Polygenic Control of Carotid Atherosclerosis in a BALB/cJ x SM/J Intercross and a Combined Cross Involving Multiple Mouse Strains

Atherosclerosis in the carotid arteries is a major cause of ischemic stroke, which accounts for 85% of all stroke cases. Genetic factors contributing to carotid atherosclerosis remain poorly understood. The aim of this study was to identify chromosomal regions harboring genes contributing to carotid atherosclerosis in mice. 228 female F2 mice were generated from an intercross between BALB/cJ (BALB) and SM/J (SM) apolipoprotein E-deficient (Apoe^-/-) mice and fed 12 weeks of western diet. Atherosclerotic lesion sizes in the left carotid artery were quantified. 149 genetic markers were genotyped across the entire genome. Quantitative trait locus (QTL) analysis revealed 8 loci for carotid lesion sizes, located on chromosomes 1, 5, 12, 13, 15, 16, and 18. Combined cross linkage analysis using data from this cross and two previous F2 crosses derived from BALB, C57BL/6J and C3H/HeJ strains identified 5 significant QTLs on chromosomes 5, 9, 12 and 13 and 9 suggestive QTLs for carotid atherosclerosis. Of them, the QTL on chromosome 12 had a high LOD score of 9.95. Bioinformatic analysis prioritized Arhgap5, Akap6, Mipol1, Clec14a, Fancm, Nin, Dact1, Rtn1, and Slc38a6 as probable candidate genes for this QTL. Atherosclerotic lesion sizes were significantly correlated with non-HDL cholesterol levels (r=0.254; p=0.00016) but inversely correlated with HDL cholesterol levels (r=-0.134; p=0.049) in the current cross. Thus, we demonstrated the polygenic control of carotid atherosclerosis in mice. The correlations of carotid lesion sizes with non-HDL and HDL suggest that genetic factors exert effect on carotid atherosclerosis partially through modulation of lipoprotein homeostasis.

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Genome-Wide Screen for Haploinsufficient Cell Size Genes in the Opportunistic Yeast Candida albicans

One of the most critical but still poorly understood aspects of eukaryotic cell proliferation is the basis for commitment to cell division in late G1 phase called Start in yeast and the Restriction Point in metazoans. In all species, a critical cell size threshold coordinates cell growth with cell division and thereby establishes a homeostatic cell size. While a comprehensive survey of cell size genetic determinism has been performed in the saprophytic yeasts Saccharomyces cerevisiae and Schizosaccharomyces pombe, very little is known in pathogenic fungi. As a number of critical Start regulators are haploinsufficient for cell size, we applied a quantitative analysis of the size phenome, using elutriation-barcode sequencing methodology, to 5,639 barcoded heterozygous deletion strains of the opportunistic yeast Candida albicans. Our screen identified conserved known regulators and biological processes required to maintain size homeostasis in the opportunistic yeast C. albicans. We also identified novel C. albicans-specific size genes and provided a conceptual framework for future mechanistic studies. Interestingly, some of the size genes identified were required for fungal pathogenicity suggesting that cell size homeostasis may be elemental to C. albicans fitness or virulence inside the host.

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Highly-Efficient Cpf1-Mediated Gene Targeting in Mice Following High Concentration Pronuclear Injection

Cpf1 has emerged as an alternative to the Cas9 RNA-guided nuclease. Here we show that gene targeting rates in mice using Cpf1 can meet or even surpass Cas9 targeting rates (approaching 100% targeting) but require higher concentrations of mRNA and guide. We also demonstrate that co-injecting two guides with close targeting sites can result in synergistic genomic cutting, even if one of the guides has minimal cutting activity.

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Genome Report: Identification and Validation of Antigenic Proteins from Pajaroellobacter abortibovis Using De Novo Genome Sequence Assembly and Reverse Vaccinology

Epizootic bovine abortion (EBA), or "foothill abortion", is the leading cause of beef cattle abortion in California and has also been reported in Nevada and Oregon. In the 1970's, the soft-shelled tick Ornithodoros coriaceus, or "pajaroello tick", was confirmed as the disease-transmitting vector. In 2005, a novel Deltaproteobacterium was discovered as the etiologic agent of EBA (aoEBA), recently named Pajaroellobacter abortibovis. This organism cannot be grown in culture using traditional microbiological techniques; it can only be grown in experimentally-infected severe combined immunodeficient (SCID) mice. The objectives of this study were to perform a de novo genome assembly for P. abortibovis and identify and validate potential antigenic proteins as candidates for future recombinant vaccine development. DNA and RNA were extracted from spleen tissue collected from experimentally-infected SCID mice following exposure to P. abortibovis. This combination of mouse and bacterial DNA was sequenced and aligned to the mouse genome. Mouse sequences were subtracted from the sequence pool and the remaining sequences were de novo assembled at 50X coverage into a 1.82 Mbp complete closed circular Deltaproteobacterial genome containing 2,250 putative protein coding sequences. Phylogenetic analysis of P. abortibovis predicts that this bacterium is most closely related to the organisms of the order Myxococcales, referred to as Myxobacteria. In silico prediction of vaccine candidates was performed using a reverse vaccinology approach resulting in the identification and ranking of the top ten candidate proteins that are likely to be antigenic. Immunologic testing of these candidate proteins confirmed antigenicity of seven of the nine expressed protein candidates using serum from P. abortibovis immunized mice.

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Latrunculin A Induced Perturbation of the Actin Cytoskeleton Mediates Pap1p-Dependent Induction of the Caf5p Efflux Pump in Schizosaccharomyces pombe

As part of an earlier study aimed at uncovering gene-products with roles in defending against latrunculin A (LatA) induced cytoskeletal perturbations, we identified three members of the oxidative stress response pathway: the Pap1p AP-1 like transcription factor, the Imp1p importin-alpha, and the Caf5p efflux pump. In this report, we characterize the pathway further and show that Pap1p translocates from the cytoplasm to the nucleus in an Imp1p-dependent manner upon LatA treatment. Moreover, preventing this translocation -- through the addition of a nuclear export signal – confers the same characteristic LatA-sensitive phenotype exhibited by pap1 cells. Lastly, we show that the caf5 gene is induced upon exposure to LatA and that Pap1p is required for this transcriptional upregulation. Importantly, the expression of trr1, a Pap1p target specifically induced in response to oxidative stress, is not significantly altered by LatA treatment. Taken together, these results suggest a model in which LatA-mediated cytoskeletal perturbations are sensed, triggering the Imp1p-dependent translocation of Pap1p to the nucleus and the induction of the caf5 gene (independently of oxidative stress).

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Genetic Analysis of the Lambda Spanins Rz and Rz1: Identification of Functional Domains

Coliphage lambda proteins Rz and Rz1 are the inner membrane and outer membrane subunits of the spanin complex, a heterotetramer that bridges the periplasm and is essential for the disruption of the outer membrane during phage lysis. Recent evidence suggests the spanin complex functions by fusing the inner and outer membrane. Here we use a genetics approach to investigate and characterize determinants of spanin function. Because Rz1 is entirely embedded in the +1 reading frame of Rz, the genes were dis-embedded before using random mutagenesis to construct a library of lysis-defective alleles for both genes. Surprisingly, most of the lysis-defective missense mutants exhibited normal accumulation or localization in vivo and also were found to be normal for complex formation in vitro. Analysis of the distribution and nature of single missense mutations revealed sub-domains that resemble key motifs in established membrane-fusion systems, i.e. two coiled-coil domains in Rz, a proline-rich region of Rz1, and flexible linkers in both proteins. When coding sequences are aligned respective to the embedded genetic architecture of Rz1 within Rz, genetically silent domains of Rz1 correspond to mutationally-sensitive domains in Rz, and vice-versa, suggesting that the modular structure of the two subunits facilitated the evolutionary compression that resulted in the unique embedded gene architecture.

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Comparative High-Density Linkage Mapping Reveals Conserved Genome Structure but Variation in Levels of Heterochiasmy and Location of Recombination Cold Spots in the Common Frog

By combining 7077 SNPs and 61 microsatellites, we present the first linkage map for some of the early diverged lineages of the common frog, Rana temporaria, and the densest linkage map to date for this species. We found high homology with the published linkage maps of the Eastern and Western lineages but with differences in the order of some markers. Homology was also strong with the genome of the Tibetan frog Nanorana parkeri and we found high synteny with the clawed frog Xenopus tropicalis. We confirmed marked heterochiasmy between sexes and detected non-recombining regions in several groups of the male linkage map. Contrary to the expectations set by the male heterogamety of the common frog, we did not find male heterozygosity excess in the chromosome previously shown to be linked to sex determination. Finally, we found blocks of loci showing strong transmission ratio distortion. These distorted genomic regions might be related to genetic incompatibilities between the parental populations, and are promising candidates for further investigation into the genetic basis of speciation and adaptation in the common frog.

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An Unbiased Estimator of Gene Diversity with Improved Variance for Samples Containing Related and Inbred Individuals of any Ploidy

Gene diversity, or expected heterozygosity (H), is a common statistic for assessing genetic variation within populations. Estimation of this statistic decreases in accuracy and precision when individuals are related or inbred, due to increased dependence among allele copies in the sample. The original unbiased estimator of expected heterozygosity underestimates true population diversity in samples containing relatives, as it only accounts for sample size. More recently, a general unbiased estimator of expected heterozygosity was developed that explicitly accounted for related and inbredindividuals in samples. Though unbiased, this estimator's variance is greater than that of the original estimator. To address this issue, we introduce a general unbiased estimator of gene diversity for samples containing related or inbred individuals, which employs the best linear unbiased estimator of allele frequencies, rather than the commonly-used sample proportion. We examine the properties of this estimator, Ĥ_BLUE, relative to alternative estimators using simulations and theoretical predictions, and show it predominantly has the smallest mean squared error relative to others. Further, we empirically assess the performance of Ĥ_BLUE on a global human microsatellite dataset of 5,795 individuals from 267 populations genotyped at 645 loci. Additionally, we show that the improved variance of Ĥ_BLUE leads to improved estimates of the population differentiation statistic F_ST, which employs measures of gene diversity within its calculation. Finally, we provide an R script, BestHet, to compute this estimator from genomic and pedigree data.

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Forward Genetics by Sequencing EMS Variation Induced Inbred Lines

In order to leverage novel sequencing techniques for cloning genes in eukaryotic organisms with complex genomes, the false positive rate of variant discovery must be controlled for by experimental design and informatics. We sequenced five lines from three pedigrees of EMS mutagenized Sorghum bicolor, including a pedigree segregating a recessive dwarf mutant. Comparing the sequences of the lines, we were able to identify and eliminate error prone positions. One genomic region contained EMS mutant alleles in dwarfs that were homozygous reference sequence in wild-type siblings and heterozygous in segregating families. This region contained a single non-synonymous change that cosegregated with dwarfism in a validation population and caused a premature stop codon in the sorghum ortholog encoding the gibberellic acid biosynthetic enzyme ent-kaurene oxidase. Application of exogenous gibberellic acid rescued the mutant phenotype. Our method for mapping did not require outcrossing and introduced no segregation variance. This enables work when line crossing is complicated by life history, permitting gene discovery outside of genetic models. This inverts the historical approach of first using recombination to define a locus and then sequencing genes. Our formally identical approach first sequences all the genes and then seeks co-segregation with the trait. Mutagenized lines lacking obvious phenotypic alterations are available for an extension of this approach: mapping with a known marker set in a line that is phenotypically identical to starting material for EMS mutant generation.

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Basic discriminative and semantic processing in patients in the vegetative and minimally conscious state

Publication date: Available online 30 December 2016
Source:International Journal of Psychophysiology
Author(s): Helena Erlbeck, Ruben G.L. Real, Boris Kotchoubey, Donatella Mattia, Jakob Bargak, Andrea Kübler
Patients who survive injuries to the brain following accidents or diseases often acquire a disorder of consciousness (DOC). Assessment of the state of consciousness in these patients is difficult since they are usually incapable of reproducible motor movements. The application of event-related potentials (ERP) recorded via EEG constitutes one promising approach to complement the assessment of cognitive functions in DOC patients. For these assessments, a hierarchical approach was suggested which means that paradigms aiming at higher order ERPs are only presented if early responses were found. In this study, 19 behaviorally unresponsive or low-responsive DOC patients were presented with three auditory paradigms using passive instructions. The paradigms aimed at eliciting the Mismatch Negativity (MMN) and N400 and were applied at two time points. One oddball paradigm (MMN) and two semantic paradigms (word-pairs: N400 Words; sentences: N400 Sentences) were included. The majority of patients (n=15) did not show any response to the stimulation. In the MMN paradigm, an MMN was identified in two patients, in the N400 Words paradigm, only an N1 was identified in one patient, and in the N400 Sentences paradigm, a late positive complex (LPC) was identified in two patients. These data contradict the hierarchical approach since the LPC was identified in patients who did not exhibit an MMN. They further support the notion that even higher information processing as addressed with the N400 paradigms is preserved in a minority of DOC patients. Thus, in this sample, around 10% of the DOC patients exhibited indicators of preserved consciousness.



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Characteristics and processing of Pol IV transcripts in Arabidopsis

Publication date: Available online 30 December 2016
Source:Journal of Genetics and Genomics
Author(s): Hsuan Yu Kuo, Elise L. Jacobsen, Yanping Long, Xinyuan Chen, Jixian Zhai




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Genetic Profiling of Children with Advanced Cholestatic Liver Disease

ABSTRACT

Advanced cholestatic liver disease is a leading referral to pediatric liver transplant centers. Recent advances in the genetic classification of this group of disorders promise a highly personalized management although the genetic heterogeneity also poses a diagnostic challenge. Using a next-generation sequencing-based multi-gene panel, we performed retrospective analysis of 98 pediatric patients who presented with advanced cholestatic liver disease. A likely causal mutation was identified in the majority (61%), spanning many genes including ones that have only rarely been reported to cause cholestatic liver disease e.g. TJP2 and VIPAS39. We find no evidence to support mono-allelic phenotypic expression in the carrier parents despite the severe nature of the respective mutations, and no evidence of oligogenicity. The high carrier frequency of the founder mutations identified in our cohort (1 in 87) suggests a minimum incidence of 1:7,246, an alarmingly high disease burden that calls for the primary prevention through carrier screening.

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Birth Settings and the Validation of Neonatal Seizures Recorded in Birth Certificates Compared to Medicaid Claims and Hospital Discharge Abstracts Among Live Births in South Carolina, 1996–2013

Abstract

Objective Neonatal seizures in the first 28 days of life often reflect underlying brain injury or abnormalities, and measure the quality of perinatal care in out-of-hospital births. Using the 2003 revision of birth certificates only, three studies reported more neonatal seizures recorded among home births ​or planned out-of-hospital births compared to hospital births. However, the validity of recording neonatal seizures or serious neurologic dysfunction across birth settings in birth certificates has not been evaluated. We aimed to validate seizure recording in birth certificates across birth settings using multiple datasets. Methods We examined checkbox items "seizures" and "seizure or serious neurologic dysfunction" in the 1989 and 2003 revisions of birth certificates in South Carolina from 1996 to 2013. Gold standards were ICD-9-CM codes 779.0, 345.X, and 780.3 in either hospital discharge abstracts or Medicaid encounters jointly. Results Sensitivity, positive predictive value, false positive rate, and the kappa statistic of neonatal seizures recording were 7%, 66%, 34%, and 0.12 for the 2003 revision of birth certificates in 547,177 hospital births from 2004 to 2013 and 5%, 33%, 67%, and 0.09 for the 1998 revision in 396,776 hospital births from 1996 to 2003, and 0, 0, 100%, −0.002 among 660 intended home births from 2004 to 2013 and 920 home births from 1996 to 2003, respectively. Conclusions for Practice Despite slight improvement across revisions, South Carolina birth certificates under-reported or falsely reported seizures among hospital births and especially home births. Birth certificates alone should not be used to measure neonatal seizures or serious neurologic dysfunction.

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The effect of component separation technique on quality of life (QOL) and surgical outcomes in complex open ventral hernia repair (OVHR)

Abstract

Introduction

Outcomes following OVHR may be affected by type of component separation. In this study, outcomes including QOL of patients undergoing OVHR were evaluated based on the utilization of transversus abdominis release (TAR), posterior rectus sheath release (PRSR) alone or in combination with external oblique release (EOR + PRSR).

Methods

A prospective, single-institution study following open ventral hernia repair involving component separation was performed from May 2005 to April 2015. Self-reported QOL outcomes were obtained preoperatively and at 1, 6 and 12 months postoperatively using the Carolinas Comfort Scale (CCS). A CCS of 2 (mild but bothersome discomfort) or greater was considered symptomatic. Comorbidities, complications, outcomes and CCS scores were reviewed. Univariate group comparisons were performed using Chi-square and Wilcoxon two-sample tests with statistical significance set at p < 0.05.

Results

During the study period, 292 OVHRs with CST met inclusion criteria. Single-sided, different releases on opposite sides, etc., were eliminated. Demographics included: average age-57.9 ± 11.9 years, BMI-34.0 ± 7.9 kgm², 53.2% female, 69% at least one prior hernia repair and average defect size-291.2 ± 236.2 cm². Preoperative discomfort (82 vs. 75 vs. 79%, p = 0.77) and movement limitation (94 vs. 70 vs. 78%, p = 0.1) in TAR, PRSR and EOR + PRSR were similar. Average follow-up was 16.4 months. At 1, 6 and 12 months postoperatively, there was no difference in reported CCS pain scores, movement limitation or mesh sensation among the groups (p > 0.05). Comparing OVHR patients outcomes by CST type, TAR was associated with decreased wound infections compared to others (3.2 vs. 16.1 vs. 20%, p = 0.07) while recurrence rates were increased in EOR + PRSR compared to TAR and PRSR alone(8.4 vs. 3 vs. 1.8%, p = 0.03). Eighty percent of recurrences had a biologic mesh secondary to contaminated field during hernia repair. The other two recurrences were one which occurred superior to the mesh at a suture site and one who developed a wound infection postoperatively. Mesh infection rates were low (0 vs. 1.5 vs. 2.6%, p > 0.05) even including contaminated cases (0 vs. 2 vs. 3.6%, p > 0.05) and were statistically equivalent among all three techniques.

Conclusion

While QOL is not impacted by type of component separation on short- or long-term follow-up, the TAR may provide benefits such as decreased wound infection rates. Overall QOL had a significant improvement from preoperative regardless of type of component separation. When controlling for field contamination, there were no differences in recurrence or infection.

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Respiratory dynamics and dead space to tidal volume ratio of volume-controlled versus pressure-controlled ventilation during prolonged gynecological laparoscopic surgery

Abstract

Background

Laparoscopic operations have become longer and more complex and applied to a broader patient population in the last decades. Prolonged gynecological laparoscopic surgeries require prolonged pneumoperitoneum and Trendelenburg position, which can influence respiratory dynamics and other measurements of pulmonary function. We investigated the differences between volume-controlled ventilation (VCV) and pressure-controlled ventilation (PCV) and tried to determine the more efficient ventilation mode during prolonged pneumoperitoneum in gynecological laparoscopy.

Methods

Twenty-six patients scheduled for laparoscopic radical hysterectomy combined with or without laparoscopic pelvic lymphadenectomy were randomly allocated to be ventilated by either VCV or PCV. Standard anesthesic management and laparoscopic procedures were performed. Measurements of respiratory and hemodynamic dynamics were obtained after induction of anesthesia, at 10, 30, 60, and 120 min after establishing pneumoperitoneum, and at 10 min after return to supine lithotomy position and removal of carbon dioxide. The logistic regression model was applied to predict the corresponding critical value of duration of pneumoperitoneum when the Ppeak was higher than 40 cmH₂O.

Results

Prolonged pneumoperitoneum and Trendelenburg position produced significant and clinically relevant changes in dynamic compliance and respiratory mechanics in anesthetized patients under PCV and VCV ventilation. Patients under PCV ventilation had a similar increase of dead space/tidal volume ratio, but had a lower Ppeak increase compared with those under VCV ventilation. The critical value of duration of pneumoperitoneum was predicted to be 355 min under VCV ventilation, corresponding to the risk of Ppeak higher than 40 cmH₂O.

Conclusions

Both VCV and PCV can be safely applied to prolonged gynecological laparoscopic surgery. However, PCV may become the better choice of ventilation after ruling out of other reasons for Ppeak increasing.

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Effect of ultrasound-guided phrenic nerve block on shoulder pain after laparoscopic cholecystectomy—a prospective, randomized controlled trial

Abstract

Background

Post-laparoscopic shoulder pain (PLSP) frequently follows a laparoscopic cholecystectomy. A proposed mechanism for PLSP is the irritation or injury of the phrenic nerve by the CO₂ pneumoperitoneum during laparoscopic surgery. Here, we investigated whether a phrenic nerve block (PNB), performed under ultrasound guidance, could reduce the incidence and severity of PLSP after laparoscopic cholecystectomy.

Method

Sixty patients were randomized into two groups, with one group receiving PNB with 4 ml (30 mg) of 0.75% ropivacaine (group P, n = 28) and a control group (group C, n = 32). The existence and severity of PLSP were assessed for 2 days postoperatively. A pulmonary function test (PFT) and diaphragmatic excursion test were performed pre- and postoperatively.

Results

With ultrasound guidance, all PNBs were performed successfully in group P. In group P, the overall incidence and severity of PLSP decreased significantly. There were no significant differences in incisional pain, visceral pain, and analgesic requirements between the groups. Right-side diaphragmatic excursion decreased significantly in group P at 1 h postoperatively. The PFT results and respiratory discomfort assessed by a modified Borg's scale were not different significantly between the groups.

Conclusion

Based on these findings, ultrasound-guided PNB can prevent or reduce the PLSP without clinically significant respiratory discomfort.

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Prevention of internal hernias and pelvic adhesions following laparoscopic left-sided colorectal resection: the role of fibrin sealant

Abstract

Background

Laparoscopy has increasingly become the standard of care for patients who undergo colorectal surgery for both benign and malignant diseases. This growing experience has also resulted in more reports of postoperative complications from the minimally invasive approach to primary colorectal resection. Small bowel obstruction from internal hernias and pre-sacral adhesions is an uncommon but not negligible complication. However, there is little literature specific to this topic with recommendations for different methods to prevent it. We report our original technique of closing the mesenteric defect and covering the pre-sacral fascia by using fibrin sealant to prevent this complication.

Methods

From January 2005 to December 2014, a total of 1079 patients underwent elective laparoscopic left colorectal resection (left hemicolectomy or anterior rectal resection) in our department. In the first 298 procedures, the mesenteric defect was left open, while in the following 781 procedures, it was closed using fibrin sealant with the aim of preventing postoperative small bowel obstruction.

Results

Among the first 298 patients, three (1%) required reoperation for small bowel obstruction due to internal hernia (0.33%) or critical pre-sacral adhesions (0.66%). These complications did not occur in the subsequent series in which all 781 patients were treated with fibrin sealant prophylactic closure of the mesenteric defect.

Conclusion

In our experience, fibrin sealant closure of the mesenteric defect has demonstrated to be safe and effective in preventing postoperative small bowel obstruction that remains a complication both in open and in laparoscopic colorectal surgeries.

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Hands-on 2.0: improving transfer of training via the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Acquisition of Data for Outcomes and Procedure Transfer (ADOPT) program

Abstract

Background

Practicing surgeons commonly learn new procedures and techniques by attending a "hands-on" course, though trainings are often ineffective at promoting subsequent procedure adoption in practice. We describe implementation of a new program with the SAGES All Things Hernia Hands-On Course, Acquisition of Data for Outcomes and Procedure Transfer (ADOPT), which employs standardized, proven teaching techniques, and 1-year mentorship. Attendee confidence and procedure adoption are compared between standard and ADOPT programs.

Methods

For the pilot ADOPT course implementation, a hands-on course focusing on abdominal wall hernia repair was chosen. ADOPT participants were recruited among enrollees for the standard Hands-On Hernia Course. Enrollment in ADOPT was capped at 10 participants and limited to a 2:1 student-to-faculty ratio, compared to the standard course 22 participants with a 4:1 student-to-faculty ratio. ADOPT mentors interacted with participants through webinars, phone conferences, and continuous email availability throughout the year. All participants were asked to provide pre- and post-course surveys inquiring about the number of targeted hernia procedures performed and related confidence level.

Results

Four of 10 ADOPT participants (40%) and six of 22 standard training participants (27%) returned questionnaires. Over the 3 months following the course, ADOPT participants performed more ventral hernia mesh insertion procedures than standard training participants (median 13 vs. 0.5, p = 0.010) and considerably more total combined procedures (median 26 vs. 7, p = 0.054). Compared to standard training, learners who participated in ADOPT reported greater confidence improvements in employing a components separation via an open approach (p = 0.051), and performing an open transversus abdominis release, though the difference did not achieve statistical significance (p = 0.14).

Discussion

These results suggest that the ADOPT program, with standardized and structured teaching, telementoring, and a longitudinal educational approach, is effective and leads to better transfer of learned skills and procedures to clinical practice.

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OR fire virtual training simulator: design and face validity

Abstract

Background

The Virtual Electrosurgical Skill Trainer is a tool for training surgeons the safe operation of electrosurgery tools in both open and minimally invasive surgery. This training includes a dedicated team-training module that focuses on operating room (OR) fire prevention and response. The module was developed to allow trainees, practicing surgeons, anesthesiologist, and nurses to interact with a virtual OR environment, which includes anesthesia apparatus, electrosurgical equipment, a virtual patient, and a fire extinguisher. Wearing a head-mounted display, participants must correctly identify the "fire triangle" elements and then successfully contain an OR fire. Within these virtual reality scenarios, trainees learn to react appropriately to the simulated emergency. A study targeted at establishing the face validity of the virtual OR fire simulator was undertaken at the 2015 Society of American Gastrointestinal and Endoscopic Surgeons conference.

Methods

Forty-nine subjects with varying experience participated in this Institutional Review Board-approved study. The subjects were asked to complete the OR fire training/prevention sequence in the VEST simulator. Subjects were then asked to answer a subjective preference questionnaire consisting of sixteen questions, focused on the usefulness and fidelity of the simulator.

Results

On a 5-point scale, 12 of 13 questions were rated at a mean of 3 or greater (92%). Five questions were rated above 4 (38%), particularly those focusing on the simulator effectiveness and its usefulness in OR fire safety training. A total of 33 of the 49 participants (67%) chose the virtual OR fire trainer over the traditional training methods such as a textbook or an animal model.

Conclusions

Training for OR fire emergencies in fully immersive VR environments, such as the VEST trainer, may be the ideal training modality. The face validity of the OR fire training module of the VEST simulator was successfully established on many aspects of the simulation.

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Polypoid lesions of the gallbladder: analysis of 1204 patients with long-term follow-up

Abstract

Background

Polypoid lesions of the gallbladder (PLG) are common, and most are benign. Few lesions are found to be malignant, but are not preoperatively distinguished as such using common imaging modalities. Therefore, we compared characteristics of benign and malignant PLGs in depth.

Methods

We enrolled 1204 consecutive patients diagnosed with PLG at Taipei Veterans General Hospital between January 2004 and December 2013. Patients underwent either surgery or regular follow-up with various imaging modalities for at least 24 months. The mean follow-up duration was 72 ± 32 months.

Results

Of 1204 patients, 194 underwent surgical treatment and 1010, regular follow-up. In addition, 73 % patients were asymptomatic. The mean PLG size was 6.9 ± 7.7 (range 0.8–129) mm; the PLGs of 337 patients (28 %) grew during their follow-up periods. The majority of PLGs (90.4 %) were single lesions, and 10.5 % of patients had associated gallstones. The PLGs of 20.1 % of surgical patients were malignant. Malignant PLGs were found in 32.4 % of patients ≥50 years old and in 4.7 % of those <50 years old (p < 0.001). Right quadrant abdominal pain, epigastric pain, and body weight loss were the three most common symptoms associated with malignancy. Malignant PLGs were significantly larger than benign lesions (means: 27.5 ± 18.4 mm vs. 12.3 ± 12.3 mm, respectively, p < 0.001). Notably, the size of 5 % of malignant PLGs was 3–5 mm, and that of 8 % was 5–10 mm. The negative predictive value for gallbladder malignancy was 92.8 % based on a size ≥10 mm and 100 % based on a size ≥3 mm.

Conclusions

Our study reassesses the PLG size that warrants more aggressive intervention. Cholecystectomy remains mandatory for PLGs > 10 mm, but should also be considered a definitive diagnostic and treatment modality for PLGs with diameters of 3–10 mm.

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Learning curve and clinical outcome of gastric endoscopic submucosal dissection performed by trainee operators

Abstract

Background

Although endoscopic submucosal dissection (ESD) represents a significant progress in therapeutic endoscopy, little is known about how trainees attain its technical proficiency. The aims of this study were to evaluate the learning curve and clinical outcomes of gastric ESD performed by trainee endoscopists.

Methods

Between April 2009 and March 2014, 334 gastric ESD procedures were performed by seven trainees (42–50 consecutive cases per trainee). The learning curve for gastric ESD was evaluated using the cumulative sum (CUSUM) method. Long-term outcomes were also analyzed.

Results

The calculated CUSUM learning curve comprised three phases: Phase I (the initial 15 cases), Phase II (the middle 15 cases), and Phase III (the final 20 cases). The resection speed was 5.7 ± 3.2 min/cm² in Phase I, 4.7 ± 2.7 min/cm² in Phase II, and 4.3 ± 2.2 min/cm² in Phase III. The resection speed was significantly faster in Phase II than in Phase I (p = 0.019). The rate of self-completion reached more than 95% in Phases II and III. The overall complete resection rate was 95%, showing no significant differences between the three phases. Local recurrence was diagnosed in none of the patients during a median follow-up of 38 months.

Conclusions

For the trainees, 30 cases were required to attain a higher technical level of competence in gastric ESD. After the learning curve phase, trainee operators could be expected to complete the procedure successfully with favorable long-term outcomes.

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Totally laparoscopic or robot-assisted pancreaticoduodenectomy versus open surgery for periampullary neoplasms: separate systematic reviews and meta-analyses

Abstract

Objective

To compare perioperative and oncologic outcomes of pure (totally) laparoscopic pancreaticoduodenectomy (TLPD) or robot-assisted pancreaticoduodenectomy (RAPD) with those of conventional open pancreaticoduodenectomy (OPD).

Methods

A systematic literature search was performed using PubMed, EMBASE, and Cochrane library databases. Studies comparing TLPD with OPD and RAPD with OPD were included; only original studies reporting more than 10 cases for each technique were included. Studies were combined using a random-effects model to report heterogeneous data, or a fixed-effects model was applied.

Results

TLPD involved longer operative time (weighted mean difference [WMD]: 116.85 min; 95% confidence interval [CI] 54.53–179.17) and significantly shorter postoperative hospital stay (WMD: −3.68 days; 95% CI −4.65 to −2.71). Overall morbidity and postoperative pancreatic fistula were not significantly different between TLPD and OPD. RAPD was associated with a longer operative time, less intraoperative blood loss, and shorter hospital stay. Oncologic outcomes were not significantly different among the procedure types.

Conclusions

Compared to OPD, TLPD and RAPD were feasible and oncologically safe procedures. However, there are no prospective studies, and the majority of the studies on TLPD and RAPD have remained in the early training phase. In addition to randomized controlled trials or prospective studies, new data from the late training phase of learning experiences should also be analyzed.

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A novel procedure for introducing large sheet-type surgical material with a self-expanding origami structure using a slim trocar (chevron pleats procedure)

Abstract

Background

Large sheet-type surgical materials (e.g., absorbable hemostat, adhesion barrier membranes, and flat surgical mesh) are difficult to introduce into a corporeal cavity using a 5-mm trocar; however, laparoscopic surgeries that use mainly 5-mm trocars are increasing. Furthermore, it is necessary not only to introduce but also to secure the applied surgical material and expand it from the original surgical site. To address these challenges, we developed a novel procedure for introducing such surgical materials into a corporeal cavity using a 5-mm trocar and a self-expanding origami structure, called the "chevron pleats procedure (CPP)".

Methods

We used CPP in 114 cases of laparoscopic surgery for gastrointestinal diseases. The chevron folding pattern is an excellent origami structure and compactly folds a large sheet of material for use with a slim trocar. Surgical materials were folded using a chevron pleats pattern and inserted into a novel, slim, long syringe-type device, which was made from a specially ordered precision polypropylene tube, for introduction into a corporeal cavity. When the surgical material was used, the end of the device was placed above the surgical site and the inner rod was pushed. The surgical material was securely injected and expanded over the surgical site.

Results

Surgical materials were introduced smoothly and securely using a 5-mm trocar to a site of intraoperative bleeding, the incisional surface of the liver, and defects of the abdominal wall or peritoneum. Efficient hemostasis was attained, the introduction and expansion of surgical mesh was made simpler, and the covering of defects of the peritoneum with adhesion barrier membranes, which is typically difficult during laparoscopic surgery, was easily performed.

Conclusions

CPP is a basic utility procedure for introducing several sheet-type surgical materials into a corporeal cavity with a 5-mm trocar and might help ensure efficient and safe laparoscopic surgery.

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Five hundred consecutive laparoscopic common bile duct explorations: 5-year experience at a single institution

Abstract

Background

Laparoscopic common bile duct exploration (LCBDE) has gained wide popularity in the treatment of choledocholithiasis. Bile leakage remains a major cause of postoperative morbidity. The aim of this study was to report 5-year results of 500 LCBDEs and identify risk factors associated with bile leakage.

Methods

Five hundred consecutive LCBDEs performed in one institution from September 2011 to June 2016 were reviewed. Patients' clinical data were retrospectively collected and analyzed. Univariable and multivariable analysis of bile leakage was performed by logistic regression.

Results

We found stones (n = 388) or bile sludge (n = 71) in 459 patients (92%) on exploration, leaving 41 patients (8%) without stones. Operative time was 128 min in the first 250 LCBDEs, and this decreased to 103 min in the second 250 LCBDEs (P = 0.0004). Four hundred and eight (82%) procedures were completed with primary closure after choledochotomy; the rate of primary closure increased significantly in the second 250 patients compared with the first (88 vs 76%; P = 0.0005), whereas T-tube placement (2 vs 6%; P = 0.0225) and transcystic approach (7 vs 12%; P = 0.0464) decreased, respectively. Stone clearance was successful in 495 patients (99%). Overall morbidity was 5%, and bile leakage occurred in 17 patients (3.4%). Two patients died from bile leakage. The median follow-up was 24 months with stone recurrence occurred in two patients and bile duct stricture in one patient. Univariable analysis identified diameter of the common bile duct (CBD), stone clearance, and T-tube insertion as risk factors related to bile leakage. Multivariable analysis taking these three factors into account identified non-dilated CBD (risk ratio (RR) = 9.87; P = 0.007) and failure in stone clearance (RR = 11.88; P = 0.024) as significant risk factors.

Conclusions

Bile leakage following LCBDE is associated with diameter of the CBD and stone clearance. LCBDE would be safer in proficient laparoscopic surgeons with a careful selection of patients.

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Effects of laparoscopic myotomy on the esophageal motility pattern of esophageal achalasia as measured by high-resolution manometry

Abstract

Background

Esophageal achalasia can be classified on the grounds of three distinct manometric patterns that correlate well with final outcome after laparoscopic Heller-Dor myotomy (LHM). No analytical data are available, however, on the postoperative picture and its possible correlation with final outcome. The aims of this study were: (a) to investigate whether manometric patterns change after LHM for achalasia; (b) to ascertain whether postoperative patterns and/or changes can predict final outcome; and (c) to test the hypothesis that the three known patterns represent different stages in the evolution of the disease.

Methods

During the study period, we prospectively enlisted 206 consecutive achalasia patients who were assessed using high-resolution manometry (HRM) before undergoing LHM. Symptoms were scored using a detailed questionnaire. Barium swallow, endoscopy and HRM were performed, before and again 6 months after surgery.

Results

Preoperative HRM revealed the three known patterns with statistically different esophageal diameters (pattern I having the largest), and patients with pattern I had the highest symptom scores. The surgical treatment failed in 10 cases (4.9%). The only predictor of final outcome was the preoperative manometric pattern (p = 0.01). All patients with pattern I preoperatively had the same pattern afterward, whereas nearly 50% of patients with pattern III before LHM had patterns I or II after surgery. There were no cases showing the opposite trend.

Conclusions

Neither a change of manometric pattern after surgery nor a patient's postoperative pattern was a predictor of final outcome, whereas preoperative pattern confirmed its prognostic significance. The three manometric patterns distinguishable in achalasia may represent different stages in the disease's evolution, pattern III and pattern I coinciding with the early and final stages of the disease, respectively.

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Radiofrequency energy delivery to the lower esophageal sphincter improves gastroesophageal reflux patient-reported outcomes in failed laparoscopic Nissen fundoplication cohort

Abstract

Background

Patients with uncontrollable gastroesophageal reflux disease (GERD) often undergo laparoscopic Nissen fundoplication (LNF); however, long-term there are often recurring symptoms and need for continuous medication use. Refractory LNF patients may receive radiofrequency energy delivery to the lower esophageal sphincter (Stretta) to ameliorate symptoms and medication requirements. The aim was to assess and compare long-term patient-reported outcomes of Stretta in refractory patients with and without previous LNF.

Methods

We prospectively assessed and compared patient-reported outcomes in 18 refractory LNF patients and 81 standard refractory GERD patients that all underwent Stretta during 10-year follow-up. Patient-reported outcomes measured were GERD-HRQL (health-related quality of life), patient satisfaction scores, and daily medication requirements.

Results

The refractory LNF subset demonstrated median improvements in GERD-HRQL, satisfaction, and medication use at all follow-up time points ≥6 months to 10 years, which was significant from a baseline of both on- and off-medications (p < 0.05). Specifically at 10 years, median GERD-HRQL decreased from 36 to 7 (p < 0.001), satisfaction increased from 1 to 4 (p < 0.001), and medication score decreased from 7 to 6 (p = 0.040). Nine patients decreased medication use by half at 10 years. No significant differences existed between refractory LNF and standard refractory GERD subsets at any follow-up time point ≥6 months to 10 years (p > 0.05) after Stretta. At 10 years, no significant differences were noted between refractory LNF and standard Stretta subsets regarding medication use (p = 0.088), patient satisfaction (p = 0.573), and GERD-HRQL (p = 0.075). Stretta procedures were completed without difficulty or significant intraoperative or long-term adverse events.

Conclusion

Within a small cohort of refractory LNF patients, Stretta resulted in sustained improvement over 10 years with equivalent outcomes to non-LNF standard Stretta patients. Refractory LNF patients are a subpopulation that may be safely, effectively, and robustly aided by Stretta with fewer complications compared to redo of Nissen or chronic medication use.

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Single-incision laparoscopic cholecystectomy versus conventional four-port laparoscopic cholecystectomy: a systematic review and meta-analysis

Abstract

Background

Single-incision laparoscopic cholecystectomy (SILC) might maximize the advantages of laparoscopic cholecystectomy (LC) by reducing postoperative pain and improving cosmesis. However, the safety and feasibility of SILC has not yet been established. This study assesses safety, patient reported outcome measures and feasibility of SILC versus conventional LC.

Methods

Literature search for RCT's comparing SILC with conventional LC in gallstone-related disease was performed in PubMed and Embase. The conventional LC was defined as two 10-mm and two 5-mm ports. Study selection was done according to predefined criteria. Two reviewers assessed the risk of bias. Pooled outcomes were calculated for adverse events, pain, cosmesis, quality of life and feasibility using fixed-effect and random-effects models.

Results

Nine RCT's were included with total of 860 patients. No mortality was observed. More mild adverse events (RR 1.55; 95% CI 0.99–2.42) and significantly more serious adverse events (RR 3.00; 95% CI 1.05–8.58) occurred in the SILC group. Postoperative pain (MD -0.46; 95% CI -0.74 to -0.18) and cosmesis (SMD 2.38; 95% CI 1.50–3.26) showed significantly better results for the SILC group, but no differences were observed in quality of life. Operating time (MD 23.12; 95% CI 11.59–34.65) and the need for additional ports (RR 11.43; 95% CI 3.48–37.50) were significantly higher in the SILC group. No difference was observed in conversion to open cholecystectomy or hospital stay longer than 24 h.

Conclusions

SILC does not provide any clear advantages over conventional LC except for less postoperative pain and improved cosmesis. It is questionable whether these advantages outweigh the higher occurrence of adverse events and shortcomings in feasibility. Considering considerable heterogeneity and low methodological quality of the studies it is advisable to perform well-designed RCT's in the future to address the safety and clinical benefits of SILC.

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Leadership development in a professional medical society using 360-degree survey feedback to assess emotional intelligence

Abstract

Background

The current research evaluated the potential utility of a 360-degree survey feedback program for measuring leadership quality in potential committee leaders of a professional medical association (PMA). Emotional intelligence as measured by the extent to which self-other agreement existed in the 360-degree survey ratings was explored as a key predictor of leadership quality in the potential leaders.

Study Design

A non-experimental correlational survey design was implemented to assess the variation in leadership quality scores across the sample of potential leaders. A total of 63 of 86 (76%) of those invited to participate did so. All potential leaders received feedback from PMA Leadership, PMA Colleagues, and PMA Staff and were asked to complete self-ratings regarding their behavior.

Results

Analyses of variance revealed a consistent pattern of results as Under-Estimators and Accurate Estimators-Favorable were rated significantly higher than Over-Estimators in several leadership behaviors.

Conclusions

Emotional intelligence as conceptualized in this study was positively related to overall performance ratings of potential leaders. The ever-increasing roles and potential responsibilities for PMAs suggest that these organizations should consider multisource performance reviews as these potential future PMA executives rise through their organizations to assume leadership positions with profound potential impact on healthcare. The current findings support the notion that potential leaders who demonstrated a humble pattern or an accurate pattern of self-rating scored significantly higher in their leadership, teamwork, and interpersonal/communication skills than those with an aggrandizing self-rating.

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Incidence of abdominal wall metastases following percutaneous endoscopic gastrostomy placement in patients with head and neck cancer

Abstract

Introduction

Percutaneous endoscopic gastrostomy (PEG) tubes are an effective modality for enteral nutrition in patients with head and neck cancer; however, there have been documented case reports of "seeding" of the abdominal wall by the theoretic risk of dragging the tube along the tumor during PEG placement. The objective of this study is to determine the incidence and contributing risk factors leading to metastasis to the abdominal wall following PEG placement in patients with head and neck cancer.

Methods

A retrospective chart review was performed on patients diagnosed with head and neck malignancy who underwent PEG placement between 1/5/2009 and 12/22/2014. Variables collected included development of abdominal wall metastases, type of malignancy and tumor characteristics, smoking history, PEG placement technique, and survival following recurrence. Data were then analyzed for overall trends.

Results

Out of 777 patients analyzed, a total of five patients with head and neck malignancy were identified with abdominal wall metastasis following PEG tube placement with an overall incidence of 0.64% over an average follow-up of 27.55 months. All of these patients underwent PEG tube insertion via a Pull technique. One patient was found to have a clinically evident and symptomatic stomal metastasis, while the other four patients had radiologically detected metastases either on CT or PET scan. All of the identified patients were found to have stage IV oral cancer at time of initial diagnosis of their head and neck malignancy, followed by widespread distant metastatic disease at time of presentation with their PEG site stomal metastasis.

Conclusion

Abdominal wall metastases following PEG placement are a rare but serious complication in patients with head and neck malignancy.

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A multicenter experience of through-the-scope balloon-assisted enteroscopy in surgically altered gastrointestinal anatomy

Abstract

Background

Surgically altered gastrointestinal anatomy poses challenges for deep enteroscopy. Current overtube-assisted methods have long procedure times and utilize endoscopes with smaller working channels that preclude use of standard accessories. A through-the-scope balloon-assisted enteroscopy (TTS-BAE) device uses standard endoscopes with a large working channel to allow metallic and plastic stent insertion. We aim to determine the efficacy and safety of TTS-BAE in patients with altered surgical anatomy.

Methods

A retrospective, multicenter study of TTS-BAE in altered anatomy patients at two USA and one German institution was performed between January 2013 and December 2014. Type of anatomy, procedure indication and duration, adverse events, and target, technical, and clinical success were recorded.

Results

A total of 32 patients (mean age 54 years, Caucasian 81.6%, female 42.1%, mean BMI 25.4 kg/m²) underwent 38 TTS-BAE procedures. Thirty-two percent of cases had a prior attempt at conventional enteroscopy which failed to reach the target site. The target was successfully reached in 23 (60.5%) cases. Of the 23 cases that reached the intended target, 22 (95.7%) achieved technical success and 21 (91.3%) achieved clinical success. The median procedure time was 43 min. Target, technical, and clinical success rates for TTS-BAE-assisted ERCP (n = 31) were 58.1, 54.8 and 54.8%. Seven self-expandable metallic stents (five biliary, two jejunal) were attempted, and all successfully deployed. Adverse events occurred in 4 (10.4%) cases, including one luminal perforation.

Conclusion

TTS-BAE is an alternative to overtube-assisted enteroscopy that is comparable in safety in patients with surgically altered anatomies. Technical success in the instances where the target had been reached was excellent. TTS-BAE confers an advantage over overtube-assisted enteroscopy as it can facilitate the deployment of self-expandable metallic stents in the biliary tree and deep small bowel.

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Is bariatric surgery safe in the elderly population?

Abstract

Background

Bariatric surgery has proven to be the most effective treatment for morbid obesity in all age groups and is considered superior to medical treatment. The aim of our study was to report the outcomes of bariatric surgery in patients over 65 years of age at our institution.

Methods

A retrospective review of a prospectively collected database was conducted of all patients > 65 years who underwent a bariatric procedure between 2005 and 2015 at our institution. We compared this group to a control group of patients < 65 years of age who were operated on during the last 5 years, from 2011 to 2015. Data analyzed included age, preoperative BMI, postoperative complications, and comorbidities.

Results

Of 1613 patients studied, 1220 patients were under 65 years of age, and in Group B, 393 were >65 years of age at time of surgery. There was a significant difference in proportion of male patients among groups; 42 % in Group B were male compared to 30 % in Group A (p < 0.001). Caucasians represented the majority in both groups. Both groups had comparable preoperative BMI 42.27 kg/m² for the younger Group A population versus 41.64 kg/m² for Group B (p = 0.074). Group B had more comorbidities than Group A: hypertension (p < 0.001), sleep apnea (p < 0.001), and hypercholesterolemia (p < 0.001). No difference was found between groups in history of depression (p = 0.409) or type II diabetes (p = 0.961). Distribution of procedures was significantly different between groups, with more LSG in Group A (p < 0.001). Elderly patients had longer length of stay (LOS) by one day on average (LOS = 3 days, p < 0.001), but a lower readmission rate (10 % vs. 7 %) (p = 0.023). Complication rates were comparable in both groups, except for incidence of de novo GERD, which was higher in Group B (5 % vs. 8 %) (p = 0.005).

Conclusions

Elderly patients are usually sicker in terms of comorbidities than the younger population. However, age does not seem to represent a risk of surgical complications after bariatric surgery.

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Resident Volunteer Firefighter/EMT - West Thurston Regional Fire Authority

Job Duties as a FF/EMT: respond to and provide various emergency services such as fire suppression, rescue, and emergency medical services. • Transport patients to the hospital • perform Basic Life Support Services • Fire suppression and prevention • Operate power tools and manual tools • Drive and operate Fire/EMS apparatuses such as an aid unit, fire engine, support unit ...

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Pain perception in patients with chronic disorders of consciousness: what can limbic system tell us?

Whether or not and to what extent patients suffering from Unresponsive Wakefulness Syndrome (UWS) can perceive pain is still a great dilemma (Arbour 2013; Demertzi et al. 2009; Chatelle et al. 2014; Schnakers et al. 2012). Indeed, clinical experience suggests that UWS individuals do not feel pain since they show no more than reflexive behaviours following nociceptive stimuli, whereas Minimally Conscious State (MCS) subjects show pain-oriented responses. Indeed, UWS patients have a repertoire of pain-induced responses, including grimacing and crying, which are similar to those that are seen in conscious individuals.

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Depth versus subdural temporal electrodes revisited: impact on surgical outcome after resective surgery for epilepsy

Temporal lobe epilepsy is the most common form of focal seizure disorder in adults (Kilpatrick et al., 2003). About 40% of patients with focal epilepsy are not controlled with antiepileptic drugs and may be candidates for surgical therapy (Stephen et al., 2001). Indeed, several studies have found a relation between correct localization of the epileptogenic focus and favorable outcome (Lieb et al., 1981; Spencer et al., 1982). Despite modern improvements in non-invasive presurgical assessment, 25-30% of patients require invasive intracranial EEG recordings to identify the epileptogenic zone (Stephen et al., 2001; Nair et al., 2008; Kumar et al., 2013).

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The Effect of Saccadic Eye Movements on the Sensor-Level Magnetoencephalogram

For both electroencephaolography (EEG) and magnetoencephalography (MEG) eye movements are a major signal source which could easily be confused with other brain-related signals. There are two primary factors which we consider here: the rotation of the eye dipoles, and the synchronous activation of the extraocular muscles.

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Interrater Reliability of Visually Evaluated High Frequency Oscillations

In the treatment of medically-refractory focal epilepsy, successfully eliminating the occurrence of seizures is dependent upon the localization and removal of the regions generating the seizures. These epileptogenic regions may be identified by localizing interictal epileptiform discharges (IEDs) on the intracranial electroencephalogram (iEEG) (Blume et al., 2001; Ebersole and Wade, 1991). Recently, high frequency oscillations (HFOs) (Cho et al., 2014; Jacobs et al., 2010a) and HFOs occurring simultaneously with IEDs (HFO+IEDs) (Jacobs et al., 2008; Wang et al., 2013) have both been shown to be more effective than IEDs alone at delineating the epileptogenic regions.

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GABAAergic dysfunction in the olivary-cerebellar-brainstem network may cause eye oscillations and body tremor

Opsoclonus and flutter are ocular oscillations consisting of continuous, involuntary, conjugate saccades without intersaccadic intervals. If these saccadic oscillations are purely horizontal, they are called ocular flutter; if they have horizontal, vertical and torsional components, they are called opsoclonus. Behavioral disturbances, cerebellar ataxia, and limb tremor may co-occur. Several infectious, paraneoplastic, metabolic, and toxic etiologies cause these disturbances, but how neural circuits generate the oscillations is not clear.

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Value of re-interpretation of controversial EEGs in a tertiary epilepsy clinic

Misdiagnosis of epilepsy is known to occur rather frequently with figures up to 30% (Scheepers et al. 1998; Uldall et al. 2006). Errors in EEG-interpretations are a major cause of this, but reliable data about the contribution of this factor are scarce (Benbadis 2007). Clinical data together with EEG results constitute the basis for the diagnosis of epilepsy. The combination of weak clinical and weak EEG conclusions is considered to be the major pitfall in the diagnosis of epilepsy (Benbadis 2007).

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Demonstration of Motor-Related Beta and High Gamma Brain Signals in Subdermal Electroencephalography Recordings

Electrical brain signals carry information about health, function, and connectivity, and are relevant to clinical care, research, and brain-computer interfacing. In general, sensors closer to the brain result in higher fidelity recordings. Electrocorticography (ECoG) sensors implanted on the surface of the brain yield much stronger signals than can be recorded with electroencephalography (EEG), however ECoG requires surgery. Conversely, EEG may provide sufficient quality data for many applications, but it requires significant setup effort and inverse modeling for source mapping.

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MUNIX in the clinic in ALS: MUNE comes of age

Motor unit counting in individual muscles – motor unit number estimation (MUNE) – is a well-established technique that has never quite become established in clinical practice, despite its obvious potential utility in assessing the motor innervation of a muscle. Although such a direct count should be intuitively better than assessing motor unit waveforms – it has remained a not quite achievable holy grail of EMG, especially in the assessment of ALS, a disorder in which a reliable MUNE test should have a major role.

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Injury Prevention Exercise Programs for Professional Soccer: Understanding the Perceptions of the End-Users

Objective: To evaluate the perceptions of professional soccer players and staff members toward injury prevention exercise programs (IPEPs). Design: Self-report survey. Setting: Four professional soccer teams in 4 different countries. Participants: 126 players, coaches, physiotherapists, and fitness coaches were invited to participate, with 72 respondents. Main Outcome Measures: Web-based survey detailing perceptions of lower limb (LL) injury susceptibility and seriousness, the value of IPEPs in general, and more specifically the International Federation of Association Football (FIFA) 11+. Results: The vast majority of the respondents believed that professional soccer players are at high risk of LL injuries (93%) and that players should perform evidence-based injury prevention exercises (98%). They also agreed that LL injuries can shorten a player's career (85%), cause physical problems later in life (82%), and negatively impact on team performance (77%). However, perceptions varied across teams regarding which types of injury prevention exercises are effective, who holds responsibility for injury prevention, and when IPEPs should be performed. Specific knowledge of the FIFA 11+ was very low and 47% of respondents believed the program would need modification for use in their team. Conclusions: Players and staff members in professional soccer teams strongly support the use of evidence-based IPEPs. However, perceptions vary considerably between teams regarding which exercises can prevent injuries, who holds the responsibility for injury prevention, and when preventive exercises should be performed. Enhancing the ultimate impact of IPEPs in professional soccer requires a detailed understanding of each team's specific implementation context.

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Peroneal Nerve Dysfunction due to Multiligament Knee Injury: Patient Characteristics and Comparative Outcomes After Posterior Tibial Tendon Transfer

Objective: To objectively compare outcomes of nonoperative management and posterior tibial tendon (PTT) transfer for peroneal nerve injury due to multiligament knee injury (MLI). Design: Retrospective cohort study with prospective follow-up. Setting: Tertiary care institution. Patients: Ten patients with peroneal nerve injury due to MLI (5 managed nonoperatively, 5 with PTT transfer) were evaluated and a control group of 4 patients without peroneal nerve injury. Interventions: Clinical examination, subjective questionnaires, and 3-D motion capture gait analysis during flat-ground walking and stair descent. Main Outcome Measures: The primary outcome measure was the result of gait analysis. The results of subjective questionnaires were a secondary outcome measure. Results: Dorsiflexion was significantly reduced at initial contact and mid–late swing phase in the nonoperative cohort. The PTT transfer cohort demonstrated increased dorsiflexion at each of these time intervals compared with patients managed nonoperatively, restoring symmetry between limbs. The PTT transfer cohort demonstrated similar gait patterns to controls but tended to be more everted. Ground reaction force was increased in the uninvolved limb in the PTT transfer group during gait and step down. There were no statistically significant differences in AOFAS, FAAM, IKDC, or Lysholm results. Conclusions: Posterior tibial tendon transfer is an option to restore dorsiflexion and eliminate the need for an orthosis in patients with foot drop due to MLI. Gait analysis demonstrates a significant improvement in sagittal plane ankle kinematics after PTT transfer. The trade-off is subtle instability, highlighting the dynamic stability that the PTT provides.

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Doping Status of DHEA Treatment for Female Athletes with Adrenal Insufficiency

Objective: To review the doping status of dehydroepiandrosterone (DHEA) for female athletes with adrenal insufficiency within the framework of Therapeutic Use Exemption (TUE) applications for this proandrogen, which is included on the World Anti-Doping Agency (WADA)'s Prohibited List. Data Sources and Main Results: Current knowledge of adrenal pathophysiology with a focus on the physiological role and pharmacological effects of DHEA in female athletes including placebo-controlled clinical trials of DHEA and consensus clinical practice and prescribing guidelines. Conclusions: Because there is no convincing clinical evidence to support the use of DHEA replacement therapy in women with adrenal failure, a TUE for DHEA is not justified by definite health benefit for either secondary or primary adrenal failure. This is consistent with the 2014 update of the US Endocrine Society guidelines, meta-analyses of DHEA treatment in women with or without adrenal failure, current WADA TUE guidance document for adrenal insufficiency and recent case law of WADA's Court of Arbitration for Sport.

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Hamstring-and-Lower-Back Flexibility in Male Amateur Soccer Players

Objective: This study investigated the hamstring-and-lower-back flexibility (HLBF) of male adult amateur soccer players, using the sit-and-reach test (SRT), with a view to obtaining population-based reference values and to determining whether SRT scores are associated with player characteristics. Design: Cross-sectional cohort study. Setting: Teams from high-level Dutch amateur soccer competitions were recruited for participation. Participants: Dutch male high-level amateur field soccer players (n = 449) of age 18 to 40 years. Players with a hamstring injury at the moment of SRT-measurement or any other injury that prevented them from following the SRT protocol were excluded. Main Outcome Measures: Sit-and-reach test scores were measured and then population-based reference values were calculated as follows: >2SD below mean (defining "very low" HLBF), 1SD-2SD below mean ("low" HLBF), 1SD below mean to 1SD above mean ("normal" HLBF), 1SD-2SD above mean ("high" HLBF), and >2SD above mean ("very high" HLBF). Whether SRT scores were correlated with player characteristics was determined using a Pearson correlation coefficient or Spearman rho. Results: Sit-and-reach test scores ranged from 0 to 43.5 cm (mean 22.0 cm, SD 9.2). The cutoff points for population-based reference values were 40.5 cm for "very high". Sit-and-reach test scores were significantly associated with players' height (ρ = −0.132, P = 0.005), body mass index (r = 0.114, P = 0.016), and history of anterior cruciate ligament surgery (P

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Reliability Testing of the Balance Error Scoring System in Children Between the Ages of 5 and 14

Objective: Pediatric concussion is an extensive public health concern with a complex clinical presentation. Balance assessment has been well-studied in the adult population, but has been limited in children. We aimed to assess the reliability and minimum detectable change (MDC) of the Balance Error Scoring System (BESS) in healthy children. Design: This prospective observational study included 373 healthy children aged 5 to 14. Interrater reliability was assessed by having 4 assessors review videos of 50 random subjects distributed evenly by age and sex across the entire cohort. Intrarater reliability was performed by having assessors review videos of other assessors' live evaluations. Test–retest reliability was obtained by comparing BESS scores as recorded live at the 2 separate time points by the same rater. Setting: Local elementary and junior high schools. Participants: Three hundred and seventy three healthy children between the ages of 5 and 14. Interventions: The BESS was performed on all children. Main Outcome Measures: Intraclass Correlation Coefficients (ICCs) and MDC Scores. Results: The overall interrater ICC was determined to be 0.93 [95% confidence interval (CI), 0.79-0.97] and intrarater ICC was 0.96 (95% CI, 0.95-0.97) with individual intrarater ICCs ranging between 0.69 and 0.99. The test–retest reliability was 0.90 (95% CI, 0.88-0.92). The MDCs were 9.6, 4.6, and 7.3 points at the 95% CIs for interrater, intrarater, and test–retest comparisons, respectively. No learning effect was seen. Conclusions: The BESS demonstrates excellent reliability in the pediatric population without evidence of a learning effect.

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Development of a Chest Wall Protector Effective in Preventing Sudden Cardiac Death by Chest Wall Impact (Commotio Cordis)

Objective: Commotio cordis, sudden death with chest impact, occurs clinically despite chest wall protectors worn in sports. In an experimental model of commotio cordis, commercially available chest wall protectors failed to prevent ventricular fibrillation (VF). The goal of the current investigation was to develop a chest wall protector effective in the prevention of commotio cordis. Design: In the Tufts experimental model of commotio cordis the ability of chest protectors to prevent VF was assessed. Impacts were delivered with a 40-mph lacrosse ball, timed to the vulnerable period for VF. Intervention: A chest wall protector or no chest wall protector (control) was randomly assigned to be placed over the chest. Four iterative series of 2 to 4 different chest wall material combinations were assessed. Materials included 3 different foams (Accelleron [Unequal Technologies, Glen Mills, PA], closed cell high density foam; Airilon [Unequal Technologies, Glen Mills, PA], closed cell low density soft foam; and an open cell memory foam) that were adhered to a layer of TriDur (Unequal Technologies, Glen Mills, PA), a flexible elastomeric coated aramid that was bonded to a semirigid polypropylene polymer (ImpacShield, Unequal Technologies, Glen Mills, PA). Main Outcome Measure: Induction of VF by chest wall impact was the primary outcome. Results: Of 80 impacts without chest protectors, 43 (54%) resulted in VF. Ventricular fibrillation with chest protectors ranged from a high of 60% to a low of 5%. Of 12 chest protectors assessed, only 3 significantly lowered the risk of VF compared with impacts without chest protectors. These 3 chest protectors were combinations of Accelleron, Airilon, TriDur, and ImpacShield of different thicknesses. Protection increased linearly with the thicker combinations. Conclusions: Effective protection against VF with chest wall protection can be achieved in an experimental model of commotio cordis. Clinical Relevance: Chest protector designs incorporating these novel materials will likely be effective in the prevention of commotio cordis on the playing field.

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Can KAATSU Exercise Cause Rhabdomyolysis?

Abstract: In recent years, there has been increasing interest in using low-load resistance exercise in combination with a reduction in blood flow to promote muscle adaptation (ie, blood flow–restricted exercise or KAATSU exercise). There has been 1 case study reported in the literature of this type of exercise resulting in exertional rhabdomyolysis, and herein, we report the second case of exertional rhabdomyolysis. In this case, a 20-year-old man performed 6 sets of blood flow–restricted exercise (3 sets of knee-extension and 3 sets of elbow-flexion exercise). The subject presented with high levels of delayed onset muscle soreness in the days after the exercise bout exhibited high levels of creatine kinase (peak recorded: 36 000 IU/L), and was hospitalized for exertional rhabdomyolysis. We urge that investigators and practitioners use caution with blood flow–restricted exercise protocols and to begin these exercise programs modestly and gradually progress them with time.

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Impact of Patellar Tendinopathy on Knee Proprioception: A Cross-Sectional Study

Objective: To determine whether high-level athletes with patellar tendinopathy have diminished knee proprioceptive acuity. Design: Cross-sectional study. Setting: University research laboratory (institutional). Participants: Twenty-one basketball and volleyball players with patellar tendinopathy (13 men and 8 women; mean age 24.5 ± 3.6; body mass index = 22.5 ± 2.0 kg/m2) and an equal number of athletes without symptoms of patellar tendinopathy injury were included in this study. Assessments: Participants underwent knee proprioception assessments on a single day. Furthermore, age, sex, height, weight, VISA-P (Victorian Institute of Sport Assessment) questionnaire sports participation, medical history, knee injuries, previous treatment, and medication were obtained. Main Outcome Measures: Knee proprioception was evaluated by assessing sense of resistance, using a weight discrimination protocol, and joint position sense (JPS). Results: No significant differences were observed in JPS at 30 and 60 degrees of knee flexion between groups (P = 0.165 and 0.481, respectively). In regard to the ability to discriminate weight, significant differences between the 2 groups were found with the tendinopathy group showing a higher percentage of error (P = 0.009), namely when the set of incremental weights varied by 10% from the standard weight. Conclusions: Athletes with patellar tendinopathy have a diminished perception of force signals required for weight discrimination, whereas JPS remains unaffected in these athletes.

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Validity, Reliability, and Responsiveness of the Anterior Cruciate Ligament Quality of Life Measure: A Continuation of Its Overall Validation

Objective: The purpose is to provide more validity, reliability, and responsiveness testing of the anterior cruciate ligament–quality of life instrument (ACL-QOL), particularly in light of consensus-based standards for the selection of health status measurement instruments (COSMIN) guidelines. Design: Prospective case series. Setting: An orthopedic surgical practice for consultation. Patients: A convenience sample of 579 ACL-deficient patients. Intervention: Anterior cruciate ligament reconstructive surgery. Main Outcome Measures: Patients completed the ACL-QOL at initial visit and underwent reconstructive surgery. Patients were followed at 6, 12, and 24 months using the ACL-QOL to determine its validity and responsiveness. Cronbach's alpha was used to determine the unidimensionality of the ACL-QOL. A subset of patients took the ACL-QOL twice in a test–retest reliability analysis (intraclass correlation coefficient or ICC 2,k). Another subset of 24-month postsurgical patients measured the success of their surgery using a 7-point global rating scale of improvement as an anchor-based method of responsiveness. Results: Cronbach's alpha coefficients = 0.93, 0.95, 0.96, and 0.98 at 6, 12, and 24 months, respectively. Intraclass correlation coefficient = 0.60, SEM = 6.16, and confidence interval of 12.1 (CI 95%). Responsiveness was measured by comparing the 4 serial time periods. Patients improved significantly at each time period (P 0.05) to being "significantly better" or "somewhat better." Conclusions: The results of this study added more validity, reliability, and responsiveness for the ACL-QOL. The ACL-QOL has completed 8 of 9 COSMIN criteria.

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Risk Factors for Collegiate Swimmers Hospitalized With Exertional Rhabdomyolysis

Objective: To identify midseason risk factors for symptomatic exertional rhabdomyolysis (sER) in swimmers after a novel upper body workout. Design: Retrospective (1) survey and (2) analyses of observational laboratory data conducted over a 16-week training period, 2 months before sER. Setting: Midwest University. Participants: Thirty-four collegiate swimmers. Independent Variables: (1) Motivation, symptoms, and supplements for survey variables. (2) Changes (midseason minus preseason) in body composition, blood pressure (BP), urinary measures, and protein shake ingestion for laboratory variables. Main Outcome Measures: Swimmers were categorized in hospitalized (H), treated and released from hospital (RH), and nonhospitalized (NH) groups for analyses. Results: (1) Six swimmers were in the H group (17.6%; 3 male/3 female) and 7 in the RH group (20.6%; 3 male/4 female). Nonsignificant trend toward H swimmers relating more upper body soreness (≥9/10) than RH (8/10) and NH (6/10) swimmers (P > 0.05) while reporting "felt bad and workout went poorly" (P = 0.009). H and RH swimmers reported more arm locking during the workout (P = 0.04) and brown urine after arm competition compared with NH-group swimmers (P = 0.03). (2) Increases in right systolic (P = 0.01) and left diastolic (P = 0.02) BP, with trends toward decreased left arm lean mass (P = 0.06) in H compared with RH and NH swimmers. Female H swimmers had more acidic urine (pH = 5.50 vs 6.9; P = 0.004), less volume, and higher specific gravity than RH + NH swimmers. All H swimmers regularly ingested protein shakes after workouts. Conclusions: Risk factors for sER included exceptional motivation, extreme soreness, increased resting BP, acidic urine (females), and regular ingestion of protein shakes.

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Bone Structure and Geometric Properties at the Radius and Tibia in Adolescent Endurance-Trained Cyclists

Objective: To describe cortical and trabecular volumetric bone mineral density (vBMD), bone mineral content (BMC), cross-sectional area (CSA), and bone strength indexes (BSIs) in adolescent endurance-trained cyclists (CYC) and compare them with controls (CON). Design: Descriptive cohort study. Participants: Twenty-five male adolescent CYC and 17 CON. Assessment of Risk Factors: Peripheral quantitative computed tomography was used to evaluate proximal and distal sites of the radius and tibia. Main Outcome Measures: Total, trabecular, and cortical BMC, vBMD, and CSA were measured. Also, cortical thickness, endosteal and periosteal circumferences, and different BSIs were calculated. Unadjusted analysis of variance and body weight-adjusted analysis of covariance tests were applied between cyclist and control groups. Results: Cyclists were almost 12% lighter than CON (P

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Injury Risk Is Increased by Changes in Perceived Recovery of Team Sport Players

Objective: The aim of this study is to investigate if changes in perceived stress and recovery over the course of a season are risk factors for acute and overuse injuries. Design: A prospective nonexperimental cohort design. Setting: Data were gathered at the SportsFieldLab Groningen and at the facilities of the participating teams. Participants: Eighty-six male and female basketball, volleyball, and korfball players aged 21.9 ± 3.5 years. Interventions: In this 10-month observational study, the independent variables are the changes in perceived stress and recovery. Main Outcome Measures: The Recovery–Stress Questionnaire for Athletes (RESTQ-Sport) was filled out every 3 weeks throughout the season to assess changes in perceived stress and recovery. Acute and overuse injuries were registered by the teams' physical therapists. Odds ratios and 95% confidence intervals were calculated. Results: During one season, 66 acute and 62 overuse injuries were registered. Multinomial regression analysis showed that perceived General Recovery, shown in the scales Social Recovery and General Well-Being, decreased in the 6-week period before an acute injury (OR 0.59 and 0.61, respectively, P ≤ 0.05) compared with healthy periods. Risk of overuse injuries increased when perceived Sport Recovery, shown in the Personal Accomplishment scale, decreased in the 3-week period before the injury (OR 0.59, P ≤ 0.05) compared with healthy periods. Conclusions: Therefore, decreased perceived recovery can indicate an increased injury risk. General Recovery affects acute injury risk and Sport Recovery affects the risk of an overuse injury. Monitoring perceived recovery over the course of a season could give guidance for recovery enhancing practices to prevent injuries.

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Use of Head Guards in AIBA Boxing Tournaments—A Cross-Sectional Observational Study

Objective: This study looks at the changes in injuries after the implementation of a new rule by the International Boxing Association (AIBA) to remove head guards from its competitions. Design: A cross-sectional observational study performed prospectively. This brief report examines the removal of head guards in 2 different ways. The first was to examine the stoppages due to blows to the head by comparing World Series Boxing (WSB), without head guards, to other AIBA competitions with head guards. Secondly, we examined the last 3 world championships: 2009 and 2011 (with head guards) and 2013 (without head guards). Setting: World Series Boxing and AIBA world championship boxing. Participants: Boxers from WSB and AIBA world championships. Interventions: The information was recorded by ringside medical physicians. Main Outcome Measures: Stoppages per 10 000 rounds; stoppages per 1000 hours. Results: Both studies show that the number of stoppages due to head blows was significantly decreased without head guards. The studies also showed that there was a notable increase in cuts. Conclusions: Removing head guards may reduce the already small risk of acute brain injury in amateur boxing.

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The Epidemiology of Concussions: Number and Nature of Concussions and Time to Recovery Among Female and Male Canadian Varsity Athletes 2008 to 2011

Objective: To provide incidence rates and days to symptom resolution and cognitive recovery stratified by sex and sport at a Canadian institution. Study Design: A retrospective chart analysis. Subjects: Seven hundred fifty-nine varsity level athletes competing in men's football, men's and women's soccer, men's and women's volleyball, men's and women's basketball, men's and women's ice hockey, women's field hockey, women's rugby, men's and women's tennis, men's and women's water polo, men's and women's swimming, badminton, cross-country, and track and field in the 2008 to 2009 season through the 2010 to 2011 season. Main Outcome Measures: Incidence of concussion, days to symptom recovery, and days to cognitive recovery as measured by clinical interpretation using the sports concussion assessment tool (SCAT)/SCAT2 and Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) with baseline and follow-up data. Results: A total of 81 concussions were reported and diagnosed among 759 athletes. Significantly, more female athletes were concussed than male athletes (13.08%–7.53%, respectively; P = 0.014) with the highest rates in women's rugby [incidence density (ID) = 20.00 concussions per athlete-season], women's ice hockey (ID = 18.67 per athlete-season), and men's basketball (ID = 20.00 per athlete-season). Sex differences in symptom recovery and cognitive recovery were not significant. Conclusions: The incidence of concussion across multiple sports in a Canadian varsity athlete population is of concern. There are inconsistencies found between the time an athlete claims to have no symptoms and the time of neurocognitive recovery as measured by computerized neurocognitive testing. Therefore, objective computerized testing is recommended to ensure that athletes are functionally recovered before return to play.

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Aggregatibacter aphrophilus Sacroiliitis Following Gastroscopy in a Young Sportsman

Abstract: We report a case of Aggregatibacter aphrophilus sacroiliitis in a young sportsman, presenting 48 hours after endoscopy and biopsy. Microbiological diagnosis was made only after repeated attempt at joint aspiration. The patient was cured after radiologically guided drainage and a prolonged course of directed antibiotics.

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Fla. EMS supervisor buys crash victim new bicycle

By EMS1 Staff

PINELLAS PARK, Fla. — An EMS supervisor's random act of kindness was recognized by police officers last week.

FOX13News reported that the Pinellas Park Police Department thanked Sunstar EMS Supervisor Josh Brumwell on their Facebook page for going above and beyond the call of duty. Brumwell, who was working a vehicle vs. bicyclist crash at a mall exit, said the bicyclist was not injured in the crash.

However, the man's bike was a total loss. Brumwell said the man broke down, saying the bike was his only means of transportation. Brumwell went to a nearby store and bought the man a new bicycle.

"This was an amazing act of goodwill during the holiday season," the Facebook post said.

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Seroprevalence of Hepatitis B Infection Among Immigrants in a Primary Care Clinic: A Case for Granular Ethnicity and Language Data Collection

Abstract

Chronic hepatitis B virus (HBV) infection is highly prevalent worldwide and is most often diagnosed through screening efforts. In order to identify the specific ethnic groups at greatest risk, it is necessary to go beyond traditional categories. We conducted a retrospective case series in a primary care clinic serving non-English speaking immigrants to determine the prevalence of HBV among patients of various primary spoken languages (used as a proxy for ethnicity). Among the 1378 patients, the overall prevalence of current infection was 8%. HBV infection was markedly higher among Somali, Oromo and Khmer speakerscompared to other groups. This study illustrates the use of granular language data in describing the serologic profiles of HBV infection among non-English speaking patients in primary care setting. The variations in prevalence by language have implications for public health HBV screening efforts, in addition to suggesting potential risk factors for transmission.

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Offending Behavior, Drug Use, and Mental Health Among Foreign-Born versus U.S. Born Latino Criminal Justice Clients

Abstract

Little is known about the offending behavior and recidivism factors of Latinos by nativity (U.S. born, foreign-born). The present study focused on Latinos in community corrections (n = 201) in Miami, Florida, and examined differences in criminal activity, drug use, and mental health by nativity. Data were collected utilizing convenience sampling between June 2014 and December 2015. The research question was: what are the offending, drug use, and mental health histories of Latinos involved in community corrections? Participants were mostly male (n = 120; 59.7%), White (n = 105; 52.2%), and Cuban (n = 97; 48.3%). U.S. born community corrections clients (n = 141) were more likely to report more lifetime and recent criminal activity; and more likely to report lifetime and recent drug use behavior than foreign-born Latinos (n = 60). No differences were found in recent mental health. Correctional healthcare should tailor services such as substance abuse treatment differently toward U.S. born and foreign-born Latinos.

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Neck disability index, Visual analog scale, and Likert scale in patients receiving pharmacotherapy for neck pain: How good do they correlate?

2016-12-30T07-12-19Z
Source: National Journal of Physiology, Pharmacy and Pharmacology
Liya Roslin Joseph, Dhanya Sasidharan Palappallil.
Background: Neck disability index (NDI) is a patient self-assessed outcome measurement tool to assess disability due to neck pain. Improvement in pain severity score by a pain intensity numerical rating scale may not necessarily produce a significant change in NDI after treatment. Aims and Objectives: This study was undertaken to study the correlation between the pain status rated by the patient using qualitative scales with the NDI in patients with neck related problems. Materials and Methods: It was prospective observational study conducted in Physical Medicine and Rehabilitation Department of Tertiary care Teaching Hospital in Kerala for duration of 6 months. 170 patients, with M: F ratio-1:2.9, having neck pain were included and treated with centrally acting muscle relaxants and analgesics for 2 weeks. Patients were assessed on their initial visit and followed up after 2 weeks. Patient rating of pain status was measured using visual analog scale (VAS) and a 5-item Likert scale varying from excellent to bad. Disability level due to neck pain was determined using NDI. Analysis was done with correlation coefficient, paired t-test and Wilcoxon signed ranks test using SPSS 20. Results: VAS and Likert scale rating showed a positive correlation with NDI, both before (correlation coefficient = 0.663, 0.589) and after (correlation coefficient = 0.845, 0.776) pharmacotherapy. Significant changes in NDI (t = 28.199, P

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Network properties of ICC affect intestinal pacemaker activity and motor patterns, according to a mathematical model of weakly coupled oscillators

Abstract

Interstitial cells of Cajal (ICC) are the pacemaker cells of gut motility and are associated with motility disorders. ICC form a network, but the contributions of its network properties to gut physiology and dysfunction are poorly understood. We modeled an ICC network as a two-dimensional network of weakly coupled oscillators with a frequency gradient and showed changes over time in video and graphical formats. Model parameters were obtained from slow wave driven contraction patterns in the mouse intestine and pacemaker slow wave activities from the cat intestine. Marked changes in propagating oscillation patterns (including changes from propagation to non-propagating) were observed by changing network parameters (coupling strength between oscillators, the frequency gradient and frequency noise) which affected synchronization, propagation velocity and occurrence of dislocations (termination of an oscillation). Complete uncoupling of a circumferential ring of oscillators caused the proximal and distal section to de-synchronize but complete synchronization was maintained with only a single oscillator connecting the sections with high enough coupling. The network of oscillators could withstand loss; even with 40% of oscillators lost randomly within the network, significant synchronization and antegrade propagation remained. Local increase in pacemaker frequency diminished antegrade propagation; the effects were strongly dependent on location, frequency gradient and coupling strength. In summary, the model puts forth the hypothesis that fundamental changes in oscillation patterns (ICC slow wave activity or circular muscle contractions) can occur through physiological modulation of network properties. Strong evidence is provided to understand the ICC network as a system of coupled oscillators.

This article is protected by copyright. All rights reserved

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Associations of pain intensity and pain-related disability with psychological and socio-demographic factors in patients with temporomandibular disorders: a cross-sectional study at a specialized dental clinic

Abstract

The study assessed whether psychological and socio-demographic factors, including somatization, depression, stress, anxiety, daytime sleepiness, optimism, gender and age are associated with pain intensity and pain-related disability in patients with temporomandibular disorders (TMD). In total, 320 TMD patients were involved in the study. The psychological status of each patient was assessed with questionnaires, including the Symptom Checklist-90 (SCL-90), Epworth Sleeping Scale (ESS), stress questionnaire, and Life Orientation Test-Revised (LOT-R). TMD pain, including pain intensity and pain-related disability, was assessed with characteristic pain intensity (CPI) and disability points scales. The associations of psychological and socio-demographic factors with pain intensity and pain-related disability were assessed through logistic regression analyses. Higher pain intensity was significantly associated with more severe anxiety (P = 0.004), more severe somatization (P < 0.001), more severe depression (P < 0.001), more severe stress (P = 0.001), and lower optimism (P = 0.025) in univariate regression analyses. However, multiple regression analysis showed that only somatization was significantly associated with pain intensity (P < 0.001). Higher pain-related disability was significantly associated with more severe anxiety (P < 0.001), more severe somatization (P < 0.001), more severe depression (P < 0.001), more severe stress (P < 0.001) and lower optimism (P = 0.003) in univariate regression analyses. However, multiple regression analysis showed that only depression was significantly associated with pain-related disability (P = 0.003). Among the psychological and socio-demographic factors in the present study, somatization was the best predictor for pain intensity, while depression was the best predictor for pain-related disability.

This article is protected by copyright. All rights reserved.

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Hepatic Encephalopathy Is Associated with Persistent Learning Impairments Despite Adequate Medical Treatment: A Multicenter, International Study

Abstract

Background

Hepatic encephalopathy (HE) is considered reversible regarding mental status but may not be cognitively in single-center studies.

Aim

To evaluate persistence of learning impairment in prior HE compared to those who never experienced HE (no-HE) in a multicenter study.

Methods

A total of 174 outpatient cirrhotics from three centers (94 Virginia, 30 Ohio, and 50 Rome; 36 prior HE) underwent psychometric hepatic encephalopathy score (PHES) and inhibitory control (ICT) testing at baseline and then at least 7 days apart. ICT learning (change in 2nd half lures compared to 1st half) was compared between patient groups at both visits. Change in the PHES individual sub-tests and total score between visits was compared in both groups. US versus Italian trends were also analyzed.

Results

HE patients had worse PHES and ICT results compared to no-HE patients at baseline. Significant improvement (1st half 7.1 vs. 2nd half 6.2, p < 0.0001) was observed in no-HE, but not in HE (1st half 7.9 vs. 2nd half 7.8, p = 0.1) at baseline. At retesting (median 20 days later), no-HE patients continued with significant learning (1st half 6.0 vs. 2nd half 5.4, p < 0.0001), while HE patients again did not improve (1st half 7.8 vs. 2nd half 6.9, p = 0.37). Between visits, no-HE patients improved significantly on four PHES sub-tests and overall score, while HE patients only improved on two sub-tests with similar overall PHES score. Trends were similar between US and Italian subjects.

Conclusion

In this multicenter study, prior HE patients showed persistent significant learning impairment compared to those without prior HE, despite adequate medical therapy. This persistent change should increase efforts to reduce the first HE episode.

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