mHealth Physical Activity Intervention for Individuals With Spinal Cord Injury: Planning and Development Processes.

BACKGROUND: Interventions to support physical activity participation among individuals with spinal cord injury (SCI) are required given this population's low levels of physical activity and extensive barriers to quality physical activity experiences. OBJECTIVE: This study aimed to develop a mobile health intervention, called SCI Step Together, to improve the quantity and quality of physical activity among individuals with SCI who walk. METHODS: Our overarching methodological framework was the Person-Based approach. This included the following 4 steps: conduct primary and secondary research (step 1); design intervention objectives and features (step 2a); conduct behavioral analysis and theory (step 2b); create a logic model (step 3); and complete the SCI Step Together program content and integrated knowledge translation (IKT; step 4), which occurred throughout development. The partnership approach was informed by the SCI IKT Guiding Principles. Three end users pilot-tested the app and participated in the interviews. RESULTS: Step 1 identified issues to be addressed when designing intervention objectives and features (step 2a) and features were mapped onto the Behavior Change Wheel (step 2b) to determine the behavior change techniques (eg, action planning) to be included in the app. The logic model linked the mechanisms of action to self-determination theory (steps 2/3). Interviews with end users generated recommendations for the technology (eg, comparing physical activity levels with guidelines), trial (eg, emailing participants' worksheets), and intervention content (eg, removing graded tasks; step 4). CONCLUSIONS: Using the SCI IKT Guiding Principles to guide partner engagement and involvement ensured that design partners had shared decision-making power in intervention development. Equal decision-making power maximizes the meaningfulness of the app for end users. Future research will include testing the acceptability, feasibility, and engagement of the program. Partners will be involved throughout the research process. TRIAL REGISTRATION: ClinicalTrials.gov: NCT05063617; https://clinicaltrials.gov/ct2/show/NCT05063617.

TuLIP (Tunnelled Line Intraluminal Plasty): An Alternative Technique for Salvaging Haemodialysis Catheter Patency in Fibrin Sheath Formation.

BACKGROUND: Renal patients with a tunnelled haemodialysis line are at risk of fibrin 'sheath' formation which can lead to occlusion. Dysfunctional lines are best treated by catheter exchange with a new subcutaneous tunnel; however, there is a risk of scarring, venous stenosis, potential loss of valuable access as well as the risk of infection. METHOD: We report a retrospective review of our experience using tunnelled line intraluminal plasty (TuLIP) in 11 patients over 16 months with fibrin sheath formation on pre-existing tunnelled haemodialysis catheters. RESULT: All patients responded well to treatment with median line patency post TuLIP reaching 112 days. CONCLUSION: TuLIP may have a role in extending catheter lifespan and delaying more invasive intervention.

Male infertility: the role of imaging in diagnosis and management.

The investigation of male infertility is assuming greater importance, with male factors implicated as a causal factor in up to half of infertile couples. Following routine history, examination and blood tests, imaging is frequently utilised in order to assess the scrotal contents for testicular volume and morphology. Additionally, this may give indirect evidence of the presence of possible reversible pathology in the form of obstructive azoospermia. Further imaging in the form of transrectal ultrasound and MRI is then often able to categorise the level of obstruction and facilitate treatment planning without resort to more invasive imaging such as vasography. Ultrasound guidance of therapy such as sperm or cyst aspiration and vasal cannulation may also be performed. This article reviews the imaging modalities used in the investigation of male infertility, and illustrates normal and abnormal findings that may be demonstrated.

Day-case angioplasty in diabetic patients with critical ischemia.

AIM: Recent studies have shown that percutaneous transluminal angioplasty (PTA) can be safely performed as a day-case procedure. Many centers consider diabetes mellitus as a contraindication to day-case PTA. In this study, the safety and efficacy of 95 day-case PTA in 66 diabetic patients with critical leg ischemia (CLI) were evaluated. METHODS: Diabetic patients with CLI were assessed in a one-stop multidisciplinary outpatient clinic. Sixty-six outpatients with CLI deemed suitable for radiological intervention by non-invasive imaging (ultrasound angiology or magnetic resonance angiography) were scheduled for day-case PTA. RESULTS: PTA was initially successful in 63 out of 66 patients (95%). In 3 patients (5%), PTA was not possible because the lesion could not be balloon dilated or crossed with a guide wire. Clinically suspected first, second and third re-stenosis confirmed by non-invasive studies occurred in 20 out of 63 (31%), 7 out of 20 (35%) and 2 out of 7 (28%) patients, respectively. Following PTA, debridement was performed in 11 patients (17%), minor amputation in 8 (13%) and major amputation in 3 (5%). Relief of the primary symptom of rest pain or healing of ulcers was achieved in 23 out of 32 (72%) and 25 out of 27 (92.5%) patients, respectively. No peri-interventional morbidity or mortality was encountered. CONCLUSION: PTA is feasible and safe as a day-case procedure in diabetic patients with CLI. Re-stenosis can be managed by repeat day-case PTA.

Day-case diagnostic and interventional peripheral angiography: 10-year experience in a radiology specialist nurse-led unit.

We describe a prospective evaluation of the safety of peripheral angiography procedures performed on day-case patients in a dedicated radiological nurse-led and administrated unit. Patients referred for peripheral vascular angiography, over a 10-year period, were pre-assessed by a radiology specialist nurse in a nurse-led clinic. Radiologists performed all procedures, whereas radiology specialist nurses were responsible for patient care before, during and after angiography and during the 24 h follow-up. Procedures were divided into diagnostic or interventional; complications were divided into immediate or delayed (24 h follow-up) either requiring hospital admission (major) or day-case unit management (minor). Patient acceptability was assessed using a standard questionnaire. Cost analysis was also performed. 401 day-case peripheral angiography procedures (144 diagnostic and 257 interventional) were performed in 310 patients. 109/401 (27.2%) procedures were performed on patients with diabetes mellitus. In diagnostic studies, 16/144 (11.1%) immediate and 6/144 (4.2%) delayed complications occurred whereas, in interventional studies, 65/257 (25.3%) immediate and 13/257 (5.1%) delayed complications were noted. A major complication occurred in 17/257 (6.6%) of patients in the interventional group and 3/144 (2.1%) in the diagnostic group. Puncture site haematoma was the most common complication. Nurse-led care was acceptable to the patient, with a high level of patient satisfaction seen. In conclusion, day-case diagnostic and interventional peripheral angiography procedures can be performed safely in a specialist nurse-led and administrated unit, with complication rates being within the accepted guidelines.

Phentolamine re-dosing during penile dynamic colour Doppler ultrasound: a practical method to abolish a false diagnosis of venous leakage in patients with erectile dysfunction.

Increased sympathetic tone may cause an equivocal response to a prostaglandin E1 (PGE1) penile Doppler ultrasound (US) examination interpreted as a venous leak. We evaluated the US parameters and erectile response to the addition of phentolamine to a PGE1 penile Doppler US examination to ascertain whether addition of phentolamine would abolish a suboptimal response. 32 patients (median age 29 years, range 17-70 years) with either a previous Doppler US pattern of venous leakage or a clinical suspicion of venogenic impotence, underwent Doppler US after a total dose of 20 microg of PGE1. Peak systolic velocity (PSV), end diastolic velocity (EDV) and grade of erection were documented. If erectile response was suboptimal irrespective of the EDV measurement, 2 mg-intracavernosal phentolamine was administered and measurements repeated. Six patients had a normal erectile response, the remaining 26 received phentolamine. A significant increase in PSV between baseline and 20 microg PGE1 (p<0.001) was observed in all cases. Following phentolamine there was a significant increase in grade of erection (p=0.0001) and a significant reduction in the EDV (p=0.0001). A reduction of the EDV to below 0.0 cm s(-1) was observed in 16 patients. Four patients with EDV <5.0 cm s(-1) but >0.0 cm s(-1) had improved erectile response following phentolamine while six showed persistent EDV elevation >5 cm s(-1). No priapism was documented. It is essential to ensure cavernosal relaxation using phentolamine before a Doppler US diagnosis of venous leak is made. This two-stage assessment will allow this to be done efficiently and with a low risk of priapism.

Colour Doppler ultrasound of the penis.

Because it is a superficial structure, the penis is ideally suited to ultrasound imaging. A number of disease processes, including Peyronie's disease, penile fractures and penile tumours, are clearly visualized with ultrasound. An assessment of priapism can also be made using spectral Doppler waveform technology. Furthermore, dynamic assessment of cavernosal arterial changes after pharmaco-stimulation allows diagnosis of arterial and venogenic causes for impotence. This pictorial review illustrates the range of diseases encountered with ultrasound of the penis.

Sevoflurane induction for emergency caesarean section: two case reports in women with needle phobia.

Needle phobia is an unusual but well-recognised clinical entity. It is claimed that it may affect up to 10% of the general population and may prevent potential patients from seeking medical care, thereby reducing its apparent incidence in the hospital population. Its occurrence in a parturient requiring urgent caesarean section presents special challenges to the anaesthetist. This report discusses the clinical, ethical and medico-legal dilemmas presented by two such cases that were successfully managed by inhalational induction of general anaesthesia using sevoflurane.

Comparison of the anesthetic requirement for tolerance of laryngeal mask airway and endotracheal tube.

We tested the hypothesis that the laryngeal mask airway (LMA) is tolerated at lighter levels of anesthesia than an endotracheal tube (ET). We studied 20 unpremedicated, nonsmoking ASA physical status I or II patients aged 18-40 yr whose surgery lasted > 1 h. Subjects were randomly assigned to receive either an ET or LMA. Anesthesia was induced with intravenous propofol and the LMA or ET was inserted. The ET-group patients received 1.5 mg/kg of succinylcholine, preceded by vecuronium (0.015 mg/kg IV). Maintenance of anesthesia was with only isoflurane and approximately 66% N2O in O2 by spontaneous ventilation. All gas concentrations were measured by a Raman spectrometer sampling from the breathing circuit end of the LMA or ET. Toward the end of the procedure, the end-tidal N2O and isoflurane concentrations were allowed to decrease to < 3 vol% and 0.8 +/- 0.05 vol%, respectively. The end-tidal isoflurane concentration was then decreased in 0.1% +/- 0.05% decrements, each stable value being held for 5 min. The patient was observed for signs of reaction to the presence of the LMA or ET. The mean (range) end-tidal isoflurane concentrations for reaction to ET and LMA were 0.55% (0.4-0.7) and 0.35% (0.2-0.51), respectively (P < 0.001). These data confirm the original hypothesis of the study.

Influence of the lumbar interspace chosen for injection on the spread of hyperbaric 0.5% bupivacaine.

Forty patients undergoing elective Caesarean section were allocated randomly to receive hyperbaric 0.5% bupivacaine 2.5 ml at either the L2-3 (n = 20) or L4-5 (n = 20) interspace. Spinal injection was performed with a 29-gauge needle in 38 patients and a 25-gauge needle in two. The onset time to analgesia at T10 and T6 was significantly faster and the level of analgesia at 5 and 10 min after injection significantly higher after injection at L2-3. Maximum height and range of analgesia, the level of analgesia at 15 and 20 min after injection and the number of episodes of hypotension were not significantly different between the two groups. One case of post-dural puncture headache was recorded after use of a 29-gauge needle. Overall, the choice of lumbar interspace influenced the rate of onset of analgesia, but not the final dermatomal level (mean and range) of analgesia achieved.

Hypoxaemia after inhalation of 50% nitrous oxide and oxygen.

We have investigated, in volunteers, the effect of inhaling 50% nitrous oxide in oxygen on subsequent oxygenation. Subjects breathed either 50% nitrous oxide in oxygen or 50% nitrogen in oxygen during hyperventilation and normal ventilation. Arterial oxygen saturation and end-expired oxygen concentrations were lower after 50% nitrous oxide in oxygen than after the other mixture with both patterns of ventilation and were lowest after hyperventilation with 50% nitrous oxide in oxygen.

Comparison of pulse oximeters: effects of vasoconstriction and venous engorgement.

The effects of cold-induced vasoconstriction and venous occlusion on the detection of induced hypoxaemia by four pulse oximeters were examined in 10 volunteers. In three further subjects vasoconstriction was maintained until at least one instrument failed to detect the induced hypoxaemia. Time taken to detect hypoxaemia was increased for all instruments to between two and three times the instrument's own control value for both vasoconstriction and venous engorgement (P less than 0.01). There was highly significant variation in detected minimum saturation between the instruments (P less than 0.001). One instrument failed to detect the full extent of desaturation under the experimental conditions and was more likely to fail completely to detect desaturation than the other test instruments when influenced by vasoconstriction (P less than 0.05). Significant impairment in the performance of all the instruments tested occurred in the presence of normal pulse signals. The duration of detected reductions in oxygen saturation was not significantly affected.

Stimulatory and inhibitory actions of excitatory amino acids on inositol phospholipid metabolism in rat cerebral cortex.

1. The effects of excitatory amino acids on [3H]-inositol phosphate levels have been examined in rat cortical slices under basal conditions or following agonist stimulation. 2. Ibotenate and quisqualate provoked a substantial dose-dependent (EC50, 30 microM and 20 microM respectively) increase in inositol phosphates; these responses were not additive suggesting a common site of action for the two amino acids. The responses to maximally effective concentrations of ibotenate and quisqualate were not blocked by verapamil, tetrodotoxin or Cd2+, indicating that these effects are not indirect. Small, but significant, increases in inositol phosphates were also seen with glutamate and N-methyl-DL-aspartate (NMDLA); kainate and aspartate were ineffective. 3. Each excitatory amino acid tested reduced carbachol (1 mM) stimulated inositol phosphate formation. Kainate (IC50, 20 microM) and NMDLA (IC50, 20 microM) were the most effective inhibitors. Kainate also reduced the responses to noradrenaline, 5-hydroxytryptamine and 20 mM K+. 4. The inhibitory action of NMDLA, but not kainate, could be reversed with the NMDA antagonists, DL-2-amino-5-phosphonovalerate (APV) and MK-801; DL-2-amino-4-phosphonobutyrate (APB) was without effect. Since MK-801 blocks the ion channels associated with the NMDA receptor, it appears that inhibition requires the entry of ions into the cell. 5. APV and MK-801 potentiated the stimulatory response to ibotenate but had no effect on the response to quisqualate. Potentiation was presumably the result of blocking the inhibition by ibotenate mediated through NMDA receptors. 6. In conclusion, excitatory amino acids appear to reduce agonist-mediated inositol phosphate formation in rat cerebral cortex by a non-specific action, possibly including the influx of Na+ ions. In addition ibotenate and quisqualate substantially enhance inositol phosphate production: the pharmacology of the response suggests that it is mediated by a receptor distinct from previously defined excitatory amino acid receptor subtypes.

A comparison of propofol and methohexitone as anaesthetic agents for electroconvulsive therapy.

This study was designed to compare the effects of propofol and methohexitone upon the haemodynamic changes during, and the recovery from, anaesthesia for electroconvulsive therapy. Thirty patients were included, each patient being studied on two successive treatments with both propofol 1-1.5 mg kg-1 body weight, and methohexitone 0.75-1 mg kg-1 body weight. The duration and intensity of the modified convulsion were similar for both agents. There was no significant difference with respect of time to eye-opening, time to walking and observer assessment of recovery at 5 and 10 min for the two drugs. The direction of haemodynamic changes during the treatment were similar with both agents, although a significantly greater decrease (P less than 0.05) in diastolic arterial pressure following induction with propofol compared to methohexitone, and a significantly greater increase (P less than 0.05) in systolic arterial pressure following the fit with methohexitone compared to propofol, were noted.