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Tibialis posterior tendinopathy is a common debilitating condition seen by foot and ankle providers. Non-operative management is difficult as patients often present in later stages of the disease. This case series evaluated the combination of radial shockwave therapy and a foot core progression exercise regimen on 10 patients who had failed standard conservative treatment techniques. Median follow-up time was 4 months. Clinically important differences in the Foot and Ankle Ability Measure were met in 9 (90%) and 8 (80%) of patients for activities of daily living and sport sub-scores, respectively. No adverse effects were observed.

Running is one of the most popular sports worldwide, with many health benefits. Injuries are also common, with running-related injuries reported in up to 79% of runners annually. Extracorporeal shockwave treatment can be used to treat soft tissue conditions, with the strongest level of evidence for management of plantar fasciitis. However, most studies have focused on nonathletes or studied a single condition, and few investigations have reported outcomes for extracorporeal pulse-activated therapy. In this case series, we evaluated the outcomes of 94 runners receiving extracorporeal pulse-activated therapy for lower-extremity running-related injuries, including plantar fasciitis and lower-extremity tendinopathy (Achilles, posterior tibialis, patellar, hamstring). We hypothesized that most runners with foot and ankle injuries would respond favorably to treatment and that success rates would be similar across conditions. Overall, 74 runners (79%) met their respective minimal clinically important difference for functional outcome measures, with no differences in response by age, sex, body mass index, or chronicity of condition. Further, no differences were noted in proportion achieving the minimal clinically important difference between foot and ankle (Achilles, posterior tibialis, and plantar fascia) compared with proximal injuries (53 [84.3%] versus 31 [72%], p = .15). A mean of 4 treatments resulted in achieving the minimal clinically important difference, with 95% achieving it by 5 treatments. No differences in bars of pressure, frequency, or other aspects of treatments were observed to predict response. Our findings suggest that a majority of runners with lower-extremity injuries respond favorably to extracorporeal pulse-activated therapy, including those with foot and ankle injuries.

Korea and the Fall of the Mongol Empire explores the experiences of the enigmatic and controversial King Gongmin of Goryeo, Wang Gi, as he navigated the upheavals of the mid-fourteenth century, including the collapse of the Mongol Empire and the rise of its successors in West, Central, and East Asia. Drawing on a wealth of Korean and Chinese sources and integrating East Asian and Western scholarship on the topic, David Robinson considers the single greatest geopolitical transformation of the fourteenth century through the experiences of this one East Asian ruler. He focuses on the motives of Wang Gi, rather than the major contemporary powers, to understand the rise and fall of empire, offering a fresh perspective on this period of history. The result is a more nuanced and accessible appreciation of Korean, Mongolian, and Chinese history, which sharpens our understanding of alliances across Eurasia.

Carpal tunnel syndrome (CTS) is the most common peripheral entrapment mononeuropathy. The purpose of this systematic review is to evaluate the reported clinical effectiveness and safety of ultrasound-guided percutaneous carpal tunnel release (USCTR) for the treatment of CTS.PubMed, EMBASE, and ScienceDirect databases were queried from database inception to February 20, 2021, to identify clinical studies on USCTR.Two reviewers independently completed title, abstract, and full-text screening, and they extracted data in duplicate for analysis. Procedure techniques, outcome measures, and complications were descriptively analyzed.Eighty-seven studies were eligible for screening. Twenty studies (three randomized controlled trials, three prospective cohort studies, and 14 case series) met inclusion criteria, with a total of 1772 USCTR cases. The overall level of evidence was very low, with seven studies with at least moderate risk of bias. Thirteen studies exceeded the minimal clinically important difference (MCID) for the Boston Carpal Tunnel Questionnaire Symptom Severity Scale (BCTQ-SS) and Boston Carpal Tunnel Questionnaire Functional Status Scale (BCTQ-FS), and six studies exceeded the MCID for the Quick Disabilities of Arm, ShoulderHand (QDASH). Five studies reported statistically significant improvement in these functional outcome measures as early as the first week post-procedure. A major complication occurred in one patient who developed suspected compartment syndrome, and minor complications were reported in 24 patients.Based on very low level of evidence, early studies suggest that USCTR may be an effective treatment for CTS, with potential for short post-procedure recovery times.

In the wake of the Second World War, the Missenden Abbey estate was purchased by Buckinghamshire County Council. At its heart, a not insignificant post-suppression house had been recast in Regency ...

The Mongol imperial enterprise produced memories and spurred migration on a continental scale among the conquerors, the vanquished, and agents of empire. During the 14th and early 15th centuries, the Ming court of China tried to shape the memory of the Mongol empire to enhance Ming political legitimacy, dampen hopes of a Mongolian revival, and facilitate the transfer of allegiance from the Mongol empire to Ming dynasty. The Ming court also integrated former Yuan personnel, including not just Chinese subjects but hundreds of thousands of Mongols and Jurchens, into the Ming polity. In examining these processes, the essay contributes to the wider discussion of how successor polities throughout Eurasia sought to turn the legacy of the Mongol empire to their own advantage, which had the unintended consequence of keeping memory of the Chinggisid age vital long after the empire’s fall.

The chapter begins by contextualizing early Ming efforts to establish itself in an Eurasia that still bore the clear imprint of the Mongolian Empire. It considers the Ming’s institutional sinews, its ideological underpinnings, and its military structures. It examines early Ming policies for managing its expansive borders, relations with neighboring peoples and polities, and incorporation of immigrants into society and state institutions. It then turns to the twin challenges of (a) negotiating the demands of competing interests, particularly those of the throne, national elites, and local notables, and (b) responding to new socioeconomic imperatives. Finally, after review of the Ming’s foreign relations, the chapter concludes with an assessment of the empire, including explanations of its final collapse in 1644.

Hamstring and calf injuries are common in athletes and may cause significant functional impairment. Etiologies range from acute strains to chronic overuse conditions. Accurate determination of injury location, severity, and mechanism is important for proper triage, treatment planning, and return to play discussions. This chapter describes the most common hamstring and calf injuries encountered in clinical practice: acute hamstring strains, proximal hamstring tendinopathy, distal hamstring injuries, gastrocnemius and soleus strains, medial tibial stress syndrome, chronic exertional compartment syndrome, and plantaris tendon ruptures. Specific injury characteristics, diagnostic features, and treatment recommendations are described for each condition. Most of these injuries can be managed effectively with appropriately targeted nonoperative strategies.

BACKGROUND: Shoulder pain from rotator cuff pathology and glenohumeral osteoarthritis is a common entity encountered in musculoskeletal practices. Orthobiologic agents are being increasingly used as a treatment option and understanding their safety and efficacy is necessary. OBJECTIVE: To systematically evaluate the available evidence for orthobiologic use in rotator cuff and glenohumeral pathology. METHODS: A systematic review was undertaken following PRISMA guidelines. Randomized clinical trials (RCTs) and prospective cohort studies evaluating non-operative treatment with prolotherapy, platelet-rich plasma (PRP), or medicinal signaling cells (MSCs) for rotator cuff pathology and glenohumeral osteoarthritis were included. Bias risk assessments used were the Cochrane tool and Newcastle-Ottawa score. RESULTS: The search yielded 852 potential articles, of which 20 met the inclusion criteria with a breakdown of 5 prolotherapy, 13 PRP, and 2 MSC. Sixteen studies were RCTs and 4 were cohort studies. Six studies were deemed “low risk of bias or good quality”. Efficacy results were mixed, and no serious adverse events were reported from orthobiologic treatment. CONCLUSIONS: Orthobiologics offer a relatively safe management option with inconclusive evidence for or against its use for rotator cuff pathology. No studies on glenohumeral osteoarthritis met the inclusion criteria. Adoption of standardized preparation reporting and consistent use of functional outcome measures is imperative for future studies to consider.

Achilles tendinopathy is a common condition and many patients have functional limitations after initial conservative treatment. Shockwave therapy has been shown to improve function within patients; however, comparative outcomes for different forms of shockwave are poorly described. In this retrospective cohort study, we describe findings from a quality improvement initiative evaluating safety and functional outcomes after treatment with radial shockwave therapy (n = 58) or combined radial and focused shockwave therapy (n = 29) for patients with Achilles tendinopathy refractory to exercise therapy. All patients were prescribed an eccentric exercise program. We hypothesized both groups would see improvements in function quantified using the Victorian Institute of Sports Assessment-Achilles with similar safety outcomes. Overall, the minimal clinically important difference (defined at 7 for insertional and 12 for noninsertional Achilles tendinopathy) was met in a greater proportion of patients treated with combined shockwave compared to radial shockwave (26 [89.7%] vs 37 [63.8%], p = .022). The change in Victorian Institute of Sports Assessment-Achilles from baseline to final treatment was not different between combined and radial-only groups (23.3 ± 12.6 vs 19.9 ± 18.7, p = .2). Within group differences from baseline to final follow-up measures (mean duration 17.9 ± 14.8 weeks) demonstrated overall functional improvement for both groups (both p.0001). No serious adverse effects were observed. Our findings suggest combined radial and focused shockwave therapy may provide more predictable functional gains for treatment of Achilles tendinopathy compared to radial shockwave therapy.

Daniel Hoffman's evocative motif of seven versions of Poe emphasizes the frequent shifts and transitions in Poe's stories and poems, giving us an author in constant shift and transition. By keeping his own voice prominent in his book and connecting his own struggles and intellectual discoveries with Poe's texts, Hoffman tied his own identity to Poe's, making criticism a form of autobiography and self-expression. Hoffman emphasized Poe's growing interest in metaphysics and cosmology in his later work, and considered Poe's interest in these ideas crucial to an understanding of his philosophy. In “Eureka,” sometimes read as a satire, Hoffman focused on Poe's deeply serious tone, and argued that the work was best regarded as a symbolic allegory. Hoffman connected “Eureka” with Poe's inner drives, and analyzed it as a forceful expression of Poe's cosmological vision of a universe bound for an eventual collapse into utterly unified force existing beyond materiality.

Conflict stimulates innovation: the more intense the conflict, the more dramatic the innovation. Many scholars will recognize this basic idea from common explanations of rapid change — including ex...

OBJECTIVES: To investigate the frequency of and reasons for readmissions to acute care (RTAC) during inpatient rehabilitation (IPR) after non-traumatic spinal cord injury (NT-SCI). To develop a predictive model for RTAC using identified risk factors. DESIGN: Retrospective case-control. SETTING: Academic IPR hospital. PARTICIPANTS: Individuals with NT-SCI admitted to an academic SCI rehabilitation unit from January 2014-December 2015. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Readmissions to acute care services from IPR. RESULTS: Thirty-seven participants (20%) experienced a RTAC for a total of 39 episodes. Thirty-five experienced 1 RTAC, while two had 2. The most common medical reasons for RTAC were infection (27%), neurological (27%), and noninfectious respiratory (16%). Multivariable logistic regression was used to develop a model to predict RTAC. Paraplegia was associated with 3.2 times increase in the odds of RTAC (P = 0.03). For every unit increase in FIM-Motor, there was a 5% reduction in the odds of RTAC (P = 0.03) Body mass index less than 30 decreased odds of RTAC by 61% (P = 0.004). CONCLUSION: RTACs were associated with body mass index greater than 30, decreased FIM-Motor subscore on admission, and paraplegia. Physiatrists caring for the non-traumatic SCI patient need be more circumspect of individuals with these parameters to potentially prevent the problems necessitating acute care transfer.

Systemic attention to military institutions sharpens our understanding of the Ming dynasty in comparative, global terms and yields a fuller perspective on the state and its role in people’s lives. First, the Ming dynasty devoted more resources, in absolute terms, to its military enterprise than any other contemporary power. It maintained enormous standing armies that drilled regularly, empire-wide logistical systems, welfare provisions for military dependents and retired or injured military personnel, and multi-tiered, standardized arms productions under state supervision. Western European states were just starting to achieve such capacity in the sixteenth and seventeenth centuries. Second, focused on civil administration, such as taxes, labor service, magistrates, land surveys, tithing communities, and mutual responsibility organizations, past scholarship has largely ignored how the state’s extensive military institutions both shaped society and served as resources that people used to advance their personal, family, and community interests.

Live attenuated viral vaccine/vector candidates are inherently unstable and infectivity titer losses can readily occur without defining appropriate formulations, storage conditions and clinical handling practices. During initial process development of a candidate vaccine against HIV-1 using a recombinant Human Cytomegalovirus vector (rHCMV-1), large vector titer losses were observed after storage at 4 °C and after undergoing freeze-thaw. Thus, the goal of this work was to develop candidate frozen liquid formulations of rHCMV-1 with improved freeze-thaw and short-term liquid stability for potential use in early clinical trials. To this end, a virus stability screening protocol was developed including use of a rapid, in vitro cell-based immunofluorescence focus assay to quantitate viral titers. A library of ∼50 pharmaceutical excipients (from various known classes of additives) were evaluated for their effect on vector stability after freeze-thaw cycling or incubation at 4 °C for several days. Certain additives including sugars and polymers (e.g., trehalose, sucrose, sorbitol, hydrolyzed gelatin, dextran 40) as well as removal of NaCl (lower ionic strength) protected rHCMV-1 against freeze-thaw mediated losses in viral titers. Optimized solution conditions (e.g., solution pH, buffers and sugar type) slowed the rate of rHCMV-1 titer losses in the liquid state at 4 °C. After evaluating various excipient combinations, three new candidate formulations were designed and rHCMV-1 stability was benchmarked against both the currently-used and a previously reported formulation. The new candidate formulations were significantly more stable in terms of reducing rHCMV-1 titer losses after 5 freeze-thaw cycles or incubation at 4 °C for 30 days. This case study highlights the utility of semi-empirical design of frozen liquid formulations of a live viral vaccine candidate, where protection against infectivity titer losses due to freeze-thaw and short-term liquid storage are sufficient to enable more rapid initiation of early clinical trials.

In the mid-fourteenth century, the Mongol empire collapsed. People and polities across east Eurasia reconsidered their alliances. For the kingdom of Koryŏ, the collapse of the Yuan dynasty and the rise of the Ming dynasty represented both danger and opportunity. Examining how the Koryŏ court navigated these challenges, this essay argues that Koryŏ’s diplomatic recognition of the Yuan and Ming courts was just as important as was their recognition of Koryŏ.

Lesser known is Henry David Thoreau's homage to the Old Marlboro Road in "Walking", an essay drawn from versions of a lecture Thoreau had delivered in the earlier 1850s, entitled first "Walking or the Wild," and then simply "The Wild". As a lengthy poem interpolated within the larger essay "Walking," "The Old Marlboro Road" poses interesting generic questions. How does the poem illuminate, or complicate, the essay? On the page, the poem visually suggests a path or road, narrow in places and wider in others, leading the eye down the page to a yet unknown objective. Rather than praise the act of settling in a particular place, "Walking" explored unending transformation, depicting Thoreau's daily walks as mythical quests, efforts to know the ever-renewing unknown in nature. Thoreau begins the poem with several references to those few who have lived along the secluded Old Marlboro Road.

Henry David Thoreau (b. 1817–d. 1862) is best known as the author of Walden (1854), a pivotal work in American nature writing, and “Civil Disobedience” (1849), an influential call to resist war and slavery. Soon after graduating from Harvard College in 1836, Thoreau was befriended by Ralph Waldo Emerson, whose Nature (1836) depicted the natural world as a book of spiritual and ethical wisdom. Emerson encouraged Thoreau’s writing and journal keeping, and provided space on his property near Walden Pond for a writing retreat. The book that Thoreau wrote there, A Week on the Concord and Merrimack Rivers (1849), was a disappointing commercial failure. However, Thoreau’s effort to explain his experiment in solitude to his Concord neighbors yielded Walden, a literary masterpiece. Walden presented not only a moving description of a life close to nature as the seasons move through the year, but also a scalding critique of social institutions, conventional politics, and the deadness of conformist life. The writing of Walden, completed after Thoreau’s 1847 return to Concord, was an extended process in which Thoreau worked through seven drafts. Midway through the composition, in the early 1850s, Thoreau underwent an intellectual reorientation that can be described as a conversion from poet-philosopher to naturalist-scientist. He devoted effort to his Journal as a record of nature observation during his daily hikes. The gathering and organization of the particular facts of natural history gradually became his principal task until his death in 1862. His developing naturalist sensibility is evident in essays such as “Walking,” “Wild Apples,” and “Autumnal Tints.” These works retained his descriptive craft and vital prose style, and demonstrated his observational practice in the natural world. These essays were published in the early 1860s, but other projects such as Wild Fruits and his seasonal “Kalendar” of Concord remained unfinished. These and other works have been brought to life by recent research and scholarly editing of his surviving manuscripts. The recent discovery that Thoreau’s seasonal records could serve as a source for the scientific measurement of climate change has brought a new attention to the value of his later natural history investigations, showing him as a naturalist fully in step with the developments of 19th-century science. Thoreau’s antislavery fervor increased as the Civil War approached, and he followed the publication of “Civil Disobedience” with political essays characterized by an ardent condemnation of slavery and an impassioned defense of abolitionist John Brown.

Objective Contrast-induced nephropathy (CIN) is a frequently used quality outcome marker after peripheral vascular interventions (PVIs). Whereas the factors associated with CIN development have been well documented, the long-term renal effects of CIN after PVI are unknown. This study was undertaken to investigate the long-term (1-year) renal consequences of CIN after PVI and to identify factors associated with renal function deterioration at 1-year follow-up. Methods From 2008 to 2015, patients who had PVI at our institution (who were part of a statewide Vascular Interventions Collaborative) were queried for those who developed CIN. CIN was defined by the Collaborative as an increase in serum creatinine concentration of at least 0.5 mg/dL within 30 days after intervention. Preprocedural dialysis patients or patients without postprocedural creatinine values were excluded. Preprocedural, postprocedural, and 1-year serum creatinine values were abstracted and used to estimate glomerular filtration rate (GFR). ΔGFR was defined as preprocedural GFR minus 1-year GFR. Univariate and multivariate analyses for ΔGFR were performed to determine factors associated with renal deterioration at 1 year. Results From 2008 to 2015, there were 1323 PVIs performed; 881 patients met the inclusion criteria. Of these, 57 (6.5%) developed CIN; 47% were male, and 51% had baseline chronic kidney disease. CIN resolved by discharge in 30 patients (53%). Using multivariate linear regression, male sex (P = .027) and congestive heart failure (P = .048) were associated with 1-year GFR decline. Periprocedural variables related to 1-year GFR decline included percentage increase in 30-day postprocedural creatinine concentration (P = .025), whereas CIN resolution by discharge (mean, 13.1 days) was protective for renal function at 1 year (P = .02). A post hoc analysis was performed with 50 PVI patients (randomly selected) who did not develop CIN, comparing their late renal function with that of the CIN group stratified by the periprocedural 30-day variables. Patients with CIN resolution at discharge had similar 1-year renal outcomes to non-CIN patients, whereas the CIN-persistent (at discharge) patients had greater renal deterioration at 1 year compared with non-CIN patients (P = .016). Conclusions Male sex and congestive heart failure are risk factors for further renal function decline in patients developing CIN after PVI. The magnitude and duration of increase in creatinine concentration (CIN persistence at discharge) correlated with late progressive renal dysfunction in CIN patients, suggesting that early-resolving CIN is relatively benign.