Muscle activation patterns during active external rotation after reverse total shoulder arthroplasty: an electrophysiological study of the teres minor and associated musculature.

BACKGROUND: Preoperative teres minor insufficiency has been identified as a risk factor for poor restoration of external rotation (ER) after reverse total shoulder arthroplasty (RTSA). However, there has been little investigation regarding muscle activation patterns generating ER. This prospective study sought to determine the timing and activation levels of the shoulder girdle musculature during ER in well-functioning RTSAs with an intact teres minor using a lateralized design. METHODS: Patients who underwent RTSA ≥1 year previously with functional ER, an American Shoulder and Elbow Surgeons (ASES) score >70, superior rotator cuff deficiency, and an intact teres minor were identified. Electrophysiological and kinematic analyses were performed during ER in the modified neutral position (arm at side with 90° of elbow flexion) and in abduction (AB) (shoulder abducted 90° with 90° of elbow flexion). Dynamometer-recorded torque and position were pattern matched to electromyography during ER. The root-mean-square and integrated electromyography (in microvolts × milliseconds with standard deviation [SD]), as well as median frequency (MF) (in hertz with SD), were calculated to determine muscle recruitment. Pair-wise t test analysis compared muscle activation (P < .05 indicated significance). RESULTS: After an a priori power analysis, 16 patients were recruited. The average ASES score, visual analog scale pain score, and ASES subscore for ER in AB ("comb hair") were 87.7, 0.5, and 2.75 of 3, respectively. In AB, muscle activation began with the upper trapezius, middle trapezius, and latissimus dorsi, followed by the anterior deltoid activating to neutral. With ER beyond neutral, the teres major (9.6 µV × ms; SD, 9.2 µV × ms) initiated ER, followed by the teres minor (14.1 µV × ms; SD, 18.2 µV × ms) and posterior deltoid (11.1 µV × ms; SD, 9.3 µV × ms). MF analysis indicated equal contributions of the teres major (1.1 Hz; SD, 0.5 Hz), teres minor (1.2 Hz; SD, 0.4 Hz), and posterior deltoid (1.1 Hz; SD, 0.4 Hz) in ER beyond neutral. In the modified neutral position, the upper trapezius and middle trapezius were not recruited to the same level as in AB. For ER beyond neutral, the teres major (9.5 µV × ms [SD, 9 µV × ms]; MF, 1.1 Hz [SD, 0.5 Hz]), teres minor (11.4 µV × ms [SD, 15.1 µV × ms]; MF, 1.1 Hz [SD, 0.5 Hz]), and posterior deltoid (8.5 µV × ms [SD, 8 µV × ms]; MF, 1.2 Hz [SD, 0.3 Hz]) were activated in similar sequence and intensity as AB. No differences in muscle activation duration or intensity were noted among the teres major, teres minor, and posterior deltoid (P > .05). CONCLUSION: Active ER after RTSA is complex and is not governed by a single muscle-tendon unit. This study establishes a sequence, duration, and intensity of muscle activation for ER in well-functioning RTSAs. In both tested positions, the teres major, teres minor, and posterior deltoid function equally and sequentially to power ER.

Increasing Breast Support is Associated With a Distal-to-Proximal Redistribution of Joint Negative Work During a Double-Limb Landing Task.

Female athletes exhibit greater rates of anterior cruciate ligament injury compared with male athletes. Biomechanical factors are suggested to contribute to sex differences in injury rates. No previous investigation has evaluated the role of breast support on landing biomechanics. This study investigates the effect of breast support on joint negative work and joint contributions to total negative work during landing. Thirty-five female athletes performed 5 landing trials in 3 breast support conditions. Lower-extremity joint negative work and relative joint contributions to total negative work were calculated. Univariate analyses of variance were used to determine the effect of breast support on negative joint work values. Increasing levels of breast support were associated with lower ankle negative work (P < .001) and ankle relative contributions (P < .001) and increases in hip negative work (P = .008) and hip relative contributions (P < .001). No changes were observed in total negative work (P = .759), knee negative work (P = .059), or knee contributions to negative work (P = .094). These data demonstrate that the level of breast support affects lower-extremity biomechanics. The distal-to-proximal shift in negative joint work and relative joint contributions may be indicative of a more protective landing strategy for anterior cruciate ligament injuries.

Systemic Lupus Erythematosus Initially Presenting as Acute Motor and Sensory Axonal Neuropathy Variant of Guillain-Barre Syndrome in a Healthy Active Duty Female.

Guillain-Barre syndrome (GBS) is an acute monophasic immune-mediated polyradiculoneuropathy characterized by rapidly evolving ascending weakness, mild sensory loss, and hypo- or areflexia, typically progressing to peak symptoms over the course of 4 weeks. The precise mechanism is unclear but is proposed to be an immune-mediated reaction with the generation of antibodies against peripheral nerves triggered by a preceding viral infection. Acute motor and sensory axonal neuropathy (AMSAN) is a rare and severe variant of Guillain-Barre syndrome with limited published literature. Discussion of risk factors for this subtype has not been done in a systematic way. This case report involves a 34-year-old, active duty, West African female, who immigrated to the United States in 2019. She presented with worsening diplopia, bilateral distal upper and lower extremity paresthesias as well as progressively worsening bilateral upper extremity weakness. Her clinical picture was complicated by constitutional symptoms, diffuse lymphadenopathy, no preceding viral illness, and marked clinical deterioration. Ultimately, she was diagnosed with acute motor and sensory axonal neuropathy in the setting of a new diagnosis of systemic lupus erythematosus, a rarely described association emphasizing the importance of a thorough evaluation for underlying causes of acute neurologic pathologies.

Increasing Trunk Mass Evokes Lower Extremity Biomechanical Plasticity during Stair Descent.

The purpose of this study was to investigate the influence of simulated changes in body mass on lower extremity joint work and relative joint contributions during stair descent. Ten healthy recreationally active college-age participants performed five stair descent trials in each of five loading conditions: no added load and with an additional 5%, 10%, 15% and 20% of their body weight. Three-dimensional ankle, knee and hip joint powers were calculated using a six degree-of-freedom model in Visual3D (C-Motion Inc., Germantown, MD, USA). Sagittal plane joint work was calculated as the joint power curve integrated with respect to time during the period between initial contact and toe off. Prism 9.0 (GraphPad Inc., San Diego, CA) was used to perform univariate 1 × 5 repeated measures analyses of variance to determine the effect of added mass on absolute and relative joint work values for total and for each lower extremity joint independently. Increasing added mass was associated with greater total lower extremity negative work during the stair descent task (p < 0.001). At the ankle, increasing added mass was associated with increasing magnitudes of negative joint work. Increasing added mass was associated with greater relative contributions of the ankle and reduced knee contributions to total negative lower extremity joint work (p = 0.014 and p = 0.006). The current findings demonstrated increases in ankle joint contributions to total lower extremity work while knee joint contributions to total lower extremity work were reduced in response to increasing added mass.

Increasing breast support is associated with altered knee joint stiffness and contributing knee joint biomechanics during treadmill running.

Introduction: Greater breast support has been associated with improved running performance as measured by oxygen cost and running economy. Several candidate mechanisms have been proposed to underlie breast support-related improvements in running performance including increased knee joint stiffness. Greater knee joint stiffness has been associated with improved running performance (speed and metabolic cost), though the influence of breast support on knee joint stiffness has not been previously investigated. Therefore, the purpose of this study was to investigate the influence of increasing breast support on knee joint stiffness and its constituent components during treadmill running. Methods: Thirteen recreational runners performed a 3-min running bout at their preferred running velocity in each of three breast support conditions: bare chested (CON), low support (LOW) and high support (HIGH) sports bras. Three-dimensional kinematics and ground reaction forces were collected simultaneously using a 10-camera motion capture system (240 Hz, Qualisys Inc.) and instrumented treadmill (1,200 Hz, Bertec Inc.). Visual3D (C-Motion Inc.) was used to calculate knee joint excursions, moments, powers and work while custom software (MATLAB) was used to calculate knee joint stiffness and breast displacements during the stance phase of running in each experimental condition. A series of 1 × 3 repeated measures analysis of covariance with post-hoc t-tests was used to evaluate the effect of breast support on knee joint biomechanics during treadmill running. Results: Increasing levels of breast support were associated with greater knee joint stiffness (p = 0.002) as a result of smaller knee flexion excursions (p < 0.001). Increases in knee extension power (p = 0.010) were observed with increasing levels of breast support while no differences were observed in knee extension moments (p = 0.202) or work (p = 0.104). Conclusion: Greater breast support is associated with increased knee joint stiffness resulting from smaller joint excursions. These findings may provide insight into the biomechanical mechanisms underlying previously reported improvements in running performance including reduced oxygen consumption and greater running economy.

Developing Military Doctors: An Institutional Approach to Medical Force Readiness in Graduate Medical Education.

Military physicians are required to not only meet civilian accreditation standards upon completion of their Graduate Medical Education (GME) training programs but also be proficient in the military-unique aspects of their field, including medical care in austere environments and management of combat casualties. They must also be familiar with the administrative and leadership aspects of military medicine, which are often absent from the training curriculum. The San Antonio Uniformed Services Health Education Consortium Military Readiness Committee, by incorporating questions of military relevance into each GME program's mandatory Annual Program Evaluation, identified curricular gaps upon which military readiness training objectives and opportunities were developed. These activities included a lecture series on the sustainment of medical and military readiness, an interactive procedural skills training event, trainee involvement in operational pre-deployment exercises, and the development of an elective operational rotation in Honduras. The Military Readiness Committee provides a model for other military GME institutions to develop training goals and opportunities to strengthen the preparedness of their trainees for military service.

Guía de práctica clínica para el tratamiento de la rinosinusitis crónica: versión completa / Clinical practice guideline for the treatment of chronic rhinosinusitis: full version

La rinosinusitis (RS) se define como la inflamación de la nariz y los senos paranasales con dos o más síntomas como bloqueo/obstrucción/congestión o secreción nasal (goteo nasal anterior/posterior) más dolor/presión facial y/o reducción o pérdida del sentido del olfato. Adicional, se tienen en cuenta los hallazgos objetivos como la presencia de pólipos nasales y/o descarga mucopurulenta en meato medio y/o edema u obstrucción de la mucosa en el meato medio en la endoscopia nasal. Se pueden considerar o no, los cambios tomográficos como cambios mucosos en el complejo osteomeatal y la mucosa de los senos paranasales. Se reconoce que los síntomas tienen alta sensibilidad, pero baja especificidad, de ahí la necesidad de hallazgos objetivos.

Rhinosinusitis (RS) is defined as inflammation of the nose and sinuses with two or more symptoms such as blockage/obstruction/congestion or nasal discharge. with two or more symptoms such as nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior runny nose) plus facial pain/pressure and/or reduction or loss of the sense of smell. sense of smell. In addition, objective findings such as the presence of nasal polyps and/or nasal presence of nasal polyps and/or mucopurulent discharge from the middle meatus and/or edema or mucosal obstruction or mucosal obstruction in the middle meatus on nasal endoscopy. Tomographic changes may or may not tomographic changes may or may not be considered as mucosal changes in the osteomeatal complex and mucosal osteomeatal complex and the mucosa of the paranasal sinuses. It is recognized that the symptoms symptoms have high sensitivity but low specificity, hence the need for objective findings. findings.

Guía de práctica clínica para el tratamiento de la rinosinusitis crónica: versión corta para profesionales de la salud. Colombia-2023 / Clinical practice guideline for the management of chronic rhinosinusitis: short version for health care professionals. Colombia-2023

La rinosinusitis (RS) se define como la inflamación de la nariz y los senos paranasales con dos o más síntomas como bloqueo/obstrucción/congestión o secreción nasal (goteo nasal anterior/posterior) más dolor/presión facial y/o reducción o pérdida del sentido del olfato. Adicional, se tienen en cuenta los hallazgos objetivos como la presencia de pólipos nasales y/o descarga mucopurulenta en meato medio y/o edema u obstrucción de la mucosa en el meato medio en la endoscopia nasal.

Rhinosinusitis (RS) is defined as inflammation of the nose and sinuses with two or more symptoms such as blockage/obstruction/congestion or nasal discharge with two or more symptoms such as nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior runny nose) plus facial pain/pressure and/or reduced or lost sense of smell sense of smell. Additionally, objective findings such as the presence of nasal polyps and/or nasal presence of nasal polyps and/or mucopurulent discharge in the middle meatus and/or edema or mucous or mucosal obstruction in the middle meatus on nasal endoscopy.

Greater Breast Support Alters Trunk and Knee Joint Biomechanics Commonly Associated With Anterior Cruciate Ligament Injury.

Objective: The female breast is a passive tissue with little intrinsic support. Therefore, women rely on external breast support (sports bras) to control breast motion during athletic tasks. Research has demonstrated that lower levels of breast support are associated with altered trunk and pelvis movement patterns during running, a common athletic task. However, no previous study has identified the effect of sports bra support on movement patterns during other athletic tasks including landing. Therefore, the purpose of this study was to examine the effects of breast support on trunk and knee joint biomechanics in female collegiate athletes during a double-leg landing task. Methods: Fourteen female collegiate athletes completed five double-leg landing trials in each of three different sports bra conditions: no support, low support, and high support. A 10-camera motion capture system (250 Hz, Qualisys, Goteburg, Sweden) and two force platforms (1,250 Hz, AMTI, Watertown, MA, USA) were used to collect three-dimensional kinematics and ground reaction forces simultaneously. Visual 3D was used to calculate trunk segment and knee joint angles and moments. Custom software (MATLAB 2021a) was used to determine discrete values of dependent variables including vertical breast displacement, knee joint and trunk segment angles at initial contact and 100 ms post-initial contact, and peak knee joint moments. A repeated measures analysis of covariance with post-hoc paired samples t-tests were used to evaluate the effect of breast support on landing biomechanics. Results: Increasing levels of breast support were associated with reductions in peak knee flexion (Right: p = 0.008; Left: p = 0.029) and peak knee valgus angles (Right: p = 0.011; Left: p = 0.003) as well as reductions in peak knee valgus moments (Right: p = 0.033; Left: p = 0.013). There were no changes in peak knee extension moments (Right: p = 0.216; Left: p = 0.261). Increasing levels of breast support were associated with greater trunk flexion angles at initial contact (p = 0.024) and greater peak trunk flexion angles (p = 0.002). Conclusions: Lower levels of breast support are associated with knee joint and trunk biomechanical profiles suggested to increase ACL injury risk.

Diagnóstico y tratamiento de la rinosinusitis crónica en adultos. Consenso de expertos: Asociación Colombiana de Otorrinolaringología-2021. / Diagnosis and treatment of chronic rhinosinusitis in adults. Expert consensus: Asociación Colombiana de Otorrinolaringología -2021.

Introducción: la Rinosinusitis Crónica se define como la inflamación crónica de la nariz y los senos paranasales por más de 12 semanas. La prevalencia varía entre el 5% - 30% de acuerdo con la zona geográfica según un estudio de carga de enfermedad (2012-2014), la prevalencia de las enfermedades respiratorias crónicas (rinitis y sinusitis crónica) varió entre el 10% y el 25%. Objetivo: establecer un conjunto de consideraciones basadas en consenso de expertos, para el diagnóstico y el tratamiento de la rinosinusitis crónica en pacientes adultos, en el contexto colombiano. Métodos: se llevó a cabo un consenso formal (Delphi y nominal). Se conformó un grupo de expertos, se definieron el alcance y las preguntas. Se realizaron dos rondas de calificación anónimas, y una discusión para las preguntas sin consenso. En las preguntas con opciones de uno a nueve, se consideró consenso con una mediana de uno a tres o de siete a nueve. En las preguntas tipo Likert, se consideró consenso un porcentaje igual o superior al 80% en acuerdos o desacuerdos. Resultados: se definieron y calificaron 18 preguntas, con la participación de 17 otorrinolaringólogos, de 8 ciudades colombianas, todos miembros de la Asociación Colombiana de Otorrinolaringología y con un promedio de experticia de 19.2 años (Desviación estándar [DE]: 10,2). Se obtuvieron 18 recomendaciones para el diagnóstico y el tratamiento de esta patología. Conclusiones: las recomendaciones emitidas por los expertos permiten orientar y estandarizar el diagnóstico y el tratamiento de la rinosinusitis crónica en adultos, en el contexto de los servicios de salud en Colombia.

Introduction: Chronic Rhinosinusitis is defined as chronic inflammation of the nose and paranasal sinuses for more than 12 weeks. The prevalence varies between 5% - 30% depending on the geographical area according to a disease burden study (2012-2014), the prevalence of chronic respiratory diseases (rhinitis and chronic sinusitis) varied between 10% - 25%. Objective: To establish a set of considerations based on expert consensus, for the diagnosis and treatment of chronic rhinosinusitis in adult patients, in the Colombian context. Methods: A formal consensus (Delphi and nominal) was carried out. A group of experts was formed, the scope and questions were defined. Two anonymous grading rounds were conducted, and a discussion for questions without consensus. In the Questions with options from one to nine were considered consensus with a median of one to three or seven to nine. In the Likert-type questions, a percentage equal to or greater than 80% in agreements or disagreements was considered consensus. Results: 18 questions were defined and scored, with the participation of 17 otorhinolaryngologists, from eight Colombian cities, all members of the Colombian Association of Otorhinolaryngology and with an average experience of 19.2 years (Standard desviation [SD]: 10.2). 18 recommendations were obtained for the diagnosis and treatment of this pathology. Conclusions: The recommendations issued by the experts allow to guide and standardize the diagnosis and treatment of chronic rhinosinusitis in adults, in the context of health services in Colombia.

A unique patient with epilepsy with cinematographic visual hallucinations.

PURPOSE: The purpose of this case report is to document a patient with cinematographic hallucinations, with corresponding right temporal lobe seizures on electroencephalogram (EEG). RESULTS: The results showed that the patient's EEG was normal. The patient subsequently reported hallucinations, which had been occurring for the last several months. During monitoring, no interictal EEG abnormalities were identified, but a total of 11 partial seizures were captured originating from the right posterior temporal area. They either were subclinical or corresponded with his visual hallucinations. CONCLUSION: The present study demonstrates focal seizures of temporal lobe origin producing complex visual hallucinations without a corresponding lesion on MRI brain imaging.

"Caracterización clínica de las fracturas faciales ocasionadas por trauma de guerra o violencia civil en el conflicto armado en Colombia del 2012 al 2013 en el Hospital Militar Central de Bogotá, D.C. " / "Clinical characterization of facial fractures caused by military trauma or civil violence in the Colombian armed conflict since 2012 to 2013 in the Central Military Hospital of Bogotá, D.C. "

Objetivo: Determinar las características clínicas y demográficas de los pacientes que ingresan al Grupo Integrado de Trauma Facial (GITF) del Hospital Militar Central (HMC), con fracturas del esqueleto facial por arma de fuego de alta o baja velocidad y heridas por armas de fragmentación, como producto de trauma de guerra o violencia civil. Diseño: Estudio observacional descriptivo realizado en el Hospital Militar Central. Metodologia: Se incluyeron todos los pacientes con trauma de guerra o violencia civil, que ingresaron del 01 de septiembre de 2012 al 1 de septiembre de 2013. Aquellos pacientes que no presentaron trauma maxilofacial fueron excluidos del presente estudio. Resultados: Se incluyeron 15 pacientes durante el periodo de observación descrito. Todos los pacientes fueron de sexo masculino con edad media de 27 años (± 5,8 años). Se encontró que el tipo de arma que más frecuentemente causaba lesiones fueron armas de fragmentación (53,3% n=8) y la característica principal de éstas era el trauma abierto (53,3% n=8). En cuanto a la distribución de las fracturas por tercios faciales se encontró́ que en el tercio superior, solo 2 pacientes (13,3%) presentaron fractura de seno frontal. En el tercio medio, la fractura malar fue la mas frecuente (n=9 60%) y en el tercio inferior la fractura de mandíbula (n=9 60%). Conclusiones: Los pacientes atendidos por el GITF en el HMC son victimas de trauma de guerra con armas de fragmentación que presentan traumas abiertos. Las principales lesiones se presentan a nivel de tercio medio y tercio inferior facial.

Objectives: To Determine the clinical and demographic characteristics of patients admitted to the Facial Trauma Integrated Group (GITF) at Central Military Hospital with injuries and fractures of the facial skeleton, gunshot high or low speed and fragmentation firearm injuries as a product of trauma of war or civil violence. Study Desing: Observational descriptive study conducted in the Central Military Hospital Methods: We included all patients with trauma of war or civil violence, which entered a period since September 1, 2012 to September 1, 2013. Those patients without lesions in the maxillofacial region were excluded from this study. Results: We enrolled 15 males with a mean age of 27 years (±5.8 years). It was found that the type of weapon that caused the injuries most frequently evaluated in the present study were weapons of fragmentation (53.3%, n=8), which also showed that the main feature of these was the open trauma (53, 3%, n=8). In the distribution of facial thirds fractures, in the upper third, only 2 patients (13.3%) had frontal sinus fracture. In the middle third, the most common fracture was malar fracture (n=9) (60%) and in the lower third, the most common fracture was mandibular fracture (n=9) (60%). Conclusion: Patients admitted for care by Facial Trauma Integrated Group (GITF) in the Central Military Hospital, are patients with war trauma, victims with weapons of fragmentation that have open traumas. The main lesions are presented in the middle third and lower third facial.

MRS findings in a patient with juvenile-onset Alexander's leukodystrophy.

Alexander's leukodystrophy is a rare cerebral white matter disorder with an onset that can be infantile, juvenile, or occur in the adult years. It is thought to be demyelinative, but the pathogenesis is ill-defined. We report a 24-year-old woman with juvenile-onset Alexander disease, of 12 years duration, who underwent magnetic resonance imaging (MRI) and magnetic resonance spectroscopy (MRS) serially as part of her care. The patient's latest MRI showed periventricular-increased signal intensity on T2 and fluid attenuation and inversion recovery sequences, which appeared stable when compared to her first study seven years ago. MRS revealed an elevated choline/creatine ratio with relative suppression of the n-acetyl aspartate peak, also similar to her previous MRS findings. MRS also showed elevation of myoinositol levels, best demonstrated with the short echo-time spectra. These findings support the primarily demyelinative characteristics of this leukodystrophy and may provide a surrogate marker of disease progression, as well as a potential response to therapeutic intervention when this becomes available.