Analgesia and sedation in hemodynamic unstable patient

Pain, restlessness, tension and delirium are almost always encountered while treating hemodynamic unstable critical patients in the intensive care units. Usually in critical patients, the evaluation of the nature and pain intensity (VAS scale) are often impossible. During the last 10 years intense nociceptor somatic and visceral post operative pain is believed to be the most crucial factor in the development of endocrine and neurohumoral disorders, within the postoperative period. Chronic post operative pain is appearing often (30%-40%), with great influence on the quality of patients life. The modern principal in treating acute pain is the use of multimodal balanced analgesia approach, which is individually catered with drug and dose for each patient. Modern systemic analgesia is understood to be the continuous use of opiates or opioids, titrated towards pain intensity, with a minimum number of complications even in hemodynamic unstable patients. The combined use of opioids with NSAID and paracetamol reduces the overall dosage of opioids by 20% - 30% and therefore significantly contributes to hemodynamic and respiratory stability. Effective and safe epidural analgesia in hemodynamic unstable patients can be optimized by simultaneous use of various drugs with different mechanisms of action (local anaesthetic, opioid, adrenalin, ketamin). The accepted concept of analgosedation in critical patients is understood to be the use of short acting drugs (fentanyl, sufentanil, remifentanil, midazolam, propofol) in which drug dosage can be quickly adjusted in respect to the present clinical state of the patient

Spectrum of a^2; Canum Venaticorum, 5000-6700 Å

A complete list is given of all lines observed between 5000 and 6650 Å in the spectrum of a^2 CVn. Approximately three-quarters of the features have been identified. Lines of Pb ii and P ii are not present. Lines of Gd m and Pr m vary in equivalent width and radial velocity in a manner similar to the singly ionized rare earths. Lines of Cl ii are present and also behave like those of a rare earth

Virtual reality for stroke rehabilitation (review)

Published version made available following 12 month embargo from the date of publication [12 Feb 2015] according to publisher policy. Accessed 10/03/2015. Published version available from 13 February 2016

Autologous Tissue Grafts in Rhinoplasty

Grafts in rhinoplasty have a wide range of use in different indications. They can be utilized for structural support, augmentation, increasing projection, replacement of over resected structures, smoothing and fine tuning of the dorsum or the tip. Various tissues can be used for those purposes to give the appropriate amount of strength, volume or coverage. We present a series of case reports with the use of autologous tissues in both primary and secondary rhinoplasties performed using both an open and closed approach. The tissues that were used are septal cartilage, conchal cartilage, rib cartilage, temporal fascia, retroauricular soft tissue, bone and fat tissue. Cartilage has been used as full thickness structural grafts, sliced cartilage, diced cartilage or cartilage paste. Fascia and soft tissues have been used as overlay, or as a wrap for diced cartilage. The understanding of the physical properties of each of these tissues and familiarity with the spectrum of use in different indications using different approaches give us the possibility to achieve stabile, aesthetically balanced results without the stigmata of surgery

Validity and Usability of a Professional Association’s Web-Based Knowledge Translation Portal: American Physical Therapy Association’s PTNow.org

Background: PTNow.org is an evidence-based, on-line portal created by a professional membership association to promote use of evidence in practice and to help decrease unwarranted variation in practice. The site contains synthesis documents designed to promote efficient clinical reasoning. These documents were written and peer-reviewed by teams of content experts and master clinicians. The purpose of this paper is to report on the content and construct validity as well as usability of the site. Methods: Physical therapist participants used clinical summaries (available in 3 formats--as a full summary with hyperlinks, quick takes with hyperlinks, and a portable two-page version) on the PTNow.org site to answer knowledge acquisition and clinical reasoning questions related to four patient scenarios. They also responded to questions about ease of use related to website navigation and about format and completeness of information using a 1-5 Likert scale. Responses were coded to reflect how participants used the site and then were summarized descriptively. Preferences for clinical summary format were analyzed using an analysis of variance (ANOVA) and a Dunnett T3 post hoc analysis. Results: Seventeen participants completed the study. Clinical relevance and completeness ratings by experienced clinicians, which were used as the measure of content validity, ranged from 3.1 to 4.6 on a 5 point scale. Construct validity based on the information on the PTNow.org site was supported for knowledge acquisition questions 66 % of the time and for clinical reasoning questions 40 % of the time. Usability ratings for the full clinical summary were 4.6 (1.2); for the quick takes, 3.5 (.98); and for the portable clinical summary, 4.0 (.45). Participants preferred the full clinical summary over the other two formats (F = 5.908, P = 0.007). One hundred percent of the participants stated that they would recommend the PTNow site to their colleagues. Conclusion: Prelimary evidence supported both content validity and construct validity of knowledge acquisition, and partially supported construct validity of clinical reasoning for the clinical summaries on the PTNow.org site. Usability was supported, with users preferring the full clinical summary over the other two formats. Iterative design is ongoing

Evidence-Based Practice Confidence and Behavior Throughout the Curriculum of Four Physical Therapy Education Programs: A Longitudinal Study

Background Evidence-based practice (EBP) is a foundational process taught in health professional education, yet it is unclear when EBP confidence and skills are obtained. Increases in EBP confidence and behaviors from the start of physical therapy programs to post graduation have been reported in studies that evaluated a single program or used non-valid questionnaires. This study aimed to describe changes in EBP confidence and behavior using validated questionnaires of students from four physical therapy education programs throughout their curriculum and one year post graduation. Methods One hundred and eighty-one students from a potential pool of 269 (67.3%) consented to participate. Students completed the Evidence-Based Practice Confidence (EPIC) Scale and the Evidence-Based Practice Implementation Scale (EBPIS) at 6 timepoints: start of the program, prior to first clinical experience, after first clinical experience, at the end of classroom instruction, graduation, and one year post. Medians (Mdn) and 25th and 75th percentiles (P25, P75) were calculated for 42 (23.2%) students with complete data across all timepoints. Change between timepoints was assessed using Friedman’s test and Wilcoxon signed rank test with a Bonferroni correction for post hoc analysis. Results There were significant changes in EPIC scores (p \u3c 0.001) from enrollment (Mdn 50.0, P25, P75 35.5, 65.9) to prior to first clinical experience (Mdn 65.5, P25, P75 57.3, 72.5) and after the first clinical experience (Mdn 67.3, P25, P75, 58.9, 73.2) to the end of classroom instruction (Mdn 78.6, P25, P75, 72.0, 84.1). Significant increases on the EBPIS (p \u3c 0.01) were only seen from after the first year of training (Mdn 15, P25, P75, 10.0, 22.5) to end of the first clinical experience (Mdn 21.5, P25, P75 12.0, 32.0). Conclusions EBP confidence increased significantly after classroom instruction but remained the same after clinical experiences and at one year post graduation. EBP behavior significantly increased only after the first clinical experience and remained the same through graduation. Confidence and behavior scores were higher than were previously reported in practicing professionals. Ongoing assessment of EBP confidence and behavior may help instructors build appropriate curricula to achieve their outlined EBP objectives

Virtual reality for stroke rehabilitation (Review)

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. This review is made available in accordance with Cochrane Database of Systematic Review's repositories policyBackground Virtual reality and interactive video gaming have emerged as recent treatment approaches in stroke rehabilitation with commercial gaming consoles in particular, being rapidly adopted in clinical settings. This is an update of a Cochrane Review published first in 2011 and then again in 2015. Objectives Primary objective: to determine the efficacy of virtual reality compared with an alternative intervention or no intervention on upper limb function and activity. Secondary objectives: to determine the efficacy of virtual reality compared with an alternative intervention or no intervention on: gait and balance, global motor function, cognitive function, activity limitation, participation restriction, quality of life, and adverse events. Search methods We searched the Cochrane Stroke Group Trials Register (April 2017), CENTRAL, MEDLINE, Embase, and seven additional databases. We also searched trials registries and reference lists. Selection criteria Randomised and quasi‐randomised trials of virtual reality ("an advanced form of human‐computer interface that allows the user to 'interact' with and become 'immersed' in a computer‐generated environment in a naturalistic fashion") in adults after stroke. The primary outcome of interest was upper limb function and activity. Secondary outcomes included gait and balance and global motor function. Data collection and analysis Two review authors independently selected trials based on pre‐defined inclusion criteria, extracted data, and assessed risk of bias. A third review author moderated disagreements when required. The review authors contacted investigators to obtain missing information. Main results We included 72 trials that involved 2470 participants. This review includes 35 new studies in addition to the studies included in the previous version of this review. Study sample sizes were generally small and interventions varied in terms of both the goals of treatment and the virtual reality devices used. The risk of bias present in many studies was unclear due to poor reporting. Thus, while there are a large number of randomised controlled trials, the evidence remains mostly low quality when rated using the GRADE system. Control groups usually received no intervention or therapy based on a standard‐care approach. Primary outcome: results were not statistically significant for upper limb function (standardised mean difference (SMD) 0.07, 95% confidence intervals (CI) ‐0.05 to 0.20, 22 studies, 1038 participants, low‐quality evidence) when comparing virtual reality to conventional therapy. However, when virtual reality was used in addition to usual care (providing a higher dose of therapy for those in the intervention group) there was a statistically significant difference between groups (SMD 0.49, 0.21 to 0.77, 10 studies, 210 participants, low‐quality evidence). Secondary outcomes: when compared to conventional therapy approaches there were no statistically significant effects for gait speed or balance. Results were statistically significant for the activities of daily living (ADL) outcome (SMD 0.25, 95% CI 0.06 to 0.43, 10 studies, 466 participants, moderate‐quality evidence); however, we were unable to pool results for cognitive function, participation restriction, or quality of life. Twenty‐three studies reported that they monitored for adverse events; across these studies there were few adverse events and those reported were relatively mild. Authors' conclusions We found evidence that the use of virtual reality and interactive video gaming was not more beneficial than conventional therapy approaches in improving upper limb function. Virtual reality may be beneficial in improving upper limb function and activities of daily living function when used as an adjunct to usual care (to increase overall therapy time). There was insufficient evidence to reach conclusions about the effect of virtual reality and interactive video gaming on gait speed, balance, participation, or quality of life. This review found that time since onset of stroke, severity of impairment, and the type of device (commercial or customised) were not strong influencers of outcome. There was a trend suggesting that higher dose (more than 15 hours of total intervention) was preferable as were customised virtual reality programs; however, these findings were not statistically significant

Time since injury limits but does not prevent improvement and maintenance of gains in balance in chronic stroke

[EN] Objective To determine the influence of time since injury on the efficacy and maintenance of gains of rehabilitation of balance after stroke. Method Forty-seven participants were assigned to a least (6-12 months), a moderate (12-24 months), or a most chronic (>24 months) group. Participants trained for 20 one-hour sessions, administered three to five times a week, combining conventional physical therapy and visual feedback-based exercises that trained the ankle and hip strategies. Participants were assessed before, after the intervention, and one month later with a posturography test (Sway Speed and Limits of Stability) and clinical scales. Results In contrast to other subjects, the most chronic participants failed to improve their sway and to maintain the benefits detected in the Limits of Stability after the intervention. Although all the participants improved in those clinical tests that better matched the trained skills, time since injury limited the improvement, and over all, the maintenance of gains. Conclusion Time since injury limits but does not prevent improvement in chronic stages post-stroke, and this effect appears to be more pronounced with maintaining gains. These findings support that training duration and intensity as well as type of therapy may need to be adjusted based on time post-stroke.This work was supported by Universitat Politecnica de Valencia (Grant PAID-10-16).Llorens Rodríguez, R.; Noé, E.; Alcañiz Raya, ML.; Deutsch, JE. (2017). Time since injury limits but does not prevent improvement and maintenance of gains in balance in chronic stroke. Brain Injury. 32(3):303-309. https://doi.org/10.1080/02699052.2017.1418905S303309323Pekna, M., Pekny, M., & Nilsson, M. (2012). Modulation of Neural Plasticity as a Basis for Stroke Rehabilitation. Stroke, 43(10), 2819-2828. doi:10.1161/strokeaha.112.654228Teasell, R., & Hussein, N. (2016). General Concepts: Therapies for Rehabilitation and Recovery. Ischemic Stroke Therapeutics, 195-201. doi:10.1007/978-3-319-17750-2_18Page, S. J., Gater, D. R., & Bach-y-Rita, P. (2004). Reconsidering the motor recovery plateau in stroke rehabilitation11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors(s) or upon any organization with which the author(s) is/are associated. Archives of Physical Medicine and Rehabilitation, 85(8), 1377-1381. doi:10.1016/j.apmr.2003.12.031Balasch i Bernat, M., Balasch i Parisi, S., Noé Sebastián, E., Dueñas Moscardó, L., Ferri Campos, J., & Lopez-Bueno, L. (2015). Study of the Recovery Patterns of Elderly Subacute Stroke Patients in an Interdisciplinary Neurorehabilitation Unit. Journal of Stroke and Cerebrovascular Diseases, 24(10), 2213-2218. doi:10.1016/j.jstrokecerebrovasdis.2015.05.014Maulden, S. A., Gassaway, J., Horn, S. D., Smout, R. J., & DeJong, G. (2005). Timing of Initiation of Rehabilitation After Stroke. Archives of Physical Medicine and Rehabilitation, 86(12), 34-40. doi:10.1016/j.apmr.2005.08.119Paolucci, S., Antonucci, G., Grasso, M. G., Morelli, D., Troisi, E., Coiro, P., & Bragoni, M. (2000). Early versus delayed inpatient stroke rehabilitation: A matched comparison conducted in Italy. Archives of Physical Medicine and Rehabilitation, 81(6), 695-700. doi:10.1016/s0003-9993(00)90095-9Cassidy, J. M., & Cramer, S. C. (2016). Spontaneous and Therapeutic-Induced Mechanisms of Functional Recovery After Stroke. Translational Stroke Research, 8(1), 33-46. doi:10.1007/s12975-016-0467-5Gauthier, L. V., Taub, E., Perkins, C., Ortmann, M., Mark, V. W., & Uswatte, G. (2008). Remodeling the Brain. Stroke, 39(5), 1520-1525. doi:10.1161/strokeaha.107.502229Yin, D., Luo, Y., Song, F., Xu, D., Peterson, B. S., Sun, L., … Fan, M. (2013). Functional reorganization associated with outcome in hand function after stroke revealed by regional homogeneity. Neuroradiology, 55(6), 761-770. doi:10.1007/s00234-013-1146-9Weiss, A., Suzuki, T., Bean, J., & Fielding, R. A. (2000). High Intensity Strength Training Improves Strength and Functional Performance After Stroke. American Journal of Physical Medicine & Rehabilitation, 79(4), 369-376. doi:10.1097/00002060-200007000-00009ENG, J. J., CHU, K. S., MARIA KIM, C., DAWSON, A. S., CARSWELL, A., & HEPBURN, K. E. (2003). A Community-Based Group Exercise Program for Persons with Chronic Stroke. Medicine & Science in Sports & Exercise, 35(8), 1271-1278. doi:10.1249/01.mss.0000079079.58477.0bMount, J., Bolton, M., Cesari, M., Guzzardo, K., & Tarsi, J. (2005). Group Balance Skills Class for People with Chronic Stroke. Journal of Neurologic Physical Therapy, 29(1), 24-33. doi:10.1097/01.npt.0000282259.81949.0eYang, Y.-R., Wang, R.-Y., Lin, K.-H., Chu, M.-Y., & Chan, R.-C. (2006). Task-oriented progressive resistance strength training improves muscle strength and functional performance in individuals with stroke. Clinical Rehabilitation, 20(10), 860-870. doi:10.1177/0269215506070701Fritz, S. L., Pittman, A. L., Robinson, A. C., Orton, S. C., & Rivers, E. D. (2007). An Intense Intervention for Improving Gait, Balance, and Mobility for Individuals With Chronic Stroke: A Pilot Study. Journal of Neurologic Physical Therapy, 31(2), 71-76. doi:10.1097/npt.0b013e3180674a3cMacko, R. F. (2008). Adaptive physical activity improves mobility function and quality of life in chronic hemiparesis. The Journal of Rehabilitation Research and Development, 45(2), 323-328. doi:10.1682/jrrd.2007.02.0025Lee, S. W., Shin, D. C., & Song, C. H. (2013). The Effects of Visual Feedback Training on Sitting Balance Ability and Visual Perception of Patients with Chronic Stroke. Journal of Physical Therapy Science, 25(5), 635-639. doi:10.1589/jpts.25.635Tsaklis, P. V., Grooten, W. J. A., & Franzén, E. (2012). Effects of Weight-Shift Training on Balance Control and Weight Distribution in Chronic Stroke: A Pilot Study. Topics in Stroke Rehabilitation, 19(1), 23-31. doi:10.1310/tsr1901-23Gil-Gómez, J.-A., Lloréns, R., Alcañiz, M., & Colomer, C. (2011). Effectiveness of a Wii balance board-based system (eBaViR) for balance rehabilitation: a pilot randomized clinical trial in patients with acquired brain injury. Journal of NeuroEngineering and Rehabilitation, 8(1), 30. doi:10.1186/1743-0003-8-30Lloréns, R., Albiol, S., Gil-Gómez, J.-A., Alcañiz, M., Colomer, C., & Noé, E. (2014). Balance rehabilitation using custom-made Wii Balance Board exercises: clinical effectiveness and maintenance of gains in an acquired brain injury population. International Journal on Disability and Human Development, 13(3). doi:10.1515/ijdhd-2014-0323Lloréns, R., Gil-Gómez, J.-A., Alcañiz, M., Colomer, C., & Noé, E. (2014). Improvement in balance using a virtual reality-based stepping exercise: a randomized controlled trial involving individuals with chronic stroke. Clinical Rehabilitation, 29(3), 261-268. doi:10.1177/0269215514543333Lloréns, R., Noé, E., Colomer, C., & Alcañiz, M. (2015). Effectiveness, Usability, and Cost-Benefit of a Virtual Reality–Based Telerehabilitation Program for Balance Recovery After Stroke: A Randomized Controlled Trial. Archives of Physical Medicine and Rehabilitation, 96(3), 418-425.e2. doi:10.1016/j.apmr.2014.10.019Dromerick, A. W., Edwardson, M. A., Edwards, D. F., Giannetti, M. L., Barth, J., Brady, K. P., … Newport, E. L. (2015). Critical periods after stroke study: translating animal stroke recovery experiments into a clinical trial. Frontiers in Human Neuroscience, 9. doi:10.3389/fnhum.2015.00231Geiger, R. A., Allen, J. B., O’Keefe, J., & Hicks, R. R. (2001). Balance and Mobility Following Stroke: Effects of Physical Therapy Interventions With and Without Biofeedback/Forceplate Training. Physical Therapy, 81(4), 995-1005. doi:10.1093/ptj/81.4.995Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). «Mini-mental state». Journal of Psychiatric Research, 12(3), 189-198. doi:10.1016/0022-3956(75)90026-6Romero, M., Sánchez, A., Marín, C., Navarro, M. D., Ferri, J., & Noé, E. (2012). Utilidad clínica de la versión en castellano del Mississippi Aphasia Screening Test (MASTsp): validación en pacientes con ictus. Neurología, 27(4), 216-224. doi:10.1016/j.nrl.2011.06.006Llorens, R., Latorre, J., Noé, E., & Keshner, E. A. (2016). Posturography using the Wii Balance Board™. Gait & Posture, 43, 228-232. doi:10.1016/j.gaitpost.2015.10.002Duncan, P. W., Weiner, D. K., Chandler, J., & Studenski, S. (1990). Functional Reach: A New Clinical Measure of Balance. Journal of Gerontology, 45(6), M192-M197. doi:10.1093/geronj/45.6.m192Jones, C. J., Rikli, R. E., & Beam, W. C. (1999). A 30-s Chair-Stand Test as a Measure of Lower Body Strength in Community-Residing Older Adults. Research Quarterly for Exercise and Sport, 70(2), 113-119. doi:10.1080/02701367.1999.10608028Hill, K. D. (1996). A New Test of Dynamic Standing Balance for Stroke Patients: Reliability, Validity and Comparison with Healthy Elderly. Physiotherapy Canada, 48(4), 257-262. doi:10.3138/ptc.48.4.257Zaino, C. A., Marchese, V. G., & Westcott, S. L. (2004). Timed Up and Down Stairs Test: Preliminary Reliability and Validity of a New Measure of Functional Mobility. Pediatric Physical Therapy, 16(2), 90-98. doi:10.1097/01.pep.0000127564.08922.6aPodsiadlo, D., & Richardson, S. (1991). The Timed «Up & Go»: A Test of Basic Functional Mobility for Frail Elderly Persons. Journal of the American Geriatrics Society, 39(2), 142-148. doi:10.1111/j.1532-5415.1991.tb01616.xBohannon, R. W., Andrews, A. W., & Thomas, M. W. (1996). Walking Speed: Reference Values and Correlates for Older Adults. Journal of Orthopaedic & Sports Physical Therapy, 24(2), 86-90. doi:10.2519/jospt.1996.24.2.86Cho, K., Lee, K., Lee, B., Lee, H., & Lee, W. (2014). Relationship between Postural Sway and Dynamic Balance in Stroke Patients. Journal of Physical Therapy Science, 26(12), 1989-1992. doi:10.1589/jpts.26.1989Gagnon, D., Nadeau, S., & Tam, V. (2006). Ideal timing to transfer from an acute care hospital to an interdisciplinary inpatient rehabilitation program following a stroke: an exploratory study. BMC Health Services Research, 6(1). doi:10.1186/1472-6963-6-151Myint, J. M. W. W., Yuen, G. F. C., Yu, T. K. K., Kng, C. P. L., Wong, A. M. Y., Chow, K. K. C., … Chun Por Wong. (2008). A study of constraint-induced movement therapy in subacute stroke patients in Hong Kong. Clinical Rehabilitation, 22(2), 112-124. doi:10.1177/0269215507080141Page, S. J., Sisto, S., Levine, P., & McGrath, R. E. (2004). Efficacy of modified constraint-induced movement therapy in chronic stroke: a single-blinded randomized controlled trial 11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors(s) or upon any organization with which the author(s) is/are associated. Archives of Physical Medicine and Rehabilitation, 85(1), 14-18. doi:10.1016/s0003-9993(03)00481-7Ullberg, T., Zia, E., Petersson, J., & Norrving, B. (2015). Changes in Functional Outcome Over the First Year After Stroke. Stroke, 46(2), 389-394. doi:10.1161/strokeaha.114.006538Clanchy, K. M., Tweedy, S. M., & Trost, S. G. (2016). Evaluation of a Physical Activity Intervention for Adults With Brain Impairment. Neurorehabilitation and Neural Repair, 30(9), 854-865. doi:10.1177/1545968316632059Colomer, C., Llorens, R., Noé, E., & Alcañiz, M. (2016). Effect of a mixed reality-based intervention on arm, hand, and finger function on chronic stroke. Journal of NeuroEngineering and Rehabilitation, 13(1). doi:10.1186/s12984-016-0153-6Geurts, A. C. H., de Haart, M., van Nes, I. J. W., & Duysens, J. (2005). A review of standing balance recovery from stroke. Gait & Posture, 22(3), 267-281. doi:10.1016/j.gaitpost.2004.10.002Lang, C. E., MacDonald, J. R., & Gnip, C. (2007). Counting Repetitions: An Observational Study of Outpatient Therapy for People with Hemiparesis Post-Stroke. Journal of Neurologic Physical Therapy, 31(1), 3-10. doi:10.1097/01.npt.0000260568.31746.34Whitall, J., Waller, S. M., Silver, K. H. C., & Macko, R. F. (2000). Repetitive Bilateral Arm Training With Rhythmic Auditory Cueing Improves Motor Function in Chronic Hemiparetic Stroke. Stroke, 31(10), 2390-2395. doi:10.1161/01.str.31.10.2390Hesse, S., Schulte-Tigges, G., Konrad, M., Bardeleben, A., & Werner, C. (2003). Robot-assisted arm trainer for the passive and active practice of bilateral forearm and wrist movements in hemiparetic subjects11An organization with which 1 or more of the authors is associated has received or will receive financial benefits from a commercial party having a direct financial interest in the results of the research supporting this article. Archives of Physical Medicine and Rehabilitation, 84(6), 915-920. doi:10.1016/s0003-9993(02)04954-