Atypical High-Altitude Cerebral Edema Presentation at an Altitude of Less Than 3000 Meters Elevation: A Case Report.

Introduction: Atypical presentations of high altitude cerebral edema may have a stuttering course that can be similar to more common and benign pathology at a lower altitude than typically causes high altitude cerebral edema. Case Report: A healthy 27-year-old male presented to a medical clinic situated at an altitude of 2829 meters with a "migraine" headache and nausea. He reported several episodes of 'blurry vision' each lasting seconds to a minute over the previous day. Symptoms had started four to five days after ascending from his home at sea level. The visual symptoms did not recur while he was in the clinic and his headache and nausea improved after oral medication. The physician recommended advanced imaging at the local hospital, but he declined and was discharged. The following day while riding a ski lift between 2830 and 3782 meters, he had a one-hour episode of visual disturbance with an intense headache. He was directed to proceed to the hospital for magnetic resonance imaging of the brain which demonstrated changes in his corpus callosum consistent with high altitude cerebral edema and he was evacuated to 1609 meters. Conclusion: An index of suspicion for high altitude cerebral edema must be maintained for any new neurological symptoms in unacclimatized individuals presenting to high alpine environments even those lower than typically associated with this high mortality condition.

Modeling Health Event Impact on Smoking Cessation.

Background: This study examined how cognitive and affective constructs related to an acute health event predict smoking relapse following an acute cardiac health event. Methods: Participants were recruited from emergency departments and completed cognitive and emotional measures at enrollment and ecological momentary assessments (EMA) for 84 days postvisit. Results: Of 394 participants, only 35 (8.9%) remained abstinent 84 days postvisit. Time to relapse was positively associated with age, actual illness severity, self-efficacy, and quit intentions. Conclusions: Older, seriously ill patients with strong confidence and intentions to quit smoking remain abstinent longer after discharge, but most still relapse within three months.

Translating 2019 ACSM Cancer Exercise Recommendations for a Physiatric Practice: Derived Recommendations from an International Expert Panel.

In 2018, the American College of Sports Medicine (ACSM) reconvened an international, multi-disciplinary group of professionals to review pertinent published literature on exercise for people with cancer. The 2018 roundtable resulted in the publication of three articles in 2019. The three articles serve as an important update to the original ACSM Roundtable on Cancer, which convened in 2010. Although the focus of the three 2019 articles is on exercise, which is only one part of comprehensive cancer rehabilitation, the evidence presented in the 2019 ACSM articles has direct implications for physiatrists and other rehabilitation professionals who care for people with cancer. As such, the narrative review presented here has two primary objectives. First, we summarize the evidence within the three ACSM articles and interpret it within a familiar rehabilitation framework, namely the Dietz model of Cancer Rehabilitation, in order to facilitate implementation broadly within rehabilitation practice. Second, via expert consensus, we have tabulated relevant exercise recommendations for specific cancer populations at different points in the cancer care continuum and translated them into text, tables, and figures for ease of reference. Notably, the authors of this article are members of the Cancer Rehabilitation Physician Consortium (CRPC), a group of physicians who subspecialize in cancer rehabilitation medicine (CRM).

Case report: The physiology of a preventable tragedy -Near death in a hot tub.

Hyperthermia in children is a known risk within enclosed vehicles. Exposure to an overheated hot tub poses a real risk in children due to unique pediatric physiology. Medical and aquatic professionals should understand the risk and mitigation strategies.

Sex- or Gender-specific Differences in the Clinical Presentation, Outcome, and Treatment of SARS-CoV-2.

This review describes the sex and gender differences in COVID-19 presentation, treatment, and outcomes. We discuss the differences between the sexes in susceptibility to infection, the role of sex chromosomes on the body's immunologic response and the influence of hormones on the body's response to the virus. Additionally, the sex differences in clinical and laboratory presentation, complications of infection and outcomes, as well as differences in response to treatment and prevention are reviewed.

Diplopia following lower blepharoplasty.

PURPOSE: To investigate the likelihood of surgeons performing lower blepharoplasties having cases of diplopia persisting for more than 1 week after surgery. METHODS: An anonymous survey (13 questions) on the frequency and characteristics of persistent diplopia (lasting >1 week) after lower blepharoplasty was sent to members of the American Society of Ophthalmic Plastic and Reconstructive Surgery. RESULTS: Of 703 members, 371 (52.8%) responded to the survey. Of these, 86 (23.2%) had at least 1 case of persistent diplopia following lower blepharoplasty. Complete data were available for 84 of the 86 physicians. The inferior oblique muscle was involved in 51 cases (61%), the inferior rectus muscle in 7 cases (8%), both the inferior oblique and inferior rectus muscles in 4 cases (5%), and the muscle involved was not identified in 22 patients (26%). The diplopia was paretic in 49 patients (58%) and restrictive in 35 (42%). The diplopia persisted in primary position in 7 patients (8%), in gaze positions other than primary position in 16 patients (19%), and resolved completely in 61 patients (73%). CONCLUSIONS: There is a significant chance of surgeons performing lower blepharoplasties having at least 1 case of diplopia lasting over a week postoperatively. Our survey results indicate that this complication may be more common than is suggested by the medical literature.

Aquatic Therapy in Contemporary Neurorehabilitation: An Update.

Aquatic therapy has been used extensively in a number of neurologic diseases and pathologies. This review describes disease-specific rehabilitative applications for this population. Recent research has offered scientific support for use in common neurological diseases that are part of rehabilitative practice, and very recent findings may create even firmer support for its use in these as well as other conditions. Stroke, Parkinsonism, and multiple sclerosis are areas that have recently received a significant number of published studies. Dementia is another area that has been more recently studied and received basic science support. Cerebral palsy has also had recent supportive evidence published. Available literature is reviewed to create a more evidence-based support for the use of aquatic therapy in neurorehabilitation.

Yoga as a Complementary Therapy for Smoking Cessation: Results From BreathEasy, a Randomized Clinical Trial.

INTRODUCTION: There is evidence that Yoga may be helpful as an aid for smoking cessation. Yoga has been shown to reduce stress and negative mood and may aid weight control, all of which have proven to be barriers to quitting smoking. This study is the first rigorous, randomized clinical trial of Yoga as a complementary therapy for smokers attempting to quit. METHODS: Adult smokers (N = 227; 55.5% women) were randomized to an 8-week program of cognitive-behavioral smoking cessation and either twice-weekly Iyengar Yoga or general Wellness classes (control). Assessments included cotinine-verified 7-day point prevalence abstinence at week 8, 3-month, and 6-month follow-ups. RESULTS: At baseline, participants' mean age was 46.2 (SD = 12.0) years and smoking rate was 17.3 (SD = 7.6) cigarettes/day. Longitudinally adjusted models of abstinence outcomes demonstrated significant group effects favoring Yoga. Yoga participants had 37% greater odds of achieving abstinence than Wellness participants at the end of treatment (EOT). Lower baseline smoking rates (≤10 cigarettes/day) were also associated with higher likelihood of quitting if given Yoga versus Wellness (OR = 2.43, 95% CI = 1.09% to 6.30%) classes at EOT. A significant dose effect was observed for Yoga (OR = 1.12, 95% CI = 1.09% to 1.26%), but not Wellness, such that each Yoga class attended increased quitting odds at EOT by 12%. Latent Class Modeling revealed a 4-class model of distinct quitting patterns among participants. CONCLUSIONS: Yoga appears to increase the odds of successful smoking abstinence, particularly among light smokers. Additional work is needed to identify predictors of quitting patterns and inform adjustments to therapy needed to achieve cessation and prevent relapse. IMPLICATIONS: This study adds to our knowledge of the types of physical activity that aid smoking cessation. Yoga increases the odds of successful smoking abstinence, and does so in a dose-response manner. This study also revealed four distinct patterns of smoking behavior among participants relevant to quitting smoking. Additional work is needed to determine whether variables that are predictive of these quitting patterns can be identified, which might suggest modifications to therapy for those who are unable to quit.

Cultures of Proximal and Distal Segments of Silicone Tubes After Dacryocystorhinostomy.

PURPOSE: To compare the results of cultures of the proximal and distal segments of silicone tubes after dacryocystorhinostomy. METHODS: The medical records of patients undergoing a dacryocystorhinostomy and silicone intubation were reviewed. The inclusion criteria were cultures of both distal and proximal stent segments after removal, dye testing, evaluation of the tear meniscus, and notation of the presence or absence of discharge before and after removal. The exclusion criteria included the use of systemic or topical antibiotics within 1 month before tube removal. RESULTS: Forty-six lacrimal systems in 40 patients were included, with 6 patients having bilateral dacryocystorhinostomies. There were no cases of dacryocystitis at the time of or after tube removal. Four (9%) of the dacryocystorhinostomies failed. Forty-one (89%) of the distal tube segments had positive cultures. The distal tube cultures grew 17 (36%) gram-positive bacteria, 21 (45%) gram-negative bacteria, 7 (15%) skin flora, and 2 (4%) fungi (6 distal segments had mixed cultures). Thirteen (28%) of the proximal tube segments had positive cultures. The proximal tube cultures were 5 (38%) gram-negative bacteria, 4 (31%) gram-positive bacteria, 3 (23%) skin flora, and 1 (8%) acid-fast bacteria. Four (31%) of the proximal tubes with positive cultures grew the same organism as the distal tube segment. Nine (69%) of the proximal tubes with positive cultures grew different organisms than the distal segment. Forty-two (91%) of all the proximal tube cultures were either negative or grew different organisms than the distal segment cultures. CONCLUSIONS: The proximal segment of a silicone tube after a dacryocystorhinostomy may be a "privileged" area. There is usually a lack of growth or the growth of different organisms than those present on the distal tube segments. This may be explained by the protective nature of the tear film. The findings may also help to explain the low incidence of dacryocystitis in spite of the growth of virulent organisms on the distal tube segment after a dacryocystorhinostomy.

Butt Why? Exploring factors associated with cigarette scavenging behaviors among adult smokers enrolling in a clinical trial for smoking cessation.

INTRODUCTION: Cigarette smoking is associated with many adverse health effects and is an important public health concern. Increased understanding of smokers' behavior is central to developing effective interventions. Cigarette scavenging, a behavior that involves smoking shared or previously used cigarettes has thus far only been shown to be prevalent among homeless or incarcerated populations. The current study examines whether cigarette scavenging is prevalent in a more general population of adult smokers enrolling in a smoking cessation clinical trial, and whether engagement in this behavior is associated with demographic or smoking-related psychosocial factors. METHODS: Baseline data was obtained from adult smokers (N=227) enrolling in a randomized clinical trial for smoking cessation. Cigarette scavenging was assessed using three items: a) sharing a cigarette with a stranger; b) smoking a "found" cigarette and c) smoking a previously used cigarette "butt". Participants who endorsed engaging in at least one of these three behaviors were categorized as a scavenger. RESULTS: Approximately 32% of participants endorsed at least one cigarette scavenging behavior. A multiple logistic regression analysis found that scavengers were more likely to be: men (p<0.001), of younger age at smoking onset (p=0.012), unemployed (p=0.003), more likely to have used marijuana in the past 30days (p=0.005), single or living alone (p=0.003), and to have experienced higher withdrawal symptoms during previous quit attempts (p=0.044) as compared to non-scavengers. CONCLUSIONS: Scavenging is common among adult smokers. Interventions that address cigarette scavenging behaviors may better meet the needs of this unique smoking subgroup.

Case Report: Aquatic Therapy and End-Stage Dementia.

A 54-year-old woman, retired due to progressive cognitive decline, was diagnosed with early-onset Alzheimer dementia. Conventional medication therapy for dementia had proven futile. Initial evaluation revealed a nonverbal female seated in a wheelchair, dependent on 2-person assist for all transfers and activities of daily living. She had been either nonresponsive or actively resistive for both activities of daily living and transfers in the 6 months before assessment. After a total of 17 1-hour therapy sessions over 19 weeks in a warm water therapy pool, she achieved the ability to tread water for 15 minutes, transfers improved to moderate-to-maximum assist from seated, and ambulation improved to 1000 feet with minimum-to-moderate assist of 2 persons. Communication increased to appropriate "yes," "no," and "okay" appropriate responses, and an occasional "thank you" and "very nice." The authors propose that her clinical progress may be related to her aquatic therapy intervention. LEVEL OF EVIDENCE: IV.

Who Enrolls in a Quit Smoking Program with Yoga Therapy?

OBJECTIVES: Yoga may improve stress, affect, and weight control, all of which are commonly cited barriers to quitting smoking. However, the importance of these concerns may vary by sex, race, ethnicity, and age. We examined smoking-relevant characteristics of individuals enrolling in an 8-week randomized controlled trial testing yoga as a complementary treatment to standard smoking cessation. METHODS: Of 958 callers, 227 were eligible and enrolled. RESULTS: The sample was 55% female, 86% non-Hispanic white, with a mean age of 46 years (SD = 12). Males smoked more cigarettes/ day than females and had lower motivation to quit smoking. Females were more likely to smoke for weight control, social and mood-related reasons, and had higher expectations for the efficacy of yoga. Age was negatively associated with the presence of other smokers in the household, and smoking in response to negative moods, and was positively associated with smoking rate, and confidence in quitting. CONCLUSIONS: This study demonstrated that both males and females were interested in a program offering yoga as a complementary therapy for smoking cessation. However, there were both sex and age-related differences with respect to smoking-related variables that may suggest a need to adapt the intervention for sub-populations.

Development and Validation of the Outcome Expectations for Yoga Scale.

OBJECTIVE: Our objective was to develop an instrument that can measure outcome expectations of yoga and to evaluate the instrument for internal consistency and initial construct validity. METHODS: A 20-item scale was developed to assess physical, mental, and spiritual health benefits related to yoga practice among adults. The scale was tested in a baseline survey with adults participating in a clinical trial. Principal component analysis was used to investigate the internal structure of the measure. Outcome expectations for yoga were examined for demographic differences. RESULTS: The sample (N = 185) was 54% women, 89% white and had a mean age of 46 years. The final 20-item scale had high item loadings that ranged from .57 to .88 with a Cronbach's alpha value of .96. Significant differences were found in outcome expectation score by sex. CONCLUSION: This newly developed scale can be used to assess outcome expectations for yoga and tailor interventions to promote adherence to yoga practice.

Differences between Men and Women Enrolling in Smoking Cessation Programs Using Yoga as a Complementary Therapy.

This study compares the characteristics of men and women, respectively, participating in two randomized controlled pilot studies whose primary aims were to test the feasibility of yoga as a complementary therapy for smoking cessation. Participants were aged 18-65, generally healthy and were daily smokers. Analysis of variance (ANOVA) and chi-square tests examined gender differences in smoking rate, potential treatment mediators, and covariates (e.g., smoking history, health status, weight concerns, mood, and prior withdrawal symptoms). A total of 55 women and 38 men participated in the study. Differences between men and women at enrollment included: women reported significantly greater withdrawal (p<0.005), anxiety (p=0.032), and depression (p=0.027) symptoms than men. More women than men (91% vs. 66%) reported having been told by their doctor to quit smoking (p=0.003), had an existing smoking-related illness (33% vs. 13%; p=0.032), and reported smoking for weight control (15% vs. 0%; p=0.014). Results showed good feasibility for recruiting both men and women into a study using yoga as a complementary therapy for smoking cessation. Results also indicate that interventions may need to be tailored to meet different needs (e.g., addressing co-morbid depression) between men and women.

Motivating parents of kids with asthma to quit smoking: the effect of the teachable moment and increasing intervention intensity using a longitudinal randomized trial design.

AIMS: We tested two aims: (1) the teachable moment (TM): whether second-hand smoke exposure (SHSe) feedback motivates cessation in parents of children with asthma versus parents of healthy children (HC); and (2) whether greater intervention intensity [enhanced-precaution adoption model (PAM)] produces greater cessation than a previously tested intervention (PAM). DESIGN AND INTERVENTIONS: Aim 1: two home visits (asthma education or child wellness), and cessation induction using motivational interviewing and SHSe feedback. Aim 2: post-home-visits, parents with asthmatic children were randomized to PAM (n = 171; six asthma education calls) or enhanced-PAM (n = 170; six asthma education/smoking cessation calls + repeat SHSe feedback). SETTING: Rhode Island, USA. PARTICIPANTS: Parents of asthmatic (n = 341) or healthy (n = 219) children who did not have to want to quit smoking to enroll. MEASUREMENTS: Measurements were given at baseline, 2, 4, 6 and 12 months. Abstinence was bioverified. Outcomes were 7-day and 30-day point prevalence abstinence (ppa) and SHSe (primary) and asthma morbidity (secondary). FINDINGS: Aim 1: the TM was supported: parents of asthmatic children were more than twice as likely to achieve 30-day [odds ratio (OR) = 2.60, 95% confidence interval (CI) = 1.22-5.54] and 7-day ppa (OR = 2.26, 95% CI = 1.13-4.51) at 2 months (primary end-point) and have non-detectable levels of SHSe than HCs. Greater treatment intensity yielded stronger TM effects (OR = 3.60; 95% CI = 1.72-7.55). Aim 2: enhanced-PAM was more likely to achieve 30-day ppa at the primary end-point, 4 months (OR = 2.12, 95% CI 1.09-4.12) and improved asthma outcomes versus PAM. CONCLUSIONS: Smoking cessation intervention (Motivational Interviewing plus biomarker feedback) appear to motivate smoking cessation more strongly among parents of asthmatic children than among parents of healthy children. Increased intervention intensity yields greater smoking cessation among parents of asthmatic children and better asthma outcomes.

Franklin Delano Roosevelt: The Diagnosis of Poliomyelitis Revisited.

Revisiting the ailments of famous historical persons in light of contemporary medical understanding has become a common academic hobby. Public discussion of Franklin Delano Roosevelt's (FDR) diagnosis of poliomyelitis after his sudden onset of paralysis in 1921 has received just such a revisitation. Recently, this 2003 historical analysis has been referenced widely on the Internet and in biographies, raising speculation that his actual diagnosis should have been Guillain-Barré Syndrome, a noncontagious disease of the peripheral nervous system rather than poliomyelitis. The authors of that 2003 analysis used a statistical analysis of his case by selectively choosing some of his reported symptoms. FDR's diagnosis of poliomyelitis, however, was fully supported by the findings of leading expert physicians of that time, who were very knowledgeable in the then-common disease and who periodically examined him during the period of 1921-1924. The most significant diagnostic features of polio are the absence of objective sensory findings in the presence of flaccid motor paralysis. These features are consistent with diagnostic criteria extant during the periods of major poliomyelitis epidemics as well as those of the Center for Disease Control 90 years later. Additional findings of fever, prodromal hyperesthesia, more severe residual proximal muscle weakness, and extensive lower extremity impairment requiring mobility with long leg braces or a wheelchair give further evidence for the diagnosis in FDR's case. Nonbulbar Guillain-Barré Syndrome, which shares the features of a flaccid paralysis and thus mimicking the initial presentation of poliomyelitis, has more than an 80% complete recovery with no reported cases of eventual wheelchair use. The most severe cases of Guillain-Barré Syndrome often have persistent objective sensory loss, associated with greater weakness in the feet and hands, which show no resemblance to FDR's impairment and disability. In light of the expert initial assessments by physicians completely familiar with the signs and symptoms of the then-common disease, review of his initial and subsequent disease course, and residual symptoms in comparison with those of Guillain-Barré syndrome, we find no reason to question the diagnostic accuracy of poliomyelitis and wish to put this debate to rest.