Correlation Between Voluntary Cough and Laryngeal Cough Reflex Flows in Patients With Traumatic Brain Injury

Objective

To correlate voluntary cough and laryngeal cough reflex (LCR) flows in patients with traumatic brain injury (TBI).

Design

Cross-sectional study.

Setting

University rehabilitation hospital.

Participants

Patients with TBI (n=25) and healthy controls (n=48).

Interventions

Not applicable.

Main Outcome Measures

Peak cough flows (PCFs) and LCR flows were measured using a peak flow meter at the oral-nasal interface. The largest value of 3 attempts was recorded for PCF and LCR, respectively. LCR was elicited by 20% solution of pharmaceutic-grade citric acid dissolved in sterile .15M NaCl solution that was inhaled from a nebulizer.

Results

PCF was 447.4±99.0L/min in the control group and 211.7±58.2L/min in the patient group. LCR was 209.2±63.8L/min in the control group and 170.0±59.7L/min in the patient group. Both PCF (P=.000) and LCR (P=.013) were significantly reduced in patients with TBI compared to that of the control group. LCR was strongly related to the PCF in both control (R=.645; P=.000) and patient (R=.711; P=.000) groups.

Conclusions

As LCR can be measured as a numerical value and significantly correlates with PCF, LCR can be used to estimate cough ability of patients with TBI who cannot cooperate with PCF measurement.     

Characterization and comparison of Re-Du-Ning aerosol particles generated by different jet nebulizers

Inhalation therapy is the first-line therapy for the treatment of respiratory diseases. Re-Du-Ning inhalation solution (RIS) is an aerosol derivative from the Re-Du-Ning injection and has been clinically used to treat respiratory diseases like pneumonia for more than twenty years in China. However, the aerosolization and inhalation performances of RIS using different nebulizers have not been characterized, which may affect the therapeutic effects of RIS on respiratory diseases. We investigated the inhalation performances of RIS using five different nebulizers utilizing Spraytec, breath simulator of BRS 2000 and NGI techniques. We tested 5 different types of jet nebulizer, using RIS and an adult breathing pattern, to determine the difference in aerosol delivery over time. The particle size distribution of RIS was monitored by a Spraytec laser particle sizer. Fine particle fraction (FPF) and mass median aerodynamic diameter (MMAD) for RIS were measured using NGI. Aerosol deposited on the filter was analysed using HPLC. Nebulization time was much longer for the Pari Boy SX (red) nebulizer than for the other nebulizers, with the minimum delivery rate (DR) and the maximum total delivered dose (TDD) and total exhalation dose (TED). Nebulization time for Pari Boy SX (blue) was the lowest, with the highest DR and the lowest TDD and TED. Furthermore, the aerodynamic particle size of RIS was much larger for the Pari blue and Pari LC Plus than other nebulizers. Pari red produced the smallest aerodynamic particle size of RIS in these five nebulizers. In addition, a good linear relationship was found between MMAD and D₅₀ in these five nebulizers. The results demonstrated that Pari Boy SX (red) delivered most slowly and produced the smallest aerodynamic particle size of the RIS aerosols, which may be applied to manage lower respiratory diseases. Moreover, Pari LC Plus and Pari Boy SX (blue) emitted quickly and generated larger aerodynamic particle size of RIS aerosols, which could be used to treat upper respiratory diseases. A good linear relationship between MMAD and D₅₀ showed Spraytec could be a reliable technique for the development, evaluation and quality control of aerosol particles of inhalation solution preparations.

Delivery dose uniformity determination by BRS 2000 breath simulator and realtime particle size distribution monitoring by Spraytec.     

Microparticles and acute renal dysfunction in septic patients

Purpose

The role of microparticles (MPs) in the pathogenesis of sepsis is not completely elucidated. We aimed to assess changes in the number of MPs during severe sepsis to follow the effect of sepsis-related organ failures, particularly renal impairment, an independent mortality factor of sepsis.

Materials and Methods

Thirty-seven severe septic patients and 20 controls were enrolled. Patient status as well as organ failure–related laboratory markers was followed up to 5 consecutive days. Microparticles (annexin V + events in MP size gate) of platelet (CD41, CD42a, and PAC1), monocyte (CD14), and myeloid cell line (CD13) origin were measured using flow cytometry.

Results

Significantly increased total MP and CD41-, CD42a-, and PAC1-positive particle numbers were found in septic patients compared with controls. Actual number of organ dysfunctions on sample collection showed no correlation with MP numbers. Septic patients with renal dysfunction showed an increase in total MP, CD41⁺, and CD13⁺ particle numbers on admission. Amounts of platelet-derived CD42a⁺ particles from patients with sepsis-related renal injury correlated negatively with actual blood urea nitrogen and creatinine concentrations.

Conclusion

The increased numbers of platelet-derived MPs in severe septic patients emphasize the possible contribution of the hemostasis system in the development of sepsis-related renal impairments.     

The use of the laryngeal tube disposable (LT-D) by paramedics during out-of-hospital resuscitation—An observational study concerning ERC guidelines 2005

Summary

In the current guidelines of the European Resuscitation Council (ERC), tracheal intubation, as an instrument for securing the airway during resuscitation, has become less important for persons not trained in this method. For those persons, different supraglottic airway devices are recommended by the ERC. The present investigation deals with the application of the laryngeal tube disposable (LT-D) during pre-hospital resuscitation by paramedics.

Methods

During a period of 2 years (2006–2008), we registered all cardiac arrest situations in which the LT-D had been applied according to the ERC guidelines 2005. Therefore, we investigated one emergency medical system in Germany.

Results

During the defined period, 92 resuscitation attempts, recorded on standardised data sheets, were included. The LT-D was used in 46% of all cardiac arrest situations. Overall, the LT-D was successfully inserted in more than 90% of all cases on first attempt. In 95% of all cases, no problems concerning ventilation of the patient were described.

Conclusion

As an alternative airway device recommended by the ERC in 2005, the LT-D may enable airway control rapidly and effectively. Additionally, by using the LT-D, a reduced “no-flow-time” and a better outcome may be possible.     

Exploring the Clinical Course of Neck Pain in Physical Therapy: A Longitudinal Study

Objective

To investigate the short-term trajectory of recovery from mechanical neck pain, and predictors of trajectory.

Design

Prospective, longitudinal cohort study with 5 repeated measurements over 4 weeks.

Setting

Community-based physical therapy clinics.

Participants

Convenience sample of community-dwelling adults (N=50) with uncomplicated mechanical neck disorders of any duration.

Interventions

Usual physical therapy care.

Main Outcome Measures

Neck Disability Index (NDI), numeric rating scale (NRS) of pain intensity.

Results

A total of 50 consecutive subjects provided 5 data points over 4 weeks. Exploratory modeling using latent class growth analysis revealed a linear trend in improvement, at a mean of 1.5 NDI points and 0.5 NRS points per week. Within the NDI trajectory, 3 latent classes were identified, each with a unique trend: worsening (14.5%), rapid improvement (19.6%), and slow improvement (65.8%). Within the NRS trajectory, 2 unique trends were identified: stable (48.0%) and improving (52.0%). Predictors of trajectory class suggest that it may be possible to predict the trajectory. Results are described in view of the sample size.

Conclusions

The mean trajectory of improvement in neck pain adequately fits a linear model and suggests slow but stable improvement over the short term. However, up to 3 different trajectories have been identified that suggest neck pain, and recovery thereof, is not homogenous. This may hold value for the design of clinical trials.     

Effects of Inpatient Rehabilitation in Hip and Knee Osteoarthritis: A Naturalistic Prospective Cohort Study With Intraindividual Control of Effects

Objectives

To quantify pain, function, and health-related quality of life in comparison with normative data, and to quantify intervention effects.

Design

Naturalistic cohort study without a control group. Correction of the effects observed during the intervention by those observed during waiting time prior to the intervention.

Setting

Inpatient rehabilitation clinic.

Participants

Patients with hip (n=88) and knee (n=164) osteoarthritis.

Intervention

Comprehensive, multidisciplinary inpatient rehabilitation lasting 3 weeks.

Main Outcome Measures

Medical Outcomes Study 36-Item Short-Form Health Survey and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).

Results

Four or more comorbid conditions had 45.3% of the hip and 51.8% of the knee patients on entry to and discharge from the clinic. On entry, physical health and some dimensions of psychosocial health were significantly diminished compared with population norms. At discharge, hip osteoarthritis had improved by a corrected effect size of .20 to .47 in pain, .04 to .39 in function, and −.04 to .32 in psychosocial health. Knee osteoarthritis showed a corrected effect size of .43 to .62 in pain, .19 to .51 in function, and .19 to .30 in psychosocial health. All but 1 effect in WOMAC pain and WOMAC function were higher than the minimal clinically important differences.

Conclusions

Hip and knee osteoarthritis patients admitted to the inpatient intervention were affected by a substantial burden of disease and comorbidities. Inpatient rehabilitation resulted in small to moderate, statistically significant, and clinically important improvements in pain, function, and psychosocial health.     

Electrically Induced Resistance Training in Individuals With Motor Complete Spinal Cord Injury

Objective

To examine the effects of 16 weeks of electrically induced resistance training on insulin resistance and glucose tolerance, and changes in muscle size, composition, and metabolism in paralyzed muscle.

Design

Pre-post intervention.

Setting

University-based trial.

Participants

Participants (N=14; 11 men and 3 women) with chronic (>2y post spinal cord injury), motor complete spinal cord injury.

Intervention

Home-based electrically induced resistance exercise training twice weekly for 16 weeks.

Main Outcome Measures

Plasma glucose and insulin throughout a standard clinical oral glucose tolerance test, thigh muscle and fat mass via dual-energy x-ray absorptiometry, quadriceps and hamstrings muscle size and composition via magnetic resonance imaging, and muscle oxidative metabolism using phosphorus magnetic resonance spectroscopy.

Results

Muscle mass increased in all participants (mean ± SD, 39%±27%; range, 5%–84%). The mean change ± SD in intramuscular fat was 3%±22%. Phosphocreatine mean recovery time constants ± SD were 102±24 and 77±18 seconds before and after electrical stimulation-induced resistance training, respectively (P<.05). There was no improvement in fasting blood glucose levels, homeostatic model assessment calculated insulin resistance, 2-hour insulin, or 2-hour glucose.

Conclusions

Sixteen weeks of electrical stimulation-induced resistance training increased muscle mass, but did not reduce intramuscular fat. Similarly, factors associated with insulin resistance or glucose tolerance did not improve with training. We did find a 25% improvement in mitochondrial function, as measured by phosphocreatine recovery rates. Larger improvements in mitochondrial function may translate into improved glucose tolerance and insulin resistance.     

Upper Extremity Kinematics and Muscle Activation Patterns in Subjects With Facioscapulohumeral Dystrophy

Objective

To compare the kinematics and muscle activity of subjects with facioscapulohumeral dystrophy (FSHD) and healthy control subjects during the performance of standardized upper extremity tasks.

Design

Exploratory case-control study.

Setting

A movement laboratory.

Participants

Subjects (N=19) with FSHD (n=11) and healthy control subjects (n=8) were measured.

Interventions

Not applicable.

Main Outcome Measures

Kinematic data were recorded using a 3-dimensional motion capturing system. Muscle activities, recorded using electromyography, were obtained from 6 superficial muscles around the glenohumeral joint. Shoulder elevation and elbow flexion angles, and maximum electromyographic activity during the movements as a percentage of maximum voluntary contraction (MVC) were calculated.

Results

Kinematic differences between the FSHD group and the healthy control group were found in the shoulder elevation angle during single shoulder movements and both reaching tasks. In general, subjects with FSHD had higher percentages of muscle activation. The median activity of the trapezius was close to the MVC activity during the single shoulder movements. Moreover, deltoid and pectoralis muscles were also highly active.

Conclusions

Higher activation of the trapezius in subjects with FSHD indicates a mechanism that could help relieve impaired shoulder muscles during arm elevation around shoulder height. Compared with healthy subjects, persons with FSHD activated their shoulder muscles to a greater extent during movements that required arm elevation.     

Effects of Wheelchair Cushions and Pressure Relief Maneuvers on Ischial Interface Pressure and Blood Flow in People With Spinal Cord Injury

Objective

To investigate the effectiveness and interactions of 2 methods of pressure ulcer prevention, wheelchair cushions and pressure relief maneuvers, on interface pressure (IP) and blood flow of the buttocks.

Design

Within-subject repeated measures.

Setting

Rehabilitation center.

Participants

Wheelchair users with a spinal cord injury or disorder (N=17).

Interventions

Participants performed 3 forward leans and 2 sideward leans with different degrees of lean while seated on each of 3 different wheelchair cushions.

Main Outcome Measures

IP measured with a custom sensor and blood flow measured with laser Doppler flowmetry were collected at the ischial tuberosity.

Results

Pressure relief maneuvers had a significant main effect on the ischial IP (P<.001); all maneuvers except for the small frontward lean resulted in a significant reduction in IP compared with upright sitting. Blood flow significantly varied across postures (P<.001) with flow during upright sitting and small forward leans being significantly lower than during the full and intermediate leans in both the forward and sideward directions.

Conclusions

The results of the study highlight the importance of positioning wheelchair users in a manner that facilitates in-seat movement. Regardless of the cushion being used, the pressure relief maneuvers resulted in very large reductions in IPs and significant increases in buttock blood flow. Only the small frontward lean was shown to be ineffective in reducing pressure or increasing blood flow. Because these pressure relief maneuvers involved postural changes that can occur during functional activities, these pressure relief maneuvers can become a part of volitional pressure relief and functional weight shifts. Therefore, clinical instruction should cover both as a means to impart sitting behaviors that may lead to better tissue health.     

Antibiotic prophylaxis for ED patients with simple hand lacerations: a feasibility randomized controlled trial

Background

The benefit of antibiotic prophylaxis for simple hand lacerations (lacerations that do not involve special structures) has not been adequately studied.

Objective

To assess the feasibility of a randomized controlled trial to determine the role of antibiotic prophylaxis in emergency department (ED) patients with simple hand lacerations.

Methods

Randomized, double-blind, placebo-controlled pilot trial in 2 urban academic EDs. Adult (≥ 18 years old) patients with simple hand lacerations were randomized to cephalexin, 500 mg; clindamycin, 300 mg; or placebo (every 6 hours for 7 days, all in identical capsules). Outcomes: (1) feasibility determined by the number of patients who agreed to enroll and number of patients who completed follow-up, (2) infection rate (determined by 2 physicians at 10-14 days), (3) satisfaction with wound appearance (measured by a visual analogue scale at 30 days via phone). Medians, quartiles, and percentages with 95% confidence intervals (CI) were used to present data. Groups were compared with Kruskal-Wallis and Fisher exact tests, when appropriate.

Results

Over a 5-month period, 123 patients were approached, and 78 consented to enrollment (63%; 95% CI, 55-71%). Five were lost to follow-up (5/78, 6%; 95% CI, 2%-14%). Only one patient had infection on follow-up for an infection rate of 1% (95% CI, 0.01%-8%). Patient’s satisfaction with wound appearance did not differ among the groups.

Conclusion

The findings of this pilot study support the feasibility of a randomized, double-blind, controlled trial. The low rate of infection suggests the need of a large sample size for the trial.     

The bougie: an inexpensive lifesaving airway device

Background

“Bougies,” otherwise known as endotracheal tube introducers, remain preferred devices for the emergency physician when faced with a difficult airway. Bougies have high success rates for the prehospital provider and the first-time emergency department (ED) user, with few reported complications. Inexpensive, disposable models provide simple yet valuable tools in the challenging patient with an anterior airway or limited neck mobility.

Objectives

Use of the bougie is similar to standard endotracheal intubation. Correct placement is determined by feeling “clicks” as the device passes over the tracheal rings and a “hold up” when entering the distal airways.

Case Reports

Three recent cases from our ED are briefly reported, in which the bougie was invaluable in the management of the difficult airway. All patients had limited visualization of the glottis but were intubated successfully.

Conclusion

This article discusses three example cases, and then reviews the history of the bougie, placement technique, and current evidence for use.     

Meta-Analysis of Botulinum Toxin A Detrusor Injections in the Treatment of Neurogenic Detrusor Overactivity After Spinal Cord Injury

Objective

To examine the effectiveness of botulinum toxin type A (BTX-A) on neurogenic detrusor overactivity (NDO) in individuals with spinal cord injury (SCI).

Data Sources

MEDLINE, CINAHL, EMBASE, and PsycINFO databases were searched for all relevant articles published from 1980 to June 2012.

Study Selection

Trials examining the use of BTX-A injections into the detrusor wall in the treatment of NDO after SCI were included if (1) ≥50% of study sample comprised subjects post-SCI; (2) outcomes of interest were assessed before and after treatment with a single injection of BTX-A; and (3) the sample size was ≥3.

Data Extraction

A standardized mean difference ± SE (95% confidence interval) was calculated for at least 1 of the following outcomes in every study: postvoid residual urine volume, reflex detrusor volume, bladder capacity, bladder compliance, catheterization frequency, and maximum flow rate. Results from all studies were then pooled using a random-effects model. Treatment effect sizes were interpreted as small, >0.2; moderate, >0.5; or large, >0.8.

Data Synthesis

Fourteen studies representing data from 734 subjects were included. After BTX-A injection, large treatment effects were observed in postvoid residual urine volume, reflex detrusor volume, bladder capacity, bladder compliance, and catheterization frequency (P<.01). Rate of incontinence episodes was reduced from 23% to 1.31% after BTX-A treatment. No significant decrease in max flow rate was observed (P=.403).

Conclusions

Results of the meta-analysis indicate BTX-A is effective in treating NDO after SCI. The use of BTX-A was associated with a decrease in incontinence episodes, catheter use, and bladder pressures.     

Can the degree of hydronephrosis on ultrasound predict kidney stone size?

Objective

The aim of the study was to determine if the degree of hydronephrosis on focused emergency renal ultrasound correlates with kidney stone size on computed tomography.

Methods

A retrospective study was performed on all adult patients in the emergency department who had a focused emergency renal ultrasound and ureterolithiasis on noncontrast computed tomography. Severity of hydronephrosis was determined by the performing physician. Ureteral stone size was grouped into 5 mm or less and larger than 5 mm based on likelihood of spontaneous passage.

Results

One hundred seventy-seven ultrasound scans were performed on patients with ureteral calculi. When dichotomized using test characteristic analysis, patients with none or mild hydronephrosis (72.9%) were less likely to have ureteral calculi larger than 5 mm than those with moderate or severe hydronephrosis (12.4% vs 35.4%; P < .001) with a negative predictive value of 0.876 (95% confidence interval, 0.803-0.925).

Conclusion

Patients with less severe hydronephrosis were less likely to have larger ureteral calculi.     

The utility of serial peak flow measurements in the acute asthmatic being treated in the ED

Background

Peak flow is used extensively in emergency departments (EDs) to both assess asthma patient's status on arrival as well as to document clinical improvement during treatment. Many algorithms suggest serial peak expiratory flow (PEF) measurements during an ED stay.

Objective

The aim of the study was to assess the contribution of serial PEF in describing the overall improvement of asthmatics over the course of an ED visit for acute exacerbation of their asthma.

Methods

This was a prospective institutional review board–approved study of mild/moderate asthmatics presenting to an inner-city ED serving a large Latino population. Peak expiratory flow was measured before treatment (baseline PEF) and after each inhaled treatment (PEF post RX#1, PEF post RX#2, PEF post RX#3) while in the ED.

Results

One hundred consecutive patients made up this study cohort. The change from baseline PEF to PEF #1 represented 86% (95% confidence interval [CI], 76%-96%) of the total improvement experienced by these patients with asthma. The change from PEF post RX#1 to PEF post RX#2 represented 7.5% (95% CI, −4.2% to 26%) of the total improvement and PEF post RX#2 to PEF post RX#3 represented 8.6% (95% CI, −1% to 34%) of the total PEF improvement seen.

Limitation

No correlation between outcome and PEF% of predicted was made or implied.

Conclusion

The improvement in PEF seen after the first ED inhaled therapy appears to describe most of the total improvement seen in asthmatic patients. Subsequent PEFs provided little additional information.     

Systematic Framework to Classify the Status of Research on Spinal Cord Injury and Physical Activity

Objectives

To systematically classify the physical activity research for individuals with a spinal cord injury by using the behavioral epidemiologic framework; and to identify where the physical activity research for individuals with a spinal cord injury has focused between 2000 and 2012.

Design

Relevant research was identified and then categorized into 1 of 5 phases by following the coding rules of the behavioral epidemiology framework. Phase 1 studies link physical activity and health outcomes, phase 2 studies validate or develop measures of physical activity, phase 3 studies identify factors that influence behavior or examine explanatory theories of behavior, phase 4 studies evaluate interventions, and phase 5 studies disseminate health promotion programs or policies and translate research into practice.

Setting

Specific keywords were identified and then searched through EBSCOhost, PubMed, and Google Scholar.

Participants

Not applicable.

Interventions

Not applicable.

Main Outcome Measures

Not applicable.

Results

One hundred and thirteen articles met the criteria. Of the articles, 55% were categorized as phase 1, 12% as phase 2, 24% as phase 3, 5% as phase 4, and 4% as phase 5.

Conclusions

Most studies were categorized as phase 1, 2, or 3, which implies that this field is still in the early stages of development and research should focus on intervention development and dissemination.     

Systematic review of the mechanisms driving effective blood flow during adult CPR

Background

High quality chest compressions is the most significant factor related to improved short-term and long-term outcome in cardiac arrest. However, considerable controversy exists over the mechanisms involved in driving blood flow.

Objectives

The aim of this systematic review is to elucidate major mechanisms involved in effective compression-mediated blood flow during adult cardiopulmonary resuscitation (CPR).

Design and setting

Systematic review of studies identified from the bibliographic databases of PubMed/Medline, Cochrane, and Scopus.

Selection criteria

All human and animal studies including information on the responsible mechanisms of compression-related blood flow. Data collection and analysis: Two reviewers (MG, TX) independently screened all potentially relevant titles and abstracts for eligibility, by using a standardized data-worksheet.

Main results

Forty seven studies met the inclusion criteria. Because of the heterogeneity in outcome measures, quantitative synthesis of evidence was not feasible. Evidence was critically synthesized in order to answer the review questions, taking into account study heterogeneity and validity. The number of included studies per category is as follows: blood flow during chest compression, nine studies; blood flow during chest decompression, six studies; effect of chest compression on cerebral blood flow, eight studies; active compression–decompression CPR, 14 studies; and effect of ventilation on compression-related blood flow, 13 studies.

Conclusion

The evidence so far is inconclusive regarding the major responsible mechanism in compression-related blood flow. Although both ‘cardiac pump’ and ‘thoracic pump’ have a key role, the effect of each mechanism is highly depended on other resuscitation parameters, such as positive pressure ventilation and compression depth.     

Correlation of corrected flow time in the carotid artery with changes in intravascular volume status

Purpose

Assessment of volume status remains a challenge in critical care. Our purpose was to determine if Doppler waveform analysis of carotid artery blood flow correlates with changes in volume status.

Materials and methods

Dehydrated patients receiving an intravenous fluid bolus were enrolled with exclusions including age less than 18 years, pregnancy, vasopressor administration, or atrial fibrillation. Ultrasound examination with Doppler analysis of the carotid artery was performed with measurements taken to calculate corrected flow time (FTc). Corrected flow time, mean arterial pressure, and pulse rate before and after fluid administration were compared using Wilcoxon matched-pairs signed rank test.

Results

Fifty-six patients were enrolled with mean fluid administration of 1110 mL. Corrected flow time increased with fluid resuscitation from prefluid mean of 299 milliseconds (95% confidence interval [CI], 282-317 milliseconds) to a postfluid mean of 340 milliseconds (95% CI, 323-358 milliseconds) (P < .0001). Mean percentage change in FTc was 14.9% (95% CI, 8.4-21.3). There were no significant changes in mean arterial pressure or heart rate from pre– to post–fluid administration.

Conclusion

Intravenous fluid administration in dehydrated patients resulted in significant changes in FTc in the carotid artery despite no change in vital signs. Corrected flow time measured from carotid arterial blood flow may be a useful means of assessing volume status in volume-depleted patients.