Identifying Racial and Ethnic Disparities in Acute Inpatient Rehabilitation.

OBJECTIVE: To investigate whether racial, ethnic, and linguistic disparities exist at discharge from an acute inpatient rehabilitation facility (IRF) by examining change in Functional Independence Measure (FIM) scores and discharge destination. DESIGN: This is a retrospective study using our IRF's data from the Uniform Data System for Medical Rehabilitation from 2013-2019. FIM scores and discharge destination were compared between race, language, and ethnic groups, with adjustment for patient characteristics. SETTING: An urban hospital with a level 1 trauma center, comprehensive stroke center, and IRF with Commission on Accreditation of Rehabilitation Facilities (CARF) certification. PARTICIPANTS: 2518 patients admitted to the IRF from 2013-2019 (N=2518). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Change in FIM score and discharge destination. RESULTS: After adjusting for covariates, non-White patients and patients with limited English proficiency had significantly lower functional recovery, as measured by smaller changes in FIM scores from IRF admission to discharge. Additionally, both groups were more likely to be discharged home with home health care than to a skilled nursing facility, compared with White and English-speaking patients. Disparities in discharge destination persisted within patients with noncommercial insurance (Medicaid or Medicare) and a stroke diagnosis but not within those who had commercial insurance or a nonstroke diagnosis. CONCLUSIONS: Racial and linguistic disparities were identified within our CARF certified IRF; however, the organization is committed to reducing health care disparities. Next steps will include investigating interventions to reduce disparities.

Geometric distortion caused by metallic femoral head prosthesis in prostate cancer imaging on an MR Linac: in-vivo measurements of spatial deformation.

OBJECTIVES: Metallic implants cause artefacts and distortion on MRI. To ensure accurate dose delivery and plan adaptation on an MR Linac, there is a need to evaluate distortion caused. METHODS: Participants were imaged on an MR Linac (Elekta Unity, Elekta AB Stockholm). Three sequences were evaluated. Two vendor supplied (T2W TSE 3D), and one T2W TSE 3D optimized to reduce metal artefact distortions. Images were rigidly registered to CT images by a single observer, using bony anatomy. Three coronal and three axial images were selected, and six paired, adjacent, bony landmarks were identified on each slice. Images bisecting treatment isocentre were included. Difference between landmark coordinates was taken to be measure of distortion. RESULTS: Five observers participated. Thirty six pairs of bony landmarks were identified. Median difference in position of landmarks was ≤3 mm (range 0.3-4.4 mm). One-way analysis of variance (ANOVA) between observer means showed no significant variation between sequences or patients (P = 1.26 in plane, P = 0.11 through plane). Interobserver intra class correlation (ICC) was 0.70 in-plane and 0.78 through-plane. Intra-observer ICC for three observers was 0.76, 0.81, 0.83, showing moderate to good reliability on this small cohort. CONCLUSIONS: This in-vivo feasibility study suggests distortion due to metallic hip prosthesis is not an obstacle for pelvic radiotherapy on an MR Linac. Research on the impact on plan quality is warranted. ADVANCES IN KNOWLEDGE: This work supports feasibility of treating patients with metallic hip prosthesis on an MR Linac.

Intentions at the End of Life: Continuous Deep Sedation and France's Claeys-Leonetti law.

In 2016, France passed a major law that is unique in giving terminally ill and suffering patients the right to the controversial procedure of continuous deep sedation until death (CDS). In so doing, the law identifies CDS as a sui generis clinical practice, distinct from other forms of palliative sedation therapy, as well as from euthanasia. As such, it reconfigures the ethical debate over CDS in interesting ways. This paper addresses one aspect of this reconfiguration and its implications for the intentions at work in this complex time at the end of life. The concept of intention is often considered central to the ethics of end-of-life care, but its role is recognized to be problematic, with charges of elusiveness and ambiguity. I aim to show that consideration of the French law affords a new understanding of the intentionality of CDS, and that in addition to the obvious importance of this for clarifying the ethics of the practice, it may suggest new ways of addressing the wider problem of ambiguous clinical intentions at end of life.

The wellbeing pandemic: Outline of a contested terrain and a proposed research agenda.

Wellbeing has emerged as a central, if not defining, feature of contemporary social life. Yet, despite its global significance spanning the political, social and economic spectrum, there is a remarkable lack of agreement regarding the conceptualization, definition or operationalisation of wellbeing nor any clear evidence of its success as an instrument of policy. This essay explores the contested terrain of wellbeing by examining the concept in relation to emerging politics, complexities and contradictions. More specifically, the essay: (1) briefly describes the historical origins and development of wellbeing; (2) discusses how it has been reconceptualised within the context of neoliberalism; and, (3) outlines a research agenda offering three ways to investigate wellbeing including: (a) as a wicked problem; (b) as part of the process of "wellbeing washing" within state and other institutional structures and policies; and, (c) in relation to alternative futures, which might encourage us to reimagine or jettison the term altogether.

A framework for clinical utilization of robotic exoskeletons in rehabilitation.

Exoskeletons are externally worn motorized devices that assist with sit-to-stand and walking in individuals with motor and functional impairments. The Food & Drug Administration (FDA) has approved several of these technologies for clinical use however, there is limited evidence to guide optimal utilization in every day clinical practice. With the diversity of technologies & equipment available, it presents a challenge for clinicians to decide which device to use, when to initiate, how to implement these technologies with different patient presentations, and when to wean off the devices. Thus, we present a clinical utilization framework specific to exoskeletons with four aims.These aims are to assist with clinical decision making of when exoskeleton use is clinically indicated, identification of which device is most appropriate based on patient deficits and device characteristics, providing guidance on dosage parameters within a plan of care and guidance for reflection following utilization. This framework streamlines how clinicians can approach implementation through the synthesis of published evidence with appropriate clinical assessment & device selection to reflection for success and understanding of these innovative & complex technologies.

The Global Business of Sport in a Brave New World: Conceptualising a Framework for Alternative Futures.

In July 1991, Sports Illustrated published a special issue featuring two articles that prognosticated about what sport would look like 10 years later. As the world entered the 21st century, Sports Illustrated writers, Oscar Johnson and Ron Fimrite, offered their visions of sport in the year 2001. Their analysis highlighted how a range of economic, social and technological changes in society would impact on how sport is structured, produced and consumed, but also offered insights into the future of the major professional sport leagues in North America. It has been 30 years since they publicised their views and, while technology continues to impact sport, the Covid-19 pandemic has forced the world to pause and to consider a range of deep, soul-searching questions about the nature of society, including sport. Against this background, we consider the opportunities and challenges for sport in the 21st century. The paper is divided into three sections including: (1) a reflection on the meaning, value and significance of sport including its privileged position in society, or what we refer to as "sporting exceptionalism"; (2) a brief overview of a case study that illustrates the challenges facing the global business of sport; and, (3) a framework for conceptualising alternative futures in the global business of sport, drawing on examples from women's sport.

Physical Therapy for Gait, Balance, and Cognition in Individuals with Cognitive Impairment: A Retrospective Analysis.

OBJECTIVES: The purpose of this study was to determine if a pragmatic physical therapy (PT) program was associated with improved cognition, gait, and balance in individuals with cognitive impairment. This study investigated these associations for individuals with Alzheimer disease (AD), vascular dementia (VaD), dementia with Lewy bodies (DLB), and mild cognitive impairment (MCI) in order to better characterize outcomes to PT for each diagnostic group. METHODS: Data before and after one month of physical therapy were extracted from patient records (67 with AD, 34 with VaD, 35 with DLB, and 37 with MCI). The mean number of PT sessions over a month was 3.4 (±1.8). Outcomes covered the domains of gait, balance, and cognition with multiple outcomes used to measure different constructs within the balance and gait domains. RESULTS: All groups showed improvements in balance and at least one gait outcome measure. Those with MCI improved in every measure of gait and balance performance. Lastly, cognition as measured by Montreal Cognitive Assessment improved in individuals in the AD, VaD, and MCI groups. CONCLUSION: While this retrospective analysis is not appropriate for causal inference, results of one month of physical therapy were associated with decreases in gait, balance, and cognitive impairment in individuals with AD, VaD, DLB<, and MCI. Clinical Implications. While physical therapy is not typically a primary treatment strategy for individuals with cognitive impairment, the results of this study are consistent with the literature that demonstrates improvement from physical therapy for other neurodegenerative diseases. Further clinical and research exploration for physical therapy as a primary treatment strategy in these populations is warranted.

Audit feasibility for geometric distortion in magnetic resonance imaging for radiotherapy.

BACKGROUND AND PURPOSE: Magnetic Resonance Imaging (MRI) is increasingly being used in radiotherapy (RT). However, geometric distortions are a known challenge of using MRI in RT. The aim of this study was to demonstrate feasibility of a national audit of MRI geometric distortions. This was achieved by assessing large field of view (FOV) MRI distortions on a number of scanners used clinically for RT. MATERIALS AND METHODS: MRI scans of a large FOV MRI geometric distortion phantom were acquired on 11 MRI scanners that are used clinically for RT in the UK. The mean and maximum distortions and variance between scanners were reported at different distances from the isocentre. RESULTS: For a small FOV representing a brain (100-150 mm from isocentre) all distortions were < 2 mm except for the maximum distortion of one scanner. For a large FOV representing a head and neck/pelvis (200-250 mm from isocentre) mean distortions were < 2 mm except for one scanner, maximum distortions were > 10 mm in some cases. The variance between scanners was low and was found to increase with distance from isocentre. CONCLUSIONS: This study demonstrated feasibility of the technique to be repeated in a country wide geometric distortion audit of all MRI scanners used clinically for RT. Recommendations were made for performing such an audit and how to derive acceptable limits of distortion in such an audit.

MRI B 0 homogeneity and geometric distortion with continuous linac gantry rotation on an Elekta Unity MR-linac.

This work aimed to quantify any principal magnetic field (B 0) inhomogeneity and changes in MR image geometric distortion with continuous linac gantry rotation on an Elekta Unity MR-linac. This situation occurs for around a second between treatment beams during current image guided radiotherapy treatment and would occur frequently in foreseeable real-time adaptive radiotherapy treatment. Pixel by pixel maps of B 0 inhomogeneity were obtained via repeated high temporal resolution pulse sequences with the linac gantry static at 36 gantry angles spaced ten degrees apart, and in continuous rotation at both 1 and 2 rpm. Individual B 0 maps were subtracted from average maps across all data and the residual peak to peak inhomogeneity was calculated for each. The bulk geometric shift and change in physical extent of a 10 cm diameter spherical flood phantom during continuous linac gantry rotation at 1 and 2 rpm was compared to the static gantry case for two pulse sequences: the real-time clinical monitoring bFFE sequence and a non-clinical EPI sequence, chosen for its susceptibility to geometric distortion. The peak to peak inhomogeneity in the deviation-from-average ppm maps, plotted against gantry angle with the gantry in continuous rotation at 1 and 2 rpm were negligibly different from equivalent data obtained with the gantry static. The real-time clinical monitoring pulse sequence was shown to give negligible geometric distortion during continuous gantry motion, whilst a non-clinical EPI sequence showed bulk shifts of the order of one pixel and gantry angle dependent changes in extent, demonstrating the sensitivity of the chosen method. MR imaging on the Elekta Unity MR-Linac with the gantry in continuous motion is negligibly different from the static gantry case with current clinical pulse sequences. Real-time tracking and treatment plan adaptation using MR images obtained with the linac gantry in motion is possible.

Solitary bone plasmacytoma compression injury disguised as back pain: a case report.

Introduction: Low back pain is a leading disability worldwide; however, it is not often the result of a serious underlying condition such as a tumor. As a result, diagnosis of a serious underlying cause of low back pain may be delayed, such as in this case. Case presentation: We describe a case of a man presenting with low back pain, who was eventually diagnosed with solitary bone plasmacytoma (SBP) causing spinal cord compression from approximately T7-T9. The patient was classified as T8 ASIA C-Incomplete Paraplegia. He underwent an emergency T7-T9 open posterior laminectomy and resection of the epidural mass/tumor. Following an intensive course of rehabilitation treatment, the patient progressed to ASIA D. Discussion: Although SBP of the spine is rare, back or neck pain is a common initial presentation. This case is unique in that we provide a detailed description of both medical and rehabilitation diagnosis and treatment. We also suggest that persistent back pain warrants complete MRI spinal imaging to provide proper diagnosis and prompt treatment for cases with a serious underlying condition.

A precise, reproducible method for measuring ultrasound probe slice thickness using a Gammex 403 phantom.

A precise, reproducible method for measuring ultrasound probe slice thickness has been developed for linear array ultrasound probes. The method used a custom built jig to draw the probe along the surface of a Gammex 403 phantom, with the image plane parallel to the filaments within the phantom. Still images at 0.5 mm intervals are saved for post-processing using in-house software. Slice thickness measurements with a precision of 0.1 mm are obtained. The method was shown to give reproducible estimates of probe slice thickness at several depths to within 0.4 mm during repeat tests. The method was able to provide information about the slice thickness of different sections of the probe face. It is expected that the method can quantify changes in probe performance due to lens wear or replacement over time that may elude both in-plane and in-air reverberation-based tests. A total of 18 linear probes were tested across eight centres, including six specialist vascular ultrasound centres.

From A to D: A Unique Case Report of Recovery After Longitudinal Myelitis Related to Lupus.

Longitudinal myelitis secondary to an acute flare of systemic lupus erythematosus has been reported in the literature. There have been few published cases of complete functional recovery in patients with systemic lupus erythematosus-related longitudinal myelitis (systemic lupus erythematosus-related longitudinal myelitis). Of those cases, none have described in detail the rehabilitation course of treatment. In the current case, intensive rehabilitation was coupled with aggressive pharmaceutical treatment resulting in almost full functional recovery. A 23-yr-old African American woman with a history of systemic lupus erythematosus was originally admitted as an inpatient for flank pain. Overnight, she progressed rapidly to complete flaccid paraplegia classified as T3 American Spinal Injury Association Impairment Scale A based on the International Standards for Neurological Classification of Spinal Cord Injury. Throughout the next year, she participated in acute inpatient rehabilitation, followed by outpatient rehabilitation (physical, occupational, and aquatic therapies). A year after her initial hospital admission, she progressed to full community ambulation T3 American Spinal Injury Association Impairment Scale D. This case illustrates the importance of proper medical treatment and a comprehensive rehabilitation program, which improved functional outcomes for a patient with a complete spinal cord injury due to systemic lupus erythematosus-related longitudinal myelitis.

Cervical Myelopathy in a Patient Referred for Lower Extremity Symptoms.

The patient was a 38-year-old male referred to physical therapy with complaints of right lower extremity radicular pain and left lower extremity weakness. Following physical therapy examination, the primary care physician referred the patient to a neurologist, who performed electromyography and nerve conduction studies and ordered a magnetic resonance image. Cervical spine imaging revealed a C5-6 disc extrusion with myelopathy. J Orthop Sports Phys Ther 2017;47(7):510. doi:10.2519/jospt.2017.5071.

Diagnosis of Paget-Schroetter Syndrome/Primary Effort Thrombosis in a Recreational Weight Lifter.

Background and Purpose: Paget-Schroetter syndrome (PSS) is a rare condition of vein thrombosis that can be manifested in athletes and laborers who overuse their upper extremities. If diagnosed early, PSS can be managed and the symptoms can be fully reversed. Venous duplex ultrasound (US), the modality most commonly used to diagnose deep vein thrombosis (DVT), has high sensitivity and specificity for detecting DVT. This case report describes the differential diagnosis and management of PSS in a weight lifter. Case Description: The patient was a 44-year-old man who had left upper extremity (UE) swelling and discoloration after performing an incline chest press 2 months earlier. He was referred to a physical therapist for the treatment of venous thoracic outlet syndrome because US imaging results were negative for DVT. The patient's signs and symptoms did not improve after 4 physical therapist treatment sessions. Outcomes: Repeat US revealed multiple thrombi in the patient's UE. He underwent immediate thrombolysis and subsequent first rib removal and scalenectomy. Five months after the surgical intervention, the patient had returned to work as a truck driver without limitation of UE use, although he had not yet returned to weight lifting. Discussion: Despite the facts that the patient was seen by several health care providers and that multiple US images were obtained, the patient's UE DVT was not detected. It is important for a clinician to consider venous pathology in the shoulder even if the results of diagnostic US imaging performed in the presence of UE swelling and pain have been negative. Timely diagnosis and management of PSS are necessary for optimal recovery.

Intrarater reliability of hand held dynamometry in measuring lower extremity isometric strength using a portable stabilization device.

Hand held dynamometry (HHD) is a more objective way to quantify muscle force production (MP) compared to traditional manual muscle testing. HHD reliability can be negatively impacted by both the strength of the tester and the subject particularly in the lower extremities due to larger muscle groups. The primary aim of this investigation was to assess intrarater reliability of HHD with use of a portable stabilization device for lower extremity MP in an athletic population. Isometric lower extremity strength was measured for bilateral lower extremities including hip abductors, external rotators, adductors, knee extensors, and ankle plantar flexors was measured in a sample of healthy recreational runners (8 male, 7 females, = 30 limbs) training for a marathon. These measurements were assessed using an intrasession intrarater reliability design. Intraclass correlation coefficients (ICC) were calculated using 3,1 model based on the single rater design. The standard error of measurement (SEM) for each muscle group was also calculated. ICC were excellent ranging from ICC (3,1) = 0.93-0.98 with standard error of measurements ranging from 0.58 to 17.2 N. This study establishes the use of a HHD with a portable stabilization device as demonstrating good reliability within testers for measuring lower extremity muscle performance in an active healthy population.

Differentiation of human embryonic stem cells to HOXA+ hemogenic vasculature that resembles the aorta-gonad-mesonephros.

The ability to generate hematopoietic stem cells from human pluripotent cells would enable many biomedical applications. We find that hematopoietic CD34+ cells in spin embryoid bodies derived from human embryonic stem cells (hESCs) lack HOXA expression compared with repopulation-competent human cord blood CD34+ cells, indicating incorrect mesoderm patterning. Using reporter hESC lines to track the endothelial (SOX17) to hematopoietic (RUNX1C) transition that occurs in development, we show that simultaneous modulation of WNT and ACTIVIN signaling yields CD34+ hematopoietic cells with HOXA expression that more closely resembles that of cord blood. The cultures generate a network of aorta-like SOX17+ vessels from which RUNX1C+ blood cells emerge, similar to hematopoiesis in the aorta-gonad-mesonephros (AGM). Nascent CD34+ hematopoietic cells and corresponding cells sorted from human AGM show similar expression of cell surface receptors, signaling molecules and transcription factors. Our findings provide an approach to mimic in vitro a key early stage in human hematopoiesis for the generation of AGM-derived hematopoietic lineages from hESCs.

Alternative Routes to Induced Pluripotent Stem Cells Revealed by Reprogramming of the Neural Lineage.

During the reprogramming of mouse embryonic fibroblasts (MEFs) to induced pluripotent stem cells, the activation of pluripotency genes such as NANOG occurs after the mesenchymal to epithelial transition. Here we report that both adult stem cells (neural stem cells) and differentiated cells (astrocytes) of the neural lineage can activate NANOG in the absence of cadherin expression during reprogramming. Gene expression analysis revealed that only the NANOG+E-cadherin+ populations expressed stabilization markers, had upregulated several cell cycle genes; and were transgene independent. Inhibition of DOT1L activity enhanced both the numbers of NANOG+ and NANOG+E-cadherin+ colonies in neural stem cells. Expressing SOX2 in MEFs prior to reprogramming did not alter the ratio of NANOG colonies that express E-cadherin. Taken together these results provide a unique pathway for reprogramming taken by cells of the neural lineage.

Phytonutrients Differentially Stimulate NAD(P)H:Quinone Oxidoreductase, Inhibit Proliferation, and Trigger Mitotic Catastrophe in Hepa1c1c7 Cells.

Phytonutrients have rapidly emerged as natural food chemicals possessing multifaceted biological actions that may support beneficial health outcomes. Among the vast array of phytonutrients currently being studied, sulforaphane, curcumin, quercetin, and resveratrol have been frequently reported to stimulate the expression of endogenous detoxification enzymes and may thereby facilitate the neutralization of otherwise harmful environmental agents. Some of these same phytonutrients, however, have also been implicated in disrupting normal cell proliferation and hence may possess toxic properties in and of themselves. In this study, we characterize the respective minimum threshold concentrations of the aforementioned phytonutrients in Hepa1c1c7 cells that stimulate NAD(P)H: quinone oxidoreductase (NQO1), a key enzyme in the hepatic neutralization of menadione, other biological oxidants, and some environmental carcinogens. Moreover, our findings demonstrate that relatively low concentrations of either sulforaphane or curcumin significantly (P < .05) increase NQO1 protein expression and activity without triggering G2/M cell cycle arrest or mitotic catastrophe. The minimal quercetin concentration inducing NQO1, however, was 100-fold higher than that which disrupted mitosis. Also, while resveratrol modestly stimulated NQO1, the minimally effective resveratrol concentration concomitantly induced evidence of cellular apoptosis. Taken together, these findings indicate that only particular phytonutrients are likely efficacious in upregulating NQO1 activity without also leading to hepatic cytotoxicity.

Supplemental genistein, quercetin, and resveratrol intake in active duty army soldiers.

Previous reports indicate that the majority of U.S. Army soldiers consume dietary supplements (DSs) > 1 time/wk. However, these studies did not evaluate phytonutrient supplementation. A growing literature suggests inclusion of phytonutrients in DSs may pose a risk for toxicity, which could impact the performance of soldier duties, as well as long-term health and wellness. This study was conducted to assess and understand soldiers' motivations to consume phytonutrient-containing DSs, specifically genistein, quercetin, and resveratrol. The study was a cross-sectional, descriptive mixed-methods design using a survey and semistructured interviews. There were 436 soldiers stationed at Joint Base Lewis-McChord, Washington who completed the survey, from which 36 soldiers completed an interview. Overall, 34% of soldiers reported taking a single or multicomponent phytonutrient DS > 1 time/wk, from which 41 soldiers took >1 supplement/wk. Soldiers' reasons for use included unsure (54%), weight loss (12%), and other, unspecified (24%). The majority of interviewees did not consume DSs based on inclusion of genistein, quercetin, or resveratrol. The majority of soldiers, in our study, appear unable to rationalize their phytonutrient DS choices. Findings from this study illuminate the need for future research to further explore DS practices within military populations and encourage informed use of DSs.

Defining patient acceptable symptom state thresholds for commonly used patient reported outcomes measures in general orthopedic practice.

BACKGROUND: Patient reported outcomes measures are distributed regularly within musculoskeletal physical therapy practice in an effort to track patient progress and response to treatment. A number of studies have reported on the amount of change necessary to identify the minimal clinically important difference. Few studies have identified thresholds signifying patient satisfaction with treatment and what patient specific factors may be influential in identifying patient satisfaction. OBJECTIVES: To identify thresholds amongst commonly used patient reported outcomes measures associated with the patient acceptable symptom state (PASS). To identify the confounding effects of demographic and psychosocial variables on reported PASS estimates. DESIGN: Prospective cohort study. METHOD: A sample of convenience consisting of consecutive patients referred for outpatient physical therapy for general orthopaedic conditions fulfilling the eligibility criteria were included. All patients completed baseline demographic information as well as baseline pain and functional outcomes measures. The PASS question was used as the anchor in this study to identify patient thresholds. Patients completed outcomes measures every 2 weeks and at patient discharge. PASS thresholds were identified using receiver-operating curves maximizing sensitivity and specificity. RESULTS: PASS thresholds were found to vary depending on baseline pain levels, functional status, socioeconomic status, educational level, and psychosocial status. CONCLUSIONS: Multiple factors are influential in determining patient success following treatment. Clinicians should be aware of patient baseline pain and functional status as well as socioeconomic status, educational level, and psychosocial status and stratify patients accordingly when determining patient prognosis and developing a plan of care.