Physical therapy management, surgical treatment, and patient-reported outcomes measures in a prospective observational cohort of patients with neurogenic thoracic outlet syndrome

OBJECTIVE: To assess the results of physical therapy management and surgical treatment in a prospective observational cohort of patients with neurogenic thoracic outlet syndrome (NTOS) using patient-reported outcomes measures. METHODS: Of 183 new patient referrals from July 1 to December 31, 2015, 150 (82%) met the established clinical diagnostic criteria for NTOS. All patients underwent an initial 6-week physical therapy trial. Those with symptom improvement continued physical therapy, and the remainder underwent surgery (supraclavicular decompression with or without pectoralis minor tenotomy). Pretreatment factors and 7 patient-reported outcomes measures were compared between the physical therapy and surgery groups using t-tests and χ RESULTS: Of the 150 patients, 20 (13%) declined further treatment or follow-up, 40 (27%) obtained satisfactory improvement with physical therapy alone, and 90 (60%) underwent surgery. Slight differences were found between the physical therapy and surgery groups in the mean ± standard error degree of local tenderness to palpation (1.7 ± 0.1 vs 2.0 ± 0.1; P = .032), the number of positive clinical diagnostic criteria (9.0 ± 0.3 vs 10.1 ± 0.1; P = .001), Cervical-Brachial Symptom Questionnaire scores (68.0 ± 4.1 vs 78.0 ± 2.7; P = .045), and Short-Form 12-item physical quality-of-life scores (35.6 ± 1.5 vs 32.0 ± 0.8; P = .019) but not other pretreatment factors. During follow-up (median, 21.1 months for physical therapy and 12.0 months for surgery), the mean change in QuickDASH scores for physical therapy was -15.6 ± 3.0 (-29.5% ± 5.7%) compared with -29.8 ± 2.4 (-47.9% ± 3.6%) for surgery (P = .001). The patient-rated outcomes for surgery were excellent for 27%, good for 36%, fair for 26%, and poor for 11%, with a strong correlation between the percentage of decline in the QuickDASH score and patient-rated outcomes (P \u3c .0001). CONCLUSIONS: The present study has demonstrated contemporary outcomes for physical therapy and surgery in a well-studied cohort of patients with NTOS, reinforcing that surgery can be effective when physical therapy is insufficient, even with substantial pretreatment disability. Substantial symptom improvement can be expected for ∼90% of patients after surgery for NTOS, with treatment outcomes accurately reflected by changes in QuickDASH scores. Within this cohort, it was difficult to identify specific predictive factors for individuals most likely to benefit from physical therapy alone vs surgery

Responsiveness to Change in PROMIS

AbstractObjectiveTo compare the responsiveness to change of the Patient-Reported Outcomes Measurement Information System (PROMIS®) asthma impact, pain interference, fatigue, depressive symptoms, mobility, and peer relationship scales to a legacy scale, the Paediatric Asthma Quality of Life Questionnaire (PAQLQ).MethodsTwo hundred and twenty-nine child-parent dyads from public insurance programs were enrolled. PROMIS pediatric short forms (SFs) and the PAQLQ were used to measure health-related quality of life across four time points (T1–T4) over 2 years. The Asthma Control and Communication Instrument was used to measure the change in asthma control, and the Global Rating of Change (GRC) Index for breathing problems and overall health was used to measure the change in health status. Responsiveness was tested by comparing the changes in health-related quality of life with the changes in asthma control and health status over time using t tests, generalized estimating equations, and relative validity approaches. Magnitudes of the responsiveness between the Pediatric PROMIS and PAQLQ were assessed through statistical significance, Cohen's d effect size (ES), and standardized response mean (SRM).ResultsThe PROMIS asthma impact scale and all PAQLQ scales exhibited significant responsiveness (p'sConclusionsThe PROMIS asthma impact SF indicated similar responsiveness to the PAQLQ scales. Due to its brevity and responsiveness, the PROMIS asthma impact SF is useful for clinical practice or research

Risk, precaution and science: towards a more constructive policy debate. Talking point on the precautionary principle

Few issues in contemporary risk policy are as momentous or contentious as the precautionary principle. Since it first emerged in German environmental policy, it has been championed by environmentalists and consumer protection groups, and resisted by the industries they oppose (Raffensperger & Tickner, 1999). Various versions of the principle now proliferate across different national and international jurisdictions and policy areas (Fisher, 2002). From a guiding theme in European Commission (EC) environmental policy, it has become a general principle of EC law (CEC, 2000; Vos & Wendler, 2006). Its influence has extended from the regulation of environmental, technological and health risks to the wider governance of science, innovation and trade (O'Riordan & Cameron, 1994)

Familial adenomatous patients with desmoid tumours show increased expression of miR-34a in serum and high levels in tumours

Familial adenomatous polyposis (FAP) is rare affecting 1 in 10,000 people and a subset (10%) are at risk of myofibroblastic desmoid tumours (DTs) after colectomy to prevent cancer. DTs are a major cause of morbidity and mortality. The absence of markers to monitor progression and a lack of treatment options are significant limitations to clinical management. We investigated microRNAs (miRNA) levels in DTs and serum using expression array analysis on two independent cohorts of FAP patients (total, n=24). Each comprised equal numbers of patients who had formed DTs (cases) and those who had not (controls). All controls had absence of DTs confirmed by clinical and radiological assessment over at least three years post- colectomy. Technical qPCR validation was performed using an expanded cohort (29 FAP patients; 16 cases and 13 controls). The most significant elevated serum miRNA marker of DTs was miR-34a-5p and in-situ hybridisation (ISH) showed most DTs analysed (5/6) expressed miRNA-34a-5p. Exome sequencing of tumour and matched germline DNA did not detect mutations within the miR-34a-5p transcript sites or 3'-UTR of target genes that would alter functional miRNA activity. In conclusion, miR-34a-5p is a potential circulatory marker and therapy target. A large prospective world-wide multi-centre study is now warranted

Longitudinal associations among asthma control, sleep problems, and health-related quality of life in children with asthma: a report from the PROMIS® Pediatric Asthma Study

Few studies have investigated the complex relationship among asthma control, sleep problems, and health-related quality of life (HRQOL) among children with asthma. This study aimed to test the longitudinal effect of asthma control status on asthma-specific HRQOL through the mechanism of nighttime sleep quality and daytime sleepiness

Parents’ knowledge of and opinions about healthcare laws and technology in primary care

Purpose Historically, parents have demonstrated poor understanding of adolescent healthcare laws. This study assessed US parents’ current knowledge and opinions about technology facilitated physician–adolescent communication and applicable laws to enhance transition to adult health care.Methods A brief survey in two low-income academic paediatric clinics asked parents about their knowledge of health care and laws, and their opinions about technology facilitated contact between physicians and adolescents.Results Almost all parents (96.7%) have internet access at home, work or via a mobile device. Only 44.1% approved of having a physician directly contact their child about annual examinations, immunisations or to discuss issues of sexuality. Half (55.4%) were aware that adolescents could receive confidential sexuality information and treatment without parents’ permission. Only one-third (32.2%) approved of a specific technology for direct communication.Conclusions Parents are divided about direct physician–adolescent contact. Future plans to engage adolescents to understand their health will require parental education and involvement on the value of physician–adolescent communication

Coupled-channels analysis of the 16^{{\bf 16}}O+208^{{\bf 208}}Pb fusion barrier distribution

Analyses using simplified coupled-channels models have been unable to describe the shape of the previously measured fusion barrier distribution for the doubly magic $^{16}$O+$^{208}$Pb system. This problem was investigated by re-measuring the fission excitation function for $^{16}$O+$^{208}$Pb with improved accuracy and performing more exact coupled-channels calculations, avoiding the constant-coupling and first-order coupling approximations often used in simplified analyses. Couplings to the single- and 2-phonon states of $^{208}$Pb, correctly taking into account the excitation energy and the phonon character of these states, particle transfers, and the effects of varying the diffuseness of the nuclear potential, were all explored. However, in contrast to other recent analyses of precise fusion data, no satisfactory simultaneous description of the shape of the experimental barrier distribution and the fusion cross-sections for $^{16}$O+$^{208}$Pb was obtained.Comment: RevTex, 29 pages, 7 postscript figures, to appear in PR

Improving continence in children and young people with neurodisability: a systematic review and survey.

Children and young people with neurodisability often need help to achieve socially acceptable bladder and bowel control. Approaches vary depending on whether or not the impairment results from spinal cord pathology that impairs motor control and sensation of the bladder and bowel. Currently, there is uncertainty about which interventions are effective. The objective was to summarise the available evidence on and current practice for improving continence in children and young people with neurodisability. A systematic review of the effectiveness, cost-effectiveness and factors that modify intervention implementation, alongside a cross-sectional, online survey of current practice with health professionals, parent carers, school and care staff and young people with neurodisability. Twelve databases were searched in the review, resulting in 5756 references; 71 studies (72 papers) were included in the analyses. Most of the evidence was for children with spinal cord pathology, which involved evaluations of pharmacological approaches and surgical techniques, whereas the evidence pertaining to those with non-spinal-cord-related pathology tended to be for behavioural interventions. The methodological quality of studies was rated as being moderate to poor. There were three robust qualitative studies about the experience of continence among children with spinal cord pathology. We found substantial heterogeneity across the interventions that we evaluated in terms of quality, study design and outcomes measured. No economic studies were found. The results were synthesised narratively and reported in text and tables. We did not find any eligible studies evaluating interventions using toilet and clothing adaptations in the review, although the survey highlighted that these types of interventions are frequently used and considered. In total, 949 people responded to the survey: 202 health professionals, 605 parent carers, 122 school and social care staff, and 20 young people. The survey results illustrated the different roles that professionals have in improving continence, highlighting the importance of a multidisciplinary approach to supporting children and young people and their families. Clinicians employ a range of assessments and interventions to improve continence or independent toileting, depending on the needs of the child. Quantitative studies in the review were not methodologically robust. The survey had a risk of response bias. Our research found a dearth of good-quality evidence for many of the interventions currently in use, and no evidence of experiences of implementing interventions for children with non-spinal-cord-related pathology. There was also no evidence of cost-effectiveness of any of the interventions. There is a need to involve young people and families in the design of high-quality evaluative research for interventions that aim to improve continence. This is especially the case for children with autism and learning disability, who have been neglected in previous evaluative and qualitative research. We recommend better training for health, education and care professionals about toileting, informed by evidence and the lived experiences of children and their families. We recommend a joined-up multidisciplinary and holistic approach to improving continence to maximise independence, dignity and comfort. It is vital that children and young people with neurodisability have early access to regular, integrated assessment of their bladder and bowel health, and are fully supported with appropriate personalised treatment. This study is registered as PROSPERO CRD42018100572. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in ; Vol. 25, No. 73. See the NIHR Journals Library website for further project information

Reconstructing the 3-D Trajectories of CMEs in the Inner Heliosphere

A method for the full three-dimensional (3-D) reconstruction of the trajectories of coronal mass ejections (CMEs) using Solar TErrestrial RElations Observatory (STEREO) data is presented. Four CMEs that were simultaneously observed by the inner and outer coronagraphs (COR1 and 2) of the Ahead and Behind STEREO satellites were analysed. These observations were used to derive CME trajectories in 3-D out to ~15Rsun. The reconstructions using COR1/2 data support a radial propagation model. Assuming pseudo-radial propagation at large distances from the Sun (15-240Rsun), the CME positions were extrapolated into the Heliospheric Imager (HI) field-of-view. We estimated the CME velocities in the different fields-of-view. It was found that CMEs slower than the solar wind were accelerated, while CMEs faster than the solar wind were decelerated, with both tending to the solar wind velocity.Comment: 17 pages, 10 figures, 1 appendi