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Background: Peripheral artery disease (PAD) is associated with high morbidity and mortality, particularly once patients develop critical limb threatening ischemia (CLTI). Minorities and vulnerable populations often present with CLTI and experience worse outcomes. The use of directional atherectomy (DA) and drug-coated balloon (DCB) during lower-extremity revascularization (LER) has not been previously described in a safety-net population., Objective: To review demographic and clinical characteristics, and short- intermediate term outcomes of patients presenting to a safety-net hospital with PAD treated with DA and DCB during LER., Methods: In this retrospective, observational cohort study, chart review was performed of all patients who underwent DA and DCB during LER for PAD from April 2016 to January 2020 in a safety-net hospital., Results: The analysis included 58 patients, with 41% female, 24% Black/African American, and 31% Hispanic. From this group, 17% spoke a non-English primary language and 10% reported current or previous housing insecurity. Most (65%) presented with CLTI and had undergone a previous index leg LER (58%). The combination of DA and DCB was efficacious, resulting in low rates of bail-out stenting (16%) and target-vessel revascularization (26%) at 2 years. Low complication rates (tibial embolism in 12% and vessel perforation in 2% of cases) were also observed. Most patients (67%) with Rutherford category 5 experienced wound healing by 2 years., Conclusion: In this safety-net population, the majority presented with CLTI and a previous LER of the index leg. The combination of DA and DCB resulted in low complication rates, and good short-intermediate outcomes in this frequently undertreated population.

Purpose: Cancer patients experience significant distress and burden of decision-making throughout treatment and beyond. These stressors can interfere with their ability to make reasoned and timely decisions about their care and lead to low physical and social functioning and poor survival. This pilot study examined the impact of offering Problem-Solving Skills Training (PSST) to adult cancer survivors to help them and their caregivers cope more successfully with post-treatment decision-making burden and distress., Patients and Methods: Fifty patients who completed their definitive treatment for colorectal, breast or prostate cancer within the last 6 months and reported distress (level > 2 on the National Comprehensive Cancer Network distress thermometer) were randomly assigned to either care as usual (CAU) or 8 weekly PSST sessions. Patients were invited to include a supportive other (n = 17). Patient and caregiver assessments at baseline (T1), end of intervention or 3 months (T2), and at 6 months (T3) focused on problem-solving skills, anxiety/depression, quality of life and healthcare utilization. We compared outcomes by study arm and interviewed participants about PSST burden and skill maintenance., Results: Trial participation rate was 60%; 76% of the participants successfully completed PSST training. PSST patients reported reduction in anxiety/depression, improvement in QoL (p < 0.05) and lower use of hospital and emergency department services compared to CAU patients (p = 0.04)., Conclusions: The evidence from this pilot study indicates that a remotely delivered PSST is a feasible and potentially effective strategy to improve mood and self-management in cancer survivors in community oncology settings., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Shared decision making (SDM) is not widely practiced in routine care due to a variety of organizational, provider, patient, and contextual factors. This article explores how implementation science-which encourages attention to the multilevel contextual factors that influence the adoption, implementation, and sustainment of health care practices-can provide useful insights for increasing SDM use in routine practice. We engaged with stakeholders representing different organizations and geographic locations over three phases: 1) multidisciplinary workgroup meeting comprising researchers and clinicians ( n = 11); 2) survey among a purposive sample of 47 patient advocates, clinicians, health care system leaders, funders, policymakers, and researchers; and 3) working session among diverse stakeholders ( n = 30). The workgroup meeting identified priorities for action and research, which included targeting multiple audiences and levels, shifting culture toward valuing and supporting SDM, and considering contextual factors influencing SDM implementation. Survey respondents provided recommendations for increasing adoption, implementation, and maintenance of SDM in practice including providing tools to support SDM, obtaining stakeholders' involvement, and raising awareness of the importance of SDM. Stakeholders in the working session provided recommendations on the design of a guide for implementation of SDM in clinical settings, strategies to disseminate educational curricula on SDM, and strategies to influence policies to increase SDM use. These specific recommendations serve as a call to action to pursuing specific promising strategies aimed at increasing SDM use in practice and enhance understanding of the perspectives of diverse stakeholders at multiple levels from an implementation science perspective that appear fruitful for further study and application., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

We investigated recovery of precision grasping of small objects between the index finger and thumb of the impaired hand without forced use after surgically placed lesions to the hand/arm areas of M1 and M1 + lateral premotor cortex in two monkeys. The unilateral lesions were contralateral to the monkey's preferred hand, which was established in prelesion testing as the hand used most often to acquire raisins in a foraging board (FB) task in which the monkey was free to use either hand to acquire treats. The lesions initially produced a clear paresis of the contralesional hand and use of only the ipsilesional hand to acquire raisins in the FB task. However, beginning about 3 weeks after the lesion both monkeys spontaneously began using the impaired contralesional hand in the FB task and increased use of that hand over the next few tests. Moreover, the monkeys clearly used precision grasp to acquire the raisins in a similar manner to prelesion performances, although grasp durations were longer. Although the monkeys used the contralesional hand more often than the ipsilesional hand in some postlesion testing sessions, they did not recover to use the hand as often as in prelesion testing when the preferred hand was used almost exclusively. These findings suggest that recovery of fine hand/digit motor function after localized damage to the lateral frontal motor areas in rhesus monkeys does not require forced use of the impaired hand.

Patients with metastatic colorectal cancer (mCRC) frequently experience treatment-related adverse events (AEs), which may lead to nonadherence or discontinuation from their treatment regimen. In the phase 3 CORRECT study, the addition of regorafenib to best supportive care (BSC) significantly increased overall survival and progression-free survival compared with placebo plus BSC in patients with mCRC who had progressed on all approved standard care therapies. Although regorafenib showed an acceptable safety profile, patients experienced treatment-related AEs such as hand-foot skin reaction, hypertension, oral mucositis, diarrhea, fatigue, and liver abnormalities. The goal of this article is to help oncology nurses implement a strategic, proactive approach to AE management in patients mCRC treated with regorafenib. The article reviews the most common AEs associated with regorafenib in patients who participated in the CORRECT study and provides a strategy and practical measures that nurses can apply to AE management. In addition, the article provides direction and guidance for educating patients and their caregivers on recognizing and managing potential side effects of regorafenib.

Purpose: The A2 and A4 pulleys have been shown to be important in finger flexor tendon function. Other authors have suggested either reconstruction or venting of portions of these pulleys in an attempt to preserve finger function in certain clinical situations. This study examines the effects of partial incision of these pulleys on finger flexion kinematics and biomechanics., Methods: The index and ring fingers of 16 cadaveric hands were studied. The flexor digitorum profundus tendon was isolated and attached to a computer driven servo-motor. Micro-potentiometers measured flexion angles of the metacarpophalangeal, proximal inter-phalangeal and distal inter-phalangeal joints. Joint inertial torques were calculated making use of this experimental kinematic data., Results: Proximal 50 % incisions of either the A2 or the A4 pulleys resulted in a statistically significant decrease in overall finger motion. This effect was greatest in the proximal inter-phalangeal joint, with a decrease in joint motion, as well as an earlier time to initiation of motion. These changes in finger motion were more pronounced with A2 pulley incision than they were with A4 pulley incision, but the changes were statistically significant in either case. No significant changes in joint inertial torques were shown., Conclusions: Our data provides evidence to the importance of the proximal portions of the A2 and A4 pulleys, and may support partial distal incision of these pulleys in certain clinical situations.

Over the past two decades, results from neurophysiological studies in animal models and neuroimaging studies in human populations have converged along a common thread. Neuroplasticity in the remaining, intact tissue accompanies functional recovery after brain injury. Now, virtually every new therapeutic approach in postinjury rehabilitation relies on the fundamental principles of neuroplasticity for theoretical validity. In this chapter, the basic tenets of plasticity are outlined, and the neural substrates in the cerebral cortex that may subserve recovered functions are reviewed., (Copyright © 2013 Elsevier B.V. All rights reserved.)

The cytoarchitecture and cortical connections of the anterior cingulate, medial and dorsal premotor, and precentral region are investigated using the Nissl and NeuN staining methods and the fluorescent retrograde tract tracing technique. There is a gradual stepwise laminar change in the cytoarchitectonic organization from the proisocortical anterior cingulate region, through the lower and upper banks of the cingulate sulcus, to the dorsolateral isocortical premotor and precentral motor regions of the frontal lobe. These changes are characterized by a gradational emphasis on the lower stratum layers (V and VI) in the proisocortical cingulate region to the upper stratum layers (II and III) in the premotor and precentral motor region. This is accompanied by a progressive widening of layers III and VI, a poorly delineated border between layers III and V and a sequential increase in the size of layer V neurons culminating in the presence of giant Betz cells in the precentral motor region. The overall patterns of corticocortical connections paralleled the sequential changes in cytoarchitectonic organization. The proisocortical areas have connections with cingulate motor, supplementary motor, premotor and precentral motor areas on the one hand and have widespread connections with the frontal, parietal, temporal and multimodal association cortex and limbic regions on the other. The dorsal premotor areas have connections with the proisocortical areas including cingulate motor areas and supplementary motor area on the one hand, and premotor and precentral motor cortex on the other. Additionally, this region has significant connections with posterior parietal cortex and limited connections with prefrontal, limbic and multimodal regions. The precentral motor cortex also has connections with the proisocortical areas and premotor areas. Its other connections are limited to the somatosensory regions of the parietal lobe. Since the isocortical motor areas on the dorsal convexity mediate voluntary motor function, their close connectional relationship with the cingulate areas form a pivotal limbic-motor interface that could provide critical sources of cognitive, emotional and motivational influence on complex motor function., (Copyright © 2011 Elsevier Inc. All rights reserved.)

The primate facial nucleus is a prominent brainstem structure that is composed of cell bodies giving rise to axons forming the facial nerve. It is musculotopically organized, but we know little about the morphological features of its motor neurons. Using the Lucifer Yellow intracellular filling method, we examined 11 morphological parameters of motor neurons innervating the monkey orbicularis oculi (OO) muscle, which plays an important role in eyelid closure and voluntary and emotional facial expressions. All somata were multipolar and remained confined to the intermediate subnucleus, as did the majority of its aspiny dendritic branches. We found a mean maximal cell diameter of 54 microm in the transverse dimension, cell diameter of 60 microm in the rostrocaudal dimension, somal surface area of 17,500 microm(2) and somal volume of 55,643 microm(3). Eight neurons were used in the analysis of dendritic parameters based upon complete filling of the distal segments of the dendritic tree. We found a mean number of 16 dendritic segments, an average dendritic length of 1036 microm, diameter of 7 microm, surface area of 12,757 microm(2) and total volume of 16,923 microm(3). Quantitative analysis of the dendritic branch segments demonstrated that the average number, diameter and volume gradually diminished from proximal to distal segments. A Sholl analysis revealed that the highest number of dendritic intersections occurred 60 microm distal to the somal center with a gradual reduction of intersections occurring distally. These observations advance our understanding of the morphological organization of the primate facial nucleus and provide structural features for comparative studies, interpreting afferent influence on OO function and for designing studies pinpointing structural alterations in OO motor neurons that may accompany disorders affecting facial movement.

Purpose: The purpose of this study was to quantify the changes in the arc of digital flexion before and after metacarpophalangeal (MCP) silicone arthroplasty with a 30 degrees preflexed design., Methods: Index, middle, and ring fingers of 4 fresh-frozen cadaver hands were used. Each hand was attached (palmar side up) to a custom test apparatus. The tendon was drawn by a small winch-type servomotor. Micropotentiometers that were attached to the centers of rotation of the MCP, distal interphalangeal, and proximal interphalangeal joints measured angular displacement before and after MCP arthroplasty as a function of tendon excursion. The data were analyzed comparing the angle of flexion initiation and the angular displacement as a function of tendon excursion before and after joint arthroplasty., Results: There were no statistical differences in the angles of the MCP joints at rest, the order of initiation of joint flexion, and the overall degree of flexion between the unoperated fingers and the fingers that had surgery. There was, however, a trend toward delay in flexion initiation, an increase in the MCP angle at rest, and a decrease in torque after implant arthroplasty., Conclusions: The decrease in initiation of flexion of the MCP joint, although not statistically significant, probably was related to the 30 degrees of preflexion built into the implant. We also noted a trend of decreased flexion at the MCP joint and increased flexion at the proximal interphalangeal and distal interphalangeal joints. This trend may be advantageous in the reconstruction of hands that initially have an MCP joint flexion deformity., Type of Study/level of Evidence: to come.

A number of studies have documented early functional declines in persons with a disability. The purpose of this study was to document (1) whether employees who are aging with their disability have experienced new work problems as a consequence of functional declines and (2) whether their work problems are being accommodated adequately. Ninety-six individuals with a disability (50 who are postpolio and 46 who had a spinal cord injury) were interviewed by phone. Each had worked at least 5 years postonset and was either currently working or unemployed for less than 5 years at the time of the interview. Forty-nine of the 50 persons who are postpolio reported they had experienced functional declines in recent years, and 41 of the 50 rated the severity of their disability greater than it was when they first began working. As a result of the functional declines they had experienced, most (90.9%) of their work problems were new and would not have been significant problems for them when they first began working. The situation was very different for the group with spinal cord injuries. Only a few members of that group had experienced functional declines that were causing new problems at work. A total of 480 work problems were reported by study participants. Three out of every eight problems did not have an accommodation satisfactory to the employee. The primary reason why a satisfactory solution was not provided was that no accommodation had been identified. Employers were generally supportive of the employee's need for accommodation; they paid for 59.1% of the accommodations that had a cost and refused to provide an accommodation for only 18 of the 480 problems.

The effects of intravenous administration of variable-dose midazolam (0, 0.05, 0.075, 0.1, 0.3 and 0.5 mg/kg) and ketamine (3 mg/kg) were studied in twenty-four healthy unmedicated cats from time of administration until full recovery. End-points were chosen to determine the optimal dose to allow a short period of restraint without noxious stimuli, a short period of restraint with noxious stimuli and endotracheal intubation. Recovery characteristics, as well as undesirable behaviours observed during recovery, were also recorded. The dose of midazolam to achieve lateral recumbency with head down was found to be 0.016 mg/kg in 50% of the population (ED50) and 0.054 mg/kg in 95% (ED95) of the population. A midazolam dose of 0.286 mg/kg was required to prevent conscious perception of a stimulus to the ulnar nerve in 50% of the population and 0.652 mg/kg in 95% of the population. The ED50 and ED95 of midazolam required to prevent swallowing in response to a laryngoscope placed on the back of the tongue were found to be 0.265 mg/kg and 0.583 mg/kg, respectively. The ED50 doses of 0.265 mg/kg for intubation and 0.286 mg/kg for restraint with noxious stimulation were close to the tested dose of 0.3 mg/kg. At that dose, the lack of responses lasted 3.67 +/- 2.27 min for laryngoscope and 2.50 +/- 2.20 min for ulnar nerve stimulation, with recovery to walking with ataxia taking 41.50 +/- 15.18 min and complete recovery taking 3.6 +/- 1.3 h. The predominant behavioural pattern during recovery was found to be normal, but some cats also exhibited abnormal behavioural patterns. Nine of the twelve cats exhibited an abnormal arousal state, with 4 being restless and 5 being sedated. Seven of the twelve cats exhibited an abnormal behaviour when approached, with three of the cats being more difficult to approach and four of the cats being easier to approach. Eight of the twelve cats exhibited an abnormal behavioural pattern when restrained, with the cats equally divided between more difficult and easier to restrain. Five of the twelve cats vocalized more during the recovery. The ED50 of 0.042 mg/kg to induce chemical restraint without a noxious stimulus is close to the tested dose of 0.05 mg/kg. At that dose, cats remained lateral with head down for 5.49 +/- 4.02 min, took 25.96 +/- 5.77 min to walk with ataxia and 1.7 +/- 0.4 h for complete recovery. The predominant behavioural patterns during recovery were normal, with several cats exhibiting some abnormal patterns. Two cats were sedated, one cat was more difficult to approach, one cat was easier to restrain and three cats were more vocal.

There are an estimated 3.9 million developmentally disabled people in the United States, 300,000 of whom reside in Florida. Oral health is an issue relevant to the quality of life of these individuals. A person's self-esteem and interpersonal relations within the community, including employment and friendships, are directly affected by--and associated with a healthy mouth and smile. There are factors at both the individual and community levels that may inhibit accessibility to comprehensive dental care for developmentally disabled citizens. Parents, caretakers, public health workers, community agencies, and dentists have their unique perspectives on this issue.

The purpose of this study was to delineate the motor point region of the gluteus medius muscle to aid in placing epimysial electrodes for functional electrical stimulation. Seven surgically dissected gluteus medius muscles were studied in five patients. The lateral surface of the muscle was sequentially probed with an electrical stimulator. The motor point region, which responded maximally to an applied electric current, was located on the posterolateral aspect of the muscle, adjacent to the superior margin of the piriformis, 3 cm lateral to the greater sciatic notch; it was rectangular or oval, measuring approximately 3.5 cm by 3.0 cm. The mean threshold current that produced a contraction was 14 mA (range = 2 to 26 mA). The mean minimum current required to produce a maximum contraction was 34 mA (range = 11 to 60 mA). This information provides guidelines for the placement of electrodes for functional electrical stimulation of this deeply situated muscle, and it provides electrical stimulation parameters required for adequate muscle activation.