Unexpected Hurdle in the Race: Hypophosphatasia Unmasked by the Female Athlete Triad.

Hypophosphatasia should be considered for any patient who presents with multiple metatarsal stress fractures and a low alkaline phosphatase.

The effect of linguistic background on rapid number naming: implications for native versus non-native English speakers on sideline-focused concussion assessments.

OBJECTIVE: To determine if native English speakers (NES) perform differently compared to non-native English speakers (NNES) on a sideline-focused rapid number naming task. A secondary aim was to characterize objective differences in eye movement behaviour between cohorts. BACKGROUND: The King-Devick (KD) test is a rapid number-naming task in which numbers are read from left-to-right. This performance measure adds vision-based assessment to sideline concussion testing. Reading strategies differ by language. Concussion may also impact language and attention. Both factors may affect test performance. METHODS: Twenty-seven healthy  NNES and healthy NES performed a computerized KD test under high-resolution video-oculography.  NNES also performed a Bilingual Dominance Scale (BDS) questionnaire to weight linguistic preferences (i.e., reliance on non-English language(s)). RESULTS: Inter-saccadic intervals were significantly longer in  NNES (346.3 ± 78.3 ms vs. 286.1 ± 49.7 ms, p = 0.001), as were KD test times (54.4 ± 15.1 s vs. 43.8 ± 8.6 s, p = 0.002). Higher BDS scores, reflecting higher native language dominance, were associated with longer inter-saccadic intervals in  NNES. CONCLUSION: These findings have direct implications for the assessment of athlete performance on vision-based and other verbal sideline concussion tests; these results are particularly important given the international scope of sport. Pre-season baseline scores are essential to evaluation in the event of concussion, and performance of sideline tests in the athlete's native language should be considered to optimize both baseline and post-injury test accuracy.

Stuck on You: Chewing Gum Adherent to the Oral Airway in Electroconvulsive Therapy (ECT).

We present a case in which a piece of chewing gum was discovered adhering to the oral airway when it was removed after an ECT procedure. We suggest that careful examination of the patient's mouth for foreign objects be a standard part of the pre-ECT protocol.

Automatic implantable cardioverter defibrillator in electroconvulsive therapy.

As the number of patients with implantable cardiac devices increases so too does the frequency with which these individuals present for electroconvulsive therapy (ECT). The rationale for deactivating an automatic implantable cardioverter defibrillator before ECT has been made based on the concern that artifacts generated during treatment could be interpreted as a treatable rhythm by the internal device, resulting in a discharge. We believe that the risk of inappropriate discharge during ECT is very low and outweighed by the considerable benefit of an active device being able to more quickly treat a malignant dysrhythmia.

Depression severity in electroconvulsive therapy (ECT) versus pharmacotherapy trials.

OBJECTIVE: We sought to compare the level of severity of depressive symptoms on entry into electroconvulsive therapy (ECT) clinical trials versus pharmacotherapy clinical trials. DATA SOURCES: English-language MEDLINE/PubMed publication databases were searched for ECT literature (search terms: ECT, electroconvulsive therapy, depression, and Hamilton) for clinical trials in which depressed patients had baseline Hamilton Rating Scale for Depression (HRSD) scores. For comparison, we used a convenience sample of 7 large pharmacotherapy trials in major depression (N = 3677). The search included articles from 1960 to 2011. STUDY SELECTION: We included 100 studies that met the following criteria: ECT trial for depression, patients adequately characterized by diagnosis at baseline, and patients rated at baseline by 15-item HRSD (HRSD15), HRSD17, HRSD21, HRSD24, or HRSD28, with mean (SD) and sample size (n) reported. For the comparator pharmacotherapy trials, we chose to use a subset of the studies (excluding one study of minor depression) in the widely publicized meta-analysis of Fournier et al, as well as the STAR*D study and one additional study by Shelton et al. This provided 7 studies of major depression using HRSD17 (total N = 3677). DATA EXTRACTION: Data extracted included number of subjects and baseline and final HRSD scores, with mean (SD) values. RESULTS: Of 100 ECT studies, 56 studies (N = 2243) used the HRSD17 version. The mean baseline HRSD17 score in the ECT trials was 27.6, the mean in the pharmacotherapy trials was 21.94, a statistically, and clinically, significant difference. In a subanalysis of the 16 ECT studies that used the HRSD24 version, the mean baseline score was 32.2. CONCLUSIONS: This selective literature review confirms that patients who entered ECT clinical trials were more severely ill than those who entered the selected comparator pharmacotherapy trials. Such data highlight the critical role of ECT in the treatment of severe and treatment-resistant mood disorders.

Treatment-resistant postictal agitation after electroconvulsive therapy (ECT) controlled with dexmedetomidine.

Emergence agitation is a common complication of electroconvulsive therapy. Standard supportive and pharmacological interventions are usually effective management strategies. We report a case of severe agitation after electroconvulsive therapy that was refractory to the usual treatments but was controlled with dexmedetomidine.

Transient hemiparesis (Todd's paralysis) after electroconvulsive therapy (ECT) in a patient with major depressive disorder.

We report the case of a 50-year-old man who exhibited transient left hemiparesis (Todd's paralysis) after electroconvulsive therapy, which completely resolved within 10 minutes. Subsequent neurological evaluation was unremarkable for discrete etiologies for this event, other than Todd's paralysis. We review the literature of this phenomenon in association with electroconvulsive therapy.

Low-dose right unilateral electroconvulsive therapy (ECT): effectiveness of the first treatment.

BACKGROUND: Electroconvulsive therapy (ECT) is a widely used, highly effective antidepressant treatment. Except for the most severely ill patients, right unilateral (RUL) electrode placement is the most frequent initial treatment choice. In current practice, RUL ECT is administered at several multiples of seizure threshold (ST) based on reports that lower stimulus intensity results in lower response/remission rates. Many patients, as part of an initial dose titration to determine ST, will receive a single treatment with low-dose RUL ECT and subsequent treatments with a stimulus at a multiple of ST. OBJECTIVE: To assess response to the first ECT. METHODS: A retrospective analysis of charts from clinical practice at Mount Sinai Medical Center was performed. RESULTS: A single treatment with low-dose (presumably near ST) RUL ECT had a significant and immediate antidepressant effect in our sample of patients with major depression. We determined that this response is similar to that of patients receiving a single initial treatment with high-dose RUL ECT (at a multiple of ST). CONCLUSIONS: These data suggest, contrary to commonly held belief, that RUL ECT may be effective at a low stimulus dose. This argues against restimulating at 6 times ST in the initial session, based on the belief that the near-threshold seizure has no antidepressant efficacy. Our findings suggest a need for further investigation of cases in which low-dose RUL ECT may be an effective antidepressant treatment. Further prospective studies, including larger numbers of patients who receive randomized treatment with low- or high-dose RUL with longer follow-up, are indicated.

Non-operative Management and Outcomes of Femoroacetabular Impingement Syndrome.

PURPOSE: To serve as a guide for non-operative physicians in the management of femoroacetabular impingement syndrome and provide an algorithm as to when to refer patients for potential surgical management. RECENT FINDINGS: Supervised physical therapy programs that focus on active strengthening and core strengthening are more effective than unsupervised, passive, and non-core-focused programs. There is promising evidence for the use of intra-articular hyaluronic acid and PRP as adjunct treatment options. Recent systematic reviews and meta-analyses have found that in young active patients, hip arthroscopy demonstrates improved short-term outcomes over physical therapy. The decision for the management of FAIS is complex and should be specific to each patient. Consideration of the patient's age, timing to return to sport, longevity of treatment, hip morphology, and degree of cartilage degeneration is required to make an informed decision in the treatment of these patients.

The Telltale Heart or the importance of the "Tap Test" in electroconvulsive therapy (ECT).

The "Tap Test" is a maneuver used to test the functioning of the electroencephalogram and electromyogram leads just prior to electroconvulsive therapy. Here we present a brief case and image that reinforces the importance of this simple test.

Multiple episodes of intraictal cessation during electroconvulsive therapy.

A recent case reported an episode of a "stop-start-stop" phenomenon during an electroconvulsive therapy treatment. We report an example of multiple stop-start-stop episodes during several electroconvulsive therapy treatments of a 16-year-old boy.

Electrocardiographic "bleed through" to the electroencephalogram on an electroconvulsive therapy (ECT) tracing: the return of the tell-tale heart.

Improper recording electrode placement can cause artifacts on electroconvulsive therapy tracings. This shows an example of electrocardiogram artifact in the electroencephalogram.

Febrile reaction with elevated CPK after a single electroconvulsive therapy (ECT) in an adolescent patient with severe bipolar disorder.

This report describes the electroconvulsive therapy (ECT) course of a 15-year-old male with severe bipolar disorder unresponsive to medical management. After his first treatment, the patient exhibited fever, elevated creatine phosphokinase levels, and leukocytosis. Treatment was halted although the patient reported an improvement in symptoms, which was not maintained with pharmacotherapy alone. Subsequent treatments were completed without adverse reactions, and the patient entered remission. We discuss the possible causes of this reaction and remind the reader that a single adverse event does not always require the abandonment of a treatment modality.

Methohexital and succinylcholine dosing for electroconvulsive therapy (ECT): actual versus ideal.

This report compares the actual doses of methohexital and succinylcholine used for optimal anesthesia and muscle relaxation in electroconvulsive therapy with written guidelines for dosing. The initial doses of methohexital and succinylcholine in milligrams per kilogram were reviewed and compared with subsequent doses of each agent after adjustments were made for individual patient responses during treatment. The dose of methohexital required to induce general anesthesia for most patients is 1.0 mg/kg. The dose of succinylcholine required to provide adequate muscle relaxation during electroconvulsive therapy is 0.9 mg/kg, although there is considerable variability in patient response to this drug.

Mesenchymal stem cells for subchondral bone marrow lesions: From bench to bedside.

Subchondral bone marrow lesions (BMLs) are areas of disease within subchondral bone that appear as T1 hypointense and T2 hyperintense ill-defined areas of bone marrow on magnetic resonance imaging. The most common bone marrow lesions include subchondral lesions related to osteoarthritis, osteochondral defects, and avascular necrosis. Emerging therapies include autologous biologic therapeutics, in particular mesenchymal stem cells (MSCs), to maintain and improve cartilage health; MSCs have become a potential treatment option for BMLs given the unmet need for disease modification. Active areas in the preclinical research of bone marrow lesions include the paracrine function of MSCs in pathways of angiogenesis and inflammation, and the use of bioactive scaffolds to optimize the environment for implanted MSCs by facilitating chondrogenesis and higher bone volumes. A review of the clinical data demonstrates improvements in pain and functional outcomes when patients with knee osteoarthritis were treated with MSCs, suggesting that BM-MSCs can be a safe and effective treatment for patients with painful knee osteoarthritis with or without bone marrow lesions. Preliminary data examining MSCs in osteochondral defects suggest they can be beneficial as a subchondral injection alone, or as a surgical augmentation. In patients with hip avascular necrosis, those with earlier stage disease have improved outcomes when core decompression is augmented with MSCs, whereas patients in later stages post-collapse have equivalent outcomes with or without MSC treatment. While the evidence for the use of MSCs in conditions with associated bone marrow lesions seems promising, there remains a need for continued investigation into this treatment as a viable treatment option.