In this article, Laura Horton discusses how she became an upskilled dental nurse and how this can be a reality for so many dental nurses today as Scope of Practice allows dental nurses to become ...providers in their own right
A pictorial review of 76 examinations of the extensor carpi ulnaris tendon using compression sonoelastography in conjunction with B-mode ultrasound imaging is presented here. A comparison of these ...two technologies is presented and the corresponding images were evaluated to determine whether there is correlation between the two technologies. Furthermore, the possibility that tendon degeneration and softening can be diagnosed earlier than has previously been possible using both of these technologies rather than B-mode imaging alone was explored and the results presented. Patients with unilateral or bilateral extensor carpi ulnaris tenosynovitis were scanned as part of a larger rheumatoid arthritis research study, which included extensor carpi ulnaris evaluation as part of its protocol. B-mode images were acquired with corresponding compression sonoelastography colour map, the region of interest being that portion of the tendon between the ulnar styloid and the insertion at the fifth metacarpal base. Seven paired images from different patients, which represent the varying appearances of extensor carpi ulnaris tenosynovitis seen in the study cohort are shown. Healthy tendons have a uniform hyperechoic fibrillar pattern longitudinally on B-mode imaging with predominantly mid-blue overlay on elastography. Tenosynovitis is shown on grey scale to have the usual appearances of loss of fibrillar echotexture and hypoechoic mucoid degeneration with the elastographic colour map showing predominantly red, yellow and green areas of tendon softening. There appears to be good correlation between the B-mode images and the elastographic overlay. The additional tissue characteristics yielded by sonoelastography in relation to tendon and peritendinous soft tissue elasticity may provide clinicians with information that could alter patient management. This technique shows promise in the earlier detection of tendon degeneration.
Introduction
The role of anorectal and defecatory dysfunction in opioid-related constipation is unclear. We aimed to evaluate the relationship between opioid use and rectal sensation, defecatory ...function, and balloon expulsion on anorectal physiology testing.
Methods
This was a retrospective cohort study of consecutive adults undergoing high-resolution anorectal manometry (HRAM) at a tertiary center for constipation. Clinical characteristics, medication use, and HRAM findings were obtained. Statistical analyses were performed using Fisher-exact/student t-test for univariate analyses and logistic/general linear regression for multivariable analyses to compare patients with no opioid use, recent (< 3 months) use, and distant (> 3 months) use.
Results
424 patients (49.8 ± 17.2 years; 85.6% female) were included. Compared to those without opioid history, patients with recent use had increased volumes for first rectal sensation (70.4 mL vs 59.4,
p
= 0.043), urge (120.5 mL vs 101.5,
p
= 0.017), and maximal tolerance (170.2 mL vs 147.2,
p
= 0.0018), but not patients with distant use. Recent opioid use was associated with increased risk of dyssynergic defecation (DD) (61.8% vs 46.4%,
p
= 0.035), but not failed balloon expulsion. On multivariable models controlling for potential confounders, recent opioid use, but not distant use, remained independently correlated with increased volumes for first rectal sensation (β-coefficient 9.78,
p
= 0.019), urge (β-coefficient 16.7,
p
= 0.0060), and maximal tolerance (β-coefficient 22.9,
p
= 0.0032), and higher risk for DD (aOR = 2.18,
p
= 0.026).
Conclusion
Recent opioid use was an independent risk factor for rectal hyposensitivity and DD on HRAM in patients with constipation, but that effect may decrease with discontinuation of use. Anorectal physiology testing should be considered in patients with opioid-associated constipation.
Introduction: Defecation requires relaxation of the external anal sphincter and puborectalis muscles, which are partially controlled by cortical inhibition of the spinal reflex. Dyssynergic ...defecation results from inappropriate contraction or insufficient relaxation of these muscles during evacuation. The pathogenesis remains unclear and may be subconsciously learned. Given that psychiatric comorbidities may contribute to these subconscious behaviors, thereby increasing the risk of dysfunction, we hypothesized that psychiatric disorders may be more prevalent among patients with dyssynergic defecation. Methods: This was a retrospective cohort study of consecutive patients with chronic constipation who underwent high-resolution anorectal manometry (HRAM) at a tertiary care center in 7/2013-9/2017. Patient demographics, clinical history including psychiatric diagnoses and opioid use, and HRAM data were reviewed. Dyssynergia was defined as impaired anal sphincter relaxation (<20% decrease from baseline) during strain maneuver, with or without presence of weak push, defined as decreased rectal contraction pressure (<40 mmHg increase from baseline). Statistical analyses were performed using Chi-squared or students t-test for univariate analyses and logistic regression for multivariate analysis. Results: 303 patients (mean age: 51.1 years, 87% female) were included, with 134 (44%) having a history of psychiatric comorbidities. HRAM findings of dyssynergia were noted in 162 (53.5%) patients, subclassified as 15.8% type I, 70.3% type II, and 13.9% type IV dysfunction. Dyssynergic defecation was associated with a higher prevalence of psychiatric diagnoses (59.7% vs 40.3%, p=0.05). On subgroup analysis, both depression (28.7% vs 16.4%, p=0.03) and anxiety (21.2% vs 10.3%, p=0.04) were more common among patients with dyssynergia. The distribution of subtypes was similar between patients with psychiatric comorbidities and those without (Table 1). On multivariate analysis controlling for potential confounders, psychiatric comorbidities (OR 2.3, p=0.004) and recent narcotics (OR 2.3, p=0.04) were independently associated with dyssynergic defecation. Conclusion: A history of psychiatric comorbidities and recent narcotics use were independently associated with dyssynergic defecation on HRAM in patients with chronic constipation, and should be considered in the etiology of defecation disorders. Future studies should assess the impact of evaluating and treating these potential targets for intervention.
Introduction: Internal hemorrhoids are common and cause many bothersome symptoms. The cause of symptomatic internal hemorrhoids is not well understood, but associations have been made with chronic ...constipation and older age. Altered bowel habits and anorectal symptoms are common after pregnancy, but the association between obstetric history and hemorrhoidal disease has not been fully evaluated. We hypothesized that internal hemorrhoids are more common in women with a history of vaginal delivery due to the disruption in anorectal anatomy and defecatory function. Methods: This was a retrospective cohort study of adult female patients who underwent both colonoscopy and high resolution anorectal manometry (HRAM) at a tertiary center in 2013 - 2017. Patient demographics, medication use, obstetric history, and endoscopic and HRAM findings were reviewed. Reports and retroflexed images of the colonoscopy were examined for the presence of internal hemorrhoids. Anorectal physiologic parameters and signs of defecation disorders were identified on HRAM. Univariate analyses were performed using Fisher exact test and student t-test, and logistic regression was used for multivariate analysis. Results: 306 patients (mean age: 57.7±11.1 years) were included. Subjects with hemorrhoids discovered on colonoscopy were significantly older (61.2±12.4 vs 54.8±16.4, p=0.0008) than those without. Hemorrhoids were more prevalent among patients with prior vaginal delivery (50% vs 36.7%, p=0.09), particularly among those reporting constipation symptoms (58.1% vs 37.8%, p=0.038). There were no significant associations between hemorrhoids and any HRAM parameters, including resting tone, squeeze pressure, rectal contraction pressure, and simulated defecation response. Trends toward higher prevalence of dyssynergia and reported constipation symptoms among patients with hemorrhoids were noted on univariate analyses, although statistical significance was not reached. On multivariate analysis controlling for potential confounders, a history of vaginal delivery (OR 2.2, p=0.04), older age (OR 3.3, p=0.002), and constipation symptoms (OR 2.5, p=0.02) were independently associated with increased hemorrhoids. Conclusion: A history of vaginal delivery, older age, and constipation symptoms were independent risk factors for internal hemorrhoids, while dyssynergic defecation and other HRAM parameters were not associated. The pathogenesis of internal hemorrhoids are likely due to more than disrupted defecation alone.
In this paper, an Anishnaabe educator and university researcher/former primary teacher make a case for viewing children's dramatic play as multimodal identity texts. Indigenous children in our ...research study take up an agentic role and construct positive identities in dramatic play, creating narratives that reflect Indigenous cultural practices, as well as some practices of mainstream Canadian society that may be imbued with colonising perspectives. We argue that the Indigenous Cultural classes and follow‐up dramatic play counter the marginalisation of Indigenous knowledge, culture and languages that has occurred with devastating effects on generations of Indigenous families. Our paper is based on video recordings of 4‐ and 5‐year‐old children's dramatic play that were analysed collectively by 12 Indigenous educators in terms of the Indigenous cultural meanings that children created in their play. We conclude with implications for non‐Indigenous teachers, arguing that a case can be made for including child‐led dramatic play in the literacy curriculum when dramatic play narratives are viewed as multimodal identity texts. These texts, which can involve multiple modes including print, draw from children's own cultural and linguistic knowledge and experience.
PDF
