The Delphi of ORACLE: An Expert Consensus Survey for the Development of the Observational Risk Assessment of Contractures (Longitudinal Evaluation).

OBJECTIVE: Despite rising prevalence rates, no standard tool is available to identify individuals at risk of developing contractures. This study aimed to gain expert consensus on items for the development of the Observational Risk Assessment Tool for Contractures: Longitudinal Evaluation (ORACLE) for care home residents. DESIGN: A two-round, online modified Delphi study. PARTICIPANTS: Panellists were qualified healthcare professionals with a background in physiotherapy, occupational therapy, nursing, and rehabilitation medicine. MAIN OUTCOME MEASURES: In the first round, the experts were asked to rate the predesigned list of items on a Likert scale while in the second round, consensus was sought in the areas of disagreement identified in the previous round. RESULTS: The two rounds of the Delphi survey included 30 and 25 panellists, respectively. The average clinical and academic experience of the panellists was 22.2 years and 10.5 years, respectively. The panel demonstrated a high level of consensus regarding the clinical factors (10 out of 15 items); preventive care approaches (9 out of 10 items), and contextual factors (12 out of 13 items) ranging from 70% to 100%. CONCLUSION: This Delphi study determined expert consensus on items to be included in a contracture risk assessment tool (ORACLE). The items were related to factors associated with joint contractures, appropriate preventive care interventions, and potentially relevant contextual factors associated with care home settings. The promise of a risk assessment tool that includes these items has the capacity to reduce the risk of contracture development or progression and to trigger timely and appropriate referrals to help prevent further loss of function and independence.

The effects of inspiratory muscle training on balance and functional mobility: a systematic review.

INTRODUCTION: Inspiratory muscle training (IMT) has been widely used in both healthy and diseased populations especially in older adults, and its effects have been proven not only on inspiratory muscle strength but also on dyspnea, exercise capacity, quality of life, and other health parameters. AIM: This study aims to review the effects of IMT on balance and functional ability of healthy and diseased populations. METHODS: A systematic literature search was conducted on MEDLINE, EMBASE, AMED, and Cochrane Central Register of Controlled Trials (CENTRAL). Randomized control trials having participants > 18 years of age and having balance and functional mobility as primary or secondary outcomes were included. Two independent reviewers screened studies against the eligibility criteria, extracted the data, and assessed the quality of evidence. The protocol was prospectively registered on PROSPERO: CRD42021261652. RESULTS: Ten studies were included in the review out of which eight had balance and six had functional mobility as an outcome measure. There was a significant improvement in balance of the participants after treatment with IMT, however the effect on functional mobility was inconclusive. CONCLUSION: The review provided evidence of improvement in balance and functional mobility following inspiratory muscle training in both healthy and diseased adults. Future studies should be conducted to determine the optimal protocol and dosage of treatment.

Factors associated with joint contractures in adults: a systematic review with narrative synthesis.

PURPOSE: The primary objective of the review was to collate the available evidence on factors associated with joint contractures in adults. METHODS: A systematic literature search was conducted on MEDLINE, CINAHL, AMED, and EMBASE. Studies that involved participants aged ≥18 and assessed joint contracture as a primary or secondary outcome were included. Two independent reviewers screened studies against the eligibility criteria, performed data extraction, and assessed the quality of evidence. A narrative synthesis by domain and sub-domain was undertaken. The protocol was registered on PROSPERO: CRD42019145079. RESULTS: Forty-seven studies were included in the review. Identified factors were broadly classified into three major domains: sociodemographic factors, physical factors, and proxies for bed confinement. Sociodemographic factors were not associated with joint contractures. Functional ability, pain, muscle weakness, physical mobility, and bed confinement provided the most consistent evidence of association with joint contractures. The evidence regarding the relationship between spasticity and joint contractures remains unclear. Other factors might be important, but there was insufficient evidence to make inferences. CONCLUSIONS: The review identified and collated evidence on factors associated with joint contractures, which can be utilised to develop effective prevention and management strategies. Implications for rehabilitationClinical interventions based on the timely identification of risks related to joint contractures in vulnerable adults have the potential to prevent or ameliorate their development or progression.Quality and consistency of care for vulnerable adults would be enhanced by developing effective joint contracture prevention and rehabilitation strategies based on the evidence presented in this review.As many vulnerable adults are located in the community or non-acute care settings, strategies should target these loci of care.Structured risk assessments that can support non-physiotherapy staff working in these loci of care to identify risks related to joint contractures would provide an important resource for risk management.

Technological advancements in stroke rehabilitation.

Early, coordinated, and multidisciplinary rehabilitation plays a major part in motor recovery after stroke. The conventional stroke rehabilitation primarily includes physical therapy, occupational therapy, and speech therapy. However, with these conventional methods, many stroke survivors still have a residual functional disability which impairs their ability to perform activities of daily living. This could be attributed to the insufficient therapy dose, low engagement and motivation of the patient, and lack of objective feedback to achieve significant improvements in function. Various technology-based stroke rehabilitation interventions have been developed in the last few decades which have shown promising results in improving stroke patients' functional mobility and independence. The use of technology promotes repetitive, task-specific training, active engagement of patients, integrating constructive and concurrent feedback, and accurately measuring functional improvement. This review summarizes the important technological advances in stroke rehabilitation, including exergames, telerehabilitation, robotic-assisted systems, virtual and augmented reality, wearable sensors, and smartphone applications.

Role of Physical Therapy in Palliative Care of Cancer Patients.

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The emerging role of virtual reality training in rehabilitation.

Virtual reality (VR) uses computer-generated simulations to create a virtual environment for users which appears, sounds, and feels like real-life objects and events. The use of VR in rehabilitation is relatively new and has demonstrated to be an effective tool in achieving desired clinical outcomes by active engagement of participants. Over the past few years, the use of VR in rehabilitation has rapidly increased because of its advantages over traditional rehabilitation techniques. These include better patient adherence to the rehabilitation protocols with high levels of engagement and motivation. This review summarises the available evidence on the role of VR in rehabilitation, its effects, and scope across different clinical conditions and outcomes. We also describe the current status of VR utilization in rehabilitation settings across Pakistan and highlight the need for further research.

Mixing effects of three Eurasian plants on root decomposition in the existence of living plant community in a meadow steppe.

In grasslands, roots of different plant species decay in combination in the presence of living plants, besides, most root decomposition studies are conducted on how roots of plants decomposed alone or in artificial compositions in the absence of living plants. Therefore, we evaluated how roots of different perennial plants induced effects on decomposition process under living plants and their associated mechanisms. By using litter bag technique, we determined the root decomposition process of three perennial plants, Leymus chinensis, Phragmites australis, and Kalimeris integrifolia grown in monocultures, bi- and tri-species mixtures, after 12 months of incubation under living plants and bare soil communities. We found both additive and non-additive effects on decomposition dynamics indicating that root mass losses of compositions cannot be calculated from decaying rates of individual species. The rich-nutrient roots of K. integrifolia in monocultures and in mixtures with other plant species decayed faster. Compared with bare soil, microbial activities were enhanced under living plant communities and hence stimulated decomposition rates. Our results indicated that microbial activities are important but secondary factors to root physico-chemical properties impacting root decomposition rates. In conclusion, the empirical relationships developed here are helpful to better understand the effects of root properties and microbial activities on decay rates.

An Interesting Case of Immunoglobulin G4-Related Retroperitoneal Fibrosis Treated With Rituximab.

Immunoglobulin G4-related disease (IgG4-RD) is a fibroinflammatory condition. Its common manifestations include type I autoimmune pancreatitis and retroperitoneal fibrosis (RPF). We present a rare case involving a 43-year-old female who presented with left lower quadrant (LLQ) pain. Imaging of the abdomen and pelvis revealed left hydroureteronephrosis to the level of an inflammatory process in the left adnexal region, possibly reflecting a tubo-ovarian abscess (TOA). The gynecologic evaluation concluded that the mass was unlikely of gynecologic sources. Transgluteal biopsy of the mass was highly suggestive of IgG4-RD. The patient received prednisone and rituximab (RTX), resulting in complete resolution of the mass, which was confirmed on repeat imaging. This case report provides a valuable addition to the literature to highlight that the diagnosis of IgG4-RD is based on the combination of characteristic clinical, serologic, radiologic, and histopathologic findings. Also, it underlines that the management of the disease is through glucocorticoids (GCs) as the first-line agent for remission induction in all patients with active, untreated IgG4-RD. RTX therapy is an effective treatment for IgG4-RD that is refractory to GCs. Recent studies have suggested that RTX monotherapy can be used to induce and maintain remission in patients with IgG4-RD.

Detection of Serous Tubal Intraepithelial Carcinoma along with High Grade Serous Carcinoma of Both Ovaries.

High-grade serous carcinoma (HGSC) of ovary is the commonest of all ovarian malignant tumours and is associated with high mortality rate. Serous tubal intraepithelial carcinoma (STIC) is believed to be the precursor lesion. In literature, only 40-50% of HGSC shows concurrent STIC, even after thorough sampling. We, herein, present a case of a 40-year female, who underwent staging laparotomy for bilateral ovarian carcinoma. She was diagnosed as HGSC of both ovaries. Left ovary capsule was focally ruptured. Peritoneal washings showed metastatic carcinoma. Provisional FIGO stage was IC. During sampling, concurrent finding of STIC was documented in right fallopian tube. No invasive carcinoma was present in both entirely submitted fallopian tubes. Key Words: High grade serous carcinoma, Ovary, Serous tubal intraepithelial carcinoma, TP53.

Effects of bilateral arm training on upper extremity function in right and left hemispheric stroke.

OBJECTIVE: This experimental study on 24 stroke patients aimed at evaluating and comparing the effects of bilateral arm training on upper extremity (UE) motor function between right and left hemispheric chronic stroke patients. METHODS: Both groups received the same intervention involving 5 functional tasks for 1 hour, 3 days per week, for a total of 6 weeks. Fugl-Meyer Assessment-Upper Extremity and Wolf-Motor Function Test were applied as outcome measures at baseline and after 6 weeks of training to assess the recovery of function in the affected area. RESULTS: Intra-group analysis showed no significant improvement in the wrist and hand function in the left hemispheric stroke (LHS) (p>0.05), while right hemispheric stroke (RHS) patients did not improve significantly in the coordination/speed domain (p>0.05). Inter-group analysis showed no significant difference between right and left hemispheric stroke patients (p>0.05). CONCLUSIONS: Bilateral arm training showed beneficial effects in improving UE function in both RHS and LHS patients. Distal UE function in LHS and coordination and speed of movement in RHS patients did not show any significant improvement.

Myxoid Liposarcoma with Cartilagenous Differentiation.

Myxoid liposarcoma (MLPS) is an adipocytic tumour and second commonest among the types of liposarcoma. It exhibits a wide histological spectrum. It is important to be aware of this diversity of morphology in this tumour to prevent a wrong diagnosis. Heterologous differentiation in myxoid liposarcoma is reported; however, this is rare. To date, seven cases of MLPS with cartilaginous differentiation have been reported. Only five of these were further confirmed by cytogenetic analysis. We are reporting the 8th case of MLPS with cartilaginous differentiation. A 66-year female presented with posterior left thigh mass. Excision was done. Microscopic examination showed sheets of bland spindle cells containing round to oval nuclei and fine, delicate chicken-wire vessels. The firm blue appearing areas, which accounted for about 20% of the tumor volume, were characterised by mature hyaline cartilage. The final diagnosis was MLPS, showing prominent cartilaginous differentiation. Anterior and lateral margins were involved. Tumour was very close to the rest of the resection margins. FNCLCC grade was 1. Provisional pathological stage, as per staging system of the Union for International Cancer Control for extremity, was pT2. Patient was examined by oncologists. Wide local excision is in plan as two margins were involved by the tumour, while rest of the margins were very close to tumour. Key Words: Liposarcoma, Myxoid, Cartilaginous differentiation.

Datura suaveolens and Verbena tenuisecta mediated silver nanoparticles, their photodynamic cytotoxic and antimicrobial evaluation.

Biogenic production of nanoparticles is eco-friendly, less expensive method with various medical and biological applications. Nanotechnology along with photodynamic therapy is gaining tremendous importance with enhanced efficacy. The present work was aimed to evaluate methanolic extracts and nanoparticles of two selected plants (Datura suavolens and Verbina tenuisecta) for cytotoxic photodynamic, antioxidant and antimicrobial study. Both extract and silver (5 mM) nanoparticles of Datura plant showed significant activities against bacterial strains. Maximum ZOI of 27.3 ± 1.6 mm was observed with nanoparticles of Datura branches with minimum inhibitory (MIC) value of 32 µg/ml. In case of antifungal and antioxidant assay samples were moderately active. Silver nanoparticles and extracts were effective against rhabdomyosarcoma cell line with lowest IC50 value of 42.5 ± 0.6 µg/ml and percent viability of 25.6 ± 1.3 of Verbena tenuisecta. However, nanoparticles of Datura leaves and branches were more potent with IC50 value of 2.4 ± 0.9 µg/ml and 7.8 ± 1.1 µg/ml respectively. The result of photodynamic study showed that efficacy of photosensitizer was enhanced and percent viability reduced when nanoparticles used as an adjunct. The color change and UV spectra (415‒425 nm) indicated the production of nanoparticles. Fourier transform infrared spectroscopy (FTIR) spectra showed presence of different functional groups e.g., hydroxyl, carbonyl and amino. Nanoparticles are sphenoid in morphology and size ranges between 20-150 nm. Current study showed these silver nanoparticles can be used as cytotoxic agent in photodynamic therapy and can play a critical role to establish medicinal potential of selected plants.

Endothelial Cysts of Adrenal Gland.

Adrenal endothelial cyst is a rare entity which has female predilection and usually presents with abdominal pain. Smaller cysts are mostly asymptomatic and detected as incidental finding during surgery. Without biopsy, it is almost impossible to depict the nature of larger cysts as benign or malignant. Herein, we report two such cases. The first case was a 24-year female who presented with a large cyst in the abdomen. The second case was of a 35-year female, who presented with a cystic lesion of right adrenal gland. The clinical, radiological and histopathological findings are discussed. These reports highlight the salient gross, microscopic and immunohistochemical features of these cysts.

Whipple Resection: Concordance Between Frozen Section And Permanent Section Diagnosis Of Surgical Margins.

BACKGROUND: Margin assessment is done in Whipple procedures which are usually performed to resect tumours of head of pancreas and ampullary/periampullary region. Aims and objective of the study are to determine the concordance between frozen sections (FS) and permanent sections (PS) of surgical margins in Whipple resections. METHODS: It is a retrospective study, from January 2008 to January 2015 (07 years). It includes the specimen with malignancy in final report and for which FS of pancreatic and/or CBD margin(s) were requested. Data was retrieved from Laboratory information system (LIS) database. RESULTS: Of the 41 bile duct margins in cases of ampullary tumours, 03 were positive on FS as well as PS, 35 were negative on FS as well as on PS. Results showed 100% sensitivity, 92.1% specificity, 50% PPV and 100% NPV. Results of 36 pancreatic margins in cases of ampullary showed 100% sensitivity, 97.1% specificity, 50% PPV and 100% NPV. In pancreatic carcinoma cases, none of CBD margins were reported as positive on FS, 02 margins reported as negative were found positive on PS, while 17 were negative on FS as well as PS. Results showed 100% specificity and 89.5% NPV. Of the 27 pancreatic margins tested in pancreatic tumours 100% sensitivity, 94.1% specificity, 88.9% PPV and 100% NPV was found. CONCLUSIONS: Factors such as absent prior tissue diagnosis and/or inflammatory processes make margin diagnosis difficult. However, a high concordance was observed between our FS and PS diagnosis.

GIANT-CELL RICH ATRIAL MYXOMA: REPORT OF TWO CASES AND REVIEW OF LITERATURE.

The cases of two middle age males are presented who were incidentally diagnosed to have atrial myxoma. Both of them underwent successful surgical interventions. Histologically, both myxomas showed abundant multinucleated giant cells, in addition to typical myxoid stroma with stellate and cord-like structures.

Complete Hydatidiform Mole Coexisting with Three Viable Fetuses in a Quadruplet Pregnancy.

We hereby report a case of quadruplet pregnancy with delivery of 3 viable infants and a complete mole. This was an induced conception with clomiphene citrate. At 22 weeks, cystic structures were noticed in one of the placentae and a suspicion of co-existant molar pregnancy was made. The case discussed with oncologist and pregnancy was continued with close monitoring of β-hCG and Ultrasound. Her β-hCG at 23 weeks was 748 mIU/ml, which continued to rise until the 29th week of gestation to a level of 305881.68 mIU/ml and declined gradually thereafter. Similarly, hydropic change in placenta also continued to increase progressively. She was given steroid cover at 32 weeks and delivery was aimed at 34 weeks of gestation. The patient went into preterm labour at 33 weeks and 3 female infants delivered by lower segment cesarean section (LSCS) followed by removal of 3 placentae along with copious molar tissue at the end. The newborns were kept in the nursery, non-requiring assisted ventilation and discharged in satisfactory condition. The histopathologyand immunohistochemistry confirmed the diagnosis of a quadruplet pregnancy comprising of one complete mole with 3 normal placentae.

Spectrum of Histopathological Findings in Live Donor Liver Graft Biopsies.

OBJECTIVE: To study the spectrum of histopathological findings in live donor liver graft biopsies. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: Histopathology Department, Shifa International Hospital, Islamabad, from January 2011 to March 2014. METHODOLOGY: The biopsies were received in formalin and routinely processed. The changes encountered were divided into three categories: (i) new-onset post liver transplantation (LT) complications (early and late), (ii) acute rejection and (iii) recurrence of original disease. Banff schema 1997 of rejection activity index (RAI), modified histological activity index (mHAI) and recent literature were utilized for evaluation. The results were finalized in the light of clinical details along with relevant laboratory investigations and radiological findings. RESULTS: Seventy eight percutaneous hepatic graft biopsies of 59 patients were evaluated. Among them, findings noticed in descending order of frequencies were Acute Cellular Rejection (ACR) in 37% (n=30), recurrent hepatitis C (HCV) in 22% (n=18), cholestasis/ductular proliferation in 27% (n=22), ischemic/reperfusion injury in 9.8% (n=8) and drug-induced liver injury in 3.7% (n=3). In the first six months post LT, ACR was the commonest cause of graft dysfunction, while recurrent HCV was noticed to be predominant reason after 6 months. CONCLUSION: In this study, ACR was the most frequent finding in graft biopsies, followed by recurrent HCV. However, in first six months, ACR is the commonest histopathological finding while recurrent HCV was more frequently documented after 6 months.

Infections in traumatic wounds sutured at a Norwegian Accident and Emergency Department.

BACKGROUND: Different countries have different wound treatment traditions. We have studied the incidence and different factors related to infections in wound injuries sutured at a Norwegian A&E department. METHOD: In this prospective study, clinical data were collected on 102 patients with traumatic wound injuries treated with sutures at Bergen Accident and Emergency Department between 30 February 2011 and 30 June 2011. Any wound infections in 97 of these patients at the time of suture removal were assessed and classified according to severity on a scale of grade 0 to grade 4. RESULTS: There were no serious infections, but mild clinical wound infections occurred in 15% of patients: 11% grade 1 and 4% grade 2 infections. Patients less than 65 years old had often cut themselves with knives (n = 33, 37%), and on their hands (n = 60, 67%), Men were most frequently injured at work (n = 38, 54%) and women most often at home (n = 18, 56%). No statistically significant correlation was found between the incidence of wound infections and the length of the wound, the time elapsed before suturing, the wound's location on the body, contamination or underlying chronic diseases. Two of the three self-inflictors in our study had clinical wound infections. Half of the bacteriological samples from ten of 15 wounds with clinical infection had plentiful growth of Staphylococcus aureus. One patient received oral antibiotic treatment for wound infection, and two had local antibiotic treatment. INTERPRETATION: Mild clinical infections were found in almost one of six wounds sutured at a Norwegian A&E department. More studies are necessary to provide basic data to enable targeted improvements in wound treatment in the primary healthcare service.