The efficacy of a supervised and a home-based core strengthening programme in adults with poor core stability: a three-arm randomised controlled trial.

BACKGROUND: Poor core stability is linked to a range of musculoskeletal pathologies and core-strengthening programmes are widely used as treatment. Treatment outcomes, however, are highly variable, which may be related to the method of delivery of core strengthening programmes. We investigated the effect of identical 8 week core strengthening programmes delivered as either supervised or home-based on measures of core stability. METHODS: Participants with poor core stability were randomised into three groups: supervised (n=26), home-based (n=26) or control (n=26). Primary outcomes were the Sahrmann test and the Star Excursion Balance Test (SEBT) for dynamic core stability and three endurance tests (side-bridge, flexor and Sorensen) for static core stability. The exercise programme was devised and supervised by an exercise physiologist. RESULTS: Analysis of covariance on the change from baseline over the 8 weeks showed that the supervised group performed significantly better on all core stability measures than both the home-based and control group. The home-based group produced significant improvements compared to the control group in all static core stability tests, but not in most of the dynamic core stability tests (Sahrmann test and two out of three directions of the SEBT). CONCLUSIONS: Our results support the use of a supervised core-strengthening programme over a home-based programme to maximise improvements in core stability, especially in its dynamic aspects. Based on our findings in healthy individuals with low core stability, further research is recommended on potential therapeutic benefits of supervised core-strengthening programmes for pathologies associated with low core stability. TRIAL REGISTRATION NUMBER: ACTRN12613000233729.

Western Nebraska family (family D) with autosomal dominant parkinsonism.

The etiology of Parkinson's disease (PD) remains uncertain. Environmental influences may have an important role, but genetic factors have been firmly implicated in several recently reported kindreds. We studied a family (family D) whose ancestors probably immigrated to the United States from England. The pedigree contains 188 individuals spanning six generations with 18 affected members. Autosomal dominant inheritance is present. Typical levodopa-responsive PD with bradykinesia, rigidity, resting tremor, and impaired postural reflexes develops. Eye movement abnormalities, pyramidal and cerebellar signs, sensory disturbances, and orthostatic blood pressure changes do not occur. Disease progression is slow. PET with [18F]-6-fluoro-L-dopa (FD) performed on an affected individual revealed decreased uptake of FD in a pattern consistent with PD. Autopsy performed on another affected individual demonstrated neuronal and pigmentary loss, gliosis, and Lewy bodies in the substantia nigra pars compacta. This large kindred appears to represent a neurodegenerative disorder closely resembling, if not identical to, idiopathic PD.

Digoxin levels in prehospital sudden-death syndrome.

Digitalis toxicity is common and has been associated with ventricular dysrhythmias. Digoxin levels in patients who suffer prehospital sudden death have never been studied. This study measured digoxin levels in a population of sudden-death patients. During the 15-week study period, 252 patients in cardiac arrest were seen by an urban paramedic system. During daytime hours, paramedics were requested to obtain a blood sample from sudden-death patients; the samples were subsequently analyzed for digoxin by means of radioimmunoassay. Thirty-nine patients had measured digoxin levels drawn; 28 (71.8%) were in the therapeutic range (0.5-2.1 ng/mL), and four (10.2%) were in the toxic range (greater than 2.1 ng/mL). The patients with toxic dogoxin levels and those with nontoxic levels had similar resuscitation rates (50.0% vs. 34.3%, P = NS), but none were found in ventricular fibrillation. Emergency medical services personnel should consider digoxin toxicity as a potential etiology of arrest.

Further data on the acute effect of intravenous steroids on canine CSF secretion and absorption.

Considerable difference of opinion has arisen as to whether intravenously administered steroids affect cerebrospinal fluid (CSF) production in the acute laboratory animal undergoing ventriculocisternal perfusion. Our experiments with ventriculocisternal perfusion in dogs indicate that, when given intravenously, neither dexamethasone, methylprednisolone, hydrocortisone, nor aldosterone result in a significant, acute effect upon CSF production. Similarly, CSF absorption and outflow resistance mechanisms are not acutely affected by intravenous methylprednisolone, hydrocortisone, and aldosterone. Dexamethasone also probably does not produce an immediate effect upon CSF absorption.

1995-1996 SAEM emergency medicine faculty salary/benefits survey.

OBJECTIVE: The Society for Academic Emergency Medicine (SAEM) commissioned an emergency medicine (EM) faculty salary and benefit survey for all 1995 Residency Review Committee in Emergency Medicine (RRC-EM)-accredited programs using the SAEM third-generation survey instrument. Responses were collected by SAEM and blinded from the investigators. POPULATION: Seventy-six of 112 (68%) accredited programs responded, yielding data for 1,032 full-time faculty among the four Association of American Medical Colleges (AAMC) regions. METHODS: Blinded program and individual faculty data were entered into a customized version of Filemaker Pro, a relational database program with a built-in statistical package. Salary data were sorted by 115 separate criteria such as program regions, faculty title, American Board of Emergency Medicine (ABEM) certification, academic rank, years postresidency, program size, and whether data were reported to AAMC. Demographic data from 132 categories were analyzed and included number of staff and residents per shift, number of intensive care unit (ICU) beds, obstacles to hiring new staff, and specific type and value of fringe benefits offered. Data were compared with those from the 1990 and 1992 SAEM and the 1995-96 AAMC studies. RESULTS: Mean salaries were reported as follows: all faculty, $158,100; first-year faculty, $131,074; programs reporting data to AAMC, $152,198; programs not reporting data to AAMC, $169,251. Mean salaries as reported by AAMC region: northeast, $155,909; south, $155,403; midwest, $172,260; west, $139,930. Mean salaries as reported by program financial source: community, $175,599; university, $152,878; municipal, $141,566. CONCLUSIONS: Reported salaries for full-time EM residency faculty continue to rise. Salaries in programs reporting data to the AAMC are considerably lower than those not reporting. The gap between ABEM-certified and non-ABEM-certified faculty continues to widen. Residency-trained faculty are now shown to earn more than non-residency-trained faculty. Significant regional differences in salaries have been present in all three SAEM surveys.

1998-1999 SAEM emergency medicine faculty salary and benefits survey.

OBJECTIVES: The Society for Academic Emergency Medicine (SAEM) commissioned an emergency medicine (EM) faculty salary and benefits survey for all 1998 residency review committee (RRC)-EM-accredited programs using the SAEM fourth-generation survey instrument. Responses were collected by SAEM and blinded from the investigators. METHODS: Blinded program and individual faculty data were entered into a customized version of FileMaker Pro, a relational database program with a built-in statistical package. Salary data were sorted by program region, faculty title, American Board of Emergency Medicine (ABEM) certification, academic rank, years postresidency, program size, and whether data were reported to the American Association of Medical Colleges (AAMC). Demographic data were analyzed with regard to numerous criteria, including department staffing levels, ED volumes, ED length of stay, department income sources, salary incentive components, and specific type and value of fringe benefits offered. Data were compared with those from previous SAEM studies. RESULTS: Seventy-three of 120 (61%) accredited programs responded, yielding usable data for 70 programs and 965 full-time faculty among the four AAMC regions. Mean salaries were reported as follows: all faculty, $167,478; first-year faculty, $140,616; programs reporting data to the AAMC, $161,794; programs not reporting data to the AAMC, $165,724. Mean salaries as reported by AAMC region: northeast, $167,876; south, $160,586; midwest, $190,957; west, $148,977. CONCLUSIONS: Reported salaries for full-time EM residency faculty continue to rise. Significant regional differences in salaries have been present in all four SAEM surveys. Nonclinical hours are compensated at approximately one-half the rate paid for clinical hours. The demographic data indicate that EM residency faculty are working at the upper extremes of numbers of patient encounters per physician, patient acuity levels, and department lengths of stay.

Selenium regulation of selenium-dependent glutathione peroxidases in animals and transfected CHO cells.

Glutathione peroxidase (GPX1) was the first identified selenium-dependent enzyme, and this enzyme has been most useful as a biochemical indicator of selenium (Se) status and the parameter of choice for determining Se requirements. We have continued to study Se regulation of GPX1 to better understand the underlying mechanism and to gain insight into how cells themselves regulate nutrient status. In progressive Se deficiency in rats, GPX1 activity, protein and mRNA all decrease in a dramatic, coordinated and exponential fashion such that Se-deficient GPX1 mRNA levels are 6-15% of Se-adequate levels. mRNA levels for other Se-dependent proteins are far less decreased in the same animals. The mRNA levels for a second Se-dependent peroxidase, phospholipid hydroperoxide glutathione peroxidase (GPX4), are little affected by Se deficiency, demonstrating that Se regulation of GPX1 is unique. Se regulation of GPX1 activity in growing male and female rats shows that the Se requirement is 100 ng/g diet, based on liver GPX1 activity; use of GPX1 mRNA as the parameter indicates that the Se requirement is nearer to 50 ng Se/g diet in both male and female rats. This approach will readily detect an altered dietary Se requirement, as shown by the incremental increases in dietary Se requirement by 150, 100 or 50 ng Se/g diet in Se-deficient rat pups repleted with Se for 3, 7 or 14 d, respectively. Studies with CHO cells stably transfected with recombinant GPX1 also show that overexpression of GPX1 does not alter the minimum level of media Se necessary for Se-adequate levels of GPX1 activity or mRNA. We hypothesize that classical GPX1 has an integral biological role in the mechanism used by cells to regulate Se status, making GPX1 an especially useful and effective parameter for determining Se requirements in animals.

The relationship of the level of training and area of medical specialization with registrant performance in an advanced trauma life-support course.

Approved advanced trauma life-support (ATLS) programs were given to 160 residents and practitioners of various specialties, utilizing a standardized 50-item, multiple-choice posttest. Level of training (practitioner v resident) and area of medical specialization with registrant performance on total score and in specific subcontent areas of ATLS were evaluated by subjecting total and subcontent percent scores to a two-way analysis of variance and Newman-Keuls pairwise comparisons. Practitioners outperformed the residents in the subcontent area of abdominal injuries, P less than .05. In specialization, emergency medicine outperformed internal medicine specialists, P less than .05. Pairwise differences among specialists were not statistically significant. In airway problems, surgeons and internists were outperformed by emergency medicine, whereas in burns, emergency medicine and family practitioners significantly outperformed the surgeons. Emergency medicine outperformed internal medicine, P less than .05, in subcontent area of extremity injuries. We conclude that registrants are likely to benefit from an ATLS course, but preliminary evidence would seem to justify some "tailoring" of the ATLS curriculum for different registrant specialty groups.

An historical commentary on the physiological effects of music: Tomatis, Mozart and neuropsychology.

This article provides an overview of the theoretical underpinnings of the Tomatis Method, along with a commentary on other forms of sound/music training and the need for research. A public debate was sparked over the "Mozart Effect." This debate has turned out to be unfortunate because the real story is being missed. The real story starts with Alfred Tomatis, M.D., scientist and innovator. Dr. Tomatis was the first to develop a technique using modified music to stimulate the rich interconnections between the ear and the nervous system to integrate aspects of human development and behavior. The originating theories behind the Tomatis Method are reviewed to describe the ear's clear connection to the brain and the nervous system. The "neuropsychology of sound training" describes how and what the Tomatis Method effects. Since Dr. Tomatis opened this field in the mid 20th century, no fewer than a dozen offshoot and related systems of training have been developed. Though each new system of treatment makes claims of effectiveness, no research exists to substantiate their claims. Rather, each simplified system bases its "right to exist and advertise" on the claimed relationship to Tomatis and his complex Method. Research is desperately needed in this area. The 50 years of clinical experience and anecdotal evidence amassed by Tomatis show that sound stimulation can provide a valuable remediation and developmental training tool for people of all ages. Offshoot systems have watered down the Tomatis Method without research to guide the decisions of simplifying the techniques and equipment.

Development of a staff training program at the Wesley Hospital.

This paper reports the development of a staff training program at The Wesley Hospital in response to perceived needs. A training needs analysis identified priorities for training. Three courses have been run: decision making workshops, stress management workshops, and an assertion seminar. The design of these courses, and staff responses are discussed. Future developments in the training program are proposed.

Health professionals' interpersonal skills and patient outcome indices.

This article examines the relationship between health professionals' interpersonal skills (e.g., active listening, information presentation, expression of warmth, and nonverbal behavior) and patient outcomes. Patient outcomes demonstrated to be related to interpersonal skills include level of post-operative pain, length of hospital stay, patient satisfaction and compliance. Patient compliance is one patient outcome of particular concern to the health care system, and it is argued that improvements in interpersonal skill, leading to increased patient satisfaction, should reduce noncompliance rates. Several studies attempting to reduce noncompliance rates in this way are reviewed, and the importance of training health professionals in interpersonal skills is stressed.

The effect of tensional load on isolated embryonic chick tendons in organ culture.

Digital flexor tendons isolated from 17-18 day embryonic chickens were cultured intact, either on steel mesh grids, or in an apparatus designed to apply a mechanical load to the tissue. Tendons cultured without an applied load continued to synthesize protein and glycosaminoglycans throughout a 7-day period, but DNA synthesis decreased during this time. Increases in both protein and DNA synthesis were observed in tendons experimentally loaded for 48-72 h. Glycosaminoglycan production by tendons isolated from 17-day embryos was also increased in loaded tendons, sulfated GAG being increased more than hyaluronic acid. The same loading regime applied to tendons from 18-day embryos produced a smaller, yet significant increase in sulfated glycosaminoglycans but hyaluronate production was reduced. These investigations demonstrate that embryonic chicken tendons can be maintained in a viable state in organ culture and may provide a useful model for studies of the effects of mechanical forces on the synthetic capability and structure of connective tissue cells.

Recommended helmet removal techniques in a cervical spine injured patient.

Helmet removal techniques in the absence of C-spine injuries have been developed and promulgated. Utilizing a cadaver model, these techniques were demonstrated to adversely affect pre-existing C-spine injury. Removal of helmets with cast cutters is recommended.

Cardiorespiratory arrest and resuscitation of children.

Ninety-one patients had cardiorespiratory arrest in a children's hospital emergency department over six years. Only five children survived, three with severe neurologic sequelae. The records of 40 other children in the same community resuscitated by paramedics, but taken to other hospitals, were reviewed and there were three survivors. The causes and outcomes of resuscitation of children are clearly different from those of adults. Cardiac disease and ventricular arrhythmias are uncommon. Neurologically intact survival was seen only in those children who received immediate resuscitation and responded promptly. Research in cerebral resuscitation at the cellular level is promising for the future. Prevention of some cardiorespiratory arrests through accident prevention and earlier recognition of serious infections is possible now.

Glycosaminoglycan synthesis by Dupuytren's cells in culture.

Glycosaminoglycan synthesis by cells cultured from nodule or band tissues of patients with Dupuytren's disease was compared with that of skin fibroblasts cultured from uninvolved areas of the palm. No differences were observed in culture which could account either for the abnormal glycosaminoglycan content or the increased cellularity of the diseased tissues. It is suggested that the behavior of Dupuytren's cells in vivo may result from a response to local conditions within the palm rather than from the expression of an irreversible change in their glycosaminoglycan metabolism.

The effect of a paramedic system on mortality of major open intra-abdominal vascular trauma.

In a 12-year period (1970-1981), there were 112 patients operated on with major open intra-abdominal vascular trauma (MOIVT). These were any penetrating injuries to the aorta, inferior vena cava, portal vein, or their primary branches. Sixty-four patients were treated without benefit of paramedics. Only four of 43 patients who had emergency department blood pressures of 60 mm Hg or greater upon entry died (9.3%), whereas 18 of 21 (85.7%) patients with blood pressures of less than 60 mm Hg died (p less than 0.0001). Forty-eight of the 112 patients have been treated by paramedics during the past 4 years. Entry level blood pressures are those first recorded by the paramedics in the field. The mortality in those with blood pressures of 60 mm Hg or greater remained essentially unchanged. However, 11 of 22 patients with blood pressures of less than 60 mm Hg survived compared to three of 21 (p less than 0.025). Over the past 12 years, the community's homicide rate has been stable (71/yr), but the case incidence of MOIVT has risen from an average of 8/yr to 12/yr during the paramedic years. The average annual aggravated assault rate increased from 796 to 1,119. It is believed the improvement in the salvage rate is due to early intervention by trained paramedics functioning within a trauma care system.

The precordial thump.

The American Heart Association (AHA) currently recommends the precordial thump as the initial maneuver in treatment of ventricular tachycardia (VT) and monitored ventricular fibrillation (VF). These recommendations are based largely on anecdotal reports of successful "thump-version" of asystole, VF, and VT. The Milwaukee County Paramedic System follows the AHA guidelines in the treatment of VT and VF. The precordial thump is included in the advanced cardiac life support (ACLS) paramedic training program, and has been used in our approach to the pulseless, nonbreathing patient. During an eight-month period, 50 pulseless, nonbreathing patients received precordial thumps during ACLS resuscitative attempts. Twenty-seven patients who developed monitored VT and 23 patients with monitored VF were thumped. Three of 27 patients (11%) with VT were thumped into a supraventricular rhythm, 12 of 27 patients (44%) remained in VT, and 12 of 27 patients were thumped from VT into more malignant rhythms: three, into asystole; eight, into VF; and one, into an idioventricular/electromechanical dissociation rhythm. A total of 23 patients were thumped without effect. Subsequently, using countershock and medications, 12 of these 23 patients were successfully resuscitated. In the prehospital setting the precordial thump is usually not beneficial, and may be detrimental. Thus its use as the initial maneuver in treating the cardiac arrest patient with VT or VF in this setting cannot be supported. The presence of acidosis and hypoxia may explain why prehospital precordial thump responses differ from those seen in the hospital environment.