Common hydrotherapy practices and the prevalence of burn wound bacterial colonisation at the University Teaching Hospital in Lusaka, Zambia.

BACKGROUND: In many parts of the world, hydrotherapy plays an important role in the management of patients with wounds including burns. Different centers practice hydrotherapy differently. At the University Teaching Hospital in Lusaka, Zambia, burn patients use a common bathtub for cleaning their wounds which theoretically increases the risk of cross-infection, an important source of morbidity and mortality. There is currently no evidence that hydrotherapy as practiced at our institution leads to cross infection among patients with burns. OBJECTIVE: The objective was to determine if our hydrotherapy practice and water plays a role in cross-infection and what organisms cause this infection. METHODS: This was a prospective analytical study. Patients meeting the selection criteria were recruited. Swabs from the burn wounds were collected on admission (day 0), day 4 and day 7. Weekly swabs of the bathtub were also collected, after the tub had been cleaned and declared ready for the next patient. Weekly water samples were also collected. Selected results, for Staphylococcus aureus and Klebsiella pneumoniae, were subjected to further analysis and PCR. Results were analyzed using statistics software, SPSS version 23. RESULTS: In this study, there were 96 participants of which 51 (53.1%) were males and 45 (46.9%) were females. Age distribution ranged from 5months to 91 years. The modal age range was 1 to 2 years. The modal burn percentage was 6%-10%, followed by 11%-15%. Hot water was the cause of burns in 65.6%. S. aureus and K. pneumoniae were the most common organisms isolated. Others were enteric organisms. In terms of readily available antibiotics, there was more sensitivity to Amikacin and Chloramphenicol than Ciprofloxacin (our commonly used antibiotic). The bathtub also had S. aureus and K. pneumoniae, besides enteric organisms. Sixty five point four percent (65.4%) of the Klebsiella were ESBL (Extended Spectrum Beta Lactamase) producers. The tub had samples that were both ESBL producers as well as widely resistant Klebsiella by other means. No growth was obtained from the water samples. Seventy-two point nine percent (72.9%) of the patients were discharged, 19.8% died, while 7.3% left against medical advice. CONCLUSION: Hydrotherapy as currently practiced at the University Teaching Hospital does contribute significantly to cross-infection among burn patients with widely resistant organisms. The main ones are S. aureus and K. pneumoniae. Switching care to a shower mechanism might help eliminate this problem as the study demonstrates that no bacteria were found in the water samples.

The Effectiveness of Multimodal Care for the Management of Soft Tissue Injuries of the Shoulder: A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.

OBJECTIVE: The purpose of this systematic review was to evaluate the effectiveness of multimodal care for the management of soft tissue injuries of the shoulder. METHODS: We conducted a systematic review and searched MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Central Register of Controlled Trials from 1990 to 2015. Two independent reviewers critically appraised studies using the Scottish Intercollegiate Guidelines Network criteria. We used best evidence synthesis to synthesize evidence from studies with low risk of bias. RESULTS: We screened 5885 articles, and 19 were eligible for critical appraisal. Ten randomized controlled trials had low risk of bias. For persistent subacromial impingement syndrome, multimodal care leads to similar outcomes as sham therapy, radial extracorporeal shock-wave therapy, or surgery. For subacromial impingement syndrome, multimodal care may be associated with small and nonclinically important improvement in pain and function compared with corticosteroid injections. For rotator cuff tendinitis, dietary-based multimodal care may be more effective than conventional multimodal care (exercise, soft tissue and manual therapy, and placebo tablets). For nonspecific shoulder pain, multimodal care may be more effective than wait list or usual care by a general practitioner, but it leads to similar outcomes as exercise or corticosteroid injections. CONCLUSIONS: The current evidence suggests that combining multiple interventions into 1 program of care does not lead to superior outcomes for patients with subacromial impingement syndrome or nonspecific shoulder pain. One randomized controlled trial suggested that dietary-based multimodal care (dietary advice, acupuncture, and enzyme tablets) may provide better outcomes over conventional multimodal care. However, these results need to be replicated.

Use of spinal manipulation in a rheumatoid patient presenting with acute thoracic pain: a case report.

BACKGROUND: There is limited research related to spinal manipulation of uncomplicated thoracic spine pain and even less when pain is associated with comorbid conditions such as rheumatoid arthritis. In the absence of trial evidence, clinical experience and appropriate selection of the type of intervention is important to informing the appropriate management of these cases. CASE PRESENTATION: We present a case of a patient with long standing rheumatoid arthritis who presented with acute thoracic pain. The patient was diagnosed with costovertebral joint dysfunction and a myofascial strain of the surrounding musculature. The patient was unresponsive to treatment involving a generalized manipulative technique; however, improved following the administration of a specific applied manipulation with modified forces. The patient was deemed recovered and discharged with ergonomic and home care recommendations. DISCUSSION: This case demonstrates a clinical situation where there is a paucity of research to guide management, thus clinicians must rely on experience and patient preferences in the selection of an appropriate and safe therapeutic intervention. The case highlights the need to contextualize the apparent contraindication of manipulation in patients with rheumatoid arthritis and calls for further research. Finally the paper advances evidence based decision making that balances the available research, clinical experience, as well as patient preferences.

HISTORIQUE: Il existe peu d'études sur la manipulation vertébrale de douleur de la colonne dorsale sans complication, et encore moins lorsque la douleur est associée à des conditions comorbides comme la polyarthrite rhumatoïde. En l'absence de résultats d'essais cliniques, l'expérience clinique et le choix approprié du type d'intervention sont importants pour trouver la gestion appropriée de ces cas. PRÉSENTATION DE CAS: Nous présentons le cas d'un patient souffrant de polyarthrite rhumatoïde de longue date avec une douleur thoracique aiguë. Le patient a reçu un diagnostic de dysfonctionnement de l'articulation costo-vertébrale et une tension myofasciale de la masse musculaire qui l'enveloppe. Le patient ne répondait pas au traitement comprenant une technique de manipulation généralisée; cependant, il a démontré une amélioration à la suite de l'administration d'une manipulation spécifique avec des forces modifiées. Le patient a été jugé rétabli et a obtenu son congé avec des recommandations de soins ergonomiques et à domicile. DISCUSSION: Ce cas illustre une situation clinique où il y a n'y a pas assez d'études permettant d'orienter la gestion; par conséquent, les cliniciens doivent s'appuyer sur l'expérience et les préférences du patient pour choisir une intervention de traitement appropriée et sécuritaire. Ce cas souligne le besoin de contextualiser la contre-indication apparente de la manipulation chez les patients avec de l'arthrite rhumatoïde et le besoin de recherche supplémentaire. Finalement, l'étude préconise un processus décisionnel fondé sur des preuves qui équilibrent les études consultables, l'expérience en clinique et les préférences du patient.

The Association Between Cervical Spine Manipulation and Carotid Artery Dissection: A Systematic Review of the Literature.

OBJECTIVE: Controversy surrounds the safety of cervical spine manipulation. Ischemic stroke secondary to cervical spine manipulation is a hypothesized adverse event. In Canada, the seriousness of these events and their perceived association to cervical spine manipulation has led some members of the public to call for a ban of the procedure. The primary objective of this study was to determine the incidence of internal carotid artery (ICA) dissection after cervical spine manipulation in patients who experience neck pain and its associated disorders. The secondary objective was to determine whether cervical spine manipulation is associated with an increased risk of ICA dissection in patients with neck pain, upper back pain, or headaches. METHODS: We systematically searched MEDLINE, CINAHL, Alternative Health, AMED, Index to Chiropractic Literature, and EMBASE from 1970 to November 2012. Two independent reviewers used standardized criteria to screen the eligibility of articles. We considered cohort studies, case-control studies, and randomized clinical trials that addressed our objectives. We planned to critically appraise eligible articles using the Scottish Intercollegiate Guideline Network methodology. RESULTS: We did not find any epidemiologic studies that measured the incidence of cervical spine manipulation and ICA dissection. Similarly, we did not find any studies that determined whether cervical spine manipulation is associated with ICA dissection. CONCLUSIONS: The incidence of ICA dissection after cervical spine manipulation is unknown. The relative risk of ICA dissection after cervical spine manipulation compared with other health care interventions for neck pain, back pain, or headache is also unknown. Although several case reports and case series raise the hypothesis of an association, we found no epidemiologic studies that validate this hypothesis.

Interprofessional collaboration and turf wars how prevalent are hidden attitudes?

PURPOSE: Interprofessional collaboration in health care is believed to enhance patient outcomes. However, where professions have overlapping scopes of practice (eg, chiropractors and physical therapists), "turf wars" can hinder effective collaboration. Deep-rooted beliefs, identified as implicit attitudes, provide a potential explanation. Even with positive explicit attitudes toward a social group, negative stereotypes may be influential. Previous studies on interprofessional attitudes have mostly used qualitative research methodologies. This study used quantitative methods to evaluate explicit and implicit attitudes of physical therapy students toward chiropractic. METHODS: A paper-and-pencil instrument was developed and administered to 49 individuals (students and faculty) associated with a Canadian University master's entry-level physical therapy program after approval by the Research Ethics Board. The instrument evaluated explicit and implicit attitudes toward the chiropractic profession. Implicit attitudes were determined by comparing response times of chiropractic paired with positive versus negative descriptors. RESULTS: Mean time to complete a word association task was significantly longer (t = 4.75, p =.00) when chiropractic was associated with positive rather than negative words. Explicit and implicit attitudes were not correlated (r = 0.13, p =.38). CONCLUSIONS: While little explicit bias existed, individuals associated with a master's entry-level physical therapy program appeared to have a significant negative implicit bias toward chiropractic.

Cyclic GMP alters the firing rate and thermosensitivity of hypothalamic neurons.

The rostral hypothalamus, especially the preoptic-anterior hypothalamus (POAH), contains temperature-sensitive and -insensitive neurons that form synaptic networks to control thermoregulatory responses. Previous studies suggest that the cyclic nucleotide cGMP is an important mediator in this neuronal network, since hypothalamic microinjections of cGMP analogs produce hypothermia in several species. In the present study, immunohistochemisty showed that rostral hypothalamic neurons contain cGMP, guanylate cyclase (necessary for cGMP synthesis), and CNG A2 (an important cyclic nucleotide-gated channel). Extracellular electrophysiological activity was recorded from different types of neurons in rat hypothalamic tissue slices. Each recorded neuron was classified according to its thermosensitivity as well as its firing rate response to 2-100 microM 8-bromo-cGMP (a membrane-permeable cGMP analog). cGMP has specific effects on different neurons in the rostral hypothalamus. In the POAH, the cGMP analog decreased the spontaneous firing rate in 45% of temperature-sensitive and -insensitive neurons, an effect that is likely due to cGMP-enhanced hyperpolarizing K(+) currents. This decreased POAH activity could attenuate thermoregulatory responses and produce hypothermia during exposures to cool or neutral ambient temperatures. Although 8-bromo-cGMP did not affect the thermosensitivity of most POAH neurons, it did increase the warm sensitivity of neurons in other hypothalamic regions located dorsal, lateral, and posterior to the POAH. This increased thermosensitivity may be due to pacemaker currents that are facilitated by cyclic nucleotides. If some of these non-POAH thermosensitive neurons promote heat loss or inhibit heat production, then their increased thermosensitivity could contribute to cGMP-induced decreases in body temperature.

Carbon dioxide and pH effects on temperature-sensitive and -insensitive hypothalamic neurons.

The preoptic-anterior hypothalamus (POAH) controls body temperature, and thermoregulatory responses are impaired during hypercapnia. If increased CO(2) or its accompanying acidosis inhibits warm-sensitive POAH neurons, this could provide an explanation for thermoregulatory impairment during hypercapnia. To test this possibility, extracellular electrophysiological recordings determined the effects of CO(2) and pH on the firing rates of both temperature-sensitive and -insensitive neurons in hypothalamic tissue slices from 89 male Sprague-Dawley rats. Firing rate activity was recorded in 121 hypothalamic neurons before, during, and after changing the CO(2) concentration aerating the tissue slice chamber or changing the pH of the solution bathing the tissue slices. Increasing the aeration CO(2) concentration from 5% (control) to 10% (hypercapnic) had no effect on most (i.e., 69%) POAH temperature-insensitive neurons; however, this hypercapnia inhibited the majority (i.e., 59%) of warm-sensitive neurons. CO(2) affected similar proportions of (non-POAH) neurons in other hypothalamic regions. These CO(2) effects appear to be due to changes in pH since the CO(2)-affected neurons responded similarly to isocapnic acidosis (i.e., normal CO(2) and decreased pH) but were not responsive to isohydric hypercapnia (i.e., increased CO(2) and normal pH). These findings may offer a neural explanation for some heat-related illnesses (e.g., exertional heat stroke) where impaired heat loss is associated with acidosis.

Ionic channels and conductance-based models for hypothalamic neuronal thermosensitivity.

Thermoregulatory responses are partially controlled by the preoptic area and anterior hypothalamus (PO/AH), which contains a mixed population of temperature-sensitive and insensitive neurons. Immunohistochemical procedures identified the extent of various ionic channels in rat PO/AH neurons. These included pacemaker current channels [i.e., hyperpolarization-activated cyclic nucleotide-gated channels (HCN)], background potassium leak channels (TASK-1 and TRAAK), and transient receptor potential channel (TRP) TRPV4. PO/AH neurons showed dense TASK-1 and HCN-2 immunoreactivity and moderate TRAAK and HCN-4 immunoreactivity. In contrast, the neuronal cell bodies did not label for TRPV4, but instead, punctate labeling was observed in traversing axons or their terminal endings. On the basis of these results and previous electrophysiological studies, Hodgkin-Huxley-like models were constructed. These models suggest that most PO/AH neurons have the same types of ionic channels, but different levels of channel expression can explain the inherent properties of the various types of temperature-sensitive and insensitive neurons.

The pharmacognosy of Humulus lupulus L. (hops) with an emphasis on estrogenic properties.

As the population ages, there is an ever-increasing need for therapeutic agents that can be used safely and efficaciously to manage symptoms related to postmenopausal estrogen deficiency. Endogenous estrogens, e.g., 17beta-estradiol, of exogenous mammalian origin, e.g., horses, have long been used to manage such symptoms. There are more than 20 different classes of phytochemicals that have demonstrated affinity for human estrogen receptors in vitro. Some studies on exogenous estrogenic substances of botanical origin (phytoestrogens), such as standardized formulations of plant extracts with in vitro and in vivo estrogenic activity from soy (Glycine max Merill.) and red clover (Trifolium pratense L.), suggest clinical efficacy. Few clinical data for phytoestrogens other than isoflavonoids are available. In an exhaustive review of the literature through 2003, only two clinical trials were identified that were designed to evaluate the effect of hops (Humulus lupulus L.) on symptoms related to menopause. Folkloric, chemical, and biological literature relating primarily to the use of hops for their estrogenic activity, and two human clinical trials, are reviewed.