Prognostic value of coronary computed tomography angiography compared to radionuclide myocardial perfusion imaging in patients With coronary stents.

Objectives: The aim of this study is to compare the prognostic value of coronary computed tomography angiography (CCTA) with single-photon emission computed tomography (SPECT) in predicting cardiovascular events in patients with stents. Design: Retrospective analysis. Setting: University Hospital, London, Ontario Canada. Participants: Between January 2007 and December 2018, 119 patients post-percutaneous coronary intervention (PCI) who were referred for hybrid imaging with CTA and 2-day rest/stress SPECT were enrolled. Primary and secondary outcome measures: Patients were followed for any major adverse cardiovascular event (MACE) including: All-cause mortality, Non-fatal myocardial infarction (MI), Unplanned revascularization, Cerebrovascular accident and hospitalization for arrhythmia or heart failure. We define hard cardiac events (HCE) as: cardiac death, non-fatal MI or unplanned revascularization. We used two cut-off values to define obstructive lesions with CCTA ≥50% and ≥70% in any coronary segment. SPECT scan defined as abnormal in the presence of >5% reversible myocardial perfusion defect. Results: During the follow-up period of 7.2 ± 3.4 years. 45/119 (37.8%) patients experienced 57 MACE: Ten deaths (2 cardiac deaths and 8 of non-cardiac deaths), 29 acute coronary syndrome including non-fatal MI (25 required revascularization), 7 hospitalizations for heart failure, 6 cerebrovascular accidents and 5 new atrial fibrillation. 31 HCEs were reported. Cox regression analysis showed that obstructive coronary stenosis (≥50% and ≥70%) and abnormal SPECT were associated of MACE (p = 0.037, 0.018 and 0.026), respectively. In contrast, HCEs were significantly associated with obstructive coronary stenosis of ≥50% and ≥70% with p = 0.004 and p = 0.007, respectively. In contrast, abnormal SPECT was a nonsignificant predictor of HCEs (p = 0.062). Conclusion: Obstructive coronary artery stenosis on CCTA can predict MACE and HCE. However, abnormal SPECT can only predict MACE but not HCE in patients post-PCI with a follow-up period of approximately 7 years.

Parallel Line Sign-A New MRI Sign Associated With Chronic Sacroiliitis: Prevalence, Characteristics, and Associations.

Purpose: The purpose is to demonstrate the existence of the parallel line sign (PLS), a dark line parallel to the sacroiliac joint (SIJ), and determine its prevalence, characteristics, and associations. Methods: 200 consecutive SIJ MRIs referred by rheumatologists were retrospectively reviewed for the presence of the PLS. Presence and extent of imaging features of sacroiliitis (bone marrow edema, fatty infiltration, erosions, sclerosis, and ankylosis) were evaluated. Results: Prevalence of PLS was 11.5% (23/200), with 9 subjects having bilateral PLS, resulting in 32 SIJs showing a PLS. Every PLS involved the synovial portion of the SIJ, and almost all (31/32, 96.9%) involved the iliac (rather than sacral) side of the SIJ. Every PLS occurred with at least one established imaging feature of sacroiliitis. Presence of a PLS was associated with higher prevalence of erosions (78.3% vs 36.7% in those without PLS, P < .001), greater extent of SIJ involvement by erosions (3.6 ± 1.3 vs 2.3 ± 1.1 quadrants of the SIJ involved, P < .001), and higher density of erosions per centimeter (88.9% vs 46.2% with >2 erosions/cm, P = .001). There was higher prevalence of bone marrow edema, fatty infiltration, and sclerosis in those with PLS compared to those without PLS (P = .001, P < .001, and P = .006, respectively). Extent of involvement by any of these features was not significantly different between the two groups (P = .22, P = .16, and P = .46, respectively). Conclusions: The PLS is associated with imaging features of chronic sacroiliitis, especially erosions. Knowledge of the existence of the PLS may help avoid misdiagnosis of an insufficiency fracture and increase confidence in the diagnosis of sacroiliitis.

Differential and Synergistic Effects of Low Birth Weight and Western Diet on Skeletal Muscle Vasculature, Mitochondrial Lipid Metabolism and Insulin Signaling in Male Guinea Pigs.

Low birth weight (LBW) offspring are at increased risk for developing insulin resistance, a key precursor in metabolic syndrome and type 2 diabetes mellitus. Altered skeletal muscle vasculature, extracellular matrix, amino acid and mitochondrial lipid metabolism, and insulin signaling are implicated in this pathogenesis. Using uteroplacental insufficiency (UPI) to induce intrauterine growth restriction (IUGR) and LBW in the guinea pig, we investigated the relationship between UPI-induced IUGR/LBW and later life skeletal muscle arteriole density, fibrosis, amino acid and mitochondrial lipid metabolism, markers of insulin signaling and glucose uptake, and how a postnatal high-fat, high-sugar "Western" diet (WD) modulates these changes. Muscle of 145-day-old male LBW glucose-tolerant offspring displayed diminished vessel density and altered acylcarnitine levels. Disrupted muscle insulin signaling despite maintained whole-body glucose homeostasis also occurred in both LBW and WD-fed male "lean" offspring. Additionally, postnatal WD unmasked LBW-induced impairment of mitochondrial lipid metabolism, as reflected by increased acylcarnitine accumulation. This study provides evidence that early markers of skeletal muscle metabolic dysfunction appear to be influenced by the in utero environment and interact with a high-fat/high-sugar postnatal environment to exacerbate altered mitochondrial lipid metabolism, promoting mitochondrial overload.

Transcranial direct current stimulation for provoked vestibulodynia: What roles do psychosexual factors play in treatment response?

There is growing evidence that provoked vestibulodynia (PVD), a frequent and debilitating condition, is characterized by central sensitization. This study aimed to examine predictive factors of transcranial direct current stimulation (tDCS) efficacy in this chronic pain population. Exploratory analysis derived from a randomized controlled trial was performed to assess predictors of pain reduction among 39 women with PVD who received 10 daily sessions of either active or sham tDCS. Clinical characteristics (e.g. pain intensity, duration and pain sensitivity) and psychosexual factors (e.g. pain catastrophizing, pain-related fear, anxiety, depressive symptoms and vaginal penetration cognitions) were assessed at baseline and used to predict tDCS response at 3-month follow-up. Analysis revealed that higher depressive symptoms and lower negative self-image cognitions were significant predictors of pain reduction at follow-up and accounted for 62.3% of the variance in the active tDCS group. Higher genital incompatibility cognitions were related to poorer response, regardless of treatment group. These findings suggest that women with PVD presenting higher depressive symptoms and lower levels of negative self-image cognitions could derive greater benefits from tDCS. These results suggest that tDCS could be effective in a subgroup of women with PVD - a possibility worth exploring with future prospective larger studies.

Coronary artery calcium progression after coronary artery bypass grafting surgery.

OBJECTIVES: Accelerated atherosclerosis is a well-established phenomenon after coronary artery bypass grafting surgery (CABG). In this study, we analysed coronary artery calcium (CCS) progression after CABG. METHODS: We retrospectively measured the CCS Agatston score (AS), volume score (VS) and mass score (MS) of 39 patients before and after CABG. The annualised CCS change and annualised CCS percent change of each coronary artery, coronary artery segments proximal and distal to anastomosis were analysed. RESULTS: Mean age at the time of the surgery was 59.8±8.5 years. Follow-up period between the first and second CT scans was 6.7±2.8 (range, 1.1-12.8) years. Annualised CCS percent change (AS, VS and MS) of the coronary segments proximal-to-anastomosis did not differ from that of the non-grafted coronary arteries as follow: segments proximal-to-anastomosis: median (Q1-Q3) 12.8 (5.0-37.4), 13.7 (6.1-41.1) and 14.9 (5.4-53.7), left main coronary artery 12.6 (7.4-43.8), 22.0 (8.1-44.4) and 18.2 (7.3-57.4), non-grafted left circumflex artery: 13.5 (4.4-38.1), 10.5 (2.9-45.2) and 11.5 (7.1-47.9) and non-grafted right coronary artery: 31.4 (14.4-74.5), 25.2 (16.7-62.0) and 31.3 (23.8-85.6), respectively. Likewise, annualised percent change (AS, VS and MS) was similar between the native coronary arteries. Multivariate regression analysis showed that diabetes mellitus was the only predictor of annualised percent progression of the total CCS of >15% (HR, 8.12; 95% CI, 1.05 to 26.6; p=0.04). CONCLUSION: The CCS post-CABG did not follow an accelerated progression process. Among coronary artery disease risk factors, diabetes mellitus is the only predictor of annualised CCS percent progression of >15% post-CABG.

Evaluation of Complications in Postpartum Women Receiving Therapeutic Anticoagulation.

OBJECTIVE: To evaluate complications associated with early postpartum therapeutic anticoagulation. METHODS: A multicenter retrospective cohort study was done to evaluate the association between therapeutic anticoagulation postpartum and major complications (hemorrhagic and wound complications). Secondary outcomes included minor complications, risk factors associated with total complications (including the time to therapeutic anticoagulation resumption after delivery) and recurrent thrombotic events within 6 weeks postpartum. RESULTS: From 2003 to 2015, 232 consecutive women were treated with therapeutic anticoagulation within 96 hours postpartum; among those treated, 91 received unfractionated heparin, 138 received low-molecular-weight heparin, and three received other anticoagulants. The primary outcome, a composite of major hemorrhagic complications (requiring transfusion, hospitalization, volume resuscitation, transfer to intensive care unit, or surgery) and major wound complications, occurred in 7 of 83 (8.4%) for cesarean deliveries and 9 of 149 (6.0%) for vaginal deliveries (P=.490). Total complications (including major and minor hemorrhagic and wound complications) occurred in 13 of 83 (15.7%) for cesarean deliveries compared with 9 of 149 (6.0%) for vaginal deliveries (P=.016). When comparing cases associated with and without complications, the median delay before resuming anticoagulation was significantly shorter for both cesarean (12 vs 33 hours, P=.033) and vaginal deliveries (6 vs 19 hours, P=.006). For vaginal deliveries, 8 of 51 (15.7%) women had complications when anticoagulation was started before 9.25 hours postpartum, compared with 1 of 98 (1.0%) when started after 9.25 hours. For cesarean deliveries, 7 of 21 (33.3%) of women experienced complications compared with 6 of 62 (9.7%) if anticoagulation was started before or after 15.1 hours, respectively. Two (0.9%) episodes of venous thromboembolism occurred within 6 weeks postpartum. CONCLUSION: Among postpartum women who received early therapeutic anticoagulation, major complications occurred in 8.4% for cesarean deliveries and 6.0% for vaginal deliveries. Complications were associated with earlier resumption of therapeutic anticoagulation, particularly before 9.25 hours for vaginal deliveries and before 15.1 hours for cesarean deliveries.

Risk for Thyroid Cancer Recurrence Is Higher in Men Than in Women Independent of Disease Stage at Presentation.

Background: Well-differentiated thyroid cancer (DTC) presents at a more advanced stage in men than in women, and the mortality in men is higher than that in women. However, it is not clear whether DTC recurrence is affected by sex independent of stage at presentation. The objective of the present study was to assess if male sex is an independent risk factor for recurrence of DTC. Methods: The Canadian Collaborative Network for Cancer of the Thyroid (CANNECT) is a collaborative registry to describe patterns of care for thyroid cancer. We included patients from the CANNECT registry with DTC diagnosed at age 18 or older between 2000 and 2010. We compared men and women with respect to presentation, management, and recurrence risk, stratified for American Joint Committee on Cancer (AJCC) stage. Results: We included 2595 patients, 2067 (79.7%) women and 528 (20.3%) men. Men presented with more advanced AJCC stage (p < 0.001), T stage (p < 0.001), N stage (p < 0.001), and M stage (p = 0.002) There was no difference in follow-up duration between women (7.7 ± 4.0 [mean ± standard deviation] years) and men (7.7 ± 4.0 years, p = 0.985). Overall recurrence was 2.2% (n = 46) for women and 8.5% (n = 45) for men (p < 0.001). In multivariate analysis adjusted for AJCC stage, men were at significantly greater risk for DTC recurrence than women (adjusted hazard ratio 2.72 [95% confidence interval [CI] 1.78-4.20]; p < 0.001). In multivariate analysis adjusted for tumor-node-metastasis (TNM) stage, men were at significantly greater risk for DTC recurrence than women (adjusted hazard ratio 2.31 [CI 1.48-3.60]; p < 0.001). Conclusions: Our study confirms that the risk for recurrence of DTC is higher in men than in women. Although men tend to present with more advanced-stage disease, the difference in recurrence risk persists when adjusted for stage of presentation. It needs to be determined whether sex should influence follow-up intensity and/or duration.

Western diet consumption through early life induces microvesicular hepatic steatosis in association with an altered metabolome in low birth weight Guinea pigs.

Uteroplacental insufficiency-induced low birth weight (LBW) and postnatal high saturated fat/high sucrose-fructose diet (Western Diet, WD) consumption have been independently associated with the development of hepatic steatosis, while their additive effect on fatty acid, acylcarnitine and amino acid profiles in early adulthood have not been widely reported. We employed LBW, generated via uterine artery ablation, and normal birth weight (NBW) male guinea pigs fed either a WD or control diet (CD) from weaning to postnatal day 150 (early adulthood). Hepatic steatosis was absent in CD-fed offspring, while NBW/WD offspring displayed macrovesicular steatosis and LBW/WD offspring exhibited microvesicular steatosis, both occurring in a lean phenotype. Life-long consumption of the WD, irrespective of birth weight, was associated with an increase in hepatic medium- and long-chain saturated fatty acids, monounsaturated fatty acids, acylcarnitines, reduced oxidative phosphorylation complex III activity and polyunsaturated fatty acids, and molecular evidence of disrupted hepatic insulin signaling. In NBW/WD, hepatic C15:1 and C16:1n-6 fatty acids in phospholipids, C16, C18 and C18:1 acylcarnitines, concentrations of aspartate, phenylalanine, tyrosine and tryptophan and expression of carnitine palmitoyltransferase 1 alpha (CPT1α) and uncoupling protein 2 (UCP2) genes were elevated compared to LBW/WD livers. Our results suggest that LBW and life-long WD combined are influential in promoting hepatic microvesicular steatosis in conjunction with a specific mitochondrial gene expression and metabolomic profile in early adulthood.

Automated Metrics in a Virtual-Reality Myringotomy Simulator: Development and Construct Validity.

OBJECTIVES: The objectives of this study were: 1) to develop and implement a set of automated performance metrics into the Western myringotomy simulator, and 2) to establish construct validity. STUDY DESIGN: Prospective simulator-based assessment study. SETTING: The Auditory Biophysics Laboratory at Western University, London, Ontario, Canada. PARTICIPANTS: Eleven participants were recruited from the Department of Otolaryngology-Head & Neck Surgery at Western University: four senior otolaryngology consultants and seven junior otolaryngology residents. INTERVENTIONS: Educational simulation. MAIN OUTCOME MEASURE: Discrimination between expert and novice participants on five primary automated performance metrics: 1) time to completion, 2) surgical errors, 3) incision angle, 4) incision length, and 5) the magnification of the microscope. METHODS: Automated performance metrics were developed, programmed, and implemented into the simulator. Participants were given a standardized simulator orientation and instructions on myringotomy and tube placement. Each participant then performed 10 procedures and automated metrics were collected. The metrics were analyzed using the Mann-Whitney U test with Bonferroni correction. RESULTS: All metrics discriminated senior otolaryngologists from junior residents with a significance of p < 0.002. Junior residents had 2.8 times more errors compared with the senior otolaryngologists. Senior otolaryngologists took significantly less time to completion compared with junior residents. The senior group also had significantly longer incision lengths, more accurate incision angles, and lower magnification keeping both the umbo and annulus in view. CONCLUSIONS: Automated quantitative performance metrics were successfully developed and implemented, and construct validity was established by discriminating between expert and novice participants.

Infraclavicular and supraclavicular approaches to brachial plexus for ambulatory elbow surgery: A randomized controlled observer-blinded trial.

STUDY OBJECTIVE: To compare the effectiveness of supraclavicular and infraclavicular approaches to brachial plexus block for elbow surgery. DESIGN: Prospective, parallel arm, observer-blinded, randomized controlled trial. SETTING: This study occurred in a designated block room at St. Joseph's hospital, a large academic tertiary hospital in London, Canada. PATIENTS: 150 adult ASA class I-III patients undergoing elective ambulatory elbow surgery. INTERVENTIONS: Patients were randomized to receive either an ultrasound-guided infraclavicular or a supraclavicular block with ropivacaine. MEASUREMENTS: Both groups were assessed for performance and sensory block onset times. Motor block, effective surgical anesthesia, procedure-related pain, axillary nerve block and ulnar nerve sparing were additional outcomes. We analyzed continuous and non-continuous variables with the independent t-test and chi-square test respectively and considered statistical significance when type 1 error was under 0.05. MAIN RESULTS: We observed similar mean block procedure times at 285 (±128) seconds in infra and 307 (±138) seconds in supra group (p = 0.3). The mean time of sensory block onset in both groups was similar: Infra 20.4 (±7.9) and supra 18.9 (±7.1) min (p = 0.4). Conversion to general anesthesia (4.2 vs 5.5%; p = 0.73) and the need for local anesthetic supplement (4.2 vs 4.1%; p = 0.98) was similar in both groups. We observed an increased incidence of paresthesia in the supra group (8.3 vs 23.2%; p = 0.014). CONCLUSION: We found that both blocks were equally effective for elbow surgery with similar procedure and block onset times and failure rates. Lower incidence of paresthesia was associated with the infraclavicular block with no change in other complications compared to the supraclavicular technique.

Scale for retrospective assessment of immediate concussion symptoms.

The retrospective diagnosis of concussion is often missed by clinicians. We present a brief scale for retrospective assessment of the immediate concussion symptoms (ICS) to facilitate the diagnosis of patients without visible head injury or full loss of consciousness. We administered the scale to 90 survivors of car accidents (mean age 42.0, SD=13.6; 33 males, 57 females) at 2 to 33 months after their accident. Our scale consists of 6 items and these were endorsed by the following % of our respondents: feeling dazed (64.4% of our 90 respondents), stunned (73.3%), confused (70.0%), disoriented (62.2%), dizzy (57.8%), and loss of consciousness (22.2%). The statistical properties of the scale are satisfactory (Cronbach alpha = 0.74). The scale correlates with post-accident insomnia (r=0.28), depression (r=0.29), and also with Rivermead measure of the chronic post-concussion syndrome (r=0.34). The ICS scale could be used as a starting point in longitudinal research with brain imaging procedures to evaluate the stages of recovery from the initial concussion. Attached are the English, Spanish, French, German, Italian, Russian, and Czech versions of our scale.

Disinhibition in Alzheimer's Disease is Associated with Reduced Right Frontal Pole Cortical Thickness.

Neuropsychiatric symptoms in Alzheimer's disease are among the most disabling and difficult aspects for caregivers and treating health professionals to manage. Despite the high prevalence of these behaviors, little is known about the factors which lead some patients to develop florid behavioral symptoms while others may progress to severe dementia without such phenomenon. We examined whether regional brain volumes as measured by cortical thickness would predict the presence or absence of disinhibition in patients with Alzheimer's disease. Using data from the ADNI, we identified 758 patients with caregiver ratings on the Neuropsychiatric Inventory and a volumetric MRI scan with cortical thickness measurements completed in FreeSurfer by the UCSF core. Of these, 177 patients were found to have disinhibition. Logistic regression models demonstrated that reduced cortical thickness in the right frontal pole was associated with the presence of disinhibition even when controlling for age, disease severity, total intracranial volume, gender, and APOE genotype. The results are considered in the context of leading models of the functions of frontopolar cortex.

Mastery Learning - does the method of learning make a difference in skills acquisition for robotic surgery?

BACKGROUND: Few studies compare the effectiveness of blocked vs random practice conditions in minimally invasive surgery training, and none have evaluated these in robotic surgery training. METHODS: The dV-Trainer® and the da Vinci® Surgical System (dVSS) were used to compare practice conditions. Forty-two participants were randomized into blocked and random practice groups. Each participant performed five tasks: Ring Walk, Thread the Rings, Needle Targeting, Suture Sponge and Tubes Level 2. Transfer to the dVSS was also assessed. RESULTS: No significant differences were observed between the two groups, except for a few instances. For example, during Ring Walk, the random group performed significantly faster than the blocked group (100.78 ± 5.26 s vs 121.59 ± 5.26 s, p < 0.01). CONCLUSIONS: The study results do not follow the current evidence presented in the education literature. This is the first time that blocked versus random practice was tested for robotic surgery training.

Intra- and Interobserver Variability of Cochlear Length Measurements in Clinical CT.

HYPOTHESIS: The cochlear A-value measurement exhibits significant inter- and intraobserver variability, and its accuracy is dependent on the visualization method in clinical computed tomography (CT) images of the cochlea. BACKGROUND: An accurate estimate of the cochlear duct length (CDL) can be used to determine electrode choice, and frequency map the cochlea based on the Greenwood equation. Studies have described estimating the CDL using a single A-value measurement, however the observer variability has not been assessed. METHODS: Clinical and micro-CT images of 20 cadaveric cochleae were acquired. Four specialists measured A-values on clinical CT images using both standard views and multiplanar reconstructed (MPR) views. Measurements were repeated to assess for intraobserver variability. Observer variabilities were evaluated using intra-class correlation and absolute differences. Accuracy was evaluated by comparison to the gold standard micro-CT images of the same specimens. RESULTS: Interobserver variability was good (average absolute difference: 0.77 ±â€Š0.42 mm) using standard views and fair (average absolute difference: 0.90 ±â€Š0.31 mm) using MPR views. Intraobserver variability had an average absolute difference of 0.31 ±â€Š0.09 mm for the standard views and 0.38 ±â€Š0.17 mm for the MPR views. MPR view measurements were more accurate than standard views, with average relative errors of 9.5 and 14.5%, respectively. CONCLUSION: There was significant observer variability in A-value measurements using both the standard and MPR views. Creating the MPR views increased variability between experts, however MPR views yielded more accurate results. Automated A-value measurement algorithms may help to reduce variability and increase accuracy in the future.

Efficacy of transcranial direct-current stimulation in women with provoked vestibulodynia.

BACKGROUND: Provoked vestibulodynia is a highly prevalent condition characterized by acute recurrent pain located at the vaginal entrance in response to pressure application or attempted vaginal penetration. Despite a wide variety of treatments offered to women with provoked vestibulodynia, a high proportion of women are refractory to conventional treatment. Transcranial direct-current stimulation is a noninvasive brain stimulation technique that has been shown effective for improving various chronic pain conditions. Growing evidence suggests that the central nervous system could play a key role in provoked vestibulodynia. Targeting the central nervous system could therefore be a promising treatment for women with provoked vestibulodynia. OBJECTIVE: The purpose of this study was to evaluate and compare the efficacy of active and sham transcranial direct-current stimulation in reducing pain intensity during intercourse in patients with provoked vestibulodynia. STUDY DESIGN: We conducted a triple-blind, parallel-group, randomized controlled trial. Women aged 17-45 years diagnosed with provoked vestibulodynia by a gynecologist using a validated protocol were randomized to 10 sessions of either active transcranial direct-current stimulation (intensity = 2 mA) or 10 sessions of sham transcranial direct-current stimulation, over a 2-week period. Both active and sham transcranial direct-current stimulation were applied for 20 minutes, with the anode positioned over the primary motor cortex, and the cathode over the contralateral supraorbital area. Outcome measures were collected at baseline, 2 weeks after treatment, and at 3-month follow-up by an evaluator blinded to group assignment. The primary objective was to assess pain intensity during intercourse, using a numerical rating scale. Secondary outcomes focused on sexual function and distress, vestibular sensitivity, psychological distress, treatment satisfaction, and patient impression of change. Statistical analyses were conducted on the intention-to-treat basis, and treatment effects were evaluated using a mixed linear model for repeated measures. RESULTS: A total of 40 patients were randomly assigned to receive either active (n = 20) or sham (n = 20) transcranial direct-current stimulation treatments from November 2014 through February 2016. Baseline characteristics were similar between the active and sham transcranial direct-current stimulation groups. In full compliance with the study protocol, every participant followed all courses of the study treatment, including assessments at 2-week and 3-month follow-up. Pain during sexual intercourse was not significantly different between active and sham treatment groups 2 weeks after treatment (P = .84) and at follow-up (P = .09). Mean baseline and 2-week assessment pain intensity were, respectively, 6.8 (95% confidence interval, 5.9-7.7) and 5.6 (95% confidence interval, 4.7-6.5) for active transcranial direct-current stimulation (P = .03) vs 7.5 (95% confidence interval, 6.6-8.4) and 5.7 (95% confidence interval, 4.8-6.6) for sham transcranial direct-current stimulation (P = .001). Nonsignificant differences between the 2 groups were also found in their sexual function and distress after treatment (P > .20) and at follow-up (P > .10). Overall, at 2-week assessment 68% assigned to active transcranial direct-current stimulation reported being very much, much, or slightly improved compared to 65% assigned to sham transcranial direct-current stimulation (P = .82), and still comparable at follow-up: 42% vs 65%, respectively (P = .15). CONCLUSION: Findings suggest that active transcranial direct-current stimulation is not more effective than sham transcranial direct-current stimulation for reducing pain in women with provoked vestibulodynia. Likewise, no significant effects were found on sexual function, vestibular sensitivity, or psychological distress.

Reduction of total labor length through the addition of parenteral dextrose solution in induction of labor in nulliparous: results of DEXTRONS prospective randomized controlled trial.

BACKGROUND: Prolonged labor is a significant cause of maternal and fetal morbidity and very few interventions are known to shorten labor course. Skeletal muscle physiology suggests that glucose supplementation might improve muscle performance in case of prolonged exercise and this situation is analogous to the gravid uterus during delivery. Therefore, it seemed imperative to evaluate the impact of adding carbohydrate supplements on the course of labor. OBJECTIVE: We sought to provide evidence as to whether intravenous glucose supplementation during labor induction in nulliparous women can reduce total duration of active labor. STUDY DESIGN: We performed a single-center prospective double-blind randomized controlled trial comparing the use of parental intravenous dextrose 5% with normal saline to normal saline in induced nulliparous women. The study was conducted in a tertiary-level university hospital setting. Participants, caregivers, and those assessing the outcomes were blinded to group assignment. Inclusion criteria were singleton pregnancy at term with cephalic presentation and favorable cervix. Based on blocked randomization, patients were assigned to receive either 250 mL/h of intravenous dextrose 5% with normal saline or 250 mL/h of normal saline for the whole duration of induction, labor, and delivery. The primary outcome studied was the total length of active labor. Secondary outcomes included duration of the active phase of second stage of labor, the mode of delivery, Apgar scores, and arterial cord pH. RESULTS: In all, 100 patients were randomized into each group. A total of 193 patients (96 in the dextrose with normal saline group and 97 in the normal saline group) were analyzed in the study. The median total duration of labor was significantly less in the dextrose with normal saline group (499 vs 423 minutes, P = .024) than in the normal saline group. The probabilities of a woman being delivered at 200 minutes and 450 minutes were 18.8% and 77.1% in the dextrose with normal saline group vs 8.2% and 59.8% in the normal saline group (Kolmogorov-Smirnov test P value = .027). There was no difference in the rate of cesarean delivery, instrumented delivery, Apgar score, or arterial cord pH. CONCLUSION: Glucose supplementation significantly reduces the total length of labor without increasing the rate of complication in induced nulliparous women. Given the low cost and the safety of this intervention, glucose should be used as the default solute during labor.

Lady with Erotic Preference for Diapers.

A patient in her 20s was referred to us for psychological assessment due to her depression and suicide attempts. She mentioned being anorgasmic except when diapered and emphasized her erotic preference for diapers. Her childhood included maternal deprivation in an impecunious family headed by an irritable physically disabled father on social assistance. Given the maternal deprivation in childhood, her erotic fixation on diapers parallels the emotional attachment to diapers observed by Harlow in mother deprived infant monkeys. Etiological hypotheses should also include the paradigm of avoidance learning from theories of behavior therapy. Our patient does not wish to change her sexual preference: in such cases, fetishism is not considered as an illness by DSM5. However, she needs to be treated for pathological levels of depression with suicidal ideation and low self-esteem.

Joint blood flow is more sensitive to inflammatory arthritis than oxyhemoglobin, deoxyhemoglobin, and oxygen saturation.

Joint hypoxia plays a central role in the progression and perpetuation of rheumatoid arthritis (RA). Thus, optical techniques that can measure surrogate markers of hypoxia such as blood flow, oxyhemoglobin, deoxyhemoglobin, and oxygen saturation are being developed to monitor RA. The purpose of the current study was to compare the sensitivity of these physiological parameters to arthritis. Experiments were conducted in a rabbit model of RA and the results revealed that joint blood flow was the most sensitive to arthritis and could detect a statistically significant difference (p<0.05, power = 0.8) between inflamed and healthy joints with a sample size of only four subjects. Considering that this a quantitative technique, the high sensitivity to arthritis suggests that joint perfusion has the potential to become a potent tool for monitoring disease progression and treatment response in RA.

Mapping Long-Term Functional Changes in Cerebral Blood Flow by Arterial Spin Labeling.

Although arterial spin labeling (ASL) is appealing for mapping long-term changes in functional activity, inter-sessional variations in basal blood flow, arterial transit times (ATTs), and alignment errors, can result in significant false activation when comparing images from separate sessions. By taking steps to reduce these sources of noise, this study assessed the ability of ASL to detect functional CBF changes between sessions. ASL data were collected in three sessions to image ATT, resting CBF and CBF changes associated with motor activation (7 participants). Activation maps were generated using rest and task images acquired in the same session and from sessions separated by up to a month. Good agreement was found when comparing between-session activation maps to within-session activation maps with only a 16% decrease in precision (within-session: 90 ± 7%) and a 13% decrease in the Dice similarity (within-session: 0.75 ± 0.07) coefficient after a month. In addition, voxel-wise reproducibility (within-session: 4.7 ± 4.5%) and reliability (within-session: 0.89 ± 0.20) of resting grey-matter CBF decreased by less than 18% for the between-session analysis relative to within-session values. ATT variability between sessions (5.0 ± 2.7%) was roughly half the between-subject variability, indicating that its effects on longitudinal CBF were minimal. These results demonstrate that conducting voxel-wise analysis on CBF images acquired on different days is feasible with only modest loss in precision, highlighting the potential of ASL for longitudinal studies.