Effect of endodontic irrigants on biofilm matrix polysaccharides.

AIM: To specifically investigate the effect of endodontic irrigants at their clinical concentration on matrix polysaccharides of cultured biofilms. METHODOLOGY: Saccharolytic effects of 3% H2 O2 , 2% chlorhexidine (CHX), 17% EDTA, 5% NaOCl and 0.9% saline (control) were tested using agarose (α 1-3 and ß 1-4 glycosidic bonds) blocks (n = 3) in a weight assay. The irrigants were also applied to three-species biofilms (Streptococcus mutans UAB 159, Streptococcus oralis OMZ 607 and Actinomyces oris OMZ 745) grown anaerobically on hydroxyapatite discs (n = 6). Glycoconjugates in the matrix and total bacterial cell volumes were determined using combined Concanavalin A-/Syto 59-staining and confocal laser-scanning microscopy. Volumes of each scanned area (triplicates/sample) were calculated using Imaris software. Data were compared between groups using one-way anova/Tukey HSD, α = 0.05. RESULTS: The weight assay revealed that NaOCl was the only irrigant under investigation capable of dissolving the agarose blocks. NaOCl eradicated stainable matrix and bacteria in cultured biofilms after 1 min of exposure (P < 0.05 compared to all groups, volumes in means ± standard deviation, 10-3  mm3 per 0.6 mm2 disc; NaOCl matrix: 0.10 ± 0.08, bacteria: 0.03 ± 0.06; saline control matrix: 4.01 ± 1.14, bacteria: 11.56 ± 3.02). EDTA also appeared to have some effect on the biofilm matrix (EDTA matrix: 1.90 ± 0.33, bacteria: 9.26 ± 2.21), whilst H2 O2 and CHX merely reduced bacterial cell volumes. CONCLUSION: Sodium hypochlorite can break glycosidic bonds. It dissolves glycoconjugates in the biofilm matrix. It also lyses bacterial cells.

Available chlorine consumption from NaOCl solutions passively placed in instrumented human root canals.

AIM: To monitor chlorine consumption from nonagitated aqueous sodium hypochlorite (NaOCl) solutions in human root canals using a recently developed assay, which can determine the order of magnitude of available chlorine in small volumes of liquid. METHODOLOGY: The root canals of 80 extracted single-rooted human teeth were instrumented to ProTaper Universal F4 and irrigated using 1% NaOCl. Subsequently, canals were irrigated with copious amounts of deionized water to rinse out the residual chlorine. Subsequently, the teeth were sealed externally and placed in a water bath of 37 °C. Root canals were filled with NaOCl of 1%, 2.75%, 5.5%, or distilled water for 1, 10, 100 or 1000 min (n = 5 teeth per solution and time). Consumption of chlorine was measured using paper points pre-impregnated with 15% potassium iodide. Colour change of the paper points was determined photo-electronically, assessing their red value after absorbing solutions from root canals. Measurements were compared to a standard series of NaOCl down to 0.001% (n = 5 paper points per concentration). RESULTS: Red values of the paper points inserted into the root canal were affected by initial NaOCl concentration and time (two-way anova, P < 0.05). If NaOCl concentrations above 0.1% are considered to be clinically relevant, then 5.5% NaOCl retained its activity in the root canal for more than 100 min, whereas 1% NaOCl lost its activity between 10 and 100 min. CONCLUSIONS: Nonagitated NaOCl solutions can remain biologically active in human root canals for extended time periods.

Autologous incubated macrophage therapy in acute, complete spinal cord injury: results of the phase 2 randomized controlled multicenter trial.

STUDY DESIGN: Randomized controlled trial with single-blinded primary outcome assessment. OBJECTIVES: To determine the efficacy and safety of autologous incubated macrophage treatment for improving neurological outcome in patients with acute, complete spinal cord injury (SCI). SETTING: Six SCI treatment centers in the United States and Israel. METHODS: Participants with traumatic complete SCI between C5 motor and T11 neurological levels who could receive macrophage therapy within 14 days of injury were randomly assigned in a 2:1 ratio to the treatment (autologous incubated macrophages) or control (standard of care) groups. Treatment group participants underwent macrophage injection into the caudal boundary of the SCI. The primary outcome measure was American Spinal Injury Association (ASIA) Impairment Scale (AIS) A-B or better at ≥6 months. Safety was assessed by analysis of adverse events (AEs). RESULTS: Of 43 participants (26 treatment, 17 control) having sufficient data for efficacy analysis, AIS A to B or better conversion was experienced by 7 treatment and 10 control participants; AIS A to C conversion was experienced by 2 treatment and 2 control participants. The primary outcome analysis for subjects with at least 6 months follow-up showed a trend favoring the control group that did not achieve statistical significance (P=0.053). The mean number of AEs reported per participant was not significantly different between the groups (P=0.942). CONCLUSION: The analysis failed to show a significant difference in primary outcome between the two groups. The study results do not support treatment of acute complete SCI with autologous incubated macrophage therapy as specified in this protocol.

A phase 2 autologous cellular therapy trial in patients with acute, complete spinal cord injury: pragmatics, recruitment, and demographics.

STUDY DESIGN: Post hoc analysis from a randomized controlled cellular therapy trial in acute, complete spinal cord injury (SCI). OBJECTIVES: Description and quantitative review of study logistics, referral patterns, current practice patterns and subject demographics. SETTING: Subjects were recruited to one of six international study centers. METHODS: Data are presented from 1816 patients pre-screened, 75 participants screened and 50 randomized. RESULTS: Of the 1816 patients pre-screened, 53.7% did not meet initial study criteria, primarily due to an injury outside the time window (14 days) or failure to meet neurological criteria (complete SCI between C5 motor/C4 sensory and T11). MRIs were obtained on 339 patients; 51.0% were ineligible based on imaging criteria. Of the 75 participants enrolled, 25 failed screening (SF), leaving 50 randomized. The primary reason for SF was based on the neurological exam (51.9%), followed by failure to meet MRI criteria (22.2%). Of the 50 randomized subjects, there were no significant differences in demographics in the active versus control arms. In those participants for whom data was available, 93.8% (45 of 48) of randomized participants received steroids before study entry, whereas 94.0% (47 of 50) had spine surgery before study enrollment. CONCLUSION: The 'funnel effect' (large numbers of potentially eligible participants with a small number enrolled) impacts all trials, but was particularly challenging in this trial due to eligibility criteria and logistics. Data collected may provide information on current practice patterns and the issues encountered and addressed may facilitate design of future trials.

Quality of life in patients with spinal cord injury--basic issues, assessment, and recommendations.

INTRODUCTION: Spinal cord injury (SCI) often causes severe disabilities. The degree of functional impairment strongly depends on the level and completeness of lesion (tetraplegic, paraplegic). But evaluation of outcomes also needs to consider the broader concept of health-related quality of the life (HRQL) for SCI patients. A multinational group of clinicians and researchers assessed this concept and reviewed the available instruments for measurement of quality of life in this group of patients. TIME POINTS: Phase I is in the acute clinic; phase II during rehabilitation; phase III after discharge home. Annual follow-up investigations should be maintained. The phase of initial care (phase 0) is important for prognosis and should, therefore, be part of the documentation. INSTRUMENTS: Criteria used to evaluate current QoL measures: reliability, validity, responsiveness, availability of translations, application in SCI patients, existing population norms. Several specific instruments or subscales exist for the following domains: physical and psychological functioning, pain, and handicap. Well-known generic measures of HRQL also have been applied to SCI patients, and a disease-specific instrument has been developed (SCIQL-23). A variety of subjective quality of life measures were evaluated as well. GROUP CONSENSUS/GUIDELINE: Prior to discharge from rehabilitation, the group suggested the use of the Functional Independence Measure, the Hospital Anxiety and Depression Scale and a Visual Analogue Scale for pain. Following discharge from the acute clinic, the SF-36, the Craig Handicap Assessment and Reporting Technique, the Quality of Well-being Scale, or the Life Satisfaction questionnaire were proposed. However, the evidence supporting the use of these instruments is sparse.

Physical medicine and rehabilitation at the Mount Sinai medical center during the 20th century.

The Department of Rehabilitation Medicine at the Mount Sinai Medical Center has a long history, beginning in 1910 with the establishment of the Department of Physical Therapy, headed by Heinrich Wolf, M.D. In 1935, William Bierman, M.D., was appointed director. He was, at that time, one of the leading physicians of physical therapy in the United States, and a prolific researcher, writer and clinician. In 1948, the name of the department was changed to the Department of Physical Medicine, reflecting the newly established specialty of the Board of Physical Medicine. In 1959, Lawrence Wisham, M.D., was appointed chairman, and shortly thereafter the name of the department was changed to Physical Medicine and Rehabilitation. Under Dr. Wisham's leadership, services were provided to inpatients on the acute wards of the hospital, and to outpatients. In 1968, the name of the department was changed to Rehabilitation Medicine. In 1986, Kristjan T. Ragnarsson, M.D., became chairman of the department, and shortly thereafter an inpatient rehabilitation medicine service was established and outpatient services expanded. Since that time, rapid growth has occurred within the department, particularly in delivery of clinical services and research. The role of rehabilitation medicine in the delivery of clinical services to people with temporary or permanent disability is now well established, but efficient and effective delivery must be ensured in the current and future healthcare environment.

Sudden quadriplegia after a minor trauma. The role of preexisting spinal stenosis.

Three patients are described who became quadriplegic after a minor trauma to the spine without suffering a spinal fracture dislocation. Radiologic investigation revealed marked stenosis of the spinal canal, due to developmental stenosis with superimposed degenerative changes in two patients, and calcification of posterior longitudinal ligament of the spine in one. Two patients recovered almost completely with conservative measures. The spinal cord may be able to tolerate slowly increasing mechanical pressure for many years and conform to the shape of the spinal canal without causing any neurological symptoms. However, when stenosis is severe, any additional pressure, for example, swelling and edema from trauma, may cause a neurologic catastrophe.

Management of pain in persons with spinal cord injury.

Pain is a common complaint following spinal cord injury (SCI). While nociceptive pain can often be effectively managed by traditional therapies, neurogenic pain is more refractory to treatment. Several categories of pain are recognized in persons with SCI and an accurate diagnosis will improve the therapeutic response. Nociceptive pain is usually perceived to be above or at the level of the cord lesion and is most commonly related to musculoskeletal pathology. Neurogenic pain is usually felt by the patient at or below the neurological level and may be classified as radicular, segmental or deafferentation central pain, depending on its hypothetical origin and the clinical presentation. Management requires recognition of all factors that may influence pain perception and knowledge of the entire range of therapeutic options.

Pain after spinal cord injury.

Evaluation of pain in a person with SCI should commence with a determination of the neurologic level and the completeness of injury. The pain then can be localized to one of three regions: above level, at level, or below level. The regional pain then should be categorized either as nociceptive or neuropathic and, after this, subdivided into a specific subtype. An evidence based treatment plan can be devised depending on the specific subtype, which may include physical measures, pharmacologic treatments, behavioral interventions, surgery, or an eclectic combination program. The treatment plan usually can provide some relief for any of the subtypes, although complete relief often is not possible.

Functional electrical stimulation after spinal cord injury: current use, therapeutic effects and future directions.

Repair of the injured spinal cord by regeneration therapy remains an elusive goal. In contrast, progress in medical care and rehabilitation has resulted in improved health and function of persons with spinal cord injury (SCI). In the absence of a cure, raising the level of achievable function in mobility and self-care will first and foremost depend on creative use of the rapidly advancing technology that has been so widely applied in our society. Building on achievements in microelectronics, microprocessing and neuroscience, rehabilitation medicine scientists have succeeded in developing functional electrical stimulation (FES) systems that enable certain individuals with SCI to use their paralyzed hands, arms, trunk, legs and diaphragm for functional purposes and gain a degree of control over bladder and bowel evacuation. This review presents an overview of the progress made, describes the current challenges and suggests ways to improve further FES systems and make these more widely available.

Physiologic effects of functional electrical stimulation-induced exercises in spinal cord-injured individuals.

Spinal cord injury (SCI) results in multiple degenerative changes that may in part be related to physical inactivity. There are indications that some of these changes may be reversed by exercise and fitness training. Computerized functional electrical stimulation (FES) allows active exercise of limbs paralyzed by upper motor neuron lesions. Thirty SCI subjects safely participated in an FES-induced exercise program for lower extremity strengthening and endurance training. Increased strength, endurance, and bulk of stimulated muscles were noted. The subjects were able to perform a greater amount of work on a lower extremity ergometer, both per unit of time and per length of time, indicating a training effect. A multistage stress test showed evidence that the subjects had increased their aerobic metabolism during the training program. Twitch time tests showed slowing of muscle contraction, and computed tomography showed increased muscle density.

Rehabilitation in spinal cord disorders. 2. Anatomy, pathogenesis, and research for neurologic recovery.

This self-directed learning module highlights advances in this topic area. It is part of the chapter on rehabilitation in spinal cord disorders in the Self-Directed Medical Knowledge Program Study Guide for practitioners and trainees in physical medicine and rehabilitation. This article contains learning objectives on the anatomy of the spine and spinal cord, pathogenesis of spinal cord trauma, mechanisms of spinal fractures and dislocations, causes of nontraumatic spinal cord disorders, and research on neurologic recovery. Advances that are covered in this section include various experimental animal models for producing spinal cord injury and new approaches to limit damage in acute injury and to promote recovery in chronic injury.

Lower extremity fractures after spinal cord injury: a retrospective study.

Lower extremity fractures after spinal cord injury (SCI) are more common in paraplegic than in quadriplegic persons, probably due to their greater activity level. Most of the fractures are pathologic in osteoporotic bones and most occur without known trauma or are caused by trivial injury. Supracondylar or shaft fractures of the femur are most common. Although callus formation is usually fast, exuberant fracture healing may be delayed. The main management goal, maintenance of functional independence without complications of SCI, is best obtained by a nonsurgical approach with traction or well-padded cast followed by early joint mobilization.

Herpetic gingivostomatitis in otherwise healthy adolescents and young adults.

The purpose of this study was to review and analyze the records of herpes simplex infections from a specialist Oral Medicine clinic in Iceland, to investigate the clinical impression that the age of patients experiencing initial infection with this virus was higher than expected and that the character of the clinical picture of the disease had changed. Records of patients with herpes infections attending the Oral Medicine clinic covering a 3-year period were examined and the clinical and virological data analyzed. Diagnosis was based on clinical appearance, history, and viral identification with culture or detection of viral DNA by means of the polymerase chain reaction. Records of 60 patients (34 female) were included in the study (mean age, 23.1 years; range, 2 68 years). No patients were known or suspected to be positive for human immunodeficiency virus, none was known to be immunocompromised, and 38 patients (mean age, 16.6 years; 21 female) were diagnosed as having primary herpetic gingivostomatitis. Eighteen patients (mean age, 36.2 years; 11 female) had lesions of recurrent herpes simplex infection present on the oral mucosa. Primary infection with herpes simplex virus was more common in young adults than had been expected. Recurrent infections appeared on the oral mucosal even in otherwise healthy patients, and the clinical course of these infections in this age group sometimes followed a more severe course than that seen in young children.

Rehabilitation of the geriatric orthopaedic patient.

Older patients who are referred for rehabilitation after undergoing orthopaedic procedures have numerous age-related conditions that may interfere with physical performance and safety. The general rehabilitation goals are to return each patient to the premorbid functional level of mobility and self-care, teach the exercises that are to be performed after hospital discharge, reduce the risk of falls, and ensure that the patient is discharged to a safe environment. Before elective surgery, the elderly orthopaedic patient should be instructed to perform breathing exercises to prevent pulmonary complications and active lower limb exercises to maintain good circulation and joint mobility, and be instructed in functional activities for mobilization in and out of bed. Postoperatively, the interdisciplinary rehabilitation team must facilitate early resumption of active exercises and self-care tasks and discourage prolonged bed rest and dependency on nursing staff and family members. Physical and occupational therapy should be provided to restore mobility and self-care functions. If discharge to home is planned, the home environment should be assessed and modifications recommended to reduce the risk of falls and ensure independent functioning to the extent possible. When the rehabilitation goals have been obtained, the patient should be discharged from the hospital, but additional therapy may be required, either at home or at an outpatient facility.

Visually displayed EMG feedback: single case studies of hemiplegic upper extremity rehabilitation.

The efficacy of visually displayed EMG feedback in treating hemiplegic upper limb motor disorders was investigated in 5 patients (0.5-4 years poststroke). A single case experimental method "multiple-baseline across target behaviors" was used to compare performance during the feedback phase to that occurring in the monitored baseline phase. The nonfeedback baseline phase was followed by the staggered introduction of audiovisual feedback for each of the targeted pairs of muscles. EMG feedback obtained from muscle pairs (shoulder: anterior deltoid and upper trapezius; elbow: brachial triceps and biceps; digits: extensor digitorum communis and digit flexors) was displayed as two distinct waveforms on a videomonitor during therapy. Nonfeedback assessment of each of the three pairs was performed during each session. The effects of feedback were not uniformly distributed. Elbow control responded best, and statistical tests confirmed the effects of intervention observed clinically in all 5 patients. Clinical improvements in shoulder flexion were observed in 4 patients but could be statistically attributed to EMG gains in just 1. Improvement in finger extension observed clinically in 3 patients was statistically attributable to EMG gains in 2. All patients regained control of at least one target activity. EMG gains were accompanied by increases in active range of motion and by varying functional improvement. Marked functional gains in 3 patients were obtained with recovery of finger control.

Three women with lupus transverse myelitis: case reports and differential diagnosis.

Although the association between transverse myelitis (TM) and systemic lupus erythematosus (SLE) has been reported previously, it remains a rare clinical condition. Our experience treating three women with lupus TM within a few months is presented. In each patient, spinal cord dysfunction was accompanied by laboratory or clinical evidence of SLE. Further neurologic manifestations, such as optic neuritis, developed in all patients, suggesting other diagnoses, including multiple sclerosis (MS), Devic's syndrome, and lupoid sclerosis. The outcomes for these three women were severe disability, death, and moderate disability, respectively. The severity of outcome did not seem to correlate with the timing or intensity of treatment. Physiatrists should be aware of the potential for neurologic progression in lupus TM, because patients with this condition invariably require rehabilitation.

Pneumatic orthosis for paraplegic patients: functional evaluation and prescription considerations.

Fourteen paraplegic patients were studied during ambulation training, 11 with pneumatic orthoses and with conventional metal orthoses, and 3 with pneumatic orthoses only. The purposes of the study were to establish whether pneumatic orthoses could be used by paraplegic patients for effective ambulation, whether these devices presented any advantages or disadvantages over conventional orthoses and how their use would affect the expected level of rehabilitation and independence. As far as application, standing up, sitting down and ambulation within a rehabilitation center are concerned, similar skills and levels of independence were obtained with both types of orthoses. Reduced tendency for orthostatic hypotension, availability, light weight and better endurance make the pneumatic orthosis especially suitable for early ambulation training, but several mechanical problems, mainly its inflation with motorized and heavy compressor units, limit its usefulness for community ambulation.