Spinal manipulative therapy is an independent risk factor for vertebral artery dissection.

OBJECTIVE: To determine whether spinal manipulative therapy (SMT) is an independent risk factor for cervical artery dissection. METHODS: Using a nested case-control design, the authors reviewed all patients under age 60 with cervical arterial dissection (n = 151) and ischemic stroke or TIA from between 1995 and 2000 at two academic stroke centers. Controls (n = 306) were selected to match cases by sex and within age strata. Cases and controls were solicited by mail, and respondents were interviewed using a structured questionnaire. The medical records of interviewed patients were reviewed by two blinded neurologists to confirm that the patient had stroke or TIA and to determine whether there was evidence of arterial dissection. RESULTS: After interview and blinded chart review, 51 patients with dissection (mean age 41 +/- 10 years; 59% female) and 100 control patients (44 +/- 9 years; 58% female) were studied. In univariate analysis, patients with dissection were more likely to have had SMT within 30 days (14% vs 3%, p = 0.032), to have had neck or head pain preceding stroke or TIA (76% vs 40%, p < 0.001), and to be current consumers of alcohol (76% vs 57%, p = 0.021). In multivariate analysis, vertebral artery dissections were independently associated with SMT within 30 days (OR 6.62, 95% CI 1.4 to 30) and pain before stroke/TIA (OR 3.76, 95% CI 1.3 to 11). CONCLUSIONS: This case-controlled study of the influence of SMT and cervical arterial dissection shows that SMT is independently associated with vertebral arterial dissection, even after controlling for neck pain. Patients undergoing SMT should be consented for risk of stroke or vascular injury from the procedure. A significant increase in neck pain following spinal manipulative therapy warrants immediate medical evaluation.

Long-term transcutaneous electrical nerve stimulation (TENS) use: impact on medication utilization and physical therapy costs.

OBJECTIVE: A study was conducted to assess a variety of treatment outcomes in long-term users of transcutaneous electrical nerve stimulation (TENS) who suffer from chronic pain. Key components of the study examined the effects of long-term TENS therapy on pain-related medications and physical/occupational therapy (PT/OT) use. DESIGN: From a population of 2,(X)3 chronic pain patients (CPPs) who acquired a TENS device (Epix XL, Empi, Inc., St. Paul, MN, U.S.A.) for pain management, a randomly selected sample of 376 patients who used TENS were interviewed by telephone by an independent research firm. The survey assessed a variety of outcome variables including changes in medication use, number of pain-related medications, and use of PT/OT prior to TENS and after a minimum 6 months of TENS treatment. The data were subjected to a paired t test analysis. A cost simulation model was then applied to the medication and PT/OT data. RESULTS: The mean duration of pain, for which TENS was prescribed, was 40 +/- 60 months. As compared with the period prior to TENS use, this long-term TENS user group reported a statistically significant reduction in the following types of pain medications: opiate analgesics, tranquilizers, muscle relaxants, nonsteroidal anti-inflammatory drugs (NSAIDs), and steroids. PT/OT use was also significantly reduced. Cost simulations of pain medications and PT/OT are presented. CONCLUSIONS: Long-term use of TENS is associated with a significant reduction in the utilization of pain medication and PT/OT. In this study population, cost simulations of medication and PT/OT indicate that with long-term TENS use, costs can be reduced up to 55% for medications and up to 69% for PT/OT. The potential for TENS associated improvement, combined with reduced medication-related complications and costs, are important points that clinicians should consider when constructing a treatment plan for chronic pain patients. Finally, cost simulation techniques provide a useful tool for assessing outcomes in pain treatment and research.

Distribution of cytopathic and noncytopathic bovine viral diarrhea virus antigens in tissues of calves following acute experimental infection.

The distribution of cytopathic and noncytopathic biotypes of bovine viral diarrhea virus (BVDV) in the tissues of colostrum-fed and colostrum-deprived calves was investigated. Colostrum-fed (group A) and colostrum-deprived (group B) calves were experimentally infected with the BVDV isolate 80/1, which contains both BVDV biotypes. Colostrum-deprived calves were also experimentally infected with a noncytopathic BVDV (group C) or with a cytopathic BVDV (group D) cloned from the 80/1 isolate. All calves were sequentially euthanized, and a wide range of tissue samples were processed for immunofluorescent and virus isolation studies. In group A, consistent immunofluorescent staining for BVDV was detected in vascular smooth muscle of numerous blood vessels in the tissues examined, mainly at 11 and 13 days postinoculation. A predominance of samples containing cytopathic BVDV was observed in the calves of this group, following virus isolation studies. Both cytopathic and noncytopathic BVDV were detected/recovered from a larger range of specimens in the calves in group B than from the calves in group A. In the calves in all the experimental groups, large amounts of BVDV antigen were detected mainly in tissue samples from the lymphoid and gastrointestinal systems, whereas only minimal amounts of BVDV were detected in the respiratory tract. Abundant noncytopathic BVDV antigen was also detected in pituitary gland and in Langerhans islets in pancreases of colostrum-deprived calves infected with the cloned noncytopathic BVDV. Noncytopathic BVDV was isolated from a wider range of tissues from calves in group C than in the colostrum-deprived calves infected with both BVDV biotypes. A cytopathic BVDV was isolated/detected in retropharyngeal, mesenteric, and abomasal lymph nodes and in thymus of 2 calves in group C. Cytopathic BVDV was detected/isolated mainly from mesenteric lymph nodes and Peyer's patches of the calves in group D.

Automating the reluctant physician.

The DISC played an essential role in the development of the organization strategic IS plan and has become a resource of knowledgeable doctors for participation in ongoing IS projects Communications and collaboration among the doctors and other care giver, the administration and the IS department have improved. The DISC model is one that other hospitals and healthcare organizations can use to involve and mobilize their own medical staffs in IS issues. It should be particularly applicable on the medical staff with the time, interest or clinical IS expertise to provide the needed medical staff IS vision and leadership.

A provisional model to predict blood pressure response to biofeedback-assisted relaxation.

Blood pressure (BP) response to biofeedback-assisted relaxation is not uniform among hypertensive individuals. The purpose of this exploratory study was to determine if selected psychophysiological variables could be used to identify individuals able to lower blood pressure using biofeedback-assisted relaxation. Responders were defined using a preset criterion of 5 mm Hg or greater decrease in mean arterial pressure. A logistic regression model derived from five variables (heart rate, finger temperature, forehead muscle tension, plasma renin response to furosemide, and mean arterial pressure response to furosemide) provided significant predictive power for BP response, exhibiting a sensitivity of 84.6% and a specificity of 80.0%. With future validation, the proposed model may provide useful information to identify patients likely to benefit from biofeedback-assisted relaxation.

The effect of interstitial hyperthermia on local pulmonary blood flow and lung parenchyma.

Hyperthermia has shown promise as an anticancer therapy, but its application to lung neoplasms has been limited by whole body hyperthermia complications and the intrathoracic location of lung neoplasms. Previous studies have shown that interstitial hyperthermia could be performed through a thoracotomy approach and that animals tolerated the procedure without biochemical or hematologic abnormalities. The normal lung's local blood flow pattern and parenchymal changes due to hyperthermia of various temperatures and durations were studied. The experimental protocol applied hyperthermia through interstitial electrodes at temperatures of 39 degrees, 41 degrees, 43 degrees, and 45 degrees C. Tissue blood flow was measured with radioactive microspheres at 20, 40, and 60 minutes of hyperthermia. Histologic examination was performed of biopsy specimens taken from the heated area, from 2 and 5 cm from the heated area, and from distant parenchyma. These initial studies demonstrate that interstitial hyperthermia in the normal lung does not cause a decrease in pulmonary vascular resistance, that interstitial hyperthermia in the normal lung at temperatures of 43 degrees or 45 degrees C for durations of longer than 20 minutes decreases local pulmonary blood flow, that interstitial hyperthermia causes mild vascular disruption at temperatures of 39 degrees C or greater in the heated area but does not affect adjacent or distant lung parenchyma, and that lung hyperthermia causes generalized vascular disruption with severe widening of the pulmonary interstitium and severe hemorrhage in the heated areas when temperatures of 43 degrees or 45 degrees C are applied. Because interstitial hyperthermia affected only local lung damage, it may be applicable in the treatment of localized lung tumors.

Acupressure: an overview of theory and application.

Treatment of pain is common to all nurse practitioners' practices. One treatment method appropriate for use by the nurse practitioner is acupressure. Upon reviewing the professional literature, a paucity of information on acupressure was discovered. This article uses acupuncture theory and research to provide a theoretical basis for the use and study of acupressure. A description of how to locate and stimulate an acupoint useful for the treatment of headaches resulting from shoulder muscle tension is presented.