Frequency and indication of non-musculoskeletal examinations: a cross-sectional survey of Quebec chiropractors.

BACKGROUND: Approximately 1% of low back pain is estimated to be caused by serious systemic diseases, including cancer, infection, or abdominal aortic dissection. This study aimed to determine the frequency of execution of non-MSK physical examination procedures among Quebec chiropractors and to identify the clinical context that prompts them to use these physical examination procedures. METHODS: Cross-sectional survey containing 44 questions administered to a random sample of Quebec chiropractors using a succession of online, postal and phone questionnaires. The 4-part survey questionnaire contained six demographic questions, 28 single-choice questions to determine the frequency of execution of non-MSK physical examination procedures, seven short clinical vignettes for which the respondents had to select the non-MSK examinations that would be required, and two questions inquiring about the proportion of new patients for which participants' felt non-MSK examinations were necessary and whether appropriate assessments were performed. The questionnaire was pilot tested, and feedback received integrated prior to administration. We conducted descriptive statistics, Pearson correlations, and an ANOVA. RESULTS: The survey was completed by 182 chiropractors (response rate: 36.4%). The most commonly non-musculoskeletal examination performed daily were blood pressure (12.1%) and cranial nerves (4.9%). The most common tests never performed were oxygen saturation (68.7%), cardiac auscultation (69.2%), tibio-brachial index (71.4%), breast (86.8%), rectal (96.7%), testicular (95.6%), and vaginal (99.9%) exams. Female chiropractors and Quebec University in Trois-Rivières graduates reported that a significantly higher proportion of their new patients required a non-musculoskeletal physical examination compared to male participants (37.2% vs 28.3%) or Canadian Memorial Chiropractic College graduates (33.9% vs 19.9%). Reason for not performing a physical examination included the belief that another healthcare professional was better positioned to perform and/or interpret the related tests (76.4%). CONCLUSIONS: Vital signs and cranial nerve examinations were the most frequency performed non-musculoskeletal examinations reported by chiropractors. Apart from the genitourinary exam almost never performed, most participants chose non-musculoskeletal examinations deemed appropriate for the patient's presentation.

Novel Screening Tool for Adolescent Idiopathic Scoliosis: A Reliability Study.

OBJECTIVE: The aim of this study was to assess the agreement between a web-based scoliosis screening tool and a standard screening procedure. METHODS: Sixty participants were selected (median age, 12 years; 75% were women) and separated into 2 groups: those with unknown spinal curvature status and those with confirmed scoliosis. Each participant was assessed by 2 blinded assessors, with one measuring the angle of trunk rotation using a scoliometer and the second using a web-based screening application. The app provided a relative risk score for having scoliosis based on a weighted algorithm. Those with an angle of trunk rotation ≥7° or risk score >2 were deemed as being at risk for having scoliosis. RESULTS: There was fair agreement (kappa = 0.34; 95% confidence interval [CI], 0.14-0.55; P < .001) between the app and the scoliometer among the unconfirmed cases. The McNemar test indicated a difference in the proportion of positive tests (P = .001), whereby the screening app produced a significantly higher number of positive tests (15/53 = 28.3%) compared to the standard screening procedure (4/53 = 7.5%) for unconfirmed cases. Among the confirmed cases, the app correctly identified 5 out of 7 (sensitivity: 71%; 95% CI, 29%-96%) participants, whereas the scoliometer correctly identified 6 out of 7 (sensitivity: 86%; 95% CI, 42%-100%) participants. CONCLUSION: These findings indicate fair agreement between the app and the scoliometer, though it was not possible to precisely estimate the sensitivity of the app in this study.

Hypertriglyceridaemia: an update.

Triglycerides (TGs) form part of the standard lipid profile. Elevations in TGs are associated with increased cardiovascular disease risk through triglyceride-rich lipoprotein particles found as part of non-HDL cholesterol. Many elevations of TGs are secondary to other causes, but primary hypertriglyceridaemia syndromes need to be identified. The genetic causes of hypertriglyceridaemia range from familial combined hyperlipidaemia through the autosomal recessive remnant hyperlipidaemia (related to apolipoprotein E variants) and familial chylomicronaemia syndromes. Patients with primary hypertriglyceridaemia >10 mmol/L require characterisation and specific intervention. Simple lipid profiles do not provide adequate information for detailed diagnosis and additional assays such as apolipoprotein (apo)B100, apoE genotype and next-generation sequencing may be useful. Management of raised TGs includes optimising diet, reducing exacerbating factors as well as lipid-lowering medications such as statins, fibrates, niacin and omega-3 fatty acids. Novel medications for orphan disease indications such as familial chylomicronaemia syndrome include volanesorsen, evinacumab and other antisense therapeutics. Extreme hypertriglyceridaemia syndromes, especially chylomicronaemia syndromes, which can be exposed by pregnancy or other factors are a medical emergency and require admission and specialist management sometimes including plasma exchange.

Into a Fluoroless Future: an Appraisal of Fluoroscopy-Free Techniques in Clinical Cardiac Electrophysiology.

PURPOSE OF REVIEW: There are risks to both patients and electrophysiology providers from radiation exposure from fluoroscopic imaging, and there is increased interest in fluoroscopic reduction. We review the imaging tools, their applications, and current uses to eliminate fluoroscopy. RECENT FINDINGS: Multiple recent studies provide supporting evidence for the transition to fluoroscopy-free techniques for both ablations and device implantation. The most frequently used alternative imaging approaches include intracardiac echocardiography, cardiac MRI guidance, and 3D electroanatomic mapping systems. Electroanatomic mapping and intracardiac echocardiography originally used to augment fluoroscopy imaging are now replacing the older imaging technique. The data supports that the future of electrophysiology can be fluoroscopy-free or very low fluoroscopy for the vast majority of cases. As provider and institution experience grows with these techniques, many EP labs may choose to completely forego the use of fluoroscopy. Trainees will benefit from early experience with these techniques.

Ultrasound-guided interventional procedures for myofascial trigger points: a systematic review.

Myofascial pain syndrome (MPS) is characterized by the presence of clinically detected myofascial trigger points (MTrPs). Diagnostic ultrasound (US) has been proposed as a method to strengthen the reliability of MTrP localization, thus potentially improving the efficacy and safety profile of interventional procedures. The objective is to evaluate the benefit and safety profile of any US-guided interventional procedure for MPS. Medline, Embase, PubMed, the Allied and Complementary Medicine Database (AMED), and Web of Science were systematically searched from their inception to May 2020 for any randomized controlled trial that evaluated treatment benefit and safety of any US-guided interventional procedure for MPS. The primary outcome of interest was pain severity. Additional outcomes of interest were function and adverse effects. The risk of bias was assessed using the Risk of Bias V.2.0 tool. eleven studies met all inclusion and exclusion criteria. Two studies (n=174) with a high risk of bias revealed some evidence supporting US guidance over blinded interventions for improvement in pain and function. Eight studies (n=483) with varying risks of bias were of head-to-head comparisons of different US modalities. These studies revealed that US-guided local anesthetic injections were inferior to US-guided pulse radiofrequency and US-guided dry needling (DN). US-guided DN was also found to be superior to US-guided platelet-rich-plasma injections but inferior to US-guided miniscalpel. Meanwhile, one study (n=21) with some concerns of bias found that US-guided local anesthetic injections were superior to non-steroidal anti-inflammatory drugs for pain outcomes and fewer adverse events. All US-guided procedures resulted in zero or minimal self-limited adverse events. Issues with clinical relevance, limited sample sizes, and small point estimates warrant more high-quality research to better characterize the possible value of US-guided injections.

Non-invasive assessment of oxidative stress in preterm infants.

Preterm newborns have an immature antioxidant defense system and are especially susceptible to oxidative stress. Resuscitation, mechanical ventilation, intermittent hypoxia and apneic episodes require frequently oxygen supplementation which leads to oxidative stress in preterm newborns. The consequences of oxidative damage are increased short and long-term morbidities, neurodevelopmental impairment and increased mortality. Oxidative stress biomarkers are determined in blood samples from preterm children during their stay in neonatal intensive care units especially for research purposes. However, there is a tendency towards reducing invasive and painful techniques in the NICU (Neonatal Intensive Care Unit) and avoiding excessive blood extractions procedures. In this paper, it has been described some studies that employed non-invasive samples to determine oxidative stress biomarkers form preterm infants in order to perform a close monitoring biomarker with a significant greater predictive value. Among these methods we describe a previously developed and validated high-performance liquid chromatography tandem mass spectrometry method that allow to accurately determine the most reliable biomarkers in biofluids, which are non-invasively and painlessly obtained.

Chiropractic Management of a Patient With Radial Nerve Entrapment Symptoms: A Case Study.

OBJECTIVE: This report describes the case of a patient with chronic radial nerve entrapment symptoms managed with chiropractic care. We propose a complementary functional neurologic assessment of muscle function in different positions that could reveal muscle dysfunctions absent with standard test position. CLINICAL FEATURES: A 45-year-old man presented to a private chiropractic clinic with a throbbing pain 5 cm above the right lateral elbow epicondyle radiating onto the back of the lower arm and increasing after using a mouse when working on a computer. A Mill test and a Cozen test created pain near the lateral epicondylitis. The use of complementary functional neurologic assessment for radial nerve entrapment showed changes in manual muscle testing after tests were done in different positions to increase the compression on the nerve. INTERVENTION AND OUTCOME: Chiropractic management was performed, including myofascial therapy, spinal and proximal radioulnar joint adjustments, neural mobilization, and the use of a splint. After 7 days (2 treatments), the patient showed no elbow pain even if he worked on his computer using a mouse. After a 2-year follow-up, no recurrence was reported. CONCLUSION: In this case of radial nerve entrapment symptoms, the patient benefited from chiropractic management using standard chiropractic, applied kinesiology, and neural mobilization techniques. The complementary functional neurologic assessment of radial nerve entrapment proposed revealed muscles dysfunctions absent with the standard test position. These changes in manual muscle testing were useful to determine the possible sites of entrapment in order to direct the therapeutic efforts to these locations.

Adherence to practice guidelines is associated with reduced referral times for patients with ovarian cancer.

BACKGROUND: Patients with ovarian cancer tend to receive the highest quality of care at high-volume cancer centers with gynecological oncologists. However, the care that they receive prior to gynecological oncology consult has not been examined. We investigated the quantity and quality of care given to patients with ovarian cancer before being seen by a gynecological oncologist. OBJECTIVE: We evaluated the variability, quantity, and quality of diagnostic testing and physician-referral patterns prior to consultation with a gynecological oncologist, in women with suspicious pelvic masses seen on imaging. STUDY DESIGN: A chart review was performed on patients treated for ovarian cancer at a single institution from 2001 to 2014. We evaluated their workup in 4 categories, drawn from National Comprehensive Care Network guidelines: provider visits, abdominal/pelvic imaging, chest imaging, and tumor markers. Workup was classified as guideline adherent or guideline nonadherent. RESULTS: We identified 335 cases that met our criteria. In the provider visit category, 83.9% of patients received guideline-adherent workup: 77% in the abdominal/pelvic imaging, 98.2% in the chest imaging, and 95.2% in the tumor marker categories. Each patient's workup was assessed as a compilation of the 4 categories, yielding 65.7% patients as having received an adherent workup and 34.3% of workup as nonadherent to guidelines. The timeframe to see a gynecological oncologist for patients with guideline-adherent workup was significantly shorter than for those whose workup was nonadherant (20 vs 86 days, P < .001). A suspicious pelvic mass was identified by obstetrics-gynecology in only 23.9% of patients; 42.7% of patients did not have tumor marker testing before a gynecological oncologist consult. When an obstetrics-gynecology specialist discovered the suspicious pelvic mass, the remaining workup was more likely to be guideline adherent prior to gynecological oncologist referral than when initial imaging was not ordered by an obstetrics-gynecology specialist (P = .18). Survival was not significantly different (P = .103). CONCLUSION: With a guideline-adherent workup, including tumor marker testing, gynecological oncologist referral times can be shortened, minimizing cost inefficiencies and delays that can compromise the effectiveness of downstream care for patients with ovarian cancer. Guidelines should be disseminated beyond the obstetrics-gynecology field.

The predictive values of three noninvasive indices in diagnosis of liver fibrosis in patients with chronic hepatitis B: a comparative study / 临床肝胆病杂志

ObjectiveTo investigate the values of FibroTouch, FIB-4 index, and aspartate aminotransferase-to-platelet ratio index (APRI) in the diagnosis of liver fibrosis in patients with chronic hepatitis B (CHB). MethodsA total of 148 patients with CHB who visited Traditional Chinese Medicine Hospital of Xinjiang Uygur Autonomous Region and underwent liver biopsy from September 2013 to May 2015 were enrolled and divided into groups according to fibrosis stage. All the patients underwent blood biochemical examination, routine blood tests, and FibroTouch measurement. Then FIB-4 and APRI were calculated, and liver stiffness was recorded. The receiver operating characteristic (ROC) curve was used to calculate the area under the ROC curve (AUC) and determine the cut-off value, sensitivity, and specificity. Chi-square test was used for comparison between two groups, and the Pearson rank correlation analysis was also performed. ResultsFibroTouch, APRI, and FIB-4 were well correlated with fibrosis stage (r=0.628, 0.486, and 0482, respectively, all P＜0.01). In the marked liver fibrosis (≥S2) group and liver cirrhosis (S4) group, FibroTouch had the best diagnostic performance, with AUCs of 0.84 and 0.93, respectively, followed by APRI, which had AUCs of 0.79 and 0.87, respectively; FIB-4 index had the worst diagnostic performance, with AUCs of 0.77 and 0.84, respectively. In patients with a fibrosis stage of ≥S2 or S4, FibroTouch had a better diagnostic value than APRI and FIB-4 (Z=21.589, P＜0.001; Z=18.896, P＜0.001; Z=11.192, P=0.001; Z=16.891, P＜0.001), and APRI had a better diagnostic value than FIB-4 (Z=46.918, P＜0.001; Z=35.334, P＜0.001). ConclusionFibroTouch can accurately evaluate the presence of liver fibrosis and fibrosis degree and help most patients avoid invasive liver biopsy.

Pneumonia. Treatment and diagnosis.

Pneumonia remains a leading cause of morbidity and mortality despite advances in treatment and therapy. The "Pneumonia: Treatment and Diagnosis" session of the Pittsburgh International Lung Conference examined topics related to improving care of patients with pneumonia. These topics included the process and quality of care for community-acquired pneumonia (CAP), diagnosis and treatment of emerging fungal pathogens, an overview of the strengths and weaknesses of different diagnostic modalities, and an example of how basic science is exploring immunomodulatory strategies for pneumonia treatment. Systematic health care provider and institutional improvements can decrease mortality rates in CAP, particularly in patients with increasingly complex comorbidities. Aspects of current guidelines for the diagnosis and treatment of fungal pneumonia were reviewed through a series of case presentations. Proper treatment of pneumonia hinges on correct pathogen identification but is complicated by the variety of diagnostic assays with variable specificity, sensitivity, and interpretation. In addressing this topic, Dr. Patrick Murray, Ph.D., discussed a range of diagnostic tests for a variety of pathogens and guidelines for their use. In addition to the current state of CAP treatment, Bill (Beibei) Chen, M.D., Ph.D., presented a new potential therapeutic agent called forsythin, an immunomodulatory compound derived from a plant used in traditional Chinese medicine. These topics, ranging from institution-sized policy to interactions at the molecular scale, paint a broad perspective of the efforts against pneumonia.

Number needed to entrain: a new criterion for entrainment mapping in patients with intra-atrial reentrant tachycardia.

BACKGROUND: Measuring postpacing intervals (PPIs) is the standard maneuver for localizing reentrant tachycardia circuits. However, changes or termination of the tachycardia during entrainment pacing, or difficulties in defining the correct local activity, limit the use of PPIs. METHODS AND RESULTS: We hypothesized that the number of pacing stimuli needed to entrain (NNE) was useful for mapping intra-atrial reentrant tachycardias. First, 10 patients with typical atrial flutter were studied to characterize the NNE. Next, 317 entrainment attempts in 30 patients with 76 intra-atrial reentrant tachycardias were analyzed to determine the efficacy of the NNE. The NNE was small at sites within the reentrant circuit (median 2) and large at remote sites during typical atrial flutter. The NNE depended on the pacing cycle length and coupling interval of the initial paced beat, where the NNE became smaller at shorter pacing cycle lengths and coupling intervals. The NNE highly correlated with the difference between the PPI and tachycardia cycle length (r = 0.906; P<0.001). When the pacing cycle length and coupling interval were 16 to 30 ms below the tachycardia cycle length, a NNE ≤2 and >3 predicted a PPI-tachycardia cycle length ≤20 and >20 ms, respectively, with 100% accuracy. Thirty-six (11%) entrainment attempts changed or terminated intra-atrial reentrant tachycardia. Importantly, the NNE remained valid in those cases. Furthermore, the NNE provided additional information in cases with some difficulties with PPI measurements. CONCLUSIONS: The NNE is a simple and reliable criterion, which facilitates mapping intra-atrial reentrant tachycardia. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT001747.

The role of pulse oximetry in chiropractic practice: a rationale for its use.

OBJECTIVE: Pulse oximetry is used regularly to assess oxygen saturation levels. The objective of this commentary is to discuss a rationale for using pulse oximetry in chiropractic practice. DISCUSSION: Pulse oximetry may offer doctors of chiropractic a way to monitor patients' oxygen saturation levels. Quantification of saturation values with heart rate may give clinical aid to the management of chiropractic patients. Markedly reduced saturation levels may necessitate medical referral, whereas mildly reduced levels could lead to changes in chiropractic management. CONCLUSIONS: Pulse oximetry has the potential to be an integral part of chiropractic practice.

Diagnóstico laboratorial da giardiose humana: comparação entre as técnicas de sedimentação espontânea em água e de centrífugo-flutuação em solução de sulfato de zinco / Laboratory diagnosis of human giardiasis: comparison between spontaneous sedimentation in water and zinc sulfate centrifugal flotation

Introdução: A giardiose é uma das enteroparasitoses mais prevalentes no nosso meio e acarreta morbidade de indivíduos e dispêndio de recursos pecuniários. O diagnóstico laboratorial da giardiose é essencial, sendo o exame parasitológico de amostras fecais por microscopia o padrão ouro, a despeito do surgimento de técnicas alternativas. Dada a possível diferença de sensibilidade empregando técnicas de concentração distintas, torna-se necessário uma comparação entre as mesmas. Objetivos: Os objetivos deste estudo foram comparar duas técnicas amplamente utilizadas para o diagnóstico da giardiose e, concomitantemente, caracterizar a população do estudo e avaliar a ocorrência de co-parasitoses. Métodos: As amostras foram coletadas no período de março a maio de 2010 (N =163), sendo provenientes de usuários do Laboratório de Análises Clínicas Prof. Rubens Dantas (LAC, Farmácia, UFRGS, Porto Alegre). As técnicas de concentração das amostras fecais empregadas para o diagnóstico foram a de sedimentação espontânea em água (HPJ) e a centrífugo- flutuação em solução de sulfato de zinco (Faust). Aplicou-se um questionário aos usuários do laboratório para melhor caracterização da população estudada. Resultados: A prevalência total de enteroparasitoses e de giardiose na população estudada foi, respectivamente, de 22,9% e de 10,7% empregando as duas técnicas de concentração. A giardiose foi mais pronunciada em crianças e idosos, principalmente, do gênero masculino. A técnica de Faust (N =11) apresentou maior sensibilidade quando comparada a técnica de HPJ (N =6). Conclusão: A técnica de Faust foi mais sensível para observação de cistos de Giardia lamblia podendo ser uma técnica complementar ao HPJ no diagnóstico deste protozoário.

Background: Giardiosis is one of the most prevalent enteric parasitic diseases in our environment and causes of morbidity and medical costs. The laboratory diagnosis of giardiosis is essential. The parasitological examination of fecal samples using microscopy is the gold standard method of diagnosis, despite of the emergence of alternative techniques. Different diagnostic methods must be compared because of the possible variation in sensitivity using different concentration techniques. Aim: The objectives of this study were to compare the two techniques widely used for diagnosis of giardiosis and, concomitantly, characterize the study population and evaluate the co-occurrence of parasitic diseases. Methods: The samples were collected between March and May 2010 (N =163) from Laboratório de Análises Clínicas Prof. Rubens Dantas (LAC, School of Pharmacy, UFRGS, Porto Alegre). The concentration techniques of fecal samples for diagnosis were spontaneous sedimentation in water (HPJ) and the zinc sulfate centrifugal-flotation (Faust). A questionnaire was completed by the users of the laboratory to better characterize the study population. Results: The prevalence of enteric parasitic diseases and giardiosis in the study population was, respectively, 22.9% and 10.7% using both techniques of concentration. Giardiosis was more pronounced in children and elderly, especially males. The Faust technique (N =11) showed higher sensitivity when compared to the HPJ technique (N =6). Conclusion: The Faust technique was more sensitive to the observation of Giardia lamblia and may be a complementary technique to HPJ.