Sonographic diagnosis of a glomus tumor of the thigh.

Extradigital glomus tumors are a very rare entity. Here, we report a rare case of a glomus tumor in an atypical anatomic site: the thigh. The clinical features together with the results of MRI, and sonography and Doppler sonographic imaging helped to distinguish glomus tumor of the thigh from other soft tissue neoplasms. The tumor arising from the thigh was excised, and following surgery, the patient was symptom free without evidence of complications or recurrence. There have only been a few previously reported cases describing the use of Doppler sonography in the evaluation of extradigital glomus tumors. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:50-52, 2017.

Short-term effect of ultrasound-guided low-molecular-weight hyaluronic acid injection on clinical outcomes and imaging changes in patients with rheumatoid arthritis of the ankle and foot joints. A randomized controlled pilot trial.

To determine whether hyaluronic acid (HA) injection into rheumatoid arthritis ankles and feet can achieve improvement in foot function and reduce synovial hyper-vascularization. Forty-four patients with RA having unilateral or bilateral painful ankle and foot involvement (N = 75) were studied. All the patients were randomized to receive HA (N = 40) or lidocaine (LI) (N = 35) injection at 2-week intervals; Clinical assessments were performed using a visual analog scale (VAS) and foot function index (FFItotal) including subscales of pain (FFIpain) before injection at baseline, 4 weeks (first evaluation) and 12 weeks (secondary evaluation). Imaging evaluation based on color Doppler ultrasound (CDUS) and synovitis scores was performed simultaneously. HA injection improved the VAS score (p = .009), FFIpain (p = .041), and FFItotal (p = .032) considerably more than LI injections did at the first evaluation. The CDUS values at first evaluation (p = .005) and secondary evaluation (p < .001) decreased significantly compared with the base line values. HA injections reduced the CDUS values of more than half of the joints (54%, p = .042) while the control group exhibited no change (20%, p = .56). However, HA injection did not reduce the CDUS values more than LI injection did. Regarding the evaluation of synovial hypertrophy, no significant difference was observed between or within the groups in the synovitis scores. HA injection improved short-term foot function and pain reduction. HA injection may have a modest effect in reducing synovial hyper-vascularization. Further large-scale study is warranted to confirm this result.

Corticospinal integrity and motor impairment predict outcomes after excitatory repetitive transcranial magnetic stimulation: a preliminary study.

OBJECTIVE: To identify the effective predictors for therapeutic outcomes based on intermittent theta-burst stimulation (iTBS). DESIGN: A sham-controlled, double-blind parallel study design. SETTING: A tertiary hospital. PARTICIPANTS: People with stroke (N=72) who presented with unilateral hemiplegia. INTERVENTIONS: Ten consecutive sessions of real or sham iTBS were implemented with the aim of enhancing hand function. Patients were categorized into 4 groups according to the presence (MEP+) or absence (MEP-) of motor-evoked potentials (MEPs) and grip strength according to the Medical Research Council (MRC) scale. MAIN OUTCOME MEASURES: Cortical excitability, Wolf Motor Function Test (WMFT), finger-tapping task (FT), and simple reaction time were performed before and after the sessions. RESULTS: MEPs and the MRC scale were predictive of iTBS therapeutic outcomes. Group A (MEP+, MRC>1) exhibited the greatest WMFT change (7.6±2.3, P<.001), followed by group B (MEP-, MRC>1; 5.2±2.2 score change) and group C (MEP-, MRC=0; 2.3±1.5 score change). These improvements were correlated significantly with baseline motor function and ipsilesional maximum MEP amplitude. CONCLUSIONS: The effectiveness of iTBS modulation for poststroke motor enhancement depends on baseline hand grip strength and the presence of MEPs. Our findings indicate that establishing neurostimulation strategies based on the proposed electrophysiological and clinical criteria can allow iTBS to be executed with substantial precision. Effective neuromodulatory strategies can be formulated by using electrophysiological features and clinical presentation information as guidelines.

Effects of interactive visual feedback training on post-stroke pusher syndrome: a pilot randomized controlled study.

OBJECTIVE: We investigated the effects of a computer-generated interactive visual feedback training program on the recovery from pusher syndrome in stroke patients. DESIGN: Assessor-blinded, pilot randomized controlled study. PARTICIPANTS: A total of 12 stroke patients with pusher syndrome were randomly assigned to either the experimental group (N = 7, computer-generated interactive visual feedback training) or control group (N = 5, mirror visual feedback training). MAIN OUTCOME MEASURES: The scale for contraversive pushing for severity of pusher syndrome, the Berg Balance Scale for balance performance, and the Fugl-Meyer assessment scale for motor control were the outcome measures. Patients were assessed pre- and posttraining. RESULTS: A comparison of pre- and posttraining assessment results revealed that both training programs led to the following significant changes: decreased severity of pusher syndrome scores (decreases of 4.0 ± 1.1 and 1.4 ± 1.0 in the experimental and control groups, respectively); improved balance scores (increases of 14.7 ± 4.3 and 7.2 ± 1.6 in the experimental and control groups, respectively); and higher scores for lower extremity motor control (increases of 8.4 ± 2.2 and 5.6 ± 3.3 in the experimental and control groups, respectively). Furthermore, the computer-generated interactive visual feedback training program produced significantly better outcomes in the improvement of pusher syndrome (p < 0.01) and balance (p < 0.05) compared with the mirror visual feedback training program. CONCLUSIONS: Although both training programs were beneficial, the computer-generated interactive visual feedback training program more effectively aided recovery from pusher syndrome compared with mirror visual feedback training.

The influence of shoulder pain on functional limitation, perceived health, and depressive mood in patients with traumatic paraplegia.

OBJECTIVE: To assess whether functional activity, perceived health, and depressive symptoms differ between individuals with traumatic paraplegia with and without shoulder pain. DESIGN: Cross sectional and comparative investigation using the unified questionnaire. SETTING: Neural Regeneration and Repair Division unit of Taipei Veterans General Hospital in Taiwan. PARTICIPANTS: Seventy-six patients with paraplegia (23 with and 53 without shoulder pain) who had experienced spinal cord injury at American Spinal Injury Association Impairment Scale T2 to T12 neurologic level (at least 6 months previously). OUTCOME MEASURES: Spinal Cord Independence Measure (SCIM), a single item from the Medical Outcomes Study 36-Item Short-Form Health Survey, and Patient Health Questionnaire-9 (PHQ-9) depression scale. RESULTS: Shoulder pain was prevalent in 30% patients. Patients with shoulder pain had significantly worse perceived health and greater depressive symptoms than those without. No significant difference was found in functional ability between groups. Greater shoulder pain intensity was related to higher depressive scores (r=0.278, P=0.017) and lower self-perceived health scores (r=-0.433, P<0.001) but not SCIM scores (P=0.342). CONCLUSION: Although shoulder pain was unrelated to functional limitation, it was associated with lower perceived health and higher depressive mood levels.

Efficacy of synchronous verbal training during repetitive transcranial magnetic stimulation in patients with chronic aphasia.

BACKGROUND AND PURPOSE: Although multiple studies have suggested that repetitive transcranial magnetic stimulation (rTMS) may facilitate recovery after stroke, the efficacy of synchronous speech therapy integrated with an rTMS protocol has yet to be determined. We investigated language responses to this strategy and determined the longevity of the resulting therapeutic outcomes. METHODS: Forty-five patients with stroke who presented with nonfluent aphasia were randomly assigned to the TMSsyn group and underwent synchronous picture-naming training together with contralesional 1 Hz-rTMS for 10 daily sessions. The TMSsub group underwent subsequent picture-naming activity after the primed 1 Hz-rTMS, and the TMSsham group received concurrent naming task along with the sham 1 Hz-rTMS. The Concise Chinese Aphasia test and the picture-naming test were performed before, immediately, and after 3 months of the intervention. RESULTS: TMSsyn showed significantly superior results in Concise Chinese Aphasia test score (P<0.001), expression and description subtests (P<0.001), and action (P=0.02) and object naming activity (P=0.008); the superior results lasted for 3 months (P=0.005), in comparison with the TMSsub and TMSsham groups. CONCLUSIONS: We established a real-time model that involved implementing verbal tasks together with the rTMS protocol. Our results confirmed that the strategy yielded favorable outcomes that were of considerable longevity. The results also indicated that the rTMS protocol and language training can be combined to achieve outcomes superior to those obtained when used separately. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT02120508.

Use of bisphosphonates and the risk of osteonecrosis among cancer patients: a systemic review and meta-analysis of the observational studies.

PURPOSE: This study aims to systematically review observational studies evaluating the use of bisphosphonates (BPs) and risk of osteonecrosis of the jaw (ONJ) among cancer patients. METHODS: PubMed, Embase, and Cochrane Library were screened from database inception to Aug 2012. Two reviewers independently identified cohort and case-control studies evaluating the use of oral or intravenous (IV) BPs and the risk of ONJ and extracted the characteristics of the studies and risk estimates. Pooled estimates of odds ratios and 95 % confidence intervals were derived by random effects meta-analysis. Subgroup analyses were carried out according to patients' characteristics and route of BP use. RESULTS: We identified eight studies, including 1,389 cases and 569,620 controls. Use of BPs was associated with a significantly increased risk of ONJ (odds ratio (OR) 4.25; 95 % confidence interval (CI) 3.67-5.36; I (2) = 0 %). The summary OR was 4.22 (95 % CI 3.21-5.54; I (2) = 0 %) for adjusted studies. IV BPs were associated with higher risk (OR 4.27; 95 % CI 3.38-5.40; I (2) = 0 %) than oral BPs (OR 1.18; 95 % CI 0.89-1.56; I (2) = 0 %). Hospital-based studies were associated with higher risk estimates than population-based studies. CONCLUSION: The available evidence suggests that use of BPs in cancer patients is associated with a substantial risk for ONJ. Patients receiving IV BP are at the highest risk. It is important to assess oral health before initiating therapy and to avoid dental procedures during the active phase of intravenous BP therapy.

Intraoperative brain mapping to identify corticospinal projections during resective epilepsy surgery in children with congenital hemiparesis.

PURPOSE: The purpose of the study is to determine corticospinal organization using intraoperative neurophysiologic monitoring (IONM) during resective epilepsy surgery for patients with congenital hemiparesis and intractable epilepsy. METHODS: Ten patients, aged 3-17, with intractable epilepsy underwent resective surgery. Transcranial stimulation (TCS) was achieved using a pair of cork screws at Cz and C3/C4, respectively. A 1 × 4 stimulating electrode strip was placed on the presumed motor cortex of the affected hemisphere for direct cortical stimulation (DCS) after craniotomy. Multipulse TCS and DCS train stimulation was delivered, with simultaneous recordings from bilateral abductor pollicis brevis and abductor halluces, to determine the corticospinal projection pattern of the paretic limbs. RESULTS: The above mapping techniques revealed ipsilateral corticospinal projections from the contralesional hemisphere to target muscles in the paretic limbs in three patients, projections from both hemispheres to target muscles in three, and preserved crossed projections from the affected hemisphere in four. Nine patients were seizure free after surgery. Five had unchanged postoperative functional status, and three showed minimally improved use of the paretic hand. Two developed new motor deficits after surgery, which may have been due to a premotor syndrome in one patient, since it completely resolved within 2 weeks. The other experienced increased weakness of the paretic lower limb because a small part of the eloquent cortex was removed for better seizure control. CONCLUSIONS: Using IONM to define the corticospinal projection pattern is a valuable technique that can potentially replace preoperative fMRI and transcranial magnetic stimulation in resective epilepsy surgery, particularly for younger patients.

Neuromuscular and biomechanical strategies of turning in ambulatory individuals post-stroke.

Given that the inter-limb asymmetry and additional balance control are required for turning, stroke subjects spend more time to turn than healthy subjects. Few studies have investigated specific turning-related neuromuscular and biomechanical strategies post-stroke to clarify factors favoring or hindering turning speed toward different directions. The purpose of this study was to compare the speed and lower-limb muscular and kinematic strategies of turning between individuals with stroke and matched controls. Fifteen ambulatory individuals with chronic stroke and 15 matched healthy controls participated in this study. Turning speed during turning along a 0.8-meter radius curved path toward both sides for 5 meters was recorded. Simultaneously, kinematics and muscle activation patterns of lower extremity were measured by the joint angle and electromyography during turning. The slower speed was noted for the turning task in stroke patients when compared to controls. Individuals with stroke have insufficient muscle activation in tibialis anterior and biceps femoris of the affected inner leg, accompanied by reduced standing knee flexion, which disturb turning toward the affected side. The augmented standing knee flexion of unaffected side in stroke patients hindered the function of the outer leg while turning toward the affected side, but assisted the role of the inner leg while turning toward the unaffected side. However, the absence of difference in turning speeds toward the affected and unaffected sides may attribute to the diminished swing phase knee flexion of the affected outer leg. Our findings suggest that there are direction-related strategies in turning for stroke subjects since the inner and outer legs, respectively, have specific roles for standing support and leg swing during turning. Therefore, in addition to turning speed, kinematics and muscular components during turning toward either direction should be considered to improve turning performance as well as to prevent falls in stroke rehabilitation.

Use of serum procalcitonin to detect bacterial infection in patients with autoimmune diseases: a systematic review and meta-analysis.

OBJECTIVE: To systematically review evidence of the accuracy of the procalcitonin test for diagnosis of bacterial infection in patients with autoimmune disease. METHODS: The major databases Medline, EMBase, and the Cochrane Library were searched for studies published between January 1966 and October 2011 that evaluated procalcitonin, alone or in comparison with other laboratory markers such as C-reactive protein (CRP), as a diagnostic marker for bacterial infection in patients with autoimmune disease and provided sufficient data to permit construction of 2 × 2 tables. RESULTS: Nine studies were included in the final meta-analysis. The area under the summary receiver operating characteristic curve values were 0.91 (95% confidence interval [95% CI] 0.88-0.93) for procalcitonin and 0.81 (95% CI 0.78-0.84) for CRP. In general, testing for procalcitonin was highly specific for identifying infectious complications, although it was not as sensitive as testing for CRP. Pooled sensitivity was 0.75 (95% CI 0.63-0.84) for procalcitonin tests and 0.77 (95% CI 0.67-0.85) for CRP tests. Pooled specificity was 0.90 (95% CI 0.85-0.93) for procalcitonin tests and 0.56 (95% CI 0.25-0.83) for CRP tests. The positive likelihood ratio for procalcitonin (7.28 [95% CI 5.10-10.38]) was sufficiently high to qualify procalcitonin testing as a rule-in diagnostic tool, while the negative likelihood ratio (0.28 [95% CI 0.18-0.40]) was not sufficiently low to qualify procalcitonin testing as a reliable rule-out diagnostic tool. CONCLUSION: Procalcitonin has higher diagnostic value than CRP for the detection of bacterial sepsis in patients with autoimmune disease, and the test for procalcitonin is more specific than sensitive. A procalcitonin test is not recommended to be used in isolation as a rule-out tool.

Ultrasound-guided perineural steroid injection to treat intractable pain due to sciatic nerve injury.

PURPOSE: Sciatic neuropathy is a rare but serious complication of cardiac surgery. Neuropathic pain following nerve injury can be severely debilitating and largely resistant to treatment. We present a case of this complication where ultrasound-guided perineural steroid injection at the site of the sciatic nerve injury provided excellent pain relief and facilitated subsequent rehabilitation. CLINICAL FEATURES: A 17-yr-old boy developed bilateral sciatic neuropathy after a nine-hour cardiac surgical procedure in the supine position, resulting in debilitating dysesthesia refractory to neuropathic pain therapies and leading to severe functional limitation. With magnetic resonance imaging of the lower extremities, the location of the lesion was determined to be from the level of the superior gemellus to the level of the quadratus femoris. An ultrasound-guided injection of triamcinolone 20 mg and lidocaine 40 mg around both sciatic nerves at the level of the lesion was administered two months after the surgery, and the pain score (rated on a scale 0-10) at rest decreased from 9-10 to 1 two weeks after the injection. CONCLUSIONS: There are a limited number of reports in the literature on sciatic nerve injuries associated with cardiac surgery. This case illustrates the efficacy of ultrasound-guided steroid injection around sciatic nerves at the level of superior gemellus in treating our patient's neuropathic pain.

Health-related quality of life in children and adolescents with spinal dysraphism: results from a Taiwanese sample.

PURPOSE: This study was designed to investigate health-related quality of life (HRQL) in children and adolescents with spinal dysraphism and to determine the differences between the myelomeningocele (MMC) and lipomyelomeningocele (LMMC) groups. METHODS: Thirty-two patients (mean age, 13.2 years) with MMC and 28 patients (mean age, 11.3 years) with LMMC participated in this study. HRQL was measured using the Child Health Questionnaire-Parent Form 50 (CHQ-PF50). The CHQ-PF50 scores for the study participants were compared with those of a reference sample of healthy Taiwanese children. Outcomes for children with MMC were compared with those for children with LMMC. We also explored the relationships of the lesion level and associated medical problems with HRQL in these subjects. RESULTS: Patients with MMC had significantly lower scores on the physical and psychosocial aspects of CHQ-PF50 than did healthy children. Patients with LMMC had lower scores on some domains but had comparable psychosocial summary scores. Significant differences were noted between the MMC and LMMC groups for all subscales and both summary scores. Children with a higher lesion level had poor physical health (r = -0.52, P < 0.001) but not poor psychosocial health. The number of associated medical problems, indicating their severity, was related to both physical (r = -0.77, P < 0.001) and psychosocial health (r = -0.57, P < 0.001). CONCLUSIONS: Children and adolescents with MMC have reduced HRQL compared with those with LMMC. Children and adolescents with more associated medical problems have the greatest risk of diminished physical and psychosocial well-being.

Ultrasound-guided refilling of an intrathecal baclofen pump--a case report.

INTRODUCTION: Refilling intrathecal baclofen (ITB) pumps can be difficult because many patients gain excessive weight after implantation due to their reduced expenditure of energy on muscle spasticity. METHODS: We report a case of a 12-year-old girl with spastic quadriplegia who gained 20 lbs after pump implantation. It was necessary to identify the access port of her pump by ultrasonography during drug refilling so as to avoid multiple needle punctures. RESULTS: The access port of the pump was readily visible by ultrasonography and stood out from other parts of the pump. CONCLUSION: Localisation of the access ports of ITB pumps by ultrasonography proved to be a feasible and easy technique for refilling the drug reservoir in patients with excessive weight gain and abundant subcutaneous fat after ITB therapy.

Impaired microvascular flow motion in subclinical diabetic feet with sudomotor dysfunction.

Impaired cutaneous blood flow and sweating dysfunction might be among the earliest manifestations of diabetic autonomic neuropathy. This study assessed the pathophysiological basis underlying skin vasomotion changes and their relation with progressive sudomotor dysfunction and other autonomic and somatic measures in subclinical diabetic feet. Laser Doppler skin perfusion was assessed on 68 diabetic and 25 control subjects. The low-frequency vasomotion was transformed into three frequency intervals 0.0095-0.021, 0.021-0.052 and 0.052-0.145 Hz, respectively, for the investigation of endothelial, neurogenic and myogenic effects on microcirculatory alterations. The diabetic patients were categorized into three groups by increasing severity of sudomotor dysfunction: SSR+ (sympathetic skin response present; 27 patients), SSR- (SSR absent; 23 patients) and at-risk (SSR absent and of preulcerative cracked skin; 18 patients). All diabetic patients underwent nerve conduction and cardiovascular autonomic studies. The total spectral and endothelial activity was significantly decreased only in the at-risk group. The SSR- group had lower neurogenic vasomotion than the SSR+ group (p<0.05). Although no statistical difference was noted between any group in absolute myogenic spectrum, the SSR- group had higher normalized myogenic activity than the SSR+ group (p<0.01). The larger drop in orthostatic pressure was paralleled by a reduction in the myogenic amplitude (r=-0.33, p<0.01). These results suggested that early impairment of low-frequency flow motion correlated closely with the presence of sudomotor dysfunction of subclinical feet mainly in neurogenic and endothelial components. Impaired systemic vascular tone as manifested by orthostatic hypotension was proportional to the degree of myogenic dysregulation in diabetic patients.

Diagnostic role of procalcitonin in patients with suspected appendicitis.

BACKGROUND: The aim of this study was to assess the diagnostic value of procalcitonin (PCT) in emergency department (ED) patients with suspected appendicitis. METHODS: A prospective observational study was carried out in the emergency department of a university hospital between July 2007 and June 2008. Adult patients who presented to the ED with clinically suspected appendicitis were enrolled. Each patient underwent serum PCT, C-reactive protein (CRP), and Alvarado score evaluation on admission. The results of these three measurements were analyzed in relation to the final diagnosis determined by histopathological findings or compatible computed tomography findings. RESULTS: Of the 214 study patients, 113 (52.8 %) had a confirmed diagnosis of appendicitis and 58 had complicated appendicitis (phlegmon, perforation, or gangrene). For the diagnosis of appendicitis, the area under the receiving operating characteristic (ROC) curve is 0.74 for Alvarado score, 0.69 for PCT, and 0.61 for CRP. Overall, the Alvarado score has the best discriminative capability among the three tested markers. We adopted two cutoff point approaches to harness both ends of the diagnostic value of a biomarker. PCT levels were significantly higher in patients with complicated appendicitis. For diagnosis of complicated appendicitis, a cutoff value of 0.5 ng/mL had a sensitivity of 29 % and a specificity of 95 %, while a cutoff value of 0.05 ng/ml had a sensitivity of 85 % and a specificity of 30 % in diagnosing complicated appendicitis. For those with a PCT value in the gray zone, clinical findings may play a more important role. CONCLUSION: The study does not support the hypothesis that the PCT test may be useful for screening ED patients for appendicitis. However, determination of the PCT level may be useful for risk assessment of ED patients with suspected complicated appendicitis.

Comparison of clinical characteristics and performance of pneumonia severity score and CURB-65 among younger adults, elderly and very old subjects.

BACKGROUND: Age-related alterations in the clinical characteristics and performance of severity scoring systems for community-acquired pneumonia (CAP) are unknown. METHODS: Consecutive patients with CAP presenting to the emergency department were prospectively studied. Patients were classified as younger adults (age 18-64 years), elderly (age 65-84 years) and very old subjects (age ≥85 years). Clinical characteristics, complications, outcomes and validity of the pneumonia severity index (PSI) and CURB-65 categories were compared across these three age categories. RESULTS: Analysis involved 348 (35.3%) younger adult patients, 438 (44.3%) elderly patients and 201 (20.0%) very old patients. Compared with younger adults, elderly and very old patients had a higher burden of comorbidities and a higher incidence of CAP-related complications. The 30-day mortality rate was 5.2% in younger adults, 7.1% in elderly patients and 9.5% in very old patients. The area under the ROC curve (AUCs) for PSI were 0.87 (95% CI 0.77 to 0.97), 0.85 (95% CI 0.803 to 0.897) and 0.69 (95% CI 0.597 to 0.787) and the AUCs for CURB-65 were 0.80 (95% CI 0.67 to 0.93), 0.73 (95% CI 0.65 to 0.82) and 0.60 (95% CI 0.47 to 0.73) in the younger adult, elderly and very old patients, respectively. A modified PSI or CURB-65 excluding the age variable increased the AUC in most age categories. There was no significant effect of age on 30-day mortality after adjusting for other PSI or CURB-65 variables. CONCLUSION: Elderly patients with CAP have more atypical clinical manifestations and worse outcomes. The underperformance of the PSI in elderly patients may be due to the inappropriate weight given to the age variable. A modification of the cut-off point for PSI or CURB-65 to define severe pneumonia may improve the score performance in elderly patients.

Evaluation of the value of rapid D-dimer test in conjunction with cardiac troponin I test for early risk stratification of myocardial infarction.

We sought to determine the diagnostic value of a D-dimer test for myocardial infarction (MI). The prospective cohort study was carried in the ED of a university hospital. All included patients were tested for D-dimer and cardiac troponin I (cTnI) on ED admission and additional cTnI 6 h later. AMI was retrospectively confirmed by employing the ESC-ACC-AHA-WHF 2007 universal definition. The discriminative value of D-dimer test was assessed by ROC curve analysis. Multivariate analysis was used to identify independent risk factors associated with D-dimer elevation other than MI. A total of 178 patients were included in this study. Median D-dimer levels were significantly higher in MI patients. A D-dimer value greater than 200 ng/ml was significantly associated with MI. When used alone, the test has a high sensitivity of 91.8% but a low specificity of 23.9%. Combined use of cTnI and D-dimer tests raised the sensitivity to 98.4% and helped early triage a subgroup of low risk patients. However, the test had the downside of 58% false positives. High false positives could be partly explained by the high prevalence of underlying hypercoagulable comorbidities. Diabetes mellitus with chronic renal insufficiency was identified as the strongest risk factor associated with D-dimer elevation in patients without MI. D-dimer test alone has a low diagnostic value for MI. Co-existing hypercoagulable conditions may confound the results. Combining cTnI and D-dimer tests enables early identification a low risk group of patients for MI at the cost of high false positives.

Efficacy of a computerized sensor system for evaluation and training of dizzy patients.

Patients with vestibular hypofunction often experience dizziness and unsteadiness while moving their heads. Appropriate sensors can effectively detect a patient's dynamic visual acuity and associated body balance control. Forty-one vestibular-deficit patients and 10 normal individuals were invited to participate in this study. Questionnaires, clinical assessment scales and objective measures were evaluated on participants' first visits. After 12 sessions of training, all scales were evaluated again on vestibular-deficit patients. The computerized system was composed of sensors, including a gyro and strain gauges, data acquisition accessories and LabVIEW software. Results revealed that the system could effectively distinguish normal subjects from subjects with vestibular deficits. In addition, after a rehabilitation program, subjects' subjective and objective performances were significantly improved. Based on our results, we concluded that the present system, which uses a gyro and strain gauges, may provide an effective method for assessing and treating vestibular-deficit patients.

Improving preventive foot care for diabetic patients participating in group education.

BACKGROUND: Diabetic foot care has yet to be enhanced in a universal health-care system in which specialized podiatric medical services are unavailable. This baseline assessment surveyed diabetic patients attending group education to improve current foot-care practices. METHODS: Of 302 diabetic patients receiving usual outpatient care, 155 received group patient education on general diabetes-related information, which included foot care and an annual checkup by a diabetes association during the previous 2 years, and 147 did not. Patient foot-care behaviors, physician practice patterns, and patient self-perceived foot risk as cross-checked with the neurologic and vascular assessments were investigated by conducting retrospective medical record reviews and structured interviews. RESULTS: More than half of the patients in both groups reported inappropriate self-care behaviors (eg, walking barefoot and heating or soaking their feet). The percentages of patients receiving documented examinations and referrals for foot problems were low in both groups and were not significantly different. Among at-risk patients, 56% of the diabetes association group but only 30% of the non-diabetes association group perceived themselves to be at risk for future foot problems (P<.01). CONCLUSIONS: Many diabetic patients were not offered adequate foot-specific information during group lectures, even those with high-risk foot problems. To improve this, combining caregiver and patient education in foot-care practices is important, and systems of networked multidisciplinary professionals are believed to be needed, particularly in delivering customized interventions to at-risk patients based on the initial evaluation.

Altered cortical morphology in patients with chronic shoulder pain.

Shoulder pain is a common condition associated with slow recovery and high recurrence rates. Persistent pain may lead to structural brain changes that may further promote pain chronification. The present study addressed whether abnormal changes in cortical surface structure exist in patients with chronic shoulder pain of myofascial origin and whether such changes would be related to pain measures. Brain structural MRIs were obtained in 22 patients with chronic pain in the bilateral upper trapezius muscles and in 22 healthy controls. Cortical thickness, gyrification index and sulcal depth were assessed together with pain measures. Shallower sulcal depth was found in patients in the right central sulcus, posterior insula, inferior frontal and dorsomedial prefrontal cortices, precuneus, and the middle temporal cortex, and in the left medial orbitofrontal cortex. Negative correlations were found between the right central sulcus and pain intensity and between the left medial orbitofrontal cortex and pain affect. Cortical thickness or gyrification index did not differ significantly between the two groups. The afflicted cortical regions constitute interacting networks responsible for sensory, affective and cognitive dimensions of the pain experience.