Effect of using a structured pacing protocol on post-exertional symptom exacerbation and health status in a longitudinal cohort with the post-COVID-19 syndrome

Post-exertional symptom exacerbation (PESE) is a characteristic symptom of post-COVID syndrome (PCS). This prospective study investigated the effect of a 6-week structured World Health Organization (WHO) Borg CR-10 5-phase pacing protocol on PESE episodes and quality of life in a cohort of individuals with long-standing PCS (average duration of symptoms was 17 months). Participants received weekly telephone calls with a clinician to complete the Leeds PESE questionnaire (LPQ) and identify the appropriate phase of the pacing protocol. EQ-5D 5L was completed at the intervention's beginning and end to measure overall health. Thirty-one participants completed the 6-week protocol, with a statistically and clinically significant reduction in the average number of PESE episodes (from 3.4 episodes in Week 1 to 1.1 in Week 6), with an average decrease of 16% (95% CI: 9%-24%; p < 0.001) each week, and reduction across all three exertional triggers (physical, cognitive, and emotional). Physical activity levels showed moderate improvements during the intervention period. Mean EQ-5D 5L scores improved from 51.4 to 60.6 points (paired difference of 9.2 points, 95% CI: 3.2-15.2 points; p = 0.004). A structured pacing protocol significantly reduces PESE episodes and improves overall health in PCS.

A Mixed-Methods Evaluation of a Virtual Rehabilitation Program for Self-Management in Post-COVID-19 Syndrome (Long COVID)

Long COVID (LC) symptoms can be long standing, diverse and debilitating; comprehensive multidisciplinary rehabilitation programs are required to address this. A 10-week LC Virtual Rehabilitation Program (VRP) was developed to provide early education and self-management techniques to address the main symptoms of LC and was delivered to a group of persons with Long COVID (PwLC) online, facilitated by members of the multi-disciplinary rehabilitation team. This paper describes an evaluation of this VRP. Questionnaires completed by Healthcare Professionals (HCP) delivering the VRP were thematically analyzed to gain a priori themes and design semi-structured telephone interview questions for PwLC. Template analysis (TA) was used to analyze interview data. Routinely collected patient demographics and service data were also examined. Seventeen HCP survey responses were obtained and 38 PwLC telephone questionnaires were completed. The HCP interviews generated three a priori themes (1. Attendance and Availability, 2. Content, 3. Use of Digital Technology). TA was applied and three further themes emerged from the combined HCP and PwLC responses (4. Group Dynamics, 5. Individual Factors, 6. Internal Change). Key outcomes demonstrated that: the VRP was highly valued; digital delivery enabled self-management; barriers to attendance included work/life balance, use of technology, health inequalities; and LC was poorly understood by employers. Recommendations are provided for the design of VRPs for LC.

A systematic review and narrative synthesis of footwear and orthotic devices used in the management of ankle haemarthrosis and haemarthropathy in haemophilia

Introduction

Haemarthrosis is a clinical feature of haemophilia leading to haemarthropathy. The ankle joint is most commonly affected, resulting in significant pain, disability and a reduction in health‐related quality of life. Footwear and orthotic devices are effective in other diseases that affect the foot and ankle, such as rheumatoid arthritis, but little is known about their effect in haemophilia.

Aims

To review the efficacy and effectiveness of footwear and orthotic devices in the management of ankle joint haemarthrosis and haemarthropathy in haemophilia.

Methods

A systematic literature review was conducted. Two review authors independently screened studies for inclusion and appraised methodological quality using Joanna Briggs Institute Critical Appraisal checklists. A narrative analysis was undertaken.

Results

Ten studies involving 271 male participants were eligible for inclusion. All studies were quasi‐experimental; three employed a within‐subject design. Two studies included an independent comparison or control group. A range of footwear and orthotic devices were investigated. Limited evidence from non‐randomised studies suggested that footwear and orthotic devices improve the number of ankle joint bleeding episodes, gait parameters and patient‐reported pain.

Conclusion

This review demonstrates a lack of robust evidence regarding the efficacy and effectiveness of footwear and orthotic devices in the management of ankle joint haemarthrosis and haemarthropathy in haemophilia. Methodological heterogeneities and limitations with the study designs, small sample sizes and limited follow‐up of participants exist. Future studies utilising randomised designs, larger sample sizes, long‐term follow‐up and validated patient‐reported outcome measures are needed to inform the clinical management of ankle joint haemarthrosis and haemarthropathy.

Expert opinion on the UK standard of care for haemophilia patients with inhibitors: a modified Delphi consensus study

Background and Aims:

Despite advances in haemophilia care, inhibitor development remains a significant complication. Although viable treatment options exist, there is some divergence of opinion in the appropriate standard approach to care and goals of treatment. The aim of this study was to assess consensus on United Kingdom (UK) standard of care for child and adult haemophilia patients with inhibitors.

Methods:

A modified Delphi study was conducted using a two-round online survey. A haemophilia expert steering committee and published literature informed the Round 1 questionnaire. Invited participants included haematologists, haemophilia nurses and physiotherapists who had treated at least one haemophilia patient with inhibitors in the past 5 years. Consensus for 6-point Likert scale questions was pre-defined as ⩾70% participants selecting 1–2 (disagreement) or 5–6 (agreement).

Results:

In all, 46.7% and 35.9% questions achieved consensus in Rounds 1 (n = 41) and 2 (n = 34), respectively. Consensus was reached on the importance of improving quality of life (QoL) and reaching clinical goals such as bleed prevention, eradication of inhibitors and pain management. There was agreement on criteria constituting adequate/inadequate responses to immune tolerance induction (ITI) and the appropriate factor VIII dose to address suboptimal ITI response. Opinions varied on treatment aims for adults and children/adolescents, when to offer prophylaxis with bypassing agents and expectations of prophylaxis. Consensus was also lacking on appropriate treatment for mild/moderate patients with inhibitors.

Conclusion:

UK healthcare professionals appear to be aligned on the clinical goals and role of ITI when managing haemophilia patients with inhibitors, although novel treatment developments may require reassessment of these goals. Lack of consensus on prophylaxis with bypassing agents and management of mild/moderate cases identifies a need for further research to establish more comprehensive, evidence-based treatment guidance, particularly for those patients who are unable/prefer not to receive non-factor therapies.

Isolated conjugate gaze palsy after frontal lobe tumour surgery

Isolated conjugate gaze palsy following unilateral frontal lobe surgery is uncommon. When it does occur, usually it recovers within hours. We report a case of isolated conjugate gaze palsy which persisted for four weeks post-operatively before recovery commenced.

Comparative analysis of the post-lumpectomy target volume versus the use of pre-lumpectomy tumor volume for early stage breast cancer: implications for the future

Abstract #5134

Purpose: Accelerated partial breast irradiation (APBI) is increasingly being utilized for the treatment of early stage breast cancer. Planning target volume (PTV) generation with this approach is based on the post-lumpectomy cavity volume (post-LPC) and is often associated with treatment of large amounts of normal breast tissue which can result in patient ineligibility for external beam APBI (EB-APBI). In malignancies such as soft tissue sarcomas, neoadjuvant radiation therapy (RT) has been shown to be associated with smaller volumes of tissue irradiated compared to adjuvant RT. However, neoadjuvant RT has not been attempted in the setting of APBI. We hypothesized that a PTV generation based on an expansion of the pre-lumpectomy (pre-LP) intact tumor volume would result in a significant reduction in the volume of irradiated normal breast tissue compared to the current approach of using the post-LPC. We further hypothesize that the use of EB-APBI utilizing the pre-LP tumor will result in greater patient eligibility for APBI.&#x2028; Materials and Methods: 40 patients with 41 early stage breast cancers previously treated with breast conserving lumpectomy and RT were analyzed. Pre-operative imaging and pathology reports were used to determine a pre-LP tumor volume. A sphere, the diameter of which was the largest determined radiographic dimension, representing the pre-LP tumor volume was placed in the center of the previously contoured and treated lumpectomy cavity. PTVs were developed for the pre-LP tumor volume and the post-LPC volume as per the NSABP-B39 protocol guidelines. The pre-LP and post-LPC PTV volumes were compared. Suitability for APBI was analyzed using criteria set forth by NSABP-B39 guidelines.&#x2028; Results: For all patients, the pre-LP PTV was smaller than the post-LPC PTV. The median volume for the pre and post-LPC PTVs were 93 cc (range 24 – 570 cc) and 250 cc (range 45 – 879 cc), respectively. Paired t-test analysis demonstrated the pre-LP PTV to be significantly smaller than the post-LPC PTV, p &lt; 0.001. The average difference between pre-LP and post-LPC PTVs represented 173 cc (range 21 – 482 cc) or 18% (range 3 - 42%) of the whole breast volume. Based on our analysis, only 3 of 41 cases were ineligible for EB-APBI when using the pre-LP tumor volume, (2 based on pathologic criteria and 1 based on dose/volume constraints) while 13 of 41 cases were ineligible when using the post-LPC PTV (2 based on pathologic criteria and 11 based on dose/volume constraints).&#x2028; Conclusion: PTVs based on the pre-LP tumor expansion are likely to be associated with a significantly reduced amount of normal breast tissue irradiated compared to post-LPC PTVs potentially leading to improved breast cosmesis, decreased dose to critical structures and decreased toxicities. Additionally, eligibility for EB-APBI would potentially increase if administered in the pre-lumpectomy setting. The findings from this study support future investigation as to the implications and feasibility of neoadjuvant APBI.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5134.

Treatment of subtotally resected intracranial plasma cell granuloma with steroids: a case report

Primary intracranial plasma cell granuloma (PCG) is a rare form of inflammatory pseudotumour often characterized by non-neoplastic proliferation of plasma cells. The following case indicates a potential role for steroid therapy after subtotal resection.

Detection of cathepsin S cysteine protease in human brain tumour microdialysates in vivo

Microdialysis enables the chemistry of extracellular fluid in body tissues to be measured. Extracellular proteases such as the cysteine protease, cathepsin S (CatS), are thought to facilitate astrocytoma invasion. Microdialysates obtained from human brain tumours in vivo were subjected to cathepsin S activity and ELISA assays. Cathepsin S ELISA expression was detected in five out of 10 tumour microdialysates, while activity was detected in five out of 11 tumour microdialysates. Cathepsin S expression was also detected in microdialysate from the normal brain control although no activity was found in the same sample. While some refinements to the technique are necessary, the authors demonstrate the feasibility and safety of microdialysis in human astrocytomas in vivo. Characterisation of the extracellular environment of brain tumours in vivo using microdialysis may be a useful tool to identify the protease profile of brain tumours.

Delayed post-surgical development of dural arteriovenous fistula after cervical meningocele repair

A 34-year-old female patient presented with an intracranial subarachnoid hemorrhage and was found to have a dural arteriovenous fistula at the site of previous cervical meningocele repair. Subsequent occlusion was achieved with endovascular embolization. To our knowledge, the phenomenon of the development of a spinal dural fistula at the site of a meningocele repair has not been recorded before.

Dinosaurs, dragons, and dwarfs: the evolution of maximal body size

Among local faunas, the maximum body size and taxonomic affiliation of the top terrestrial vertebrate vary greatly. Does this variation reflect how food requirements differ between trophic levels (herbivores vs. carnivores) and with taxonomic affiliation (mammals and birds vs. reptiles)? We gathered data on the body size and food requirements of the top terrestrial herbivores and carnivores, over the past 65,000 years, from oceanic islands and continents. The body mass of the top species was found to increase with increasing land area, with a slope similar to that of the relation between body mass and home range area, suggesting that maximum body size is determined by the number of home ranges that can fit into a given land area. For a given land area, the body size of the top species decreased in the sequence: ectothermic herbivore > endothermic herbivore > ectothermic carnivore > endothermic carnivore. When we converted body mass to food requirements, the food consumption of a top herbivore was about 8 times that of a top carnivore, in accord with the factor expected from the trophic pyramid. Although top ectotherms were heavier than top endotherms at a given trophic level, lower metabolic rates per gram of body mass in ectotherms resulted in endotherms and ectotherms having the same food consumption. These patterns explain the size of the largest-ever extinct mammal, but the size of the largest dinosaurs exceeds that predicted from land areas and remains unexplained.

Cranioplasty: why throw the bone flap out?

Patients who undergo decompressive craniectomy for intracranial hypertension often require interval cranioplasty. Many cranioplasty agents are currently in use. The authors suggest that storage of the patient's own bone flap in the subcutaneous tissue of the abdominal wall, is a safe, efficacious and cost-effective alternative to use of synthetic cranioplasty materials.

Sildenafil (Viagra)-induced spontaneous intracerebral haemorrhage

Sildenafil (Viagra) has been developed as a drug to help male impotence. It has a direct effect on the vasculature of the corpus cavernosum. A case of spontaneous intracerebral haemorrhage (ICH) following the illicit use of Viagra is reported. A discussion of drug-induced ICH is included.

Modern management of head injuries

Management of the head-injured patient is designed to prevent secondary injury and to provide the neurosurgeon with a live patient who has some hope of recovery. This review sets out the background essentials for the non-neurosurgeon dealing with the initial care of a head-injured patient.

DNA hybridization, cladistics, and the phylogeny of phalangerid marsupials

Single-copy DNA/DNA hybridization experiments and numerical cladistic analyses of anatomical characters were used to investigate relationships among nine phalangerid (Marsupialia) species from four different genera. Both rate-dependent and rate-independent analyses of molecular data indicate that species of Trichosurus from one clade and that Strigocuscus, Phalanger, and Spilocuscus form a second. Within the latter group, Spilocuscus is excluded from a Strigocuscus-Phalanger clade, which, in turn, is not fully resolved on a jackknife strict consensus tree. Minimum-length Dollo, Wagner, and Camin-Sokal parisomy trees based on 35 anatomical characters, in contrast, suggest placement of Strigocuscus with Trichosurus rather than with Spilocuscus and Phalanger. However, there are two derived characters that support the alternative arrange of Strigocuscus with Spilocuscus and Phalanger and one character that further unites Strigocuscus and Phalanger. Thus, DNA hybridization results are not inconsistent with the distribution of derived character states among anatomical characters, only with minimum-length trees based on character data.

Notes on the distribution, abundance, diet and habitat of the New Guinea murid (Rodentia) Xenuromys barbatus (Milne-Edwards, 1900)

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Taxonomic and Phylogenetic Status of Living and Fossil Kangaroos and Wallabies of the Genus Macropus Shaw (Macropodidae: Marsupialia), with a New Subgeneric Name for the Larger Wallabies

Historical concepts of the generic status of the macropodines commonly known as kangaroos and wallabies are reviewed in this paper. A new diagnosis is provided for the genus Macropus, encompassing both living and fossil forms, and using cladistic principles to assess the phylogenetic value of diagnostic characters where possible. Cytological, biochemical and anatomical characters are used. Fourteen living and 11 extinct species of Macropus are recognized. Of these, 20 species have been classified into three subgenera, M.(Macropus), M.(Osphranter) and a new subgenus, M.(Notamacropus), as follows: M.(M.) giganteus, M.(M.) fuliginosus, M.(M.) mundjabus, M.(M.) pan, M.(M.) pearsoni and M.(M.) ferragus; M.(O.) antilopinus, M.(O.) bernardus, M.(O.) robustus, M.(O.) rufus and M.(O.) pavana; ,M.(N.) rufogriseus, M.(N.) eugenii, M.(N.) parryi, M.(N.) dorsalis, M.(N.) irma, M.(N.) agilis, M.(N.) greyi, M.(N.) parma, M.(N.) wombeyensis and M.(N) thor. Four poorly known extinct species, M. dryas, M. rama, M. woodsi and M. narada, have not yet been allocated to a subgenus. Prionotemnus palankarinnicus Stirton, 1957 is shown to belong outside Macropus. Because it is the type-species of Prionotemnus, that name is not available for a subgenus of Macropus. A current synonymy is presented for fossil species and the known stratigraphic range is given for each species. A phylogeny is presented expressing our view that M. (,Votamacropus) is the most plesiomorphic subgenus and M. (Macropus) is the most derived.

The taxonomy and distribution of Macropus (Fissuridon) pearsoni (Marsupialia: Macropodidae)

Macropus pearsoni, previously known only from the Pleistocene eastern Darling Downs, Queensland, is now recorded from the early Pleistocene Kanunka local fauna of the Katipiri Sands, South Australia. The presence of M. pearsoni as well as other species of macropodids in both the Darling Downs and Kanunka deposits may indicate a close temporal relationship between the faunas from these two localities. Fissuridon Bartholomai, 1973, appears to be a junior synonym of Macropus Shaw, 1790, but is retained as a subgeneric name and expanded to include Macropus (Fissuridon) pan DeVis, 1895.