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The device consists of two plastic tubes that slide into one another and allow the blunted needle to cause a pricking sensation when pushed against the skin. This sham needle allows the patient to have the feeling that the needle is entering the skin while also maintaining therapist-patient contact time and treatment explanation.

Sham dry needling is proposed to have less effect when compared to true dry needling [ 68 ]. Sham dry needling sites will be determined in the exact same fashion as in the MTEX-Needle group by the physical therapist after assessment. Therapists will be asked to sham needle at least six sites up to a maximum of 10, but the muscles that are sham treated will be left at the discretion of the physical therapist. The number of sites and specific muscles sham treated will be recorded by the therapist.

Only posterior muscles of the cervical spine and upper thoracic spine, the same muscles targeted in the dry needling group, will be treated in order to ensure patients will be blinded to whether they received the real or sham needling. Descriptive statistics, including frequency counts for categorical variables and measures of central tendency and dispersion for continuous variables, will be calculated to summarize the data.

Baseline demographic data will be compared across treatment groups to assess the adequacy of the randomization. We will compare baseline variables between groups by using independent t tests or Mann-Whitney U tests for continuous data and chi-square tests of independence for categorical data.

An intention-to-treat analysis will be utilized, in which all participants will be analyzed in the group to which they were originally assigned. All dropouts and the reasons for dropping out of the study will be reported. All data will be checked to ensure they meet the assumptions for the inferential statistical analyses described below.

If they do not meet the necessary assumptions, appropriate nonparametric procedures will be utilized. We will examine the primary aim with a two-way repeated-measures analysis of variance with treatment group ie, manual therapy, exercise, and dry needling vs manual therapy, exercise, and sham dry needling as the between-subjects independent variables and time ie, baseline, 4 weeks, 6 months, and 12 months as the within-subjects independent variable.

Bonferroni-corrected post hoc tests will be used to determine difference between group means. This requires a minimum sample size of 29 subjects per group. Patients may experience an increase in pain intensity from completing the range of motion exercise due to a muscle or ligament injury.

We have attempted to minimize this risk by having a licensed physical therapist examine all patients and instruct them in the proper exercise technique. In addition, a therapist will re-examine a patient at any time, if appropriate. It is also possible that patients will experience mild muscle soreness after the manipulation is performed. However, this soreness typically resolves within hours after manipulation. We have minimized the risks associated with manipulation by ensuring that the licensed physical therapists participating in this study already routinely use manipulation in the management of patients with neck pain.

We have further minimized this risk by ensuring that each physical therapist participating in this study has been specifically trained in the use of the manipulation techniques to be used in this study.

Furthermore, all potential subjects will be screened to ensure they do not exhibit any exclusion criteria that may place the individual at increased risk for a serious complication. When dry needling treatment is performed, it is possible that patients will experience the following common adverse events: bruising, bleeding, pain during treatment, pain after treatment, or aggravation of symptoms 1. Uncommon adverse events include the following: drowsiness, headache, or nausea 0.

Possible rare adverse events include fatigue, altered emotions, shaking, itching, claustrophobia, or numbness 0. Dry needling is very safe; however, the most serious side effect from dry needling is pneumothorax ie, lung collapse due to air inside the chest wall , which can occur in less than 0.

This risk is very low and in a recent survey of physical therapists who use dry needling, Brady et al reported that no episodes of pneumothorax occurred in over treatments. We have minimized the risks associated with dry needling by ensuring that the licensed physical therapists participating in this study already routinely use dry needling in the management of patients with neck pain. We have further minimized this risk by ensuring that each physical therapist participating in this study has been specifically trained in the use of the dry needling techniques to be used in this study.

Should any adverse event occur, it would be appropriately managed by the treating physical therapist by activating emergency services if immediate medical attention is required; standard clinical advice will be used in the case of minor events, such as transient soreness. This trial is registered at ClinicalTrials. See Table 5 for the study timeline and milestones. Dry needling may be one intervention that could lead to improved outcomes when used in conjunction with exercise and manual therapy [ 11 , 39 ].

In addition, it may improve patient compliance with exercise, which may lead to improved results from an exercise program. Therefore, the aim of this trial is to determine if the addition of dry needling to an exercise and manual therapy treatment program will further reduce pain and improve disability in patients with mechanical neck pain, as compared to exercise and manual therapy and sham needling. As the use of dry needling by physical therapists becomes more widespread, and more therapists are trained in this approach, research is needed to support or refute its effectiveness.

The results of this trial will assist in providing long-term outcomes examining the effectiveness of dry needling, which are currently lacking in the literature.

We anticipate the potential challenges to this study to include the following: difficulty with patient recruitment, patient compliance with follow-up schedule, and patients lost to follow-up over the 1-year, long-term, follow-up period.

To address these challenges, we have utilized two large clinics in different locations in the United States to improve the ability to recruit patients in a timely manner. Further, we will provide a small financial reimbursement for patients as incentive for completion of the 4-week, 6-month, and month follow-up in order to assist with compliance and reduce the numbers lost to follow-up.

We recognize that there are a number of potential limitations in the study design. The treating therapists cannot be blinded to group assignment, which may influence the verbal and nonverbal interaction with subjects. To try to manage this limitation, all therapists will be trained to maximize the consistency with which the dry needling intervention and the sham intervention will be performed. We have chosen to allow therapists to perform individualized dry needling treatment specific to each patient within the outlined treatment algorithm to be consistent with clinical practice and improve external generalizability.

We understand this may be seen as a limitation as it may lead to variation in the treatments that will be applied by therapists, which may mask the difference between groups. However, individualized treatment better reflects clinical practice.

Another potential limitation is that we are not including physical measures such as range of motion or pain pressure threshold in our analyses. We have chosen to limit our outcomes to validated questionnaires in an effort to decrease loss to follow-up, especially at the long-term time points. The authors would like to thank the Orthopaedic Section of the American Physical Therapy Association for providing funding for this trial.

Conflicts of Interest: None declared. Europe PMC requires Javascript to function effectively. Search life-sciences literature 41,, articles, preprints and more Search Advanced search. This website requires cookies, and the limited processing of your personal data in order to function.

By using the site you are agreeing to this as outlined in our privacy notice and cookie policy. Recent Activity. OBJECTIVE:The aim of this trial will be to examine the short- and long-term effectiveness of dry needling delivered by a physical therapist on pain, disability, and patient-perceived improvements in patients with mechanical neck pain. The snippet could not be located in the article text.

This may be because the snippet appears in a figure legend, contains special characters or spans different sections of the article. Published online Nov PMID: Author information Article notes Copyright and License information Disclaimer. Corresponding author. Corresponding Author: Eric Robert Gattie moc. This article has been cited by other articles in PMC.

Multimedia Appendix 2. Abstract Background Neck pain is a costly and common problem. Objective The aim of this trial will be to examine the short- and long-term effectiveness of dry needling delivered by a physical therapist on pain, disability, and patient-perceived improvements in patients with mechanical neck pain.

Results Recruitment is currently underway and is expected to be completed by the end of Conclusions The successful completion of this trial will provide evidence to demonstrate whether dry needling is effective for the management of mechanical neck pain when used in a combined treatment approach, as is the common clinical practice.

Patients may present with end-organ failure, ARDS, shock, acute kidney injury, or even death. An year-old woman with COPD and diastolic heart failure presented with shortness of breath. She had hypoxemia on room air upon presentation. Lungs were clear on physical examination. Her chest radiograph demonstrated no pulmonary infiltrates.

Transthoracic echocardiography TTE demonstrated a large, irregularly shaped echogenic mass in both the right atrium and right ventricle consistent with a large thrombus. The mass in the right atrium was 3. A previous TTE study in this patient did not reveal an intra-cardiac thrombus. No deep venous thrombosis was found. She was begun on anticoagulation and refused catheter-directed therapy. She improved and was discharged to her home.

The most common are deep venous thrombosis and pulmonary embolism in critically ill patients despite the use of prophylactic anticoagulation. Several studies have reported post-mortem biopsies with widespread microthrombi. Arterial thrombosis with stroke and limb ischemia has also been described.

Our case had an unusual presentation since the cause of her shortness of breath was the intra-cardiac thrombus. Some studies propose direct endothelial injury by the COVID virus, causing microvascular inflammation, endothelial exocytosis, and endothelitis. Yet, no definitive mechanism has been identified. Criteria for ME include 6 months of fatigue-limited daily activities, unrefreshing sleep, and symptom exacerbation following physical or mental strain, and orthostatic intolerance.

New reports indicate that ME incidence may be higher in specific patient populations. The patient population used for this study includes 19 patients that were referred to the Amarillo Heart Group in Amarillo, TX who also tested positive for Covid at least 6 months prior to September 1, The patients that fit this timeline were asked a series of standardized questions and rate the severity of their symptoms on a scale of 0 to 5, with 0 being the absence of symptoms and 5 being the most severe.

Rating more than 1 Life Spheres question as a 3 or higher or rating all 3 Symptoms Criteria questions as a 3 or higher indicated Chronic Fatigue Syndrome.

Information from the survey, including time since infection, demographics, and question scores, were analyzed. Our study included 10 women and 10 men, with the average amount of time since Covid infection being Worsening of symptoms with mild exertion was the most commonly endorsed criteria 3.

Women scored higher in every category except reduced activity in school when compared to men. However, there was no significant difference in symptom scores between the two groups with the Combined Fatigue Score being 2. Nearly all symptom scores significantly positively correlated with one another, meaning if one category was high it was likely for other categories to be high as well. Ultimately, when looking at the Cumulative Pearson Correlation Scores, reduced social life, difficulty concentrating, and symptoms worsening with mild exertion were found to be most predictive of a high Combined Fatigue Score.

To our knowledge, this is the first study to examine ME in patients with both of these predisposing conditions. A high degree of clinical suspicion for ME should be used when screening and treating cardiac patients who have been infected with COVID Coronary artery aneurysms CAAs , especially multiple, are a rare cardiac pathology and an unusual cause of cardiac chest pain.

A year-old African American woman with hypertension and non-insulin dependent type II diabetes mellitus presented with one day of chest pain.

She was evaluated five months prior for a similar presentation and had negative cardiac stress test and normal echocardiogram at that time. She followed with cardiology and was compliant with a regimen that included aspirin, statin, beta blocker, calcium channel blocker, thiazide and metformin.

Troponin was elevated to 0. A subsequent coronary angiogram revealed no atherosclerotic disease but multiple saccular coronary artery aneurysms: 6 mm in the left anterior descending artery segment D1 and two 6—8 mm aneurysms in the left circumflex artery OM1 lower pole and OM2 upper pole. The patient was discharged on long-term clopidogrel. Subsequent rheumatologic workup has been unrevealing and she continues to follow with cardiology. Coronary artery aneurysms involving multiple vessels is an extremely rare finding, particularly in this patient without any other significant risk factors.

CAAs should be considered as a rare differential diagnosis in a patient with cardiac chest pain who does not fit the classic ACS illness script. CAA require close follow up, and can be managed percutaneously, surgically, or medically, depending on factors such as size, location, and if they are causing cardiac ischemia.

Further reporting and study of this rare condition is crucial for better understanding and delineation of best management. Reverse takotsubo cardiomyopathy is a rare variant of takotsubo cardiomyopathy which is characterized by basal wall ballooning and apical hyperkinesis. In this case, we present the first documented incidence of reverse takotsubo cardiomyopathy caused by profound hypokalemia.

A 62 year old male was resuscitated following cardiac arrest secondary to ventricular fibrillation in the field. After resuscitation, initial lab work was notable for hypokalemia with a potassium level of 2.

The patient underwent emergent left heart catheterization which demonstrated angiographically normal coronary arteries. It should be noted that, takotsubo cardiomyopathy is a rare syndrome characterised by temporary and reversible left ventricular dysfunction that is provoked by a stressor that can be either physical or emotional.

There are 4 types of takotsubo cardiomyopathy; reverse takotsubo is unique in that it causes ballooning of the left ventricular base rather than the apex. As evidenced in this case, takotsubo cardiomyopathy is generally considered a diagnosis of exclusion and paitents must undergo detailed evaluation in order to exclude alternative causes of left ventricular dysfunction prior to diagnosis.

Hyperdynamic left ventricular apex circle relative to ballooned base on transthoracic echocardiogram A-diastole, B-systole and left vetriculogram C-diastole, D-systole. Left Ventricular Non-Compaction LVNC is a rare congenital cardiomyopathy which carries a high risk of malignant arrhythmias, thromboembolic phenomenon and left ventricular dysfunction.

Prominent trabeculations were noted in the LV apical and anterolateral segments. There was no evidence of stress induced myocardial ischemia. The patient responded to intravenous diuresis and was counselled on the diagnosis of LVNC cardiomyopathy, fitted with a LifeVest and discharged on warfarin anticoagulation. LVNC is congenital cardiomyopathy characterized by extensive endomyocardial trabeculations and recesses within the ventricular cavity. The clinical sequelae of LVNC mainly involve congestive heart failure CHF , arrhythmogenesis, thromboembolism, and a small percentage of patients may remain asymptomatic.

The diagnosis is made through imaging, with echocardiography as the first-line method. Cardiac Magnetic Resonance Imaging has also emerged as a potentially superior method due to its 3-dimensional nature and higher image quality. After the diagnosis of LVNC is made, treatment is directed at the different elements of disease.

Due to the increased thromboembolism risk of LVNC, the strategy of anticoagulation has been a subject of debate. Due to the genetic nature of the disease, it is recommended that a thorough 3 generation family history is obtained and genetic testing be done in appropriate relatives if a specific genetic mutation was determined.

Genetic cardiomyopathies should be considered in the differential diagnosis of young patients presenting with symptoms of heart failure with no known comorbidities or prior history of cardiac disease. Gender differences in systolic heart failure HF patients for the implantation of various cardiac implantable electronic devices CIEDs using ICD have not been studied.

We aim to explore the gender differences for each type of procedure. Demographic data were obtained using the variables provided in the NIS. We identified 4,, HF hospitalizations from January to December Overall, two third of patients were male Among the CIEDs, males had a higher rates of procedure utilization compared to females : Percutaneous insertion of defibrillator in right ventricle 1.

Reword to support the conclusion. Despite minimal differences in baseline characteristics, implantation of CIEDs appear to be utilized less often in women than in men, less often in blacks than in white, and more often in urban hospitals.

Further studies are required to confirm these findings and further explore gender differences. Coronary calcium is an independent risk factor for adverse outcomes in coronary artery intervention. Modification of this calcium via intravascular lithotripsy is accomplished through acoustic pressure waves that disrupt the calcium and improve vessel compliance. Studies have shown intravascular lithotripsy is effective in the management of heavily calcified de novo coronary lesions.

Evidence for use in in-stent restenosis is limited and is still off-label. The purpose of this study is to evaluate the effectiveness and safety of intravascular lithotripsy for management of calcium-mediated in-stent restenosis. A retrospective, single-center study was performed for four cases of in-stent restenosis with evidence of significant underlying calcium burden resulting in stent under-expansion and probable calcium intimal neoplasia.

Lesions were treated with intravascular lithotripsy Shockwave Medical. Complications were defined as vessel dissection, decrease in Thrombolysis in Myocardial Infarction flow, recurrent anginal symptoms, or death. In-stent intravascular lithotripsy followed by angioplasty with non-compliant balloon inflations at high pressures was performed.

There were no complications identified in the study group. The role of intravascular lithotripsy has been established in patients with de novo calcified lesions. This study demonstrates the effectiveness and safety of intravascular lithotripsy for calcium-mediated coronary in-stent restenosis. Given the challenges of in-stent restenosis, particularly associated with underlying calcium, additional studies are warranted.

Other risk factors include smoking half a pack-year for 45 years, hyperlipidemia, BMI 34, no family history of heart disease, carvedilol, aspirin, and statin. The BP was controlled with IV labetalol and amlodipine. He was observed for two days without any further events. Chest pain was more suggestive of costochondritis than cardiac. He was recommended to avoid weight lifting one week, smoking and drug cessation, and follow up with a cardiologist.

In all three admissions, the patient was admitted and discharged with elevated troponins with no definite diagnosis. Potential reasons a patient with clinically suspected acute MI may be misdiagnosed can be a Test-related issues, b myocardial injury not related to coronary artery atherothrombosis, and c acute myocardial injury not related to the coronary circulation.

In most high-sensitivity cardiac troponin hs-cTn assays, the 99 th percentile URL values are higher in men than in women. The United States recommends sex-specific cut-off values; however, not adopted in Europe. A subgroup of these patients have a Type 2 MI, consequent to increased oxygen demand or decreased supply, and will not have significant epicardial coronary artery disease when coronary angiography is performed.

The patients with acute ischemia and elevated troponin benefit from diagnostic coronary angiography and possible percutaneous coronary intervention. This may almost be true with hs-cTn assays, as the increased sensitivity means that more significant numbers of patients with type 2 MI will also be detected.

Hence, these patients may not benefit from an invasive approach. In most studies, short- and long-term mortality rates were higher in type 2 MI than in type 1 MI patients. In a multivariable model accounted for competing risk of death between subgroups, the adjusted 5-year risk of MACE was lower in type 2 MI versus type 1 MI with risk ratio, 0.

Higher mortality but similar or lower MACE rate among type 2 MI and nonischemic myocardial injury versus type 1 MI advocates this risk of death is from comorbidities rather than by complications of ischemia or necrosis.

The patient is a year-old man with a history of dextro-transposition of the great arteries for which he underwent an atrial switch Senning operation with VSD closure at 3 years of age. As an adult, he required pacemaker and ICD implantation for complete heart block and ventricular tachycardia. He endorsed functional class II symptoms in clinic. Right and left heart catheterizations demonstrated no coronary disease, normal filling pressures, and a preserved cardiac index. ICD interrogation revealed that the subpulmonic LV threshold was elevated and the battery was at replacement time.

He was referred for generator replacement and ventricular resynchronization. A plan was made to attempt His bundle pacing, and if that failed, to implant a new pacing lead in the LV septum. The His bundle could not be located, so we proceeded with placement of a lead in the interventricular septum. We first attempted placement of a Medtronic pacing lead; however, due to the tortuosity of the baffle, we could not affix the lead. We advanced a Medtronic pacing lead and, using a primary and secondary curved stylette, successfully positioned and affixed the lead to the LV septum.

Pacing from this location demonstrated appropriate pacing and sensing parameters. Three months later, the patient reported functional class I symptoms. A 2-year-old male presented to the Emergency Department ED for the 3rd time in 2 months with staring spells and mild encephalopathy. Parents had also noted irritability, headaches, emesis, diarrhea, generalized erythematous rash, lymphadenopathy, and intermittent fevers. Symptoms started shortly after the family moved into a new home from out of state 2 months prior to presentation but had worsened in the preceding 2 weeks.

Lab results during the prior two ED visits included microcytic anemia and elevated ESR; investigation for Kawasaki disease including TTE was negative and on both occasions was diagnosed with a presumed viral infection.

On this visit to the ED, he was afebrile and tachycardic. Exam showed a tired, irritable, but consolable male with tachycardia with regular rhythm, faint bibasilar crackles, occipital and inguinal lymphadenopathy, excoriations in various stages of healing over torso and legs.

He had an episode concerning for seizure while in the emergency department. He was started on oxcarbazepine and discharged home. Following discharge, patient continued to be sleepier than normal and re-presented to the ED. A detailed social history was obtained and revealed the unexpected deaths of two family cats who died shortly after moving to the area, raising concern for environmental toxins. Patient was subsequently given chelation therapy.

This case highlights several challenges with identification of a subacute pediatric environmental exposure. Acute mercury inhalation injury secondary to a solution being spilled then inhaled over at least a month presented initially as an acute upper respiratory illness.

Later, the initial morbilliform rash was recognized as acrodynia, an idiosyncratic hypersensitivity to mercuric salts. Unfortunately, each of these symptoms can be found in a spectrum of clinical pathologies. The key to diagnosis in this scenario was the identification of the unexpected death of two pets that ultimately led to the timely detection of a very dangerous environmental toxin. The management of pain in vaso-occlusive crises VOC in patients with sickle cell disease SCD often involves opioids, putting patients at risk for adverse effects.

However, the management of VOC-related pain with continuous peripheral nerve blocks CPNBs shows potential as a viable alternative to opioids. The purpose of this study is to examine the outcome of a patient with a chronic non-healing medial malleolar ulcer related to repeated VOC which was effectively managed with a series of CPNBs. A year-old female patient with SCD and acute-on-chronic pain due to a VOC-related chronic ulcer on her right medial malleolus was referred to the Acute Pain Service.

The patient required daily oral opioids for pain control and had been hospitalized 15 times for pain control since the wound developed. With informed consent, a CPNB of the saphenous nerve was performed midthigh with an gauge Touhy needle. An elastomeric pump was attached, and an infusion of 0. The patient was allowed to adjust the rate as needed after discharge. One week later, the pump was removed with no complications.

These techniques were repeated periodically over a span of days. Wound healing progress was documented with photos. The wound was reduced to a small scab, and the patient no longer required opioids to manage her chronic wound pain. Hospital admissions for pain control decreased during the period of CPNB infusions and the average length of stay decreased by 2.

Pain scores and opioid dosage also decreased. These metrics support the use of CPNBs for their ability to decrease costs and reduce opioid dependence. CPNBs can be used to effectively eliminate acute or acute-on-chronic pain and reduce opioid use, healthcare costs, and hospital visits in patients with VOC related to SCD.

The degree to which the serial CPNBs contributed to the closure of the chronic wound in this case requires further study, however, there are plausible mechanisms by which a CPNB might contribute to wound closure.

For example, the sympathectomy-induced vasodilation by perineural local anesthetic infusions increases blood flow and oxygen delivery to wounds, counteracting the peripheral vasoconstriction observed in reaction to acute pain. Anorexia Nervosa is a mental health disorder with significant morbidity and mortality.

Acute food refusal is one of the indications for admission. We present a patient who went to extreme lengths to restrict food intake, requiring intensive care sedation and ventilation to enable enteral feedings.

He was treated with supervised eating on an inpatient pediatric floor with no need for enteral feeding. Psychiatry consultation confirmed the diagnosis of anorexia nervosa and recommended the addition of Olanzapine to his Sertraline.

He was discharged pending placement in an eating disorder center after 21 days of hospitalization with discharge BMI of He was followed as an outpatient by his pediatrician, dietician and counselor but unfortunately, he required readmission 11 days after discharge due to acute food refusal, with BMI that had dropped to Patient was readmitted and started on nasogastric NG feeds but he became severely agitated, pulling NG out multiple times and continued to lose weight with BMI dropping to Sedation was attempted to facilitate maintenance of NG feedings, with Benadryl, Haldol and Ativan, but was ineffective at levels deemed safe without compromising his airway and breathing.

Due to severe malnourishment and unsuccessful NG feeds he was transferred to PICU for sedation, endotracheal intubation and continuous nasoduodenal ND tube feedings on two separate occasions while inpatient.

He was able to wean from the ventilator but once awake he found ways to manipulate delivery of his calories, even finding scissors and cutting the ND tube. The patient ultimately agreed to eat in order to avoid replacement of the feeding tube. He was finally transferred to an eating disorder facility, with a BMI of Patient completed three months of an inpatient program and had significant improvement in BMI to He was subsequently discharged for continued outpatient follow-up and since discharge from the eating disorder center, his BMI has shown steady improvement in outpatient follow-up.

He shows no signs of food refusal and is doing well with Family Based Therapy. This case highlights several unique characteristics in management of eating disorder patients. The age and being male along with extreme food refusal and resistance to enteral feeding that led to the requirement of deep sedation are quite unusual and not well described in the medical literature. The severity of his illness was a significant barrier to inpatient placement.

In addition, despite a nationwide attempt to find an inpatient facility for him, which took several weeks, we identified shortages in eating disorder beds that have been exacerbated by the COVID pandemic. Asthma is an obstructive, inflammatory lung disease which is often recognized by wheezing and increased work of breathing. Although mild exacerbations may be controlled in an outpatient setting, an episode of significant exacerbation may lead to status asthmaticus SA.

With increased prevalence in pediatric populations, SA generates concern for hypoxic injury and mortality. Obesity is also associated with adverse outcomes leading to significant morbidity in asthmatic populations.

However, the association in children, particularly those with acute asthma has remained poorly defined. This study aims to investigate the relationship between obesity and SA in children requiring hospital admission.

Renal Medulla. Durongphan et al. Culture type. Numerous mixed bacteria,. Few mixed. Yeast seen. Moderate Yeasts. Pseudomonas aeruginosa, Numerous Prevotella spp. No growth. Candida tropicalis,. Candida krusei. Clostridium perfringens,. No fungal.

Costridium perfringens Yeast seen. Clostridium perfringens. Hyphae seen. Yeast seen in direct. No AFB. Pre-embalming and post-embalming culture results. Embalming technique and the gross evaluations. There are few publications concerning the human embalming technique with the saturated salt solution. Because in a 50 kg male cadaver, the injected fluid amount is Their method involved storing a wrapped embalmed cadaver in the solution. The gross tissue qualities resembled that of living humans or fresh cadavers on scales of 3 and 4 Table 2.

The NSG had excellent joint flexibility Fig 1. These results are similar to previous studies performed in both human cadavers and rats. However, a study of different salt concentration solutions to preserve human brain and liver slices found that saturated salt fluid can preserve brain slices without signs of decomposition.

We also tested the submerged method by directly placing cadavers in the fluid and decreasing the injected fluid amount. Histological evaluations. Coleman and Kogan reported the saturated salt method preserved adipose tissue, striated muscles, liver, and spinal cord microanatomy. Most of them were rated on Likert scales 4 and 5 Table 3.

It is presumed that the saturated salt with the non- submerged technique has preservative properties for the histological structures. Microbiological evaluations. The saturated salt solution molarity was. The pathogenic bacteria in that study were Escherichia coli, Salmonella typhimurium, Listeria monocytogenes, Staphylococcus aureus, Clostridium perfringens, and.

The results showed that Gram-positive and spore-forming bacteria were more resistant to high osmotic pressure than the others, resulting in a need for at least day preservation to eliminate the pathogens.

We found bacteria and fungus at the end of the embalming. The post-embalming pathogenic bacteria were Clostridium perfringens and Pseudomonas aeruginosa. Burns et al. There was no microbiological evidence of putrefaction in Burn et al. We speculated that the climate in our country Thailand plays a role in microorganism growth since no prior SSS studies have been done in a tropical.

The putrefied cadavers. We found that the death records and post-mortem signs in cadavers SS and SS were mismatched. The cadavers might have entered the bloated stated before we embalmed. A questionnaire-based study asking medical students, residents, and specialists from five Israel medical schools about how anatomy should be taught showed Moreover, longitudinal integration such as cadaveric biopsy during dissection is helpful in pathology learning correlation, and practice suturing during dissection makes medical students at ease in the clinical year.

Moreover, the gross anatomy evaluators were randomly invited to avoid bias. In future research, more cadaver numbers and randomly selected staff forming an evaluator team to evaluate every cadaver may yield a different result.

Further study of this technique adjustment, such as changing the solution composition and storing cadavers in low-temperature conditions, is advised. Human preservation techniques in anatomy: A 21st century medical education perspective. Clinical Anatomy. Workshop in clinical anatomy for residents in gynecology and obstetrics. World J Surg. A world survey about its use.

Surgical and radiologic anatomy. Comparison of modified Thiel embalming and ethanol-glycerin fixation in an anatomy environment: Potentials and limitations of two complementary techniques.

Advanced cadaver-based educational seminar for trauma surgery using saturated salt solution-embalmed cadavers. Acute Med Surg. One academic year laboratory and student breathing zone formaldehyde level, measured by gas-piston hand pump at gross anatomy laboratory, Siriraj Hospital, Thailand. Environ Sci Pollut Res Int. Coleman R, Kogan I.

An improved low-formaldehyde embalming fluid to preserve cadavers for anatomy teaching. J Anat. Saturated salt solution method: a useful cadaver embalming for surgical skills training. Medicine Baltimore. Total body water volumes for adult males and females estimated from simple anthropometric measurements.

Am J Clin Nutr. A century of trends in adult human height. J Bone Joint Surg Am. Plast Reconstr Surg Glob Open. Effects of different cadaver preservation methods on muscles and tendons: a morphometric, biomechanical and histological study.

Anat Sci Int. Jumlongkul A TP. Comparison between formaldehyde and salt solutions for preservation of human liver and brain slices. Chula Med J. Burgess J. Metal ions in solution. Antimicrobial properties of salt NaCl used for the preservation of natural casings.

Food Microbiol. Pinheiro J. Decay process of a cadaver. Forensic anthropology and medicine. Humana Press; Lee Goff M. Early post-mortem changes and stages of decomposition in exposed cadavers. Exp Appl Acarol.

Marom A, Tarrasch R. On behalf of tradition: An analysis of medical student and physician beliefs on how anatomy should be taught. Active learning classes in a preclinical year may help improving some soft skills of medical students.

Cadaver biopsies positively impact the Medical Student Educational Experience. Medical Science Educator. Early and prolonged opportunities to practice suturing increases medical student comfort with suturing during clerkships: Suturing during cadaver dissection.

Chairat Turbpaiboon, M. Objective: This study investigated the frequency and types of 1 orientation of the deep peroneal nerve DPN and its branches relative to the dorsalis pedis artery DPA and the extensor hallucis longus tendon EHLT and 2 branching site and pattern of DPN at the distal area of leg and the proximal zone of the foot.

Materials and Methods: One-hundred and sixty specimens from the lower extremities of 80 formalin-embalmed cadavers were investigated for anatomical position, orientation and the branching pattern of DPN by manual dissection, starting from the anterior side of lower extremity just proximal to ankle joint down to the area distal to inferior extensor retinaculum.

Regarding branching sites and patterns of DPN in the intermalleolar and ATT areas, nearly half of the studied specimens had DPN bifurcation at the intermalleolar level and more than half of the bifurcations were inside the ATT. Conclusion: This study establishes novel data regarding type variation and prevalence of DPN in areas of ankle and proximal part of foot in the Thai population which could be helpful in clinical practice.

Keywords: Deep peroneal nerve; inferior extensor retinaculum; anterior tarsal tunnel; dorsalis pedis artery; extensor hallucis longus tendon Siriraj Med J ; The deep peroneal nerve DPN is composed of both sensory and motor components that innervate certain regions of the lower extremity.

While passing through the anterior compartment of the leg, DPN provides muscular branches and runs downward along the anterior tibial vessels laterally. At the distal part of the leg, DPN runs superficially in companion with the dorsalis pedis artery DPA, the artery continuing from the anterior tibial artery and the extensor hallucis.

Corresponding author: Woratee Dacharux E-mail: woratee. However, variations in DPN orientation and branching have been reported and this reveals their inconsistency. These findings play a crucial role in providing safety information for surgeons and anesthetists to ensure high accuracy and effectiveness of clinical practice with DPN and to reduce the risk of nearby structures.

This study was conducted in 80 formalin-embalmed cadavers donated to the Department of Anatomy, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand for academic and research purposes. One-hundred and sixty specimens of lower extremities were investigated for anatomical position, orientation and branching pattern of DPN by manual dissection starting from the area of anterior side of lower extremity just proximal to ankle joint down to the area distal to IER.

The dissected zone was horizontally enlarged to adequately visualize the related anatomical information. Results from the right-sided and left-sided specimens were compared for correlation. The DPN branching site was identified to determine its location in relation to an imaginary line, connecting medial and lateral malleoli, and ATT.

The demographic data of All six possible types of orientations were identified in this study. Examples of the common types are shown in Fig 1. Three most-common types of orientation are shown in Fig 2. Almost half of the studied specimens had bifurcation of DPN at the same vertical level as the intermalleolar line type L2 , while the majority of the remaining specimens had bifurcation distal to this line type L3.

However, 1. Correlations between results from right-sided and the left-sided specimens in this study were similar among different investigated parameters. As this study focused on the DPN at the lower area of the leg, near the proximal part of the foot, the orientation of the DPN main trunk together with its companions anterior to the ankle was examined first Table 1. T at the area anterior to ankle joint. O1: T-A-N.

O2: T-N-A. O3: A-N-T. O4: A-T-N. O5: N-A-T. O6: N-T-A. Side correlation. Compared with imaginary line connecting medial. Compared with IER. Proximal to imaginary line. Midway between medial and lateral malleoli. Distal to imaginary line. By using EHLT as a fixed medial landmark, this is useful for clinical procedures involving the area anterior to the ankle joint e.

A total of six patterns were found in this study Table 2. Variations of the DPN branching level was also observed in our specimens. There were two stable landmarks used for positional reference. The first was an. These two landmarks were independently located, so the IER was equally proximal, anterior, and distal to the ankle mortise. However, the prevalence was to a much different extent Meanwhile, bifurcation below ATT type R3 was comparable to a prior study 7.

In addition to the studies aforementioned, there still have been a number of studies regarding the structural variation of both DPN and DPA by presenting significantly diverse data on type and prevalence which depended on either numbers of studied specimen or cadaveric ethnicity. For example, a study on DPA course compared to DPN branching performed in an Asian population revealed the different levels of variation prevalence from our current study.

Interestingly, there was no existence of types A3 and A4 in this study. For instance, it has been found for many decades in other ethnic groups that the termination of DPN can also exist in multiple branching similar to the type M reported in our current study, not only the bifurcation into MTB and LTB.

Another structural variation that has been commonly found in other populations and is worth determining its prevalence in our population is the accessory deep peroneal nerve ADPN which branches from the superficial peroneal nerve. It carries the motor component to supply several muscles including certain or total parts of the extensor digitorum brevis EDB 12,13 and the sensory innervation for areas of fibula periosteum, lateral zone of ankle and metatarsal area.

No significant difference between the males and females in ADPN prevalence was detected. Besides the variations detected in DPN course and branching, the arterial system that runs parallelly with DPN also displays its variation in several patterns as encountered in several cadaveric and angiographic studies. Starting from the constant anterior tibial artery ATA that mostly lies medially to the DPN except for the middle-third of this nerve, leading to another name of DPN as nervus hesitans, the distal part DPA inconstantly varies in its orientation into several types as described in Table 1.

Apart from the orientation variation of the distal part of DPA described in Table 2 , there have been additional variations in terms of number, location and also its branching pattern. DPN is a nerve that courses profoundly among the muscular tissue in the leg compartment and superficially beneath the cutaneous tissue as found in 1 the neck of the fibula as the part branching from the common peroneal nerve and 2 the area anterior to the ankle joint before running down to the ATT.

However, our findings are in agreement and disagreement with previous studies. This can be elucidated by two explanations: the difference in ethnicities of the investigated cadavers and the numbers of cadavers used in each study.

A sufficient number of specimens were included in this study in order to achieve high reliability of the results and to reach. Variability in type and prevalence in the course of DPN and its branching pattern found in this study can be used in clinical practice under various contexts such as population-specific treatment.

The main application of this research is the direct procedures on DPN and its branches, eg. DPN unveiled in this study can also correlate to clinical imaging information 32,33 and be used to predict clinical neurovascular consequences following a traumatic injury or treatment in the ankle and foot region.

Based on the specimens, this study provides novel information on the type of variation and prevalence of DPN in the ankle and proximal part of the foot in the multiracial population inhabiting in Thailand. Therefore, this information can be used to help update population- specific clinical databases in this region. Due to significant differences found in our study when compared with data from other studies in other population groups, our study confirms that population-specific studies on structural variation is required before application in practice.

The authors are grateful to Dr. Supin Chompoopong, Dr. Pawinee Pangthipampai and Dr. Prae Plansangkate for their guidance and suggestions in this study. The authors would also like to thank the teaching assistants departmental interns from the Department of Anatomy, Faculty of Medicine Siriraj Hospital for their help during this study. Conflict of interest: The authors declare no conflicts of interest.

Standring S. The deep peroneal nerve in the foot and ankle: an anatomic study. Foot Ankle Int. The clinical importance of the relationship between the deep peroneal nerve and the dorsalis pedis artery on the dorsum of the foot.

Relationship between the deep peroneal nerve and dorsalis pedis artery in the foot: a cadaveric study. Innervation of the sinus tarsi and implications for treating anterolateral ankle pain. Ann Plast Surg. Dimensions of the anterior tarsal tunnel and features of the deep peroneal nerve in relation to clinical application.

Surg Radiol Anat. Chitra R. The relationship between the deep fibular nerve and the dorsalis pedis artery and its surgical importance. Indian J Plast Surg. Geller M, Barbato D. Nervus peronaeus profundus. Hospital Rio J. Anterior tarsal tunnel syndrome. Arch Phys Med Rehabil.

Compression of the deep branch of the peroneal nerve by the extensor hallucis brevis muscle: a variation of the anterior tarsal tunnel syndrome. Can J Surg. Dellon AL. Deep peroneal nerve entrapment on the dorsum of the foot. Foot Ankle. Lambert EH. The accessory deep peroneal nerve. A common variation in innervation of extensor digitorum brevis. Total innervation of the extensor digitorum brevis by the accessory deep peroneal nerve.

Eur J Neurol. The consistent presence of the human accessory deep peroneal nerve. Anatomic variations of superficial peroneal nerve: clinical implications of a cadaver study. Ital J Anat Embryol. Prevalence of the accessory deep peroneal nerve: A cadaveric study and meta-analysis. Clin Neurol Neurosurg. Acta Inform Med. Crutchfield CA, Gutmann L. Hereditary aspects of accessory deep peroneal nerve. J Neurol Neurosurg Psychiatry. The ISI will be used to assess self-reported quality of sleep. It contains 7 questions than consider the ability to fall asleep, the ability to stay asleep, and effects on daily life.

Each question is rated with a Likert-scale from 0 to 4, with lower ratings indicating a higher quality of sleep. Scores between 0 and 7 indicating no clinically significant insomnia, 8 to 14 indicating subthreshold insomnia, 15 to 21 indicating moderate insomnia, and 22 to 28 indicating severe insomnia. Fourteen has been commonly used as the cut-off score to detect primary insomnia. The reliability and validity of this tool has been demonstrated [ 59 ].

The number of minutes per category is then added up and results are classified as high, moderate, or low physical activity based on the total MET minutes. This measure has been deemed both reliable and valid [ 60 ]. The occurrence of adverse events e. Adherence with the exercise program will be assessed and noted by the therapists using the participants treatment files.

At the end of the intervention, the adherence with home exercises program after discharge will be measured using the following ordinal scale; How often did you perform home exercises?

Participants will be asked to report any type of co-interventions e. Pain medication will be allowed as it would be unethical to withhold medication, but this information will be collected for all participants. The database will be saved and maintained on a secured network at the institution.

Any inconsistencies in the data will be reported, explored and resolved. Only study personnel will have access to the password-protected database. Investigators will allow verification of the data from the ethics board and maintain adequate and accurate records of all documents. Any modifications to the protocol will be reported and communicated to the REB. Confidentiality of the data will be protected and maintained during and after the trial. Sample size calculation was determined by using the effect size e.

The mean effect size over the 4 different spinal levels was calculated and used for sample size estimation. Pre-post results were considered as independent independent from two groups to concur with the present study statistical analysis between-group factor. Descriptive statistics for demographic characteristics and outcomes will be calculated.

The pre to post intervention changes in primary and secondary measures will be evaluated with the use of a between-subjects repeated measures ANOVA. Linear mixed models will be used to assess whether baseline psychological scores can modify the response to the exercise therapy treatment. The results of this trial will be published in peer-reviewed journals and presented at conferences.

After publication of manuscripts, data request can be submitted to the principal investigator MF. LBP is one of the most disabling diseases and a major health issue. In accordance with the ever-increasing body of evidence demonstrating accelerate atrophy and fatty infiltration in patients with chronic LBP, improving strength, function and control of the trunk muscle through therapeutic exercises is a primary goal in physical rehabilitation of patients with LBP.

As such, strengthening, lumbar stability, and motor control exercises are recommended and amongst the most popular exercises for the management of chronic LBP [ 14 — 16 , 63 ]. If specific targeted lumbar muscle exercises are to be prescribed and used clinically, the evaluation of physiological muscle changes, such as hypertrophy and reversal of fatty infiltration and whether they mediate improvements in functional status should be considered when assessing the effectiveness of different exercise interventions.

Our research protocol through measurement of muscle morphology and function, clinical symptoms and psychological factors will shed some light into this field. The results of this trial are expected to improve the efficacy of prescriptive exercise training in subjects with non-specific chronic LBP.

The limitations of this study include the use of only two recruitment locations, which primarily represents the anglophone population of Montreal. This will decrease the generalizability of this study. We are also restricting inclusion to those able to understand and read English or French, which will also limit generalizability. However, the participants will not be told their group assignment and only that they are completing an exercise protocol with the aim of decreasing their LBP and increasing their function.

Written informed consent to participate in the study will be obtained from earch participant. Written informed consent to publish the data of this study will be obtained from each participant. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

BMC Musculoskelet Disord. Published online May James M. Michael H. Author information Article notes Copyright and License information Disclaimer. Maryse Fortin, Email: ac. Corresponding author. Received Apr 26; Accepted May The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material.

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Abstract Background Exercise is a common approach for the management of patients with chronic non-specific low back pain LBP. Methods A total of 50 participants with chronic non-specific LBP and moderate to severe disability, aged between 18 and 60, will be recruited from the local orthopaedic clinics and university community. Discussion The results of this study will help clarify which of these two common interventions promote better results in terms of overall paraspinal muscle heath, back pain, disability and psychological factors in adults with chronic LBP.

Background Low back pain LBP is one of the leading causes of disability worldwide [ 1 , 2 ], costing billions of dollars in Canada alone each year, including health care costs and missed work [ 3 ]. Open in a separate window. Participant recruitment Participants will be recruited by clinicians in local orthopaedic clinics working in Montreal, Canada and from the local university community by email advertising. Exclusion criteria Participants will be excluded if they meet one of the following criteria: Any evidence of nerve root compression or reflex motor sign deficits.

Major lumbar spine structural abnormalities e. Health conditions that prevent the safe participation in physical exercise as determined by the Physical Activity Readiness Questionnaire. Randomization Participants will be randomly assigned to treatment groups using consecutively numbered sealed opaque envelopes e. To relieve tension over the compression site, the muscle inhibition technique was applied. The application targeted four muscles: subclavian, pectoralis minor, biceps, and anterior scalene.

Four kinesio strips were prepared prior to application: three Y-shaped strips and one I-shaped strip. The procedure included four steps as described below Figure 1. Placebo KT was performed by using three I-shaped strips. The strips were applied with no tension and perpendicular to the axes of KT applications used in the experimental group Figure 2. The patients were evaluated prior to the intervention t0 , just after the removal of the third tape t1 , and 8 weeks after baseline t2.

The outcome measures were pain and paresthesia, upper extremity functionality, and general health perception. The distribution of the variables was checked by analyzing skewness and kurtosis for each variable, as well as by using the Shapiro-Wilk test. Baseline categorical variables and continuous variables were compared between groups by Chi-square test and the Mann-Whitney U test, respectively.

Within-group changes in outcome measures by time comparison among three time values were evaluated by using the Friedman test with further Bonferroni correction.

Post hoc test was performed for pairwise comparisons. Between-group comparison of change in outcome measures was assessed by the Mann-Whitney U test. This study included 62 patients with sTOS. Each group comprised 31 patients. One patient from each group was withdrawn from the study because of skin allergy to the kinesio tape material. Therefore, the statistical analysis included a total of 60 patients 30 in each group Figure 3.

Baseline characteristics of the groups are given in Table 1. In the KT group, all outcome measures except NHP social isolation showed statistically significant improvement from baseline to t1. Except NHP emotional reaction and NHP social isolation, median changes in outcome measures from t0 to t1 were significantly higher in the KT group when compared with those in the placebo. Results of Mann—Whitney U test. Values are presented as median min—max ; t0—t1: change from baseline to posttreatment, t1—t2: change from posttreatment to 8th week, t0—t2: change from baseline to 8th week.

Treating TOS in clinical practice is often challenging because patients not only present with pain and paresthesia but also experience impairment in the upper extremity functionality and general health status. Treatment options include surgical and nonsurgical approaches. Landry et al. Sixty-four patients were treated with conservative approaches, whereas 15 underwent surgery. There was no difference between groups in terms of disease progression and current level of symptoms There is still a debate on the optimal management of TOS.

Conservative treatment includes exercise, physical modalities, behavioral modification techniques, and chemodenervation local anesthetics, botulinum toxin A 10 , 19 — KT is a safe and effective treatment option for several musculoskeletal disorders 22 , However, it has a relatively limited therapeutic role in patients with musculoskeletal injuries 24 , Recently, the effectiveness of KT was evaluated in patients with shoulder impingement syndrome.

Addition of KT to nonsteroidal anti-inflammatory drugs provided favorable effects on clinical outcomes Reynard et al. Although KT provided a decrease in muscle overactivity, it showed no clinical benefits in terms of pain, range of motion, and muscle strength KT was also studied in entrapment neuropathies such as carpal tunnel syndrome.

In the short term, KT applied with low-power laser did not provide any additional benefit. However, in the long term, hand grip strength and finger pinch strength improved significantly A single-blind randomized controlled study showed that add-on KT therapy to night orthotic devices provided additional benefits in patients with carpal tunnel syndrome Patient-reported clinical variables including pain and paresthesia, upper extremity functionality, and health-related quality of life improved after KT application.

However, the improvement in NHP social isolation was not statistically significant. The therapeutic effect of KT might be explained by several mechanisms. Being related to the tension applied to the material, KT can stimulate mechanoreceptors inside the skin. The tension applied creates skin folds and thereby lifts the skin. The lifting effect of the adhesive material might not only provide a fascial correction but also cause a fluid charge from high-pressured areas to the areas with lower pressure.