Intratidal Analysis of Intraoperative Respiratory System Mechanics: Keep it Simple

No abstract available

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MicroRNAs as Clinical Biomarkers and Therapeutic Tools in Perioperative Medicine

Over the past decade, evolutionarily conserved, noncoding small RNAs—so-called microRNAs (miRNAs)—have emerged as important regulators of virtually all cellular processes. miRNAs influence gene expression by binding to the 3′-untranslated region of protein-coding RNA, leading to its degradation and translational repression. In medicine, miRNAs have been revealed as novel, highly promising biomarkers and as attractive tools and targets for novel therapeutic approaches. miRNAs are currently entering the field of perioperative medicine, and they may open up new perspectives in anesthesia, critical care, and pain medicine. In this review, we provide an overview of the biology of miRNAs and their potential role in human disease. We highlight current paradigms of miRNA-mediated effects in perioperative medicine and provide a survey of miRNA biomarkers in the field known so far. Finally, we provide a perspective on miRNA-based therapeutic opportunities and perspectives.

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Alkalinized Lidocaine Preloaded Endotracheal Tube Cuffs Reduce Emergence Cough After Brief Surgery: A Prospective Randomized Trial

BACKGROUND: Alkalinized lidocaine in the endotracheal tube (ETT) cuff decreases the incidence of cough and throat pain on emergence after surgery lasting more than 2 hours. However, alkalinized lidocaine needs 60–120 minutes to cross the ETT cuff membrane; therefore, its usefulness in shorter duration surgery is unknown. This prospective double-blind randomized controlled trial tested the hypothesis that alkalinized lidocaine would reduce the incidence of emergence cough after surgeries lasting 90 minutes before intubation with either 2 mL of 2% lidocaine and 8 mL of 8.4% bicarbonate (group AL) or 10 mL of normal saline (group S). Cuffs were emptied immediately before intubation. After intubation, either 2 mL of 2% lidocaine (AL) or 2 mL of saline (S) were injected into the cuff. Additional 8.4% bicarbonate (AL) or saline (S) was injected into the cuff until there was no air leak. Anesthesia was maintained using desflurane, rocuronium, and either fentanyl or sufentanil to maintain vital signs within 20% of baseline values. Opioids administered in prophylaxis of extubation cough were proscribed. A standardized "no touch" emergence technique was used. A blinded assessor noted any cough above 0.2 minimum alveolar concentration (MAC) of expired desflurane. At 0.2 MAC, once every 30 seconds, the patient was instructed to open his eyes and extubation occurred once a directed response was noted. RESULTS: A total of 213 patients were randomized and 100 patients in each group completed the experimental protocol. The incidence of extubation cough in group AL was 12%, significantly lower (1-sided P = .045) than the 22% incidence in group S. The 1-tailed risk ratio for cough in group AL was 0.55 (0–0.94, P = .045). Total amount of opioids administered (P = .194), ETT cuff preloading times (P = .259), and extubation times (P = .331) were not significantly different between groups. The average duration of surgery was 59 ± 28 minutes in group AL and 52 ± 29 minutes in group S (P = .057). CONCLUSIONS: Alkalinized lidocaine in the ETT cuff significantly decreased general anesthesia emergence cough after surgeries with an average duration of slightly

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“Mirror, Mirror on the Wall”: Learning From Reflections on Quality

No abstract available

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The Syringe Driver: Continuous Subcutaneous Infusions in Palliative Care, 4th ed.

No abstract available

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A Novel Approach to Synthesize the Evidence on Analgesic Adjuvants for Postoperative Pain

No abstract available

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Sugammadex and Oral Contraceptives: Is It Time for a Revision of the Anesthesia Informed Consent?

No abstract available

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Learning From Human Factors Can Make Anesthesia Even Safer

No abstract available

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Pediatric Anesthesiology Fellows’ Perception of Quality of Attending Supervision and Medical Errors

BACKGROUND: Appropriate supervision has been shown to reduce medical errors in anesthesiology residents and other trainees across various specialties. Nonetheless, supervision of pediatric anesthesiology fellows has yet to be evaluated. The main objective of this survey investigation was to evaluate supervision of pediatric anesthesiology fellows in the United States. We hypothesized that there was an indirect association between perceived quality of faculty supervision of pediatric anesthesiology fellow trainees and the frequency of medical errors reported. METHODS: A survey of pediatric fellows from 53 pediatric anesthesiology fellowship programs in the United States was performed. The primary outcome was the frequency of self-reported errors by fellows, and the primary independent variable was supervision scores. Questions also assessed barriers for effective faculty supervision. RESULTS: One hundred seventy-six pediatric anesthesiology fellows were invited to participate, and 104 (59%) responded to the survey. Nine of 103 (9%, 95% confidence interval [CI], 4%–16%) respondents reported performing procedures, on >1 occasion, for which they were not properly trained for. Thirteen of 101 (13%, 95% CI, 7%–21%) reported making >1 mistake with negative consequence to patients, and 23 of 104 (22%, 95% CI, 15%–31%) reported >1 medication error in the last year. There were no differences in median (interquartile range) supervision scores between fellows who reported >1 medication error compared to those reporting ≤1 errors (3.4 [3.0–3.7] vs 3.4 [3.1–3.7]; median difference, 0; 99% CI, −0.3 to 0.3; P = .96). Similarly, there were no differences in those who reported >1 mistake with negative patient consequences, 3.3 (3.0–3.7), compared with those who did not report mistakes with negative patient consequences (3.4 [3.3–3.7]; median difference, 0.1; 99% CI, −0.2 to 0.6; P = .35). CONCLUSIONS: We detected a high rate of self-reported medication errors in pediatric anesthesiology fellows in the United States. Interestingly, fellows' perception of quality of faculty supervision was not associated with the frequency of reported errors. The current results with a narrow CI suggest the need to evaluate other potential factors that can be associated with the high frequency of reported errors by pediatric fellows (eg, fatigue, burnout). The identification of factors that lead to medical errors by pediatric anesthesiology fellows should be a main research priority to improve both trainee education and best practices of pediatric anesthesia.

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Ischemic Preconditioning and the Role of Antifibrinolytic Drugs: Translation From Bench to Bedside

No abstract available

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Emergency General Surgery: Time for Anesthesiology and Surgery to Work Together to Drive Improvement in Outcomes

No abstract available

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Developing Reflective Practice: A Guide for Medical Students, Doctors, and Teachers

No abstract available

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New Diabetes Medications Raise New Perioperative Concerns for the Anesthesiologist

No abstract available

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Not All Calcium Formulations Are Alike

No abstract available

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“That’s Not What I Said”: Seeking Fidelity in Citations

No abstract available

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Disparities in Anesthesia Care

No abstract available

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Informed Consent and Cognitive Dysfunction After Noncardiac Surgery in the Elderly

Cognitive dysfunction 3 months after noncardiac surgery in the elderly satisfies informed consent thresholds of foreseeability in 10%–15% of patients, and materiality with new deficits observed in memory and executive function in patients with normal test performance beforehand. At present, the only safety step to avoid cognitive dysfunction after surgery is to forego surgery, thereby precluding the benefits of surgery with removal of pain and inflammation, and resumption of normal nutrition, physical activity, and sleep. To assure that consent for surgery is properly informed, risks of both cognitive dysfunction and alternative management strategies must be discussed with patients by the surgery team before a procedure is scheduled.

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Insulin receptor substrate-4 is overexpressed in colorectal cancer and promotes retinoblastoma–cyclin-dependent kinase activation

Abstract

Background

Insulin receptor substrate 4 (IRS-4) is an adaptor protein for which new evidence suggests plays a role in tumour promotion.

Methods

We described nuclear IRS-4 in RKO colon cancer cell lines in biopsies of patients with colorectal cancer (CRC) (n = 20) and in matched adjacent normal colorectal (MANC) tissue (n = 20).

Results

Treatment with physiological doses of IGF-1 promoted nuclear influx of IRS-4 from cellular cytosol in RKO cells. When exogenous IRS-4 was overexpressed in RKO cells, there was an increase in cyclin D1, cyclin E, E2F1, pRB Ser 809/811 and pRB Ser 705 levels compared with the empty vector-transfected cells. Some of these changes returned to control values after wortmannin treatment. Subcellular fractionation showed an overexpression of IRS-4 in the cytoplasm, membrane, and nuclei of tumour samples, whereas the levels of the protein were barely detectable in the three compartments of normal samples. Immunohistochemical studies showed positive nuclear IRS-4 staining in over 74% of the tumour cells. IRS-4 was strongly overexpressed in tumoural tissues from CRC patients compared to MANC tissues. The up-regulation of IRS-4 in CRC samples correlated significantly with the increase of several G1 checkpoint proteins including cyclin D1 (r = 0.6662), Rb (r = 0.7779), pRb Serine 809/811 (r = 0.6864), pRb serine 705 (r = 0.6261) and E2F1 (r = 0.8702).

Conclusions

Taken together, our findings suggest that IRS-4 promotes retinoblastoma–cyclin-dependent kinase activation and it may serve as a pharmacological target since its expression is very low in normal tissue, including colonic epithelium.

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Awake intubation in a patient with huge orocutaneous fistula: a case report.

Awake intubation in a patient with huge orocutaneous fistula: a case report.

J Dent Anesth Pain Med. 2017 Dec;17(4):313-316

Authors: Kim HJ, Kim SH, Kim TH, Yoon JY, Kim CH, Kim EJ

Abstract
Mask ventilation, the first step in airway management, is a rescue technique when endotracheal intubation fails. Therefore, ordinary airway management for the induction of general anesthesia cannot be conducted in the situation of difficult mask ventilation (DMV). Here, we report a case of awake intubation in a patient with a huge orocutaneous fistula. A 58-year-old woman was scheduled to undergo a wide excision, reconstruction with a reconstruction plate, and supraomohyoid neck dissection on the left side and an anterolateral thigh flap due to a huge orocutaneous fistula that occurred after a previous mandibulectomy and flap surgery. During induction, DMV was predicted, and we planned an awake intubation. The patient was sedated with dexmedetomidine and remifentanil. She was intubated with a nasotracheal tube using a video laryngoscope, and spontaneous ventilation was maintained. This case demonstrates that awake intubation using a video laryngoscope can be as good as a fiberoptic scope.

PMID: 29349354 [PubMed]

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Estimation of optimal nasotracheal tube depth in adult patients.

Estimation of optimal nasotracheal tube depth in adult patients.

J Dent Anesth Pain Med. 2017 Dec;17(4):307-312

Authors: Ji SM

Abstract
Background: The aim of this study was to estimate the optimal depth of nasotracheal tube placement.
Methods: We enrolled 110 patients scheduled to undergo oral and maxillofacial surgery, requiring nasotracheal intubation. After intubation, the depth of tube insertion was measured. The neck circumference and distances from nares to tragus, tragus to angle of the mandible, and angle of the mandible to sternal notch were measured. To estimate optimal tube depth, correlation and regression analyses were performed using clinical and anthropometric parameters.
Results: The mean tube depth was 28.9 ± 1.3 cm in men (n = 62), and 26.6 ± 1.5 cm in women (n = 48). Tube depth significantly correlated with height (r = 0.735, P < 0.001). Distances from nares to tragus, tragus to angle of the mandible, and angle of the mandible to sternal notch correlated with depth of the endotracheal tube (r = 0.363, r = 0.362, and r = 0.546, P < 0.05). The tube depth also correlated with the sum of these distances (r = 0.646, P < 0.001). We devised the following formula for estimating tube depth: 19.856 + 0.267 × sum of the three distances (R2 = 0.432, P < 0.001).
Conclusion: The optimal tube depth for nasotracheally intubated adult patients correlated with height and sum of the distances from nares to tragus, tragus to angle of the mandible, and angle of the mandible to sternal notch. The proposed equation would be a useful guide to determine optimal nasotracheal tube placement.

PMID: 29349353 [PubMed]

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Learning fiberoptic intubation for awake nasotracheal intubation.

Learning fiberoptic intubation for awake nasotracheal intubation.

J Dent Anesth Pain Med. 2017 Dec;17(4):297-305

Authors: Kim H, So E, Karm MH, Kim HJ, Seo KS

Abstract
Background: Fiberoptic nasotracheal intubation (FNI) is performed if it is difficult to open the mouth or if intubation using laryngoscope is expected to be difficult. However, training is necessary because intubation performed by inexperienced operators leads to complications.
Methods: Every resident performed intubation in 40 patients. Success of FNI was evaluated as the time of FNI. First intubation time was restricted to 2 min 30 s. If the second attempt was unsuccessful, it was considered a failed case, and a specialist performed nasotracheal intubation. If the general method of intubation was expected to be difficult, awake intubation was performed. The degree of nasal bleeding during intubation was also evaluated.
Results: The mean age of the operators (11 men, 7 women) was 27.8 years. FNI was performed in a total of 716 patients. The success rate was 88.3% for the first attempt and 94.6% for the second attempt. The failure rate of intubation in anesthetized patients was 4.9%, and 13.6% in awake patients. When intubation was performed in anesthetized patients, the failure rate from the first to fifth trial was 9.6%, which decreased to 0.7% when the number of trials increased to > 30 times. In terms of awake intubation, there was no failed attempt when the resident had performed the FNI > 30 times. The number of FNIs performed and nasal bleeding were important factors influencing the failure rate.
Conclusion: The success rate of FNI increased as the number of FNI performed by residents increased despite the nasal bleeding.

PMID: 29349352 [PubMed]

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A comparison of the effects of epinephrine and xylometazoline in decreasing nasal bleeding during nasotracheal intubation.

A comparison of the effects of epinephrine and xylometazoline in decreasing nasal bleeding during nasotracheal intubation.

J Dent Anesth Pain Med. 2017 Dec;17(4):281-287

Authors: Song J

Abstract
Background: Various techniques have been introduced to decrease complications during nasotracheal intubation. A common practice is to use nasal packing with a cotton stick and 0.01% epinephrine jelly. However, this procedure can be painful to patients and can damage the nasal mucosa. Xylometazoline spray can induce effective vasoconstriction of the nasal mucosa without direct nasal trauma. In this study, we aimed to compare the efficacy of these two methods.
Methods: Patients were randomly allocated into two groups (n = 40 each): xylometazoline spray group or epinephrine packing group. After the induction of general anesthesia, patients allocated to the xylometazoline spray group were treated with xylometazoline spray to induce nasal cavity mucosa vasoconstriction, and the epinephrine packing group was treated with nasal packing with two cotton sticks and 0.01% epinephrine jelly. The number of attempts to insert the endotracheal tube into the nasopharynx, the degree of difficulty during insertion, and bleeding during bronchoscopy were recorded. An anesthesiologist, blinded to the intubation method, estimated the severity of epistaxis 5 min after intubation and postoperative complications.
Results: No significant intergroup difference was observed in navigability (P = 0.465). The xylometazoline spray group showed significantly less epistaxis during intubation (P = 0.02). However, no differences were observed in epistaxis 5 min after intubation or postoperative epistaxis (P = 0.201). No inter-group differences were observed in complications related to nasal intubation and nasal pain.
Conclusion: Xylometazoline spray is a good alternative to nasal packing for nasal preparation before nasotracheal intubation.

PMID: 29349350 [PubMed]

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Serum pepsinogen levels indicate the requirement of upper gastrointestinal endoscopy among Group A subjects of ABC classification: a multicenter study

Abstract

Background

ABC classification has been used to assess the risk for gastric cancer. The current problem of ABC classification is that Group A contains individuals with current and past H. pylori infection. The aims of this study were to assesse the proportion of current and past infection in Group A and to establish a criteria for the identification of subjects with past infection from Group A subjects with negative results of urea breath test (UBT) and/or stool antigen test.

Methods

201 subjects classified into Group A received UBT and/or stool antigen test, and also subsequent upper gastrointestinal endoscopy. The subjects were classified by the status of H. pylori infection defined by endoscopic findings. Levels of pepsinogen (PG) I, PG II and PG I/II ratio were compared between the groups, and receiver operating characteristic curves were constructed to extract the corresponding cutoff values.

Results

22 subjects were tested positive by UBT and/or stool antigen test. Endoscopic images of 157 out of 179 subjects were studied. 15 of the subjects were regarded to have past H. pylori infection. The optimal cut-off value of PG I and PG I/II ratio for the determination of past H. pylori infection were ≤ 31.2 ng/mL and ≤ 4.6, respectively.

Conclusions

Approximately 20% of Group A subjects have current or past H. pylori infection. Addition of UBT and/or stool antigen test can identify current but not past infection. Serum PG levels would be useful to identify subjects with past H. pylori infection.

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Persistent pain following common outpatient surgeries in children: A multicenter study in Italy

Summary

Introduction

The prevalence of persistent postsurgical pain in children is over 20% after major surgeries; however, data are scarce on the prevalence, character, and risk factors among children undergoing common ambulatory surgeries. The primary aim of this study was to evaluate the prevalence of persistent pain following pediatric ambulatory surgery at 1, 3, and 6 months. Secondary aims were to identify risk factors and characterize the pain and consequences of persistent postsurgical pain.

Methods

ASA I-II, ages 1 month to 16 years old, undergoing elective hypospadias repair, herniorraphy, orchiopexy, and orthopedic surgery were enrolled in a prospective, longitudinal, observational study at 3 pediatric centers in Italy. All patients received general plus regional anesthesia. Postoperative pain was evaluated using age appropriate pain scales at 1 and 3 hours. At 1, 3, and 6 months, pain scores were obtained and Parent's Postoperative Pain Measures (<8 yo) and Child Activity Limitations Interview (>8 yo) surveys were administered.

Results

About 350 patients completed the study. The prevalence of pain at 1, 3, and 6 months was 24% (84/350), 6.0% (21/350), and 4.0% (14/350), respectively. Inguinal herniorraphy patients experienced significantly higher pain at all 3-time points; 35.6%, 14.9%, and 9.2%. There was no significant association between mean pain scores >4 in PACU and persistent pain. Pain persisting at 6 months had neuropathic characteristics and frequently interfered with daily activities and sleep.

Conclusion

Our data support the presence of persistent pain in pediatric patients after common surgeries. Most patients who developed persistent pain at 6 months had pain at 1 month. We recommend questioning at follow-up visit about persistent pain and functional impairment with follow-up until resolution.

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The Use of Infant Confinement Equipment in Community-Based Child Care Centers: An Analysis of Centers Participating in a Statewide Quality Rating and Improvement System

Abstract

Objectives Although infants increasingly spend time in community-based child care centers, little attention has been paid to their physical activity experiences while in group care. In particular, the use of devices to restrict infant mobility, such as bouncy seats, high chairs, cribs, and stationary activity centers, has received little attention in the physical activity literature. The current study examines the presence and use of these confinement devices in infant classrooms. Methods A secondary analysis of observational data in child care centers participating in Delaware's Quality Rating and Improvement System was conducted. Quality assessment observations were coded for the use of confinement devices and the actual amount of time the confinement device was employed per child. The sample consisted of 38 infant classrooms serving a total of 162 infants in the statewide system. Results Findings suggest a high level of utilization of confinement devices in infant child care classrooms with each classroom averaging three pieces of equipment used during the observations and 22% of observed children being confined 30 min or longer during the observation period. Conclusions for Practice The reliance on confinement devices in group child care is a potential concern in the quest to prevent childhood obesity by ensuring adequate physical activity and mobility for infants in group care settings. More research is needed to understand the implications of the use of confinement devices on physical activity in group care settings.

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Coordinates for the somatosensory homunculus

Abstract

In the text surrounding their drawing of the simiusculus (little monkey), Clinton Woolsey and colleagues wrote (Woolsey et al. 1952), "It must be emphasized, however, that this diagram is an inadequate representation of the localization pattern, since in a line drawing one cannot indicate the successive overlap which is so characteristic a feature of cortical representation, not only in the motor but also in the sensory areas."

This article is protected by copyright. All rights reserved

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Developmental plasticity of GABAergic neurotransmission to brainstem motoneurons

Abstract

Nicotinic acetylcholine receptor (nAChR) signalling regulates neuronal differentiation and synaptogenesis. Here we test the hypothesis that developmental nicotine exposure (DNE) disrupts the development of GABAergic synaptic transmission to hypoglossal motoneurons (XIIMNs). GABAergic spontaneous and miniature inhibitory postsynaptic currents (sIPSC/mIPSC) were recorded from XIIMNs in brainstem slices from control and DNE rat pups of either sex, 1–5 days old, at baseline and following acute stimulation of nAChRs with nicotine. At baseline, sIPSCs were less frequent and smaller in DNE cells (consistent with decreased action potential mediated GABA release), and mIPSCs were more frequent (consistent with increased vesicular GABA release from presynaptic terminals). Acute nicotine challenge increased sIPSC frequency in both groups, though the increase was greater in DNE cells. Acute nicotine challenge did not change the frequency of mIPSCs in either group, though mIPSC amplitude increased significantly in DNE cells, but not control cells. Stimulation of postsynaptic GABA_A receptors with muscimol caused a significantly greater chloride current in DNE cells than in control cells. The increased quantal release of GABA, coupled with the rise in the strength of postsynaptic inhibition may be homeostatic adjustments to the decreased action-potential mediated input from GABAergic interneurons. However, this will exaggerate synaptic inhibition under conditions where the release of GABA (e.g. hypoxia) or ACh (sleep-wake transitions) is increased. These findings reveal a mechanism that may explain why DNE is associated with deficits in the ability to respond appropriately to chemosensory stimuli or to changes in neuromodulation secondary to changes in central nervous system state.

This article is protected by copyright. All rights reserved

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Hypermethylation of NF-κB-Activating Protein-Like ( NKAPL ) Promoter in Hepatocellular Carcinoma Suppresses Its Expression and Predicts a Poor Prognosis

Abstract

Background and Aim

Hepatocellular carcinoma (HCC) is a complicated disease with low survival rate partially due to frequent recurrence and no efficient therapy. Promoter hypermethylation of tumor suppressor genes has been demonstrated as one of the molecular mechanisms contributing to tumorigenesis and progression in HCC. This study aims to investigate regulation of NKAPL expression by promoter methylation and its clinical relevance as a biomarker for HCC.

Methods

We measured mRNA expression of NKAPL in 5 HCC cell lines and a cohort of 62 pairs of primary HCC tumor and their adjacent non-cancer liver tissues. NKAPL protein expression on HCC cell lines and clinical samples was assessed by Western blot and immunohistochemistry, respectively. Association analyses between NKAPL expression and clinicopathologic characteristics in the cohort were conducted. Methylation statuses of NKAPL promoter in 18 pairs of tumor and adjacent non-tumor HCC samples were studied using methylation-specific PCR. Biological functions of NKAPL in HCC were investigated by ectopic expression of NKAPL in HCC cells, and cell viability and cell cycle analyses were performed.

Results

Our present study showed suppressed expression and promoter hypermethylation are common events in HCC. Demethylation experiment in HCC cells demonstrated that the NKAPL expression was regulated by promoter methylation. In addition, high methylation level of NKAPL and its low expression predict poor outcome. Furthermore, ectopic expression of NKAPL in the HCC cells inhibited cell growth.

Conclusions

Our findings suggest that methylation of NKAPL is a frequent event and is a potential prognosis biomarker in HCC.

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Authors' Response to a Letter to the Editor on Radial Extracorporeal Shockwave in the Management of Lateral Epicondylitis

No abstract available

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Physiatry Reviews for Evidence in Practice Second-Order Peer Review: Does Massage Therapy Have Value in the Treatment for Tension Type Headache?

No abstract available

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Comparison Between Corticosteroid and Lidocaine Injection in the Treatment of Tennis Elbow: A Randomized, Double-Blinded, Controlled Trial

Objective The aim of the study was to compare the effects of corticosteroid injection with lidocaine injection in treating tennis elbow. Design It is a prospective, double-blinded, randomized controlled trial. Patients with tennis elbow for more than 1 mo were recruited from a hospital-based rehabilitation outpatient clinic. A total of 70 patients were recruited, and 61 patients completed the study. Patients received an injection of either 10 mg (1 ml) of triamcinolone (corticosteroid group, n = 30) or 1 ml of 1% lidocaine (lidocaine group, n = 31). All of the outcome measures were evaluated before the intervention and at 2 wks and 2 mos after treatment. Results No significant group differences were observed between the corticosteroid and lidocaine groups regarding Patient-Rated Tennis Elbow Evaluation, Disability of the Arm, Shoulder, and Hand, visual analog scale for pain, and grip strength at baseline and at 2 wks and 2 mos after treatment (P > 0.05). However, within-group comparison showed significant improvement after injection with regard to Patient-Rated Tennis Elbow Evaluation, Disability of the Arm, Shoulder, and Hand, visual analog scale for pain, and grip strength in both groups (P > 0.05). Conclusions No differences in the short-term outcomes were found between lidocaine and corticosteroid injection in a small sample of people with tennis elbow with mean duration of 3.8 mos.

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Association Between Altered Hip Extension and Kinetic Gait Variables

Kinematic and kinetic outcome measures are tightly linked in walking. Although altering motor output is a major goal of gait rehabilitation, little is understood regarding the relationship between altering a single kinematic variable and kinetic outcome changes. We designed a strategy to isolate hip extension alterations during walking on a treadmill to assess the change in kinetic outcomes. Ten healthy individuals walked on an instrumented split-belt treadmill with motion capture to calculate hip extension and kinetic outcomes at the following five different randomized cadences: self-selected cadence, self-selected ± 10%, and self-selected ± 20%. The treadmill speed was held constant at the individual's self-selected walking speed, forcing cadence changes to result in successful alterations to hip extension, varying 8.3 degrees from the self-selected −20% to +20% cadence conditions. Kinetic outcomes demonstrated similar alterations. Hip extension changes at each cadence significantly correlated with kinetic changes in propulsive impulse (r = 0.852, P

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Functional Balance Deterioration on Daily Activities in Patients With Migraine: A Controlled Study

Objective This study aimed to assess functional activities in different subgroups of patients with migraine. Design One-hundred forty subjects were uniformly divided into the following four groups: headache-free controls, migraine with aura, without aura, and chronic migraine. Subjects performed the tests walk across, tandem walk, sit to stand, and step up and over at the Balance Master system (Neurocom). Results All migraine groups had slower velocity and shorter step length at the walk across test (P

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Development of Systemic Inflammatory Polyarthritis After Zygapophyseal Joint Injection With Hylan G-F 20 (Synvisc-One)

Hylan G-F 20 (Synvisc-One) is a hyaluronic acid derivative used for viscosupplementation of synovial fluid in osteoarthritic joints. Injection of hylan G-F 20 is Federal Drug Administration approved for use in knee osteoarthritis and is generally well tolerated with few reported adverse effects, the most common being local pain or swelling. We present the case of a 72-year-old man with bilateral, diffuse, joint pain and swelling with elevated inflammatory markers suggestive of a systemic inflammatory polyarthropathy that developed acutely 2 days after lumbar zygapophyseal joint injection with hylan G-F 20. Systemic effects after hylan G-F 20 injection have not been well documented, and this is the first reported case of systemic inflammatory polyarthritis after injection, to our knowledge. Further research is needed to better establish the safety and efficacy of lumbar zygapophyseal joint injections with hylan G-F 20.

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Could Activity Modifications Indicate Physical Decline Among Adults With Symptomatic Knee Osteoarthritis?

Objectives Mobility activity modifications indicate early functional losses that act as precursors to future declines among community-dwelling older adults. However, there is scarce evidence on whether activity modifications indicate poorer physical health among adults with symptomatic osteoarthritis, a major cause of disability. Our purpose was to investigate whether patient-reported mobility activity modifications indicated poorer physical health among adults with symptomatic knee osteoarthritis. Design Secondary cross-sectional analysis of randomized trial data was performed. Preclinical Disability Questionnaire was used to group participants into the following three categories: difficulty, modified, and no difficulty walking/stair climbing. Kruskal Wallis and χ2 tests were used to compare clinical factors across groups. Results Among 121 participants (median age = 60 yrs; 73% female; 60% white), less than 10% had modified walking/stair climbing. Compared with those with no walking difficulty, participants with modified walking had significantly less balance (P = 0.01) and global health (P = 0.01) as well as greater knee pain (P = 0.05) and physical disability (P = 0.04). Those with modified stair climbing had significantly smaller walking distances (P = 0.03) compared with those with no difficulty stair climbing. Conclusions Activity modifications may signal early impairments in physical health among people with symptomatic knee osteoarthritis. If confirmed, patient-reported activity modifications may enhance symptom evaluation in osteoarthritis and enable a better understanding of the disablement process.

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Alterations in the Mechanical Response of Deep Dorsal Neck Muscles in Individuals Experiencing Whiplash-Associated Disorders Compared to Healthy Controls: An Ultrasound Study

Objective The aim of this study was to investigate and compare the mechanical responses of dorsal neck muscles in individuals with whiplash-associated disorders (WAD) versus healthy individuals. Design This study included 36 individuals with WAD (26 women and 10 men) and 36 healthy controls (26 women and 10 men). Ultrasound imaging with speckle tracking was used to measure deformation and deformation rate in five dorsal neck muscles during a neck extension task. Results Compared with controls, individuals with WAD showed higher deformations of the semispinalis cervicis (P = 0.02) and multifidus (P = 0.002) muscles and higher deformation rates (P = 0.03 and 0.0001, respectively). Among individuals with WAD, multifidus deformation and deformation rate were significantly associated with pain, disability, and fatigue (r = 0.31–0.46, P = 0.0001–0.01). Conclusions These findings indicate that the mechanical responses of the deep dorsal neck muscles differ between individuals with WAD and healthy controls, possibly reflecting that these muscles use altered strategies while performing a neck extension task. This finding provides new insight into neck muscles pathology in patients with chronic WAD and may help improve rehabilitation programs. To Claim CME Credits Complete the self-assessment activity and evaluation online at http://ift.tt/1l80W45 CME Objectives Upon completion of this article, the reader should be able to: (1) Summarize the mechanical responses of dorsal neck muscles during loading of the neck muscles via an extension task in individuals with chronic whiplash associated disorders and healthy volunteers; (2) Differentiate mechanical responses between five dorsal neck muscles while loading the neck via an extension task; and (3) Describe the relationships between the mechanical responses of the dorsal neck muscles with the patients' perception of neck pain, disability, and fatigue. Level Advanced Accreditation The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

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Effect of Group Exercising and Adjusting the Brace at Shorter Intervals on Cobb Angle and Quality of Life of Patients With Idiopathic Scoliosis

Objective The aim of the study was to evaluate the effect of group exercise with brace adjustment at shorter intervals than used in routine practice in late-onset idiopathic scoliosis patients. Design This was a quasi-experimental study. Thirty patients with progressive scoliosis curves of 15–50 degrees and a prescription for a brace were divided into experimental and control groups, both of which participated in an 11-wk treatment program. Those in the experimental group underwent brace adjustment twice per week and performed group exercise, whereas those in the control group received a routine protocol. The quality of life and Cobb angle of patients in both groups were evaluated based on baseline and final results of the 22-item Scoliosis Research Society questionnaire and primary and secondary radiographs. Results In the experimental group, the improvement in Cobb angle and patient satisfaction was greater than that in the control group (P

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Implementation of a Multifaceted Interactive Electrodiagnostic Medicine Workshop in a Physical Medicine and Rehabilitation Residency Program

Electrodiagnostic medicine is a required component of Physical Medicine and Rehabilitation residency education, but limited resources exist to guide curriculum development. Our objective was to create a focused workshop to enhance our residency program's electrodiagnostic curriculum. We created two separate 1.5-day workshops, one basic and one advanced, for all residents. Each workshop included didactic sessions, case discussion, question and answer sessions, demonstrations, and hands-on participation with direct supervision and feedback. Presurveys and postsurveys were administered to evaluate the value of the workshops. We also assessed trends in electrodiagnostic self-assessment examination scores. Residents reported clinical electrodiagnostic rotations to be more valuable to their education than previous didactic sessions and independent learning. Self-reported knowledge of electrodiagnostic concepts, resident comfort level in planning, performing, and interpreting studies, and perceived value in independent learning of electrodiagnostic medicine improved after implementation of the workshops. There was a 7% improvement in the American Association of Neuromuscular and Electrodiagnostic Medicine electrodiagnostic self-assessment examination score compared with the previous year and a 15% improvement in the Physical Medicine and Rehabilitation self-assessment examination electrodiagnostic subscore compared with the previous 5 yrs. All participants recommended similar educational experience for other residents. This successful workshop may serve as a resource for other training programs.

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Effectiveness of a Group Physiotherapy Intervention in Nontraumatic, Inoperable Painful Shoulder: A Randomized Clinical Trial

Purpose The aim of the study was to assess the effectiveness of a group intervention in painful shoulder. Design This was a two-arm controlled clinical trial with a 5-wk follow-up and 1:1 allocation ratio with pretreatment and posttreatment assessments in a Spanish hospital in 2015–2016. This study comprised 74 patients with nontraumatic, inoperable painful shoulder. Patients were randomized into two groups: (1) in intervention, patients underwent group rehabilitation exercises supervised by a physical therapist and (2) in control, patients performed the same exercises as the intervention group but in their own home. The main variables were the differences preintervention and postintervention between scores on the visual analog scale, Constant-Murley scale, and Disabilities of the Arm, Shoulder and Hand scale. The mean differences in the main variables were compared between the two interventions (t test). Registration code is NCT02541279 (clinicaltrials.gov). Results Differences were found in favor of the intervention group: (1) visual analog scale = −0.1 (P = 0.723), (2) Constant-Murley = 4.1 (P = 0.085), and (3) Disabilities of the Arm, Shoulder and Hand = 14.7 (P

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Tibialis Posterior Tenosynovitis: A Unique Musculoskeletal Manifestation of Gout

Extra-articular manifestations of gout can present in several ways, including tenosynovitis. We present a rare case of acute tibialis posterior gouty tenosynovitis. An 82-year-old man with a history of well-controlled gout presented with acute onset of left ankle pain, occurring without inciting event. The medial ankle was slightly erythematous with moderate dorsal-medial swelling and mild dorsal-lateral swelling, with severe tenderness to palpation over the medial retro-malleolar region. Range of motion and manual muscle testing were pain limited throughout. Ultrasound examination revealed a left posterior tibialis tendon sheath tenosynovitis with effusion and overlying soft tissue edema. Tendon sheath aspirate revealed sodium urate crystals and a white blood cell count of 6400/μL. Tendon sheath injection with a mixture of 1% lidocaine and dexamethasone 4 mg resulted in symptom resolution. Repeat ultrasound examination demonstrated no evidence of tibialis posterior tendon sheath effusion. This case is unique not only because acute gouty posterior tibialis tenosynovitis is very rare, particularly in a normouricemic individual, but also because the sonographic evidence of gouty infiltration into the posterior tibialis tendon and overlying subcutaneous tissue considerably aided in arriving at the correct diagnosis in a timely manner.

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Aquatic Exercises in the Treatment of Low Back Pain: A Systematic Review of the Literature and Meta-Analysis of Eight Studies

Objective Low back pain is the most common musculoskeletal condition with a high prevalence. There was no sufficient evidence to recommend that aquatic exercise was potentially beneficial to patients with low back pain. The aim of this study was to systematically analyze all evidence available in the literature about effectiveness of the aquatic exercise. Design A comprehensive search of PubMed, the Cochrane Library, Embase, and Cumulative Index to Nursing and Allied Health was conducted from their inceptions to November 2016 for randomized controlled trials, which concerned the therapeutic aquatic exercise for low back pain. The results were expressed in terms of standardized mean difference and the corresponding 95% confidence interval. Results Eight trials involving 331 patients were included in the meta-analysis, and the results showed a relief of pain (standardized mean difference = −0.65, 95% confidence interval = −1.16 to −0.14) and physical function (standardized mean difference = 0.63, 95% confidence interval = 0.17 to 1.09) after aquatic exercise. However, there was no significant effectiveness with regard to general mental health in aquatic group (standardized mean difference = 0.46; 95% confidence interval = −0.22 to 1.15). Conclusions Aquatic exercise can statistically significantly reduce pain and increase physical function in patients with low back pain. Further high-quality investigations on a larger scale are required to confirm the results.

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Regarding: Radial Extracorporeal Shockwave Therapy Is No More Effective Than Placebo in the Management of Lateral Epicondylitis A Double-Blind, Randomized, Placebo-Controlled Trial

No abstract available

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Evaluation of the Effectiveness of Neuromuscular Electrical Stimulation After Total Knee Arthroplasty: A Meta-Analysis

Objective The aim of the study was to evaluate the efficacy of the use of the neuromuscular electrical stimulation after total knee arthroplasty. Design The study used a systematic review of randomized controlled trials (MEDLINE, PubMed, Cochrane Library, and PEDro) using Patient Population or Problem, Intervention, Comparison, Outcomes, Setting approach to formulate the research question, controlled terms, and Boolean operators. Inclusion and exclusion criteria were defined in advance. "Neuromuscular electrical stimulation" and "total knee arthroplasty" were used as keywords. The overall risk of bias was determined according to the following: random sequence generation, concealment, blinding mass of participants and staff, commissioning blind assessment results, incomplete data, and loans received. Results Of the 36 identified studies, six were included in the review (496 participants). In these studies, one group of patients followed a rehabilitation protocol (control group) and the other followed a rehabilitation program plus a session of neuromuscular electrical stimulation (neuromuscular electrical stimulation group). Patients of neuromuscular electrical stimulation groups got the best scores (timed up and go test, stair climbing test, and walk test). Neuromuscular electrical stimulation benefits were strong in the first postoperative weeks/months and gradually diminished. Conclusions Neuromuscular electrical stimulation allows a slightly better functional recovery after total knee arthroplasty, especially in the first period, with more evident benefits in patients with a severe lack of muscular activation. Nevertheless, there is no difference at medium-long term.

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Dynamic Change in Ultrasonographic Findings in Iliotibial Band Syndrome After Running

No abstract available

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Random regression analysis for body weights and main morphological traits in genetically improved farmed tilapia ( Oreochromis niloticus )

Abstract

To genetically analyse growth traits in genetically improved farmed tilapia (GIFT), the body weight (BWE) and main morphological traits, including body length (BL), body depth (BD), body width (BWI), head length (HL) and length of the caudal peduncle (CPL), were measured six times in growth duration on 1451 fish from 45 mixed families of full and half sibs. A random regression model (RRM) was used to model genetic changes of the growth traits with days of age and estimate the heritability for any growth point and genetic correlations between pairwise growth points. Using the covariance function based on optimal RRMs, the heritabilities were estimated to be from 0.102 to 0.662 for BWE, 0.157 to 0.591 for BL, 0.047 to 0.621 for BD, 0.018 to 0.577 for BWI, 0.075 to 0.597 for HL and 0.032 to 0.610 for CPL between 60 and 140 days of age. All genetic correlations exceeded 0.5 between pairwise growth points. Moreover, the traits at initial days of age showed less correlation with those at later days of age. With phenotypes observed repeatedly, the model choice showed that the optimal RRMs could more precisely predict breeding values at a specific growth time than repeatability models or multiple trait animal models, which enhanced the efficiency of selection for the BWE and main morphological traits.

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Origin of heterogeneous spiking patterns from continuously distributed ion channel densities: a computational study in spinal dorsal horn neurons

Abstract

Neurons are often classified by spiking pattern. Yet some neurons exhibit distinct patterns under subtly different test conditions, which suggests that they operate near an abrupt transition, or bifurcation. A set of such neurons may exhibit heterogeneous spiking patterns not because of qualitative differences in which ion channels they express, but rather because quantitative differences in expression levels cause neurons to operate on opposite sides of a bifurcation. Neurons in the spinal dorsal horn, for example, respond to somatic current injection with patterns that include tonic-, single-, gap-, delayed- and reluctant-spiking. It is unclear whether these patterns reflect five cell populations (defined by distinct ion channel expression patterns), heterogeneity within a single population, or some combination thereof. We reproduced all five spiking patterns in a computational model by varying the densities of a low-threshold (K_V1-type) potassium conductance and an inactivating (A-type) potassium conductance and found that single-, gap-, delayed- and reluctant-spiking arise when the joint probability distribution of those channel densities spans two intersecting bifurcations that divide the parameter space into quadrants, each associated with a different spiking pattern. Tonic-spiking likely arises from a separate distribution of potassium channel densities. These results argue in favor of two cell populations, one characterized by tonic-spiking and the other by heterogeneous spiking patterns. We present algorithms to predict spiking pattern proportions based on ion channel density distributions and, conversely, to estimate ion channel density distributions based on spiking pattern proportions. The implications for classifying cells based on spiking pattern are discussed.

This article is protected by copyright. All rights reserved

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Role of Fluorescent In Situ Hybridization, Cholangioscopic Biopsies, and EUS-FNA in the Evaluation of Biliary Strictures

Abstract

Background and Aims

Our goal was to compare the diagnostic accuracy of FISH in the detection of malignancy compared with other standard diagnostic modalities, including brush cytology and biopsy specimens over a 10-year period of prospective data collection.

Methods

We conducted a review of all consecutive biliary strictures evaluated between 2006 and 2016. Patients with a final pathologic diagnosis or conclusive follow-up were included. We evaluated the performance of FISH polysomy (CEP 3, 7, and 17) and 9p21 deletion as well as cholangioscopic biopsy (CBx) and EUS-FNA. Statistical analysis was performed with the Mann–Whitney U and Fisher's exact tests.

Results

Of 382 patients with indeterminate strictures, 281 met inclusion criteria. Forty-nine percent were malignant. Cytology, FISH polysomy, and FISH polysomy/9p21 showed a specificity of 99.3%. FISH polysomy/9p21 as a single modality was the most sensitive at 56% (p < 0.001). The sensitivity of FISH polysomy/9p21 and cytology was significantly higher than cytology alone at 63 versus 35% (p < 0.05). EUS-FNA for distal strictures and CBx for proximal strictures increased sensitivity from 33 to 93% (p < 0.001) and 48–76% (p = 0.05) in cytology-negative strictures.

Conclusions

The high specificity of FISH polysomy/9p21 suggests that a positive result is sufficient for diagnosing malignancy in indeterminate strictures. The significantly higher sensitivity of FISH polysomy/9p21 compared to cytology supports the use of FISH in all non-diagnostic cases. Although both EUS-FNA and CBx were complimentary, our results suggest that distal strictures should be evaluated by EUS initially. Proximal strictures may be evaluated by FISH first and then by CBx if inconclusive.

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Mortality Is Rare Following Elective and Non-elective Surgery for Ulcerative Colitis, but Mild Postoperative Complications Are Common

Abstract

Background Data

Currently, data regarding the rates of morbidity and mortality following non-elective colectomy for ulcerative colitis (UC) are variable. We sought to determine the rates and predictors of 90-day mortality and complications following colectomy for UC.

Methods

Patients undergoing an initial surgery for UC at a tertiary care center between January 2002 and January 2014 were included. Patients were identified using ICD-9 code 556.x. Each record was manually reviewed for demographic information, medical histories, UC history, medications, and data regarding the admission and discharge. Charts were reviewed for mortality and complications within 90 days of surgery. Complications were classified using the Clavien–Dindo classification system. Univariate and multivariate analyses were performed using IBM SPSS Statistics, version 23.0.

Results

Two hundred and fifty-eight patients underwent surgery for UC. 69% were elective, and 31% were urgent/emergent. There were no deaths reported within 30 days of surgery. At 90 days, there were 2 deaths in the elective group and 1 death in the urgent/emergent group. The death in the urgent/emergent group was likely related to the initial surgery, while the elective group death was not directly related to the initial surgery for UC. Complications occurred in 47% of patients. There were no significant differences in rates of complications in either surgical cohort. Majority (62%) of the complications were Clavien–Dindo grade 1 or 2 with no difference in the elective or urgent/emergent group. Unplanned readmissions occurred in 24% of cases.

Conclusion

Surgery for UC is not associated with any mortality at 30 days and very low mortality at 90 days. However, surgery is associated with an increased rate of minor postoperative complications and readmissions.

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