Time to adapt in the pandemic era: a prospective randomized non -inferiority study comparing time to intubate with and without the barrier box.

BACKGROUND: The challenges posed by the spread of COVID-19 disease through aerosols have compelled anesthesiologists to modify their airway management practices. Devices such as barrier boxes are being considered as potential adjuncts to full PPE's to limit the aerosol spread. Usage of the barrier box raises concerns of delay in time to intubate (TTI). We designed our study to determine if using a barrier box with glidescope delays TTI within acceptable parameters to make relevant clinical conclusions. METHODS: Seventy-eight patients were enrolled in this prospective non-inferiority controlled trial and were randomly allocated to either group C (without the barrier box) or the study group BB (using barrier box). The primary measured endpoint is time to intubate (TTI), which is defined as time taken from loss of twitches confirmed with a peripheral nerve stimulator to confirmation of end-tidal CO 2. 15 s was used as non-inferiority margin for the purpose of the study. We used an unpaired two-sample single-sided t-test to test our non- inferiority hypothesis (H 0: Mean TTI diff ≥15 s, H A: Mean TTI diff < 15 s). Secondary endpoints include the number of attempts at intubation, lowest oxygen saturation during induction, and the need for bag-mask ventilation. RESULTS: Mean TTI in group C was 42 s (CI 19.2 to 64.8) vs. 52.1 s (CI 26.1 to 78) in group BB. The difference in mean TTI was 10.1 s (CI -∞ to 14.9). We rejected the null hypothesis and concluded with 95% confidence that the difference of the mean TTI between the groups is less than < 15 s (95% CI -∞ to 14.9,p = 0.0461). Our induction times were comparable (67.7 vs. 65.9 s).100% of our patients were intubated on the first attempt in both groups. None of our patients needed rescue breaths. CONCLUSIONS: We conclude that in patients with normal airway exam, scheduled for elective surgeries, our barrier box did not cause any clinically significant delay in TTI when airway manipulation is performed by well-trained providers. The study was retrospectively registered at clinicaltrials.gov (NCT04411056) on May 27, 2020.

A pilot study on the relationship between physical impairment and activity restriction in persons with anterior cruciate ligament reconstruction at long-term follow-up.

This study examined the relationship between impairment of the knee and activity restriction during activities of daily living and sports following anterior cruciate ligament reconstruction. Knee range of motion, swelling, pain, instability, ligamentous laxity, isometric and isokinetic muscle function and performance-based measures of activity restriction were measured in 44 subjects. Four measures of patient-reported activity restrictions, including the Activities of Daily Living, Sports Activities Scales of the Knee Outcome Survey, and global ratings of function during activities of daily life and sports, were statistically combined to create a composite variable representing the level of patient-reported activity restrictions for each subject. Hierarchical regression analysis revealed that 17% of the variability in patient-reported activity restrictions was accounted for by age, length of postoperative follow-up, and mechanism of injury. Addition of the one-legged hop, Lachman, anterior drawer, and varus stress tests accounted for an additional 40% of the variability of function. When pain and giving way were added to the model, 79% of the variability was explained.

Durkan gauge and carpal compression test: accuracy and diagnostic test properties.

STUDY DESIGN: A prospective, criterion-based validity study. OBJECTIVES: To assess the diagnostic properties of the carpal compression test (CCT) when performed with the Durkan carpal tunnel syndrome (CTS) gauge, and to determine the measurement validity of the gauge. BACKGROUND: The CCT has been reported to be highly sensitive (.87-.89) and specific (.93-1.0) in the diagnosis of CTS when it is done with thumb pressure. The accuracy of measurements with the Durkan CTS gauge, however, has not been established and the diagnostic sensitivity and specificity of the CCT when the gauge is used has not been independently confirmed. METHODS AND MEASURES: The study sample included 33 women and 19 men, aged 18 to 85 years (45.7 +/- 13.5 years). The accuracy of the gauge was determined with a force dynamometer and holding frame. Standard nerve conduction studies (NCS) and the CCT were performed on the symptomatic extremity of all subjects. A compatible history and the NCS results were used to confirm CTS. RESULTS: The Durkan gauge registered pressures of 11.94 psi and 15.25 psi at the 12 and 15 psi gauge marks, respectively. Test sensitivity and specificity were .36 (95% CI = .17-.54) and .57 (95% CI = .39-.74), respectively. CONCLUSIONS: Pressure measurements obtained with the Durkan CTS gauge were accurate. The CCT when performed with the Durkan gauge, however, was neither sensitive or specific for the diagnosis of CTS.

Postural changes with aging in tetraplegia: effects on life satisfaction and pain.

OBJECTIVES: (1) To measure kyphosis and scoliosis in individuals with tetraplegia; (2) to examine the relation between kyphosis and scoliosis and years since injury; and (3) to determine the association between kyphosis and scoliosis and measures of pain, depression, and life satisfaction. DESIGN: Cross-sectional, case-control study. SETTING: University medical center and a free-standing university-affiliated rehabilitation hospital. PARTICIPANTS: (1) Ten individuals with tetraplegia I to 3 years postinjury (NT); (2) 10 individuals with tetraplegia 10 to 20 years postinjury (OT); and (3) 10 control individuals (C) matched to the other subjects on the basis of age, height, and weight. MAIN OUTCOME MEASURES: Radiographic measurements of kyphosis and scoliosis taken in a seated position, pain as measured by the short form of the McGill Pain Questionnaire (SF-MPQ), depression as measured by the Center for Epidemiological Studies-Depression Scale (CES-D), and life satisfaction as measured by the Life Satisfaction Index Assessment (LSIA) and the Craig Handicap Assessment and Reporting Technique (CHART). RESULTS: No significant differences were seen between the OT and NT groups with respect to age, height, or weight. In addition, no significant differences were found between the NT and OT groups with respect to measures of kyphosis and scoliosis. Individuals with tetraplegia had significantly higher (p < .05) measures of kyphosis (42 + 16.0 ) and scoliosis (14 degrees +/-9.2 degrees) than the C subjects (kyphosis, 32 degrees +/- 7.9 degrees ; scoliosis, 5 degrees+/-3.8 degrees). No correlation was found between scores on the SF-MPQ and degree of kyphosis or scoliosis. Significant differences were seen between the NT and OT groups on both CES-D (NT, 15.2+/-8.1; OT, 5.8+/-5.5) and LSIA (NT, 9.9+/-2.8; OT, 14.4+/-2.9). CONCLUSION: This study indicates that seated kyphosis and scoliosis develop early in individuals with tetraplegia and may not be progressive. No association was seen between pain and kyphosis or scoliosis in this relatively young sample (mean age of OT and NT combined, 34.8 years). Future research is needed to determine whether pain becomes a problem in individuals with significant kyphosis or scoliosis as they age.

An electromyographic study of vastus medialis oblique and vastus lateralis activity while ascending and descending steps.

Imbalances in the firing pattern and contraction intensity of the vastus medialis oblique (VMO) and the vastus lateralis (VL) have been considered important factors contributing to patellofemoral joint dysfunction. Vastus medialis oblique and vastus lateralis electromyographic (EMG) activity were measured for 15 individuals without patellofemoral pain (asymptomatic group) and 13 subjects with patellofemoral pain (symptomatic group) while ascending and descending steps. The peak VMO/VL ratios of EMG activity and the difference in peak VMO and VL onset times were measured. Two-way mixed-model analyses of variance (ANOVA) were used to determine the main effects of group (asymptomatic and symptomatic), phase (concentric phase ascending and two eccentric phases descending stairs), and the interaction between group and phase. The ANOVAs indicated no difference between groups for the peak VMO/VL EMG ratio or for the onset timing between peak VMO and VL muscle activity. Combining groups, the peak VMO/VL EMG ratio was less for the eccentric weight acceptance phase of descent compared with the concentric phase of ascent. These findings suggest no differences between asymptomatic and symptomatic individuals, but differences may exist between concentric and eccentric VMO/VL ratios. Further research is needed to determine if VMO and VL muscle imbalances contribute to patellofemoral dysfunction.

The effect of sudden inversion stress on EMG activity of the peroneal and tibialis anterior muscles in the chronically unstable ankle.

Residual symptoms resulting from recurrent episodes of inversion-type ankle sprains may be attributed to a decreased neuromuscular response of the peroneal or tibialis anterior muscles, thereby increasing the probability for reinjury. The purpose of this study was to examine the electromyographic (EMG) response time of the peroneal and tibialis anterior muscles in response to sudden plantar flexion/inversion stress in the chronically functional unstable and normal ankle. Subjects for this study consisted of 13 athletically active individuals (five males and eight females, mean age = 19.2 +/- 1.51 years) with a previous history of a unilateral inversion-type ankle sprain. A specially designed platform that allows each foot to drop into plantar flexion/inversion from a standing neutral position was used. Reaction time in milliseconds for the peroneal and tibialis anterior muscles to sudden plantar flexion/inversion was measured via surface EMG. A paired t test was performed with the Bonferroni-Dunn correction factor to determine differences between the peroneal and tibialis anterior as well as between the chronically unstable and contralateral normal ankle. The results indicated no significant differences between the stable and unstable ankles for the peroneal or the tibialis anterior muscles. The results also indicated no significant differences existed between the tibialis anterior and peroneal muscles in either the stable or unstable ankles. The findings from the present study suggest that self-reported functional ankle instability may not result in a diminished reflex response time of the peroneal and tibialis anterior muscles to sudden plantar flexion/inversion stress.

Electromyographic analysis of the squat performed in self-selected lower extremity neutral rotation and 30 degrees of lower extremity turn-out from the self-selected neutral position.

Little research is available on the muscle activity patterns of the lower extremity muscles during dynamic closed chain squatting activities. The purpose of this study was to examine the effect of lower extremity position during an Olympic squat on the muscle activity patterns of the vastus medialis, vastus lateralis, semimembranosus/semitendinosus, and biceps femoris. Twenty-five healthy, untrained subjects, 18-35 years old, were randomly assigned initial squatting positions of either self-selected neutral or 30 degrees of lower extremity turn-out from the self-selected neutral position. Surface electromyography and motion analysis data were collected simultaneously in 10 degrees intervals and analyzed from 10-60 degrees of knee flexion in both the ascending and descending phases of the squat. A four-way analysis of variance indicated that the main effect of lower extremity position and the interaction of extremity position and knee joint angles were not found to cause significant changes in muscle activity patterns. Significant changes in muscle activity did occur with changes in knee flexion angles in the vastus medialis and vastus lateralis but not in the semimembranosus/semitendinosus or biceps femoris.

Subtalar joint motion and the relationship to lower extremity overuse injuries.

The purpose of this study was to determine if there was a difference between the subtalar joint ratio (transverse plane component to frontal plane component) in subjects with overuse symptoms in the foot compared with subjects with overuse symptoms in the leg and knee. Superior and posterior photographs were taken with the subtalar joint in pronation and supination while the subjects were in a seated position. The ratio of the transverse plane to frontal plane components of subtalar joint motion was calculated. A significant (p < 0.05) difference in the subtalar joint ratio existed between subjects with foot overuse symptoms and subjects with leg and knee overuse symptoms.

A comparison of gait characteristics in young and old subjects.

BACKGROUND AND PURPOSE: The purpose of this study was to describe and compare active range of motion during free-speed gait in younger and older people. SUBJECTS: Sixty volunteers in good health were studied. Thirty subjects (15 male, 15 female) were between 20 and 40 years of age, and 30 subjects (15 male, 15 female) were between 60 and 80 years of age. METHODS: Subjects were videotaped walking down a 6-m walkway with reflective markers at six locations along their right side. The videotape was analyzed for nine gait characteristics using a two-dimensional video motion analysis system. Differences in gait characteristics between the two groups were examined using a multivariate analysis of variance, followed by univariate F tests. RESULTS: Two gait variables--knee extension and stride length--were significantly different between groups, and differences in velocity approached significance. CONCLUSION AND DISCUSSION: For individuals in good health, the gait of older people differs from the walking pattern of young people for selected variables. Older people demonstrate less knee extension and a shorter stride length compared with younger people. Differences in self-paced walking velocity between old and young people may have influenced the gait characteristics measured.

The effects of foot orthotics on the EMG activity of selected leg muscles during gait.

Foot orthotics have been successfully used to treat muscular overuse leg injuries in athletes. The purpose of this study was to examine the effects of foot orthotics on the electromyographic (EMG) activity of the tibialis anterior, peroneus longus, and gastrocnemius muscles during walking. Ten volunteers with leg symptoms resulting from compensatory subtalar joint pronation were fitted with foot orthotics. The duration of tibialis anterior EMG activity following heel strike and the average EMG activity of the tibialis anterior, peroneus longus, and gastrocnemius muscles were collected with surface electrodes. Comparisons were made between the orthotic and nonorthotic conditions. A t-test for nonindependent samples with a significance level of p < 0.05 was used for data analysis. There was a statistically significant increase in the duration of tibialis anterior activity following heel strike in the orthotic condition. There were no significant differences in the average EMG activity for any of the three muscles between the orthotic and the nonorthotic conditions. This study suggests that foot orthotics had minimal effects on the muscles studied and that further research is necessary to determine the effectiveness of orthotics on the EMG activity of other leg muscles.

Lower extremity muscular flexibility in long distance runners.

Muscle tightness is often considered to be a predisposing factor in muscle injuries. The purpose of this study was to assess the muscle flexibility of the hamstrings, rectus femoris, iliopsoas, gastrocnemius, and soleus muscles in long distance runners. Range of motion measurements of five movements, including hip flexion with knee extended, hip extension with knee flexed, hip extension with knee extended, ankle dorsiflexion with knee extended, and ankle dorsiflexion with knee flexed, were evaluated to determine muscle tightness. Twenty runners and 20 nonrunners volunteered for the study. Each group consisted of 10 males and 10 females. The observed means were compared between runners and nonrunners, males and females, plus the dominant and nondominant leg using a three-way analysis of variance. The runners were found to have tighter hamstrings (p < .05), and soleus (p < .05) muscles than nonrunners. There was no significant difference in rectus femoris and iliopsoas muscle tightness in runners compared with nonrunners. In addition, the males had tighter hamstring muscles than the females in both runners and nonrunners (p < .05). The hamstring muscles of the dominant leg were tighter than the hamstrings of the nondominant leg in all subjects (p < .05). In conclusion, long distance runners appear to have posterior muscle tightness in the lower extremity.

Effects of muscle group and placement site on reliability of hand-held dynamometry strength measurements.

Studies of measuring muscle strength with hand-held dynamometers have produced a variety of results. The purpose of this research was to further investigate the effect of muscle group and placement site on reliability. The purpose of Part I of this study was to examine reliabilities of force measurements generated by four specific muscle groups using a hand-held dynamometer (HHD). Part II's purpose was to determine the effects of HHD placement site on the variability of HHD force measurements. In Part I, two testers obtained measurements of right shoulder abductor, wrist extensor, hip flexor, and ankle dorsiflexor forces in 20 subjects. Two-way analysis of variance indicated a main effect due to tester, but no tester by session interaction and no main effect due to session (p < 0.5). Intraclass correlation coefficients ranged from .76-.93 for within-session, intratester reliabilities, .67-.84, for between-session intratester reliabilities, and .30-.83 for within-session, intertester reliabilities. Reliability tended to be higher when HHD placement sites were farther from joint centers. Part II explored the hypothesis that HHD forces would be less variable if measured distally. One tester measured shoulder abductor forces for 30 subjects at three sites on the upper extremity. Bartlett's Test for homogeneity of variance indicated a lower variability at the distal placement site (p < 0.05). J Orthop Sports Phys Ther 1992;15(5):236-242.

The validity of regulating exercise intensity by ratings of perceived exertion.

The purpose of this investigation was to examine the regulation of exercise intensity by using Ratings of Perceived Exertion (RPE). The RPE equivalent to 50% and 70% VO2max was estimated by using standard clinical protocols on a treadmill and cycle ergometer. Subjects then produced the target RPEs on these modalities. Physiological validity of perceptually regulated exercise intensity was determined by comparing VO2 and heart rate between estimation and production trials at the same relative intensity. With one exception, RPE was found to be a valid means of regulating exercise intensity both intra- and intermodally at 50% and 70% VO2max. Perceptual regulation of intramodal treadmill exercise was not valid at 70% VO2max in that both VO2 and heart rate were significantly lower during production than estimation. The present results also indicate that target RPE estimated during a cycle ergometer graded exercise test is more accurate for regulating exercise intensity than when the target RPE is estimated during a treadmill test. The lower accuracy found for treadmill production at the higher exercise intensity may have been caused by the use of a test protocol during the estimation trial that included relatively slow speeds and large inclines. In general, RPE provide a physiologically valid method of regulating exercise intensity.

Muscle strength as an indicator of the habitual level of physical activity.

This study focused on age and physical activity as determinants of muscle strength. The study involved 620 women 25-73 yr of age. The five muscle groups assessed were: grip, plantarflexors, hip abductors, trunk flexors, and trunk extensors. Pearson correlations yielded significant negative correlations of muscle strength with age and positive correlations with height as well as physical activity. The greatest decremental differences in muscle strength were registered in the perimenopausal years between the age decades of 45-54 yr and 55-64 yr. In stepwise regression analyses age was the strongest predictor of the strength of all muscle groups, with smaller contributions to the variance by physical activity and anthropometric variables. When the sample population, divided by decades of age, was further subdivided by tertiles of physical activity, the results of factorial analysis indicated that the main effects due to age and physical activity were significant. It was concluded that 1) moderate levels of physical activity tend to improve muscle strength even in older women, and 2) normative values of muscle strength could serve as an indicator of the adequacy of the habitual levels of physical activity.

Cost control should extend to legal services.

While a healthcare organization may consider legal services to be outside its management scope, control of legal spending is within a hospital's grasp. Whether an organization is large or active enough to merit an internal legal staff, an administrative position should be established to centralize management of legal services. A hospital may choose to undertake a cost reduction audit, which can determine the feasibility of an internal legal staff and coordinate competitive proposals from outside law firms handling litigation.

Hyperthyroid myopathy and the response to treatment.

Hyperthyroidism is accompanied by significant dysfunction of both proximal and distal skeletal muscles. The purpose of this study was to quantitate the degree of muscle weakness in newly diagnosed patients with Graves' disease and to assess the response to treatment. Ten patients were prospectively studied with objective measures of strength and endurance of proximal and distal muscles while hyperthyroid (stage I), after 2 weeks of propranolol (stage II), and about 6 months later when euthyroid (stage III). Propranolol treatment for 2 weeks resulted in a subjective decrease in weakness, which was accompanied by a statistically significant improvement in grip strength (P less than 0.01), shoulder strength (P less than 0.02), and grip endurance (P less than 0.01) but not shoulder endurance. Muscle function further improved and attained control levels when the patients were chemically and clinically euthyroid. In contrast, a control group subjected to the same muscle testing protocol before and after 1 week of propranolol treatment showed no improvement in grip, shoulder strength, or shoulder endurance but had decreased grip endurance (P less than 0.01) and increased subjective weakness. These results confirm that muscle weakness commonly is associated with hyperthyroidism and can be quantitatively profound. In contrast to the effects of beta-blockade in normal controls, propranolol partially improves muscle weakness in thyrotoxic patients. We conclude that thyroid hormone and catecholamines in concert mediate the muscle dysfunction of hyperthyroidism.