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Amputees are prone to experiencing discomfort when wearing their prosthetic devices. As the amputee population grows this becomes a more prevalent and pressing concern. There is a need for new prosthetic technologies to construct more comfortable and well-fitted liners and sockets. One of the well-recognized impediments to the development of new prosthetic technology is the lack of practical inner socket sensors to monitor the inner socket environment (ISE), or the region between the residual limb and the socket. Here we present a capacitive pressure sensor fabricated through a simple, and scalable sewing process using commercially available conductive yarns and textile materials. This fully-textile sensor provides a soft, flexible, and comfortable sensing system for monitoring the ISE. We provide details of our low-power sensor system capable of high-speed data collection from up to four sensor arrays. Additionally, we demonstrate two custom set-ups to test and validate the textile-based sensors in a simulated prosthetic environment. Finally, we utilize the textile-based sensors to study the ISE of a bilateral transtibial amputee. Results indicate that the textile-based sensors provide a promising potential for seamlessly monitoring the ISE.

Our mobility requires muscle regeneration throughout life. Yet our knowledge of the interplay of cell types required to rebuild injured muscle is lacking, because most single cell assays require tissue dissociation. Here we use multiplexed spatial proteomics and neural network analyses to resolve a single cell spatiotemporal atlas of 34 cell types during muscle regeneration and aging. This atlas maps interactions of immune, fibrogenic, vascular, nerve, and myogenic cells at sites of injury in relation to tissue architecture and extracellular matrix. Spatial pseudotime mapping reveals sequential cellular neighborhoods that mediate repair and a nodal role for immune cells. We confirm this role by macrophage depletion, which triggers formation of aberrant neighborhoods that obstruct repair. In aging, immune dysregulation is chronic, cellular neighborhoods are disrupted, and an autoimmune response is evident at sites of denervation. Our findings highlight the spatial cellular ecosystem that orchestrates muscle regeneration, and is altered in aging.HighlightsSingle cell resolution spatial atlas resolves a cellular ecosystem of 34 cell types in multicellular neighborhoods that mediate efficient skeletal muscle repairHighly multiplexed spatial proteomics, neural network and machine learning uncovers temporal dynamics in the spatial crosstalk between immune, fibrogenic, vascular, nerve, and muscle stem cells and myofibers during regenerationSpatial pseudotime mapping reveals coherent formation of multicellular neighborhoods during efficacious repair and the nodal role of immune cells in coordinating muscle repairIn aged muscle, cellular neighborhoods are disrupted by a chronically inflamed state and autoimmunity

Despite well-accepted understanding that relational dynamics characterized by respect, openness, and connectedness are critical for healthy team functioning, we know little about how to foster such...

The aim of the study was to report the training characteristics, academic accomplishments, and motivation of current United States academic physical medicine and rehabilitation chairs.The authors developed a 23-question survey that was disseminated via e-mail to 86 current chairs who were members of the Chairs Council from the Association of Academic Physiatrists in May 2020. Follow-up e-mails were sent 2 and 4 wks after the initial distribution, and the survey closed after 6 wks in June 2020. The data collected were deidentified. Descriptive analysis was performed.Forty-nine chair responses were received, which had a response rate of 60%. A total of 69.4% of the chairs (32 of 49) were men and 30.6% (17 of 49) were women. A total of 75.5% (37 of 49) were White/Caucasian, 12.2% (6 of 49) Hispanic/Latinx, 10.2% (5 of 49) Asian, and 2% (1 of 49) were Black/African American. A total of 8.2% of the chairs (4 of 49) reported having a disability. Sixty-seven percent of the female chairs (10 of 15) reported experiencing gender discrimination in the workplace versus 3% of male chairs (1 of 34). Twenty-nine percent of the chairs were full professors in physical medicine and rehabilitation when first appointed, 57.1% associate professors, and 6% assistant professors. A total of 73.5% of the chairs had served as a reviewer for a peer-reviewed publication. Fifty-two percent of the chairs had a leadership role in a national physical medicine and rehabilitation organization. Fifty-eight percent of the chairs had at least 16 peer-reviewed publications when first appointed.This survey provides insight to the training characteristics, accomplishments, and motivation of current chairs for physiatrists aspiring to enter these ranks. It also highlights the underrepresentation of women and minorities among leadership positions in physical medicine and rehabilitation.

The theory, design, fabrication, and measurement of a new class of planar ultrawideband modular antenna (PUMA) arrays are presented. The proposed PUMA array class achieves twice the bandwidth (from 3:1 to 6:1) of the conventional shorted via-based PUMA without using an external matching network and while retaining convenient unbalanced feeding, manufacturing, and assembly characteristics. The chief enabling technical innovation hinges upon the reconfiguration of shorting vias into capacitively-loaded vias that simultaneously: 1) mitigate low-frequency bandwidth-limiting loop modes and 2) shift problematic common-mode resonances out-of-band. A simple theoretical model based on ridged waveguides is proposed that qualitatively and quantitatively explains this novel common-mode mitigation. An infinite array operating over 3.53–21.2 GHz (6:1) is designed to achieve active VSWR < {2, 2.5, 3.8} while scanning to {broadside, 45°, 60°}, respectively, without oversampling the aperture. D-plane cross-polarization is around {−15, −10} dB for {45°, 60°} scans with high efficiency, i.e., 0.5 dB co-polarized gain loss on average. A dual-polarized prototype 256-port (128 elements per polarization) array is fabricated and measured having good agreement with full-wave finite array simulations.

OBJECTIVEThe 30-day readmission rate has emerged as an important marker of the quality of in-hospital care in several fields of medicine. This review aims to summarize available research reporting readmission rates after cranial procedures and to establish an association with demographic, clinical, and system-related factors and clinical outcomes.METHODSThe authors conducted a systematic review of several databases; a manual search of the Journal of Neurosurgery, Neurosurgery, Acta Neurochirurgica, Canadian Journal of Neurological Sciences; and the cited references of the selected articles. Quality review was performed using the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) criteria. Findings are reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.RESULTSA total of 1344 articles published between 1947 and 2015 were identified; 25 were considered potentially eligible, of which 12 met inclusion criteria. The 30-day readmission rates varied from 6.9% to 23.89%. Complications arising during or after neurosurgical procedures were a prime reason for readmission. Race, comorbidities, and longer hospital stay put patients at risk for readmission.CONCLUSIONSAlthough readmission may be an important indicator for good care for the subset of acutely declining patients, neurosurgery should aim to reduce 30-day readmission rates with improved quality of care through systemic changes in the care of neurosurgical patients that promote preventive measures.

Background Intra-articular corticosteroid injection is a commonly used therapy for adhesive capsulitis, but not enough studies exist on the optimal timing of the injection. Objective To determine whether intra-articular corticosteroid injection has better outcomes in patients with earlier stage than later stage of adhesive capsulitis. Study Design Retrospective longitudinal study Setting University-affiliated tertiary care hospital. Participants Primary adhesive capsulitis patients (n=339) who were unresponsive to at least 1 month of conservative treatment and who had ultrasound-guided corticosteroid injection. Interventions Not applicable. Main Outcome Measurements Visual analogue scale, Shoulder Pain and Disability Index, and passive range of motion (flexion, abduction, external rotation, and internal rotation and extension) were evaluated at pretreatment, month 1 and 12 after the first injection. Results The result of the multiple regressions, which considered the main and the interaction effect of confounding variables, showed that the differences of all outcomes in both short-term effect at month 1 and long-term effect at month 12 are greater when the duration of pain prior to injection is shorter. Among the confounders, the injection number in the difference of internal rotation and extension between month 0 and 12 (IRE Δ(0-12)) was statistically significant. IRE Δ(0-12) was also greater when the pain duration was shorter, though the decrease in IRE Δ(0-12) differed depending on the number of injections. Conclusions Early injection improves outcomes of adhesive capsulitis at both short- and long-term follow-ups. If pain persists despite non-invasive and conservative treatments, early injection may be considered to shorten its natural history. Level of Evidence III

Objective To determine whether capsule-preserved hydrodilatation with corticosteroid improves pain and function in patients with refractory adhesive capsulitis (AC) better than intra-articular corticosteroid injection (IACI) alone. Design Prospective randomized controlled study. Setting University-affiliated tertiary care hospital. Participants Subjects with primary AC (N=64) with shoulder pain level of visual analog scale (VAS) score ≥5, even after the initial administration of IACI alone. Interventions Participants randomly received ultrasound-guided IACI alone with 1mL of 40mg/mL triamcinolone acetonide and 3mL of 1% lidocaine (n=32) or ultrasound-guided capsule-preserved hydrodilatation with corticosteroid with a mixture of 1mL of 40mg/mL triamcinolone acetonide, 6mL of 1% lidocaine, and normative saline (n=32). Main Outcome Measures The primary outcome measure was the Shoulder Pain and Disability Index score. Secondary outcomes were the VAS of shoulder pain level and angles of shoulder passive range of motion, including flexion, abduction, extension, external rotation, and internal rotation at pretreatment and weeks 3, 6, and 12 of posttreatment. Results There were no significant differences between the 2 groups in terms of demographic characteristics (age, sex, duration of symptoms, shoulder affected, and body mass index) at baseline. Repeated-measures analysis of variance showed significant effect of time in all outcome measurements in both groups. However, group-by-time interactions were not significantly different for any of the outcomes between groups. Conclusions This study shows that compared with pretreatment, all outcome measures improved significantly in both groups by time; however, there was no significant difference between the 2 groups. Therefore, we recommend IACI alone over capsule-preserved hydrodilatation with corticosteroid when considering the corticosteroid injection as a secondary option after the initial IACI fails to improve symptoms for patients with refractory AC.

Fascination with organizations that eschew the conventional managerial hierarchy and instead radically decentralize authority has been longstanding, albeit at the margins of scholarly and practitioner attention. Recently, however, organizational experiments in radical decentralization have gained mainstream consideration, giving rise to a need for new theory and new research. This paper reviews the literature on less-hierarchical organizing and identifies three categories of research: post-bureaucratic organizations, humanistic management and organizational democracy. Despite this extensive prior work, scholarly understanding of radical decentralization remains limited. Using the term self-managing organizations to capture efforts that radically decentralize authority in a formal and systematic way throughout the organization, we set forth a research agenda to better understand less-hierarchical organizing at its limits.

The joint pursuit of commercial and societal objectives will likely require non-traditional (non-hierarchical) ways of organizing. This chapter discusses the prospects for one promising alternative: “organizational democracy.” This is a flatter form characterized by distributed decision rights, a deliberative culture, and employee ownership. Other alternatives to hierarchy have emphasized individualistic values of autonomy and empowerment. In contrast, organizational democracy emphasizes the collective. Relevant work in political philosophy underlines analogous dimensions including representation, deliberation, and a collective point of view. The last point makes it different from work on solidarity and class or group interest. In multi-objective organizational democracy there are trade-offs and these are negotiated. Representation and deliberation come to the foreground. Unlike in traditional organizations, however, negotiations are not regarded as transaction costs to be minimized; rather they are brought to the foreground and cultivated. The chapter illustrates these ideas and discusses challenges and avenues for future research.

Traumatic brain injury (TBI) is a leading cause of death and disability throughout the world, particularly among young adults, affecting untold numbers of women of childbearing age. TBIs can disrupt almost any aspect of physical, cognitive, and/or emotional functioning, potentially complicating a woman’s ability to conceive, carry, and deliver a healthy child. For women who are already pregnant and sustain a TBI, medical stabilization of the mother and management of risk of further injury to the fetus are priorities. For women with a previous history of TBI, comprehensive assessment and optimal management of common sequelae of TBI (eg, seizures, endocrine dysfunction, physical and cognitive impairments, and neuropsychiatric symptoms) are essential to maximizing outcomes for both mother and child. Consultation with physiatry and neuropsychology, utilization of rehabilitation therapies to maximize the mother’s functional recovery, and consistent communication among all medical team members throughout pregnancy are essential.

Objective The aim of this study was to elucidate clinical trial efficacy, safety, and dosing practices of abobotulinumtoxinA (ABO) treatment in adult patients with upper limb spasticity (ULS). Methods A systematic literature review was performed to identify randomized controlled trials and other comparative clinical studies of ABO in the treatment of adult ULS published in English between January 1991 and January 2013. Medical literature databases (PubMed, Cochrane Library, and EMBASE) were searched, and a total of 295 records were identified. Of these, 12 primary publications that evaluated ABO for the management of ULS were included in the final data report. Synthesis Total ABO doses ranged between 500 and 1500 U for ULS. Most of the studies in ULS showed statistically significant benefits (reduction in muscle tone based on Ashworth score) of ABO vs. placebo. Statistical significance was reached for most evaluations of spasticity using the Modified Ashworth Scale. Statistically significant effects on active movement and pain were demonstrated, albeit less consistently. ABO was generally well tolerated across the individual studies; most adverse events reported were considered unrelated to treatment. Adverse events considered associated with ABO treatment included fatigue, tiredness, arm pain, skin rashes, flu-like symptoms, worsening of spasm, and weakness. Conclusions On the basis of data extracted from 12 randomized clinical studies, a strong evidence base (9/12 studies) exists for the use of ABO to reduce ULS caused by stroke.

A Planar Ultra-Wideband Modular Antenna (PUMA) array with 7mm element spacing is presented that operates over roughly 3.5GHz to 21GHz, validating the first PUMA with a 6:1 operational bandwidth. The design consists mainly of plated through vias on Rogers 5880LZ substrate with Rogers 3000-class materials integrated as a radome superstrate. The aperture is less than 0.5 wavelengths thick at the highest frequency of operation. Scan VSWR performance is good, with VSWR < 2.5 for 45-degree scans in all planes, VSWR < 3.8 for 60-degree scans in all planes and over all frequencies. An all-metal flared notch array of the same element spacing and footprint is presented for performance comparison. It is shown that the PUMA has significantly-better polarization patterns than legacy ultra-wideband flared notch arrays over all frequency and scan space. Measured results are presented.

This paper discusses bandwidth and polarization challenges in modern dual-polarized ultra-wideband (UWB) electronically scanned array (ESA) aperture design and two recent solution advances aiming to remedy such issues: a 6:1 Planar Ultrawideband Modular Antenna (PUMA) array and a 10:1 Sliced Notch Antenna (SNA) array. The proposed arrays enable wide bandwidth, low cross-polarization, and high efficiency from both low-profile and high-profile array research directions to appeal to a wider variety of applications and design embodiments. The proposed UWB-ESAs are analyzed alongside a conventional 10:1 all-metal Vivaldi array to shed light upon modern design trends and implications.

The wavelength-scaled array architecture reduces element count and associated T/R module costs by replacing a portion of a periodic array by fewer, but scaled up elements that are excited only at lower frequency bands. We propose the implementation of the wavelength-scaled array using low-cost Planar Ultrawideband Modular Antenna (PUMA) radiators to further reduce cost, profile and improve polarization performance. Full wave finite array simulations are used to quantify the impedance and far-field radiation performance of the PUMA wavelength-scaled array and to compare it to conventional square array counterparts.

Objective: To evaluate the effect of an arm sling on gait speed and energy efficiency of patients with hemiplegia. Design: A randomized crossover design. Setting: A rehabilitation department of a university hospital. Subjects: Thirty-seven outpatients with hemiplegia were included in this study. Interventions: All patients walked on a 20-m walkway twice on the same day, randomly with and without an arm sling, at a self selected speed. Main measures: The heart rate, gait speed, oxygen cost and oxygen rate were measured on all patients. We analysed all values with and without an arm sling and also compared them after all patients being stratified according to demographic and clinical characteristics. Results: When we compared the heart rate between walking with (90.7 ± 17.2 beats/min) and without (91.2 ± 18.6 beats/min) the arm sling, it was significantly decreased while walking with the arm sling. When we compared the gait speed between walking with (32.8 m/min) and without (30.1 m/min), it was significantly increased with the arm sling walking. The O2 rate in hemiplegic patients walking with the arm sling was significantly decreased by 7%, compared to walking without arm sling (5.8 mL/kg min and 6.2 mL/kg min, respectively). The O2 cost in hemiplegic patients walking without arm sling was significantly 1.4 times greater than walking with it (0.2 mL/kg m and 0.3 mL/kg m, respectively). Conclusion: An arm sling can be used to improve the gait efficiency.

Park G-Y, Lee S-M, Lee MY. Diagnostic value of ultrasonography for clinical medial epicondylitis. Objectives To assess the ultrasonographic findings and to evaluate the value of ultrasonography as a diagnostic method for detecting clinical medial epicondylitis. Design A prospective, single-blind study. Setting An outpatient rehabilitation clinic in a tertiary university hospital. Participants Twenty-one elbows from 18 patients with clinical medial epicondylitis and 25 elbows without medial epicondylitis were evaluated. Interventions Not applicable. Main Outcome Measures The clinical diagnosis of medial epicondylitis was based on the patient's symptoms and clinical signs in a physical examination performed by a physiatrist. An experienced radiologist made the real-time ultrasonographic diagnosis based on the detection of at least one of the following abnormal findings: a focal hypoechoic or anechoic area, tendon nonvisualization, intratendinous calcifications, and cortical irregularity. Results Ultrasonography revealed positive findings in 20 of 21 elbows with medial epicondylitis and was negative in 23 of 25 without medial epicondylitis. Ultrasonography showed sensitivity, specificity, accuracy, positive predictive value, and negative predictive value for clinical medial epicondylitis of 95.2%, 92%, 93.5%, 90.9%, and 95.8%, respectively. Tendinosis was observed in 15 elbows, and a partial-thickness tear, including 1 intrasubstance tear, was detected in 5 elbows. The most common ultrasonographic abnormality was a focal echogenic abnormality (15 hypoechoic, 5 anechoic) of the tendons. Conclusions Our results indicate that ultrasonography is informative and accurate for the detection of clinical medial epicondylitis. Therefore, ultrasonography should be considered as an initial imaging method for evaluating medial epicondylitis.

OBJECT Thirty-day readmission has been cited as an important indicator of the quality of care in several fields of medicine. The aim of this systematic review was to examine rate of readmission and factors relevant to readmission after neurosurgery of the spine. METHODS The authors carried out a systematic review using several databases, searches of cited reference lists, and a manual search of the JNS Publishing Group journals (Journal of Neurosurgery; Journal of Neurosurgery: Spine; Journal of Neurosurgery: Pediatrics; and Neurosurgical Focus), Neurosurgery, Acta Neurochirurgica, and Canadian Journal of Neurological Sciences. A quality review was performed using STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) criteria and reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. RESULTS A systematic review of 1136 records published between 1947 and 2014 revealed 31 potentially eligible studies, and 5 studies met inclusion criteria for content and quality. Readmission rates varied from 2.54% to 14.7%. Sequelae that could be traced back to complications that arose during neurosurgery of the spine were a prime reason for readmission after discharge. Increasing age, poor physical status, and comorbid illnesses were also important risk factors for 30-day readmission. CONCLUSIONS Readmission rates have predictable factors that can be addressed. Strategies to reduce readmission that relate to patient-centered factors, complication avoidance during neurosurgery, standardization with system-wide protocols, and moving toward a culture of nonpunitive system-wide error and “near miss” investigations and quality improvement are discussed.

Advances in Planar Ultra-wideband Modular Antenna (PUMA) array architecture which have culminated into a 6∶1 bandwidth design without the use of an external backplane matching network are presented. This paper will examine the additional bandwidth-enhancing operational principles of the proposed dual-polarized 6∶1 PUMA array. A design and its respective full-wave simulations will then be presented, with results yielding a 6∶1 bandwidth with VSWR < 2 at broadside, VSWR < 2.6 scanning out to θ = 45°, and a diagonal plane cross-polarization greater than 15 dB at θ = 45° for the majority of the band.

An important system design specification for electronically scanned arrays (ESAs) is the polarization purity for certain scan volume. Methods for determining the polarization levels of an array will be discussed and used to quantify finite array truncation effects on polarization purity of ultra-wideband (UWB) arrays. Simulated finite array results are used to examine the polarization properties of a Vivaldi array and a Planar Ultra-wideband Modular Antenna (PUMA) array, and are compared with their respective infinite array results.

Korean Oriental medicine (KOM), known as Hanbang in Korea, is the primary health care system for more than 20% of the population in Korea. Often integrated with allopathic Western medicine, it has been used and studied extensively in Korea for a variety of conditions, including stroke and Parkinson’s disease. Although KOM shares its origins with traditional Chinese medicine, its unique cultural contributions include a number of innovations in diagnosis and technique, such as Sasang constitutional medicine, Saam acupuncture, herbal acupuncture, and Korean hand acupuncture. This article reviews the development and use of KOM in Korea, focusing on a major component, Sasang constitutional medicine. It describes a preliminary study of effectiveness of Sasang constitutional medicine in the treatment of stroke and discusses the directions of future research in KOM.

To enable intuitive operation of powered artificial legs, an interface between user and prosthesis that can recognize the user's movement intent is desired. A novel neural-machine interface (NMI) based on neuromuscular-mechanical fusion developed in our previous study has demonstrated a great potential to accurately identify the intended movement of transfemoral amputees. However, this interface has not yet been integrated with a powered prosthetic leg for true neural control. This study aimed to report (1) a flexible platform to implement and optimize neural control of powered lower limb prosthesis and (2) an experimental setup and protocol to evaluate neural prosthesis control on patients with lower limb amputations. First a platform based on a PC and a visual programming environment were developed to implement the prosthesis control algorithms, including NMI training algorithm, NMI online testing algorithm, and intrinsic control algorithm. To demonstrate the function of this platform, in this study the NMI based on neuromuscular-mechanical fusion was hierarchically integrated with intrinsic control of a prototypical transfemoral prosthesis. One patient with a unilateral transfemoral amputation was recruited to evaluate our implemented neural controller when performing activities, such as standing, level-ground walking, ramp ascent, and ramp descent continuously in the laboratory. A novel experimental setup and protocol were developed in order to test the new prosthesis control safely and efficiently. The presented proof-of-concept platform and experimental setup and protocol could aid the future development and application of neurally-controlled powered artificial legs.

Spasticity is often experienced by individuals with injury or illness of the central nervous system from etiologies such as stroke, spinal cord injury, brain injury, multiple sclerosis, or other neurologic conditions. Although spasticity may provide benefits in some patients, it more often leads to complications negatively impacting the patient. Nonpharmacologic treatment options often do not provide long-term reduction of spasticity, and systemic interventions, such as oral medications, can have intolerable side effects. The use of botulinum neurotoxin injections is one option for management of focal spasticity. Several localization techniques are available to physicians that allow for identification of the selected target muscles. These methods include anatomic localization in isolation or in conjunction with electromyography guidance, electrical stimulation guidance, or ultrasound guidance. This article will focus on further description of each of these techniques in relation to the treatment of adult spasticity and will discuss the advantages and disadvantages of each technique, as well as review the literature comparing the techniques.

Patients with end-stage renal disease (ESRD) undergoing hemodialysis (HD) are typically sedentary and functionally limited as a consequence of their condition. The purpose of this study is to test the effect of a lifestyle physical rehabilitation program (The Life Readiness Program) on physical function in patients with ESRD undergoing HD. Physical function was measured by the Kidney Disease Quality of Life Short Form (KDQOL-SF) physical function score (range, 0 to 100). Eighty-two patients were randomly assigned to a 6-month rehabilitation program (intervention; n = 39) or to standard clinical management alone (control; n = 43). The groups were frequency matched by age, sex, ethnicity, and diabetes as the cause of ESRD. General linear modeling of the change in physical function score was used for multivariate analysis. Physical function scores were not different between groups at baseline. Change in physical function score increased significantly in the intervention group compared with the control group when data were adjusted for the matching variables and adequacy of dialysis (3.2, -3.6; P = 0.04). Additionally, the control group reported more problems with work or daily functions because of emotional problems (P

Acute administration of glucagon-like peptide 1 (GLP-1) and its agonists slows gastric emptying, which represents the major mechanism underlying their attenuation of postprandial glycemic excursions. However, this effect may diminish during prolonged use. We compared the effects of prolonged and intermittent stimulation of the GLP-1 receptor on gastric emptying and glycemia. Ten healthy men received intravenous saline (placebo) or GLP-1 (0.8 pmol/kg ⋅ min), as a continuous 24-h infusion (“prolonged”), two 4.5-h infusions separated by 20 h (“intermittent”), and a 4.5-h infusion (“acute”) in a randomized, double-blind, crossover fashion. Gastric emptying of a radiolabeled mashed potato meal was measured using scintigraphy. Acute GLP-1 markedly slowed gastric emptying. The magnitude of the slowing was attenuated with prolonged but maintained with intermittent infusions. GLP-1 potently diminished postprandial glycemia during acute and intermittent regimens. These observations suggest that short-acting GLP-1 agonists may be superior to long-acting agonists when aiming specifically to reduce postprandial glycemic excursions in the treatment of type 2 diabetes.

Moyamoya is a disease characterized by occlusion of the internal carotid, anterior, and middle cerebral arteries with associated rich collateral flow that presents a cloudy appearance on angiogram resembling a puff of smoke. The disease is most often progressive with associated hemiparesis and cognitive impairment. The functional outcome of patients with moyamoya is not well described in the literature. We describe four women (ages 25-36) who were transferred to a rehabilitation service after an average 17 days (12-26 days) in an acute care setting. Initial functional impairment was estimated using the Functional Independence Measure (FIM) score after discharge from inpatient rehabilitation (23-53 days) and was compared to the Uniform Data System for Medical Rehabilitation (UDSMR) for "first stroke" patients. Average admission FIM scores were similar in the two groups. The patients with moyamoya had a higher discharge FIM, longer length of stay, and slower rate of progress. Data on long-term survival and functional level would be useful, but it appears patients with moyamoya disease may benefit from rehabilitation oriented toward neurological deficits.

OBJECTIVE Glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) have additive insulinotropic effects when coadministered in health. We aimed to determine whether GIP confers additional glucose lowering to that of GLP-1 in the critically ill. RESEARCH DESIGN AND METHODS Twenty mechanically ventilated critically ill patients without known diabetes were studied in a prospective, randomized, double-blind, crossover fashion on 2 consecutive days. Between T0 and T420 minutes, GLP-1 (1.2 pmol/kg · min−1) was infused intravenously with either GIP (2 pmol/kg · min−1) or 0.9% saline. Between T60 and T420 minutes, nutrient liquid was infused into the small intestine at 1.5 kcal/min. RESULTS Adding GIP did not alter blood glucose or insulin responses to small intestinal nutrient. GIP increased glucagon concentrations slightly before nutrient delivery (P = 0.03), but not thereafter. CONCLUSIONS The addition of GIP to GLP-1 does not result in additional glucose-lowering or insulinotropic effects in critically ill patients with acute-onset hyperglycemia.

The aim of this study was to elucidate the anatomical location of tibial nerve (TN) and common peroneal nerve (CPN) in the popliteal crease for specific nerve block. Fifty fresh specimens from 27 adult Korean cadavers (16 males and 11 females, age 35–87 years) were investigated. Five of the 27 cadavers were used to determine the depths of nerves in cross-section. Tibial nerve was located 50 % from the most lateral point of the popliteal crease and 1.4-cm deep to the surface. In 20 % of the 50 specimens, the medial sural cutaneous nerve branched out below or at the popliteal crease, whereas the CPN was located at 26 % from the most lateral point of the popliteal crease and 0.7-cm deep from the surface. Furthermore, in 6 % of specimens the lateral sural cutaneous nerve branched out below or at the popliteal crease. The results concerning the location of the TN and CPN at the popliteal crease offer a good guide to optimal nerve block.

Phantom limb pain (PLP) is a significant source of chronic pain in most persons with amputation at some time in their clinical course. Pharmacologic therapies for this condition are often only moderately effective and may produce unwanted adverse effects. There is growing empirical evidence of the therapeutic effectiveness of mind-body therapies for the relief of chronic pain; therefore, an exploration of their role in relieving amputation-related chronic pain is warranted. We undertook a focused literature review on mind-body interventions for patients with amputation who experience PLP. Because of study heterogeneity, only descriptive presentations of the studies are presented. Only studies of hypnosis, imagery, and biofeedback, including visual mirror feedback, were found; studies on meditation, yoga, and tai chi/qigong were missing from the literature. Few studies of specific mind-body therapies were dedicated to management of PLP, with the exception of mirror visual therapy. Overall, studies were largely exploratory and reflect considerable variability in the application of mind-body techniques, making definitive conclusions inadvisable. Nevertheless, the weight of existing findings indicates that a mind-body approach to PLP pain management is promising and that specific methods may offer either temporary or long-term relief, either alone or in combination with conventional therapies. The authors discuss the potential for usefulness of specific mind-body therapies and the relevance of their mechanisms of action to those of PLP, including targeting cortical reorganization, autonomic nervous system deregulation, stress management, coping ability, and quality-of-life. The authors recommend more and better quality research exploring the efficacy and mechanisms of action.

Heterotopic ossification in the residual lower limb in an adult nontraumatic amputee patient.Heterotopic ossification usually occurs in association with various neurologic injuries, trauma, and burns. There have been few reports in the literature of heterotopic bone formation at the distal residual limb in the adult amputee population. All previous cases with a documented cause have involved traumatic amputations. An adult diabetic patient who underwent left below-the-knee amputation for progressive Charcot foot is presented. The patient began to experience residual limb pain and decline in functional mobility 4-5 mos after surgery. Radiographs demonstrated heterotopic bone around the distal tibial and fibular remnant with extension into adjacent soft tissue. Triple-phase bone scan testing and tissue biopsy verified active heterotopic ossification. The patient was treated with etidronate and eventually was able to ambulate with a prosthesis on a regular basis. This case demonstrates that heterotopic ossification may occur and be a source of residual limb pain in the adult nontraumatic amputee population.

Treating rats with vanadate, a nonspecific inhibitor of protein tyrosine phosphatases, optimizes the uniform packing of collagen fiber bundles in wound granulation tissue and doubles wound breaking strength in rat incisional wounds. The speculation is vanadate optimizes the packing of collagen fiber bundles through the orientation of newly arrived wound fibroblasts in the fibrin clot filling the defect. Segments of 14 day chick embryo tendons were placed on fibrin clots and maintained in organ culture with and without 30 µM vanadate. On day 7 explants were examined histologically and biochemically. Tendon fibroblast outgrowth from untreated explants migrated in a random fashion, while fibroblasts from vanadate-treated explants migrated out in linear arrays. Fibroblasts were elongated by 20% form vanadate treated explant compared to controls. Myosin ATPase, required for optimal cell motility, is optimized by the phosphorylation of its myosin light chain (MLC). Western blot analysis of lysates from the fibroblasts that migrated into the fibrin showed vanadate increased MLC-P levles. These findings support the notion that vanadate promotes the deposition of regular, parallel collagen fiber bundles by advancing the orientation of fibroblasts in parallel linear arrays early in the wound repair process. J. Cell. Physiol. 217: 72–76, 2008. © 2008 Wiley-Liss, Inc.

Spastic paresis is a complex condition associated with damage to the upper motor neurons, typically caused by cerebral palsy, multiple sclerosis, stroke or trauma. Despite substantial impact on patients’ independence and burden on caregivers, there is a lack of consensus on optimal management of this condition and the patient journey remains unclear. A group of physicians, experienced in spasticity management, recently convened with the objective of analysing the patient journey from a care pathway perspective in different geographical regions and under different conditions from acute phase to long-term/chronic disease status. The experts reviewed results from recent patient and healthcare practitioner surveys on the subject and assessed how current patient pathways could be improved, using their own experiences to highlight the issues related to management deficiencies in their individual countries. The group divided the patient journey into steps, considering the evidence from the point of view of healthcare practitioners, patients, caregivers and funders/payors. This paper is a response to the lack of consensus on the optimal management of spastic paresis, and acts as a call to action to develop a consistent care pathway that could be applied across a broad range of illnesses, using an interdisciplinary approach.

To elucidate clinical trial efficacy, safety, and dosing practices of AbobotulinumtoxinA (ABO) treatment in adult patients with lower limb spasticity. A systematic literature review was performed to identify randomized controlled trials of ABO in the treatment of adult lower limb spasticity. Of the 295 records identified, 6 primary publications evaluated ABO for the management of lower limb spasticity of various etiologies and were evaluated. Total ABO doses ranged between 500 and 2000 U for lower limb spasticity, depending on the muscles injected. All studies in lower limb spasticity showed statistically significant reduction in muscle tone based on Modified Ashworth Scale of ABO versus placebo. Significant effects on active movement and pain were demonstrated albeit less consistently. ABO was generally well tolerated across the individual studies; most adverse events reported were considered unrelated to treatment. Treatment-related adverse events included but not limited to fatigue, local pain at injection site, hypertonia, dry mouth, weakness of the noninjected muscle, abnormal gait, and urinary tract infection. These data from 6 randomized clinical studies provide the beginnings of an evidence base for the use of ABO to reduce lower limb spasticity. Ongoing studies in this area will add to this evidence base.

How to structure organizations for optimal effectiveness has long been a central question for management research. One of the predominant assumptions in this literature has often been that hierarch...

To evaluate the diagnostic value of ultrasonography in meniscal tears that were diagnosed by magnetic resonance imaging (MRI).Twenty-seven knees with meniscal tears and 14 knees without tears on MRI were prospectively evaluated. A radiologist performed the ultrasonography and evaluated the presence and locations of the meniscal tears. MRI was used as the reference standard.Twenty-nine menisci with tears and 53 menisci without tears were identified by MRI. Twenty-two tears were in the medial menisci, and seven tears were in the lateral menisci. In the 29 meniscal tears, the ultrasonographic diagnosis was correct in 25 (86.2%) and incorrect in 4 (13.8%) menisci. In the 53 menisci without tears, the ultrasonographic diagnosis was correct in 45 (84.9%) and incorrect in 8 (15.1%) menisci. Ultrasonography showed a sensitivity, specificity, accuracy, and positive and negative predictive values for meniscal tears of 86.2%, 84.9%, 85.4%, 75.8%, and 91.8%, respectively. Of the four intracapsular injuries observed by MRI in injured knees, an osteochondritis dessecans was only observed by ultrasonography.Ultrasonography is an accurate imaging study for diagnosing meniscal tears. The results correlated with those obtained by MRI; this suggests that ultrasonography can be a useful imaging modality in uninjured knees.

Peripheral neuropathy in burn patients may be frequently missed in clinical settings. Although its incidence has been reported, little is known regarding the factors that cause burn-related peripheral neuropathy. A retrospective chart review of the demographic and clinical characteristics of patients admitted to a university hospital based burn center was conducted to explore the characteristics of burn-related neuropathy and factors affecting its types or extent. The variables collected were gender, age, length of hospital stay, site and surface area of burn, type of burn, and electrodiagnostic findings. We found that flame injuries, and third degree injuries were the most common in patients with peripheral neuropathy. Axonotmesis was more common than demyelinating injury and polyneuropathy was more common than mononeuropathy. Higher degree and larger area burns were more frequently associated with axonotmesis than with demyelination. Length of hospital stay was significantly longer in patients with axonotmesis. Overall, more severe burns showed a significant association with axonotmesis and a tendency to be related to polyneuropathy.

OBJECTIVE: To evaluate the ultrasonographic measurement of shoulder subluxation in patients with post-stroke hemiplegia. DESIGN: Prospective, single blind study. PATIENTS: A total of 41 patients with post-stroke hemiplegia were included (24 men and 17 women, mean age 56 years (standard deviation 11), age range 34-78 years). METHODS: Clinical evaluation of the affected shoulder was assessed using the Motricity Index scores and the Modified Ashworth Scale. Two ultrasonographic measurements were taken to check intra-rater reliability. The shoulder subluxation ratio was determined as the ratio of the radiographic vertical and horizontal distance, and the ultrasonographic lateral and anterior distances in the affected shoulder divided by that in the unaffected shoulder. RESULTS: Intraclass correlation coefficients of the repeated ultrasonographic lateral/anterior distance measurements in the unaffected and affected shoulders were 0.979/0.969 and 0.950/0.947, respectively. Ultrasonographic lateral/anterior distance ratios were negatively correlated with Motricity Index scores of the affected shoulder abduction (r = -0.490, p < 0.001/ r = -0.671, p < 0.001). Ultrasonographic anterior distance ratio was negatively correlated with Modified Ashworth Scale score of the affected shoulder (r = -0.374, p < 0.05). However, there was no correlation between radiographic distance ratios and clinical evaluation scores. CONCLUSION: We strongly recommend ultrasonography as a diagnostic tool to measure the degree of shoulder subluxation in patients with post-stroke hemiplegia.

Benign tumors and cysts of the esophagus are rare, and malignant transformation of esophageal cysts is even more rare. In this article, we report on the first case to our knowledge of a patient presenting with metastatic adenocarcinoma arising in a congenital foregut cyst of the esophagus. A 37-year-old woman had multiple cysts along the aerodigestive tract and diffuse soft tissue metastases. Endoscopic biopsies of a mediastinal mass revealed an enteric cyst with a spectrum of columnar epithelium ranging from benign through adenomatous to frankly malignant. There was only transient response to radiotherapy and chemotherapy. Only three other cases of carcinoma arising from esophageal duplication foregut cysts have been reported, and none of these were metastatic. Given the rarity of malignant transformation within an esophageal cyst, prophylactic excision of known esophageal cysts is not warranted. However, biopsy of the cyst may be useful to exclude the possibility of malignancy, particularly if the onset of symptoms has been recent.

Background: Pregnancy is a high-risk indication for influenza vaccination; however, rates of vaccination fall short of Centers for Disease Control and Prevention-recommended guidelines. Methods: Brief educational sessions with family physicians and obstetricians were undertaken in the fall of 2002. Notes reading “Think Flu Vaccine” were placed on active obstetric charts during the study period. Charts were reviewed at the end of influenza season for documentation of discussion or administration of influenza vaccination. Charts for the same period during the previous 2 years were also reviewed for baseline. Results: Baseline rates of vaccination or discussion averaged 1.5% over the 2000–2002 influenza seasons. After intervention, the 2002–2003 rate of vaccination or discussion demonstrated an almost 15-fold increase to 21.9%. This was greater in family practices (3.2% to 44.9%) versus obstetric practices (1.2% to 19.4%), and in small (3.3% to 46.7%) versus large (1.1% to 16%) practices (all values were P Conclusions: Provider education with simple chart prompts seems an effective way to increase rates of physician discussion of influenza vaccination with pregnant women. The increased rates seen in this study across various practice settings also suggest that inclusion of influenza vaccination on standardized prenatal care flowsheets may achieve similar goals with less individualized effort and should be considered.