Platelets in Thrombosis and Atherosclerosis: A Double-Edged Sword.

This review focuses on the dual role of platelets in atherosclerosis and thrombosis, exploring their involvement in inflammation, angiogenesis, and plaque formation, as well as their hemostatic and prothrombotic functions. Beyond their thrombotic functions, platelets engage in complex interactions with diverse cell types, influencing disease resolution and progression. The contribution of platelet degranulation helps in the formation of atheromatous plaque, whereas the reciprocal interaction with monocytes adds complexity. Alterations in platelet membrane receptors and signaling cascades contribute to advanced atherosclerosis, culminating in atherothrombotic events. Understanding these multifaceted roles of platelets will lead to the development of targeted antiplatelet strategies for effective cardiovascular disease prevention and treatment. Understanding platelet functions in atherosclerosis and atherothrombosis at different stages of disease will be critical for designing targeted treatments and medications to prevent or cure the disease Through this understanding, platelets can be targeted at specific times in the atherosclerosis process, possibly preventing the development of atherothrombosis.

Cost and outcomes of Hospital-based Usual cAre versus Tele-monitor self-directed Rehabilitation (HUATR) in patients with total knee arthroplasty: A randomized, controlled, non-inferiority trial.

OBJECTIVE: To evaluate the clinical efficacy and cost-effectiveness of telemonitored self-directed rehabilitation (TR) compared with hospital-based rehabilitation (HBR) for patients with total knee arthroplasty (TKA). DESIGN: In this randomized, non-inferiority clinical trial, 114 patients with primary TKA who were able to walk independently preoperatively were randomized to receive HBR (n = 58) or TR (n = 56). HBR comprised at least five physical therapy sessions over 10 weeks. TR comprised a therapist-led onboarding session, followed by a 10-week unsupervised home-based exercise program, with asynchronous monitoring of rehabilitation outcomes using a telemonitoring system. The primary outcome was fast-paced gait speed at 12 weeks, with a non-inferiority margin of 0.10 m/s. For economic analysis, quality-adjusted-life-years (QALY) was the primary economic outcome (non-inferiority margin, 0.027 points). RESULTS: In Bayesian analyses, TR had >95% posterior probability of being non-inferior to HBR in gait speed (week-12 adjusted TR-HBR difference, 0.02 m/s; 95%CrI, -0.05 to 0.10 m/s; week-24 difference, 0.01 m/s; 95%CrI, -0.07 to 0.10 m/s) and QALY (0.006 points; 95%CrI, -0.006 to 0.018 points). When evaluated from a societal perspective, TR was associated with lower mean intervention cost (adjusted TR-HBR difference, -S$227; 95%CrI, -112 to -330) after 24 weeks, with 82% probability of being cost-effective compared with HBR at a willingness to pay of S$0/unit of effect for the QALYs. CONCLUSIONS: In patients with uncomplicated TKAs and relatively good preoperative physical function, home-based, self-directed TR was non-inferior to and more cost-effective than HBR over a 24-week follow-up period. TR should be considered for this patient subgroup.

Racial and sex disparities in inpatient outcomes of patients with ruptured abdominal aortic aneurysms in the United States.

BACKGROUND: Ruptured abdominal aortic aneurysm (AAA) is a medical emergency that requires immediate surgical intervention. The aim of this analysis was to identify the sex- and race-specific disparities that exist in outcomes of patients hospitalized with this condition in the United States using the National Inpatient Sample (NIS) to identify targets for improvement and support of specific patient populations. METHODS: In this descriptive, retrospective study, we analyzed the patients admitted with a primary diagnosis of ruptured AAA between January 1, 2016, and December 31, 2020, using the NIS database. We compared demographics, comorbidities, and in-hospital outcomes in AAA patients, and compared these results between different racial groups and sexes. RESULTS: A total of 22,395 patients with ruptured AAA were included for analysis. Of these, 16,125 patients (72.0%) were male, and 6270 were female (28.0%). The majority of patients (18,655 [83.3%]) identified as Caucasian, with the remaining patients identifying as African American (1555 [6.9%]), Hispanic (1095 [4.9%]), Asian or Pacific Islander (470 [2.1%]), or Native American (80 [0.5%]). Females had a higher risk of mortality than males (OR, 1.7; 95% confidence interval [CI], 1.45-1.96; P < .001) and were less likely to undergo endovascular aortic repair (OR, 0.70; 95% CI, 0.61-0.81; P < .001) or fenestrated endovascular aortic repair (OR, 0.71; 95% CI, 0.55-0.91; P = .007). Relative to Caucasian race, patients who identified as African American had a lower risk of inpatient mortality (OR, 0.50; 95% CI, 0.37-0.68; P < .001). CONCLUSIONS: In this retrospective study of the NIS database from 2016 to 2020, females were less likely to undergo endovascular intervention and more likely to die during their initial hospitalization. African American patients had lower rates in-hospital mortality than Caucasian patients, despite a higher burden of comorbidities. Future studies are needed to elucidate the potential factors affecting racial and sex disparities in ruptured AAA outcomes, including screening practices, rupture risk stratification, and more personalized guidelines for both elective and emergent intervention.

Database Integration Correlates Street Crossing Design Strategies With Pedestrian Injury.

INTRODUCTION: Transportation databases have limited data regarding injury severity of pedestrian versus automobile patients. To identify opportunities to reduce injury severity, transportation and trauma databases were integrated to examine the differences in pedestrian injury severity at street crossings that were signalized crossings (SCs) versus nonsignalized crossings (NSCs). It was hypothesized that trauma database integration would enhance safety analysis and pedestrians struck at NSC would have greater injury severity. METHODS: Single-center retrospective review of all pedestrian versus automobile patients treated at a level 1 trauma center from 2014 to 2018 was performed. Patients were matched to the transportation database by name, gender, and crash date. Google Earth Pro satellite imagery was used to identify SC versus NSC. Injury severity of pedestrians struck at SC was compared to NSC. RESULTS: A total of 512 patients were matched (median age = 41 y [Q1 = 26, Q3 = 55], 74% male). Pedestrians struck at SC (n = 206) had a lower injury severity score (ISS) (median = 9 [4, 14] versus 17 [9, 26], P < 0.001), hospital length of stay (median = 3 [0, 7] versus 6 [1, 15] days, P < 0.001), and mortality (21 [10%] versus 52 [17%], P = 0.04), as compared to those struck at NSC (n = 306). The transportation database had a sensitivity of 63.4% (55.8%-70.4%) and specificity of 63.4% (57.7%-68.9%) for classifying severe injuries (ISS >15). CONCLUSIONS: Pedestrians struck at SC were correlated with a lower ISS and mortality compared to those at NSC. Linkage with the trauma database could increase the transportation database's accuracy of injury severity assessment for nonfatal injuries. Database integration can be used for evidence-based action plans to reduce pedestrian morbidity, such as increasing the number of SC.

Effect of Context Specificity on Response to the Shortened WOMAC Function Scale in Patients Undergoing Total Knee Arthroplasty.

OBJECTIVE: To determine, in patients undergoing total knee arthroplasty (TKA), whether increasing context specificity of selected items of the shortened version of the Western Ontario and McMaster Universities Osteoarthritis Index function (WOMAC-F) scale (ShortMAC-F) (1) enhanced the convergent validity of the ShortMAC-F with performance-based mobility measures (ii) affected mean scale score, structural validity, reliability, and interpretability. DESIGN: Secondary analysis of randomized clinical trial data. SETTING: A tertiary teaching hospital. PARTICIPANTS: Patients undergoing TKA (N=114). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The ShortMAC-F was modified by specifying the "ascending stairs" and "rising from sitting" items to enquire about difficulty in performing the tasks without reliance on compensatory strategies, whereas the modified "level walking" item enquired about difficulty in walking 400 m. Before and 12 weeks after TKA, patients completed the WOMAC-F questionnaire, modified ShortMAC-F questionnaire, knee pain scale questionnaire, sit-to-stand test, fast gait speed test, and stair climb test. Interpretability was evaluated by calculating anchor-based substantial clinical benefit estimates. RESULTS: The modified ShortMAC-F correlated significantly more strongly than ShortMAC-F or WOMAC-F with pooled performance measures (differences in correlation values, 0.12-0.14). Increasing item context specificity of the ShortMAC-F did not influence its psychometric properties of unidimensionality (comparative fit and Tucker-Lewis indices, >0.95; root mean square error of approximation, 0.05-0.08), reliability (Cronbach's α, 0.75-0.83), correlation with pain intensity (correlation values, 0.48-0.52), and substantial clinical benefit estimates (16 percentage points); however, it resulted in lower mean score (4.5-4.8 points lower). CONCLUSIONS: The modified ShortMAC-F showed sufficient measurement properties for clinical application, and it seemed more adept than WOMAC-F at correlating with performance-based measures in TKA.

Machine learning for automating subjective clinical assessment of gait impairment in people with acquired brain injury - a comparison of an image extraction and classification system to expert scoring.

BACKGROUND: Walking impairment is a common disability post acquired brain injury (ABI), with visually evident arm movement abnormality identified as negatively impacting a multitude of psychological factors. The International Classification of Functioning, Disability and Health (ICF) qualifiers scale has been used to subjectively assess arm movement abnormality, showing strong intra-rater and test-retest reliability, however, only moderate inter-rater reliability. This impacts clinical utility, limiting its use as a measurement tool. To both automate the analysis and overcome these errors, the primary aim of this study was to evaluate the ability of a novel two-level machine learning model to assess arm movement abnormality during walking in people with ABI. METHODS: Frontal plane gait videos were used to train four networks with 50%, 75%, 90%, and 100% of participants (ABI: n = 42, healthy controls: n = 34) to automatically identify anatomical landmarks using DeepLabCut™ and calculate two-dimensional kinematic joint angles. Assessment scores from three experienced neurorehabilitation clinicians were used with these joint angles to train random forest networks with nested cross-validation to predict assessor scores for all videos. Agreement between unseen participant (i.e. test group participants that were not used to train the model) predictions and each individual assessor's scores were compared using quadratic weighted kappa. One sample t-tests (to determine over/underprediction against clinician ratings) and one-way ANOVA (to determine differences between networks) were applied to the four networks. RESULTS: The machine learning predictions have similar agreement to experienced human assessors, with no statistically significant (p < 0.05) difference for any match contingency. There was no statistically significant difference between the predictions from the four networks (F = 0.119; p = 0.949). The four networks did however under-predict scores with small effect sizes (p range = 0.007 to 0.040; Cohen's d range = 0.156 to 0.217). CONCLUSIONS: This study demonstrated that machine learning can perform similarly to experienced clinicians when subjectively assessing arm movement abnormality in people with ABI. The relatively small sample size may have resulted in under-prediction of some scores, albeit with small effect sizes. Studies with larger sample sizes that objectively and automatically assess dynamic movement in both local and telerehabilitation assessments, for example using smartphones and edge-based machine learning, to reduce measurement error and healthcare access inequality are needed.

Assessment of association between lower ureteric excision technique and oncological outcomes for upper urinary tract urothelial carcinoma: retrospective analysis from the Scottish Renal Cancer Consortium.

PURPOSE: Nephroureterectomy(NU) remains the gold-standard surgical option for the management of upper urinary tract urothelial carcinoma(UTUC). Controversy exists regarding the optimal excision technique of the lower ureter. We sought to compare post-UTUC bladder tumour recurrence across the Scottish Renal Cancer Consortium(SRCC). METHODS: Patients who underwent NU for UTUC across the SRCC 2012-2019 were identified. The impact of lower-end surgical technique along with T-stage, N-stage, tumour location and focality, positive surgical margin, pre-NU ureteroscopy, upper-end technique and adjuvant mitomycin C administration were assessed by Kaplan-Meier and Cox-regression. The primary outcome was intra-vesical recurrence-free survival (B-RFS). RESULTS: In 402 patients, the median follow-up was 29 months. The lower ureter was managed by open transvesical excision in 90 individuals, transurethral and laparoscopic dissection in 76, laparoscopic or open extra-vesical excision in 31 and 42 respectively, and transurethral dissection and pluck in 163. 114(28.4%) patients had a bladder recurrence during follow-up. There was no difference in B-RFS between lower-end techniques by Kaplan-Meier (p = 0.94). When all factors were taken into account by adjusted Cox-regression, preceding ureteroscopy (HR 2.65, p = 0.001), lower ureteric tumour location (HR 2.16, p = 0.02), previous bladder cancer (HR 1.75, p = 0.01) and male gender (HR 1.61, p = 0.03) were associated with B-RFS. CONCLUSION: These data suggest in appropriately selected patients, lower ureteric management technique does not affect B-RFS. Along with lower ureteric tumour location, male gender and previous bladder cancer, preceding ureteroscopy was associated with a higher recurrence rate following NU, and the indication for this should be carefully considered.

Vascular Surgery Role in Vascular Trauma: 11-Year Analysis of Peripheral Vascular Trauma Management at a Level-1 Trauma Center.

BACKGROUND: Vascular surgeons are increasingly relied upon in the management of complex peripheral vascular trauma. The degree however that vascular surgery (VS) is involved in vascular trauma care is not well established. We hypothesize that VS consultation is required in a high portion of complex lower extremity vascular trauma. METHODS: A single-center retrospective review of all consecutive patients who sustained traumatic arterial injury of the lower extremity requiring open operative repair at a level-1 trauma center (from February 2009 to May 2020) was performed. Patients who underwent surgical repair were stratified by the service that performed the operation (VS versus trauma surgery [TS]). Secondary outcomes assessed included location of arterial injury, type of repair, and clinical outcomes. RESULTS: A total of 111 patients underwent operative repair of lower extremity arterial injury (mean age 34.5 ± 15.5 years, 89% male). The most common vessels requiring intervention were the superficial femoral artery (n = 42, 38%), popliteal artery (n = 35, 31.5%), and tibial vessels (n = 19, 17.1%). The most common intervention required in patients was an autologous bypass (n = 85, 76.5%), followed by ligation (n = 9, 8.1%) and primary repair (n = 6, 5.4%). Most interventions overall required VS involvement (n = 95, 86%). VS performed a higher proportion of autologous graft procedures compared to TS (n = 79, 92.9% vs. n = 6, 7.1%). VS case load overall was likewise predominantly autologous grafts (n = 79/95, 83.2%). TS operated on a higher proportion of injuries to the tibial vessels (44% vs. 13%, P = 0.01), whereas VS intervened more frequently on popliteal injuries (36% vs. 6%, P = 0.02). With regard to the method of arterial repair, TS was more likely to perform ligation (38% vs. 3 %, P < 0.001) or primary repair (13% vs. 3%, P = 0.04) compared to VS. However, VS was more likely to perform repair with autologous graft (83% vs. 38%, P < 0.001). There were no significant differences in rates of mortality, limb loss, transfusions requirement, fasciotomy, deep venous thrombosis, hematoma formation, or length of stay between groups. Although, surgical site infections were more common in the TS group (38% vs. 15%, P = 0.04). CONCLUSIONS: Vascular surgeons play a large role in managing complex lower extremity vascular trauma. In particular, VS remains integral for the management of more difficult injuries (e.g., popliteal injuries) and is more likely to provide more complex repairs (e.g., autologous grafts).

Long-Term Outcomes of Open and Endovascular Axillosubclavian Interventions After Traumatic Injury Reveal High Rates of Limb Dysfunction.

BACKGROUND: Arterial axillosubclavian injuries (ASIs) are currently managed with open repair (OR) and endovascular stenting (ES). The long-term prognosis of patients with these and associated brachial plexus injuries is poorly understood. We hypothesize that OR and ES for ASI have similar long-term patency rates and that brachial plexus injuries would confer high long-term morbidity. METHODS: All patients at a level-1 trauma center who underwent procedures for ASI over a 12-year period (2010 to 2022) were identified. Long-term outcomes of patency rates, types of reintervention, rates of brachial plexus injury, and functional outcomes were then investigated. RESULTS: Thirty-three patients underwent operations for ASI. OR was performed in 72.7% (n = 24) and ES in 27.3% (n = 9). ES patency was 85.7% (n = 6/7) and OR patency was 75% (n = 12/16), at a median follow-up of 20 and 5.5 months respectively. In subclavian artery injuries, ES patency was 100% (n = 4/4) and OR patency was 50% (n = 4/8) at a median follow-up of 24 and 12 months respectively. Long-term patency rates were similar between OR and ES (P = 1.0). Brachial plexus injuries occurred in 42.9% (n = 12/28) of patients. Ninety percent (n = 9/10) of patients with brachial plexus injuries who were followed postdischarge had persistent motor deficits at median follow-up of 12 months, occurring at significantly higher rates in patients with brachial plexus injuries (90%) compared to those without brachial plexus injuries (14.3%) (P = 0.0005). CONCLUSIONS: Multiyear follow-up demonstrates similar OR and ES patency rates for ASI. Subclavian ES patency was excellent (100%) and prosthetic subclavian bypass patency was poor (25%). brachial plexus injuries were common (42.9%) and devastating, with a significant portion of patients having persistent limb motor deficits (45.8%) on long-term follow-up. Algorithms to optimize brachial plexus injuries management for patients with ASI are high-yield, and likely to influence long-term outcomes more than the technique of initial revascularization.

Controlling modified Tardieu scale assessment speeds to match joint angular velocities during walking impacts spasticity assessment outcomes.

OBJECTIVE: To investigate whether tailoring the speed of the Modified Tardieu Scale to reflect an individual's joint angular velocity during walking influences spasticity assessment outcomes. DESIGN: Observational trial. SETTING: Inpatient and outpatient neurological hospital department. SUBJECTS: Ninety adults with lower-limb spasticity. INTERVENTIONS: N/A. MAIN MEASURES: The Modified Tardieu Scale was used to assess the gastrocnemius, soleus, hamstrings and quadriceps. The V1 (slow) and V3 (fast) movements were completed as per standardised testing. Two additional assessments were completed, reflecting joint angular velocities during walking based on (i) a healthy control database (controlled velocity) and (ii) the individual's real-time joint angular velocities during walking (matched velocity). The agreement was compared using Cohen's and Weighted Kappa statistics, sensitivity and specificity. RESULTS: There was poor agreement when rating trials as spastic or not spastic at the ankle joint (Cohen's Kappa = 0.01-0.17). Trials were classified as spastic during V3 and not spastic during the controlled conditions in 81.6-85.1% of trials when compared to stance phase dorsiflexion angular velocities and 48.0-56.4% when compared to swing phase dorsiflexion angular velocities. The severity of muscle reaction demonstrated poor agreement at the ankle (Weighted Kappa = 0.01-0.28). At the knee, there was a moderate-excellent agreement between the V3 and controlled conditions when rating a trial as spastic or not spastic (Cohen's Kappa = 0.66-0.84) and excellent agreement when comparing severity (Weighted Kappa = 0.73-0.94). CONCLUSION: The speed of assessment impacted spasticity outcomes. It is possible that the standardised protocol may overestimate the impact spasticity has on walking, especially at the ankle.

Vestibular function and balance performance in children with sensorineural hearing loss.

OBJECTIVE: Balance difficulties are common in children with sensorineural hearing loss (SNHL). For some of these children, concomitant vestibular deficits may impact postural control. This study aimed to explore vestibular function, functional balance and postural control, and the relationship between these measures in children with SNHL. DESIGN: Cross-sectional study quantifying peripheral vestibular function (vestibular evoked myogenic potentials [VEMP], video head impulse test), functional balance (Bruininks-Oseretsky Test of Motor Proficiency [BOT]) and postural control (static posturography with modified sensory inputs). The relationship between the degree of vestibular impairment, functional balance and postural control was explored. STUDY SAMPLE: Eleven with SNHL, and 11 with normal sound detection (NSD) between 5 and 12 years of age. RESULTS: Children with SNHL had varying degrees of vestibular dysfunction and differences in overall balance performance. Across all children, greater degrees of vestibular impairment were associated with significantly poorer functional balance and postural control performance for complex standing conditions (BOT percentile rank p = 0.001; compliant surface eyes open [EO]: p = 0.027; compliant surface eyes closed: p = 0.048). CONCLUSIONS: Vestibular dysfunction in children with SNHL was variable. Vestibular impairment predicted poorer functional balance performance and postural control abilities, including differences in postural sway patterns.

Discordance Between Self-Reported and Performance-Based Physical Function in Patients Who Have Knee Osteoarthritis: Associations With Pain Intensity and Negative Affect.

BACKGROUND: Although self-reported measures of physical disability are strong indication criterion for total knee arthroplasty (TKA) in painful knee osteoarthritis (OA), some patients may report greater-than-observed disability. Contributing factors to this discordance are relatively unexplored. We aimed to examine whether pain and negative affect, including anxiety and depression, were associated with the discordance of self-reported measures with performance-based measures (PPM) of physical function. METHODS: We used cross-sectional data (n = 212) from two randomized rehabilitation trials in knee OA. All patients were assessed for knee pain intensity and symptoms of anxiety and depression. Self-reported function was assessed by the Western Ontario and McMaster Universities Arthritis Index (WOMAC) physical-function subscale. Objective performance-based measures (PPMs) of physical function were assessed by timed gait and stair tests. Continuous discordance scores were quantified by the difference in percentiles between WOMAC and PPMs (WOMAC-PPM), where a positive discordance, WOMAC-PPM >0, implied greater perceived than observed disability. RESULTS: Around 1 in 4 patients had >20 percentile units in WOMAC-PPM discordance. In Bayesian regression analyses, knee pain intensity had >99% posterior probability of positive associations with WOMAC-PPM discordance. Among patients awaiting TKA, anxiety intensity had approximately 99% probability of positive associations with discordance, and these associations had >65% probability of exceeding 10 percentile units. In contrast, depression had low (79% to 88%) probability of any association with discordance. CONCLUSION: In patients who have knee OA, a sizable proportion reported substantially greater physical disability than actually observed. Pain and anxiety intensity, but not depression, were meaningful predictors of this discordance. If validated, our findings may help in refining patient selection criteria for TKA.

Impaired Lumbar Extensor Force Control Is Associated with Increased Lifting Knee Velocity in People with Chronic Low-Back Pain.

The ability of the lumbar extensor muscles to accurately control static and dynamic forces is important during daily activities such as lifting. Lumbar extensor force control is impaired in low-back pain patients and may therefore explain the variances in lifting kinematics. Thirty-three chronic low-back pain participants were instructed to lift weight using a self-selected technique. Participants also performed an isometric lumbar extension task where they increased and decreased their lumbar extensor force output to match a variable target force within 20-50% lumbar extensor maximal voluntary contraction. Lifting trunk and lower limb range of motion and angular velocity variables derived from phase plane analysis in all planes were calculated. Lumbar extensor force control was analyzed by calculating the Root-Mean-Square Error (RMSE) between the participants' force and the target force during the increasing (RMSEA), decreasing (RMSED) force portions and for the overall force error (RMSET) of the test. The relationship between lifting kinematics and RMSE variables was analyzed using multiple linear regression. Knee angular velocity in the sagittal and coronal planes were positively associated with RMSEA (R2 = 0.10, ß = 0.35, p = 0.046 and R2 = 0.21, ß = 0.48, p = 0.004, respectively). Impaired lumbar extensor force control is associated with increased multiplanar knee movement velocity during lifting. The study findings suggest a potential relationship between lumbar and lower limb neuromuscular function in people with chronic low-back pain.

Development and test-retest reliability assessment of a low-cost, 3D printed tool for assessing different aspects of hand dexterity.

BACKGROUND: Hand dexterity assessments related to fine motor movements are routinely administered in clinical settings to ascertain an individual's hand function. However, to perform a detailed assessment multiple devices are needed which can be time-consuming and costly to administer. PURPOSE: We designed and assessed the test-retest reliability of a 3D printed dexterity device in a cohort of healthy young adults and community-dwelling older adults. This study examines the reliability of the device, association between perceived fine motor gripping and manipulation dexterity components, and dominant hand outperformance during both tasks. STUDY DESIGN: Test-retest study of a clinical measurement tool. METHODS: A convenience sample of thirty-six healthy community-dwelling older and young adults was included in our study. The device was used to collect data at two testing sessions to establish test-retest reliability. Fine motor manipulation dexterity was assessed by lifting notched pegs over a vertical barrier and inserting them into randomly oriented holes sequentially. Fine motor gripping dexterity was assessed by taking these notched pegs out of the holes, lifting them over the barrier and dropping them into a large container. RESULTS: Intraclass correlation coefficient (ICC)2,1 showed good to excellent test-retest reliability on the dominant and nondominant hands when using the device. Only modest association was found within-hand for the gripping versus manipulation dexterity tests. The between-hand motor gripping dexterity test demonstrated a strong association; however, between-hand the motor manipulation dexterity test was only moderately associated. CONCLUSION: The device was reliable, discriminated between the motor gripping and motor manipulating dexterity tasks, and was sensitive to handedness during the motor manipulating dexterity task. It shows promise as a hand dexterity assessment device which may provide efficiency and cost advantages. It is freely available via http://www.rehabtools.org/dexterity.html.

Hydrogen sulfide and miR21 are suitable biomarkers of hypoxic exposure.

Hypoxia is the reduction of alveolar partial pressure of oxygen ([Formula: see text]). Military members and people who practice recreational activities from moderate to high altitudes are at risk for hypoxic exposure. Hypoxemia's signs and symptoms vary from asymptomatic to severe responses, such as excessive hypoxic ventilatory responses and residual neurobehavioral impairment. Therefore, it is essential to identify hypoxia-induced biomarkers to indicate people with exposure to hypoxia. Advances have been made in understanding physiological responses to hypoxia, including elevations in circulating levels of endothelin 1 (ET-1) and microRNA 21 (miR-21) and reduction in circulating levels of hydrogen sulfide (H2S). Although the levels of these factors change upon exposure to hypoxia, it is unclear if these changes are sustained on return to normoxia. We hypothesize that hypoxia-induced ET-1 and miR-21 remain elevated, whereas hypoxia-reduction in H2S sustains after returning to normoxic conditions. To test this hypothesis, we exposed male rats to 6 h of 12% O2 and measured circulating levels of ET-1 and miR-21, pre, during, and posthypoxia. We found that ET-1 plasma levels increased in response to hypoxia but returned to normal levels within 30 min after the restoration of normoxia. miR-21 plasma levels and transdermal H2S emissions decreased in response to hypoxia, remaining decreased on return to normoxia, thus following the biomarker criteria. Therefore, this study supports a unique role for plasma miR21 and transdermal H2S as hypoxia biomarkers that could be used to identify individuals after exposure to hypoxia.

The neglected barrier to medication use: a systematic review of difficulties associated with opening medication packaging.

Difficulty opening medication packaging can have serious consequences that can lead to patient harm via medication mismanagement or poor adherence. However, the quality of literature pertaining to these issues has yet to be collated and critiqued. This systematic review examined cross-sectional studies that objectively examined the ability of participants to open different medication packaging. Of the 8,692 studies identified, 12 met the inclusion criteria, all of which were direct observational studies given that prior research has identified a mismatch between self-report and actual ability. Scoring via the Appraisal Tool for Cross Sectional Studies revealed that the methodological quality of included studies was typically low. Study samples mostly consisted of older adults. All studies reported a non-negligible proportion of participants unable to open packaging, with the most difficulty associated with child-resistant containers. Several studies examined associations; however, no factor was consistently found to be significantly associated with the ability to open packaging. Despite these studies spanning >40 years, the packaging types examined remained largely the same. This suggests that, despite decades of research demonstrating that packaging is problematic, there has been a stagnation in medication packaging development. Whether this is attributed to a paucity of high-quality research, and therefore a lack of strong evidence that change is needed, is unclear. Future research should strive for better methodological quality, with generalisable cohorts assessed via observation in their home. If the problems identified in prior research persist, this may provide the impetus for change that is overdue in the medication packaging industry.

Developing the Freezing of Gait Severity Tool: A Delphi consensus study to determine the content of a clinician-rated assessment for freezing of gait severity.

OBJECTIVES: There is no standardisation of tasks or measures for evaluation of freezing of gait severity in people with Parkinson's disease. This study aimed to develop a clinician-rated tool for freezing of gait severity (i.e. Freezing of Gait Severity Tool), through determining clinicians' ratings of the most important triggering circumstances to be examined and aspects of freezing of gait to be measured. DESIGN: A three-round, web-based Delphi study. PARTICIPANTS: Healthcare professionals, with at least five years' experience in managing freezing of gait in people with Parkinson. MAIN OUTCOME MEASURES: Round 1 required participants (n = 28) to rate items on a 5-point Likert scale, based on priority for inclusion in the Freezing of Gait Severity Tool. In Round 2, participants (n = 18) ranked the items based on priority for inclusion. In Round 3, participants (n = 18) confirmed or rejected the shortlisted items by judging their ability, on a binary scale, to screen for freezing of gait, detect changes in freezing severity, and discriminate between degrees of severity. RESULTS: Participants agreed with the triggering circumstances of turning hesitation, narrow space hesitation, start hesitation, cognitive dual-tasking, and open space hesitation should be assessed; and the aspects of gait freezing to be measured included freezing type, number of freezing episodes during a task, and average duration of freezing episodes. CONCLUSIONS: This study attained a consensus for the items to be included in a clinician-rated tool for freezing of gait severity. Future studies should investigate psychometric properties and clinical feasibility of the Freezing of Gait Severity Tool.

The Effectiveness of Aquatic Plyometric Training in Improving Strength, Jumping, and Sprinting: A Systematic Review.

CONTEXT: Aquatic plyometric training may provide benefits due to reduced joint loading compared with land plyometric training; however, the reduced loading may also limit performance gains. OBJECTIVE: To systematically review the effect of aquatic plyometric training on strength, performance outcomes, soreness, and adverse events in healthy individuals. EVIDENCE ACQUISITION: Five databases were searched from inception to June 2020. Quality assessment and data extraction were independently completed by 2 investigators. When similar outcome measures were used, standardized mean differences were calculated. EVIDENCE SYNTHESIS: A total of 19 randomized controlled trials with 633 participants (mean age, range 14-30 y) were included. Aquatic plyometric training was most commonly performed in waist to chest deep water (12/19 studies), 2 to 3 times per week for 6 to 12 weeks (18/19 studies), with final program foot contacts ranging from 120 to 550. Meta-analyses were not completed due to the clinical and statistical heterogeneity between studies. Compared with land plyometric training, aquatic plyometric training exercises and dosage were replicated (15/16 studies) and showed typically similar performance gains (3/4 knee extensor strength measures, 2/4 leg extensor strength measures, 3/4 knee flexor strength measures, 7/10 vertical jump measures, 3/3 sprint measures). In total, 2 of 3 studies monitoring muscle soreness reported significantly less soreness following training in water compared with on land. Compared with no active training (no exercise control group or passive stretching), most effect sizes demonstrated a mean improvement favoring aquatic plyometric training (23/32 measures). However, these were not significant for the majority of studies measuring isokinetic knee strength, vertical jump, and sprinting. The effect sizes for both studies assessing leg press strength indicated that aquatic plyometric training is significantly more effective than no training. CONCLUSION: Aquatic plyometric training appears similarly effective to land plyometric exercise for improving strength, jumping, and sprinting and may be indicated when joint impact loading needs to be minimized. However, the low quality of studies limits the strength of the conclusions.

Initial Outcomes Following Introduction of Percutaneous Arteriovenous Fistula Program with Comparison to Historical Surgically Created Fistulas.

BACKGROUND: Recently, there has been an abundance of encouraging data regarding the creation of percutaneous arteriovenous fistulas. Despite promising data regarding their clinical maturation, a paucity of data exists which provides direct comparison between percutaneously created AVFs (pAVF) and open surgically created AVFs (sAVF). This study has 2 primary objectives: First, to compare clinical outcomes of pAVFs to sAVFs, with emphasis on clinical maturation and frequency of postoperative interventions to facilitate maturation. Second, to contribute toward the evidence-based incorporation of the pAVF procedure into the hemodialysis access algorithm. METHODS: A single-center retrospective review was performed on all consecutive patients undergoing surgically created brachiocephalic arteriovenous fistula (BC-AVF, sAVF group) from January 1, 2018 to December 31, 2018 and Ellipsys-created percutaneous arteriovenous fistula (pAVF group) from January 1, 2019 to December 31, 2019. Comparative analysis between groups was performed. RESULTS: A total of 24 patients underwent Ellipsys-created pAVF with mean age of 56.7 ± 22.6 years (12 males [50%], 12 females [50%]) and 62 patients underwent surgically created BC-AVF with mean age of 62.5 ± 13.2 years (32 males [52%], 30 females [48%]). Both the pAVF and sAVF groups had comparable mean operating times (60 ± 40 vs. 56 ± 25 min, P = 0.67) and frequency of procedural technical success (23 [96%] vs. 62 [100%], P = 0.28), respectively. The pAVF group had a lower clinical maturation rate (12 [52%] vs. 54 [87%], P = 0.003) and a higher primary failure rate (9 [39%] vs. 6 [10%], P = 0.003) when compared to the sAVF group. The pAVF group had an increased overall rate of undergoing a postoperative intervention (18 [78%] vs. 13 [21%], P< 0.001), as well as an increased number of total postoperative interventions (1.1 ± 0.9 vs. 0.3 ± 0.6 interventions, P< 0.001) compared to the sAVF group. Percutaneous transluminal angioplasty of the juxta anastomotic segment was the most prevalent postoperative intervention performed in the pAVF group and occurred at a significantly increased frequency when compared to the sAVF group rate (13 [57%] vs. 5 [8%], P< 0.001). CONCLUSIONS: In our single-center retrospective review, patients undergoing Ellipsys-created pAVF in the first year following introduction of percutaneous endovascular had inferior rates of clinical maturation and underwent more postoperative interventions when compared to historical patients undergoing surgically created BC-AVF. Outcome discrepancies compared to previously reported Ellipsys data demonstrate a need for further studies examining the practical translatability of the pAVF.

Rest Intervals during Virtual Reality Gaming Augments Standing Postural Sway Disturbance.

Immersive virtual reality (VR) can cause acute sickness, visual disturbance, and balance impairment. Some manufacturers recommend intermittent breaks to overcome these issues; however, limited evidence examining whether this is beneficial exists. The aim of this study was to examine whether taking breaks during VR gaming reduced its effect on postural sway during standing balance assessments. Twenty-five people participated in this crossover design study, performing 50 min of VR gaming either continuously or with intermittent 10 min exposure/rest intervals. Standing eyes open, two-legged balance assessments were performed immediately pre-, immediately post- and 40 min post-exposure. The primary outcome measure was total path length; secondary measures included independent axis path velocity, amplitude, standard deviation, discrete and continuous wavelet transform-derived variables, and detrended fluctuation analysis. Total path length was significantly (p < 0.05) reduced immediately post-VR gaming exposure in the intermittent rest break group both in comparison to within-condition baseline values and between-condition timepoint results. Conversely, it remained consistent across timepoints in the continuous exposure group. These changes consisted of a more clustered movement speed pattern about a lower central frequency, evidenced by signal frequency content. These findings indicate that caution is required before recommending rest breaks during VR exposure until we know more about how balance and falls risk are affected.