Out-of-hospital cardiac arrest continues to be an important public health problem, with large and important regional variations in outcomes. Survival rates vary widely among patients treated with ...out-of-hospital cardiac arrest by emergency medical services and among patients transported to the hospital after return of spontaneous circulation. Most regions lack a well-coordinated approach to post-cardiac arrest care. Effective hospital-based interventions for out-of-hospital cardiac arrest exist but are used infrequently. Barriers to implementation of these interventions include lack of knowledge, experience, personnel, resources, and infrastructure. A well-defined relationship between an increased volume of patients or procedures and better outcomes among individual providers and hospitals has been observed for several other clinical disorders. Regional systems of care have improved provider experience and patient outcomes for those with ST-elevation myocardial infarction and life-threatening traumatic injury. This statement describes the rationale for regional systems of care for patients resuscitated from cardiac arrest and the preliminary recommended elements of such systems. Many more people could potentially survive out-of-hospital cardiac arrest if regional systems of cardiac resuscitation were established. A national process is necessary to develop and implement evidence-based guidelines for such systems that must include standards for the categorization, verification, and designation of components of such systems. The time to do so is now.
Muscle force production and power output in active males, regardless of the site of measurement (hand, leg, or back), are higher in the evening than in the morning. This diurnal variation is ...attributed to motivational, peripheral and central factors, and higher core and, possibly, muscle temperatures in the evening. This study investigated whether increasing morning rectal temperatures to evening resting values, by active or passive warm-ups, leads to muscle force production and power output becoming equal to evening values in motivated subjects. Ten healthy active males (mean ± SD: age, 21.2 ± 1.9 yrs; body mass, 75.4 ± 8 kg; height, 1.76 ± .06 m) completed the study, which was approved by the University Ethics Committee. The subjects were familiarized with the techniques and protocol and then completed four sessions (separated by at least 48 h): control morning (07:30 h) and evening (17:30 h) sessions (with an active 5-min warm-up) and then two further sessions at 07:30 h but proceeded by an extended active or passive warm-up to raise rectal temperature to evening values. These last two sessions were counterbalanced in order of administration. During each trial, three measures of handgrip strength, isokinetic leg strength measurements (of knee flexion and extension at 1.05 and 4.19 rad.s−1 through a 90° range of motion), and four measures of maximal voluntary contraction (MVC) on an isometric ergometer (utilizing the twitch-interpolation technique) were performed. Rectal and intra-aural temperatures, ratings of perceived exertion (RPE) and thermal comfort (TC) were measured. Measurements were made after the subjects had reclined for 30 min and after the warm-ups and prior to the measurement of handgrip and isokinetic and isometric ergometry. Muscle temperature was taken after the warm-up and immediately before the isokinetic and MVC measurements. Warm-ups were either active (cycle ergometer at 150 W) or passive (resting in a room at 35°C, relative humidity 45%). Data were analyzed using analysis of variance models with repeated measures. Rectal and intra-aural temperatures were higher at rest in the evening (.56°C and .74°C; p < .05) than in the morning, but there were no differences after the active or passive warm-ups, the subjects' ratings of thermal comfort reflecting this. Muscle temperatures also displayed significant diurnal variation, with higher values in the evening (∼.31°C; p < .05). Grip strength, isokinetic knee flexion for peak torque and peak power at 1.05 rad.s−1, and knee extension for peak torque at 4.19 rad.s−1 all showed higher values in the evening. All other measures of strength or power showed a trend to be higher in the evening ( .10 > p > .05). There was no significant effect of active or passive warm-ups on any strength or power variable, and subjects reported maximal values for effort for each strength measure. In summary, effects of time of day were seen in some measures of muscle performance but, in this population of motivated subjects, there was no evidence that increasing morning rectal temperature to evening values by active or passive warm-up increased muscle strength to evening values. (Author correspondence: B.J.Edwards@ljmu.ac.uk)
Background:
This video presents assessment and management of hallux limitus using intrinsic foot strengthening and joint mobilization techniques with combination of extracorporeal shockwave therapy ...(ESWT).
Indications:
Clinical history includes pain with walking, running, jumping, or loaded plantarflexion localized to the first metatarsophalangeal (MTP) joint. Indications for our treatment approach of hallux limitus include pain localized to the first MTP joint, corresponding lack of active range of motion/passive range of motion, and reduced foot/ankle strength often with joint space narrowing on imaging.
Technique Description:
Our program uses the principle of foot core exercises that enhance intrinsic muscles of the foot to assist in medial longitudinal arch stabilization and hallux strengthening. Progression of these exercises can be done in weight-bearing and impact activities specific to patient goals. In addition to these foot intrinsic exercises, calf raises should be incorporated to strengthen the gastroc-soleus complex to both improve plantar foot strength and facilitate extension of the first MTP joint. Manual therapy techniques reduce the rigidity of the first MTP joint and restore appropriate medial-lateral and plantar-dorsal balance. With severe limitations in mobility or pain limitations, ESWT can be incorporated to treat the joint and surrounding soft tissue restrictions.
Results:
Increased first MTP extension is observed. Reduced symptoms of first MTP joint pain with activity allow patients to return to walking and other physical activities with improved comfort. Complications are rare. Pain over the first MTP joint is expected during ESWT. Rarely, irritation of the plantar components of the first MTP joint, including the tibial and fibular sesamoid bones, may occur.
Discussion/Conclusion:
Non-surgical management of hallux limitus may improve using the described technique of intrinsic foot strengthening with focus on stabilization of the medial longitudinal arch and strategies of improved mobility of the first MTP joint. Adding ESWT may address joint limitations and facilitate gains in exercise and mobility.
Graphical Abstract
This is a visual representation of the abstract.
Mental disorders account for six of the 20 leading causes of disability worldwide with a very high prevalence of psychiatric morbidity in youth aged 15-24 years. However, healthcare professionals are ...faced with many challenges in the identification and treatment of mental and substance use disorders in young people (e.g. young people's unwillingness to seek help from healthcare professionals, lack of training, limited resources etc.) The challenge of youth mental health for primary care is especially evident in urban deprived areas, where rates of and risk factors for mental health problems are especially common. There is an emerging consensus that primary care is well placed to address mental and substance use disorders in young people especially in deprived urban areas. This study aims to describe healthcare professionals' experience and attitudes towards screening and early intervention for mental and substance use disorders among young people (16-25 years) in primary care in deprived urban settings in Ireland.
The chosen method for this qualitative study was inductive thematic analysis which involved semi-structured interviews with 37 healthcare professionals from primary care, secondary care and community agencies at two deprived urban centres.
We identified three themes in respect of interventions to increase screening and treatment: (1) Identification is optimised by a range of strategies, including raising awareness, training, more systematic and formalised assessment, and youth-friendly practices (e.g. communication skills, ensuring confidentiality); (2) Treatment is enhanced by closer inter-agency collaboration and training for all healthcare professionals working in primary care; (3) Ongoing engagement is enhanced by motivational work with young people, setting achievable treatment goals, supporting transition between child and adult mental health services and recognising primary care's longitudinal nature as a key asset in promoting treatment engagement.
Especially in deprived areas, primary care is central to early intervention for youth mental health. Identification, treatment and continuing engagement are likely to be enhanced by a range of strategies with young people, healthcare professionals and systems. Further research on youth mental health and primary care, including qualitative accounts of young people's experience and developing complex interventions that promote early intervention are priorities.
This series characterises nine patients with neurohistopathologically proven peripheral nerve neurolymphomatosis. A search of the hospital neuropathology database from 2002 to 2019 identified biopsy ...proven cases. Clinical data, investigation modalities, treatments, and outcomes were collated. Median age at neuropathy onset was 47 y, the neuropathy commonly as the initial lymphoma disease manifestation. Most (8/9) presented with painful asymmetrical sensory disturbance, with additional cranial nerve involvement in three. Neurophysiology typically demonstrated multiple axonal mononeuropathies. Cerebrospinal fluid protein was often raised (6/8). Magnetic resonance imaging suggested peripheral nerve infiltration in 6/9 and positron emission tomography CT in 4/9. Bone marrow biopsy was abnormal in 6/8. Treatment involved systemic or intrathecal chemotherapy and radiotherapy. Median survival was 23 mo. Neurolymphomatosis is a rare but important cause of neuropathy, particularly in those lacking systemic evidence of lymphoma as correct aggressive treatment can prolong survival. Nerve biopsy is essential to classify lymphoma type and rule out alternatives.
Ischemic stroke (IS) and coronary artery disease (CAD) share several risk factors and each has a substantial heritability. We conducted a genome-wide analysis to evaluate the extent of shared genetic ...determination of the two diseases.
Genome-wide association data were obtained from the METASTROKE, Coronary Artery Disease Genome-wide Replication and Meta-analysis (CARDIoGRAM), and Coronary Artery Disease (C4D) Genetics consortia. We first analyzed common variants reaching a nominal threshold of significance (P<0.01) for CAD for their association with IS and vice versa. We then examined specific overlap across phenotypes for variants that reached a high threshold of significance. Finally, we conducted a joint meta-analysis on the combined phenotype of IS or CAD. Corresponding analyses were performed restricted to the 2167 individuals with the ischemic large artery stroke (LAS) subtype.
Common variants associated with CAD at P<0.01 were associated with a significant excess risk for IS and for LAS and vice versa. Among the 42 known genome-wide significant loci for CAD, 3 and 5 loci were significantly associated with IS and LAS, respectively. In the joint meta-analyses, 15 loci passed genome-wide significance (P<5×10(-8)) for the combined phenotype of IS or CAD and 17 loci passed genome-wide significance for LAS or CAD. Because these loci had prior evidence for genome-wide significance for CAD, we specifically analyzed the respective signals for IS and LAS and found evidence for association at chr12q24/SH2B3 (PIS=1.62×10(-7)) and ABO (PIS=2.6×10(-4)), as well as at HDAC9 (PLAS=2.32×10(-12)), 9p21 (PLAS=3.70×10(-6)), RAI1-PEMT-RASD1 (PLAS=2.69×10(-5)), EDNRA (PLAS=7.29×10(-4)), and CYP17A1-CNNM2-NT5C2 (PLAS=4.9×10(-4)).
Our results demonstrate substantial overlap in the genetic risk of IS and particularly the LAS subtype with CAD.
We use a biologically grounded neural network model to investigate the brain mechanisms underlying individual differences specific to the selection and instantiation of representations that exert ...cognitive control in task switching. Existing computational models of task switching do not focus on individual differences and so cannot explain why task switching abilities are separable from other executive function (EF) abilities (such as response inhibition). We explore hypotheses regarding neural mechanisms underlying the “Shifting-Specific” and “Common EF” components of EF proposed in the Unity/Diversity model (Miyake & Friedman, 2012) and similar components in related theoretical frameworks. We do so by adapting a well-developed neural network model of working memory (Prefrontal cortex, Basal ganglia Working Memory or PBWM; Hazy, Frank, & O’Reilly, 2007) to task switching and the Stroop task, and comparing its behavior on those tasks under a variety of individual difference manipulations. Results are consistent with the hypotheses that variation specific to task switching (i.e., Shifting-Specific) may be related to uncontrolled, automatic persistence of goal representations, whereas variation general to multiple EFs (i.e., Common EF) may be related to the strength of PFC representations and their effect on processing in the remainder of the cognitive system. Moreover, increasing signal to noise ratio in PFC, theoretically tied to levels of tonic dopamine and a genetic polymorphism in the COMT gene, reduced Stroop interference but increased switch costs. This stability–flexibility tradeoff provides an explanation for why these two EF components sometimes show opposing correlations with other variables such as attention problems and self-restraint.
•We present a neural network model of individual differences in task switching.•We compared results for a Stroop model that captures general executive ability.•Active goal maintenance and top-down biasing affected both switch and Stroop cost.•Persistence of no-longer-relevant goals increased switch cost but not Stroop cost.•These mechanisms may create some of the unity and diversity of executive functions.
BACKGROUND:The selection of the lowest instrumented vertebra (LIV) in patients with adolescent idiopathic scoliosis (AIS) is still controversial. Although multiple radiographic methods have been ...proposed, there is no universally accepted guideline for appropriate selection of the LIV. We developed a simple and reproducible method for selection of the LIV in patients with Lenke type-1 (main thoracic) and 2 (double thoracic) curves and investigated its effectiveness in producing optimal positioning of the LIV at 5 years of follow-up.
METHODS:The radiographs for 299 patients with Lenke type-1 or 2 AIS curves that were included in a multicenter database were evaluated after a minimum duration of follow-up of 5 years. The “touched vertebra” (TV) was selected on preoperative radiographs by 2 independent examiners. The LIV on postoperative radiographs was compared with the preoperative TV. The final LIV position in relation to the center sacral vertical line (CSVL) was assessed. The CSVL-LIV distance and coronal balance in patients who had fusion to the TV were compared with those in patients who had fusion cephalad and caudad to the TV. The sagittal plane was also reviewed.
RESULTS:In 86.6% of patients, the LIV was selected at or immediately adjacent to the TV. Among patients with an “A” lumbar modifier, those who had fusion cephalad to the TV had a significantly greater CSVL-LIV distance than those who had fusion to the TV (p = 0.006) or caudad to the TV (p = 0.002). In the groups with “B” (p = 0.424) and “C” (p = 0.326) lumbar modifiers, there were no differences among the TV groups.
CONCLUSIONS:We recommend the TV rule as a third modifier in the Lenke AIS classification system. Selecting the TV as the LIV in patients with Lenke type-1 and 2 curves provides acceptable positioning of the LIV at long-term follow-up. The position of the LIV was not different when fusion was performed caudad to the TV but came at the expense of fewer motion segments. Patients with lumbar modifier “A” who had fusion cephalad to the TV had greater translation of the LIV, putting these patients at risk for poor long-term outcomes.
LEVEL OF EVIDENCE:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Anterior vertebral body tethering (AVBT) is an alternative to posterior spinal fusion (PSF) for the surgical treatment of scoliosis. The present study utilized a large, multicenter database and ...propensity matching to compare outcomes of AVBT to PSF in patients with idiopathic scoliosis.
Patients with thoracic idiopathic scoliosis who underwent AVBT with a minimum 2-year follow-up retrospectively underwent 2 methods of propensity-guided matching to PSF patients from an idiopathic scoliosis registry. Radiographic, clinical, and Scoliosis Research Society 22-Item Questionnaire (SRS-22) data were compared preoperatively and at the ≥2-year follow-up.
A total of 237 AVBT patients were matched with 237 PSF patients. In the AVBT group, the mean age was 12.1 ± 1.6 years, the mean follow-up was 2.2 ± 0.5 years, 84% of patients were female, and 79% of patients had a Risser sign of 0 or 1, compared with 13.4 ± 1.4 years, 2.3 ± 0.5 years, 84% female, and 43% Risser 0 or 1 in the PSF group. The AVBT group was younger (p < 0.001), had a smaller mean thoracic curve preoperatively (48 ± 9°; range, 30° to 74°; compared with 53 ± 8°; range, 40° to 78° in the PSF group; p < 0.001), and had less initial correction (41% ± 16% correction to 28° ± 9° compared with 70% ± 11% correction to 16° ± 6° in the PSF group; p < 0.001). Thoracic deformity at the time of the latest follow-up was 27° ± 12° (range, 1° to 61°) for AVBT compared with 20° ± 7° (range, 3° to 42°) for PSF (p < 0.001). A total of 76% of AVBT patients had a thoracic curve of <35° at the latest follow-up compared with 97.4% of PSF patients (p < 0.001). A residual curve of >50° was present in 7 AVBT patients (3%), 3 of whom underwent subsequent PSF, and in 0 PSF patients (0%). Forty-six subsequent procedures were performed in 38 AVBT patients (16%), including 17 conversions to PSF and 16 revisions for excessive correction, compared with 4 revision procedures in 3 PSF patients (1.3%; p < 0.01). AVBT patients had lower median preoperative SRS-22 mental-health component scores (p < 0.01) and less improvement in the pain and self-image scores between preoperatively and the ≥2-year follow-up (p < 0.05). In the more strictly matched analysis (n = 108 each), 10% of patients in the AVBT group and 2% of patients in the PSF group required a subsequent surgical procedure.
At a mean follow-up of 2.2 years, 76% of thoracic idiopathic scoliosis patients who underwent AVBT had a residual curve of <35° compared with 97.4% of patients who underwent PSF. A total of 16% of cases in the AVBT group required a subsequent surgical procedure compared with 1.3% in the PSF group. An additional 4 cases (1.3%) in the AVBT group had a residual curve of >50° that may require revision or conversion to PSF.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Francisella tularensis contains four putative acid phosphatases that are conserved in Francisella novicida. An F. novicida quadruple mutant (AcpA, AcpB, AcpC, and Hap DeltaABCH) is unable to escape ...the phagosome or survive in macrophages and is attenuated in the mouse model. We explored whether reduced survival of the DeltaABCH mutant within phagocytes is related to the oxidative response by human neutrophils and macrophages. F. novicida and F. tularensis subspecies failed to stimulate reactive oxygen species production in the phagocytes, whereas the F. novicida DeltaABCH strain stimulated a significant level of reactive oxygen species. The DeltaABCH mutant, but not the wild-type strain, strongly colocalized with p47(phox) and replicated in phagocytes only in the presence of an NADPH oxidase inhibitor or within macrophages isolated from p47(phox) knockout mice. Finally, purified AcpA strongly dephosphorylated p47(phox) and p40(phox), but not p67(phox), in vitro. Thus, Francisella acid phosphatases play a major role in intramacrophage survival and virulence by regulating the generation of the oxidative burst in human phagocytes.
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