Triplet photochemistry of effluent and natural organic matter in whole water and isolates from effluent-receiving rivers.

Effluent organic matter (EfOM), contained in treated municipal wastewater, differs in composition from naturally occurring dissolved organic matter (DOM). The presence of EfOM may thus alter the photochemical production of reactive intermediates in rivers that receive measurable contributions of treated municipal wastewater. Quantum yield coefficients for excited triplet-state OM (3OM*) and apparent quantum yields for singlet oxygen (1O2) were measured for both whole water samples and OM isolated by solid phase extraction from whole water samples collected upstream and downstream of municipal wastewater treatment plant discharges in three rivers receiving differing effluent contributions: Hockanum R., CT (22% (v/v) effluent flow), E. Fork Little Miami R., OH (11%), and Pomperaug R., CT (6%). While only small differences in production of these reactive intermediates were observed between upstream and downstream whole water samples collected from the same river, yields of 3OM* and 1O2 varied by 30-50% between the rivers. Apparent quantum yields of 1O2 followed similar trends to those of 3OM*, consistent with 3OM* as a precursor to 1O2 formation. Higher 3OM* reactivity was observed for whole water samples than for OM isolates of the same water, suggesting differential recoveries of photoreactive moieties by solid phase extraction. 3OM* and 1O2 yields increased with increasing E2/E3 ratio (A254 nm divided by A365 nm) and decreased with increasing electron donating capacities of the samples, thus exhibiting trends also observed for reference humic and fulvic acid isolates. Mixing experiments with EfOM and DOM isolates showed evidence of quenching of triplet DOM by EfOM when measured yields were compared to theoretical yields. Together, the results suggest that effluent contributions of up to 25% (v/v) to river systems have a negligible influence on photochemical production of 3OM* and 1O2 apparently because of quenching of triplet DOM by EfOM. Furthermore, the results highlight the importance of whole water studies for quantifying in situ photoreactivity, particularly for 3OM*.

Identification and validation of N-acetylputrescine in combination with non-canonical clinical features as a Parkinson's disease biomarker panel.

Parkinson's disease is a progressive neurodegenerative disorder in which loss of dopaminergic neurons in the substantia nigra results in a clinically heterogeneous group with variable motor and non-motor symptoms with a degree of misdiagnosis. Only 3-25% of sporadic Parkinson's patients present with genetic abnormalities that could represent a risk factor, thus environmental, metabolic, and other unknown causes contribute to the pathogenesis of Parkinson's disease, which highlights the critical need for biomarkers. In the present study, we prospectively collected and analyzed plasma samples from 194 Parkinson's disease patients and 197 age-matched non-diseased controls. N-acetyl putrescine (NAP) in combination with sense of smell (B-SIT), depression/anxiety (HADS), and acting out dreams (RBD1Q) clinical measurements demonstrated combined diagnostic utility. NAP was increased by 28% in Parkinsons disease patients and exhibited an AUC of 0.72 as well as an OR of 4.79. The clinical and NAP panel demonstrated an area under the curve, AUC = 0.9 and an OR of 20.4. The assessed diagnostic panel demonstrates combinatorial utility in diagnosing Parkinson's disease, allowing for an integrated interpretation of disease pathophysiology and highlighting the use of multi-tiered panels in neurological disease diagnosis.

A double-blind, delayed-start trial of rasagiline in Parkinson's disease.

BACKGROUND: A therapy that slows disease progression is the major unmet need in Parkinson's disease. METHODS: In this double-blind trial, we examined the possibility that rasagiline has disease-modifying effects in Parkinson's disease. A total of 1176 subjects with untreated Parkinson's disease were randomly assigned to receive rasagiline (at a dose of either 1 mg or 2 mg per day) for 72 weeks (the early-start group) or placebo for 36 weeks followed by rasagiline (at a dose of either 1 mg or 2 mg per day) for 36 weeks (the delayed-start group). To determine a positive result with either dose, the early-start treatment group had to meet each of three hierarchical end points of the primary analysis based on the Unified Parkinson's Disease Rating Scale (UPDRS, a 176-point scale, with higher numbers indicating more severe disease): superiority to placebo in the rate of change in the UPDRS score between weeks 12 and 36, superiority to delayed-start treatment in the change in the score between baseline and week 72, and noninferiority to delayed-start treatment in the rate of change in the score between weeks 48 and 72. RESULTS: Early-start treatment with rasagiline at a dose of 1 mg per day met all end points in the primary analysis: a smaller mean (+/-SE) increase (rate of worsening) in the UPDRS score between weeks 12 and 36 (0.09+/-0.02 points per week in the early-start group vs. 0.14+/-0.01 points per week in the placebo group, P=0.01), less worsening in the score between baseline and week 72 (2.82+/-0.53 points in the early-start group vs. 4.52+/-0.56 points in the delayed-start group, P=0.02), and noninferiority between the two groups with respect to the rate of change in the UPDRS score between weeks 48 and 72 (0.085+/-0.02 points per week in the early-start group vs. 0.085+/-0.02 points per week in the delayed-start group, P<0.001). All three end points were not met with rasagiline at a dose of 2 mg per day, since the change in the UPDRS score between baseline and week 72 was not significantly different in the two groups (3.47+/-0.50 points in the early-start group and 3.11+/-0.50 points in the delayed-start group, P=0.60). CONCLUSIONS: Early treatment with rasagiline at a dose of 1 mg per day provided benefits that were consistent with a possible disease-modifying effect, but early treatment with rasagiline at a dose of 2 mg per day did not. Because the two doses were associated with different outcomes, the study results must be interpreted with caution. (ClinicalTrials.gov number, NCT00256204.)

Intersex in Scrobicularia plana: transcriptomic analysis reveals novel genes involved in endocrine disruption.

Intersex, the appearance of female characteristics in male gonads, has been identified in a wide range of aquatic species worldwide, yet the underpinning molecular etiology remains uncharacterized. The presence of intersex has been shown to be a widespread phenomenon in bivalve, S. plana, populations from the southwest coast of the U.K., as well as inducible in an experimental exposure regime using endocrine disrupting compounds (EDCs). Herein, we use the suppressive subtractive hybridization approach to isolate differentially expressed transcripts in S. plana males exhibiting intersex. Transcripts involved in cell signaling, cell cycle control, energy production/metabolism, microtubule assembly, and sperm physiology are all highlighted as differentially expressed in intersex male clams. These provide both an insight into the molecular mechanisms of action involved in the development of intersex, as well as facilitating potential molecular-level "early warning" biomarkers of the condition.

Imposex levels and tributyltin pollution in Ria de Aveiro (NW Portugal) between 1997 and 2007: evaluation of legislation effectiveness.

Nucella lapillus imposex levels and organotin (OT) concentrations in water and female tissues were measured in samples collected from the Ria de Aveiro (NW Portugal) between 1997 and 2007. Vas deferens sequence index (VDSI), relative penis size index (RPSI), mean female penis length (FPL) and percentage of imposex affected females (%I) were used to determine imposex levels at each site. A significant temporal decline in imposex intensity was observed during the assessed period. Imposex decrease was evident after 2003 although improvements were most notable from 2005 to 2007, probably due to the implementation of the EU Council Regulation no.782/2003 forbidding further application of tributyltin (TBT) antifouling on vessels carrying EU flags. Despite these improvements, OT analysis in N. lapillus female tissues and water indicate there are still recent TBT inputs into the study area.

Pathologic modifications of alpha-synuclein in 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP)-treated squirrel monkeys.

alpha-Synuclein expression is increased in dopaminergic neurons challenged by toxic insults. Here, we assessed whether this upregulation is accompanied by pathologic accumulation of alpha-synuclein and protein modifications (i.e. nitration, phosphorylation, and aggregation) that are typically observed in Parkinson disease and in other synucleinopathies. A single injection of the neurotoxicant 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) to squirrel monkeys caused a buildup of alpha-synuclein but not of beta-synuclein or synaptophysin within nigral dopaminergic cell bodies. Immunohistochemistry and immunoelectron microscopy also revealed large numbers of dystrophic axons labeled with alpha-synuclein. Antibodies that recognize nitrated and phosphorylated (at serine 129) alpha-synuclein stained neuronal cell bodies and dystrophic axons in the midbrain of MPTP-treated animals. After toxicant exposure, alpha-synuclein deposition occurred at the level of neuronal axons in which amorphous protein aggregates were observed by immunoelectron microscopy. In a subset of these axons, immunoreactivity for alpha-synuclein was still evident after tissue digestion with proteinase K, further indicating the accumulation of insoluble protein. These data indicate that toxic injury can induce alpha-synuclein modifications that have been implicated in the pathogenesis of human synucleinopathies. The findings are also consistent with a pattern of evolution of alpha-synuclein pathology that may begin with the accumulation and aggregation of the protein within damaged axons.

Insulin stimulation of gamma-glutamylcysteine ligase catalytic subunit expression increases endothelial GSH during oxidative stress: influence of low glucose.

Previously, we demonstrated an important role for insulin in the protection of endothelial cells against hyperglycemic stress through maintaining cellular glutathione (GSH) redox balance. The current study focuses on the contribution of insulin to transcriptional control of endothelial cell GSH recovery during acute oxidative challenge and the influence of low glucose. The results show that insulin induced an approximate 2-fold increase in expression of gamma-glutamylcysteine ligase catalytic subunit (GCLc) mRNA and protein; interestingly, cellular GSH levels were not elevated accordingly. However, on tert-butylhydroperoxide challenge, insulin-treated cells demonstrated a robust GSH recovery that was attributed to a greater capacity for de novo synthesis via elevated GCLc levels. Notably, the effects of insulin were observed under low, but not normal, glucose conditions. Our results implicate a role for Nrf2 involvement in both constitutive and inducible endothelial GCLc expression and GSH synthesis, while PI3K/Akt/mTOR signaling appears to participate only in insulin-inducible GSH synthesis. Collectively, these results support the functional importance of insulin in Nrf2-dependent transcriptional upregulation of GCLc in GSH recovery during oxidative challenge and suggest a possible role for hypoglycemia in promoting insulin-mediated GCLc upregulation.

Cytoprotective effects of nitrite during in vivo ischemia-reperfusion of the heart and liver.

Nitrite represents a circulating and tissue storage form of NO whose bioactivation is mediated by the enzymatic action of xanthine oxidoreductase, nonenzymatic disproportionation, and reduction by deoxyhemoglobin, myoglobin, and tissue heme proteins. Because the rate of NO generation from nitrite is linearly dependent on reductions in oxygen and pH levels, we hypothesized that nitrite would be reduced to NO in ischemic tissue and exert NO-dependent protective effects. Solutions of sodium nitrite were administered in the setting of hepatic and cardiac ischemia-reperfusion (I/R) injury in mice. In hepatic I/R, nitrite exerted profound dose-dependent protective effects on cellular necrosis and apoptosis, with highly significant protective effects observed at near-physiological nitrite concentrations. In myocardial I/R injury, nitrite reduced cardiac infarct size by 67%. Consistent with hypoxia-dependent nitrite bioactivation, nitrite was reduced to NO, S-nitrosothiols, N-nitros-amines, and iron-nitrosylated heme proteins within 1-30 minutes of reperfusion. Nitrite-mediated protection of both the liver and the heart was dependent on NO generation and independent of eNOS and heme oxygenase-1 enzyme activities. These results suggest that nitrite is a biological storage reserve of NO subserving a critical function in tissue protection from ischemic injury. These studies reveal an unexpected and novel therapy for diseases such as myocardial infarction, organ preservation and transplantation, and shock states.

A randomized, double-blind, placebo-controlled, delayed start study to assess rasagiline as a disease modifying therapy in Parkinson's disease (the ADAGIO study): rationale, design, and baseline characteristics.

A neuroprotective therapy is the single most important unmet medical need in Parkinson's disease. Several promising agents in the laboratory have been tested in the clinic, but none has been established in clinical trials to have a disease modifying effect despite positive results because of potential confounding symptomatic or pharmacologic effects. The delayed start design was developed to try to avoid a symptomatic confound when testing a putative neuroprotective therapy. In this study design, patients are randomly assigned to study drug or placebo in the first phase of the study, and both groups receive the active drug in the second phase. If benefits seen at the end of phase I persist through the end of phase II, they cannot be readily explained by a symptomatic effect (as patients in both groups are receiving the same medication) and benefits in the early start group must relate to the early initiation of the treatment. Although the precise mechanism responsible for such an effect can be debated, positive results in a delayed start study indicate that patients who receive early treatment have a better outcome than those where the treatment is delayed. We are using the delayed start design to assess the potential disease modifying effects of rasagiline in a prospective double blind controlled trial (the ADAGIO study). We here describe the rationale for the study and baseline characteristics of the 1,176 patients who have been enrolled into the trial.

Effect of ondansetron on the incidence of vomiting associated with ketamine sedation in children: a double-blind, randomized, placebo-controlled trial.

STUDY OBJECTIVE: We investigate the effect of ondansetron on the incidence of vomiting in children who receive intravenous (IV) ketamine for procedural sedation and analgesia in the emergency department (ED). METHODS: In this double-blind, randomized, placebo-controlled trial in a children's hospital ED, patients receiving IV ketamine (1 mg/kg) for ED procedures were randomized to receive either IV ondansetron (0.15 mg/kg; maximum 4 mg) or identical placebo. We recorded whether vomiting occurred in the ED postsedation or up to 12 hours after discharge with telephone follow-up and compared ED length of stay and parental satisfaction. RESULTS: One hundred twenty-seven children were randomized to placebo and 128 to ondansetron. The groups were similar in age, sex, and fasting duration. ED vomiting was less common with ondansetron: 6 of 128 (4.7%) versus 16 of 127 (12.6%), P=.02, difference 7.9% (95% confidence interval 1.1% to 14.7%), number needed to treat 13. Follow-up was successful in 82.7%, with vomiting in the ED or after discharge less frequent with ondansetron: 10 of 128 (7.8%) versus 24 of 127 (18.9%), P=.01, difference 11.1% (95% confidence interval 2.7% to 19.5%), number needed to treat 9. ED length of stay and parental satisfaction were similar between groups. CONCLUSION: IV ondansetron significantly reduces the incidence of vomiting associated with IV ketamine procedural sedation in children.

The etiopathogenesis of Parkinson disease and suggestions for future research. Part II.

We are at a critical juncture in our knowledge of the etiology and pathogenesis of Parkinson disease (PD). It is clear that PD is not a single entity simply resulting from a dopaminergic deficit; rather it is most likely caused by a combination of genetic and environmental factors. Although there is extensive new information on the etiology and pathogenesis of PD, which may advance its treatment, new syntheses of this information are needed. The second part of this two-part, state-of-the-art review by leaders in PD research critically examines the research field to identify areas for which new knowledge and ideas might be helpful for treatment purposes. Topics reviewed in Part II are genetics, animal models, and oxidative stress.

Assessment of inshore/offshore tributyltin pollution gradients in the northwest Portugal continental shelf using Nassarius reticulatus as a bioindicator.

Imposex and organotin tissue contamination were assessed in Nassarius reticulatus (L.) populations in the northwest Portuguese continental shelf between 2002 and 2005 over an area of 735 km2, involving 366 sampling sites. The objective was to evaluate the dispersion of tributyltin (TBT) from inshore sources inside the Ria de Aveiro estuary into the adjacent deeper sea and to assess endocrine disruption in the netted whelk N. reticulatus, using imposex as a biomarker. The highest levels of TBT tissue contamination and imposex were found in the whelks inside the Ria de Aveiro, and these declined logarithmically with distance from the mouth of this estuary. Remarkably, we found that offshore populations were also extensively affected: TBT (the dominant organotin) tissue concentration was above the detection limits at all sites where whelks were analyzed (12-356 ng TBT-Sn/g dry wt), and imposex occurred at 80% of the sampling stations, with relatively high values at some sites from the deepest area surveyed. This work shows clearly that TBT pollution is not restricted to the Ria de Aveiro but affects a significant part of the adjacent continental shelf as well. The ecological impacts of TBT pollution on offshore ecosystems are discussed.

Toxicity of redox cycling pesticides in primary mesencephalic cultures.

A loss of nigrostriatal dopaminergic neurons is the primary neurodegenerative feature of Parkinson's disease. Paraquat, a known redox cycling herbicide, has recently been shown to kill selectively nigrostriatal dopaminergic cells in the mouse model. The purpose of this study was to test the ability of paraquat and other redox cycling pesticides to damage dopaminergic neurons in primary mesencephalic cultures. Addition of paraquat, diquat, or benzyl viologen to mesencephalic cultures induced morphological changes (e.g., dystrophic neuronal processes) consistent with dopaminergic cell injury. The three pesticides also caused cell death as assessed by a reduction of the number of tyrosine hydroxylase-immunoreactive neurons and a dose-dependent decrease in [(3)H]dopamine uptake. Quite interestingly, diquat and benzyl viologen were significantly more toxic than paraquat, probably reflecting their more pronounced ability to trigger redox cycling reactions. The data support a role of redox cycling as a mechanism of dopaminergic cell degeneration and suggest that the property of redox cycling should be taken into consideration when evaluating putative environmental risk factors for Parkinson's disease.

Redox cycling of the herbicide paraquat in microglial cultures.

Mechanisms involved in paraquat neurotoxicity that selectively target nigrostriatal dopaminergic neurons remain relatively unknown. In this study, we tested the hypotheses that paraquat exposure leads to the production of reactive oxygen species (ROS) through a process of redox cycling and that microglia represent an important site for the initiation of redox cycling reactions. Addition of paraquat to N9 microglial cultures resulted in a dose- and time-dependent release of superoxide radicals. Other agents that share with paraquat the property of redox cycling, i.e., benzyl viologen and diquat, also induced a marked production of superoxide radicals by microglia. The ability of paraquat, benzyl viologen, and diquat to induce superoxide release was correlated to their one-electron reduction potentials and thus their tendency to redox cycle. Nitric oxide synthase and NADPH oxidase were identified as enzymatic sources of electrons that triggered paraquat redox cycling by microglia. Taken together, these data provide evidence in favor of a new mechanism by which microglia could play a role in oxidative injury during neurodegenerative processes. Microglial NOS and NADPH oxidase could promote the generation of ROS via the redox cycling of paraquat-like toxicants.

Widespread contamination of coastal sediments in the Transmanche Channel with anti-androgenic compounds.

This study analysed the levels of androgen receptor antagonist activity in extracts of coastal sediments sampled from estuaries in southern UK and northern France. Anti-androgenic (AA) activity varied between <0.2 and 224.3±38.4µg flutamide equivalents/g dry weight of sediment and was significantly correlated with the total organic carbon and silt content of samples. AA activity was detected in tissues extracts of clams, Scrobicularia plana, sampled from a contaminated estuary, some of which was due to uptake of a series of 4 or 5 ring polycyclic aromatic hydrocarbons (PAHs). Initial studies also indicated that fractionated extracts of male, but not female, clams also contained androgen receptor agonist activity due to the presence of dihydrotestosterone in tissues. This study reveals widespread contamination of coastal sediments of the Transmanche region with anti-androgenic compounds and these contaminants should be investigated for their potential to disrupt sexual differentiation in aquatic organisms.

Intersex related gene expression profiles in clams Scrobicularia plana: Molecular markers and environmental application.

Intersex, the appearance of female characteristics in male gonads, has been identified in several aquatic species. It is a widespread phenomenon in populations of the bivalve, Scrobicularia plana, from the southwest coast of the U.K. Genes previously identified as differentially expressed (ferritin, testicular haploid expressed gene, THEG, proliferating cell nuclear antigen, PCNA; receptor activated protein kinase C, RACK; cytochrome B, CYB; and cytochrome c oxidase 1, COX1) in intersex clams relative to normal male clams, were selected for characterisation and an environmental survey of the Channel region. Transcripts were significantly differentially expressed at sites with varying intersex incidence and contaminant burdens. Significant correlations between specific gene expressions, key contaminants and sampling locations have been identified, though no single gene was associated with intersex incidence. The results highlight the difficulty in understanding the intersex phenomenon in molluscs where there is still a lack of knowledge on the control of normal reproduction.

Aging of the nigrostriatal system in the squirrel monkey.

Increasing incidence of Parkinson's disease with advancing age suggests that age-related processes predispose the nigrostriatal dopaminergic system to neurodegeneration. Several hypotheses concerning the effects of aging on nigrostriatal neurons were assessed in this study using a non-human primate model. First, we examined the possibility that the total number of dopaminergic neurons decline in the substantia nigra as a function of age. Stereological counting based on both tyrosine hydroxylase immunoreactivity (TH-ir) and neuromelanin (NM) content revealed no difference in cell number between young, middle-aged and old squirrel monkeys. We then determined whether advancing age changed the relative proportion of neurons characterized by 1) TH-ir in the absence of NM, 2) the presence of both TH-ir and NM, or 3) NM without TH-ir. Indeed, a progressive age-related depletion of TH only cells was paralleled by an increase in NM only neurons. The possibility that these changes could underlie a functional impairment of the nigrostriatal system was supported by striatal dopamine measurements showing a decrease in older monkeys. Finally, we tested the hypotheses that aging may enhance cell vulnerability to injury and that different dopaminergic subpopulations display varying degrees of susceptibility. When monkeys were exposed to the neurotoxicant 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine, cell loss was markedly more pronounced in older animals, and the ranking of vulnerability was TH only < TH/NM < NM only cells. The data indicate that, even in the absence of an overall neuronal loss, changes in the characteristics of dopaminergic cells reflect functional deficits and increased vulnerability to injury with age. NM content appears to be an important marker of these age-related effects.

Spatial configuration of vertically related word pairs modulates the N400 component.

This study examined the effect of spatial iconicity on the N400 component. Spatial iconicity is defined as the spatial arrangement of words on a screen relative to the spatial arrangement of their referents (e.g. attic-basement). In two experiments, electroencephalograms were recorded in 32 participants while performing a semantic relatedness judgment task on pairs of words that were either related or unrelated. All of the related word pairs were parts of objects that shared a vertical spatial relationship. In Experiment 1, the words of each pair were presented simultaneously on top of one another. Results showed that related word pairs presented in a spatial arrangement that mismatched the spatial relationship of their referents were associated with increased error rates as well as larger N400 components known to index semantic/conceptual processing cost. These findings thus suggest that the words automatically activated visuospatial simulations of their referents and that semantic/conceptual processing difficulty arose when the vertical arrangement of the word pairs was inconsistent with those simulations. In line with this interpretation, these effects were not present in Experiment 2 when the words of each pair were presented in succession in the middle of the screen. Overall, these results provide evidence that perceptual simulations contribute to some of the underlying processes of the N400 component (see video abstract, Supplemental digital content 1, http://links.lww.com/WNR/A304).

Influence of patterned electrical neuromuscular stimulation on quadriceps activation in individuals with knee joint injury.

BACKGROUND: Neuromuscular Electrical Stimulation is a common intervention to address muscle weakness, however presents with many limitations such as fatigue, muscle damage, and patient discomfort that may influence its effectiveness. One novel form of electrical stimulation purported to improve neuromuscular re-education is Patterned Electrical Neuromuscular Stimulation (PENS), which is proposed to mimic muscle-firing patterns of healthy individuals. PENS provides patterned stimulating to the agonist muscle, antagonist muscle and then agonist muscle again in an effort to replicate firing patterns. PURPOSE: The purpose of this study was to determine the effect of a single PENS treatment on knee extension torque and quadriceps activation in individuals with quadriceps inhibition. METHODS: 18 subjects (10 males and 8 females: 24.2±3.4 years, 175.3±11.8cm, 81.8±12.4kg) with a history of knee injury/pain participated in this double-blinded randomized controlled laboratory trial. Participants demonstrated quadriceps inhibition with a central activation ratio of ≤90%. Maximal voluntary isometric contraction of the quadriceps and central activation ratio were measured before and after treatment. The treatment intervention was a 15-minute patterned electrical stimulation applied to the quadriceps and hamstring muscles with a strong motor contraction or a sham group, who received an identical set up as the PENS group, but received a 1mA subsensory stimulation. A 2×2 (group × time) ANCOVA was used to determine differences in maximal voluntary isometric contraction and central activation ratio between groups. The maximal voluntary isometric contraction was selected as a covariate due to baseline differences. RESULTS: There were no differences in change scores between pre- and post-intervention for maximal voluntary isometric contraction: (PENS: 0.09±0.32Nm/kg and Sham 0.15±0.18Nm/kg, p=0.713), or central activation ratio:(PENS: -1.22±6.06 and Sham: 1.48±3.7, p=0.270). CONCLUSIONS: A single Patterned Electrical Neuromuscular Stimulation treatment did not alter quadriceps central activation ratio or maximal voluntary isometric contraction. Unlike other types of muscle stimulation, PENS did not result in a reduction of quadriceps torque. LEVEL OF EVIDENCE: Level III.