Inflammatory Bowel Disease-Associated Arthritis Is Associated with Concomitant Autoimmune and Inflammatory Disorders.

BACKGROUND: Extraintestinal Manifestations (EIMs) are a common and potentially debilitating complication of Inflammatory Bowel Diseases (IBD), sometimes requiring additional treatment beyond those used to control intestinal disease. IBD-associated arthritis (IAA), a form of spondyloarthritis, is associated with several factors including disease location, sex, and IBD type. However, much remains unknown about other clinical factors predicting development of EIMs. Our goal was to identify additional factors associated with IAA. METHODS: Participants in the LOCATION-IBD cohort were included in this analysis. We performed univariate and multivariate analysis of demographics, clinical data, and patient-reported outcomes data. RESULTS: The LOCATION-IBD cohort included 182 participants with (n = 53) and without (n = 110) joint EIMs and with joint pain of unclear etiology (n = 19). In a multivariate analysis comparing those with and without joint EIMs, female sex (OR = 2.5, p = 0.014), the presence of concomitant autoimmune and inflammatory disorders (OR = 2.5, p = 0.038), and Crohn's disease (OR = 2.9, p = 0.026) were associated with the presence of joint EIMs. CONCLUSION: This analysis reveals patients with IAA are more likely to have concomitant autoimmune disorders. Further studies are needed to confirm this association, understand the mechanisms underlying the common pathogenesis of these concurrent disorders, and evaluate their impact on the treatment of IAA.

ExpLOring the role of the intestinal MiCrobiome in InflammATory bowel disease-AssocIated SpONdylarthritis (LOCATION-IBD).

Background: Inflammatory Bowel Disease (IBD)-associated arthritis is a frequent and potentially debilitating complication of IBD, that can affect those with or without active intestinal disease, and is often difficult to treat. The microbiome is known to play a role in IBD development and has been shown to be associated with inflammatory arthritis without concomitant IBD, but its role in IBD-associated arthritis is still unexplored. Further, disease localization is associated with development of IBD-associated arthritis, and stool compositional profiles are predictive of disease localization, yet mucosal location-specific microbiomes have not been well characterized. To address this gap in understanding, we designed a study (LOCATION-IBD) to characterize the mucosa-associated intestinal microbiome and metabolome in IBD-associated arthritis. Methods: Adults with an established diagnosis of IBD undergoing clinical colonoscopy between May of 2021 and February of 2023 were invited to participate in this study; those interested in participation who met inclusion criteria were enrolled. Prior to enrollment, participants were stratified into those with or without IBD-associated arthritis. All participants were interviewed and had clinical and demographic data collected, and 97.8% completed clinical colonoscopy with biopsy collection. Results and conclusion: A total of 182 participants, 53 with confirmed IBD-associated arthritis, were enrolled in this study, resulting in 1151 biopsies obtained for microbiome and metabolome analysis (median 6, mean 6.3 per participant). Clinical and demographic data obtained from the study population will be analyzed with microbiome and metabolome data obtained from biopsies, with the goal of better understanding the mechanisms underpinning the host-microbiome relationship associated the development of IBD-associated arthritis.

Atypical autonomic dysreflexia during robotic-assisted body weight supported treadmill training in an individual with motor incomplete spinal cord injury.

CONTEXT/OBJECTIVE: A 41-year-old man with a history of C6 American Spinal Injury Association (ASIA) Impairment Scale (AIS) C spinal cord injury (SCI), enrolled in an Institutional Review Board (IRB)-approved, robotic-assisted body weight-supported treadmill training (BWSTT), and aquatic exercise research protocol developed asymptomatic autonomic dysreflexia (AD) during training. Little information is available regarding the relationship of robotic-assisted BWSTT and AD. FINDINGS: After successfully completing 36 sessions of aquatic exercise, he reported exertional fatigue during his 10th Lokomat intervention and exhibited asymptomatic or silent AD during this and the three subsequent BWSTT sessions. Standard facilitators of AD were assessed and no obvious irritant identified other than the actual physical exertion and positioning required during robotic-assisted BWSTT. CONCLUSIONS/CLINICAL RELEVANCE: Increased awareness of potential silent AD presenting during robotic assisted BWSTT training for individuals with motor incomplete SCI is required as in this case AD clinical signs were not concurrent with occurrence. Frequent vital sign assessment before, during, and at conclusion of each BWSTT session is strongly recommended.

Metabolic and cardiopulmonary impact of aquatic exercise and nutritional guidance for four individuals with chronic motor incomplete spinal cord injury: a case series.

BACKGROUND: Persons living with chronic spinal cord injury (SCI) demonstrate an increased risk of cardiovascular diseases.Purpose The aim of this report was to assess the cardiopulmonary and metabolic impact of prescribed aquatic exercise in combination with dietary guidance for four individuals experiencing chronic SCI. CASE DESCRIPTION: We measured peak oxygen consumption (peak VO2), resting energy expenditure (REE), weight, food logs, fasting glucose, insulin and glycated hemoglobin (HbA1C) in four men with incomplete SCI, aged 34 to 63 years. INTERVENTION: The men received a group aquatic exercise program three times per week for 10 weeks, and a weekly individual nutritional consultation by phone. OUTCOMES: Peak VO2 increased by 7.9% and 34.4% in participants #3 and #4 and decreased by 12% and 16.4% in #1 and #2. Glucose values decreased by 19.6% and 14.2% for #1 and #3, and increased by 9.3% for both #2 and #4. Body mass decreased by 9.9%, 3.0% and 5.7% for participants #1, #2 and #3, but demonstrated no change for participant #4. Dietary guidance and education produced positive changes, including reduced fat, carbohydrate, daily sugar, and average calorie intake. CONCLUSION: Moderate exercise with weekly nutritional guidance appeared to positively impact body mass and dietary selections with varied metabolic and cardiopulmonary results.

Continuous Glucose Monitoring-Guided Insulin Administration in Hospitalized Patients With Diabetes: A Randomized Clinical Trial.

OBJECTIVE: The efficacy and safety of continuous glucose monitoring (CGM) in adjusting inpatient insulin therapy have not been evaluated. RESEARCH DESIGN AND METHODS: This randomized trial included 185 general medicine and surgery patients with type 1 and type 2 diabetes treated with a basal-bolus insulin regimen. All subjects underwent point-of-care (POC) capillary glucose testing before meals and bedtime. Patients in the standard of care (POC group) wore a blinded Dexcom G6 CGM with insulin dose adjusted based on POC results, while in the CGM group, insulin adjustment was based on daily CGM profile. Primary end points were differences in time in range (TIR; 70-180 mg/dL) and hypoglycemia (<70 mg/dL and <54 mg/dL). RESULTS: There were no significant differences in TIR (54.51% ± 27.72 vs. 48.64% ± 24.25; P = 0.14), mean daily glucose (183.2 ± 40 vs. 186.8 ± 39 mg/dL; P = 0.36), or percent of patients with CGM values <70 mg/dL (36% vs. 39%; P = 0.68) or <54 mg/dL (14 vs. 24%; P = 0.12) between the CGM-guided and POC groups. Among patients with one or more hypoglycemic events, compared with POC, the CGM group experienced a significant reduction in hypoglycemia reoccurrence (1.80 ± 1.54 vs. 2.94 ± 2.76 events/patient; P = 0.03), lower percentage of time below range <70 mg/dL (1.89% ± 3.27 vs. 5.47% ± 8.49; P = 0.02), and lower incidence rate ratio <70 mg/dL (0.53 [95% CI 0.31-0.92]) and <54 mg/dL (0.37 [95% CI 0.17-0.83]). CONCLUSIONS: The inpatient use of real-time Dexcom G6 CGM is safe and effective in guiding insulin therapy, resulting in a similar improvement in glycemic control and a significant reduction of recurrent hypoglycemic events compared with POC-guided insulin adjustment.

Accuracy of Dexcom G6 Continuous Glucose Monitoring in Non-Critically Ill Hospitalized Patients With Diabetes.

OBJECTIVE: Advances in continuous glucose monitoring (CGM) have transformed ambulatory diabetes management. Until recently, inpatient use of CGM has remained investigational, with limited data on its accuracy in the hospital setting. RESEARCH DESIGN AND METHODS: To analyze the accuracy of Dexcom G6, we compared retrospective matched-pair CGM and capillary point-of-care (POC) glucose data from three inpatient CGM studies (two interventional and one observational) in general medicine and surgery patients with diabetes treated with insulin. Analysis of accuracy metrics included mean absolute relative difference (MARD), median absolute relative difference (ARD), and proportion of CGM values within 15, 20, and 30% or 15, 20, and 30 mg/dL of POC reference values for blood glucose >100 mg/dL or ≤100 mg/dL, respectively (% 15/15, % 20/20, % 30/30). Clinical reliability was assessed with Clarke error grid (CEG) analyses. RESULTS: A total of 218 patients were included (96% with type 2 diabetes) with a mean age of 60.6 ± 12 years. The overall MARD (n = 4,067 matched glucose pairs) was 12.8%, and median ARD was 10.1% (interquartile range 4.6, 17.6]. The proportions of readings meeting % 15/15, % 20/20, and % 30/30 criteria were 68.7, 81.7, and 93.8%, respectively. CEG analysis showed 98.7% of all values in zones A and B. MARD and median ARD were higher in the case of hypoglycemia (<70 mg/dL) and severe anemia (hemoglobin <7 g/dL). CONCLUSIONS: Our results indicate that CGM technology is a reliable tool for hospital use and may help improve glucose monitoring in non-critically ill hospitalized patients with diabetes.

Reducing Inpatient Hypoglycemia in the General Wards Using Real-time Continuous Glucose Monitoring: The Glucose Telemetry System, a Randomized Clinical Trial.

OBJECTIVE: Use of real-time continuous glucose monitoring (RT-CGM) systems in the inpatient setting is considered investigational. The objective of this study was to evaluate whether RT-CGM, using the glucose telemetry system (GTS), can prevent hypoglycemia in the general wards. RESEARCH DESIGN AND METHODS: In a randomized clinical trial, insulin-treated patients with type 2 diabetes at high risk for hypoglycemia were recruited. Participants were randomized to RT-CGM/GTS or point-of-care (POC) blood glucose testing. The primary outcome was difference in inpatient hypoglycemia. RESULTS: Seventy-two participants were included in this interim analysis, 36 in the RT-CGM/GTS group and 36 in the POC group. The RT-CGM/GTS group experienced fewer hypoglycemic events (<70 mg/dL) per patient (0.67 [95% CI 0.34-1.30] vs. 1.69 [1.11-2.58], P = 0.024), fewer clinically significant hypoglycemic events (<54 mg/dL) per patient (0.08 [0.03-0.26] vs. 0.75 [0.51-1.09], P = 0.003), and a lower percentage of time spent below range <70 mg/dL (0.40% [0.18-0.92%] vs. 1.88% [1.26-2.81%], P = 0.002) and <54 mg/dL (0.05% [0.01-0.43%] vs. 0.82% [0.47-1.43%], P = 0.017) compared with the POC group. No differences in nocturnal hypoglycemia, time in range 70-180 mg/dL, and time above range >180-250 mg/dL and >250 mg/dL were found between the groups. The RT-CGM/GTS group had no prolonged hypoglycemia compared with 0.20 episodes <54 mg/dL and 0.40 episodes <70 mg/dL per patient in the POC group. CONCLUSIONS: RT-CGM/GTS can decrease hypoglycemia among hospitalized high-risk insulin-treated patients with type 2 diabetes.

Aquatic, deep water peak VO2 testing for individuals with spinal cord injury.

Objective: To determine the reliability of peak VO2 testing for individuals with spinal cord injury (SCI) in deep water and on land; and to examine the relationship between these two testing conditions. Design: Reliability study. Setting: Comprehensive rehabilitation center in Baltimore, MD, USA. Participants: 17 participants (13 men, 4 women) with motor complete and incomplete SCI. Participants were randomized into either aquatic or arm cycle ergometer first measurements. Intervention: Pilot study to assess peak VO2. Outcome measures: Peak VO2 measured with metabolic cart in supported deep water with the addition of Aquatrainer® connection, and on land with arm cycle ergometer. Two trials were conducted for each condition with 48 h separating each test. Results: Peak oxygen consumption reliability was statistically significant for both conditions, aquatic (r = 0.93, P < 0.001) and arm cycle ergometry (r = 0.96, P < 0.001). Additionally, aquatic and arm cycle peak VO2 correlation existed (r = 0.72, P < 0.001). For these 17 participants, lower extremity motor score influenced supported, deep water peak VO2, B = 0.57, P < 0.02, whereas age, sex, and weight did not impact deep water or ergometer values. Conclusion: Determining peak VO2 for individuals with SCI is highly reproducible for arm cycle ergometry and in deep water assessment. Additionally, aquatic, deep water peak VO2 testing is valid when compared to arm cycle ergometry. Although the peak VO2 relationship between deep water and arm cycle ergometry is high, variance in the two conditions does exist. Therefore, it is important to assess peak VO2 via the same exercise modality utilized in the treatment intervention.

Testing limits to airflow perturbation device (APD) measurements.

BACKGROUND: The Airflow Perturbation Device (APD) is a lightweight, portable device that can be used to measure total respiratory resistance as well as inhalation and exhalation resistances. There is a need to determine limits to the accuracy of APD measurements for different conditions likely to occur: leaks around the mouthpiece, use of an oronasal mask, and the addition of resistance in the respiratory system. Also, there is a need for resistance measurements in patients who are ventilated. METHOD: Ten subjects between the ages of 18 and 35 were tested for each station in the experiment. The first station involved testing the effects of leaks of known sizes on APD measurements. The second station tested the use of an oronasal mask used in conjunction with the APD during nose and mouth breathing. The third station tested the effects of two different resistances added in series with the APD mouthpiece. The fourth station tested the usage of a flexible ventilator tube in conjunction with the APD. RESULTS: All leaks reduced APD resistance measurement values. Leaks represented by two 3.2 mm diameter tubes reduced measured resistance by about 10% (4.2 cmH2O.sec/L for control and 3.9 cm H2O.sec/L for the leak). This was not statistically significant. Larger leaks given by 4.8 and 6.4 mm tubes reduced measurements significantly (3.4 and 3.0 cm cmH2O.sec/L, respectively). Mouth resistance measured with a cardboard mouthpiece gave an APD measurement of 4.2 cm H2O.sec/L and mouth resistance measured with an oronasal mask was 4.5 cm H2O.sec/L; the two were not significantly different. Nose resistance measured with the oronasal mask was 7.6 cm H2O.sec/L. Adding airflow resistances of 1.12 and 2.10 cm H2O.sec/L to the breathing circuit between the mouth and APD yielded respiratory resistance values higher than the control by 0.7 and 2.0 cm H2O.sec/L. Although breathing through a 52 cm length of flexible ventilator tubing reduced the APD measurement from 4.0 cm H2O.sec/L for the control to 3.6 cm H2O.sec/L for the tube, the difference was not statistically significant. CONCLUSION: The APD can be adapted for use in ventilated, unconscious, and uncooperative patients with use of a ventilator tube and an oronasal mask without significantly affecting measurements. Adding a resistance in series with the APD mouthpiece has an additive effect on resistance measurements, and can be used for qualitative calibration. A leak size of at least the equivalent of two 3.2 mm diameter tubes can be tolerated without significantly affecting APD measurements.

Maximum static inspiratory and expiratory pressures with different lung volumes.

BACKGROUND: Maximum pressures developed by the respiratory muscles can indicate the health of the respiratory system, help to determine maximum respiratory flow rates, and contribute to respiratory power development. Past measurements of maximum pressures have been found to be inadequate for inclusion in some exercise models involving respiration. METHODS: Maximum inspiratory and expiratory airway pressures were measured over a range of lung volumes in 29 female and 19 male adults. A commercial bell spirometry system was programmed to occlude airflow at nine target lung volumes ranging from 10% to 90% of vital capacity. RESULTS: In women, maximum expiratory pressure increased with volume from 39 to 61 cmH2O and maximum inspiratory pressure decreased with volume from 66 to 28 cmH2O. In men, maximum expiratory pressure increased with volume from 63 to 97 cmH2O and maximum inspiratory pressure decreased with volume from 97 to 39 cmH2O. Equations describing pressures for both sexes are: Pe/Pmax = 0.1426 Ln( %VC) + 0.3402 R2 = 0.95 Pi/Pmax = 0.234 Ln(100 - %VC) - 0.0828 R2 = 0.96 CONCLUSION: These results were found to be consistent with values and trends obtained by other authors. Regression equations may be suitable for respiratory mechanics models.

Exercise-induced respiratory resistance changes as measured with the airflow perturbation device.

Respiratory resistance (Rrs) changes during physical labor can modify the work of breathing and thus influence the time that the labor can be performed. Ideal in vivo human respiratory performance measurements should have fine temporal resolution and minimally impact the respiratory system itself. The airflow perturbation device (APD) provides respiratory resistance measurements in this manner. Pre-exercise Rrs was compared with post-exercise Rrs, continuously monitored for 6 min in 12 non-asthmatic subjects. Rrs following exercise at 70-75% VO2max was below pre-exercise levels for 40 s into recovery (p < 0.05) and inhalation resistance differed more markedly than exhalation resistance. The same post-exercise Rrs decline was found when Rrs measurements were compared to those taken during flow rates comparable to those found late in recovery. Results indicate that (1) Rrs indeed declines following exercise in non-asthmatic subjects, probably due to bronchial dilation, (2) Rrs changes can occur on short time scales, (3) Rrs changes are not related primarily to flow rate.

Effects of caffeine on performance of low intensity tasks.

31 college age men and women who consume less than three caffeinated beverages per week agreed to participate as subjects in research on the effects of acute caffeine intake on low intensity task performance. All subjects performed two randomly administered test conditions: (1) caffeine (5 mg/kg) and (2) placebo on separate visits following an initial 1-hr. orientation visit. Subjects were administered the beverage 30 min. prior to performing 12 separate tests assessing basic mathematics, simple response, logical reasoning, hand-eye coordination, and spatial and assembly skills. The Spielberger State Anxiety test was administered immediately after consuming the test beverage and once again at posttest. Analysis showed that caffeine did not significantly affect performance on all tests with the exception of the peripheral awareness (hand-eye coordination) test on which performance was higher after ingesting caffeine. The placebo treatment produced no effect on state anxiety, which contrasted with a significant rise in anxiety after caffeine consumption. State anxiety values were significantly greater after caffeine treatment relative to the placebo at pretest, and this difference persisted at posttest. These results demonstrated that the dose of caffeine increased scores on state anxiety for individuals who consumed less than three caffeinated beverages weekly but had very little effect on performance of low intensity tasks, except for a hand-eye coordination test involving peripheral awareness. Perhaps longer continuous performance of more demanding tasks would be more sensitive.

Using CO(2) to determine inhaled contaminant volumes and blower effectiveness in several types of respirators.

This experiment was conducted to determine how much contaminant could be expected to be inhaled when overbreathing several different types of respirators. These included several tight-fitting and loose-fitting powered air-purifying respirators (PAPRs) and one air-purifying respirator (APR). CO(2) was used as a tracer gas in the ambient air, and several loose-and tight-fitting respirators were tested on the head form of a breathing machine. CO(2) concentration in the exhaled breath was monitored as well as CO(2) concentration in the ambient air. This concentration ratio was able to give a measurement of protection factor, not for the respirator necessarily, but for the wearer. Flow rates in the filter/blower inlet and breathing machine outlet were also monitored, so blower effectiveness (defined as the blower contribution to inhaled air) could also be determined. Wearer protection factors were found to range from 1.1 for the Racal AirMate loose-fitting PAPR to infinity for the 3M Hood, 3M Breath-Easy PAPR, and SE 400 breath-responsive PAPR. Inhaled contaminant volumes depended on tidal volume but ranged from 2.02 L to 0 L for the same respirators, respectively. Blower effectiveness was about 1.0 for tight-fitting APRs, 0.18 for the Racal, and greater than 1.0 for two of the loose-fitting PAPRs. With blower effectiveness greater than 1.0, some blower flow during the exhalation phase contributes to the subsequent inhalation. Results from this experiment point to different ways to measure respirator efficacy.

Pediatric neurosurgery during Operation Enduring Freedom.

OBJECT: Operation Enduring Freedom (OEF) is the current US military conflict against terrorist elements in Afghanistan. Deepening US involvement in this conflict and increasing coalition casualties prompted the establishment of continuous neurosurgical assets at Craig Joint Theater Hospital (CJTH) at Bagram Airfield, Afghanistan, in September 2007. As part of the military's medical mission, children with battlefield-related injuries and, on a selective case-by-case basis, non-war-related pathological conditions are treated at CJTH. METHODS: A prospectively maintained record was created in which all rotating neurosurgeons at CJTH recorded their personal procedures. From this record, the authors were able to extract all cases involving patients 18 years of age or younger. Variables recorded included: age, sex, and category of patient (for example, local national, enemy combatant), date, indication and description of the neurosurgical procedure, mechanism of injury, and in-hospital morbidity and mortality data. RESULTS: From September 2007 to October 2009, 296 neurosurgical procedures were performed at CJTH. Fifty-seven (19%) were performed in 43 pediatric patients (16 girls and 27 boys) with an average age of 7.5 years (range 11 days-18 years). Thirty-one of the 57 procedures (54%) were for battlefield-related trauma and 26 for humanitarian reasons (46%). The vast majority of cases were cranial (49/57, 86%) compared with spinal (7/54, 13%), with one peripheral nerve case. Craniotomies or craniectomies for penetrating brain injuries were the most common procedures. There were 5 complications (11.6%) and 4 in-hospital deaths (9.3%). CONCLUSIONS: As in previous military conflicts, children are the unfortunate victims of the current Afghanistan campaign. Extremely limited pediatric neurosurgical service and care is rendered under challenging conditions and Air Force neurosurgeons provide valuable, life-saving pediatric treatment for both war-related injuries and humanitarian needs. As the conflict in Afghanistan continues, military neurosurgeons will continue to care for injured children to the best of their abilities.

How far can one walk wearing a self-contained self rescuer?

Self-contained self rescuers (SCSRs) are used for emergency escapes in oxygen-deficit atmospheres. Certified by NIOSH to last 1 hour, SCSRs generate oxygen by chemical reaction and must meet a minimum oxygen generation time of 60 min when used according to instructions. Wearers must walk or crawl at a controlled rate to conform to the limits of the devices. The aim of the is study was intended to determine the distance that can be walked when using SCSRs as intended. Fourteen volunteer subjects walked on a treadmill at moderate rates that they controlled. They were instructed to walk as far as possible without using oxygen at a rate higher than the SCSR could produce. Distances walked ranged from 2.1 km to 9.2 km with an average distance of 6.0 km. SCSR operating times ranged from 30 min to 94 min. If the required walking distance is farther than this, multiple units will have to be available to allow safe escape.

The correlation between personality type and performance time while wearing a respirator.

Many studies have shown that individuals perform better if not wearing a respirator compared with wearing a respirator. This study examined the degree of performance reduction attributable to specific dominant character traits. The subjects performed on a treadmill at a constant speed and grade resulting in 80-85% VO(2)max. A modified M40 respirator was used to create three levels of inspiratory resistance: 2.8, 16.8, and 27.3 cmH(2)O*(sec/L). The 31 subjects were tested using a Myers-Briggs Type Indicator and State-Trait Anxiety Inventory. Multiple regressions and an ANOVA were used to test for correlation. When air intake is very constricted, the only multiple regression equation that was found to be statistically significant was sensing-intuition (how one takes in information) and thinking-feeling (how one makes a decision) vs. performance time for the highest value of inhalation resistance. A simple linear regression between trait anxiety level and performance time was not found to be statistically significant for the same highest value of inhalation resistance.

Exercise performance while wearing a tight-fitting powered air purifying respirator with limited flow.

Sixteen subjects exercised at 80-85% of maximal aerobic capacity on a treadmill while wearing a tight-fitting, FRM40-Turbo Powered Air Purifying Respirator (PAPR). The PAPR was powered by a DC power supply to give flow rates of 0%, 30%, 66%, 94%, and 100% of rated maximum blower capacity of 110 L/min. As flow rate was reduced, so was performance time. There was a 20% reduction in performance time as blower flow changed from 100% to 0% of maximum. Significant differences in breathing apparatus comfort and facial thermal comfort were found as flow rate varied. It was concluded that inadequate blower flow rate decreases performance time, facial cooling, and respirator comfort.

Effect of differing facial characteristics on breathing resistance inside a respirator mask.

A group of subjects with a large range of facial characteristics was asked to breathe deeply while wearing a full facepiece respirator. The facial characteristics noted were head length, head depth, bizygomatic breadth, lip length, and Menton-Sellion length. External resistances to inhalation or exhalation were varied in each of the trials. The data collected were analyzed for possible correlation between facial characteristics and breathing resistance. Although respirator resistances were found to vary, no statistically significant correlation was found with anthropometric measurements.