Manual Treatment for Cervicogenic Headache and Active Trigger Point in the Sternocleidomastoid Muscle: A Pilot Randomized Clinical Trial

Objective

The purpose of this preliminary study was to determine feasibility of a clinical trial to measure the effects of manual therapy on sternocleidomastoid active trigger points (TrPs) in patients with cervicogenic headache (CeH).

Methods

Twenty patients, 7 males and 13 females (mean ± SD age, 39 ± 13 years), with a clinical diagnosis of CeH and active TrPs in the sternocleidomastoid muscle were randomly divided into 2 groups. One group received TrP therapy (manual pressure applied to taut bands and passive stretching), and the other group received simulated TrP therapy (after TrP localization no additional pressure was added, and inclusion of longitudinal stroking but no additional stretching). The primary outcome was headache intensity (numeric pain scale) based on the headaches experienced in the preceding week. Secondary outcomes included neck pain intensity, cervical range of motion (CROM), pressure pain thresholds (PPT) over the upper cervical spine joints and deep cervical flexors motor performance. Outcomes were captured at baseline and 1 week after the treatment.

Results

Patients receiving TrP therapy showed greater reduction in headache and neck pain intensity than those receiving the simulation (P < .001). Patients receiving the TrP therapy experienced greater improvements in motor performance of the deep cervical flexors, active CROM, and PPT (all, P < .001) than those receiving the simulation. Between-groups effect sizes were large (all, standardized mean difference, > 0.84).

Conclusion

This study provides preliminary evidence that a trial of this nature is feasible. The preliminary findings show that manual therapy targeted to active TrPs in the sternocleidomastoid muscle may be effective for reducing headache and neck pain intensity and increasing motor performance of the deep cervical flexors, PPT, and active CROM in individuals with CeH showing active TrPs in this muscle. Studies including greater sample sizes and examining long-term effects are needed.     

Appropriateness of ambulance transportation to a suburban pediatric emergency department

Objective. To assess the appropriateness of ambulance use in patients presenting to a pediatric emergency department (ED), with regard to both medical necessity and insurance status. Methods. The authors conducted a one-year retrospective chart analysis of all patients (age range 2 weeks to 19 years) who were transported via ambulance in 1994 to a suburban children's hospital ED. ED records of all patients who arrived by ambulance were abstracted for demographic data, type of insurance, chief complaint, medical interventions, discharge diagnosis, and disposition. Ambulance transportation was deemed unnecessary unless the medical record revealed any of the following criteria: 1) requiring cardiopulmonary resuscitation, 2) respiratory distress, 3) altered mental status or seizure, 4) immobilization, 5) inability to walk, 6) admission to intensive care, 7) ambulance recommended by medical personnel, 8) motor vehicle collision, or 9) parents not on scene. Results. 43% of the ambulance patients were insured by Medicaid, compared with 29% of the overall ED population. Thus, Medicaid patients were significantly more likely to use ambulance transportation than were patients with commercial insurance (p<0.001). 28% of patients who arrived by ambulance were judged to have used the ambulance transportation unnecessarily. Of the unnecessary transports, 60% were insured by Medicaid. Thus, Medicaid patients were significantly more likely to have used ambulance transportation unnecessarily (p<0.001). The most common reason for appropriate ambulance use was seizure activity; the most common reason for inappropriate use was fever. Conclusion. Inappropriate use of ambulance transportation is common in this pediatric population, with Medicaid patients accounting for a significant majority of the misuse.     

Acute liver failure due to herpes simplex virus: diagnostic clues and potential role of plasmapheresis: A case report

Introduction:Acute liver failure (ALF) is a life-threatening condition that remains challenging for physicians despite several advances in supportive care. Etiologies vary worldwide, with herpes simplex virus (HSV) hepatitis representing less than 1% of cases. Despite its low incidence, ALF is a lethal cause of acute necrotizing hepatitis and has a high mortality. Early antiviral treatment is beneficial for survival and decreased liver transplantation necessity. However, plasmapheresis, despite its theoretical potential benefit, is scarcely reported.Patient concerns:A 25-year-old woman with no known disease presented with painful pharynx ulcers, increased transaminases and impaired liver function.Diagnosis:ALF due to a disseminated HSV-2 primary infection was diagnosed with a positive polymerase chain reaction for HSV-2 in the biopsied liver tissue and blood.Interventions:Empiric antiviral treatment was initiated. After clinical deterioration, plasmapheresis was also initiated.Outcomes:After 6 cycles of plasmapheresis and supportive care, the patient''s condition improved without undergoing liver transplantation.Conclusions:ALF is a life-threatening condition, and HSV as an etiology must be suspected based on background, clinical manifestation, and laboratory information. The potential role of plasmapheresis in HSV hepatitis should be considered.     

Analysis of some phenotypic traits of feces-borne temperate lambdoid bacteriophages from different immunity groups: a high incidence of cor+, FhuA-dependent phages

A group of previously isolated heterogeneous mEp lambdoid phages (43) from 19 different immunity groups for phage infection was further characterized to gain insight into some phenotypic traits and to assess their relationship with phage lambda. Interestingly, the FhuA host receptor was required by the majority of mEp phages (37 out of 43; approximately 85%). The cor gene, which has been reported to be involved in FhuA-dependent exclusion of lambdoid phages, was also found in most of the FhuA-dependent phages. Accordingly, no cor amplification by PCR was obtained among the six FhuA-independent mEp lambdoid phages. In contrast, it was found that around 25% of the population (10 out of 43 phages) required the specific and essential lambda N antitermination function, and the lambda site-specific DNA recombination function was observed only in two members (4.6%). Thus, a larger proportion of phages require the FhuA receptor for infection, and this is frequently correlated with the cor gene.     

Analysis of the genotype and virulence of Staphylococcus epidermidis isolates from patients with infective endocarditis

Staphylococcus epidermidis is one of the most common causes of infections of prosthetic heart valves (prosthetic valve endocarditis [PVE]) and an increasingly common cause of infections of native heart valves (native valve endocarditis [NVE]). While S. epidermidis typically causes indolent infections of prosthetic devices, including prosthetic valves and intravascular catheters, S. epidermidis NVE is a virulent infection associated with valve destruction and high mortality. In order to see if the differences in the course of infection were due to characteristics of the infecting organisms, we examined 31 S. epidermidis NVE and 65 PVE isolates, as well as 21 isolates from blood cultures (representing bloodstream infections [BSI]) and 28 isolates from nasal specimens or cultures considered to indicate skin carriage. Multilocus sequence typing showed both NVE and PVE isolates to have more unique sequence types (types not shared by the other groups; 74 and 71%, respectively) than either BSI isolates (10%) or skin isolates (42%). Thirty NVE, 16 PVE, and a total of 9 of the nasal, skin, and BSI isolates were tested for virulence in Caenorhabditis elegans. Twenty-one (70%) of the 30 NVE isolates killed at least 50% of the worms by day 5, compared to 1 (6%) of 16 PVE isolates and 1 (11%) of 9 nasal, skin, or BSI isolates. In addition, the C. elegans survival rate as assessed by log rank analyses of Kaplan-Meier survival curves was significantly lower for NVE isolates than for each other group of isolates (P < 0.0001). There was no correlation between the production of poly-β(1-6)-N-acetylglucosamine exopolysaccharide and virulence in worms. This study is the first analysis suggesting that S. epidermidis isolates from patients with NVE constitute a more virulent subset within this species.     

Role of CYP2A5 in the bioactivation of the lung carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone in mice

The tobacco-specific nitrosamine 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) is a potent lung carcinogen. Previously, we have demonstrated that NNK-induced lung tumorigenesis in mice depends on target-tissue bioactivation by pulmonary cytochrome P450 (P450) enzymes. The present study was designed to test the hypothesis that mouse CYP2A5 plays an essential role in NNK bioactivation in mouse lung. The role of CYP2A5 in NNK bioactivation was studied both in vitro and in vivo, by comparing the kinetic parameters of microsomal NNK metabolism and tissue levels of O(6)-methylguanine (O(6)-mG) (the DNA adduct highly correlated with lung tumorigenesis) between wild-type (WT) and Cyp2a5-null mice. In both liver and lung microsomes, the loss of CYP2A5 resulted in significant increases in the apparent K(m) values for the formation of 4-oxo-4-(3-pyridyl)butanone, which represents the reactive intermediate that produces O(6)-mG in vivo. The loss of CYP2A5 did not change circulating levels of NNK or 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol in mice treated intraperitoneally with NNK at either 20 or 100 mg/kg. However, the levels of lung O(6)-mG were significantly lower in Cyp2a5-null than in WT mice; the extent of the reduction was greater at the 20 mg/kg dose (～40%) than at the 100 mg/kg dose (～20%). These results indicate that CYP2A5 is the low-K(m) enzyme for NNK bioactivation in mouse lung. It is noteworthy that the remaining NNK bioactivation activities in the Cyp2a5-null mice could be inhibited by 8-methoxypsoralen, a P450 inhibitor used previously to demonstrate the role of CYP2A5 in NNK-induced lung tumorigenesis. Thus, P450 enzymes other than CYP2A5 probably also contribute to NNK-induced lung tumorigenesis in mice.     

Crystallization of bioinspired citrate-functionalized nanoapatite with tailored carbonate content

Novel citrate-functionalized carbonate-apatite nanoparticles with mean lengths ranging from 20 to 100 nm were synthesized by a thermal-decomplexing batch method. Needle-like and plate-shaped morphologies were obtained in the absence and presence of sodium carbonate in the precipitation medium, respectively. The precipitation time and the presence of sodium carbonate strongly affect the chemical composition as well as the dimensions and the crystallinity of nanoparticles. At a short precipitation time, poorly crystalline apatites of 100 nm mean length with a low degree of carbonation (1.5% w/w, mainly in B-position) and a high citrate content (5.9% w/w) were precipitated. This citrate content is close to that recently measured in bone apatite. When increasing the precipitation time up to 96 h the mean length and the citrate content progressively decrease and at the same time the nanoparticles become more crystalline. They are composed of a well-ordered carbonate-substituted apatitic core embedded in a non-apatitic hydrated layer containing citrate ions. This layer progressively transforms into a more stable apatite domain upon maturation in aqueous media. The nanoparticles displayed excellent compatibility properties in cell biological systems, since they were not cytotoxic to a mouse carcinoma cell line when added to a final concentration of 100 μgml(-1). This work provides new insights into the role of citrate on the crystallization of nanoapatites. Moreover, the synthesized nanoparticles are promising materials for use as nanocarriers for local targeted drug delivery systems as well as building blocks for the preparation of nanostructured scaffolds for cells in bone tissue engineering.     

Utilizing registries in systemic lupus erythematosus clinical research

Systemic lupus erythematosus is a complex and heterogeneous autoimmune disease with a relatively low incidence. Clinical research in this disease at individual centers is complicated by the difficulty of accruing enough patient numbers. In this context, the development of cohorts and multi-institutional registries during the last decades has allowed an increase in knowledge regarding the clinical course and management of this disease. This article aims to describe the main study designs linked to lupus registries and to give an overview of the main international registries and cohorts, as well as their principal achievements in the context of this complex entity.