Kashin Beck Disease: more than just osteoarthrosis

The purpose of this study was to investigate the influence of body function, activities and pain on the level of activity in adults with Kashin Beck Disease (KBD). Seventy-five KBD patients with a mean age of 54.8 years (SD 11.3) participated. Anthropometrics, range of joint motion (ROM) and muscle strength were measured as well as the time-up-and-go test and functional tests for the lower and upper extremities. Activity was assessed with the participation scale and the WHO DAS II. In the shoulder, elbow, hip and knee joints, a severe decrease in ROM and bilateral pain was noted. A decrease in muscle strength was observed in almost all muscles. The timed-up-and-go test scores decreased. No or mild restriction in activity was found in 35%, and 33% experienced a moderate restriction whereas 32% had severe to extreme restriction. Activities in the lower extremities were mildly to moderately correlated to ROM and muscle strength, whereas in the upper extremities activities were correlated to range of joint motion. Activity was significantly associated with ROM after correction for muscle strength, gender and age. Participation was borderline significantly associated with ROM after correction for muscle strength, gender, age and the activity time-up-and-go. In KBD adults, a severe decrease in activity is primarily caused by decrease in ROM. These findings have strong influence on rehabilitation and surgical interventio

Ultrasonographic tissue characterisation of human Achilles tendons: quantification of tendon structure through a novel non-invasive approach

OBJECTIVE: To asses if three-dimensional imaging of the Achilles tendon by Ultrasonographic Tissue Characterisation (UTC) can differentiate between symptomatic and asymptomatic tendons. DESIGN: Case-control study. SETTING: Sports medical department of The Hague medical centre. PATIENTS: Twenty-six tendons from patients with chronic midportion Achilles tendinopathy were included. The "matched" control group consisted of 26 asymptomatic tendons. INTERVENTIONS: Symptomatic and asymptomatic tendons were scanned using the UTC-procedure. One researcher performed the ultrasonographic data-collection. These blinded data were randomised and outcome measures were determined by two independent observers. Main outcome measurements: The raw ultrasonographic images were analysed with a custom-designed algorithm that quantifies the three-dimensional stability of echopatterns, qua intensity and distribution over contiguous transverse images. This three-dimensional stability was related to tendon structure in previous studies. UTC categorizes four different echo-types that represent: I) highly stable; II) medium stable; III) highly variable and IV) constantly low intensity and variable distribution. The percentages of echo-types were calculated and the maximum tendon-thickness was measured. Finally, the inter-observer reliability of UTC was determined. RESULTS: Symptomatic tendons showed less pixels in echo-types I and II than asymptomatic tendons (51.5% versus 76.6%, p<0.001), thus less three-dimensional stability of the echopattern. The mean maximum tendon thickness was 9.2 mm in the symptomatic group and 6.8 mm in the asymptomatic group (p<0.001). The Intra-class Correlation Coefficient (ICC) for the inter-observer reliability of determining the echo-types I+II was 0.95. The ICC for tendon thickness was 0.84. CONCLUSION: UTC can quantitatively evaluate tendon structure and thereby discriminate symptomatic and asymptomatic tendons. As such UTC might be useful to monitor treatment protocols

Do not attempt resuscitation decisions in a cancer centre: addressing difficult ethical and communication issues

Talking to patients about ‘Do Not Attempt Resuscitation’ decisions is difficult for many doctors. Communication about ‘Do Not Attempt Resuscitation’ decisions should occur as part of a wider discussion of treatment goals at an earlier stage in the patient's illness. A doctor should not initiate any treatment, including cardio-pulmonary resuscitation if he/she does not believe it will benefit the patient. An ethical framework is offered which may be of practical help in clarifying decision-making

Decision making in interhospital transport of critically ill patients: national questionnaire survey among critical care physicians

Objective: This study assessed the relative importance of clinical and transport-related factors in physicians' decision-making regarding the interhospital transport of critically ill patients. Methods: The medical heads of all 95 ICUs in The Netherlands were surveyed with a questionnaire using 16 case vignettes to evaluate preferences for transportability; 78 physicians (82%) participated. The vignettes varied in eight factors with regard to severity of illness and transport conditions. Their relative weights were calculated for each level of the factors by conjoint analysis and expressed in beta. The reference value (beta = 0) was defined as the optimal conditions for critical care transport; a negative beta indicated preference against transportability. Results: The type of escorting personnel (paramedic only: beta = 3.1) and transport facilities (standard ambulance beta = 1.21) had the greatest negative effect on preference for transportability. Determinants reflecting severity of illness were of relative minor importance (dose of noradrenaline beta = 0.6, arterial oxygenation beta = 0.8, level of peep beta = 0.6). Age, cardiac arrhythmia, and the indication for transport had no significant effect. Conclusions: Escorting personnel and transport facilities in interhospital transport were considered as most important by intensive care physicians in determining transportability. When these factors are optimal, even severely critically ill patients are considered able to undergo transport. Further clinical research should tailor transport conditions to optimize the use of expensive resources in those inevitable road trip

Automated entire thrombus density measurements for robust and comprehensive thrombus characterization in patients with acute ischemic stroke

Background and Purpose: In acute ischemic stroke (AIS) management, CT-based thrombus density has been associated with treatment success. However, currently used thrombus measurements are prone to inter-observer variability and oversimplify the heterogeneous thrombus composition. Our aim was first to introduce an automated method to assess the entire thrombus density and then to compare the measured entire thrombus density with respect to current standard manual measurements. Materials and Method: In 135 AIS patients, the density distribution of the entire thrombus was determined. Density distributions were described usingmedians, interquartile ranges (IQR), kurtosis, and skewedness. Differences between themedian of entire thrombusmeasurements and commonly applied manualmeasurements using 3 regions of interest were determined using linear regression. Results: Density distributions varied considerably with medians ranging from 20.0 to 62.8 HU and IQRs ranging from 9.3 to 55.8 HU. The average median of the thrombus density distributions (43.5 ± 10.2 HU) was lower than the manual assessment (49.6 ± 8.0 HU) (p<0.05). The difference between manual measurements and median density of entire thrombus decreased with increasing density (r = 0.64; p<0.05), revealing relatively higher manual measurements for low density thrombi such that manual density measurement tend overestimates the real thrombus density. Conclusions: Automatic measurements of the full thrombus expose a wide variety of thrombi density distribution, which is not grasped with currently used manual measurement. Furthermore, d

Two-year clinical follow-up of the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in The Netherlands (MR CLEAN): Design and statistical analysis plan of the extended follow-up study

Background: MR CLEAN was the first randomized trial to demonstrate the short-term clinical effectiveness of endovascular treatment in patients with acute ischemic stroke caused by large vessel occlusion in the anterior circulation. Several other trials confirmed that endovascular treatment improves clinical outcome at three months. However, limited data are available on long-term clinical outcome. We aimed to estimate the effect of endovascular treatment on functional outcome at two-year follow-up in patients with acute ischemic stroke. Secondly, we aimed to assess the effect of endovascular treatment on major vascular events and mortality during two years of follow-up. Methods: MR CLEAN is a multicenter clinical trial with randomized treatment allocation, open-label treatment, and blinded endpoint evaluation. Patients included were 18 years or older with acute ischemic stroke caused by a proven anterior proximal artery occlusion who could be treated within six hours after stroke onset. The intervention contrast was endovascular treatment and usual care versus no endovascular treatment and usual care. The current study extended the follow-up duration from three months to two years. The primary outcome is the score on the modified Rankin scale at two years. Secondary outcomes include all-cause mortality and the occurrence of major vascular events within two years of follow-up. Discussion: The results of our study provide information on the long-term clinical effectiveness of endovascular treatment, which may have implications for individual treatment decisions and estimates of cost-effectiveness. Trial registration:NTR1804. Registered on 7 May 2009; ISRCTN10888758. Registered on 24 July 2012 (main MR CLEAN trial); NTR5073. Registered on 26 February 2015 (extended follow-up study)

The effect on quality of chest compressions and exhaustion of a compression--ventilation ratio of 30:2 versus 15:2 during cardiopulmonary resuscitation--a randomised trial

Recent cardio pulmonary resuscitation (CPR) guidelines changed the compression:ventilation ratio in 30:2. To compare the quality of chest compressions and exhaustion using the ratio 30:2 versus 15:2. A prospective, randomised crossover design was used. Subjects were recruited from the H.-Hart hospital personnel and the University College Katho for nurses and bio-engineering. Each participant performed 5min of CPR using either the ratio 30:2 or 15:2, then after a 15min rest switched to the other ratio. The data were collected using a questionnaire and an adult resuscitation manikin. The outcomes included exhaustion as measured by a visual analogue scale (VAS) score, depth of chest compressions, rates of chest compressions, total number of chest compressions, number of correct chest compressions and incomplete release. Data were compared using the Wilcoxon Signed Ranks Test. The results are presented as medians and interquartile ranges (IQR). One hundred and thirty subjects completed the study. The exhaustion-score using the VAS was 5.9 (IQR 2.25) for the ratio 30:2 and 4.5 (IQR 2.88) for the ratio 15:2 (P <0.001). The compression depth was 40.5mm (IQR 15.75) for 30:2 and 41mm (IQR 15.5) for 15:2 (P=0.5). The compression rate was 118beats/min (IQR 29) for 30:2 and 115beats/min (IQR 32) for 15:2 (P=0.02). The total number of compressions/5min was 347 (IQR 79) for 30:2 and 244compressions/5min (IQR 72.5) for 15:2 (P <0.001). The number of correct compression/5min was 61.5 (IQR 211.75) for 30:2 and 55.5 (IQR 142.75) for 15:2 (P=0.001). The relative risk (RR) of incomplete release in 30:2 versus 15:2 was 1.087 (95% CI=0.633-1.867). Although the 30:2 ratio is rated to be more exhausting, the 30:2 technique delivers more chest compressions and the quality of chest compressions remains unchange

The impact of an emergency motorcycle response vehicle on prehospital care in an urban area

Introduction Faster emergency response times are generally considered to have a positive effect on life expectancy of patients with a life-threatening event, leading many communities to determine response time intervals. However, worldwide, increasing urbanization and traffic congestion threatens ambulance response times. An emergency motorcycle response vehicle (MRV) can overcome these hurdles more easily than a larger ambulance. It also offers dispatch flexibility in responding to calls estimated to have a low likelihood of a patient who needs transport. The first aim of this study was to determine whether an MRV can shorten response times and impact on resuscitation outcomes in a heavily urbanized and densely populated region in the Netherlands. The second aim was to evaluate differences in dispatch and transport between MRV and ambulance. Methods This was a nonrandomized, prospective cohort study comparing an MRV unit with regular ambulances in a Dutch city of 265 000 people. Included were all 'urgent patient' cases within operating time of the MRV between January 2003 and August 2003. Results A total of 1664 patients was evaluated, including 468 motorcycle and 1196 ambulance responses. Use of MRVs led to a decrease in response time of 54 s (P <= 0.01). We could not show a decrease in mortality risk in cases of resuscitation [relative risk (RR): 2.50, confidence interval (CI): 0.17-36.21]. There was a slightly improved 1-year survival in other life-threatening cases (RR: 1.13, CI: 1.03-1.24). However, this is most likely because of differences in dispatch decisions (the MRV is sent to 'lighter' cases) and not because of faster assistance. The MRV paramedic was more likely to treat and release the patient (RR: 2.21, CI: 1.80-2.73) or refer them to a general practitioner (RR: 2.11, CI: 1.73-2.58) and much less likely to refer them to the hospital emergency department (41.2 vs. 72.6%). Referrals to the hospital by the MRV were mostly by the patient's own means of transportation (RR: 13.14, CI: 5.89-29.32) rather than by ambulance. Conclusion Using motorcycles in a Dutch setting lead to better emergency medical service response times. The MRV serves a different population. Resulting in a higher treat and release rate and less transportation to hospital. European Journal of Emergency Medicine 18:328-333 (C) 2011 Wolters Kluwer Health | Lippincott Williams & Wilkin