Patient-controlled oral analgesia versus nurse-controlled parenteral analgesia after caesarean section: a randomised controlled trial.

We assessed the effectiveness of early patient-controlled oral analgesia compared with parenteral analgesia in a randomised controlled non-inferiority trial of women undergoing elective caesarean section under regional anaesthesia. Seventy-seven women received multimodal paracetamol, ketoprofen and morphine analgesia. The woman having patient-controlled oral analgesia were administered four pillboxes on the postnatal ward containing tablets and instructions for self-medication, the first at 7 h after the spinal injection and then three more at 12-hourly intervals. Pain at rest and on movement was evaluated using an 11-point verbal rating scale at 2 h and then at 6-hourly intervals for 48 h. The pre-defined non-inferiority limit for the difference in mean pain scores (patient-controlled oral analgesia minus parenteral) was one. The one-sided 95% CI of the difference in mean pain scores was significantly lower than one at all time-points at rest and on movement, demonstrating non-inferiority of patient-controlled oral analgesia. More women used morphine in the patient-controlled oral analgesia group (22 (58%)) than in the parenteral group (9 (23%); p = 0.002). The median (IQR [range]) number of morphine doses in the patient-controlled oral analgesia group was 2 (1-3 [1-7]) compared with 1 (1-1 [1-2]); p = 0.006) in the parenteral group. Minor drug errors or omissions were identified in five (13%) women receiving patient-controlled oral analgesia. Pruritus was more frequent in the patient-controlled oral analgesia group (14 (37%) vs 6 (15%) respectively; p = 0.03), but no differences were noted for other adverse events and maternal satisfaction. After elective caesarean section, early patient-controlled oral analgesia is non-inferior to standard parenteral analgesia for pain management, and can be one of the steps of an enhanced recovery process.

Diffusion-weighted imaging score of the brain stem: A predictor of outcome in acute basilar artery occlusion treated with the Solitaire FR device.

BACKGROUND AND PURPOSE: The prognosis for ischemic stroke due to acute basilar artery occlusion is very poor: Early recanalization remains the main factor that can improve outcomes. The baseline extent of brain stem ischemic damage can also influence outcomes. We evaluated the validity of an easy-to-use DWI score to predict clinical outcome in patients with acute basilar artery occlusion treated by mechanical thrombectomy. MATERIALS AND METHODS: We analyzed the baseline clinical and DWI parameters of 31 patients with acute basilar artery occlusion, treated within 24 hours of symptom onset by using a Solitaire FR device. The DWI score of the brain stem was assessed with a 12-point semiquantitative score that separately considered each side of the medulla, pons, and midbrain. Clinical outcome was assessed at 180 days by using the mRS. According to receiver operating characteristic analyses, the cutoff score determined the optimal positive predictive value for outcome. The Spearman rank correlation coefficient assessed the correlation between the DWI brain stem score and baseline characteristics. RESULTS: Successful recanalization (Thrombolysis in Cerebral Infarction 3-2b) was achieved in 23 patients (74%). A favorable outcome (mRS ≤ 2) was observed in 11 patients (35%). An optimal DWI brain stem score of <3 predicted a favorable outcome. The probability of a very poor outcome (mRS ≥ 5) if the DWI brain stem score was ≥5 reached 80% (positive predictive value) and 100% if this score was ≥6. Interobserver reliability of the DWI brain stem score was excellent, with an intraclass correlation coefficient of 0.97 (95% CI, 0.96-0.99). The DWI brain stem score was significantly associated with baseline tetraplegia (P = .001) and coma (P = .005). CONCLUSIONS: In patients with acute basilar artery occlusion treated by mechanical thrombectomy, the baseline DWI brain lesion score seems to predict clinical outcome.

Lack of referral for genetic counseling and testing in BRCA1/2 and Lynch syndromes: a nationwide study based on 240,134 consultations and 134,652 genetic tests.

Based on nationwide data from the French national cancer institute (INCa), we analyzed the evolution of cancer genetics consultations and testing over time, and the uptake of targeted tests in relatives of families with BRCA1/2 or MMR genes mutation. Genetic testing and consultations for familial high-risk individuals are exclusively funded and monitored by the INCa in France. All nationwide cancer genetics centers reported annually standardized parameters of activity from 2003 to 2011. The analysis included a total of 240,134 consultations and 134,652 genetic tests enabling to identify 32,494 mutation carriers. Referral for hereditary breast and ovarian cancer (HBOC) or colorectal cancer predisposition syndromes represented 59 % (141,639) and 23.2 % (55,698) consultations, respectively. From 2003 to 2011, we found a dramatic and steady increase of tests performed for BRCA1/2 (from 2,095 to 7,393 tests/year, P < 0.0001) but not for MMR genes (from 1,144 to 1,635/year, P = NS). The overall percentage of deleterious mutations identified in the probands tested was 13.8 and 20.9 % in HBOC and Lynch syndromes, respectively. Pooled analysis for BRCA1/2 and Lynch syndrome tests showed an inverse relationship between the percentage of mutation detected and the absolute number of tests performed over the time (overall Cochran-Armitage test for trend: P < 0.001). In families with BRCA1/2 or MMR identified mutations, there was an average number of 2.94 and 3.28 relatives performing targeted tests, respectively. This nationwide study shows a lack of referral and genetic testing in Lynch as compared to HBOC syndromes. Only a third of relatives of a proband with a predisposing mutation performed a targeted test. Enhanced information about benefit of genetic testing should be given to clinicians and patients for Lynch syndrome and relatives of a proband carrying an identified predisposing mutation.

Shoulder Antagonistic Strength Ratios: A Comparison between College-Level Baseball Pitchers and Nonpitchers.

The purpose of this study was to investigate the shoulder strength ratios obtained from college-level baseball pitchers and age- and sex-matched nonpitchers. Shoulder flexion/extension and externallinternal rotation strength ratios were assessed in 10 pitchers and 9 nonpitchers. Speeds selected for testing were 180 and 300 degrees /sec on the Cybex /I.@R esults indicated that both pitchers and nonpitchers generated greater peak torque values for the extensors and internal rotators than for the flexors and external rotators of the shoulder. A comparison of shoulder strength ratios between a pitcher's throwing arm and his nonthrowing arm was statistically significant (p < 0.05) for shoulder external/internal rotation at the speeds of 180 and 300 "/set. A comparison of shoulder strength ratios between pitchers and nonpitchers on the nondominant arm was not statistically significant for any of the speeds or directions tested. A comparison of the shoulder strength ratios between pitchers and nonpitchers on the dominant arm was statistically significant (p < 0.05) for all directions and speeds tested. The relationship between shoulder muscle imbalance and injury was discussed. J Orthop Sports Phys Ther 1987;8(9):451-461.

A Preliminary Investigation: History, Physical, and lsokinetic Exam Results versus Arthroscopic Diagnosis of Chondromalacia Patella *.

The purpose of this pilot study was to identify those clinical exam findings most often seen in patients with a positive chondromalacia patella (CMP) arthroscopic exam. Twenty patients with a clinical diagnosis of CMP or meniscal lesions (M) or both (CMP+M) were evaluated by two physical therapists using the history, physical, and Cybex(R) II isokinetic testing data. More than 50% of the patients with arthroscopically confirmed CMP complained of peripatellar pain, pain with ascending and descending stairs, and pain with prolonged flexion. At least 50% of these patients also demonstrated pain with a patellar grinding test and crepitus during the active knee extension test. Chi square analysis of the clinical exam data between the arthroscopically diagnosed CMP+M patients and 20 age- and sex-matched normal subjects revealed a significant difference in response to the three history questions analyzed. No significant differences were found on the physical exam, including Cybex II isokinetic testing results. Our findings demonstrate the significant role of the history in diagnosing symptomatic CMP.J Orthop Sports Phys Ther 1985;7(3):115-123.

A comparison of muscular tightness in runners and nonrunners and the relation of muscular tightness to low back pain in runners.

The focus of this experimental study was to compare muscular tightness at the hip between runners and nonrunners, and to determine if there is a relation between muscular tightness and low back pain in runners. Goniometric range of motion measurements of three hip movements, abduction, flexion with the knee extended, and extension, were taken on two subject populations, runners (N = 45), and nonrunners (n = 43), in order to determine tightness of the hip adductor, extensor, and flexor muscles, respectively. The mean score values obtained for each of the three measurements for both the right and left sides were compared for differences between the running and nonrunning populations and between male and female subjects. Runners were found to be significantly limited in the movement of hip flexion with the knee extended. The mean score values obtained for all male subjects for this movement were lower than those for all female subjects. The incidence of low back pain in runners was examined; however, no correlation could be drawn between muscular tightness in these subjects and low back pain. J Orthop Sports Phys Ther 1985;6(6):315-323.