improved quality of life, and reduced medical and societal costs.
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Intensive Rehabilitation Enhances Lymphocyte BDNF-TrkB Signaling in Patients With Parkinsons Disease
Background. In a combined animal and human study, we have previously found that a 5-day treatment that enhances cortical plasticity also facilitates brain-derived neurotrophic factor (BDNF)-tyrosine receptor kinase B (TrkB) signaling and increases activated TrkB and N-methyl-d-aspartate receptor (NMDAR) association in both the cortex and the peripheral lymphocytes. Patients with Parkinson's disease (PD), in general, show decreased cortical plasticity, as demonstrated by electrophysiological and behavioral studies. Here, we test the hypothesis that an exercise program that improves motor function and seems to slow down symptom progression can enhance BDNF-TrkB signaling in lymphocytes. Methods. A total of 16 patients with PD underwent a 4-week multidisciplinary intensive rehabilitation treatment (MIRT), which included aerobic training and physical and occupational therapy. Blood was collected before and after 2 and 4 weeks of MIRT. Lymphocytes were isolated to examine BDNF-TrkB signaling induced by incubation with recombinant human BDNF. TrkB signaling complexes, extracellular-signal-regulated kinase-2 and protein-kinase-B were immunoprecipitated; the content of immunocomplexes was determined by Western blotting. Results. After MIRT, all patients showed improvement in motor function. TrkB interaction with NMDAR and BDNF-TrkB signaling increased in peripheral lymphocytes at receptor, intracellular mediator, and downstream levels. The decrements in Unified Parkinson's Disease Rating Scale II (UPDRSII) and total scores were significantly correlated with the increases in TrkB signaling at receptor, intracellular mediator, and NMDAR interaction levels. Conclusions. The significant correlation between reduced UPDRS scores and the changes in lymphocyte activity suggest that enhanced BDNF-TrkB signaling in lymphocyte and reduced severity of PD symptoms may be related.
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Interactive Effects Between Exercise and Serotonergic Pharmacotherapy on Cortical Reorganization After Spinal Cord Injury
Background. In rat models of spinal cord injury, at least 3 different strategies can be used to promote long-term cortical reorganization: (1) active exercise above the level of the lesion; (2) passive exercise below the level of the lesion; and (3) serotonergic pharmacotherapy. Whether and how these potential therapeutic strategies—and their underlying mechanisms of action—interact remains unknown. Methods. In spinally transected adult rats, we compared the effects of active exercise above the level of the lesion (treadmill), passive exercise below the level of the lesion (bike), serotonergic pharmacotherapy (quipazine), and combinations of the above therapies (bike+quipazine, treadmill+quipazine, bike+treadmill+quipazine) on long-term cortical reorganization (9 weeks after the spinal transection). Cortical reorganization was measured as the percentage of cells recorded in the deafferented hindlimb cortex that responded to tactile stimulation of the contralateral forelimb. Results. Bike and quipazine are "competing" therapies for cortical reorganization, in the sense that quipazine limits the cortical reorganization induced by bike, whereas treadmill and quipazine are "collaborative" therapies, in the sense that the reorganization induced by quipazine combined with treadmill is greater than the reorganization induced by either quipazine or treadmill. Conclusions. These results uncover the interactive effects between active/passive exercise and serotonergic pharmacotherapy on cortical reorganization after spinal cord injury, emphasizing the importance of understanding the effects of therapeutic strategies in spinal cord injury (and in other forms of deafferentation) from an integrated system-level approach.
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Preliminary Associations Between Brain-Derived Neurotrophic Factor, Memory Impairment, Functional Cognition, and Depressive Symptoms Following Severe TBI
Background. Traumatic brain injury (TBI) often leads to mood and cognitive complications, affecting functional recovery. Understanding neurobiological alterations common in post-TBI depression (PTD) and cognition may identify novel biomarkers for TBI complications. Brain-derived neurotrophic factor (BDNF) is a likely target based on evidence of reduced BDNF signaling in experimental TBI and depression models and its role in learning and memory. Objective. To evaluate BDNF as a biomarker for PTD, cognitive impairment, and functional cognition in a prospective cohort with severe TBI. Methods. Participants with TBI (n = 113) were evaluated for PTD (Patient Health Questionnaire-9 [PHQ-9]), cognitive impairment (cognitive composite score), and functional cognition (Functional Independence Measure–Cognition, FIM-Cog). BDNF levels were measured in cerebrospinal fluid and serum at 0 to 6 days postinjury and in serum at 6 and 12 months postinjury. Results. Serum BDNF was reduced after TBI versus controls at all time points. Acute serum BDNF positively correlated with memory composites (6 months: r = 0.43, P = .019, n = 30; 12 months: r = 0.53, P = .005, n = 26) and FIM-Memory scores (6 months: r = 0.35, P = .019, n = 45; 12 months: r = 0.38, P = .018, n = 38). Acute serum BDNF negatively correlated with 12-month PHQ-9 scores (r = –0.38; P = .044; n = 29). At 12 months, chronic serum BDNF tended to be lower in participants with PTD (P = .07) and correlated with PHQ-9 scores (r = –0.41; P = .019; n = 32). Conclusions. Acute BDNF associations with memory recovery may implicate hippocampal damage/degeneration. Comparatively, BDNF associations with PTD status were not as strong as associations with PTD severity. Further investigation may delineate longitudinal BDNF patterns, and BDNF responsive treatments, reflecting mood and cognitive recovery following TBI.
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Spatial Neglect Hinders Success of Inpatient Rehabilitation in Individuals With Traumatic Brain Injury: A Retrospective Study
Background. Current knowledge about spatial neglect and its impact on rehabilitation mostly originates from stroke studies. Objective. To examine the impact of spatial neglect on rehabilitation outcome in individuals with traumatic brain injury (TBI). Methods. The retrospective study included 156 consecutive patients with TBI (73 women; median age = 69.5 years; interquartile range = 50-81 years) at an inpatient rehabilitation facility (IRF). We examined whether the presence of spatial neglect affected the Functional Independence Measure (FIM) scores, length of stay, or discharge disposition. Based on the available medical records, we also explored whether spatial neglect was associated with tactile sensation or muscle strength asymmetry in the extremities and whether specific brain injuries or lesions predicted spatial neglect. Results. In all, 30.1% (47 of 156) of the sample had spatial neglect. Sex, age, severity of TBI, or time postinjury did not differ between patients with and without spatial neglect. In comparison to patients without spatial neglect, patients with the disorder stayed in IRF 5 days longer, had lower FIM scores at discharge, improved slower in both Cognitive and Motor FIM scores, and might have less likelihood of return home. In addition, left-sided neglect was associated with asymmetric strength in the lower extremities, specifically left weaker than the right. Finally, brain injury–induced mass effect predicted left-sided neglect. Conclusions. Spatial neglect is common following TBI, impedes rehabilitation progress in both motor and cognitive domains, and prolongs length of stay. Future research is needed for linking specific traumatic injuries and lesioned networks to spatial neglect and related impairment.
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Opposite Effects of Visual Cueing During Writing-Like Movements of Different Amplitudes in Parkinsons Disease
Background. Handwriting is often impaired in Parkinson's disease (PD). Several studies have shown that writing in PD benefits from the use of cues. However, this was typically studied with writing and drawing sizes that are usually not used in daily life. Objective. This study examines the effect of visual cueing on a prewriting task at small amplitudes (≤1.0 cm) in PD patients and healthy controls to better understand the working action of cueing for writing. Methods. A total of 15 PD patients and 15 healthy, age-matched controls performed a prewriting task at 0.6 cm and 1.0 cm in the presence and absence of visual cues (target lines). Writing amplitude, variability of amplitude, and speed were chosen as dependent variables, measured using a newly developed touch-sensitive tablet. Results. Cueing led to immediate improvements in writing size, variability of writing size, and speed in both groups in the 1.0 cm condition. However, when writing at 0.6 cm with cues, a decrease in writing size was apparent in both groups (P < .001) and the difference in variability of amplitude between cued and uncued writing disappeared. In addition, the writing speed of controls decreased when the cue was present. Conclusions. Visual target lines of 1.0 cm improved the writing of sequential loops in contrast to lines spaced at 0.6 cm. These results illustrate that, unlike for gait, visual cueing for fine-motor tasks requires a differentiated approach, taking into account the possible increases of accuracy constraints imposed by cueing.
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The Specific Requirements of Neural Repair Trials for Stroke
Novel molecular, cellular, and pharmacological therapies to stimulate repair of sensorimotor circuits after stroke are entering clinical trials. Compared with acute neuroprotection and thrombolysis studies, clinical trials for repair in subacute and chronic hemiplegic participants have a different time course for delivery of an intervention, different mechanisms of action within the milieu of the injury, distinct relationships to the amount of physical activity and skills practice of participants, and need to include more refined outcome measures. This review examines the biological interaction of targeted rehabilitation with neural repair strategies to optimize outcomes. We suggest practical guidelines for the incorporation of inexpensive skills training and exercise at home. In addition, we describe some novel outcome measurement tools, including wearable sensors, to obtain the more detailed outcomes that may identify at least some minimal level of success from cellular and regeneration interventions. Thus, proceeding in the shadow of acute stroke trial designs may unnecessarily limit the mechanisms of action of new repair strategies, reduce their impact on participants, and risk missing important behavioral outcomes.
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Variable Intensive Early Walking Poststroke (VIEWS): A Randomized Controlled Trial
Background. Converging evidence suggests that the amount of stepping practice is an important training parameter that influences locomotor recovery poststroke. More recent data suggest that stepping intensity and variability are also important, although such strategies are often discouraged early poststroke. Objective. The present study examined the efficacy of high-intensity, variable stepping training on walking and nonwalking outcomes in individuals 1 to 6 months poststroke as compared with conventional interventions. Methods. Individuals with unilateral stroke (mean duration = 101 days) were randomized to receive ≤40, 1-hour experimental or control training sessions over 10 weeks. Experimental interventions consisted only of stepping practice at high cardiovascular intensity (70%-80% heart rate reserve) in variable contexts (tasks or environments). Control interventions were determined by clinical physical therapists and supplemented using standardized conventional strategies. Blinded assessments were obtained at baseline, midtraining, and posttraining with a 2-month follow-up. Results. A total of 32 individuals (15 experimental) received different training paradigms that varied in the amount, intensity, and types of tasks performed. Primary outcomes of walking speed (experimental, 0.27 ± 0.22 m/s vs control, 0.09 ± 0.09 m/s) and distances (119 ± 113 m vs 30 ± 32 m) were different between groups, with stepping amount and intensity related to these differences. Gains in temporal gait symmetry and self-reported participation scores were greater following experimental training, without differences in balance or sit-to-stand performance. Conclusion. Variable intensive stepping training resulted in greater improvements in walking ability than conventional interventions early poststroke. Future studies should evaluate the relative contributions of these training parameters.
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Electrical Stimulation to Promote Peripheral Nerve Regeneration
Peripheral nerve injury afflicts individuals from all walks of life. Despite the peripheral nervous system's intrinsic ability to regenerate, many patients experience incomplete functional recovery. Surgical repair aims to expedite this recovery process in the most thorough manner possible. However, full recovery is still rarely seen especially when nerve injury is compounded with polytrauma where surgical repair is delayed. Pharmaceutical strategies supplementary to nerve microsurgery have been investigated but surgery remains the only viable option. Brief low-frequency electrical stimulation of the proximal nerve stump after primary repair has been widely investigated. This article aims to review the currently known biological basis for the regenerative effects of acute brief low-frequency electrical stimulation on axonal regeneration and outline the recent clinical applications of the electrical stimulation protocol to demonstrate the significant translational potential of this modality for repairing peripheral nerve injuries. The review concludes with a discussion of emerging new advancements in this exciting area of research. The current literature indicates the imminent clinical applicability of acute brief low-frequency electrical stimulation after surgical repair to effectively promote axonal regeneration as the stimulation has yielded promising evidence to maximize functional recovery in diverse types of peripheral nerve injuries.
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Whisker-related afferents in superior colliculus
Rodents use their whiskers to explore the environment, and the superior colliculus is part of the neural circuits that process this sensorimotor information. Cells in the intermediate layers of the superior colliculus integrate trigeminotectal afferents from trigeminal complex and corticotectal afferents from barrel cortex. Using histological methods in mice, we found that trigeminotectal and corticotectal synapses overlap somewhat as they innervate the lower and upper portions of the intermediate granular layer, respectively. Using electrophysiological recordings and optogenetics in anesthetized mice in vivo, we showed that, similar to rats, whisker deflections produce two successive responses that are driven by trigeminotectal and corticotectal afferents. We then employed in vivo and slice experiments to characterize the response properties of these afferents. In vivo, corticotectal responses triggered by electrical stimulation of the barrel cortex evoke activity in the superior colliculus that increases with stimulus intensity and depresses with increasing frequency. In slices from adult mice, optogenetic activation of channelrhodopsin-expressing trigeminotectal and corticotectal fibers revealed that cells in the intermediate layers receive more efficacious trigeminotectal, than corticotectal, synaptic inputs. Moreover, the efficacy of trigeminotectal inputs depresses more strongly with increasing frequency than that of corticotectal inputs. The intermediate layers of superior colliculus appear to be tuned to process strong but infrequent trigeminal inputs and weak but more persistent cortical inputs, which explains features of sensory responsiveness, such as the robust rapid sensory adaptation of whisker responses in the superior colliculus.
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Cerebellar contributions to self-motion perception: evidence from patients with congenital cerebellar agenesis
The cerebellum was historically considered a brain region dedicated to motor control, but it has become clear that it also contributes to sensory processing, particularly when sensory discrimination is required. Prior work, for example, has demonstrated a cerebellar contribution to sensory discrimination in the visual and auditory systems. The cerebellum also receives extensive inputs from the motion and gravity sensors in the vestibular labyrinth, but its role in the perception of head motion and orientation has received little attention. Drawing on the lesion-deficit approach to understanding brain function, we evaluated the contributions of the cerebellum to head motion perception by measuring perceptual thresholds in two subjects with congenital agenesis of the cerebellum. We used a set of passive motion paradigms that activated the semicircular canals or otolith organs in isolation or combination, and compared results of the agenesis patients with healthy control subjects. Perceptual thresholds for head motion were elevated in the agenesis subjects for all motion protocols, most prominently for paradigms that only activated otolith inputs. These results demonstrate that the cerebellum increases the sensitivity of the brain to the motion and orientation signals provided by the labyrinth during passive head movements.
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Influence of vigilance state on physiological consequences of seizures and seizure-induced death in mice
Sudden unexpected death in epilepsy (SUDEP) is the leading cause of death in patients with refractory epilepsy. SUDEP occurs more commonly during nighttime sleep. The details of why SUDEP occurs at night are not well understood. Understanding why SUDEP occurs at night during sleep might help to better understand why SUDEP occurs at all and hasten development of preventive strategies. Here we aimed to understand circumstances causing seizures that occur during sleep to result in death. Groups of 12 adult male mice were instrumented for EEG, EMG, and EKG recording and subjected to seizure induction via maximal electroshock (MES) during wakefulness, nonrapid eye movement (NREM) sleep, and rapid eye movement (REM) sleep. Seizure inductions were performed with concomitant EEG, EMG, and EKG recording and breathing assessment via whole body plethysmography. Seizures induced via MES during sleep were associated with more profound respiratory suppression and were more likely to result in death. Despite REM sleep being a time when seizures do not typically occur spontaneously, when seizures were forced to occur during REM sleep, they were invariably fatal in this model. An examination of baseline breathing revealed that mice that died following a seizure had increased baseline respiratory rate variability compared with those that did not die. These data demonstrate that sleep, especially REM sleep, can be a dangerous time for a seizure to occur. These data also demonstrate that there may be baseline respiratory abnormalities that can predict which individuals have higher risk for seizure-induced death.
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Odors enhance slow-wave activity in non-rapid eye movement sleep
Most forms of suprathreshold sensory stimulation perturb sleep. In contrast, presentation of pure olfactory or mild trigeminal odorants does not lead to behavioral or physiological arousal. In fact, some odors promote objective and subjective measures of sleep quality in humans and rodents. The brain mechanisms underlying these sleep-protective properties of olfaction remain unclear. Slow oscillations in the electroencephalogram (EEG) are a marker of deep sleep, and K complexes (KCs) are an EEG marker of cortical response to sensory interference. We therefore hypothesized that odorants presented during sleep will increase power in slow EEG oscillations. Moreover, given that odorants do not drive sleep interruption, we hypothesized that unlike other sensory stimuli odorants would not drive KCs. To test these hypotheses we used polysomnography to measure sleep in 34 healthy subjects (19 women, 15 men; mean age 26.5 ± 2.5 yr) who were repeatedly presented with odor stimuli via a computer-controlled air-dilution olfactometer over the course of a single night. Each participant was exposed to one of four odorants, lavender oil (n = 13), vetiver oil (n = 5), vanillin (n = 12), or ammonium sulfide (n = 4), for durations of 5, 10, and 20 s every 9–15 min. Consistent with our hypotheses, we found that odor presentation during sleep enhanced the power of delta (0.5–4 Hz) and slow spindle (9–12 Hz) frequencies during non-rapid eye movement sleep. The increase was proportionate to odor duration. In addition, odor presentation did not modulate the occurrence of KCs. These findings imply a sleep-promoting olfactory mechanism that may deepen sleep through driving increased slow-frequency oscillations.
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COMT and ANKK1 Genetics Interact With Depression to Influence Behavior Following Severe TBI: An Initial Assessment
Objective. Genetic variations in the dopamine (DA) system are associated with cortical-striatal behavior in multiple populations. This study assessed associations of functional polymorphisms in the ankyrin repeat and kinase domain (ANKK1; Taq1a) and catechol-O-methyltransferase (COMT; Val158Met) genes with behavioral dysfunction following traumatic brain injury (TBI). Participants. This was a prospective study of 90 survivors of severe TBI recruited from a level 1 trauma center. Main measures. The Frontal Systems Behavior Scale, a self- or family report questionnaire evaluating behavior associated with frontal lobe dysfunction, was completed 6 and 12 months postinjury. Depression was measured concurrently with the Patient Health Questionnaire-9. Study participants were genotyped for Val158Met and Taq1a polymorphisms. Results. No statistically significant behavioral differences were observed by Taq1a or Val158Met genotype alone. At 12 months, among those with depression, Met homozygotes (Val158Met) self-reported worse behavior than Val carriers (P = .015), and A2 homozygotes (Taq1a) self-reported worse behavior than A1 carriers (P = .028) in bivariable analysis. Multivariable models suggest an interaction between depression and genetic variation with behavior at 12 months post-TBI, and descriptive analysis suggests that carriage of both risk alleles may contribute to worse behavioral performance than carriage of either risk allele alone. Conclusion. In the context of depression, Val158Met and Taq1a polymorphisms are individually associated with behavioral dysfunction 12 months following severe TBI, with preliminary evidence suggesting cumulative, or perhaps epistatic, effects of COMT and ANKK1 on behavioral dysfunction.
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Continuous Professional Development: Faculty Views On Need, Impact And Barriers
2016-05-06T20-02-20Z
Source: National Journal of Integrated Research in Medicine
Mrs. M P Jiandani*,Dr.Rahul Bogam**, Dr.Chinmay Shah***,Dr S Prabhu#, Dr B Taksande##.
Background& Objective:Ever changing dynamic field of science, technology and health care had made it essential for a health care professional to keep abreast of the latest development. Continuous Professional Development (CPD) can be considered as a process in which individual practitioners identify their own learning needs, makes plan to meet those objectives and finally evaluates the effectiveness of the plan .Perceived barriers to CPD vary significantly by individuals personal characteristics, job position, and organizational factors. Present study was done to explore the faculty views of CPD in terms of its need, methods, impact and barriers. Objectives: 1.To assess the perceptions of healthcare faculty about Continuous Professional Development 2.To identify the barriers perceived by health care faculty for Continuous Professional Development.Methodology:A Cross Sectional study was conducted among 32 faculty,enrolled for Foundation for Advancement in International Medical Education and Research (FAIMER) Fellowship programme at one of the regional institutes of India. A self- administered structured and modified questionnaire was given to participants as a part of Mentoring and Learning (ML) web sessions through Survey Monkey.Results:In the study, 16 (50%) out of 32 faculty members participated, where majority of participants considered attending conferences, reading journals and E-learning Modules as a CPD activity undertaken in the past one year . Nearly all participants agreed that CPD can make positive change in terms of diagnostic and treatment practices (81.25%), knowledge acquisition (100%) as well as attitude (93.75%) towards patients. Availability of study leave (56.25%) and work-life balance (75%) were significant barriers to participation. Participants strongly believed that CPD helps to recognize knowledge gaps, promoted self-reflection and focused endeavours.Conclusion:Present study reported good knowledge, favourable attitudes and practices towards Continuous Professional Development activities among health care faculty members. The study also revealed combination of responses among faculty about their own CPD activities. [Jiandani M NJIRM 2016; 7(2):106-109]
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Influence of variations in arterial Formula on surgical conditions during laparoscopic retroperitoneal surgery
Background
Although deep neuromuscular block (post-tetanic-count 1-2 twitches) improves surgical conditions during laparoscopic retroperitoneal surgery compared with standard block (train-of-four 1-2 twitches), the quality of surgical conditions varies widely, often related to diaphragmatic contractions. Hypocapnia may improve surgical conditions. Therefore we studied the effect of changes in arterial carbon dioxide concentrations on surgical conditions in patients undergoing laparoscopic surgery under general anaesthesia and deep neuromuscular block.
MethodsForty patients undergoing elective laparoscopic surgery for prostatectomy or nephrectomy received propofol/remifentanil anaesthesia and deep neuromuscular block with rocuronium. Patients were randomized to surgery under hypocapnic or hypercapnic conditions. During surgery, the surgical conditions were evaluated using the 5-point Leiden-Surgical Rating Scale (L-SRS) ranging from 1 (extremely poor conditions) to 5 (optimal conditions) by the surgeon, who was blinded to group.
ResultsMean (sd) arterial carbon dioxide concentrations were 4.5 (0.6) [range: 3.8–5.6] kPa under hypocapnic and 6.9 (0.6) [6.1–8.1] kPa under hypercapnic conditions. The L-SRS did not differ between groups: 4.84 (0.4) [4-5] in hypocapnia and 4.77 (0.4) [3.9–5] in hypercapnia. Ninety-nine percent of ratings were good or excellent irrespective of treatment.
ConclusionsDeep neuromuscular block provides good to optimal surgical conditions in laparoscopic retroperitoneal urological surgery, independent of the level of arterial PCO2.
Clinical trial registrationNCT01968447.
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Role of methylenetetrahydrofolate reductase 677C→T polymorphism in the development of myocardial infarction: evidence from an original study and updated meta-analysis
Abstract
The methylenetetrahydrofolate reductase (MTHFR) gene variant 677C→T is considered a risk factor for myocardial infarction (MI) in Caucasians, but it remains unclear whether this applies to Chinese or other Asian populations. A total of 551 controls and 304 age-matched Chinese MI patients were recruited. MTHFR genotypes were determined. A subsequent meta-analysis was performed to determine the association between MTHFR and MI in Asia. Conventional risk factors such as hypertension, diabetes mellitus and low-density lipoprotein exhibited no significant differences between the two groups. Genotype frequencies among cases and controls were compatible with Hardy–Weinberg equilibrium. The frequencies of CC, CT and TT genotypes were 28, 46 and 26 % for patients with MI and 31, 52 and 17 % for the matched control group (p = 0.006). T-allele frequency in MI patients was higher than in controls (49 vs. 43 %, odds ratio = 0.785, 95 % confidence interval = 0.644–0.958, p = 0.017). A total of 16 studies including ours were identified, involving 4053 patients and 6791 controls. A recessive genotype model of MTHFR 677C→T polymorphism, but not a dominant genotype model, was significantly associated with greater MI risk in Asians. MI risk increased 48, 37 and 47 % for the TT homozygote compared with the CC wild type, CT heterozygote and the combination of CT and CC. Thus, we conclude that the MTHFR gene variant 677C→T is a risk factor for MI in the Chinese population and the TT genotype is associated with a significant increase in MI risk in Asia.
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Time Sequence Evaluation of Biliary Stent Occlusion by Dissection Analysis of Retrieved Stents
Abstract
Background and Aims
Multiple factors can affect the occlusion of plastic stents. Previous data demonstrate that side holes may induce more biofilm formation probably via microturbulence and bile flow disturbances that could lead to occlusion. These results, however, have not been replicated in subsequent clinical studies with different methods. The objective of this study is to evaluate the physical characteristics of plastic stent occlusion over time.
Methods
This is a plastic stent sequential analysis study. Biliary stents removed via ERCP from February 24, 2015, to June 2, 2015, were included. One hundred and forty-eight retrieved straight-type plastic stents were longitudinally cut by a custom-made cutting device. These dissected stents were then evaluated in detail with regard to the location of stent occlusion and the stent patency period. Location of stent occlusive debris was the primary outcome in this study.
Results
Biofilm formations and occlusions by debris were sequentially but separately tallied. Biofilm formations were initially seen around the side hole areas within 30 days and spread to the entire stent by 60 days. Then, occlusion process by debris was mainly initiated by 80 days and progressed to full occlusion by median of 90 days. Although some occlusions were also observed around the side hole areas within 30 days, affected areas were more widely observed after biofilm formation.
Conclusions
This study is the first to attempt to describe the distribution of stent occlusions over time. These observations may help guide future stent development.
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Transjugular Intrahepatic Porto-Systemic Shunt in Patients with Liver Cirrhosis and Model for End-Stage Liver Disease ≥15
Abstract
Background
It is not known whether transjugular intrahepatic porto-systemic shunt (TIPS) is safe in patients with advanced liver cirrhosis. The aim of our study was to evaluate the impact of TIPS on transplant-free survival in patients with liver cirrhosis and MELD score ≥15.
Methods
All adult patients who underwent TIPS at our institution between 2004 and 2011 were identified (N = 470). A total of 144 patients had MELD ≥15 at the time of TIPS. These patients were matched 1:1 to patients with liver cirrhosis who did not undergo TIPS based on age and MELD score using the greedy algorithm. Patients were followed up until time of death or liver transplantation. Kaplan–Meier curves and log-rank tests were used to test for differences in survival outcome between the two groups.
Results
A total of 288 patients with liver cirrhosis were included, of whom 144 underwent TIPS and 144 did not. The two groups were matched based on age and MELD score and were comparable with regard to gender and ethnicity. Mean MELD and Child–Pugh scores in the study population were 20.9 ± 6.5 and 10.5 ± 1.8, respectively. The most common indication for TIPS was varices (49 %), followed by refractory ascites (42 %). In the first 2 months post-TIPS, there was increased mortality or liver transplantation in patients who had TIPS compared to those who did not, but this did not reach statistical significance (p = 0.07). However, after 2 months, TIPS is associated with 56 % lower risk of dying or needing liver transplantation (p < 0.01) than cirrhotic patients who did not undergo TIPS.
Conclusion
In patients with liver cirrhosis and MELD ≥15, TIPS might improve transplant-free survival for patients who live for at least 2 months after the procedure.
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The dentist's care-taking perspective of dental fear patients – a continuous and changing challenge
Summary
The aim was to analyse the care taking of dental fear patients from the perspective of the dentist, using a qualitative methodology. In total, 11 dentists from both the private and public dental service were selected through a purposive sampling according to their experience of treating dental fear patients, their gender, age, service affiliation and location of undergraduate education. Data were obtained using one semi-structured interview with each informant. The interviews were taped and verbatim transcribed. The text was analysed using qualitative content analysis. The theme, 'The transforming autodidactic process of care taking', covering the interpretative level of data content was identified. The first main category covering the descriptive level of data was 'The continuous and changing challenge', with the subcategories 'The emotional demand' and 'The financial stress'. The second main category identified was 'The repeated collection of experience', with the subcategories 'The development of resources' and 'The emotional change'. The dentists′ experience of treating dental fear patients was considered a challenging self-taught process under continuous transformation. The competence and routine platform expanded over time, parallel to a change of connected emotions from frustration towards safety, although challenges remained.
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Genotype–phenotype correlation of Charcot-Marie-Tooth type 1E patients with PMP22 mutations
Abstract
Charcot-Marie-Tooth disease type 1E (CMT1E) is a demyelinating motor and sensory neuropathy with peripheral myelin protein 22 (PMP22) point mutations. The objective of this study was to identify genetic causes and determine genotype–phenotype correlation in two Korean demyelinating CMT patients based on whole exome sequencing (WES), histological examination of distal sural nerve, and magnetic resonance imaging (MRI) of leg. WES revealed two de novo PMP22 mutations in the two demyelinating CMT patients, including one novel p.Leu82Pro (c.245T>A) mutation in one patient and one previously reported p.Ser72Leu (c.215C>T) mutation in the other patient. Both mutation sites were located in the well conserved second transmembrane domain. No control had the same mutations. The affected individual with the novel p.Leu82Pro mutation showed early onset, scoliosis, and sensory ataxia with ability to walk without assistance. Histopathological examination showed severe damage of myelin and axons. No compound muscle action potentials (CMAPs) were evoked in the upper or lower limb nerves. Leg MRIs revealed mild fatty infiltration of the bilateral peronei muscles consistent with clinical manifestations. The patient with the p.Ser72Leu mutation showed developmental delay in infancy. No CMAPs were elicited. However, she was also able to walk without assistance. In spite of markedly severe electrophysiological defects, leg MRIs showed almost normal findings except slight muscle atrophies of the lower legs. Both patients presented similar clinical features including no CMAPs in electrophysiological tests and mild fatty replacement in the lower leg MRI. Therefore, there was a good genotype–phenotype correlation in both cases.
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Introducing the NARCAN Now App, a Smartphone Application Providing Opioid Overdose Recognition Education and Treatment Instructions
Smartphone app for the education of administering NARCAN® (naloxone HCI) Nasal Spray in emergency opioid overdose situation DUBLIN – Adapt Pharma, Limited, (www.adaptpharma.com) today announced the launch of a new smartphone app, NARCAN® Now. This free app provides guidance and education for recognizing symptoms of a suspected opioid overdose, a 3-step guide for administering NARCAN® ...
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Professional Sports Drug Testing Collector (Nationwide) - Comprehensive Drug Testing (CDT)
CDT is seeking qualified candidates with a background in law enforcement, emergency medical response, or laboratory science/toxicology for a unique part-time opportunity as a Professional Sports Drug Testing Collector. ABOUT US CDT, Inc. (Comprehensive Drug Testing, Inc.) manages drug-testing programs for several major professional sports organizations. Administering a nationwide drug-testing program ...
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Effect of eccentric exercise with reduced muscle glycogen on plasma interleukin-6 and neuromuscular responses of m. quadriceps femoris
Eccentric exercise can result in muscle damage and interleukin-6 (IL-6) secretion. Glycogen availability is a potent stimulator of IL-6 secretion. We examined effects of eccentric exercise in a low glycogen state on neuromuscular function and plasma IL-6 secretion. Twelve active males (23 ± 4 years, 179 ± 5 cm, 77 ± 10 kg) completed two downhill treadmill runs (gradient, -12%, 5x8 min; speed, 12.1 ± 1.1 km•h-1) with normal (NG) and reduced muscle glycogen (RG) in randomized order and at least six weeks apart. Muscle glycogen was reduced using an established cycling protocol until exhaustion and dietary manipulation the evening before the morning run. Physiological responses were measured up to 48 h after the downhill runs. During recovery, force deficits of m. quadriceps femoris by maximal isometric contractions were similar. Changes in low-frequency fatigue were larger with RG. Voluntary activation and plasma IL-6 levels were similar in recovery between conditions. It is concluded that unaccustomed, damaging eccentric exercise with low muscle glycogen of the m. quadriceps femoris: i) exacerbated low-frequency fatigue, but ii) had no additional effect on IL-6 secretion. Neuromuscular impairment after eccentric exercise with low muscle glycogen appears to have a greater peripheral component in early recovery.
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Perfusion-related stimuli for compensatory lung growth following pneumonectomy
Following pneumonectomy (PNX), two separate mechanical forces act on the remaining lung: parenchymal stress caused by lung expansion, and microvascular distension and shear caused by increased perfusion. We previously showed that parenchymal stress and strain explains approximately one-half of overall compensation; the remainder was presumptively attributed to perfusion-related factors. In this study we directly tested the hypothesis that perturbation of regional pulmonary perfusion modulates post-PNX lung growth. Adult canines underwent banding of the pulmonary artery (PAB) to the left caudal (LCa) lobe, which caused a reduction in basal perfusion to LCa lobe without preventing the subsequent increase in its perfusion following right PNX while simultaneously exaggerating the post-PNX increase in perfusion to the unbanded lobes, thereby creating differential perfusion changes between banded and unbanded lobes. Control animals underwent Sham PA banding followed by right PNX. Pulmonary function, regional pulmonary perfusion, and high-resolution computed tomography of the chest were analyzed pre-PNX and 3 months post-PNX. Terminally the remaining lobes were fixed for detailed morphometric analysis. Results were compared to corresponding lobes in two control (Sham banding and normal unoperated) groups. PAB impaired the indices of post-PNX extravascular alveolar tissue growth by up to 50% in all remaining lobes. PAB enhanced the expected post-PNX increase in alveolar capillary formation, measured by the prevalence of double-capillary profiles, in both unbanded and banded lobes. We conclude that perfusion distribution provides major stimuli for post-PNX compensatory lung growth independent of the stimuli provided by lung expansion and parenchyma stress and strain.
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The effect of aging and exercise on the tendon
Here we review the literature on how tendons respond and adapt to ageing and exercise. With respect to aging, there are considerable changes early in life, but this seems to be maturation rather than aging per se. In vitro data indicate that aging is associated with a decreased potential for cell proliferation and a reduction in the number of stem/progenitor like cells. Further, there is persuasive evidence that turnover in the core of the tendon after maturity is very slow or absent. Tendon fibril diameter, collagen content, and whole tendon size appear to be largely unchanged with aging, while glycation derived cross-links increase substantially. Mechanically, aging appears to be associated with a reduction in modulus and strength. With respect to exercise, tendon cells respond by producing growth factors, and there is some support for a loading-induced increase in tendon collagen synthesis in humans, which likely reflects synthesis at the very periphery of the tendon rather than the core. Average collagen fibril diameter is largely unaffected by exercise, while there can be some hypertrophy of the whole tendon. In addition it seems that resistance training can yield increased stiffness and modulus of the tendon and may reduce the amount of glycation. Exercise thereby tends to counteract the effects of aging.
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Effects of commonly used inotropes on myocardial function and oxygen consumption under constant ventricular loading conditions
Inotropic medications are routinely used to increase cardiac output and arterial blood pressure during critical illness. However, few comparative data exist between these medications, particularly independent of their effects on venous capacitance and systemic vascular resistance. We hypothesized that an isolated working heart model which maintained constant left atrial pressure and aortic blood pressure could identify load-independent differences between inotropic medications. In an isolated heart preparation, the aorta and left atrium of Sprague Dawley rats were cannulated and placed in working mode with fixed left atrial and aortic pressure. Hearts were then exposed to common doses of a catecholamine (dopamine, epinephrine, norepinephrine, or dobutamine), milrinone, or triiodothyronine (n=10 per dose per combination). Cardiac output, contractility (dP/dTmax), diastolic performance (dP/dTmin and Tau), stroke work, heart rate, and myocardial oxygen consumption were compared during each 10 minute infusion to an immediately preceding baseline. Of the catecholamines, dobutamine increased cardiac output, contractility, and diastolic performance more than clinically equivalent doses of norepinephrine (second most potent), dopamine, or epinephrine (P<0.001). The use of triiodothyronine and milrinone was not associated with significant changes in cardiac output, contractility or diastolic function, either alone or added to a baseline catecholamine infusion. Myocardial oxygen consumption was closely related to dP/dTmax (r2 = 0.72), dP/dTmin (r2=0.70), and stroke work (r2 = 0.53). In uninjured, isolated working rodent hearts under constant ventricular loading conditions, dobutamine increased contractility and cardiac output more than clinically equivalent doses of norepinephrine, dopamine and epinephrine; milrinone and T3 did not have significant effects on contractility.
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The Utility of Nuclear Medicine Scans for Diagnosing Pediatric Biliary Dyskinesia Remains Unclear.
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Oral Motor Impairment in Children with Feeding Difficulties.
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The Key Clinical Manifestations of Lysosomal Acid Lipase Deficency.
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Clinical Use of Infliximab Trough Levels and Antibodies to Infliximab in Pediatric Inflammatory Bowel Disease Patients.
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Patients With Coeliac Disease Reported Highter Consumption of Added Sugar and Total Fat Than Healthy Individuals.
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Estimation of Fat-Free Mass at Discharge in Preterm Infants Fed with Optimized Feeding Regimen.
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