'Physio's not going to repair a torn tendon': patient decision-making related to surgery for rotator cuff related shoulder pain

BACKGROUND

Rotator cuff related shoulder pain (RCRSP) is a common and disabling shoulder condition and surgical management is becoming more common. The rates and costs of surgical interventions have been on the rise. Understanding decision-making related to surgery and providing adequate information to people with RCRSP may improve patient-centred care and potentially reduce rates of surgery.

OBJECTIVES

To explore the decision-making processors of people who have undertaken surgery for RCRSP.

DESIGN

An in-depth thematic analysis.

METHOD

Interviews were conducted with patients from Melbourne who had had surgical management for RCRSP. Data were analysed using an inductive thematic approach.

RESULTS

Fifteen participants were recruited. Six key themes emerged: (1) Needing to get it done: "It was necessary to remedy the dire situation"; (2) Non-surgical treatment experience:" I knew that I'd done all I could"; (3) Mechanical problem:" Physio's not going to repair a torn tendon"; (4) Trust in medical professionals "If they told me that I needed to swallow a thousand spiders, I would have done it."; (5) Varied information sources "Dr Google played a big part in it"; (6) Organisational barriers "It was absolutely useless, my insurance."

CONCLUSION

Surgery appears to be commonly precipitated by unremitted severe symptoms and failed non-surgical treatment. While there was strong trust in highly trained surgeons, decision to undergo surgery also drew on questionable pathoanatomical beliefs and instances of inadequate patient information about treatment choices and risks that may be addressed by adopting a more patient-centred care approach.IMPLICATIONS FOR REHABILITATIONUnderstanding decision-making related to surgery and providing adequate information to people with rotator cuff related shoulder pain may improve patient-centred care.Surgery appears to be commonly precipitated by unremitted severe symptoms and failed non-surgical treatment.Decision to undergo surgery sometimes drew on questionable pathoanatomical beliefs.There was strong trust in highly trained surgeons but there were instances of inadequate patient information about treatment choices and risks.

Telehealth sounds a bit challenging, but it has potential: participant and physiotherapist experiences of gym-based exercise intervention for Achilles tendinopathy monitored via telehealth

Background

Although telehealth is becoming more popular for delivery of care for individuals with musculoskeletal pain, to our knowledge telehealth has not been used to manage Achilles tendinopathy. This research aimed to explore the experience of participants and physiotherapists with gym-based exercise interventions for Achilles tendinopathy monitored via videoconference.

Methods

A qualitative, interpretive description design was performed using semi-structured interviews (8 participants) and a focus group (7 physiotherapists). Participants and physiotherapists were interviewed about their experiences of the use of telehealth during a gym-based exercise intervention incorporating different calf load parameters for Achilles tendinopathy. We employed an inductive thematic analysis approach to analyse the data.

Results

Three themes identified from both participants and physiotherapists included i) acceptability of telehealth; ii) enablers to adherence with telehealth; and iii) barriers to adherence with telehealth. Two extra themes arose from participants regarding adherence with gym-based exercise, including enablers to adherence with the exercise intervention, and barriers to adherence with the exercise intervention. Both participants and physiotherapists expressed overall satisfaction and acceptability of telehealth monitoring of gym-based exercise.

Conclusion

Gym-based exercise intervention for Achilles tendinopathy involving weekly telehealth monitoring was acceptable to both participants and physiotherapists. Potential enablers and barriers were identified that may improve adherence to this type of intervention.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-020-03907-w.

Investigation of the First Seven Reported Cases of Candida auris, a Globally Emerging Invasive, Multidrug-Resistant Fungus-United States, May 2013-August 2016

November 11, 2016/65(44);1234-1237. What is already known about this topic? Candida auris is an emerging pathogenic fungus that has been reported from at least a dozen countries on four continents during 2009-2015. The organism is difficult to identify using traditional biochemical methods, some isolates have been found to be resistant to all three major classes of antifungal medications, and C. auris has caused health care-associated outbreaks. What is added by this report? This is the first description of C. auris cases in the United States. C. auris appears to have emerged in the United States only in the last few years, and U.S. isolates are related to isolates from South America and South Asia. Evidence from U.S. case investigations suggests likely transmission of the organism occurred in health care settings. What are the implications for public health practice? It is important that U.S. laboratories accurately identify C. auris and for health care facilities to implement recommended infection control practices to prevent the spread of C. auris. Local and state health departments and CDC should be notified of possible cases of C. auris and of isolates of C. haemulonii and Candida spp. that cannot be identified after routine testing.

Possible causal association of idiopathic inflammatory bowel disease with thrombocytopenia in the dog

Extraintestinal manifestations of inflammatory bowel disease (IBD) are commonly observed in humans but are poorly documented in companion animals. Thrombocytopenia is an uncommon but well-documented extraintestinal hematological abnormality in humans; however, there are no previous reports of IBD and concurrent thrombocytopenia in the veterinary literature. Seven dogs having idiopathic IBD and concurrent thrombocytopenia were identified and evaluated retrospectively (this represents an incidence of 2.5% in the authors' IBD population). Obvious known causes for thrombocytopenia were eliminated by diagnostic testing as deemed appropriate by the clinician of record. Thrombocytopenia resolved with treatment for the IBD in some but not all patients. This is similar to reports in humans. Thrombocytopenia typically appears to be subclinical, and the severity does not correlate with the degree of intestinal inflammation defined histopathologically. However, quantitative platelet counts should be monitored during IBD therapy, as additional immunosuppression may be required to treat thrombocytopenia, despite resolution of gastrointestinal signs. It is speculated that thrombocytopenia may be causally associated with canine IBD, possibly secondary to immune stimulation from lumenal bacterial antigens, altered immunological regulation, or both.

Holocene sediment storage in the Humber Estuary

In order to determine the processes that have governed the accumulation and erosion of sediments in the Humber Estuary (English North Sea coast) through the Holocene, the character, volume and source of sediments were studied. Eight sediment suites were identified on the basis of chemostratigraphy, lithostratigraphy and mineralogy. The locally sourced, freshwater, Basal Suite is overlain by the Newland and Butterwick Suites, deposited between c. 8 and 7.4 cal. ka bp in brackish environments behind a morainic barrier at St Andrew’s Dock, Hull. These are overlain by the largely marine, saltmarsh sediments of the Garthorpe Suite, which in turn are overlain, with erosional contact, by the channel sandflat and mudflat deposits of the Saltend, Sunk Island and Skeffling Suites. Most of the Saltend Suite is likely to have been deposited since c. 4 ka ago, whilst the Sunk Island and Skeffling Suites are likely to have been deposited since Medieval times and from the late eighteenth century onwards, respectively, as indicated by their concentrations of anthropogenic metals. On the coast, the Spurn Suite consists of sediments, associated with a spit system, which are almost entirely marine in origin. The suites show a progressive increase in marine influence; sediments of the oldest suite being entirely from the terrestrial catchment, those of the younger suites from erosion of the North Sea floor and coast. The relationships between suites show that during the last 4 ka the geomorphological evolution of the estuary has been marked by widespread erosion episodes that have led to the partial removal or redistribution of earlier deposits. By modelling the volumes of the suites it can be shown that, of the total volume of the estuarine fill (9.6 km3), over half is likely to have been deposited during this period.

Sediment provenance and flux in the Tees Estuary: the record from the Late Devensian to the present

The influences of sea-level, climate, human activity and coastal morphology on post-glacial sediment flux and deposition in the Tees Estuary were considered in a multidisciplinary investigation of the Late Pleistocene and Holocene sedimentary record. The following tripartite division was identified using a combination of lithostratigraphic and geochemical data: a Late Glacial laminated clay providing evidence of a former proglacial lake and a proxy record of climate change; an early-mid-Holocene intercalated sequence of tidal silts and clays and peats; and a late Holocene succession characterized by increasing evidence of human activity and metal contamination. Sea-level change has been identified as the main control on sedimentationviadecelerating sea-level rise and changing tidal dynamics betweenc.8 and 3 kabp. Climate controlled the sequence of rhythmite thickness in the Late Glacial clays, whilst increased wetness afterc.3 kabpmay have encouraged terrestrial sediment influx. Enhanced sediment supply to the coastal zone can also be attributed to increasing human activity in the catchment from the Bronze Age onward, first as a consequence of clearance, and subsequently as a result of mining and industrial expansion. Fine-grained sediment flux has almost exclusively been from the Tees catchment to the coast, extending offshore during rebound-induced collapse and erosion of the Late Glacial lake basin. The only notable onshore sediment flux has been the deposition of marine sands in the outer estuary betweenc.6.5 and 3.5 kabp.

The relationship between synovitis and bone changes in early untreated rheumatoid arthritis: a controlled magnetic resonance imaging study

OBJECTIVE

The interrelationship between synovitis and bone damage in rheumatoid arthritis (RA) is a subject of controversy. Using magnetic resonance imaging (MRI), this study followed the bone changes in early RA and determined their relationship to synovitis.

METHODS

Thirty-one patients with early RA who had swelling of the metacarpophalangeal (MCP) joints and 31 healthy control subjects with no clinical evidence of arthritis underwent MRI of the second through fifth MCP joints of the dominant hand by use of a 1.5T scanner. Coronal T1-weighted and T2-fat suppressed (FS) sequences were performed to evaluate bone edema, and gadolinium-diethylenetriaminepentaacetic acid (Gd-DTPA) pulse sequences were obtained to evaluate synovitis. Bony abnormalities were described as bone edema (low signal on T1-weighted sequences and intermediate/high signal on T2 FS sequences adjacent to the bone cortex) or as bone cysts (circular juxtacortical abnormalities with low signal on T1-weighted images and with very high signal on T2 FS sequences). Contrast and noncontrast MRI films were scored in a blinded manner, and Fisher's exact probability test was used to determine differences between groups.

RESULTS

Twenty-one of the 31 RA patients (68%) had bone edema, which was seen in 43 of 124 joints (35% of joints) and 3 of the 31 control subjects had bone edema seen in 3 of 124 joints (2% of joints) (P < 0.0001). Thirty RA patients (97%) had Gd-DTPA-confirmed MCP joint synovitis, and bone edema was seen in 40 of the 75 joints with Gd-DTPA-proven synovitis (53%), but in only 3 of 49 without (6%) (P < 0.0001).

CONCLUSION

MCP joint bone edema is present in the majority of patients with RA at presentation, but is seen only occasionally in normal control subjects. The fact that bone edema occurred rarely in the absence of synovitis in patients with RA suggests that bony changes in RA are secondary to synovitis.

Cytologic examination of exfoliative specimens obtained during endoscopy for diagnosis of gastrointestinal tract disease in dogs and cats

OBJECTIVE

To determine whether cytologic examination of exfoliative specimens obtained during endoscopy was as useful as histologic examination of mucosal biopsy specimens for the diagnosis of gastrointestinal tract disease in dogs and cats and to compare the diagnostic accuracy of 2 techniques (brush or touch) in preparing specimens for cytologic examination.

DESIGN

Prospective case series.

ANIMALS

85 dogs and 23 cats.

PROCEDURE

Specimens for cytologic and histologic examination were obtained during routine endoscopic examination of the stomach, small intestine, and colon. A diagnosis was made on the basis of cytologic findings (graded objectively) and compared with the diagnosis on the basis of histologic findings.

RESULTS

The diagnostic accuracy of cytologic examination was high for all 3 organs. Sensitivities, specificities, and predictive values of positive and negative results were > 90% in most instances. The diagnostic accuracy of the brush technique was equal or superior to that of the touch technique for 84% of specimens. The brush technique was most useful in detecting cellular infiltrates in the lamina propria, whereas the touch technique was more likely to detect acute mucosal inflammation. Percentages of false-positive (3.2%) and false-negative (6.9%) cytologic interpretations were low.

CLINICAL IMPLICATIONS

Endoscopy is safe and requires little time to procure specimens for cytologic examination, which can be obtained concurrently with mucosal biopsy specimens. Cytologic examination of exfoliative specimens obtained during endoscopy is a useful and reliable adjunct to histologic examination of biopsy specimens in the diagnosis of gastrointestinal tract disease in dogs and cats.

Xenopus laevis fertilisation: analysis of sperm motility in egg jelly using video light microscopy

Xenopus laevis eggs are surrounded by an extracellular matrix consisting of a vitelline envelope, and three jelly layers, J1, J2, and J3 (from egg surface outward). The jelly layers vary in thickness (about 150, 15 and 200 microns for J1, J2 and J3 respectively) but all are translucent allowing observation of sperm penetration. Video microscopy demonstrated that sperm are able to penetrate and traverse J3 at velocities approaching 30 microns/s. Sperm swim through jelly in a corkscrew-like manner with their rotational and forward velocities being tightly coupled at about 30 degrees/micron forward travel. They are propelled by whip-like power strokes involving hairpin bends in the flagellum that are generated every 180 degrees of rotation and which are propagated from base to tip. The overall trajectories of individual sperm are quite variable. Many sperm head directly for J2 but some do not, these swimming circumferentially, or even away from the egg surface. Most sperm (over 97%) that enter the jelly do not get to the egg surface but are stopped at a variety of positions within J3 or at the outer surface of J2. Efficient sperm penetration and passage through the jelly layers requires a low electrolyte concentration in the surrounding medium, and is inhibited by the lectin wheat germ agglutin (WGA) in a dose-dependent manner. WGA does not block sperm penetration of J3 but does block further progression towards the egg surface. This observation suggests that sperm motility within the jelly is dependent on the carbohydrate moieties of the large glycoconjugates present, and that their alteration by WGA binding accounts for the inability of sperm to reach the egg surface and fertilise the egg.

Staff:staff and staff:client reliability of the Schalock & Keith (1993) Quality of Life Questionnaire

A small-scale study of the inter-rater and staff:client reliability of the Schalock & Keith (1993) Quality of Life Questionnaire (QOL-Q) was conducted. Whilst the sample size was small and the QOL-Q achieved an acceptable overall level of reliability, the study replicated the pattern of low staff:client concordance and staff overestimation of the independence and autonomy of clients reported by Reiter & Bendov (1996). The results are briefly discussed in the context of the ongoing debate about the utility of proxy response in the literature.

Toward the production of bispecific antibody fragments for clinical applications

The clinical potential of bispecific antibodies (BsAb) has been hindered by the difficulty of obtaining clinical grade material, together with the immunogenicity of rodent-derived BsAb in patients. The supply issue is being directly addressed by recombinant methods for BsAb fragment production reviewed here. The immunogenicity issue will likely be overcome by the use of humanized or human antibodies. Currently, three technologies appear suitable for the production of BsAb fragments for clinical applications: BsF(ab')2 assembled from Fab' fragments expressed in Escherichia coli, BsF(ab')2 assembled using leucine zippers, and diabodies.

Human FcERI-IgG and humanized anti-IgE monoclonal antibody MaE11 block passive sensitization of human and rhesus monkey lung

IgE antibodies are thought to play an important role in the induction of allergic inflammation of the bronchi. In this study we assessed the capacity of two inhibitors, FcERI-IgG, an immunoadhesin made up of the alpha chain of the high-affinity IgE receptor joined to a truncated IgG heavy chain, and MaE11, a humanized murine anti-human IgE antibody, to prevent allergen sensitization. Lung parenchyma strips from rhesus monkeys and human beings were passively sensitized for 20 hours with serum from a ragweed-sensitive patient in the presence of 0, 1-, 5-, or 10-fold concentrations of the inhibitors relative to IgE. The parenchymal strips were then suspended in a superfusion apparatus for measurement of isometric tone and collection of superfusate for histamine analysis in response to challenge with antigen E (AgE). Nonsensitized tissues did not react to AgE challenge, whereas AgE challenge of passively sensitized tissues resulted in a time-dependent parenchymal contraction and histamine release. Both FcERI-IgG and MaE11 completely abolished the AgE-induced contraction and histamine release in a dose-dependent manner. In addition, passively sensitized lung tissues failed to respond to direct challenge with either FcERI-IgG or MaE11. The results of this study suggest that FcERI-IgG and MaE11 may have important immunotherapeutic benefit for the amelioration of IgE-mediated diseases.

Dynamic MRI of the pancreas--gadolinium enhancement in normal tissue

The purpose of this study was to measure signal enhancement over time in the normal pancreas after intravenous bolus infection of gadolinium-DTPA (Schering Health Care Ltd) (Gd-DTPA). Data was obtained from 25 patients with no evidence of pancreatic disease before, immediately after and over a 2 min period following injection of Gd-DTPA (Magnevist 0.2 ml per kg). Scans were obtained using a turboFLASH sequence which allows 11 slices to be acquired during a single breathhold period of 19 s. Five mm thick slices were acquired in the coronal/oblique plane at 0.5 mm intervals. A pre-contrast block of slices was obtained followed by dynamic post-contrast scanning with the first of four acquisitions beginning 12-15 s after bolus injection. A 10 s interval between each acquisition was selected to allow the patients to breathe. Signal intensity for each acquisition was measured for the pancreatic head and tail and also for the liver. All values were normalized to fat. Marked enhancement of the pancreas was seen in all cases with peak enhancement occurring in the first and second post-contrast acquisition. The pancreatic duct was more easily seen after contrast injection.

Comparison of MR and CT scanning in severe acute pancreatitis: initial experiences

Magnetic resonance imaging was performed at 1.0 T in seven patients with severe acute pancreatitis. A T2-weighted spin echo sequence and a breath-hold multislice rapid gradient echo sequence (TurboFLASH) were used in each patient. TurboFLASH imaging was performed before and after intravenous gadopentetate-dimeglumine (Gd-DTPA). All MRI images were compared with a recent contrast-enhanced CT scan. Postgadolinium MRI was equivalent to contrast-enhanced CT in differentiating viable pancreatic parenchyma from areas of pancreatic necrosis. MRI identified the presence of gas in a case of pancreatic abscess but failed to identify small foci of pancreatic calcification demonstrated in one case by CT. MRI was also equivalent to CT in assessing the location and extent of peripancreatic inflammatory changes and fluid collections. However, MRI, particularly the T2-weighted spin echo, was superior to CT in characterizing the complex nature of such inflammatory changes in one case. Initial experience suggests that MRI is a valuable technique in assessing patients with severe acute pancreatitis.

Human IgE receptor alpha-chain IgG chimera blocks passive cutaneous anaphylaxis reaction in vivo

Cross-linking of the high affinity IgE receptor (Fc epsilon RI) expressed on mast cells and basophils is essential for triggering anaphylaxis in vivo. Previously, other investigators have tried to produce competitive inhibitors using IgE peptide analogues and anti-IgE antibodies with limited success. To create a novel specific inhibitor of IgE that can block binding of IgE to Fc epsilon RI without the capacity to stimulate degranulation, we made an Fc epsilon RI-IgG immunoadhesin. The Fc epsilon RI-IgG was constructed by gene fusion of the extracellular portion of the human alpha-chain of Fc epsilon RI, which contains the high affinity binding site for IgE, with a truncated human IgG1 H chain C region. The Fc epsilon RI-IgG recognizes both human and murine IgE. Coincubation of Fc epsilon RI-IgG with murine IgE prevented sensitization of RBL-2H3 cells and the subsequent histamine release in response to anti-IgE. Similarly, when the Fc epsilon RI-IgG was preincubated with equimolar concentrations of either hyperimmune mouse sera or purified mouse IgE, it completely blocked the passive cutaneous anaphylaxis reaction in rats. Furthermore, i.v. administration of Fc epsilon RI-IgG following intracutaneous injection of serum from DNP-immunized mice was able to block the passive cutaneous anaphylaxis reaction in a time-dependent fashion. These results demonstrate that Fc epsilon RI-IgG is a potent inhibitor of IgE binding to intracutaneous mast cells in vivo and may prove clinically useful for the treatment of IgE-mediated disease.

Human IgE receptor alpha-chain IgG chimera blocks passive cutaneous anaphylaxis reaction in vivo

Cross-linking of the high affinity IgE receptor (Fc epsilon RI) expressed on mast cells and basophils is essential for triggering anaphylaxis in vivo. Previously, other investigators have tried to produce competitive inhibitors using IgE peptide analogues and anti-IgE antibodies with limited success. To create a novel specific inhibitor of IgE that can block binding of IgE to Fc epsilon RI without the capacity to stimulate degranulation, we made an Fc epsilon RI-IgG immunoadhesin. The Fc epsilon RI-IgG was constructed by gene fusion of the extracellular portion of the human alpha-chain of Fc epsilon RI, which contains the high affinity binding site for IgE, with a truncated human IgG1 H chain C region. The Fc epsilon RI-IgG recognizes both human and murine IgE. Coincubation of Fc epsilon RI-IgG with murine IgE prevented sensitization of RBL-2H3 cells and the subsequent histamine release in response to anti-IgE. Similarly, when the Fc epsilon RI-IgG was preincubated with equimolar concentrations of either hyperimmune mouse sera or purified mouse IgE, it completely blocked the passive cutaneous anaphylaxis reaction in rats. Furthermore, i.v. administration of Fc epsilon RI-IgG following intracutaneous injection of serum from DNP-immunized mice was able to block the passive cutaneous anaphylaxis reaction in a time-dependent fashion. These results demonstrate that Fc epsilon RI-IgG is a potent inhibitor of IgE binding to intracutaneous mast cells in vivo and may prove clinically useful for the treatment of IgE-mediated disease.

Rapid dynamic contrast-enhanced magnetic resonance imaging of the liver and portal vein

The purpose of this study was firstly to show the diagnostic value of a rapid acquisition multislice sequence (TurboFLASH) during bolus injection of gadolinium-DTPA by comparing it with the pulse sequences currently used for abdominal studies and secondly to develop improved scanning protocols for the liver. Patients were referred for upper abdominal studies including portal vein assessment. 40 patients were imaged in the coronal plane using a multislice TurboFLASH (TF) sequence (TR = 100; TE = 4) acquired during a breath-hold period of 19 s. The short echo time allows up to 11 slices of 5 mm thickness to be acquired simultaneously. Images were obtained before, during and after bolus administration of Gd-DTPA. The slices from each acquisition were combined using a maximum intensity projection algorithm to include all the vessels on a single image. Initially each patient was scanned using a conventional axial T2 weighted spin-echo sequence (T2W-SE) (TR2000; TE = 45/90) and a coronal T1 weighted spin-echo sequence (TR450; TE = 15). The clarity of the demonstration of vascular anatomy was compared and scored for all sequences by two radiologists. Vessel patency, the conspicuity of mass lesions and the spread of tumour to adjacent structures were also scored. The anatomy of the main portal vein was significantly better shown by coronal TF images after bolus injection than on T2W-SE images or TF before Gd-DTPA. The right and left portal veins were equally well shown by coronal TF with Gd-DTPA and T2W-SE images. There was no significant difference between contrast enhanced TF and T2W-SE imaging in visualization of the hepatic veins. More lesions were demonstrated by post-contrast TF than by T2W-SE imaging. Portal venous occlusion was better appreciated by post-contrast TF. Our results demonstrate that Gd-DTPA TF imaging improves visualization of the main portal vein compared with SE sequences and provides a more accurate assessment of vessel patency. The segmental anatomy of the liver is better appreciated and the demonstration of focal liver lesions compared with T2W-SE images is improved during the non-equilibrium phase of enhancement. TF acquisitions before and after Gd-DTPA are obtained in approximately 5 min; thus a marked reduction in examination time can be achieved.

NMR T1 relaxation time of the brain during alcohol withdrawal and its lack of relationship with symptom severity

A significant fall in brain T1 relaxation time, consistent with a reduction in brain water of approximately 0.3%, occurred in 19 chronic alcoholic patients admitted for detoxification. There was no correlation between T1 and the severity of withdrawal symptoms and hence no evidence that changes in brain water levels contributed to the abstinence syndrome.