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Background: Physical therapy interventions of exercise and manual therapy provide benefit in treatment of subacromial pain syndrome (SAPS). Dry needling is an emerging technique for treating musculoskeletal conditions; however, conflicting investigative evidence exists regarding the use of dry needling for SAPS., Purpose: The purpose of this case series was to describe the use of dry needling, in conjunction with exercise, as a management strategy for patients meeting clinical diagnostic criteria of SAPS and to observe the short- and intermediate-term effects of dry needling with therapeutic exercise in this population. A secondary purpose was to describe a framework of clinical reasoning to guide the pragmatic application of dry needling and exercise in clinical practice., Study Design: Case series., Methods: Twenty-five patients met criteria for SAPS and provided informed consent. Patients received examination-based dry needling for the first two visits with exercises added beginning at the third treatment session to help distinguish treatment effects. The primary outcome measure used in this study was the Quick Disabilities of the Arm, Shoulder, and Hand (Q-DASH) survey assessed at their third clinical visit, at four-weeks after starting intervention and again at a three-month follow up visit., Results: On the Q-DASH survey 21 of 24 patients reported improvement at the third visit (range 4.5 to 38.6 points) and 19 of 22 reported improvement at the 3-month follow-up (range 0.1-54.5 points) relative to baseline. Sixteen of 24 patients at the third visit and 19 of 22 patients at the 3-month follow-up reported Global Rating of Changes scores of +3 or greater., Conclusion: This case series provides insight to the observed short- and intermediate-term effects of dry needling combined with exercise for SAPS. Additionally, it discusses the framework of clinical reasoning when applying this intervention. The results are encouraging for dry needling as an adjunct to exercise for treating patients with SAPS., Level of Evidence: Therapy, level 4.

Purpose: To characterize trends and prognosis of severe traumatic brain injury (TBI)., Methods: This 5-year multicenter retrospective study included patients with TBI and Glasgow Coma Scale of 3. We analyzed demographic and clinical characteristics and mortality using Pearson χ 2 tests, Cochran-Armitage trend tests, and stepwise logistic regression. Analyses were stratified by vehicular and fall etiologies; other etiologies were excluded (24%)., Results: Included were 481 patients. Fall-related injuries increased 58% (P=.001) but vehicular etiology did not change (P=.63). The characteristics of the populations changed over time; with falls, the population became older and increasingly presented with normal vital signs, whereas with vehicular etiology, the population became younger, with more alcohol-related injury (P<.05 for all). Mortality from falls increased substantially from 25% to 63% (P<.001), whereas death from vehicular injures remained statistically unchanged but with a downward trend (50%-38%, P=.28). Predictors of mortality included injury severity and age at least 65 years for both groups. Additional variables that were prognostic were abnormal vital signs and subdural hematoma for vehicular injuries, and sex for fall injuries., Conclusions: The epidemiology of severe TBI is changing. These epidemiologic data may be used for management and resource decisions, monitoring, and directing injury prevention measures., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background and Purpose: Clinical reasoning is essential to physical therapist practice. Solid clinical reasoning processes may lead to greater understanding of the patient condition, early diagnostic hypothesis development, and well-tolerated examination and intervention strategies, as well as mitigate the risk of diagnostic error. However, the complex and often subconscious nature of clinical reasoning can impede the development of this skill. Protracted tools have been published to help guide self-reflection on clinical reasoning but might not be feasible in typical clinical settings., Case Description: This case illustrates how the Systematic Clinical Reasoning in Physical Therapy (SCRIPT) tool can be used to guide the clinical reasoning process and prompt a physical therapist to search the literature to answer a clinical question and facilitate formal mentorship sessions in postprofessional physical therapist training programs., Outcomes: The SCRIPT tool enabled the mentee to generate appropriate hypotheses, plan the examination, query the literature to answer a clinical question, establish a physical therapist diagnosis, and design an effective treatment plan. The SCRIPT tool also facilitated the mentee's clinical reasoning and provided the mentor insight into the mentee's clinical reasoning. The reliability and validity of the SCRIPT tool have not been formally studied., Discussion: Clinical mentorship is a cornerstone of postprofessional training programs and intended to develop advanced clinical reasoning skills. However, clinical reasoning is often subconscious and, therefore, a challenging skill to develop. The use of a tool such as the SCRIPT may facilitate developing clinical reasoning skills by providing a systematic approach to data gathering and making clinical judgments to bring clinical reasoning to the conscious level, facilitate self-reflection, and make a mentored physical therapist's thought processes explicit to his or her clinical mentor., (© 2017 American Physical Therapy Association)

Introduction: Prognosis in patients with traumatic brain injury (TBI) and Glasgow Coma Scale (GCS) score of 3 is poor, raising concern regarding the utility of aggressive operative neurosurgical management. Our purpose was to describe outcomes in a propensity matched population with TBI and GCS3 treated with operative neurosurgical procedures of craniotomy or craniectomy (CRANI)., Methods: We conducted a five-year, multicenter retrospective cohort study of patients with an ED GCS 3 and a positive head CT identified by ICD-9CM diagnosis codes. Two populations were examined: (1) patients with extra-axial mass lesion (subdural or epidural haematoma), (2) patients without mass lesion (subarachnoid and intraparenchymal haemorrhage including contusion, other intracerebral haemorrhage or intracranial injury including diffuse axonal injury). In patients with extra-axial mass lesion, propensity score techniques were used to match patients 1:1 by CRANI, and the following outcomes were analysed with conditional logistic regression: survival, favourable hospital disposition to home or rehabilitation, and development of complications., Results: There were 541 patients with TBI and GCS3; 19% had a CRANI, 83% were initiated within 4h. In those with mass lesion, 27% (91/338) had a CRANI; after matching, a significant survival benefit was observed with CRANI vs. without CRANI (65% vs. 34% survival, OR: 3.9 (1.6-10.5) p<0.001). There was borderline increased odds of favourable disposition (43% vs. 26%, OR: 2.4 (0.99-6.3, p=0.052) with CRANI vs. without CRANI, and no difference in developing a complication (58% vs. 48%, OR: 1.5 (0.7-3.4), p=0.30)., Conclusions: Survival was achieved in 65% of patients that underwent surgical intervention for subdural and epidural haematoma, despite a presenting GCS of 3. These results demonstrate prompt operative neurosurgical management of mass lesion is warranted for selected patients with a GCS of 3, contributing to a significant 4-fold survival benefit. In the absence of mass lesion the effect of immediate neurosurgery on outcomes is inconclusive., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Retinoic acid is a naturally occurring metabolite of vitamin A that influences the differentiation of a variety of neural cells in vitro. In the LA-N-1 human neuroblastoma line, retinoic acid treatment increases the binding of nerve growth factor (Bmax). The purpose of this study was to examine the effects of retinoic acid on PC12 rat pheochromocytoma, a neural crest-derived cell line that can be induced to express a sympathetic neuroblast-like phenotype by nerve growth factor treatment. In contrast to the differentiating effects of nerve growth factor, retinoic acid treatment of PC12 cells had a negligible effect on cellular morphology. However, treatment with retinoic acid enhanced the survival of PC12 cells following oxidative injury generated by H2O2 treatment in a manner that is qualitatively similar to that observed after nerve growth factor treatment. Also, there was an increase in 125I-nerve growth factor binding activity in solubilized PC12 membrane preparations derived from retinoic acid-treated PC12 cells. These data suggest that retinoic acid may play a role in neuronal development and in neuronal injury by stimulating the ability of neurons to cope with oxidative stress and/or by enhancing neuronal responsiveness to trophic factors such as the nerve growth factor.

A 4.5-month-old infant with transposition of great vessels and large ventricular septal defect developed acute infective endocarditis following cardiac catheterization. Beta-hemolytic streptococcus was recovered from three blood cultures. The infant survived after 6 weeks intravenous antibiotic therapy. The occurrence of infective endocarditis following cardiac catheterization during infancy is briefly reviewed and discussed. The importance of distinguishing febrile episodes of infancy from infective endocarditis and the use of two-dimensional echocardiography for diagnosis is re-emphasized.

Eight youngsters (five female, three male, ages 10 to 19 years, mean 15 years) with isolated severe rheumatic mitral regurgitation have been subjected to mitral annuloplasty because of limiting symptoms and prominent ECG and X-ray changes. They have been followed for up to 11 years (mean 3.7 years), and 7 have had excellent results. An early (1961) patient had a small annulus and was not a favorable candidate; he had only transient improvement. Seven are greatly improved, have decreased cardiac size (often dramatic), and have improved ECG's. One has undergone successful pregnancy, and none has been limited in activities. The extent and duration of improvement, lack of mortality, and resumption of normal activities by these youngsters indicate surgical success. The essence of childhood and youth is activity and the future life span hopefully long; hence, annuloplasty would appear to be the procedure of choice for severe rheumatic mitral regurgitation in the pediatric age group, avoiding the usual need for anticoagulation and uncertain long-term results associated with mitral valve replacement.

The delivery of health care to children living on isolated island communities presents unique challenges to health professionals. An evolved method of providing longitudinal services to infants and children residing on islands of the Marshall Island chain--a central Pacific portion of the Micronesian archipelago--is presented. The difficulties associated with provision of comprehensive health care in a vast ocean area are discussed.

The mortality for infants with transposition of the great arteries (TGA) prior to the introduction of medical and surgical septostomy was over 80% by 6 months of age. The mortality has fallen recently, due to balloon atrial septostomy (BAS), but still exceeds 25% by 6 months of age in major centers. The cumulative mortality rises to 40% by 1 year of age with or without additional surgical atrial septectomy. In our center, 12 patients with an average age of 3 months were operated on for interatrial baffle correction of their TGA under surface-induced deep hypothermia. BAS had been done preliminarily in those patients without an adequate atrial communication. Ten of these 12 patients (83%) survived. These patients have been followed up from one month to eight years with an average follow-up of over four years. Surgical correction during infancy offers a better survival rate for infants with TGA than does medical management, with or without palliative surgery.

Hypertension is a common disease which may often be modified, sometimes cured and, perhaps in some cases, prevented. This communication emphasizes the importance of obtaining blood pressure measurements in children no later than at the age of 3 years and sequentially thereafter, and stresses the importance of using techniques for measuring blood pressure which assure accuracy. Levels of blood pressure readings diagnostic of hypertension are suggested. The evaluation of hypertensive children is outlined. The classification and differential diagnosis of hypertension is reviewed. Current concepts in nonpharmacologic and pharmacologic therapy for hypertension in children and youths are presented. Therapy for acute hypertensive crisis is described.

The hematologic status of infants and children living on the small islands of the Pacific basin has been poorly documented. This report determines the normal ranges for hemoglobin (Hb) and mean corpuscular volume (MCV) for children residing on four of the small atolls of the Republic of the Marshall Islands in the archipelago of Micronesia. The difficulty in establishing normal hematologic values in pediatric populations is discussed and a methodology suggested that does not exclude any Hb value above the mean in determining the normal range for Hb. The study population was comprised of 563 Marshallese children representing approximately 3.4% of all children less than 16 years of age living in the Marshall Islands. The local prevalence of anemia and iron deficiency was also established.

In 1976 the Secretary of the Department of Health, Education and Welfare appointed the Graduate Medical Education National Advisory Committee (GMENAC) with the charge to advise the Secretary on five national health planning objectives, including estimates of the numbers of physicians required to meet the health care needs of the nation, recommendations regarding the most appropriate specialty distribution of these physicians, and development of strategies to achieve the recommendations formulated by the committee. GMENAC evaluated projected supply and requirements for all major specialties, including child health care, for 1990, and recommended strategies to bring supply and requirement into reasonable balance. Despite the range of error of the methodology used, these data represent the most detailed scientific study to date on this subject. Pediatrics, the portion of child health care accruing to the pediatrician in 1990 was projected to be in "near balance" for supply/requirement ratio. Inasmuch as GMENAC recommended that larger surpluses be created deliberately in the three primary care fields, it is unlikely that the numbers of pediatric residency training programs will be decreased. As several hundred pediatric residency positions are unfilled each year, a concomitant decrease in residency offerings in oversupplied fields would be required to accomplish the recommended subspecialty distribution.