Evaluating caregiver-child interactions in low- and middle-income countries: a systematic review of tools and methods.

AIMS/BACKGROUND: The United Nations Sustainable Development Goals (SDGs) has placed emphasis on improving early child development globally. This is supported through the Nurturing Care Framework which includes responsive caregiving. To evaluate responsive caregiving, tools to assess quality of caregiver-child interactions are used, however there is little information on how they are currently employed and/or adapted particularly in low- and middle-income countries (LMICs) where children have a greater risk of adverse outcomes. The aim of this review is to provide a comprehensive guide on methodologies used to evaluate caregiver-child interaction - including their feasibility and cultural adaptation. DESIGN/METHODS: We conducted a systematic review of studies over 20years in LMICs which assessed caregiver-child interactions. Characteristics of each tool, their validity (assessed with COSMIN Risk of Bias checklist), and the quality of the study (Mixed Methods Appraisal Tool) are reported. RESULTS: We identified 59 studies using 34 tools across 20 different LMICs. Most tools (86.5%) employed video-recorded observations of caregiver-child interactions at home (e.g. Ainsworth's Sensitivity Scale, OMI) or in the laboratory (e.g. PICCOLO) with a few conducting direct observations in the field (e.g. OMCI, HOME); 13.5% were self-reported. Tools varied in methodology with limited or no mention of validity and reliability. Most tools are developed in Western countries and have not been culturally validated for use in LMIC settings. CONCLUSION: There are limited caregiver-child interaction measures used in LMIC settings, with only some locally validated locally. Future studies should aim to ensure better validity, applicability and feasibility of caregiver-child interaction tools for global settings.

Methadone Maintenance Treatment for Opioid Dependents: a Retrospective Study.

OBJECTIVES: To determine the prevalence of continued illicit drug use among people enrolled in methadone maintenance treatment (MMT), the association between hepatitis C status and methadone dosage, and the predictors for illicit drug abstinence during MMT. METHODS: Clinical records of active opioid dependents who underwent MMT between 1 January 2007 and 31 March 2021 in Hospital Tuanku Fauziah, Perlis, Malaysia were retrospectively reviewed. Data collected included baseline demographics, history of illicit drug use, temporal trend in methadone dosage modulation, and co-use of illicit drugs during the MMT. RESULTS: A total of 87 patients (mean age, 43.9 ± 8.33 years) were included. Their mean duration of involvement in MMT was 7.8 ± 3.69 years. The most commonly used drug was heroin (88.5%), followed by kratom (51.7%). Between 2019 and 2021, 61 (70.1%) patients had ceased abusing opioid, but 51 (58.6%) patients continued using any of the illicit drugs. Methamphetamine and amphetamine co-use was most common (n = 12, 37.5%). Hepatitis C status was not associated with the current methadone dose (U = 539.5, p = 0.186) or the highest dose required (t = -0.291, df = 74, p = 0.772). No predictor for illicit drug abstinence during MMT was identified. Methadone dose positively correlated with frequency of defaulting treatments (r = 0.22, p = 0.042). CONCLUSION: Among our patients, MMT for opioid dependents cannot sufficiently curb illicit drug use, and there is a shift toward stimulants abuse.

Defining the rate of nutritional and metabolic derangements after pancreatic resection.

BACKGROUND AND AIMS: Pancreatic resection is associated with pancreatic exocrine insufficiency (PEI) leading to nutritional consequences. The Pancreatic Nutrition Clinic was established to diagnose and manage PEI through standardised nutritional assessment. In this prospective observational study, we aimed to define the rate of PEI, diabetes mellitus and nutritional abnormalities in patients who underwent pancreatic resection. METHODS: All Pancreatic Nutrition Clinic patients were included for analysis. Clinical data were prospectively obtained at initial assessment. Biochemical data included micronutrient levels, faecal elastase-1 and haemoglobin A1c. Bone mineral density and nutritional assessment were undertaken. RESULTS: Ninety-eight patients were included. Fifty-nine per cent (58/98) had undergone a pancreatoduodenectomy. Ninety-three patients had a faecal elastase-1 result, 65% (60/93) of which had a faecal elastase-1 less than 200 µg/g of faeces. Seventy-five patients (76%) of the total population required PERT, and thirty-nine (40%) were classified as malnourished using the patient-generated subjective global assessment tool. Seventy-two per cent (70/97) had a biochemical deficiency of one or more micronutrients. Thirty-eight people (39%) had diabetes mellitus. Of the seventy-eight patients with a bone mineral density scan available for analysis, 29% (23/78) had osteoporosis and 49% (38/78) osteopenia. CONCLUSIONS: Pancreatic exocrine insufficiency, micronutrient deficiency, bone disease, diabetes mellitus and malnutrition are highly prevalent in patients who have undergone pancreatic resection.

Pulmonary arteriovenous malformations: A case of missed diagnosis in a neonate.

Pulmonary arteriovenous malformation (PAVM) is a congenital vascular abnormality that can cause persistent cyanosis in children. PAVMs can go undetected till adulthood; however, there have been several neonatal cases reported over the years. This case report describes a classical manifestation of a child with isolated PAVM whose diagnosis was likely missed during the neonatal period. A high level of clinical awareness of this condition is crucial as early diagnosis and appropriate treatment can prevent lifethreatening complications and mortality. Diagnosis was confirmed by computed tomography pulmonary angiography and percutaneous transcatheter embolotherapy resulted in complete resolution of symptoms.

Evaluation of Encephaloduroarteriosynangiosis Efficacy Using Probabilistic Independent Component Analysis Applied to Dynamic Susceptibility Contrast Perfusion MRI.

BACKGROUND AND PURPOSE: Indirect cerebral revascularization has been successfully used for treatment in Moyamoya disease and symptomatic intracranial atherosclerosis. While angiographic neovascularization has been demonstrated after surgery, measurements of local tissue perfusion are scarce and may not reflect the reported successful clinical outcomes. We investigated probabilistic independent component analysis and conventional perfusion parameters from DSC-MR imaging to measure postsurgical changes in tissue perfusion. MATERIALS AND METHODS: In this prospective study, 13 patients underwent unilateral indirect cerebral revascularization and DSC-MR imaging before and after surgery. Conventional perfusion parameters (relative cerebral blood volume, relative cerebral blood flow, and TTP) and probabilistic independent components that reflect the relative contributions of DSC signals consistent with arterial, capillary, and venous hemodynamics were calculated and examined for significant changes after surgery. Results were compared with postsurgical DSA studies to determine whether changes in tissue perfusion were due to postsurgical neovascularization. RESULTS: Before surgery, tissue within the affected hemisphere demonstrated a high probability for hemodynamics consistent with venous flow and a low probability for hemodynamics consistent with arterial flow, whereas the contralateral control hemisphere demonstrated the reverse. Consistent with symptomatic improvement, the probability for venous hemodynamics within the affected hemisphere decreased with time after surgery (P = .002). No other perfusion parameters demonstrated this association. Postsurgical DSA revealed an association between an increased preoperative venous probability in the symptomatic hemisphere and neovascularization after surgery. CONCLUSIONS: Probabilistic independent component analysis yielded sensitive measurements of changes in local tissue perfusion that may be associated with newly formed vasculature after indirect cerebral revascularization surgery.

Angiographic Structural Differentiation between Native Arteriogenesis and Therapeutic Synangiosis in Intracranial Arterial Steno-Occlusive Disease.

BACKGROUND AND PURPOSE: Encephaloduroarteriosynangiosis has been shown to generate collateral vessels from the extracranial-to-intracranial circulation in patients with Moyamoya disease and intracranial arterial steno-occlusive disease. The mechanisms involved are not well-understood. We hypothesized that angiogenesis is the leading mechanism forming collaterals after encephaloduroarteriosynangiosis because there are no pre-existing connections. Angiogenesis-generated collaterals should exhibit higher architectural complexity compared with innate collaterals. MATERIALS AND METHODS: Pre- and postoperative digital subtraction angiograms were analyzed in patients enrolled in a prospective trial of encephaloduroarteriosynangiosis surgery. Branching angioscore, tortuosity index, and local connected fractal dimension were compared between innate and postoperative collaterals. RESULTS: One hundred one angiograms (50 preoperative, 51 postoperative) were analyzed from 44 patients (22 with intracranial atherosclerosis and 22 with Moyamoya disease). There was a significantly higher median branching angioscore (13 versus 4, P < .001) and a lower median tortuosity index (1.08 versus 1.76, P < .001) in the encephaloduroarteriosynangiosis collaterals compared with innate collaterals. Higher mean local fractal dimension peaks (1.28 ± 0.1 versus 1.16 ± 0.11, P < .001) were observed in the encephaloduroarteriosynangiosis collaterals compared with innate collaterals for both intracranial atherosclerosis (P < .001) and Moyamoya disease (P < .001) groups. The observed increase in high connectivity was greater in the intracranial atherosclerosis group compared with patients with Moyamoya disease (P = .01). CONCLUSIONS: The higher median branching angioscore and local connected fractal dimension, along with the lower median tortuosity index of encephaloduroarteriosynangiosis collaterals, are consistent with the greater complexity observed in the process of sprouting and splitting associated with angiogenesis.

Omega-3 fatty acids in the management of autism spectrum disorders: findings from an open-label pilot study in Singapore.

The goal of this open-label trial was to examine the efficacy and safety of a 12-week omega-3 fatty acids supplementation among children suffering with Autism Spectrum Disorders (ASD). A total of 41 children and adolescents aged 7-18 years (36 boys, 5 girls; mean age = 11.66, s.d. = 3.05) diagnosed with ASD participated in the study. At post-treatment, participants showed significant improvements on all subscales of the Social Responsiveness Scale (P < 0.01) and the Social and Attention Problems syndrome scales of the Child Behavior Checklist (P < 0.05). Blood fatty acid levels were significantly correlated with changes in the core symptoms of ASD. Baseline levels of blood fatty acid levels were also predictive of response to the omega-3 treatment. Omega-3 fatty acids supplementation was well-tolerated and did not cause any serious side effects. Our findings lend some preliminary support for the use of omega-3 fatty acids supplementation in addressing ASD. Future randomized controlled trials of omega-3 fatty acids in ASD with blood fatty acid measurements with a larger sample and longer follow-up period is warranted.

The structural effect of intravitreal Brilliant blue G and Indocyanine green in rats eyes.

PURPOSE: To compare the potential retinal toxicity of two commercially Brilliant blue G dyes (Brilliant Peel and Ocublue Plus) and Indocyanine green (ICG) at usual clinical concentration. METHODS: Brilliant Peel 0.025% (n=9), Ocublue Plus 0.025% (n=9), and ICG 0.05% (n=9) were injected intravitreally into Sprague-Dawley rat left eyes with balanced salt solution injected in the contralateral eyes as control. Evaluation of the effect of the dyes on retinal architecture was done by histological analysis of neurosensory retinal thickness and retinal ganglion cell (RGC) counts 7 days after intravitreal injection. Paired t-test was done to detect the presence of biologically significant thinning in neurosensory retina and five retinal layers for each dye (paired t-tests). One-way ANOVA and Tukey's Honestly Significant Difference test were used to assess whether different dyes caused significant thinning in mean neurosensory retinal thickness and reduction of mean RGC density. RESULTS: Eyes treated with ICG had significantly thinner mean total neurosensory retinal thickness compared with the control eyes (P-value=0.01), followed by those treated with Ocublue Plus (P-value=0.03). Brilliant Peel did not cause significant thinning in any of the five retinal layers (all P-values>0.05). No significant difference in mean thinning of the total retinal thickness was detected between dyes (P-value=0.11). The mean thickness of the photoreceptor outer segment and outer plexiform layers were significantly reduced in ICG-injected eyes when compared with the control eyes (P-value=0.02). No significant difference in mean thinning between the three dyes was detected at all five retinal layers using one-way ANOVA (all P-values>0.35). RGC density was significantly reduced for ICG (P-value=0.01) but only marginally for Ocublue Plus (P-value=0.05). No significant reduction in RGC density was observed for Brilliant Peel (P-value=0.2). CONCLUSION: Intravitreal Brilliant Peel is safe to rats retina. The retinal thinning and reduction in RGC density induced by Ocublue Plus requires further studies to determine the safety profile of this product. Potential retinal toxicity is seen with ICG 0.05%.

Combined optic neuropathy and central retinal artery occlusion in presumed ocular tuberculosis without detectable systemic infection.

PURPOSE: To report a rare case of combined optic neuropathy and central retinal artery occlusion in presumed ocular tuberculosis without systemic infection. CASE REPORT: A young man presented with sudden onset of decreased vision in his left eye with combined optic disc swelling and central retinal artery occlusion in a background of vasculitic changes of the same eye. There were no signs or symptoms of active systemic tuberculosis infection. Chest X-ray and computed tomography thorax findings were normal and sputum cultures for tuberculosis were negative. The Mantoux and QuantiFERON-TB Gold tests were strongly positive. No tuberculosis polymerase chain reaction testing was done. Anti-tuberculosis therapy was initiated, based on the strong clinical evidence. CONCLUSION: The ocular findings improved remarkably with the anti-tuberculosis treatment, although the left eye vision remained poor. A high index of suspicion is required to diagnose ocular tuberculosis when all other systemic investigations are negative, especially in this part of the world where tuberculosis is endemic.

Influence of Chinese cultural health beliefs among Malaysian Chinese in a suburban population: a survey.

INTRODUCTION: In a multiethnic nation, it is not uncommon for doctors to encounter patients of different cultural backgrounds. Often, patients' cultural beliefs influence their perception of health and illnesses, and their treatment option. Many Chinese cultural beliefs are influenced by the Taoist concept of yin-yang balance. METHODS: We interviewed 50 Malaysian Chinese from the general public of a suburban population in order to unravel the impact of Chinese cultural health beliefs on their decision-making, and this was compared with the opinions of 50 Chinese medical students from second to final year. Convenience sampling was then applied. RESULTS: From the survey, 78 percent of the general public believed that 'too much heat' or 'too much coldness' in the body could cause diseases. Compared to the medical students, a significantly higher number of the respondents held such beliefs, including the beliefs that abdominal colic is due to excessive 'wind' in the abdomen, consuming certain food can dispel wind from the body, and the importance of observing taboos during the confinement period after delivery. The majority of respondents from both groups believed that it is acceptable to combine both traditional Chinese medicine and modern medicine. CONCLUSION: There is a discrepancy in the extent to which these beliefs influence the perception of health and illnesses among the general public and among medical students. Healthcare providers need to be aware of such beliefs and practices regarding traditional Chinese medicine among their Chinese patients.

The brain mapping of the retrieval of conditioned taste aversion memory using manganese-enhanced magnetic resonance imaging in rats.

Manganese-enhanced MRI (MEMRI) is a newly developed noninvasive imaging technique of brain activities. The signal intensity of MEMRI reflects cumulative activities of the neurons. To validate the use of MEMRI technique to investigate the neural mechanisms of learning and memory, we tried to map brain areas involved in the retrieval of conditioned taste aversion (CTA) memory. CTAs were established to saccharin (conditioned stimulus: CS) by pairing its ingestion with an i.p. injection of LiCl (unconditioned stimulus: US). LiCl solutions (as a robust aversion chemical) of 0.15 M were injected i.p. 15 min after drinking the saccharine solution (CS). After the two times conditionings, these rats showed a robust aversion to the saccharine solution (CS). Rats of the control group were injected saline i.p. instead of LiCl solutions. The MRI signal intensities at the gustatory cortex (GC), the core subregion of the nucleus accumbens (NAcC), the shell subregion of the nucleus accumbens (NAcSh), the ventral pallidum (VP), the central nucleus of amygdala (CeA), the lateral hypothalamus (LH), and the basolateral nucleus of amygdala (BLA) of the conditioned group were higher than those of the control group. There were no significant differences between the conditioned and the control groups in the intensities for other regions, such as the striatum area, motor cortex, cingulate cortex, interstitial nucleus of the posterior limb of the anterior commissure and hippocampus. These indicate that the GC, NAcC, NAcSh, VP, CeA, LH and BLA have important roles in the memory retrieval of CTA.

Mouse bone marrow mesenchymal stem cells acquire CD45-CD106+ immunophenotype only at later passages.

Classically, MSC are identified by a CD45-CD106+ phenotype. In this study, we found that mouse MSC achieve this characteristic phenotype only at later passages. With increasing passages, CD45 (hematopoietic marker) expression shifts to negativity, whereas CD106 (vascular cell adhesion molecule-1) expression becomes increasingly positive. These results demonstrate that MSC cells cultured from mouse bone marrow acquire a classical MSC immunophenotype (CD45-CD106+) in later passages.

Effects of cognitive-behavioural therapy on anxiety for children with high-functioning autistic spectrum disorders.

INTRODUCTION: Children with autistic spectrum disorders (ASD) often exhibit one or more comorbid disorders, including anxiety, disruptive behaviour, mental retardation, and depression. Various studies have documented the effectiveness of cognitive-behavioural therapy (CBT) in treating children with anxiety. Although studies have indicated a high prevalence of anxiety in individuals with ASD, there is a lack of systematic studies substantiating the effectiveness of cognitive-behavioural interventions among children with high-functioning autism. METHODS: This pilot study investigated the effects of a 16-session CBT programme on six high-functioning children diagnosed with ASD (mean age 11.50 years, standard deviation 0.84 years). These children were diagnosed with ASD or Asperger's syndrome by the DSM-IV criteria. Measures on levels of child's anxiety, parental and teacher stress were administered at pre- and post-treatment. RESULTS: Children showed lower levels of anxiety at post-treatment. Parents and teachers also reported lower levels of stress following the CBT programme. CONCLUSION: Findings from the present study provided some evidence of the effects of CBT for high-functioning autistic children in reducing anxiety, parental and teacher stress. Interpretation of the findings, recommendations for future research and implications of the present study are presented.

Velocity pulse advances pressure pulse by close to 45 degrees in the rat pial arterioles.

In order to clarify the phase relationship between velocity pulse and pressure pulse propagating along microvessels, the red cell velocity and intravascular pressure were simultaneously measured in the rat pial arterioles of 41-53 microm in diameter with a high temporal resolution by a laser-Doppler anemometer and a servo-null micropressure system. It was found that the velocity pulse preceded the pressure pulse in all the measured arterioles by 18.7-35.6 ms. The corresponding phase difference was 43.6+/-6.9 degrees (mean +/- SD), which is not statistically different from 45 degrees. The value is consistent with the phase difference predicted for the blood flow in microvessels with a small reflection coefficient at frequencies as low as the heart rate of the rats. The present results suggest that the upstream changes in blood flow are transmitted by the velocity pulse faster than by the pressure pulse in the microvasculature.

A survey of white line disease in Japanese racehorses.

A survey was carried out into white line disease in 1781 Thoroughbred racehorses kept in stables at the Japan Racing Association (JRA) Miho Training Center (MTC) September-October 1996. The survey was conducted while horses were being shod by farriers. The horses that still exhibited damaged white lines after regular trimming were diagnosed as having white line disease. The factors recorded were age, sex, number of diseased horses, number of diseased hooves, number of lesions by region over the bearing border of the hoof and the classified length of such lesions. The percentage of total diseased horses was 11.5% (204 animals), with incidence increasing significantly with age (P< or =0.01). Occurrence was independent of sex (P>0.05) was more frequent in the fore- than in the hindhoof and developed more frequently at the toe than at any other region of the forehoof-bearing border. Most lesions ranged from 20 to 30 mm in length.

Morphine prevents peroxynitrite-induced death of human neuroblastoma SH-SY5Y cells through a direct scavenging action.

N-ethyl-2-(1-ethyl-2-hydroxy-2-nitrosohydrazino)-ethanamine (NOC12), a nitric oxide donor, 3-morpholinosydnonimine (SIN-1), a generator of peroxynitrite (ONOO-), and peroxynitrite induced cell death accompanied by DNA fragmentation in human neuroblastoma SH-SY5Y cell cultures. Morphine prevented the cell death induced by SIN-1 or peroxynitrite, but not that induced by NOC12. The protective effect of morphine was concentration-dependent (10-100 microM), but was not antagonized by naloxone. The selective ligands for opioid receptor subtypes, [D-Ala2, N-Me-Phe4, Gly-ol5]enkephalin (DAMGO, micro-opioid receptor agonist), [D-Pen2,5]enkephalin (DPDPE, delta-opioid receptor agonist) and trans-(+/-)-3,4-dichloro-N-methyl-N-(2-[1-pyrrolidinyl]-cyclohexyl)benze neacetamide (U-50488, kappa-opioid receptor agonist) even at the concentration of 100 microM did not prevent the cell death induced by SIN-1. From measurement of the absorbance spectrum of peroxynitrite, the decomposition of peroxynitrite in 0.25 M potassium phosphate buffer (pH 7.4) was very rapid and complete within seconds. However, the absorbance was very stable in the presence of morphine. In addition, morphine inhibited peroxynitrite-induced nitration of tyrosine in a concentration-dependent manner. These results indicate that morphine rapidly reacts with peroxynitrite. The present study showed that morphine prevented peroxynitrite-induced cell death through its direct scavenging action, suggesting that morphine can protect cells against damage caused by peroxynitrite.

Lipopolysaccharide (LPS) stimulates the production of tumor necrosis factor (TNF)-alpha and expression of inducible nitric oxide synthase (iNOS) by osteoclasts (OCL) in murine bone marrow cell culture.

Osteoclasts (OCL) resorb bone. They are essential for the development of normal bones and the repair of impaired bones. The function of OCL is presumed to be supported by cytokines and other biological mediators, including tumor necrosis factor (TNF)-alpha and nitric oxide (NO). Bacterial lipopolysaccharide (LPS) is a potent inducer of TNF-alpha and inducible nitric oxide synthase (iNOS), which is the specific enzyme for synthesizing NO from L-arginine. To obtain direct evidence on LPS-induced TNF-alpha production and iNOS expression by OCL, OCL-enriched cultures were prepared by 7-day cocultures of bone marrow cells of adult BALB/c mice and osteoblastic cells (OBs) derived from calvaria of newborn BALB/c mice, and the generation of TNF-alpha and iNOS in OCL stimulated with LPS was examined immunocytochemically. When the cultured cells were stimulated with 100 ng/ml of LPS, OCL clearly showed TNF-alpha and iNOS expression. Without LPS-stimulation, no expression was observed. TNF activity in the culture supernatants of the OCL-enriched cultures in the presence of LPS was also detected by cytotoxic assay that used TNF-sensitive L929 cells. The dentin resorption activity of OCL was estimated by area and number of pits formed on dentin slices, which were covered by the OCL fraction and cultured in the presence or absence of LPS, sodium nitroprusside (SNP; a NO generating compound), N(G)-monomethyl L-arginine acetate (L-NMMA; a competitive inhibitor of NO synthase (NOS)), or LPS plus L-NMMA. Pit formation was obviously inhibited in the presence of SNP and slightly inhibited in the presence of L-NMMA, but it was not affected in the presence of LPS or LPS plus L-NMMA. These findings indicate that OCL produces TNF and expresses iNOS in response to LPS, but the LPS-activation of OCL scarcely affects pit formation by them.

Thermoregulatory effects of spinal and epidural anesthesia during cesarean delivery.

BACKGROUND AND OBJECTIVES: Hypothermia is likely to develop faster during spinal anesthesia than epidural anesthesia. A natural consequence of the rapid temperature decrease during spinal anesthesia is that the shivering threshold will be reached sooner and that more shivering will be required to prevent further hypothermia. We tested the hypotheses that the onset of hypothermia is more rapid and the onset and intensity of shivering earlier during spinal than epidural anesthesia. METHODS: Patients undergoing cesarean delivery were randomly assigned to spinal anesthesia or epidural anesthesia. Spinal anesthesia was induced by injecting 2 mL 0.5% dibucaine into the L4-L5 interspace. Epidural anesthesia was induced with 20 mL 2% mepivacaine injected into the L2-L3 interspace. Thermal comfort and shivering were scored by a blinded observer. RESULTS: Fifteen patients given each type of anesthesia had upper sensory levels > or =T4 dermatome. Sensation was entirely absent from the leg during spinal anesthesia, but lower block levels were near S5 during epidural anesthesia. Tympanic membrane temperatures initially decreased faster during spinal anesthesia, but subsequently decreased at a rate of 0.5 degrees C/h in both groups. The onset and incidence of shivering (detected qualitatively) did not differ significantly between the two groups, but shivering intensity was significantly reduced during spinal anesthesia. Furthermore, the shivering thresholds were 36.4+/-0.3 degrees C (mean+/-SD) during spinal anesthesia versus 37.1+/-0.4 degrees C in those given epidural anesthesia (P=.006). There were no clinically important differences in thermal comfort with the two kinds of neuraxial anesthesia. CONCLUSIONS: We failed to confirm our hypothesis, but for an unexpected reason: Thermoregulation was impaired more by spinal anesthesia than epidural anesthesia. It seems likely that in our patients spinal anesthesia inhibited thermoregulatory control more than epidural anesthesia because it better blocked sensory input from the legs.