What are the unsupervised exercise adherence rates in clinical trials for knee osteoarthritis? A systematic review.

BACKGROUND: Exercise is an effective intervention for knee osteoarthritis (OA), and unsupervised exercise programs should be a common adjunct to most treatments. However, it is unknown if current clinical trials are capturing information regarding adherence. OBJECTIVE: To summarize the extent and quality of reporting of unsupervised exercise adherence in clinical trials for knee OA. METHODS: Reviewers searched five databases (PubMed, CINAHL, Medline (OVID), EMBASE and Cochrane). Randomized controlled trials where participants with knee OA engaged in an unsupervised exercise program were included. The extent to which exercise adherence was monitored and reported was assessed and findings were subgrouped according to method for tracking adherence. The types of adherence measurement categories were synthesized. A quality assessment was completed using the Physiotherapy Evidence Database (PEDro) scores. RESULTS: Of 3622 abstracts screened, 176 studies met criteria for inclusion. PEDro scores for study quality ranged from two to ten (mean=6.3). Exercise adherence data was reported in 72 (40.9%) studies. Twenty-six (14.8%) studies only mentioned collection of adherence. Adherence rates ranged from 3.7 to 100% in trials that reported adherence. For 18 studies (10.2%) that tracked acceptable adherence, there was no clear superiority in treatment effect based on adherence rates. CONCLUSIONS: Clinical trials for knee OA do not consistently collect or report adherence with unsupervised exercise programs. Slightly more than half of the studies reported collecting adherence data while only 40.9% reported findings with substantial heterogeneity in tracking methodology. The clinical relevance of these programs cannot be properly contextualized without this information.

Physical therapy students' application of an imaging decision rule for acute knee pain.

BACKGROUND: Evidence supports direct referral for imaging by physical therapists. Accuracy and self-efficacy for imaging decisions have not been investigated in entry-level doctor of physical therapy (DPT) students. OBJECTIVE: The purpose of this study was to understand the relationship between entry-level DPT instruction and accuracy and self-efficacy for imaging referral due to acute knee trauma. A second purpose was to identify relationships between accuracy and self-efficacy. METHODS: An online survey was sent via e-mail to program directors in accredited DPT programs in the United States with an invitation to forward the survey to DPT students. The survey captured demographic information and included five questions that assessed the respondent's ability to apply the Ottawa Knee Rules (OKR). Self-efficacy was assessed using the Physiotherapist Student Self-Efficacy (PSE) questionnaire, a self-rated 5-point Likert scaled tool. RESULTS: Of 240 surveys, DPT students who completed imaging coursework had greater accuracy and higher self-efficacy (68.0% correct (95% CI, 63.6-72.5), PSE = 3.67, P < .001) compared to students who had not (45.8% correct (95% CI, 40.8-50.7), PSE = 2.67, P < .001). Conclusion: Accuracy by DPT students who completed imaging coursework was significantly improved and comparable to values from autonomous providers.

A closer look at 30 day hospital readmissions after head and neck cancer surgery.

PURPOSE: 30-day hospital readmissions after head and neck cancer surgery continue to be a significant source of patient harm and healthcare expenditure. While there is substantial data in the literature assessing predictive factors for readmissions after head and neck cancer surgery, there are a paucity of studies which attempt to understand if such readmissions are preventable. The goal of this paper is to determine factors associated with 30-day hospital readmissions after head and neck cancer surgery and to understand if these readmissions were preventable. MATERIALS AND METHODS: Retrospective review from a single academic tertiary care center. Patients readmitted within 30 days after undergoing surgery for cancers of the head and neck between 2015 and 2018 were identified. RESULTS: Over a 3-year period, 26 patients undergoing resection with or without reconstruction of head and neck cancers were readmitted to the hospital within 30 days of discharge. There were 15 (58%) men and 11 (42%) women with a mean age of 68 years (SD 14 years). Twenty-one (81%) patients had squamous cell carcinoma and 13 (50%) had a primary site in the oral cavity. Thirteen (50%) had undergone free or regional flap reconstruction. The indication for readmission was related to the surgical wound in 19 (73%) and to medical complications in 7 (27%). Each case was categorized as "possibly preventable" versus "uncertain if preventable" based on whether a reasonable and feasible change in management may have prevented readmission. Six (23%) readmissions were deemed possibly preventable. Four were related to the surgical wound where initial free or regional flaps may have prevented complication. Two were medical complications that may have benefited from longer inpatient observation. CONCLUSIONS: For a subset of patients readmitted within 30 days of head and neck cancer surgery, a reasonable and feasible change in management may have prevented their hospital readmission. The significance of better understanding this patient population is underscored by the high mortality rate.

Case report: Traumatic lingual hematoma.

We describe a case of traumatic lingual hematoma in a patient on dual antiplatelet therapy. After securing the airway, bilateral lingual artery embolization successfully halted expanding hematoma formation. Patient subsequently required tracheostomy for continued airway edema. Although patient course was wrought with postoperative complications, we review this case to illustrate how prompt hematoma evacuation and embolization can resolve significant vasovagal bradycardia and hypotension secondary to expansile lingual hematoma.

Pressure exposure and catheter impingement affect the recorded pressure in the Manoscan 360™ system.

BACKGROUND: The accuracy of pressure measurements by Manoscan high-resolution manometry (HRM) system is affected by pressure drift (PD). The PD is partly related to temperature and study duration, but other factors that contribute to errant pressure recording have not been systematically evaluated. The aim of this study was to investigate and quantify contributing factors to pressure recording error. METHODS: In total, 660 in vitro experiments were conducted on seven HRM catheters to determine the effects of sustained pressure exposure, catheter impingement, temperature, duration of study, and immersion in saline or acid on recorded pressure and PD. KEY RESULTS: At room temperature and without application of pressure, the PD was negligible. Application of sustained pressure significantly increased PD and catheter impingement of even 15° produced remarkable increases in the recorded pressure as well as post-recording PD. There was significant variability across sensors in their propensity to develop PD with temperature. Body (37°C) and freezing (0°C) temperatures resulted in significantly higher absolute value of PD in the opposite algebraic direction, respectively (for individual sensors). Although the overall trend was for higher PD with increasing temperature, some of the pressure sensors demonstrated inherently negative PD at body temperature. CONCLUSIONS AND INFERENCES: In addition to the known effects of temperature, both sustained pressure exposure and catheter impingement significantly affect the recorded pressure and the magnitude of the PD observed at the end of the recording. These effects can be substantial enough to result in erroneous manometric diagnoses.

Feasibility of a bone and soft tissue chimeric anterolateral thigh free flap? Anatomic study and report of two cases for oral cavity reconstruction.

The anterolateral thigh flap (ALT) is a workhorse for a spectrum of reconstructive problems including head and neck defects. Its versatility as a chimeric flap employing a variety of soft tissues with a robust pedicle is useful for three-dimensional defects. The authors investigated the anatomical relationship between the vascular supply to the ALT and anterior femur. We studied 16 fresh cadaver limbs to identify the typical branching patterns to the femur off the descending branch of the lateral circumflex femoral artery. These patterns can facilitate dissection of this type of chimeric ALT. The authors have integrated a bone component of vascularised femur in this flap off the lateral circumflex femoral artery system to address oral cancer defects in two patients. A retrospective review of these cases correlating with the anatomic study was undertaken. Both patients had recurrent disease with limited donor site options. Both had extensive floor of mouth and tongue defects as well as small mandible defects of 2 cm. Both went on to heal at the donor and recipient sites at 32 months' follow-up.

Esophageal function testing: Billing and coding update.

BACKGROUND AND PURPOSE: Esophageal function testing is being increasingly utilized in diagnosis and management of esophageal disorders. There have been several recent technological advances in the field to allow practitioners the ability to more accurately assess and treat such conditions, but there has been a relative lack of education in the literature regarding the associated Common Procedural Terminology (CPT) codes and methods of reimbursement. This review, commissioned and supported by the American Neurogastroenterology and Motility Society Council, aims to summarize each of the CPT codes for esophageal function testing and show the trends of associated reimbursement, as well as recommend coding methods in a practical context. We also aim to encourage many of these codes to be reviewed on a gastrointestinal (GI) societal level, by providing evidence of both discrepancies in coding definitions and inadequate reimbursement in this new era of esophageal function testing.

Mercury concentrations in bald eagles across an impacted watershed in Maine, USA.

Mercury (Hg) exposure was evaluated in bald eagles (Haliaeetus leucocephalus) in the lower Penobscot River watershed (PRW) in Maine to assess whether Hg discharges from a chlor-alkali plant (HoltraChem) influenced Hg concentrations in nestling tissues. Mean Hg concentrations in nestling blood and breast feathers sampled in marine and estuarine areas potentially contaminated with Hg from HoltraChem (the potential Hg impact zone) were significantly greater than those from reference sites spanning the Maine coast. To place Hg exposure in the potential Hg impact zone into a broader context, Hg exposure in bald eagle nestlings from four habitat types in the PRW was assessed. Mercury concentrations varied significantly across habitat types within the PRW, generally following the pattern: marine=estuarine

Determinants of pressure drift in Manoscan(™) esophageal high-resolution manometry system.

BACKGROUND: Manoscan(™) is one of the commonly used high-resolution manometry (HRM) systems with declared measurement accuracy of 1-2 mmHg. However, the accuracy of pressure measurements is limited by development of pressure drift (PD) throughout recording. To date, there has been no systematic investigation to identify the factors contributing to PD. The aim of the present study was to characterize the frequency and magnitude of PD in Manoscan(™) system and identify the factors contributing to PD. METHODS: Records of 560 consecutive clinical esophageal HRM studies recorded by six distinct HRM catheters were retrospectively reviewed. PD was defined as the residual pressure measurement by each sensor immediately after removal of the catheter. Non-parametric locally weighted regression analysis was performed to assess the effect of duration of study, number of prior uses of a catheter, peak and average pressure exposure during a study on the PD. KEY RESULTS: The majority (95%) of clinical manometry studies showed a non-negligible PD of more than 5 mmHg. The overall PD was 13 ± 5 mmHg and the sensor with greatest amount of PD showed 23 ± 12 mmHg of drift. The upper esophageal sphincter showed the highest PD. Average pressure exposure of a sensor throughout the recording was the most important predictor of PD. PD inversely correlated with number of prior uses of a catheter. CONCLUSIONS & INFERENCES: The PD preferentially affects esophageal high-pressure zones, and strongly correlates with 'average pressure exposure' of a sensor during manometry. Available algorithms of the analysis software do not adequately correct the PD.

Recognition and management of BPPV for an elderly female patient referred for low back pain: a resident's case study.

Benign paroxysmal positional vertigo (BPPV) is common among older adults and frequently misdiagnosed or unidentified. Undiagnosed BPPV has been associated with depression, falls and ADL limitations. This case study describes the diagnostic process and management of BPPV for a 65-year-old patient with a primary complaint of chronic low back pain (LBP) in an outpatient orthopedic physical therapy setting. Following routine screening performed on initial evaluation, the patient was educated about examination findings that indicated the potential for BPPV and given the option to proceed with further assessment or defer until LBP was under control. The patient attended 16 visits over the course of care and the complaint of vertigo, described as a true spinning sensation, was assessed further on the visit 5. Continued assessment confirmed BPPV and the canalith repositioning procedure was administered. Following positive response to this intervention, the maneuver was re-administered on visit 6. Complete resolution of symptoms was reported on visit 7 and for the remainder of physical therapy services over the following month. Physical therapists may play a vital role in reducing healthcare expenses associated with cost to arrive at the diagnosis of BPPV, as well as improving the quality of life and safety of the older adult population affected by BPPV.

Serotonin receptors as targets for drugs useful to treat psychosis and cognitive impairment in schizophrenia.

The concept that the efficacy of all antipsychotic drugs (APDs) can be explained by their action on dopamine (DA) D2 receptors is most challenged by drugs such as clozapine which target serotonin (5-HT)2A receptors as an essential component of their efficacy and tolerability. The 5-HT2A receptor, along with 5-HT1A, 5-HT 2C, 5-HT 6 or 5-HT 7 receptors, all of which are components of the mechanism of action of clozapine, represent important targets for treating multiple aspects of schizophrenia, especially psychosis and cognitive impairment. The class of atypical antipsychotic drugs (APDs), of which clozapine is the prototype, share in common more effective 5-HT 2A receptor inverse agonism and weaker interference with D2 receptor stimulation, either through D2 receptor blockade or partial D2 receptor agonism. This has led to development of a selective 5-HT2A antagonist, ACP-103 (pimavanserin), which has been found to be effective as monotherapy in L-DOPA psychosis and has promise as an add-on agent for sub-effective doses of atypical APDs. We review here the extensive preclinical evidence to support the importance of 5-HT2A receptor inverse agonism to the action of clozapine and related atypical APDs, and evidence supporting the potential of selective 5-HT2A, 5-HT 6 , and 5-HT 7, antagonists, 5-HT1A partial agonists and 5-HT2C agonists for development of drugs which ameliorate psychosis or cognitive impairment.

The role of serotonin receptors in the action of atypical antipsychotic drugs.

The main class of atypical antipsychotic drugs (APDs) in current use includes the protypical atypical APD, clozapine, as well as aripiprazole, asenapine, iloperidone, lurasidone, olanzapine, quetiapine, risperidone, and ziprasidone. At clinically effective doses, these agents produce extensive blockade of serotonin (5-HT)(2A) receptors, direct or indirect stimulation of 5-HT(1A) receptors, and to a lesser extent, reduction in dopamine (DA) D(2) receptor-mediated neurotransmission. This contrasts with typical APDs, for example haloperidol and perphenazine, which are mainly DA D(2/)D(3) receptor antagonists and have weaker, if any, potency as 5-HT(2A) receptor antagonists. Some, but not all, atypical APDs are also effective 5-HT(2C) receptor inverse agonists or neutral antagonists, 5-HT(6) or 5-HT(7) receptor antagonists. This diverse action on 5-HT receptors may contribute to significant differences in efficacy and tolerability among the atypical APDs. There is considerable preclinical and some clinical evidence that effects on 5-HT receptors contribute to the low risk of producing extrapyramidal side effects, which is the defining characteristic of an atypical APD, the lack of elevation in plasma prolactin levels (with risperidone and 9-hydroxyrisperidone being exceptions), antipsychotic action, and ability to improve some domains of cognition in patients with schizophrenia. The serotonergic actions of the atypical APDs, especially 5-HT(2A) receptor antagonism, are particularly important to the differential effects of typical and atypical APDs to overcome the effects of acute or subchronic administration of N-methyl-d-aspartate (NMDA) receptor antagonists, such as phencyclidine, ketamine, and dizocipline (MK-801). 5-HT(1A) receptor stimulation and 5-HT(6) and 5-HT(7) receptor antagonism may contribute to beneficial effects of these agents on cognition. In particular, 5-HT(7) receptor antagonism may be the basis for the pro-cognitive effects of the atypical APD, amisulpride, a D(2)/D(3) receptor antagonist, which has no effect on other 5-HT receptor. 5-HT(2C) receptor antagonism appears to contribute to the weight gain produced by some atypical APDs and may also affect cognition and psychosis via its influence on cortical and limbic dopaminergic activity.

Radial asymmetry of the upper oesophageal sphincter pressure profile: fact or artefact.

Radial asymmetry of the upper oesophageal sphincter high-pressure zone (UESHPZ) is an accepted notion based on manometric studies. Our aim was to evaluate the effect of the catheter diameter and configuration on the resting pressure profile of the UES. We studied 14 young (30 +/- 2 years) and 14 healthy elderly volunteers (77 +/- 2 years) using the station pull-through technique. We used a specially designed water perfused manometric assembly that incorporated a proximal round cross-section (4.8 mm) and a distal flat cross-section (4.8 x 1.2 mm). Anterior and posterior manometric sites on the round catheter measured significantly higher pressure values than did the sites oriented laterally at the same level (P < 0.001) in both young and elderly. In contrast, the flat-shaped catheter measured statistically indistinguishable pressures from all four orientations in both age groups. In both young and elderly the anterio-posterior, but not lateral pressures by the round catheter were significantly higher (P < 0.001) than those of the flat catheter. An exaggerated anteriorly and posteriorly oriented pressure may be recorded compared with lateral pressures depending on the diameter and non-conforming shape of the recording catheter with respect to the UES producing the appearance of radial asymmetry in the UESHPZ.

Potential control of gastroesophageal reflux by local modulation of transient lower esophageal sphincter relaxations.

Transient lower esophageal sphincter relaxations (TLESRs) are neurally mediated abrupt reductions in lower esophageal sphincter (LES) pressure. TLESRs are not usually associated with deglutition or secondary peristalsis but are thought to be necessary for venting swallowed air from the stomach. Their central role in acid reflux, however, makes them a compelling therapeutic target for patients with gastroesophageal reflux disease. Pharmacologic approaches for reducing TLESR frequency are being studied, but theoretically more promising are endoscopic approaches that interfere with mechanoreceptor function. Further study into the mechanisms of action of these approaches is needed, as are controlled clinical trials to define the true utility of these techniques and identify patients who will receive the most benefit.

Liposuction as an adjunct procedure in reduction mammaplasty.

Liposuction has been recognized as a useful adjunct to breast reduction surgery for fine contouring of adjacent areas to achieve aesthetic balance and preservation of nipple sensation. In particular, the liposuction technique has provided an acceptable way of treating the "fat roll" of the lateral portion of the breast, which extends to the axilla and lateral chest. The purpose of this study was to review the authors' approach to adjunctive lipoplasty with breast reduction surgery and to review their experience. Examination of their own results in 70 consecutive women who underwent reduction mammaplasty in 1998 by the senior surgeon did not reveal any substantial difference in the complication rate of those women who had adjunctive liposuction with their breast reduction surgery vs. those who did not. All complications such as fat necrosis, cellulitis, and seromas were confined to the breast and were not related to the liposuction. Furthermore, there was no additional morbidity associated with ultrasonic liposuction compared with traditional suction-assisted lipectomy. Their experience indicates that patients undergoing reduction mammaplasty may benefit aesthetically from adjunct lateral chest wall liposuction without additional morbidity.

Post-fundoplication symptoms: the role for endoscopic assessment of fundoplication integrity.

BACKGROUND: Fundoplication is now almost exclusively a laparoscopic procedure. The aim of this study was the comparison of the diagnostic usefulness of endoscopy and barium esophagram in the detection of fundoplication abnormalities. METHODS: Twenty-two patients presented with symptoms post-laparoscopic (Nissen) fundoplication that included dysphagia (14 patients), heartburn (5 patients), dyspepsia (2 patients), and chest pain (1 patient). Barium esophagram and upper endoscopy were performed in all patients and the results were compared. Key features included presence of esophagitis, resistance to endoscope passage, location of the wrap relative to the diaphragmatic hiatus, location of squamocolumnar junction greater than 1 cm proximal to the wrap zone, and the appearance of the wrap (intact, loose, disrupted, or tight). RESULTS: The key features explained symptoms in 20 of 22 patients. Endoscopy detected twice as many key features as radiography. Disruption of the wrap or excessive proximal location of the squamocolumnar junction proximal to the wrap zone were the most incriminating endoscopic findings. Resistance to endoscope passage was rarely encountered and the esophagram was more accurate in detecting an overly tight wrap. CONCLUSIONS: Endoscopic evaluation is more accurate than barium esophagram in detecting post-fundoplication abnormalities. The appearance of the fundoplication wrap and an abnormal proximal location of the squamocolumnar junction appear to be major endoscopic clues in diagnosis of post-fundoplication problems.

Sustainability of coastal resource use in San Quintin, Mexico.

San Quintin, Mexico, provides a useful site for integrated analyses of material fluxes and socioeconomic constraints in a geographically isolated system. Natural resource utilization on the land is dominated by groundwater exploitation for cultivation of horticulture crops (primarily tomatoes). Irrigation exceeds water recharge minus export by a factor of 6. Resource utilization in the bay is dominated by oyster culture; food for the oysters is provided by tidal exchange of bay and ocean water. Consideration of oyster respiration and system respiration suggests that the present level of aquaculture is about 40% of the sustainable level. A "physical unsustainability index" (PhUI) was developed to measure the proportional departure of utilization of the most limiting resource for sustainability: 6 on land; 0.4 in the bay. Based on PhUI and measures of economic development, we conclude that aquaculture is more viable than agriculture.