Biomechanical and ergonomic risks associated with cervical musculoskeletal dysfunction amongst surgeons: A systematic review

INTRODUCTION

Surgeons are at high risk of developing musculoskeletal symptoms due to a range of factors including, maladaptive positioning and surgical ergonomics. Cervical muscle strain and biomechanical load is most prevalent due to repetitive motions and prolonged static neck positioning. This issue is apparent through reports of prevalence between 10 and 74.4% among surgeons. The aim of this systematic review is to provide an objective assessment of the clinical evidence available and a descriptive analysis of the effects of kinematics and surgical ergonomics on the prevalence of surgeons' cervical musculoskeletal pain.

METHODS

This is PRISMA-compliant systematic review of clinical studies assessing the prevalence of cervical musculoskeletal dysfunction in surgeons by searching PUBMED and Ovid EMBASE databases from inception to 19th October 2023. Study quality was graded according to the National Institutes of Health study quality assessment tools.

RESULTS

A total of 9 studies were included in the final qualitative analysis. The use of loupes, open surgery and excessive neck flexion (>30°) were associated with cervical dysfunction. Comparison of study outcomes was challenging due to heterogeneity within study methods and the paucity of methodological quality.

CONCLUSION

The current literature assessing ergonomic and biomechanical factors predisposing surgeons to cervical musculoskeletal dysfunction is insufficient to provide reliable guidance for clinicians. Although the literature identifies factors contributing to work-related cervical dysfunction, few attempt to evaluate interventions for improved surgical ergonomics. An objective assessment of interventions that prompt postural correction with the aim to improve neck pain in surgeon cohorts is warranted.

The correlation between altmetric score and traditional measures of article impact for studies pertaining to spine trauma

PURPOSE

It is becoming increasingly common for researchers to share scientific literature via social media. Traditional bibliometrics have long been utilized to measure a study's academic impact, but they fail to capture the impact generated through social media sharing. Altmetric Attention Score (AAS) is a weighted count of all the online attention garnered by a study, and it is currently unclear whether a relationship with traditional bibliometrics exists.

METHODS

We identified the five highest-rated spine-specific and five highest-rated general orthopedic journals by Scopus CiteScore 2020. We then identified all the spine trauma studies across a 5-year span (2016-2020) within these journals and compared AAS with traditional bibliometrics using Independent t-tests and Pearson's correlational analyses.

RESULTS

No statistically significant relationships were identified between AAS and traditional bibliometrics for articles pertaining to spine trauma: Level of Evidence (R = - 0.02, p = 0.34), H-Index Primary Author (R =  < - 0.01, p = 0.50), H-Index Senior Author (R = - 0.04, p = 0.24), and Number of Citations (R = 0.01, p = 0.40). The top five articles by AAS include those pertaining to motorcycle injuries (AAS = 687), orthosis in thoracolumbar fractures (AAS = 199), golfing injuries (AAS = 166), smartphone-based teleradiology (AAS = 41), and auto racing injuries (AAS = 39).

CONCLUSION

The lack of overlap between these types of metrics suggests that AAS or similar alternative metrics should be used to measure an article's social impact. The social impact of an article should likewise be a factor in determining an article's overall impact along with its academic impact as measured by bibliometrics.

Ability to Process Multisensory Information Is Impaired in Open Angle Glaucoma

PRCIS

Patients with glaucoma demonstrated deficiencies in their ability to process multisensory information when compared with controls, with those deficiencies being related to glaucoma severity. Impaired multisensory integration (MSI) may affect the quality of life in individuals with glaucoma and may contribute to the increased prevalence of falls and driving safety concerns. Therapeutic possibilities to influence cognition in glaucoma should be explored.

PURPOSE

Glaucoma is a neurodegenerative disease of the optic nerve that has also been linked to cognitive health decline. This study explored MSI as a function of glaucoma status and severity.

METHODS

MSI was assessed in 37 participants with open angle glaucoma relative to 18 age-matched healthy controls. The sound-induced flash illusion was used to assess MSI efficiency. Participants were presented with various combinations of simultaneous visual and/or auditory stimuli and were required to indicate the number of visual stimuli observed for each of the 96 total presentations. Central retinal sensitivity was assessed as an indicator of glaucoma severity (MAIA; CenterVue).

RESULTS

Participants with glaucoma performed with equivalent capacity to healthy controls on unisensory trials ( F1,53 =2.222, P =0.142). Both groups performed equivalently on congruent multisensory trials involving equal numbers of auditory and visual stimuli F1,53 =1.032, P =0.314). For incongruent presentations, that is, 2 beeps and 1 flash stimulus, individuals with glaucoma demonstrated a greater influence of the incongruent beeps when judging the number of flashes, indicating less efficient MSI relative to age-matched controls ( F1,53 =11.45, P <0.002). In addition, MSI performance was positively correlated with retinal sensitivity ( F3,49 =4.042, P <0.025), adjusted R ²=0.15).

CONCLUSIONS

Individuals with open angle glaucoma exhibited MSI deficiencies that relate to disease severity. The type of deficiencies observed were similar to those observed among older individuals with cognitive impairment and balance issues. Impaired MSI may, therefore, be relevant to the increased prevalence of falls observed among individuals with glaucoma, a concept that merits further investigation.

Neural correlates of audiovisual narrative speech perception in children and adults on the autism spectrum: A functional magnetic resonance imaging study

Autistic individuals show substantially reduced benefit from observing visual articulations during audiovisual speech perception, a multisensory integration deficit that is particularly relevant to social communication. This has mostly been studied using simple syllabic or word-level stimuli and it remains unclear how altered lower-level multisensory integration translates to the processing of more complex natural multisensory stimulus environments in autism. Here, functional neuroimaging was used to examine neural correlates of audiovisual gain (AV-gain) in 41 autistic individuals to those of 41 age-matched non-autistic controls when presented with a complex audiovisual narrative. Participants were presented with continuous narration of a story in auditory-alone, visual-alone, and both synchronous and asynchronous audiovisual speech conditions. We hypothesized that previously identified differences in audiovisual speech processing in autism would be characterized by activation differences in brain regions well known to be associated with audiovisual enhancement in neurotypicals. However, our results did not provide evidence for altered processing of auditory alone, visual alone, audiovisual conditions or AV- gain in regions associated with the respective task when comparing activation patterns between groups. Instead, we found that autistic individuals responded with higher activations in mostly frontal regions where the activation to the experimental conditions was below baseline (de-activations) in the control group. These frontal effects were observed in both unisensory and audiovisual conditions, suggesting that these altered activations were not specific to multisensory processing but reflective of more general mechanisms such as an altered disengagement of Default Mode Network processes during the observation of the language stimulus across conditions.

Probing a neural unreliability account of auditory sensory processing atypicalities in Rett Syndrome

Background In the search for objective tools to quantify neural function in Rett Syndrome (RTT), which are crucial in the evaluation of therapeutic efficacy in clinical trials, recordings of sensory-perceptual functioning using event-related potential (ERP) approaches have emerged as potentially powerful tools. Considerable work points to highly anomalous auditory evoked potentials (AEPs) in RTT. However, an assumption of the typical signal-averaging method used to derive these measures is "stationarity" of the underlying responses - i.e. neural responses to each input are highly stereotyped. An alternate possibility is that responses to repeated stimuli are highly variable in RTT. If so, this will significantly impact the validity of assumptions about underlying neural dysfunction, and likely lead to overestimation of underlying neuropathology. To assess this possibility, analyses at the single-trial level assessing signal-to-noise ratios (SNR), inter-trial variability (ITV) and inter-trial phase coherence (ITPC) are necessary. Methods AEPs were recorded to simple 100Hz tones from 18 RTT and 27 age-matched controls (Ages: 6-22 years). We applied standard AEP averaging, as well as measures of neuronal reliability at the single-trial level (i.e. SNR, ITV, ITPC). To separate signal-carrying components from non-neural noise sources, we also applied a denoising source separation (DSS) algorithm and then repeated the reliability measures. Results Substantially increased ITV, lower SNRs, and reduced ITPC were observed in auditory responses of RTT participants, supporting a "neural unreliability" account. Application of the DSS technique made it clear that non-neural noise sources contribute to overestimation of the extent of processing deficits in RTT. Post-DSS, ITV measures were substantially reduced, so much so that pre-DSS ITV differences between RTT and TD populations were no longer detected. In the case of SNR and ITPC, DSS substantially improved these estimates in the RTT population, but robust differences between RTT and TD were still fully evident. Conclusions To accurately represent the degree of neural dysfunction in RTT using the ERP technique, a consideration of response reliability at the single-trial level is highly advised. Non-neural sources of noise lead to overestimation of the degree of pathological processing in RTT, and denoising source separation techniques during signal processing substantially ameliorate this issue.

Probing a neural unreliability account of auditory sensory processing atypicalities in Rett Syndrome

Background

In the search for objective tools to quantify neural function in Rett Syndrome (RTT), which are crucial in the evaluation of therapeutic efficacy in clinical trials, recordings of sensory-perceptual functioning using event-related potential (ERP) approaches have emerged as potentially powerful tools. Considerable work points to highly anomalous auditory evoked potentials (AEPs) in RTT. However, an assumption of the typical signal-averaging method used to derive these measures is "stationarity" of the underlying responses - i.e. neural responses to each input are highly stereotyped. An alternate possibility is that responses to repeated stimuli are highly variable in RTT. If so, this will significantly impact the validity of assumptions about underlying neural dysfunction, and likely lead to overestimation of underlying neuropathology. To assess this possibility, analyses at the single-trial level assessing signal-to-noise ratios (SNR), inter-trial variability (ITV) and inter-trial phase coherence (ITPC) are necessary.

Methods

AEPs were recorded to simple 100Hz tones from 18 RTT and 27 age-matched controls (Ages: 6-22 years). We applied standard AEP averaging, as well as measures of neuronal reliability at the single-trial level (i.e. SNR, ITV, ITPC). To separate signal-carrying components from non-neural noise sources, we also applied a denoising source separation (DSS) algorithm and then repeated the reliability measures.

Results

Substantially increased ITV, lower SNRs, and reduced ITPC were observed in auditory responses of RTT participants, supporting a "neural unreliability" account. Application of the DSS technique made it clear that non-neural noise sources contribute to overestimation of the extent of processing deficits in RTT. Post-DSS, ITV measures were substantially reduced, so much so that pre-DSS ITV differences between RTT and TD populations were no longer detected. In the case of SNR and ITPC, DSS substantially improved these estimates in the RTT population, but robust differences between RTT and TD were still fully evident.

Conclusions

To accurately represent the degree of neural dysfunction in RTT using the ERP technique, a consideration of response reliability at the single-trial level is highly advised. Non-neural sources of noise lead to overestimation of the degree of pathological processing in RTT, and denoising source separation techniques during signal processing substantially ameliorate this issue.

Neural correlates of multisensory enhancement in audiovisual narrative speech perception: a fMRI investigation

This fMRI study investigated the effect of seeing articulatory movements of a speaker while listening to a naturalistic narrative stimulus. It had the goal to identify regions of the language network showing multisensory enhancement under synchronous audiovisual conditions. We expected this enhancement to emerge in regions known to underlie the integration of auditory and visual information such as the posterior superior temporal gyrus as well as parts of the broader language network, including the semantic system. To this end we presented 53 participants with a continuous narration of a story in auditory alone, visual alone, and both synchronous and asynchronous audiovisual speech conditions while recording brain activity using BOLD fMRI. We found multisensory enhancement in an extensive network of regions underlying multisensory integration and parts of the semantic network as well as extralinguistic regions not usually associated with multisensory integration, namely the primary visual cortex and the bilateral amygdala. Analysis also revealed involvement of thalamic brain regions along the visual and auditory pathways more commonly associated with early sensory processing. We conclude that under natural listening conditions, multisensory enhancement not only involves sites of multisensory integration but many regions of the wider semantic network and includes regions associated with extralinguistic sensory, perceptual and cognitive processing.

Attentional influences on neural processing of biological motion in typically developing children and those on the autism spectrum

BACKGROUND

Biological motion imparts rich information related to the movement, actions, intentions and affective state of others, which can provide foundational support for various aspects of social cognition and behavior. Given that atypical social communication and cognition are hallmark symptoms of autism spectrum disorder (ASD), many have theorized that a potential source of this deficit may lie in dysfunctional neural mechanisms of biological motion processing. Synthesis of existing literature provides some support for biological motion processing deficits in autism spectrum disorder, although high study heterogeneity and inconsistent findings complicate interpretation. Here, we attempted to reconcile some of this residual controversy by investigating a possible modulating role for attention in biological motion processing in ASD.

METHODS

We employed high-density electroencephalographic recordings while participants observed point-light displays of upright, inverted and scrambled biological motion under two task conditions to explore spatiotemporal dynamics of intentional and unintentional biological motion processing in children and adolescents with ASD (n = 27), comparing them to a control cohort of neurotypical (NT) participants (n = 35).

RESULTS

Behaviorally, ASD participants were able to discriminate biological motion with similar accuracy to NT controls. However, electrophysiologic investigation revealed reduced automatic selective processing of upright biologic versus scrambled motion stimuli in ASD relative to NT individuals, which was ameliorated when task demands required explicit attention to biological motion. Additionally, we observed distinctive patterns of covariance between visual potentials evoked by biological motion and functional social ability, such that Vineland Adaptive Behavior Scale-Socialization domain scores were differentially associated with biological motion processing in the N1 period in the ASD but not the NT group.

LIMITATIONS

The cross-sectional design of this study does not allow us to definitively answer the question of whether developmental differences in attention to biological motion cause disruption in social communication, and the sample was limited to children with average or above cognitive ability.

CONCLUSIONS

Together, these data suggest that individuals with ASD are able to discriminate, with explicit attention, biological from non-biological motion but demonstrate diminished automatic neural specificity for biological motion processing, which may have cascading implications for the development of higher-order social cognition.

The Refractive Error and Vision Impairment Estimation with Spectacle Data Study

Purpose

To investigate whether spectacle lens sales data can be used to estimate the population distribution of refractive error among patients with ametropia and hence to estimate the current and future risk of vision impairment.

Design

Cross-sectional study.

Participants

A total of 141 547 436 spectacle lens sales records from an international European lens manufacturer between 1998 and 2016.

Methods

Anonymized patient spectacle lens sales data, including refractive error information, was provided by a major European spectacle lens manufacturer. Data from the Gutenberg Health Survey was digitized to allow comparison of a representative, population-based sample with the spectacle lens sales data. A bootstrap analysis was completed to assess the comparability of both datasets. The expected level of vision impairment resulting from myopia at 75 years of age was calculated for both datasets using a previously published risk estimation equation combined with a saturation function.

Main Outcome Measures

Comparability of spectacle lens sales data on refractive error with typical population surveys of refractive error and its potential usefulness to predict vision impairment resulting from refractive error.

Results

Equivalent estimates of the population distribution of spherical equivalent refraction can be provided from spectacle lens data within limits. For myopia, the population distribution was equivalent to the Gutenberg Health Survey (≤ 5% deviation) for levels of –2.0 diopters (D) or less, whereas for hyperopia, the distribution was equivalent (≤ 5% deviation) for levels of +3.0 D or more. The estimated rates of vision impairment resulting from myopia were not statistically significantly different (chi-square, 182; degrees of freedom, 169; P = 0.234) between the spectacle lens dataset and Gutenberg Health Survey dataset.

Conclusions

The distribution of refractive error and hence the risk of vision impairment resulting from refractive error within a population can be determined using spectacle lens sales data. Pooling this type of data from multiple industry sources could provide a cost-effective, timely, and globally representative mechanism for monitoring the evolving epidemiologic features of refractive error and associated vision impairment.

Big Data analysis of vision screening standards used to evaluate fitness to drive

PURPOSE

Visual acuity assessment is the most commonly performed vision screening method for drivers. The standards and repeat assessment intervals used, however, are arbitrary, lack an evidence base and are highly variable across different countries. This study utilises the power of Big Data to provide evidence-based recommendations for standardised driver vision screening.

METHODS

Anonymised electronic medical record data was gathered from 40 Irish optometry practices comprising 81,184 unique patients. A Kaplan-Meier Survival (KMS) analysis was used to determine the effect of increasing age and time since screening on the likelihood of passing the visual acuity standard for driving. A logistic function was fit to assess the effect of varying the minimum visual acuity standard required to drive on the screening pass rate within the population.

RESULTS

The likelihood of failing repeat screening increased as a function of time since initial screening for all age groups (χ²=1447, df =6, p < 0.001), with older patients most affected. Rescreening intervals for individuals who initially met the vision standard unaided reduced as a function of age. Using an 80% survivability threshold, intervals ranged from every eight years for drivers under 50, reducing to every two years for those aged over 80. Rescreening intervals for drivers requiring optical correction to meet the standard, also decreased with age. Approximately 1% of individuals are excluded from driving using a 0.3 logMAR visual acuity standard with correction.

CONCLUSION

Visual acuity-based screening should take place at regular intervals for all drivers, not just those over 70. Re-screening intervals should be based on age, with shorter intervals for older drivers due to the combined effect of age and time on the likelihood of passing the driving visual acuity standards. The most commonly used standard of 0.3 logMAR results in a minimal number of potential drivers being excluded from driving.

Smartphone use as a possible risk factor for myopia

CLINICAL RELEVANCE

This study demonstrates an association between myopia and smartphone data usage. Youths now spend more time participating in near tasks as a result of smartphone usage. This poses an additional risk factor for myopia development/progression and is an important research question in relation to potential myopia management strategies.

BACKGROUND

Children are now exposed to another possible environmental risk factor for myopia - smartphones. This study investigates the amount of time students spend on their smartphones and their patterns of smartphone usage from a myopia perspective.

METHODS

Primary, secondary and tertiary level students completed a questionnaire exploring patterns of smartphone usage and assessing their attitudes toward potential myopia risk factors. Device-recorded data usage over an extended period was quantified as the primary and objective indicator of phone use. Average daily time spent using a smartphone was also quantified by self-reported estimates. Refractive status was verified by an optometrist.

RESULTS

Smartphone ownership among the 418 students invited to participate was over 99-per cent. Average daily smartphone data and time usage was 800.37 ± 1,299.88-MB and 265.16 ± 168.02-minutes respectively. Myopic students used almost double the amount of smartphone data at 1,130.71 ± 1,748.14-MB per day compared to non-myopes at 613.63 ± 902.15-MB (p = 0.001). Smartphone time usage was not significantly different (p = 0.09, 12-per cent higher among myopes). Multinomial logistic regression revealed that myopic refractive error was statistically significantly associated with increasing daily smartphone data usage (odds ratio 1.08, 95% CI 1.03-1.14) as well as increasing age (odds ratio 1.09, 95% CI 1.02-1.17) and number of myopic parents (odds ratio 1.55, 95% CI 1.06-2.3). Seventy-three per cent of students believed that digital technology may adversely affect their eyes.

CONCLUSION

This study demonstrates an association between myopia and smartphone data usage. Given the serious nature of the ocular health risks associated with myopia, our findings indicate that this relationship merits more detailed investigation.

The relationship between serum zinc levels and myopia

CLINICAL SIGNIFICANCE

Nutritional status influences growth and development, including that of the eye. However, little attention has been given to possible dietary influences in myopia. This study demonstrates that serum zinc has no relationship with myopia development.

BACKGROUND

Myopia is inherently associated with eye growth and thereby possibly amenable to nutritional influence. A number of Asian studies have reported lower levels of serum zinc in myopic children. This study was designed to assess the relationship between serum zinc and myopia in the Korean population - using a subsample of participants from nationally representative data.

METHODS

Data from the fifth Korea National Health and Nutrition Examination Survey (KNHANES) 2010 were used to explore zinc status in relation to refraction. A total of 304 participants were analysed, ranging in age from 12 to 19-years. Serum zinc levels were measured using inductively coupled plasma mass spectrometry, while refractive error was determined by non-cycloplegic autorefraction. Multivariate analysis was used to examine the association.

RESULTS

A significant majority of participants (n = 255; 84 per cent) were myopic. There was no significant difference in serum zinc levels between myopic and non-myopic children (p = 0.81). In multivariate logistic regression, serum zinc was not significantly associated with myopia after adjustment for age, gender, residence, body mass index, family income and recreational activity. Similarly, no relationship was observed between spherical equivalent refraction and serum zinc within the myopic group (p = 0.46).

CONCLUSION

In a subset of 12-19-year-old participants from the population-representative KNHANES study, no association was found between serum zinc and myopia. However, the lack of a sensitive biomarker for zinc status remains a major limitation in this, and all current studies.

Macular Pigment Response to Lutein, Zeaxanthin, and Meso-zeaxanthin Supplementation in Open-Angle Glaucoma

Purpose

To evaluate macular pigment response to carotenoid supplementation in glaucomatous eyes.

Design

Double-masked, randomized, placebo-controlled clinical trial, the European Nutrition in Glaucoma Management Study (ClinicalTrials.gov identifier, NCT04460365).

Participants

Sixty-two participants (38 men, 24 women) with a diagnosis of open-angle glaucoma were enrolled. Forty-two were randomized to receive the active supplement, 20 participants were allocated to placebo.

Methods

Macular pigment optical density (MPOD) was measured by autofluorescence using the Heidelberg Spectralis scanning laser ophthalmoscope. Macular pigment optical density volume within the central 6° of retinal eccentricity as well as MPOD at 0.23°, 0.51°, 0.74°, and 1.02° were recorded at baseline and at 6-month intervals over 18 months. Visual function was assessed using visual acuity, mesopic and photopic contrast sensitivity under glare conditions, photo stress recovery time, microperimetry, and Glaucoma Activities Limitation 9 questionnaire. Advanced glaucoma module scans of retinal nerve fiber layer thickness and ganglion cell complex thickness over the central 6° of retinal eccentricity also were completed at each study visit.

Main Outcome Measures

Change in MPOD after supplementation with 10 mg lutein, 2 mg zeaxanthin, and 10 mg meso-zeaxanthin or placebo over 18 months.

Results

A mixed-model repeated measures analysis of variance revealed a statistically significant increase in MPOD volume (significant time effect: F(3,111) = 89.31, mean square error (MSE) = 1656.9; P < 0.01). Post hoc t tests revealed a significant difference in MPOD volume at each study visit for the treatment group (P < 0.01 for all), but no change in the placebo group (P > 0.05 for all). A statistically significant increase in mesopic contrast sensitivity under glare conditions was noted at 18 months in the treatment group, but not placebo. No other structural or functional changes were observed. No serious adverse events were noted during the trial.

Conclusions

Macular pigment can be augmented in glaucomatous eyes by supplementation with a formulation containing the carotenoids lutein, zeaxanthin, and meso-zeaxanthin. The greatest relative benefit was observed in those with the lowest baseline levels, but increases were noted across all participants and each retinal eccentricity. The potential benefits of MP augmentation for macular health in glaucoma merit further long-term evaluation.

Consistent Honor, Persistent Disadvantage: American Indian and Alaska Native Veteran Health in the National Survey of Veterans

Objective: To examine self-rated health and activities of daily living (ADLs) limitations among American Indian and Alaska Native (AI/AN) veterans relative to white veterans. Methods: We use the 2010 National Survey of Veterans and limit the sample to veterans who identify as AI/AN or non-Hispanic white. We calculated descriptive statistics, confidence intervals, and used logistic regression. Results: AI/AN veterans are younger, have lower levels of income, and have higher levels of exposure to combat and environmental hazards compared to white veterans. We found that AI/AN veterans are significantly more likely to report fair/poor health controlling for socioeconomic status and experience an ADL controlling for age, health behaviors, socioeconomic status, and military factors. Discussion: The results indicate that AI/AN veterans are a disadvantaged population in terms of their health and disability compared to white veterans. AI/AN veterans may require additional support from family members and/or Veteran Affairs to address ADLs.

Response to "isolated head tremor: A DAT SPECT and somatosensory temporal discrimination study."

In response to Ferrazano and colleagues' observation of normal DAT binding in patients with isolated head tremor but with abnormal STDT, we report normal 123-IBZM SPECT in a cohort of patients with adult-onset idiopathic focal dystonia with cervical dystonia and their unaffected first-degree relatives both with normal and abnormal TDTs. We discuss molecular imaging findings in dystonia.

931 COVID-19 and the Irish National Spinal Injuries Unit: Impact on Service Provision and Strategies to Protect Urgent Care

Introduction

The COVID-19 pandemic has had a dramatic impact on the provision of healthcare worldwide. The delivery of a national spinal service for emergent surgery, elective surgery and outpatient assessment has been incredibly challenging.

Method

Prospectively collected data regarding referrals to, and operative workload of, the Irish National Spinal Injuries Unit (NSIU) during the period of national lockdown in response to the COVID-19 pandemic was compared to the same period in 2019.

Results

During the period of national lockdown there was a 47% decrease in the number of urgent referrals to the NSIU and a 61% reduction in the number of surgical cases performed. A particularly concerning finding was that for surgical cases there was a 400% increase in attempted suicide as the cause of injury with this cohort representing 11% of all surgical cases performed during the pandemic lockdown. The introduction of a national instant messaging application (Siilo) referral group resulted in a median time to first response by a National Spinal Injuries Unit (NSIU) surgeon of 15.5 minutes.

Conclusions

The COVID-19 pandemic has had a significant impact on the provision of a national spinal service, however innovative strategies have been adopted to protect the capacity to provide urgent care.

Application of big-data for epidemiological studies of refractive error

PURPOSE

To examine whether data sourced from electronic medical records (EMR) and a large industrial spectacle lens manufacturing database can estimate refractive error distribution within large populations as an alternative to typical population surveys of refractive error.

SUBJECTS

A total of 555,528 patient visits from 28 Irish primary care optometry practices between the years 1980 and 2019 and 141,547,436 spectacle lens sales records from an international European lens manufacturer between the years 1998 and 2016.

METHODS

Anonymized EMR data included demographic, refractive and visual acuity values. Anonymized spectacle lens data included refractive data. Spectacle lens data was separated into lenses containing an addition (ADD) and those without an addition (SV). The proportions of refractive errors from the EMR data and ADD lenses were compared to published results from the European Eye Epidemiology (E3) Consortium and the Gutenberg Health Study (GHS).

RESULTS

Age and gender matched proportions of refractive error were comparable in the E3 data and the EMR data, with no significant difference in the overall refractive error distribution (χ2 = 527, p = 0.29, DoF = 510). EMR data provided a closer match to the E3 refractive error distribution by age than the ADD lens data. The ADD lens data, however, provided a closer approximation to the E3 data for total myopia prevalence than the GHS data, up to age 64.

CONCLUSIONS

The prevalence of refractive error within a population can be estimated using EMR data in the absence of population surveys. Industry derived sales data can also provide insights on the epidemiology of refractive errors in a population over certain age ranges. EMR and industrial data may therefore provide a fast and cost-effective surrogate measure of refractive error distribution that can be used for future health service planning purposes.

A randomised trial of bilateral erector spinae plane block vs. no block for thoracolumbar decompressive spinal surgery

Major spinal surgery causes significant postoperative pain. We tested the efficacy and safety of bilateral erector spinae block on quality of recovery and pain after thoracolumbar decompression. We randomly allocated 60 adults to standard care or erector spinae block. Erector spinae block improved the mean (SD) quality of recovery-15 score at 24 postoperative hours, from 119 (20) to 132 (14), an increase (95%CI) of 13 (4-22), p = 0.0044. Median (IQR [range]) comprehensive complication index was 1 (0-3 [0-5]) in the control group vs. 1 (0-1 [0-4]) after block, p = 0.4. Erector spinae block reduced mean (SD) area under the curve pain during the first 24 postoperative hours: at rest, from 78 (49) to 50 (39), p = 0.018; and on sitting, from 125 (51) to 91 (50), p = 0.009. The cumulative mean (SD) oxycodone consumption to 24 h was 27 (18) mg in the control group and 19 (26) mg after block, p = 0.20. In conclusion, erector spinae block improved recovery and reduced pain for 24 h after thoracolumbar decompression surgery.

Neurophysiological correlates of dual tasking in people with Parkinson's disease and freezing of gait

Freezing of gait in people with Parkinson's disease (PwP) is associated with executive dysfunction and motor preparation deficits. We have recently shown that electrophysiological markers of motor preparation, rather than decision-making, differentiate PwP with freezing of gait (FOG +) and without (FOG -) while sitting. To examine the effect of locomotion on these results, we measured behavioural and electrophysiological responses in PwP with and without FOG during a target response time task while sitting (single-task) and stepping-in-place (dual-task). Behavioural and electroencephalographic data were acquired from 18 PwP (eight FOG +) and seven young controls performing the task while sitting and stepping-in-place. FOG + had slower response times while stepping compared with sitting. However, response times were significantly faster while stepping compared with sitting for controls. Electrophysiological responses showed no difference in decision-making potentials (centroparietal positivity) between groups or conditions but there were differences in neurophysiological markers of response inhibition (N2) and motor preparation (lateralized readiness potential, LRP) in FOG + while performing a dual-task. This suggests that the addition of a second complex motor task (stepping-in-place) impacts automatic allocation of resources in FOG +, resulting in delayed response times. The impact of locomotion on the generation of the N2 and LRP potentials, particularly in freezers, indirectly implies that these functions compete with locomotion for resources. In the setting of multiple complex tasks or cognitive impairment, severe motor dysfunction may result, leading to freezing of gait.

Macular Pigment Optical Density Fluctuation as a Function of Pupillary Mydriasis: Methodological Considerations for Dual-Wavelength Autofluorescence

PURPOSE OF THE STUDY

Macular pigment (MP), comprising the dietary carotenoids lutein, zeaxanthin and meso-zeaxanthin, is believed to benefit eye health and vision. Numerous clinical and research devices and techniques are currently available to facilitate MP optical density (MPOD) measurement. One of those techniques, dual-wavelength fundus autofluorescence (AF) is being increasingly used for measurement of MP in the eye. There is substantial methodological variation across the published studies that have employed this technique, including in relation to the use of mydriasis, the possible influence of which does not appear to have been addressed in the literature. This prospective cross-sectional study was designed to investigate the effect of mydriasis on MP measurement quality and MPOD values obtained with dual-wavelength AF using the Heidelberg Spectralis HRA+OCT device.

MATERIALS AND METHODS

Twenty-one healthy participants were recruited to the study. The mean age of participants was 44.8 years (± 14.63). Pupil size and MPOD were measured in one eye for each participant, initially under natural pupil conditions and subsequently 30 minutes following instillation of one drop of 0.5% tropicamide.

RESULTS

Despite providing MPOD measurements for the majority of undilated eyes (85.7% of eyes herein), pupillary dilation resulted in statistically significant changes in MPOD (p < .001 for central eccentricities). Our results indicate that the changes in MPOD were not uniform across the spatial profile. Marked improvements were also observed in image quality post-dilation (p < .002 for central eccentricities).

CONCLUSIONS

This study clearly demonstrates that dual-wavelength AF measurements of MPOD in the same eye vary as a function of pupillary dilation status, with MPOD under-estimated across the entire spatial profile of MP for natural relative to dilated pupillary conditions. Mydriasis should, therefore, be used routinely for MPOD measurements using dual wavelength AF, pupil size should be reported and image quality optimized in order to ensure accurate MPOD quantification.

Auto-Decompression - Preserved Neurological Function in Bilateral Cervical Facet Dislocations

Introduction Bilateral cervical facet dislocation (BCFD) is an uncommon injury with a high incidence of severe neurological impairment. We describe 4 cases of BCFD with preserved neurological function. Cases Case 1: A 78-year-old female who suffered two ground level falls (GLFs). Pre-operative American Spinal Injury Association (ASIA) Score was C5D. Imaging revealed a BCFD at C6/C7 and a C6 laminar fracture. Case 2: A 63-year-old male suffered a fall down 14 steps. Pre-operative ASIA score was E. Imaging demonstrated a BCFD at C7/T1, and a C6 laminar fracture. Case 3: A 46-year-old male collided with a tree while descending a hill on a bicycle. Pre-operative ASIA score was C6D. Imaging revealed a BCFD at C7/T1 and a C7 laminar fracture. Case 4: A 67-year-old male suffered a GLF while exiting a stationary car. Pre-operative ASIA score on admission was E. Imaging revealed a BCFD at C6/C7 with bilateral laminar fractures at C5 and C6. Outcome All cases underwent 2-stage surgical fixation. All cases maintained or had an improved ASIA score post-operatively. Conclusion In all cases, the presence of concurrent laminar fractures resulted in an auto-decompression of the spinal canal, preserving neurological function.

Myopia Outcome Study of Atropine in Children (MOSAIC): an investigator-led, double-masked, placebo-controlled, randomised clinical trial protocol

Background: The Myopia Outcome Study of Atropine in Children (MOSAIC) aims to explore the efficacy, safety, acceptability and mechanisms of action of 0.01% unpreserved atropine for myopia control in a European population. Methods: MOSAIC is an investigator-led, double-masked, placebo-controlled, randomised clinical trial (RCT) investigating the efficacy, safety and mechanisms of action of 0.01% atropine for managing progression of myopia. During Phase 1 of the trial, 250 children aged 6-16 years with progressive myopia instil eye drops once nightly in both eyes from randomisation to month 24. From month 24 to 36  participants are re-randomised in Phase 2 of the trial, into continued 0.01% atropine, and washout, at 1:1 ratio for those participants initially randomised to the intervention arm (n=167), during which any potential rebound effects on cessation of treatment will be monitored. All participants initially assigned to the placebo (n=83) crossover to the intervention arm of the study for Phase 2, and from month 24 to 36, instil 0.01% atropine eye drops in both eyes once nightly. Further treatment and monitoring beyond 36 months is planned (Phase 3) and will be designed dependent on the outcomes of Phase 1. Results: The primary outcome measure is cycloplegic spherical equivalent refractive error progression at 24 months. Secondary outcome measures include axial length change as well as the rebound, safety and acceptability profile of 0.01% atropine. Additional analyses will include the mechanisms of action of 0.01% atropine for myopia control. Conclusions: The generalisability of results from previous clinical trials investigating atropine for myopia control is limited by the predominantly Asian ethnicity of previous study populations. MOSAIC is the first RCT to explore the efficacy, safety and mechanisms of action of unpreserved 0.01% atropine in a predominantly White population.

Myopia Outcome Study of Atropine in Children (MOSAIC): an investigator-led, double-masked, placebo-controlled, randomised clinical trial protocol

Background: The Myopia Outcome Study of Atropine in Children (MOSAIC) aims to explore the efficacy, safety, acceptability and mechanisms of action of 0.01% unpreserved atropine for myopia control in a European population.

Methods: MOSAIC is an investigator-led, double-masked, placebo-controlled, randomised clinical trial (RCT) investigating the efficacy, safety and mechanisms of action of 0.01% atropine for managing progression of myopia. During Phase 1 of the trial, 250 children aged 6-16 years with progressive myopia instil eye drops once nightly in both eyes from randomisation to month 24. No treatment is given during Phase 2 from month 24 to 36 (washout period) for those participants initially randomised to the intervention arm (n=167), during which any potential rebound effects on cessation of treatment will be monitored. All participants initially assigned to the placebo (n=83) crossover to the intervention arm of the study for Phase 2, and from month 24 to 36, instil 0.01% atropine eye drops in both eyes once nightly. Further treatment and monitoring beyond 36 months is planned (Phase 3) and will be designed dependent on the outcomes of Phase 1.

Results: The primary outcome measure is cycloplegic spherical equivalent refractive error progression at 24 months. Secondary outcome measures include axial length change as well as the rebound, safety and acceptability profile of 0.01% atropine. Additional analyses will include the mechanisms of action of 0.01% atropine for myopia control.

Conclusions: The generalisability of results from previous clinical trials investigating atropine for myopia control is limited by the predominantly Asian ethnicity of previous study populations. MOSAIC is the first RCT to explore the efficacy, safety and mechanisms of action of unpreserved 0.01% atropine in a predominantly White population.

Trial registration: ISRCTN: ISRCTN36732601 (04/10/2017), EudraCTdatabase 2016-003340-37 (03/07/2018).

Identification of Surrogate Biomarkers for the Prediction of Patients at Risk of Low Macular Pigment in Type 2 Diabetes

Purpose: This cross-sectional study compared macular pigment (MP) levels among persons with Type 2 diabetes relative to healthy controls. Additionally, a range of behavioral, anthropometric, clinical and serum measures were explored as possible predictors of low MP optical density (MPOD) in diabetes.Methods: Two health status groups; Group 1: Type 2 diabetes (n = 188), and Group 2: Healthy controls (n = 2,594) completed a full MP assessment using customized heterochromatic flicker photometry, as part of The Irish Longitudinal Study on Aging (TILDA). Clinical [blood pressure; cataract status; MPOD] and anthropometric [waist (cm); weight (kg); hip (cm)] measurements were taken, and a blood sample drawn for analysis of serum biomarkers [lipoproteins; inflammatory markers (C reactive protein and vitamin-D)].Results: One-way ANOVA revealed lower MPOD in subjects with Type 2 diabetes relative to controls (p = .047). Amongst participants with diabetes, those with low serum vitamin D (≤50 nmol/L) had significantly lower mean MPOD compared to those with sufficient serum vitamin D levels >50 nmol/L (0.173(0.148) vs. 0.226(0.145); p = .006). Concomitantly, MP was significantly lower in diabetes participants with raised serum triglyceride (TG) to high density lipoprotein (HDL) ratio (TG/HDL); values >1.74 mmol/L (0.172 (0.140) vs 0.215 (0.152); p = .039). Body mass index, waist-to-height ratio and waist circumference, were all significantly negatively correlated with MPOD (Pearson's correlation, p < .05 for all). Significant correlates of MPOD in the multivariate regression model included smoking, cataract, and vitamin D, which collectively contributed 18.5% of the overall variability in MPOD status amongst participants with Type 2 diabetes.Conclusions: This study provides additional evidence that low MP may indeed be a feature of Type 2 diabetes, and further identifies smoking, cataract and vitamin D status as plausible predictors of low MPOD amongst persons with Type 2 diabetes.

Lutein and zeaxanthin: The possible contribution, mechanisms of action and implications of modern dietary intake for cognitive development in children

Background:Studies suggest that lutein and zeaxanthin may be important for cognitive development in children, but a comprehensive evidence synthesis is lacking. The purpose of this evidence synthesis was to analyse the available data regarding the role of lutein and zeaxanthin for cognition in children and propose a theoretical basis for future studies.Methods:The PubMed, Scopus, the ISRCTN registry and Cochrane Library databases were searched for studies that evaluated the relationship between lutein and zeaxanthin and cognitive function in children. Reference list and ancestry searches were performed on relevant articles. A total of 543 articles were identified, of which six cross-sectional studies were included.Results:The literature search revealed that the evidence concerning the effect of lutein and zeaxanthin on cognition in children is sparse. However, there is some preliminary evidence indicating a positive association between lutein and zeaxanthin and cognition in childhood.Conclusions:The cross-sectional nature of the few studies available and the lack of RCT data indicates a need for further investigation before any firm conclusions can be drawn.

Operative Management of Perinatal Lumbar Disc Herniation and Cauda Equina Syndrome: A Case Series

Introduction Perinatal lumbar discectomy for lumbar disc herniation or cauda equina syndrome is a rare clinical scenario. This case series outlines the surgical management of this clinical scenario at a national tertiary referral centre over a 10-year period Methods A retrospective review of all females who underwent discectomy / decompression for lumbar disc herniation or cauda equina syndrome in the perinatal period at a national tertiary referral centre for spine surgery over a 10-year period between January 2008 to December 2017. Results 6 cases required surgical intervention. All patients were successfully managed with surgical decompressive procedures and recovered well in the postoperative period without complication. Conclusions The principles of management remain the same in the pregnant and non-pregnant populations, although treatment options are complicated by the desire to avoid risk to the developing foetus. Surgical intervention is safe to both mother and baby and if performed promptly is associated with an excellent functional outcome.

Cognitive load reduces the effects of optic flow on gait and electrocortical dynamics during treadmill walking

During navigation of complex environments, the brain must continuously adapt to both external demands, such as fluctuating sensory inputs, and internal demands, such as engagement in a cognitively demanding task. Previous studies have demonstrated changes in behavior and gait with increased sensory and cognitive load, but the underlying cortical mechanisms remain largely unknown. In the present study, in a mobile brain/body imaging (MoBI) approach, 16 young adults walked on a treadmill with high-density EEG while 3-dimensional (3D) motion capture tracked kinematics of the head and feet. Visual load was manipulated with the presentation of optic flow with and without continuous mediolateral perturbations. The effects of cognitive load were assessed by the performance of a go/no-go task on half of the blocks. During increased sensory load, participants walked with shorter and wider strides, which may indicate a more restrained pattern of gait. Interestingly, cognitive task engagement attenuated these effects of sensory load on gait. Using an independent component analysis and dipole-fitting approach, we found that cautious gait was accompanied by neuro-oscillatory modulations localized to frontal (supplementary motor area, anterior cingulate cortex) and parietal (inferior parietal lobule, precuneus) areas. Our results show suppression in alpha/mu (8-12 Hz) and beta (13-30 Hz) rhythms, suggesting enhanced activation of these regions with unreliable sensory inputs. These findings provide insight into the neural correlates of gait adaptation and may be particularly relevant to older adults who are less able to adjust to ongoing cognitive and sensory demands while walking. NEW & NOTEWORTHY The neural underpinnings of gait adaptation in humans are poorly understood. To this end, we recorded high-density EEG combined with three-dimensional body motion tracking as participants walked on a treadmill while exposed to full-field optic flow stimulation. Perturbed visual input led to a more cautious gait pattern with neuro-oscillatory modulations localized to premotor and parietal regions. Our findings show a possible brain-behavior link that might further our understanding of gait and mobility impairments.

Measurement & Analysis of the Temporal Discrimination Threshold Applied to Cervical Dystonia

The temporal discrimination threshold (TDT) is the shortest time interval at which an observer can discriminate two sequential stimuli as being asynchronous (typically 30-50 ms). It has been shown to be abnormal (prolonged) in neurological disorders, including cervical dystonia, a phenotype of adult onset idiopathic isolated focal dystonia. The TDT is a quantitative measure of the ability to perceive rapid changes in the environment and is considered indicative of the behavior of the visual neurons in the superior colliculus, a key node in covert attentional orienting. This article sets out methods for measuring the TDT (including two hardware options and two modes of stimuli presentation). We also explore two approaches of data analysis and TDT calculation. The application of the assessment of temporal discrimination to the understanding of the pathogenesis of cervical dystonia and adult onset idiopathic isolated focal dystonia is also discussed.

An Examination of the Neural Unreliability Thesis of Autism

An emerging neuropathological theory of Autism, referred to here as “the neural unreliability thesis,” proposes greater variability in moment-to-moment cortical representation of environmental events, such that the system shows general instability in its impulse response function. Leading evidence for this thesis derives from functional neuroimaging, a methodology ill-suited for detailed assessment of sensory transmission dynamics occurring at the millisecond scale. Electrophysiological assessments of this thesis, however, are sparse and unconvincing. We conducted detailed examination of visual and somatosensory evoked activity using high-density electrical mapping in individuals with autism (N = 20) and precisely matched neurotypical controls (N = 20), recording large numbers of trials that allowed for exhaustive time-frequency analyses at the single-trial level. Measures of intertrial coherence and event-related spectral perturbation revealed no convincing evidence for an unreliability account of sensory responsivity in autism. Indeed, results point to robust, highly reproducible response functions marked for their exceedingly close correspondence to those in neurotypical controls

Long-term test-retest reliability of event-related potential (ERP) recordings during treadmill walking using the mobile brain/body imaging (MoBI) approach

Advancements in acquisition technology and signal-processing techniques have spurred numerous recent investigations on the electro-cortical signals generated during whole-body motion. This approach, termed Mobile Brain/Body Imaging (MoBI), has the potential to elucidate the neural correlates of perceptual and cognitive processes during real-life activities, such as locomotion. However, as of yet, no one has assessed the long-term stability of event-related potentials (ERPs) recorded under these conditions. Therefore, the objective of the current study was to evaluate the test-retest reliability of cognitive ERPs recorded while walking. High-density EEG was acquired from 12 young adults on two occasions, separated by an average of 2.3years, as they performed a Go/No-Go response inhibition paradigm. During each testing session, participants performed the task while walking on a treadmill and seated. Using the intraclass correlation coefficient (ICC) as a measure of agreement, we focused on two well-established neurophysiological correlates of cognitive control, the N2 and P3 ERPs. Following ICA-based artifact rejection, the earlier N2 yielded good to excellent levels of reliability for both amplitude and latency, while measurements for the later P3 component were generally less robust but still indicative of adequate to good levels of stability. Interestingly, the N2 was more consistent between walking sessions, compared to sitting, for both hits and correct rejection trials. In contrast, the P3 waveform tended to have a higher degree of consistency during sitting conditions. Overall, these results suggest that the electro-cortical signals obtained during active walking are representative of stable indices of neurophysiological function.

Menstrual cycle and the temporal discrimination threshold

The temporal discrimination threshold (TDT) is a proposed pre-clinical biomarker (endophenotype) for adult onset isolated focal dystonia (AOIFD). Age- and sex-related effects on temporal discrimination demonstrate that women, before the age of 40 years, have faster temporal discrimination than men but their TDTs worsen with age at almost three times the rate of men. Thus after 40 years the TDT in women is progressively worse than in men. AOIFD is an increasingly female-predominant disorder after the age of 40; it is not clear whether this age-related sexually-dimorphic difference observed for both the TDT and sex ratio at disease onset in AOIFD is a hormonal or chromosomal effect. The aim of this study was to examine temporal discrimination at weekly intervals during two consecutive menstrual cycles in 14 healthy female volunteers to determine whether physiological hormonal changes affected temporal discrimination. We observed no significant differences in weekly temporal discrimination threshold values during the menstrual cycles and no significant correlation with the menstrual cycle stage. This observed stability of temporal discrimination during cyclical hormonal change raises interesting questions concerning the age-related sexually-dimorphic decline observed in temporal discrimination. Our findings pave the way for future studies exploring potential pathomechanisms for this age-related deterioration.

A comparison of stimulus presentation methods in temporal discrimination testing

The temporal discrimination threshold (TDT) is the shortest time interval at which an individual detects two stimuli to be asynchronous (normal  =  30-50 ms). It has been shown to be abnormal in patients with disorders affecting the basal ganglia including adult onset idiopathic focal dystonia (AOIFD). Up to 97% of patients have an abnormal TDT with age- and sex-related penetrance in unaffected relatives, demonstrating an autosomal dominant inheritance pattern. These findings support the use of the TDT as a pre-clinical biomarker for AOIFD. The usual stimulus presentation method involves the presentation of progressively asynchronous stimuli; when three sequential stimuli are reported asynchronous is taken as a participant's TDT. To investigate the robustness of the 'staircase' method of presentation, we introduced a method of randomised presentation order to explore any potential 'learning effect' that may be associated with this existing method. The aim of this study was to investigate differences in temporal discrimination using two methods of stimulus presentation. Thirty healthy volunteers were recruited to the study (mean age 33.73  ±  3.4 years). Visual and tactile TDT testing using a staircase and randomised method of presentation order was carried out in a single session. There was a strong relationship between the staircase and random method for TDT values. This observed consistency between testing methods suggests that the existing experimental approach is a robust method of recording an individual's TDT. In addition, our newly devised randomised paradigm is a reproducible and more efficient method for data acquisition in the clinic setting. However, the two presentation methods yield different absolute TDT results and either of the two methods should be used uniformly in all participants in any one particular study.

Characterization of Community-Acquired Staphylococcus aureus Infections in Children

Background:

Limited data exist concerning characteristics of community-acquired Staphylococcus aureus infections (CA-SAI) in central and eastern Kentucky.

Objective:

To describe the incidence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infections from January 1, 2004 through December 31, 2005, compare the number of CA-MRSA infections between years, and contrast treatment interventions and antibiotic susceptibility patterns of CA-SAI.

Methods:

A concurrent and retrospective study was conducted in 125 patients less than 18 years of age with CA-SAI admitted to the hospital/clinic based on criteria from the Centers for Disease Control and Prevention. Data on demographics, length of stay, antibiotic therapy, and antibiotic susceptibilities were collected.

Results:

Seventy patients were included for analysis (CA-MRSA, n = 51; community-acquired methicillin-susceptible S. aureus [CA-MSSA], n = 19). No statistically significant differences were noted between the number of CA-MRSA infections and the total CA-SAI (9/15 in 2004 vs 42/55 in 2005; p = 0.15). Approximately 75% of patients with CA-SAI were admitted to the hospital with no significant difference in length of stay. Ninety percent of CA-SAI were skin and soft tissue infections. There was a significant difference between groups with cutaneous abscesses (CA-MRSA, n = 37 vs CA-MSSA, n = 6; p = 0.002). Greater than 95% of all isolates were susceptible to vancomycin and trimethoprim/sulfamethoxazole. Half of CA-MRSA patients received inappropriate antibiotic therapy with β-lactam antibiotics or clindamycin without confirmatory disk diffusion test. Twenty-five (49%) patients with CA-MRSA received surgical debridement (S/D) and/or incision and drainage (I/D) with concomitant antibiotic therapy. Four patients with CA-MRSA were rehospitalized for subsequent infections; all 4 received appropriate antibiotic therapy.

Conclusions:

A noticeable increase in CA-MRSA infections with cutaneous abscess between 2004 and 2005 was noted. In patients receiving inappropriate antibiotic therapy, treatment success was attributed to concomitant S/D and I/D. Further analysis should focus on the impact of antibiotic therapy alone or in combination with S/D and I/D on the incidence of subsequent CA-MRSA infections.

Application of virtual reality head mounted display for investigation of movement: a novel effect of orientation of attention

OBJECTIVE

To date human kinematics research has relied on video processing, motion capture and magnetic search coil data acquisition techniques. However, the use of head mounted display virtual reality systems, as a novel research tool, could facilitate novel studies into human movement and movement disorders. These systems have the unique ability of presenting immersive 3D stimulus while also allowing participants to make ecologically valid movement-based responses.

APPROACH

We employed one such system (Oculus Rift DK2) in this study to present visual stimulus and acquire head-turn data from a cohort of 40 healthy adults. Participants were asked to complete head movements towards eccentrically located visual targets following valid and invalid cues. Such tasks are commonly employed for investigating the effects orientation of attention and are known as Posner cueing paradigms. Electrooculography was also recorded for a subset of 18 participants.

MAIN RESULTS

A delay was observed in onset of head movement and saccade onset during invalid trials, both at the group and single participant level. We found that participants initiated head turns 57.4 ms earlier during valid trials. A strong relationship between saccade onset and head movement onset was also observed during valid trials.

SIGNIFICANCE

This work represents the first time that the Posner cueing effect has been observed in onset of head movement in humans. The results presented here highlight the role of head-mounted display systems as a novel and practical research tool for investigations of normal and abnormal movement patterns.

Analysis of Morbidity in Liver Transplant Recipients following Human Albumin Supplementation: A Retrospective Pilot Study

Objectives

To assess incidence of morbidity (ie, documented infection, acute renal failure, acute graft rejection, acute cardiovascular events, and hospital read-mission rates) 6 months following liver transplantation using linear regression as a function of cumulative albumin dose.

Design

Retrospective chart review.

Setting

A 473-bed tertiary care teaching facility with a solid-organ transplantation center.

Patients

Forty liver transplant recipients examined from January 1 to December 31, 2003.

Measurements and Results

Data from 40 liver transplant recipients were collected. Mean albumin dose administered was 190.9 ± 162.3 g. No statistical differences were identified in patients receiving less than 140 g (n = 20) or more than 140 g (n = 20) with respect to demographic data other than gender and ethnicity. The mean APACHE III (Acute Physiology and Chronic Health) score was 69.7 ± 24.3. Approximately 70 episodes of morbidity and 23 readmissions were observed. Regardless of the APACHE III score, albumin was associated with increased overall morbidity and cardiovascular complications. Liver transplant recipients receiving more than 140 g had a longer hospital stay (14 vs 8 days, P = .025) and intensive care unit stay (6 vs 3 days, P = .051) than patients receiving 140 g or less. No correlation with risk of acute rejection was seen with albumin or tacrolimus.

Conclusion

Albumin supplementation among liver transplant recipients was associated with a significant risk for cardiovascular complications and overall number of complications regardless of APACHE III score. Future prospective studies are needed to further define the potential risk for complications in this patient population.

Sun exposure is an environmental factor for the development of blepharospasm

BACKGROUND

Adult-onset isolated focal dystonia may present with various phenotypes including blepharospasm and cervical dystonia. Although inherited in an autosomal dominant manner with a markedly reduced penetrance, environmental factors are considered important in disease penetrance and expression. We observed a marked variation by latitude in the reports of the frequency of patients with blepharospasm relative to those with cervical dystonia; we hypothesised that sun exposure is an environmental risk factor for the development of blepharospasm in genetically susceptible individuals.

METHODS

From published clinic cohorts and epidemiological reports, the ratio of the number of cases of blepharospasm to cervical dystonia (phenotype case ratio) at each study site was analysed with regard to latitude and measures of annual insolation. Meta-regression analyses of the phenotype case ratio to these environmental factors were performed.

RESULTS

The phenotype case ratio in 15 eligible study sites over 41° of latitude demonstrated a statistically significant inverse association with latitude (p=0.0004, R(2)=53.5%). There were significant positive associations between the phenotype case ratio and quarter-one (January-March) insolation (p=0.0005, R(2)=53%) and average annual insolation (p=0.003, R(2)=40%).

CONCLUSION

The increase in the blepharospasm: cervical dystonia case ratio with decreasing latitude and increasing insolation suggests that sunlight exposure is an environmental risk factor for the development of blepharospasm (rather than cervical dystonia) in individuals genetically susceptible to adult-onset dystonia.

Exploring the unknown: electrophysiological and behavioural measures of visuospatial learning

Visuospatial memory describes our ability to temporarily store and manipulate visual and spatial information and is employed for a wide variety of complex cognitive tasks. Here, a visuospatial learning task requiring fine motor control is employed to investigate visuospatial learning in a group of typically developing adults. Electrophysiological and behavioural data are collected during a target location task under two experimental conditions: Target Learning and Target Cued. Movement times (MTs) are employed as a behavioural metric of performance, while dynamic P3b amplitudes and power in the alpha band (approximately 10 Hz) are explored as electrophysiological metrics during visuospatial learning. Results demonstrate that task performance, as measured by MT, is highly correlated with P3b amplitude and alpha power at a consecutive trial level (trials 1-30). The current set of results, in conjunction with the existing literature, suggests that changes in P3b amplitude and alpha power could correspond to different aspects of the learning process. Here it is hypothesized that changes in P3b correspond to a diminishing inter-stimulus interval and reduced stimulus relevance, while the corresponding changes in alpha power represent an automation of response as habituation occurs in participants. The novel analysis presented in the current study demonstrates how gradual electrophysiological changes can be tracked during the visuospatial learning process under the current paradigm.

The neural dynamics of somatosensory processing and adaptation across childhood: a high-density electrical mapping study

Young children are often hyperreactive to somatosensory inputs hardly noticed by adults, as exemplified by irritation to seams or labels in clothing. The neurodevelopmental mechanisms underlying changes in sensory reactivity are not well understood. Based on the idea that neurodevelopmental changes in somatosensory processing and/or changes in sensory adaptation might underlie developmental differences in somatosensory reactivity, high-density electroencephalography was used to examine how the nervous system responds and adapts to repeated vibrotactile stimulation over childhood. Participants aged 6-18 yr old were presented with 50-ms vibrotactile stimuli to the right wrist over the median nerve at 5 blocked interstimulus intervals (ranging from ∼7 to ∼1 stimulus per second). Somatosensory evoked potentials (SEPs) revealed three major phases of activation within the first 200 ms, with scalp topographies suggestive of neural generators in contralateral somatosensory cortex. Although overall SEPs were highly similar for younger, middle, and older age groups (6.1-9.8, 10.0-12.9, and 13.0-17.8 yr old), there were significant age-related amplitude differences in initial and later phases of the SEP. In contrast, robust adaptation effects for fast vs. slow presentation rates were observed that did not differ as a function of age. A greater amplitude response in the later portion of the SEP was observed for the youngest group and may be related to developmental changes in responsivity to somatosensory stimuli. These data suggest the protracted development of the somatosensory system over childhood, whereas adaptation, as assayed in this study, is largely in place by ∼7 yr of age.

Age-Related Sexual Dimorphism in Temporal Discrimination and in Adult-Onset Dystonia Suggests GABAergic Mechanisms

Background

Adult-onset isolated focal dystonia (AOIFD) presenting in early adult life is more frequent in men, whereas in middle age it is female predominant. Temporal discrimination, an endophenotype of adult-onset idiopathic isolated focal dystonia, shows evidence of sexual dimorphism in healthy participants.

Objectives

We assessed the distinctive features of age-related sexual dimorphism of (i) sex ratios in dystonia phenotypes and (ii) sexual dimorphism in temporal discrimination in unaffected relatives of cervical dystonia patients.

Methods

We performed (i) a meta-regression analysis of the proportion of men in published cohorts of phenotypes of adult-onset dystonia in relation to their mean age of onset and (ii) an analysis of temporal discrimination thresholds in 220 unaffected first-degree relatives (125 women) of cervical dystonia patients.

Results

In 53 studies of dystonia phenotypes, the proportion of men showed a highly significant negative association with mean age of onset (p < 0.0001, pseudo-R² = 59.6%), with increasing female predominance from 40 years of age. Age of onset and phenotype together explained 92.8% of the variance in proportion of men. Temporal discrimination in relatives under the age of 35 years is faster in women than men but the age-related rate of deterioration in women is twice that of men; after 45 years of age, men have faster temporal discrimination than women.

Conclusion

Temporal discrimination in unaffected relatives of cervical dystonia patients and sex ratios in adult-onset dystonia phenotypes show similar patterns of age-related sexual dimorphism. Such age-related sexual dimorphism in temporal discrimination and adult-onset focal dystonia may reflect common underlying mechanisms. Cerebral GABA levels have been reported to show similar age-related sexual dimorphism in healthy participants and may be the mechanism underlying the observed age-related sexual dimorphism in temporal discrimination and the sex ratios in AOIFD.

Keeping in touch with the visual system: spatial alignment and multisensory integration of visual-somatosensory inputs

Correlated sensory inputs coursing along the individual sensory processing hierarchies arrive at multisensory convergence zones in cortex where inputs are processed in an integrative manner. The exact hierarchical level of multisensory convergence zones and the timing of their inputs are still under debate, although increasingly, evidence points to multisensory integration (MSI) at very early sensory processing levels. While MSI is said to be governed by stimulus properties including space, time, and magnitude, violations of these rules have been documented. The objective of the current study was to determine, both psychophysically and electrophysiologically, whether differential visual-somatosensory (VS) integration patterns exist for stimuli presented to the same versus opposite hemifields. Using high-density electrical mapping and complementary psychophysical data, we examined multisensory integrative processing for combinations of visual and somatosensory inputs presented to both left and right spatial locations. We assessed how early during sensory processing VS interactions were seen in the event-related potential and whether spatial alignment of the visual and somatosensory elements resulted in differential integration effects. Reaction times to all VS pairings were significantly faster than those to the unisensory conditions, regardless of spatial alignment, pointing to engagement of integrative multisensory processing in all conditions. In support, electrophysiological results revealed significant differences between multisensory simultaneous VS and summed V + S responses, regardless of the spatial alignment of the constituent inputs. Nonetheless, multisensory effects were earlier in the aligned conditions, and were found to be particularly robust in the case of right-sided inputs (beginning at just 55 ms). In contrast to previous work on audio-visual and audio-somatosensory inputs, the current work suggests a degree of spatial specificity to the earliest detectable multisensory integrative effects in response to VS pairings.

Young Women do it Better: Sexual Dimorphism in Temporal Discrimination

The temporal discrimination threshold (TDT) is the shortest time interval at which two sensory stimuli presented sequentially are detected as asynchronous by the observer. TDTs are known to increase with age. Having previously observed shorter thresholds in young women than in men, in this work we sought to systematically examine the effect of sex and age on temporal discrimination. The aims of this study were to examine, in a large group of men and women aged 20–65 years, the distribution of TDTs with an analysis of the individual participant’s responses, assessing the “point of subjective equality” and the “just noticeable difference” (JND). These respectively assess sensitivity and accuracy of an individual’s response. In 175 participants (88 women) aged 20–65 years, temporal discrimination was faster in women than in men under the age of 40 years by a mean of approximately 13 ms. However, age-related decline in temporal discrimination was three times faster in women so that, in the age group of 40–65 years, the female superiority was reversed. The point of subjective equality showed a similar advantage in younger women and more marked age-related decline in women than men, as the TDT. JND values declined equally in both sexes, showing no sexual dimorphism. This observed sexual dimorphism in temporal discrimination is important for both (a) future clinical research assessing disordered mid-brain covert attention in basal-ganglia disorders, and (b) understanding the biology of this sexual dimorphism which may be genetic or hormonal.

Non-parametric bootstrapping method for measuring the temporal discrimination threshold for movement disorders

OBJECTIVE

Recent studies have proposed that the temporal discrimination threshold (TDT), the shortest detectable time period between two stimuli, is a possible endophenotype for adult onset idiopathic isolated focal dystonia (AOIFD). Patients with AOIFD, the third most common movement disorder, and their first-degree relatives have been shown to have abnormal visual and tactile TDTs. For this reason it is important to fully characterize each participant's data. To date the TDT has only been reported as a single value.

APPROACH

Here, we fit individual participant data with a cumulative Gaussian to extract the mean and standard deviation of the distribution. The mean represents the point of subjective equality (PSE), the inter-stimulus interval at which participants are equally likely to respond that two stimuli are one stimulus (synchronous) or two different stimuli (asynchronous). The standard deviation represents the just noticeable difference (JND) which is how sensitive participants are to changes in temporal asynchrony around the PSE. We extended this method by submitting the data to a non-parametric bootstrapped analysis to get 95% confidence intervals on individual participant data.

MAIN RESULTS

Both the JND and PSE correlate with the TDT value but are independent of each other. Hence this suggests that they represent different facets of the TDT. Furthermore, we divided groups by age and compared the TDT, PSE, and JND values. The analysis revealed a statistical difference for the PSE which was only trending for the TDT.

SIGNIFICANCE

The analysis method will enable deeper analysis of the TDT to leverage subtle differences within and between control and patient groups, not apparent in the standard TDT measure.

Post operative complications in a dedicated elective orthopaedic hospital: transfers requiring specialist critical care support

We aim to report our experience with out of hospital transfers for postoperative complications in a stand-alone elective orthopaedic hospital. We aim to describe the cohort of patients transferred, the rate of transfer and assess the risk factors for transfer. Patients were identified who were transferred out of the hospital to another acute hospital for management of non-routine medical problems. Patient data was collected relating to age, BMI, ASA, type of surgery, nature of the complication, timing and the outcome of transfer. In 2012, 2,853 inpatient surgical procedures were carried out, 51 patients (1.8%) developed a postoperative complication that required out of hospital transfer. Mean age of patients transferred was 67 (12-86) years, mean age of the overall case mix 58 years (0-96) (p = 0.01). 37.7% of the overall case mix of surgeries was made up of primary hip and knee arthroplasty procedures, these patients made up 63.7% of patients transferred out (p = 0.001). Mean BMI recorded was 31.7 (22-48) compared to the mean BMI of the total arthroplasty case mix of 28.8 (20-44) (p = 0.02). 59% of all patients at our institution were ASA category II or III. 76% of patients transferred were ASA category II or III (p = 0.005). We can conclude that patients requiring transfer are typically older. Arthroplasty patients are more likely to require transfer than patients undergoing other orthopaedic procedures. Among the arthroplasty cohort transferred patients will typically have a higher BMI than average. Patients with ASA category II or III make up nearly three quarters of those patients transferred. The mean age of patients transferred is typically older by 9 years.