STI initiative: Improving testing for sexually transmitted infections in women.

Canadian urgent care and walk-in medical clinics provide health care for a population that may be poorly covered by traditional health care structures. Despite evidence suggesting that women with urinary complaints experience a high incidence of sexually transmitted infections (STIs), this population may be under-tested in this particular setting. The aim of this quality improvement initiative was to increase STI testing in women presenting with GU complaints. Implementation of an opt-out method of STI testing for women ages 16 and older was introduced at three walk-in clinics. Women presenting with GU complaints were given the opportunity to provide samples for both conventional urine culture and nucleic acid amplification testing (NAAT) for non-viral STIs. Patients received treatment according to standard of care and public health was notified as per local regulations. Testing rate and STI incidence was tracked via clinic electronic medical records (EMRs). Overall results were tracked using run charts and compared to historical data for the year prior to the start of the project. Over a 1 year period prior to this intervention, only 65 STI tests were performed in over 1100 GU complaints (5.5%). Six STIs were identified during this time. During the 36-week project period, testing increased to 45% of the patient population (320/707). The STI detected incidence increased from 0.51% to 1.4% in all women, and from 0.84% to 3.4% in women aged 16-29 years. An opt-out method was an effective intervention for increasing STI testing within the walk-in clinic setting. With optimisation, significant increases in testing rates can be obtained without substantially increasing clinic workload and at no economic cost to the clinic. As expected, detected incidence rates of STIs were higher than the recognised population prevalence.

Respiratory difficulty with palatal, laryngeal and respiratory muscle tremor in adult-onset Alexander's disease.

Sleep apnoea and respiratory difficulties are reported in adult-onset Alexander's disease (AOAD), an autosomal-dominant leukodystrophy that presents mainly with progressive ataxia. We demonstrate for the first time that the respiratory symptoms can result from association of palatal tremor with a similar tremor of laryngeal and respiratory muscles that interrupts normal inspiration and expiration.A 60-year-old woman presented with progressive ataxia, palatal tremor and breathlessness. MRI revealed medullary atrophy, bilateral T2 hyperintensities in the dentate nuclei and hypertrophic olivary degeneration (HOD). AOAD was confirmed genetically with a positive glial fibrillary acidic protein (GFAP) mutation. Electrophysiological study revealed 1.5 Hz rhythmic laryngeal and respiratory muscle activity. Her respiratory symptoms were significantly improved at night with variable positive pressure ventilation.This case illustrates that palatal tremor in AOAD, and potentially in other conditions, may be associated with treatable breathlessness due to a similar tremor of respiratory muscles.

Neurosyphilis presenting as parkinsonism.

In the postantibiotic era, neurosyphilis continues to have a significant incidence, especially in certain subpopulations. We report, for the first time, neurosyphilis presenting as parkinsonism without more typical neurosyphilitic clinical features. A 53-year-old man developed clinical features of gradual onset consistent with idiopathic Parkinson's disease but was found to have positive treponemal serology and cerebrospinal fluid Venereal Disease Research Laboratory (VRDL) reaction. Antibiotic treatment dramatically improved all the parkinsonian symptoms. However, over the subsequent 15 years, the patient slowly deteriorated again in a manner typical of idiopathic Parkinson's disease. A dopaminergic deficit was demonstrated on ((123)I)FP-CIT SPECT. This is the first report in the postantibiotic era of neurosyphilis presenting as relatively pure parkinsonism. Blood test screening for syphilis is therefore appropriate if there is any clinical doubt about an idiopathic parkinsonian presentation. The patient's late second deterioration may suggest that the neurosyphilitic basal ganglial insult primed or accelerated development of idiopathic-like disease.

A questionnaire-based study on patients' experiences with rechargeable implanted programmable generators for spinal cord stimulation to treat chronic lumbar spondylosis pain.

OBJECTIVE: The latest generation of rechargeable implantable programmable generators (IPGs) for spinal cord stimulation may greatly extend IPG lifespan compared with previous nonrechargeable devices. This study explores patients' experiences with these devices. MATERIALS AND METHODS: Twenty-five patients attending the Department of Neurostimulation, Royal London Hospital, who were implanted with a rechargeable IPG (SC-1110; Boston Scientific, Minneapolis, MN, USA) to provide pain relief from post-surgical lumbosacral spondylosis were surveyed using a questionnaire. RESULTS: Patients reported a mean (SD) benefit from stimulation of 43.7% (32.6%). On a 1 (worst) to 5 (best) scale, the median score was 5 for ease of recharging. Eight patients who had previously had nonrechargeable IPGs felt the rechargeable system was better (p= 0.0143). A particular issue with nonrechargeable batteries was that, while patients considered 5 years an acceptable interval for battery replacements and the procedure itself not too inconvenient, they felt an acceptable wait for replacement after failure to be only 1 week, much shorter than actual waiting times. CONCLUSIONS: Patients found the rechargeable IPG easy to recharge and those who had had previous experience with nonrechargeable devices preferred using the rechargeable device. Its benefits in terms of pain relief fell within the range expected from previous studies using nonrechargeable batteries. The main disadvantage of nonrechargeable devices as reported by the patients in this study was concern over the length of time they would have to wait without pain relief between battery replacements.

Spinal cord stimulation for intractable pain following limb amputation.

OBJECTIVE: €‚ Spinal cord stimulation (SCS) by high-frequency electrical pulses has been used since the early 1970s for relief of chronic intractable pain following limb amputation. The long-€term effectiveness of SCS for amputation-€related pain with ongoing after-care is reviewed by assessment of all such cases managed over 20 years in the Neurostimulator Clinic at the Royal London Hospital. MATERIALS AND METHODS: €‚ Twelve amputation-€related pain patients had quadripolar paddle electrodes (Resume; Medtronic Inc., Minneapolis, MN, USA) inserted epidurally by laminectomy over the thoracic or cervical dorsal spinal cord and connected to remotely controlled subcutaneously implanted stimulators (Itrel2, Itrel3, Synergy; Medtronic). RESULTS: €‚ Two of 12 patients had unsuccessful stimulation, one despite repeated electrode revisions. Two were subsequently lost to follow-€up, one had delayed spontaneous resolution of phantom limb pain, one had a technical fault, and one had gradually waning benefit over 19 years. In the remaining five patients having ongoing follow-up, self-€reported initial and final magnitudes of pain relief were unchanged, with a mean (SD) of 66% (18.2%). Benefits calculated from local and general visual analogue pain scores were similarly unchanged (initial local 48.8% [18.7%]; final local 50.0% [17.6%]; initial general 60.8% [10.9%]; final general 57.9% [12.3%]). Continued successful stimulation often required frequent changes of stimulating electrode contacts. Revision procedures for technical problems or pain at the battery site were universally successful. CONCLUSIONS: €‚ Successful SCS in some patients with amputation-€related pain otherwise resistant to treatment indicates that the procedure merits continued use with further efforts to refine technique.

Identification of psychogenic, dystonic, and other organic tremors by a coherence entrainment test.

The differentiation of psychogenic from organic tremors, particularly those of a dystonic nature, can be difficult on clinical grounds. Entrainment of tremulous movements of different body parts into a single rhythm has been used clinically as a means of distinguishing these tremor forms, based on the inability of a patient with hysterical tremor to generate voluntary tapping oscillations independent of their ongoing tremor oscillation. The coherence entrainment test is a quantified electrophysiological entrainment test performed on accelerometer or surface EMG tremor signals. This test was carried out on 25 patients referred with suspected psychogenic tremor or dystonic tremor and on 10 normal subjects attempting to tap two independent voluntary oscillations. Using established and new clinical diagnostic criteria, patients were assigned the following final clinical diagnoses: 6 cases of clinically definite dystonic tremor, 5 cases of probable dystonic tremor, 2 cases of classic essential tremor, 5 cases of clinically definite psychogenic tremor, 3 cases of probable psychogenic tremor and 4 uncertain cases. On comparing these clinical diagnoses with those reached by a coherence entrainment test subsequently carried out on each patient, there was 100% concordance in both clinically definite and clinically probable patients. In uncertain cases, when later clinical information came to light, this also corroborated with the coherence entrainment diagnosis. No normal subjects were able to "mimic" organic tremor. The coherence entrainment test appears to be a sensitive and specific means of distinguishing psychogenic tremor from dystonic and other organic tremors.

Analysis of force profile during a maximum voluntary isometric contraction task.

This study analyses maximum voluntary isometric contraction (MVIC) and its measurement by recording the force profile during maximal-effort, 7-s hand-grip contractions. Six healthy subjects each performed three trials repeated at short intervals to study variation from fatigue. These three trials were performed during three separate sessions at daily intervals to look at random variation. A pattern of force development during a trial was identified. An initiation phase, with or without an initiation peak, was followed by a maintenance phase, sometimes with secondary pulses and an underlying decline in force. Of these three MVIC parameters, maximum force during the maintenance phase showed less random variability compared to intertrial fatigue variability than did maximum force during the initiation phase or absolute maximum force. Analysis of MVIC as a task, rather than a single, maximal value reveals deeper levels of motor control in its generation. Thus, force parameters other than the absolute maximum force may be better suited to quantification of muscle performance in health and disease.

Alcohol-induced paroxysmal nonkinesogenic dyskinesia after pallidal hypoxic insult.

We describe the first case of paroxysmal nonkinesogenic dyskinesia secondary to pallidal ischaemia, which is uniquely and specifically triggered by alcohol.

Global sustainability and key needs in future automotive design.

The number of light vehicle registrations is forecast to increase worldwide by a factor of 3-5 over the next 50 years. This will dramatically increase environmental impacts worldwide of automobiles and light trucks. If light vehicles are to be environmentally sustainable globally, the automotive industry must implement fundamental changes in future automotive design. Important factors in assessing automobile design needs include fuel economy and reduced emissions. Many design parameters can impact vehicle air emissions and energy consumption including alternative fuel or engine technologies, rolling resistance, aerodynamics, drive train design, friction, and vehicle weight. Of these, vehicle weight is key and will translate into reduced energy demand across all energy distribution elements. A new class of vehicles is needed that combines ultra-light design with a likely hybrid or fuel cell engine technology. This could increase efficiency by a factor of 3-5 and reduce air emissions as well. Advanced lightweight materials, such as plastics or composites, will need to overtake the present metal-based infrastructure. Incorporating design features to facilitate end-of-life recycling and recovery is also important. The trend will be towards fewer materials and parts in vehicle design, combined with ease of disassembly. Mono-material construction can create vehicle design with improved recyclability as well as reduced numbers of parts and weight.