Highly Enantioselective Polymerization of ß-Butyrolactone by a Bimetallic Magnesium Catalyst: An Interdependent Relationship Between Favored and Unfavored Enantiomers.

Herein, we report that (S,S)-prophenolMg2(µ-OnBu)(THF)2 ((S,S)-1, prophenol = (S,S)-2,6-bis[2-(hydroxydiphenylmethyl)pyrrolidin-1-ylmethyl]-4-methylphenol) is a highly enantioselective (kR/kS = 140) precatalyst for ring-opening polymerization of rac-ß-butyrolactone (ß-BL) to isotactic poly(3-hydroxybutyrate) (i-PHB), a high performance, biodegradable polyester. Precatalyst (S,S)-1 polymerizes (R)-ß-BL with an inversion of stereochemistry to (S)-PHB with a m% (percentage of adjacent linkages with a meso configuration) of 98% at 41% conversion and Tm of 165 °C under a variety of conditions. Complex (S,S)-1 demonstrates unique polymerization kinetics, as it does not polymerize the preferred enantiomer, (R)-ß-BL, alone. Mechanistic studies revealed that (S)-ß-BL is needed to convert (S,S)-1 into the active enantioselective polymerization catalyst. To the best of our knowledge, (S,S)-1 produces i-PHB with the highest degree of isotacticity observed from a polymerization of rac-ß-BL. This study informs the design and understanding of future enantioselective and earth-abundant metal catalysts for ring-opening polymerization of ß-lactones.

Longitudinal analysis of cardiac structure and function in incident-automated peritoneal dialysis: comparison between icodextrin solution and glucose-based solution.

BACKGROUND: This study aimed to evaluate the longitudinal changes in cardiac structure and function in incident-automated peritoneal dialysis (APD) patients. METHODS: We conducted a 2-year prospective, randomized, open-label, parallel-group study to compare the efficacy of icodextrin solution versus glucose-based solution. Echocardiography was performed at baseline, 1 and 2 years. Echocardiographic parameters over 2 years were evaluated for each group, using the Friedman test. Generalized linear regression analysis was used to test the associations between baseline clinical variables and echocardiographic changes, and a multivariate model was used to analyze cardiac function between the two groups. RESULTS: A total of 43 APD patients were enrolled in the beginning of this study. Twenty patients in the icodextrin group (ICO) and 18 patients in the glucose group (GLU) completed the study. In left ventricular (LV) systolic function measurements, ejection fraction (EF) increased significantly in the GLU group. Measurements of LV diastolic function and septal early mitral annulus velocity (EMV) increased significantly from baseline to 24-months in the ICO group (5.43-5.51 ms). The GLU group showed a significant decrease in peak early diastolic velocity (EDV) (70.67-68.25 cm/s), but a significant increase in septal EMV (5.94-7.57 ms) from baseline to 24-months. No significant association was found between the baseline clinical variables and echocardiographic changes within 24 months in the generalized linear regression analysis. Multivariate models were used to investigate changes in the four primary endpoints, namely, myocardial performance index (MPI), left ventricular ejection fraction (LVEF), deceleration time (DT), and E/e' ratio. These primary endpoints show no significant association with the baseline values in both the ICO and GLU groups. CONCLUSION: The present study demonstrates that long-dwell icodextrin solution can maintain reasonable cardiac structure and function in incident-APD patients. TRIAL REGISTRATION: ISRCTN14931270 (retrospectively registered on 23/03/2018).

Interexaminer Reliability of Seated Motion Palpation for the Stiffest Spinal Site.

OBJECTIVES: The purpose of this study was to assess the interexaminer reliability of palpation for stiffness in the cervical, thoracic, and lumbar spinal regions. METHODS: In this secondary data analysis, data from 70 patients from a chiropractic college outpatient clinic were analyzed. Two doctors of chiropractic palpated for the stiffest site within each spinal region. Each were asked to select the stiffest segment and to rate their confidence in their palpation findings. Reliability between examiners was calculated as Median Absolute Examiner Differences (MedianAED) and data dispersion as Median Absolute Deviation (MAD). Interquartile analysis of the paired examiner differences was performed. RESULTS: In total, 210 paired observations were analyzed. Nonparametric data precluded reliability determination using intraclass correlation. Findings included lumbar MedianAED = 0.5 vertebral equivalents (VE), thoracic = 1.7 VE, and cervical = 1.4 VE. For the combined dataset, the findings were MedianAED = 1.1 VE; MAD was lowest in the lumbar spine (0.3 VE) and highest in thoracic spine (1.4 VE), and for the combined dataset, MAD = 1.1 VE. Examiners agreed on the segment or the motion segment containing the stiffest site in 54% of the observations. CONCLUSIONS: Interexaminer reliability for palpation was good between 2 clinicians for the stiffest site in each region of the spine and in the combined dataset. This is consistent with previous studies of motion palpation using continuous analysis.

Natural History Constrains the Macroevolution of Foot Morphology in European Plethodontid Salamanders.

The natural history of organisms can have major effects on the tempo and mode of evolution, but few examples show how unique natural histories affect rates of evolution at macroevolutionary scales. European plethodontid salamanders (Plethodontidae: Hydromantes) display a particular natural history relative to other members of the family. Hydromantes commonly occupy caves and small crevices, where they cling to the walls and ceilings. On the basis of this unique and strongly selected behavior, we test the prediction that rates of phenotypic evolution will be lower in traits associated with climbing. We find that, within Hydromantes, foot morphological traits evolve at significantly lower rates than do other phenotypic traits. Additionally, Hydromantes displays a lower rate of foot morphology evolution than does a nonclimbing genus, Plethodon. Our findings suggest that macroevolutionary trends of phenotypic diversification can be mediated by the unique behavioral responses in taxa related to particular attributes of their natural history.

Revisiting poly(vinyl chloride) reactivity in the context of chemical recycling.

Poly(vinyl chloride) (PVC) is one of the highest production volume polymers due to its many applications, and it is one of the least recycled due to its chemical structure and frequent formulation with additives. Developing efficient PVC recycling techniques would enable PVC waste to be reused or repurposed in other processes. Within this context, the literature on PVC modification offers considerable insight into versatile reaction pathways, potentially inspiring new approaches for repurposing PVC waste into value-added products. This perspective provides an overview of PVC functionalization through a lens of chemical recycling, discussing various PVC reactivity trends and their applications with a critical assessment and future outlook of their recycling implications.

Development of Preliminary Integrated Health Care Clinical Competencies for United States Doctor of Chiropractic Programs: A Modified Delphi Consensus Process.

Background: There has been rapid growth of chiropractors pursuing career opportunities in both public and private hospitals and other integrated care settings. Chiropractors that prosper in integrated care settings deliver patient-centered care, focus on the institutional mission, understand and adhere to organizational rules, and are proficient in navigating complex systems. The Council on Chiropractic Education Accreditation Standards do not outline specific meta-competencies for integrated care clinical training. Objective: The purpose of this study was to develop preliminary integrated health care competencies for DC programs to guide the advancement of clinical chiropractic education. Methods: A systematic literature search was performed. Articles were screened for eligibility and extracted in duplicate. Domains and seed statements were generated from this literature, piloted at a conference workshop, and evaluated via a modified Delphi consensus process. Of 42 invited, 36 chiropractors participated as panelists. Public comment period yielded 20 comments, none resulting in substantive changes to the competencies. Results: Of 1718 citations, 23 articles met eligibility criteria. After 2 modified Delphi rounds, consensus was reached on all competency statements. A total of 78 competency statements were agreed upon, which encompassed 4 domains and 11 subdomains. The 4 domains were: 1) Collaboration, (2) Clinical Excellence, (3) Communication, and (4) Systems Administration. Conclusion: We identified 78 preliminary competencies appropriate for preparing DC students and early career chiropractors for clinical practice in integrated healthcare settings. Educational programs may consider these competencies for curricular design and reform to strengthen DC program graduates for integrated practice, advanced training, and employment.

Trends and Disparities in the Use of Telehealth Among Injured Workers During the COVID-19 Pandemic.

OBJECTIVE: To describe telehealth trends within a population-based workers' compensation system during the COVID-19 pandemic, and to assess telehealth utilization by sociodemographic characteristics. METHODS: This cross-sectional study used Washington State workers' compensation claims and medical billing data from January 2019 to October 2020. RESULTS: Telehealth use averaged 1.2% of medical bills pre-pandemic, peaked in April 2020 at 8.8%, and leveled off to around 3.6% from July to October 2020. Telehealth utilization differed significantly by age, sex, number of dependents, injury, industry, and receipt of interpreter services. Workers residing in counties with higher population, lower poverty rates, and greater Internet access had higher telehealth usage. CONCLUSIONS: There were dramatic shifts in telehealth; usage differed by sociodemographic characteristics. Further studies evaluating disparities in tele-health access among injured workers are needed.

Neurosarcoidosis in children: A systematic review and summary of cases, imaging and management.

Neurosarcoidosis is a rare disorder in children. We identified 30 pediatric NS cases through a systematic review. Twenty-one (70%) had systemic sarcoidosis with 30% having primary neurosarcoidosis. Eyes (37%), lymph nodes (37%) and lungs (30%) were most commonly involved. Isolated neurosarcoidosis were more likely in children (30%) than in adults (6%, p = 0.0005). Seizures and optic neuritis were also more common in children than adults (33% vs 14%, p = 0.002; and 30% versus 6%, p = 0.008, respectively). Evaluation, imaging, laboratory findings, and treatments are discussed. Additional research, including multi-center studies, is needed.

The effect of vegetation barriers at reducing the transmission of Salmonella and Escherichia coli from animal operations to fresh produce.

Due to the recent outbreaks of Salmonella and Escherichia coli in fresh produce in the United States, the transfer of foodborne pathogens between animal feeding operations and fresh produce continues to be a considerable risk. The purpose of this study was to determine if the establishment of a vegetation barrier (VB) on small-scale sustainable farms could prevent the transmission of Salmonella and E. coli to nearby fresh produce fields. A 5-layer VB (31 × 49 m) was constructed between a dairy farm, a poultry farm, and a nearby produce field. Fresh produce (i.e., romaine lettuce and tomato), animal feces, and environmental (i.e., air, soil, and barrier) samples were collected for 15 months from 2018 to 2019. Four replicates of soil and fresh produce samples were taken from three plots located 10 m, 61 m, and 122 m away from the respective animal locations and processed for Salmonella and E. coli. Air and vegetative strip samples were sampled at 15-day intervals. Multiple colonies were processed from each positive sample, and a total of 143 positive Salmonella (n = 15) and E. coli (n = 128) isolates were retrieved from the soil, produce, air, and fecal samples. Interestingly, 18.2% of the Salmonella and E. coli isolates (n = 26) were recovered from fresh produce (n = 9) samples. Surprisingly, Salmonella isolates (n = 9) were only found in fecal (n = 3) samples collected from the dairy pasture. Data analysis suggests that the VB is an effective tool at reducing the transmission of E. coli and Salmonella from animal farms to fresh produce fields. However, based on phenotypic and genotypic testing, it is clear that fecal samples from animal farms are not the only source of pathogen contamination. This indicates that the environment (e.g., soil and wind), as well as the initial setup of the farm (e.g., proximity to service roads and produce plot placement), can contribute to the contamination of fresh produce. Our study recommends the need for more effective bioremediation and prevention control measures to use in conjunction with VBs to reduce pathogen transmission.

A review of intraexaminer and interexaminer reliability of static spinal palpation: a literature synthesis.

OBJECTIVE: The purposes of this study were to locate articles that assessed the reliability of static palpation of the spine and sacroiliac joints, to appraise the quality of these studies, and synthesize their results. METHODS: A structured literature search was conducted of chiropractic and medical databases PubMed, Manual Alternative and Natural Therapy System, Index to Chiropractic Literature, and Cumulative Index to Nursing and Allied Health Literature from 1965 through October 2007. Reference sections were inspected for additional citations. Only peer-reviewed articles in English containing information about static palpation of the spine or sacroiliac joints were selected. The resulting studies were appraised for quality by both of the authors using a 6-point scale instrument developed to assess the quality of reproducibility studies. RESULTS: The search generated 343 citations, and another 7 were harvested from the reference lists. After removing articles not meeting the inclusion criteria, 29 were retained. A total of 14 studies focused on the reliability of locating painful or tender points, 10 on the location of landmarks, and 5 on position or alignment of bone structures. A higher proportion of studies that assessed painful or tender points reported acceptable levels of reliability. However, there were no significant differences between methods of palpation when considering the proportions of high-quality studies that reported good reliability. Thus, no form of static palpation could be considered to be superior. CONCLUSION: Reported indices of agreement were generally low. More of the pain palpation studies reported acceptable kappa levels, although no one method of palpation could be deemed clearly superior.

Spinal motion palpation: a comparison of studies that assessed intersegmental end feel vs excursion.

OBJECTIVE: Spinal motion palpation (MP) is a procedure used to detect intersegmental hypomobility/hypermobility. Different means of assessing intersegmental mobility are described, assessing either excursion of the segments (quantity of movement) or end feel (quality of motion when stressed against the paraphysiological space). The objective of this review was to classify and compare studies based on method of MP used, considering that some studies may have used both methods. METHODS: Four databases were searched: MEDLINE-PubMed, Manual Alternative and Natural Therapy System, Index to Chiropractic Literature, and Cumulative Index to Nursing and Allied Health Literature databases for the years 1965 through January 2007. Retrieved citations were independently screened for inclusion by 2 of the authors consistent with the inclusion and exclusion criteria. Included studies were appraised for quality, and data were extracted and recorded in tables. RESULTS: The search strategy generated 415 citations, and 29 were harvested from reference lists. After removing articles that did not meet the inclusion criteria, 44 were considered relevant and appraised for quality. Fifteen studies focused on MP excursion, 24 focused on end feel, and 5 used both. Eight studies reported high levels of reproducibility (kappa = >or=0.4), although 4 were not of acceptable quality, and 2 were only marginally acceptable. When only high-quality studies were considered, 3 of 24 end-feel studies reported good reliability compared with 1 of 15 excursion studies. There was no statistical support for a difference between the 2 groupings. CONCLUSIONS: A difference in reported reliability was observed when the method of MP varied, although it was not statistically significant. There was no support in the literature for the advantage of one MP method over the other.

Analysis of 334 Cases of Pediatric Esophageal Foreign Body Removal Suggests that Traditional Methods Have Similar Outcomes Whereas a Magnetic Tip Orogastric Tube Appears to Be an Effective, Efficient, and Safe Technique for Disc Battery Removal.

Procedures and outcomes for pediatric esophageal foreign body removal were analyzed. Traditional methods of battery removal were compared with a magnetic tip orogastric tube (MtOGT). A single institution retrospective review from 1997 to 2014 of pediatric patients with esophageal foreign bodies was performed. Balloon extraction with fluoroscopy (performed in 173 patients with 91% success), flexible endoscopy (92% success in 102 patients), and rigid esophagoscopy (95% in 38 patients) had excellent success rates. A MtOGT had 100 per cent success in six disc battery patients, when other methods were more likely to fail, and was the fastest. Power analysis suggested 20 patients in the MtOGT group would be needed for significant savings in procedural time. Thirty-two per cent of all foreign bodies and 95 per cent of batteries had complications (P = 0.002) because of the foreign body. Overall, 1.2 per cent had severe complications, whereas 10 per cent of batteries had severe complications (P = 0.04). Each technique if applied appropriately can be a reasonable option for esophageal foreign body removal. Magnetic tip orogastric tubes used to extract ferromagnetic objects like disc batteries had the shortest procedure time and highest success rate although it was not statistically significant. Disc batteries require emergent removal and have a significant complication rate.

Mathematical modeling of the socalled Allis test: a field study in orthopedic confusion.

BACKGROUND: Chiropractors use a variety of supine and prone leg checking procedures. Some, including the Allis test, purport to distinguish anatomic from functional leg length inequality. Although the reliability and to a lesser extent the validity of some leg checking procedures has been assessed, little is known on the Allis test. The present study mathematically models the test under a variety of hypothetical clinical conditions. In our search for historical and clinical information on the Allis test, nomenclatural and procedural issues became apparent. METHODS: The test is performed with the subject carefully positioned in the supine position, with the head, pelvis, and feet centered on the table. After an assessment for anatomic leg length inequality, the knees are flexed to approximately 90 degrees . The examiner then sights the short leg side knee sequentially from both the foot and side of the table, noting its relative locations: both its height from the table and Y axis position. The traditional interpretation of the Allis test is that a low knee identifies a short tibia and a cephalad knee a short femur. Assuming arbitrary lengths and a tibio/femoral ratio of 1/1.26, and a hip to foot distance that placed the knee near 90 degrees , we trigonometrically calculated changes in the location of the right knee that would result from hypothetical reductions in tibial and femoral length. We also modeled changes in the tibio/femoral ratio that did not change overall leg length, and also a change in hip location. RESULTS: The knee altitude diminishes with either femoral or tibial length reduction. The knee shifts cephalad when the femoral length is reduced, and caudally when the tibial length is reduced. Changes in the femur/tibia ratio also influence knee position, as does cephalad shifting of the hip. CONCLUSION: The original Allis (aka Galeazzi) test was developed to identify gross hip deformity in pediatric patients. The extension of this test to adults suspected of having anatomical leg length inequality is problematic, and needs refinement at the least. Our modeling questions whether this test can accurately identify aLLI, let alone distinguish a short tibia from a short femur.

Conservative Care of Pediatric Acquired Torticollis: A Report of 2 Cases.

OBJECTIVE: The purpose of this case report is to describe the conservative management of 2 cases of acquired torticollis in children under 3 years of age. CLINICAL FEATURES: Both patients awoke with painful, stiff, twisted necks the day after play in a bouncy house. Range of motion was limited, and hypertonic muscles were palpated. Their neurologic and physical evaluation was consistent with a diagnosis of acquired torticollis of musculoskeletal origin. INTERVENTION AND OUTCOMES: Both children were treated with chiropractic care that consisted of light myofascial release, use of an Activator instrument, and home stretching. Patients improved in pain and range of motion immediately posttreatment and returned to normal ranges in 1 or 2 visits. CONCLUSION: Chiropractic care provided relief for these 2 young patients with acquired torticollis.

The reliability of spinal motion palpation determination of the location of the stiffest spinal site is influenced by confidence ratings: a secondary analysis of three studies.

BACKGROUND: This is a secondary analysis of three previous studies on the cervical, thoracic, and lumbar spines. It uses continuous analysis of the stiffest spinal site rather than more typical level-by-level analysis to assess interexaminer reliability, and the impacts of examiner confidence and spinal region. The primary goal was secondary analysis of the combined data; secondary goal was de novo analysis of combined data emphasizing absolute indices of examiner agreement; and tertiary goal was analysis of actual vs. simulated data to determine to what degree the information provided by motion palpation impacted interexaminer reliability. METHODS: This study emphasized Median Absolute Examiner Differences and Bland-Altman Limits of Agreement to calculate examiner differences, which are immune to subject homogeneity, and de-emphasized intraclass correlation, which is not. It calculated Median Absolute Deviation to determine data dispersion. The study analyzed the entire n = 113 combined dataset, as well as subgroups stratified by examiner confidence and spinal region. Simulations were run using a random number generator to provide chance data for examiners' findings of the stiffest spinal site, the analysis of which was compared with that of the actual data. RESULTS: Median Absolute Examiner Differences for the combined dataset were 0.7 of one vertebral level, suggesting examiners usually agreed on the stiffest spinal site or the motion segment including it. When both examiners were confident in their findings (53.4%), the median examiner difference decreased to 0.6 levels, increasing to 1.0 levels when one lacked confidence and to 1.8 levels when both lacked confidence. Reliability was greater in the cervical and lumbar spines (each 0.6 vertebral levels examiner differences) than in the thoracic spine (1.1 levels examiner differences). The actual information provided by motion palpation compared to simulated data improved interexaminer reliability by a factor ranging from 1.8 times to 4.7 times, depending on the regional subset analyzed. CONCLUSIONS: Examiner decisions regarding the location of the stiffest spinal site were deemed adequately reliable, especially when the examiners were confident. Researchers and clinicians alike might best design their study protocols and practice methods using the stiffest segment protocol as an alternative to level-by-level spinal analysis.

The reliability of lumbar motion palpation using continuous analysis and confidence ratings: choosing a relevant index of agreement.

INTRODUCTION: Most studies show motion palpation unreliable. This study's primary objective was assessing its reliability using a continuous measure methods, most-fixated level paradigm, stratified by examiners' confidence; and the secondary objective was comparing various indices of examiner agreement. METHODS: Thirty-four minimally symptomatic participants were palpated in side posture by two experienced examiners. Interexaminer differences in identifying the most-fixated level and degree of examiner confidence were recorded. Indices of agreement were: Intraclass correlation coefficient, Mean and Median Examiner Absolute Examiner Differences, Root-Mean-Square Error and Bland-Altman Limits of Agreement. RESULTS: Three of four reliability indices (excluding intraclass correlation) suggested on average examiners agreed on the most fixated motion segment, and agreement increased with confidence. Statistical measures of data dispersion were low. The analyses of subgroups were "fragile" due to small sample size. DISCUSSION: Although subject homogeneity lowered ICC levels, the other reliability measures were not similarly impacted. Continuous measures statistical analysis demonstrates examiner agreement in situations where discrete analysis with kappa may not. CONCLUSION: Continuous analysis for the lumbar most-fixated level is reliable. Future studies will need a larger sample size to properly analyze subgroups based on examiner confidence.

INTRODUCTION: La plupart des études montrent que la palpation dynamique n'est pas fiable. L'objectif principal de cette étude était d'évaluer sa fiabilité en utilisant des méthodes de mesure continue, le paradigme du niveau intervertébral le plus fixé, empreint du degré d'incertitude des examinateurs; et l>objectif secondaire était de comparer divers indices de concordance des examinateurs. MÉTHODOLOGIE: Trente-quatre participants minimalement symptomatiques ont été palpés en position couchée par deux examinateurs expérimentés. Les différences, dans la capacité de désigner le niveau intervertébral le plus fixé, entre les examinateurs et le degré d'incertitude de ces derniers ont été enregistrés. La liste suivante constitue les indices de concordance : le coefficient de corrélation intraclasse, la moyenne et la médiane des examinateurs, les différences absolues entre les examinateurs, et les limites de concordance selon Bland-Altman. RÉSULTATS: Trois des quatre indices de fiabilité (à l'exception de la corrélation intraclasse) ont suggéré qu'en moyenne les examinateurs concordent sur le niveau intervertébral le plus fixé en palpation dynamique; la concordance augmente avec le niveau de certitude. Les mesures statistiques de dispersion étaient faibles. Les analyses des sous-groupes n'étaient pas fiables en raison de la petite taille des échantillons. DISCUSSION: Bien que l'homogénéité des sujets réduise les niveaux du CCI, cela n'affecte pas pour autant les autres mesures de fiabilité. Les analyses statistiques des mesures continues révèlent une concordance entre les examinateurs dans des circonstances où une analyse discrète avec l'indice de concordance kappa en serait incapable. CONCLUSION: L'analyse continue du niveau intervertébral le plus fixé est fiable. Les études futures auront besoin d'un plus grand échantillon afin d'analyser correctement les sous-groupes en fonction du niveau de certitude des examinateurs.

The location of the inferior angle of the scapula in relation to the spine in the upright position: a systematic review of the literature and meta-analysis.

Practitioners in several of the health care professions use anatomical landmarks to identify spinal levels, both in order to enhance diagnostic accuracy and to specifically target the site of intervention. Authoritative sources usually state the upright inferior scapular angle (IAS) aligns with the spinous process (SP) of T7, but some specify the T7-8 interspace or the T8 SP. The primary goals of this study were to systematically review the relevant literature; and conduct a meta-analysis of the pooled data from retrieved studies to increase their statistical power. Electronic searching retrieved primary studies relating the IAS to a spinal level, as determined by an imaging reference standard, using combinations of these search terms: scapula, location, landmark, spinous process, thoracic vertebrae, vertebral level, palpation, and spine. Only primary studies were included; review articles and reliability studies related to scapular position but lacking spinal correlations were excluded. Eight-hundred and eighty (880) articles of interest were identified, 43 abstracts were read, 22 full text articles were inspected, and 5 survived the final cut. Each article (with one exception) was rated for quality using the QUADAS instrument. Pooling data from 5 studies resulted in normal distribution in which the upright IAS on average aligns closely with the T8 SP, range T4-T11. Since on average the IAS most closely identifies the T8 SP in the upright position, it is very likely that health professionals, both manual therapists and others, who have been diagnosing and treating patients based on the IAS = T7 SP rule (the conventional wisdom), have not been as segmentally accurate as they may have supposed. They either addressed non-intended levels, or made numeration errors in their charting. There is evidence that using the IAS is less preferred than using the vertebra prominens, and may be less preferred than using the iliac crest for identifying spinal levels Manual therapists, acupuncturists, anesthesiologists, nurses, and surgeons should reconsider their procedures for identifying spinal sites in light of this modified information. Inaccurate landmark benchmark rules will add to patient variation and examiner errors in producing spine care targeting errors, and confound research on the importance of specificity in treating spinal levels.

Validity of palpation of the C1 transverse process: comparison with a radiographic reference standard.

OBJECTIVES: Primary goal: to determine the validity of C1 transverse process (TVP) palpation compared to an imaging reference standard. METHODS: Radiopaque markers were affixed to the skin at the putative location of the C1 TVPs in 21 participants receiving APOM radiographs. The radiographic vertical distances from the marker to the C1 TVP, mastoid process, and C2 TVP were evaluated to determine palpatory accuracy. RESULTS: Interexaminer agreement for radiometric analysis was "excellent." Stringent accuracy (marker placed ±4mm from the most lateral projection of the C1 TVP) = 57.1%; expansive accuracy (marker placed closer to contiguous structures) = 90.5%. Mean Absolute Deviation (MAD) = 4.34 (3.65, 5.03) mm; root-mean-squared error = 5.40mm. CONCLUSIONS: Manual palpation of the C1 TVP can be very accurate and likely to direct a manual therapist or other health professional to the intended diagnostic or therapeutic target. This work is relevant to manual therapists, anesthetists, surgeons, and other health professionals.

OBJECTIFS: But principal : Déterminer la validité de la palpation de l'apophyse transverse C1 par rapport à une référence d'imagerie normale. MÉTHODOLOGIE: On a posé des marqueurs radioopaques sur la peau à l'emplacement supposé de l'apophyse transverse C1 chez 21 participants recevant une radiographie APOM (bouche ouverte en incidence antéro-postérieure). Les distances verticales radiographiques entre le marqueur de l'apophyse transverse C1, l'apophyse mastoïde et l'apophyse transverse C2 ont été évaluées afin de déterminer la précision de la palpation. RÉSULTATS: Les examinateurs se sont accordés pour dire que l'analyse radiométrique était « excellente ¼. Précision rigoureuse (marqueur placé à ± 4 mm de la projection la plus latérale de l'apophyse transverse C1) = 57,1 %; précision expansive (marqueur placé plus près des structures contiguës) = 90,5 %. Écart absolu moyen (EAM) = 4,34 (3,65, 5,03) mm; valeur quadratique moyenne d'erreur = 5,40 mm. CONCLUSIONS: La palpation manuelle de l'apophyse transverse C1 peut être très précise et présente de fortes chances de guider un thérapeute manuel ou un autre professionnel de la santé vers le diagnostic ou la cible thérapeutique souhaités. Ce travail concerne les thérapeutes manuels, anesthésistes, chirurgiens et autres professionnels de la santé.

Mapping intended spinal site of care from the upright to prone position: an interexaminer reliability study.

BACKGROUND: Upright examination procedures like radiology, thermography, manual muscle testing, and spinal motion palpation may lead to spinal interventions with the patient prone. The reliability and accuracy of mapping upright examination findings to the prone position is unknown. This study had 2 primary goals: (1) investigate how erroneous spine-scapular landmark associations may lead to errors in treating and charting spine levels; and (2) study the interexaminer reliability of a novel method for mapping upright spinal sites to the prone position. METHODS: Experiment 1 was a thought experiment exploring the consequences of depending on the erroneous landmark association of the inferior scapular tip with the T7 spinous process upright and T6 spinous process prone (relatively recent studies suggest these levels are T8 and T9, respectively). This allowed deduction of targeting and charting errors. In experiment 2, 10 examiners (2 experienced, 8 novice) used an index finger to maintain contact with a mid-thoracic spinous process as each of 2 participants slowly moved from the upright to the prone position. Interexaminer reliability was assessed by computing Intraclass Correlation Coefficient, standard error of the mean, root mean squared error, and the absolute value of the mean difference for each examiner from the 10 examiner mean for each of the 2 participants. RESULTS: The thought experiment suggesting that using the (inaccurate) scapular tip landmark rule would result in a 3 level targeting and charting error when radiological findings are mapped to the prone position. Physical upright exam procedures like motion palpation would result in a 2 level targeting error for intervention, and a 3 level error for charting. The reliability experiment showed examiners accurately maintained contact with the same thoracic spinous process as the participant went from upright to prone, ICC (2,1) = 0.83. CONCLUSIONS: As manual therapists, the authors have emphasized how targeting errors may impact upon manual care of the spine. Practitioners in other fields that need to accurately locate spinal levels, such as acupuncture and anesthesiology, would also be expected to draw important conclusions from these findings.

Interexaminer reliability of cervical motion palpation using continuous measures and rater confidence levels.

INTRODUCTION: Motion palpators usually rate the movement of each spinal level palpated, and their reliability is assessed based upon discrete paired observations. We hypothesized that asking motion palpators to identify the most fixated cervical spinal level to allow calculating reliability at the group level might be a useful alternative approach. METHODS: Three examiners palpated 29 asymptomatic supine participants for cervical joint hypomobility. The location of identified hypomobile sites was based on their distance from the T1 spinous process. Interexaminer concordance was estimated by calculating Intraclass Correlation Coefficient (ICC) and mean absolute differences (MAD) values, stratified by degree of examiner confidence. RESULTS: For the entire participant pool, ICC [2,1] = 0.61, judged "good." MAD=1.35 cm, corresponding to mean interexaminer differences of about 75% of one cervical vertebral level. Stratification by examiner confidence levels resulted in small subgroups with equivocal results. DISCUSSION AND CONCLUSION: A continuous measures study methodology for assessing cervical motion palpation reliability showed more examiner concordance than was usually the case in previous studies using discrete methodology.

INTRODUCTION: Généralement, la palpation évalue le mouvement de chaque niveau de la moelle épinière palpé, et sa fiabilité est évaluée sur des observations jumelées et séparées. Nous avons émis l'hypothèse que l'utilisation de la palpation afin d'identifier le niveau de la moelle épinière cervicale le moins mobile, dans le but de permettre le calcul de sa fiabilité à l'échelle du groupe pourrait être une approche alternative utile. MÉTHODOLOGIE: Trois examinateurs ont palpé 29 participants asymptomatiques allongés atteints d'hypomobilité de l'articulation cervicale. L'emplacement de ces segments hypomobiles s'est fondé sur leurs distances par rapport à l'apophyse épineuse T1. La concordance entre les examinateurs a été estimée en calculant le coefficient de corrélation interne (ICC) et les valeurs de la différence absolue moyenne (MAD), stratifiés selon le degré de confiance de l'examinateur. RÉSULTATS: Pour tout le bassin de participants, ICC [2,1] = 0,61, jugé « bon ¼. MAD = 1,35 cm, ce qui correspond à la différence moyenne entre les examinateurs d'environ 75 % d'un segment de la colonne vertébrale. La stratification par le niveau de confiance de l'examinateur a entraîné des petits sousgroupes avec des résultats équivoques. DISCUSSION ET CONCLUSION: Une méthodologie ayant recours à des mesures continues pour l'évaluation de la fiabilité de la palpation de la colonne vertébrale a indiqué une plus grande concordance entre les examinateurs qu'à l'accoutumée lors des précédentes études, qui utilisaient la méthodologie séparée.