Παρασκευή 10 Αυγούστου 2018

Rocuronium pharmacodynamic models for published five pharmacokinetic models: age and sex are covariates in pharmacodynamic models

Abstract

Purpose

Equilibration rate constant is necessary to calculate effect-site concentration, which is useful to control drug effect. We developed pharmacodynamic models for published five compartmental pharmacokinetic models published by Wierda, Szenohradszky, Cooper, Alvarez-Gomez, and McCoy.

Methods

We used 3848 train-of-four ratios from 15 male and nine female patients (21–76 years; 44–93 kg body weight; 148–181 cm height; and 17.3–29.8 kg/m2 body mass index) as pharmacodynamic measures, which were collected at the start of 0.6 mg/kg rocuronium administration until the end of the surgery. Effect compartment was assumed to be connected to central compartment of the pharmacokinetic model with equilibration rate constant (ke0). Sigmoid Emax model was fitted to describe the relationship between train-of-four ratio and effect-site concentration. Age, sex, and body mass index were assessed as possible covariates of the following model parameters: ke0, effect-site concentration for half of maximum effect, and the steepness of the effect-site concentration versus effect relationship.

Results

The duration of neuromuscular monitoring was 69 (37–129) [median (range)] min. All pharmacodynamic models included age and three included sex as significant covariates. Ke0 values ranged between 0.0820 and 0.247 depending on the pharmacokinetic model. The time-courses of the effect-site concentration were similar among the pharmacodynamic models for Wierda, Cooper, and Alvarez-Gomez pharmacokinetic models, which were lower than that for the Szenohradszky pharmacokinetic model.

Conclusion

Each pharmacodynamic model with the corresponding pharmacokinetic model can be described the time course of rocuronium effect appropriately. The required effect-site concentration of rocuronium for a pharmacodynamic effect was depending on the applied models.



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Maximizing Recovery From Concussions for Youth Participating in Sports and Recreational Activities

Concussions have become a public health issue. This public health concern has drawn the attention of many states in which laws were created to address concussions safety, recognition of signs and symptoms, immediate removal, medical clearance, and return to play protocols. The vast majority of state legislation focused on student athletes participating in organized sports. However the rise in concussion can be directly attributed to children, youth and adolescents participating in non-sports related events. Maximizing recovery from a concussion involves implementing education programs that focus on recognition of symptoms, treatment, and return to learn options. Treatment strategies employed to address concussed youth include physical and cognitive rest and minimizing external stimuli that can increase symptoms. Since learning is a direct outcome for all youth, a return to learn protocol based on a collaborative school-based team approach is suggested. All authors report no conflict of interest All authors report no funding, grants, or equipment for this project All authors report no financial benefits All authors report no previous research, manuscript, or abstract in any form Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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"Author's Response to Letter to the Editor On "Ultrasound-Guided Botulinum Toxin Injections in Cervical Dystonia Needs Prompt Muscle Selection, Appropriate Dosage and Precise Guidance"

No abstract available

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Double Selection Enhances the Efficiency of Target-AID and Cas9-Based Genome Editing in Yeast

CRISPR-Cas9 loss of function (LOF) and base editing screens are powerful tools in genetics and genomics. Yeast is one of the main models in these fields, but has only recently started to adopt this new toolkit for high throughput experiments. We developed a double selection strategy based on co-selection that increases LOF mutation rates using the Target-AID base editor. We constructed the pDYSCKO vector, which is amenable to high throughput double selection experiments, and show that the improvement in Target-AID efficiency generalizes across loci. Using modeling, we show that this improvement in efficiency provides the required increased in detection power to measure the fitness effects of thousands of mutations in typical yeast pooled screens. We show that double selection can also improve Cas9 mediated LOF rates, but that this multiplex genome editing causes programmable chromosomal translocations at high frequency. This suggests that multiplex LOF editing should be performed with caution and that base-editors could be preferable tools for some screens in yeast. Base editing using double selection is simple and straightforward and provides an alternative to homology directed repair-based high throughput variant strain construction methods.



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Whole Genome Sequencing, de Novo Assembly and Phenotypic Profiling for the New Budding Yeast Species Saccharomyces jurei

Saccharomyces sensu stricto complex consist of yeast species, which are not only important in the fermentation industry but are also model systems for genomic and ecological analysis. Here, we present the complete genome assemblies of Saccharomyces jurei, a newly discovered Saccharomyces sensu stricto species from high altitude oaks. Phylogenetic and phenotypic analysis revealed that S. jurei is more closely related to S. mikatae, than S. cerevisiae, and S. paradoxus. The karyotype of S. jurei presents two reciprocal chromosomal translocations between chromosome VI/VII and I/XIII when compared to the S. cerevisiae genome. Interestingly, while the rearrangement I/XIII is unique to S. jurei, the other is in common with S. mikatae strain IFO1815, suggesting shared evolutionary history of this species after the split between S. cerevisiae and S. mikatae. The number of Ty elements differed in the new species, with a higher number of Ty elements present in S. jurei than in S. cerevisiae. Phenotypically, the S. jurei strain NCYC 3962 has relatively higher fitness than the other strain NCYC 3947T under most of the environmental stress conditions tested and showed remarkably increased fitness in higher concentration of acetic acid compared to the other sensu stricto species. Both strains were found to be better adapted to lower temperatures compared to S. cerevisiae.



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Genomic Signatures of Adaptation to a Precipitation Gradient in Nigerian Sorghum

Evolution of plants under climatic gradients may lead to clinal adaptation. Understanding the genomic basis of clinal adaptation in crops species could facilitate breeding for climate resilience. We investigated signatures of clinal adaptation in the cereal crop sorghum (Sorghum bicolor L. [Moench]) to the precipitation gradient in West Africa using a panel (n = 607) of sorghum accessions from diverse agroclimatic zones of Nigeria. Significant correlations were observed between common-garden phenotypes of three putative climate-adaptive traits (flowering time, plant height, and panicle length) and climatic variables. The panel was characterized at >400,000 single nucleotide polymorphisms (SNPs) using genotyping-by-sequencing (GBS). Redundancy analysis indicated that a small proportion of SNP variation can be explained by climate (1%), space (1%), and climate collinear with space (3%). Discriminant analysis of principal components identified three genetic groups that are distributed differently along the precipitation gradient. Genome-wide association studies were conducted with phenotypes and three climatic variables (annual mean precipitation, precipitation in the driest quarter, and annual mean temperature). There was no overall enrichment of associations near a priori candidate genes implicated in flowering time, height, and inflorescence architecture in cereals, but several significant associations were found near a priori candidates including photoperiodic flowering regulators SbCN12 and Ma6. Together, the findings suggest that a small (3%) but significant proportion of nucleotide variation in Nigerian sorghum landraces reflects clinal adaptation along the West African precipitation gradient.



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Predicting self-reported disability level by a number of pain sites marked on pain drawing

imageTo evaluate the connection between the number of pain sites (head and neck, upper extremities, trunk, and lower extremities) marked on pain drawing and general disability level measured by a 12-item WHO Disability Assessment Schedule 2.0 (WHODAS 2.0) score. A cross-sectional survey of 1988 patients with chronic musculoskeletal pain was conducted. Analysis of variance with contrasts was performed along with regression analysis. Despite the relatively mild median disability level measured as WHODAS 2.0 total score at 25%, the majority of the participants experienced, in the last month, severe pain with 8.1 points on a 0–10 numeric rating scale. Only 1% had left the pain drawing unmarked. Otherwise, 15% had marks in one area, 34% in two, 23% in three, and 27% in all four areas. The characteristics of those groups were similar except for disability. Disability level was 30–50% worse when pain was experienced in all four sites. The analysis of variance showed that both the number of pain sites and pain severity affected disability level (P

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Effect of a distal weight-bearing implant on visual analog scale scores in 23 transfemoral amputees

imageThe objective of this interrupted time series clinical trial was to evaluate the effect of a distal weight-bearing implant on well-being in patients with transfemoral amputations using the visual analog scale (VAS). A total of 29 patients from five hospitals with previous transfemoral amputations were surgically implanted with an osseoanchored implant with a distal spacer that allows a direct load on the residuum over the distal surface of the socket. Patients were followed for a 14-month period and assessed presurgically and postsurgically using the VAS. The Wilcoxon test was used to evaluate the differences between variables. VAS mean scores improved significantly after intervention. Significant and clinically meaningful improvements in the VAS score suggest overall improvement in well-being for patients after receiving a distal weight-bearing implant.

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Mental practice for upper limb rehabilitation after stroke: a systematic review and meta-analysis

imageMental practice (MP) is usually provided in combination with other therapies, and new developments for neurofeedback to support MP have been made recently. The objectives of this study were to evaluate the effectiveness of MP and to investigate the intervention characteristics including neurofeedback that may affect treatment outcome. The Cochrane Central Register of Controlled Trials, PubMed, Embase, KoreaMed, Scopus, Web of Science, PEDro, and CIRRIE were searched from inception to March 2017 for randomized controlled trials to assess the effect of MP for upper limb rehabilitation after stroke. Fugl-Meyer Assessment (FMA) was used as the outcome measure for meta-analysis. Twenty-five trials met the inclusion criteria, and 15 trials were eligible for meta-analysis. Among the trials selected for meta-analysis, MP was added to conventional therapy in eight trials or to modified constraint-induced movement therapy in one trial. The other trials provided neurofeedback to support MP: MP-guided neuromuscular electrical stimulation (NMES) in four trials and MP-guided robot-assisted therapy (RAT) in two trials. MP added to conventional therapy resulted in significantly higher FMA gain than conventional therapy alone. MP-guided NMES showed superior result than conventional NMES as well. However, the FMA gain of MP-guided RAT was not significantly higher than RAT alone. We suggest that MP is an effective complementary therapy either given with neurofeedback or not. Neurofeedback applied to MP showed different results depending on the therapy provided. This study has limitations because of heterogeneity and inadequate quality of trials. Further research is requested.

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Effect of telerehabilitation on mobility in people after hip surgery: a pilot feasibility study

imageThe goal of this study was to evaluate the effects of telerehabilitation on mobility in people following hip surgery. This feasibility pilot randomized controlled trial included a sample of 40 participants, with 22 male and 18 female patients and mean age (SD) of 67.5 (7.8) years following a surgical intervention. Participants were equally divided and randomly assigned to a telerehabilitation or control intervention group (6 weeks, 3 sessions/week). Telerehabilitation was based on video clips of common rehabilitation exercises focusing on the lower limbs. The control group received an exercise booklet. Both groups participated in physical therapy sessions, twice a week. Outcome measures included the Timed Up and Go test, 2-min walk test, 10-m walk test, sit to stand test, walking speed, and mean step length. Measurements were completed at baseline, at termination of the intervention, and at a 4-week follow-up examination. Improvements in both groups were demonstrated in all outcome measures in the postintervention evaluation. Improvements in the telerehabilitation group were greater in five of six tests compared with those achieved by the controls. The telerehabilitation group showed greater improvements in the 2-min walking test (86.1%) and walking speed (65.6%). During follow-up, the telerehabilitation group continued to improve in all outcome measures in contrast to the control group, who showed no changes in five of the six outcome measures. Telerehabilitation, a complementary treatment to standard physical therapy, generates a positive effect on mobility in people following hip surgery.

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The effects of tongue pressure strength and accuracy training on tongue pressure strength, swallowing function, and quality of life in subacute stroke patients with dysphagia: a preliminary randomized clinical trial

imageTongue pressure strength and accuracy training (TPSAT) has been proposed as an intervention to improve dysphagia. However, the effects of TPSAT on dysphagia in subacute stroke patients remain unclear. The aim of this study was to investigate the effects of TPSAT on tongue pressure strength, swallowing function, and quality of life in subacute stroke patients with dysphagia. Sixteen subacute stroke patients were assigned randomly to two groups: the TPSAT group (n=8) or the control group (n=8). In the former, both TPSAT and traditional dysphagia therapies were performed for 30 min each per day; in the latter, only traditional dysphagia therapy was performed for 30 min twice a day. Both groups performed each daily intervention five times per week for 8 weeks. To assess the tongue pressure strength, maximum isometric tongue pressures (MIPs) of the anterior and posterior tongue using the Iowa Oral Performance Instrument were measured before and after the intervention. Mann Assessment of Swallowing Ability (MASA) and Swallowing-Quality of Life (SWAL-QOL) were also used to assess the swallowing function and quality of life, respectively. TPSAT with traditional dysphagia therapy significantly improved MASA, SWAL-QOL, and MIPs both anteriorly and posteriorly, and traditional dysphagia therapy significantly increased MASA, SWAL-QOL, and MIPs anteriorly (P

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No association of leg strength asymmetry with walking ability, fatigability, and fatigue in multiple sclerosis

imageThis cross-sectional study aims to determine whether leg strength asymmetries are associated with walking ability, objective measures of fatigability, or subjective perceptions of fatigue. Maximal knee extensor strength was assessed in 19 patients with multiple sclerosis (PwMS), and a symmetry index was calculated. Walking ability was determined through the total distance covered during a 6-min walk test (6MWT) and fatigability by calculating the change in distance covered between minutes 6 and 1. Perceptions of fatigue were assessed using the Fatigue Severity Scale and by obtaining ratings of perceived exertion during the first and final minute of the 6MWT. PwMS covered less distance (P=0.01) and perceived greater exertion (P

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Effect of low-intensity versus high-intensity resistance training on the functioning of the institutionalized frail elderly

imageFrailty has emerged as an important risk factor for disability. Age-related declines in physical and physiological function lead to increased risk of loss of independence and poor quality of life. Recent evidence has shown the effectiveness of physical exercise programmes in preventing or reversing frailty. The aim of this study was to evaluate changes in the functioning of frail elderly individuals after undergoing resistance training for 3 days a week for 8 weeks. The effectiveness of exercise training was investigated in 48 frail elderly individuals who were randomly assigned to the following intervention groups: high-intensity (HI; n=16; age: 69–96 years) or low-intensity (LI; n=16; age: 77–93 years) strength training groups or a control group (n=16; age: 76–93 years) with no specific exercise programme. Participants were assessed for muscle strength, physical function, activities of daily living, depression and quality of life. The HI group had significantly better results (P0.05). The study showed that LI exercise was as effective as HI exercise for most parameters tested. Exercise training is useful for the prevention or treatment of frailty, as it improves functioning by contributing positively to muscle strength, gait, balance and quality of life.

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The effect of preoperative exercise on upper extremity recovery following breast cancer surgery: a systematic review

imagePrehabilitation benefits among patients undergoing various oncological surgeries have been demonstrated. However, the effects of presurgical exercise and fitness on postoperative ipsilateral upper extremity recovery outcomes in patients with breast cancer surgery are less evident. A systematic review was performed to assess the effects of preoperative exercise and fitness on postmastectomy recovery. Systematic literature search was performed in 12 electronic databases. Study eligibility was accessed using the PICOS (Participants, Interventions, Comparison, Outcome and Study Design) criteria. Six eligible studies were found: three cohort–control and three prospective observational studies. One randomized-controlled trial showed that prehabilitation was beneficial in shoulder range of motion (ROM) and upper extremity functional recovery. One cohort–control study demonstrated that preoperative exercises reduced postoperative pain without increasing the risk of developing a seroma. A prospective cohort study showed that preoperatively active individuals had a significantly better chance of feeling recovered physically at 3 weeks after surgery. Baseline ipsilateral grip strength, shoulder flexion, and abduction ROM were reliable predictors of shoulder flexion and abduction ROM and grip strength improvements at 1 month following breast cancer surgery. One study showed that preoperative conditioning alone without postoperative rehabilitation was insufficient to aid recovery. Implementing exercise program and optimizing preoperative fitness, especially shoulder ROM, before breast cancer surgery in conjunction with individualized rehabilitation program may benefit postmastectomy ipsilateral upper extremity recovery.

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The effect of a single textured insole in gait rehabilitation of individuals with stroke

imageRehabilitation interventions designed to restore gait symmetry in individuals with stroke are not always effective. The goal was to evaluate the long-term effect of using a single textured insole in gait rehabilitation. Ten individuals with stroke who showed asymmetrical stance were randomly divided into two groups and participated in physical therapy. Individuals in the experimental group received a 6-week physical therapy while being provided with a textured insole in the shoe on the unaffected side. Individuals in the control group received a 6-week physical therapy only. Both groups underwent a battery of identical tests before the start of the rehabilitation intervention, following its completion, and 4 months after the end of therapy. After the intervention, weight bearing (WB) on the affected side and gait velocity increased in the experimental group (P

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Does galvanic vestibular stimulation decrease spasticity in clinically complete spinal cord injury?

imageThe aim of this study was to determine changes in clinical and biomechanical measures of spasticity after administering galvanic vestibular stimulation in patients with a complete spinal cord injury (SCI). The spasticity in the lower limbs was assessed using the Modified Ashworth Scale and the pendulum test in seven SCI patients (grade A on the ASIA Impairment Scale) before (0−), immediately after (0+), and at 5 and 30 min after the real versus sham galvanic vestibular stimulation (15 s each, anode over the right mastoid). Overall, the changes in spasticity were not significantly different between the real and sham galvanic vestibular stimulation. However, the Modified Ashworth Scale and the pendulum test indicated a reduction in spasticity in two out of seven patients. The results suggest that galvanic vestibular stimulation may modify spasticity in some patients with complete SCI, presumably through the residual vestibulospinal influences. Future studies should determine clinical and neurophysiological profiles of responders versus nonresponders and optimize parameters of galvanic vestibular stimulation.

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Disability in amyotrophic lateral sclerosis compared with traumatic brain injury using the World Health Organization Disability Assessment Schedule 2.0 and the International Classification of Functioning minimal generic set

imageWe compared the functioning of two neurological patient groups, amyotrophic lateral sclerosis (ALS) and traumatic brain injury (TBI), using brief and validated International Classification of Functioning (ICF)-based tools. A 12-item World Health Organization Disability Assessment Schedule (WHODAS 2.0) questionnaire was mailed to ALS and TBI patients and their significant others 2 weeks before their appointment at an outpatient clinic of a university hospital. In addition, a neurologist filled in the ICF minimal generic set. Two years after diagnosis, no significant differences between the two diagnosis groups were found in overall functioning or in working ability using either patient or proxy WHODAS or physician-rated minimal generic set. In single items, however, clear differences were found. Patients and significant others rated household activities, mobility, and self-care as more impaired in the group with ALS, and learning, concentrating, and maintaining friendships in the group with TBI. There were no differences between the two diagnosis groups in the WHODAS items emotional functions, engaging in community, relating with strangers, or in working ability. Both brief ICF-based generic scales, WHODAS and the ICF generic set, could show differences between these patient groups with severe disability. The results of this study should promote assessment of disability with WHODAS 2.0 in ALS and TBI.

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Self-reported upper limb functioning of pupils with cerebral palsy by the International Classification of Functioning, Disability, and Health

imageInternational Classification of Functioning, Disability, and Health: Children and Youth Version has shown an increasing role in the assessment of children with cerebral palsy (CP), but just a few researchers use it for individuals' self-assessment. In this study, we present the self-assessment of functioning of students with CP and changes by the end of a school year. Thirty-seven pupils with spastic CP involving upper limbs, 24 pupils with typical development, and 20 pupils with speech and language disorders were studied by International Classification of Functioning, Disability, and Health core sets for CP. The CP group reported limitations in sensory functions (P

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Can telerehabilitation games lead to functional improvement of upper extremities in individuals with Parkinson’s disease?

imageParkinson's disease (PD) is treated by medication, less with deep brain stimulation and physiotherapy. Different opinions on the clinical meaningfulness of the physiotherapy or recommended intensive physiotherapy were found. Our objectives were to design intensive target-based physiotherapy for upper extremities suitable for telerehabilitation services and examine the clinical meaningfulness of the exergaming at an unchanged medication plan. A telerehabilitation exergaming system using the Kinect sensor was developed; 28 patients with PD participated in the study. The system followed the participants' movements and adapted the difficulty level of the game in real time. The outcomes of the study showed that seven out of 26 participants could set up the equipment at home alone. Clinical outcomes of Box and Blocks Test (mean: 47 vs. 52, P=0.002, Cohen's d=0.40), UPDRS III (mean: 27 vs. 29, P=0.001, d=0.22), and daily activity Jebsen's test; writing a letter (mean: 24.0 vs. 20.6, P=0.003, d=0.23); and moving light objects (mean: 4.4 vs. 3.9, P=0.006, d=0.46) were statistically significant (P

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The regularity of orthosis use and the reasons for disuse in stroke patients

imageThis is a Retrospective descriptive study. Orthoses and walking aids are used frequently in stroke rehabilitation to facilitate ambulation. The aim was to describe the regularity of orthosis use and the reasons for disuse in stroke after discharge from inpatient rehabilitation. The study included 64 (43 men, 21 women) subacute stroke patients who had been discharged from our clinic in the last 6 months. Demographic and clinical findings, proposed orthoses and walking aids, frequency of usage for the proposed orthoses, reasons for disuse, and the ambulation levels were recorded. A total of 54 (84.4%) patients had an ankle–foot orthosis and 10 (15.6%) patients had a knee–ankle–foot orthosis. The orthosis frequency of use was every day in 38 (59.4%) patients and one to seven times a week in seven (10.9%) patients, whereas 19 (29.7%) did not use them. The reasons for orthosis disuse were finding them unnecessary in seven (27%) patients, usage difficulties in six (23%) patients, pressure sensation in five (19.2%) patients, the belief that they did not make life easier in five (19.2%) patients, lack of a suitable environment in one (3.8%) patient, orthosis wear in one (3.8%) patient, and systemic disease in one (3.8%) patient. Age, sex, residence, the disease duration, and recommended orthosis duration (how long the prescribed orthosis was used), recommended orthosis, range of motion limitation in the lower extremities, presence of spasticity, type of orthosis, and the ambulation level were not statistically significantly associated with the frequency of orthosis use (P>0.05). The only significant clinical factor for the frequency of orthosis use was the lower extremity Brunnstrom neurophysiological recovery stage (P

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Effects of gait training with auditory feedback on walking and balancing ability in adults after hemiplegic stroke: a preliminary, randomized, controlled study

imageThe aim of this study was to identify a gait training type that better improves the walking and balancing abilities of adult patients with chronic hemiplegic stroke. Single-blinded, randomized, controlled, comparative preliminary study was carried out. Patients were recruited from the inpatient unit of a Rehabilitation Hospital. Thirty-one patients who had experienced hemiplegic stroke were randomly assigned to three groups: the heel group (gait training by active weight bearing on the paretic heel with auditory feedback), the forefoot group (gait training with auditory feedback from paretic metatarsals), and the control group (general gait intervention). All patients performed 30 min of comprehensive rehabilitation therapy followed by an additional 20 min of gait intervention with or without auditory feedback three times a week for 6 weeks. Significant improvements in walking and balancing variables were observed after gait training in all three groups (P

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Motor learning in dystonia: distorted feedback results in distorted motor learning and information-seeking compensatory behaviour

imageMotor learning is possible in dystonia, but distorted feedback results in distorted motor performance and information-seeking compensatory behavior, as observed in this case. With globus pallidus internal segment deep brain stimulation, the postural background of hand writing improved, but the learned left compensatory grip did not change.

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EMS Paramedic - Tri-Lakes Monument Fire Department

Essential Duties and Responsibilities: Provide first aid and life support needs for sick and injured persons. Administer, manage and control patient care, at the ALS level, on an emergency medical scene and during transport until patient care is transferred to someone of equal or higher medical certification. Respond to emergent and non-emergent requests for assistance concerning fire, hazardous materials ...

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Promising Antituberculosis Activity of Piperine Combined with Antimicrobials: A Systematic Review

Microbial Drug Resistance, Ahead of Print.


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Molecular Epidemiological Characterization of Methicillin-Susceptible and -Resistant Staphylococcus aureus Isolated from Skin and Soft Tissue Infections in Bangladesh

Microbial Drug Resistance, Ahead of Print.


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Recurrence of Hepatocellular Carcinoma after Direct Acting Antiviral Treatment for Hepatitis C Virus Infection: Literature Review and Risk Analysis

Although studies suggest decreased incident hepatocellular carcinoma (HCC) after treatment with direct-acting antivirals (DAAs) for hepatitis C virus (HCV) infection, data are conflicting regarding risk and aggressiveness of recurrence in patients who have a history of treated HCC. This review analyses data available in literature in order to elucidate the impact of DAAs on the risk of HCC recurrence after successful treatment of the tumor. Overall 24 papers were identified. The available data cannot be considered definitive, but the initial alarmist data indicating an increased risk of recurrence have not been confirmed by most subsequent studies.

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Effectiveness and safety of vedolizumab for maintenance treatment in inflammatory bowel disease- the Israeli real world experience

Several real-world experience (RWE) studies with vedolizumab (VDZ) for induction of remission in inflammatory bowel diseases (IBD) have been published; However, long-term RWE data is scarce.

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Implementation of the Asthma Control Test in Primary Care to Improve Patient Outcomes

Asthma is one of the major chronic diseases in the pediatric population, affecting 9.5% of children. The National Heart, Lung, and Blood Institute recommends the use of the Asthma Control Test (ACT) for periodic assessment of asthma control. The purpose of this evidence-based project was to implement the Asthma Control Test screening tool into the primary care practice to improve management of patients with asthma by more accurately addressing asthma control.

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Recurrence of Hepatocellular Carcinoma after Direct Acting Antiviral Treatment for Hepatitis C Virus Infection: Literature Review and Risk Analysis

Although studies suggest decreased incident hepatocellular carcinoma (HCC) after treatment with direct-acting antivirals (DAAs) for hepatitis C virus (HCV) infection, data are conflicting regarding risk and aggressiveness of recurrence in patients who have a history of treated HCC. This review analyses data available in literature in order to elucidate the impact of DAAs on the risk of HCC recurrence after successful treatment of the tumor. Overall 24 papers were identified. The available data cannot be considered definitive, but the initial alarmist data indicating an increased risk of recurrence have not been confirmed by most subsequent studies.

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Effectiveness and safety of vedolizumab for maintenance treatment in inflammatory bowel disease- the Israeli real world experience

Several real-world experience (RWE) studies with vedolizumab (VDZ) for induction of remission in inflammatory bowel diseases (IBD) have been published; However, long-term RWE data is scarce.

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Genome-wide investigation of an ID cohort reveals de novo 3′UTR variants affecting gene expression

Abstract

Intellectual disability (ID) is a severe neurodevelopmental disorder with genetically heterogeneous causes. Large-scale sequencing has led to the identification of many gene-disrupting mutations; however, a substantial proportion of cases lack a molecular diagnosis. As such, there remains much to uncover for a complete understanding of the genetic underpinnings of ID. Genetic variants present in non-coding regions of the genome have been highlighted as potential contributors to neurodevelopmental disorders given their role in regulating gene expression. Nevertheless the functional characterization of non-coding variants remains challenging. We describe the identification and characterization of de novo non-coding variation in 3′UTR regulatory regions within an ID cohort of 50 patients. This cohort was previously screened for structural and coding pathogenic variants via CNV, whole exome and whole genome analysis. We identified 44 high-confidence single nucleotide non-coding variants within the 3′UTR regions of these 50 genomes. Four of these variants were located within predicted miRNA binding sites and were thus hypothesised to have regulatory consequences. Functional testing showed that two of the variants interfered with miRNA-mediated regulation of their target genes, AMD1 and FAIM. Both these variants were found in the same individual and their functional consequences may point to a potential role for such variants in intellectual disability.



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Opioid prescription patterns for adults with longstanding disability and inflammatory conditions compared to other users, using a nationally representative sample

Publication date: Available online 10 August 2018

Source: Archives of Physical Medicine and Rehabilitation

Author(s): Yuan Hong, Marco Geraci, Margaret A. Turk, Bryan L. Love, Suzanne W. McDermott

Abstract
Objectives

To investigate the opioid prescription patterns for adults with longstanding physical disability and inflammatory conditions, compared to a mixed group of other opioid users, after excluding cancer patients.

Design

Nationally representative cross-sectional study, 2010-2014

Setting

Medical Expenditure Panel Survey (MEPS)

Participants

The subjects were adults who participated in MEPS and had at least one opioid prescription, did not have cancer, and were between 18 years and 64 years of age.

The subjects were grouped as: longstanding physical disability (group 1), inflammatory conditions (group 2) and a mixed group with at least one opioid prescription during the 2 year study period (comparison group). Subjects with both groups of conditions were excluded.

Interventions

Not applicable.

Main outcome measure(s)

Morphine milligram equivalent (MME) doses for each participant were cumulated over a two-year panel period.

Results

By using quantile regression, Cumulative MME in group 1 and 2 was higher than the comparison group across all the centiles, and differences between condition groups and comparison group became larger in higher centiles. Subjects in group 1 had the highest cumulative MME in 75th and 90th centiles after controlling for other covariates.

Conclusions

This study documented the opioid prescription patterns for patients with longstanding physical disability or inflammatory conditions. All indexed groups (group 1 and 2) had higher MME use compared to the comparison group.



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Are seating systems with a medial knee support really helpful for hip displacement in children with spastic cerebral palsy GMFCS IV and V?

Publication date: Available online 10 August 2018

Source: Archives of Physical Medicine and Rehabilitation

Author(s): In Soo Kim, Donghwi Park, Jin Young Ko, Ju Seok Ryu

Abstract
Objective

To evaluate whether medial knee support in seating systems aggravates hip displacement in children with cerebral palsy.

Design

:Retrospective chart review

Setting

Rehabilitation department of tertiary university hospital

Participants

Children with cerebral palsy using seating systems (Intervention group, n=42; mean age 6.86y) and using regular wheelchairs (Control group, n=34; mean age 8.15y).

Interventions

The intervention group was provided with a seating system with medial knee support. We enrolled children who did not use a seating system in the control group, retrospectively.

Main Outcome Measure(s)

By radiographic images, Reimer's migration index, lateral center edge angle, and femur neck shaft angle were measured. We compared the demographic data, clinical variables, and radiographs between the two groups.

Results

In the intervention group, there was a significant deterioration in the Reimer's migration index, from 26.89% to 44.18% after using the system (p<0.001). The progression of migration index was 14.72 % and 7.82 % per year in the intervention and control groups, respectively (p=0.016).

Conclusion

We should consider the possibility that seating systems with medial knee support may exacerbate hip displacement in children with cerebral palsy.



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Urban-Rural Differences in Service Utilization and Costs of Care for Racial-Ethnic Groups Hospitalized with Post-Stroke Aphasia

Publication date: Available online 10 August 2018

Source: Archives of Physical Medicine and Rehabilitation

Author(s): Rose Y. Hardy, Richard C. Lindrooth, Richard K. Peach, Charles Ellis

Abstract
Objective

Although residence is a key contributor to cost and utilization in stroke patient care, its contribution to the care of persons with aphasia (PWA) is unknown. The objective of this study was to use discharge-level hospital inpatient data to examine the influence of patient residence (rural vs. urban) and race-ethnicity on service utilization and cost of care among PWA.

Design

Cross-sectional

Setting

Administrative data from acute care hospitals in the state of North Carolina

Participants

Individuals with post-stroke aphasia

Interventions

N/A

Main Outcome Measures

length of stay, speech-language pathology service utilization, costs of care

Methods

2011-2012 Healthcare Cost and Utilization Project (HCUP) State Inpatient Database (SID) data were analyzed to examine the impact of rural/urban residence to lengths of stay (LOS), Speech-Language Pathology (SLP) service utilization, as well as total inpatient and SLP service costs. These outcomes were further analyzed across both residence and racial groups (Non-Hispanic White and Non-Hispanic Black). Outcomes were analyzed using generalized linear models (GLM).

Results

Both rural and urban Black PWA experienced longer average LOS after controlling for demographics, illness severity, and the hospital where they received care. Rural Blacks experienced longer LOS, received greater SLP services, and incurred greater average total hospital costs than their rural White counterparts after adjusting for differences in their demographics and stroke/illness severity. The differences were attenuated after controlling for the hospital where they received care.

Conclusions

For PWA, race-ethnicity has a larger impact on average total medical costs, SLP service utilization, and LOS than residence. It is unclear how and why Blacks with aphasia have greater service utilization and costs in acute care, yet their aphasia outcomes are worse. Future studies are required to explore potential factors such as quality of care.



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Limiting exposure to asbestos during and after disaster management

Environmental disasters can expose first responders to asbestos, putting them at risk for mesothelioma

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How to keep PTSD out of your EMS department

Recognize the risk factors and symptoms of PTSD, and how to manage self-talk and meditate to reduce its physical and emotional effects

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PARAMEDIC (ENTRY-LEVEL CANDIDATES FOR PARAMEDIC TRAINING) - New Castle County EMS

PROBABLE WEIGHTING OF EXAMINATION: Candidates must pass an examination required for entry into the paramedic training program to continue in the process. A written examination, a comprehensive background investigation to include an oral board interview examination, an evaluation of training and education, or any combination of the above, may be used to determine placement on the eligible list. Candidates ...

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Paramedic - FT, PT, Casual - Community Care Ambulance

**Benefits: ** -Leading in paid time off, wages, health insurance, and other benefits -Tuition provided & reimbursed for Paramedic training -Opportunity to be CICP certified (comes with a pay raise!) -Flexible Schedule -Full time sign on bonus -Referral Bonuses -Attendance bonuses -New equipment -All box trucks -Challenging and rewarding experiences -Advanced Protocols -Team work setting **Station Locations:** ...

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Paramedic - FT, PT, Casual - Community Care Ambulance

**Benefits: ** -Leading in paid time off, wages, health insurance, and other benefits -Tuition provided & reimbursed for Paramedic training -Opportunity to be CICP certified (comes with a pay raise!) -Flexible Schedule -Full time sign on bonus -Referral Bonuses -Attendance bonuses -New equipment -All box trucks -Challenging and rewarding experiences -Advanced Protocols -Team work setting **Station Locations:** ...

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Paramedic - FT, PT, Casual - Community Care Ambulance

**Benefits: ** -Leading in paid time off, wages, health insurance, and other benefits -Tuition provided & reimbursed for Paramedic training -Opportunity to be CICP certified (comes with a pay raise!) -Flexible Schedule -Full time sign on bonus -Referral Bonuses -Attendance bonuses -New equipment -All box trucks -Challenging and rewarding experiences -Advanced Protocols -Team work setting **Station Locations:** ...

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Md. hits record-high drug deaths, fueled by fentanyl

Maryland, a state that already had one of the country's most punishing overdose mortality rates, notched a record-high number of drug deaths last year

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ERP indices of performance monitoring and feedback processing in psychosis: A meta-analysis

Publication date: Available online 10 August 2018

Source: International Journal of Psychophysiology

Author(s): Elizabeth A. Martin, Amanda McCleery, Melody M. Moore, Jonathan K. Wynn, Michael F. Green, William P. Horan

Abstract
Background

Although individuals with, or at risk for, psychotic disorders often show difficulties with performance monitoring and feedback processing, findings from studies using event-related potentials (ERPs) to index these processes are not consistent. This meta-analytic review focused on studies of two different indexes of performance monitoring, the early error-related negativity (ERN; n = 25) and the later error positivity (Pe; n = 17), and one index of feedback processing, the feedback negativity (FN; n = 6).

Methods

We evaluated whether individuals (1) with psychotic disorders, or (2) at heightened risk for these disorders differ from healthy controls in available studies of the ERN, Pe, and FN.

Results

There was a significant, large ERN reduction in those with psychosis (g = −0.96) compared to controls, and a significant, moderate ERN reduction in those at-risk (g = −0.48). In contrast, there were uniformly non-significant, small between-group differences for Pe and FN (gs ≤ |0.16|).

Conclusions

The results reveal a differential pattern of impairment in psychosis. Early performance monitoring (ERN) impairments are substantial among those with psychotic disorders in general and may be a useful vulnerability indicator for these disorders. However, later performance monitoring (Pe) and basic feedback processing (FN) appear to be relatively spared in psychosis.



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Paramedic Supervisor - Seals Ambulance

**Seals Ambulance: **Seals Ambulance has been serving Central Indiana for over fifty years. We offer a wide variety of medical transportation services including Wheelchair Van, BLS Ambulance, ALS Ambulance, ALS Intercept Services and Critical Care Transport Services. Our employees provide general transport, 911 response, special event and disaster response services across all of Central Indiana. Seals ...

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Paramedic - Seals Ambulance

**Seals Ambulance: **Seals Ambulance has been serving Central Indiana for over fifty years. We offer a wide  variety of medical transportation services including Wheelchair Van, BLS Ambulance, ALS Ambulance, ALS Intercept Services and Critical Care Transport Services. Our employees provide general transport, 911 response, special event and disaster response services across all of Central Indiana. Seals ...

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Medical Prophylaxis of Post-Surgical Crohn’s Disease Recurrence: Towards Timely Anti-TNF Therapy



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IL-17A Promotes Initiation and Development of Intestinal Fibrosis Through EMT

Abstract

Background

Intestinal fibrosis is a common complication of Crohn's disease (CD). Its exact mechanism is still unclear, and effective treatments to control or reverse the fibrosis process are unavailable. Epithelial–mesenchymal transition (EMT) may promote intestinal fibrosis by increasing deposition of extracellular matrix protein. IL-17A is a pro-inflammatory cytokine, and it has been shown as a profibrotic factor as its association with fibrosis of multiple organs was reported.

Aims

To assess the roles of IL-17A and EMT in the initiation and development of intestinal fibrosis and to verify the potential inductive effect of IL-17A on EMT.

Methods

In this study, we evaluated the expression of IL-17A and EMT-related genes in colonic mucosal biopsy tissues of CD patients and control individuals. Then, we examined the changes of EMT-related genes and fibrosis-related genes of IEC-6 cells which cultured for 72 h under increasing concentrations of IL-17A or with TGF-β1, to verify the potential inductive effect of IL-17A on EMT in vitro. We blocked the IL-17A of the mouse model of TNBS-induced experimental intestinal colitis and fibrosis to further verify the potential inductive effect of IL-17A on EMT in vivo.

Results

We found the occurrence of EMT and high-level expression of IL-17A in intestinal mucosa of CD patients. Using IEC-6 cells, we showed that IL-17A may induce EMT in intestinal epithelial cells that come with reduced E-cadherin expression and increased expression of vimentin, snail, and α-SMA. We further found that anti-IL-17A treatment alleviated intestinal fibrosis through reducing EMT in mouse intestine.

Conclusions

Our study confirmed the involvement of IL-17A in the development of intestinal fibrosis through inducing EMT.



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The Runs: Sudden Copious Ostomy Output in an Acolonic Hirschsprung Disease Patient with Short Gut Syndrome



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Celiac disease is not more prevalent in patients undergoing in vitro fertilization and does not affect reproductive outcomes with or without treatment: a large prospective cohort study

Fertility and Sterility

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Helicobacter pylori antimicrobial resistance in a pediatric population

Helicobacter

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Dietary Patterns in Chinese Americans are Associated with Cardiovascular Disease Risk Factors, the Chinese American Cardiovascular Health Assessment (CHA CHA)

Abstract

Little is known about the dietary patterns of Chinese Americans. Understanding their dietary patterns can provide insights for addressing cardiovascular disease (CVD) risk among Chinese American immigrants. The objective of this study was to identify dietary patterns among Chinese American immigrants living in New York City (NYC) and to describe associations with demographic and CVD risk factors. A validated Food Frequency Questionnaire assessed usual dietary intake in Chinese American immigrants living in NYC as part of the Chinese American Cardiovascular Health Assessment (CHA CHA) in 2010–2011 (n = 1973, age range 21–89 years). Principal components analysis with varimax rotation retaining three factors with eigenvalues > 1.5 identified dietary patterns. Multivariable linear regression models tested associations between CVD risk factors and dietary pattern scores. In multivariable analyses, each unit of increase in the Sweets factor was associated with 0.76 ± 0.33 (mean ± SD) mg/dL higher HDL cholesterol and a 6.2 ± 2.7% increase in HOMA-IR. In contrast, each unit increase in the Fried Noodles factor was associated with a 0.27 ± 0.11 inch greater waist circumference, − 0.89 ± 0.40 mg/dL lower HDL cholesterol, and also a 6.9 ± 2.6% increase in HOMA-IR. Each unit increase in the Vegetables factor was associated with a − 1.40 ± 0.43 mmHg and − 0.95 ± 0.27 mm Hg decrease in systolic and diastolic blood pressure, respectively. Dietary patterns are significantly associated with CVD risk factors among Chinese American immigrants in NYC. Future work will inform how dietary patterns relate to level of acculturation in order to guide the development of dietary interventions to reduce CVD risk.



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How Sickle Cell Disease Impairs Skeletal Muscle Function: Implications in Daily Life

Sickle cell disease (SCD) is the most frequent life-threatening genetic hemoglobinopathy in the world and occurs due to the synthesis of abnormal hemoglobin S (HbS). HbS-containing red blood cells (RBCs) are fragile, leading to hemolysis and anemia, and adhere to the endothelium, leading to hemorheological and hemodynamical disturbances. In its deoxygenated form, HbS may polymerize, leading to sickling of RBCs and potentially to vaso-occlusive crises. Recent findings observed that sickle cell disease patients demonstrate significant skeletal muscle remodeling and display reduced muscle functional capacities, contributing to exercise intolerance and poor quality of life. While acute high-intensity exercise is not recommended for sickle cell disease patients as it may increase the risk of sickling, regular moderate-intensity physical activity could have beneficial effects on skeletal muscle and more generally on the well-being of sickle cell disease patients. This paper reviews the literature regarding the impact of the disease on muscular tissue characteristics and function, as well as the corresponding implications for SCD patients' quality of life. *These authors contributed equally to this study Corresponding author: Laurent A. Messonnier, Université Savoie Mont Blanc, Campus Universitaire Savoie Technolac, F-73376 Le Bourget du Lac Cedex, France. Phone: (33) 4-79-75-81-15, Fax: (33) 4-79-75-81-85. e-mail: laurent.messonnier@univ-smb.fr The results of the studies referenced in this review are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation. The results of the present study do not constitute endorsement by the American College of Sports Medicine. This study was supported by a grant from the University Savoie Mont Blanc (n° DrépH_AAP2017). The funder had no role in study, decision to publish, or preparation of the manuscript. No conflicts of interest, financial or otherwise, are declared by the authors. Accepted for Publication: 30 July 2018. © 2018 American College of Sports Medicine

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Thermal Behavior Differs between Males and Females during Exercise and Recovery

Introduction This study tested the hypothesis that females rely on thermal behavior to a greater extent during and following exercise, relative to males. Methods In a 24±1°C; (45±10% RH) environment, 10 males (M) and 10 females (F) (22±2 y) cycled for 60 min (metabolic heat production-M: 117±18; F: 129±21 W·m2), followed by 60 min recovery. Mean skin and core temperatures, skin blood flow and local sweat rates were measured continually. Subjects controlled the temperature of their dorsal neck to perceived thermal comfort using a custom-made device. Neck device temperature provided an index of thermal behavior and mean body temperature provided an index of the stimulus for thermal behavior. Data were analyzed for total area under the curve (AUC) for exercise and recovery time points. To further isolate the effect of exercise on thermal behavior during recovery, data were also analyzed the minute mean body temperature returned to pre-exercise levels within a subject. Results There were no sex differences in metabolic heat production (P=0.71) or body temperatures (P≥0.10) during exercise. AUC for neck device temperature during exercise was greater for F (-98.4±33.6 vs. -64.5±47.8°C·min, P=0.04), but did not differ during recovery (F: 86.8±37.8; M: 65.6±35.9°C·min, P=0.11). In M, mean skin (P=0.90), core (P=0.70) and neck device (P=0.99) temperatures had recovered by the time that mean body temperature had returned to pre-exercise levels. However, in F, neck device temperature (P=0.04) was reduced while core temperature remained elevated (P

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Anti-MAG neuropathy: role of IgM antibodies, the paranodal junction and juxtaparanodal potassium channels

Publication date: Available online 10 August 2018

Source: Clinical Neurophysiology

Author(s): Nidhi Garg, Susanna B. Park, James Howells, Yu-ichi Noto, Steve Vucic, Con Yiannikas, Susan E. Tomlinson, William Huynh, Neil G. Simon, Emily K. Mathey, Judith Spies, John D. Pollard, Arun V. Krishnan, Matthew C. Kiernan

Abstract
Objective

To improve understanding of disease pathophysiology in anti-myelin-associated glycoprotein (anti-MAG) neuropathy to guide further treatment approaches.

Methods

Anti-MAG neuropathy patients underwent clinical assessments, nerve conduction and excitability studies, and ultrasound assessment.

Results

Patients demonstrated a distinctive axonal excitability profile characterised by a reduction in superexcitability [MAG:-14.18±1.6% vs healthy controls (HC):-21.8±1.2%; p<0.01] without alterations in most other excitability parameters. Mathematical modelling of nerve excitability recordings suggested that changes in axonal function could be explained by a 72.5% increase in juxtaparanodal fast potassium channel activation and an accompanying hyperpolarization of resting membrane potential (by 0.3mV) resulting in a 94.2% reduction in discrepancy between anti-MAG data and the healthy control model. Superexcitability changes correlated strongly with clinical and neurophysiological parameters. Furthermore, structural assessments demonstrated a proximal pattern of nerve enlargement (C6 nerve root cross-sectional area: 15.9±8.1mm2 vs HC:9.1±2.3mm2; p<0.05).

Conclusions

The imaging and neurophysiological results support the pathogenicity of anti-MAG IgM. Widening between adjacent loops of paranodal myelin due to antibodies would expand the pathway from the node to the juxtaparanode, increasing activation of juxtaparanodal fast potassium channels, thereby impairing saltatory conduction.

Significance

Potassium channel blockers may prove beneficial in restoring conduction closer to its normal state and improving nerve function in anti-MAG neuropathy.



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Introduction: the why and whither of genomic data sharing



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Pectoral Block Failure May Be Due to Incomplete Coverage of Anatomical Targets: A Dissection Study

Background and Objectives The popularization of ultrasound-guided nerve blocks in cosmetic and reconstructive breast surgery calls for better anatomical understanding of chest wall innervation. When inserting subpectoral implants, pain from pocket dissection, stretching of muscle, and release of costal attachments may be relieved by blocking the pectoral nerves in the interpectoral (IP) space. We describe the variable anatomy of the pectoral nerves in the IP space in order to define the area to be covered for sufficient blockade, based on cadaver dissections. Methods Twenty-six fresh cadavers were dissected bilaterally. The number, location, and course of the pectoral nerves were recorded. Distances to surface landmarks (sternum, clavicle, and costae) and ultrasound landmarks (thoracoacromial artery [TAA] and pectoralis minor muscle [Pm]) were recorded. Results The lateral pectoral nerve and the TAA entered together into the IP space 8.9 cm (range, 8.0–12.0 cm) lateral to the midsternal line. The medial pectoral nerve (MPN) had between 1 and 4 branches that pierced the Pm, and 69% had additional branches lateral to the Pm. The muscle-piercing MPN branches were located 3.8 cm (range, 0.4–8.1 cm) and the lateral MPN branches 5.4 cm (range, 3.0–8.4 cm) from the lateral pectoral nerve. The IP course was 2.6 cm (range, 0.7–6.5 cm). All specimens were asymmetrical in location or number of MPN branches. Conclusions The MPN branches that innervate the lower part of the pectoralis major muscle are asymmetrical and variable in location and length; all located in a triangular area easily defined by sonographic landmarks, lateral to the TAA. Accepted for publication April 4, 2018. Address correspondence to: Lena F. Carstensen, MD, Department of Breast Surgery, Sydvestjysk Sygehus, 6700 Esbjerg, Denmark (e-mail: lena.carstensen@dadlnet.dk). The authors declare no conflict of interest. Preliminary results were presented at the poster session, Oncoplastic & Reconstructive Breast Surgery (ORBS) International Scientific Meeting, Nottingham, September 2015. Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine.

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Efficacy and safety of dexmedetomidine in peripheral nerve blocks: A meta-analysis and trial sequential analysis

BACKGROUND The duration of analgesia provided by nerve blocks is limited if local anaesthetics are administered alone. Therefore, several additives, including dexmedetomidine (DEX), have been investigated in order to prolong postoperative analgesia following single-shot regional anaesthesia. OBJECTIVES The aim of this meta-analysis was to assess the efficacy and safety of the addition of perineural DEX to local anaesthetics compared with local anaesthetics alone or local anaesthetics combined with systemic administration of DEX. DESIGN A systematic review of randomised controlled trials (RCT) with meta-analysis, trial sequential analysis and assessment of the quality of evidence by the GRADE approach. DATA SOURCES The databases MEDLINE, CENTRAL and EMBASE (to May 2017) were systematically searched. ELIGIBILITY CRITERIA All prospective RCTs investigating the efficacy and safety of perineural DEX combined with local anaesthetics compared with local anaesthetics alone or local anaesthetics in combination with systemic DEX in peripheral nerve blocks of adults undergoing surgery were included. RESULTS A total of 46 RCTs (3149 patients) were included. Patients receiving perineural DEX combined with local anaesthetics had a longer duration of analgesia than local anaesthetics alone [mean difference 4.87 h; 95% confidence interval (95% CI) 4.02 to 5.73; P 

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Effects of a single subanaesthetic dose of ketamine on pain and mood after laparoscopic bariatric surgery: A randomised double-blind placebo controlled study

BACKGROUND When administered as a continuous infusion, ketamine is known to be a potent analgesic and general anaesthetic. Recent studies suggest that a single low-dose administration of ketamine can provide a long-lasting effect on mood, but its effects when given in the postoperative period have not been studied. OBJECTIVE We hypothesised that a single low-dose administration of ketamine after bariatric surgery can improve pain and mood scores in the immediate postoperative period. DESIGN We performed a randomised, double-blind, placebo-controlled study to compare a single subanaesthetic dose of ketamine (0.4 mg kg−1) with a normal saline placebo in the postanaesthesia care unit after laparoscopic gastric bypass and gastrectomy. SETTING Single-centre, tertiary care hospital, October 2014 to January 2018. PATIENTS A total of 100 patients were randomised into the ketamine and saline groups. INTERVENTION Patients in the ketamine group received a single dose of ketamine infusion (0.4 mg kg−1) in the postanaesthesia care unit. Patients in the placebo groups received 0.9% saline. OUTCOME MEASURES The primary outcome was the visual analogue pain score. A secondary outcome was performance on the short-form McGill's Pain Questionnaire (SF-MPQ). RESULTS There were no significant differences in visual analogue pain scores between groups (group-by-time interaction P = 0.966; marginal group effect P = 0.137). However, scores on the affective scale of SF-MPQ (secondary outcome) significantly decreased in the ketamine group as early as postoperative day (POD) 2 [mean difference = −2.2 (95% bootstrap CI −2.9 to 1.6), Bonferroni adjusted P 

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Ultrasound assessment of gastric emptying time after a standardised light breakfast in healthy children: A prospective observational study

OBJECTIVES Current guidelines recommend 6 h of fasting for solids before anaesthesia. However, prolonged fasting may lead to discomfort, hunger, thirst, misbehaviour and lipolysis. To prevent this, a more liberal fasting regimen has been empirically implemented in our children's hospital, allowing a shorter fasting time of 4 h for a standardised light breakfast. AIM The aim of this study was to determine the gastric emptying time after a standardised light breakfast in healthy children. DESIGN A prospective observational noninterventional study. METHODS After fasting overnight, the children had a standardised light breakfast. Before and afterwards, ultrasound examinations of the gastric antrum were performed hourly to determine the gastric antral area (GAA), which is a surrogate parameter for gastric volume in children in the right lateral position (RLP). Demographic data and fasting times are presented as mean ± SD (range) and GAA as median (interquartile range). RESULTS Twenty-two children aged 7.8 (2.5 to 13.6) years volunteered for this study. After fasting overnight [735 ± 120 (467 to 930) min], the initial GAA was 3.06 (2.35 to 4.03) cm2 in RLP. After the light breakfast, GAA in RLP initially increased and decreased subsequently. After 4 h, GAA in RLP was lower than the initial value (median of differences −0.54, 95% confidence interval −1.00 to −0.07, P 

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Association of pre-operative troponin levels with major adverse cardiac events and mortality after noncardiac surgery: A systematic review and meta-analysis

BACKGROUND Circulating cardiac troponin levels are powerful predictors of prognosis in many clinical settings, but their association with outcomes after noncardiac surgery is unclear. OBJECTIVES The aim of this systematic review was to summarise current evidence on the association of pre-operative troponin elevation with postoperative major adverse cardiac events (MACE) and mortality in patients undergoing noncardiac surgery. DESIGN Systematic review of observational studies with meta-analysis. DATA SOURCES PubMed, EMBASE and Science Citation Index Expanded (ISI Web of Science) from their inception to 1 October 2017. ELIGIBILITY CRITERIA Observational studies reporting the associations between pre-operative troponin levels and MACE and all-cause mortality after noncardiac surgeries were included. RESULTS Ten studies met the eligibility criteria. The entire body of evidence addressing the research question was based on a total of 10 371 patients: 4.7 to 68.3% (median 23.8%) of patients had elevated troponin levels before surgery. Elevated pre-operative troponin was significantly associated with short-term MACE (seven studies, 5180 patients: odds ratio (OR) 6.92, 95% confidence interval (CI) 3.85 to 12.42), short-term mortality (five studies, 6103 patients: OR 4.23, 95% CI 2.27 to 7.89) and long-term mortality (two studies, 760 patients: OR 2.51, 95% CI 1.47 to 4.29). The associations remained significant when only multivariate-adjusted results were analysed. Overall, the reviewers' certainty about the summary estimates of the associations was very low. CONCLUSION Current evidence suggests that pre-operative high troponin levels are significantly associated with adverse cardiac events and mortality after noncardiac surgery. TRIAL REGISTRATION This systematic review was registered in the International Prospective Register of Systematic Reviews (Centre for Reviews and Dissemination 42017077837). Correspondence to Bing-Cheng Zhao, MD, Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-Sen University, 58 Zhongshan II Road, Guangzhou 510080, China E-mail: zhaobch@mail2.sysu.edu.cn Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (https://ift.tt/2ylyqmW). © 2018 European Society of Anaesthesiology

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Parent-child Agreement on Health Related Quality of Life in Children With Functional Constipation in Primary Care

Objective: Functional constipation (FC) has a major impact on the health related quality of life (HRQoL) of children. The aim of this study was to evaluate parent-child agreement on HRQoL in children (8 to 17 years) with FC in primary care. Methods: Children diagnosed with FC by their clinician were eligible. HRQoL was measured with the Defecation Disorder List (DDL, score 0–100), and the EuroQol™-5-Dimension-Youth Visual Analogue Scale (EQ-5D-Y-VAS, scale 0–100). Parent-child agreement was examined with discrepancy scores, Intraclass Correlation Coefficients (ICC) and Bland-Altman plots. Results: Fifty-six children, median age of 10 years (IQR 8–12) and their parents were included. Parent-child agreement at a group level was good, with an ICC of 0.80 (95%-CI 0.67–0.88) for the DDL, and 0.78 (95%-CI 0.65–0.87) for the EQ-5D-Y-VAS. Mean discrepancy scores for the DDL and EQ-5D-Y-VAS were small: −2.6 and −2.9, implying that parents were slightly more positive about the HRQoL than their children. Bland-Altman plots showed considerable discordance between individual parent-child pairs. Limits of agreement were −19.7 and 14.6 for the DDL and −27.6 and 21.8 for the EQ-5D-Y-VAS. Conclusion: There is good parent-child agreement on HRQoL in children with FC at group level. However, a substantial number of parent-child pairs differed considerably on their rating of the HRQoL of the child. Therefore, we recommend clinicians, if they want to have an impression of the impact of the FC on the HRQoL of the child, to ask both the child and the parent(s). Trial identification number: Netherlands trial register number 4797, https://ift.tt/2nqp2KM. This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. https://ift.tt/OBJ4xP Address correspondence and reprint requests to Janny H. Dekker, MD, PhD, Department of General practice and Elderly care medicine, PO Box 196, 9700 AD Groningen, The Netherlands (E-mail: j.h.dekker@umcg.nl); Jojanneke J.G.T. van Summeren, MSC, University of Groningen, University Medical Center Groningen, Groningen, Netherlands (e-mail: j.j.g.t.van.summeren@umcg.nl). Received 23 March, 2018 Accepted 24 July, 2018 Conflict of interest: The authors have no conflicts of interest disclose. Funding source: All phases of this study were supported by the Netherlands organization for Health Research and Development (ZonMw), project number 837001409. Financial disclosure: The funding organization had no role in the design or conduct of the study; the collection, management, analysis, or interpretation of the data; the preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication. © 2018 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Increasing Vitamin D Serum Levels Is Associated with Reduced Pulmonary Exacerbations in Patients with Cystic Fibrosis

Context: In 2012, The North American CF Foundation published new guidelines for the treatment of vitamin D deficiency in individuals with CF. Objective: The objectives of our study were to assess the efficacy of these guidelines, and to test the effect of increasing vitamin D dosage on pulmonary function and exacerbations. Design: Pulmonary function tests and serum concentrations of 25-hydroxyvitamin D [25(OH)D] were measured one year prior to increasing vitamin D dosage according to the guidelines and at least one year later. In addition, days of hospitalization (DOH) and pulmonary exacerbations (PE) were counted and an average per year (DOHA and PEA, respectively) was calculated. Setting and Participants: 90 patients from The CF Clinic at Hadassah Mount-Scopus Hospital, Jerusalem, Israel. Results: The mean serum concentration of vitamin D increased significantly from 20.97 ng/ml (52.34 nmol/L) at baseline to 25.41 ng/ml (63.42 nmol/L) at the end of follow-up (p 

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Prognosis of Biliary Atresia after two-year Survival with Native Liver: A Nationwide Cohort Analysis

Objectives: To determine the prognosis of patients with biliary atresia (BA) after two years of native liver survival (NLS) and to identify prognostic factors for continued NLS after two years of age. Methods: We retrospectively analyzed perioperative, laboratory and outcome parameters of all BA patients in The Netherlands between January 1987-June 2015 with NLS of at least two years. We compared parameters between patients who continued to have their native liver (NLS+) to those who did not, either by transplant or death (NLS-). Results: We included 100 patients. Upon a median follow-up of 16.4 years, NLS ended in 37% by liver transplantation (LTx) and in 6% by (pre-transplant) mortality. NLS rates at 5, 10, 15, 18 years of age were 89, 72, 60, 54%, respectively. Corresponding overall survival rates were 98, 90, 87, 87%, respectively. Six months post-Kasai, NLS+ patients had higher clearance of jaundice (COJ) rate, significantly lower total and direct serum bilirubin, aspartate-aminotransferase and alkaline phosphatase levels, compared with NLS- patients (each P 

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Early Infant Risk Factors for Pediatric Eosinophilic Esophagitis

Objectives: Eosinophilic esophagitis (EoE) is an inflammatory, atopic disease of the esophagus without a clear etiology. Our objective was to identify exposures and conditions in early infancy associated with the development of EoE. Methods: A case-control study was performed using the Military Health System Database. Subjects diagnosed with EoE from October 2008 to September 2015 were matched 1:2 on age and sex. Early infant risk factors from the first six months of life were investigated. Results: 1,410 cases with EoE were matched to 2,820 controls. The median (interquartile range) age at diagnosis of EoE was 4.2 years (2.1–7.2) and 68.7% were male. Proton pump inhibitors (adjusted odds ratio [aOR], 2.73; 95% confidence interval [CI], 1.93–3.88), histamine-2 receptor antagonists (aOR, 1.64; 95% CI, 1.27–2.13), and antibiotics (aOR, 1.31; 95% CI, 1.10–1.56) were associated with EoE. Prematurity (aOR, 1.46; 95% CI, 1.12–1.89) and early manifestations of atopic disease such as milk protein allergy (aOR, 2.37; 95% CI, 1.26–4.44) and eczema (aOR, 1.97; 95% CI, 1.64–2.36) were related to increased odds for EoE. Erythema toxicum in infancy was strongly associated with a diagnosis of EoE (aOR 3.52; 95% CI, 1.03–12.04). Infants with feeding difficulty (aOR, 1.45; 95% CI, 1.18–1.77) and gastroesophageal reflux disease (aOR, 1.79; 96% CI, 1.43–2.26) were also at increased risk for EoE. Conclusion: Acid-blocking medications and antibiotics during infancy were associated with later diagnosis of EoE. Erythema toxicum neonatorum, an eosinophilic immune phenomenon, was strongly associated with EoE. Identifying early infant risk factors for EoE may help to risk stratify the need for endoscopy. Address correspondence and reprint requests to Claire Daniels, MD, Walter Reed National Military Medical Center Bethesda 4954 North Palmer Road Bethesda, MD 20889-5630 (E-mail: Claire.p.daniels.mil@mail.mil). Received 21 May, 2017 Accepted 5 May, 2018 Potential Conflicts of Interests and Source of Funding: Salary funding was provided by the United States Department of Defense. The authors have no conflicts of interest relevant to this article to disclose. Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the United States Air Force, the United States Army, the Department of Defense, or the U.S. Government. Title 17 U.S.C. 101 defines a United States Government work as 'a work prepared by a military service member or employee of the United States Government as part of that person's official duties.' This work was prepared as part of the official duties of the authors. Title 17 U.S.C. 105 provides that 'Copyright protection under this title is not available for any work of the United States Government.' Contributors Statement: Dr. Daniels conceptualized and designed the study, analyzed and interpreted the data, drafted the initial manuscript, and approved the final manuscript as submitted. Ms. Susi collected the data, analyzed and interpreted the results, critically reviewed and revised the manuscript, and approved the final manuscript as submitted. Dr. Min conceptualized and designed the study, and interpreted the data. He has reviewed and revised the manuscript, and approved the final manuscript as submitted. Dr. Nylund conceptualized and designed the study, assisted with data analysis and interpretation, critically reviewed and revised the manuscript, and approved the final manuscript as submitted. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.jpgn.org). © 2018 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Incidence and clinical features of autoimmune hepatitis in the province of santa fe (Argentina)

Objetives: To investigate the incidence and clinical features of autoimmune hepatitis (AIH) in children from the province of Santa Fe, Argentina, over ten years. Methods: From the records of all of the pediatric hepatologists in the province of Santa Fe, Argentina, we reviewed the clinical charts of patients 6 points) and followed between January 2003 and December 2013. Population data were extracted from the 2010 national census. Values were expressed as percentages and median +/- interquartile range. Mann-Whitney test was used for comparison between groups. Results: 67 patients fulfilled inclusion criteria, from which 11 (16%) were later reclassified as "autoimmune sclerosing cholangitis" (ASC) according to biochemical, histological and radiological findings. A final sample of 56 patients (39 F) with AIH was analyzed, giving an annual incidence of 0.56/100,000. Median age at presentation was 8 (5.7 -11) years, and the median follow-up was 4 (2–7) years. Type 1 AIH was diagnosed in 89%. An acute presentation was observed in 53%, while 13 (23%) showed cirrhosis on initial biopsy. Prednisone (87%), and azathioprine (60%) were the most common drugs prescribed. At the end of follow-up, 53/56 (95%) were alive, including four patients (7%) who underwent liver transplantation. Conclusion: AIH has an estimated incidence of 0.56/100000/year in children from the province of Santa Fe (Argentina). Overall survival was 95%. A subgroup of patients diagnosed as AIH develops predominant biliary disease and should be better classified as ASC. Address correspondence and reprint requests to Alejandro Carlos Costaguta, MD, Division of Hepatology. Sanatorio de Niños. Alvear, 863 (2000) Rosario (SF), Argentina (e-mail: alejandro.costaguta@gmail.com). Received 9 May, 2018 Accepted 19 July, 2018 Conflict of interest, and source of founding: None to declare. © 2018 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Acute Kidney Injury May Not Be As Uncommon As Believed In Children With Advanced Chronic Liver Diseases

No abstract available

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Postanesthesia care by remote monitoring of vital signs in surgical wards

Purpose of review This narrative review summarizes recent insights into the role of remote monitoring of vital signs in the postoperative period in surgical wards. Recent findings Despite recent improvements in the safety of anesthesia and surgical procedures, postoperative complication rates are still unacceptably high. This is partly attributable to the intermittent provision of personal care to patients by nurses and ward physicians. Continuous remote monitoring of vital functions in the early postoperative period may reduce these complication rates. There are several medical-grade remote monitoring platforms available that integrate a biosensor signal with electronic patient records, enabling automated prediction or notification of patient deterioration. Most available platforms have technical limitations with respect to the accuracy of respiratory rate measurements. Of note, although the implementation of automated notifications of patient deterioration is associated with a reduced activation of acute response teams, the involvement of ward physicians in the early diagnosis and treatment of subtle changes in vital functions is increased. Summary Remote monitoring of vital signs in the surgical ward may contribute to prevention of severe complications and reduction in failure-to-rescue rates, although evidence for this association is still lacking. Anesthesiologists should contribute their knowledge and skills with respect to perioperative abnormalities in vital functions to improve patient safety during the postoperative period. Correspondence to Dr Christa Boer, Professor, Department of Anesthesiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands. Tel: +31 204443830; e-mail: c.boer@vumc.nl Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Three‐dimensional laparoscopy‐assisted bowel resection for cavernous hemangioma of the rectum: Report of two cases

Asian Journal of Endoscopic Surgery, EarlyView.


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Do Long-time Team-mates Lead to Better Team Performance? A Social Network Analysis of Data from Major League Baseball

Abstract

Objectives

To estimate the effects of team-mate shared experience on overall team performance as well as to determine whether concentration of time together among subgroups of players and/or focal players enhances team performance.

Methods

Social network analysis (SNA) was used to model 30 active Major League Baseball teams from 2006 to 2015 with years of experience together connecting players resulting in 300 individual team networks. Social network metrics of network density, network centralization, and average weighted degree were computed and analyzed with team attributes by generalized least squares regression to predict wins, and team rank. Logistic regression was used to predict binary outcomes of world series and division wins.

Results

Network density was negatively associated with team rank (β = − 0.115, p = .05), while average weighted degree was positively associated with team rank (β = 0.147, p = .01). On average, each extra year of shared player time per team was associated with 14.86% higher probability of winning a division title (B = 2.69, exp(B) = 14.86, p = .05). Each extra shared year of infield membership among team-mates predicted 2.4% lower odds of winning the world series (B = −0.024, exp(B) = 0.976, p = .01), and each extra shared year between outfield players predicted 2.9% lower probability of winning a team's division (B = −0.029. exp(B) = 0.972, p = .05).

Conclusions

Prolonged shared time between players is beneficial when it is spread evenly among all players of the team, whereas having few focal players who have been on a team together for many years is a disadvantage to overall performance.



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