Large Cuff Research Articles

Bilateral rotator cuff repair utilizing augmentation nine patch grafts over 24 years in one patient with polio paraplegia: A case report

This case report describes the management of sequential rotator cuff (RC) tears with multiple patch graft augmentation in a polio-paraplegic athlete. The patient underwent these operations over a twenty-four year span from 1986-2010. The patient’s case was complicated due to the fact he had more than a dozen upper extremity surgeries during this time period. The grafts used were autograft illiotibial band, followed by porcine xenografts, and finally allograft dermal collagen matrixes. This report describes the advancements in graft technology, and the surgical procedure associated with the grafts. After the most recent surgery, the patient exhibited full range of motion in both shoulders, the ability to perform independent transfers and was able to discontinue pain medication. Our case provides evidence of the success rate of using patch grafts in both frail tissue repairs as well as large cuff defects in a patient who places high demand on his upper extremities for daily activities.

A randomized clinical trial to compare the effectiveness of rotator cuff repair with or without augmentation using porcine small intestine submucosa for patients with moderate to large rotator cuff tears: a pilot study

The rate of rotator cuff repair failure is between 13% and 67%. Porcine small intestine submucosa (SIS) may be suitable to augment the repair. There were 62 patients with moderate and large cuff tears randomized to repair alone (control) or augmentation with SIS (Restore Orthobiologic Implant; DePuy, Warsaw, IN, USA). Primary outcome was repair failure using magnetic resonance arthrography. Randomization occurred on completion of the repair. Patients and assessors were blind to group. Assessments occurred preoperatively and postoperatively at 2 and 6 weeks and 3, 6, 12, and 24 months. There were 62 patients randomized (34 SIS, 28 control). Patient demographics, rotator cuff tear characteristics, and repair details were similar between groups. At 1 year, risk of failure was 52.9% (18/34) in the SIS group and 65.4% (17/26) in the control group for a risk difference of 12% (80% confidence interval, -7% to 32%) or relative risk of 0.81 (95% confidence interval, 0.53-1.24, P = .33) in favor of SIS. At 1 and 2 years, the mean difference between groups for patient-reported outcomes was small and consistent with chance but did not exclude the possibility of a clinically important difference. There was no statistically significant difference (P = .50) between the SIS group (59.6 ± 38.9; range, 3-112) and the control group (52.7 ± 38.6; range, 5-112) in number of days to being narcotic and pain free (<20 mm on a 100-mm visual analog scale). We found no evidence that SIS-augmented rotator cuff repair provides superior outcomes in patients with moderate rotator cuff tears.

Endothelial hyperpermeability in severe pulmonary arterial hypertension: role of store-operated calcium entry.

Here, we tested the hypothesis that animals with severe pulmonary arterial hypertension (PAH) display increased sensitivity to vascular permeability induced by activation of store-operated calcium entry. To test this hypothesis, wild-type and transient receptor potential channel 4 (TRPC4) knockout Fischer 344 rats were given a single injection of Semaxanib (SU5416; 20 mg/kg) followed by 3 wk of exposure to hypoxia (10% oxygen) and a return to normoxia (21% oxygen) for an additional 2-3 wk. This Semaxanib/hypoxia/normoxia (i.e., SU5416/hypoxia/normoxia) treatment caused PAH, as evidenced by development of right ventricular hypertrophy, pulmonary artery medial hypertrophy, and occlusive lesions within precapillary arterioles. Pulmonary artery pressure was increased fivefold in Semaxanib/hypoxia/normoxia-treated animals compared with untreated, Semaxanib-treated, and hypoxia-treated controls, determined by isolated perfused lung studies. Thapsigargin induced a dose-dependent increase in permeability that was dependent on TRPC4 in the normotensive perfused lung. This increase in permeability was accentuated in PAH lungs but not in Semaxanib- or hypoxia-treated lungs. Fluid accumulated in large perivascular cuffs, and although alveolar fluid accumulation was not seen in histological sections, Evans blue dye conjugated to albumin was present in bronchoalveolar lavage fluid of hypertensive but not normotensive lungs. Thus PAH is accompanied by a TRPC4-dependent increase in the sensitivity to edemagenic agents that activate store-operated calcium entry.

Does application of moderately concentrated platelet-rich plasma improve clinical and structural outcome after arthroscopic repair of medium-sized to large rotator cuff tear? A randomized controlled trial

Platelet-rich plasma (PRP) has the potential to improve tendon-bone healing. The evidence is still controversial as to whether PRP application after repair of medium-sized to large cuff tears leads to superior structural and clinical outcome, especially after single-row repair. In a randomized study, 102 patients (PRP group, 52 patients; control group, 50 patients) with medium-sized and large degenerative posterosuperior tears were included for arthroscopic repair with a minimum follow-up of 2 years. Patients were evaluated with clinical scores (visual analog scale score, Constant-Murley score, University of California-Los Angeles score, and American Shoulder and Elbow Surgeons score) and ultrasound to assess retear and vascularity pattern of the cuff. Visual analog scale scores were significantly lower in the PRP group than in controls at 1 month, 3 months, and 6 months but not later. Constant-Murley scores were significantly better in the PRP group compared with controls at 12 and 24 months, whereas University of California-Los Angeles scores were significantly higher in the PRP group at 6 and 12 months (P < .05). The American Shoulder and Elbow Surgeons score in both groups was comparable at all the times. At 24 months, retear in the PRP group (n = 2; 3.8%) was significantly lower than in the control group (n = 10; 20%; P = .01). The retear difference was significant only for large tears (PRP:control group, 1:6; P = .03). Doppler ultrasound examination showed significant vascularity in the PRP group repair site at 3 months postoperatively (P < .05) and in peribursal tissue until 12 months. Application of moderately concentrated PRP improves clinical and structural outcome in large cuff tears. PRP also enhances vascularity around the repair site in the early phase.

Predominance of the critical shoulder angle in the pathogenesis of degenerative diseases of the shoulder

The critical shoulder angle (CSA) could be responsible for cuff tears and concentric osteoarthritis. We aimed to assess this association when potential confounding factors were excluded and to test the hypothesis that more extreme CSAs are associated with larger tears and more severe osteoarthritis. The study cohort was composed of 200 patients with primary concentric osteoarthritis (40 patients), isolated supraspinatus tears (40 patients), cuff tears involving at least the supraspinatus and infraspinatus (40 patients), and no history of shoulder problems (control group, 80 patients). Data pertaining to CSA, age, gender, dominant arm, smoking, hypertension, body mass index, and type of work were collected. The average CSA angle was 34° ± 3° in the control group, 36° ± 3° with supraspinatus tears, 40° ± 3.5° with supraspinatus and infraspinatus tears, and 28° ± 2° with concentric osteoarthritis. Patients with large cuff tears had a significantly greater CSA compared with those with isolated supraspinatus tears (P = .03). The CSA (odds, 1.7; confidence interval [CI], 1.4-2.0) was the most relevant risk factor for cuff tears. The Spearman coefficient between CSA and grade of eccentric osteoarthritis was 0.4 (P = .01). The 2 significant risk factors for concentric osteoarthritis were the CSA (odds, 0.5; CI 0.4-0.6) and age (odds, 1.1; CI, 1.0-1.2). Larger CSAs are associated with increased risk of symptomatic cuff tears, larger cuff tears, and the severity of eccentric osteoarthritis. Smaller angles increased the risk and severity of concentric symptomatic osteoarthritis. These associations remained significant even after removal of some of the potentially confounding variables.

Factors Affecting Clinical Outcome in Patients With Structural Failure After Arthroscopic Rotator Cuff Repair

(1) To compare clinical outcomes between patients with large or massive rotator cuff tears who have healed cuffs and patients with postoperative structural failure (retear after complete or partial repair) and (2) to identify factors associated with clinical outcomes in patients with postoperative structural failure. We conducted a retrospective study of consecutive patients with large or massive cuff tears who underwent arthroscopic repair at our institution between 2005 and 2012. On the basis of intraoperative findings and magnetic resonance imaging at final follow-up, the patients were divided into 3 groups: healed group, retear group (after complete repair), and partial-repair group. The outcome measures comprised the Japanese Orthopaedic Association (JOA) and University of California, Los Angeles (UCLA) scores; muscle strength; and range of motion. The tear length, tear width, muscle atrophy, and fatty degeneration were evaluated by preoperative and postoperative magnetic resonance imaging. The extent of tendon reattachment to the superior, middle, and inferior facets and the lesser tuberosity was examined on magnetic resonance images at final follow-up. In total, 74 patients (healed, 41; retear, 19; and partial repair, 14) were included in this study. The mean age was 63.8 ± 8.5 years, with a mean follow-up period of 3.6 ± 1.4 years. The postoperative JOA and UCLA scores significantly improved in all 3 groups, but the differences were not significant. In the retear and partial-repair groups, postoperative tendon preservation at the middle facet significantly affected the JOA and UCLA scores (P= .003 and P=.014, respectively). The JOA and UCLA scores were significantly improved in patients with structural failure. Under these conditions, the only clinical factor that affected patient outcome was tendon healing at the middlefacet. Thus tendon preservation at the middle facet was a predictor of good clinical outcomes in patients who underwent arthroscopic rotator cuff repair of large or massive tears and had postoperative structural failure. Level III, case-control study.

The correlation between body mass index, limb circumferences and blood pressure cuff fit in bariatric surgical patients.

Introduction:The purpose of this study was to determine the correlation between body mass index (BMI) and upper and lower arm as well as lower leg circumferences and the frequency of correct blood pressure (BP) cuff fit. We explored recommendations for the most likely BP cuff size and location for the three BMI categories.Materials and Methods:Following IRB approval we retrospectively analyzed a research database of bariatric surgical patients with a BMI of ≥40 kg/m2. Data included patients’ characteristics, upper and lower arm as well as lower leg circumferences. Patients were divided into three groups based on BMI (kg/m2, Group I: <45, Group II: 45-55, and Group III: >55). Appropriate cuff fit using a standard or large adult BP cuff (CRITIKON®, GE Healthcare, Waukesha, Wisconsin, USA) on the upper and lower arm, and lower leg was determined. We analyzed the percent proportion of proper cuff fit for cuff sizes and locations between groups using appropriate nonparametric testing.Results:Limb circumference correlated significantly with BMI (P = 0.01), and the upper arm correlated most closely (r = 0.76). A standard adult BP cuff on the lower arm fit properly in >90% and >80% and in Groups I and II, respectively. A large cuff on the lower arm was appropriate in 87% of Group III. In two participants, a large cuff fit properly on the lower leg.Discussion:Limb circumference significantly correlated with BMI. Recommendations for proper cuff fit in different BMI categories can be made.

Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 6: Hypertension: A Scientific Statement from the American Heart Association and the American College of Cardiology.

An elevation of blood pressure (BP) in the systemic circulation (hypertension) is the most common cardiovascular condition in the general population and considered to be the most ubiquitous cardiovascular risk factor in competitive athletes. Competitive athletes include those athletes involved in organized sports that typically occur in schools, communities, and professional leagues, including but not limited to intramural and league sports in which medical supervision is typically required. Although most competitive athletes are between the ages of 20 and 40 years, many younger people now participate in competitive athletics. The 2013 update from the American Heart Association using the National Health and Nutrition Examination (NHANES) data from 2007 to 2010 estimates that 9.1% of men aged 20 to 34 years and 6.7% of women of that age are hypertensive, based on having an elevated BP measurement or answering “yes” to the question, “Are you taking antihypertensive medication or were you told that you had hypertension?”1 The prevalence in children and adolescents is estimated to be ≈3.5%, with higher percentages in older and obese children.2 The diagnosis of hypertension is based on the subject having an elevated BP at or above certain levels measured by routine sphygmomanometry under appropriate conditions on at least 2 separate occasions separated by at least 1 week.3 However, BP measurements in the competitive athlete are typically obtained by different healthcare providers, which makes it particularly necessary that the testing conditions be standardized before the diagnosis of hypertension is made. People >18 years of age with a BP >140 mm Hg systolic and/or >90 mm Hg diastolic are considered to have hypertension.3 In children and adolescents, hypertension is defined as average systolic or diastolic BP levels greater than the 95th percentile for sex, age, and height; however, earlier physical maturation of the competitive athlete leaves …

Blood pressure measurement in children

In pediatric age diagnosis of hypertension is defined using a statistical criterion, the limit being the 95th percentile of the distribution of the blood pressure values, according to gender, age and height [1]. Pre-hypertension is defined as blood pressure (BP) values consistently above or equal to the 90th percentile, but lower than the 95th [Table ​[Table1].1]. The “gold standard” method to measure BP in children is auscultatory, using an aneroid non-mercury manometer (proscribed due to their toxicity). The aneroid devices need to be calibrated every six months. At least three measurements performed on different occasions are necessary for the diagnosis of hypertension [2]. Children above 3 years of age should have their blood pressure measured every year. In all children including the youngers ones blood pressure should be measured under special circumstances that increase the risk for hypertension: intensive neonatal care, renal disease, treatment with drugs known to increase blood pressure, evidence of elevated intracranial pressure. The cuff should be of the appropriate size for the children's upper arm. Small cuffs tend to overestimate while large cuffs underestimate. The width of the cuff should be 40% of the arm circumference at a point midway between the olecranon and the acromion. The children should be calm and relaxed, seated with their right arm resting at heart level. Systolic blood pressure is defined by the first Korotkoff sound (K1) whereas diastolic blood pressure coincides with the disappearance of the pulse (K5). The use of oscillometric devices is increased in the last years. Despite their large use, only few, reported on the internet site http://www.dableducational.org were been validated in children. A diagnosis of hypertension based on an oscillometric measurement should be confirmed by an auscultatory method. Currently other two methods are used in children to measure BP values: ambulatory blood pressure monitoring (ABPM) and home blood pressure measurement. In children the use of ABPM has significant limitations due to the lack of reference values. It allows to identify “white coat hypertension” (elevated office BP values and normal ABPM values), “masked hypertension” (normal office BP values and elevated ABPM values) and subjects with or without reduced physiological day-night blood pressure variations (dipping) [3]. A new methods is represented by the self-measurement of blood pressure at home [4]. Even in this case available data from children are scanty. Correct self-measurement requires two measurements within a few minutes, performed in the morning and in the evening for 3 consecutive days. Table 1 Definition and classification of hypertension in children and adolescents

Arthroscopic suture-bridge repair for moderate to massive full-thickness rotator cuff tear

Objective To evaluate the early clinical outcomes of arthroscopic suture-bridge repair of media to large full-thickness rotator cuff tear. Methods One hundred patients that underwent arthroscopic suture-bridge (suture-bridge group, n=50) or single-row repair (single-row suture group, n=50) for media to massive full-thickness rotator cuff tear from June 2010 to June 2014 were enrolled in this study. The patients (63 males and 37 females), aged 58.7 years (range, 46 to 75 years), were all available to the follow-up. Thirty-one patients were injured in traffic crashes, 30 in falls, 27 in strains and 12 with no apparent reasons. Early passive activity was allowed in suture-bridge group, while shoulder abduction was maintained for 6 weeks postoperatively in control group. Clinical and functional outcomes were measured using the visual analogue scale (VAS), range of motion, University of California at Los Angeles (UCLA) score, and American Shoulder and Elbow Surgeons (ASES) score. Results Mean duration of follow-up was 16.7 months (range, 8 to 24 months). Prior to the surgery, these measurements were similar between the two groups. After a follow-up of 3 months, the differences were significant in suture-bridge group compared to control group: VAS [(1.7±1.5) points vs (3.9±2.1) points], forward flexion [(168.3±30.2)° vs (120.2±51.6)°], external rotation [(47.0±11.0)° vs (31.8±13.8)°], UCLA score [(31.7±4.2) points vs (18.2±4.8) points], ASES score [(86.2±14.6) points vs (35.9±17.7) points] (P<0.05). No re-tear occurred after operation. Conclusion Arthroscopic suture-bridge repair of moderate to massive full-thickness rotator cuff tear results in significant improvement of function outcomes and clinical results, indicating a reliable and effective treatment technique. Key words: Arthroscopy; Shoulder; Suture bridge technique

Effect of overcuffing on the accuracy of oscillometric blood pressure measurements

Overcuffing (using too large a blood pressure [BP] cuff), is known to artificially lower auscultatory BP measurements; however, its effect on oscillometric readings is unclear. The possibility that overcuffing biases oscillometric readings is currently widely disregarded. We sought to confirm that overcuffing lowers auscultatory readings and to assess its effect on oscillometric measurements. Community–dwelling adults (aged ≥18 years) with arm circumferences within the standard range of 25–32 cm were recruited. Using primarily the International Standards Organization 2009 protocol, we compared the standard Baum adult (25–35 cm) to the large adult (33–47 cm) cuff. The standard cuff was considered the “reference standard.” In Phase I, auscultatory measurements were performed by two trained observers. In Phase II, oscillometric measurements were performed. Each phase was analyzed independently using paired t–tests and by generating Bland–Altman plots. Of 108 participants, 87 contributed data for Phase I, 85 for Phase II, and 69 were common to both phases. Phase I mean age was 38.0 ± 18.5 years, mean arm circumference was 28.0 ± 1.9 cm, and 21% had a past hypertension. The Phase I results confirmed that overcuffing reduced auscultatory BP measurements by 3.6 ± 5.1/2.8 ± 4.0 mm Hg (P–values <.0001 for both). For Phase II, mean age was 39.3 ± 18.3 years, mean arm circumference was 28.0 ± 1.9 cm, and 22% had past hypertension. Mean BPs were 112.2 ± 13.1/67.8 ± 7.3 mm Hg for the large cuff and 117.8 ± 13.3/71.2 ± 7.1 mm Hg for the standard cuff (5.5 ± 5.9/3.4 ± 5.2 mm Hg lower with the large cuff; P–values <.0001).Overcuffing leads to a clinically important downward bias in oscillometric measurements. An upper size limits for oscillometric cuffs should be specified.

Muscle relaxant effects on insertion efficacy of the laryngeal mask ProSeal(®) in anesthetized patients: a prospective randomized controlled trial.

Anesthesiologists often encounter LMA-ProSeal(®) (ProSeal) insertion difficulty due to its large cuff size. We performed a randomized clinical trial to examine how insertion efficacy and sealing pressure of ProSeal are affected by muscle relaxant administration in anesthetized patients. Our adult patients were either administered rocuronium (0.9 mg kg(-1)) as a muscle relaxant (R group; 40 patients) or not (C group; 40 patients). Anesthesia was induced with propofol and fentanyl. We compared the two groups with regard to the number of attempts required for successful insertion, sealing pressure, and subjective difficulty for insertion. Total insertion attempts required for successful ventilation in the two groups were one (R group, 38 patients; C group, 28 patients), two (R group, one patient; C group, seven patients), and three (R group, one patient; C group, five patients), revealing a significant difference between groups (p < 0.001). Sealing pressure was significantly higher in the R group than in the C group (R group, 27.4 ± 5.4 cmH2O; C group, 21.2 ± 5.2 cmH2O; p < 0.001). Leakage volume by mechanical ventilation was significantly smaller in the R group than in the C group (R group, 17.4 ± 29.1 ml; C group, 46.8 ± 45.5 ml; p < 0.001). Subjective difficulty of insertion was significantly lower in the R group than in the C group (R group, 12.3 ± 23.1 mm; C group, 39.4 ± 31.9 mm; p < 0.001). Muscle relaxation appears to facilitate ProSeal insertion efficacy by enabling higher successful insertion rates, higher sealing pressure, lower leakage volume, and lower subjective difficulty of insertion in anesthetized patients.

Big cuff: Big problem.

Sir, Flexometallic/reinforced tubes are often used to replace the tracheostomy tubes during laryngectomy procedures. This report identifies the problem that can happen with the insertion of flexometallic tube (Rusch®, Teleflex Medical, Germany) through a low tracheostoma that was solved with the use of flexometallic tube from another manufacturer (UnoFlex™, Unomedical Sdn Bhd, Kedah, Malaysia). A 38-year-old male with carcinoma larynx was scheduled for total laryngectomy. He had already been tracheostomised with 8.0 mm ID Portex® tube. Following induction of anaesthesia, the Portex® tracheostomy tube was replaced with 8.0 mm ID flexometallic tube (Rusch®, Teleflex Medical, Germany) till its black mark was at the tracheostoma and the cuff was inflated. However, soon after this, auscultation of the chest revealed absence of air entry on left side and a drop in saturation to 92% with 100% O2, associated with sudden increase in peak airway pressures to 30 cm H2O leading to suspicion of endobronchial intubation. Therefore, the tracheal tube was gradually withdrawn with simultaneous auscultation for air entry on the left side. However, the tube appeared to remain endobronchial despite pulling the tracheal tube till proximal portion of its cuff was visible at the stomal site. At this juncture, we replaced the existing flexometallic tube (Rusch®, Teleflex Medical, Germany) with another 8.0 mm ID flexometallic tube from another manufacturer (UnoFlex™, Unomedical Sdn Bhd, Kedah, Malaysia) which was inserted until its cuff was well below the stomal site. This resulted in bilateral equal air entry, improvement in SpO2 to 100% and return of airway pressures to 16 cm H2O. Rest of the intraoperative period was uneventful and at the end of the surgery, the flexometallic tube was replaced by 8.0 mm ID Portex® tube. Most patients with carcinoma larynx scheduled for total laryngectomy would have been already tracheostomised or will require a preoperative tracheostomy. Proceeding to total laryngectomy with standard tracheostomy tube has got various problems like flange interfering with surgical site, difficulty in fixation and accidental dislodgement due to excessive drag by ventilator circuits. Whereas flexometallic tubes can be easily angled away from the surgical site without getting kinked and safely secured by suturing or taping it to the chest wall of the patient.[1] Though these tubes are certainly useful, there are various complications associated with these tubes like narrowing of the lumen and complete obstruction.[2,3,4] Flexometallic (Rusch®, Teleflex Medical, Germany) tubes usually contain a barrel shaped large cuff meant for a better seal and their use in patients with low tracheostomy may lead to endobronchial intubation as the distance between the proximal end of the cuff and the tip of the tube is relatively long (8 cm) compared to the other brand (UnoFlex™, Unomedical Sdn Bhd, Kedah, Malaysia) tube, where it is 6 cm [Figure 1]. Thus, changeover to UnoFlex™ tube, (which has smaller cuff) solved the problem of endobronchial intubation in our case. Though different manufacturers produce tubes with different cuff size for added advantage, this may become detrimental at specific situations. Figure 1 (a) Flexometallic (Rusch®) tube 8.0 mm ID. (b) Flexometallic (UnoFlex™) tube 8.0 mm ID. (c) Tracheostomy (Portex®) tube 8.0 mm ID In cases where low tracheostomy is anticipated, this problem can be avoided by the use of laryngectomy tubes. Laryngectomy (Montando®) tubes are reinforced cuffed tubes with J-configuration that have a short distance between cuff and tip and also short bevel to avoid endobronchial intubation.[5]

Mid-arm circumference and recommended blood pressure cuffs for children and adolescents aged between 3 and 19 years

Accurately measuring blood pressure (BP) requires choosing an appropriate BP cuff size. This study examined trends in mid-arm circumference (mid-AC) and in the distribution of appropriate BP cuffs using 1999-2010 National Health and Nutrition Examination Survey (NHANES) data. NHANES uses a complex multistage probability sample design to select participants who are representative of the entire civilian, noninstitutionalized US population. The analytic sample consisted of 21 350 participants aged between 3 and 19 years at the time of examination. The mean mid-AC and the percentage of children requiring recommended BP cuff sizes were analyzed across survey years and by sex, age, race/ethnicity, and age-specific and sex-specific BMI categories. During NHANES 1999-2010, the overall trend in mean mid-AC in cm for boys and girls was not significant. During NHANES 2007-2010, 24% of boys aged between 9 and 11 years, 53% of boys aged between 12 and 15 years, and 89% of boys aged between 16 and 19 years required a standard adult cuff or larger to be cuffed correctly. Corresponding estimates for girls were 22, 48, and 57%, respectively. During NHANES 2007-2010, 30.4% of obese boys and 24.3% of obese girls required a large adult cuff and 2.1% of obese boys and 0.9% of obese girls required a thigh cuff for appropriate cuffing. During NHANES 2007-2010, 20% of boys and girls as young as 9-11 years required a standard adult cuff to be cuffed appropriately. In addition, approximately one-third of obese participants required adult large BP cuffs to be cuffed appropriately.

Will the Taper Shaped Cuff Replace the Conventional High Volume-Low Pressured Cuff on Endotracheal Tube?

An effective tracheal seal plays an essential role in precluding aspiration and boosting efficiency with mechanical ventilation when endotracheal tube is inflated. High cuff pressure can cause damage to the tracheal wall and lead to serious complications such as tracheal stenosis. Endotracheal tube (ET) cuff pressures greater than 30 cmH2O may impede capillary blood flow in the tracheal wall, and ET cuff pressures greater than 50 cmH2O is considered high enough to completely block capillary blood flow.[1] Low volume high pressure cuff was used in early ETs but replaced by high volume low pressure (HVLP) cuff because the former causes mucosal injury along the lateral tracheal wall. HVLP cuffs appeared ideal because they are capable of producing a seal with low pressure. However, HVLP's large cuff diameter has emerged as a key issue as it is 1.5 to 2 times larger than the adult trachea. Longitudinal or oblique folds are developed upon inflation within the larger sized HVLP cuffs. The seal then becomes incomplete and allows secretions and air to leak as a result. Pulmonary aspiration of microorganism mass found in the oral cavity is considered one of leading causes of ventilator-associated pneumonia. In addition, over inflation of HVLP cuff can markedly increase cuff pressure, particularly around the folds and result in injury to the tracheal mucosa.[2] Low volume cuff tubes has recently drawn attention again while many researchers explored benefits of modified low volume low pressure (LVLP) cuff tubes. A taper-shaped cuff is designed to fit into the trachea at its narrow end and provides smaller cuff volume. This tapered cuff design is more effective in minimizing longitudinal folds when inflated, improving tracheal seal and preventing leakage of secretions and air even under high airway pressures, compared with conventional HVLP cuffs.[2,3] The transition from HVLP cuffs to taper-shaped cuffs is currently underway in endotracheal tubes. That is, the trend is moving back to low volume cuff tracheal tubes, which exert low pressure, in favor of better outcomes. Then we can have a question: Are tapered cuffs safe from pressure injury that is the most critical complication of low volume high pressure cuffs? While transmission of intracuff pressure to the tracheal wall depends on the cuff material, taper-shaped cuffs can transmit all the intracuff pressure to the tracheal wall.[4] In endoracheal position, the intracuff pressure of LVLP cuffs can be significantly increased by a slight change in inflating volume. In addition, the tapered cuff design provides smaller area of contact with the tracheal wall, compared to cylindrical shaped HVLP cuffs,[2] meaning that the extent of transmitted pressure is higher on the tracheal wall. It is therefore important to examine pressure changes with volume in tracheal tube cuff inflated. Special attention to pressure changes is also crucial in the tracheal tube cuff exposed to nitrous oxide for anesthesia because cuff pressure can significantly increase with increasing volume.[5] In case the taper-shaped cuff is not inflated adequately and develops an asymmetrical shape,

Accuracy of drug store blood pressure monitors

Publically accessible blood pressure monitors are widely used, but little information is available on their accuracy. We compared blood pressure readings of 17 drug store monitors with those obtained using a validated home monitor (Omron BP742CAN) and both with those taken at home using the Canadian Hypertension Education Program protocol. Duplicate readings were taken using the drug store monitor (VitaStat, n=6, and PharmaSmart, n=11) on the left arm and the Omron on the right in three participants: two normal and one untreated hypertensive patient. We used Bland-Altman methods for comparison. We explored the correlation with average home blood pressure readings. Home average blood pressure for our three participants was 121±6/73±5, 106±6/62±4, and 142±8/81±7 mmHg. The mean systolic blood pressure difference (drug store-Omron) was -1.8±8.2 mmHg. Diastolic pressure difference was 1.7±5.6. Individual paired systolic differences varied from -19 to 14 mmHg. For the participant who required a large cuff, drug store systolic readings tended to be higher (4.1±6.7). In our three participants, drug store monitors as a group read higher than home systolic blood pressure: 7.5 [95% confidence interval (CI) 1.5-13.4], 1.2 (95% CI -4.0 to 6.4), and 1.0 (95% CI -2.5 to 4.4) mmHg. Diastolic blood pressure and heart rate differences were similar in magnitude. On average, drug store monitors recorded lower systolic blood pressures and higher diastolic blood pressures than a validated monitor, but the difference was neither statistically nor clinically significant. Single reading comparisons showed a much broader range. In three participants, drug store monitors did reflect the average home blood pressure.

Using a large cuff reduces the difference between peripheral and central blood pressure readings. The BP-CUFF study

To the EditorClinical measurement of blood pressure (BP) is an essential part ofthe diagnosis and monitoring of hypertension. A strict methodologymust be used to limit measuring errors as much as possible and obtainBP readings which are as representative as possible of the patients' BPlevel [1].International guidelines on the management of arterial hyperten-sioninsistontheneedtouseacuffwhichisappropriatetoarmcircum-ference for measuring BP [1]. They also remind us that when BP self-measurement methods are used, brachial measurement must be pre-ferred to radial. Indeed, peripheral values differ from central values(i.e. aortic BP), increasingly with distance from the heart. Thus, systolicBP (SBP) is lower with a central reading than a humeral reading. Thisdifference in SBP is all the more important in that the large arteriesare stiff. A study carried out in intensive care with 30 patients showedthat non-invasive brachial BP measurements (with appropriate cuffsize) were lower than invasive radial measurements [2]. In this samestudy,iftoosmallacuffwasused,therewerefewerdifferencesbetweenthe two methods.Theaimofourstudywastodeterminetheimpactofcuffsizeondif-ferences observed between non-invasive brachial BP measurementsand BP measured simultaneously and invasively at the ascending aortaduring cardiac catheterization.Patients (age ≥ 18 years) who required non-emergency cardiaccatheterisation were enrolled in 5 cardiology centres. Non-inclusioncriteriawere:SBPdifferencebetweenthetwoarms≥10 mm Hg,aorticinsufficiency(grade2ormore),atrialfibrillationor flutter,andfrequentextrasystoles (≥10/min). The circumference of the patient's left armhad to be between 24 and 40 cm.BPwasmeasuredsimultaneouslyattheinitialaorta(pigtailcatheter,BP averaged over 10 successive cycles) and on the upper left arm, firstusing a standard cuff (24–32 cm) and then a large cuff (32–42 cm),via a non-invasive Omron® device (a single measurement for eachcuff). General characteristics, cardiovascular clinical examination, elec-trocardiogram, biological parameters, history of cardiovascular eventsand current treatment were recorded. Ethical approval was obtainedfromthelocalethicscommitteeandalloftheparticipantsgavetheirin-formed consent.WeusedSPSSsoftware®(SPSSInc.,Chicago,IL,USA)toperformourstatistical analyses. We expressed continuous data as means +/− SDandnon-continuousvariablesaspercentages.Weassessedtherelation-ships between the continuous variables using Pearson's or Spearman'scorrelation analysis, and we compared non-continuous variables usingaChi-squaretest.WeusedaStudent'sTtesttocomparecontinuousvar-iables between groups. Values of p b 0.05 were considered significantfor all analyses.Seventy patients (45 men, mean age 67.1 ± 11.2 years, BMI26.8 ± 6.1 kg/m

한국인 맞춤형 혈압계 커프 블래더

고혈압은 임상 현장에서 매우 흔한 질환인데 그 유병률이 국제적으로 상승세를 보이고 있다. 고혈압의 폐해는 너무 많으며 여러 장기들에 영향을 미친다. 필요 시 보통 평생 동안 치료해야 한다. 한국질병관리본부에 따르면 고혈압 유병률이 날로 증가하고 있다. 2011 조사에서 성인 중 28.9%가 고혈압이었으며, 여자 보다 남자가 약간 더 높았다. 환자를 분류하고, 혈압관련 위험을 확인하고 그리고 치료법을 안내하는 데 있어 정확한 혈압 측정은 필수적이다. 혈압계의 정확도에 영향을 미치는 요인 중 블래더 크기의 일탈이 장비 에러의 주된 원인이 된다. 혈압을 정확히 측정하기 위해, 위 팔 중심의 둘레에 따른 올바른 크기의 블래더 사용은 필수적이다. 시중의 혈압계를 조사한 결과, 커프 블래더들이 국제 규격 ISO 81060-1:2007에서 권유된 크기와 다름을 알 수 있었다. 블래더가 클 경우 혈압이 더 낮게 나오고, 더 작을 경우 더 높게 나온다는 것은 잘 알려져 있다. 미)심장협회(AHA)가 권고하는 어른용 블래더의 크기는 17-25cm의 팔 둘레를 가진 작은 어른, 24-32 cm의 팔 둘레를 가진 어른, 32-42cm의 팔 둘레를 가진 대다수 어른, 그리고 42-50cm의 팔 둘레를 가진 비만 어른으로 구분 된다. 반면에 한국 어른의 팔 둘레는 23-31cm에 불과하므로 AHA의 어른용 블래더 한 가지에 해당한다. 23-31cm의 팔 둘레를 가진 한국 어른을 위한 블래더의 종류는 ISO 81060-1을 따를 경우 3 개의 블래더가 필요하다. 병원들은 어른 환자들을 위해 보통 하나 혹은 두 가지 크기의 서양식 커프를 사용한다. 이 때문에 일부 환자들은 정확한 혈압 측정을 기대할 수 없다. 한국인에서 취합한 인체치수 참조 데이터에 기초한 블래더의 크기는 한국에서 가장 정확한 혈압을 측정하는데 도움이 될 것이다. Hypertension is one of the most common clinical diseases, with an increasing prevalence globally. Hypertension triggers various harmful consequences and affects multiple organs. Life-long care may be required in some cases. According to the Korea Center for Disease Control and Prevention, the prevalence of hypertension is gradually increasing. A 2011 survey revealed that 28.9% of Korean adults had hypertension. The prevalence rates were slightly higher among men than women. Accurate measurement of blood pressure(BP) is crucial to classify patients, to identify BP-related risks, and to inform correct treatment. For accurate blood pressure measurement, the use of a cuff bladder size appropriate for the mid-upper arm circumference(MUAC) is essential. Incorrect sized cuff bladder is one of the main causes of equipment error affecting sphygmomanometer accuracy. When commercial sphygmomanometers were examined, the cuff bladders differed from the dimensions specified in the ISO 81060-1:2007 standards. Undercuffing is responsible for a spurious overestimation of BP in patients with large arms leading to overdiagnosis of hypertension, whereas overcuffing (that is, use of relatively large cuffs with small arms), may be responsible for an opposite problem, leading to erroneous underestimation of BP levels. The cuff bladder sizes recommended by the American Heart Association(AHA) are an arm circumference(AC) of 17-25 cm for small-sized adults, AC of 24-32 cm for adults, AC of 32-42 cm for normal-sized adults, and AC of 42-50 cm for obese adults. In contrast, the AC of Korean adults ranges from 23-31 cm, belonging to a single type of adult bladder. Three types of bladders are necessary for Korean adults with an AC of 23-31cm. Hospitals often use one or two differently-sized Western cuffs for adult patients, which can yield inaccurate BP determinations. Cuff bladders with dimensions based on anthropometric reference data obtained from Koreans will aid hospitals to measure BP more accurately.

White chest in the west: pelage colour and mitochondrial variation in the common hamster (Cricetus cricetus) across Europe

The common hamster (Cricetus cricetus L.), a rodent of the Eurasian steppes and agricultural areas, is threatened by habitat loss. Remnant populations in Western and Central Europe are small, isolated and genetically impoverished. The populations of Belgium, The Netherlands and North Rhine-Westphalia, Germany (BNN), for which Nehring proposed the epiphet canescens, are most affected by this decline. They are distinguished from more eastern populations by large, white areas on throat, chest and forelegs. These traits are sometimes also found in other populations, which casts doubt on their value as diagnostic characteristics. Here, we show that the frequency of occurrence of relatively large chest spots, chin streaks and cuffs on the forelegs is highest in BNN, where a white chest spot occurs in 67–100 % of the sampled individuals, compared to 0–8 % in Central and Eastern European populations. Additionally, hamsters from the Upper Rhine area also display relatively high frequencies of these characters (7–44 %). This suggests a common origin of BNN and Upper Rhine hamsters and an ancient expansion route along the Rhine Valley. A supplementary genetic study of two mitochondrial genes revealed extremely low diversity in both BNN and Upper Rhine hamsters but also clear differentiation and isolation between the two remaining relict populations of North Rhine-Westphalia.

Returning to overuse activity following a supraspinatus and infraspinatus tear leads to joint damage in a rat model

Large rotator cuff tears (supraspinatus and infraspinatus) are common in patients who perform overhead activities (laborers, athletes). In addition, following large cuff tears, these patients commonly attempt to return to pre-injury activity levels. However, there is a limited understanding of the damaging effects on the uninjured joint tissues when doing so. Therefore, the objective of this study was to investigate the effect of returning to overuse activity following a supraspinatus and infraspinatus tear on shoulder function and the structural and biological properties of the intact tendons and glenoid cartilage. Forty rats underwent 4 weeks of overuse followed by detachment of the supraspinatus and infraspinatus tendons and were then randomized into two groups: return to overuse or cage activity. Ambulatory measurements were performed over time and structural and biological properties of the adjacent tendons and cartilage were evaluated. Results demonstrated that animals returning to overuse activity did not have altered shoulder function but despite this, did have altered cartilage and tendon properties. These mechanical changes corresponded to altered transcriptional regulation of chondrogenic genes within cartilage and tendon. This study helps define the mechanical and biological mechanisms leading to joint damage and provides a framework for treating active cuff tear patients.