Σάββατο, 14 Μαΐου 2016

5th-graders, school nurse save teacher who suffered stroke

By Jamie Forsythe
The Belleville News-Democrat

BELLEVILLE, Ill. — Fifth-grader Rebecca Bagby says she "sprinted down the hall like a cheetah" to the school nurse's office when her teacher was in distress.

The students at Whiteside Middle School knew something was wrong. Russell was mumbling, his face was drooping on one side and he couldn't stay seated in his chair.

School nurse Amanda Eversgerd identified the signs of a stroke right away, and a staff member called 911.

Eversgerd is familiar with emergency situations from her previous job as a trauma nurse at St. Louis University Hospital.

"I've dealt with life-threatening situations before. It definitely is scary," Eversgerd said. "We moved very, very quickly."

When she got to Russell's classroom, he was on the floor behind his desk.

"I immediately knew something was terribly wrong," Eversgerd said. "I knew when I first spoke to him that it was a stroke. One side of his body was paralyzed. He was unable to move it."

Another teacher came in to help evacuate the students as they waited for paramedics to arrive.

"They were obviously very shaken up," Eversgerd said.

I immediately knew something was terribly wrong. I knew when I first spoke to him that it was a stroke. One side of his body was paralyzed. He was unable to move it.

One year later, the scary incident is still fresh in the minds of Russell, his former students and colleagues.

Most of the students in class were crying. "We thought he was going to die," Rebecca said. "We didn't know what was happening."

Student Dasia Napper said she was scared. "It was just crazy," she said. "I've never seen somebody have a stroke before."

Student Anaia Crow-Vindiola was "very, very scared. I was starting to cry, because I didn't know if he was going to die or if he was going to live."

Eversgerd was impressed with the maturity of the students.

"I was very, very taken back by the maturity students showed in the emergency situation and afterward," Eversgerd said. "Everyone was extremely mature about it."

She was especially impressed that the students were able to identify that Russell needed help even if he didn't say he did.

"It was beyond Mr. Russell to be able to help himself," Eversgerd said. "That fills me with a lot of pride — the caliber of the character of the students that were in the classroom."

At first, Rebecca, said she and other students thought their teacher was "being funny because he likes to joke with us." Then, "We saw him starting to drool. One side of his lip was drooping down."

Dasia said she got another teacher while Rebecca went to the school nurse's office.

Now in sixth grade, Whiteside Middle School students remember what happened and what they did to help their teacher Blair Russell who suffered a stroke while teaching math last May.

Russell's perspective
Russell, 38, vividly remembers suffering a stroke at 1:30 p.m. May 4, 2015. The day before, Russell said he and his wife, Macy, were coming back from Wisconsin where they were visiting family. It was a 9-hour drive.

"I felt fine. I just felt very tired all day," he said. "I just thought it was the trip that we did."

Around 1:20 p.m. Russell recalled getting numbness in his left hand. "My last three fingers, they just started feeling numb. I started pinching them. I bit them. I couldn't feel anything.

"My kids started saying 'Mr. Russell, you sound funny.' I was teaching math at the time."

Russell got a glass of water from behind his desk. "Water started coming out of the side of my mouth whenever I started talking," he said.

He went back to his desk to sit down, because he said he "wasn't feeling right."

That's when the tingling started coming up his arm and his leg started becoming numb. "I sat down or I attempted to sit down," Russell said. "I fell out of my chair. The kids thought I was joking because I mess around with my kids a lot and joke around with them."

Three boys in his class tried to pick him up, he said. "I was deadweight. I couldn't move," Russell said. "They couldn't move me, and at that point I started getting scarred."

I was just scared out of my mind that I was going to die right there on the floor.

Russell has a had a heart condition since birth — hypertrophic cardiomyopathy. "At first since it was my left arm, I thought I was having a heart attack," he said.

Then after thinking about the slurred speech, Russell said he thought he may be having a stroke. "I didn't think I was old enough to have one of those," said Russell, whose grandfather had a stroke when he was in his late 70s.

The school nurse, Eversgerd, came in and told Russell he was having a stroke. "That's when it hit me very hard," he said. "I tried to remember everything. Anything I ever heard about a stroke is you forget things and lose your money."

Russell said he was "scared to death" that his kids were in the room. He remembers wondering what they must be thinking and feeling.

"I was just scared out of my mind that I was going to die right there on the floor," he said.

The EMTs took him to St. Elizabeth's Hospital in Belleville. "I had no idea what's going on. I was going in and out," Russell said.

Blood clot removal
Russell suffered an ischemic stroke, which means a clot was blocking blood supply to the brain, said Dr .Jin-Moo Lee, a neurologist who specializes in strokes. Lee treated Russell at Barnes-Jewish Hospital in St. Louis.

"He had a blockage of a major artery — one of the largest arteries in the brain," Lee said. "This was on the right side of the brain, which is why he had the weakness on the left side."

In Russell's case, blood was not flowing through the part of the brain where the clot was. It was critical to get the blockage removed and blood flowing as quickly as possible.

At St. Elizabeth's, Russell remembers seeing a doctor on a computer screen. "They wanted to see my face to see how serious it was," he said. "I remember them saying, 'You have to get him to Barnes as soon as possible. He's going to lose more if we don't take care of this right now.'"

According to Lee, there's a shortage of stroke specialists in the country, which is where telemedicine comes in. It's hard for a doctor not familiar with strokes to determine the right course of action.

As a result of the specialist seeing Russell's face, he received a tissue plasminogen activator. "It's an intravenous medicine that is used to dissolve blood clots that cause blockages in the arteries," Lee said. "Then he was immediately transferred to us at Barnes-Jewish Hospital."

Russell said he doesn't remember anything about the helicopter ride except the noise.

Upon arrival, he was taken into surgery where an interventional neuroradiologist used a small catheter, threaded it up through his leg to his brain, grabbed the clot and removed it.

"You can actually snare that clot and pull it out mechanically," Lee said. "It took three passes (with Russell). They had to go in and out three times. They finally got it. They pulled the clot out and then shortly thereafter his symptoms began to resolve. ... He was able to regain a lot of the function that was initially lost."

The procedure was done less than six months after several studies were published in January 2015, Lee said, that found this new therapy called thrombectomy was "proven to be effective for exactly this type of stroke."

At Barnes, Lee explained thrombectomy wasn't adopted as the standard of care until those studies came out. "Before that, we did it on a case-by-case basis," he said.

Eight days later, Russell returned to his classroom to finish out the school year and, most importantly, let his kids know he was OK.

"I wanted to prove to my kids that I was strong enough to come back, and I wanted them to see me, because they saved my life too by going to get the nurse," he said. "I was stubborn, telling them no, no, I'm fine, I'm fine. They went out of their way and got the nurse and made sure I was OK."

His students were thankful to have him back.

"I was really, really relieved," Anaia said. "I was glad, because he was one of my favorite teachers. It made me feel a lot better, and I didn't have to worry anymore."

Rebecca said Russell is her "favorite teacher of all time."

Now a year later, Russell said he has only minimal lasting effects from the stroke. Three of his fingers on his left hand are still weak, and he has some memory issues.

"To have those two be my only side effects after a stroke, I consider myself very lucky," he said.

Russell admits he still doesn't sleep "great" as he's worried it's going to happen again. He's taking blood thinners, which doctors say reduce the risk.

I wanted to prove to my kids that I was strong enough to come back, and I wanted them to see me, because they saved my life too by going to get the nurse.

The stroke wasn't Russell's only major medical emergency last year. Right before Thanksgiving, Russell's defibrillator shocked his heart while he was dancing as part of a skit. He was transported by ambulance to the hospital from the school.

"It felt like somebody punched me in the chest as hard as they could," he said. "It was a crazy, crazy year."

Stroke symptoms, awareness
Lee said it can be difficult to identify a stroke since the signs are different depending on what area of the brain it's in.

The most common symptoms, he said, are the sudden onset of weakness on one side of the body; numbness on one side of the body; inability to communicate, either understand or create speech; and inability to see out of one eye or one visual field.

"The hallmark of a stroke is it happens suddenly," Lee said. "One moment you're OK and within moments, you have these deficits."

When a stroke happens, time is of the essence. "When a stroke occurs, the brain tissue doesn't all die at once. ...The death occurs over a period of minutes to hours," he said. "As the stroke is evolving, the earlier you intervene with the therapy, the more effective that therapy is."

For the procedure Russell had, Lee said, that therapy window is six hours. "Time is really critical," he said.

May is National Stroke Awareness month.

"It's important for everyone to recognize a stroke," said Eversgerd, the school nurse at Whiteside.

Whiteside Middle School has cardiopulmonary resuscitation training with staff members, which includes stroke symptom awareness.

The school has a first aid and CPR unit for sixth-grade classes.

Training children and young people is important, Eversgerd said. "Who is going to be with those people who are most likely to suffer from a stroke? Their kids,"

Russell appreciates all the support he received from students and staff members at Whiteside.

"The students and teachers all helped me get my strength back," he said, "and I owe them a lot."

Since his life scares last year, Russell said he appreciates life even more now.

"Live everyday like its your last, hug everybody; and that's what I've done," he said. "I don't let things get to me as much as they did back then. I would get mad and frustrated a lot, but now I have even more patience than I did when I first started teaching. It could be my last day. I almost died twice."

Copyright 2016 the Belleville News-Democrat



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Correlation of probability scores of placenta accreta on magnetic resonance imaging with hemorrhagic morbidity

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To evaluate the hypothesis that assigning grades to magnetic resonance imaging (MRI) findings of suspected placenta accreta will correlate with hemorrhagic outcomes. We chose a single-center, retrospective, observational design.

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Impact of aortic root size on left ventricular afterload and stroke volume

Abstract

Purpose

The left ventricle (LV) ejects blood into the proximal aorta. Age and hypertension are associated with stiffening and dilation of the aortic root, typically viewed as indicative of adverse remodeling. Based on analytical considerations, we hypothesized that a larger aortic root should be associated with lower global afterload (effective arterial elastance, EA) and larger stroke volume (SV). Moreover, as antihypertensive drugs differ in their effect on central blood pressure, we examined the role of antihypertensive drugs for the relation between aortic root size and afterload.

Methods

We studied a large group of patients (n = 1250; 61 ± 12 years; 78 % males; 64 % hypertensives) from a single-center registry with known or suspected coronary artery disease. Aortic root size was measured by echocardiography as the diameter of the tubular portion of the ascending aorta. LV outflow tract Doppler was used to record SV.

Results

In the population as a whole, after adjusting for key covariates in separate regression models, aortic root size was an independent determinant of both SV and EA. This association was found to be heterogeneous and stronger in patients taking a calcium channel blocker (CCB; 10.6 % of entire population; aortic root size accounted for 8 % of the explained variance of EA).

Conclusion

Larger aortic root size is an independent determinant of EA and SV. This association was heterogeneous and stronger in patients on CCB therapy.



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Analysis of cardio-pulmonary and respiratory kinetics in different body positions: impact of venous return on pulmonary measurements

Abstract

Purpose

The aim of the study was to compare the kinetics responses of heart rate (HR), pulmonary ( \(\dot{V}\) O2pulm), and muscular ( \(\dot{V}\) O2musc) oxygen uptake during dynamic leg exercise across different body positions (−6°, 45°, and 75°).

Methods

Ten healthy individuals [six men, four women; age 23.4 ± 2.8 years; height 179.7 ± 8.3 cm; body mass 73 ± 12 kg (mean ± SD)] completed pseudo-random binary sequence (PRBS) work rate (WR) changes between 30 and 80 W in each posture. HR was measured beat-to-beat by echocardiogram and \(\dot{V}\) O2pulm by breath-by-breath gas exchange. \(\dot{V}\) O2musc kinetics were assessed by the procedure of Hoffmann et al. (Eur J Appl Physiol 113:1745–1754, 2013) applying a circulatory model and cross-correlation functions (CCF).

Results

For \(\dot{V}\) O2pulm kinetics significant differences between −6° (CCF-values: 0.292 ± 0.040) and 45° (0.256 ± 0.034; p < 0.01; n = 10) as well as between −6° and 75° (0.214 ± 0.057; p < 0.05; n = 10) were detected at lag '40 s' of the CCF course as interaction effects (factors: Lag × Posture). HR and \(\dot{V}\) O2musc kinetics yield no significant differences across the postures.

Conclusions

The analysis of cardio-dynamic and respiratory kinetics, especially with an emphasis on muscular and cellular level, has to consider venous return and cardiac output distortions. Simplified observations of kinetics responses resulting in time constants and time delays only should be replaced by the time-series analysis for a more sophisticated evaluation. The results illustrate that isolated \(\dot{V}\) O2pulm measurements without cardio-dynamic influences may not represent the kinetics responses originally revealed at muscular level.



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Increased IL-17A/IL-17F expression ratio represents the key mucosal T helper/regulatory cell-related gene signature paralleling disease activity in ulcerative colitis

Abstract

Background

T helper (Th) and regulatory T (Treg) cell-related cytokines are implicated in inflammatory bowel diseases, including ulcerative colitis (UC). While these cytokines are generally upregulated in inflamed mucosae, the key cytokine profile explaining disease severity has not been determined.

Methods

The Rachmilewitz endoscopic index (REI) was assessed in 61 UC patients undergoing colonoscopy. Biopsies obtained from inflamed (REI 3–12) and noninflamed (REI 0–2) areas were analyzed by quantitative PCR for expression of mRNAs encoding cytokines and transcription factors related to Th1 (TNF-α, IFN-γ, IL-12p35, IL-12p40, and T-bet), Th2 (IL-4, IL-13, IL-33, and GATA3), Th17 (IL-17A, IL-17F, IL-21, IL-22, IL-23p19, IL-6, and RORC), Th9 (IL-9, IRF4, and PU.1), and Treg (TGF-β and Foxp3). Expression patterns associated with higher REI were determined by univariate and multivariate analyses.

Results

Despite general upregulation, none of these mRNAs showed univariate correlation with REI in inflamed samples. Multiple regression analysis, however, found that joint expression of IL-17A, IL-17F, IL-21, RORC, and TGF-β was significantly predictive of REI (P < 0.0002, R2 = 0.380), with major individual contributions by IL-17A (P < 0.0001) and IL-17F (P < 0.0001), which were associated with increased and decreased REI, respectively. Partial correlation analysis, validating this model, indicated differences between IL-17A and IL-17F in correlating with other targets. The IL-17A/IL-17F ratio showed a significant correlation with REI (r = 0.5124, P < 0.0001), whereas no other mRNAs were essentially predictive of REI.

Conclusions

Mucosal IL-17A/IL-17F ratio significantly correlates with endoscopic score in UC patients, accompanied by their disparate interactions with other Th/Treg-related genes.



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Burst-suppression is reactive to photic stimulation in comatose children with acquired brain injury

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Publication date: Available online 14 May 2016
Source:Clinical Neurophysiology
Author(s): Dragos A. Nita, Mihai Moldovan, Roy Sharma, Sinziana Avramescu, Hiroshi Otsubo, Cecil D. Hahn
ObjectiveBurst-suppression is an electroencephalographic pattern observed during coma. In individuals without known brain pathologies undergoing deep general anesthesia, somatosensory stimulation transiently increases the occurrence of bursts. We investigated the reactivity of burst-suppression in children with acquired brain injury.MethodsIntensive care unit electroencephalographic monitoring recordings containing burst-suppression were obtained from 5 comatose children with acquired brain injury of various etiologies. Intermittent photic stimulation was performed at 1 Hz for 1 minute to assess reactivity. We quantified reactivity by measuring the change in the burst ratio (fraction of time in burst) following photic stimulation.ResultsPhotic stimulation evoked bursts in all patients, resulting in a transient increase in the burst ratio, while the mean heart rate remained unchanged. The regression slope of the change in burst ratio, referred to as the standardized burst ratio reactivity, correlated with subjects' Glasgow Coma Scale scores.ConclusionsReactivity of the burst-suppression pattern to photic stimulation occurs across diverse coma etiologies. Standardized burst ratio reactivity appears to reflect coma severity.SignificanceMeasurement of burst ratio reactivity could represent a simple method to monitor coma severity in critically ill children.



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Median arcuate ligament syndrome in athletes

Abstract

Background

Exercise-related transient abdominal pain (ETAP) is a common entity in young athletes. Most occurrences are due to a "cramp" or "stitch," but an uncommon, and often overlooked, etiology of ETAP is median arcuate ligament syndrome (MALS). The initial presentation of MALS typically includes postprandial nausea, bloating, abdominal pain, and diarrhea, but in athletes, the initial presentation may be ETAP.

Methods

We present a case series of three athletes who presented with exercise-related transient abdominal pain and were ultimately diagnosed and treated for MALS. Unlike other patients with median arcuate ligament syndrome, these athletes presented with exercise-induced pain, rather than the common postprandial symptoms. These symptoms persisted despite conservative measures. Work-up of patients with suspected MALS include a computed tomography or magnetic resonance angiography showing compression of the celiac artery with post-stenotic dilation, or a celiac artery ultrasound demonstrating increased velocities (>200 cm/s2) with deep exhalation.

Results

All patients underwent a laparoscopic median arcuate ligament release. Postoperatively, there were no complications, and all were discharged home on postoperative day #2. All patients have subsequently returned to athletics with resolution of their symptoms.

Conclusion

ETAP is common in athletes and often resolves with preventative or conservative strategies. When ETAP persists despite these methods, alternative causes, including MALS, should be considered. A combination of a thorough history and physical exam, as well as radiographic data, is essential to make the appropriate diagnosis and treatment strategy.



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Surgical management of empyematous cholecystitis: a register study of over 12,000 cases from a regional quality control database in Germany

Abstract

Background

Acute cholecystitis is a common indication for surgery. Surgical outcomes depend among other factors on the extent of gallbladder inflammation. Data on the outcomes of patients undergoing cholecystectomy due to acute empyematous cholecystitis are rare.

Methods

Data from a prospectively maintained quality control database in Germany were analyzed. Cases with empyematous cholecystitis were compared to cases without gallbladder empyema with regard to baseline features, clinical parameters and surgical outcomes.

Results

A total of 12,069 patients with empyematous cholecystitis (EC) were compared to 33,296 patients without empyema. The male gender, advanced age, ASA score >2, elevated white blood count and fever were confirmed as risk factors for EC. The EC group differed significantly from the control group with regard to fever (28.0 vs. 9.5 %), elevated WBC (82.5 vs. 62.3 %) and positive findings from ultrasound sonography (87.4 vs. 76.9 %), p < 0001. Surgery lasted significantly longer in the EC group (86.1 ± 38.5 vs. 72.2 ± 33.6, p < 0.001). The rates of conversion (15.2 vs. 5.8 %), bile duct injury (0.8 vs. 0.4 %), re-intervention (5.5 vs. 2.6 %) and mortality (2.8 vs. 1.2 %) were significantly higher in the EC group, p < 0.001. Similarly, the length of stay (11.9 ± 10.5 vs. 8.8 ± 8.3, p < 0.001) was significantly longer in the EC group.

Conclusion

Empyematous cholecystitis is a severe form of acute cholecystitis with high rates of morbidity and mortality. Even the experienced laparoscopic surgeon should expect dissection difficulties, therefore the threshold for conversion in order to prevent bile duct injury should be low.



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Type 2 diabetes remission following gastric bypass: does diarem stand the test of time?

Abstract

Objective(s)

Roux-en-Y Gastric Bypass (RYGB) is well known to ameliorate type 2 diabetes mellitus (T2DM), and recent work suggests that the preoperative DiaREM model predicts successful remission up to 1 year post-RYGB. However, no data exist for long-term validity. Therefore, we sought to determine the utility of this score on long-term RYGB effectiveness for T2DM resolution at 2 and 10 years, respectively.

Methods

T2DM patients (Age: 48, BMI: 49, HbA1C: 8.1) undergoing RYGB at the University of Virginia between 2004–2006 (n = 42) and 2012–2014 (n = 59) were evaluated prospectively to assess preoperative DiaREM score, defined from insulin use, age, HbA1C, and type of antidiabetic medication. T2DM partial remission status was based on the American Diabetes Association guidelines (HbA1C < 6.5 % and fasting glycemia <125 mg/dL, and no anti-diabetic medications). Chi-square test was used to compare patient's T2DM status to their DiaREM probability of remission.

Results

Among RYGB patients with 2-year postoperative data, 2 were lost (n = 1 no follow-up and n = 1 died) resulting in 57 patients for analysis. For the 10-year postoperative data, 11 were lost (n = 6 no follow-up and n = 5 died), thereby resulting in only 31 patients for analysis. Patients were distributed by DiaREM score to correlate with the predicted probability of remission as follows: 0–2 (Predicted 94 %, 2-year 100 % p = 0.61, 10-year 100 % p = 0.72), 3–7 (Predicted 76 %, 2-year 94 % p = 0.08, 10-year 83 % p = 0.57), 8–12 (Predicted 36 %, 2-year 47 % p = 0.38, 10-year 43 % p = 0.72), 13–17 (Predicted 22 %, 2-year 20 % p = 0.92, 10-year 33 % p = 0.64), and 18–22 (Predicted 9 %, 2-year 15 % p = 0.40, 10-year 14 % p = 0.64).

Conclusions

Preoperative DiaREM scores are a good tool for predicting both short- and long-term T2DM remissions following RYGB. This study highlights the need to identify strategies that improve T2DM remission in those at highest risk.



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Crus incision without repair is a risk factor for esophageal hiatal hernia after laparoscopic total gastrectomy: a retrospective cohort study

Abstract

Background

Although postoperative esophageal hiatal hernia (EHH) is primarily considered a post-operative complication of esophagectomy, it is also a rare post-operative complication of laparoscopic total gastrectomy (LTG), with a reported incidence rate of 0.5 %. The purpose of this study is to analyze the incidence, clinical features, and prevention of EHH following LTG for gastric cancer.

Methods

Between October 2008 and July 2014, 78 patients who underwent LTG for gastric cancer in our hospital were analyzed. We compared the crus incision group (in which the left crus of the diaphragm was incised without suture repair) with the crus conserving or repair group (in which the crus was preserved or the crus was incised and underwent suture repair). The primary endpoint was incidence of postoperative EHH.

Results

Of the 78 patients, 7 (9.0 %) developed postoperative EHH. Three of seven patients (42.9 %) were symptomatic and required an emergency operation for intestinal obstruction. Four of seven patients (57.1 %) were asymptomatic and did not require an operation. Incising the left crus of the diaphragm without suture repair during LTG was considered the only risk factor for postoperative EHH (0 of 29 for preserving the crus or incising and performing suture repair of the crus vs. 7 of 49 in crus incision without suture repair; p = 0.033).

Conclusions

The present data suggest that incision of the crus without suture repair is associated with EHH after LTG. If crus incision is required, crus repair may be effective for the prevention of postoperative EHH.



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An application research on a novel internal grasper platform and magnetic anchoring guide system (MAGS) in laparoscopic surgery

Abstract

Background

Laparoendoscopic single-site surgery and natural orifice transluminal endoscopic surgery attempt to reduce transabdominal port sites. These require all instruments to pass through a single access point, leading to instruments collide or work at unfamiliar angles. Thus, we designed an internal grasper under magnetic anchoring guide system (MAGS) platform and investigated its utility and operability.

Methods

We measured the configuration for magnetic force decay over distance using a standardized, ex vivo laboratory testing apparatus. An electronic balance was used to measure the force of the gallbladder pull in ten patients with gallbladder stones. One pig (11 mm abdominal wall thickness) underwent a compressed trial of MAGS platform. The device was left in place for 20 min before tissue sections were harvested, and histologic assessment was performed. The utility and operability were investigated in four pigs (38–280 kg weight).

Results

The magnetic attraction force decayed exponentially over distance; the force of pulling gallbladder was 7.46 ± 0.54 N. This pairing of components allowed for coupling to a theoretical distance of 10 mm. No gross tissue damage was observed. H–E stain showed no necrosis in all specimens. One failed due to wall thickness of 45 mm. Others showed the critical view, triangulation of instruments was obtained, and instrument collision or "sword fighting" was reduced.

Conclusions

The MAGS platform overcomes limitations such as collisions and lack of triangulation, reduces transabdominal port sites, and is easy to operate. However, our internal grasper requires the abdominal wall thickness below 10 mm.



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Effect of bag extraction to prevent wound infection on umbilical port site wound on elective laparoscopic cholecystectomy: a prospective randomised clinical trial

Abstract

Background

Laparoscopic cholecystectomy is the gold standard treatment for gallbladder stones. Complications due to laparoscopic procedure are rare, but rate of wound infection in some studies is about 8 %. From January 2007 to December 2008, 320 laparoscopic cholecystectomies were performed at our hospital, and in 4.7 % of them, wound infection of the umbilical trocar was identified. We believe that this infection rate could be lower and that it is necessary to implement a new technique to reduce the wound infection. The aim of the study was to evaluate the benefits of bag extraction of gallbladder to prevent the wound infection.

Methods

Two-arm, parallel, 1:1, randomised controlled trial (ISRCTN38095251). All patients suffering from symptomatic gallbladder stones of low risk were enrolled for this study and were divided into two groups in basics gallbladder extraction: with (80 patients) or, as usually, without bag (76 patients). All patients with cholecystitis or accidental gallbladder perforation were excluded. We compared all the results to establish whether meaningful differences were found.

Results

The final sample analysed (156 patients) consisted of 121 women and 35 men; there were 80 in the control group and 76 in the study group. There were 15 (9.6 %) diagnosed wound infections, eight cases in the study group and seven in the control group. There were no statistically significant differences.

Conclusions

The determinant of wound infection in elective laparoscopic cholecystectomy is not the direct contact of the gallbladder with the wound; therefore, bag extraction is not necessary.



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Value of routine polysomnography in bariatric surgery

Abstract

Background

Obstructive sleep apnea (OSA), present in 60–70 % of bariatric surgery patients, is a potentially life-threatening condition when not detected and managed appropriately. The best available method to identify the severity of OSA is polysomnography. However, routine polysomnography measurements have not been accepted as standard modality in bariatric surgery. We report our experience with routine polysomnography in a cohort of patients undergoing bariatric surgery to determine the true prevalence of OSA with respect to the different severity levels as determined by the apnea–hypopnea index (AHI).

Methods

AHI data were retrospectively collected from all patients who underwent bariatric surgery from 2012 onward, when the performance of preoperative polysomnography became mandatory. Mild, moderate and severe OSA were defined as an AHI ≥5, ≥15 and ≥30/h, respectively. Prevalence and number needed to screen (NNS) were calculated for all OSA severity levels.

Results

A total of 1358 patients were included. OSA was detected in 813 (59.9 %; NNS: 2) patients. Moreover, 405 (29.8 %; NNS: 4) patients were diagnosed with an AHI ≥15/h and 213 (15.7 %; NNS: 7) with severe OSA (AHI ≥30/h). Extreme AHI thresholds of ≥60 and ≥90/h were detected in 79 (5.8 %; NNS: 18) and 17 (1.3 %; NNS: 77) patients, respectively.

Conclusion

One-third of the bariatric surgery patients have an AHI ≥15/h and would benefit from continuous positive airway pressure therapy. In order to increase perioperative safety and avoid the preventable risk of perioperative complications, we recommend mandatory P(S)G prior to bariatric surgery.



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Postoperative pain after laparoscopic sleeve gastrectomy: comparison of three analgesic schemes (isolated intravenous analgesia, epidural analgesia associated with intravenous analgesia and port-sites infiltration with bupivacaine associated with intravenous analgesia)

Abstract

Introduction

Although bariatric surgery is actually mainly performed laparoscopically, analgesic optimization continues being essential to reduce complications and to improve the patients' comfort. The aim of this study is to evaluate the postoperative pain after analgesia iv exclusively, or associated with epidural analgesia or port-sites infiltration with bupivacaine.

Patients and methods

A prospective randomized study of patients undergoing laparoscopic sleeve gastrectomy between 2012 and 2014 was performed. Patients were divided into three groups: Analgesia iv exclusively (Group 1), epidural analgesia + analgesia iv (Group 2) and port-sites infiltration + analgesia iv (Group 3). Pain was quantified by means of a Visual Analogic Scale, and morphine rescue needs were determined 24 h after surgery.

Results

A total of 147 were included. Groups were comparable in age, gender and BMI. There were no differences in operation time, complications, mortality or hospital stay between groups. Median pain 24 h after surgery was 5 in Group 1, 2.5 in Group 2 and 2 in Group 3 (P = 0.01), without statistically significant differences between Groups 2 and 3. In Group 1, morphine rescue was necessary in 16.3 % of the cases, 2 % in Group 2 and 2 % in Group 3 (P = 0.014), without statistically significant differences between Groups 2 and 3.

Conclusion

Epidural analgesia and port-sites infiltration with bupivacaine, associated with analgesia iv, reduce the postoperative pain, when compared with analgesia iv exclusively.

Clinical trials

ClinicalTrials.gov Identifier: NCT02662660.



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Laparoscopic bilateral cortical-sparing adrenalectomy for pheochromocytoma

Abstract

Introduction

Since laparoscopic adrenalectomy for pheochromocytoma was reported in 1992, the laparoscopic technique has largely replaced the open approach [4]. Numerous studies have demonstrated that the laparoscopic approach is associated with decreased blood loss, shorter hospitalization, faster recovery, and lower cost [1]. Conversion rates are reported at less than 5.5 %, yet concern still exists that intraoperative hypertensive crisis may be more severe with laparoscopy due to increased intraabdominal pressure [3]. Bilateral pheochromocytomas are common in patients with multiple endocrine neoplasia type 2 (MEN 2) or von Hippel-Lindau (VHL) disease. Total adrenalectomy commits the patient to lifelong steroid hormone replacement and the risk of Addisonian crisis after bilateral adrenalectomy [5]; [8]. The risk of malignant pheochromocytomas in patients with or without MEN 2 or VHL is low. The current literature supports cortical-sparing adrenalectomy in patients with bilateral pheochromocytomas [2, 7, 10]. This video presents a patient with bilateral pheochromocytomas who underwent bilateral laparoscopic cortical-sparing adrenalectomies.

Methods

A 40-year-old female presented to her primary care physician with a history of a hypertensive crisis that required an emergent cesarean section. Her workup revealed elevated urinary metanephrines, and a CT scan showed a left adrenal lesion measuring 3.9 cm and a right adrenal lesion measuring 2.7 cm. After undergoing alpha blockade, she was consented for bilateral partial adrenalectomies. A left partial adrenalectomy was performed first using four ports. The ports were then closed and the patient was repositioned in a left lateral decubitus position for a subsequent right partial adrenalectomy.

Results

The patient had an uncomplicated hospital course and was discharged home on postoperative day 4. She returned for follow-up at 2 weeks and 1 month and had returned to her normal activities. Testing for MEN and von Hippel-Lindau was both negative. Her electrolyte and cortisol levels normalized, and she was weaned off her postoperative steroids by week five. At 1-year follow-up, she remains off steroids and no longer requires anti-hypertensive medications.

Conclusion

Laparoscopic adrenalectomy is the gold standard for removal of benign lesions of the adrenal gland. Bilateral pheochromocytomas are more common in the presence of hereditary conditions such as MEN and von Hippel-Lindau and should be ruled out [8, 10]. The risk of Addisonian crisis and lifelong steroid replacement should prompt cortical preservation with bilateral disease [9]. Laparoscopic bilateral partial adrenalectomies should be considered in patients with bilateral pheochromocytomas [6]. Finally, all patients undergoing pheochromocytoma excision require lifelong follow-up to monitor for recurrence.



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NM AMR offering free CPR training as part of National EMS Week

By Jacqueline Devine
The Alamogordo Daily News

OTERO COUNTY, N.M. — The American Medical Response of Otero County is offering the community free compression-only cardiopulmonary resuscitation training that can possibly help save a life on Wednesday, May 18, outside of Walmart.

In observation of National Emergency Medical Services Week and World CPR Challenge Day, American Medical Response operations across the country will train thousands of people to save lives through compression-only CPR.

CPR is a lifesaving technique used when someone is suffering from a heart attack or has been in a near drowning situation where their breathing or heartbeat has stopped.

Compressions-only CPR involves hands compressing on the chest uninterrupted about 100 times a minute until paramedics arrive. Rescuing breathing is not necessary. The maneuver applies to adults, children and infants but not newborns.

AMR Administrator Supervisor David Wheeler said compression-only CPR allows bystanders to keep blood flowing through a victim's body just by pressing on the chest in a hard, fast rhythm.

"We do compressions at 100 per minute and we don't stop and that's the big key with doing compressions, is to not stop so that when the responders get to the scene we continue CPR. We don't move the patient," Wheeler said. "That's what's going to keep the oxygen going to the brain and then we can do the rest of the lifesaving maneuvers with the medications and the IVs plus we talk to physicians on the communications systems that way we get the best chances of the patient surviving."

Wheeler has been working for the Otero County American Medical Response team for 17 years and he was a paramedic for 37 years. When he was 16-years-old he became a junior volunteer firefighter and has wanted to help people ever since he witnessed an infant get hit by a car.

"I was a junior volunteer firefighter and I actually saw an 18 month old get hit by a car. I felt helpless," Wheeler said. "I was 16-years-old, I didn't know what to do and from that point on I decided I will never be in that situation ever again. I was an Emergency Medical Technician (EMT) before I graduated high school, the year I graduated high school I was a licensed paramedic. I was one of the youngest licensed paramedics in the state of Texas."

He said the American Medical Response has really been pushing communities across the nation to learn compression-only CPR because heart attacks are one of the top causes of death in the United States and the training only lasts about 5 to 10 minutes.

"We're really pushing it this year and trying to educate the public as much as we can. It doesn't take long, they can do it before they get their groceries," Wheeler said. "We are really enhancing the emergency responders in Otero County. Anyone can learn CPR, even kids. After a course, people will receive certificates. It's not a full CPR course, they have those for workplaces or if you're a healthcare provider. The compression-only CPR is designed for the general public."

He said it is crucial that a victim receives CPR if they are unconscious because as soon as their heart stops it takes an average of about seven minutes for heart damage and brain failure to occur.

"When the heart stops that's when zero time starts, within four to six minutes that's when brain death starts. Beyond 10 minutes the brain is without resuscitation," Wheeler said. "Our average response time for Alamogordo is seven minutes, so anything after that brain damage can start occurring. We want the public to be doing CPR. If the brain goes without oxygen for too long it can be tough to bring the patient back."

In July 2015 Gerald Champion Regional Medical Center (GCRMC) opened their first cardiac catheterization lab which has increased the chance of survival for victims of cardiac arrest.

Wheeler said before the cath lab opened patients were transferred to Las Cruces by ambulance or helicopter and CPR was one of the only ways to keep a patient alive. But now that the cath lab is in operation medical physicians can now guide a catheter into a clogged artery.

"In the cath lab they will go in and guide a catheter into a clogged artery in the heart and put stents in to keep that area alive so blood supply will keep going," he said. "We are progressing with medicine in rural communities, it's getting sophisticated. It's all about saving patients. With the cath lab here hopefully we catch a lot more patients before they get into major trouble and they can correct them there that way they don't get into that cardiac arrest situation."

Wheeler said if anyone experiences any chest pains, pain running down their left arm, shortness of breath or nausea must dial 9-1-1 immediately. Compression-only CPR should only be done if the victim is unconscious and they are waiting for a paramedic to arrive.

"We don't move the patient because we don't want to interrupt CPR. We used to put them on a board and put them in an ambulance but every time we stop CPR the blood supply drastically stops. The pressure we built on the chest drastically drops and now the brain is without oxygen and it takes time to build that back up," he said. "Every time we do that chances of survival decreases significantly. Always dial 9-1-1 if you are feeling any kind of chest discomfort."

Wheeler said a healthy lifestyle is key to maintaining a healthy heart.

"Exercise watch your diet, if you smoke, stop. That's the number one contributor to heart attacks," he said. "Getting annual physicals is also important."

Copyright 2016 the Alamogordo Daily News



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Empire State building to light tower to celebrate EMS Week

NEW YORK — The Empire State Building, in partnership with the FDNY, will be illuminated in yellow, white and blue with a red and white halo at sunset May 15 in celebration of National EMS Week.
 
EMS Week is an annual week-long series of events designed to promote public safety among all New Yorkers, attract potential EMS recruits and celebrate the life-saving efforts of more than 4,000 FDNY EMS members.
 
This is the eighth consecutive year that the Empire State Building has partnered with the FDNY to celebrate National EMS Week.

 



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Assessment of functional status of outer hair cells in Type 2 diabetes using distortion product otoacoustic emissions

2016-05-14T09-19-46Z
Source: National Journal of Physiology, Pharmacy and Pharmacology
Rajesh Paluru, Yoganandareddy Indla, Ramaswamy Chellam, Rajani Santhakumari.
Background: Outer hair cells in the organ of Corti are not directly involved in deciding the threshold of the acoustic stimulus, but their damage will increase the hearing threshold and may even cause the neuronal deafness. Type 2 diabetes is increasing globally at an alarming rate; one of many complications of Type 2 diabetes is loss of hearing. In Type 2 diabetes, poor glycemic status is the cause for neuropathy or microangiopathy which may affect the normal hearing. Aims and Objectives: To observe the effect of Type 2 diabetes on the functional status of outer hair cells. To illustrate the effect of Type 2 diabetes on outer hair cells for right and left ear is same or different. Materials and Methods: A total of 50 Type 2 diabetic subjects, aged between 30 to 55 years, both sexes were included as test group after assessing their glycemic index. 50 age and sex matched healthy individuals are also included as control group. Functioning of outer hair cells was assessed with distortion product otoacoustic emissions (DPOAEs). Results: Glycosylated hemoglobin percentage among test (8.58 ± 0.83) and control group subjects (5.28 ± 0.50) is statistically significant (


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Intravenous Sedation Without Intubation and the Risk of Anesthesia Complications for Obese and Non-Obese Women Undergoing Surgical Abortion: A Retrospective Cohort Study.

BACKGROUND: The primary objective of this study was to assess the risk of perioperative anesthesia-related complications in a cohort of obese and non-obese women undergoing outpatient surgical abortion under IV sedation without tracheal intubation. METHODS: We performed a retrospective cohort study of all surgical abortions through 22 6/7 weeks' gestation at an outpatient clinic from 2012 to 2013. Women receiving IV sedation were included. Obesity status was defined by the World Health Organization criteria. The primary outcome was the rate of perioperative anesthesia complications defined as tracheal intubation, pulmonary aspiration, hospital transfer for an anesthesia indication, or anesthesia-related adverse events (persistent hypoxemia and allergic reaction). The use of opioid reversal (naloxone) was assessed as a secondary outcome measure. Multivariate analysis for the secondary outcome measure was performed with adjustment for confounding factors. RESULTS: During the study period, 9348 abortions were performed. Of the 5579 patients who received IV sedation, 1438 (25.8%) were obese, 1707 (30.6%) were in the second trimester, and 851 (15.3%) were >=17 weeks' gestation. No patients experienced a primary outcome measure. Based on the upper 95% confidence interval (CI) for the sample size, the maximal risk of an anesthesia-related complication is 1 in 1860 procedures. Naloxone use occurred in 13 (0.2%) patients and was not more frequent among obese patients (0.14% vs 0.27%; 95% CI of odds ratio [OR], 0.12-2.36; P = 0.54) or procedures at >=17 weeks' gestation (0.47% vs 0.19%; 95% CI of OR, 0.76-8.06; P = 0.12). These negative findings should be interpreted with caution, given the limitations of the sample size to assess these secondary outcome measures. Naloxone use was associated with fentanyl doses >200 [mu]g (0.82% vs 0.13%; P = 0.002), an association that remained significant when we controlled for confounding factors (adjusted OR, 5.51; 95% CI, 1.61-18.91). Further analysis revealed that fentanyl dose >200 [mu]g was associated with naloxone use for procedures in the first trimester (incident rate ratio, 9.02; 95% CI, 3.73-21.80) but not in the second trimester (incident rate ratio, 0.92; 95% CI, 0.23-3.70). CONCLUSIONS: Among women receiving IV sedation without tracheal intubation for surgical abortion, anesthesia complications are rare and may not be greater for obese women or procedures at gestational age >=17 weeks. IV sedation without tracheal intubation may be considered for women undergoing first- and second-trimester surgical abortion; however, the rarity of anesthesia-related complications in our cohort precludes a definitive conclusion regarding the overall safety of IV sedation without tracheal intubation. (C) 2016 International Anesthesia Research Society

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The cost effectiveness of transesophageal echocardiography for pediatric cardiac surgery: a systematic review

Summary

Background

Intraoperative transesophageal echocardiography (ITEE) for pediatric cardiac surgery has been described as clinically efficacious and cost-effective. There are a small number of publications supporting these claims.

Aims

The objectives were to assess the quality of the research, the variability of results across studies and, if possible, to make a consensus statement based on the results.

Methods

In March 2015, a systematic search of MEDLINE and MEDLINE In-Process, EMBASE, and the National Health Service Economic Evaluation Database was performed. The search was supplemented with a review of Health Technology Assessment reports through the Centre for Reviews and Dissemination database. English language articles including any quantitative economic evaluation were included. The quality of each study was assessed using the British Medical Journal economic evaluation quality checklist. Data extracted included the main outcomes from each study, study methodologies, itemized costs, sensitivity ranges, biases, and delayed reoperation prevented with ITEE. When possible, a cost-savings per ITEE was calculated to facilitate comparison across studies and used to create a synthesis of the results.

Results

Seven studies met the inclusion criteria; of these, five were included in the synthesis of results. The cost-savings per ITEE ranged from $194 to $4910 with a mean of $1930 (95%CI: $845 to $3015) (2015 USD). Prevented delayed reoperation rates using ITEE ranged from 2.8% to 10%. Earlier studies were of poorer quality (scores 8–17) and more recent studies were of higher quality (scores 22–25). Methodologies used were either retrospective chart reviews (57%) or prospective observational studies (43%) with a range of approaches to estimate costs.

Conclusion

ITEE for pediatric cardiac surgery is effective and cost-saving. This is a validation of the current practice patterns. These finding may influence the expansion of the use of this technology.

Thumbnail image of graphical abstract

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The Association between Openness and Physiological Responses to Recurrent Social Stress

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Publication date: Available online 13 May 2016
Source:International Journal of Psychophysiology
Author(s): Wei Lü, Zhenhong Wang, Brian M. Hughes
The association between openness (assessed by shortened Chinese version of NEO Five-Factor Inventory, NEO-FFI) and physiological reactivity to, and recovery from, social stress (a video-recorded, timed public speaking task with evaluators present in the room), and physiological adaptation to repeated social stress was examined in the present study. Subjective and physiological data were collected from 70 college students across five laboratory stages: baseline, stress exposure period 1, post-stress period 1, stress exposure period 2, and post-stress period 2. Results indicated that higher openness was associated with lesser heart rate (HR) reactivity to the first and second stress exposure, and lesser systolic blood pressure (SBP) reactivity to the second stress exposure. Higher openness was associated with higher resting respiratory sinus arrhythmia (RSA), lesser RSA withdrawals to the first stress exposure, and more complete RSA recovery after the first stress exposure. Moreover, higher openness was associated with pronounced systolic and diastolic blood pressure (SBP, DBP) adaptation with greater decreases in SBP and DBP reactivity across the two successive stress exposures. These findings might shed light on the biological basis linking openness to health.



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Increased N250 amplitudes for other-race faces reflect more effortful processing at the individual level

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Publication date: Available online 14 May 2016
Source:International Journal of Psychophysiology
Author(s): Grit Herzmann
The N250 and N250r (r for repetition, signaling a difference measure of priming) has been proposed to reflect the activation of perceptual memory representations for individual faces. Increased N250r and N250 amplitudes have been associated with higher levels of familiarity and expertise, respectively. In contrast to these observations, the N250 amplitude has been found to be larger for other-race than own-race faces in recognition memory tasks. This study investigated if these findings were due to increased identity-specific processing demands for other-race relative to own-race faces and whether or not similar results would be obtained for the N250 in a repetition priming paradigm. Only Caucasian participants were available for testing and completed two tasks with Caucasian, African-American, and Chinese faces. In a repetition priming task, participants decided whether or not sequentially presented faces were of the same identity (individuation task) or same race (categorization task). Increased N250 amplitudes were found for African-American and Chinese faces relative to Caucasian faces, replicating previous results in recognition memory tasks. Contrary to the expectation that increased N250 amplitudes for other-race face would be confined to the individuation task, both tasks showed similar results. This could be due to the fact that face identity information needed to be maintained across the sequential presentation of prime and target in both tasks. Increased N250 amplitudes for other-race faces are taken to represent increased neural demands on the identity-specific processing of other-race faces, which are typically processed less holistically and less on the level of the individual.



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Predictive Capacity of Thigh Muscle Strength in Symptomatic and/or Radiographic Knee Osteoarthritis Progression: Data from the Foundation for the National Institutes of Health Osteoarthritis Biomarkers Consortium.

Thigh muscle weakness is a risk factor for incident radiographic and symptomatic knee osteoarthritis (KOA). The role of thigh muscle weakness in radiographic and/or symptomatic KOA progression remains elusive. Five hundred twenty-seven knees of 527 Osteoarthritis Initiative participants with baseline Kellgren-Lawrence grades 1 to 3 were included in this nested case-control study evaluating whether baseline muscle strength predicted symptomatic and/or radiographic KOA progression. Case knees (n = 173) displayed both medial tibiofemoral joint space loss (>=0.7 mm) and a persistent increase in Western Ontario McMasters Osteoarthritis Index pain (>=9 on a 0- to 100-point scale) over 24 to 48 months from baseline. Control knees (n = 354) included 174 with neither radiographic nor symptomatic progression, 91 with radiographic progression only, and 89 with symptomatic progression only. Isometric knee extensor and flexor strength were recorded at baseline. Using logistic regression models, muscle strength was not associated with case status. However, knee extensor (odds ratio, 1.7; 95% confidence interval, 1.1-3.3; P = 0.035) and flexor weakness (odds ratio, 2.0; 95% confidence interval, 1.1, 3.3; P = 0.016) predicted isolated symptomatic progression in males, but not in females. The results indicate that thigh muscle strength may affect symptomatic and structural progression differently in males with KOA and identify an important window for potentially lowering risk of symptomatic osteoarthritis progression in men. Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved.

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Second-Order Peer Reviews of Clinically Relevant Articles for the Physiatrist: Rehabilitation that Incorporates Virtual Reality Is More Effective than Standard Rehabilitation for Improving Walking Speed, Balance, and Mobility After Stroke: A Systematic Review.

No abstract available

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Dynamic Ultrasonography of the Intra-Articular Long Head Biceps Tendon and Superior Labrum.

No abstract available

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Ultrasonographic Diagnosis and Management of Dorsal Bursitis of the Hand.

No abstract available

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Compromised Cardiopulmonary Exercise Capacity in Patients Early After Endoscopic Atraumatic Coronary Artery Bypass Graft: Implications for Rehabilitation.

Objective: The purpose of this work was to test the hypothesis that cardiopulmonary exercise tolerance is better preserved early after endoscopic atraumatic coronary artery bypass graft (endo-ACAB) surgery versus coronary artery bypass graft (CABG) surgery. Design: Twenty endo-ACAB surgery patients, 20 CABG surgery patients, and 15 healthy subjects executed a maximal cardiopulmonary exercise test, with assessment and comparison of cycling power output, O2 uptake, CO2 output, respiratory gas exchange ratio, end-tidal O2 and CO2 pressures, equivalents for O2 uptake and CO2 output, heart rate, O2 pulse, expiratory volume, tidal volume, respiratory rate, at peak exercise and ventilatory threshold. In patients, forced expiratory volume and forced vital capacity were measured. Results: Oxygen uptake, CO2 output, expiratory and tidal volume, equivalents for O2 uptake and CO2 output, end-tidal O2 and CO2 pressures at peak exercise (matched peak respiratory gas exchange ratio between patient groups), and ventilatory threshold were significantly worse in patients versus healthy controls (P 0.80). All these parameters, and lung function, were, however, comparable between CABG and endo-ACAB surgery patients (P > 0.10). Conclusions: Exercise tolerance and ventilatory function during exercise seems, in contrast to expectation, equally compromised early after endo-ACAB surgery as opposed to after CABG surgery. These data may signify the need for exercise-based rehabilitation intervention early after endo-ACAB surgery. Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved.

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Systematic Review of Central Post Stroke Pain: What Is Happening in the Central Nervous System?.

Central poststroke pain (CPSP) is one of the most common central neuropathic pain syndromes seen after stroke. It is mainly related with vascular damage at certain brain territory and pain related to corresponding body areas. In the past, it was described as one of the definitive symptoms of thalamic lesion. However, recent findings suggest that it is not only seen after thalamic lesions but also seen after vascular lesions in any part of the central nervous system. Although there are certain hypotheses to explain physiopathologic mechanisms of CPSP, further evidence is needed. The majority of the cases are intractable and unresponsive to analgesic treatment. Electrical stimulation such as deep brain stimulation and repetitive transcranial magnetic stimulation seems to be effective in certain cases. In this systematic review, recent advancements related to CPSP mechanisms have been evaluated. Further investigations are needed in order to reveal the mystery of the pathophysiologic mechanisms of CPSP. Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved.

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Case Report of Lewis and Sumner Syndrome with Bilateral Vagus Nerves Paralysis for 16 Years.

This report describes a patient with dysphonia for 16 years in combination with asymmetric and progressive decrease in sense and power of both upper and lower extremities for the past 3 years. Electrophysiological study revealed asymmetric conduction block and abnormal sensory action potential in 4 limbs. The vagus nerves palsy and abnormal electrodiagnosis of the limbs led us to diagnose the disease as Lewis and Sumner syndrome, also called multifocal acquired demyelinating sensory and motor neuropathy diagnosis, which improved by corticosteroid consumption to some extent. This case is uncommon by its long time presentation and progression. To the best of the authors' knowledge, this is the first report of simultaneous bilateral vagus nerve palsy in combination with upper and lower limbs' demyelinating neuropathy. In conclusion, persistent dysphonia can be a part of the presentation of demyelinating neuropathy. Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved.

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Comparison of Carbohydrate and Lipid Oxidation During Different High-Intensity Interval Exercise in Patients with Chronic Heart Failure.

Substrate oxidation was compared during different high-intensity intermittent exercise (HIIE) protocols in patients with heart failure and reduced ejection fraction (HFREF). Eighteen males with HFREF (58.8 +/- 9 years) were randomly assigned to 4 different HIIEs: 30 seconds (A and B) or 90 seconds (C and D) at 100% peak power output, with passive (A and C) or active recovery (50% of peak power output; B and D). Each HIIE protocol was separated by 1 week. Substrate oxidation (carbohydrate [CHO] and lipid: in g/min and in %) was calculated with gas exchange analysis. A 2-way analysis of variance and Bonferroni post hoc test were used (P

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Tendon Sheath Fibroma Mimicking Submetatarsal Bursitis with a Concomitant Morton Neuroma: Imaging with Ultrasound and Magnetic Resonance.

No abstract available

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Encoding of natural sounds by variance of the cortical local field potential

Neural encoding of sensory stimuli is typically studied by averaging neural signals across repetitions of the same stimulus. However, recent work has suggested that the variance of neural activity across repeated trials can also depend on sensory inputs. Here we characterize how intertrial variance of the local field potential (LFP) in primary auditory cortex of awake ferrets is affected by continuous natural sound stimuli. We find that natural sounds often suppress the intertrial variance of low-frequency LFP (<16 Hz). However, the amount of the variance reduction is not significantly correlated with the amplitude of the mean response at the same recording site. Moreover, the variance changes occur with longer latency than the mean response. Although the dynamics of the mean response and intertrial variance differ, spectro-temporal receptive field analysis reveals that changes in LFP variance have frequency tuning similar to multiunit activity at the same recording site, suggesting a local origin for changes in LFP variance. In summary, the spectral tuning of LFP intertrial variance and the absence of a correlation with the amplitude of the mean evoked LFP suggest substantial heterogeneity in the interaction between spontaneous and stimulus-driven activity across local neural populations in auditory cortex.



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Effects of a Brief Curricular Intervention on Medical Students' Attitudes Toward People with Disabilities in Healthcare Settings.

This study sought to evaluate the effects of a brief curricular intervention on medical students' attitudes toward physical disability in healthcare settings. Students participated in a focused curriculum about people with disabilities (PWDs), which included 2.5 hours of lectures, panel discussions, and video presentations. After the curricular sessions, students were surveyed (n = 237), and their attitudes toward PWDs in healthcare settings were compared with those of students who did not undergo the intervention (n = 251) using the Disability Attitudes in Health Care (DAHC) scale. Thematic analysis of the students' comments regarding the session was performed to supplement the DAHC scale. The intervention group responded with significantly more positive attitudes on 6 of the 17 items on the DAHC scale, and multiple linear regression analysis confirmed the independent effect of the curriculum on higher DAHC scale scores. Female students had more positive attitudes on the survey than did male students, although the effect of the curriculum was independent of gender. Previous experiences with PWDs did not correlate to higher attitude scores. These results suggest that a brief curricular intervention on disability can engender more positive attitudes in medical students toward PWDs. Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved.

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Neuronal responses to tactile stimuli and tactile sensations evoked by microstimulation in the human thalamic principal somatic sensory nucleus (ventral caudal)

The normal organization and plasticity of the cutaneous core of the thalamic principal somatosensory nucleus (ventral caudal, Vc) have been studied by single-neuron recordings and microstimulation in patients undergoing awake stereotactic operations for essential tremor (ET) without apparent somatic sensory abnormality and in patients with dystonia or chronic pain secondary to major nervous system injury. In patients with ET, most Vc neurons responded to one of the four stimuli, each of which optimally activates one mechanoreceptor type. Sensations evoked by microstimulation were similar to those evoked by the optimal stimulus only among rapidly adapting neurons. In patients with ET, Vc was highly segmented somatotopically, and vibration, movement, pressure, and sharp sensations were usually evoked by microstimulation at separate sites in Vc. In patients with conditions including spinal cord transection, amputation, or dystonia, RFs were mismatched with projected fields more commonly than in patients with ET. The representation of the border of the anesthetic area (e.g., stump) or of the dystonic limb was much larger than that of the same part of the body in patients with ET. This review describes the organization and reorganization of human Vc neuronal activity in nervous system injury and dystonia and then proposes basic mechanisms.



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Examining hand dominance using dynamometric grip strength testing as evidence for overwork weakness in Charcot-Marie-Tooth disease: a systematic review and meta-analysis.

This systematic review with a meta-analysis of studies was carried out to evaluate the potential of overwork weakness on the basis of grip strength of dominant and nondominant hands in individuals with Charcot-Marie-Tooth disease (CMT). Numerous electronic databases were searched from the earliest records to February 2016. Studies of any design including participants older than 18 years of age with a confirmed diagnosis of CMT that measured grip strength of both hands using dynamometric testing were eligible for inclusion. Of 12 593 articles identified following removal of duplicates, five articles fulfilled the criteria. A total of 166 participants, mostly with CMT1 or CMT2, were described from the studies included. Hand and finger pinch grip strength for the dominant compared with the nondominant hand was not statistically different. There is no definitive evidence that preferential use of the dominant hand in CMT impairs function relative to the nondominant hand. Thus, robust exercise trials of progressive resistance training are needed to understand the extent of adaptations possible and provide evidence of the safety of such regimens. Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved.

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Response reliability observed with voltage-sensitive dye imaging of cortical layer 2/3: the probability of activation hypothesis

A central assertion in the study of neural processing is that our perception of the environment directly reflects the activity of our sensory neurons. This assertion reinforces the intuition that the strength of a sensory input directly modulates the amount of neural activity observed in response to that sensory feature: an increase in the strength of the input yields a graded increase in the amount of neural activity. However, cortical activity across a range of sensory pathways can be sparse, with individual neurons having remarkably low firing rates, often exhibiting suprathreshold activity on only a fraction of experimental trials. To compensate for this observed apparent unreliability, it is assumed that instead the local population of neurons, although not explicitly measured, does reliably represent the strength of the sensory input. This assumption, however, is largely untested. In this study, using wide-field voltage-sensitive dye (VSD) imaging of the somatosensory cortex in the anesthetized rat, we show that whisker deflection velocity, or stimulus strength, is not encoded by the magnitude of the population response at the level of cortex. Instead, modulation of whisker deflection velocity affects the likelihood of the cortical response, impacting the magnitude, rate of change, and spatial extent of the cortical response. An ideal observer analysis of the cortical response points to a probabilistic code based on repeated sampling across cortical columns and/or time, which we refer to as the probability of activation hypothesis. This hypothesis motivates a range of testable predictions for both future electrophysiological and future behavioral studies.



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Role of Ih in differentiating the dynamics of the gastric and pyloric neurons in the stomatogastric ganglion of the lobster, Homarus americanus

The hyperpolarization-activated inward cationic current (Ih) is known to regulate the rhythmicity, excitability, and synaptic transmission in heart cells and many types of neurons across a variety of species, including some pyloric and gastric mill neurons in the stomatogastric ganglion (STG) in Cancer borealis and Panulirus interruptus. However, little is known about the role of Ih in regulating the gastric mill dynamics and its contribution to the dynamical bifurcation of the gastric mill and pyloric networks. We investigated the role of Ih in the rhythmic activity and cellular excitability of both the gastric mill neurons (medial gastric, gastric mill) and pyloric neurons (pyloric dilator, lateral pyloric) in Homarus americanus. Through testing the burst period between 5 and 50 mM CsCl, and elimination of postinhibitory rebound and voltage sag, we found that 30 mM CsCl can sufficiently block Ih in both the pyloric and gastric mill neurons. Our results show that Ih maintains the excitability of both the pyloric and gastric mill neurons. However, Ih regulates slow oscillations of the pyloric and gastric mill neurons differently. Specifically, blocking Ih diminishes the difference between the pyloric and gastric mill burst periods by increasing the pyloric burst period and decreasing the gastric mill burst period. Moreover, the phase-plane analysis shows that blocking Ih causes the trajectory of slow oscillations of the gastric mill neurons to change toward the pyloric sinusoidal-like trajectories. In addition to regulating the pyloric rhythm, we found that Ih is also essential for the gastric mill rhythms and differentially regulates these two dynamics.



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mGlu1 receptor mediates homeostatic control of intrinsic excitability through Ih in cerebellar Purkinje cells

Homeostatic intrinsic plasticity is a cellular mechanism for maintaining a stable neuronal activity level in response to developmental or activity-dependent changes. Type 1 metabotropic glutamate receptor (mGlu1 receptor) has been widely known to monitor neuronal activity, which plays a role as a modulator of intrinsic and synaptic plasticity of neurons. Whether mGlu1 receptor contributes to the compensatory adjustment of Purkinje cells (PCs), the sole output of the cerebellar cortex, in response to chronic changes in excitability remains unclear. Here, we demonstrate that the mGlu1 receptor is involved in homeostatic intrinsic plasticity through the upregulation of the hyperpolarization-activated current (Ih) in cerebellar PCs. This plasticity was prevented by inhibiting the mGlu1 receptor with Bay 36–7620, an mGlu1 receptor inverse agonist, but not with CPCCOEt, a neutral antagonist. Chronic inactivation with tetrodotoxin (TTX) increased the components of Ih in the PCs, and ZD 7288, a hyperpolarization-activated cyclic nucleotide-gated channel selective inhibitor, fully restored reduction of firing rates in the deprived neurons. The homeostatic elevation of Ih was also prevented by BAY 36–7620, but not CPCCOEt. Furthermore, KT 5720, a blocker of protein kinase A (PKA), prevented the effect of TTX reducing the evoked firing rates, indicating the reduction in excitability of PCs due to PKA activation. Our study shows that both the mGlu1 receptor and the PKA pathway are involved in the homeostatic intrinsic plasticity of PCs after chronic blockade of the network activity, which provides a novel understanding on how cerebellar PCs can preserve the homeostatic state under activity-deprived conditions.



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Desensitization-resistant and -sensitive GPCR-mediated inhibition of GABA release occurs by Ca2+-dependent and -independent mechanisms at a hypothalamic synapse

Whereas the activation of Gαi/o-coupled receptors commonly results in postsynaptic responses that show acute desensitization, the presynaptic inhibition of transmitter release caused by many Gαi/o-coupled receptors is maintained during agonist exposure. However, an exception has been noted where GABAB receptor (GABABR)-mediated inhibition of inhibitory postsynaptic currents (IPSCs) recorded in mouse proopiomelanocortin (POMC) neurons exhibit acute desensitization in ~25% of experiments. To determine whether differential effector coupling confers sensitivity to desensitization, voltage-clamp recordings were made from POMC neurons to compare the mechanism by which μ-opioid receptors (MORs) and GABABRs inhibit transmitter release. Neither MOR- nor GABABR-mediated inhibition of release relied on the activation of presynaptic K+ channels. Both receptors maintained the ability to inhibit release in the absence of external Ca2+ or in the presence of ionomycin-induced Ca2+ influx, indicating that inhibition of release can occur through a Ca2+-independent mechanism. Replacing Ca2+ with Sr2+ to disrupt G-protein-mediated inhibition of release occurring directly at the release machinery did not alter MOR- or GABAB -mediated inhibition of IPSCs, suggesting that reductions in evoked release can occur through the inhibition of Ca2+ channels. Additionally, both receptors inhibited evoked IPSCs in the presence of selective blockers of N- or P/Q-type Ca2+ channels. Altogether, the results show that MORs and GABABRs can inhibit transmitter release through the inhibition of calcium influx and by direct actions at the release machinery. Furthermore, since both the desensitizing and nondesensitizing presynaptic receptors are similarly coupled, differential effector coupling is unlikely responsible for differential desensitization of the inhibition of release.



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Increased intensity and reduced frequency of EMG signals from feline self-reinnervated ankle extensors during walking do not normalize excessive lengthening

Kinematics of cat level walking recover after elimination of length-dependent sensory feedback from the major ankle extensor muscles induced by self-reinnervation. Little is known, however, about changes in locomotor myoelectric activity of self-reinnervated muscles. We examined the myoelectric activity of self-reinnervated muscles and intact synergists to determine the extent to which patterns of muscle activity change as almost normal walking is restored following muscle self-reinnervation. Nerves to soleus (SO) and lateral gastrocnemius (LG) of six adult cats were surgically transected and repaired. Intramuscular myoelectric signals of SO, LG, medial gastrocnemius (MG), and plantaris (PL), muscle fascicle length of SO and MG, and hindlimb mechanics were recorded during level and slope (±27°) walking before and after (10–12 wk postsurgery) self-reinnervation of LG and SO. Mean myoelectric signal intensity and frequency were determined using wavelet analysis. Following SO and LG self-reinnervation, mean myoelectric signal intensity increased and frequency decreased in most conditions for SO and LG as well as for intact synergist MG (P < 0.05). Greater elongation of SO muscle-tendon unit during downslope and unchanged magnitudes of ankle extensor moment during the stance phase in all walking conditions suggested a functional deficiency of ankle extensors after self-reinnervation. Possible effects of morphological reorganization of motor units of ankle extensors and altered sensory and central inputs on the changes in myoelectric activity of self-reinnervated SO and LG are discussed.



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Utility of EEG measures of brain function in patients with acute stroke

EEG has been used to study acute stroke for decades; however, because of several limitations EEG-based measures rarely inform clinical decision-making in this setting. Recent advances in EEG hardware, recording electrodes, and EEG software could overcome these limitations. The present study examined how well dense-array (256 electrodes) EEG, acquired with a saline-lead net and analyzed with whole brain partial least squares (PLS) modeling, captured extent of acute stroke behavioral deficits and varied in relation to acute brain injury. In 24 patients admitted for acute ischemic stroke, 3 min of resting-state EEG was acquired at bedside, including in the ER and ICU. Traditional quantitative EEG measures (power in a specific lead, in any frequency band) showed a modest association with behavioral deficits [NIH Stroke Scale (NIHSS) score] in bivariate models. However, PLS models of delta or beta power across whole brain correlated strongly with NIHSS score (R2 = 0.85–0.90) and remained robust when further analyzed with cross-validation models (R2 = 0.72–0.73). Larger infarct volume was associated with higher delta power, bilaterally; the contralesional findings were not attributable to mass effect, indicating that EEG captures significant information about acute stroke effects not available from MRI. We conclude that 1) dense-array EEG data are feasible as a bedside measure of brain function in patients with acute stroke; 2) high-dimension EEG data are strongly correlated with acute stroke behavioral deficits and are superior to traditional single-lead metrics in this regard; and 3) EEG captures significant information about acute stroke injury not available from structural brain imaging.



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The vertical obturator nerve block: A randomised controlled double-blind pilot trial.

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Association of preoperative cardiovascular drugs with short-term mortality after coronary artery bypass grafting.

No abstract available

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