Atrial fibrillation considerations in the fourth trimester (postpartum period).

Postpartum atrial fibrillation is an uncommon but increasingly prevalent tachyarrhythmia that merits special management considerations with regards to the safety and efficacy of anticoagulation, rate and rhythm control as well as drug exposure to infants throughout breastfeeding. In this state-of-the-art review, we examine the demographics of postpartum atrial fibrillation with its associated risk factors, describe the safety of commonly used atrial fibrillation therapies, and discuss important considerations for women considering subsequent pregnancies.

Interventional Spine Course: Improving Fluoroscopic Safety and Procedural Efficacy Among Physical Medicine and Rehabilitation Residents Using a Lecture and Model-Based Curriculum.

ABSTRACT: Therapeutic interventional techniques using fluoroscopy are often used in the management of spinal pain. Currently, there are no standardized means of instruction and assessment of fluoroscopic interventional spinal procedures for physiatry trainees. The aim of our study is to evaluate the utility of an interventional spine training course for physical medicine and rehabilitation residents in improving safety and efficacy when performing these procedures. We performed a prospective multiple cohort study analyzing interventional spine knowledge and procedural ability among physical medicine and rehabilitation residents after implementing a training course that used lectures, hands-on training, and video-recorded objective structured clinical examination self-assessments. Of the total of 28 physical medicine and rehabilitation residents over the 2-yr study period, each class saw a statistically significant improvement in mean objective structured clinical examination scores from pre-examination to postexamination ( P < 0.05). Written examination scores also had a statistically significant preimprovement to postimprovement in the postgraduate years 2 and 3 classes. Our study supports the use of an interventional spine course for physical medicine and rehabilitation residents, and by following the existing cohorts and adding more cohorts in the future, we will continue to demonstrate valuable and comprehensive results.

Hemiplegic Migraine with Concurrent SARS-CoV-2 Infection Leads to Motor Vehicle Collision: a Case Report.

Hemiplegic migraine (HM) is a rare, heterogenous form of migraine characterized by unilateral weakness. This motor aura can present with reversible visual, sensory, and language deficits. HM can be difficult to diagnose due to overlapping presentation with other complex conditions such as multiple sclerosis, seizure disorders, and transient ischemic attack (TIA). We describe a case of a 40-year-old female with asymptomatic COVID-19 infection who presented after a motor vehicle collision caused by HM consistent with left-sided weakness and loss of consciousness. To date, this is the first description of a patient with known complex migraines to have a motor vehicle collision as a result of HM. The risk of HM-associated neurologic symptoms while driving poses a significant public safety concern. We suggest driving restrictions be considered in patients with HM when migraine aura is present. This case presents support to examine active infection with SARS-CoV-2 as a trigger for HM.

A Novel Approach for Fluoroscopic Guided Intra-articular Hip Injections: Technique Description and Case Series.

ABSTRACT: Fluoroscopic guided intra-articular hip injections generally utilize a standard anterior-posterior view. However, this approach can expose patients to inadvertent femoral nerve or vessel infiltration owing to the proximity of the neurovascular bundle to the joint space. This case-series study describes a novel technique using fluoroscopic ipsilateral oblique angulation and caudal tilt of the image intensifier. With this view, the clinician can advance the needle in a lateral to medial trajectory to obtain intra-articular access and minimize the risk of complications. This method was performed in five patients with refractory chronic hip osteoarthritis, which resulted in notable pain improvements and no reported adverse events. The suggested technique could provide a safer alternative to the anterior-posterior imaging technique for intra-articular hip injections by avoiding the femoral neurovascular bundle, limiting needle repositioning, and offering a satisfactory postprocedural analgesic effect.

Virtually Possible: Medical Student Rehabilitation Rotations During a Pandemic.

ABSTRACT: The novel coronavirus 2019 pandemic has led to new dilemmas in medical education because of an initial shortage of personal protective equipment, uncertainty regarding disease transmission and treatments, travel restrictions, and social distancing guidelines. These new problems further compound the already existing problem of limited medical student exposure to the field of physical medicine and rehabilitation, particularly for students in medical schools lacking a department of physical medicine and rehabilitation, approximately 50% of medical schools. A virtual medical student physical medicine and rehabilitation rotation was created to mitigate coronavirus 2019-related limitations and impact on medical education. Using audiovisual technology, students had the opportunity to participate in clinical inpatient and outpatient care, live-streamed procedures, and virtual didactics, develop and showcase their clinical knowledge and reasoning skills, and become familiar with the culture of the physical medicine and rehabilitation residency program. Adaptive educational approaches, including integration of the flipped classroom model, success, pitfalls, and areas for improvement will be described and discussed. Providing nontraditional methods for physical medicine and rehabilitation education and exposure to medical students is crucial to maintain and promote growth of the field in this unprecedented and increasingly virtual era.

Medical Comorbidities and Complications Associated with Poliomyelitis and Its Sequelae.

Survivors of poliomyelitis may experience long-term sequelae that put them at increased risk for injury, pain, cardiovascular deconditioning, and functional decline. Osteoporotic fractures and entrapment neuropathies, in particular, may result in greater impairments in one's mobility and ability to perform activities of daily living. Dysphagia may necessitate the use of compensatory swallow strategies to minimize aspiration risk. Comorbid conditions, including hypertension, dyslipidemia, obesity, and stroke, are also very prevalent in this population. Risk factor modification, including diet, exercise, and medication compliance, is essential to achieve optimal health and function among survivors of poliomyelitis.

The Use of Bedside Ultrasound for Gallstone Disease Care within a Community-based Emergency Department: A Confirmation Bias.

INTRODUCTION: Traditional evaluation for suspicion of gallstone or gallbladder-related disease includes evaluation with a formal technician-performed ultrasound. However, the use of point-of-care bedside ultrasounds (Bedside US) has been shown to be a viable alternative for the diagnosis of gallstones and gallbladder-related diseases. Purpose Statement: The purpose of this study was to evaluate the impact of Bedside US use in gallbladder evaluation on key patient care outcomes within our community-based emergency department setting. METHODS: This retrospective study compared the use of no ultrasound (No US), a formal technician performed ultrasound (Tech US) and Bedside US for gallstone and gallbladder related diseases within a community hospital emergency department between January 1, 2015 and January 1, 2018. Initial vitals, lab work, patient socio-demographics, medical history, emergency department length of stay in hours and disposition were reviewed. RESULTS: Of a total N = 449 patients included, patients who received a Bedside US had the fewest computerized tomography scans (No US 62% vs. Tech US 29% vs. Bedside US 16%; p < 0.0001), the shortest median emergency department length of stay (No US 4.5 days vs. Tech US 5.0 days vs. Bedside US 3.0 days; p < 0.0001), and were more likely to be discharged home (No US 41% vs. Tech US 55% vs. Bedside US 81%; p = 0.0006) compared to those that received no ultrasound or a formal ultrasound. Patients who received a Bedside US also had the statistically significant highest incidence of prior cholelithiasis (No US 29.4% vs Tech US 14.3% vs. Bedside US 31.3%; p = 0.001) and lowest total median bilirubin levels (No US 0.5 vs. Tech US 0.5 vs. Bedside US 0.3; p = 0.016) when compared to the other two groups. CONCLUSIONS: Although there was a confirmation bias, these study results indicate that point-of-care bedside ultrasound could be a viable alternative for gallstones and gallbladder-related diseases with benefits of use in a community hospital setting.

Football (soccer)-related spinal cord injury-reported cases from 1976 to 2020.

STUDY DESIGN: An analysis of reported cases. OBJECTIVES: To analyze the existing data on soccer (international football)-related spinal cord injury (SCI). SETTING: Cases of soccer (international football)-related SCI that were reported globally. METHODS: PubMed/MEDLINE, EMBASE, and online news publication databases were searched. RESULTS: Fourteen cases of football-related SCI that occurred between 1976 and 2020 were found. Average age at the time of injury was 19 and 86% of individuals were males. Eight of 14 individuals had vertebral fracture/dislocation, whereas two individuals had concomitant traumatic brain injury. Neurologically, 54% had tetraplegia, 39% had paraplegia, and 8% each suffered from hemiplegia and sensory deficit. Two cases could regain ability to walk with orthosis and four had full mobility with "Return to Play" (RTP). The mortality was 14%. CONCLUSIONS: Younger males were most commonly affected. The most common etiology, vertebral level of injury, and neurological manifestation was fall, cervical spine, and tetraplegia respectively. More than 50% of the individuals with football-related SCI were able to walk or RTP after rehabilitation. Further studies are required to establish universal RTP criteria and formulate preventive measures.

Cold-water immersion blunts and delays increases in circulating testosterone and cytokines post-resistance exercise.

INTRODUCTION: Cold-water immersion (CWI) is often used to promote recovery by reducing exercise-induced muscle damage, soreness, and inflammation. However, recent reports have cautioned that CWI may attenuate the adaptive response to resistance training. PURPOSE: To determine the effect of post resistance-exercise CWI on circulating free testosterone (T) and cytokine (IL-6 and TNF-α) response. METHODS: Using a randomized and counterbalanced repeated-measures design, 11 resistance-trained men completed two workouts (6 sets of 10 repetitions of back squats at 80% of maximum load) a week apart after which they took part in either 15 min of CWI (15 °C) or passive recovery. T, IL-6, and TNFα were measured in blood samples taken before (PRE) and 5 (5POST), 15 (15POST), 30 (30POST), and 60 (60POST) min post-exercise and compared between treatments and over time. RESULTS: For T, a significant interaction effect of condition over time (p = 0.030) as well as greater relative concentrations of T in CON (Δ9.2%) than CWI (Δ-0.5%, p = 0.049) at 30POST were observed. In addition, at 60POST, T dropped below PRE values in CWI (Δ-10.4%, p = 0.028) but not in CON (Δ-1.6%, p = 0.850). A suppressed cytokine response was observed after CWI in IL-6 at 30POST (CWI: Δ4.9%, CON: Δ47.5%, p = 0.041) and TNFα at 15POST (CWI: Δ5.3%, CON: Δ17.0%, p = 0.022). CONCLUSIONS: CWI blunted the T and cytokine response after a bout of resistance exercise. These results indicate that CWI results in an altered anabolic response and may help to explain the previous observation of attenuated hypertrophy when CWI is used after resistance exercise.

The emerging use of platelet-rich plasma in musculoskeletal medicine.

Platelet-rich plasma (PRP) is one of many new developments within the expanding field of regenerative medicine. Specialists in areas such as orthopedics, physical medicine and rehabilitation, and rheumatology have been exploring the benefits of this novel therapy. Although PRP therapy remains controversial and has minimal clinical trial support, the use of orthobiologics such as PRP continues to advance as patients seek nonsurgical approaches to acute and chronic musculoskeletal injury and disease. However, academic acceptance as well as insurance reimbursement remain reliant on solid and repeatable positive results from large clinical trials. The authors summarize the evolution of PRP therapy and report on its status.

Hypothermia as a clinical neuroprotectant.

Applying therapeutic hypothermia (TH) for the purposes of neuroprotection, originally termed "hibernation," started nearly 100 years ago. Because TH cooling systems have improved to the point where it is practical and safe for general application, interest in providing such treatment in conditions such as spinal cord injury, traumatic brain injury, stroke, and cardiac arrest has increased. This article reviews the mechanisms by which TH mitigates secondary neurologic injury, the clinical scenarios where TH is being applied, and reviews selected published studies using TH for central nervous system neuroprotection.

Mesenchymal stem cell therapies in the treatment of musculoskeletal diseases.

The application of regenerative strategies to musculoskeletal ailments offers extraordinary promise to transform management of the conditions of numerous patients. The use of cell-based therapies and adjunct strategies is under active investigation for injuries and illnesses affecting bones, joints, tendons, and skeletal muscle. Of particular interest to the field is the mesenchymal stem cell, an adult stem cell found in bone marrow and adipose tissue. This cell type can be expanded ex vivo, has allogeneic application, and has the capacity for engraftment and differentiation into mesodermal lineages. Also of major interest in the field is the use of platelet-rich plasma, a strategy to concentrate endogenous cytokines and growth factors with reparative potential. Here we review the biological basis, clinical studies, safety, and current state of mesenchymal stem cell and platelet-rich plasma therapies in the treatment of musculoskeletal disease.

Use of glucosamine and chondroitin in persons with osteoarthritis.

Glucosamine and chondroitin are members of a group of dietary supplements often termed "complementary agents," "disease-modifying agents," or "disease-modifying osteoarthritis drugs" (DMOADs). They are among the best-selling dietary supplements in the United States. DMOADs are thought to act by affecting cytokine-mediated pathways regulating inflammation, cartilage degradation, and immune responses. Given the results of recent studies, investigators have begun to question whether the popular combination of glucosamine and chondroitin alleviates disease progression or pain in people with mild to moderate knee osteoarthritis. Reasons proposed for the lack of benefit include incorrect dosing, suboptimal compound manufacture, and a lack of complete understanding of when and how to apply the compounds. In addition, adjuvant medications also could augment the therapeutic potential of these agents. Although these agents are considered safe, some uncommon and minor adverse effects have been reported, including epigastric pain or tenderness (3.5%), heartburn (2.7%), diarrhea (2.5%), and nausea (1%). In conclusion, although some questions have arisen about whether DMOADs are as effective as has been claimed, a trial should be considered in in selected patients with sustained refractory cases of osteoarthritis.

Evaluating rare earth element availability: a case with revolutionary demand from clean technologies.

The future availability of rare earth elements (REEs) is of concern due to monopolistic supply conditions, environmentally unsustainable mining practices, and rapid demand growth. We present an evaluation of potential future demand scenarios for REEs with a focus on the issue of comining. Many assumptions were made to simplify the analysis, but the scenarios identify some key variables that could affect future rare earth markets and market behavior. Increased use of wind energy and electric vehicles are key elements of a more sustainable future. However, since present technologies for electric vehicles and wind turbines rely heavily on dysprosium (Dy) and neodymium (Nd), in rare-earth magnets, future adoption of these technologies may result in large and disproportionate increases in the demand for these two elements. For this study, upper and lower bound usage projections for REE in these applications were developed to evaluate the state of future REE supply availability. In the absence of efficient reuse and recycling or the development of technologies which use lower amounts of Dy and Nd, following a path consistent with stabilization of atmospheric CO(2) at 450 ppm may lead to an increase of more than 700% and 2600% for Nd and Dy, respectively, over the next 25 years if the present REE needs in automotive and wind applications are representative of future needs.

Imaging in radiculopathy.

All patients presenting with signs and symptoms of lumbar radiculopathy must undergo a thorough history taking and physical examination. Often, however, the diagnosis remains unclear; it is accurate anatomically, but the underlying cause of the lesion is not confirmed, or the symptoms are so severe that more information on the anatomy is required. Therefore, the next step in the diagnostic process is imaging studies. This article discusses imaging modalities, including plain radiographs, magnetic resonance imaging, computed tomography (CT), CT myelogram, selective nerve root block, and bone scan.

Cell-specific information processing in segregating populations of Eph receptor ephrin-expressing cells.

Cells have self-organizing properties that control their behavior in complex tissues. Contact between cells expressing either B-type Eph receptors or their transmembrane ephrin ligands initiates bidirectional signals that regulate cell positioning. However, simultaneously investigating how information is processed in two interacting cell types remains a challenge. We implemented a proteomic strategy to systematically determine cell-specific signaling networks underlying EphB2- and ephrin-B1-controlled cell sorting. Quantitative mass spectrometric analysis of mixed populations of EphB2- and ephrin-B1-expressing cells that were labeled with different isotopes revealed cell-specific tyrosine phosphorylation events. Functional associations between these phosphotyrosine signaling networks and cell sorting were established with small interfering RNA screening. Data-driven network modeling revealed that signaling between mixed EphB2- and ephrin-B1-expressing cells is asymmetric and that the distinct cell types use different tyrosine kinases and targets to process signals induced by cell-cell contact. We provide systems- and cell-specific network models of contact-initiated signaling between two distinct cell types.