The efficacy of a supervised and a home-based core strengthening programme in adults with poor core stability: a three-arm randomised controlled trial.

BACKGROUND: Poor core stability is linked to a range of musculoskeletal pathologies and core-strengthening programmes are widely used as treatment. Treatment outcomes, however, are highly variable, which may be related to the method of delivery of core strengthening programmes. We investigated the effect of identical 8 week core strengthening programmes delivered as either supervised or home-based on measures of core stability. METHODS: Participants with poor core stability were randomised into three groups: supervised (n=26), home-based (n=26) or control (n=26). Primary outcomes were the Sahrmann test and the Star Excursion Balance Test (SEBT) for dynamic core stability and three endurance tests (side-bridge, flexor and Sorensen) for static core stability. The exercise programme was devised and supervised by an exercise physiologist. RESULTS: Analysis of covariance on the change from baseline over the 8 weeks showed that the supervised group performed significantly better on all core stability measures than both the home-based and control group. The home-based group produced significant improvements compared to the control group in all static core stability tests, but not in most of the dynamic core stability tests (Sahrmann test and two out of three directions of the SEBT). CONCLUSIONS: Our results support the use of a supervised core-strengthening programme over a home-based programme to maximise improvements in core stability, especially in its dynamic aspects. Based on our findings in healthy individuals with low core stability, further research is recommended on potential therapeutic benefits of supervised core-strengthening programmes for pathologies associated with low core stability. TRIAL REGISTRATION NUMBER: ACTRN12613000233729.

An historical commentary on the physiological effects of music: Tomatis, Mozart and neuropsychology.

This article provides an overview of the theoretical underpinnings of the Tomatis Method, along with a commentary on other forms of sound/music training and the need for research. A public debate was sparked over the "Mozart Effect." This debate has turned out to be unfortunate because the real story is being missed. The real story starts with Alfred Tomatis, M.D., scientist and innovator. Dr. Tomatis was the first to develop a technique using modified music to stimulate the rich interconnections between the ear and the nervous system to integrate aspects of human development and behavior. The originating theories behind the Tomatis Method are reviewed to describe the ear's clear connection to the brain and the nervous system. The "neuropsychology of sound training" describes how and what the Tomatis Method effects. Since Dr. Tomatis opened this field in the mid 20th century, no fewer than a dozen offshoot and related systems of training have been developed. Though each new system of treatment makes claims of effectiveness, no research exists to substantiate their claims. Rather, each simplified system bases its "right to exist and advertise" on the claimed relationship to Tomatis and his complex Method. Research is desperately needed in this area. The 50 years of clinical experience and anecdotal evidence amassed by Tomatis show that sound stimulation can provide a valuable remediation and developmental training tool for people of all ages. Offshoot systems have watered down the Tomatis Method without research to guide the decisions of simplifying the techniques and equipment.

1998-1999 SAEM emergency medicine faculty salary and benefits survey.

OBJECTIVES: The Society for Academic Emergency Medicine (SAEM) commissioned an emergency medicine (EM) faculty salary and benefits survey for all 1998 residency review committee (RRC)-EM-accredited programs using the SAEM fourth-generation survey instrument. Responses were collected by SAEM and blinded from the investigators. METHODS: Blinded program and individual faculty data were entered into a customized version of FileMaker Pro, a relational database program with a built-in statistical package. Salary data were sorted by program region, faculty title, American Board of Emergency Medicine (ABEM) certification, academic rank, years postresidency, program size, and whether data were reported to the American Association of Medical Colleges (AAMC). Demographic data were analyzed with regard to numerous criteria, including department staffing levels, ED volumes, ED length of stay, department income sources, salary incentive components, and specific type and value of fringe benefits offered. Data were compared with those from previous SAEM studies. RESULTS: Seventy-three of 120 (61%) accredited programs responded, yielding usable data for 70 programs and 965 full-time faculty among the four AAMC regions. Mean salaries were reported as follows: all faculty, $167,478; first-year faculty, $140,616; programs reporting data to the AAMC, $161,794; programs not reporting data to the AAMC, $165,724. Mean salaries as reported by AAMC region: northeast, $167,876; south, $160,586; midwest, $190,957; west, $148,977. CONCLUSIONS: Reported salaries for full-time EM residency faculty continue to rise. Significant regional differences in salaries have been present in all four SAEM surveys. Nonclinical hours are compensated at approximately one-half the rate paid for clinical hours. The demographic data indicate that EM residency faculty are working at the upper extremes of numbers of patient encounters per physician, patient acuity levels, and department lengths of stay.

1995-1996 SAEM emergency medicine faculty salary/benefits survey.

OBJECTIVE: The Society for Academic Emergency Medicine (SAEM) commissioned an emergency medicine (EM) faculty salary and benefit survey for all 1995 Residency Review Committee in Emergency Medicine (RRC-EM)-accredited programs using the SAEM third-generation survey instrument. Responses were collected by SAEM and blinded from the investigators. POPULATION: Seventy-six of 112 (68%) accredited programs responded, yielding data for 1,032 full-time faculty among the four Association of American Medical Colleges (AAMC) regions. METHODS: Blinded program and individual faculty data were entered into a customized version of Filemaker Pro, a relational database program with a built-in statistical package. Salary data were sorted by 115 separate criteria such as program regions, faculty title, American Board of Emergency Medicine (ABEM) certification, academic rank, years postresidency, program size, and whether data were reported to AAMC. Demographic data from 132 categories were analyzed and included number of staff and residents per shift, number of intensive care unit (ICU) beds, obstacles to hiring new staff, and specific type and value of fringe benefits offered. Data were compared with those from the 1990 and 1992 SAEM and the 1995-96 AAMC studies. RESULTS: Mean salaries were reported as follows: all faculty, $158,100; first-year faculty, $131,074; programs reporting data to AAMC, $152,198; programs not reporting data to AAMC, $169,251. Mean salaries as reported by AAMC region: northeast, $155,909; south, $155,403; midwest, $172,260; west, $139,930. Mean salaries as reported by program financial source: community, $175,599; university, $152,878; municipal, $141,566. CONCLUSIONS: Reported salaries for full-time EM residency faculty continue to rise. Salaries in programs reporting data to the AAMC are considerably lower than those not reporting. The gap between ABEM-certified and non-ABEM-certified faculty continues to widen. Residency-trained faculty are now shown to earn more than non-residency-trained faculty. Significant regional differences in salaries have been present in all three SAEM surveys.

Selenium regulation of selenium-dependent glutathione peroxidases in animals and transfected CHO cells.

Glutathione peroxidase (GPX1) was the first identified selenium-dependent enzyme, and this enzyme has been most useful as a biochemical indicator of selenium (Se) status and the parameter of choice for determining Se requirements. We have continued to study Se regulation of GPX1 to better understand the underlying mechanism and to gain insight into how cells themselves regulate nutrient status. In progressive Se deficiency in rats, GPX1 activity, protein and mRNA all decrease in a dramatic, coordinated and exponential fashion such that Se-deficient GPX1 mRNA levels are 6-15% of Se-adequate levels. mRNA levels for other Se-dependent proteins are far less decreased in the same animals. The mRNA levels for a second Se-dependent peroxidase, phospholipid hydroperoxide glutathione peroxidase (GPX4), are little affected by Se deficiency, demonstrating that Se regulation of GPX1 is unique. Se regulation of GPX1 activity in growing male and female rats shows that the Se requirement is 100 ng/g diet, based on liver GPX1 activity; use of GPX1 mRNA as the parameter indicates that the Se requirement is nearer to 50 ng Se/g diet in both male and female rats. This approach will readily detect an altered dietary Se requirement, as shown by the incremental increases in dietary Se requirement by 150, 100 or 50 ng Se/g diet in Se-deficient rat pups repleted with Se for 3, 7 or 14 d, respectively. Studies with CHO cells stably transfected with recombinant GPX1 also show that overexpression of GPX1 does not alter the minimum level of media Se necessary for Se-adequate levels of GPX1 activity or mRNA. We hypothesize that classical GPX1 has an integral biological role in the mechanism used by cells to regulate Se status, making GPX1 an especially useful and effective parameter for determining Se requirements in animals.

Western Nebraska family (family D) with autosomal dominant parkinsonism.

The etiology of Parkinson's disease (PD) remains uncertain. Environmental influences may have an important role, but genetic factors have been firmly implicated in several recently reported kindreds. We studied a family (family D) whose ancestors probably immigrated to the United States from England. The pedigree contains 188 individuals spanning six generations with 18 affected members. Autosomal dominant inheritance is present. Typical levodopa-responsive PD with bradykinesia, rigidity, resting tremor, and impaired postural reflexes develops. Eye movement abnormalities, pyramidal and cerebellar signs, sensory disturbances, and orthostatic blood pressure changes do not occur. Disease progression is slow. PET with [18F]-6-fluoro-L-dopa (FD) performed on an affected individual revealed decreased uptake of FD in a pattern consistent with PD. Autopsy performed on another affected individual demonstrated neuronal and pigmentary loss, gliosis, and Lewy bodies in the substantia nigra pars compacta. This large kindred appears to represent a neurodegenerative disorder closely resembling, if not identical to, idiopathic PD.

Iontophoretic treatment of herpetic whitlow.

Herpetic whitlow can be a vector for spread of infection, especially among health care professionals. Until now, treatment has been inadequate. In two patients with documented herpetic infections of the finger, the antiviral drug idoxuridine was applied to the lesions by cathodal iontophoresis. Results were characterized by rapid relief of discomfort and swelling, rapid appearance and coalescence of vesicles, and rapid healing, with reduced pain and little or no paresthesia. No recurrences have been noted in the two patients after 42 and 38 months. The positive beneficial results indicate that aggressive iontophoretic treatment for herpetic whitlow is useful and justified.

Digoxin levels in prehospital sudden-death syndrome.

Digitalis toxicity is common and has been associated with ventricular dysrhythmias. Digoxin levels in patients who suffer prehospital sudden death have never been studied. This study measured digoxin levels in a population of sudden-death patients. During the 15-week study period, 252 patients in cardiac arrest were seen by an urban paramedic system. During daytime hours, paramedics were requested to obtain a blood sample from sudden-death patients; the samples were subsequently analyzed for digoxin by means of radioimmunoassay. Thirty-nine patients had measured digoxin levels drawn; 28 (71.8%) were in the therapeutic range (0.5-2.1 ng/mL), and four (10.2%) were in the toxic range (greater than 2.1 ng/mL). The patients with toxic dogoxin levels and those with nontoxic levels had similar resuscitation rates (50.0% vs. 34.3%, P = NS), but none were found in ventricular fibrillation. Emergency medical services personnel should consider digoxin toxicity as a potential etiology of arrest.

Development of a staff training program at the Wesley Hospital.

This paper reports the development of a staff training program at The Wesley Hospital in response to perceived needs. A training needs analysis identified priorities for training. Three courses have been run: decision making workshops, stress management workshops, and an assertion seminar. The design of these courses, and staff responses are discussed. Future developments in the training program are proposed.

Calcium: limited indications, some danger.

Calcium chloride has been advocated since the 1920s for the resuscitation of asystole, electromechanical dissociation (EMD), and ventricular fibrillation. Reports of side effects and complications have been numerous. Studies of calcium assays following American Heart Association recommended dosages have shown dangerously elevated serum levels. Large retrospective clinical studies in Milwaukee and Tampa have found no evidence of improved survival with calcium chloride in asystole and EMD. A prospective randomized double-blind study comparing calcium chloride and saline controls in the Milwaukee Paramedic system for asystole and EMD using standard AHA protocols showed no statistically significant difference in resuscitation rates or long-term survival between the calcium and no-calcium groups for the rhythm of asystole. Although patients with EMD had statistically improved resuscitation rates when calcium chloride was given, only one of the patients survived to hospital discharge. Because of the low rates of resuscitation and long-term survival in patients presenting in asystole and EMD, proving that calcium chloride does not enhance survival would require large multicenter trials. However, since no controlled study has ever documented significant benefit, its routine use in asystole and EMD cannot be supported. Calcium has long been used in medical treatment of hypocalcemic and hyperkalemic states and should be administered in moribund patients who have the proper clinical history and clinical signs of hypocalcemia.

Prophylactic lidocaine in the prehospital patient with chest pain of suspected cardiac origin.

The prophylactic use of lidocaine in the patient with cardiac chest pain has been reported to reduce the incidence of sudden death from ventricular dysrhythmias in the hospital setting, but few studies have been done in the early prehospital phase. We conducted a randomized, prospective study comparing the effects of lidocaine versus no lidocaine in stable patients presenting with chest pain to a paramedic system. In a one-year period, 446 patients qualified for the study; 222 received lidocaine and 224 did not. The overall hospital mortality of the two groups was 8.1% and 6.7%, respectively (P = .35). Four patients in each group developed sudden death in the prehospital and emergency department settings with ventricular dysrhythmia as the precipitating rhythm. One hundred twenty-nine (29%) had an acute myocardial infarction. The lidocaine and control group contained 68 and 61 of the patients, respectively, with an overall mortality rate of 14.7% and 13.1% (P = .45). The development of significant dysrhythmias (frequent premature ventricular contractions, ventricular tachycardia, bradycardia, second- and third-degree heart blocks) after initiation into the study was similar in both groups of patients. The use of lidocaine was a factor in decreasing systolic blood pressure (P less than 0.03) but did not appear to be clinically significant. For stable patients presenting with chest pain of suspected cardiac origin, prophylactic lidocaine in the prehospital setting was not effective in preventing life-threatening dysrhythmias, but clinically significant side effects were not noted either.

Decision making in prehospital sudden cardiac arrest.

Many studies of prehospital resuscitation report on selected populations. We examined a series of 445 unselected nontraumatic cardiac arrests. Emergency cardiac care (ECC) was not initiated in 126 (28%). ECC was begun in 319 (78%), but was terminated in 132 (33%). Ninety-four (21%) were admitted to the hospital with palpable pulses and organized rhythm (successful resuscitation/save rate for patients presenting in ventricular fibrillation was 50%/25%. Multivariate regression analysis was used to identify the relative importance of significant variables in predicting survival, and the analysis identified the presence of ventricular fibrillation, short paramedic response times, and short paramedic treatment times.

Rib radiographs for trauma: useful or wasteful?

In trauma to the chest, the clinical impression and the physical findings of rib fractures are nonspecific. Fractures often are not seen on initial films. The principal diagnostic goal should be the detection of significant complications (pneumothorax, hemothorax, major vascular injury, or pulmonary contusion) requiring admission. The therapeutic effort should be to provide pain relief and prevent the delayed development of atelectasis or pneumonia in patients with painful chest wall injuries, whether or not a fracture is detected initially. An upright posteroanterior chest radiograph has the greatest yield in detecting fractures and complications resulting from them. Tomograms and expiratory, oblique, and "coned-down" views should not be done routinely. The use of these more specific examinations may be indicated, however, in such cases as trauma to ribs 1 to 3 or 9 to 12. Their selective use in isolated cases (trauma to ribs 1 to 3 or 9 to 12) and suspected child abuse may indicate the need for these more specific examinations. Because detection of pulmonary complications of chest trauma is most important, a delayed or repeat upright posteroanterior chest radiograph may be the most cost-effective second radiograph. Significant medical care cost savings may be appreciated by limiting the use of specific rib views to instances in which it might influence the patient's therapy.

Effects of rapid infusion with high pressure and large-bore i.v. tubing on red blood cell lysis and warming.

A prototype large-bore intravenous tubing was developed and tested. Mean flow rates for blood (Hct 45%) and tap water were determined for several catheters at 600 mm Hg, 300 mm Hg, and gravity flow and were statistically analyzed by calculating the 95% confidence intervals. The degree of hemolysis during high pressure and flow was determined by measuring the plasma free hemoglobin using the spectrophotometric method. To determine if cold banked blood can be adequately warmed at high flow rates, thermocouples were used to measure the blood temperature before and after rapid infusion through a blood warmer. Results included maximum flow rates of 1,764 mL/min for tap water, and 1,714 mL/min for blood (Hct 45%) at 600 mm Hg through the large-bore tubing and an 8.5-F catheter. Flow rates for other pressure and catheter combinations were tabulated. The plasma-free hemoglobin increased slightly compared to controls with high pressure (less than or equal to 600 mm Hg) and flow rates. The increase correlated with less than 1% red blood cell lysis in all trials. When 13 C blood was infused through a warmer, blood temperature increased to 25.3 C at the maximum flow rate of 732 mL/min. Slightly higher heat gain resulted with slower infusion rates. We conclude that the prototype large-bore tubing and up to 600 mm Hg pressure provide rapid flow rates without significant hemolysis. Blood warming may be inadequate at higher flow rates.

Intraosseous infusion: an alternative route of pediatric intravascular access.

Substantial difficulties can be encountered when establishing rapid intravascular access in critically ill children. The historic technique of tibial intraosseous infusion is presented as an alternate intravenous route in children less than 3 years old. Review of the literature reveals this technique to be a rapid, reliable method with an acceptably low complication rate. Substances absorbed through the marrow, flow rates, technical difficulties, and complications are discussed.

Comparison of clinical CPR studies in Milwaukee and elsewhere in the United States.

As we mark the 25th anniversary of the clinical application of closed-chest cardiopulmonary resuscitation (SCPR), it is time to look back and analyze the progress we have made in the resuscitation of sudden death syndrome. Recent studies of SCPR's effectiveness have yielded mixed results, in comparison to early studies that were universally favorable. The continued toll of neurologic injury following SCPR resuscitation, and reinforcement of the importance of defibrillation in resuscitation, stimulate us to find improved forms of SCPR and improved methods of resuscitation delivery in emergency medical systems.