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To determine whether classification systems improve patient-reported outcomes for people with low back pain (LBP).Systematic review with meta-analysis.The MEDLINE, Embase, CINAHL, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials databases were searched from inception to June 21, 2021. Reference lists of prior systematic reviews and included trials were screened.We included randomized trials comparing a classification system (eg, the McKenzie method or the STarT Back Tool) to any comparator. Studies evaluating participants with specific spinal conditions (eg, fractures or tumors) were excluded.Outcomes were patient-reported LBP intensity, leg pain intensity, and disability. We used the revised Cochrane Collaboration Risk of Bias Tool to assess risk of bias, and the Grading of Recommendations Assessment, Development and Evaluation approach to judge the certainty of evidence. We used random-effects meta-analysis, with the Hartung-Knapp-Sidik- Jonkman adjustment, to estimate the standardized mean difference (SMD; Hedges'Twenty-four trials assessing classification systems and 34 assessing subclasses were included. There was low certainty of a small effect at the end of intervention for LBP intensity (SMD, -0.31; 95% CI: -0.54, -0.07;For patient-reported pain intensity and disability, there is insufficient evidence supporting the use of classification systems over generalized interventions when managing LBP.

The blood pressure response to exercise is exaggerated in type 2 diabetes mellitus (T2DM). However, the underlying mechanisms remain unclear. It is hypothesized that one mechanism mediating the potentiated cardiovascular response in T2DM is the sensitization of chemically sensitive afferent neurons by activation of metaboreceptors. To test this hypothesis, we examined transient receptor potential cation channel subfamily V member 1 (TRPV1)-induced cardiovascular responses in vivo and muscle afferent discharge ex vivo in T2DM rats. Additionally, TRPV1 and protein kinase C (PKC) protein levels in dorsal root ganglia (DRG) subserving skeletal muscle were assessed. For 14-16 weeks, Sprague-Dawley rats were given either a normal diet (control) or high fat diet in combination with a low dose (35 and 25 mg/kg) of streptozotocin (T2DM). Administration of capsaicin, TRPV1 agonist, in hindlimb evoked significantly greater increases in mean arterial pressure and renal sympathetic neve activity in decerebrated T2DM than control. In a muscle-nerve preparation, the discharge to capsaicin exposure in group IV afferents isolated from T2DM was likewise significantly augmented at a magnitude that was proportional to glucose concentration. Moreover, the discharge to capsaicin was potentiated by acute exposure of group IV afferents to a high glucose environment. T2DM showed significantly increased phospholyrated-TRPV1 and −PKCα levels in DRG neurons as compared with control. These findings suggest that group IV muscle afferents are sensitized by PKC-induced TRPV1 overactivity in early-stage T2DM with hyperglycemia and, thereby, may contribute to the potentiated circulatory response to TRPV1 activation in the disease.

Background The strength and size of core muscles, including the abdominal muscles, are crucial to proper function in most activities. Therefore, it is important to reliably assess these characteristics. Our primary objective was to determine if the length, thickness and cross-sectional area of the transversus abdominis (TrA) can be visualized independently from the internal and external abdominal oblique muscles using extended field of view ultrasound imaging at rest and with contraction and to establish its intra- and inter-tester reliability. Methods Twenty-six individuals were recruited to participate in the study (20 F, 6 M), average age 24.0 years (SD 9.4), height 170.7 cm (SD 8.6) and weight 63.9 kg (SD 9.0). From this total number of participants, two groups of 16 randomly selected participants were assessed to determine intra- and inter-tester reliability respectively. Extended field of view ultrasound images were obtained at three vertebral levels during rest and contraction in the side lying position for both the right and left sides of the trunk. Results Excellent intra-tester and inter-tester reliability was seen (ICC range of 0.972 to 0.984). The overall average percent standard error of the measurement for all measurements and locations was approximately 4%. The overall average minimal difference for the thickness measurement for the resting and contraction conditions combined were as follows: intratester 0.056 (0.014) cm and intertester 0.054 (0.017) cm, for area intratester 0.287 (0.086) cm2 and intertester 0.289 (0.101) cm2 and for length intratester 0.519 (0.097) cm and intertester 0.507 (0.085) cm. Conclusions Extended field of view ultrasound imaging is an effective method of reliably capturing clear images of the TrA during rest and contraction. It provides an efficient mechanism for the analysis of muscle morphology by being able to measure the cross-sectional area, thickness, and length on one image. This methodology is recommended for studies investigating TrA function and training.

Patients with type 2 diabetes display an exaggerated pressor response to exercise. However, evidence supporting the association between the magnitude of the pressor response to exercise and insulin resistance-related factors including hemoglobin A1c (HbA1c) or homeostatic model assessment of insulin resistance (HOMA-IR) in nondiabetic subjects has remained sparse and inconclusive. Thus we investigated the relationship between cardiovascular responses to exercise and insulin resistance-related factors in nondiabetic healthy men (n = 23) and women (n = 22) above 60 yr old. We measured heart rate (HR) and blood pressure (BP) responses during: isometric handgrip (IHG) exercise of 30% maximal voluntary contraction, a period of skeletal muscle ischemia (SMI) induced by tourniqueting the arm after IHG, and rhythmic dynamic handgrip (DHG) exercise during SMI. Greater diastolic BP (DBP) responses to DHG with SMI was associated with male sex (r = 0.44, P = 0.02) and higher HbA1c (r = 0.33, P = 0.03), heart-ankle pulse wave velocity (haPWV) (r = 0.45, P < 0.01), and resting systolic BP (SBP) (r = 0.36, P = 0.02). HbA1c persisted as a significant determinant explaining the variance in the DBP response to DHG with SMI in multivariate models despite adjustment for sex, haPWV, and resting SBP. It was also determined that the DBP response to DHG with SMI in a group in which HOMA-IR was abnormal (Δ33 ± 3 mmHg) was significantly higher than that of groups in which HOMA-IR was at intermediate (Δ20 ± 4 mmHg) and normal (Δ23 ± 2 mmHg) levels. These data suggest that even in nondiabetic older adults, insulin resistance is related to an exaggerated pressor response to exercise especially when performed under ischemic conditions. NEW & NOTEWORTHY The diastolic blood pressure response to rhythmic dynamic handgrip exercise under ischemic conditions was demonstrated to be correlated with insulin resistance-related factors in nondiabetic older adults. This finding provides important insight to the prescription of exercise in this particular patient population as the blood pressure response to exercise, especially under ischemic conditions, could be exaggerated to nonsafe levels.

BACKGROUND Rapid access to blood products can be lifesaving for hemorrhaging patients, but placing blood components in easily accessible locations in the emergency department (ED) can lead to wasteful patterns of use. Education can lead to improvements in transfusion behavior, but such changes for the better are often short lived. METHODS To facilitate the early initiation of balanced resuscitation, an emergency blood refrigerator was placed in our ED in February 2015. Physician education to give blood components in a 1:1 plasma:red blood cell (RBC) unit ratio with the plasma given first was given repeatedly with short-term success. Finally, nurses were trained and empowered to strongly suggest that blood components be given in balanced ratios and that plasma be given first. Plasma:RBC unit ratios were compared in successive years with the chi-square test for trend. RESULTS A total of 1165 RBC units and 623 plasma units were issued from the ED emergency blood refrigerator over 5 years. Intensive physician education is documented at start, in late 2016 to early 2017, and again in early and late 2018. Ratios of components (U plasma/U RBCs) were 2015, 17%; 2016, 26%; 2017, 61%; 2018, 49%; and 2019, 91% (p

PURPOSE This study aimed to investigate if the Functional Movement Screen (FMS) total score, individual component test scores, or number of asymmetries can predict noncontact injury risk over three consecutive seasons of National Collegiate Athletic Association Division I football. METHODS Because football teams comprise individuals with vastly different physical characteristics and playing responsibilities, we divided the subjects into three homogeneous groups based on position (big, combo, and skill). Each FMS score was assessed with regard to the total team score and by individual position groups. For our injury analysis, we also controlled for exposure. Two hundred and eight National Collegiate Athletic Association Division I athletes participated over three consecutive seasons, yielding a total of 343 observations. RESULTS There was no significant relationship between total FMS score and likelihood of injury when analyzed by the total team or by position group. These findings were the same for all groups, for both the total number of injuries and injuries weighted by injury exposure. The only significant findings occurred when we considered individual test item scores to injury by position group. We only found a significant relationship in the expected direction with push-up stability in the combo group. CONCLUSIONS FMS was not a good predictor of noncontact injury.

Injury of the tooth pulp is excruciatingly painful and yet the receptors and neural circuit mechanisms that transmit this form of pain remain poorly defined in both the clinic and preclinical rodent models. Easily quantifiable behavioral assessment in the mouse orofacial area remains a major bottleneck in uncovering molecular mechanisms that govern inflammatory pain in the tooth. In this study we sought to address this problem using the Mouse Grimace Scale and a novel approach to the application of mechanical Von Frey hair stimuli. We use a dental pulp injury model that exposes the pulp to the outside environment, a procedure we have previously shown produces inflammation. Using RNAscope technology, we demonstrate an upregulation of genes that contribute to the pain state in the trigeminal ganglia of injured mice. We found that mice with dental pulp injury have greater Mouse Grimace Scores than sham within 24 hours of injury, suggestive of spontaneous pain. We developed a scoring system of mouse refusal to determine thresholds for mechanical stimulation of the face with Von Frey filaments. This method revealed that mice with a unilateral dental injury develop bilateral mechanical allodynia that is delayed relative to the onset of spontaneous pain. This work demonstrates that tooth pain can be quantified in freely behaving mice using approaches common for other types of pain assessment. Harnessing these assays in the orofacial area during gene manipulation should assist in uncovering mechanisms for tooth pulp inflammatory pain and other forms of trigeminal pain.

Purpose This study aimed to determine if brief psychosocial/behavioral therapy directed to reduce poststroke depression would decrease fatigue and improve sleep-wake disturbance. Design A preplanned secondary data analysis from a completed clinical trial was conducted. Methods One hundred participants received usual care, in-person intervention, or telephone intervention. Depression, fatigue, and sleep-wake disturbance were measured at entry, 8 weeks, 21 weeks, and 12 months following the intervention. Findings Fatigue (within: p = .042, between: p = .394), sleep disturbance (within: p = .024, between: p = .102), and wake disturbance (within: p = .004, between: p = .508) decreased over the 12 months in the intervention groups, but not in the control group. This difference was clinically meaningful for wake disturbance and approached the clinically important difference for fatigue. Conclusions/clinical relevance Reduction in wake disturbance was consistent with clinically meaningful difference standards for patient-reported outcomes, warranting further research in larger samples.

Background Consumer engagement is a requirement of high quality clinical guidelines. Developing strategies to engage consumers and incorporate the perspectives of individuals with or at risk of pressure ulcers/injuries and their informal caregivers was one priority in the recent update of the EPUAP/NPIAP/PPPIA's Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. Aims The aims were to determine the goals of individuals and caregivers for pressure ulcer/injury care, priorities for pressure ulcer/injury education and biggest problems related to pressure ulcers/injuries. Methods An online, anonymous, international 10-item survey, accessible in nine languages was provided to individuals and their caregivers from April to October 2018. Descriptive statistics were used for quantitative data and a thematic analysis approach was used to analyse qualitative data. Results There were 1233 individuals from 27 countries who completed the survey. Overall, individuals and caregivers had similar goals of care. Reducing the size of pressure ulcer/injury was selected more often as a care goal than complete healing. Individuals, compared to caregivers, considered managing pain more important. Qualitative data analysis identified five themes including knowledge, attitudes, and skills; risk factors for pressure ulcer/injury; accessing pressure ulcer/injury care; quality of life for patients and caregivers; and the pressure ulcer/injury. Conclusions The consumer survey provided consumer engagement and perspective that was incorporated into guideline development, including consideration during evaluation of the relevance and acceptability of recommendations, and assignment of recommendation strength ratings.

Introduction The most common cancers in the UK are keratinocyte cancers (KCs): the combined term for basal cell carcinomas (BCCs) and cutaneous squamous cell carcinomas (cSCCs). Registration of KC is challenging due to high numbers and multiplicity of tumours per person. Methods We provide an updated report on the descriptive epidemiology of trends in KC incidence for the resident populations of UK countries (England, Northern Ireland, Scotland and Wales) using population‐based cancer registry and pathology report data, 2013–18. Results Substantial increases in cSCC incidence in England, Scotland and Northern Ireland can be detected for the period of 2013–18, and the incidence of cSCC also increased in Wales from 2016 to 2018. In contrast, however, the pattern of annual change in the incidence of BCC across the nations differs. In England, the incidence of BCC declined slightly from 2016 to 2018, however, the overall trend across 2013–18 is not statistically significant. In Scotland, the incidence of BCC shows some variability, declining in 2017 before increasing in 2018, and the overall trend across 2013–18 was also not statistically significant. In Northern Ireland, the incidence of BCC increased significantly over the study period, and in Wales, the incidence of BCC increased from 2016 to 2018. One in five people will develop non‐melanoma skin cancers (NMSC) in their lifetime in England. This estimate is much higher than the lifetime risk of melanoma (1 in 36 males and 1 in 47 females born after 1960 in the UK), which further highlights the burden of the disease and importance of early prevention strategies. Conclusions We highlight how common these tumours are by publishing the first ever lifetime incidence of NMSC. Additionally, the first time reporting of the age standardised incidence of KC in Wales further confirms the scale of the disease burden posed by these cancers in the UK. With approximately one in five people developing NMSC in their lifetime, optimisation of skin cancer prevention, management and research are essential.

Skin cancer is the commonest cancer in the UK. Skin cancer referrals via the two-week wait (urgent suspected cancer) pathway outnumber any other suspected malignancy.1, 2 The commonest skin cancers are keratinocyte cancers (KCs) which represents Basal Cell Carcinomas (BCC) and Cutaneous Squamous Cell Carcinomas (cSCC). Accurate KC incidence reporting is crucial for healthcare planning.

Mitochondrial dysfunction and excessive inflammatory responses are both sufficient to induce pathology in age-dependent neurodegenerations. However, emerging evidence indicates crosstalk between damaged mitochondrial and inflammatory signaling can exacerbate issues in chronic neurodegenerations. This review discusses evidence for the interaction between mitochondrial damage and inflammation, with a focus on glaucomatous neurodegeneration, and proposes that positive feedback resulting from this crosstalk drives pathology. Mitochondrial dysfunction exacerbates inflammatory signaling in multiple ways. Damaged mitochondrial DNA is a damage-associated molecular pattern, which activates the NLRP3 inflammasome; priming and activation of the NLRP3 inflammasome, and the resulting liberation of IL-1β and IL-18 via the gasdermin D pore, is a major pathway to enhance inflammatory responses. The rise in reactive oxygen species induced by mitochondrial damage also activates inflammatory pathways, while blockage of Complex enzymes is sufficient to increase inflammatory signaling. Impaired mitophagy contributes to inflammation as the inability to turnover mitochondria in a timely manner increases levels of ROS and damaged mtDNA, with the latter likely to stimulate the cGAS-STING pathway to increase interferon signaling. Mitochondrial associated ER membrane contacts and the mitochondria-associated adaptor molecule MAVS can activate NLRP3 inflammasome signaling. In addition to dysfunctional mitochondria increasing inflammation, the corollary also occurs, with inflammation reducing mitochondrial function and ATP production; the resulting downward spiral accelerates degeneration. Evidence from several preclinical models including the DBA/2J mouse, microbead injection and transient elevation of IOP, in addition to patient data, implicates both mitochondrial damage and inflammation in glaucomatous neurodegeneration. The pressure-dependent hypoxia and the resulting metabolic vulnerability is associated with mitochondrial damage and IL-1β release. Links between mitochondrial dysfunction and inflammation can occur in retinal ganglion cells, microglia cells and astrocytes. In summary, crosstalk between damaged mitochondria and increased inflammatory signaling enhances pathology in glaucomatous neurodegeneration, with implications for other complex age-dependent neurodegenerations like Alzheimer’s and Parkinson’s disease.

Patients with diabetes display heightened blood pressure response to exercise but the underlying mechanism are remains to be elucidated. There is no direct evidence that insulin resistance (hyperinsulinemia or hyperglycemia) impact neural cardiovascular control during exercise. We propose a novel paradigm in which hyperinsulinemia or hyperglycemia significantly influence neural regulatory pathways controlling the circulation during exercise in diabetes.

PURPOSE This study investigated the relationship between blood flow restriction (BFR) cuff pressure and blood flow at rest and during exercise, with the aim of determining if lower cuff pressures will provide an ischemic stimulus comparable to higher pressures. METHODS The relationship between blood flow and cuff pressure at rest was determined by measuring blood flow (Doppler Ultrasound) through the superficial femoral artery (SFA) in 23 adults across a range of pressures (0%-100% Arterial Occlusion Pressure at rest [rAOP]). The interplay between cuff pressure, blood flow and exercise was assessed by determining AOP at rest and during plantar flexion exercise (eAOP) and subsequently measuring the blood flow response to plantar flexion exercise with BFR cuff pressure set to either 40% rAOP or 40% eAOP. RESULTS At rest, a nonlinear relationship between cuff pressure and blood flow through the SFA exhibited a plateau at moderate pressures, with nonsignificant differences in blood flow (~9%, P = 1.0) appearing between pressures ranging from 40% to 80% rAOP. While eAOP was greater than rAOP (229 ± 1.5 mm Hg vs 202 ± 1.5 mm Hg, P < 0.01), blood flow during plantar flexion exercise did not significantly differ (P = 0.49) when applying 40% rAOP or 40% eAOP. CONCLUSIONS Blood flow through the SFA exhibits a nonlinear relationship with cuff pressure, such that cuff pressures in the range of 40% to 80% rAOP reduce blood flow to approximately the same degree. The BFR interventions opting for lower (e.g., 40% AOP), more comfortable pressures will likely provide an ischemic stimulus comparable to that of higher (80% AOP), less-comfortable pressures.

Objective This study was conducted to measure and to determine differences in tissue depth in the upper back for two prone positions and to stratify the results by body composition and sex of the patient. In addition, muscle thickness changes with positioning were assessed. This information is important for clinicians who dry needle in the thorax area, cognizant of the dangers of inadvertently piercing the pleura or lung tissue. Design Descriptive cross-sectional. Setting Health and Human Performance laboratory at a university campus. Participants Sample of convenience of 60 college-aged subjects, 20 subjects in three body composition groups. Main outcome measures Distances from skin to lung tissue, skin to ribs and muscle thickness were measured and compared between two prone positions. Results There was a significant increase in depth to the lung tissue (0.7 cm, 95% confidence interval 0.4–1.0 cm) when using a bolster under the shoulder. There were also differences in depths between body composition classifications and between sexes, but not between sides. The average thickness of all muscles increased significantly by up to 0.4 cm (95% confidence interval 0.3–0.5) when the shoulder was positioned in retraction. Conclusions Positioning, body constitution and sex of the patient change tissue depth significantly and should be considered when dry needling. This change is largely attributed to a modification in muscle thickness.

The cardiovascular responses to exercise are potentiated in patients with type 2 diabetes mellitus (T2DM). However, the underlying mechanisms causing this abnormality remain unknown. Central command (CC) and the exercise pressor reflex (EPR) are known to contribute significantly to cardiovascular control during exercise. Thus these neural signals are viable candidates for the generation of the abnormal circulatory regulation in this disease. We hypothesized that augmentations in CC as well as EPR function contribute to the heightened cardiovascular responses during exercise in T2DM. To test this hypothesis, changes in mean arterial pressure (MAP) and renal sympathetic nerve activity (RSNA) in response to electrical stimulation of mesencephalic locomotor region (MLR), a putative component of the central command pathway, and activation of the EPR, evoked by electrically induced hindlimb muscle contraction, were examined in decerebrate animals. Sprague-Dawley rats were given either a normal diet (control) or a high-fat diet (14–16 wk) in combination with two low doses (35 mg/kg week 1, 25 mg/kg week 2) of streptozotocin (T2DM). The changes in MAP and RSNA responses to MLR stimulation were significantly greater in T2DM compared with control (2,739 ± 123 vs. 1,298 ± 371 mmHg/s, 6,326 ± 1,621 vs. 1,390 ± 277%/s, respectively, P < 0.05). Similarly, pressor and sympathetic responses to activation of the EPR in diabetic animals were significantly augmented compared with control animals (436 ± 74 vs. 134 ± 44 mmHg/s, 645 ± 135 vs. 139 ± 65%/s, respectively, P < 0.05). These findings provide the first evidence that CC and the EPR may generate the exaggerated rise in sympathetic activity and blood pressure during exercise in T2DM.

Purpose In hospital-based studies, patients intubated by physicians while in an inclined position compared to supine position had a higher rate of first pass success and lower rate of peri-intubation complications. We evaluated the impact of patient positioning on prehospital endotracheal intubation in an EMS system with rapid sequence induction capability. We hypothesized that patients in the inclined position would have a higher first-pass success rate. Methods Prehospital endotracheal intubation cases performed by paramedics between 2012 and 2017 were prospectively collected in airway registries maintained by a metropolitan EMS system. We included all adult (age ≥ 18 years) non-traumatic, non-arrest patients who received any attempt at intubation. Patients were categorized according to initial positioning: supine or inclined. The primary outcome measure was first pass success with secondary outcomes of laryngoscopic view and challenges to intubation. Results Of the 13,353 patients with endotracheal intubation attempted by paramedics during the study period, 4879 were included for analysis. Of these, 1924 (39.4%) were intubated in the inclined position. First pass success was 86.3% among the inclined group versus 82.5% for the supine group (difference 3.8%, 95% CI: 1.5%–6.1%). First attempt laryngeal grade I view was 62.9% in the inclined group versus 57.1% for the supine group (difference 5.8%, 2.0–9.6). Challenges to intubation were more frequent in the supine group (42.3% versus 38.8%, difference 3.5%, 0.6–6.3). Conclusion Inclined positioning was associated with a better grade view and higher rate of first pass success. The technique should be considered as a viable approach for prehospital airway management.

Background: Inorganic phosphate (Pi) is used extensively as a preservative and a flavor enhancer in the Western diet. Physical inactivity, a common feature of Western societies, is associated with increased cardiovascular morbidity and mortality. It is unknown whether dietary Pi excess contributes to exercise intolerance and physical inactivity. Methods: To determine an association between Pi excess and physical activity in humans, we assessed the relationship between serum Pi and actigraphy-determined physical activity level, as well as left ventricular function by cardiac magnetic resonance imaging, in DHS-2 (Dallas Heart Study phase 2) participants after adjusting for relevant variables. To determine direct effects of dietary Pi on exercise capacity, oxygen uptake, serum nonesterified fatty acid, and glucose were measured during exercise treadmill test in C57/BL6 mice fed either a high-Pi (2%) or normal-Pi (0.6%) diet for 12 weeks. To determine the direct effect of Pi on muscle metabolism and expression of genes involved in fatty acid metabolism, additional studies in differentiated C2C12 myotubes were conducted after subjecting to media containing 1 to 3 mmol/L Pi (pH 7.0) to simulate in vivo phosphate conditions. Results: In participants of the DHS-2 (n=1603), higher serum Pi was independently associated with reduced time spent in moderate to vigorous physical activity ( P =0.01) and increased sedentary time ( P =0.004). There was no association between serum Pi and left ventricular ejection fraction or volumes. In animal studies, compared with the control diet, consumption of high-Pi diet for 12 weeks did not alter body weight or left ventricular function but reduced maximal oxygen uptake, treadmill duration, spontaneous locomotor activity, fat oxidation, and fatty acid levels and led to downregulation of genes involved in fatty acid synthesis, release, and oxidation, including Fabp4 , Hsl , Fasn , and Pparγ , in muscle. Similar results were recapitulated in vitro by incubating C2C12 myotubes with high-Pi media. Conclusions: Our data demonstrate a detrimental effect of dietary Pi excess on skeletal muscle fatty acid metabolism and exercise capacity that is independent of obesity and cardiac contractile function. Dietary Pi may represent a novel and modifiable target to reduce physical inactivity associated with the Western diet.

Rationale: Early antibiotics improve outcomes for patients with sepsis. Factors influencing antibiotic timing in emergency department (ED) sepsis remain unclear.Objectives: Determine the relationsh...

BACKGROUND: Drug resistance poses a major barrier to global control of TB – a leading infectious cause of death. Depression and stigma occur commonly among people with TB. However, the relationship between drug-resistant forms of TB, depression and stigma are not well understood.OBJECTIVE: To compare depression, stigma and health-related quality of life (HRQoL), among people with drug-susceptible TB (DS-TB) and multidrug-resistant TB (MDR-TB).METHODS: A cross-sectional study of people treated for DS-TB and MDR-TB in four provinces of Vietnam. The survey included a stigma scale (Vietnamese Tuberculosis Stigma Scale), depression scale (9-item Patient Health Questionnaire) and HRQoL scale (Functional Assessment of Chronic Illness Therapy – Tuberculosis). Differences between the two populations were compared using linear regression.RESULTS: Eighty-one people with DS-TB and 315 people with MDR-TB participated in the study. People with MDR-TB had a higher prevalence of depression than those with DS-TB (difference 17.8%, χ2 8.64). The mean depression and stigma scores were higher for people with MDR-TB than those with DS-TB (adjusted difference [AD] 8.6 and 7.6 respectively). People with MDR-TB reported lower HRQoL than those with DS-TB (AD –23.8).CONCLUSION: Depression and stigma are common among people with TB in Vietnam. Strategies to prevent and treat depressive symptoms and stigma in people with TB are critical to a holistic, patient-centred approach to care.

Numerous studies have demonstrated that sympathetic nervous system overactivation during exercise in hypertensive rodents and humans is due, in part, to an exaggerated reflex response known as the exercise pressor reflex. Our prior studies have implicated a key role of mineralocorticoid receptor activation in mediating an augmented exercise pressor reflex in spontaneously hypertensive rats, which is mitigated by blockade with eplerenone. However, the effect of eplerenone on exercise pressor reflex has not been assessed in human hypertension. Accordingly, the authors performed a randomized crossover study to compare the effects of eplerenone to another antihypertensive drug from a different class amlodipine on sympathetic nerve activity (SNA) in 14 patients with uncomplicated hypertension. The authors found that amlodipine unexpectedly augmented the increase in SNA during the second minute of isometric handgrip, which persisted into the post‐exercise circulatory arrest period (∆ SNA, from rest of 15 ± 2 vs. 9 ± 2 vs. 10 ± 2 bursts/min, amlodipine vs. baseline vs. eplerenone, respectively, p

Background: The endogenous signals leading to microglial activation represent central components of neuroinflammatory cascades. Given ATP release accompanies mechanical strain to neural tissue, and the P2X7R for ATP is expressed on microglial cells, we examined the morphological and molecular consequences of P2X7R stimulation in vivo and in vitro in detail to enhance understanding of the response. Methods: IL-1β release was determined with ELISA. Expression of mRNA used qPCR. ATP release was determined with the luciferin/luciferase assay while fura-2 indicated cytoplasmic calcium. Microglial migration used Boyden chambers. Morphological changes were quantified from Iba1-immunostained cells. Results: Sholl analysis of Iba1-stained cells showed retraction of microglial ramifications one day after injection of P2X7R agonist BzATP into mouse retinae. Mean branch length also decreased, while cell body size and expression of Nos2, Tnfa, Arg1, Chil3 increased. BzATP induced similar morphological changes in ex vivo tissue isolated from Cx3CR1-GFP mice, suggesting cell recruitment was unnecessary. Primary microglial cultures were developed to investigate the autonomous nature of the response. Isolated microglial cells expressed P2X7R, while increased intracellular Ca 2+ triggered by BzATP and blocked by antagonist A839977 confirmed functional expression. BzATP induced process retraction and cell body enlargement within minutes in isolated microglial cells, and increased expression of Nos2 and Arg1 . BzATP both increased expression of IL-1β, and triggered a substantial release, suggesting P2X7R both primes and activates the NLRP3 inflammasome. ATP increased microglial migration, but this required P2Y12R, not P2X7R involvement. As ATP release often accompanies mechanical strain, responses to intraocular pressure elevation were determined. Transient elevation increased ATP release and led to microglial process retraction, cell body enlargement and gene upregulation resembling the responses to BzATP injection. These pressure-dependent changes to microglia were reduced in P2X7R -/- mice. Critically, the loss of retinal ganglion cell neurons accompanying increased pressure was correlated with microglial activation in C57Bl/6J, but not P2X7R -/- mice.Conclusions: P2X7R stimulation induced morphological and molecular markers of activation in retinal microglial cells in vivo and in vitro , affecting IL-1β release and rapid process retraction but not cell migration. Parallel responses accompanied transient pressure elevation, suggesting ATP release and P2X7R stimulation contribute to the microglial response to rising pressure.

Statement of purpose Community violence exposure is known to have adverse effects on children’s long-term mental health. We aimed to examine the association between episodes of neighborhood gun violence and subsequent acute mental health-related pediatric emergency department (ED) utilization. Methods/Approach This location-based neighborhood study included children living in Philadelphia, PA who presented to a children’s hospital ED from 1/1/2014–12/31/2018. We included children in the study if they had one or more ED visits within 7, 30, and 60 days of a neighborhood shooting and lived within 660 feet (2–3 city blocks) of where the incident occurred. Mental health-related presentations were identified using ED chief complaint data. We used multivariable logistic regression to compare odds of mental health-related ED utilization before and after neighborhood shootings. Results There were 4,217 episodes of gun violence in the study area from 2014–2018, and 54,465 children living near a shooting had one or more ED visits in the 60 days before or after this shooting. Most of these children were Black (84.5%) and Medicaid-insured (78.2%). After adjusting for age, race, ethnicity, insurance status, and zip code, children residing within 660 feet of an episode of gun violence had greater odds of mental health-related ED presentations in the subsequent 7 days (aOR 1.49, 95% CI, 1.08–2.04), 30 days (aOR 1.25, 95%CI 1.05–1.48), and 60 days (adjusted odds ratio (aOR 1.14, 95%CI 1.01–1.29). In stratified analyses, this effect was strongest for Black children (7-day aOR 1.52, 95%CI 1.08–2.14) and children ages 11–19 (7-day aOR 1.60, 95%CI 1.08–2.39). Conclusions and Significance Neighborhood gun violence has immediate adverse effects on children’s mental health. Recognizing the potentially triggering event and mitigating these health impacts will require both community-based support for children exposed to violence, and trauma- informed approaches during and after ED visits.

Introduction and Objectives The disease spectrum of COVID-19 ranges from mild viral illness to devastating lung injury that heralds the acute respiratory distress syndrome Different risk factors of adverse outcomes have been identified but prospectively stratified and externally validated studies of prognosis are lacking We set out to identify independent predictors of mortality and to develop and validate a clinically applicable risk prediction model of COVID-19 Methods 983 consecutive patients with COVID-19 were prospectively recruited over an 11-week period for an outcome of in-hospital death Multiple imputation was used to address randomly missing data 12 independent mortality predictors were identified by multivariate regression and internally validated by bootstrapping A prognostic score was constructed and validated in an external cohort (N=277) and assessed for predictive accuracy including goodness-of-fit by the Hosmer-Lemeshow test Results The median age of the derivation cohort was 70 (IQR: 53-83) Among non-survivors (29 9%;294/983), the highest odds ratios for death (with 95% confidence intervals) were age >70 (7 65;4 89-11 98;P30 (2 39;1 88-3 03;P

COVID-19 posed unprecedented challenges on healthcare systems globally especially on inpatient beds, oxygen and ventilatory support: Continuous positive airway pressure (CPAP), high flow nasal oxygen and invasive mechanical ventilation (IMV) West Herts NHS Trust, a secondary care provider for a population of 650,000 had 1200 admissions during the first wave (March to June) with a 30% mortality Ventilatory outcomes in 116 consecutive admissions were analysed to assess the utility of CPAP in a respiratory specialist ward versus ITU, and prompt versus delayed invasive mechanical ventilation (IMV) Respiratory support was provided in four pathways: CPAP in intensive care unit (ITU) (n=18), CPAP in respiratory ward setting (usually as ceiling of care, n=50), IMV after initial trial of CPAP (n=21) and IMV with no delay or interim CPAP (n=27) The demographics, comorbidities, functional status, severity of presentation and outcomes differed greatly between the ward group and all the ITU arms Within the ITU arms, patients were younger, had worse chest X-rays, higher CRP as well as had lower lymphocyte counts, PF (PaO2/FiO2) ratios and comorbidities Delayed intubation with a trial of CPAP was associated with significant mortality compared to prompt IMV All ventilatory outcomes were poor in patients over 80 years Mortality rate was significantly lower in prompt IMV, 37%, compared to 95% in those with a delayed intubation by a median of 6 days with a prior CPAP trial Median PF ratio on admission for patients with prompt IMV was 73 mmHg vs 115 mmHg in those with CPAP prior to IMV In summary, ward CPAP as ceiling of care for older patients and with comorbidities is safe and associated with a relatively similar mortality rate compared to ITU CPAP but must be reviewed regularly to ensure improvement on treatment Mortality is significant in those with lower PF ratios especially if IMV is delayed Whilst acknowledging the heavy burden on clinicians to rationalise treatment during times of limited resources, we believe that careful assessment of age, comorbidities (cardiac and frailty), PF ratios, CRP and a 24 hourly review should be undertaken to prevent delayed IMV in appropriate patients

An increasing number of studies have reported a deleterious role of inorganic phosphate (Pi) in promoting hypertension. Previously, we have shown high Pi diet-induced excessive pressor and sympathetic responses to muscle contraction in otherwise normal rats, which were primarily mediated by an overactive exercise pressor reflex (EPR), a reflex arising from contracting muscle. However, the mechanism underlying these abnormalities generated by excess Pi intake remains unclear. Dietary Pi is known to increase release of bone-derived fibroblast growth factor (FGF) 23 to regulate Pi homeostasis. Evidence suggests that FGF23 and FGF receptors (FGFRs) are also present in the central nervous system. The aim of this study was to determine the role of brain FGFRs in mediating augmented EPR activity induced by dietary Pi excess. Accordingly, we assessed cerebrospinal fluid FGF23 levels in Sprague-Dawley rats fed either a normal 0.6% Pi diet (NP) or a high 1.2% Pi diet (HP) for 12 weeks. To determine the role of central FGFRs in mediating the EPR, we measured mean arterial pressure (MAP) and renal sympathetic nerve activity (RSNA) responses to hindlimb muscle contraction before and after intracerebroventricular (ICV) administration of either a selective FGFR4 inhibitor BLU9931 or a FGFR1/2/3 inhibitor AZD4547 in decerebrate NP and HP animals. Cerebrospinal fluid FGF23 levels were significantly higher in HP rats compared to NP rats (8.3±0.9 vs. 7.2±0.8 pM, P

Mitchell, UH, Owen, PJ, Rantalainen, T, and Belavý, DL. Increased joint mobility is associated with impaired transversus abdominis contraction. J Strength Cond Res 36(9): 2472-2478, 2022-Increased joint mobility is a risk factor for joint injury, but muscle function may be able to compensate for it. Current evidence suggests reduced force production capacity in people with hypermobility. However, little is known about the lumbar spine. The purpose of this cross-sectional study was to assess whether there was a link between joint mobility and transverse abdominis and multifidus muscles contraction, muscles ascribed a core-stability role. Using a modified quantitative version of the Beighton scale (BOM score), we measured joint mobility of 30 middle-aged individuals without low back pain. These scores were correlated with magnetic resonance imaging-derived measures of transverse abdominis and multifidus muscle contraction during a spinal loading maneuver. The level of significance was set for p ≤ 0.05. The results showed greater joint mobility (a higher BOM score) correlated ( r = 0.468; p = 0.009) with reduced transversus abdominis (TrA) shortening during contraction (i.e., less muscle shortening in people with greater joint mobility). The trunk subdomain score exhibited a correlation of 0.354 with TrA length change, but this did not reach statistical significance ( p = 0.055). The subdomains of the BOM score did not correlate significantly with each other ( p ≥ 0.097). No association was seen between multifidus contraction and joint mobility. The results suggest that greater general joint mobility is associated with impaired contraction of the TrA muscle. This should be considered when coaching athletes or treating patients with (functional) spinal instability. The quantitative approach we developed to measure joint mobility could be used in the future studies of global flexibility.

Long‐term care facilities have been identified as a local epicenter of disease among populations vulnerable to coronavirus disease 2019 (COVID‐19). A skilled nursing facility in Washington State was the first major site of COVID‐19 infections in the United States. Many lessons were learned during the events surrounding this outbreak, including how to develop, and the importance of, a coordinated response between emergency medical services and local area hospitals. As these events came early in the U.S. pandemic, unfortunately, disease spread and mortality was high. However, these events also resulted in rapid mobilization of the regional response to the COVID‐19 pandemic. Understanding the events surrounding this outbreak demonstrate some of the challenges involved in responding to acute infectious illnesses within these unique environments and associated vulnerable populations.

Summary A measles outbreak in London is described, involving 34 cases across two hospitals and a local community across two countries. After a single introduction to hospital, spread propagated via unvaccinated retail shop workers to healthcare staff, highlighting the importance of expanding occupational health policies to non-clinical hospital staff. Further spread into an under-vaccinated Traveller community is a reminder that measles can spread in the absence of herd immunity. Subsequently endemic measles transmission has been re-established in the UK.

SETTING AND OBJECTIVES: There is an urgent need to improve tuberculosis (TB) case detection globally. This would require greater focus on the implementation of TB screening programs. However, to be productive, cost-effective, and ethical, TB screening efforts should be tailored to their local context, targeted to the populations most likely to benefit and utilizing diagnostic tools with sufficient accuracy.DESIGN AND RESULTS: We have developed an online tool, ScreenTB to help National TB Programmes (NTPs) and their partners plan TB screening activities by modeling the potential outcomes of screening programs, including yield of TB cases diagnosed (true- and false-positives), costs, and cost-effectiveness, specific to the populations screened and the diagnostic algorithms used. In Myanmar, ScreenTB was used to assist the NTP in prioritizing risk groups for screening efforts and selecting appropriate screening algorithms to maximize case detection and minimize false-positive diagnoses.CONCLUSION: The ScreenTB tool can help facilitate the prioritization of risk groups for screening and the selection of appropriate screening algorithms. This is useful when used as part of a larger planning process that considers feasibility of screening, vulnerability of risk groups, potential impact of screening on TB transmission, human rights implications of screening and equity in health care access.

There has been an ongoing debate in the healthcare community about what pressure ulcers/injuries are, and how to name, define and classify them. The aim of this discussion paper is to provide a brief theoretical background about pressure ulcer/injury classification, to explain the approach the Guideline Governance Group has taken during the 2019 update of the International Guideline for 'Prevention and Treatment of Pressure Ulcers/Injuries' and to share views on how to best implement pressure ulcer/injury classification. First formal pressure ulcer/injury classifications were introduced in the 1950s and today various pressure ulcer/injury classification systems are used worldwide. Dissimilarities between commonly used classification systems may be considered a limitation that impedes clinical and scientific communication. However, the conceptual meaning of pressure ulcer/injury categories described within the various classification systems is comparable and the current evidence does not indicate that one classification is superior to another. Therefore, the Guideline Governance Group created a crosswalk of the major pressure ulcer/injury classifications in common use across different geographic regions. Clinicians are encouraged to use the classification system adopted by their healthcare setting in the most consistent way. The validity of pressure ulcer/injury classification is closely linked to its intended purpose. Studying measurement properties of pressure ulcer/injury classification systems must follow state-of-the-art methods. Structured educational interventions are helpful for improving diagnostic accuracy and reducing misclassification of pressure ulcers/injuries. Implementation of innovative skin and soft tissue assessments and revised pressure ulcer/injury classifications are only worth implementing, when the diagnostic information improves clinical care.

Tuberculosis is the deadliest infection of our time. In contrast, about 11,000 people died of Ebola between 2014 and 2016. Despite this manifest difference in mortality, there is now a vaccine licensed in the United States and by the European Medicines Agency, with up to 100% efficacy against Ebola. The developments that led to the trialing of the Ebola vaccine were historic and unprecedented. The single licensed TB vaccine (BCG) has limited efficacy. There is a dire need for a more efficacious TB vaccine. To deploy such vaccines, trials are needed in sites that combine high disease incidence and research infrastructure. We describe our twelve-year experience building a TB vaccine trial site in contrast to the process in the recent Ebola outbreak. There are additional differences. Relative to the Ebola pipeline, TB vaccines have fewer trials and a paucity of government and industry led trials. While pathogens have varying levels of difficulty in the development of new vaccine candidates, there yet appears to be greater interest in funding and coordinating Ebola interventions. TB is a global threat that requires similar concerted effort for elimination.

The blood pressure response to exercise is exaggerated in the type 1 diabetes mellitus (T1DM). An overactive exercise pressor reflex (EPR) contributes to the potentiated pressor response. However, the mechanism(s) underlying this abnormal EPR activity remains unclear. This study tested the hypothesis that the heightened blood pressure response to exercise in T1DM is mediated by EPR-induced sympathetic overactivity. Additionally, the study examined whether the single muscle afferents are sensitized by PKC (protein kinase C) activation in this disease. Sprague-Dawley rats were intraperitoneally administered either 50 mg/kg streptozotocin (T1DM) or saline (control). At 1 to 3 weeks after administration, renal sympathetic nerve activity and mean arterial pressure responses to activation of the EPR, mechanoreflex, and metaboreflex were measured in decerebrate animals. Action potential responses to mechanical and chemical stimulation were determined in group IV afferents with pPKCα (phosphorylated-PKCα) levels assessed in dorsal root ganglia. Compared with control, EPR (58±18 versus 96±33%; P P P P P

Aerobic exercise training has many known cardiovascular benefits that may promote healthy aging. It is not known if long-term aerobic exercise training is also associated with structural benefits (e.g., lower fat mass, higher areal bone mineral density (BMD) and greater muscle mass). We evaluated these parameters in middle-aged long-term endurance runners compared to sex-, age‐, height-, and weight-matched non-running controls. Total and regional lean and fat mass and areal BMD were assessed by dual-energy X-ray absorptiometry. Sagittal magnetic resonance images captured the cross-sectional area and thickness of the lumbar multifidus. Runners (n = 10, all male) had a mean (standard deviation, SD) age of 49 (4) years, height of 178.9 (4.9) cm, weight of 67.8 (5.8) kg, body mass index (BMI) of 21.4 (1.4) kg/m2 and had been running 82.6 (27.9) km/week for 23 (13) years. Controls (n = 9) had a mean (SD) age of 51 (5) years, height of 176.0 (5.1) cm, weight of 72.8 (7.1) kg, and BMI of 23.7 (2.1) kg/m2. BMI was greater in controls (p = 0.010). When compared to controls on average, runners had a 10 percentage-point greater total body lean mass than controls (p = 0.001) and 14% greater trunk lean mass (p = 0.010), as well as less total body (8.6 kg, p &lt, 0.001), arm (58%, p = 0.002), leg (52%, 0.001), trunk (73%, 0.001), android (91%, 0.001), and gynoid fat mass (64%, 0.001). No differences were observed between groups for BMD outcomes or multifidus size. These results underscore the benefits of endurance running to body composition that carry over to middle-age.

Postsurgical dental pain is mainly driven by inflammation, particularly through the generation of prostaglandins via the cyclooxygenase system. Thus, it is no surprise that numerous randomized placebo-controlled trials studying acute pain following the surgical extraction of impacted third molars have demonstrated the remarkable efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen sodium, etodolac, diclofenac, and ketorolac in this prototypic condition of acute inflammatory pain. Combining an optimal dose of an NSAID with an appropriate dose of acetaminophen appears to further enhance analgesic efficacy and potentially reduce the need for opioids. In addition to being on average inferior to NSAIDs as analgesics in postsurgical dental pain, opioids produce a higher incidence of side effects in dental outpatients, including dizziness, drowsiness, psychomotor impairment, nausea/vomiting, and constipation. Unused opioids are also subject to misuse and diversion, and they may cause addiction. Despite these risks, some dental surgical outpatients may benefit from a 1- or 2-d course of opioids added to their NSAID regimen. NSAID use may carry significant risks in certain patient populations, in which a short course of an acetaminophen/opioid combination may provide a more favorable benefit versus risk ratio than an NSAID regimen.

Tuberculosis is the deadliest infection of our time, with about 1.3 million deaths in 2017. In contrast, about 11,000 people died of Ebola between 2014 and 2016. Despite this manifest difference in mortality, there is now a licensed vaccine with up to 100% efficacy against Ebola. The developments that led to the trialing and licensure of the Ebola vaccine were historic and unprecedented. The single licensed TB vaccine (BCG) has limited efficacy. There is a dire need for a new, more efficacious TB vaccine. In order to license and deploy such vaccines, trials are needed in a limited number of sites that combine high disease incidence, research infrastructure and expertise. We first chronologically describe our twelve-year experience in building a TB vaccine trial site, an arduous and incremental process in contrast to the recent Ebola outbreak, which illustrates that sites can be set up under great adversity. Due to the striking differences in the vaccine development of the two diseases, we also compare the number of respective human trials between the two diseases, using publicly available data. Relative to the Ebola pipeline, TB vaccines have fewer trials and a paucity of government and industry led trials. While acknowledging pathogens have varying levels of difficulty in the development of new vaccine candidates, there yet appears to be greater interest in funding and coordinating Ebola interventions. We are convinced that TB is a global threat that requires similar concerted effort for elimination. Funding Statement: AERAS, EDCTP and GSK funded the studies included in the manuscript. None had a role in interpreting results in the article or the decision to publish. Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: The authors stated that ethics approval was obtained for all the studies included, but was not applicable to this article.

BACKGROUND: Hepatitis C virus infected (HCV+) adults evidence increased rates of psychiatric and cognitive difficulties. This is the first study to use functional magnetic resonance imaging (fMRI) to examine brain activation in untreated HCV+ adults. OBJECTIVE: To determine whether, relative to non-infected controls (CTLs), HCV+ adults exhibit differences in brain activation during a delay discounting task (DDT), a measure of one’s tendency to choose smaller immediate rewards over larger delayed rewards - one aspect of impulsivity. METHODS: 20 adults with HCV and 26 CTLs completed an fMRI protocol during the DDT. RESULTS: Mixed effects regression analyses of Hard versus Easy trials of the DDT showed that, compared with CTLs, the HCV+ group exhibited less activation in the left lateral occipital gyrus, precuneus and superior frontal gyrus. There were also significant interactive effects for Hard – Easy contrasts in the bilateral medial frontal gyrus, left insula, left precuneus, left inferior parietal lobule, and right temporal occipital gyrus; the CTL group evidenced a positive relationship between impulsivity and activation, while the HCV+ group exhibited a negative relationship. Within the HCV+ group, those with high viral load chose immediate rewards more often than those with low viral load, regardless of choice difficulty; those with low viral load chose immediate rewards more often on hard choices relative to easy choices. CONCLUSIONS: Results show that HCV+ patients exhibit greater impulsive behavior when presented with difficult choices, and impulsivity is negatively related to activation in regions important for cognitive control. Thus, interventions that decrease impulsive choice may be warranted with some HCV+ patients.

Continuous peripheral nerve blockade is a common technique in the analgesic management for many procedures. Leakage of local anaesthetic from around the nerve catheter insertion site can increase the chance of catheter dislodgement, risks infective complications, and could divert anaesthetic away from the nerve causing the block to fail. We conducted a randomised controlled trial to assess whether the type of nerve catheter influenced local anaesthetic leak rate. One hundred and ten patients scheduled for elective unilateral total knee arthroplasty were randomised to receive a perineural catheter with either a catheter over needle (CON) system (Pajunk® E-Cath) (PAJUNK® GmbH, Medizintechnologie, Geisingen, Germany), or catheter through needle (CTN) system (Pajunk® SonoLong) (PAJUNK® GmbH, Medizintechnologie, Geisingen, Germany). There was no statistically significant difference in the rate of leaking catheters between groups (CON 1.8% versus CTN 3.7%; P=0.618), however, the overall leak rate was much lower than anticipated from pilot data. The CON system was on average faster to insert (CON 357 seconds versus CTN 482 seconds; P=0.004), but associated with poorer needle visibility under ultrasound (Likert scale 1–5, mean [SD], CON 3.31 [0.96] versus CTN 3.89 [0.84]; P=0.001). All seven instances of inadvertent catheter dislodgement occurred in the CTN group (P=0.006). There was no statistically significant difference between groups in the proportion of patients who had adequate analgesia on day one (CON 80% versus CTN 86.5%; P=0.294) and day two postoperatively (CON 85.5% versus CTN 91.8%; P=0.369). Our findings show the overall leak rate to be very low with both catheter systems; however, the CON system may have advantages in terms of speed of use and rate of inadvertent catheter dislodgement.

The incidence of low back pain (LBP) among elite ballroom dancers is high and understanding associations between muscle morphology and pain may provide insight into treatment or training options. Research has linked multifidus muscle atrophy to LBP in the general and some athletic populations; however, this has not been examined in ballroom dancers. We compared the lumbar multifidus cross-sectional area (CSA) at rest in 57 elite level ballroom dancers (age 23±2.4 years; height, 174±11 cm; mass, 64±10 kg) divided into one of three pain groups, according to their self-reported symptoms, 1) LBP group (n=19), 2) minimal LBP (n=17), and 3) no LBP (n=21). There were no significant difference in demographics between the groups (P>0.05). The LBP group demonstrated significant differences in reported pain and Oswestry Disability Index scores compared to the other two groups. There was no significant difference between groups in multifidus cross-sectional area (P=0.49). Asymmetry was found in all groups with the overall left side being significantly larger than the right (P

OBJECTIVES Early resuscitation may improve outcomes in pediatric traumatic brain injury (TBI). We examined the association between timely treatment of hypotension and hypoxia during early care (prehospital or emergency department locations) and discharge outcomes in children with severe TBI. METHODS Hypotension was defined as systolic blood pressure less than 70 + 2 (age in years), and hypoxia was defined as PaO2 less than 60 mm Hg or oxygen saturation less than 90% in accordance with the 2003 Brain Trauma Foundation guidelines. Timely treatment of hypotension and hypoxia during early care was defined as the treatment within 30 minutes of a documented respective episode. Two hundred thirty-six medical records of children younger than 18 years with severe TBI from 5 regional pediatric trauma centers were examined. Main outcomes were in-hospital mortality and discharge Glasgow Outcome Scale (GOS) score. RESULTS Hypotension occurred in 26% (60/234) during early care and was associated with in-hospital mortality (23.3% vs 8.6%; P = 0.01). Timely treatment of hypotension during early care occurred in 92% (55/60) by use of intravenous fluids, blood products, or vasopressors and was associated with reduced in-hospital mortality [adjusted relative risk (aRR), 0.46; 95% confidence interval, 0.24-0.90] and less likelihood of poor discharge GOS (aRR, 0.54; 95% confidence interval, 0.39-0.76) when compared to children with hypotension who were not treated in a timely manner. Early hypoxia occurred in 17% (41/236) and all patients received timely oxygen treatment. CONCLUSIONS Timely resuscitation during early care was common and associated with lower in-hospital mortality and favorable discharge GOS in severe pediatric TBI.

Physical activity impacts health and disease in multiple body tissues including the intervertebral discs. Fluid flow within the disc is an indicator of disc health that can be observed using diffusion weighted magnetic resonance imaging. We monitored activity levels of 26 participants, age 35-55 yrs, using Actigraph accelerometers for 4 days to evaluate vigorous-intensity activity, moderate to vigorous intensity activity, and sedentary time. Participants underwent structural and diffusion weighted magnetic resonance imaging to evaluate intervertebral disc health and fluid flow. They also underwent bone density scans, carotid artery ultrasounds, a treadmill test, and a physical exam for pain, range of motion, and instability. These measures were used to correlate MRI indicators of intervertebral disc health with participant activity levels. Participants with any vigorous-intensity physical activity compared with no vigorous-intensity activity had significantly greater L5/S1 apparent diffusion coefficient values (p = 0.002), corresponding to higher freedom of diffusive movement for cellular nutrients and metabolic waste. Sagittal T2 values in the L5/S1 were also higher (p = 0.004), corresponding to a higher water content in the discs. Higher apparent diffusion coefficients were also found in participants with more than 30 min compared with less than 30 min of daily moderate to vigorous physical activity (p = 0.03), and in participants with less than 67% awake time as sedentary time compared with more than 67% sedentary time (p = 0.03). Increased dynamic loading through physical activity and decreased static loading from sedentary time benefit intervertebral disc health. Physical activity, particularly vigorous activity, is beneficial in helping maintain intervertebral disc health. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1313-1323, 2018.

Digital nerves are intrinsic to the sensory and motor function of the hand. These nerves represent the terminal ramifications of the ulnar, median, and radial nerves and are located distal to the carpal tunnel and Guyon canal. With magnetic resonance imaging, traumatic and nontraumatic abnormalities of the digital nerves can be shown with high contrast as well as high spatial resolution. Digital nerve abnormalities are most commonly posttraumatic in nature; however, infection, inflammatory, vascular malformations, and neoplasms can rarely occur. Magnetic resonance imaging is playing an increasing role in the assessment of peripheral nerve injury throughout the body, and in the hand, which can accurately identify the extent and character of digital nerve abnormalities before operative intervention.

Date Presented Accepted for AOTA INSPIRE 2021 but unable to be presented due to online event limitations. OTs and other health care professionals frequently experience low back pain. This has been associated with multifidus cross-sectional area in various populations, but not previously in health care workers. This project observed multifidus cross-sectional area in OTs and other health care personnel. A pain group was compared with a nonpain group to assess differences between them. At the S1 level (with a trend at L5), those with more pain had smaller multifidus. Primary Author and Speaker: Robert E. Larson Contributing Authors: Ulrike H. Mitchell, A. Wayne Johnson

Setting Tuberculosis (TB) stigma is thought to delay or prevent the decision to seek health care, but the strength of this association and the prevalence of anticipated TB stigma in the general population in most countries is unknown. Objective To examine epidemiological, cultural and sociodemographic factors associated with TB courtesy stigma in 15 surveys across 13 countries, and its link to health seeking for cough in children under five. Design A multilevel survey weighted logistic regression model was used to analyse how individual characteristics and social contexts affect the occurrence of TB courtesy stigma. The same modelling approach was used to analyse associations between TB courtesy stigma and individual-level predictors of health-seeking behaviour of mothers for children with cough. Results TB courtesy stigma varies greatly among countries. TB courtesy stigma was negatively correlated with knowledge of TB's curability (adjusted OR [aOR] 0.82; 95%CI 0.78-0.86) and human immunodeficiency virus (HIV) accepting attitudes (proxy for HIV stigma) (aOR 0.15, 95%CI 0.15-0.16). Mothers' health-seeking behaviour for children under five with cough was found to be positively correlated with HIV accepting attitudes (OR 1.16, 95%CI 1.08-1.25), but was marginally affected by TB courtesy stigma (OR 0.99, 95%CI 0.98-1.00). Conclusion Improving the general awareness of the effectiveness of anti-tuberculosis treatment will help to diminish TB courtesy stigma, and should be prioritised over expanding knowledge of mode of transmission. Efforts to reduce HIV and TB stigma may increase care seeking for childhood TB symptoms.