Add-on effect of clarithromycin to oral steroids as post- operative therapy for chronic rhinosinusitis with nasal polyps: a randomised controlled trial.

BACKGROUND: Evidence is lacking regarding the efficacy of macrolides and oral corticosteroids in chronic rhinosinusitis with nasal polyps (CRSwNP) after endoscopic sinus surgery (ESS). Therefore, we examined the benefits of adding clarithromycin to oral pred- nisolone as post-ESS medical therapy in patients with CRSwNP. METHODS: In this randomised, double-blind, placebo-controlled trial, patients were enrolled and allocated to three study groups receiving different post-ESS medical therapies: group A (placebo for 14 weeks), group B (oral prednisolone [15 mg twice daily] for 2 weeks, followed by placebo for 12 weeks), and group C (oral prednisolone [15 mg twice daily] for 2 weeks, followed by clari- thromycin [500 mg daily] for 12 weeks). All enrolled patients received the perioperative care following a routine protocol, which included oral amoxicillin/clavulanate, and intranasal corticosteroid spray. The baseline and post-operative visual analogue scale (VAS) scores, Sino-nasal Outcome Test (SNOT-22) scores, and Lund-Kennedy endoscopy scores (LKES) were determined as the primary outcomes. RESULTS: One hundred twenty-six patients who received ESS for bilateral CRSwNP were randomised into group A (n=43), B (n=42), or C (n=41). Compared to groups A and B, group C showed greater VAS and SNOT-22 score improvement at 12 weeks after ESS. Group C showed significantly better LKES than did groups A and B at 8, 12, and 24 weeks after ESS. On stratifying the LKES results according to the presence/absence of tissue eosinophilia, greater add-on effects of clarithromycin were observed in the patient subgroup without tissue eosinophilia. CONCLUSIONS: Adding low-dose clarithromycin to oral corticosteroids as post-ESS therapy was well tolerated and showed benefi- cial subjective and objective outcomes in patients with CRSwNP, especially those without tissue eosinophilia.

End-of-life care following leg amputation in patients with peripheral artery disease or diabetes.

BACKGROUND: The aim was to characterize end-of-life care in patients who have had a leg amputated for peripheral artery disease (PAD) or diabetes. METHODS: This was a population-based retrospective cohort study of patients with PAD or diabetes who died in Ontario, Canada, between 2011 and 2017. Those who had a leg amputation within 3 years of death were compared with a control cohort of deceased patients with PAD or diabetes, but without leg amputation. The patients were identified from linked health records within the single-payer healthcare system. Place and cause of death, as well as health services and costs within 90 days of death, were compared between the amputee and control cohorts. Among amputees, multivariable regression models were used to characterize the association between receipt of home palliative care and in-hospital death, as well as time spent in hospital at the end of life. RESULTS: Compared with 213 300 controls, 3113 amputees were less likely to die at home (15·5 versus 24·9 per cent; P < 0·001) and spent a greater number of their last 90 days of life in hospital (median 19 versus 8 days; P < 0·001). Amputees also had higher end-of-life healthcare costs across all sectors. However, receipt of palliative care was less frequent among amputees than controls (inpatient: 13·4 versus 16·8 per cent, P < 0·001; home: 14·5 versus 23·8 per cent, P < 0·001). Among amputees, receipt of home palliative care was associated with a lower likelihood of in-hospital death (odds ratio 0·49, 95 per cent c.i. 0·40 to 0·60) and fewer days in hospital (rate ratio 0·84, 0·76 to 0·93). CONCLUSION: Palliative care is underused after amputation in patients with PAD or diabetes, and could contribute to reducing in-hospital death and time spent in hospital at the end of life.

ANTECEDENTES: Caracterizar la atención al final de la vida en pacientes con amputación de la extremidad inferior por enfermedad arterial periférica (peripheral arterial disease, PAD) o diabetes. MÉTODOS: Se trata de un estudio de cohortes retrospectivo de base poblacional en sujetos fallecidos con PAD o diabetes en Ontario, Canadá (2011-2017). A partir de los registros sanitarios incluidos en un sistema de salud de una sola entidad pagadora, se identificaron los individuos con amputación de la extremidad inferior en los 3 años previos al fallecimiento y una cohorte control de fallecidos con PAD o diabetes sin amputación. Entre las cohortes de amputados y controles se comparó el lugar del fallecimiento y la causa, así como el uso de servicios sanitarios y costes en los últimos 90 días de vida. En el grupo de los amputados, se utilizaron modelos de regresión para caracterizar la asociación entre recibir cuidados paliativos domiciliarios y el fallecimiento en el hospital, así como los días de estancia hospitalaria al final de la vida. RESULTADOS: En comparación con los controles (n = 213.300), los sujetos con amputación (n = 3.113) era menos probable que fallecieran en el domicilio (16% versus 25%, P < 0,001) y pasaron un mayor número de sus últimos 90 días de vida en el hospital (mediana 19 versus 8 días, P < 0,001). Los costes de atención sanitaria al final de la vida en todos los sectores también fueron mayores para los amputados. Sin embargo, recibir cuidados paliativos fue menos frecuente en los amputados que en los controles (en el hospital 13% versus 17%, P < 0,001; domiciliarios 14% versus 24%, P < 0,001). En el grupo de los amputados, recibir cuidados paliativos domiciliarios se asociaba con una menor probabilidad de fallecimiento en el hospital (razón de oportunidades, odds ratio 0,49, i.c. del 95% 0,40-0,60) y menos días de hospitalización (tasa de riesgo 0,84, i.c. del 95% 0,76-0,93). CONCLUSIÓN: Los cuidados paliativos están infrautilizados en pacientes con PAD o diabetes y pueden contribuir a disminuir los fallecimientos en el hospital y los días de hospitalización al final de la vida.

Blood clotting and traumatic injury with shock mediates complement-dependent neutrophil priming for extracellular ROS, ROS-dependent organ injury and coagulopathy.

Polymorphonuclear (PMN) leucocytes participate in acute inflammatory pathologies such as acute respiratory distress syndrome (ARDS) following traumatic injury and shock, which also activates the coagulation system systemically. Trauma can prime the PMN nicotinamide adenine dinucleotide phosphate (NADPH) oxidase complex for an enhanced respiratory burst, but the relative role of various priming agents in this process remains incompletely understood. We therefore set out to identify mediators of PMN priming during coagulation and trauma-shock and determine whether PMN reactive oxygen species (ROS) generated in this manner could influence organ injury and coagulation. Initial experiments demonstrated that PMN are primed for predominantly extracellular ROS production by products of coagulation, which was abrogated by CD88/C5a receptor(C5aR) inhibition. The importance of this was highlighted further by demonstrating that known PMN priming agents result in fractionally different amounts of extracellular versus intracellular ROS release depending on the agent used. Plasma from trauma patients in haemodynamic shock (n = 10) also primed PMN for extracellular ROS in a C5a-dependent manner, which correlated with both complement alternative pathway activation and thrombin generation. Furthermore, PMN primed by preincubation with products of blood coagulation directly caused loss of endothelial barrier function in vitro that was abrogated by C5aR blockade or NADPH oxidase inhibition. Finally, we show in a murine model of trauma-shock that p47phox knock-out (KO) mice with PMN incapable of generating ROS were protected from inflammatory end-organ injury and activated protein C-mediated coagulopathy. In summary, we demonstrate that trauma-shock and coagulation primes PMN for predominantly extracellular ROS production in a C5a-dependent manner that contributes to endothelial barrier loss and organ injury, and potentially enhances traumatic coagulopathy.

Dimensional accuracy and retentive strength of a retrievable cement-retained implant-supported prosthesis.

The purpose of this research project was to compare the fit of a retrievable cement-retained implant-supported framework to that of a traditional wax and cast, screw-retained framework and to test the strength of the cemented restoration. Ten telescopic frameworks were luted to gold cylinders with a bis-GMA resin cement. The control group consisted of 10 frameworks fabricated with traditional wax and casting techniques directly to the gold cylinders. Frameworks were analyzed for distortion in the z-axis using scanning electron microscopy and a single screw test. Results demonstrated that the retrievable cement-retained group had a decreased gap distance and improved angular distortion (statistical significance P < .01) compared to the control group. Retentive strength measurements for the cement-retained group with a direct pull-out test revealed a mean pull-out force of 65.7 kg. Three of the 5 samples surpassed the tensile strength of the gold retaining screws (76 kg). Cement-retained restorations demonstrated superior fit in the z-axis and angular distortion compared to traditional wax and cast screw-retained frameworks. Retentive tests support a simplified technique of clinically luting telescopic implant-supported frameworks with adequate retentive strength.

Immediate response of glenohumeral abduction range of motion to a caudally directed translational mobilization: a fresh cadaver simulation.

OBJECTIVE: To investigate the immediate effect of caudal glide translational mobilization on the range of motion (ROM) of passive glenohumeral abduction with a fresh cadaver model to simulate the mobilization movement performed by a physical therapist treating patients with glenohumeral hypomobility. DESIGN: Mechanical simulation of caudal glide mobilization and abduction torque range of motion (TROM) measurement of the glenohumeral joint with 2 material testing systems. Mobilizations were conducted with the glenohumeral joint positioned at a resting position (IGR) and at the end range of abduction (IGE). SETTING: Biomechanics laboratory. CADAVERS: Twenty fresh shoulder specimens from 10 cadavers (mean age, 68 +/- 8 yr). MAIN OUTCOME MEASURE: Changes in TROM of the glenohumeral abduction in response to 5 bouts of caudal glide mobilization. RESULTS: At least 3 repetitions of TROM were required to attain consistent measurements on glenohumeral abduction ROM. Significant differences were found among changes in TROM because of rest, IGR, and IGE (Kruskal-Wallis statistics, (chi2 = 14.58, p = .001). A greater increase in glenohumeral abduction TROM was found after IGE (mean +/- standard error of the mean, 4.38 degrees +/- 0.95 degrees) compared with the rest control (0.03 degrees +/- 0.07 degrees; Mann-Whitney test, p = .001, alpha = .017) or its IGR counterpart (0.26 degrees +/- 0.46 degrees, p = .001, alpha = .017). CONCLUSION: This simulation of caudal glide translational mobilization at the end range using cadaver models improved passive glenohumeral abduction ROM but was ineffective when performed with the shoulder placed in a resting position. The mechanical responses of the glenohumeral joint to translational mobilization in a live patient may be similar, but some caution should be used in generalizing these findings.

Physical activity, physical fitness, and osteopenia in postmenopausal Taiwanese women.

BACKGROUND AND PURPOSE: The purpose of this cross-sectional study was to investigate whether physical activity level and physical fitness parameters differ between postmenopausal Taiwanese women with normal and subnormal bone mineral density (BMD). METHODS: Seventy-six postmenopausal women aged from 42 to 65 years participated in this study. Women taking medication that might influence BMD measurements were not included. The BMDs of the lumbar spine (L2-4) and right femoral neck were measured using dual energy x-ray absorptiometry. Thirty-one women with both BMD values within the normal ranges (1.055 +/- 0.092 g/cm2 for the spine and 0.845 +/- 0.088 g/cm2 for the right femoral neck) of premenopausal Chinese women served as the normal density group. Another 43 women with both BMD values more than one standard deviation below the normal value (0.760 +/- 0.089 g/cm2 for the spine and 0.656 +/- 0.052 g/cm2 for the femoral neck) were recruited as the osteopenic group. Physical activity level was assessed with a 7-day recall questionnaire. Physical fitness assessment included tests of flexibility, muscular strength, endurance, body composition, and cardiopulmonary fitness. A multiple linear regression model adjusted for age, body weight, height, and years since menopause was used. RESULTS: The results revealed that energy expenditure and maximal oxygen consumption were significantly lower in the osteopenic group than in the non-osteopenic group (p < 0.05), while flexibility, body composition, muscle strength and muscular endurance did not differ significantly between the two groups (p > 0.05). CONCLUSIONS: These findings indicate that physical activity may play a major role in BMD levels in postmenopausal women in Taiwan. Future studies should emphasize the effect of physical exercise training on BMD in postmenopausal women.

Joint position during anterior-posterior glide mobilization: its effect on glenohumeral abduction range of motion.

OBJECTIVE: To investigate the effect of joint position during an anterior-posterior glide (APG) procedure on the range of motion (ROM) of glenohumeral abduction in cadaver specimens. DESIGN: Mechanical simulation of APG mobilization and abduction torque ROM measurement of the glenohumeral joint with a material testing system. The immediate mechanical efficacy of APG was compared in two groups of specimens at two different joint positions: midrange (n = 5) and end range (n = 6) of glenohumeral abduction. SETTING: Biomechanics laboratory. SPECIMENS: Eleven fresh cadaver shoulder specimens (mean age, 66.9+/-2.5 yrs). MAIN OUTCOME MEASURE: Improvement in glenohumeral abduction torque ROM obtained before and after APG procedure. RESULTS: Glenohumeral abduction improved significantly, as indicated by a significant increase (Kruskal-Wallis statistics, chi2 = 7.50, p = .006) in the torque ROM of the end range group (mean +/- standard error of the mean, 2.02 degrees +/- .20 degrees) over the midrange group (.64 degrees +/- .08 degrees). A significant difference in the magnitude of peak displacement of the humeral head between midrange (14.44+/-3.56 mm) and end range (3.19+/-.81 mm) groups was also found (Mann-Whitney test, p < .030). CONCLUSION: This study demonstrated that APG technique performed at close to the end of the range of abduction is more effective in improving glenohumeral abduction ROM than that performed at the middle of the range of abduction.

Efficacy of a 24-week aerobic exercise program for osteopenic postmenopausal women.

Osteoporosis is one of the most common skeletal disorders affecting postmenopausal women. The purpose of this study was to investigate whether a 24-week program of aerobic high-impact loading exercise was beneficial for enhancing physical fitness and bone mineral density (BMD) in osteopenic postmenopausal women. Forty-three postmenopausal women aged 48-65 years participated in this study. The BMD of the spine (L2-L4) and right femoral neck of each woman was below 1 SD of the mean of premenopausal women, as examined by dual X-ray absorptiometry. The assignment of subjects into exercise or control group was not randomized but based on each subject's anticipated compliance to the 6-month long exercise program. Twenty-two subjects joined the exercise group and attended the training programs and 21 served as the control group. Exercise programs included treadmill walking at an intensity above 70% of maximal oxygen consumption (VO2max) for 30 minutes, followed by 10 minutes of stepping exercise using a 20-cm-high bench. The program was conducted three times per week for 24 weeks. Physical fitness measurements included testing of flexibility, muscular strength and endurance, body composition, and cardiopulmonary fitness. The results showed that the quadriceps strength, muscular endurance, and VO2max in the exercise group had significant improvements, whereas no improvement was found in any of the physical fitness parameters in the control group. The BMD of the L2-L4 and the femoral neck in the exercise group increased 2.0% (P > 0.05) and 6.8% (P < 0.05) and those in the control group decreased 2.3% (P < 0.05) and 1.5% (P > 0.05), respectively. In conclusion, aerobics combined with high-impact exercise at a moderate intensity was effective in offsetting the decline in BMD in osteopenic postmenopausal women.

Application of an unstructured grid algorithm to artificial heart valve simulations.

The time varying flow pattern in the vicinity of mechanical heart valves (MHV) is fairly complex: it involves multiple passages and moving leaflets. The numeric simulation of unsteady flows in these multiple passages with moving boundaries presents a major challenge to computational fluid dynamics (CFD). Two major difficulties in the numeric simulation of MHV flows are 1) the generation of a body fitted grid within the multipassage device and 2) moving leaflets. The conventional finite difference and finite volume scheme obtained by using a structured grid have serious deficiencies in these applications. To fit the grid lines with the various angles of the moving MHV, the grid may often become too skewed for accurate numeric solution. To overcome these deficiencies, significant effort and attention should be placed on the grid generation and moving grid scheme. We present an unstructured moving grid finite volume method for heart valve simulations. The Navier-Stokes equations are discretized on a general tetrahedral mesh by using a finite volume scheme. With this scheme, the mesh can be automatically generated with any commercial software. The method is applied to a tilting disk (Medtronic Hall 29mm, Medtronic, Inc., Minneapolis, MN) heart valve, and results are compared with that of the steady flow solutions. Significant differences between steady and unsteady flow solutions are observed.

Quadriceps force and myoelectric activity during flexed knee stance.

The purpose of this study was to determine the quadriceps demand during single limb stance with the knee in five positions of flexion (0 degree -60 degrees). Two variables were used to estimate the quadriceps demands: the integrated electromyogram (EMG) of three vasti and the torque about the knee joint. Ten normal subjects 23-29 years of age were tested. Myoelectric activity was recorded with intramuscular electrodes and knee joint angle with an electrogoniometer. The EMG data were integrated and normalized. A visible vector system was used to determine knee flexion torque. A significant linear correlation was found between values of patellar ligament force and knee angle (R2 = 0.86). The patellar ligament force increased 4.16% of body weight per degree of knee flexion between 0 degree and 60 degrees. Both vector-estimated quadriceps force and normalized EMG showed significant correlations with knee angle (R2 = 0.91 and R2 = 0.88, respectively). Both exhibited a slower rate of rise below 30 degrees flexion and a higher rate of rise above 30 degrees. The authors' findings suggest that the stabilizing effects of plantar flexors (except gastrocnemius) on the knee joint, changing muscle moment arm length, and force ratio between the patellar ligament and quadriceps muscle with respect to knee angle are primary reasons for the quadratic normalized integrated EMG (NIEMG)-force nonlineality during flexed stance. This might indicate the existence of a critical angle of knee flexion contracture beyond which patients cope poorly with standing and functional ambulation.