Evaluation of inner teat morphology by using high-resolution ultrasound: Changes due to milking and establishment of measurement traits of the distal teat canal.

The teat canal is important in the defense against invading pathogens, but its functional features can be impeded by the milking process. The objective of our study was to compare teat morphology before and after a standard milking procedure using high-resolution ultrasonography. Tissue changes were determined by measuring inner traits of teat morphology: teat width, teat end width, teat cistern width, diameter of the lower and upper teat wall, teat canal length, and teat canal diameter. Additionally, 3 traits describing the distal teat canal and its external orifice were established: diameter of the distal teat canal orifice, distal teat canal perimeter, and distal teat canal surface. In the first trial, we verified the repeatability of scanning over time with a mixed model. During the second trial, significant changes after milking were observed for all measured traits of teat morphology except teat end width. The traits from the distal teat canal and its orifice were remarkably changed by milking: distal teat canal orifice, +28.9%; distal teat canal perimeter, +25.0%; and distal teat canal surface, +41.5%. Comparing multiparous versus primiparous cows, higher values of teat width, teat end width, and teat canal length were observed in the older animals. Testing the effect of milk yield on teat dimensions, cows with milk yields >11.0 kg/afternoon milking were found to have larger teat widths, teat end widths, and cistern widths before attachment of the cluster. Furthermore, we observed associations of inner teat morphology toward bacterial counts in the appropriate milk. Regarding this udder health-related parameter especially, the newly established traits showed a connection. Teats in which milk showed bacterial growth had larger distal teat canal perimeters and distal teat canal surfaces. High-resolution ultrasonographic scanning of dairy teats allowed a detailed visualization of the inner morphology. The applied procedure can therefore serve as a useful tool for comparison and evaluation of different milking techniques by analyzing the resulting changes of the morphological traits. The thorough description of teat tissue can also be applied for drawing conclusions on the status of the teat canal's physical and mechanical defense function.

Striatal volume deficits in children with ADHD who present a poor response to methylphenidate.

Methylphenidate (MPH) is the first choice of medical treatment for attention-deficit/hyperactivity disorder (ADHD). Its mechanism of action is to inhibit the reuptake of dopamine and noradrenaline mainly in the region of the striatum. It has been estimated that 10-30 % of patients with ADHD do not respond adequately to MPH. The aim of this study was to evaluate whether striatal differences exist between good and poor responders to MPH. The sample included 27 treatment-naïve children with ADHD between the ages of 6 and 14. MPH administration started 1 day after the MRI acquisition. After a month, psychiatrists established the good or poor response to treatment according to clinical criteria. MRI images were analyzed using a technique based on regions of interest applied specifically to the caudate and accumbens nuclei. Sixteen patients showed good response to MPH and 11 a poor one. Regions of interest analysis showed that good responders had a higher concentration of gray matter in the head of both caudate nuclei and the right nucleus accumbens. Furthermore, a significant correlation was found between caudate and accumbens nuclei volume and the Conners' Parent Rating Scale and Continuous Performance Test improvement. These results support the hypothesis of the involvement of the caudate and accumbens nuclei in MPH response and in ADHD pathophysiology.

[Sensitivity of the sympathetic skin response and scintigraphy in the diagnosis of complex regional pain syndrome]. / Sensibilidad de la respuesta simpática cutánea y de la gammagrafía en el diagnóstico del síndrome dolor regional complejo.

OBJECTIVE: To evaluate the sensitivity of sympathetic skin response (SSR) and compare it with scintigraphy in patients with complex regional pain syndrome diagnosed according to the Budapest criteria. MATERIAL AND METHODS: Twenty-two patients with complex regional pain syndrome who attended the Rehabilitation and Physical Medicine Department between January-2018 and May-2022 have been prospectively evaluated. The scintigraphy was considered positive if in the 1st-2nd phase slight asymmetric and diffuse uptake was observed, or when in the 3rd phase marked periarticular radioisotope uptake was observed. SSR was abnormal if: a) no response after 20 stimuli; b) lack of habituation with permanence of the stimuli greater than 67.2%. RESULTS: Age 55.4±8.57 years. Complex regional pain syndrome was more frequent in women (90.9%), more common in upper limbs (68.2%) than lower limbs (31.8%). In SSR, we have observed normal response (<67.2%) in 2 patients (11.1%), lack of SSR in 2 patients (11.1%) and lack of habituation (>67.2%) in 14 patients (77.8%). In total, 16 patients presented abnormal or absent responses (88.8%). The diagnostic sensitivity of scintigraphy is similar to that of SSR (89.5% vs 88.8%), with no statistical difference (P=.6721). CONCLUSION: Scintigraphy has shown similar sensitivity to SSR, although the simplicity, security, low cost, non-ionizing and non-invasiveness of the latter technique suggest that it could be more cost-effective. The lack of habituation and the absence of response could identify response patterns and localize the involvement in the afferent, central, efferent or post-ganglionic pathways.

Central venous thrombosis and perioperative vascular access in adult intestinal transplantation.

BACKGROUND: Venous access is crucial in intestinal transplantation, but a thrombosed venous system may prevent the use of central veins of the upper body. The incidence of venous thrombosis and the necessity to perform alternative vascular access (AVA) in intestinal transplant recipients have not been fully investigated. METHODS: Records of adult patients who underwent intestinal transplantation between January 1, 2001, and December 31, 2009, were reviewed. Contrast venography was performed as pre-transplantation screening. Vascular accesses at the transplantation were categorized as I (percutaneous line via the upper body veins), II (percutaneous line via the lower body veins), and III (vascular accesses secured surgically, with interventional radiology, or using non-venous sites). Categories II and III were defined as AVA. Risk factors for central venous thrombosis and those for requiring AVA were analysed, respectively. RESULTS: Among 173 patients, central venous obstruction or stenosis (<50% of normal diameter) was found in 82% (141 patients). AVA was required in 4.6% (eight patients: four in each category II and III). Large-bore infusion lines were placed via the femoral arteries in all category III patients without complications. Existing inferior vena cava filter and hypercoagulable states were identified as the risk factors for the use of AVA, but not for central venous thrombosis. Outcomes of patients who underwent AVA were similar to those of patients without AVA. CONCLUSIONS: The majority of adult patients undergoing intestinal transplantation had at least one central venous stenosis or obstruction. The recipient outcomes were comparable when either standard vascular access or AVA was used for transplantation.

[Transcutaneous stimulation of the posterior tibial nerve modifies the sympathetic skin response and improves overactive bladder syndrome: Case series and possible diagnostic test]. / La estimulación transcutánea del nervio tibial posterior modifica la respuesta simpática cutánea y mejora el síndrome de vejiga hiperactiva: serie de casos y posible prueba diagnóstica.

OBJECTIVE: (a) To assess the effect of transcutaneous neuromodulation (TNM) of the posterior tibial nerve plus biofeedback on the sympathetic skin response (SSR). (b) Evaluate its effect on clinical symptoms. (c) Consider SSR as a probable neurophysiological test useful both for diagnosis and for follow-up in patients with overactive bladder (OAB). (d) Evaluate its cost compared to other techniques. MATERIAL AND METHODS: A prospective quasi-experimental before and after study in 10 OAB patients. OUTCOME VARIABLES: daytime (DUF) and nighttime (NUF) urinary frequency, strength of the pelvic floor muscles measured by manometry (maximum and mean pressure) and sympathetic skin response (SSR). RESULTS: DUF improved from 10.3±5.45 to 5.9±2.42 episodes (P=.0050). The NUF improved from 2.4±1.5 to 0.6±0.69 episodes (P=.0012). The maximum pressure ranged from 34.7±16.51 to 39.7±3.65mmHg (P=.0195). The mean pressure of the pelvic floor muscles improved from 6.6±3.65 to 9.3±5.43mmHg (P=.0333). SSR changed from 100% hyperexcitability prior to treatment to 50±14.14% (P=.0000). CONCLUSION: TNM plus biofeedback could modify SSR and improve clinical and manometry variables in a series of patients with OAB. The probable diagnostic and prognostic utility of this neurophysiological test in OAB and detrusor hyperactivity is reported for the first time. A larger sample study is needed to confirm the promising findings seen in this preliminary study.

Feasibility and acceptability of a remotely-delivered behavioural health coaching intervention to limit gestational weight gain.

INTRODUCTION: Gestational weight gain (GWG) and postpartum weight retention (PPWR) are significant, potentially modifiable, contributors to women's future weight and health trajectories. There is a need for feasible and patient-centered (i.e., convenient, remotely-delivered, technology-enhanced, and accessible through the prenatal care setting) behavioural interventions that limit GWG and PPWR. This study tests the feasibility and acceptability of a remotely-delivered behavioural health coaching intervention to limit gestational weight gain and postpartum weight retention. METHODS: Pregnant women (11-16 weeks gestation) were recruited from two prenatal clinics and randomized to the active intervention or health education comparison group. Completion of the program was monitored and perceived helpfulness was rated (0-100). RESULTS: Twenty-six women were randomized (n = 13 per arm; mean age = 31.6 years, SD = 3.6; mean BMI = 26.7 kg/m2, SD = 7.4). Participants completed a median of 18 coaching calls and 16/19 learning activities during pregnancy, and a median of 6 calls and 5/6 learning activities postpartum. They logged weights at least once/week for a median of 36/38 expected weeks and tracked daily calories and exercise for a median of 154/266 days and 72/266 days, respectively. Median (Q1, Q3) helpfulness ratings of the program during pregnancy were 80 (64, 91) and 62 (50, 81) postpartum; helpfulness ratings of coaching calls were 85 (58, 98). At 37 weeks gestation, 77% of participants achieved IOM weight gain recommendations compared to 54% in the comparison group. CONCLUSIONS: This study provides evidence for the feasibility and acceptability of a remotely-delivered behavioural weight control intervention in pregnancy and postpartum.

[Tarlov cyst and faecal incontinence: A case report and literature review]. / Quiste de Tarlov e incontinencia fecal: caso clínico y revisión de la literatura.

Tarlov, or perineural cysts, are lesions of the nerve root usually located at the sacral level of the spine. Their cause is unclear. These cysts are generally identified as an incidental finding and are usually asymptomatic. Symptomatic cysts are infrequent, with symptoms usually consisting of pain, radiculopathy and, less frequently, bladder, bowel and sexual dysfunction. We report the case of a 70-year-old woman with Tarlov cyst, provoking faecal incontinence, and review the aetiology, pathophysiology and management of this particular case.

Cerumen types in Choctaw Indians.

Certinen from 432 Choctaw Indians from Mississippi was classified as sticky or dry. The frequency of the autosomal recessive dry type was intermediate between that for Indians of western North America and that for Mayan groups of southern Mexico.

Pharmacokinetics of intravenous lithium chloride and assessment of agreement between two methods of lithium concentration measurement in the horse.

BACKGROUND: Pharmacokinetics of lithium chloride (LiCl) administered as a bolus, once i.v. have not been determined in horses. There is no point-of-care test to measure lithium (Li+ ) concentrations in horses in order to monitor therapeutic levels and avoid toxicity. OBJECTIVES: To determine the pharmacokinetics of LiCl in healthy adult horses and to compare agreement between two methods of plasma Li+ concentration measurement: spectrophotometric enzymatic assay (SEA) and inductively coupled plasma mass spectrometry (ICP-MS). STUDY DESIGN: Nonrandomised, single exposure with repeated measures over time. METHODS: Lithium chloride was administered (0.15 mmol/kg bwt) as an i.v. bolus to eight healthy adult horses. Blood samples were collected pre-administration and at multiple times until 48 h post-administration. Samples were analysed by two methods (SEA and ICP-MS) to determine plasma Li+ concentrations. Pharmacokinetics were determined based on the reference ICP-MS data. RESULTS: Adverse side effects were not observed. The SEA showed linearity, R2 = 0.9752; intraday coefficient of variation, 2.5%; and recovery, 96.3%. Both noncompartmental and compartmental analyses (traditional two-stage and nonlinear mixed-effects [NLME] modelling) were performed. Geometric mean values of noncompartmental parameters were plasma Li+ concentration at time zero, 2.19 mmol/L; terminal elimination half-life, 25.68 h; area under the plasma concentration-time curve from time zero to the limit of quantification, 550 mmol/L min; clearance, 0.273 mL/min/kg; mean residence time, 31.22 h; and volume of distribution at steady state, 511 mL/kg. Results of the traditional two-stage analysis showed good agreement with the NLME modelling approach. Bland-Altman analyses demonstrated poor agreement between the SEA and ICP-MS methods (95% limits of agreement = 0.14 ± 0.13 mmol/L). MAIN LIMITATIONS: Clinical effects of LiCl have not been investigated. CONCLUSIONS: The LiCl i.v. bolus displayed pharmacokinetics similar to those reported in other species. The SEA displayed acceptable precision but did not agree well with the reference method (ICP-MS). The Summary is available in Spanish - see Supporting Information.

[Recommendations for the care of patients with community-acquired pneumonia in the Emergency Department]. / Recomendaciones para la atención del paciente con neumonía adquirida en la comunidad en los Servicios de Urgencias.

The incidence of community-acquired pneumonia (CAP) ranges from 2-15 cases / 1,000 inhabitants / year, being higher in those older than 65 years and in patients with high co-morbidity. Around 75% of all CAP diagnosed are treated in the Emergency Department (ED). The CAP represents the main cause for sepsis and septic shock in ED, and the most frequent cause of death and admission to the Intensive Care Unit (ICU) due to infectious disease. Overall mortality is 10-14% according to age and associated risk factors. Forty to 60% of CAP will require hospital admission, including observation units (with very variable ranges from 22-65% according to centers, seasonal of the year and patients´ characteristics). Between the admissions, 2-10% will be in the ICU. All of previously mentioned reflects the importance of the CAP in the ED, as well as the "impact of the emergency care on the patient with CAP", as it is the establishment where the initial, but key decisions, are made and could condition the outcome of the illness. It is known the great variability among physicians in the diagnostic and therapeutic management of CAP, which is one of the reasons that explains the great differences in the admission rates, achievement of the microbiological diagnosis, request for complementary studies, the choice of antimicrobial treatment, or the diversity of applied care. In this sense, the implementation of clinical practice guidelines with the use of the severity scores and the new tools available, such as biomarkers, can improve patient care with CAP in ED. Therefore, a multidisciplinary group of emergency professionals and specialists involved in the care process of CAP has designed a guideline with several recommendations for decisions-making during the key moments in patients with CAP attended in the ED.

Do Patient Profiles Influence the Effects of Massage? A Controlled Clinical Trial.

Considerable scientific evidence has been published on the effectiveness of massage in different conditions, but it remains unclear whether this effectiveness is modulated by the profile of patients. The aim of this study was to compare the effects of a 21-min myofascial therapy protocol on stress responders and nonresponders stressed in the laboratory with a cold pressor test. Dependent variables included heart rate variability (HRV), blood pressure, and salivary markers such as flow rate, cortisol, immunoglobulin A (IgA), and α-amylase activity. A controlled, repeated measures, single-blind trial was conducted in 30 Caucasian students with a mean (SD) age of 20.70 (4.50) years. We found no significant between-group differences in descriptive characteristics or in any preintervention outcome measure. Analysis of covariance revealed significant increases in HRV index (F = 0.18, p = .01), salivary flow rate (F = 0.16, p = .02), and salivary IgA concentration (F = 4.36, p = .04) and significant decreases in the low-frequency domain (F = 0.18, p = .04) and LF-high-frequency ratio (F = 0.18, p = .01) in the stress responder group in comparison to the nonresponder group. In conclusion, a better response to massage was observed in stress responders than in nonresponders across various HRV parameters and salivary measures.

Management of breast cancer in the elderly.

The management of breast cancer in elderly women was analysed by a retrospective study of 150 women over 70 years old referred to our department between 1984 and 1988. 80 were T1-T2, 33 were T3 and 34 were T4. 107 were N0 and 43 were N1-N2. 16 women (11%) were in poor health, preventing conventional treatment. Treatment choice varied with age: 60% of the women aged 70-79 (group 1) and 23% of the oldest women (group 2) were treated conventionally. The use of surgery decreased with age and surgical procedures were conventional in only 85% of the group 1 women and in 56% of the group 2 women. Definitive radiation therapy was used more frequently in the oldest women, as was primary hormone therapy. Quality of follow-up also varied with age. Five-year survival rates were still high in both groups while relapses were frequent. Breast cancer was consequently a frequent cause of death. The increase in the proportion of elderly people with breast cancers over the next few years will require validated guidelines. Specific protocols and specific rules of management must be drawn up.

Recognition and management of depression in the elderly.

Depression is probably the most common psychiatric disorder of the elderly. Societal stereotypes and atypical clinical features are contributing factors to inadequate diagnosis and treatment. Somatic complaints without an obvious mood defect and a syndrome of pseudodementia are commonly encountered. Treatment strategies rest firmly on a comprehensive evaluation that considers the biological, psychologic, and social factors involved. Psychotherapy is a valuable tool in some elderly persons. When antidepressant agents are used, it should be recognized that lower than usual dosage may be effective and that the elderly person is particularly sensitive to the autonomic side effects of these chemical agents. Electroconvulsive therapy remains a helpful and sometimes lifesaving resource when other methods have failed.

Recognition and management of anxiety and depression in elderly patients.

OBJECTIVE: To describe important aspects of the recognition and management of anxiety and depression in elderly patients. DESIGN: We reviewed pertinent recent articles in the medical literature and compiled guidelines for diagnosing and treating anxiety and depression in the geriatric population. RESULTS: Depression and anxiety are common in the elderly population. The development of depression in elderly subjects is associated with a higher risk of death from suicide than for any other age-group. Recognition of depression in elderly patients is often hampered by an inability or reluctance on the part of these patients to report depressive symptoms. In addition, anxiety and depression are often attributed to organic illness in this age-group. Pharmacotherapy is effective; however, older patients are probably more likely than young patients to experience adverse effects. Using medications at lower doses, choosing drugs with shorter half-lives, and avoiding drugs with potent anticholinergic side effects are often advisable. CONCLUSION: Anxiety and depression are common conditions among the elderly population. Correct recognition, attention to underlying precipitating factors, and compassionate, supportive care can vastly improve the quality of the lives of these patients.

Ten-year review of otitis media pathogens.

Data collected from 1980 to 1989 by investigators at the Pittsburgh Otitis Media Research Center were examined to detect changes over time in the prevalence of bacteria isolated from middle ear effusions in patients with otitis media. The organisms isolated most commonly from the 7396 effusions cultured at the center were Streptococcus pneumoniae and Haemophilus influenzae. S. pneumoniae predominated in the subgroup of patients with acute otitis media, whereas H. influenzae was isolated most frequently from patients with otitis media with effusion. The most notable changes to occur during the 10-year period were a statistically significant increase in the prevalence of S. pneumoniae in patients with acute otitis media and a progressive rise in the percentage of beta-lactamase-producing strains of H. influenzae and Moraxella (Branhamella) catarrhalis. The latter finding suggests the need for therapeutic alternatives to amoxicillin, which is not active against beta-lactamase-producing organisms, when these organisms are suspected or cultured from the middle ear.

Erectile dysfunction in men with diabetes mellitus.

During a fourteen-month period, 497 men were evaluated for a primary complaint of erectile dysfunction. The initial evaluation consisted of a history taken in a conventional manner and supplemented by a patient-completed sexual function questionnaire, a physical examination, and serum testosterone, serum prolactin, and nocturnal penile tumescence studies. When appropriate, additional evaluations, including penile vascular studies, two-hour oral glucose tolerance tests, and psychiatric consultation were obtained. Abnormal glucose metabolism was present in 161 men (32%). Five men (1%) had insulin-dependent diabetes mellitus (IDDM), 80 men (16%) had noninsulin-dependent diabetes mellitus (NIDDM), 55 men (11.1%) had newly diagnosed noninsulin-dependent diabetes mellitus, and 21 men (4.2%) had impaired glucose tolerance tests. One hundred forty-seven of these men (91.3%) had organic pattern impotence, and 14 (8.7%) had psychogenic pattern impotence.

Cost-effective evaluation of impotence.

Two hundred consecutive men presenting with a chief complaint of impotence have been evaluated with a protocol involving one or two outpatient visits. The initial evaluation for all patients consisted of a history taken in a conventional manner and supplemented by a patient-completed sexual function questionnaire, physical examination, serum testosterone and prolactin, and two-night nocturnal penile tumescence studies. Following the initial evaluation the patients were placed in one of three categories: (1) organic impotence, (2) functional impotence, (3) ambiguous impotence (mixed functional and organic impotence or organic impotence of undetermined etiology). Patients in the latter group underwent additional testing including penile vascular studies, two-hour oral glucose tolerance test, and psychiatric consultation. With this protocol, patients can be efficiently and effectively evaluated as outpatients with costs ranging from +250 to +450.

Diagnostic evaluation, classification, and treatment of men with sexual dysfunction.

During a two-year period, 165 men were evaluated for sexual dysfunction. Most evaluations were conducted on an outpatient basis and required two separate visits. Fifty-one per cent, 47 per cent, and 2 per cent of the patients were found to have functional disorders, organic disorders, and incomplete evaluations, respectively. Treatment recommendations were tailored to each patient using information gathered during the diagnostic evaluation.

Comparison of mammography and Pap test use from the 1987 and 1992 National Health Interview Surveys: are we closing the gaps?

Using data from the National Health Interview Survey Cancer Control Supplements, we examined the trends in mammogram and Pap smear test screening between 1987 and 1992 and the demographic characteristics associated with the use of those screening tests in 1992. In 1992, 67% of women 40 years of age and older reported ever having had a mammogram compared with 36% in 1987. A mammogram within the past year was reported by 29% of women in 1992, an increase from 14% in 1987. Among women 18 and older, 91% had ever had a Pap smear test in 1992, and 43% had one within the past year, an increase from 89% and 38%, respectively, in 1987. These changes represented significant increases in the use of both mammograms and Pap smear tests between 1987 and 1992 (P < .05). Race was not significantly associated with underutilization of mammograms, but income showed a significant relationship, with a declining likelihood of mammogram use as income decreased (odds ratio [OR] = 0.4, 95% confidence interval [CI] = 0.3, 0.6 for the income less than poverty level). Pap smear tests were less likely to be reported by older women ( > or = 65), widows, and never-married women, African-American women were more likely than Caucasian women to have had a Pap smear test, and women of other races were the least likely of any race/ethnic group to have ever had one (OR = 0.2, 95% CI = 0.1, 0.4). Women with less than 12 years of education had about a 40% decreased risk of having had a recent mammogram or Pap smear test. Women without a usual source of medical care also underutilized both screening procedures. Significant gains in the use of mammograms were found for all groups between 1987 and 1992. However, for the Pap smear test, some groups reported no differences during the five-year period. Although race and ethnic differences in the rates of screening use have been reduced somewhat, socioeconomically disadvantaged women and those with poor access to health care are still important target populations for increasing screening, particularly mammograms.