Dislocation of the hip after normal sonographic screening examination: a case report and literature review.

We report the case of a five-month-old girl presenting with a subluxed left hip following normal neonatal clinical examination and serial ultrasound screening. Her only risk factor for developmental dysplasia of the hip (DDH) was breech presentation. She underwent closed reduction with successful concentric reduction. This case demonstrates that hip subluxation can occur after normal ultrasound screening, and has important clinical and medicolegal implications. Consideration should be given to further follow-up in children with overt risk factors for DDH, even after normal ultrasound examination.

Randomized clinical trial of capnometry-assisted respiratory training in veterans with posttraumatic stress disorder hyperarousal.

OBJECTIVE: To investigate whether capnometry-assisted antihyperventilation respiratory training, successful in treating panic, and sleep hygiene instructions would reduce posttraumatic stress disorder (PTSD) hyperarousal symptoms in U.S. military veterans. METHOD: We conducted a parallel, nonblinded clinical trial and randomized 80 veterans with PTSD hyperarousal into treatment or wait list. Primary treatment outcomes from baseline to 1st follow-up were analyzed using mixed modeling. Baseline physiological measures were compared between the PTSD hyperarousal group and a no-PTSD group (n = 68). RESULTS: Baseline respiration rate but not partial-pressure of end-tidal carbon dioxide (PCO2) was higher in the PTSD hyperarousal group than in the no-PTSD group during 3 min of quiet sitting, indicating no difference in baseline hyperventilation. There was no significant effect of the intervention on PTSD hyperarousal symptoms or hyperventilation compared to wait list, but treatment did lower respiratory rate. CONCLUSION: This intervention did not reduce PTSD hyperarousal symptoms, perhaps due to differences between underlying mechanisms of PTSD hyperarousal and panic disorder or to differences between veteran and civilian populations. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Habituation or Normalization? Experiential and Respiratory Recovery From Voluntary Hyperventilation in Treated Versus Untreated Patients With Panic Disorder.

Psychophysiological theories postulate respiratory dysregulation as a mechanism contributing to panic disorder (PD). Additionally, symptomatic and respiratory recovery from voluntary hyperventilation (HVT-recovery) have been shown to lag in PD and it is unclear if HVT-recovery normalizes with treatment. Thirty-seven panic disorder patients were randomized to hypoventilation therapy (TX, n = 20) or waitlist control (WL, n = 17) (Meuret et al., 2008). In a secondary analysis, their HVT-recovery was analyzed at pre- and post-TX/WL, compared to 29 healthy controls (HC). HVT included three phases: 5-min baseline, 3-min hyperventilation, and 8-min recovery. HVT-elicited symptom severity and anxiety were rated following each phase, and end-tidal PCO2 and respiratory rate (RR) were recorded throughout. Treatment, compared to WL, was highly effective in reducing PD pathology (d=2.21, Meuret et al., 2008). At pre-TX/WL, PD demonstrated delayed HVT-recovery PCO2 and higher RR. Treated patients demonstrated normalization of HVT-recovery for PCO2 and RR; however, improvements of HVT-recovery for symptom severity and anxiety did not differ between TX and WL. Results replicate pretreatment HVT respiratory recovery abnormalities in PD and further demonstrate normalization, comparable to HC, following successful treatment. The results provide support for respiratory dysregulation as a feature of PD and demonstrate the utility of HVT respiratory recovery as treatment outcome measure for respiration-based PD therapy.

Thirty-day mortality following surgical management of hip fractures during the COVID-19 pandemic: findings from a prospective multi-centre UK study.

PURPOSE: Thirty-day mortality of patients with hip fracture is well researched and predictive; validated scoring tools have been developed (Nottingham Hip Fracture Score, NHFS). COVID-19 has significantly greater mortality in the elderly and comorbid patients which includes hip fracture patients. Non-operative treatment is not appropriate due to significantly higher mortality, and therefore, these patients are often exposed to COVID-19 in the peri-operative period. What is unclear is the effect of concomitant COVID-19 infection in these patients. METHODS: A multicentre prospective study across ten sites in the United Kingdom (responsible for 7% of hip fracture patients per annum in the UK). Demographic and background information were collected by independent chart review. Data on surgical factors included American Society of Anesthesiologists (ASA) score, time to theatre, Nottingham Hip fracture score (NHFS) and classification of fracture were also collected between 1st March 2020 and 30th April 2020 with a matched cohort from the same period in 2019. RESULTS: Actual and expected 30-day mortality was found to be significantly higher than expected for 2020 COVID-19 positive patients (RR 3.00 95% CI 1.57-5.75, p < 0.001), with 30 observed deaths compared against the 10 expected from NHFS risk stratification. CONCLUSION: COVID-19 infection appears to be an independent risk factor for increased mortality in hip fracture patients. Whilst non-operative management of these fractures is not suggested due to the documented increased risks and mortality, this study provides evidence to the emerging literature of the severity of COVID-19 infection in surgical patients and the potential impact of COVID-19 on elective surgical patients in the peri-operative period.

Correction to: Thirty-day mortality following surgical management of hip fractures during the COVID-19 pandemic: findings from a prospective multi-centre UK study.

The published online version contains mistake, as the Fig. 1 legend should read "Kaplan-Meier survival curve for 30-day survival for 2020 cohort COVID-19 positive vs COVID-19 negative" whilst the Fig. 2 legend should read "Kaplan-Meier survival curve for 30-day survival 2020 COVID-19 negative group vs 2019 cohort".

Supplementing sleep actigraphy with button pressing while awake.

OBJECTIVE/BACKGROUND: Wrist-worn sleep actigraphs are limited for evaluating sleep, especially in sleepers who lie awake in bed without moving for extended periods. Sleep logs depend on the accuracy of perceiving and remembering times of being awake. Here we evaluated pressing an event-marker button while lying awake under two conditions: self-initiated pressing every 5 to 10 minutes or pressing when signaled every 5 minutes by a vibration pulse from a wristband. We evaluated the two conditions for acceptability and their concordance with actigraphically scored sleep. PARTICIPANTS AND METHODS: Twenty-nine adults wore actigraphs on six nights. On nights 1 and 4, they pressed the marker to a vibration signal, and on nights 2 and 5, they self-initiated presses without any signal. On nights 3 and 6, they were told not to press the marker. Every morning they filled out a sleep log about how they had slept. RESULTS: The vibration band was unacceptable to 42% of the participants, who judged it too disturbing to their sleep. Self-initiated pressing was acceptable to all, although it reduced log reported sleep depth compared to a no pressing condition. Estimations of sleep onset latency were considerably longer by button pressing than by actigraphy. Agreement of epoch-by-epoch sleep scoring by actigraphy and by button pressing was poor (kappa = 0.23) for self-initiated pressing and moderate (kappa = 0.46) for pressing in response to a vibration. CONCLUSIONS: Self-initiated button pressing to indicate being awake while lying in bed is acceptable to many, interferes little with sleep, and adds substantially to the information given by actigraphy.

Effects of psychosocial and physical stress on lactate and anxiety levels.

Both intense physical activity and potent psychosocial stressors increase blood lactate. Raising lactate levels by infusing the chemical can have an anxiogenic effect. Here, we compare the relationship between changes in lactate and anxiety levels resulting from two standardized stressors. We investigated the effects of the Multiple Wingate All-Out Performance Test (WG), a strong physical stressor, and the Trier Social Stress Test (TSST), a well-documented psychosocial stressor, in 32 healthy young men using a crossover design. Before and after each stressor, venous blood was analyzed for lactate levels and the State-Trait-Anxiety Inventory (STAI) was given. Both stressors raised both lactate and anxiety significantly above their baseline levels. While the rise in lactate was much higher for the WG than for the TSST, the rises in anxiety were nearly equal. Individual fitness did not influence the results for lactate or anxiety. No significant relation between lactate and anxiety changes were found. Thus, our results as well as the literature suggest that lactate is an important variable for understanding the impact of sport participation.

Does a dedicated hip fracture unit improve clinical outcomes? A five-year case series.

INTRODUCTION: The aim of the study was to establish whether a dedicated hip fracture unit, geographically separate from the local major trauma centre, could improve clinical outcomes for patients sustaining proximal femoral fragility fractures. MATERIALS AND METHODS: This study was a retrospective case series, using data collected from Brighton and Sussex University Hospitals NHS Trust's submissions to the National Hip Fracture Database between 1 April 2011 and 16 September 2016. The outcomes measured were mortality, length of hospital stay, time from admission to surgical intervention and return to premorbid residence. Patients were compared before and after reconfiguration of services into a separate dedicated hip fracture unit geographically distinct from the major trauma centre. RESULTS: A total of 2117 patients (2178 injuries) were managed before the existence of the hip fracture unit, while 660 patients (673 injuries) were treated within the hip fracture unit. During the five-year study period, the 30-day mortality rate (pre-hip fracture unit 5.47% vs hip fracture unit 3.13%, P = 0.014), variance in the length of hospital stay (P < 0.001), mean time to surgical intervention (P = 0.044) and return to premorbid residence were significantly improved. An immediate 12-month comparison demonstrated significantly improved variance in length of hospital stay (P = 0.020) and return to premorbid residence (P = 0.015). DISCUSSION: The reconfiguration of services significantly reduced variance in length of stay, enabling accurate resource planning in future. Multiple incremental improvements in service provision, in addition to the hip fracture unit, may explain the lower mortality observed. CONCLUSION: While further research is required, replication of the hip fracture unit service model may potentially afford significant clinical and financial gains.

Measurement of Final-State Correlations in Neutrino Muon-Proton Mesonless Production on Hydrocarbon at ⟨E_{ν}⟩=3 GeV.

Final-state kinematic imbalances are measured in mesonless production of ν_{µ}+A→µ^{-}+p+X in the MINERvA tracker. Initial- and final-state nuclear effects are probed using the direction of the µ^{-}-p transverse momentum imbalance and the initial-state momentum of the struck neutron. Differential cross sections are compared to predictions based on current approaches to medium modeling. These models underpredict the cross section at intermediate intranuclear momentum transfers that generally exceed the Fermi momenta. As neutrino interaction models need to correctly incorporate the effect of the nucleus in order to predict neutrino energy resolution in oscillation experiments, this result points to a region of phase space where additional cross section strength is needed in current models, and demonstrates a new technique that would be suitable for use in fine-grained liquid argon detectors where the effect of the nucleus may be even larger.

Hypoventilation Therapy Alleviates Panic by Repeated Induction of Dyspnea.

BACKGROUND: Previous research has shown that hypoventilation therapy reduces panic symptoms in part by increasing basal partial pressure of carbon dioxide (PCO2) levels. We tested an additional pathway by which hypoventilation therapy could exert its therapeutic effects: through repeated interoceptive exposure to sensations of dyspnea. METHODS: A total of 35 patients with panic disorder were trained to perform exercises to raise their end-tidal PCO2 levels using a portable capnometry device. Anxiety, dyspnea, end-tidal PCO2, and respiratory rate were assessed during each exercise across 4 weeks of training. Mixed-model analysis examined whether within-exercise levels of dyspnea were predictive of reduction of panicogenic cognitions. RESULTS: As expected, within-exercise anxiety and respiratory rate decreased over time. Unexpectedly, PCO2 dropped significantly from the beginning to the end of exercise, with these drops becoming progressively smaller across weeks. Dyspnea increased and remained consistently above basal levels across weeks. As hypothesized, greater dyspnea was related to significantly lower panicogenic cognitions over time even after controlling for anxiety and PCO2. Additional exploratory analyses showed that within-exercise increases in dyspnea were related to within-exercise increases in anxiety but were not related to within-exercise increases in PCO2. CONCLUSIONS: In support of the interoceptive exposure model, we found that greater dyspnea during hypoventilation exercises resulted in lower panicogenic cognitions even after the effect of PCO2 was taken into account. The findings offer an additional important target in panic treatment.

Assessing sleep quality using self-report and actigraphy in PTSD.

Sleep disturbance is commonly reported by participants with post-traumatic stress disorder, but objective evidence of poor sleep is often absent. Here we compared self-report and actigraphic evaluations of sleep between veterans with post-traumatic stress disorder and controls. Participants reported their sleep retrospectively for the month before the recording night and on the recording night. On the recording night, they wore an Actiwatch-64 and were instructed to press the marker button upon getting into bed, each time they awoke, and at their final awakening. The post-traumatic stress disorder group reported much worse sleep than controls on the Pittsburgh Sleep Quality Index for the previous month and somewhat poorer sleep on the recording night. However, on the recording night, neither diary nor actigraphic measures of number of awakenings, total time in bed, nor time lying awake after sleep onset differed between participants with and without post-traumatic stress disorder. Diary-reported number of awakenings was fewer than actigraphically captured awakenings. These results suggest a memory bias towards remembering worse sleep on the nights before the recording night.

Direct Measurement of Nuclear Dependence of Charged Current Quasielasticlike Neutrino Interactions Using MINERvA.

Charged-current ν_{µ} interactions on carbon, iron, and lead with a final state hadronic system of one or more protons with zero mesons are used to investigate the influence of the nuclear environment on quasielasticlike interactions. The transferred four-momentum squared to the target nucleus, Q^{2}, is reconstructed based on the kinematics of the leading proton, and differential cross sections versus Q^{2} and the cross-section ratios of iron, lead, and carbon to scintillator are measured for the first time in a single experiment. The measurements show a dependence on the atomic number. While the quasielasticlike scattering on carbon is compatible with predictions, the trends exhibited by scattering on iron and lead favor a prediction with intranuclear rescattering of hadrons accounted for by a conventional particle cascade treatment. These measurements help discriminate between different models of both initial state nucleons and final state interactions used in the neutrino oscillation experiments.

Effects of therapeutic relationship, expectancy, and credibility in breathing therapies for anxiety.

The authors investigated the effects of the quality of the therapeutic alliance, expectancy of improvement, and credibility of treatment on the outcome of two breathing therapies for anxiety and panic. Data were collected during a randomized clinical trial evaluating the efficacy of two theoretically opposing, end-tidal pCO2 feedback-assisted breathing therapies for patients experiencing anxiety attacks. In this study, five weekly individual breathing therapy sessions were administered for the patients who were experiencing anxiety attacks as symptoms of various anxiety disorders. The outcome of this trial indicated that regardless of the opposing breathing instructions (raise or lower pCO2) used in the two breathing therapies, patients in both treatment groups improved equally after treatment. Nonspecific factors rather than the different directions of pCO2 changes could have played a role in the improvement. Regression analyses showed that for both therapies patient-rated therapeutic alliance was predictive of improvement at the 1-month follow-up, and that patient-rated confidence that the therapy would produce improvement, an aspect of its credibility, accounted for almost half of the variance in improvement at the 6-month follow-up. Thus, two factors usually considered nonspecific were identified to be potent predictors of treatment outcome.

Pro-protein convertase subtilisin/kexin 9 concentrations correlate with coronary artery disease atheroma burden in a Pakistani cohort with chronic chest pain.

OBJECTIVE: To determine the relationship between proprotein convertase subtilisin kexin 9 (PCSK9) levels and atheroma burden in Pakistanis presenting to an ambulatory centre with chest pain. METHODS: A prospective matched case-control study of 400 patients selected for presence/absence of angiographic disease referred between 2001 and 2003. A comprehensive cardiovascular disease risk factor profile was assessed including demographics, environmental and biochemical risk factors including insulin resistance and PCSK-9 levels. Coronary atheroma burden was quantified by Gensini score. RESULTS: In this population, PCSK-9 levels were weakly correlated (r = 0.23) with male gender (p = 0.06) and number of diabetes years (p = 0.09), and inversely with log10 of lipoprotein (a) concentration (p = 0.07) but not LDL-C. In multiple regression analysis, Gensini score was associated with age (p = 0.002), established angina (p = 0.001), duration of diabetes (p = 0.05), low HDL-C (p < 0.001), lipoprotein (a) (p = 0.01), creatinine (p < 0.001), C-Reactive Protein (p = 0.02) and PSCK-9 (p = 0.05) concentrations. PCSK9 added to the regression model. Neither total cholesterol nor LDL-C were significant risk factors in this study. CONCLUSIONS: Proprotein convertase subtilisin kexin 9 concentrations are correlated with atheroma burden in Indian Asian populations from the sub-continent, not taking statin therapy, independent of LDL-C or other CVD risk factors.

Autonomic arousal during actigraphically estimated waking and sleep in male veterans with PTSD.

Physiological hyperarousal is manifested acutely by increased heart rate, decreased respiratory sinus arrhythmia, and increased skin conductance level and variability. Yet it is uncertain to what extent such activation occurs with the symptomatic hyperarousal of posttraumatic stress disorder (PTSD). We compared 56 male veterans with current PTSD to 54 males who never had PTSD. Subjects wore ambulatory devices that recorded electrocardiograms, finger skin conductance, and wrist movement while in their normal environments. Wrist movement was monitored to estimate sleep and waking periods. Heart rate, but not the other variables, was elevated in subjects with PTSD equally during waking and during actigraphic sleep (effect sizes, Cohen's d, ranged from 0.63 to 0.89). The length of the sleep periods and estimated sleep fragmentation did not differ between groups. Group heart rate differences could not be explained by differences in body activity, PTSD hyperarousal symptom scores, depression, physical fitness, or antidepressant use.

Angiographic coronary artery disease and high-sensitivity troponin-T in a native Pakistani cohort presenting with chronic chest pain.

OBJECTIVE: To determine the relationship between troponin-T levels and atheroma burden in Pakistanis presenting to an ambulatory centre with chest pain. METHODS: A prospective case-control study of 400 patients selected for presence/absence of angiographic disease referred between 2001 and 2003. A comprehensive cardiovascular disease (CVD) risk factor profile was assessed including demographics, environmental and biochemical risk factors including insulin resistance and troponin-T levels. Coronary atheroma burden was quantified by Gensini score. RESULTS: Clinically significant elevated troponin-T levels (> 30 pmol/l) were found in 40 patients (10%) with equal numbers in groups selected with or without angiographic disease. Troponin-T elevation (> 13 pmol/l) was present in 59 vs. 47 patients (30% vs. 24%; p = 0.04). Troponin-T levels did not correlate with any measured demographical, environmental, drug therapy or biochemical risk factor. No difference was found in concentrations of lipids, apolipoproteins, insulin resistance, C-reactive protein or sialic acid in cohorts stratified by troponin-T concentrations. In univariate analysis comparing patients with high (> 30 pmol/l) and low troponin-T levels (< 13 pmol/l) higher plasma total protein (91 g/l vs. 85 g/l; p = 0.01), increased immunoglobulin levels (41 g/l vs. 36 g/l; p = 0.02) and prevalence of hyperparathyroidism (40% vs. 21%; p = 0.04) were associated with higher troponin-T concentrations. CONCLUSIONS: This study shows that measurement of troponin-T is not an alternative to imaging in an Indian asian population, but that it does identify a separate potentially high-risk population that would not be identified by the use of imaging alone which is potentially at higher risk of CVD events.

Psychiatry on trial: the Norway 2011 massacre.

On July 22, 2011, Anders Breivik, a Norwegian citizen, detonated a fertilizer bomb near government buildings in Oslo, killing eight people, and then proceeded to a nearby island where the Labor Party was holding a youth camp. There, he killed 69 people before being arrested. Just before these events, he posted a "compendium" on the Web explaining his actions and encouraging others to do likewise. Much of the ensuing media coverage and trial focused on whether he was sane and whether he had a psychiatric diagnosis. One team of court-appointed psychiatrists found him to be psychotic with a diagnosis of paranoid schizophrenia and legally insane. A second team found him neither psychotic nor schizophrenic and, thus, legally sane. Their contrary opinions were not reconciled by observing his behavior in court. We discuss why experienced psychiatrists reached such fundamentally opposing diagnostic conclusions about a "home-grown" terrorist holding extreme political views.