Subjective Functional Improvement Research Articles

Bimonthly Medical Visits Reduce Sickle Cell Admissions

Background: Sickle cell disease (SCD) is a chronic medical disease that in some patients is characterized by frequent vasoocculsive crisis (VOC). A minority of sickle cell patients comprises a majority of hospital VOC admissions, and the transition to adult care is a particularly high risk time period. We sought to identify if increased frequency of outpatient medical care led to a reduction of hospital days following intervention and if there were improvements in daily function, and reduction of premature requests for opiate refills.Methods: Retrospective review of 11 patients, average age of 25 (range 19-37 years old), 63% were female. Genotype of SCD included 8/11 with SS, 2/11 with SC and 1/11 with SBeta Thal. Sickle cell standard of care medical visits were monthly at our institution. Two nurse practitioners and 2 hematologists at the medical center implemented the intervention of increased frequency of medical visits to bimonthly follow up for between 5 and 48 weeks, with a mean length of 12 weeks of increased frequency of medical visits.Results: In the 6 months preceding intervention there were a total of 300 hospital days of admission for VOC (2 patients <10 hospital days, 6 patients with 10-20 hospital days, 3 patients with over 20 hospital days; range 27-111 days). During the intervention 7/11 patients had no hospitalizations, 2/11 were discharged from the emergency department and never admitted. Another patient had 7 days of admission over 34 weeks of bimonthly medical visits and 1 patient had increase to days 37 days over 22 weeks of bimonthly medical visits. The average length of follow up after the intervention was 25 weeks: 4/11 had reduction of hospital days, 2/11 had the same number of hospital days and 4/11 had more hospital days. Secondary benefits were 3/11 patients were able to restart and maintain employment, 2/11 were able to re-enroll in educational programs, and 3/11 had a reduction in premature requests for opiate refills.Conclusions: Increased frequency of outpatient medical visits leads to reduced hospital admission time for some patients and subjective improvement in daily function as measured by the ability to work or go to school. Future research is needed address the small subset of young adults who had an increase in hospital admission. DisclosuresNo relevant conflicts of interest to declare.

Combined reconstruction of the medial patellofemoral and medial patellotibial ligaments: outcomes and prognostic factors.

To report outcomes after combined medial patellofemoral ligament (MPFL) and medial patellotibial ligament (MPTL) reconstruction and test associations between prognostic factors and clinical outcomes. It was hypothesised that combined MPFL and MPTL reconstruction would result in significant improvement in function, and that outcomes would be associated with age, sex, Beighton score, concomitant articular lesions, and preoperative function. All combined reconstructions of MPFL and MPTL were reviewed. Inclusion criterion was minimum 2-year follow-up. Exclusion criteria were age at surgery ≥ 35years and concomitant osteotomies. Kujala, Tegner and Marx scores were completed prospectively. Patients were evaluated at a minimum 2-year follow-up. Associations between potential prognostic factors and Kujala and Tegner scores were tested using bivariate analyses followed by multivariate regression models. Of 22 patients (26 knees), 19 (23 knees) met inclusion criteria, and 16 (20 knees) were available for follow-up. Mean age at surgery was 18years (range 14.5-23). Mean follow-up was 43months (range 24-73). Postoperative Kujala score significantly improved compared to before surgery (86.4 ± 12.5 vs. 54.9 ± 15.2, p < 0.01). Postoperative Tegner score was nonsignificantly higher compared to before surgery (4.8 ± 2.4 vs. 4 ± 3, p = ns) and lower compared to before first patella dislocation (4.8 ± 2.4 vs. 5.9 ± 1.2, p < 0.01). Postoperative Kujala score was associated with male sex (p = 0.02), with medial patellofemoral chondral lesions (p = 0.01) and with preoperative Kujala score (p = 0.05). Postoperative Tegner score was associated with male sex (p < 0.01), with preoperative Tegner level (p < 0.01), and with Beighton score (p < 0.01). Patella apprehension was recorded in two knees (10%) in two patients. Combined MPFL and MPTL reconstruction in young adults results in significant improvement in subjective knee function with minimal risks, although preinjury activity levels are not consistently restored. Associated factors of improved outcome include higher preoperative knee scores and activity levels, medial patellofemoral chondral lesions, decreased Beighton scores, and male sex. This supports the advisability of the procedure and can also assist in setting realistic goals for specific groups of patients. Case series, Level IV.

Visual outcome and patient satisfaction after cataract surgery: A pragmatic study

IntroductionCataract is a leading cause of blindness globally. This study compared the best corrected visual acuity (BCVA), surgically induced astigmatism (SIA), endothelial cell loss, and patient satisfaction between corneal section phacoemulsification (CSP) and Blumenthal manual small incision cataract surgery (MSICS). MethodsIn this pragmatic study, following pre-operative assessment, patients made a choice to undergo either CSP or MSICS after the options were explained by the ophthalmologist. Pre- and post-operative (Day 1, 1-week, 6-weeks) refraction, keratometry and specular microscopy were performed. Subjective improvement in visual function was assessed before surgery and at 6-weeks post-surgery using the 7-item VF-7 scale that assesses functional status and quality-of-life changes. ResultsOf the 178 eyes, 99 had CSP and 79 MSICS. At 6-weeks, BCVA of <6/18 was achieved in 100% in CSP and 96.2% in MSICS (p = 0.27). The mean (SD) SIA was significantly lower (p = 0.003) with CSP (1.29 ± 0.71 D) than MSICS (1.01 ± 0.49 D). Endothelial loss was lower (p = 0.008) with MSICS (271 ± 280 vs. 527 ± 475 cells/mm2). Subjective improvement in visual function was better after MSICS than with CSP. ConclusionDespite similar visual acuity with CSP and MSICS, subjective improvement was better with MSICS. SIA was lower with CSP while endothelial loss was lower with MSICS.

078 Amniotic fluid allograft for the treatment of erectile dysfunction: a pilot series

Amniotic fluid allograft has been used by orthopedic surgeons in joint replacement procedures to expedite recovery. Although it consists of a host of elements that may be beneficial in the treatment of erectile dysfunction (ED), it has never been tested for this disease process. Proflo® (Urostem Biologics; Coral Springs, FL) is a human allograft derived from amniotic fluid that does not contain stem cells. We present our pilot series using AmnioFactor® amniotic fluid allograft injections for the treatment of ED. After IRB approval, patients undergoing amniotic fluid allograft injections for the treatment of ED were prospectively identified. A baseline Sexual Health Inventory for Men (SHIM) score and a penile Doppler ultrasound were obtained on each patient prior to treatment. Each cycle was performed four to six weeks apart and consisted of 1.5 cc of amniotic fluid allograft injected into each corpora cavernosum for a total of 3 cc. All patients underwent at least two cycles, with a maximum of four cycles being offered. A post-treatment SHIM score and a post-treatment penile Doppler ultrasound were obtained for comparison. The primary endpoint was the development of post-treatment complications. Secondary endpoints looked to evaluate subjective improvement in erectile function (SHIM scores) and objective changes in peak systolic velocity (PSV) and end-diastolic velocity (EDV) on penile Doppler ultrasound.

A Nonhuman Primate PET Study: Measurement of Brain PDE4 Occupancy by Roflumilast Using (R)-[11C]Rolipram

PurposePhosphodiesterase 4 (PDE4) inhibition in the brain has been reported to improve cognitive function in animal models. Therefore, PDE4 inhibitors are one of key targets potential for drug development. Investigation of brain PDE4 occupancy would help to understand the effects of PDE4 inhibition to cognitive functions. Roflumilast is a selective phosphodiesterase type 4 (PDE4) inhibitor used clinically for severe chronic obstructive pulmonary disease, but the effects to the brain have not been well investigated. In this study, we aimed to investigate whether roflumilast entered the brain and occupied PDE4 in nonhuman primates.ProceduresPositron emission tomography (PET) measurements with (R)-[11C]rolipram were performed at baseline and after intravenous (i.v.) administration of roflumilast (3.6 to 200 μg/kg) in three female rhesus monkeys. Arterial blood samples were taken to obtain the input function. Protein binding was measured to obtain the free fraction (fp) of the radioligand. Total distribution volume (VT) and VT/fp were calculated as outcome measures from two tissue compartment model. Lassen plot approach was taken to estimate the target occupancy.ResultsThe brain uptake of (R)-[11C]rolipram decreased after roflumilast administration. PDE 4 occupancy by roflumilast showed dose- and plasma concentration-dependent increase, although PDE4 occupancy did not reach 50 % even after the administration of up to 200 μg/kg of roflumilast, regardless of outcome measures, VT or VT/fp.ConclusionsThis PET study showed that the brain PDE4 binding was blocked to a certain extent after i.v. administration of clinical relevant doses of roflumilast in nonhuman primates. Further clinical PET evaluation is needed to understand the relationship between PDE4 inhibition and potential improvement of cognitive function in human subjects.

The Effects of Open versus Closed Kinetic Chain Exercises on Ankle Joint Function in Athletes with Chronic Ankle Instability

Objective: Lateral ankle sprains are common sport injuries that often result in structural and functional alterations leading to chronic ankle instability (CAI). Insufficiencies in proprioception, neuromuscular control, and strength are suggested as contributing factors to CAI. Open Kinetic Chain (OKC) and Closed Kinetic Chain (CKC) exercises often constitute the core of ankle specific training before progression to advanced training. Though commonly used in the management of CAI, there is no consensus regarding their efficacy on physical therapy outcomes. The purpose of this study was to compare the effect of OKC and CKC exercises on dynamic postural control, self-reported function, and subjective sense of instability in subjects with CAI. Methods: Subjects with unilateral CAI were randomly assigned into three groups: OKC (n=5), CKC (n=6), and control (n=6). Outcome measures included star excursion balance test (SEBT) reach distance, center of pressure (COP) sway velocity, sway area, and path length; and Foot and Ankle Ability Measure-Sport Subscale. Intervention groups completed 6 weeks of exercises. Also, subjects completed a global rating of change (GROC) form at week 6 post-intervention. Results: Following intervention, both OKC and CKC groups had significant improvements in the outcome measures, indicating an improvement in dynamic postural control and subjective function; however, CKC had greater improvements than OKC. The control group did not show improvements. GROC revealed a significant difference in median score for CKC group when compared to OKC and control groups (p=0.04 and p=0.03, respectively). Conclusion: The 6-week of OKC and CKC exercise programs improved parameters of postural control and subjective function in CAI subjects. CKC exercises, however, were more effective than OKC exercises. Hence, exercise programs should become more functional and task oriented. Further research is needed in a larger cohort of subjects to determine effects of both training programs on ankle joint injury risk factors.

Bioabsorbable poly-L/D-lactide (96/4) scaffold arthroplasty (RegJoint™) for trapeziometacarpal osteoarthritis: a 3-year follow-up study.

IV.

Arthroscopic management of suprascapular neuropathy of the shoulder improves pain and functional outcomes with minimal complication rates.

The purpose of this study was to systematically assess the arthroscopic management of suprascapular neuropathy, including the aetiology, surgical decision-making, clinical outcomes, and complications associated with the procedure. Three databases [PubMed, Ovid (Medline), and Embase] were searched. Systematic literature screening and data abstraction was performed in duplicate to present a review of studies reporting on arthroscopic management of suprascapular neuropathy. The quality of the included studies was assessed using level of evidence and the MINORS (Methodological Index for Nonrandomized Studies) checklist. In total, 40 studies (17 case reports, 20 case series, 2 retrospective comparative studies, and 1 prospective comparative study) were identified, including 259 patients (261 shoulders) treated arthroscopically for suprascapular neuropathy. The most common aetiology of suprascapular neuropathy was suprascapular nerve compression by a cyst at the spinoglenoid notch (42%), and the decision to pursue arthroscopic surgery was most commonly based on the results of clinical findings and investigations (47%). Overall, 97% of patients reported significant improvement in or complete resolution of their pre-operative symptoms (including pain, strength, and subjective function of the shoulder) over a mean follow-up period of 23.7months. Further, there was a low overall complication rate (4%) associated with the arthroscopic procedures. While most studies evaluating arthroscopic management of suprascapular neuropathy are uncontrolled studies with lower levels of evidence, results indicate that such management provides patients with significant improvements in pain, strength, and subjective function of the shoulder, and has a low incidence of complications. Patients managed arthroscopically for suprascapular neuropathy may expect significant improvements in pain, strength, and subjective function of the shoulder. Level IV, systematic review of level II to IV studies.

Arthroscopic Acetabular Labral Reconstruction with Fascia Lata Allograft: Clinical Outcomes at Minimum One-Year Follow-Up.

Background:The integrity of the acetabular labrum is crucial to normal biomechanics of the hip joint. Disruption of the labral seal could be detrimental to the overall nutrition of the cartilage, leading to its premature degeneration.Purpose:The aim of this study is to determine the clinical effectiveness of arthroscopic hip labral reconstruction using fascia lata allograft. The hypothesis is that labral reconstruction would provide good clinical outcomes.Methods:We retrospectively reviewed all 10 patients who underwent labral reconstruction with fascia lata allograft from January 2013 to October 2015. We assessed improvement in pain and function, complications, and subsequent surgery. The minimum follow-up was 12 months (average, 22.9 months; range, 16–36 months).Results:All patients reported subjective improvement in preoperative pain and function. The mean modified Harris hip score improved significantly from 58 (55-60) to 95 (91-98). The mean change of modified Harris hip score was 36 (31-41) and mean post-operative patient satisfaction score was 9.5(8-10). We observed no radiological progression of arthritis as well as no patient had revision procedure including total hip replacement.Conclusion:Arthroscopic labral reconstruction using a fascia lata tendon allograft is an effective and safe procedure that not only provides excellent clinical outcomes in short term but also potentially prevent continued cartilage degeneration by restoring acetabular labral seal in patients with deficient or resected labrums.

WHOLE-BODY VIBRATION EXERCISE IS WELL TOLERATED IN PATIENTS WITH DUCHENNE MUSCULAR DYSTROPHY: A SYSTEMATIC REVIEW.

Background:Duchenne muscular dystrophy (DMD) is caused by a defective gene located on the X-chromosome, responsible for the production of the dystrophin protein. Complications in the musculoskeletal system have been previously described in DMD patients. Whole body vibration exercise (WBVE) is a treatment that improves musculoskeletal function in movement disorders. The aim of this study was to review the effects of WBVE on functional mobility, bone and muscle in DMD patients.Materials and Methods:Four databases were searched. Three eligible studies were found; all three conclude the management of DMD patients with WBV was clinically well tolerated. The studies used a side-alternating WBV system, frequencies 7 - 24 Hz; and amplitudes 2 - 4 mm.Results:A work indicates that a temporary increase in creatine kinase in DMD during the first days of WBV was observed, but other authors did not find changes. No significant changes in bone mass, muscle strength or bone markers. Some patients reported subjective functional improvement during training. Interpretation:Conclusion:It is concluded that WBV seems to be a feasible and well tolerated exercise modality in DMD patients.

Subjective perception of sleep benefit in Parkinson's disease: Valid or irrelevant?

IntroductionThe phenomenon of sleep benefit (SB) in Parkinson's disease (PD), whereby waking motor function is improved despite no dopaminergic treatment overnight, is controversial. Previous studies suggested a significant discrepancy between subjective functional and objective motor improvement. The aim of this study was to determine how well subjective reporting of SB correlates with objective measures and if true motor improvement can be predicted by a standardized questionnaire. MethodsNinety-two patients with PD participated. A structured questionnaire was developed to assess subjective SB. Quantitative motor assessment was performed using a validated smartphone application. Objective motor SB was considered to be present when the waking motor function was similar or superior to the daytime on-state. ResultsTwenty (22%) patients showed objective motor improvement on waking compared to end-of-dose. Most patients (77%) reported subjective SB without corresponding objective motor benefit. Our structured questionnaire could not predict Motor SB. The ability to delay morning medications and a perception of indifference or paradoxical worsening following the morning levodopa dose may suggest Motor SB. ConclusionsMost patients experience subjective SB with no measureable motor improvement. This perceived benefit could be related to non-motor improvement that is distinctly different to objective motor benefit.

No differences in subjective knee function between surgical techniques of anterior cruciate ligament reconstruction at 2-year follow-up: a cohort study from the Swedish National Knee Ligament Register

PurposeThe purpose of this study was to investigate how different techniques of single-bundle anterior cruciate ligament (ACL) reconstruction affect subjective knee function via the Knee injury and Osteoarthritis Outcome Score (KOOS) evaluation 2 years after surgery. It was hypothesized that the surgical techniques of single-bundle ACL reconstruction would result in equivalent results with respect to subjective knee function 2 years after surgery.MethodsThis cohort study was based on data from the Swedish National Knee Ligament Register during the 10-year period of 1 January 2005 through 31 December 2014. Patients who underwent primary single-bundle ACL reconstruction with hamstrings tendon autograft were included. Details on surgical technique were collected using a web-based questionnaire comprised of essential AARSC items, including utilization of accessory medial portal drilling, anatomic tunnel placement, and visualization of insertion sites and landmarks. A repeated measures ANOVA and an additional linear mixed model analysis were used to investigate the effect of surgical technique on the KOOS4 from the pre-operative period to 2-year follow-up.ResultsA total of 13,636 patients who had undergone single-bundle ACL reconstruction comprised the study group for this analysis. A repeated measures ANOVA determined that mean subjective knee function differed between the pre-operative time period and at 2-year follow-up (p < 0.001). No differences were found with respect to the interaction between KOOS4 and surgical technique or gender. Additionally, the linear mixed model adjusted for age at reconstruction, gender, and concomitant injuries showed no difference between surgical techniques in KOOS4 improvement from baseline to 2-year follow-up. However, KOOS4 improved significantly in patients for all surgical techniques of single-bundle ACL reconstruction (p < 0.001); the largest improvement was seen between the pre-operative time period and at 1-year follow-up.ConclusionSurgical techniques of primary single-bundle ACL reconstruction did not demonstrate differences in the improvement in baseline subjective knee function as measured with the KOOS4 during the first 2 years after surgery. However, subjective knee function improved from pre-operative baseline to 2-year follow-up independently of surgical technique.

Obstructive sleep apnoea/hypopnoea syndrome in adults with Down syndrome.

Key pointsAdults with Down syndrome are predisposed to obstructive sleep apnoea/hypopnoea syndrome (OSAHS) due to overlap between the Down syndrome phenotype and OSAHS risk factors.The prevalence of OSAHS in adults with Down syndrome is estimated at 35–42%. This is up to ten-times higher than in the general adult population.Symptoms of OSAHS, including behavioural and emotional disturbances as well as standard symptoms such as sleepiness, should be monitored as part of regular health surveillance in adults with Down syndrome.There is evidence that the use of continuous positive airway pressure (CPAP) therapy in adults with Down syndrome and comorbid OSAHS can lead to significant improvements in subjective sleepiness, behaviour and cognitive function, though further large-scale trials are required.Educational aimsTo discuss the relationship between the phenotypic features of Down syndrome and the risk factors for obstructive sleep apnoea/hypopnoea syndrome (OSAHS).To examine the prevalence of OSAHS in adults with Down syndrome.To review recent research into the effectiveness of treatment of OSAHS in adults with Down syndrome using continuous positive airway pressure (CPAP) therapy.Obstructive sleep apnoea/hypopnoea syndrome (OSAHS) is characterised by repeated cycles of upper airway obstruction during sleep, leading to diurnal symptoms. Individuals with Down syndrome are predisposed to OSAHS due to overlap between the Down syndrome phenotype and OSAHS risk factors. Recent large studies using subjective and objective measures estimate that OSAHS affects around 40% of adults with Down syndrome, in contrast to 2–4% of the general adult population. The “double-hit” of comorbid Down syndrome and OSAHS may accelerate cognitive decline in adults with Down syndrome. However, with the appropriate care and support, OSAHS can be treated effectively in this group using continuous positive airway pressure (CPAP) therapy, improving daytime function and behaviour. Symptoms of OSAHS should be routinely monitored in this population, with testing and treatment available to all adults with Down syndrome; however, this is not currently commonplace, and health inequalities are evident.

Open inferior capsular shift for multidirectional shoulder instability in adolescents with generalized ligamentous hyperlaxity or Ehlers-Danlos syndrome

The objective of this study was to assess the outcome of open inferior capsular shift for multidirectional shoulder instability in patients with generalized ligamentous hyperlaxity or Ehlers-Danlos syndrome. Data were obtained for 18 open inferior capsular shift surgeries in 15 adolescent patients with generalized ligamentous hyperlaxity or Ehlers-Danlos syndrome with a mean follow-up of 7.5 years. End points were subjective clinical outcome (pain, stability, satisfaction, return to sport), objective clinical outcome (recurrence, complications), and functional outcome scores (American Shoulder and Elbow Surgeons, 11-item version of the Disabilities of Arm, Shoulder and Hand). Thirteen patients (87%) reported improved pain and stability and were satisfied with the procedure. Nine patients (64%) were able to return to sports. One patient (7%) was dissatisfied with continuous pain and recurrent instability and considered a surgical failure. Seven patients (47%) reported no further episodes of instability. The mean American Shoulder and Elbow Surgeons score at a mean of 7.5 years of follow-up was 88 ± 10 points, and the mean score for the 11-item version of the Disabilities of Arm, Shoulder and Hand was 14 ± 14 points. The management of multidirectional shoulder instability in adolescent patients with generalized ligamentous hyperlaxity or Ehlers-Danlos syndrome is challenging. Open inferior capsular shift results in improvement in subjective and objective shoulder function and stability in adolescent patients with ligamentous hyperlaxity or Ehlers-Danlos who have failed nonoperative treatment. We found no effect of the recalled number of prior dislocations, laterality, and type of hyperlaxity on subjective and objective clinical outcomes. Level IV; Case Series; Treatment Study.

A Novel, Nonoperative Treatment Demonstrates Success for Stiff Total Knee Arthroplasty after Failure of Conventional Therapy.

Certain patients continue to suffer from knee stiffness following total knee arthroplasty (TKA) despite undergoing conventional therapies. Astym therapy to these patients may offer an effective, safe, nonoperative treatment. This study evaluates the effects of Astym therapy upon (1) range of motion and (2) subjective functional improvements in post-TKA patients who suffered from stiffness recalcitrant to other nonoperative interventions. Twenty-three post-TKA patients (29 knees) who had recalcitrant knee stiffness were included in this study. Pre- and post-Astym improvements in range of motion and Knee Society scores were compared. We analyzed knees based on the presence of flexion deficit or contracture. Further stratification was made into knees that received Astym therapy before and after a 3-month period of standard rehabilitation. Differences in range of motion from pre- to post-Astym were evaluated by measuring (1) degree of flexion deficit or contracture and (2) total arc of passive motion. Improvements in subjective functional status were determined by evaluating Knee Society scores pre- and post-Astym therapy. A two-tailed Student t-test was used to compare weighted mean differences from pre- to post-Astym for the above parameters. The mean flexion deficit improved significantly (p < 0.001) in all patients after Astym therapy. The mean flexion contracture improved significantly in (p = 0.001) in 91% of patients after Astym therapy. Knees with flexion deficits or contractures both improved in total arc of motion when compared with pretherapy. Overall, patients who underwent treatment with Astym therapy reported significant mean improvements in both Knee Society objective (80 vs. 57 points; p < 0.0001) and functional scores (80 vs. 54 points; p = 0.0003) when compared with their pretherapy objective and functional scores. No harms were reported. Astym therapy is a novel, nonoperative treatment that may be an effective treatment option for post-TKA patients suffering from persistent knee stiffness. Further studies are needed to validate this intervention as a part of cost-effective, standard treatment after TKA.

Vagal Nerve Stimulation in Autonomic Dysfunction – A Case Study

Background: Autonomic nervous system function is influenced by the balance of the parasympathetic and sympathetic systems. Management for imbalance of these components causing dysfunction is largely focused on medications primarily improving cardiovascular tone. However, there appears to be an opportunity for therapy by modulating neurotransmission. Methods: Our patient is a nine year old female with history of intractable epilepsy and developmental delay related to confirmed genetic abnormalities and also complaints of episodic pallor, fatigue, light-headedness and headaches concerning for dysautonomia. Results: Our patient underwent vagal nerve stimulator (VNS) implantation for treatment of epilepsy and showed improvement of these symptoms at typical settings. Headup tilt test (HUTT) was subsequently performed and revealed normal findings and no subjective symptoms of autonomic dysfunction. A repeat HUTT was performed five months later with VNS output currents set to zero and revealed cardiovascular changes and clinical symptoms consistent with dysautonomia. With resumption of previous VNS settings, clinical symptoms resolved. Conclusions: Neurotransmission fromvagal afferents to brainstemnuclei is increased during VNS affecting multiple brainstem areas and the cerebral cortex, including regions controlling autonomic function. Studies have suggested a role for VNS in patients with clinical signs of autonomic dysfunction showing improvement in sympathovagal balance after VNS implantation. In our patient, we observed subjective and objective improvement in autonomic function. This initial case demonstrates a phenomenon that requires further study, may lead to improved understanding of autonomic function and the response to vagal nerve stimulation, and possibly a new indication for VNS therapy.

Cerebrovascular and blood-brain barrier morphology in spontaneously hypertensive rats: effect of treatment with choline alphoscerate.

Cholinergic precursors increasing choline availability and acetylcholine synthesis/release may represent a therapeutic approach for countering cognitive impairment occurring in adult-onset dementia disorders. Choline alphoscerate (alpha-gliceryl-phosphoryl-choline, GPC) is among cholinergic precursors the most effective in enhancing acetylcholine biosynthesis and release in animal models. This study was designed to assess if a long-term treatment with GPC modify cerebrovascular components [perivascular astrocytes, blood-brain barrier (BBB) and microvessels] and endothelial inflammatory markers expression in spontaneously hypertensive rats (SHR) used as a model of brain vascular injury. Male SHR aged 32 weeks and age-matched normotensive Wistar-Kyoto rats were treated for 4 weeks with GPC (150 mg/kg/day) or a vehicle. Intracerebral arteries of different brain areas, perivascular astrocytes, BBB and endothelial inflammatory markers were assessed by quantitative morphological and immunohistochemical techniques. No significant changes in the size of perivascular astrocytes were observed in SHR versus normotensive Wistar-Kyoto rats, whereas the expression of the BBB marker aquaporin-4 increased in SHR. This phenomenon was countered by GPC treatment. On the contrary, GPC has no vasodilator effect on brain micro-vessels. Endothelial markers and vascular adhesion molecules expression were not homogeneously affected by hypertension and GPC treatment in intracerebral vessels. The observation that treatment with GPC reversed BBB changes and countered to some extent micro-vessels changes occurring in SHR could explain data of clinical trials reporting an improvement of cognitive function in subjects suffering from cerebrovascular disorders and treated with GPC. These preclinical data suggest that the compound could have a cerebrovascular protective effect deserving a further characterization.

Clinical Experience With Continuous Intrathecal Baclofen Trials Prior to Pump Implantation

ObjectiveTo report our clinical experience using continuous intrathecal baclofen (ITB) trials prior to permanent pump implantation. DesignRetrospective chart review. SettingAn inpatient neurosurgery unit and outpatient physical medicine and rehabilitation clinics. ParticipantsFifty-seven patients with refractory spasticity who underwent a continuous ITB trial during the years 2006-2012. MethodsPatients underwent placement of a temporary intrathecal catheter that was connected to an external pump. A successful trial was defined as a one-level reduction in lower limb modified Ashworth scores in key spastic lower limb muscles identified for each individual patient. Subjective improvement in function or ease of performing functional tasks also were monitored. Main Outcome MeasuresModified Ashworth scores, functional mobility in ambulatory patients only, and the incidence and severity of adverse events during the trial and up to 1 year after implantation. ResultsSpasticity significantly decreased during the trial. Average ambulation distance was unchanged, although 34% of ambulatory patients progressed to a less restrictive assistive device by trial completion. Adverse events (AEs) occurred in 26 patients. Minor AEs were seen in 18 patients, with the most common being nausea, transient urinary retention, and headache. Pumps were implanted in 86% of patients; 14% did not receive a pump because of AEs or because goals were not met. Six patients had their pump removed at 12 months for the following reasons: pump malfunctions (3), skin breakdown around the pump (1), infection (1), and expectations not met (1). ConclusionsContinuous trials via an external catheter could be an option if patients and clinicians desire a comprehensive assessment of systemic and functional effects of ITB before pump implantation. The majority of AEs were minor and resolved spontaneously, and the most effective starting intrathecal dose was determined by pump insertion.

Prospective Case Series of NMES for Quadriceps Weakness and Decrease Function in Patients with Osteoarthritis of the Knee.

Osteoarthritis of the knee can lead to substantial disability. The purpose of this study was to evaluate the outcomes of a neuromuscular electrical stimulation (NMES) device in a small case series of treatment of quadriceps muscle weakness and decreased function in patients with knee osteoarthritis. We evaluated isokinetic quadriceps muscle strength, objective functional improvement, subjective functional improvement, quality of life, and pain relief. Patients were then matched with a previously studied cohort with similar osteoarthritic characteristics. Testing demonstrated improvement in isokinetic quadriceps and hamstring muscle strength, as well as several functional and patient-reported metrics. Conversely, patients reported a decrease in Knee Society Score (KSS) functional score, short-form 36 health survey (SF-36), lower extremity functional scale (LEFS), and visual analog scale (VAS) for pain; however, no changes were observed in relation to the mean reported VAS pain score and SF-36 physical component. Control cohort analysis of the patient reported outcomes showed that patients improved from their first visit to 3 months follow-up in functional KSS, SF-36 physical component, and LEFS. However, VAS pain score and objective KSS were unchanged at follow-up. Similarly, a decrease was observed in the scores of the SF-36 mental component. In conclusion, the use of NMES for quadriceps muscle weakness has been shown to improve muscle strength. Additionally, NMES was shown to potentially improve functionality but demonstrated minimal effects on quality of life and patient-reported outcomes compared with the initial visit. However, larger, longer-term, prospective, randomized studies are needed to better evaluate these outcomes.

Significance of Inulin Fructans in the Human Diet.

This paper reviews the physicochemical properties and nutritional significance of inulin fructans (oligofructose and inulin). These compounds are naturally present in a large number of food crops and serve in our diet as dietary fiber. Inulin fructans can be isolated and purified from the chicory root and used as ingredients in a large range of foods to improve structure and/or taste and to increase the intake of dietary fiber. Inulin fructans have a low caloric value, are safe, and generally well tolerated up to a level of 20 g/d. They exert a range of effects, which can be differentiated into direct effects on the gut and the intestinal flora and indirect systemic effects. Direct effects on the gut include prebiotic (bifidogenic) effects, improvement of bowel habits and bowel function in constipated subjects, increased colonic absorption of minerals (Ca and Mg), and secretion of satiety hormones. Indirect effects are on blood lipids, bone mineral content, the immune system, and energy homeostasis. These issues are discussed and it is argued that promising avenues for research are particularly in the areas of energy homeostasis and systemic low-grade inflammation in relation to changes in the composition of the intestinal microbiota.