The Pressure Is Rising: Evaluation and Treatment of Chronic Exertional Compartment Syndrome.

ABSTRACT: Chronic exertional compartment syndrome is a condition that typically affects athletic/active individuals. Chronic exertional compartment syndrome predominantly affects the lower leg; however, there are cases involving the hand, forearm, foot, and thigh. The signs and symptoms of chronic exertional compartment syndrome are severe pain, tightness, cramping, muscle weakness, and paresthesias during participation in exercise. Dynamic intramuscular compartmental pressure (preexertion and postexertion) is the standard diagnostic test. Although other imaging modalities, such as radiography, ultrasound, and magnetic resonance imaging are typically incorporated to rule out other pathologies. In addition, these modalities are being utilized to limit invasiveness of the diagnostic experience. Initial care commonly involves conservative treatment, such as physical therapy, modifications of patient's exercise technique, foot orthoses, and various procedures over a period of 3 to 6 months. Recalcitrant cases may be referred for surgical intervention (fasciotomy), which has inconclusive head-to-head data with conservative management with regard to return to prior sport and specific activity level.

Reaching underserved domestic and international populations through Physical Medicine & Rehabilitation Residency training: A survey of residents and program directors.

INTRODUCTION: In 2015, the World Health Organization (WHO) reported that over 400 million individuals worldwide lack access to medical care. In addition, clinicians are more likely to treat underserved patients during their careers if they have exposure to these populations during their training. OBJECTIVES: To analyze what forms of didactic experiences are available and which opportunities are the most valuable with domestic/international underserved populations in Physical Medicine & Rehabilitation (PM&R) residency programs in the United States. DESIGN: Cross-sectional survey using REDCap software. SETTING: PM&R residency programs in the United States. PARTICIPANTS: A total of 137 participants in Accreditation Council of Graduate Medical Education (ACGME)-accredited PM&R residencies in the United States (24 program directors and 113 residents). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Surveys collected information regarding demographic data, prior global health training experiences, current residency training experiences involving domestic/international underserved populations being offered, participants' perceived importance of training experiences with domestic/international underserved population, barriers that impede these experiences, and if availability of these opportunities affected resident recruitment. RESULTS: Participants reported that their PM&R programs did not offer global health simulations (91.2%), educational tracks (75.2%), international electives (71.5%), or rotations with domestic underserved populations (48.9%). Residents viewed exposure to simulation labs (3.25/5), educational tracks (3.42/5), and electives (4.02/5) more importantly than attending physicians. Conversely, attending physicians viewed lectures (3.92/5), journal clubs (3.58), and rotations treating domestic underserved populations (4.42/5) more favorably. Both residents and attending physicians endorse lack of financial support and mentorship as barriers to these opportunities. Participants from all regions outside the Midwest reported that these educational opportunities would affect residency recruitment (56% vs. 31%). CONCLUSIONS: This is the first study assessing the current state of global health training opportunities for PM&R residents as well as the perceived value of such experiences. Many PM&R medical trainees desire exposure to global health medicine curriculum, and many would alter their residency selection based on its availability.

Performance of six different soilless green roof substrates for the Mediterranean region.

The objectives of this research were to assess the physical properties of six different growing substrate mixtures destined for roof gardens and determine the influence of these substrates on the morphology, physiology, growth and flower quality of pansy (Viola × wittrockiana), Madagascar periwinkle (Catharanthus roseus), and Pavia lily (Longiflorum×Asiatic lilies (Lilium) 'Pavia'). Six green roof growing substrate mixtures (by volume) were used [T1: coarse tuff+fine tuff+cocopeat (5:1:4), T2:coarse tuff+medium tuff+fine tuff+cocopeat (5:5:2:8), T3: medium tuff+fine tuff+cocopeat (5:1:4), T4:medium tuff+fine tuff + peat moss (5:1:4), T5: perlite+medium tuff+fine tuff+cocopeat (5:5:2:8), and T6: lightweight expandable clay aggregates+fine tuff+cocopeat (5:1:4)]. The T6 (LECA-cocopeat) had the lowest weight at field capacity and good aeration and WHC to sustain optimal plant growth. Medium tuff-peat moss (T4) produced the highest pansy flowers number per plants. However, peat moss (T4) has been identified by environmentalists as an unsustainable media. LECA-cocopeat (T6) had a higher number of lily flowers and leaf area than T1-T4. The cost of the LECA substrate ($US 215 m-3, T6) is extremely higher than that of volcanic tuff ($US 36 m-3, T1-T4), and perlite ($US 100 m-3, T5). Overall, T6 can be an ideal option in terms of physical properties of growing substrate and flower quality but it might not be the best option for green roofs when cost is the primary concern. In addition, certain growing substrates could be used to satisfy specific growing requirements without sacrificing performance. For example, the combination of medium tuff and peat moss (T4) produced the highest pansy flower numbers per plant but required a longer period to flower (95 days). So, this growing substrate could be used where plentiful blooms are desired and the time to bloom is not a concern.

A thiocyanopalladation/carbocyclization transformation identified through enzymatic screening: stereocontrolled tandem C-SCN and C-C bond formation.

Herein we describe a formal thiocyanopalladation/carbocyclization transformation and its parametrization and optimization using a new elevated temperature plate-based version of our visual colorimetric enzymatic screening method for reaction discovery. The carbocyclization step leads to C-SCN bond formation in tandem with C-C bond construction and is highly stereoselective, showing nearly absolute 1,2-anti-stereoinduction (5 examples) for substrates bearing allylic substitution, and nearly absolute 1,3-syn-stereoinduction (16 examples) for substrates bearing propargylic substitution. Based upon these high levels of stereoinduction, the dependence of the 1,2-stereoinduction upon cyclization substrate geometry, and the generally high preference for the transoid vinyl thiocyanate alkene geometry, a mechanistic model is proposed, involving (i) Pd(ii)-enyne coordination, (ii) thiocyanopalladation, (iii) migratory insertion and (iv) ß-elimination. Examples of transition metal-mediated C-SCN bond formation that proceed smoothly on unactivated substrates and allow for preservation of the SCN moiety are lacking. Yet, the thiocyanate functionality is of great value for biophysical chemistry (vibrational Stark effect) and medicinal chemistry (S,N-heterocycle construction). The title transformation accommodates C-, O-, N- and S-bridged substrates (6 examples), thereby providing the corresponding carbocyclic or heterocyclic scaffolds. The reaction is also shown to be compatible with a significant range of substituents, varying in steric and electronic demand, including a wide range of substituted aromatics, fused bicyclic and heterocyclic systems, and even biaryl systems. Combination of this new transformation with asymmetric allylation and Grubbs ring-closing metathesis provides for a streamlined enantio- and diastereoselective entry into the oxabicyclo[3.2.1]octyl core of the natural products massarilactone and annuionone A, as also evidenced by low temperature X-ray crystal structure determination. Utilizing this bicyclic scaffold, we demonstrate the versatility of the thiocyanate moiety for structural diversification post-cyclization. Thus, the bridging vinyl thiocyanate moiety is smoothly elaborated into a range of derivative functionalities utilizing transformations that cleave the S-CN bond, add the elements of RS-CN across a π-system and exploit the SCN moiety as a cycloaddition partner (7 diverse examples). Among the new functionalities thereby generated are thiotetrazole and sulfonyl tetrazole heterocycles that serve as carboxylate and phosphate surrogates, respectively, highlighting the potential of this approach for future applications in medicinal chemistry or chemical biology.

Guillain-barré syndrome in pregnancy: an unusual case.

Guillain-Barré syndrome (GBS) is rare in pregnancy with an estimated incidence between 1.2 and 1.9 cases per 100,000 people annually, and it carries a high maternal risk. We report a 29-year-old primigravida who had pain and progressive heaviness of both lower limbs in her third trimester of pregnancy. The attending gynecologist ascribed these symptoms to ongoing pregnancy. The intrapartum period (lower segment caesarian section) passed uneventfully. On third postpartum day, the patient developed weakness of all the four limbs. A detailed history and physical examination pointed toward GBS although there was no antecedent infective episode. Subsequent nerve conduction velocity studies and cerebrospinal fluid analysis confirmed GBS. All other investigations including electrolytes were normal. The patient improved without the introduction of immunomodulating therapy.

High frequency oscillatory ventilation versus synchronized intermittent mandatory ventilation in preterm neonates with hyaline membrane disease: a randomized controlled trial.

This randomized controlled study was conducted to compare the efficacy and safety of High frequency oscillatory ventilation (HFOV) and Synchronized intermittent mandatory ventilation (SIMV) in preterm neonates with hyaline membrane disease requiring ventilation. The ventilation strategy in both the groups included achieving optimal lung recruitment and targeted blood gases. 49 patients received HFOV and 61 SIMV. The baseline characteristics were similar in both the groups. HFOV group demonstrated better early oxygenation, enabled reduction in oxygenation index (OI) within 24 h of ventilation (difference in mean OI at 1, 6, and 24 h of ventilation: P=0.004 in HFOV, and 0.271 in SIMV group). Duration of hospital stay was shorter in HFOV group (P=0.003). The complication rate and survival were similar in two groups.

The prevalence of neuromyelitis optica in South East Wales.

BACKGROUND AND PURPOSE: Neuromyeltis optica (NMO) is a neuroinflammatory disorder considered rare in Caucasian populations. However, accurate population-based epidemiological data for NMO and NMO spectrum disorder (NMO-SD) from Western populations employing validated diagnostic criteria remain limited. We sought therefore to estimate the prevalence and clinical features of NMO in a north European Caucasian population in South East Wales. METHODS: Patients were identified by a comprehensive, multistage ascertainment strategy employing a regional neuroinflammatory disease register, hospital diagnostic databases personal physician referrals and regional requests for anti-aquaporin-4 antibodies (anti-AQP4). RESULTS: Fourteen Caucasian patients (11 patients with NMO and three with NMO-SD) were identified in a population of 712,572 (19.6/million; 95% CIs: 12.2-29.7). There was an excess of females (female:male 12:2), 11/14 were anti-AQP4 positive and 5/14 had disease onset under the age of 20 years. CONCLUSION: This study suggests that NMO and related spectrum disorders are at least as frequent in Northern European populations as in non-Caucasian populations and that the demographic profile of prevalent patients differs from clinic-based cohorts.

Isoflurane late preconditioning against myocardial stunning is associated with enhanced antioxidant defenses.

BACKGROUND: We tested the hypothesis that an upregulation of antioxidant proteins [Cu-Zn superoxide dismutase (SOD), Mn SOD, catalase, glutathione peroxidase, and glutathione peroxidase] plays a role in the delayed protection against myocardial stunning produced by isoflurane preconditioning (ISOPC). Findings were compared with late ischemic PC (IPC). METHODS: Fourteen mongrel dogs were chronically instrumented to measure coronary blood flow and myocardial wall thickening (WT) in conscious state. In Group 1, dogs underwent IPC, induced by a 10-min coronary artery occlusion (CAO); after 24 h of reperfusion, they were subjected to a second 10-min ischemia CAO-reperfusion. In Group 2 (ISOPC), dogs inhaled one minimum alveolar concentration (MAC) ISO (1.4% in O(2)) for 60 min, allowed to recover for 24 h, and then subjected to CAO ischemia-reperfusion. Recovery of WT following the initial 10-min CAO in Group 1 served as control response for both ISOPC and IPC. Expression and activity of antioxidant proteins were measured using Western blotting and spectrophotometric techniques, respectively. RESULTS: Two to three hours of reperfusion were required for recovery of WT following either ISOPC or IPC; in contrast, without PC, WT remained markedly reduced (30% below baseline) at this time point and required more than 6 h of reperfusion for recovery. Neither IPC nor ISOPC affected expression of Cu-Zn SOD, Mn SOD, or catalase. However, ISOPC increased activity of Mn SOD (+40%), catalase (+39%), glutathione peroxidase (+37%), and glutathione reductase (+93%) (P < 0.05); IPC had similar effects. CONCLUSION: ISOPC had powerful, delayed anti-stunning effect that was associated with an enhancement of endogenous antioxidant defenses.

Unsynchronized Nasal Intermittent Positive Pressure Ventilation to prevent extubation failure in neonates: a randomized controlled trial.

OBJECTIVE: To evaluate the role of Unsynchronized Nasal Intermittent Positive Pressure Ventilation (NIPPV) in prevention of extubation failure in mechanically ventilated preterm neonates weighing less than 2,000 g. METHODS: This randomized controlled trial was conducted in the neonatal intensive care unit of a tertiary care teaching hospital. Preterm neonates weighing less than 2,000 g, mechanically ventilated for more than 24 h were included after extubation. Neonates were randomized into two groups. Group 1 was given unsynchronized nasal intermittent positive pressure ventilation with shortened endotracheal tube by ventilator and Group 2 was given head box oxygen, fraction of oxygen in inspired air was 50%. Primary outcome variable was rate of extubation failure within 72 h of extubation. RESULTS: Birth weight, gestational age, age at intubation, indication for mechanical ventilation and antenatal details were comparable in the two groups. Extubation failure rate was 16% in Group 1 vs 63% in Group 2 (RR = 0.25; 95% CI: 0.12, 0.51, p value = 0.00), that is a reduction of 47%. Unsynchronized nasal intermittent positive pressure ventilation did not have any serious side effects, however it did not reduce total hospital stay. CONCLUSIONS: Unsynchronized Nasal Intermittent Positive Pressure Ventilation is a simple technique of noninvasive ventilation which significantly reduces the rate of extubation failure in preterm neonates and is not associated with serious side effects.

Changing trends in asthma in 9-12 year olds between 1964 and 2009.

INTRODUCTION: Childhood asthma is a common condition and the prevalence has increased in many countries during the late 20th century. The Aberdeen schools asthma surveys reported rising lifetime prevalence of asthma between 1964 and 2004 in children aged 9-12 years, but a fall in wheeze in the last 3 years between 1999 and 2004. The present study tested the hypothesis that lifetime childhood asthma prevalence has fallen since 2004. METHODS: Children aged 9-12 years who attended the same schools surveyed since 1964 were invited to participate. A lifetime history of asthma or eczema and also wheeze in the past 3 years and 12 months was ascertained from a questionnaire. Trends over 1999, 2004 and 2009 were analysed with adjustment for age, gender and an index of deprivation. RESULTS: There were 2253 eligible children and 1196 (53%) questionnaires were returned. The lifetime prevalence of asthma rose from 24.3% in 1999 to 28.4% in 2004 but fell to 22.1% in 2009 (p<0.001), while wheeze in the last 3 years fell from 27.9% in 1999 to 25.2% in 2004 and fell further to 22.2% in 2009 (p<0.001). The lifetime prevalence of eczema among 9-12 year olds was 21.4% in 1999, 34.1% in 2004 and 30.7% in 2009 (p<0.001). Reductions in symptom prevalences between 2004 and 2009 were significant for girls but not boys. CONCLUSION: The prevalence of lifetime asthma and wheeze appear to have fallen in school children, especially girls, although the low response rate means some caution is required when interpreting the results. Asthma prevalence remains high and the underlying mechanisms remain incompletely understood.

Physico-chemical characteristics of groundwater in and around Surat City (India).

Groundwater samples were collected from different locations of Surat city, Gujarat (India). These samples from 32 locations of Surat city were analysed for their physico-chemical characteristics involving pH, colour, odour, hardness, chloride, alkalinity, COD, sulfate, TDS, SS, iron, Cu, boron, chromium, temperature and Langelier Saturation Index. On comparing the results against drinking water quality standards laid by Indian Council of Medical Research (ICMR) and World Health Organization (WHO), it is found that most of the water samples are non-potable. Most of the samples indicated Total Alkalinity, Hardness, Chloride and TDS values much higher than the permissible level stipulated by ICMR and WHO. Even at some places Langelier Saturation Index values found higher too. The high values of these parameters may have health implications and therefore these need attention.

Light emitting diodes versus compact fluorescent tubes for phototherapy in neonatal jaundice: a multi center randomized controlled trial.

OBJECTIVE: To evaluate whether light-emitting diode (LED) phototherapy is as efficacious as compact fluorescent tube (CFT) phototherapy for the treatment of non-hemolytic jaundice in healthy term and late preterm neonates. STUDY DESIGN: Multi centre open label randomized controlled trial. SETTING: Four tertiary care neonatal units. SUBJECTS: Healthy term and late preterm neonates with non-hemolytic jaundice. INTERVENTION: Single-surface LED or CFT phototherapy. PRIMARY OUTCOME VARIABLE: Duration of phototherapy. RESULTS: A total of 272 neonates were randomized to receive LED (n=142) or CFT (n=130) phototherapy. The baseline demographic and biochemical variables were similar in the two groups. The median duration of phototherapy (IQR) in the two groups was comparable (26 (22-36) h vs. 25(22-36) h; P=0.44). At any time point, a similar proportion of neonates were under phototherapy in the two groups (log-rank test, P=0.38). The rate of fall of serum total bilirubin (STB) during phototherapy and the incidence of failure of phototherapy were also not different. An equal proportion of neonates had a rebound increase in STB needing restarting of phototherapy. Side effects were rare, comparable in the two groups and included hypothermia, hyperthermia, rash, skin darkening and dehydration. CONCLUSIONS: LED and CFT phototherapy units were equally efficacious in the management of non-hemolytic hyperbilirubinemia in healthy term and late preterm neonates.

Genetic diversity and bottleneck analysis of Nagpuri buffalo breed of India based on microsatellite data.

In this study, 25 heterologous bovine microsatellite markers have been used for the assessment of genetic diversity in Nagpuri buffalo, an important breed of Central India. For this, 48 DNA samples of unrelated individuals of Nagpuri buffalo were PCR amplified and microsatellite alleles were resolved in 6% denaturing, silver stained Urea-PAGE gel. Genotypic status of individuals at each locus was identified manually and data analysis carried out using POPGENE software. Observed number of alleles varied from 2 (ILSTS073 locus) to 8 (HEL13 & ILSTS058 loci) with a mean of 5.24 alleles per locus. Moderate level of heterozygosity (0.45) indicated sufficient genetic diversity existing in this buffalo population. PIC values for the microsatellite loci analysed, ranged from 0.10 (ILSTS019 locus) to 0.81 (ILSTS058 locus) with a mean of 0.53. No shift in the frequency distribution of alleles and a normal L-shaped curve indicated non-existence of any bottleneck in Nagpuri. The study thus highlights the usefulness of heterologous bovine microsatellite markers to assess the genetic variability in buffalo breeds as well. Also various diversity indices suggest sufficient genetic variability within Nagpuri buffalo that can be utilized as initial guidelines for future breeding strategies and conservation.

Apparent absorption of methionine and 2-hydroxy-4-methylthiobutanoic acid from gastrointestinal tract of conventional and gnotobiotic pigs.

The effect of commensal microbiota and feeding corn or wheat/barley-based diets on the apparent gastrointestinal absorption of dl-methionine (MET) and 2-hydroxy-4-methylthiobutanoic acid (MHA-FA) was studied in conventional (n = 32) and gnotobiotic pigs (n = 24). Conventional pigs (CON) were vaginally delivered and sow-reared until weaning at 14 days of age. Gnotobiotic pigs were derived by caesarian section and reared in HEPA (high efficiency particulate air)-filtered isolator units with ad libitum access to a milk-based formula. Corn or wheat/barley-based diets were fed to all pigs from 14 to 24 days of age. At 24 days of age, after an overnight fast, pigs were fed 20 g/kg BW of experimental diet supplemented with 107 Bq of either 3H-l-MET or 3H-l-MHA-FA per kg of feed and chromic oxide (0.5% wt/wt). Pigs were killed for sample collection 3 h after consuming the meal. Residual 3H-MET and 3H-MHA-FA were estimated in gastrointestinal contents as the ratio of 3H : chromic oxide in digesta samples to the ratio of 3H : chromic oxide in feed. In CON pigs, feeding a wheat/barley-based diet increased (P < 0.05) total aerobes, whereas supplementation with MHA-FA increased (P < 0.05) total aerobes and lactobacilli populations in proximal small intestine (SI). Among the gnotobiotic pigs, bacterial contamination occurred such that eight pigs (two isolators) were monoassociated with a Gram-negative bacteria closely related to Providencia spp. and 16 pigs (four isolators) were monoassociated with Gram positive Enterococcus faecium. Species of monoassociated bacterial contaminant and diet composition did not affect residual methionine or MHA-FA in digesta. In both CON and monoassociated (MA) pigs, methionine and MHA-FA were retained in stomach (92%) but disappeared rapidly from proximal SI. Residual methionine and MHA-FA in digesta was not different in MA pigs; however, in CON pigs, less (P < 0.01) apparent residual methionine was found in digesta recovered at 25% (from cranial to caudal) and 75% of SI length compared with MHA-FA. Apparent residual methionine was 16% and 8% compared with 34% and 15% for MHA-FA, at the 25% and 75% locations, respectively. In proximal SI tissue, significantly (P < 0.05) higher radioactivity (cpm/mg wet tissue) was associated with MET pigs (8.56 ± 0.47) as compared to MHA-FA ones (5.45 ± 0.50). This study suggests that microbial metabolism of MHA-FA increases retention in small intestinal digesta relative to methionine and contributes, in part, to the lower bioefficacy of MHA-FA compared to methionine.

Single nucleotide polymorphism (SNP) in prion protein gene (PRNP) exon-3 in Gaddi sheep.

Nine PCR-SSCP conformations in PRNPthe exon-3 genomic DNA segment covering codons 136, 154 and 171 were observed. DNA sequences revealed 9 unique variants (DQ885789-DQ885796). At codon 171 of exon-3, two alleles, Q and R, had a frequency of 0.336 and 0.664, respectively. Genotypes QQ, QR and RR were observed in 25.86, 15.51 and 58.62% of animals, respectively, showing deviation from Hardy-Weinberg equilibrium. At codon 154, all genotypes were RR. At codon 136 AA, AV and W genotypes were 86.21, 10.34 and 3.44%, respectively, and frequencies of the alanine (A) and valine (V) alleles were 0.914 and 0.086, respectively, where the W genotype had lower frequency than expected. Polymorphisms were also observed at codons 137, 143 and 173 of exon-3.

Congenital duodenal obstruction with situs inversus totalis: Report of a rare association and discussion.

This report is to present and discuss an extremely rare association of situs inversus with duodenal atresia in an 11-day-old male neonate born full term and weighing 1.9 kg. The baby presented with recurrent bilious vomiting. Babygram revealed situs inversus and duodenal obstruction. Echocardiography showed dextrocardia with a small ASD. Exploration confirmed a duodenal diaphragm with a central perforation between the third and fourth part of the duodenum and situs inversus. The literature search revealed 20 cases reported so far.

Genetic diversity and bottleneck analysis of Indian bellary sheep by microsatellite markers.

Bellary sheep population variability and structure was investigated genetically utilizing FAO recommended microsatellite markers. Genetic variation at 20 microsatellite loci, population structure, and genetic bottleneck hypothesis were examined. Estimates of genetic variability such as effective number of alleles and gene diversities revealed substantial genetic variation frequently displayed by microsatellite markers. A total of 133 alleles were detected. Average polymorphism across the studied loci and expected gene diversity in the population were 1.419 +/- 0.405 and 0.684 +/- 0.140, respectively. No significant genotypic linkage disequilibrium was detected across population, suggesting no evidence of linkage between loci. The population was observed to be significantly differentiated into different groups, showed fairly high level of inbreeding (f = 0.253 +/- 0.050) and global heterozygote deficit. Population structure analysis indicated the intermixing/introduction of unique/rare alleles in these migrating flocks. A normal L-shaped distribution of mode-shift test, non-significant heterozygosity excess on the basis of different models, as revealed from Sign, Standardized differences and Wilcoxon sign rank tests suggested that there was no recent bottleneck. The study revealed that even breed with increasing population trend needs genetic management for the conservation and improvement.