A modified passive-dynamic ankle-foot orthosis: can it prevent amputation and arthrodesis in patients with ankle-foot trauma?

INTRODUCTION: High-energy lower extremity trauma (HELET) may cause severe damage within the foot-ankle complex. Occasionally, arthrodesis or amputation are the only remaining options to increase activity levels. The modified passive dynamic ankle-foot orthosis (PDAFO) may prove to be a nonsurgical alternative. This study evaluated the effect of a modified PDAFO with a 6-week training program on pain and performance in patients after HELET. MATERIALS AND METHODS: A retrospective cohort study was conducted on seventeen patients who considered an arthrodesis or an amputation after HELET. In an attempt to avoid surgery, the modified PDAFO with a 6-week training program was provided. Pain scores was measured with the Numeric Rating Scale and administered at the start of testing, immediately after the two performance tests and at the end of the day of testing. Performance was evaluated with the 6-min walk test (6MWT) and the Comprehensive high-level activity mobility predictor (CHAMP). RESULTS: A significant pain reduction was achieved after the treatment procedure. At the start of the test days (p = 0.002), after the 6MWT (p = 0.001), after the CHAMP (p < 0.001) and at the end of the day (p < 0.001). In addition, a significant improvement on performance was observed in the 6MWT (p < 0.001) and the CHAMP (p = 0.01). None of the patients considered a surgical intervention anymore. CONCLUSIONS: Patients after HELET show a decrease in pain and an improvement in performance after a 6-week training program with modified PD-AFO. The results suggest that the modified PDAFO is an effective alternative for a surgical approach.

A Guideline-Based Policy to Decrease Intensive Care Unit Admission Rates for Accidental Hypothermia.

RATIONALE: Despite guidelines advising passive rewarming for mild accidental hypothermia (AH), patients are frequently admitted to intensive care unit (ICU) for active rewarming using a forced-air warming device. We implemented a new policy at our institution aimed at safely reducing ICU admissions for AH. We analyzed our practice pre- and post-policy intervention and compared our experiences with acute care hospitals in Connecticut. METHODS: A retrospective chart review was performed on 203 participants with AH identified by primary and secondary discharge codes. Our new policy recommended passive rewarming on the medical floors for mild hypothermia (>32°C) and ICU admission for moderate hypothermia (<32°C). Practices of other Connecticut hospitals were obtained by surveying ICU nurse managers and medical directors. RESULTS: Over a 3-year period, prior to rewarming policy change, 64% (n = 92) of patients with AH were admitted to ICU, with a mean ICU length of stay (LOS [SD]) of 2.75 (2.2) days. After the policy change, over a 3-year period, 15% (n = 9) were admitted to ICU (P < .001), with an ICU LOS of 2.11 (0.9) days (P = 0.005). In both groups with AH, altered mental status, infection, and acute alcohol intoxication were the most common diagnoses at presentation. Alcohol intoxication was more prevalent in the post-policy intervention group, pre 17% versus post 46% (P < .001). No complications such as dermal burns or cardiac arrhythmias were noted with forced-air warming device use during either time period. Among the 29 hospitals surveyed, 20 used active rewarming in ICU or intermediate care units and 9 cared for patients on telemetry units. Most hospitals used active external rewarming for core body temperature of <35°C; however, 37% of hospitals performed active rewarming at temperatures >35°Cor lacked a policy. CONCLUSIONS: Reserving forced-air warming devices for the treatment of moderate-to-severe hypothermia (<32°C) significantly reduced ICU admissions for AH.

Evaluation of a Brief, Skill-Building, Supportive, and Educational Intervention for Couples After Brain Injury.

OBJECTIVE: To examine the effectiveness of an intervention (Therapeutic Couples Intervention, TCI) designed to improve relationship quality for couples after acquired brain injury. SETTING: Outpatient brain injury rehabilitation center. PARTICIPANTS: Persons with brain injury (n = 75) and their intimate partners (n = 75). DESIGN: Two-arm parallel, randomized, controlled trial with wait-listed control. METHODS: Composed of 5 to 6 2-hour sessions, the TCI is a manualized, treatment program designed to enhance relationship quality by addressing issues and concerns most often identified by persons with brain injury and their partners. MAIN MEASURE: Revised Dyadic Adjustment Scale completed by the persons with brain injury and their partners. RESULTS: Persons with brain injury and their partners in the treatment group showed an improvement in relationship quality, both compared with their own baseline values and the control group. CONCLUSIONS: Investigation provided evidence that a curriculum-based education, skill-building, and supportive intervention can benefit couples for up to 3 months after treatment. Additional research is needed to ascertain the long-term benefits of intervention and the efficacy of alternative delivery methods (eg, Internet, telephone, and group).

Apremilast in psoriasis - a prospective real-world study.

BACKGROUND: Apremilast is a novel oral phosphodiesterase-4 inhibitor approved for psoriasis treatment. Randomized trials have documented its efficacy and safety, but data on real-world patients are scarce. OBJECTIVES: We aim to characterize psoriasis patients treated with apremilast in a real-world setting and calculate drug survival as an important measure of efficacy and compliance. METHODS: All patients with psoriasis who received apremilast between 1 April 2015 and 19 January 2017 were evaluated every 4 weeks, and we documented: age, weight, height, smoking status, family history of psoriasis, joint involvement, previous treatments, psoriasis area severity index (PASI) scores, and the onset and duration of adverse events (AE). Efficacy was analysed by PASI50, PASI75 and PASI90, reflecting the improvement of skin lesions compared to the PASI-baseline. Kaplan-Meier statistics were used for drug survival estimates. RESULTS: Forty-eight patients were included. The median apremilast drug survival was 12.5 weeks (range 1-87). Three patients (6.3%) reached PASI90, nine (18.8%) PASI75 and eight patients (16.7%) PASI50. Patient weight inversely correlated with a PASI50 response (P < 0.05, n = 37), and none of the obese patients (BMI > 30.0, n = 6) reached PASI75, compared to 32% of the non-obese patients (BMI < 30.0, n = 31). Thirty-one patients (64.6%) reported at least one AE, most frequently diarrhoea (n = 21, 43.8%), headache (n = 7, 14.6%) and joint pain (n = 5, 10.4%). CONCLUSIONS: Despite differences between real-world and trial patients, apremilast is safe and effective for the treatment of skin psoriasis in the daily practice. Up to 40% of patients will reach PASI50 or higher, but only few patients will reach PASI90. Bodyweight might affect drug efficacy.

Efficacy of the resilience and adjustment intervention after traumatic brain injury: a randomized controlled trial.

OBJECTIVE: Examine a psychoeducational and skill-building intervention's effectiveness for individuals after traumatic brain injury (TBI), using a two-arm, parallel, randomized, controlled trial with wait-listed control. METHODS: The Resilience and Adjustment Intervention (RAI) targets adjustment challenges and emphasizes education, skill-building and psychological support. Overall, 160 outpatients were randomly assigned to a treatment or wait-list control (WLC) group. The manualized treatment was delivered in seven 1-h sessions. The Connor-Davidson Resilience Scale (CD-RISC) was the primary outcome measure. Secondary measures included the Mayo Portland Adaptability Inventory-4 (MPAI-4), Brief Symptom Inventory-18 (BSI-18) and 13-Item Stress Test. RESULTS: After adjusting for injury severity, education and time postinjury, the RAI group (N = 75) demonstrated a significantly greater increase in resilience (effect size = 1.03) compared to the WLC group (N = 73). Participants in the RAI group demonstrated more favourable scores on the MPAI-4 Adjustment and Ability Indices, BSI-18 and the 13-item Stress Test. However, only the CD-RISC and BSI-18 demonstrated a clinically significant difference. In addition, RAI participants demonstrated maintenance of gains from pre-treatment to 3-month follow-up; however, only the BSI-18 maintained a clinically significant difference. CONCLUSIONS: Investigation provided evidence that a resilience-focused intervention can improve psychological health and adjustment after TBI. Additional research is needed to ascertain the longer term benefits of intervention and the efficacy of alternative delivery methods (e.g., via telephone, Internet).

Technical Aspects and Validation of a New Biofeedback System for Measuring Lower Limb Loading in the Dynamic Situation.

BACKGROUND: A variety of techniques for measuring lower limb loading exists, each with their own limitations. A new ambulatory biofeedback system was developed to overcome these limitations. In this study, we described the technical aspects and validated the accuracy of this system. METHODS: A bench press was used to validate the system in the static situation. Ten healthy volunteers were measured by the new biofeedback system and a dual-belt instrumented treadmill to validate the system in the dynamic situation. RESULTS: Bench press results showed that the sensor accurately measured peak loads up to 1000 N in the static situation. In the healthy volunteers, the load curves measured by the biofeedback system were similar to the treadmill. However, the peak loads and loading rates were lower in the biofeedback system in all participants at all speeds. CONCLUSIONS: Advanced sensor technologies used in the new biofeedback system resulted in highly accurate measurements in the static situation. The position of the sensor and the design of the biofeedback system should be optimized to improve results in the dynamic situation.

Defining the histopathological changes induced by nonablative radiofrequency treatment of faecal incontinence--a blinded assessment in an animal model.

AIM: Nonablative radiofrequency (RF) sphincter remodelling has been used to treat gastro-oesophageal reflux disease (GERD) and faecal incontinence (FI). Its mechanism of action is unclear. We aimed to investigate the histomorphological and pathophysiological changes to the internal and external anal sphincter (IAS and EAS) following RF remodelling. METHOD: An experimental FI model was created in 12 female pigs: eight underwent RF 6 weeks following induction of FI (FI+RF) and four were untreated (UFI). Four animals served as controls (CG). Two blinded pathologists examined all haematoxylin and eosin and trichrome stained slides. RESULTS: Compared with the UFI group, histological examination of the IAS in the FI+RF group demonstrated an increased smooth muscle (SM)/connective tissue ratio (77.2 vs 68.1%, P < 0.05) and increased collagen I compared with collagen III content (67.2 vs 54.9%, P < 0.001). The RF+FI group exhibited greater SM bundle thickness compared with the UFI group (SM width 486.93 vs 338.59 µm, P < 0.01; height 4384.4 vs 3321.0 µm, P < 0.05). The EAS of the FI+RF animals showed a significantly higher type I/II fibre ratio (33.5 vs 25.2%, P = 0.023) and fibre type I diameter (67.2 vs 59.7 µm, P < 0.001) compared with the UFI group. Post-RF manometry showed higher basal (18.8 vs 0 mmHg, P < 0.001) and squeeze (76.8 vs 12.4 mmHg, P < 0.05) anal pressures. After RF treatment, the number of interstitial cells of Cajal was significantly reduced compared with the UFI and CG groups [0.9 (FI+RF) vs 6.7 (UFI) vs 0.7 (CG) per mm(2) , P < 0.001]. CONCLUSION: In an animal model nonablative RF appeared to induce morphological changes in the IAS and EAS leading to an anatomical state reminiscent of normal sphincter structure.

Relationship Between Resilience, Adjustment, and Psychological Functioning After Traumatic Brain Injury: A Preliminary Report.

OBJECTIVE: To examine the relationship between resilience, psychological distress, adjustment, and community participation after traumatic brain injury (TBI). SETTING: Large university health system. PARTICIPANTS: Adult survivors of mild to severe TBI (N = 96). DESIGN: Descriptive, preliminary. MAIN MEASURES: The Connor-Davidson Resilience Scale (10-item version) was used to assess resilience, the Brief Symptom Inventory (BSI-18) was used to characterize psychological distress, and the Mayo-Portland Adaptability Index (MPAI-4) was used to measure ability, adjustment, and participation. RESULTS: Resilience scores were substantially lower than those of the general population. Significant relationships were found between resilience, psychological distress, and adjustment. Partial correlations (adjusting for the other MPAI-4 indices) showed significant correlation (P < .05) between MPAI-4 Adjustment and resilience. Partial correlations (adjusting for the other BSI-18 scales) also showed significance for Depression (P < .01) and resilience. Resilience scores differed significantly (P < .001) between individuals meeting BSI-18 caseness criteria for psychological distress (n = 55) and those not meeting criteria (n = 41). CONCLUSIONS: Individuals with TBI are at risk for low resilience, which was found to correlate with psychological distress and psychosocial maladjustment. Developing interventions to strengthen resilience skills has the potential to improve postinjury psychosocial adjustment, an important area for future research.

Growth Hormone, Atherosclerosis and Peripheral Arterial Disease: Exploring the Spectrum from Acromegaly to Growth Hormone Deficiency.

Growth hormone (GH) and insulin-like growth factor 1 (IGF-1) are increasingly recognised for their role in cardiovascular (CV) physiology. The GH-IGF-1 axis plays an essential role in the development of the CV system as well as in the complex molecular network that regulates cardiac and endothelial structure and function. A considerable correlation between GH levels and CV mortality exists even among individuals in the general population without a notable deviation in the GHIGF- 1 axis functioning. In addition, over the last decades, evidence has demonstrated that pathologic conditions involving the GH-IGF-1 axis, as seen in GH excess to GH deficiency, are associated with an increased risk for CV morbidity and mortality. A significant part of that risk can be attributed to several accompanying comorbidities. In both conditions, disease control is associated with a consistent improvement of CV risk factors, reduction of CV mortality, and achievement of standardised mortality ratio similar to that of the general population. Data on the prevalence of peripheral arterial disease in patients with acromegaly or growth hormone deficiency and the effects of GH and IGF-1 levels on the disease progression is limited. In this review, we will consider the pivotal role of the GH-IGF-1 axis on CV system function, as well as the far-reaching consequences that arise when disorders within this axis occur, particularly in relation to the atherosclerosis process.

Assessment of optimum stent deployment by stent boost imaging: comparison with intravascular ultrasound.

Stent boost (SB) imaging is an enhancement of the radiologic edge of the stent by digital management of regular X-ray images. The purpose of the present study was to validate SB imaging by comparison with the anatomical standard using intravascular ultrasound (IVUS). We investigated SB and IVUS after stent implantation in 68 arteries in 60 patients. Based on those findings, we added high-pressure dilatation in four patients and another stent implantation in four patients. We defined the SB criteria for adequate stent deployment as: complete stent expansion, stent minimum diameter ≥70% of reference diameter, and stent minimum diameter ≥2.0 mm; and IVUS criteria for adequate stent deployment as: minimal stent area ≥5.0 mm(2). If the reference vessel was <2.8 mm, adequate stent deployment was defined as minimum stent area ≥4.5 mm(2). IVUS findings indicated inadequate stent deployment in 21/72 observations (29%). Seven SB images showed inadequate stent expansion. SB predicted inadequate findings of IVUS with 100% specificity, 33% sensitivity, and 81% agreement. Although the sensitivity of SB image for adequate stent deployment is low, the specificity is sufficiently high for it to be the first-line for monitoring just after stent implantation in centers where IVUS is not used routinely.

Liraglutide attenuates nicotine self-administration as well as nicotine seeking and hyperphagia during withdrawal in male and female rats.

RATIONALE: Nicotine cessation is associated with increased consumption of highly palatable foods and body weight gain in most smokers. Concerns about body weight gain are a major barrier to maintaining long-term smoking abstinence, and current treatments for nicotine use disorder (NUD) delay, but do not prevent, body weight gain during abstinence. Glucagon-like peptide-1 receptor (GLP-1R) agonists reduce food intake and are FDA-approved for treating obesity. However, the effects of GLP-1R agonist monotherapy on nicotine seeking and withdrawal-induced hyperphagia are unknown. OBJECTIVES: We screened the efficacy of the long-lasting GLP-1R agonist liraglutide to reduce nicotine-mediated behaviors including voluntary nicotine taking, as well as nicotine seeking and hyperphagia during withdrawal. METHODS: Male and female rats self-administered intravenous nicotine (0.03 mg/kg/inf) for ~21 days. Daily liraglutide administration (25 µg/kg, i.p.) started on the last self-administration day and continued throughout the extinction and reinstatement phases of the experiment. Once nicotine taking was extinguished, the reinstatement of nicotine-seeking behavior was assessed after an acute priming injection of nicotine (0.2 mg/kg, s.c.) and re-exposure to conditioned light cues. Using a novel model of nicotine withdrawal-induced hyperphagia, intake of a high fat diet (HFD) was measured during home cage abstinence in male and female rats with a history of nicotine self-administration. RESULTS: Liraglutide attenuated nicotine self-administration and reinstatement in male and female rats. Repeated liraglutide attenuated withdrawal-induced hyperphagia and body weight gain in male and female rats at a dose that was not associated with malaise-like effects. CONCLUSIONS: These findings support further studies investigating the translational potential of GLP-1R agonists to treat NUD.

Technology for reducing distracted driving in developing countries: the level of usage and intention to use in Indonesia.

Distracted driving is a major cause of car crashes. Considering the dangers of distracted driving, efforts to develop prevention and/or reduction technology are underway. The purpose of this study is to observe the level of usage of distracted-driving-reduction technology in Indonesia and model the intention to use this technology on the technology acceptance model (TAM). The participants in this study included 418 Indonesian drivers (217 males, 201 females, mean age = 30.96 years), who volunteered to fill out an online questionnaire that the researcher developed, based on the TAM. The questionnaire comprised constructs including subjective norm, perceived usefulness, perceived ease of use, and intention to use, as well as the additional constructs of trust in technology and personal innovativeness. Participants used a five-point Likert scale to record their responses. The results showed the level of respondents' use of distracted-driving-reduction technology as 88.52%. The most frequently used technology for this purpose was Bluetooth-enabled audio systems. The factors that significantly influenced the intention to use distracted-driving-reduction technology were the subjective norm, perceived usefulness, perceived ease of use, and personal innovativeness. The paper also discusses the implications of the results.

Doppler guided haemorrhoidal arterial ligation with recto-anal-repair (RAR) for the treatment of advanced haemorrhoidal disease.

OBJECTIVE: A modification of Doppler guided haemorrhoidal artery ligation (DGHAL) to include the addition of recto-anal repair is reported. Preliminary results of function and safety of third and fourth degree haemorrhoidals are given. METHOD: Thirty patients underwent DGHAL combined with recto-anal-repair (RAR). Each had rectal examination, anorectal manometry and Quality of Life assessment before and 3 months after the procedure. RESULTS: Twenty-nine patients were included in the final analysis. There were three (10.34%) patients of intra-operative and one (3.45%) of postoperative bleeding. Three months after RAR (17.24%) patients with minor residual mucosal prolapse were detected, three (10.34%) patients reported residual symptoms. There was no case of recurrent bleeding. Anal manometry at 3 months after RAR was significantly lower than before the procedure (P < 0.05). One (3.45%) patient reported occasional soiling 3 months after RAR. CONCLUSION: Recto-anal-repair is safe in treating third and fourth degree haemorrhoids with no major complications and low rate of residual disease.

Mobile phone use among Indonesian motorcyclists: prevalence and influencing factors.

OBJECTIVE: Indonesia is one of many developing countries that relies on motorcycles as a major mode of transportation. Unfortunately, the widespread use of motorcycles in Indonesia coincides with a high number of motorcycle accidents which can often be attributed to unsafe behaviors of the motorcyclist. One unsafe behavior that is common and hypothetically associated with accidents is the use of a mobile phone while motorcycling. The aim of the present study was to observe the prevalence and behavior of mobile phone use among Indonesian motorcyclists and the factors that might have influenced their behavior. METHODS: Five hundred Indonesian motorcyclists voluntarily participated in this study by filling out a questionnaire that gathered demographic data, motorcycling behaviors, and a statement related to what factors might influence their likelihood to use a mobile phone while motorcycling. A descriptive statistic and Structural Equation Modeling were applied in analyzing the data. RESULTS: Results showed that the prevalence of mobile phone use among Indonesian motorcyclists was 75%. The demographic data that significantly influenced mobile phone use during motorcycling were age, education level, marital status, and number of children. Occupation, gender, and prior experiences that included accidents and tickets with fines did not influence the use of mobile phones during motorcycling. The behavioral model showed that the factors that influenced motorcyclist's intentions to avoid mobile phone use during motorcycling were attitude, perceived behavioral control, and cues to action. CONCLUSIONS: This study supports previous findings regarding the high prevalence of mobile phone use among motorcyclists in developing countries. The models implied that further investigation on intervention strategy to minimize mobile phone use during motorcycling is a necessity.

Heterogeneous nuclear RNA-protein fibers in chromatin-depleted nuclei.

The heterogeneous nuclear RNA-protein (hnRNP) fibers in HeLa cell nuclei are visualized by a nuclear subfractionation technique which removes 96% of the chromatin in a single step and 99% in a two-step elution but leaves the bulk of the hnRNA complexed with the remnant nuclear structure or lamina. Both steady-state and newly synthesized (approximately 15-s label) hnRNA are associated with the remnant nuclei to about the same extent. This association does not appear to depend on the presence of chromatin and exists in addition to any possible association of hnRNP with chromatin itself. Electron microscopy of partially purified nuclear hnRNA complexes shows that the hnRNP fibers form a ribonucleoprotein network throughout the nucleus, whose integrity is dependent on the RNA. Autoradiography confirms that hnRNA is a constituent of the fibers. The RNA network visualized in these remnant nuclei may be similar to RNA networks seen in intact cells. The hnRNA molecules appear to be associated with the nuclear lamina, at least in part, by unusual hnRNA sequences. More than half of the recovered poly(A) and double-stranded hnRNA regions remains associated with the nuclear structures or the laminae after digestion with RNase and elution with 0.4 M ammonium sulfate. In contrast, the majority of oligo(A), another ribonuclease resistant segment, is released together with most of the partially digested but still acid-precipitable single-stranded hnRNA and the hnRNP proteins not eluted by the ammonium sulfate alone. These special RNA regions appear to be tightly bound and may serve as points of attachment of the hnRNA to nuclear substructures. It is suggested that hnRNA metabolism does not take place in a soluble nucleoplasmic compartment but on organized structures firmly bound to the nuclear structure.

Transcription and intragenic recombination in polar mutants of Escherichia coli.

Mitotic recombination within the beta-galactosidase gene was followed in F' merodiploids grown in the presence and absence of inducer. Inducer inhibited recombination when the two mutations in the merodiploid were nonpolar but had no effect when the mutations were strongly polar. These results are interpreted to mean that transcription inhibits intragenic mitotic recombination and that strongly polar mutations inhibit transcription.

A two-fluid approach to town traffic.

A two-fluid model of town traffic has been developed by extending ideas formulated in an earlier kinetic theory of multilane traffic. The-two fluids are taken to consist of moving cars and cars stopped as a result of traffic conditions. The average speed of the moving vehicles is assumed to be proportional to the fraction of the vehicles that are moving raised to a power that reflects the "goodness" of the traffic. It is then found that the trip time per unit distance is essentially linearly related to the stop time per unit distance, in general accord with data obtained in many cities. Relations are developed on this basis for flow, among other variables, versus average speed. These relations contain a new parameter that is identified with the quality of the traffic network system.

Multilane vehicular traffic and adaptive human behavior.

The parameters in a statistical theory of multiple-lane traffic have been determined from two independent sets of data. The numerical values of the parameters calculated by four different methods of estimation are in essential agreement with one another. The data suggest the important role of adaptive human behavior in determining the characteristics of congested flow.

Dietary regulation of galactose-metabolizing enzymes: adaptive changes in rat jejunum.

The effects of dietary galactose, sucrose, fructose, glucose, casein, and fasting upon the activity of four galactose-metabolizing enzymes (galactokinase, galactose-1-phosphate uridyltransferase, uridine diphosphate galactose 4-epimerase, and galactose dehydrogenase) were studied in the jejunum of rats. Galactose produced the greatest increase in enzyme activity, fructose and sucrose produced effects intermediate between galactose and glucose, and casein produced a greater activity increase than fasting, but less than the sugars.