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BACKGROUND Continuous peripheral nerve blocks can be administered as continuous infusion, patient-controlled boluses, automated boluses, or a combination of these modalities. MATERIAL AND METHODS Ten patients undergoing either ankle (5) or distal radius (5) open reduction and internal fixation received single-injection ropivacaine sciatic nerve block or infraclavicular brachial plexus block and catheter. Infusion pumps were set to begin administering additional ropivacaine 6 h following the initial block as automated boluses supplemented with patient-controlled boluses. RESULTS Patients had similar pain scores when compared to previously published controls; however, local anesthetic consumption was lower in the patients, resulting in increased infusion and analgesia duration by 1 or more days in each group. CONCLUSIONS For infraclavicular and popliteal sciatic catheters, automated boluses may provide a longer duration of analgesia than continuous infusions following painful hand and ankle surgeries, respectively.
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Analgesia/métodos , Anestésicos Locales/administración & dosificación , Tobillo/cirugía , Dolor Postoperatorio/tratamiento farmacológico , Ropivacaína/administración & dosificación , Muñeca/cirugía , Adulto , Analgesia Controlada por el Paciente/métodos , Estudios de Casos y Controles , Femenino , Humanos , Bombas de Infusión , Masculino , Persona de Mediana Edad , Bloqueo Nervioso/métodos , Procedimientos Ortopédicos/métodos , Manejo del Dolor/métodos , Ropivacaína/uso terapéuticoRESUMEN
OBJECTIVES: To assess the feasibility of using ultrasound (US) image features related to the median nerve echogenicity and shape for carpal tunnel syndrome (CTS) diagnosis. METHODS: In 31 participants (21 healthy participants and 10 patients with CTS), US images were collected with a 30-MHz transducer from median nerves at the wrist crease in 2 configurations: a neutral position and with wrist extension. Various morphologic features, including the cross-sectional area (CSA), were calculated to assess the nerve shape. Carpal tunnel syndrome commonly results in loss of visualization of the nerve fascicular pattern on US images. To assess this phenomenon, we developed a nerve-tissue contrast index (NTI) method. The NTI is a ratio of average brightness levels of surrounding tissue and the median nerve, both calculated on the basis of a US image. The area under the curve (AUC) from a receiver operating characteristic curve analysis and t test were used to assess the usefulness of the features for differentiation of patients with CTS from control participants. RESULTS: We obtained significant differences in the CSA and NTI parameters between the patients with CTS and control participants (P < .01), with the corresponding highest AUC values equal to 0.885 and 0.938, respectively. For the remaining investigated morphologic features, the AUC values were less than 0.685, and the differences in means between the patients and control participants were not statistically significant (P > .10). The wrist configuration had no impact on differences in average parameter values (P > .09). CONCLUSIONS: Patients with CTS can be differentiated from healthy individuals on the basis of the median nerve CSA and echogenicity. Carpal tunnel syndrome is not manifested in a change of the median nerve shape that could be related to circularity or contour variability.
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Síndrome del Túnel Carpiano/diagnóstico por imagen , Nervio Mediano/diagnóstico por imagen , Ultrasonografía/métodos , Adulto , Anciano , Diagnóstico Diferencial , Estudios de Factibilidad , Femenino , Humanos , Masculino , Reproducibilidad de los Resultados , Sensibilidad y Especificidad , Articulación de la Muñeca/diagnóstico por imagenRESUMEN
PURPOSE: Simple decompression and anterior subcutaneous transposition are effective surgical interventions for cubital tunnel syndrome and yield similarly favorable outcomes. However, a substantial proportion of patients demonstrate unsatisfactory outcomes for reasons that remain unclear. We compared effects of decompression and transposition on regional ulnar nerve strain to better understand the biomechanical impacts of each strategy. METHODS: Patients diagnosed with cubital tunnel syndrome and scheduled for anterior subcutaneous transposition surgery were enrolled. Simple decompression, circumferential decompression, and anterior transposition of the ulnar nerve were performed during the course of the transposition procedure. Regional ulnar nerve strain around the elbow was measured for each surgical intervention based on 4 wrist and elbow joint configurations. RESULTS: With elbow extension at 180°, both circumferential decompression and anterior transposition resulted in approximately 68% higher nerve strains than simple decompression. Conversely, with elbow flexion, simple decompression resulted in higher average strains than anterior transposition. Limited regional differences in strain were observed for any surgical intervention with elbow extension. However, with elbow flexion, strains were higher in distal and central regions compared with the proximal region within all surgical groups, and proximal region strain was higher after simple decompression compared with anterior transposition. CONCLUSIONS: As predicted by the altered anatomic course, anterior transposition results in lower ulnar nerve strains than simple decompression during elbow flexion and higher nerve strains during elbow extension. Irrespective of anatomic course, circumferential release of paraneurial tissues may also influence nerve strain. Nerve strain varies regionally and is influenced by surgery and joint configuration. CLINICAL RELEVANCE: Our data provide insight into how surgery resolves and redistributes traction on the ulnar nerve. These findings may help inform which surgical procedure to perform for a specific patient, guide rehabilitation protocols, and suggest regions of anatomic concern during index and revision surgery.
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Síndrome del Túnel Cubital/cirugía , Descompresión Quirúrgica/efectos adversos , Transferencia de Nervios/métodos , Rango del Movimiento Articular/fisiología , Esguinces y Distensiones/fisiopatología , Nervio Cubital/cirugía , Anciano , Síndrome del Túnel Cubital/diagnóstico , Descompresión Quirúrgica/métodos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Procedimientos Neuroquirúrgicos/métodos , Dimensión del Dolor , Reoperación/métodos , Estudios Retrospectivos , Medición de Riesgo , Muestreo , Esguinces y Distensiones/etiología , Resultado del Tratamiento , Nervio Cubital/fisiopatologíaRESUMEN
PURPOSE: Open reduction and internal fixation of distal radius fractures often necessitates release of the brachioradialis from the radial styloid. However, this common procedure has the potential to decrease elbow flexion strength. To determine the potential morbidity associated with brachioradialis release, we measured the change in elbow torque as a function of incremental release of the brachioradialis insertion footprint. METHODS: In 5 upper extremity cadaveric specimens, we systematically released the brachioradialis tendon from the radius and measured the resultant effect on brachioradialis elbow flexion torque. We defined release distance as the distance between the release point and the tip of the radial styloid. RESULTS: Brachioradialis elbow flexion torque dropped to 95%, 90%, and 86% of its original value at release distances of 27, 46, and 52 mm, respectively. Importantly, brachioradialis torque remained above 80% of its original value at release distances up to 7 cm. CONCLUSIONS: Our data demonstrate that release of the brachioradialis tendon from its insertion has minor effects on its ability to transmit force to the distal radius. CLINICAL RELEVANCE: These data imply that release of the distal brachioradialis tendon during distal radius open reduction internal fixation can be performed without meaningful functional consequences to elbow flexion torque. Even at large release distances, overall elbow flexion torque loss after brachioradialis release would be expected to be less than 5% because of the much larger contributions of the biceps and brachialis. Use of the brachioradialis as a tendon transfer donor should not be limited by concerns of elbow flexion loss, and the tendon could be considered as an autograft donor.
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Articulación del Codo/cirugía , Fracturas del Radio/cirugía , Tendones/cirugía , Anciano , Anciano de 80 o más Años , Fenómenos Biomecánicos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Técnicas de Sutura , TorqueRESUMEN
BACKGROUND: Posterolateral rotatory instability (PLRI) results from lateral ulnar collateral ligament (LCL) deficiency. The lateral pivot shift test is used to diagnose PLRI but can be difficult to perform and is poorly tolerated. We present a new maneuver, the Posterior Radiocapitellar Subluxation Test (PRST), that we believe is easier to perform. The purpose of this study was to compare the efficacy and reproducibility of the PRST with the lateral pivot shift test. METHODS: We obtained 10 cadaveric upper extremity specimens, performed a Kocher approach on each, released the LCL origin in 5, then closed. The specimens were randomized, and 3 attending orthopedic surgeons and 1 resident blindly performed the PRST then the lateral pivot shift test after re-randomization and assessed presence or absence of PLRI. This process was repeated the following day. The data for each test were analyzed for sensitivity, specificity, and accuracy. RESULTS: For the blinded testing when comparing PRST with the pivot shift test, overall accuracy was 77.5%, compared with 67.5% (P = .03), sensitivity was 75.0%, compared with 50.0% (P = .003), and specificity was 80.0%, compared with 85.0% (P = .55). Conclusions: The PRST appears to be at least as accurate as the lateral pivot shift test, with comparable intraobserver and interobserver reliability.
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We characterized the architecture, fiber type, titin isoform distribution, and collagen content of 27 portions of 22 muscles in the murine forelimb. The mouse forelimb was different from the human arm in that it had the extensor digitorum lateralis muscle and no brachioradialis muscle. Architecturally, the mouse forelimb differed from humans with regard to load bearing, having a much larger contribution from extensors than flexors. In mice, the extensor : flexor PCSA ratio is 2.7, whereas in humans it is only 1.4. When the architectural difference index was calculated, similarities became especially apparent between flexors and extensors of the distal forelimb, as well as pronators. Discriminant analysis revealed that biochemical measures of collagen, titin, and myosin heavy chain were all strong between-species discriminators. In terms of composition, when compared with similar muscles in humans, mice had, on average, faster muscles with higher collagen content and larger titin isoforms. This report establishes the anatomical and biochemical properties of mouse forelimb muscles. Given the prevalence of this species in biological studies, these data will be invaluable for studying the biological basis of mouse muscle structure and function.
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Miembro Anterior/anatomía & histología , Ratones/anatomía & histología , Músculo Esquelético/anatomía & histología , Músculo Esquelético/metabolismo , Anatomía Comparada , Animales , Colágeno/análisis , Miembro Anterior/metabolismo , Humanos , Ratones/metabolismo , Cadenas Pesadas de Miosina/análisis , Especificidad de la EspecieRESUMEN
PURPOSE: The side-to-side (SS) tendon suture technique was designed to function as a repair that permits immediate postoperative activation and mobilization of a transferred muscle. This study was designed to test the strength and stiffness of the SS technique against a variation of the Pulvertaft (PT) repair technique. METHODS: Flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) tendons were harvested from 4 fresh cadavers and used as a model system. Seven SS and 6 PT repairs were performed, using the FDS as the donor and the FDP as the recipient tendon. For SS repairs, the FDS was woven through one incision in the FDP and was joined with 4 cross-stitch running sutures down both sides and one double-loop suture at each tendon free end. For PT repairs, the FDS was woven through 3 incisions in the FDP and joined with a double-loop suture at both ends of the overlap and 4 evenly spaced mattress sutures between the ends. Tendon repairs were placed in a tensile testing machine, preconditioned, and tested to failure. RESULTS: There were no statistically significant differences in cross-sectional area (p = .99) or initial length (p = .93) between SS and PT repairs. Therefore, all comparisons between methods were made using measures of loads and deformations, rather than stresses and strains. All failures occurred in the repair region, rather than at the clamps. However, failure mechanisms were different between the 2 techniques-PT repairs failed by the suture knots either slipping or pulling through the tendon material, followed by the FDS tendon pulling through the FDP tendon; SS repairs failed by shearing of fibers within the FDS. Load at first failure, ultimate load, and repair stiffness were all significantly different between SS and PT techniques; in all cases, the mean value for SS was higher than for PT. CONCLUSIONS: The SS repair using a cross-stitch suture technique was significantly stronger and stiffer than the PT repair using a mattress suture technique. This suggests that using SS repairs could enable patients to load the repair soon after surgery. Ultimately, this should reduce the risk of developing adhesions and result in improved functional outcome and fewer complications in the acute postoperative period. Future work will address the specific mechanisms (eg, suture-throw technique and tendon-weave technique) that underlie the improved strength and stiffness of the SS repair.
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Dedos/cirugía , Técnicas de Sutura , Tendones/cirugía , Tenodesis/métodos , Fenómenos Biomecánicos , Cadáver , Humanos , Tereftalatos Polietilenos , Estadísticas no Paramétricas , Estrés Mecánico , Resistencia a la TracciónRESUMEN
BACKGROUND AND OBJECTIVES: Percutaneous peripheral nerve stimulation (PNS) is an analgesic modality involving the insertion of a lead through an introducing needle followed by the delivery of electric current. This modality has been reported to treat chronic pain as well as postoperative pain following knee and foot surgery. However, it remains unknown if this analgesic technique may be used in ambulatory patients following upper extremity surgery. The purpose of this proof-of-concept study was to investigate various lead implantation locations and evaluate the feasibility of using percutaneous brachial plexus PNS to treat surgical pain following ambulatory rotator cuff repair in the immediate postoperative period. METHODS: Preoperatively, an electrical lead (SPR Therapeutics, Cleveland, Ohio) was percutaneously implanted to target the suprascapular nerve or brachial plexus roots or trunks using ultrasound guidance. Postoperatively, subjects received 5 min of either stimulation or sham in a randomized, double-masked fashion followed by a 5 min crossover period, and then continuous stimulation until lead removal postoperative days 14-28. RESULTS: Leads (n=2) implanted at the suprascapular notch did not appear to provide analgesia, and subsequent leads (n=14) were inserted through the middle scalene muscle and placed to target the brachial plexus. Three subjects withdrew prior to data collection. Within the recovery room, stimulation did not decrease pain scores during the first 40 min of the remaining subjects with brachial plexus leads, regardless of which treatment subjects were randomized to initially. Seven of these 11 subjects required a single-injection interscalene nerve block for rescue analgesia prior to discharge. However, subsequent average resting and dynamic pain scores postoperative days 1-14 had a median of 1 or less on the Numeric Rating Scale, and opioid requirements averaged less than 1 tablet daily with active stimulation. Two leads dislodged during use and four fractured on withdrawal, but no infections, nerve injuries, or adverse sequelae were reported. CONCLUSIONS: This proof-of-concept study demonstrates that ultrasound-guided percutaneous PNS of the brachial plexus is feasible for ambulatory shoulder surgery, and although analgesia immediately following surgery does not appear to be as potent as local anesthetic-based peripheral nerve blocks, the study suggests that this modality may provide analgesia and decrease opioid requirements in the days following rotator cuff repair. Therefore, it suggests that a subsequent, large, randomized clinical trial with an adequate control group is warranted to further investigate this therapy in the management of surgical pain in the immediate postoperative period. However, multiple technical issues remain to be resolved, such as the optimal lead location, insertion technique, and stimulating protocol, as well as preventing lead dislodgment and fracture. TRIAL REGISTRATION NUMBER: NCT02898103.
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Traumatismos de los Dedos/fisiopatología , Articulaciones de los Dedos/fisiopatología , Traumatismos de los Tendones/fisiopatología , Adulto , Fenómenos Biomecánicos , Traumatismos de los Dedos/cirugía , Fuerza de la Mano , Humanos , Imagen por Resonancia Magnética , Masculino , Procedimientos Ortopédicos/métodos , Rango del Movimiento Articular , Rotura , Traumatismos de los Tendones/cirugía , Resistencia a la Tracción/fisiología , Resultado del TratamientoAsunto(s)
Fracturas Conminutas/complicaciones , Fracturas del Radio/complicaciones , Traumatismos de los Tendones/complicaciones , Baloncesto/lesiones , Disección , Articulación del Codo/diagnóstico por imagen , Articulación del Codo/fisiopatología , Fijación Interna de Fracturas , Fracturas Conminutas/cirugía , Humanos , Ligamentos Articulares/cirugía , Masculino , Pronación , Fracturas del Radio/fisiopatología , Fracturas del Radio/cirugía , Rango del Movimiento Articular , Supinación , Tomografía Computarizada por Rayos X , Adulto JovenRESUMEN
For the extrinsic hand flexors (flexor digitorum profundus, FDP; flexor digitorum superficialis, FDS; flexor pollicis longus, FPL), moment arm corresponds to the tendon's distance from the center of the metacarpalphalangeal (MP), proximal interphalangeal (PIP), or distal interphalangeal (DIP) joint. The clinical value of establishing accurate moment arms has been highlighted for biomechanical modeling, the development of robotic hands, designing rehabilitation protocols, and repairing flexor tendon pulleys (Brand et al., 1975; An et al., 1983; Thompson and Giurintano, 1989; Deshpande et al., 2010; Wu et al., 2010). In this study, we define the moment arms for all of the extrinsic flexor tendons of the hand across all digital joints for all digits in cadaveric hands.
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Articulaciones de los Dedos/fisiología , Tendones/patología , Anciano , Anciano de 80 o más Años , Fenómenos Biomecánicos , Cadáver , Síndrome del Túnel Carpiano/patología , Femenino , Dedos , Mano/fisiología , Humanos , Húmero/patología , Masculino , Persona de Mediana Edad , Estrés MecánicoRESUMEN
The relationship between muscle mechanical conditions and gene expression was investigated by varying both stress and contraction mode imposed upon rat dorsiflexors (n= 25), activating them at high or low frequencies (150 Hz or 40 Hz) either eccentrically or isometrically. Muscle physiological, immunohistochemical and gene expression changes were then measured 24 h after the exercise bout. Peak stress was the best predictor of muscle injury, independent of contraction mode (i.e. eccentric or isometric). When peak stresses were matched, no physiological or immunohistochemical differences were detected between isometric and eccentric contractions. The expression of certain myogenic regulatory and muscle ankyrin repeat protein (MARP) genes (myoD, myogenin, MLP and CARP) depended both on peak muscle stress achieved during contraction and contraction mode. In contrast, Arpp/Ankrd2 was dramatically upregulated only by eccentric contractions, but not by isometric contractions, even though the stress level of the eccentric contractions varied over a three-fold range and overlapped with that of the isometric group. The role that Arpp/Ankrd2 upregulation plays in the biological response to eccentric contraction remains to be determined, as does the control mechanism whereby the expression of certain genes (such as myoD, myogenin, MLP and CARP) is sensitive to muscle stress while another (Arpp/Ankrd2) is sensitive only to contraction mode.
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Proteínas Musculares/genética , Proteínas Represoras/genética , Animales , Desmina/metabolismo , Fibronectinas , Regulación de la Expresión Génica , Inmunohistoquímica , Contracción Isométrica , Proteínas con Dominio LIM , Masculino , Modelos Animales , Análisis Multivariante , Proteínas Musculares/metabolismo , Músculo Esquelético/lesiones , Músculo Esquelético/metabolismo , Proteína MioD/genética , Proteína MioD/metabolismo , Miogenina/genética , Miogenina/metabolismo , ARN Mensajero/metabolismo , Ratas , Ratas Sprague-Dawley , Análisis de Regresión , Proteínas Represoras/metabolismo , Estrés Mecánico , Factores de Tiempo , Vimentina/metabolismoRESUMEN
We examined the architectural properties of the rotator cuff muscles in 10 cadaveric specimens to understand their functional design. Based on our data and previously published joint angle-muscle excursion data, sarcomere length operating ranges were modeled through all permutations in 75 masculine medial and lateral rotation and 75 masculine abduction at the glenohumeral joint. Based on physiologic cross-sectional area, the subscapularis would have the greatest force-producing capacity, followed by the infraspinatus, supraspinatus, and teres minor. Based on fiber length, the supraspinatus would operate over the widest range of sarcomere lengths. The supraspinatus and infraspinatus had relatively long sarcomere lengths in the anatomic position, and were under relatively high passive tensions at rest, indicating they are responsible for glenohumeral resting stability. However, the subscapularis contributed passive tension at maximum abduction and lateral rotation, indicating it plays a critical role in glenohumeral stability in the position of apprehension. These data illustrate the exquisite coupling of muscle architecture and joint mechanics, which allows the rotator cuff to produce near maximal active tensions in the midrange and produce passive tensions in the various end-range positions. During surgery relatively small changes to rotator cuff muscle length may result in relatively large changes in shoulder function.
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Rango del Movimiento Articular/fisiología , Manguito de los Rotadores/anatomía & histología , Articulación del Hombro/anatomía & histología , Anciano de 80 o más Años , Cadáver , Femenino , Humanos , Técnicas In Vitro , Masculino , Contracción Muscular/fisiología , Articulación del Hombro/fisiologíaRESUMEN
Granulocyte colony stimulating factor (G-CSF) is well known for its ability to drive the maturation and mobilization of neutrophils. G-CSF also appears to have the potential to activate functions of mature neutrophils, influencing recruitment at sites of inflammation and tissue injury. We investigated the ability of G-CSF to stimulate adhesion of isolated blood neutrophils. G-CSF induced significant adherence to intercellular adhesion molecule (ICAM)-1 that was both macrophage antigen-1 (Mac-1) and leukocyte function-associated antigen-1 dependent. The kinetics of G-CSF-stimulated adhesion to ICAM-1 peaked at 11 min without detectable surface upregulation of Mac-1. This was in marked contrast to chemokines, in which peak activation of adhesion is seen within 1 min of stimulation. In contrast to chemokine-induced adhesion, G-CSF stimulation was not inhibited by pertussis toxin. G-CSF also augmented the attachment of neutrophils to activated human umbilical vein endothelial cells (HUVEC) through specific effects on neutrophils, because HUVEC appear to lack functional G-CSF receptors.
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Factor Estimulante de Colonias de Granulocitos/farmacología , Neutrófilos/fisiología , Animales , Adhesión Celular/efectos de los fármacos , Adhesión Celular/fisiología , Línea Celular , Relación Dosis-Respuesta a Droga , Humanos , Ratones , Neutrófilos/citología , Neutrófilos/efectos de los fármacos , Proteínas RecombinantesRESUMEN
PURPOSE: Metacarpal fractures are common in hand surgery. Metacarpal shortening ranging from 2 mm to as much as 10 mm has been deemed acceptable in the literature. We examined the effect of metacarpal shortening on interosseous muscle architecture and predicted force production capacity based on the standard muscle length-tension curve (commonly known as the Blix curve). METHODS: The dorsal interosseous muscles between the middle and ring finger metacarpals from 9 adult human cadaver hands were exposed and studied. The ring finger metacarpal was translated proximally in 2-mm increments in relation to a stationary middle finger metacarpal. Digital images were obtained and analyzed to define the length and orientation of individual muscle fibers with each incremental change in position. RESULTS: Interosseous muscle fiber length increased and pennation angle decreased uniformly with increasing proximal translation of the ring finger metacarpal. At 10 mm of shortening the fiber length had increased to 20.8 +/- 1.8 mm, or to approximately 125% of optimum fiber length, and the pennation angle had decreased to 6.7 degrees +/- 2.2 degrees or by approximately 50%. CONCLUSIONS: The interosseous muscles have been shown to have a high fiber-to-muscle length ratio. This ratio indicates that these muscles function optimally over a short range of lengths, leaving them vulnerable to derangement in function owing to alteration in the surrounding bony architecture. Based on the standard muscle length--tension relationship we had predicted a steady linear decrease in interosseous power with proximal translation of the metacarpal. The results indicate an initial linear progression with a plateau at approximately 8 mm of shortening. At 2 mm of shortening there is an approximately 8% loss of power generation, at 10 mm of metacarpal shortening we predict the interosseous muscle to be capable of only approximately 55% of its optimum power compared with the resting position.
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Fracturas Óseas/cirugía , Metacarpo/lesiones , Metacarpo/cirugía , Músculo Esquelético/fisiopatología , Fenómenos Biomecánicos , Fuerza de la Mano/fisiología , Humanos , SarcómerosRESUMEN
Recently, we reported that tethering and rolling of neutrophils in shear flow over a substrate of E-selectin signals activation of beta 2-integrins and firm adhesion via an intracellular signaling pathway involving phosphorylation of p38 MAP kinase. In the current study the objective was to examine the molecular mechanisms and shear dependence underlying activation and adhesion of beta 2-integrin during shear-induced collisions between human neutrophils and murine B cells (300.19) transfected to express either E-selectin or L-selectin. Three separate parameters of cell activation were assessed over the time course of application of a defined shear field to heterotypic cell suspensions in a cone-plate viscometer. These were the two-body collision doublet lifetime and capture efficiency, surface upregulation of CD11b/CD18, and tyrosine phosphorylation of p38 MAP kinase. The data indicate that neutrophil adhesion to E-selectin expressing 300.19 cells occurs with a fourfold higher efficiency of firm adhesion than do collisions with L-selectin or parent control cells. Visual analysis of aggregation in a transparent cone-plate rheoscope revealed that the lifetime and efficiency of doublet formation increased fourfold as the applied shear stress increased. Neutrophil tethering via E-selectin was associated with rapid activation as indicated by upregulation of surface CD11b/CD18 and phosphorylation of p38 MAP kinase within seconds of application of shear. Activation greatly exceeded that observed for neutrophils sheared alone or with B cells expressing L-selectin. A distinct dependence of activation on the magnitude of the shear rate suggests a coupling between the fluid mechanical effects of shear and signaling of neutrophil adhesion.