Low-frequency ultrasound (20-40 kHz) as an adjunctive therapy for chronic wound healing: a systematic review of the literature and meta-analysis of eight randomized controlled trials

Ultrasound as a therapeutic agent in chronic wound healing has been studied extensively. This systematic review and meta-analysis specifically examines low-frequency (20-30 kHz) ultrasound delivered at either low or high intensity. The objective of this review was to determine whether low-frequency ultrasound used as an adjunctive therapy improves the outcomes of complete healing and reduction of size of chronic lower limb wounds. PubMed, Cochrane/CENTRAL, technical assessment, relevant wound-related journals, and clinical guidelines were searched along with contacting manufacturers and authors of relevant randomized controlled trials were completed. Searches focused on the use of low-frequency ultrasound in randomized controlled trials. Data were collected via a data collection form and was adjudicated independently via coauthors. Meta-analyses and heterogeneity checks were performed using Mantel-Haenszel and inverse variance (fixed and random effects) statistical methods on studies with similar outcomes (complete healing and percent wound area reduction) over similar time periods. Single study results were reported via the statistical methods used in the study. Eight randomized controlled trials were identified. Results demonstrated that early healing (at ≤5 months) in patients with venous stasis and diabetic foot ulcers was favorably influenced by both high- and low-intensity ultrasound delivered at a low frequency-either via contact or noncontact techniques. However, the quality of the data may be suspect, especially for low-frequency low-intensity noncontact ultrasound because of significant biases. In patients presenting with either venous stasis or diabetic foot ulcers (Wagner classification 1-3), early healing appears to be facilitated by either low-frequency low-intensity noncontact ultrasound or low-frequency high-intensity contact ultrasound.     

A two-center experience with the exclusive use of laparoscopic transperitoneal nephrectomy for benign renal disease in children

Background This study aimed to evaluate a two-center experience with pediatric transperitoneal laparoscopic nephrectomy, specifically focusing on the outcome parameters of operative time, complication, analgesic requirement, and postoperative stay. Methods This ambispective study was conducted over a 4-year period between May 2001 and May 2005 in two tertiary pediatric surgical centers. Data were prospectively recorded from an in-house expanded medical audit system (EMAS) and a Microsoft Excel database. Information on patient demographics, operative time, complications, analgesic requirement, and length of hospital stay were retrieved and analyzed. Results A total of 30 consecutive patients with a mean age of 4.43 years (range, 3 months to 15 years) underwent laparoscopic nephrectomy. All the patients underwent unilateral nephrectomy/nephroureterectomy for multidysplastic kidney (n = 12), reflux nephropathy (n = 13), pelvicoureteric junction obstruction (n = 4), or cystic disease of indeterminate cause (n = 1). The mean operative time was 93 ± 30 min. The principal hemostatic devices used were the Harmonic Scalpel (20 cases), liga clips (5 cases), and hook diathermy and endoshears exclusively (4 cases). There were no conversions, but the intraoperative complications of bleeding (n = 2), difficult location (n = 1), difficult extraction (n = 1), and requirement for a liver retractor (n = 2) were encountered. An additional five patients had problems in the immediate postoperative period, two of whom went on to have long term difficulties with recurrent urinary tract infections resulting from a residual ureteric stump, which required surgery. Nearly one-third of the patients required morphine for analgesia in the immediate postoperative period, with the figure falling to 20% by day 1. The median postoperative hospital stay was 1 day (range, 0–16 days). At this writing, all the patients remain under surveillance with a mean follow-up period of 2.88 years, and no patients have experienced complications secondary to intraabdominal adhesions. Conclusion Transperitoneal laparoscopic nephrectomy is technically feasible in most cases of benign renal disease. The intraoperative complications are minimal, and recovery for most is robust. Two-thirds of the patients are discharged within 24 h. In this study, narcotic analgesics were prescribed in about a one-third of all the cases for a limited period. Further problems may be seen when refluxing ureters are incompletely excised. However, the transperitoneal approach does not mitigate against complete excision because the exposure to the pelvis is adequate. At the midterm follow-up assessment, adhesive obstruction was not encountered, confirming this approach as a tenable alternative to other laparoscopic approaches for nephrectomy.     

Neural correlates of crossmodal visual-tactile extinction and of tactile awareness revealed by fMRI in a right-hemisphere stroke patient

We used fMRI to study the neural correlates of crossmodal, visual-tactile extinction in a single case (patient GK). GK has chronic extinction after a lesion centred on right inferior parietal cortex, and has previously been investigated extensively in purely visual fMRI studies [e.g. Rees, G., Wojciulik, E., Clarke, K., Husain, M., Frith, C., & Driver, J. (2000). Unconscious activation of visual cortex in the damaged right hemisphere of a parietal patient with extinction. Brain, 123(Pt 8), 1624-1633; Rees, G., Kreiman, G., & Koch, C. (2002). Neural correlates of consciousness in humans. Nature Reviews Neuroscience, 3(4), 261-270]. With concurrent stimulation of the right visual field plus left index finger, GK showed crossmodal extinction of left touch on approximately half of such trials here (reflecting impaired sensitivity, i.e. lowered d-prime), albeit becoming aware of left touch on the other half. fMRI revealed activation of contralateral primary somatosensory cortex on crossmodal trials when touch was extinguished from awareness, suggesting unconscious residual processing there. When GK became aware of the left touch, additional activation was found in surviving right parietal cortex, and in frontal regions; moreover, functional coupling was enhanced with a region of frontal cortex implicated in awareness by previous work. Finally, on trials where crossmodal extinction arose, surviving right parietal cortex showed stronger functional coupling with the left visual and right somatosensory regions driven by the competing stimuli, indicating that crossmodal extinction arises when inputs to separate modalities interact competitively via multimodal cortex.     

Seen Gaze-Direction Modulates Fusiform Activity and Its Coupling with Other Brain Areas during Face Processing

Gaze-contact is often a preliminary to social interaction and so constitutes a signal for the allocation of processing resources to the gazing face. We investigated how gaze direction influences face processing in an fMRI study, where seen gaze and head direction could independently be direct or deviated. Direct relative to averted gaze elicited stronger activation for faces in ventral occipitotemporal cortices around the fusiform gyrus, regardless of head orientation. Moreover, direct gaze led to greater correlation between activity in the fusiform and the amygdala, a region associated with emotional responses and stimulus saliency. By contrast, faces with averted gaze (again, regardless of head orientation) yielded increased correlation between activity in the fusiform and the intraparietal sulcus, a region associated with shifting attention to the periphery.     

Eye-movements intervening between two successive sounds disrupt comparisons of auditory location

Many studies have investigated how saccades may affect the internal representation of visual locations across eye-movements. Here, we studied, instead, whether eye-movements can affect auditory spatial cognition. In two experiments, participants judged the relative azimuth (same/different) of two successive sounds presented from a horizontal array of loudspeakers, separated by a 2.5-s delay. Eye-position was either held constant throughout the trial (being directed in a fixed manner to the far left or right of the loudspeaker array) or had to be shifted to the opposite side of the array during the retention delay between the two sounds, after the first sound but before the second. Loudspeakers were either visible (Experiment 1) or occluded from sight (Experiment 2). In both cases, shifting eye-position during the silent delay-period affected auditory performance in thn the successive auditory comparison task, even though the auditory inputs to be judged were equivalent. Sensitivity (d′) for the auditory discrimination was disrupted, specifically when the second sound shifted in the opposite direction to the intervening eye-movement with respect to the first sound. These results indicate that eye-movements affect internal representation of auditory location.

Response to comment on: Exp Brain Res. 2011 May 5th. Transcranial magnetic stimulation of macaque frontal eye fields decreases saccadic reaction time. Pierre Pouget PhD,Nicolas Wattiez MSc and Antoni Valero-Cabre MDPhD

Abstract  

(not available)     

Rescue Sedation When Treating Acute Agitation in the Emergency Department With Intramuscular Antipsychotics

Background

Rapid treatment of agitation in the emergency department (ED) is critical to avoid injury to patients and providers. Treatment with intramuscular antipsychotics is often utilized, but there is a paucity of comparative effectiveness evidence available.